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Admission Date: [**2177-7-24**] Discharge Date: [**2177-7-29**] Date of Birth: [**2135-5-20**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7262**] is a 42-year-old HIV, hepatitis C positive man currently under evaluation for liver transplantation in [**Location (un) 19061**] for liver failure. Over the past four months or so he has noted some exertional chest discomfort. He describes this as a pressure sensation that occurs in his mid chest when walking quickly or going up any incline. This is occasionally associated with dizziness, shortness of breath and diaphoresis, resolving quickly with rest. He has never taken any Nitroglycerin. He was also having significant dyspnea on exertion at the time of admission. A Persantine stress test on [**2177-6-24**] was notable for ischemia in the distribution of the right coronary artery with a normal ejection fraction at 67%. The patient denies claudication, orthopnea, PND or lightheadedness. He does state that he has intermittent lower extremity edema, and he also states that he has ascites. PHYSICAL EXAMINATION: The patient was afebrile with stable vital signs upon presentation to the hospital. Neck, no JVD, 2+ carotid pulses without bruits. Heart, normal S1 and S2, regular rate and rhythm, grade 2/6 systolic ejection murmur at the right upper sternal border. Lungs, clear to auscultation bilaterally. Abdomen, soft, distended, nontender, normoactive bowel sounds. Extremities, trace ankle edema bilaterally. HOSPITAL COURSE: The patient was therefore admitted to [**Hospital1 1444**] on [**7-24**] for an elective coronary catheterization during which time a stent was placed in the right coronary artery. As per standard catheterization protocol, the patient received 2,000 units of Heparin during the procedure. He was also placed on Aspirin and Plavix following the procedure in order to maintain patency of the new stent. On [**2177-7-25**] (the first day following the procedure), the patient developed hematemesis. It should be noted that the patient has a baseline coagulopathy; in addition the patient has had periods of hematemesis in the past and has a known past medical history significant for esophageal varices which have been banded. An EGD was done at this time, and it revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear at the GE junction. Ulcers in the antrum, varices at the lower third of the esophagus and an otherwise normal EGD to the third part of the duodenum. Subsequent to this, the patient was taken off of Aspirin and Plavix due to the risk of repeated bleeds and was transfused with two units of packed red cells as well as FFP and platelets. Subsequent to this, his hematocrit stabilized and the patient was clinically stable. On the day prior to discharge the patient did experience some right upper quadrant pain; as a result an abdominal ultrasound was performed which was negative. In addition, a KUB was done which was negative and an EKG was done which showed no change from prior studies. The patient's hematocrit remained stable and he was therefore discharged to home on [**2177-7-29**]. DISCHARGE DIAGNOSIS: 1. Human immunodeficiency virus. 2. Hepatitis C virus with cirrhosis. 3. Esophageal varices. 4. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. 5. Multiple ulcers of the gastric antrum. 6. Ascites. 7. Upper GI bleed while in the hospital. 8. Prior history of spontaneous bacterial peritonitis. 9. Coronary disease, now status post stenting of the right coronary artery. DR. [**First Name (STitle) **] [**Name8 (MD) **] m.d. [**MD Number(2) **] Dictated By:[**Name8 (MD) 106782**] MEDQUIST36 D: [**2177-7-29**] 17:00 T: [**2177-7-29**] 17:23 JOB#: [**Job Number **] cc:[**CC Contact Info 106783**]

Admission Date: [**2179-10-21**] Discharge Date: [**2179-11-5**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2840**] Chief Complaint: Fever and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: The pt is an 84 yo female with past hx significant for DM type II, CHF, HTN, hypothyroidism, A-fib, chronic leg ulcers, and chronic renal insufficiency who presented to the ED on [**10-21**] with fever to 102 F and hypotension. She was transferred to the ICU where the hospital course was as follows: Sepsis protocol was initiated. Coverage of multiple possible sources was begun with vancomycin, levofloxacin, and metronidazole. Pt was aggressively fluid resuscitated. Norepinephrine drip was required to maintain blood pressure in adequate range. Urine culture was positive for Klebsiella pneumoniae, and the patient also had stool positive for C. diff toxin. Vancomyin was discontinued after osteomyelitis was ruled out as a possible infection in this patient. The patient's blood pressure was stable and the norepinephrine drip was discontinued. She was transferred to 12R on the am of [**2179-10-26**]. On arrival to the floor her temp was 100, hr 90-110, bp 100/60. Past Medical History: - Hypertension - DM II - Atrial Fibrillation - Gastroesophageal Reflux Disease - Total abdominal hysterectomy, bilateral salpingoophorectomy - Anemia - Chronic renal insufficiency (baseline 1.4 - 1.5) - Chronic leg ulcers - Anemia - Hypothyroidism Social History: - Denies smoking, EtOH, or drinking history. - Pt was independent until recent stay at [**Hospital3 2558**] - POA is [**Name (NI) **] [**Name (NI) 71227**] Family History: Non-contributory Physical Exam: Exam on arrival to the floors: VS: 97.8, 110/80, 78, 18, 98% on 4L NC Gen: lying in bed moaning, leaning to the right side, with preferential right gaze, difficult to understand speech HEENT: NC/AT, perrl, mmd, o/p clear Neck: L IJ CVL in place CV: irreg irreg, s1 and s2, no m/r/g Pulm: crackles bilaterally Abd: obese, soft, nt, nd, active bs Extr: 2+ edema throughout arms, legs, eye-lids; multiple deep ulcers bilaterally that are bandaged, bandages c/d/i Pertinent Results: [**2179-10-21**] 05:00PM GLUCOSE-98 UREA N-89* CREAT-2.9*# SODIUM-153* POTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-25 ANION GAP-20 [**2179-10-21**] 05:00PM WBC-21.7*# RBC-5.41* HGB-13.4 HCT-43.0 MCV-79* MCH-24.7* MCHC-31.2 RDW-18.9* [**2179-10-21**] 05:00PM NEUTS-87.9* BANDS-0 LYMPHS-7.1* MONOS-3.1 EOS-1.3 BASOS-0.4 [**2179-10-21**] 05:00PM PLT SMR-NORMAL PLT COUNT-323 [**2179-10-21**] 05:00PM PT-13.8* PTT-25.7 INR(PT)-1.2 [**2179-10-21**] 05:00PM ALT(SGPT)-13 AST(SGOT)-18 CK(CPK)-35 ALK PHOS-110 AMYLASE-69 TOT BILI-0.4 [**2179-10-21**] 05:18PM LACTATE-3.8* [**2179-10-21**] 05:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2179-10-21**] 05:55PM URINE RBC-[**3-19**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2179-10-21**] 06:55PM DIGOXIN-1.7 [**2179-10-21**] 06:55PM CORTISOL-24.9* [**2179-10-21**] 11:15PM CK-MB-3 cTropnT-0.03* [**2179-10-21**] 05:00PM cTropnT-0.02* [**2179-10-22**] 12:00AM CORTISOL-42.9* On discharge: [**2179-11-5**] 05:49AM BLOOD WBC-12.5* RBC-3.59* Hgb-9.2* Hct-28.6* MCV-80* MCH-25.6* MCHC-32.1 RDW-26.4* Plt Ct-316 [**2179-11-5**] 05:49AM BLOOD PT-13.0 PTT-31.8 INR(PT)-1.1 [**2179-11-5**] 05:49AM BLOOD Glucose-147* UreaN-29* Creat-0.6 Na-143 K-3.7 Cl-110* HCO3-28 AnGap-9 [**2179-10-27**] 10:45AM BLOOD calTIBC-131* Ferritn-196* TRF-101* TSH: [**2179-10-21**] 09:16PM BLOOD TSH-8.0* [**2179-10-27**] 10:45AM BLOOD TSH-16* [**2179-11-3**] 06:19AM BLOOD TSH-30* [**2179-10-27**] 10:45AM BLOOD Free T4-0.6* Digoxin: [**2179-10-21**] 06:55PM BLOOD Digoxin-1.7 [**2179-11-3**] 06:19AM BLOOD Digoxin-0.9 CXR [**11-2**]: A left internal jugular vascular catheter remains in satisfactory position. The cardiac silhouette is enlarged but stable. There is some degree of respiratory motion present, resulting in blurring of the pulmonary vasculature. This limits assessment for mild congestive heart failure. Bilateral pleural effusions are present and are partially layering on this semi-erect study. Increased opacity persists in the left retrocardiac region. AXR [**11-2**]: Gas present in colon. No abnormalities. Brief Hospital Course: 84 yo F presented with sepsis, transfered to ICU on arrival. In the ICU, a sepsis protocol was initiated. Coverage of multiple possible sources was begun with vancomycin, levofloxacin, and metronidazole. She was aggressively fluid resuscitated. A norepinephrine drip was required to maintain blood pressure in adequate range. Urine culture was positive for Klebsiella pneumoniae, and the patient also had stool positive for C. diff toxin. Vancomyin was discontinued after osteomyelitis was ruled out as a possible infection in this patient. The patient's blood pressure was stable and the norepinephrine drip was discontinued. She was transferred to 12R on the am of [**2179-10-26**]. On arrival to the floor her temp was 100, hr 90-110, bp 100/60. 1) ID: On the floors she completed 14 day courses of both flagyl and meropenem, and remained afebrile and hemodynamically stable throughout the remainder of her hospital course. 2) Leg Ulcers: The patient was seen by vascular surgery who felt that her ulcers were a combination of venous stasis and pressure ulcers. ABIs were not done as it would cause the patient too much pain, and the patient was not felt to be a surgical candidate regardless in light of her condition and comorbidities. Her dressings were changed once a day, however this was causing her extreme pain, despite morphine and ativan premedication, and dressing changes were decreased to every three days, and then not at all. She should not have any further dressing changes, as the pain is excrutiating for her. 3) Anasarca/fluid balance/hypernatremia: Ms. [**Known lastname 97599**] was found to be intravascularly depleted (high sodium), but total body fluid overloaded. We attempted diuresis, but this only elevated her sodium. We therefore fluid resuscitated her to lower her sodium, and then began diuresis once her hypernatremia had resolved. We had hoped that her fluid balance would improve with initiation of TPN to raise her albumin, however, after a week of TPN, her albumin continues to decrease, and she is not eating anything. Her anasarca persists. She will get maintenance IVF at [**Hospital3 2558**] with D5, in the absence of other forms of nutrition. 4) Nutrition: TPN was initiated through her central line on [**10-29**]. Her albumin was 2.6 on [**10-21**], declining to 1.9 on [**11-3**]. She occasionally ate spoonfulls of pudding, however largely refused food and PO medications. 5) Anemia: The patient had a baseline hct ranging from 35-43 prior to admission, while declined to 29-31 for much of her stay. Her iron studies indicated anemia of chronic disease, and her stool was guaiac negative. She did not receive any transfusions. 6) Hypothyroidism: Ms. [**Known lastname 95808**] was profoundly hypothyroid, with a TSH of 8 on admission, increasing to 16 and then 30 at discharge despite increasing her thyroxine dose (it takes [**6-22**] weeks for the new dose to take effect, however the TSH should not continue to rise to such an extent). 7) Pain: Ms. [**Known lastname 95808**] [**Last Name (Titles) 97600**] anytime she was touched. She persistenly denied pain, only admitting to pain during her dressing changes. Despite this, she [**Last Name (Titles) 97600**] anytime anyone touched her. We decreased the frequency of her dressing changes secondary to her extreme pain, and used morphine concentrated solution 4 mg Q 4 hours for pain. She should be given tylenol 1000 mg PR Q 6 hours as needed for pain, as well as morphine concentrated solution 5 mg Q 4 hours around the clock. 8) Atrial fibrillation: Her a-fib was poorly controlled with digoxin in the unit, and not responsive to amiodarone. On the floors her rate was well-controlled in the 60s, though her pulse was irregularly irregular. She was therefore maintained on digoxin and coumadin for anticoagulation. Her coumadin was maintained at 1 mg qhs and INR was therapeutic for the most part. 9) Mental status: The patient had waxing and [**Doctor Last Name 688**] mental status, but mostly was delirious. She leaned to the right side, with R lateral gaze preference. A head CT was performed due to concern for stroke, and was negative for any acute intracranial process. 10) Code status: She was DNR/DNI during the hospitalization. During a family meeting with her long-time boyfriend [**Name (NI) **], for whom she cares a lot, and who cares for her, on her last day of hospitalization it was decided that in light of her failure to demonstrate any improvement, persistent refusal to eat and worsening albumin in spite of TPN, along with continued extreme pain and incredibly poor prognosis, the best thing for her would be comfort care only. She should be given pain medications, with PRN zyprexa for aggitation for the next 3 weeks. Her boyfriend, [**Name (NI) **], would like her to receive fluids for the time being, in order to try to buy her a little bit more time to see if she will eat. It has been explained that this may only prolong her life for a little while, and he will consider stopping the fluids in the future. She will get maintenance fluids through her central line, which can be flushed with heparin to keep it patent. Medications on Admission: citalopram 20 mg po daily mirtazapine 15 mg qhs docusate 100 mg po senna po bid bisacodyl 2 mg daily prn levothyroxine 125 mcg daily glipizide 25 mg daily regular insulin protonix 40 mg daily albuterol MDI q6 prn simethicone qid prn metoprolol 75 mg tid tylenol750 mg q6 tramadol 25 mg q6 prn coumadin 1 mg qhs enalapril 10 mg daily lasix 40 mg po daily oxycodone/APAP fentanyl zinc keflex MVI Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). 2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD (once a day) as needed: 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen QD and PRN. . 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for aggitation for 3 weeks. 4. Acetaminophen 650 mg Suppository Sig: 1-2 tabs Rectal Q6H (every 6 hours) as needed for pain. 5. IV fluids Please give IVF: D5, [**1-15**] normal saline at a rate of 50 cc/hr continuously. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: urosepsis c. difficile colitis venous stasis/pressure ulcers on legs b/l Anasarca DM type 2 Hypothyroidism A-fib Hypertension Discharge Condition: poor Discharge Instructions: Comfort care only. Followup Instructions: none

Admission Date: [**2128-12-16**] Discharge Date: [**2128-12-19**] Date of Birth: [**2046-2-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: transferred from OSH for pericardial effusion found on echocardiogram Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: 82 [**Last Name (NamePattern4) 76663**] RN with hx of non-hodgkins lymphoma (dx in [**2122**]) thought to be in remission s/p XRT, atrial fibrillation on coumadin, labile HTN, hyperlipidemia, and anxiety who initially presented to [**Hospital3 3583**] on [**12-14**] with 2 day history of shortness of breath. She says that she felt well when she developed gradual onset of shortness of breath which was worse with exertion and lying flat. Denies any chest pain or palpitations. She normally receives her care at [**Hospital6 **] but asked her son to drive her to [**Name (NI) 26580**]. Of note, she has a history of pericardial effusion found on Echo performed in [**Month (only) **] of this year as a prelude to a cardiac stress test. At that time her cardiologist referred her to oncology. Patient says her oncologist was absolutely certain that this effusion was not a result of her NHL. She says she did not receive any more work-up at that time. . At [**Last Name (un) 26580**], she had a repeat ECHO which showed a large pericardial effusion measuring 4cm posteriorly and 3cm anteriorly. Her vital signs remained stable (124/70's and a HR 60-90's afib) and she was transferred for pericardiocentesis and further work-up of the effusion. Given her elevated INR (4.1) she received 10mg of SQ Vit K as well as a repeat Echo prior to transfer. . The transfer note also reports that patient was ordered for a unit of blood prior to transfer for a HCT drop from 29 --> 26, but that she did not receive it prior to transfer. Patient denies any BRBPR, or other abnormal bleeding. She had a colonoscopy this year and had a polyp excised, but it was otherwise normal. On review of systems, she does have a history of myalgias and joint pains (chronic, has hx of OA), black stools in the setting of iron supplementation, mild cough (non-productive), and syncope, last episode in [**2123**]. She also recently has some R leg swelling for which she had an U/S performed but she does not know the results. The swelling has since resolved. . She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, recent syncope or presyncope. Past Medical History: labile HTN chronic A fib (on coumadin) Hx of vasovagal syncope Non-Hogkin's Lymphoma (diagnosed in [**2122**], s/p XRT) Hx of compression fracture of the spine GERD diverticulosis chronic diarrhea (followed by GI, on lomotil) Osteoarthritis fractured R shoulder [**2122**] s/p abdominal hysterectomy at age 68 s/p tonsil and adenoid surgery in [**2054**] . Cardiac Risk Factors: Dyslipidemia (not on statin [**1-23**] myalgias), Hypertension Social History: Widowed, lives with son and daughter-in-law. Social history is significant for the absence of current or past tobacco use. There is no no history of alcohol abuse but + occaisional drinks. Family History: Father dies at age 49 from stroke. Physical Exam: VS: 97.4 145/80 62 22 99% 2L Gen: elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NC, AT. Sclera anicteric. PERRLA, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 12 cm. CV: irregularly irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Pulses paradoxus is ~8 Chest: No chest wall deformities, scoliosis or kyphosis. Breathing with mouth open, speaking in short sentences, no accessory muscle use. faint crackles at bases. Abd: Soft, NT,ND. No HSM or tenderness. Abd aorta not enlarged by palpation. Ext: No c/c/e. Multiple varicosities BL. Skin: No stasis dermatitis, ulcers, or xanthomas. Pertinent Results: [**2128-12-16**] 04:30PM WBC-6.1 RBC-3.52* HGB-9.7* HCT-30.4* MCV-86 MCH-27.6 MCHC-32.0 RDW-13.2 [**2128-12-16**] 04:30PM PLT COUNT-352 [**2128-12-16**] 04:30PM PT-38.4* PTT-39.1* INR(PT)-4.1* [**2128-12-16**] 04:30PM GLUCOSE-144* UREA N-30* CREAT-1.0 SODIUM-140 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2128-12-16**] 04:30PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-68 TOT BILI-0.3 [**2128-12-16**] 04:30PM CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-1.7 [**2128-12-16**] 04:30PM TSH-2.0 [**2128-12-16**] 04:30PM dsDNA-NEGATIVE TTE [**12-17**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. There is a small pericardial effusion measuring 0.9cm around the inferior and inferolateral left ventricle with minimal effusion around the apex and anterior right ventricle. A catheter is seen in the pericardial space. Compared with the prior study (images reviewed) of [**2128-12-16**], the pericardial effusion is much smaller and tamponade physiology is no longer suggested. TTE [**12-16**]: The left atrium is dilated. The right atrium is dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-23**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a large pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There is brief right atrial diastolic collapse. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Cath [**12-17**]: 1. Pericardiocentesis was performed with needle entry from the subxiphoid position. 1100cc of bloody fluid was removed and sent for studies. 2. Pulsis paradoxus is difficult to assess due to atrial fibrillation. 3. Right heart catheterization prior to pericardiocentesis shows elevated and equalized diastolic pressure which were equal to the pericardial pressure (for details see above). Subsequent to removal of 1100cc of pericardial fluid, pericardial pressure decreased to 1mmHg. Left ventricular filling pressure remains elevated and unchanged with (22mmHg) greater than RVEDP (14mmHg) suggesting underlying diastolic dysfunction. Given bifid RA waveform, there maybe a component of constrictive physiology. 4. Pulmonary hypertension with PA systolic pressure of 49mmHg prior to pericardiocentesis and 56mmHg after pericardiocentesis. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Severe diastolic ventricular dysfunction. 3. pericardial tamponade. 4. possible co-existing constrictive physiology. Brief Hospital Course: Patient is an 82 [**Last Name (NamePattern4) 76663**] RN with hx of non-hodgkins lymphoma, atrial fibrillation on coumadin, labile HTN, hyperlipidemia, and anxiety who is transferred from [**Hospital 26580**] Hospital for pericardiocentesis of symptomatic pericardial effusion of unknown etiology. . #. pericardial effusion: Hemodynamically stable on admission. However on the evening of [**12-16**], she was hypotensive transiently to 90s after being given labetalol. SBP back up to 110s following fluid bolus of 500cc. Pulsus increased from 6 to 12 overnight. However, due to INR of 4.1 at OSH, pericardiocentesis held until [**2128-12-17**]. At the OSH she had an INR of 4.1 was given 10 mg sq vitamin k. Here she was given 10 mg po vit K x 2. Her INR was 1.8 when she was sent to the cath lab for pericardiocentesis with 1 unit of FFP to be given in the holding area. . Underwent pericardiocentesis with drainage of 1100cc of bloody fluid with resolution of tamponade. Residual 0.9mm effusion noted on post-procedure ECHO. Pulsus [**7-29**]. Drain in place overnight with minimal output. Pulled day post procedure. Pulsus followed for worsening and was stable. Patient discharged to home shortness of breath resolved. . #. Rhythm: Has atrial fibrillation, on coumadin, digoxin and labetalol at home. Reversed coumadin and labetalol initially held for hypotension. Restarted labetalol day after procedure. Coumadin started after drain was pulled. . #. HTN: Patient was on lisinopril and norvasc until recently, which were both stopped by Dr. [**Last Name (STitle) 5310**] at OSH. Labetalol held as became hypotensive. Later, during pericardiocentesis, developed hypotension. Started briefly on nitro drip. Patient improved rapidly when transitioned back to home dose labetalol. . #. UTI: Pt with foul-smelling urine [**Name8 (MD) **] RN, and thus u/a sent. Urinalysis c/w UTI, and thus being treated for 3 days with ciprofloxacin. Urine culture + for pansensitive E. coli. She has a history of recurrent yeast infections with antibiotics. . #. Code: FULL. Son is her health care proxy. Medications on Admission: Digoxin 0.125 mg PO Daily except for Mon/Thurs when she takes 0.25 mg Labetolol 200 mg PO BID Protonix 40 mg PO QDAY Zolpidem 5 mg PO QHS PRN Acetaminophen 650 mg PO Q4-6 hours PRN Alprazolam 0.25 PO BID PRN anxiety Diphenoxylate/atropine 2.5 mg PO QID PRN Coumadin (being held) MVI Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO DAILY AT 4PM (). 4. Labetalol 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Labetalol 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO QMOTHU (). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK ([**Doctor First Name **],TU,WE,FR,SA). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Pericardial effusion Secondary: Hypertension Atrial fibrillation Anemia Urinary tract infection Discharge Condition: Stable Discharge Instructions: You were admitted with a pericardial effusion (fluid in the lining of your heart). You had a procedure called pericardiocentesis to remove some of this fluid. Your coumadin was discontinued during admission due to the blood found in your pericardial effusion. You should discontinue coumadin until further characterization of the etiology of the pericardial effusion. The laboratory studies from the fluid is still pending. If you have any of the following symptoms you should return to the ED or see your primary care provider: [**Name10 (NameIs) **] pain, shortness of breath, palpitations, lower extremity swelling, fever, or any other serious concerns. Followup Instructions: You will need to schedule an appointment with your primary care provider [**Last Name (NamePattern4) **] 2 weeks. Your primary care provder, Dr. [**Last Name (STitle) 32467**] can be reached at [**Telephone/Fax (1) 17663**]. In addition you should also schedule a follow up appointment with your oncologist, Dr. [**First Name (STitle) 3443**].

Admission Date: [**2176-9-4**] Discharge Date: [**2176-9-13**] Date of Birth: [**2139-9-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Bentall procedure, mechanical AVR, 24mm composite graft, replacement of asc. aorta, hemiarch, inominate to asc. ao bypass, left carotid to inominate bypass graft History of Present Illness: 36 y/o male w/no significant past medical history, presented to outside hospital on [**2176-9-3**] with new onset mid-sternal chest pain. Workup revealed large (8cm) ascending aortic aneurysm with dissection, occlusion of left carotid artery, and wide open aortic valve insufficiency. He was transferred to [**Hospital1 18**] for emergent surgery. Past Medical History: none Social History: non-smoker denies ETOH or drugs Family History: non-contributory Physical Exam: unremarkable upon admission Pertinent Results: [**2176-9-12**] 06:45AM BLOOD WBC-9.4 RBC-3.53* Hgb-10.8* Hct-30.2* MCV-86 MCH-30.6 MCHC-35.7* RDW-13.5 Plt Ct-369 [**2176-9-13**] 07:10AM BLOOD PT-28.6* PTT-30.2 INR(PT)-3.0* [**2176-9-12**] 06:45AM BLOOD PT-32.2* PTT-30.2 INR(PT)-3.4* [**2176-9-12**] 06:45AM BLOOD Glucose-85 UreaN-18 Creat-1.0 Na-135 K-4.8 Cl-95* HCO3-27 AnGap-18 Brief Hospital Course: Admitted directly to the ICU from outside hospital, taken emergently to the OR on [**2176-9-4**]. Underwent Bentall procedure w/mechanical aortic valve, 24 mm composite graft, inominate to asc. ao. bypass, Left carotid to inominate bypass. Please see operative report for details of surgical procedure. Post-operatively, he was taken to the Cardiac surgical recovery unit in stable condition. He was weaned from mechanical ventilator on POD # 1 & extubated. Over the next few days, he remained in the ICU for BP control and pulmonary toilet. He has continued to have hoarseness since extubation. Anticoagulation was started with heparin drip, chest tubes were removed, and he was transferred to the post-op telemetry floor on POD # 5. He continued to progress well from a physical therapy standpoint. His heparin was discontinued as his INR became therapeutic. Speech therapy was consulted to r/o aspiration risk, and pt. underwent swallowing eval which was normal. Dr. [**Last Name (STitle) 3878**] (ENT) will follow patient as an outpatient due to continued hoarseness. He is being discharged home today. Coumadin management will be followed by Dr.[**Initials (NamePattern4) 8716**] [**Last Name (NamePattern4) 12299**]. Medications on Admission: Creatine Testosterone 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. 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* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: 2 mg on [**7-8**], & [**9-15**], then check with Dr. [**Name (NI) 20929**] office for continued dosing. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: ascending aortic aneurysm aortic insufficiency Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no lifting > 10 # for 10 weeks no driving for 1 month No creams, lotions or powders to any incisions Followup Instructions: [**Last Name (NamePattern4) **]. [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 1504**] With Dr. [**Last Name (STitle) **] in [**3-8**] weeks Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**] (ENT) [**Telephone/Fax (1) 2349**], make appt. to see him in 2 weeks.(regarding hoarseness) Completed by:[**2176-9-13**]

Admission Date: [**2164-4-1**] Discharge Date: [**2164-4-11**] Date of Birth: [**2096-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain shortness of breath Major Surgical or Invasive Procedure: [**2164-4-6**] - Coronary artery bypass grafting to four vessels. (Left internal mammary->left anterior descending artery, saphenous vein graft(SVG)->Ramus artery, SVG->Obtuse marginal artery, SVG->Posterior descending artery.) History of Present Illness: 68 year old male admitted to Caritas [**Hospital3 **] ED with complaint of chest pain and shortness of breath, where he was intubated and underwent diagnostic cardiac catheterization and is transferred here for management of his coronary artery disease. Per records, patient complained to his wife chest discomfort at 4:45 AM and drove himself to the emergency room. Chest pain was described as [**9-24**] non-pleuratic substernal discomfort radiating into left shoulder and arm and associated with shortness of breath. He received aspirin and sublingual nitroglycerin PO in the ED initially. He was noted to be progressivel dyspneic and then required furosemide 20mg IV, morphine 4mg IV and initiation of nitroglycerin gtt, and metoprolol 5mg IV x 3, and was subsequently intubated due to dyspnea. Initial ECG showed sinus tachycardia at 115 with LBBB and no prior for comparison. TnI was 1.04 (normal 0.00-0.49) with CPK 182 and MB of 15.2. He initially went to the ICU, where he received clopidogrel 500mg x 1, and started on heparin gtt with 4500 unit bolus. He was transferred to cardiac catheterization laboratory and underwent left and right heart catheterization showing RCA and LCx occlusion, 50% LMCA lesion, and 90% pLAD stenoses with elevated left-sided filling pressures. He was transferred on heparin gtt to [**Hospital1 18**] for further management. Of note, patient was also ordered for empiric Vancomycin and ceftriaxone and had already received ceftriaxone prior to transfer. . On arrival to CCU, patient was intubated, but awake, alert, and in NAD. JVP was 10cm and chest x-ray did not demonstrate pulmonary oedema. Patient was extubated without event. Initial laboratory evaluation showed markedly elevated CPK and patient was started on eptifibatide in addition to heparin. Cardiac surgery is now evaluating for surgical resvascularization. Past Medical History: hypertension hypercholesterolemia Type 2 DM, on metformin as outpatient, last A1c 6.2 Peripheral vascular disease B12 deficiency Chronic bronchitis Myocardial infarction acute systolic heart failure Social History: - Worked in landscaping and steel industry - 4 children, second marriage -Tobacco history: Smoked 1ppd since age 15, quit 2 weeks ago -ETOH: Occasional -Illicit drugs: None Family History: Two brothers and one sister alive. On brother with diabetes and one sister with lung disease. Mother had CVA. Father died of MI in 60s. Physical Exam: GENERAL: Middle aged male, intubated, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur RUSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Coarse breath sounds but no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Femoral 1+, no hematoma or bruit at site, DP and PT dopplerable Left: Femoral 1+ DP and PT dopplerable Pertinent Results: [**2164-4-2**] Carotid Ultrasound Mild atherosclerotic plaque with bilateral 1-39% ICA stenosis. Antegrade vertebral flow bilaterally [**2164-4-6**] ECHO The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed (LVEF= 25 %). with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. [**2164-04-14**] PFT SPIROMETRY 1:45 PM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.60 3.98 65 FEV1 1.85 2.73 68 MMF 1.14 2.60 44 FEV1/FVC 71 68 104 LUNG VOLUMES 1:45 PM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 4.48 6.29 71 FRC 2.24 3.55 63 RV 1.68 2.30 73 VC 2.84 3.98 71 IC 2.24 2.73 82 ERV 0.56 1.25 45 RV/TLC 37 37 102 He Mix Time 1.88 DLCO 1:45 PM Actual Pred %Pred DSB 13.30 24.64 54 VA(sb) 3.98 6.29 63 HB 12.20 DSB(HB) 14.38 24.64 58 DL/VA 3.61 3.92 92 [**2164-4-11**] 06:33AM BLOOD WBC-10.2 RBC-3.01* Hgb-9.3* Hct-26.9* MCV-89 MCH-30.8 MCHC-34.4 RDW-13.3 Plt Ct-308 [**2164-4-11**] 06:33AM BLOOD Glucose-125* UreaN-31* Creat-1.2 Na-138 K-4.0 Cl-100 HCO3-29 AnGap-13 Brief Hospital Course: Mr. [**Known lastname 81180**] was admitted to the [**Hospital1 18**] on [**2164-4-1**] for further management of his myocardial infarction and coronary artery disease. As his enzymes were trending downward, integrillin was stopped. He was worked up by the cardiac surgical service in preparation for revascularization. A carotid duplex ultrasound was obtained which revealed only mild bilateral internal carotid artery disease. Pulmonary function testing was performed given his heavy smoking history. His forced expiratory volume in the first second was diminished at 2.73L or 68% predicted. A dental consult was obtained in anticipation of surgically addressing his mitral regurgitation. After a panorex was obtained, Mr. [**Known lastname 81180**] was cleared for surgery from an oral standpoint. On [**2164-4-6**], Mr. [**Known lastname 81180**] was taken to the operating where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. By POD 1, the patient was extubated, alert and oriented and breathing comfortably. He was neurologically intact and hemodynamically stable, off all vasoactive drips. Chest tubes and pacing wires were discontinued without complication. The physical therapy service was consulted for strength and mobility. The patient was transferred to the telemetry floor on POD 3. His blood sugars were well controlled on his home dose of metformin 1000mg two times per day. By post-operative day five he was ready for discharge to home with continued lasix. Medications on Admission: Medications at home: Simvastatin 40 mg PO qhs Metformin 1000 mg [**Hospital1 **] Amlodipine [**6-24**]? mg PO daily Aspirin 81 mg PO daily B12 vitamin Discharge Medications: 1. 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:*0* 2. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. 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* 6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 20mg tablets (40mg daily total) for 5 days, then decrease to 1 20mg tablet (20mg total) daily for 10 more days. Please ask PCP to assess for further need for lasix. Disp:*30 Tablet(s)* Refills:*2* 9. Potassium Chloride 20 mEq Packet Sig: One (1) 20 meq packet PO once a day for 15 days. Disp:*15 packets* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: ST Elevation Myocardial Infarction Acute Respiratory Failure diabetes Mellitus Type 2 Acute systolic Dysfunction, EF 25% Hypertension Acute Renal Failure Hyperlipidemia Tobacco Abuse Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) No more then 2 grams of sodium (salt) daily 8) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 9585**] (cardiologist) in 2 weeks. Please follow-up with Dr. [**First Name (STitle) 29069**] [**Name (STitle) 67247**] (PCP)in [**3-20**] weeks.([**Telephone/Fax (1) 81181**] Completed by:[**2164-4-11**]

Admission Date: [**2102-12-26**] Discharge Date: [**2103-1-5**] Date of Birth: [**2102-12-26**] Sex: M Service: NB SERVICE: Neonatology HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 59275**], twin number one, delivered at 36 2/7 weeks gestation with a birth weight of 2,400 grams and was admitted to the Newborn Intensive Care Nursery from the Newborn Nursery at around 17 hours of age for management of hypothermia and poor feeding. The infant was born to a 42-year-old gravida I, para 0 now 2 mother. Prenatal screens included blood type A positive, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and group B Streptococcus unknown. The pregnancy was complicated by diamniotic/dichorionic twin gestation. Twin number one was in breech position. Twin number two was transverse. The mother presented with preterm premature ruptured membranes of twin number one on the day of delivery. No maternal fever. Membranes were ruptured about seven hours prior to delivery. The delivery was by cesarean section due to the infant's positions of breech and transverse. This infant emerged with a good cry, received some free-flow oxygen. Apgar scores were eight at one minute and nine at five minutes. In the Newborn Nursery, this infant required heat lamps for hyperthermia and was not interested in feeding thus prompting the admission to the Intensive Care Nursery. PHYSICAL EXAMINATION: The physical examination on admission revealed a weight of 2,400 grams (25th to 50th percentile), length 43.5 cm (15th to 25th percentile), head circumference 33 cm (50th percentile). On examination, the patient was a sleepy, pink premature infant in no respiratory distress. The anterior fontanelle was soft, open, flat. Red reflex present in both eyes, palate intact, poor suck. The lungs were clear to auscultation and equal, regular rate and rhythm without murmur. There were 2 plus femoral pulses. The abdomen was soft, flat, with bowel sounds, normal male genitalia with testes descended bilaterally, patent anus, no sacral anomalies, hips stable, extremities pink and well perfuse. HOSPITAL COURSE: RESPIRATORY: No respiratory issues during this hospitalization. No apnea or bradycardia of prematurity. CARDIOVASCULAR: Has been hemodynamically stable throughout the hospital stay. No murmur. FLUIDS, ELECTROLYTES, AND NUTRITION: Has been feeding breast milk or Similac 20 with iron every three to four hours since admission. Required gavage feedings on admission for inadequate intake. The last gavage feed was on [**2103-1-1**]. At discharge, he is taking breast milk mixed with Enfamil powder to equal 24 calories per ounce or Similac 24 with iron, taking about 70-80 mls per feed. He also breast feeds when mother visits. Discharge weight 2510 grams. Length 46.5cm. Head circumference 32.5cm. GASTROINTESTINAL: Peak total bilirubin 6.5 mg percent on day of life three. Did not receive phototherapy. HEMATOLOGY: The hematocrit on admission was 50 percent. NEUROLOGY: Ultrasound not indicated. Age appropriate examination. SENSORY: Hearing screening was passed prior to discharge. PSYCHOSOCIAL: Parents involved. Intact family. CONDITION ON DISCHARGE: A ten-day-old 37 5/7 weeks postmental age infant feeding well. DISCHARGE DISPOSITION: Discharged home with parents. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Doctor Last Name 43699**] of [**Hospital **] Pediatrics, telephone number [**Telephone/Fax (1) 43701**]. CARE AND RECOMMENDATIONS: 1. FEEDS: Breast feed ad lib demand supplemented with breast milk mixed with Enfamil powder to equal 24 calories per ounce or Similac 24 calories per ounce. 2. MEDICATIONS: Poly-Vi-[**Male First Name (un) **] 1 ml daily. 3. CAR SEAT POSITION TEST: Passed. 4. STATE SCREEN: Drawn on [**2102-12-29**] and [**2103-1-5**] results are pending. 5. IMMUNIZATIONS RECEIVED: The infant received hepatitis B immunization on [**2103-1-3**]. 6. IMMUNIZATIONS RECOMMENDED: Influenzae immunization is 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 a childs life immunizations against influenzae is recommended for household contacts and out of home caregivers. Syangis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) born at <32 wks: 2) born bwtween 32 and 35 wks with 2 of the following : daycare durign RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings: or 3) with chronic lung disease. FOLLOW-UP APPOINTMENT SCHEDULE RECOMMENDED: 1. Appointment with pediatrician to be for [**2103-1-8**]. 2. VNA referral. DISCHARGE DIAGNOSIS: 1. Prematurity at 36 2/7 weeks, appropriate for gestational age. 2. Twin number one. 3. Sepsis ruled out. 4. Newborn jaundice. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) 59276**] MEDQUIST36 D: [**2103-1-4**] 13:24:07 T: [**2103-1-4**] 14:01:10 Job#: [**Job Number 59277**]

Admission Date: [**2136-12-19**] Discharge Date: [**2136-12-26**] Date of Birth: [**2055-10-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: Chronic Blood Loss Anemia, respiratory distress Major Surgical or Invasive Procedure: EGD with banding blood transfusion History of Present Illness: Ms. [**Known lastname 75806**] is an 81 y/o F with a history of dCHF (EF 50-65% in [**2133**]), afib, and chronic blood loss from GAVE syndrome who presented today for elective EGD under MAC anesthesia. Per endoscopy report, the findings were consistent with known diagnosis of nodular gastric antral vascular ectasia. Mild sponaneous oozing was noted. Band ligation was performed for homeostasis. After the procedure the patient was complaining of shortness of breath. She reports that she has been chronically short of breath for 11 years, however she does not require any oxygen at home. Of note the patient had not taken her lasix the morning of the procedure and received 800cc of lactated ringers during the endoscopy. She denies chest pain, cough, wheeze, or leg pain. No known history of COPD or asthma. She reports that her bilateral leg swelling is no worse than baseline (documented to be 3+ edema in recent PCP [**Name Initial (PRE) 626**]). . On arrival to the medicine floor she was desatting to the low 80s on nasal cannula and was placed on 5liter facemask. Her blood pressures were in the 90s systolic which is slightly below baseline according to outpatient records of 100s-110s systolic. Heart rates 90s in afib. Diuresis was not initiated on the floor because of concern for low blood pressures. The patient was therefore transfered to the [**Hospital Unit Name 153**] for further management. VS prior to transfer were 87/57 87 20 99% on 5liter facemask. EKG showed Atrial fibrillation with rate of 96, NA/NI no majors change compared to prior. . On arrival to the ICU, patient denies any chest pain. She reports shortness of breath is improved while wearing the oxygen. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, 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: Gastric Antral Vascular Ectasia [GAVE] Anemia requiring transfusion related to GI bleed Right heart failure (EF 50-65% in [**2133**]), 3+ Tricuspid regurgitation Atrial fibrillation, not on Coumadin or ASA due to chronic blood loss Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Hypothyroidism Chronic Kidney Disease Stage II (Recent Creatinine 1.3) Social History: Lives at home with husband - [**Name (NI) 1139**]: none - Alcohol: [**1-25**] drinks/month - Illicits: none Family History: 3 siblings had lung cancer Physical Exam: Physical Exam: General: Alert, oriented with face mask in place HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated 5cm above sternal angle Lungs: Diminished breath sounds diffusely. No wheezes, rales, or rhonchi. No accessory muscle use. CV: Irregular. 4/6 systolic murmur heard throughout. 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, 2+ pitting edema bilaterally at baseline per patient. No tenderness or erythema. . Pertinent Results: . [**Location (un) **] hosp records: - Echo [**2130**]: EF 60%, RV enlarged with preserved systolic function, biatrial enlargement, mild AS with valve area 2.2, moderate MR, severe TR, mildly elevated pulm artery systolic pressure 29 plus estimated right atrial pressure. -On [**10/2136**] admitted to [**Hospital **] hosp seen for SOB and pedal edema, given lasix diuresed from weight 73->70 Kg . On initial presentation during that admission, she was satting 96% on 2L. BP 125/65. HR 48.Cr 1.4, D-dimer 0.4. They transfused her 1 U PRBC on [**11-12**], discharge HCT 31. Sent out on lasix 40mg PO daily. (of note, in past: Was on amiodarone 200mg daily in [**2130**].) . [**Hospital1 18**] REPORTS/LABS- [**12-20**] EKG- Atrial fibrillation. Low voltage throughout. Non-specific T wave abnormality in the lateral leads. Abnormal tracing. No previous tracing available for comparison. . CXR [**12-20**]: FINDINGS: Cardiac silhouette is enlarged. Prominence of right cardiac border could reflect enlarged right-sided cardiac [**Doctor Last Name 1754**] or adjacent pericardial abnormality such as a pericardial cyst or prominent fat pad. Attention to this on standard PA and lateral chest radiograph is recommended when the patient's condition permits. No focal areas of consolidation are present within the lungs. Questionable small pleural effusions, which could also be more fully address by standard PA and lateral chest radiographs. . EKG [**12-21**]: Atrial fibrillation. Low voltage throughout. Abnormal tracing. Compared to the previous tracing ST segment abnormalities are resolved. TRACING #2 . ECHO [**Hospital1 18**] [**2136-12-20**] The left atrium is moderately dilated. The right atrium is markedly dilated. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric jet of moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. . IMPRESSION: Moderately dilated right ventricle with mild systolic dysfunction. Normal global and regional left ventricular systolic function. Severe tricuspid regurgitation. Moderate to severe mitral regurgitation. At least mild pulmonary hypertension. . CXR [**2136-12-20**]: IMPRESSION: No acute intrathoracic process. . [**12-21**] LENI: IMPRESSION: No evidence of DVT in the right or left lower extremities. . VQ SCAN [**2136-12-21**] INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate some accumulation of tracer in the large airways. Matched defects in the right lung base, is likely due to pleural effusion. Perfusion images in the same 8 views show >2 mismatched segmental defects in the right upper lobe and superior segment of the right lower lobe. Chest x-ray shows a small right pleural effusion and cardiomegaly. The above findings are consistent with a high likelihood ratio for pulmonary embolism. IMPRESSION: High likelihood ratio of pulmonary embolism in the right upper lobe. . Renal u/s [**12-22**]: 1. Limited study showing no evidence of hydronephrosis and no direct evidence of venous clot. 2. Suggested reversal of diastaolic flow in the left renal artery. The significance of this is unclear given the limitations noted, and may be related to a high-resistance system including acute tubular necrosis, or might be artifactual. If vascular thrombus is still of concern, noncontrast MRV of the renal veins may be of use to confirm patency. 3. Small bilateral kidneys, consistent with chronic medical renal disease. . EKG [**12-22**]- Significant baseline artifact precludes an accurate interpretation of the rhythm. No clear P waves are seen suggesting possible atrial fibrillation. Poor R wave progression in leads V1-V3 of unclear significance. No other interpretation is possible based on this tracing. Compared to the previous tracing of [**2136-12-20**] atrial fibrillation is likely still present. . EKG [**12-22**]: FINDINGS: Since [**2136-12-20**], mild right pleural effusion and mild to moderate right basilar atelectasis is worse. Mildly enlarged heart size is stable and a suspicion for pericardial effusion was raised. Findings were discussed with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who mentioned regarding recent echocardiogrpaphy which revealed sever cardiomegaly secondary to multivalvular involvement, but no pericardial effusion. Aorta is generally larger, however, there is no evidence of a focal aneurysm. There is no evidence of pulmonary edema. . CXR [**2136-12-25**]: FINDINGS: In comparison with the study of [**12-22**], there is further accumulation of fluid within the right pleural space with compressive atelectasis. The upper right lung and the entire left lung are clear with no evidence of pulmonary vascular congestion . BCX-negative . labs: [**2136-12-26**] 08:30AM BLOOD WBC-8.0 RBC-3.25* Hgb-8.9* Hct-28.0* MCV-86 MCH-27.4 MCHC-31.9 RDW-18.0* Plt Ct-361 [**2136-12-25**] 04:20AM BLOOD WBC-7.1 RBC-3.17* Hgb-8.6* Hct-27.2* MCV-86 MCH-27.2 MCHC-31.8 RDW-17.7* Plt Ct-352 [**2136-12-24**] 06:33AM BLOOD WBC-5.3 RBC-3.07* Hgb-8.3* Hct-26.7* MCV-87 MCH-27.0 MCHC-31.0 RDW-17.8* Plt Ct-336 [**2136-12-23**] 07:15AM BLOOD WBC-6.4 RBC-2.63* Hgb-7.0* Hct-23.6* MCV-90 MCH-26.8* MCHC-29.9* RDW-17.0* Plt Ct-340 [**2136-12-22**] 12:50PM BLOOD WBC-7.2 RBC-2.80* Hgb-7.7* Hct-25.1* MCV-90 MCH-27.4 MCHC-30.6* RDW-17.1* Plt Ct-379 [**2136-12-22**] 07:00AM BLOOD WBC-6.9 RBC-2.68* Hgb-7.4* Hct-24.1* MCV-90 MCH-27.8 MCHC-30.9* RDW-17.0* Plt Ct-339 [**2136-12-21**] 03:43PM BLOOD WBC-6.5 RBC-2.81* Hgb-7.8* Hct-25.4* MCV-91 MCH-27.7 MCHC-30.6* RDW-17.1* Plt Ct-368 [**2136-12-21**] 03:02AM BLOOD WBC-8.6 RBC-2.81* Hgb-7.8* Hct-25.7* MCV-91 MCH-27.9 MCHC-30.5* RDW-17.4* Plt Ct-328 [**2136-12-20**] 05:08AM BLOOD WBC-7.6 RBC-2.93* Hgb-8.1* Hct-26.3* MCV-90 MCH-27.6 MCHC-30.7* RDW-17.2* Plt Ct-367 [**2136-12-19**] 07:46PM BLOOD WBC-5.7 RBC-3.22* Hgb-9.0* Hct-29.7* MCV-92 MCH-28.1 MCHC-30.4* RDW-17.4* Plt Ct-387 [**2136-12-20**] 05:08AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-12-19**] 07:46PM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-10 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2136-12-20**] 05:08AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Fragmen-OCCASIONAL [**2136-12-19**] 07:46PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL [**2136-12-22**] 07:00AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.3* [**2136-12-26**] 08:30AM BLOOD Glucose-170* UreaN-23* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-29 AnGap-10 [**2136-12-25**] 04:20AM BLOOD Glucose-94 UreaN-32* Creat-1.0 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 [**2136-12-24**] 06:33AM BLOOD Glucose-91 UreaN-39* Creat-1.2* Na-138 K-3.7 Cl-103 HCO3-30 AnGap-9 [**2136-12-23**] 07:15AM BLOOD Glucose-109* UreaN-47* Creat-1.3* Na-140 K-4.1 Cl-105 HCO3-29 AnGap-10 [**2136-12-22**] 07:00AM BLOOD Glucose-149* UreaN-58* Creat-1.6* Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 [**2136-12-21**] 03:43PM BLOOD Glucose-187* UreaN-60* Creat-1.7* Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 [**2136-12-21**] 03:02AM BLOOD Glucose-151* UreaN-62* Creat-1.8* Na-138 K-4.1 Cl-102 HCO3-26 AnGap-14 [**2136-12-20**] 05:08AM BLOOD Glucose-146* UreaN-63* Creat-1.7* Na-139 K-4.8 Cl-102 HCO3-28 AnGap-14 [**2136-12-19**] 07:46PM BLOOD Glucose-108* UreaN-62* Creat-1.6* Na-141 K-4.6 Cl-103 HCO3-29 AnGap-14 [**2136-12-21**] 03:02AM BLOOD CK(CPK)-37 [**2136-12-20**] 03:52PM BLOOD CK(CPK)-24* [**2136-12-20**] 05:08AM BLOOD CK(CPK)-27* [**2136-12-19**] 07:46PM BLOOD CK(CPK)-31 [**2136-12-21**] 03:02AM BLOOD CK-MB-2 cTropnT-0.02* [**2136-12-20**] 03:52PM BLOOD CK-MB-2 cTropnT-0.02* [**2136-12-20**] 05:08AM BLOOD CK-MB-3 cTropnT-0.02* proBNP-4777* [**2136-12-19**] 07:46PM BLOOD CK-MB-3 cTropnT-<0.01 [**2136-12-26**] 08:30AM BLOOD Calcium-8.4 Phos-1.8* Mg-1.7 [**2136-12-22**] 07:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.8* [**2136-12-21**] 03:02AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.8* [**2136-12-20**] 05:08AM BLOOD Calcium-8.6 Phos-5.4* Mg-3.1* [**2136-12-19**] 07:46PM BLOOD Calcium-9.3 Phos-5.4* Mg-3.1* [**2136-12-21**] 03:43PM BLOOD TSH-3.9 [**2136-12-20**] 05:34AM BLOOD Lactate-1.5 [**2136-12-20**] 12:49AM BLOOD Lactate-3.0* [**2136-12-20**] 12:49AM BLOOD Type-ART pO2-82* pCO2-43 pH-7.36 calTCO2-25 Base XS--1 Brief Hospital Course: 81 y/o female with a history of chronic diastolic CHF (EF 50-65% in [**2133**]), atrial fibrillation, not on Coumadin, and chronic blood loss anemia from gasric antral vascular ectasias admitted with hypoxemia following endoscopic banding of her gastric AVMs. #Hypoxemia/Acute vs. chronic pulmonary embolism/Chronic diastolic heart failure with secondary pulmonary hypertension: Etiology of acute onset worsening hypoxemia on admission was initially not obvious. Physical exam was consistent with volume overload but exam was complicated by tricuspid regurgitation and v-waves to the jaw. Aspiration was considered but absence of significant lung pathology on exam or chest X-ray made this less likely. A V/Q scan was performed and was read as having high probability for PE in the right upper lobe. Additionally, an echocardiogram was notable for preserved EF, but with mod-severe mitral regurgitation, right ventricular dilatation and reduced systolic function with severe tricuspid regurgitation and the presence of a PFO (No valsalva or agitated saline contrast maneuvers were performed). These echo findings were similar to echo in [**2130**]. . Given her multiple contraindications for anticoagulation, including history of requiring blood transfusions every 10 days for her gastric AVMs transfusion dependance and recurrent GI bleeds, anticoagulation was not pursued. Additionally, bilateral lower extremity ultrasounds were negative for DVT, so an IVC filter was not placed. Despite lack of intervention, the patient improved slowly with reduced oxygen requirement with re-initiation of diuretic regimen. The risks and benefits of anticoagulation and the current clinical dilemma were discussed with the patient and the patient's PCP [**Last Name (NamePattern4) **] [**2136-12-25**] and pt's son [**Name (NI) **] [**Name (NI) 75806**] on [**2136-12-25**]. In addition, pt was given 1 unit of PRBCs during admission. However, should the patient get to a place where she may only require monthly transfusion or should she develop chest pain, hypotension, tachycardia, increasing hypoxia, etc, the risk/benefit ratio of anticoagulation for PE may change to favor anticoagulation. In addition, the patient also did not show signs of a hemodynamically significant PE. She did have periods of relative hypotension during times of afib with RVR. Pt carries a diagnosis of afib prior to admission and her BP was improved predictably with better HR control. In addition, there was question of the acute vs. chronic PE. The echo findings appear to be present in [**2130**] and could be explained by her valvular disease. Pt had sats of ~94-96% on RA, ambulatory sats 92-93% on RA. However, pt did experience occasional noctural hypoxia to 84% on RA and was therefore sent home with home oxygen at 1-2L nightly for now. Troponins 0.02 x3, BNP ~4000 during admission. Oxygenation much improved during admission. VNA can also help with monitoring for hypoxia. Pt has a scheduled appointment with her cardiologist and PCP after DC to continue this discussion. Can discuss whether patient may benefit from an IVC filter in the future. # Atrial Fibrillation: Not on coumadin or aspirin due to chronic GI bleeding. The patient is on rate control with atenolol at home (25mg TID?). She was restarted on metoprolol given her renal failure and CKD and this was uptitrated to 25mg TID by day of discharge. Pt tolerated this well and seemed to have better BP's with appropriate rate control. BP range 90's-110's during admission. She did have periods of afib with RVR prior to uptitration of meds. She was discharged with VNA for cardiopulmonary monitoring. . #Chronic blood loss anemia/Gastric Antral Vascular Ectasia [GAVE] s/p banding on the day of admission: She requires transfusion ~every 2 weeks at the present time. Work up to date has included multiple EGDs with argon plasma coagulation which has been unsuccessful thus far and therefore patient had scheduled EGD on admission for banding. The patient did have drop in her hematocrit during her admission and was transfused 1 unit PRBCs. A repeat EGD with banding was recommended in 1 month follow-up with GI. HCT on discharge was 28. She was instructed to have repeat HCT at PCP follow up. . #Chronic diastolic heart failure: continued outpt regimen of lasix, BB . # LE edema: She reports chronic worsening bilateral LE edema over the last 5-6 weeks. LENIs were negative for PE. Pt was continued on lasix therapy . #Hypertension: Home anti-hypertensives were initially held upon admission and then restarted. She was discharged on metoprolol 25mg TID . # Hyperlipidemia: She was continued on home simvastatin. . # Type 2 Diabetes Mellitus: Home oral medications including glipizide were held on admission. She was treated with an insulin sliding scale. She was instructed to resume glipizide upon discharge. . # Hypothyroidism: She was continued on levothyroxine. . #Acute-on-Chronic renal failure, stage II-III: Her renal function on admission was 1.6 and rose to 1.8, but improved during admission. Cr on discharge was 1.1. Pt should also have repeat Cr at PCP f/u to ensure continued improvement. . TRANSITIONAL ISSUES: Code: DNR/I Follow-up: Repeat EGD and banding with GI in 1 month Should have PCP and Cardiology follow up given chronic diastolic heart failure, pulmonary hypertension and now PE with minimal therapeutic options. Should discuss whether there may be benefit to IVC filter in the future. Medications on Admission: From MICU admit note: Simvastatin 10mg qhs Levothyroxine 112mcg daily Glipizide 5mg daily MVI 1 tab daily Loratadine 10mg daily Iron 160mg slow realease PO BID Omperazole 20mg PO BID Ascorbic Acid 250mg PO BID Atenolol 25mg PO TID Furosemide 40mg PO daily Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. iron 160 mg (50 mg iron) Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. dm glipizide 5mg daily 9. ascorbic acid 250 mg Tablet Sig: One (1) Tablet PO twice a day. 10. home oxygen therapy 2 liters continuous oxygen therapy at night. DX: pulmonary embolism, pulmonary hypertension saturation 84% on RA at night 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Steward VNA Discharge Diagnosis: GI bleed secondary to GAVE Probable pulmonary embolism Chronic diastolic heart failure atrial fibrilliation with RVR . chronic -diabetes -CKD -hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were initially admitted to the hospital after an elective endoscopic banding procedure for the abnormal blood vessels in your stomach causing gastrointestinal bleeding and chronic anemia. After the procedure, you were noted to have low blood pressure and low oxygen levels, due most likely to a combination of an aspiration event(inhaling some of your mouth secretions) and also to a blood clot (pulmonary embolism) in the lungs. However, after discussion with the GI specialists, given the risk of bleeding, especially in the GI tract, we have decided not to put you on blood thinning medication for the lung clot. You initially required a significant amount of oxygen, however, your oxygen levels improved and you will only need oxygen at night time for now. You will be continuing this discussion with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and cardiologist Dr. [**Last Name (STitle) **] after discharge. . Also, your kidney function was slightly impaired during admission. This improved, but should be followed up after discharge. . Medication changes: 1.your atenolol was changed to metoprolol given your kidney function. Your discharge dose will be 25mg of metoprolol three times a day. Stop taking atenolol. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] A./ PCP [**Name Initial (PRE) **]: [**Street Address(2) 75807**], [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 61040**] When: [**Last Name (LF) 766**], [**2136-1-1**]:00 AM Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD/ CARDIOLOGY Address: [**Street Address(2) 75807**],STE 2C, [**Location (un) **],[**Numeric Identifier 23881**] Phone: [**Telephone/Fax (1) 44655**] When: [**Last Name (LF) 766**], [**2137-1-14**]:00 PM Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: S. W. GASTROENTEROLOGICAL ASSOCIATES Address: 886 [**State **] [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 23881**] Phone: [**Telephone/Fax (1) 25843**] *It is recommended that you see Dr. [**Last Name (STitle) 1437**] within 2 weeks. His office staff will contact you to schedule an appointment.

Admission Date: [**2191-1-27**] Discharge Date: [**2191-2-3**] Date of Birth: [**2128-6-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Pt referred after cardiac cath revealed 50% LM, 70%LAD, 100%RCA for CABG Major Surgical or Invasive Procedure: CABGx3 (LIMA->LAD, SVG->Ramus, SVG->PDA History of Present Illness: Increasing frequency ofchest pain w/associated SOB x several months. +ETT at OSH which lead to cardiac cath then referal to [**Hospital1 18**] Past Medical History: HTN, ^chol, L rotator cuff surgery, Legionaires PNA(30yrs ago) Social History: Married lives w/wife. Retired water works remote tobacco (quit 30 years ago), raree ETOH use, Family History: nc Physical Exam: Preop: GEN: 62yoM NAD Neuro: Grossly intact Pulm: CTA B Cor: RRR Abdm: obese, soft, NT, +BS Ext: Warm well perfused D/C VS 98.2 92SR 127/71 20 96%RA Gen: NAD Neuro: A&Ox3 MAE follows commands. Left peripheral vision deficit. Cognitively slow to respond to direct questions Pulm: CTA B Cor: RRR, sternum stable, incision C&D Abdm: Soft NT/ND/NABS Ext warm, well perfused. L LE incision C&D Pertinent Results: [**2191-1-27**] 08:07PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-141 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 [**2191-1-27**] 08:07PM ALT(SGPT)-27 AST(SGOT)-24 LD(LDH)-240 ALK PHOS-43 AMYLASE-45 TOT BILI-1.0 [**2191-1-27**] 08:07PM ALBUMIN-4.3 [**2191-1-27**] 08:07PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2191-1-27**] 08:07PM WBC-7.6 HCT-42.5 [**2191-1-27**] 08:07PM PLT COUNT-148* [**2191-1-27**] 08:07PM PT-13.0 PTT-24.9 INR(PT)-1.1 [**2191-1-27**] 07:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2191-1-27**] 07:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2191-2-2**] 06:30AM BLOOD WBC-7.6 RBC-3.76* Hgb-11.7* Hct-31.8* MCV-85 MCH-31.2 MCHC-36.9* RDW-15.4 Plt Ct-119* [**2191-1-31**] 12:13AM BLOOD PT-13.6* PTT-25.6 INR(PT)-1.2 [**2191-2-2**] 06:30AM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-141 K-3.5 Cl-107 HCO3-22 AnGap-16 Brief Hospital Course: Pt admitted from OSH [**1-27**], prepped for OR on [**1-28**] Pt to OR fro CABG on [**1-28**], please see OR report for full details, in summary had CABGx3 with LIMA->LAD, SVG->Ramus, SVG->PDA. Pt tolerated operation well. In immediate postop period pt hemodynamically stable, successfully extubated and weaned from all vasoactive medications. On post-op day 1 patient was transferred to postop surgery floors for continued postop recovery. On POD2 was noted to be lethargic, neurology consulted and pt had head CT that revealed multiple small infarcts involving R parietal/occipital area with main deficit being L peripheral vision loss and slow cognitive response. Pt was transferred back to ICU for stroke w/u that included Heme eval/carotid US/LE ultrasound. After largely negative w/u pt returned to floors where he had an uneventful hospital course. Medications on Admission: Lisinopril 20 QD HCTZ 12.5 QD Atenolol 100 QD Zocor 20 QD ASA 81 QD Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: s/p cabg x3 c/b CVA(rt parietal) PMH: HTN, ^chol, L rotator cuff surgery, Legioaires PNA(30 yrs ago) Discharge Condition: good Discharge Instructions: Keep wounds clean nad dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) 4783**] in [**3-12**] weeks Dr [**First Name (STitle) **] ([**Hospital1 65344**] neurology in 6 weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2191-2-3**]

Unit No: [**Numeric Identifier 75482**] Admission Date: [**2199-12-4**] Discharge Date: [**2199-12-5**] Date of Birth: [**2199-12-4**] Sex: M Service: NEONATOLOGY IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname 75483**] is a 1-day-old former 32-6/7 week infant who expired this afternoon in the [**Hospital1 18**] NICU secondary to cardiopulmonary failure from severe pulmonary hypoplasia. HISTORY: Baby [**Name (NI) **] [**Known lastname 75483**] was born on [**2199-12-4**] at 8:56 p.m. as the 2175 gram product of a 32-6/7 week gestation pregnancy to a 30-year-old gravida 1, para 0 mother with estimated date of delivery of [**2199-1-24**]. Prenatal laboratory studies included blood type B+, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B strep unknown. The pregnancy was complicated with the development of severe bilateral hydronephrosis, presumed bladder outlet obstruction and progressive oligohydramnios beginning at approximately 19 week' gestation. The mother was followed closely by the [**Hospital **] Care Center at [**Hospital3 18242**] including Dr. [**Last Name (STitle) 61096**] from Urology, and Dr. [**Last Name (STitle) 37080**] from Surgery. Mother underwent 2 attempted vesicoamniotic shunt placements at 21 weeks and again at 24 weeks. Both catheters initially achieved bladder drainage but subsequently migrated from the bladder. The mother received a course of betamethasone at 24 weeks. No other abnormalities were noted on ultrasound and most likely diagnosis was thought to be posterior urethral valves. On the day of delivery, mother presented in preterm labor. Due to the presumed intrauterine location of the previous shunts, mother was taken for [**Name (NI) 32007**] delivery. Membranes were intact at the time of delivery and there were no specific sepsis risk factors noted. In the delivery room, the patient emerged with moderate tone but poor respiratory effort and cyanosis. Status appeared to improve with bag mask ventilation and heart rate was always greater than 100. Infant was intubated in the delivery room and then brought to the NICU. Apgar scores were 6 and 7. ADMISSION PHYSICAL EXAMINATION: Initial examination was notable for a somewhat edematous 32-week gestational age infant with several areas of bruising in the arms, the scalp and legs. Mild deformational abnormalities of the ears were noted. Lungs had very distant breath sounds that required significant pressures with positive pressure ventilation to aerate. Heart exam was regular rate and rhythm without murmurs. Abdomen was noted to be quite distended in the lower segment. Testes were not descended. HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Infant was initially placed on conventional ventilation of SIMV with settings of 35/5 with a rate of 40. Initially, oxygen saturations were reasonable with FIO2 of 100%. However, secondary to inability to adequately ventilate, infant was quickly changed to high-frequency oscillatory ventilation. Infant received 2 doses of surfactant and escalated in ventilator settings to a MAP of 24 and amplitude of 52. Over the course of the first hospital night, infant had persistent difficulty with ventilation as well as increasing difficulties with oxygenation eventually prompting the initiation of nitric oxide at approximately 8 hours of life due to persistent inability to achieve oxygen saturations above 60%. Infant status transiently improved with achievement of oxygen saturations of 90-100%; however, PO2 in blood gases consistently remained under 50. At approximately 12 hours of life, infant experienced a further deterioration with a prolonged period of desaturation with oxygen saturations in the 60-70% range. Numerous maneuvers were attempt including increase of ventilator settings, volume support, and increase of nitric oxide with eventual improvement of oxygenation on settings of a MAP of 26, amplitude of 60 and nitric oxide of 40 ppm. However, approximately 1 hour later infant experienced an acute decompensation with severe desaturation and severe hypotension that was found to be due to the development of a right-sided pneumothorax. This was drained initially with multiple procedures of needle thoracentesis. Status initially improved but then remained quite tenuous. A right-sided chest tube was placed without notable improvement. Infant's status continued to fluctuate with eventual further decompensation leading to severe bradycardia, hypotension and hypoxia. A left-sided pneumothorax at that time was noted which was drained by needle thoracentesis without improvement. 2. CARDIOVASCULAR: Umbilical venous catheter, umbilical arterial catheter were placed on admission. Over the first couple hours of life infant required blood pressure support with normal saline boluses as well as initiation of dopamine. Systemic blood pressure was attempted to be maintained in a generous range due to presumed pulmonary hypertension. Infant initially appeared to stabilize on a dopamine of 15 mcg/kg/min but subsequent deterioration in status eventually resulted in dopamine of 25 mcg/kg/min, as well as additional volume support with a total of approximately 5 boluses of normal saline. Preductal and postductal oxygen saturations were measured and were found to have a 10 to 15-point gradient suggestive of pulmonary hypertension. Cardiology consultation was obtained on the morning of [**2199-12-5**], and an echocardiogram at that time showed evidence of pulmonary hypertension with systemic right- sided pressure, right-to-left shunting at the PFO, bidirectional shunting at the PDA, and mild to moderate ventricular dysfunction. 3. FEN: Infant was maintained on maintenance IV fluids from admission with fluid restriction to 60-80 cc/kg/D secondary to unclear renal function. Blood sugars and blood chemistries over the first 12 hours of life were largely within acceptable range. Due to the prenatal diagnosis of bladder obstruction, a Urology consultation was obtained after birth and a Foley catheter was placed by the Urology with difficulty. Following placement of the Foley catheter, a large amount of urine was drained, approximately 190 cc. This urine was found to have a sodium concentration of 131 mEq/L similar to serum. Subsequently to the initial drainage, very little urine output was seen, although it was not zero. A renal ultrasound was performed which revealed a severely dysplastic left kidney with diffuse cystic changes, a right kidney with severe hydronephrosis and an echogenic cortex although overall architecture was within normal limits, and a bladder with severely thickened wall. The bladder was empty on ultrasound with the catheter in place. 4. ID: Initial CBC and blood culture were sent on admission. White blood cell count was 22.4 thousand with 26% polys, 5% bands, 43% lymphs and 23% atypical lymphs. Initial hematocrit was 52 and platelets were 177. Infant was begun on ampicillin and cefotaxime. Blood culture was sent and is negative at time of this dictation. 5. GI: A bilirubin at 12 hours of life was measured and was 2.3/0.2. 6. NEURO: Shortly after admission, infant was maintained on sedation with fentanyl due to the precarious cardiopulmonary status. Eventually, the infant received muscle relaxation with Pancuronium due to difficulties with maintaining ventilatory support. Infant was maintained on muscle relaxation and sedation with fentanyl subsequently. 7. DISPOSITION: At approximately 15 hours of life, the infant was noted to experience an acute decompensation, as mentioned above, related to pneumothorax. Despite aggressive interventions, infant's status remained precarious. Eventually, infant developed bradycardia with heart rates to the 40s and 60s in a setting of severe hypoxia and severe hypotension. Cardiopulmonary resuscitation was begun with chest compressions and administration of several doses of epinephrine. Transient improvement in heart rates were seen but these were not persistent. The parents were brought to the bedside and after a discussion of the severity of the infant's illness and the extremely low likelihood of survival, the parents asked for resuscitative measures to be stopped. CPR was given for approximately 15 minutes for a total of 4 doses of epinephrine, chest compressions and administration of volume and bicarbonate. Intensive care measures were stopped at 1:05 p.m. Parents held their child briefly and the infant expired at 1:23 p.m. Cause of death was cardiopulmonary failure presumably secondary to pulmonary hypoplasia, respiratory distress syndrome and pulmonary hypertension. Underlying diagnoses included prematurity, bladder outlet obstruction, renal failure and presumed posterior urethral valves. DISCHARGE DISPOSITION: Expired. [**Location (un) 511**] Organ Bank and medical examiner were notified and both declined participation. The family agreed to a full autopsy. Obstetrician, Dr. [**MD Number(4) **] [**Name (STitle) **], was notified. NAME OF PRIMARY PEDIATRICIAN: Not identified in chart. DISCHARGE DIAGNOSES: 1. Prematurity at 32-6/7 weeks. 2. Presumed posterior urethral valves. 3. Bladder outlet obstruction. 4. Presumed pulmonary hypoplasia. 5. Respiratory distress syndrome. 6. Pulmonary hypertension. 7. Sepsis evaluation. 8. Renal dysplasia. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2199-12-5**] 19:10:41 T: [**2199-12-5**] 20:26:23 Job#: [**Job Number 75484**]

Admission Date: [**2139-1-3**] Discharge Date: [**2139-1-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization with 2 stents placed History of Present Illness: 81yo man with tobacco use with several weeks of stuttering self limited exertional and nonexertional ssCP with right shoulder pain increasing in frequency. Awoke this morning with acute worsening of same pain but persisted. Presented to [**Hospital1 5979**] Hosp where ECG showed ST elevation v1-v4. Given nitro with some improvement. Transferred here for emergent cath where he had 90% discrete lesion mid-LAD, 90% discrete D-1, and 100% discrete LCx. Mild pulm HTN with PCWP 15. Got [**Hospital1 **] to LAD x1, D-1 x1, and LCx x1. Procedure complicated by groin hematoma. Received BB, asa, plavix. Integrillin and heparin stopped for bleeding. Past Medical History: bipolar disorder Social History: lives with wife. Former tobacco, quit 1 year ago. Family History: Non-contributory Physical Exam: vs: 110/60, p40-50, 12, 98% 2liters n/c gen: well appearing, comfortable heent: eomi, perrla, no op erythema, no lad lungs: CTA b cv: s1/s2, rrr, no m/r/g, no carotid bruits abd: soft, nttp ext: groin hematoma left with pressure dsg, DP2+ bilat, warm and dry neuro: alert and orient x3 Pertinent Results: [**2139-1-3**] 09:43AM WBC-7.6 RBC-2.87* HGB-9.4* HCT-26.7* MCV-93 MCH-32.8* MCHC-35.3* RDW-13.4 [**2139-1-3**] 09:43AM PLT COUNT-168 [**2139-1-3**] 09:43AM PT-13.9* PTT-92.4* INR(PT)-1.3 [**2139-1-3**] 09:43AM GLUCOSE-116* UREA N-23* CREAT-1.3* SODIUM-139 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13 . [**2139-1-3**] 05:39PM BLOOD Lithium-0.9 [**2139-1-6**] 06:44AM BLOOD Lithium-1.0 . ecg: ST elevation v2, v3; resolved STE in v1 and v4. q's v1-3. NSR with freqent PVCs, nml axis and conduction intervals . [**2139-1-3**] 05:39PM BLOOD CK(CPK)-917* CK-MB-88* MB Indx-9.6* cTropnT-9.70* [**2139-1-4**] 12:43AM BLOOD CK(CPK)-593* CK-MB-56* MB Indx-9.4* cTropnT-7.04* [**2139-1-4**] 05:53AM BLOOD CK(CPK)-460* CK-MB-39* MB Indx-8.5* cTropnT-6.18* . [**2139-1-3**] 09:43AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2139-1-3**] 09:43AM BLOOD Triglyc-82 HDL-27 CHOL/HD-4.3 LDLcalc-72 . CARDIAC CATHETERIZATION [**Numeric Identifier 111553**] - CCC *** PRELIMINARY *** PROCEDURE DATE: [**2139-1-3**] INDICATIONS FOR CATHETERIZATION: STEMI, FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Mild elevation of right and left filling pressures with preserved CI. 3. Acute MI likely due to the mid LAD lesion with possible multivessel acute ischemia. 4. Successful stenting of the mid LAD, Proximal D1 and mid CX. COMMENTS: 1. Selective coronary angiography in this right dominant patient revealed three vessel CAD. The LMCA was angiographically normal. The LAD had a 90% occlusion after D1 with slightly decreased flow distal to this lesion. The D1 had a ostial 60% lesion and proximal 90% lesion. The LCX [**Male First Name (un) **] mid occlusion after OM1 with faint filling of distal vessel. The RCA had moderate disease with 70% posteroloateral branch and 60% mid PDA. 2. Resting hemodynamics revealed mild elevation of right and left filling pressures with RA of 10 and PCWP of 15mmHG. The cardiac index was preserved at 2.56. There was very mild pulmonary hypertension. The systemic blood pressure was normal at 118/59. There were no arrhythmias during the case. 3. Successful predilation using 2.0 X 08mm Voyager balloon and stenting using a 2.5 X 08mm Cypher stent of the mid LAD with lesion reduction from 90% to 0%. 4. successful predilation using 2.0 X 08mm Voyager balloon and stenting using 2.5 X 08mm Cypher stent of the proximal D1 with lesion reduction from 90% to 0%. 5. Successful predilation using 2.0 X 15mm sprinter balloon, stenting using 2.5 X 28mm Cypher stent and post dilation using 3.0 X 20mm Maverick balloon with lesion reuduction from 99% to 0%. >>> The final angiogram showd TIMI III flow in the left coronary system with no dissection or embolisation. (see PTCA comments) TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 35 minutes. Arterial time = 1 hour 30 minutes. Fluoro time = 37 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 305 ml, Indications - Renal Premedications: ASA 325 mg P.O. Integrelin and heparin protocol Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Heparin 4000 give prior to case Fentanyl 75 mcg IV Integrelin drip 7cc/hr Nitroglycerin 850mcg IC over multiple injections Versed 1.5mg Complications: Hematoma Cardiac Cath Supplies Used: - [**Doctor Last Name **], ASAHI PROWATER, 300 - GUIDANT, WHISPER 2 GUIDANT, VOYAGER 8 2 [**Company **], SPRINTER, 6 3.0 [**Company **], QUANTUM MAVERICK, 20 6 CORDIS, XBLAD 3.5 200CC MALLINCRODT, OPTIRAY 200CC 100CC MALLINCRODT, OPTIRAY 100CC 2.5 CORDIS, CYPHER OTW, 8 2.5 CORDIS, CYPHER OTW, 8 2.5 CORDIS, CYPHER RX, 28 . STUDY: AP chest performed on [**2139-1-4**]. FINDINGS: The cardiac silhouette and mediastinum is unremarkable. There is some mild prominence of interstitial markings without evidence for focal infiltrates, pleural effusions, or pulmonary edema. Bony structures are intact. IMPRESSION: No evidence for acute cardiopulmonary process. . Echo [**2139-1-6**]: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed, EF 40%. Distal anterior, distal septal, and apical hypokinesis to akinesis is present. 2. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Right groin u/s:([**2139-1-7**]) In the right groin, there are findings consistent with a partially thrombosed pseudoaneurysm measuring approximately 22 x 21 x 24 mm in maximum diameters originated from the common femoral artery, the width of the neck is 3 mm. The adjacent superficial femoral artery, superficial femoral vein and deep femoral vein are unremarkable. Multiple benign-appearing lymph nodes measure less than 17 mm are seen in the right groin. IMPRESSION: Partially thrombosed pseudoaneurysm as described originated from the common femoral artery. Right groin U/S: [**2139-1-8**] A pseudoaneurysm is present in the right inguinal region related to the common femoral artery which is mostly thrombosed. The overall size of the pseudoaneurysm is 2.8 x 0.8 cm with the size of the patent portion of the pseudoaneurysm measuring 0.9 x 0.4 cm. The neck of the pseudoaneurysm is patent currently. The common femoral artery appears patent on these limited images. On comparison with the prior study, the area of flow within the right inguinal pseudoaneurysm appears to have decreased in the interval. Given the above findings, it is likely that this pseudoaneurysm will thrombose spontaneously and we consider that it does not require intervention (such as thrombin injection) at this time. A followup ultrasound in [**4-8**] days' time is recommended to confirm continued resolution of this pseudoaneurysm. Brief Hospital Course: Impression: 81 M with acute anterior STEMI s/p successful percutaneous revascularization. . a/p: 81yo man with h/o smoking transferred from OSH with STEMI, s/p PCI . Cards # Ischemia: 2 vessel disease. s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 10157**] to mid-LAD, D-1, and LCx. Integrillin held for groin hematoma. On BB, ASA, Plavix, and statin. Cardiac enzymes trended down post-cath. Hct stable, s/p 1U transfusion of pRBC on [**1-3**]. - continue medical mgmt # pump: no known history of congestive heart failure. - echo to assess LV function and EF post MI was performed. - beta blocker as above, held off on ACE-i initially for secondary elevated creatinine. Later on it was re-started with no change of his kidney funcion. - heparin gtt continued until patient had Echo to see if thrombus, decrased EF or apical hypokinesis. Given apical hypokinesis, patient was started on Coumadin on [**2139-1-6**] to continue likely for 6 months. He was bridged with Heparin given risk of clot formation and this was changed to Lovenox. [**Name (NI) **] wife [**Name (NI) 111554**] how to give Lovenox injections. # rhythm: NSR with frequent PVC in peri-MI period. . # Groin Hematoma: U/S showed a partially thrombosed pseudoaneurism [**2139-1-7**]. follow up ultrasound on [**2139-1-8**] showed increased thrombosis. Interventional Radiology thought that it would likely will finish up trhombosing itself. No intervention for now. follow up with u/s Monday [**2139-1-12**] . # Bipolar - No evidence of mania or depression now. On lithium. Level 0.9 and no signs of toxicity. . # CRI - Followed by Nephrology at OSH. Per family suspected from lithium toxicity but has been stable. No history of diabetes or HTN. Good uop. Likely [**2-5**] contrast nephropathy from cath. Creatinine increased from 1.6 to 1.8 on [**2139-1-6**]. creatinine 1.7 on discharge. stable. . # Hyperglycemia - sugars can be elevated peri-MI period. Well-controlled so far. HgbA1c 5.6.He was managed with insulin sliding scale on the floor. . # CODE: FULL . # dispo: Patient admitted to CCU post-MI. He was tranferred to the floor 1 day post-cath. Physical therapy saw him on [**1-6**] and recommended patient have another day of physical therapy as deconditioned being in bed for several days. Patient has follow-up scheduled with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 111555**] at [**Hospital3 **] on [**2139-1-12**]. PCP will arrange [**Name9 (PRE) 702**] (possibly also on [**2139-1-12**]) with cardiologist at [**Hospital3 **]. Patient will need PT/INR checked every couple of days until INR therapeutic so Lovenox can be stopped. Lovenox should continue until INR therpeutic. INR/PT should be checked on [**1-9**] and again on [**1-12**], these results can be sent to PCP's office. Patient will require VNA for PT and lab draws for PT/INR Medications on Admission: Lithium 300mg po bid 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 30 days. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*10 * Refills:*1* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: ST elevation myocardial infarction chronic renal insufficiency Discharge Condition: stable Discharge Instructions: Please call your physician or return to the hospital if you experience chest pain, shortness of breath, or increased leg swelling. . You were treated for a heart attack with 3 stents that were placed into the blood vessels that supply your heart, in order to prevent them from becoming blocked. . Please follow up your appointments as schedule. . You have an appointment for an ultrasound on Monday [**9-9**] Please continue to take all medications exactly as prescribed, especially plavix, which will prevent failure of the stents. Followup Instructions: You have an appointment scheduled with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 111555**] on [**2139-1-12**] at 4:30 p.m. at [**Hospital3 2358**]. The [**Hospital3 **] will schedule you for an appointment with a cardiologist and call or mail you an appointment (will try to get appointment on [**2139-1-12**]). Please fax INR results Dr. [**Last Name (STitle) 111555**] at [**Hospital1 1774**] Fax# [**Telephone/Fax (1) 111556**]. Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2139-1-12**] 8:00 Completed by:[**2139-1-8**]

Admission Date: [**2158-5-14**] Discharge Date: [**2158-6-23**] Date of Birth: [**2083-7-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Fall from wheelchair Major Surgical or Invasive Procedure: Abdominal drain placements Chest drain placements Chest tube placement bilaterally Ureteral Stent Placement Bilateral nasal bone stabilization Exploratory Laparotomy History of Present Illness: 75 M on coumadin for AFib, wheelchair bound [**1-17**] cerebral palsy fell from wheelchair onto face after accidentally driving off of curb. C/O facial pain, No LOC, intubated for airway protection. Pt was seen and stabilized at [**Hospital3 **] with vitK and 2 units FFP for elevated INR. Past Medical History: Cerebral palsy, Central Cervical Cord Contusion, BPH, Nephrolithiasis, AFib. Social History: Wheelchair bound, lives at home. Family History: NC Physical Exam: 100.0 99.6 99AF 114/55 26 100% PS50% 7/5 --> 410x24 NAD, trach in place Card: Tachy, AFib Resp: Coarse breath sounds bilaterally, CT sites clean/dry and intact Abd: Soft, NTND. GJ tube intact w/ G capped Ext: Waffle boots in place. Pertinent Results: Microbiology: [**5-15**] Sputum: oropharnygeal flora [**5-15**] MRSA: neg [**5-25**]: Sputum ecoli pan [**Last Name (un) 36**] (R ampicillin) [**5-25**] Bcx [**12-17**]: coag +staph, pan [**Last Name (un) 36**]. [**5-26**] Ucx: neg [**5-29**] Bcx: NGTD x2 [**5-31**] Bcx: NGTD x2 [**5-31**] Ucx: NGTD [**5-31**] Sputum: NGTD [**6-1**] Cdiff: Neg [**6-2**] Ucx:NG [**6-2**] pl Fluid:NGTD [**6-5**] Bl Cx: neg [**6-5**] Ucx: NG [**6-6**] Stool clx - C. diff negative [**6-7**] BClx - neg [**6-7**] UClx - NG [**6-7**] sputum cx - NGTD [**6-8**] BAL - NGTD [**6-8**] Bcx - NGTD [**6-9**] Cath tip neg [**6-9**] Abd fluid - 3+ PMNs, NGTD [**6-9**] Abd LUQ fluid - 1+ PMNS, NGTD [**6-10**] Pleural fluid - NGTD [**6-10**] Ucx - neg [**6-12**] sputum - contaminated [**6-12**] Bclx x2 - NG [**6-12**] Uclx - NG [**6-13**] wound clx swab - Staph coag neg rare, 1+ PMNs [**6-14**] pleural fluid x1 - NG [**6-14**] pleural fluid x2 - NG [**6-14**] pleural fluid x3 - NG [**6-18**] sputum cx GNR [**6-18**] Blcx - (aerobic/anaerobic) GPC in pairs/clusters, Coag neg Staph [**6-19**] C. diff - negative [**6-21**] C. diff - negative [**6-21**] BCx - P [**6-21**] UCx - P [**6-21**] Sputum Cx - P Imaging: [**5-14**] CT Cspine: severe central canal stenosis [**1-17**] severe djd from c3-c7. fusion of c6 and c7. no acute fracture. djd can predispose to cord injury in setting of trauma. [**5-15**] CT torso: RLL opacification. Small left pleural effusion. Large hiatal hernia. [**5-25**] CT torso: Right mod-severe hydro/pyoureteronephrosis with heterogeneous enhancement of the r kidney compatible with pyelonephritis. Multiple obstructing distal ureteral calculi measuring up to 7mm. Free air and contrast in the peritneal cavity. PEG tube is not in the stomach. small contrast in the rectum likely from video swallow from [**2158-5-17**]. While bowel perforation can not be entirely excluded on the basis of this study findings most likely represent injection of contrast and air into the peritoneum through the PEG that is extraluminal. Bowel and a drenal enhancement pattern is compatible with shock. Small free abd.pelvic fluid. Small pericardial effusion. cardiomegaly. dilated esophagus. Small bilat pleural eff (L>R) and rll atx or pna. Possible left shoulder osteochondromatosis. scoliosis. l renal small hypodensities likely cyst. [**5-26**] CXR: Pulmonary and mediastinal vasculature are now engorged but there is no edema. Atelectasis persists at the right lung base. The stomach is now distended with fluid. [**5-29**] CXR: Increased bilateral moderate pleural effusion [**5-30**] CXR: RLL opacity is consistent with almost complete collapse of the right lower lobe and a large hiatal hernia [**5-31**] RUQ US: no biliary dilatation,edematous gall bladder [**6-1**] CT head: no ICH. Increased mucosal thikcening of the sphenoid sinuses, with persistent fluid within the ethmoid and maxillary sinuses. [**6-1**] CT torso w/I: no abscess. [**6-2**]: pleural catheter right hemithorax with resolution pl eff. Left enlargement of a moderate-to-large left pleural effusion [**6-3**]:Large left and small right pleural effusions are similar in size, but there has been apparent development of a small component of loculation of the left effusion at the level of the second left anterior rib. A confluent area of atelectasis in this region could potentially mimic loculated pleural fluid,however. [**6-4**] BLE US: No DVT [**6-5**] CXR: Moderate R pl eff and RLL collapse, and l pl eff and LLL atelectasis all more severe [**2158-6-11**] CXR: small to moderate pleural effusions b/l stable, area of linear consolidation within LUL, stable [**6-12**] CT Chest - bilateral pleural effusions. [**6-13**] CT chest - Interval decrease in the loculated areas of ascites. Interval decrease in R pleural effusion most likely [**1-17**] draining. Slight interval increase in the L pleural effusion. Still present areas of loculated fluid within the abdomen as well as at the hiatal junction [**6-14**] CXR - decrease of the left pleural effusion. no evidence of ptx, There is also new R chest tube,additional decrease R pleural effusion [**6-14**] post WS CXR [**6-15**] CXR - no interval change [**6-18**] am CXR - right pigtail catheter has been removed. Right chest tube is seen at the base with some loculated pneumothorax in the subpulmonic region. On the left, the chest tube has also been pulled back somewhat and there is new subpulmonic and medial lower lung pneumothorax on this side as well. Right IJ catheter has been removed. Tracheostomy tube remains in place. [**6-18**] pm CXR - post d/c of LEFT chest tube, small PTx remains. [**6-19**] CXR - In comparison with the study of [**6-18**], there is progressive decrease in the left pneumothorax with only a minimal possible subpulmonic collection. Right chest tube remains in place and persistent opacification is seen at the right base. [**6-19**] CT Torso - Multiple foci of loculated intraperitoneal fluid, the largest in the left upper quadrant with 2 cm thickness, none of which appear large enough to warrant drainage placement. Bilateral small pneumothoraces. Resolution of right hydronephrosis with persistent urolithiasis with stones seen in the right collecting system and urinary bladder. One of the stones appears to be located at the right UVJ, but none in the distal ureter. Bilateral small pleural effusions with near right lower lobe collapse and atelectasis in the left lower lobe. [**6-19**] CT sinus - Redemonstration of extensive facial fractures, thoroughly characterized on [**2158-5-14**] CT. There is pansinus mucosal disease, though decreased compared to [**2158-6-1**]. There is hyperdense fluid seen layering in the left maxillary and right sphenoid sinus, compatible with inspissated secretions. No aerosolized secretions are identified. There is fluid opacification of the bilateral mastoid air cells. There are no osseous changes associated with these processes. Clinical correlation is advised to exclude acute mastoiditis. Stable ventriculomegaly. No extra-axial fluid collections in the visualized cranium Brief Hospital Course: Pt was stabilized at an OSH ([**Hospital3 2005**]) and transferred to [**Hospital1 18**] for definitive management. He was seen and evaluated in the Trauma Bay and found to have a LeFort I fx, for which he had been intubated for airway protection. His other imaging was negative for acute injury, although his CSpine was relevant for severe central canal stenosiss from degenerative disc disease from C3-C7. On admission to the ICU, the patient was noted to have labile pressures, but was flluid responsive. He was started on Unasyn with plastic surgery's recommendations for nonoperative management of LeFort I Fracture. He was noted to be in AFib and this was managemd with lopressor and diltiazem for the duration of his admission, although his coumadin was held for concern of bleeding. His left metacarpal fracture was seen by Orthopedics and stabilized with a splint. On [**5-16**] he was succesfully extubated and his nasal packings were removed without evidence of rebleeding. At this time he was alert and oriented and able to sit up in bed. On [**5-18**] the patient was transferred to the floor. Because of his facial fractures, he was unable to tolerate POs, and Dobhoff/NG tube placement was contraindicated, so the patient was planned for a GTube. In the interim the patient was nutrionally maintained on TPN. On [**5-24**] the patient had a percutaneous gastric tube placed in the operating room with concurrant nasal fracture reduction. At the end of the procedure, the tube was endoscopically examined and determined to be properly placed and secured into place with nonabsorbable suture. His Gtube was placed to gravity prior to initiation of tube feedings. On [**5-25**] the patient was noted to be in rapid afib and respiratory distress for which he required intubation. The patient was transferred to the ICU and resuscitatied with crystalloid and maintained on neosynephrine for unstable pressures. Cardiac enzymes were cycled and the patient underwent both bronchoscopy and CT Torso to evaluate for potential causes of his septic picture. His minimum pressure prior to resuscitation was 50/30, and recovvered appropritately with pressures and IVF resuscitation. His CT torso was reviewed and demonstrated that PO contrast instilled through the G tube was free within the peritoneum along with free air, and herniation of the stomach through the hiatus of the diaphragm. Additionally a right sided hydronephrosis [**1-17**] ureteral calculus was identified. Urology was consulted for hydronephrosis and a ureteral stent was placed along with a percutaneous nephrostomy tube. Additionally the patient was noted to be in acute renal failure for which the nephrology service was consulted and the patient started on CRRT as tolerated by his labile blood pressures. On [**5-26**] the patient was taken to the OR for ex-lap and resiting of his PEG with reduction of his hiatal hernia. He was maintained on levofloxacin, cefepime and flagyl initially and his antibiotics tailored to known cultures for the remainder of his admission with the help of the Infectious Disease service. Blood cultures were positive from prior to OR. He continued to require levophed and vasopressin for maintainance of perfusing pressures postoperatively. On weaning sedation the patient was noted to have significant decrease in mental status, but was responsive to stimulus. On [**5-30**] the patient was restarted on tube feedings without any worsening peritoneal signs or evidence of worsening sepsis. By [**6-2**] the patient was succesfully weaned from his pressors, but remained intubated [**1-17**] mental status changes, and CT head and Torso obtained on [**6-1**] indicated no intracranial hemorrhage and no abscesses intrabdominally, but did demonstrate large bilateral pleural effusions, for which IR was consulted and placed a R pigtail catheter. He failed a trial extubation on [**6-4**]. On [**6-6**] he underwent tracheostomy placement for his prolonged intubation and this was performed without difficulty, although the patient did have difficulty tolerating tube feeds at this time, and his G tube was changed to a G-J by IR on [**6-7**]. He continued to have persistent fevers and on [**6-8**] CT Torso demonstrated multiple abdominal fluid collections for which an IR pigtails x3 were placed with serous output. His thoracic pigtail output was noted to be decreased oon [**6-13**] and he continued to have persistent pleural effusions were noted, so bilateral chest tubes were placed without difficulty. Additionally, he was noted to have a large purulent fluid collection underlying his wound and this was opened and packed with wet to dry dressings initially, then converted to a wound vac. His tube feeds were advanced to goal and his chest tubes and abdominal pig tails were allowed to drain until they were observed to have decreased output, then removed. His GTube was capped and the Jejunal portion remained functional without increased residuals. Repeat imaging showed stable fluid collections the largest of which was 2cm. On HD 40 the patient was afebrile and maintained on Vancomycin and Zosyn, at which time he was screened and transferred to a Long Term Acute Care facility for further management. Medications on Admission: 1. Coumadin 2.5mg po qM-W-F-[**Doctor First Name **], 5mg po qTu-Th-Sa 2. Metoprolol XL 100mg po qd 3. Enablex daily 4. Proscar daily 5. Protonix daily 6. Tylenol prn Discharge Medications: 1. Acetaminophen 640 mg/20 mL Suspension [**Doctor First Name **]: One (1) PO Q6H (every 6 hours) as needed for fever, pain. Disp:*1000 mL* Refills:*0* 2. Glucagon (Human Recombinant) 1 mg Recon Soln [**Doctor First Name **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Bisacodyl 10 mg Suppository [**Doctor First Name **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 4. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment [**Doctor First Name **]: One (1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes. 5. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor First Name **]: One (1) Injection TID (3 times a day). 6. Ipratropium Bromide 0.02 % Solution [**Doctor First Name **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 7. Docusate Sodium 50 mg/5 mL Liquid [**Doctor First Name **]: One (1) PO BID (2 times a day) as needed for constipation. 8. Senna 8.6 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Insulin Regular Human 100 unit/mL Solution [**Doctor First Name **]: One (1) Injection ASDIR (AS DIRECTED) as needed for hyperglycemia. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 12. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a day. 13. Dextrose 50% in Water (D50W) Syringe [**Last Name (STitle) **]: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 14. 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. 15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) as needed for pneumonia for 7 days. Disp:*21 * Refills:*0* 16. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 7 days. Disp:*14 Recon Soln(s)* Refills:*0* 17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center- MACU Discharge Diagnosis: Sepsis PEG placement, Dislodged PEG Trach placement Pulmonary Effusion Abdominal Abscesses LeFort I facial fracture Left 1st metacarpal fracture Discharge Condition: Mental Status - Responds to stimulus Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: In addition to the below standardized instructions, the patient will require: IV antibiotics as ordered until [**6-28**] Tracheostomy care/Respiratory Care - Currently maintained on pressure support with a peep of 5 and pressure support of 5 at 50% Wound care (Wound Vac) General Discharge Instructions: You have had an abdominal operation. This sheet goes over some questions and concerns you or your family may have. If you have additional questions, or [**Male First Name (un) **]??????t understand something about your operation, please call your [**Male First Name (un) 5059**]. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside. But avoid traveling long distances until you see your [**Male First Name (un) 5059**] at your next visit. [**Male First Name (un) **]??????t lift more than 20-25 pounds for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU [**Month (only) **] FEEL: You may feel weak or ??????washed out?????? for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: Your incision may be slightly red around the stitches or staples. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that, it??????s OK. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as Milk of Magnesia, 1 tablespoon) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. After some operations, diarrhea can occur. If you get diarrhea, [**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your [**Male First Name (un) 5059**] PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as ??????soreness.?????? Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. You will receive a prescription from your [**Name2 (NI) 5059**] for pain medicine to take by mouth. It is important you take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please [**Male First Name (un) **]??????t take any other pain medicine, including non-prescription pain medicine, unless your [**Male First Name (un) 5059**] has said it is OK. If you are experiencing no pain, it is OK to skip a dose of pain medicine. To reduce pain, remember to exhale with any exertion or when you change positions. Remember to use your ??????cough pillow?????? for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [**Name2 (NI) 5059**]: sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than 101 a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases, you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. DANGER SIGNS: Please call your [**Name2 (NI) 5059**] if you develop: Worsening abdominal pain Sharp or severe pain that lasts several hours Temperature of 101 degrees or higher &#[**Numeric Identifier 96557**]; My doctor: Name:___________________________ Phone number: _ Severe diarrhea Vomiting Redness around the incision that is spreading Increased swelling around the incision Excessive bruising around the incision Cloudy fluid coming from the wound Bright red blood or foul smelling discharge coming from the wound An increase in drainage from the wound Followup Instructions: Please follow up in the [**Hospital 2536**] clinic in [**1-18**] weeks. Call Acute Care Surgery [**Telephone/Fax (1) 600**] to make an appointment

Admission Date: [**2152-2-21**] Discharge Date: [**2152-2-29**] Date of Birth: [**2074-10-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: Fever, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 77M h/o hypertension, hyperlipidemia, presented to ED after fatigue, poor PO intake x1 week; congestion, coryza x4 days; and shaking chills, urinary/bowel incontinence, weakness, and altered mental status x1 day (pt also experienced one episode of shaking chills x1 day last week). . ROS: (+) See above. Positive sick contact (wife with [**Name2 (NI) **], weakness x1wk) (-) Myalgias, recorded or subjective fevers, night sweats, SOB, nausea, vomiting, abdominal pain, diarrhea. . ED course: # Vitals: T 102.8, HR 99, BP 159/103, RR 16, O2sat 98 on RA # Meds: Ceftriaxone 2g IV x1 (empiric treatment for meningitis), acetaminophen 650mg PO x1, acyclovir 250mg IV x1 (empiric treatment for HSV encephalitis). # Therapies: --1:1 sitter as pt was trying to get out of bed --LP given ?meningitis, encephalitis Past Medical History: Hypertension Hyperlipidemia Social History: # Personal: Lives at home with wife [**Name (NI) **]; son [**Name (NI) **] in [**Name (NI) 5426**]. Two home health care workers. # Professional: Retired from political policy. # Tobacco: Never # Alcohol: Rare # Recreational drugs: None Family History: # Father, died 67: MI # Mother, died 96 Physical Exam: Tm 103.1, BP 121/61, HR 86, RR 18, O2 sat 97% 2L Gen: Slouched in bed, rousable. HEENT: NCAT. No LAD, OP clear, MM dry. NECK: Supple, no JVD Cardiac: RRR, S1 S2, no m/r/g. Chest: Diminished breath sounds but otherwise clear; no notable rales, rhonchi or wheezes. Abdomen: Soft, NT, ND, +BS, no HSM. Extremities: No BLE, w/w/p, 2+ DP bilaterally. Presented with contracted arms but easily repositioned. R 4/5 strength on hand clench; L 5/5 strength on hand clench. Tone WNL. Neuro: A&O x person, city. CN II-XII nonfocal. Slow to respond but appropriate replies. Skin: Dry, decreased turgor. Pertinent Results: Notable labs: . [**2152-2-21**] 03:30PM WBC-7.9 RBC-4.64 HGB-13.5* HCT-40.0 MCV-86 MCH-29.1 MCHC-33.7 RDW-12.6 [**2152-2-21**] 03:30PM NEUTS-81.1* LYMPHS-8.6* MONOS-8.2 EOS-1.8 BASOS-0.3 [**2152-2-21**] 03:41PM LACTATE-1.2 . Microbiology: . # Influenza A positive . # LP (Tube 4): WBC 1, RBC 2475, polys 50, lymph 34 . Imaging: . # CT HEAD W/O CONTRAST [**2152-2-21**] 4:51 PM 1. Prominence of ventricular system is proportional to sulcal prominence and therefore consistent with central atrophy. A normal pressure hydrocephalus cannot be excluded, however. 2. No evidence of intracranial hemorrhage. 3. Extensive chronic microvascular angiopathy. . # CHEST (PORTABLE AP) [**2152-2-22**] 8:41 AM Ill-defined opacities in the left mid and lower zones are new, worrisome for aspiration. The right lung remains clear. Cardiomediastinal contours are unchanged. No pneumothorax or pleural effusions. The left apex is obscured by the ____. . # CHEST (PA & LAT) [**2152-2-21**] 4:36 PM Two views, with the lateral view is slightly limited by overlying sheets, dorsally and no comparisons. Allowing for the slightly low lung volumes, the lungs are clear. Other than a tortuous, unfolded and calcified aorta, the cardiomediastinal silhouette and pulmonary vessels are within normal limits with no evidence of CHF. There is diffuse osteopenia with anterior wedging of several mid-thoracic vertebrae and resultant kyphosis, which may be chronic. Brief Hospital Course: 77M h/o HTN, hyperlipidemia, admitted with influenza, now complicated by aspiration pneumonia/pneumonitis. . # Respiratory distress: Pt initially presented in some acute respiraotry distress with high NC O2 requirements. he was found to be positive for influenza A and a CXR showed evidence of pneumonia. He was treated with oseltamivir and antibiotics (levo and vancomycin). He briefly required a MICU stay given the desaturations and higher nursing needs. In the MICU, pt was placed on aggressive nebulizers, supplemental oxygen, telemetry, chest PT, and suctioning. Once his respiratory status improved after more aggressive suctioning and chest PT he was transferred to the floor. His respiratory distress improved and he was able to be weaned off of supplemental oxygen. He was continued on the levofloxacin and vancomycin for the pneumonia to complete a 7 day course which was complete prior to discharge. . # Mental status change: Pt had presented with some acute MS changes which was felt to be likely secondary to his infectioon as well as dehydration. However he was empirically started in ED on ceftriaxone for meningitis and acyclovir for herpetic encephalitis. A CT head was negative for acute pathology; LP negative for meningitis, but because of traumatic tap, unable to rule out herpetic enchepalitis with RBCs. His MS subsequently improved after treatment for his pneumonia and after IVF hydration; thus the Acyclovir and ceftriaxone were discontinued. His mental status thus improved to his baseline off the acyclovir and therefore not restarted (low suspicion for viral meningitis). . # HTN: Pt on lisinopril 5mg daily as home regimen; however, given dehydration and elevated Cr, this was initially held. He initially was treated with IV blood pressure medication and then transitioned to po metoprolol. Once his ARF resolved his Lisinopril was restarted and he was continued on the Toprol with good BP control. . # FEN-Pt was evaluated by speech and swallow who felt pt could tolearte thin liquids/pureed solids but as his respiratory status/mental status improved; this was advanced and pt was tolearting a regular diet on dishcarge. . #Dispo-Pt was evaluated by PT who felt that pt warranted an acute rehab stay. Medications on Admission: Lisinopril 5mg daily Citalopram 20mg daily Simvastatin 40mg daily Fish oil MVI Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. Fish Oil Oral 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Influenza Pneumonia . Secondary HTN Hyperlipidemia Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you were found to have influenza and pneumonia. You were treated with antibiotics and completed the course while you were here. . In addition you were dehydrated and were given fluids. . You were started on a medication called Toprol XL, this is to help control your blood pressure. You will need to continue this when you go home. . Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] 1 week after discharge from the rehab facility. You can call to set up this appointment. . If you have any ongoing fevers, chills, shortness of breath, chest pain, nausea, vomiting, abdominal pain, or other concerning symptoms please call your doctor or return to the ER Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**] Date/Time:[**2152-5-1**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

Admission Date: [**2147-6-15**] Discharge Date: [**2147-6-23**] Date of Birth: [**2093-8-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 7926**] Chief Complaint: Incarcerated ventral hernia atrial fibrillation with rapid ventricular response chronic obstruction pulmonary disease obstructive sleep apnea diabetes mellitus pulmonary artery hypertension Major Surgical or Invasive Procedure: [**2147-6-16**] - ventral hernia repair with mesh History of Present Illness: 53F transfer from OSH for an incarcerated ventral hernia. Patient reports a history of a ventral hernia repair in [**2144**] that recurred 1 month after the initial surgery but was always reducible until 2 days ago, when she was no longer able to manually reduce it. It has since become increasingly painful and she is experiencing worsening nausea, no vomiting. Her last BM was 3 days ago and she has not passed flatus since. Patient reports a complicated post-operative course after her initial hernia operation at [**Hospital3 **] requiring an ICU stay for "breathing problems". She says this is why she was referred to [**Hospital1 18**] for repair of her hernia. Transfer to cardiology floor: 53F h/o COPD Aflutter s/p ablation [**2145**] transfer from OSH for an incarcerated ventral hernia s/p repair on [**2147-6-16**]. In the [**Name (NI) 13042**], pt had Afib with RVR to 140s (no hypotension) and was transferred on [**6-18**] to the SICU where a dilt gtt was started. Her dilt gtt was weaned off, and propafenone (home med) and metoprolol (home med) were started. On day of transfer, HR on this regimen has been 90s-110s with blood pressure 120s-140s/40s-80s. O2 sats were low 90s on 5L N/C. She was noted to be volume overloaded on exam, and lasix was initiated. She was 4L negative during stay in SICU. On day of transfer she was given 20mg IV lasix once in the SICU and was 1L negative as of 3pm. She occasionally converts back to sinus. Past Medical History: PMH: Paroxysmal Afib (onset after ablation therapy for aflutter dx [**10/2146**]), on coumadin 6 mg daily with q2 week INR checks Hyperlipidemia Hypertension Diabetes Mellitus Type II COPD OSA Pulmonary artery hypertension PSH: Ventral hernia repair, [**2144**] Hysterectomy, [**2140**] Appendectomy, [**2120**] C-section, [**2113**], [**2120**] Social History: quit smoking [**2147-2-17**], denies alcohol, illicit drugs Family History: Family hx of CAD Physical Exam: PE on transfer to the cardiology floor: PHYSICAL EXAMINATION: VS: VS: 99.3 130/62 81 19 95%4L GEN: NAD, comfortable HEENT: PERRL, OP clear NECK: Supple, JVD 6cm, no LAD CARDIAC: Irregularly irregular, nlS1S2, no m/r/g LUNGS: Resp unlabored, bilateral basilar crackles, good air movement ABDOMEN: Soft, NTND, no rebound/guarding, 6cm horizontal incision w staples mild surounding erythema EXTREMITIES: No c/c/e. 2+ DP/PT/radial pulses Has healing abdominal incision c/w recent surgery. No erythema or drainage SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Has healing abdominal incision c/w recent surgery. No erythema or drainage PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ PE on discharge: VS: 98.8 98/51 53 18 93%RA GEN: NAD, comfortable HEENT: PERRL, OP clear NECK: Supple, JVD 6cm, no LAD CARDIAC: regular rhythm, no m/r/g LUNGS: Resp unlabored, scattered bilateral crackles, good air movement ABDOMEN: Soft, NTND, no rebound/guarding, 6cm horizontal incision w staples mild tenderness. EXTREMITIES: No c/c/e. 2+ DP/PT/radial pulses Has healing abdominal incision c/w recent surgery. No erythema or drainage SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Has healing abdominal incision c/w recent surgery. No erythema or drainage 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: Admission labs: [**2147-6-15**] 03:25PM BLOOD WBC-6.9 RBC-6.15* Hgb-16.6* Hct-48.5* MCV-79* MCH-27.0 MCHC-34.2 RDW-15.2 Plt Ct-283 [**2147-6-15**] 03:25PM BLOOD Neuts-71.6* Lymphs-21.1 Monos-5.7 Eos-0.6 Baso-1.0 [**2147-6-15**] 03:25PM BLOOD PT-42.4* PTT-34.7 INR(PT)-4.4* [**2147-6-15**] 03:25PM BLOOD Plt Ct-283 [**2147-6-15**] 03:25PM BLOOD Glucose-192* UreaN-11 Creat-0.9 Na-137 K-4.4 Cl-96 HCO3-30 AnGap-15 [**2147-6-16**] 05:15AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0 [**2147-6-16**] 11:48AM BLOOD Type-ART pO2-65* pCO2-50* pH-7.38 calTCO2-31* Base XS-2 Intubat-INTUBATED [**2147-6-16**] 11:48AM BLOOD freeCa-1.14 Imaging: [**6-15**] CXR: Mild-to-moderate pulmonary edema. NG tube passes out of view below the diaphragm. [**6-19**] CXR: As compared to the previous radiograph, there is no relevant change. Moderate-to-severe pulmonary edema with cardiomegaly and retrocardiac atelectasis. Suspected small left pleural effusion. No newly appeared focal parenchymal opacities. [**6-21**] TTE: The left atrium is dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Diastolic function could not be assessed. 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global lef ventricular systolic function. The right ventricle is not well seen but is probably dilated and hypokinetic with severe pulmonary artery systolic hypertension. [**6-21**] EKG: Atrial fibrillation with rapid ventricular response. Right axis deviation.Compared to the previous tracing of [**2147-6-18**] the ventricular response has slowed. Otherwise, no diagnostic interim change. Discharge labs: [**2147-6-23**] 10:18AM BLOOD WBC-9.5 RBC-5.04 Hgb-13.0 Hct-39.8 MCV-79* MCH-25.8* MCHC-32.7 RDW-14.6 Plt Ct-344 [**2147-6-15**] 03:25PM BLOOD Neuts-71.6* Lymphs-21.1 Monos-5.7 Eos-0.6 Baso-1.0 [**2147-6-23**] 10:18AM BLOOD PT-21.2* PTT-88.3* INR(PT)-2.0* [**2147-6-23**] 10:18AM BLOOD Plt Ct-344 [**2147-6-23**] 10:18AM BLOOD Glucose-192* UreaN-18 Creat-1.1 Na-142 K-4.3 Cl-99 HCO3-33* AnGap-14 [**2147-6-23**] 10:18AM BLOOD Calcium-10.0 Phos-2.9# Mg-2.4 Brief Hospital Course: Surgical course: Ms. [**Known lastname **] was admitted from the ED with intent to take her to the operating room the next day. Her hernia was incarcerated but was able to be reduced in the ED. Her hernia continued to recur, however and plans were made to take her to the operating room the next day. She was kept NPO with IVF. Overnight into HD 2, she triggered for Afib with RVR in the 130s-140s. She responded well to IV lopressor and converted back into normal sinus rythym. She was taken to the operating room on [**2147-6-16**] for repair. Please refer to Dr.[**Name (NI) 1863**] operative note for additional details. Her post-operative course was uncomplicated from a surgical standpoint. Her wound dressings were removed on POD 2 and the incision was clean, dry, intact. There was a small seroma visible at the superior aspect of the wound. It was monitored and did not show signs of infection. The patient was instructed on signs of infection prior to her discharge. On POD 1 into POD 2, she passed flatus and was advanced in her diet. She tolerated a regular diet without difficulty. Her cardiac and respiratory status, though, required attention. This patient had baseline paroxysmal afib and COPD prompting continuous oxygen therapy in the initial post-op period. She went into atrial fibrillation with a heart rate in the 140s on POD 1 in the [**Name (NI) 13042**]. The cardiology consult team assessed the patient and recommended resumption of her home antiarrythmic and beta blocker (propafenone and metoprolol). She converted back into normal sinus rythym but was transferred from the [**Name (NI) 13042**] to the ICU in the case that she reverted and needed a diltiazem drip. On POD 2, she was placed on a diltiazem drip for a brief period of time. Her metoprolol dose was increased to 75 mg TID. Propafenone was continued. On POD 3, she was tolerating a regular diet, having bowel movements and overall stable from a surgical perspective. She was hemodynamically stable but continued to be in persistent afib with a heart rate in the 100s-120s. The cardiology team accepted transfer to their service. Cardiology course: # Pulmonary hypertension with PASP on TTE estimated at >70 - new since [**9-/2146**], however both TTE's were sub-optimal studies. [**Month (only) 116**] be related to underlying lung disease/COPD and OSA. Was off anticoagulation for short time post-op, so at risk for PE. However, no tachycardia currently, O2 requirement has been improving so less likely. Bridged with heparin, INR therapeutic at discharge. Will need follow-up for COPD, OSA and her elevated Pulmonary artery pressure. . # Oxygen Requirement: Pt on no home O2 prior to admission, though has required in past while recovering from pna. New O2 requirement likely related to underlying lung disease and volume overload as has dilated LA with normal LV and has had decreasing O2 requirement with increasing diuresis. ***wt prior to adm 107kg (per pt). ***on [**6-22**] wt was 110kg ***on [**6-23**] wt was 108kg - I/O goal -1L / day -- sent home on 10mg daily which should be reassesed at follow up. - Now down to RA at rest but desats to mid 80s. Will send home with 1-4L PRN O2 . # RHYTHM: Pt w afib w RVR, now back in sinus 60s-70s - cont home propafenone and increased metoprolol dose. Her heart rate is 50s-60s and may need some adjustment of this dose. #S/p hernia repair -incision healing well -outpt surgery f/u . # DM: - cont home levemir, novoLOG - hold glip, metformin while inhouse, continued on d/c. . # CAD - cont home pravastatin . ------------ Transitional Issues: 1) PA hypertension: This is a new finding since [**46**]/[**2145**]. However, both the recent and the [**2145**] echo were sub-optimal studies due to body habitus. She very likely has OSA and COPD and these may be causes. Chronic PEs are a possibility and she is anticoagulated for AFib. She should have close follow-up regarding this. 2) COPD/OSA: She understands that CPAP would be beneficial and it is worth discussing this with her again. 3) AFib: She is on coumadin. Evaluate if candidate for dabigatran. She spontaneously converts to sinus. Metoprolol was increased for rate control, but this dose may need changing as outpatient. 4) Lasix: She was sent out on 10mg PO daily. This may need adjustment based on volume status and lab results at follow up with PCP next week. Medications on Admission: Levelmir 94 units Qam Insulin sliding scale. Metformin XR 750mg [**Hospital1 **] Metoprolol Tartrate 50mg [**Hospital1 **] ASA 81mg daily Coumadin 6mg daily prevachol 80mg daily glimepiride 4mg PO daily Propafenone 225mg PO BID Spireva Discharge Medications: 1. propafenone 225 mg Tablet Sig: One (1) Tablet PO twice a day. 2. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Outpatient Lab Work Please obtain a chemistry panel with blood urea nitrogen and creatinine prior to seeing your primary care doctor within one week. Please fax results to Dr.[**Name (NI) 86039**] office at [**Telephone/Fax (1) 86038**]. 4. Levemir Flexpen 100 unit/mL Insulin Pen Sig: Ninety Four (94) units Subcutaneous QAM (once a day (in the morning)). 5. Novolog Please continue your sliding scale as previously prescribed 6. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 7. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*4* 8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 9. Xopenex Please continue Xopenex as previously prescribed 10. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day. 11. metformin 750 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day for 7 days. Disp:*5 Tablet(s)* Refills:*0* 14. Continuous supplemental Oxygen Continuous Oxygen 1-4L Nasal cannula as needed. Discharge Disposition: Home Discharge Diagnosis: Incarcerated ventral hernia atrial fibrillation with rapid ventricular response chronic obstruction pulmonary disease obstructive sleep apnea diabetes mellitus pulmonary artery hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent (with O2). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure meeting and taking care of you. You were initially admitted for repair of your hernia. After surgery, you had a rapid heart rate that was treated with medications. Your blood was thinned to prevent clots from forming. You also required oxygen for several days, and it was thought this was related to your chronic lung disease and sleep apnea. You should be sure to follow up with your doctors. Specifically you should talk to them about continuing the lasix we have prescribed for you and obtain a chemistry panel with creatinine (lab tests) at your primary provider [**Name9 (PRE) 702**] in the next week. You should also talk about sleep apnea, and as we discussed, consider using the continuous positive airway pressure mask (at night) to prevent complications from worsening. You should use the oxygen we have prescribed for you at home as needed. Please also note the following medication changes: Please START: -Lasix 20mg (take one half tablet by mouth daily) and be sure to follow up the lab work with your primary care doctor within one week -Metoprolol tartrate 100mg twice a day (this is a slight increase from your previous dose) -Oxygen 1-4Liters as needed. Please CONTINUE your other medications as previously prescribed. Followup Instructions: Please follow up for your surgical care in the Acute Care Surgery clinic on [**7-6**] at 3:45. Please call [**Telephone/Fax (1) 600**] if you need to change this appointment. It is in the [**Hospital Ward Name **], specifically the [**Hospital Unit Name **]. Name: [**Last Name (LF) 56849**],[**First Name3 (LF) **] Specialty: FAMILY MEDICINE Address: [**State **], [**Location **],[**Numeric Identifier 21771**] Phone: [**Telephone/Fax (1) 56850**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within 1 week. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above Name: [**Doctor Last Name **], [**Name8 (MD) **] MD Location: ASSOCIATES IN CARDIOVASCULAR MEDICINE Address: [**Location (un) 85348**], [**Location **],[**Numeric Identifier 21918**] Phone: [**Telephone/Fax (1) 84020**] We are working on a follow up appointment with Dr. [**Last Name (STitle) 4922**] within 2-4 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above Please call your pulmonologist Dr.[**Name (NI) 88120**] office at [**Telephone/Fax (1) 40799**] on Monday to schedule a follow-up visit for COPD and sleep apnea. Completed by:[**2147-6-23**]

Admission Date: [**2189-2-26**] Discharge Date: [**2189-3-16**] Date of Birth: [**2110-11-15**] Sex: M Service: CARDIOTHORACIC Allergies: Monopril / Lipitor / Amiodarone / adhesive tape Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [**2189-2-27**] - Redo sternotomy x2 with resection of ascending aortic aneurysm and ascending aortic replacement with a 32-mm Gelweave tube graft under deep hypothermic circulatory arrest and redo coronary artery bypass grafting x4. [**2189-3-2**] - Mediastinal washout and chest closure History of Present Illness: This 78 year old man with prior CABGx4 in [**2175**], a redo CABGx1 and mitral valve repair in [**2178**] now has an ascending aortic aneurysm which he has known about since [**2184**]. This has been followed by serial CT scans and has shown nearly a 1cm growth over the past 3 years. It now measures 6cm. Of note he two previous cardiac surgeries were complicated by bleeding with re-exploration. Given the size of his aneurysm he has been referred for surgical evaluation. He denies any symptoms other then fatigue. Past Medical History: -Hypertension -Hyperlipidemia -[**2175**] CAD s/p Inferior wall MI -[**2-/2177**] TIA -s/p CVA '[**79**]-no residual -Cardiomyopathy/CHF admissions chronic diastolic heart failure s/p mitral valve repair/coronary artery bypass grafts s/p redo sternotomy, coronary artery bypass Paroxysmal atrial fibrillation s/p resection of colon cancer gastroesophageal reflux Arthritis Anemia Loss of hearing left ear Sleep apnea (does not use CPAP) Mild memory loss Social History: Lives with:wife Contact:[**Name (NI) **] cell# [**Telephone/Fax (1) 68465**] Occupation:runs a machine shop. Enjoys sailing. Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**1-27**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: noncontributory Physical Exam: Pulse: 62 Resp:18 O2 sat:98/RA B/P 140/80 Height:5'7" Weight:170 lbs General: NAD WDWN Skin: Dry [x] intact [x] HEENT: NCAT, PERRLA, EOMI, Anciteric sclera. OP benign. Teeth in fair repair. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x]; well healed sternotomy scar Heart: Irregular rate and rhythm, soft [**12-26**] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel sounds; healed laparotomy scar Extremities: Warm [x], well-perfused [x] 1+ Edema; no Varicosities but skin is thickened and with BLE chronic venous insufficiency changes; The vein has been endoscopically harvested from likely the entire right and the left thigh. Well healed incisions noted at bilateral knees. Likely suitable vein below knee on left. Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left: 2+ DP Right:2+ Left: 2+ PT [**Name (NI) 167**]:2+ Left: 2+ Radial Right:2+ Left: 2+ Carotid Bruit Right:no Left:no Pertinent Results: [**2189-2-27**] ECHO PRE-BYPASS: 1. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to distal inferior and septal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is severely dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild to moderate ([**12-22**]+) aortic regurgitation is seen. 7. A mitral valve annuloplasty ring is present. An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. 8. There is no pericardial effusion. POST-BYPASS: 1. The patient is V paced. The patient is on epinephrine, milrinone, and norepinephrine infusions. 2. Left ventricular function appears moderately depressed (LVEF = 35-40%) 3. The right ventricle is severely dilated with severe global dysfunction. 4. Moderate (2+) tricuspid regurgitation is seen. 5. Mitral regurgitation is unchanged. 6. Aortic regurgitation is unchanged. 6. The aorta is intact post-decannulation. [**2189-2-28**] ECHO No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular function is probably preserved. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The anterior mitral valve leaflet is mildly thickened. A mitral valve annuloplasty ring is present. An eccentric, anteriorly directed jet of Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Probably preserved LV function and RV function. There is mild eccentric MR. [**2189-3-16**] 04:15AM BLOOD WBC-13.5* RBC-2.95* Hgb-9.1* Hct-31.4* MCV-107* MCH-30.8 MCHC-28.9* RDW-23.2* Plt Ct-517* [**2189-2-26**] 07:15PM BLOOD WBC-8.6 RBC-4.31* Hgb-13.0* Hct-38.4* MCV-89 MCH-30.2 MCHC-33.9 RDW-15.7* Plt Ct-184 [**2189-3-16**] 04:15AM BLOOD PT-31.9* INR(PT)-3.1* [**2189-3-15**] 04:20AM BLOOD PT-32.0* INR(PT)-3.1* [**2189-3-14**] 05:40AM BLOOD PT-27.9* INR(PT)-2.7* [**2189-3-13**] 05:34AM BLOOD PT-20.8* INR(PT)-2.0* [**2189-3-12**] 10:49AM BLOOD PT-19.5* INR(PT)-1.8* [**2189-3-16**] 04:15AM BLOOD UreaN-29* Creat-1.3* Na-142 K-4.4 Cl-110* Brief Hospital Course: Mr. [**Known lastname 284**] was admitted to the [**Hospital1 18**] on [**2189-2-26**] for surgical management of his aneurysm. He underwent preoperative testing and was placed on Heparin as he had been off his Coumadin for five days. On [**2189-2-27**], he was taken to the Operating Room where he underwent replacement of his ascending aorta and hemiarch with reimplantation of his saphenous vein grafts. Please see operative note for details. Due to a coagulopathy, he was left with an open chest and taken to the intensive care unit. He received multiple blood products for his coagulopathy. The renal service was consulted for acute renal failure and possible need for dialysis. He was aggressively diuresed and his renal function stabilized. On [**2189-3-2**], he was returned to the Operating rRoom where he underwent mediastinal washout and sternal closure. Postoperatively he was taken to the intensive care unit for monitoring. On [**2189-3-4**] he awoke and was extubated. He had some confusion but was without any focal deficits. His renal function continued to improve. He was placed on Amiodarone for ventricular tachycardia in the OR. EP followed the patient. He developed first degree AV block and beta blocker was held until it resolved. He then vascilated between sinus rhythm and AFib. Coumadin was resumed for paroxysmal atrial fibrillation . Vascular surgery was consulted and ruled out compartment syndrome in the right lower extremity. Leukocytosis developed to a peak of [**Numeric Identifier 14157**] and he was pan-cultured. Infectious Disease was consulted. Cultures were unrevealing, CDiff toxin was negative on 4 occassions and torso and leg CT were negative for source. The patient was started empirically on Flagyl with a fall in the white count. Other antibiotics were stopped and the Flagyl changed to oral Vancomycin per Infectious Disease. He will be treated with a 14 day course of PO vancomycin in the setting of persistent leukocytosis and loose stool. Ultrasound of the edematous right leg revealed only edema, no focal collections. despite being below his preoperative weight he continued to have edema and diuretics were continued. Spironolactone was given due to his underlying heart failure. On [**3-16**] his WBC had fallen to 13,500, he was afebrile and felt well. He was trasnsferred to Genesis [**Hospital 11252**] rehab . Follow up appointments were made and medications are as listed. Medications on Admission: AMLODIPINE 10 mg daily DIGOXIN 125 mcg every other day DONEPEZIL 5 mg daily FUROSEMIDE 40 mg daily HYDROCHLOROTHIAZIDE 12.5 mg daily POTASSIUM CHLORIDE 20 mEq TID TELMISARTAN-HYDROCHLOROTHIAZID [MICARDIS HCT] 80 mg-12.5 mg - 1 Tablet daily Telmisartan 40 mg daily Allopurinol 300 mg daily ***WARFARIN 4 mg daily***- last dose [**2189-2-22**] ASPIRIN 81 mg daily Discharge Medications: 1. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO DAILY (Daily). 13. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): INR [**1-23**]. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 15. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): through [**2189-3-27**]. Discharge Disposition: Extended Care Facility: [**Location (un) **] center Discharge Diagnosis: s/p redo sternotomy (3rd),graft repair ascending aortic aneurysm w/ open chest s/p chest closure hypertension Hyperlipidemia [**2175**] CAD s/p Inferior wall MI s/p CVA '[**79**]-no residual Cardiomyopathy-chronic diastolic heart failure Mitral regurgitation s/p mitral valve repair Paroxysmal atrial fibrillation s/p colon resection for cancer gastroesophageal reflux Arthritis Loss of hearing left ear obstructive Sleep apnea (does not use CPAP) ascending aorta aneurysm mild memory loss Discharge Condition: Alert and oriented x3,,nonfocal Deconditioned Incisional pain managed with Acetaminophen Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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** Followup Instructions: You are scheduled for the following appointments Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time:[**2189-4-15**] 1:30 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 59323**] [**2189-4-2**] at 3:15p **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication AFib Goal INR [**1-23**] First draw [**3-17**] MD to dose daily. **Please arrange for coumadin follow-up prior to discharge from rehab** Completed by:[**2189-3-16**]

Admission Date: [**2201-1-27**] Discharge Date: [**2201-2-1**] Date of Birth: [**2125-4-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: exertional chest pain (snow shoveling) Major Surgical or Invasive Procedure: coronary artery bypass grafting x 4 (LIMA-LAD, SVG-OM1&OM2, SVG-PDA) closure of atrial septal defect [**2201-1-28**] History of Present Illness: The patient is a 75 year old white male who has experienced an increase in frequency of exertional angina over the past several months. He recently developed rest pain and was scheduled for cardiac catheterization and coronary angiography which revealed severe 3 vessel coronary artery disease. He was admitted for surgical management. Past Medical History: coronary artery disease s/p inferior wall myocardial infarction hypertension hyperlipidemia alcohol dependence Social History: retired lives with wife tobacco: 40 pack year hx, quit 40 [**Year (4 digits) 1686**]. ago alcohol: [**4-8**] drinks daily Family History: father- MI @ 65 [**Name2 (NI) 1686**]. old Physical Exam: VS: 98.3, 134/73, 81SR, 20, 98%2L Gen: NAD, WG, WN white male HEENT: unremarkable Chest: lungs CTAB CV: RRR, no murmur or rub Abd: +BS, soft, non-tender, non-distended Ext: warm, well-perfused, trace edema Incision: sternal-c/d/i without erythema or drainage, EVH- c/d/i Pertinent Results: [**2201-1-30**] 05:55AM BLOOD WBC-8.1 RBC-3.16* Hgb-10.4* Hct-28.9* MCV-91 MCH-32.9* MCHC-36.0* RDW-12.8 Plt Ct-110* [**2201-1-30**] 05:55AM BLOOD Glucose-111* UreaN-18 Creat-1.3* Na-136 K-3.9 Cl-97 HCO3-31 AnGap-12 [**2201-1-30**] 05:55AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 81420**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81421**] (Congenital) Done [**2201-1-28**] at 10:39:46 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2125-4-10**] Age (years): 75 M Hgt (in): 78 BP (mm Hg): 156/89 Wgt (lb): 189 HR (bpm): 78 BSA (m2): 2.21 m2 Indication: Intraoperative TEE for CABG procedure and Secundum ASD closure. Chest pain. Hypertension. Left ventricular function. Mitral valve disease. Preoperative assessment. ICD-9 Codes: 745.5, 746.9, 786.51, 440.0, 424.0 Test Information Date/Time: [**2201-1-28**] at 10:39 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Congenital) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Limited Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2008AW1-: Machine: [**Doctor Last Name 11422**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: *3.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Bidirectional shunt across the interatrial septum at rest. Large secundum ASD. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated aortic sinus. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. 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 Prebypass 1. There is a bidirectional shunt across the interatrial septum at rest. A large secundum atrial septal defect is present. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2201-1-28**] at 900am. Post Bypass 1. Patient is A paced and receiving an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Small residual flow across the interatrial septum at the site of the pledgets is seen. Dr [**Last Name (STitle) **] made aware. 4. Aorta intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2201-1-28**] 14:39 ?????? [**2195**] CareGroup IS. All rights reserved. Brief Hospital Course: The patient was brought to the operating room on [**2201-1-28**] where he underwent CABG x 3 and closure of ASD. The patient received vancomycin for perioperative antibiotic prophylaxis because he was inpatient 24hours prior to surgery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for further recovery and invasive monitoring. By POD 1 the patient was extubated, alert and oriented and breathing comfortably. He was hemodynamically stable and neurologically intact. He did develop some rapid atrial fibrillation in the 120s. This was managed with amiodarone and beta blockers, and the patient would convert to sinus rhythm. He was transferred to the step down unit where he made excellent progress with physical therapy, showing good strength and mobility prior to discharge. Chest tubes and pacing wires were discontinued without complication. The patient was discharged home on POD 4. Medications on Admission: lisinopril 20', atenolol 50', asa 162', HCTZ 25', lipitor 20' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 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:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day until further instructed. Disp:*120 Tablet(s)* Refills:*0* 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: coronary artery disease 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, and while taking narcotics 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) **] in [**3-9**] weeks for wound check and post-operative follow-up : [**Telephone/Fax (1) 6256**] Dr. [**Last Name (STitle) 32255**] in [**3-9**] weeks Dr. [**First Name (STitle) 4640**] in 2 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2201-2-1**]

Admission Date: [**2130-12-17**] Discharge Date: [**2130-12-23**] Date of Birth: [**2068-4-2**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old patient with Down syndrome who was transferred to [**Hospital3 **]Hospital for an expanding left subdural hematoma with change in mental status and aspiration pneumonia. ALLERGIES: The patient has no known allergies. PHYSICAL EXAM: Temp 98, BP 136/54, heart rate 80, respiratory rate 20, sats 96 percent on room air. The patient was awake, noncommunicative, at baseline, attends examiner, noncooperative. Pupils 4 down to 3 mm and briskly reactive. EOMs full. Face symmetric. Follows commands in the upper extremity. Moves the left lower extremity spontaneously. Toes were downgoing bilaterally. Deep tendon reflexes were 2 plus and symmetric. CT showed a left temporal acute-on-chronic subdural hematoma with minimal midline shift. HOSPITAL COURSE: The patient was admitted to the ICU for close neurologic observation. CT also showed an inferior left temporal bone fracture. On [**2130-12-18**], the patient had a subdural drain placed at the bedside for evacuation of the subdural hematoma. She had a repeat head CT on postprocedure day number 1 which showed good evacuation, and improvement of midline shift. The subdural drain was removed on [**2130-12-20**], and the patient was transferred to the regular floor. She was more awake, not following commands, but moving all extremities spontaneously. She had a swallow eval on [**2130-12-21**] which she passed, and the following day had a video swallow which she again passed, and was able to have a pureed diet with thin liquids. Physical therapy and occupational evaluated her and found her a maximum assist of 2 out-of-bed to chair, which was supposedly her baseline. The patient was felt to require a short rehab stay prior to discharge back to her group home.FU in 6 weeks with head CT. DISCHARGE MEDICATIONS: 1. Dilantin 200 mg po tid. 2. Pantoprazole 40 mg po once daily. 3. Levothyroxine 50 mcg po once daily. 4. Atorvastatin 10 mg po once daily. 5. Heparin 5,000 units subcu [**Hospital1 **]. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2130-12-22**] 10:30:29 T: [**2130-12-22**] 10:56:36 Job#: [**Job Number 58852**]

Admission Date: [**2102-11-4**] Discharge Date: [**2102-11-14**] Date of Birth: [**2054-5-26**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male, ex-smoker, without any prior cardiac or hypertensive history who presented to an outside with chest pain and was transferred to [**Hospital6 256**] for cardiac catheterization. Upon catheterization, the patient was found to have an increased LVEDP to 30, apical inferior and posterior basal akinesis, [**3-18**] grade mitral regurgitation, and an ejection fraction of about 30%. The LMCA was 60% distal, the left anterior descending was 100% mid, the eft circumflex was 80% at angle origin of the OM1, the right coronary artery was 100% thrombotic. PHYSICAL EXAMINATION: Chest: Clear. Heart: Regular, rate and rhythm. No murmur noted. Normal S1 and S2. LABORATORY DATA: Electrocardiogram showed normal sinus rhythm, with Q-wave in II, AVF, and ST elevation in V1 and V3. HOSPITAL COURSE: The patient was evaluated by Dr. [**Last Name (STitle) 1537**] from Thoracic Surgery and was taken to the Operating Room on [**2102-11-7**]. Dr. [**Last Name (STitle) 1537**] performed coronary artery bypass grafting times four with LIMA to left anterior descending, saphenous vein graft to OM1 and diagonal, and saphenous vein graft to posterior descending artery, and also the patient had a mechanical MVR. Postoperatively the patient did well. His chest tube was discontinued without any problem, and the patient was transferred to the floor on postoperative day #3 without any incident. Pacing wires were discontinued without incident. CONDITION ON DISCHARGE: Stable. No drainage. Chest was clear. Regular, rate and rhythm. Incision was clean, dry and intact. No drainage and no pus. Sternum was stable. DISCHARGE MEDICATIONS: Lipitor 10 mg p.o. q.d., Aspirin 81 mg p.o. q.d., Lopressor 12.5 mg p.o. b.i.d., Percocet 5 p.o. [**2-14**] q.4-6h. p.r.n., Coumadin 5 mg p.o. q.d., Ranitidine 150 mg q.h.s. FOLLOW-UP: The patient was arranged to follow-up with Dr. [**Last Name (STitle) 1537**] in [**4-16**] weeks, and also to follow-up with Dr. [**Last Name (STitle) **], his primary cardiologist, for Coumadin dosing for the mechanical valve. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2102-11-14**] 09:10 T: [**2102-11-14**] 08:58 JOB#: [**Job Number 36716**]

Admission Date: [**2189-1-17**] Discharge Date: [**2189-1-25**] Date of Birth: [**2138-6-15**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2189-1-19**] Coronary artery bypass graft x4 -- left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal 1, and obtuse marginal 2 History of Present Illness: Mr. [**Known lastname **] is a 50 year old man who had four days of chest and left arm pain and was admitted to [**Hospital6 3105**] after a subsequent cardiac catheterization revealed multi-vessel coronary artery disease. He was transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: Hypertension Diabetes Mellitus Depression Anxiety Benign prostatic hypertrophy Skin lesion removal of right infraorbital area s/p TURP Social History: Race:hispanic Last Dental Exam:> 1 year Lives with:wife Contact: [**Name (NI) **] [**Last Name (NamePattern1) 91012**] Phone #([**Telephone/Fax (1) 92458**] Occupation:disability due to depression Cigarettes: Smoked no [x] yes [] last cigarette [**2172**] Hx: 1.5ppd times 25 years ETOH: < 1 drink/week [x] [**2-3**] drinks/week [] >8 drinks/week [] Illicit drug use - no Family History: No Premature coronary artery disease Physical Exam: Pulse:50 Resp:16 O2 sat:100%RA B/P L:147/81 Height:5"3 Weight:151 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade I/VI diastolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: CT [**2189-1-18**]: No intrathoracic, intra-abdominal, or intrapelvic pathology identified. . Echo: [**2189-1-19**]: 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. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. 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. No mitral regurgitation is seen. There is no pericardial effusion. Dr.[**First Name (STitle) **] was notified in person of the results before surgical incision. Postbypass: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. No new valvular findings. Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred from outside hospital after cardiac cath revealed severe coronary artery disease. Upon admission he was medically managed and underwent pre-operative work-up. On [**1-20**] he was brought to the operating room where he underwent a coronary arterty bypass graft x 4. Please see operative note for details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. His awoke from sedation hemodynamically stable and was weaned from the ventilator and extubated. He was started on betablockers, lasix, ASA and statin therapy. CT and temporary pacing wires were removed per protocol. He was evaluated by physical tehrpay for strnegth and conditioning. On 3 separate occasions when he was walking on the stairs he became hypotensive w/ SBP 70's-80's and diaphoretic. His medications were adjusted and he was given 2 UPRBC for post-op anemia( HCT 22) with stabilization of his hemodynamics. An ECHO was done without evidence of pericardial effusion. CXR revealed a moderate left effusion which has responded to diuresis. On POD# 6 he was cleared for dischrge to home and all follow up instructions and appointments were advised. Medications on Admission: lisinopril 20mg daily, lantus 50 units at bedtime, aspirin 81mg daily, remeron 45mg daily, zocor 80mg daily, relafen 750mg [**Hospital1 **] PRN, colace 100mg [**Hospital1 **], metformin 1000mg [**Hospital1 **] Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*1* 9. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Disp:*10 Tablet Extended Release(s)* Refills:*1* 10. glargine take only 10 units of lantus at bedtime and check you fingerstick before meals and at bedtime Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Hypertension Diabetes Mellitus Depression Anxiety Benign prostatic hypertrophy Skin lesion removal of right infraorbital area s/p TURP Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema- none 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**] **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. [**First Name (STitle) **] on [**2189-3-3**] at 1:00pm in the [**Hospital **] medical office building, [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 66588**] on [**2189-2-25**] at 10:45am Wound check: [**Hospital Unit Name **], [**Hospital Unit Name **] on [**2189-1-29**] at 11:00am Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] in [**4-2**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2189-1-25**]

Admission Date: [**2158-3-31**] Discharge Date: [**2158-4-19**] Date of Birth: [**2086-2-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Location (un) 1279**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PEG placement Thoracentesis Chest Tube History of Present Illness: The patient is a 72 year old male with a history of MI, s/p CABG [**1-14**] followed by 5 week ICU stay notable for CHF, pericardial effusion drainage transferred from [**Hospital **] [**Hospital **] Hospital with shortness of breath and hypoxia. Since d/c from [**Hospital1 18**] to [**Hospital1 **] on [**2158-2-21**], pt per family has had little imporvement in overall condition. He is cachectic, very limited in activity [**3-15**] fatigue, and has suffered several setbacks in his recovery including pna and CDiff colitis. His respiratory status has been stable until 10 days PTA when he gradually became more SOB, orthopneic, and had PND. He had 1 day per report by family, of CP but doctors told [**Name5 (PTitle) **] there was no evidence of MI. Over past several days patient became more tachypneic and short of breath. CXR showed increased bilateral effusions. He did not diurese and became acutely worse on day of admission. He was transferred to [**Hospital1 18**] where in the ED he was urgently intubated for hypoxia and decreased responsiveness. Past Medical History: CAD, s/p MI [**2143**], angioplasties in '[**43**], '[**45**], '[**46**], '[**47**], CABG [**2158-1-11**] CHF, chronic afib mild CRI HTN DM 2 peripheral neuropathy prostate cancer s/p XRT '[**42**] skin cancer, s/p multiple excisions anxiety, depression restless leg syndrome gout ingiunal hernia repair s/p cardiac arrest [**2152**] (hyperkalemia) Social History: Lives in [**Hospital1 392**] with wife, retired, drives himself, quit smoking more than 40 years ago (<20PPY hx), no ETOH Family History: Mother died of "CAD" in [**2137**] Physical Exam: Tc=100 P=84 BP=140/98 RR=18 97% on 2 liters Gen - Flattened affect, mumbles to himself, does not answer questions appropriately, waxes and wanes (at most, alert and oriented x 2) Heart - Irregularly irregular, no M/R/G Lungs - CTAB Chest - Small hematoma (stable) on right upper aspect of chest wall Abdomen - PEG tube in place, active bowel sounds, NT, ND Ext - Left medial knee with stable, hard hematoma, no C/C/E, with SCD bilaterally and +1 pulses bilaterally Pertinent Results: [**2158-4-9**] 06:00AM BLOOD WBC-13.1* RBC-3.46* Hgb-11.0* Hct-33.4* MCV-97 MCH-31.9 MCHC-33.1 RDW-15.3 Plt Ct-188 [**2158-4-8**] 06:45AM BLOOD WBC-12.6* RBC-3.50* Hgb-11.3* Hct-34.6* MCV-99* MCH-32.2* MCHC-32.7 RDW-15.1 Plt Ct-187 [**2158-4-7**] 07:05AM BLOOD WBC-12.3* RBC-3.37* Hgb-10.6* Hct-32.5* MCV-97 MCH-31.6 MCHC-32.7 RDW-15.5 Plt Ct-195 [**2158-4-6**] 04:49AM BLOOD WBC-10.5 RBC-3.50* Hgb-11.0* Hct-34.5* MCV-99* MCH-31.5 MCHC-32.0 RDW-15.7* Plt Ct-199 [**2158-4-5**] 03:58PM BLOOD WBC-10.5 RBC-2.99* Hgb-9.6* Hct-30.1* MCV-101* MCH-32.0 MCHC-31.8 RDW-15.1 Plt Ct-233 [**2158-4-5**] 02:39PM BLOOD WBC-9.0 RBC-2.74* Hgb-8.8* Hct-28.3* MCV-103* MCH-32.2* MCHC-31.1 RDW-14.9 Plt Ct-207 [**2158-4-4**] 05:56AM BLOOD WBC-10.7 RBC-3.13* Hgb-9.9* Hct-30.8* MCV-99* MCH-31.7 MCHC-32.2 RDW-15.5 Plt Ct-229 [**2158-4-1**] 02:22AM BLOOD WBC-13.9* RBC-3.06* Hgb-10.3* Hct-29.5* MCV-96 MCH-33.5* MCHC-34.8 RDW-15.9* Plt Ct-375 [**2158-3-31**] 01:15PM BLOOD WBC-13.4* RBC-3.85* Hgb-12.4* Hct-38.4* MCV-100* MCH-32.1* MCHC-32.2 RDW-15.5 Plt Ct-443*# [**2158-4-9**] 06:00AM BLOOD PT-16.8* PTT-38.2* INR(PT)-1.8 [**2158-4-9**] 06:00AM BLOOD Glucose-154* UreaN-57* Creat-1.1 Na-147* K-2.5* Cl-112* HCO3-26 AnGap-12 [**2158-4-9**] 05:20PM BLOOD K-3.9 [**2158-4-8**] 06:45AM BLOOD Glucose-149* UreaN-49* Creat-1.2 Na-148* K-2.9* Cl-114* HCO3-25 AnGap-12 [**2158-4-7**] 07:05AM BLOOD Glucose-138* UreaN-42* Creat-1.2 Na-146* K-2.8* Cl-112* HCO3-25 AnGap-12 [**2158-4-6**] 04:49AM BLOOD Glucose-117* UreaN-35* Creat-1.2 Na-148* K-3.1* Cl-111* HCO3-29 AnGap-11 [**2158-4-5**] 08:32PM BLOOD Glucose-144* UreaN-33* Creat-1.2 Na-145 K-3.5 HCO3-27 [**2158-4-5**] 03:58PM BLOOD Glucose-114* UreaN-32* Creat-1.2 Na-145 K-3.3 Cl-113* HCO3-26 AnGap-9 [**2158-4-5**] 02:39PM BLOOD Glucose-525* UreaN-29* Creat-1.1 Na-132* K-3.2* Cl-102 HCO3-24 AnGap-9 [**2158-4-5**] 05:44AM BLOOD Glucose-132* UreaN-31* Creat-1.2 Na-149* K-2.7* Cl-114* HCO3-28 AnGap-10 [**2158-4-4**] 05:56AM BLOOD Glucose-72 UreaN-32* Creat-1.3* Na-149* K-3.0* Cl-113* HCO3-28 AnGap-11 [**2158-4-3**] 04:36AM BLOOD Glucose-87 UreaN-35* Creat-1.3* Na-144 K-3.2* Cl-104 HCO3-34* AnGap-9 [**2158-3-31**] 01:15PM BLOOD Glucose-168* UreaN-38* Creat-1.0 Na-149* K-5.0 Cl-103 HCO3-44* AnGap-7* [**2158-3-31**] 01:15PM BLOOD ALT-68* AST-58* LD(LDH)-320* AlkPhos-158* Amylase-73 TotBili-0.6 [**2158-4-2**] 04:11AM BLOOD CK-MB-NotDone cTropnT-0.21* [**2158-3-31**] 07:59PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2158-3-31**] 01:15PM BLOOD cTropnT-0.07* [**2158-4-9**] 06:00AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.5* [**2158-4-1**] 02:22AM BLOOD %HbA1c-4.4 TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal septum, distal anterior wall and apex. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There is a large left pleural effusion. COMPARISON: [**2158-1-24**]. TECHNIQUE: Noncontrast head CT. HEAD CT W/O IV CONTRAST: There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. Differentiation of [**Doctor Last Name 352**] and white matter is preserved. There are white matter chronic infarctions and basal ganglia lacunes. There is prominence of the sulci and ventricles, consistent with atrophy. Otherwise, paranasal sinuses and mastoid air cells are clear. The surrounding osseous and soft tissue structures are within normal limits. IMPRESSION: No intracranial hemorrhage or mass effect. Chronic microvascular and lacunar infarction. COMPARISON: Comparison is made to [**2158-4-8**]. TECHNIQUE: Noncontrast head CT. FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally midline structures, major vascular territorial infarcts. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There are chronic periventricular hypodensities consistent with chronic ischemic changes. There is a round hypodense area in the left frontal lobe that is unchanged compared to the prior study and most likely represents an old lacune. The paranasal sinuses are normally aerated. IMPRESSION: Stable appearance of the brain. No evidence of acute intracranial hemorrhage. Brief Hospital Course: 1. CHF-etiology likely inadequate afterload reduction (no ACE inhibitor and low dose lasix.) Possible EF significantly lower than pre-CABG LV gram indicated. He diuresed well with nesiritide gtt accompanied by boluses of Lasix (responded to lasix 100 mg IV). He was able to be extubated on [**4-4**] after considerable diuresis. He also had a thoracentesis (pleural fluid c/w transudate), which was complicated by a pneumothorax on the right. Thoracic surgery placed a chest tube, which was able to be discontinued 2 days later (ptx resolved). His medical management was optimized. His ACE inhibitor was titrated up along with his metoprolol to 100 mg TID, and he still had relatively poor bp control, in the 130s to 150s. Aldactone was added. He was placed on standing lasix 80 [**Hospital1 **] which was decreased to once a day, as well as ASA and a statin. 2. Hypoxemia-likely all due to CHF but question of infiltrate on initial CXR. His sputum grew GNR but culture negative. He was originally placed on vanc/zosyn, but was changed to levaquin for total 7 day course. He remained afebrile. His oxygen saturation improved greatly with diuresis. 3. Afib-labled chronic. His coumadin was originally held, and he was placed on a heparin gtt. This was discontinued when he had the chest tube placed. His coumadin was restarted when the tube was pulled, and he was not bridged with heparin given the risk of bleeding. His INR was supratherapeutic upon discharge and his INR should be checked by his visiting nurse the day after discharge. 4. Metabolic Alkalosis-likely contraction from diuresis. Improved with diamox, although not resolved. Question if pt has hyperaldo - hypernatremia, hypokalemia, and difficult to treat hypertension. However, he would need to have all his diuretics stop to appropriately diagnose this, and that isn't feasible at this time. 5. Psych: He was intermittently confused and agitated throughout his course. He was originally kept on his outpatient regimen of seroquel 25 qhs and zyprexa 2.5 tid. He was evaluated by psychiatry who recommended a delirium workup. His head CT was neg, as was his TSH. Psychiatry recommended discontinuing the zyprexa and seroquel and instead recommended standing haldol TID and [**Hospital1 **] prn for agitation. At times, the patient exhibited extreme behavior by verbally attacking his nurses and physicians. 6. Gout: He developed an erythematous, painful R MTP joint, which was treated wiht prednisone 30 mg po qd x 2 d. Because of his altered mental status, which became acutely worse the same day the steroids were started, he only had 2 days of prednisone. His toe pain resolved, and the steroids were discontinued (?steroid psychosis). 7. Hematuria-Foley catheter was placed last admission in [**1-14**]. This was placed by urology with cystoscopy and ureteral dilation secondary to anatomical difficulty from BPH. Foley was removed this admission as it had been in place for three months. Due to urinary incontinence and skin breakdown from fungal infection the catheter was replaced by urology. It should be removed once skin condition improves. 8. Clostridium Difficile Colitis: Patient had been started on oral vancomycin for clostridium difficile colitis diagnosed at [**Hospital1 **] Rehabilitation Center. (Presumably he was started on vancomycin since had previously been treated [**Date range (1) 40058**] for C difficile colitis with Flagyl and this was assumed to be a relapse.) He completed his course on [**2158-4-7**], however, continued to have diarrhea with positive C diff toxin. Therefore, the vancomycin was restarted on [**2158-4-12**] with plan for 10 days to complete [**2158-4-21**]. Flagyl was added for a ten day course ([**2158-4-15**] to [**2158-4-25**]). 9. Placement: Many discussions with the family were made. The patient's wife felt that he had suffered emotionally and physically in a rehab hospital where he recently stayed and refused to place him in another rehab hospital. Instead, she felt that the patient was nearing the end of his life and preferred him to be home for his quality of life and happiness. All those actively involved in Mr. [**Known lastname 40059**] care, including nurses, doctors, and case managers, advised his wife that caring for Mr. [**Known lastname 2523**] required a high degree of nursing care and were strongly against sending the patient home as he appeared medically unfit. However, Mrs. [**Known lastname 2523**] insisted on taking him home. As a result, case management was involved in setting up home VNA and maximal medical services available. In addition, the wife met on several occasions with the nursing staff to care for her husband under nursing supervision and guidance 5-6 days before discharge. As the patient is at risk for aspiration and thus must remain strictly NPO, his wife was also provided teaching regarding tube feeding through his PEG. 10. On the day of discharge, the patient was found to have a urinary tract infection (he has a chronic foley in place). Thus, he was given Levaquin for 10 days for a complicated UTI. Medications on Admission: amlodipine 10 mg vitamin C Buproprion 100 mg cholestyramine 4 mg [**Hospital1 **] digoxin 0.125 mg folate lasix 20 mg daily labetalol 200 mg [**Hospital1 **] lansoprazole 30 mg SR mg oxide 400 mg [**Hospital1 **] megace 400 mg qd neutraphos 1 pkt tid nystatin S&S qid seroquel 25 mg qhs KCl 60 meq qd aldactone 25 mg [**Hospital1 **] thiamine warfarin 2 mg po qd vancomycin 125 mg po q6h through [**2158-4-7**] Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*3* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*3* 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*3* 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*3* 6. Enteral feeding pump Enteral feeding pump with supplies 7. Nutrition Promode with fiber at 70 cc continuous feeds 7 cans/day, 9 cases/month 8. Suction Suction machine with yankeur tip 9. saline Saline bullets 1 box 10. Bed [**Hospital 485**] hospital bed 11. Mattress Alternate pressure mattress 12. Wheelchair Wheelchair with removable legs 13. Commode 3 in 1 commode 14. [**First Name4 (NamePattern1) 4886**] [**Last Name (NamePattern1) 4886**] 15. oxygen O2 at 2 liters continuous 16. Lancets Regular Misc Sig: One (1) Miscell. four times a day. Disp:*180 180* Refills:*3* 17. Insulin Test strips #180 3 refills 18. insulin Insulin syringe 100 unit # [**Unit Number **] 3 refills 19. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 20. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 21. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*90 Packet(s)* Refills:*2* 22. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*3* 23. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*3 3* Refills:*2* 24. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*3 3* Refills:*3* 25. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 26. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*3* 27. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 28. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*3* 29. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 30. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*4 4* Refills:*3* 31. Outpatient Physical Therapy INR check on [**2158-4-20**]. Please have results faxed to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and have coumadin adjusted accordingly. 32. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 33. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 34. Vancomycin HCl 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 4 days. Disp:*16 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Congestive heart failure Atrial fibrillation Discharge Condition: fair Discharge Instructions: Please continue your current medications and tube feedings. Please take nothing by mouth as Mr. [**Known lastname 2523**] is at risk for aspiration. Please return to the hospital or call your doctor if you experience shortness of breath or chest pain or if there are any concerns at all Followup Instructions: Please make an appointment in the next 2 weeks with: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] T [**Telephone/Fax (1) 4475**]. Please make an appointment in the next 2 weeks with Congestive Heart Failure Clinic at [**Telephone/Fax (1) 3512**]

Admission Date: [**2190-4-27**] Discharge Date: [**2190-5-1**] Date of Birth: [**2161-4-27**] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 613**] Chief Complaint: Altered mental status, fever and myalgias Major Surgical or Invasive Procedure: None History of Present Illness: 29 year old man with no significant past medical history who presents with altered mental status, fever and myalgias after recent trip to [**University/College **]. As part of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Business School trip, [**Known firstname 35861**] and approximately 150 classmates went to [**University/College **] from [**4-17**] to [**4-25**]. Prior to leaving he went to Travel Clinic and received vaccination for yellow fever and a few others which he cannot recall. He received all the immunizations that were recommended to him. While there he stayed at hotels and drank bottled water for most of the trip. He does report that he used ice and drank some tap water on the last day of his trip. He reports that he and other travelers had bug bites, but does not recall any ticks or other animal exposures. He [**Last Name (un) **] 2 days worth of malaria prophylaxis while there, but self d/ced the medication [**Last Name (un) **] being told the area he was in was low risk. Overall he reports having no symptoms other than exhaustion and a ? of heat rash throughout his stay in [**University/College **]. The day after returning home, he noted that his muscles felt very sore as if he had been working out. He attended class but was feeling ill and therefore went to UHS at the recommendation of a friend. The physician there sent labs and [**Known firstname 35861**] returned home. He reports not sleeping well overnight and waking up on Tuesday morning with confusion. His muscle pain was gone, but he was "incoherent". He called the UHS physician which he said took him 6-7 minutes as he was disoriented and found it difficult to dial the numbers. Per report, the UHS physician was very concerned about how he sounded and called EMS. At [**Hospital1 **], Temp was 101, and per records he was found to be disoriented with expressive aphasia. CT and MRI/MRA were normal, UTox negative, Blood smear negative for malaria or babesia. LP performed with 6 WBC, 5 RBC, glucose 68, protein 48. He was started empirically on ceftriaxone, vancomycin, acyclovir, and dexamethasone. Transferred to [**Hospital1 18**] for further workup. He was initially on the [**Hospital Ward Name **] Hospital Medicine Service but was promptly transferred to ICU due to deteriorating mental status. ID was consulted. As he had no signs of bacterial meningitis, his antibiotic regimen was tailored to acyclovir (for possible HSV) and doxycycline (for tick-borne pathogens). He was transferred to the Hospital Medicine service on the [**Hospital Ward Name **], where he reported feeling better and felt his mental status was improved to 80-90% of baseline. His muscle pain completely resolved. He has a lingering headache but no other current symptoms. ROS: Denies current fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Otherwise negative. Past Medical History: Eczema Wisdom tooth extraction Social History: He is a first year HBS student. He lives with his fiance in [**Hospital1 8**]. He is sexually active only with his fiance, does not use condoms and had a negative HIV test 6 years ago when he first started dating her. He does not regularly smoke, but he smokes [**1-29**] cigars per year. He drinks 1 alcoholic beverage per night; typically has 1 glass of wine nightly with dinner. He was raised as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist and did not have any immunizations until age 20 when he fell and was told to get a tetanus shot. At that point in time he decided to get all of his immunizations and believes he is up to date. He has traveled all througout Europe, studied in New [**Country 6679**] and [**Country 26467**], and went to [**Country 12603**] and [**Country 12602**] for work in [**2184-4-27**]. He went to Travel Clinic before his trip to [**Female First Name (un) 8489**] and received all immunizations recommended at that time. Family History: Father has skin cancer, grandmother with dementia, and grandfather with multiple MIs. Physical Exam: On Presentation: T: 99.9 P: 92 R: 16 BP: 144/90, O2Sat 100% 2L, 97% RA General: somnolent but arousable, diaphoretic, agitated with any disturbance, non-verbal in NAD HEENT: NCAT, PERRL on limited exam due to non-cooperative, OP clear without exudates/lesions on limited exam Neck: no LAD/JVD Lungs: CTA B Heart: RRR, no m/r/g Abdom: +BS, NT, ND, soft Extrem: no edema, all joints without effusion or erythema GU: Normal male genitalia, no discharge, Foley in. External inspection of anus with small piece of toilet paper at anal verge, otherwise no discharge or erythema Neuro: ocassional moans with nonsensical [**1-29**] word eruptions, does not follow commands but eyes tracking examiner movement. No CN abnorm, but exam limited by not cooperation. Strength 5/5 both distal/proximal muscles all extrem but again limited as not following commands. DTR 3+ B patella and bicep, no clonus. Skin: no rash . On Transfer to floor: PHYSICAL EXAM: GENERAL: in NAD, comfortable, lying in bed, appears stated age HEENT: normocephalic, atraumatic, PERRL, EOMI, no lymphadenopathy appreciated CARDIAC: RRR, nl S1/S2, no murmurs, rubs or gallops appreciated, no carotid bruits LUNG: CTAB, no crackles or wheezing ABDOMEN: +BS, nontender to palpation, nondistended EXT: warm to palpation, pulses palpable bilaterally, no edema or erythema. NEURO: alert and oriented x 3; good fund of knowledge. Able to name high and low frequency objects. Good attention - able to recite days of the week backwards. CN intact, full strength in UE and LE. DTRs 2+ in patellas bilaterally. Downgoing toes. Difficulty only with using proximal muscles to sit up. DERM: No rash appreciated Pertinent Results: - WBC-6.1 RBC-4.14* Hgb-13.1* Hct-38.2* MCV-92 MCH-31.6 MCHC-34.2 RDW-13.2 Plt Ct-186 - Glucose-116* UreaN-18 Creat-1.3* Na-144 K-3.6 Cl-106 HCO3-27 AnGap-15 - HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE - [**Doctor First Name **]-NEGATIVE - HIV Ab-NEGATIVE - HCV Ab-NEGATIVE - DENGUE-PND - LP from OSH: negative culture, HSV 1&2 negative Brief Hospital Course: 29 yo man with no past medical history presented with altered mental status after a trip to [**University/College **], with concern for encephalitis. Infectious work up thus far has been negative and patient clinically improved back to baseline mental status. He was discharged in stable condition with new PCP and infectious disease follow up. MICU course: The patient was sent from [**Hospital3 2568**] to the ED at [**Hospital1 18**]. Given his altered mental status he was admitted to the MICU for further monitoring. Upon arrival he was placed on vancomycin, ampicillin, ceftriaxone, acyclovir, and doxycylcine. LP had been performed at [**Hospital3 2568**] and CSF culture was preliminarily negative. Infectious disease and neurology was consulted. MRI was performed and was negative for acute pathology. Clinically he was not oriented to person, place, or time, and was very inattentive and mumbled his words. He was hemodynamically stable. The chief concern was for viral encephalitis. Multiple serologies and PCR were sent. However, within 24hrs his mental status cleared markedly. Repeat LP and MRI were deferred. He was subsequently tranferred to the medical floor. # Viral Encephalitis: As noted, LP results did not suggest a bacterial meningitis and he was changed to only IV acyclovir and IV doxycycline. His mental status rapidly improved and he was transferred to the floor. A number of tests were ordered including [**Doctor First Name **], Hepatitis A/B/C, HIV, RPR, measles, mumps, and rubella; all negative. His CSF from [**Hospital3 **] had a gram stain with no PMNs and no organisms seen. His CSF culture has no growth to date. CSF cryptococcal antigen was negative and HSV PCR was undetectable. Pending tests include CSF VZV, Dengue, West [**Doctor First Name **], EEE, EBV, HHV6, CMV, and Enterovirus. # Acute Renal Failure: On hospital day 3, creatinine was elevated from 1.0 to 1.3. There was associated increase in BUN from 7 to 13 and hyperphosphatemia. He had not been taking adequate PO fluids and his IV infiltrated, so it was assumed to be prerenal secondary to volume depletion. CPK was checked to rule out rhabdomyolysis and was normal. Repeat creatinine was 1.4 then 1.3. Medications on Admission: Topical cream for eczema Sudafed PRN Zyrtec for seasonal allergies Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 11 days: Be sure complete medication regimen. Disp:*22 Capsule(s)* Refills:*0* 3. Outpatient Lab Work Please draw blood for creatinine and BUN and send results to primary care physician. Discharge Disposition: Home Discharge Diagnosis: Primary: Encephalitis of undetermined etiology mild prerenal acute renal failure attributed to hypovolemia Discharge Condition: Stable, tolerating PO, O2 sat >95%, ambulating, mental status improved and close to baseline. Discharge Instructions: It was a pleasure taking care of you at the [**Hospital1 18**]. You were transferred here from [**Hospital6 **] with altered mental status and fever. You underwent multiple imaging tests including MRI/MRA, CT, and chest Xray all of which were normal. There was no evidence of seizures. You had a lumbar puncture which showed signs of inflammation likely due to a viral infection. Laboratory tests were sent on your cerebrospinal fluid as well as blood; none of the returned tests have identified the organism causing the infection. Please avoid ibuprofen and continue to take your antibiotic, doxycycline, two times per day for two weeks. It is critically important that you complete this regimen. Return to the hospital if you notice fevers, chills, confusion, stiff neck, nausea, vomiting, rash, or any other concerning symptoms. Followup Instructions: Please follow-up at Infectious Disease Clinic. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-6-4**] 9:30 Please follow-up with your new primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-6-16**] 8:30 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2157-10-16**] Discharge Date: [**2157-10-19**] Date of Birth: [**2093-9-28**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old female tobacco user and other cardiac risk factors who presented with chest pain, nausea, vomiting and diaphoresis. The patient was in her usual state of health until the day prior to admission when at 4:00 p.m. that day she noted 10 out of 10 stabbing nonradiating mid back infrascapular pain lasting several minutes some relieved with raising arms. This pain was not associated iwth shortness of breath, nausea, vomiting or diaphoresis. The pain recurred several times for the next several hours with exertion. The pain became constant around 11:00 p.m. The evening of admission the patient took some Maalox without relief. She had sudden associated nausea, vomiting, diaphoresis and then developed radiation of pain down into her arms. The patient went to an outside hospital. Vital signs at the outside hospital showed a heart rate of 52, blood pressure 101/55, respiratory rate 20. The patient was found to have ST elevations in 2, 3 and F with depression in V1 through V3. The patient received morphine, oxygen, aspirin and was started on heparin, Integrilin and nitro drip. She was transferred to [**Hospital1 1444**] for catheterization. There was a report of transient hypotension during transport. In the catheterization laboratory the patient was found to have a 99% proximal right coronary artery lesion that was stented times two with TIMI three residual flow. The left main coronary artery had 30% lesion, left anterior descending coronary artery had minimal disease and the left circumflex was normal. Hemodynamics showed wedge of 11, right ventricular pressure of 35, PA pressure of 26/13 and a cardiac index of 2.9. Her catheterization course was complicated by the transient bradycardia to the 30s and hypotension to the systolic blood pressure in the 60s without symptoms. Pacing wires were placed though not used due to the transient nature of the bradycardia. The patient was then started on a Dopamine drip in the cardiac catheterization laboratory, which was weaned by the time she arrived in the coronary care unit, given fluids and presented to the Coronary Care Unit chest pain free. PAST MEDICAL HISTORY: Total abdominal hysterectomy secondary to uterine cancer, status post appendectomy. MEDICATIONS ON ADMISSION: None. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient has a fifteen to twenty pack year tobacco history. No alcohol. No intravenous drug use. The patient works as a nurses aid. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: Vital signs on arrival in the Coronary Care Unit, pulse 93, blood pressure 125/49, respiratory rate 14, sating 96% on 2 liters. The patient was generally alert and oriented times three. Neck showed jugulovenous pressure at 9 cm at a 30 degree angle. No carotid bruits were appreciated. Chest was clear to auscultation anteriorly and laterally. Cardiovascular examination revealed normal S1 and S2. Regular rate. No murmurs. Abdomen was benign. Extremities she had a right groin sheath with no ooze or frank bleeding and palpable dorsalis pedis and posterior tibial pulses bilaterally. LABORATORY: Significant for a hematocrit of 30.6, platelets 288, INR 1.5, PTT of greater then 150. The patient's first set of cardiac enzymes revealed a CK of 224, MB 65, MB index of 8.5 and a troponin of 14.5. ECG showed sinus rhythm at [**Street Address(2) 44088**] elevations in 2, 3 and F, depressions in 1, L and V1 through V3. Post catheterization ECG showed sinus tachycardia at 100 with low voltage. No alternans with complete resolution of ST changes. Catheterization report is discussed fully in the history of present illness. HOSPITAL COURSE: In short, this is a 54 year-old woman with acute inferior myocardial infarction admitted to the Coronary Care Unit status post stent times two to the right coronary artery with resolution of chest pain and ST changes. Course was complicated by transient bradycardia and hypotension neither of which was a continuing issue after the patient reached the Coronary Care Unit. 1. Coronary artery disease: The patient was on aspirin, Plavix, Integrilin at the time of her admission to the Coronary Care Unit. She was continued on aspirin for life, Plavix for the next thirty days. Integrilin was stopped after the first twelve hours. The patient was pain free. Her CKs were cycled. Her maximum CK peaked at 500 and her troponin at greater then 50. The patient remained pain free throughout the course of her stay. The patient's lipid panel was sent showing her lipids to be within normal limits, however, she was started on low dose statin. Pump wise, the patient had an echocardiogram following catheterization given the low voltage on her electrocardiogram in the setting of pacer placement. There was some concern about pericardial effusion possibly perforation of the right ventricle, though the patient had no signs or symptoms consistent with this. Echocardiogram showed no pericardial effusion and a left ventricular was preserved. Ejection fraction greater then 55% with no focal wall abnormalities. The patient was initial continued on aggressive fluid to maintain her preload in the setting of an inferior myocardial infarction and had no further episodes of hypotension during the course of her stay. The patient was started on an ace inhibitor and a beta blocker. The patient normally has blood pressures in the range of 90s to low 100s systolic and had difficulty tolerating low dose Captopril without dropping her pressure into the low 80s. Thus she was continued on low dose Captopril only as tolerated, but tolerated her beta blocker well. Rhythm wise, the patient had multiple runs of nonsustained ventricular tachycardia post procedure, the longest one being around 20 beats. Because of this the patient was started on Lidocaine and remained on Lidocaine for the first 24 hours of her stay without further episodes of nonsustained ventricular tachycardia. The patient was transferred to the floor on [**2157-10-18**] and discharged home on [**2157-10-19**]. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and with Dr. [**First Name (STitle) **] of the Cardiology Department. The patient is discharged in good health. FINAL DIAGNOSIS: Acute myocardial infarction. DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Plavix 75 mg po q day times twenty seven days, Lipitor 10 mg po q day, lisinopril 2.5 mg po once a day, Metoprolol 12.5 mg po b.i.d. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-953 Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2157-10-19**] 13:22 T: [**2157-10-26**] 07:18 JOB#: [**Job Number 44089**]

Admission Date: [**2175-6-25**] Discharge Date: [**2175-7-5**] Date of Birth: [**2175-6-25**] Sex: M Service: NB ID: Baby [**Name (NI) **] ([**Known lastname **]) [**Known lastname 63970**] is a 10 day old former 30 [**5-2**] wk premature infant being transferred from [**Hospital1 18**] NICU to [**Hospital **] Hospital special care nursery. HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 63970**] is the former 1.52 kg product of a 30 and [**5-2**] week gestation born to a 36 year- old, G3, P0 woman. Prenatal screens included blood type 0 positive, antibody negative, Rubella immune, hepatitis B surface antigen negative, RPR nonreactive, group beta strep status unknown, and cystic fibrosis screen negative. Pregnancy was achieved with in-[**Last Name (un) 5153**] fertilization assistance. The mother's history is notable for uterine fibroids with two previous myomectomies. This pregnancy was complicated by cervical shortening at 17 weeks, treated with a cerclage placement amd bed rest. She received betamethasone at 26 weeks gestation. The mother presented early on the day of delivery with spontaneous rupture of membranes. She was admitted to the [**Hospital1 346**] in labor; trial of tocolysis was considered but decided against, and infant was eventually delivered by c-section. Apgars were 9 at 1 minute and 9 at 5 minutes. The infant was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight was 1.52 kg, length was 40.5 cm, head circumference 29 cm, all 50th percentile for gestational age. General: Non dysmorphic preterm male in mild respiratory distress. HEENT: Anterior fontanel soft and flat. Sutures mobile. Palate intact. Positive red reflex bilaterally. Pupils are equal, round, and reactive to light and accommodation. Chest: Good air movement. Breath sounds clear. Intermittent apnea. Cardiovascular: Normal S1 and S2, no murmur. Perfusion fair. Some acrocyanosis. Pulses good upper and lower extremities. Abdomen soft with normal bowel sounds, three vessel cord. Testes down on the left, undescended on the right. Musculoskeletal: Hips stable. Spine intact. Neurologic: Good tone, active, symmetrical examination. HOSPITAL COURSE: By systems:0 1. Respiratory: [**Known lastname **] was placed on continuous positive airway pressure upon admission to the Neonatal Intensive Care Unit. He had increased work of breathing and was electively intubated and received 2 doses of Surfactant. He was extubated to continuous positive airway pressure on day of life number 1. He remained on C-Pap through day of life number 4 when he was transitioned to nasal cannula oxygen, and then transitioned to room air on day of life number 8. At the time of transfer, he continues on room air, with respiratory rate of 60 to 70 breaths per minute. He is also being treated for apnea of prematurity with caffeine. He has had rare episodes of apnea/bradycardia and desaturation during admission, last on [**7-3**]. 2. Cardiovascular: [**Known lastname **] required a normal saline bolus shortly after admission for decreased perfusion and low blood pressure. His blood pressure stabilized and he has maintained normal heart rates and blood pressures since that time. Baseline heart rate is 150 to 170 beats per minute. Recent blood pressure is 74 over 31 with a mean of 47. No murmurs have been noted. 3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially n.p.o. and maintained on intravenous fluids. Enteral feeds were started on day of life number 1 and gradually advanced to full volume. At the time of discharge, he is taking 150 cc/kg/day of breast milk or premature Enfamil fortified to 26 calories per ounce. His feedings are all by gavage. Serum electrolytes were checked several times during the first week of life and were within normal limits. Weight on the day of discharge is 1.515 kg with a corresponding length of 41.5 cm and a head circumference of 28 cm. 4. Infectious disease: [**Known lastname **] was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. A complete blood count initially had a white count of 8,800 with 5% polys, 0% bands. This was repeated on day of life number 1 and the white count had increased to 14,100 with 40% polys, 0% band neutrophils. A culture was obtained prior to starting intravenous Ampicillin and Gentamycin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. Gastrointestinal: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life number 3 with a total of 10.2 over 0.3 mg/dl direct. He was treated with phototherapy for approximately 96 hours. Phototherapy was discontinued on [**2175-6-30**] and a rebound bilirubin in 24 hours was a total of 6.3/0.3 mg/dl direct. 6. Hematologic: Hematocrit at birth was 55%. [**Known lastname **] has not received any transfusions of blood products. 7. Neurologic: Head ultrasound was obtained on [**2175-7-3**], which was normal. [**Known lastname **] has maintained a normal neurologic examination during admission and there are no neurologic concerns at the time of discharge. 8. Sensory: hearing screening has not yet been performed. Opthalmologic examination screening for retinopathy of prematurity is recommended at 4 to 5 weeks of age. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital for continuing level II care. No primary pediatrician has yet been selected. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Breast milk or preemie Enfamil 26 calorie per ounce, 150 cc/kg/day by gavage. Anticipate increase to 28. 2. Ferrous sulfate 0.15 ml p.o. once daily, 25 mg per ml dilution. 3. Car seat position screening is recommended prior to discharge. 4. State newborn screen was sent on [**2175-6-28**] with no notification of abnormal results to date. 5. No immunizations administered. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] 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 RSV season , a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or (3) with chronic lung disease. Influenza immunization is 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 house hold contacts and out of home caregivers. DISCHARGE DIAGNOSES: 1. Prematurity at 30 and 6/7 weeks gestation. 2. Respiratory distress syndrome. 3. Suspicion for sepsis, ruled out. 4. Apnea of prematurity. 5. Unconjugated hyperbilirubinemia. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2175-7-3**] 01:39:30 T: [**2175-7-3**] 05:49:23 Job#: [**Job Number 63971**]

Admission Date: [**2157-7-29**] Discharge Date: [**2157-8-1**] Date of Birth: [**2129-12-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p 30ft fall Major Surgical or Invasive Procedure: None History of Present Illness: 27 yo male s/p a ~30ft fall, no LOC, c/o back and left flank pain. Brought in by ambulance to [**Hospital1 18**]. CT imaging revealed a Grade 3 left renal laceration and a Grade 2 splenic laceration. Past Medical History: Denies Family History: Noncontributory Pertinent Results: [**2157-7-29**] 09:55PM HCT-34.0* [**2157-7-29**] 06:42PM HCT-36.7* [**2157-7-29**] 06:42PM GLUCOSE-148* UREA N-15 CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [**2157-7-29**] 06:42PM PT-12.0 PTT-23.2 INR(PT)-1.0 [**2157-7-29**] 06:42PM PT-12.0 PTT-23.2 INR(PT)-1.0 CT HEAD W/O CONTRAST Reason: bleed? [**Hospital 93**] MEDICAL CONDITION: 27 year old man s/p fall REASON FOR THIS EXAMINATION: bleed? CONTRAINDICATIONS for IV CONTRAST: None. CT HEAD WITHOUT CONTRAST. HISTORY: Status post fall. Question hemorrhage. Contiguous axial images were obtained through the brain. No contrast was administered. No prior brain imaging studies are available for comparison. FINDINGS: There is a left frontal scalp hematoma. There is no evidence of intracranial hemorrhage. No fractures are identified. There is no evidence of edema or mass effect. CONCLUSION: Left frontal scalp hematoma. Otherwise, normal study. CT C-SPINE W/O CONTRAST Reason: fracture [**Hospital 93**] MEDICAL CONDITION: 27 year old man s/p fall REASON FOR THIS EXAMINATION: fracture CONTRAINDICATIONS for IV CONTRAST: None. CT CERVICAL SPINE [**2157-7-29**] HISTORY: Status post fall. Contiguous axial images were obtained through the cervical spine. No contrast was administered. No prior spine imaging studies are available for comparison. FINDINGS: Alignment of the cervical spine is normal. No fractures are identified. There is no evidence of prevertebral soft tissue swelling. Non-contrast CT has limited sensitivity for intraspinal soft tissue abnormalities such as disc protrusion or hematoma. Within the limits of this examination, no such abnormalities are detected. However, if this is a clinical concern, an MR examination would be required. CONCLUSION: Normal study. No evidence of fracture or subluxation. Brief Hospital Course: He was admitted to the Trauma Service. He was placed on bedrest and monitored closely; serial hematocrits and physcial exams were followed closely as well. Plastic surgery was consulted for left 3rd PIP dislocation; this was closed reduced and splinted. he will follow up in [**Hospital 3595**] clinic in 1 week. His hematocrit remained stable and his diet was subsequently advanced. He began to ambulate and was discharged home with instructions for follow up. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) for 5 days. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 5 days. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: S/p fall (30ft) Grade 3 Renal Laceration Grade 2 Splenic Laceration Blood loss anemia (stable) Discharge Condition: Stable Discharge Instructions: Return to the Emergency room immediately if you develop any dizziness; feeling as if you are going to pass out; weakness; chest discomfort. No contact sports, heavy lifting greater than 20lbs x 4 weeks, may take showers, walk stairs, etc. Followup Instructions: Call the Trauma Clinic for an appointment and follow-up in 2 weeks with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 600**]. Follow up in [**Hospital 3595**] Clinic as instructed by calling [**Telephone/Fax (1) 5343**] for an appointment. Completed by:[**2157-8-3**]

Admission Date: [**2138-10-3**] Discharge Date: [**2138-10-14**] Date of Birth: [**2086-2-26**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 52-year-old gentleman with a past medical history of alcohol abuse who was diagnosed with alcoholic cirrhosis on this admission. He was admitted on [**10-3**] with eight episodes of hematochezia and melena and one episode of hematemesis on the day of admission. The patient called the Emergency Medical Service. His blood pressure was found to be 80/palp with a heart rate in the 130s. He was transferred to the Emergency Department. Hemodynamically, the patient was stabilized. In the Emergency Department, the patient's hematocrit was found to be 16.9. The patient was transfused 4 units of packed red blood cells, 4 units of fresh frozen plasma, and intravenous proton pump inhibitor. He was started on an octreotide drip and intravenous erythromycin. The patient had an nasogastric tube lavage which was positive for bright red blood. The Gastrointestinal Service was consulted for an emergent esophagogastroduodenoscopy. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Question diabetes mellitus. MEDICATIONS ON ADMISSION: 1. Multivitamin. 2. Vitamin A. 3. Vitamin B. 4. Vitamin C. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with his partner. [**Name (NI) **] drinks a 6-pack of alcohol and half a pint of gin every evening for the past several years. He quit tobacco 10 years ago. He has no history of intravenous drug use or illicit drug use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Medicine Service revealed the patient's blood pressure was 131/78, his heart rate was 70, his respiratory rate was 16, and his oxygen saturation was 96% on room air. In general, the patient was a pleasant African-American gentleman in no apparent distress. Head, eyes, ears, nose, and throat examination revealed he did have scleral icterus. The oropharynx was clear. The mucous membranes were moist. Cardiovascular examination revealed a regular rate and rhythm. Respiratory examination revealed the patient's lungs were clear to auscultation bilaterally with decreased breath sounds at the bases and crackles at the left base. The abdomen was soft, distended, and nontender. He had tympanitic bowel sounds throughout. There was no hepatosplenomegaly. Extremity examination revealed he had 1+ edema to the his knees. His pulses were 2+. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission to the Medicine Service revealed the patient's hematocrit was 30.3. His Chemistry-7 was within normal limits. His INR was 1.8. His hepatology series was positive for HBAB antibody. At this point, all cultures were negative to date. BRIEF SUMMARY OF INTENSIVE CARE UNIT COURSE: At this point, the patient was intubated for airway protection. The esophagogastroduodenoscopy showed active bleeding from the gastric varix. The patient had 2+ bleeding varus in the esophagus. The bleeding site was injected with epinephrine and morrhuate sodium to sclerose the varix; however, the bleeding did not subside. He was then treated with intravenous vasopressin and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed. The [**Last Name (un) **] tube remained in place until [**10-4**]. He had no more episodes of bleeding. The Pitressin was discontinued; however, the patient remained to be hypertensive. A sepsis workup ensued, and he was started on Levophed as his hypertension did not respond to fluid boluses. On [**10-5**], the patient had a right upper quadrant ultrasound to see if there was enough ascites to tap. Minimal fluid was tapped. At this point, the patient became febrile. An echocardiogram was done which showed that he had no vegetations, but there was possibly a left lower lobe pneumonia. Therefore, the patient was started intravenous antibiotics. On [**10-6**], the [**Last Name (un) **] tube was removed. During his Intensive Care Unit course, the patient was weaned off pressors. He was dependent on fresh frozen plasma during his hospital course due to his coagulopathy secondary to his liver disease. On the evening of [**10-7**], the patient was extubated. He tolerated this well. His vital signs were stable. His hematocrit had been stable in the 30s for over 24 hours, so the patient was called out to the Medicine floor for further treatment. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. GASTROINTESTINAL/VARICEAL BLEED ISSUES: The patient was followed by the Liver Service throughout his hospital course. His hematocrit levels had remained stable. He was maintained on twice per day Protonix. He had a repeat endoscopy on [**10-9**] which showed that he had varices or cardia at the gastroesophageal junction and at the lower one-third of the esophagus. This varix was banded successfully. He also had an ulcer in the gastroesophageal junction and cardia and blood in the body and antrum of his stomach. The patient was started on carafate 1 g four times per day. He was continued on Protonix twice per day, and he was started on nadolol and titrated up as tolerated. However, during his hospital course the nadolol had to be discontinued given that he had worsening renal function. In order to maximize renal perfusion, the nadolol was discontinued. Per the patient's computed tomography, it appeared that the patient had chronic pancreatitis. He did have significant steatorrhea during his hospital stay; however, he was asymptomatic. 2. INFECTIOUS DISEASE ISSUES: The patient had spiked a fever on [**2138-10-6**] and was continued on ceftriaxone and vancomycin in the Intensive Care Unit. As his cultures had been negative for any suspicious organisms, his vancomycin was discontinued, and he was continued on ceftriaxone during his hospital course. He had a repeat paracentesis done on [**10-11**] which showed no evidence of spontaneous bacterial peritonitis. He remained afebrile and was completing the course for his left lower lobe pneumonia. The patient had been on stress-dose steroids in the Intensive Care Unit. On [**10-10**], as it appeared that the patient had not been septic and remained afebrile, his stress-dose steroids were discontinued. 3. PULMONARY ISSUES: The patient was extubated on [**10-7**]. He had no respiratory issues during his Medicine Service stay. 4. ENDOCRINE ISSUES: For the patient's diabetes mellitus ? secondary to steroid use ? previous to his admission, he remained on fingersticks four times per day and an insulin sliding-scale as needed. 5. RENAL ISSUES: During the [**Hospital 228**] hospital course, he had acute renal failure which started on [**10-9**]. His creatinine increased to 1.1. The source of his renal failure was unclear. Initially, this was thought to be an acute tubular necrosis secondary to his hypotension while in the Intensive Care Unit; however, it persisted so it was likely secondary to hepatorenal syndrome. The patient's diuretics were discontinued. he was started on intravenous albumin infusions daily. He was continued on his octreotide in order to maximize renal perfusion. During his hospital course, upon until [**10-12**], the patient's creatinine continued to rise. Therefore, on [**10-12**], the nadolol was discontinued and he was started on Trental 400 mg by mouth three times per day and midodrine 75 mg by mouth three times per day. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient remained nothing by mouth during his hospital stay in the Intensive Care Unit. His diet was advanced on [**10-11**], and the patient tolerated this well. The Medicine Service tried to optimize his nutritional status with additional Boost supplements and Mighty shakes. 7. HEMATOLOGIC/COAGULOPATHY ISSUES: The patient was admitted with an INR of 2.6, and it appeared that he was dependent on fresh frozen plasma in order to reverse his coagulopathy; however, during his hospital course an empiric trial of vitamin K was started on [**10-9**]. 8. CONSULTATION ISSUES: The Addiction Service and Social Work were consulted, and the patient will likely continue with an outpatient detoxification treatment. DISCHARGE DIAGNOSES: 1. Alcoholic cirrhosis. 2. Ascites. 3. Alcohol abuse; continuous. 4. Acute renal failure secondary to hepatorenal syndrome. 5. Coagulopathy. 6. Esophagitis. 7. Hypoalbuminemia. 8. Esophageal varices with bleed. 9. Hypophosphatemia; repleted. 10. Hypokalemia; repleted. NOTE: The patient was to be discharged at a later date, and someone else will complete the Discharge Summary at that time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 34978**], M.D. [**MD Number(1) 24755**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2138-10-14**] 14:45 T: [**2138-10-14**] 19:26 JOB#: [**Job Number 34979**]

Admission Date: [**2161-9-7**] Discharge Date: [**2161-9-12**] Service: C-MEDICINE CHIEF COMPLAINT: Transfer from [**Hospital3 3583**] for cardiac catheterization. HISTORY OF PRESENT ILLNESS: The patient is an 81 year old male with a history of hypertension, coronary artery disease, ischemic cardiomyopathy, congestive heart failure with an ejection fraction of 20%, atrial fibrillation and chronic obstructive pulmonary disease, who was transferred from [**Hospital3 3583**], after having a non ST elevation myocardial infarction, for cardiac catheterization. He was admitted to [**Hospital3 3583**] on [**2161-9-3**], with a complaint of chest heaviness and dyspnea occurring at rest. These symptoms were accompanied by diaphoresis and nausea. Upon presentation to [**Hospital3 3583**], he was found to be in rapid atrial fibrillation with a rate of 160 beats per minute. He was converted with intravenous Diltiazem and he ruled in for non ST elevation myocardial infarction with a troponin of 3.0 and a CK peak of 177. PAST MEDICAL HISTORY: 1. Coronary artery disease, myocardial infarction times six from [**2135**] to present. 2. Hypertension. 3. Ischemic cardiomyopathy. 4. Congestive heart failure with ejection fraction of 20%. 5. Chronic atrial fibrillation. 6. Chronic obstructive pulmonary disease. 7. Hypercholesterolemia. 8. Peripheral vascular disease. 9. Gout. 10. Status post shrapnel injuries to the head in World War II. 11. Status post coronary artery bypass graft in [**2156**]. 12. Status post thyroidectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. daily. 2. Isordil 40 mg p.o. three times a day. 3. Captopril 50 mg p.o. three times a day. 4. Lasix 40 mg p.o. once daily. 5. Synthroid 25 mcg p.o. daily. 6. Zocor 40 mg p.o. daily. 7. Aldactone 25 mg p.o. daily. 8. Toprol XL 25 mg p.o. once daily. 9. Digoxin 0.125 mg p.o. q.o.d. 10. Coumadin 2.5 mg p.o. six days of the week and Coumadin 5 mg p.o. every Wednesday. 11. Ambien 10 mg p.o. q.h.s. p.r.n. SOCIAL HISTORY: He lives with his wife in a single story dwelling. He lives in [**State 108**] six months of the year. He uses a cane or walker at all times and he has a hospital bed at home. FAMILY HISTORY: Father with coronary artery disease, brother with coronary artery disease in his 50s. PHYSICAL EXAMINATION: The patient is afebrile, heart rate 81, blood pressure 142/70, respiratory rate 25, oxygen saturation 97% on five liters nasal cannula. In general, the patient is alert and oriented, slightly tachypneic. Head, eyes, ears, nose and throat - The neck is supple. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cardiovascular is irregularly irregular, no murmurs, rubs or gallops. Respiratory - Crackles bilaterally at the bases. The abdomen is soft, nontender, nondistended. Extremities - Dorsalis pedis pulses are weakly palpable bilaterally, warm extremities. Neurologically, the patient is alert and oriented. Cranial nerves II through XII are intact bilaterally. Sensation is grossly intact bilaterally. LABORATORY DATA: White blood cell count was 6.9, hematocrit 39.0, platelet count 160,000. Sodium 141, potassium 4.0, chloride 103, bicarbonate 24, blood urea nitrogen 14, creatinine 0.9, glucose 188. INR 1.4. Digoxin level less than 0.4. Electrocardiogram showed atrial fibrillation in the 70s, right bundle branch block, inferior and anterior Q waves were present. Chest x-ray showed marked cardiomegaly without definite evidence of congestive heart failure, no acute pulmonary disease. HOSPITAL COURSE: 1. Non ST elevation myocardial infarction - The patient underwent cardiac catheterization which revealed three vessel coronary artery disease, elevated left and right sided filling pressures with right ventricular end diastolic pressure of 17, left ventricular filling pressures were also elevated with pulmonary capillary wedge pressure of 31. The patient had 40 to 50% left main stenosis, left anterior descending artery was occluded at the origin. The circumflex had a 70% lesion with an occluded OM1 branch. The right coronary artery had a 90% proximal lesion. Both saphenous vein grafts to the posterior descending artery and the OM1 were widely patent. The proximal ramus branch was successfully stented. The patient was placed on Aspirin and Plavix. In addition, his Metoprolol XL was titrated up to 75 mg once daily. He was continued on his statin, his ace inhibitor and his nitrate. He will follow-up with his outpatient cardiologist in one to two weeks. 2. Congestive heart failure - The patient has an ejection fraction of 20% and elevated pulmonary capillary wedge pressure. After his cardiac catheterization, the patient developed mild pulmonary edema and increased shortness of breath. He was diuresed with additional intravenous Lasix and a negative to even fluid balance was maintained throughout the remainder of his hospital stay. He was continued on a two gram sodium diet and a fluid restriction of 1.5 liters. He was continued on his ace inhibitor and his Toprol XL as well as his Digoxin and daily 40 mg of Lasix. 3. Nonsustained ventricular tachycardia - The patient had multiple short episodes of nonsustained ventricular tachycardia after his catheterization. However, he also had one episode of 50 minutes of nonsustained hemodynamically stable ventricular tachycardia that spontaneously converted. He was evaluated by electrophysiology cardiology and was taken to the electrophysiology laboratory for ablation therapy. In addition, an ICD was placed and was programmed to attempt to overdrive pace his ventricular tachycardia multiple times before shocking as his nonsustained ventricular tachycardia is asymptomatic. On the day of discharge, the patient was started on new antiarrhythmic, Amiodarone. He will take 400 mg p.o. daily of Amiodarone for the first twenty-eight days and he will then be switched to 200 mg of Amiodarone daily. AST and ALT were ordered upon discharge and his liver function tests should be followed as an outpatient. In addition, the patient was instructed to call and schedule pulmonary function tests within one week of discharge. 4. Atrial fibrillation - The patient has had chronic atrial fibrillation. His Coumadin was held for his electrophysiology study and was restarted after his ICD was placed. He was given one dose of 5 mg q.h.s. and then was started on new daily dose of 2 mg a day. He will have his INR checked within four to five days at the [**Hospital 197**] Clinic at [**Hospital3 3583**] where this result will be called to his primary care physician. [**Name10 (NameIs) **] patient will have a follow-up appointment at the Device Clinic on [**2161-9-18**]. 5. Hypothyroidism - The patient was continued on his outpatient dose of Levoxyl throughout his admission. 6. Hypertension - The patient's blood pressure was well controlled at his increased dose of Metoprolol XL. Spironolactone, Lasix, Captopril and Isosorbide Dinitrate were continued at his admission doses. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS:: Please follow-up with primary care physician within one week. Please follow-up with cardiologist within one to two weeks. Please follow-up with the Device Clinic on [**2161-9-18**], at 11:30 a.m. Please have INR checked within four to five days of discharge at the [**Hospital 197**] Clinic and have the result called to your primary care physician. [**Name10 (NameIs) 357**] schedule outpatient pulmonary function tests within one week of discharge. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once daily. 2. Plavix 75 mg p.o. once daily. 3. Isosorbide Dinitrate 40 mg three times a day. 4. Levoxyl 25 mcg once daily. 5. Lasix 40 mg p.o. once daily. 6. Simvastatin 40 mg p.o. once daily. 7. Captopril 50 mg p.o. three times a day. 8. Spironolactone 25 mg once daily. 9. Digoxin 125 mcg every other day. 10. Metoprolol XL 75 mg p.o. once daily. 11. Coumadin 2 mg once daily. 12. Amiodarone 400 mg once daily times four weeks and then 200 mg once daily. 13. Keflex 500 mg p.o. four times a day for two days. DISCHARGE DIAGNOSES: 1. Non ST elevation myocardial infarction. 2. Nonsustained ventricular tachycardia. 3. Atrial fibrillation. 4. Coronary artery disease. 5. Hypertension. 6. Congestive heart failure. 7. Chronic obstructive pulmonary disease. 8. Ischemic cardiomyopathy. 9. Hypercholesterolemia. 10. Peripheral vascular disease. 11. Hypothyroidism. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Last Name (NamePattern1) 9609**] MEDQUIST36 D: [**2161-9-12**] 13:58 T: [**2161-9-12**] 14:39 JOB#: [**Job Number 51394**]

Admission Date: [**2186-2-7**] Discharge Date: [**2186-2-14**] Service: MICU HOSPITAL SUMMARY: The patient was initially admitted to the hospital on [**2186-2-7**] for hypothermia, hypotension, and sepsis protocol. The patient was brought to the hospital by her son because she had had a slurring of her speech which had resolved by the time she arrived at the hospital. In the hospital the patient was fluid resuscitated initially, and her blood pressure improved. However, she became hypotensive again and required intermittent pressors for blood pressure support. The patient had an echocardiogram which revealed severe pulmonary hypertension with RV dysfunction. In the setting of fluid resuscitation, she developed bilateral pleural effusions. The patient had a diagnostic and therapeutic thoracentesis on [**2186-2-8**] which was complicated by a pneumothorax requiring a right anterior chest tube. She had a bronchoscopy which showed a large amount of mucus plugs. She was diuresed under the guidance of a Swan Ganz catheter, and she underwent a trial of vasodilators with nitric oxide and Viagra for pulmonary hypertension. However, she did not respond, and she was felt not to be a candidate for ............ therapy. She was extubated on [**2186-2-10**], transferred out of the Medical Intensive Care Unit on [**2186-2-11**] in stable condition. She was on the floor until [**2186-2-13**] when she was found to be hypoxic, hypotensive, and tachycardiac. Chest x-ray was done at that time which showed left lung collapse secondary to mucus plugging. The patient initially on hospital admission was "Do Not Resuscitate"/"Do Not Intubate," but her family had reversed her code status. At the time of worsening medical deterioration on [**2186-2-13**], discussions were held with the family about her code status and whether or not they would want her to be rebronched, and the patient and the family decided on [**2186-2-14**] that they did not want any further intervention, so the patient was not bronched. The hypotension at that time responded to fluid boluses. However, on [**2186-2-14**] at 9 p.m. the patient became unresponsive, her heart rate decreased to the 40s, and she had no blood pressure. The patient had fixed and dilated pupils, no breath sounds, no pulse, no heart sounds. Time of death was 8:54 p.m. Her sons were notified. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2186-3-27**] 15:56 T: [**2186-3-29**] 21:56 JOB#: [**Job Number 53151**]

Admission Date: [**2132-4-23**] Discharge Date: [**2132-5-7**] Date of Birth: [**2057-12-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: GI bleed. MRSA bacteremia. Major Surgical or Invasive Procedure: -Esophagogastroduodenoscopy (EGD), [**2132-4-24**] -PICC line, [**2132-5-2**] History of Present Illness: Mrs. [**Known lastname 76318**] is a 74 year old woman with past medical history significant for rheumatoid arthritis (on chronic prednisone), asthma, hypertension, hyperthyroidism, presenting from rehab facilty after being found to have altered mental status and bright red blood per rectum. Per transfer notes, patient was intially taken to [**Hospital 1474**] hospital where she was evaluated for abdominal pain. Vitals on arrival 94/52, 83, 14, 98 F. Given her altered mental status, CT head was performed with preliminary read raising the question of a basal ganglia hemorrhage. Labs there revealed AST 103 / ALT 112, Ap 451, T bili 3.0 and D bili 2.1. Patient was transferred for further management of suspected intracraneal hemorrhage. In our ED, 98.2, 110/63, 85, 22 100% 4L NC. Patient underwent repeat head CT which did not reveal any acute intracraneal process. Patient was also noted to have two bowel movements with bright red blood. Labs repeated and given OSH elevation in liver enzymes and congestive pattern, CT abdomen was performed. Surgery, GI and ERCP services were [**Name (NI) 653**], and decision was made to admit patient to ICU for further management. At this time, patient denies any pain or discomfort. She is not accompanied by family and she reports feeling slightly confused. She is unable to relate why she was brought to the hospital and believes she was home earlier today. Denies any chest pain, but reports some difficulty breathing. Also reports single episode of vomiting earlier in the week with gastric contents and clear liquid. She denied any light headedness or palipiations. Past Medical History: -Asthma -Rheumatoid Arthritis, on Prednisone since [**2097**] per patient -Hypertension -Hyperthyroidism, on methimazole -Anxiety -Transient Ischemic Attack (9 years ago) -Glaucoma -Status-post bilateral knee replacements -Status-post bilateral hip replacements Social History: Does not smoke, drink alcohol or take other drugs. Lives with husband and has visiting home health aid. Last walked two weeks ago, however prior to that did require a walker and assistance. Family History: Sister with pancreatic cancer. Physical Exam: On admission: Tmax: 37.4 ??????C (99.4 ??????F) Tcurrent: 37.4 ??????C (99.4 ??????F) HR: 90 (86 - 90) bpm BP: 128/65(65) {84/45(55) - 128/65(65)} mmHg RR: 24 (24 - 29) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) General Appearance: No acute distress Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI at left base Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: , Rhonchorous: ) Abdominal: Soft, Bowel sounds present, Tender: Right upper and lower quadrants, Obese GU: Anus with tender external hemorrhoid and small fissure at the 6 o??????clock position, Extremities: Right: Trace, Left: Trace, (+) Ecchymoses Musculoskeletal: Muscle wasting Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): Self, place, Movement: Not assessed, Tone: Not assessed On discharge: Vitals: T 98.0, BP 120/66, HR 76, RR 24, O2 sat 93% on room air. Tm 100.1, 120-131/59-81, 70-101, 22-24, 91-93% on room air I/O [**Telephone/Fax (1) 76319**], 0/450 since midnight. General Appearance: No acute distress Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Poor dentition, evidence of thrush Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: normal S1/S2, +systolic murmur Peripheral Vascular: normal radial and pedal pulses Respiratory/Chest: good air movement with upper airway coarse breath sounds present on anterior exam, no crackles noted on posterior exam Abdominal: Soft, Bowel sounds present, diffuse tenderness, no guarding Extremities: severe joint disruption due to RA, s/p bilateral hip and knee replacements, large amount of anasarca noted with 3+ edema in right lower extremity, 2+ in left lower, 1+ in left upper, and significant improvement in right upper back to baseline; overall improving slowly Skin: Warm, + multiple ecchymoses Neurologic: Attentive, Follows commands, alert and oriented. Pertinent Results: Labs on admission: [**2132-4-24**] 09:41AM BLOOD WBC-16.7* RBC-3.04* Hgb-9.0* Hct-27.7* MCV-91 MCH-29.5 MCHC-32.4 RDW-17.0* Plt Ct-326 [**2132-4-23**] 05:10PM BLOOD WBC-18.2* RBC-3.67* Hgb-10.8* Hct-33.3* MCV-91 MCH-29.3 MCHC-32.3 RDW-17.9* Plt Ct-318 [**2132-4-23**] 10:02PM BLOOD Neuts-96.3* Lymphs-2.6* Monos-1.1* Eos-0 Baso-0 [**2132-4-23**] 05:10PM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0 [**2132-4-23**] 10:02PM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2* [**2132-4-23**] 05:10PM BLOOD Glucose-163* UreaN-44* Creat-1.0 Na-131* K-5.3* Cl-89* HCO3-29 AnGap-18 [**2132-4-24**] 09:41AM BLOOD Glucose-150* UreaN-30* Creat-0.8 Na-133 K-4.5 Cl-98 HCO3-27 AnGap-13 [**2132-4-23**] 05:10PM BLOOD ALT-82* AST-60* CK(CPK)-107 AlkPhos-463* TotBili-4.7* DirBili-3.5* IndBili-1.2 [**2132-4-24**] 03:06AM BLOOD ALT-65* AST-48* AlkPhos-392* TotBili-4.3* [**2132-4-23**] 05:10PM BLOOD cTropnT-0.02* [**2132-4-24**] 09:41AM BLOOD Calcium-7.4* Phos-1.7* Mg-2.4 [**2132-4-23**] 05:10PM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.2 Mg-2.8* [**2132-4-23**] 05:28PM BLOOD Lactate-1.6 Labs on discharge: [**2132-5-5**] 05:33AM BLOOD WBC-11.9* RBC-2.52* Hgb-7.3* Hct-23.3* MCV-93 MCH-29.0 MCHC-31.3 RDW-19.5* Plt Ct-353 [**2132-5-3**] 05:23AM BLOOD Neuts-87.6* Lymphs-8.6* Monos-2.4 Eos-1.1 Baso-0.3 [**2132-5-3**] 05:23AM BLOOD PT-13.7* PTT-32.1 INR(PT)-1.2* [**2132-5-5**] 05:33AM BLOOD Glucose-111* UreaN-14 Creat-0.8 Na-133 K-4.6 Cl-99 HCO3-30 AnGap-9 [**2132-5-4**] 05:58AM BLOOD ALT-36 AST-43* LD(LDH)-304* AlkPhos-487* TotBili-1.9* [**2132-5-5**] 05:33AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9 Additional labs: [**2132-4-25**] 06:40AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE [**2132-4-25**] 06:40AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [**2132-4-25**] 06:40AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2132-4-26**] 06:18AM BLOOD PEP-HYPOGAMMAG IgG-545* IgA-204 IgM-465* IFE-NO MONOCLO [**2132-4-24**]: EGD: esophageal candidiasis [**2132-4-28**]: CT ABD/PELV: 1. Small amount of new perihepatic free fluid. 2. No evidence of obstruction. 3. Small bilateral pleural effusions with associated atelectasis and/or consolidation of the adjacent lung. 4. Calcified rounded lesion within the uterus, c/w calcified fibroid. 5. Bilateral renal hypodensities, too small to characterize, may reflect renal cysts. [**2132-4-28**]: ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Diastolic function could not be assessed. There is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic LV systolic dysfunction with an abnormal systolic flow contour without LVOT gradient. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. PICC Line placement [**2132-5-2**]: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the right basilic venous approach. Final internal length is 36 cm with the tip positioned in the SVC. The line is ready to use. Brief Hospital Course: Mrs [**Known lastname 76318**] is a 74 year old woman with rheumatoid arthritis, asthma, hypertension, presenting from [**Hospital1 **] with question of basal gangia ICH, found not to have any intracraneal process but having abdominal pain, leukocytosis, bright red blood per rectum. # MRSA Sepsis - Patient was initially admitted to the ICU with GI bleed and was quickly transitioned to the floor once her Hct was stable. On the floor, GI planned for a colonoscopy, but during the prep, she triggered for hypotension, tachypnia with anxiety and altered mental status. She was transfered to the ICU, started on levaphed and her vitals were T: 100.8 BP: 116/50 on 0.3 of levo P: 90 R: 18 O2: 100% on 3L NC. A Left IJ was placed and her Right IJ, which was placed in the ED for access due to GIB, was pulled. She was given 6 liters of IV fluid and was off of pressors by the next morning. She was started on Vanc/Zosyn. Blood cultures grew out 4/4 bottles of MRSA (presumed from initial CVL) with GNR in [**11-25**] bottles. A TTE showed mildly thickened mitral valve, but no evidence of valvular vegitation. She defervesed and was tranfered from the ICU on Vanc/Zosyn. Zosyn was discontinued and the patient was continued on Vancomycin for a planned six week total course for line infection. Her surveillance blood cultures remained negative at the time of discharge. The decision was made to treat for six weeks (a full course for endocarditis) as the patient did not want to undergo further invasive procedures including TEE. The patient will follow up with Infectious Disease Clinic after her course of Vancomycin to monitor for recurrence of infection. In addition to endocarditis, there remains a concern for potential seeding of her artifical joints (knees and hips). Her white count was trending down throught the day of discharge. # New Atrial fibrillation with RVR: During fluid resuscitation in the ICU, the patient developed a-fib with RVR in the setting of pressors. Amiodarone bolus and drip were started and on day 2, metoprolol was started. This was titrated up to 25 mg TID and the patient converted back into sinus rhythm briefly. Over the course of her 3rd night in the ICU, her rhythm continued to flip back and forth between sinus and a-fib, but primarily in sinus with rates of 80s. She was discharged with heart rate in the 70's on 12.5mg twice daily of Metoprolol, which may titrated up if needed. # GI bleeding: She was initially sent to the ICU for a questionable history of melena, she had no melena during a period of observation and no significant HCT drop to suggest an upper GI bleed. She did have bright red blood per rectum and on exam a rectal fissure and hemorrhoids. In the ICU she underwent an EGD which revealed esophageal candidiasis. She was then transferred to the floor where she underwent a prep for a colonoscopy, but decompensated as above. She had possible proctitis on CT scan and treated with cipro flagyl. GI followed and did not want to do colonoscopy in setting of sepsis. She expressed a desire to limit invasive testing and due to the fact that she had a recent (2 years ago) colonoscopy which did not show any masses, it was felt that colonoscopy could be deferred at this time. Her HCT remained stable throughout the remainder of the admission. On [**2132-5-6**] she received one unit of pRBC's for a HCT of 22.7 for symptommatic relief. There was no evidence of continued bleeding at the time of discharge. It recommended for her to have weekly CBC checked for HCT monitoring. # Hyperbilirubinemia / elevated transaminases: The patient is status-post cholecystectomy, however this does not exclude intrabiliary obstruction. Gastroenterology was consulted and LFTs were trended. At discharge, her LFTs were slowly improving. She is negative Ab for autoimmune hepatitis, PSC, and viral hepatitis. The differential includes drug induced liver disease (methimazole and AZT ?????? recently discontinued, chronic prednisone ?????? recently lowered) or possibly congestive hepatitis. Her methimazole was held on this admission. If her TSH, T3 and T4 remain within normal limits, this will not be restarted. # [**Female First Name (un) 564**] Esophagitis: Seen on intial EGD - likely due to chronic prednisone. She was treated with fluconazole, and completed a 10 day course starting from [**2132-4-24**]. # Arthritis, rheumatoid (RA): On prednisone 10mg daily at baseline. Initially she presented on 40mg PO prednisone for question of COPD flare, and this was tapered in the setting of GI bleed. Her steriods were transiently increased to stress doses in the ICU for possible adrenal insufficiency in the face of long standing steriod use, but once septic picture presented itself, prednisone was restarted at 5mg [**Hospital1 **]. # Hypertension: Initially on telemetry the patient had short bursts of a long PR narrow complex tachycardia, likely causes are atrial tachycardia, AVRT or uncommon AVNRT. Lisinopril was held, and initially metoprolol was held as well during hypotension, but restarted in the face of A-fib with RVR. Metoprolol was titrated up to acheive rate control and at discharge was titrated back down to 12.5mg [**Hospital1 **]. This may be titrated as needed. # Anasarca: The patient received +7L while in ICU. She is clearly edematous and has been diruesed approximately 3L since arriving to floor. The plan is to continue gentle diruesis as this is helping with her anasarca and her assoiciated pain. It should be noted that she is incontinent, making monitoring of urine output difficult. She should be regularly bladder scanned and straight cath performed if needed. Please avoid foley as this would be an additional source of potential infection. # Leg pain: Likely due to anasarca and patient states it is new pain and not in ankle (ie- not due to RA). She is asking for pain control and clearly bothered by the pain. Low dose opiate has been started though she is worried about somnolence with these medications. Please use low doses as needed. Medications on Admission: Xanax 0.5mg QHS, .375 Daily Albuterol atrovent Nystatin Alphagan Ferrous sulfate Calcitriol Gabapentin 300mg qhs, 100mg AM Naproxen Docusate Alendronate 70mg Azathioprine 75mg [**Hospital1 **] Protonix 40mg daily Lisinopril 20mg Methimazole 10mg daily Xalatal Metoprolol 50mg [**Hospital1 **] Vitamin D Tums Aspirin Amlodipine Prednisone 40mg daily Singulair Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB. 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO q8am. 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q2PM (). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane DAILY (Daily) as needed for mouth pain. 16. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale. Subcutaneous ASDIR (AS DIRECTED). 17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain: Hold for oversedation or RR<12. 18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for pain: Hold for oversedation or RR<12. 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 20. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 22. Vancomycin 500 mg IV Q 24H Discharge Disposition: Extended Care Facility: [**Hospital 8971**] Rehab Discharge Diagnosis: Primary: -Gastrointestinal (GI) bleed -MRSA Bacteremia -Septic shock Secondary: -Rheumatoid arthritis Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted for gastrointestinal (GI) bleed. While you were here, you developed a blood infection with MRSA bacteria. You were treated briefly in the ICU for this and received fluids and antibiotics. You had a PICC line placed which you will use to complete a six week course of vancomycin which will be completed on [**2132-6-9**]. Your Lisinopril and your Methimazole were discontinued. Your Metoprolol was reduced to 12.5mg twice a day. Your Prednisone was resumed at your long-term dose of 5mg twice a day. You are to continue Vancomycin through [**2132-6-9**]. Your Azathioprine was also held and this may be resumed at follow up with your PCP. You are being given low dose Percocet to help manage your pain. Please be careful when taking these medications as they can make you drowsy and increase your risk for falls. You should not attempt to operate any kind of machinery (incuding driving) while on this medication. 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: You have a follow up appoitment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2132-5-19**] at 1:45pm. The office can be reached [**Telephone/Fax (1) 3183**]. Please discuss resumption of Azathioprine, Methimazole and Lisinopril at this visit. You also have a follow up appointment with Infectious Disease Clinic to monitor your progress in treating your infeciton: -Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2132-6-11**] 1:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2132-5-8**]

Admission Date: [**2124-1-23**] Discharge Date: [**2124-1-28**] Date of Birth: [**2049-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: hypoxia (transfer from outside hospital) Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 74 y/o male with hx of CAD, HTN, s/p PM for sick sinus syndrome, CRI s/p nephrectomy who was recently discharged from [**Hospital1 18**] [**2124-1-18**] now returns from OSH after being intubated for CHF, initially hypotensive after lasix given then became hypertensive and also found to have + blood from NGT. . During previous admission patient admitted for abdominal pain underwent EGD and c-scope and found to have multiple diverticulae and gastritis. Shortly after EGD patient had respiratory failure was intubated thought to be [**1-14**] CHF, extubated the next day. Patient also thought to have NSTEMI which was medically managed and patient eventually discharged [**2124-1-18**]. . Patient presented to OSH with presumed CHF after being hypertensive and was intubated. Per daughter patient missed his blood pressure medications the day of admission. Patient denies any fever,chills, coughs or gradual SOB prior to event. He recieved lasix at home and then en route however still SOB in ED so was put on Bipap and then intubated. During his admission at OSH his BP has been labile with hypertension SBP 190s. Patient started on nitro gtt for BP control and got lopressor 5mg x3. At OSH CXR showed initially diffuse infiltrates c/w pulmonary edema vs PNA; repeat CXR the following day showed improved infiltrates. Patient's peak TropI was 1.8 and CK 68 at OSH. EKG done at OSH showed pattern c/w LVH and more pronounced ST depression in lateral leads. Repeat EKG done on arrival to [**Hospital1 18**] was similar to old EKGs. Upon arrival to [**Hospital1 18**] patient on minimal vent support with well controlled BP on nitro gtt. Past Medical History: CAD; NSTEMI [**10-17**] and [**1-19**] Anemia CRI (baseline Cre 3.1) s/p nephrectomy Gastritis Diverticulosis Hiatal Hernia Aortic Stenosis SSS s/p pacemaker Social History: Lives with daughter since recent d/c from hospital + tobacco 1 cig per day; formerly 1ppd no etoh use Family History: Reported family hisotry of CAD Physical Exam: T 98.6 BP 118/62 P 60 AC RR 16 TV 500 FiO2 0.4 100% Gen: NAD, intubated, awake Heent: PERRL, EOMI, OG tube in place Neck: no obvious JVD, RIJ in place Lungs: Clear ant/lat Cardiac: RRR S1/S2 grade III/VI SEM at RUSB Abd: soft non-tender Ext: no edema, DP and PT +1 Pertinent Results: [**2124-1-23**] 12:56PM WBC-7.9 RBC-3.17* HGB-9.7* HCT-29.5* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.3 [**2124-1-23**] 12:56PM GLUCOSE-94 UREA N-46* CREAT-3.0* SODIUM-141 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-25 ANION GAP-9 [**2124-1-23**] 12:56PM CK-MB-NotDone cTropnT-0.42* proBNP-[**Numeric Identifier 41959**]* . P-MIBI ([**2124-1-27**]): No anginal symptoms with an uninterpretable ECG for ischemia. There is a mild fixed perfusion defect involving the inferior and inferolateral walls. The left ventricle is moderately dilated at stress and rest and there is global hypokinesis with a calculated LVEF of 35%. . TTE ([**2124-1-24**]): The left atrium is mildly 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 mildly depressed (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 0.8-1.19cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) eccentric mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. . Renal ultrasound (with Dopplers) [**2124-1-24**]: 2.0 cm cyst of the right renal lower pole. Otherwise, normal appearance of the right kidney with patent vasculature and no son[**Name (NI) 493**] evidence of renal artery stenosis. Surgically absent left kidney. Brief Hospital Course: Mr. [**Known lastname 41957**] was transferred to the [**Hospital1 18**] CCU intubated. Upon arrival, he had a favorable ABG and wsa quickly extubated without difficulty. His BP was intially controlled with a nitroglycerin drip which was slowly weaned off over the first night of his hospitalization. On the morning of hospital day #2, he became acutely short of breath with acute development of pulmonary edema at the same time that his blood pressure suddenly rose to 220-240/100-120. He was given IV Lasix and metoprolol and his nitroglycerin drip was quickly titrated back up. He was put on BiPAP with improvement in his oxygenation. Over the course of the day, he was weaned easily off BiPAP. The focus at this point became controlling his hypertension which was done with a high dose of Toprol XL, increasing his dose of Imdur, and starting him on amlodipine. He was temporarily controlled on PO hydralazine but this was titrated off due to his history of poor medication compliance. His history of a nephrectomy precluded the use of an ACEi or [**Last Name (un) **]. As far as working up the etiology of his refractory hypertension, a renal ultrasound showed no evidence of renal artery stenosis and a random cortisol level was within normal limits; a 24-hour urine collecion had normal levels of VMA and metanephrines. For his presumed coronary artery disease, he underwent a pharmacologic stress test which showed only a mild fixed defect in the inferior/inferolateral walls along with an LVEF of 35%. He was discharged home to stay with his daughter with plans to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of cardiology. Medications on Admission: Meds at home: Lipitor 80mg qhs Mirtazapine 15mg qhs Buspirone 5mg [**Hospital1 **] Trazadone 25mg Sucralfate 1g qid ASA 325mg Protonix 80mg [**Hospital1 **] Atrovent Imdur 60mg Toprol XL 300mg . Meds on transfer: Nitro gtt SQ heparin ASA 325mg carafate lopressor 25mg q6 lasix 70mg IV plavix 75mg Humulog sliding scale Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*QS Disk with Device(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): total dose 180mg. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO at bedtime: total dose 300mg. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Hypertensive crisis with pulmonary edema . Secondary diagnoses: Aortic stenosis, hypertension, diastolic dysfunction, Chronic kidney disease Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name (STitle) 13277**] [**Name (STitle) **] ([**Telephone/Fax (1) 2636**] or return to the Emergency department if you experience shortness of breath, chest pain or pressure, dizziness, abdominal pain, nausea or vomitting or any symptoms that concern you. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 13277**] [**Name (STitle) **] within 1-2 weeks of discharge ([**Telephone/Fax (1) 2636**]. . You will be seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from the department of cardiology for follow up. His office will get in contact with you within the next 1-2 days to tell you when and where to attend the appointment. If you have not heard anything within the next 2 days, you should call his office at [**Telephone/Fax (1) 10012**].

Admission Date: [**2130-3-24**] Discharge Date: [**2130-3-29**] Date of Birth: [**2089-3-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 41 y/o male with EtOH cirrhosis, chronic pancreatitis, who presented to an OSH with hematemesis. He was recently discharged from [**Location (un) 3320**] Corrections three days PTA. On the morning of admission, he spoke with his mother who reported that he sounded well. Later that day, he felt sick and had several episodes of hematemesis (approx 900 cc with 8+ episodes). He then went to [**Hospital3 3583**] for further care. At the OSH, his VS were stable as was his Hct. He reportedly had a transfusion reaction when getting 1 U PRBCs (chest redness and tremors). He was subsequently intubated and transferred to [**Hospital1 18**]. Past Medical History: 1. ETOH cirrhosis 2. Chronic pleural effusions Social History: He is currently homeless. His kids live with his sister, who is his HCP. [**Name (NI) **] denies smoking, admits ETOH in the past, which he can stop when he wants to. Family History: Non-contributory Physical Exam: VS: Tc 98.2, 98.0, BP 118/62, HR 107, RR 16, SaO2 97%/RA General: Middle-aged male in NAD, AO x 3 HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae. MMM, OP clear Neck: supple, no LAD or JVD Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, no m/g/r Abd: soft, distended, +TTP over the epigastrum without rebound or guarding, quiet BS Ext: no c/c/e, wwp Neuro: AO x 3, +tremulous, no asterixis Skin: + few spider angiomas and palmar erythema Pertinent Results: [**2130-3-24**] 04:05PM BLOOD WBC-5.3 RBC-3.31* Hgb-9.4* Hct-26.8* MCV-81*# MCH-28.3 MCHC-35.0 RDW-16.0* Plt Ct-107*# [**2130-3-24**] 04:05PM BLOOD Neuts-82.1* Lymphs-14.1* Monos-2.2 Eos-1.3 Baso-0.2 [**2130-3-24**] 04:05PM BLOOD PT-16.6* PTT-34.8 INR(PT)-1.5* [**2130-3-24**] 04:05PM BLOOD Glucose-138* UreaN-15 Creat-0.5 Na-142 K-3.5 Cl-105 HCO3-22 AnGap-19 [**2130-3-24**] 04:05PM BLOOD ALT-18 AST-36 TotBili-1.3 [**2130-3-24**] 04:05PM BLOOD Lipase-110* [**2130-3-24**] 04:05PM BLOOD TotProt-6.0* Albumin-3.7 Globuln-2.3 Calcium-8.1* Phos-3.8 Mg-1.3* [**2130-3-26**] 06:35AM BLOOD Hapto-69 [**3-24**] Blood cultures-pending EGD Esophagus: Mucosa: Abnormal mucosa was noted in the distal esophagus with erythema and friability consistant with moderate esophagitis. Stomach: Mucosa: Two blood clots were noted below the GE junction with no evidence of active bleeding. One hemostatic clip was placed and 4 ml of epinephrine were injected into the mucosa underneath one of the clots. Duodenum: Mucosa: Normal mucosa was noted. Impression: Abnormal mucosa in the esophagus Abnormal mucosa in the stomach Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 41 y/o male with EtOH cirrhosis, chronic pancreatitis, who presented to an OSH with hematemesis. He was recently discharged from [**Location (un) 3320**] Corrections three days PTA. On the morning of admission, he spoke with his mother who reported that he sounded well. Later that day, he felt sick and had several episodes of hematemesis (approx 900 cc with 8+ episodes). He then went to [**Hospital3 3583**] for further care. At the OSH, his VS were stable as was his Hct. He reportedly had a transfusion reaction when getting 1 U PRBCs (chest redness and tremors). He was subsequently intubated and transferred to [**Hospital1 18**]. . Of note, patient was admitted to [**Hospital1 18**] in [**2129-10-20**] with an upper GI bleed. At that time an upper endoscopy revealed severe esophagitis, probably portal hypertensive gastropathy but no evidence of varices. Patient reports that he had an admission at [**Hospital3 3583**] 1-2 months ago for hematemesis and at the time the EGD revealed varices. . In the ED, initial VS were significant for tachycardia into the 110's. He was given 1 L NS, started on an octreotide gtt, and given 1 gm CTX IV. . MICU course: He was extubated on arrival successfully. His VS remained stable although HR was in the 110's. He was continued on an octreotide gtt overnight and kept NPO. He had an EGD [**2130-3-25**] which revealed 2 clots at the GE junction (no active bleeding); epi was injected and clips were placed. The octreotide gtt was stopped and the patient was continued on IV PPI only. His Hct remained stable and he required no further transfusions. During his course he has had persistent abdominal pain, c/w pancreatitis, and was kept NPO with sips only and given dilaudid for pain. He has required ativan per CIWA for withdrawal approx q3 hours. . # Hematemesis - His hematemesis was most likely due to esophagitis and portal gastropathy, with abnormal mucosa at the GE junction. There was no evidence of varices on EGD. His Hct remained stable while on the medical floor and patient had been hemodynamically stable. Initially after his endoscopy his had further episodes of hematemesis and there was a question of re-scoping but as his Hct stabilized this was not felt to be indicated. He was on a PPI IV bid, and he had antiemetics prn. He started tolerating a clear liquid diet which was slowly advanced and he was felt to be stable for discharge. . # Abdominal pain - His pain was consistent with a prior history of pancreatitis, patient reports flares 1-2x/month. Lipase/amylase not elevated, possibly [**1-21**] chronic pancreatitis. His diet was slowly advanced and his pain was controlled with IV dilaudid initially then po dilaudid. . # Cirrhosis - Secondary to EtOH, patient with ongoing EtOH abuse. INR mildly elevated but albumin normal, suggesting intact synthetic function. His coags/platelets and albumin were followed and platelets were maintained above 50, with FFP given for INR>1.5. He also received lasix and aldactone but they commonly had to be held due to borderline blood pressure (systolic 100's). The liver service followed him while he was hospitalized but he is not currently adherent to therapy. . # Thrombocytopenia - His baseline platelets normal around 200 back in [**10-27**], now down to 80's. This is likely due to worsening cirrhosis and possible marrow suppression from EtOH. There is no evidence of hemolysis as Hct has been stable. Hemolysis labs were negative and platelets were kept above 50 given his active bleeding on admission. . # EtOH abuse -He was maintained on an ativan CIWA (avoiding valium given cirrhosis) as patient high-risk to withdraw. He continued thiamine/folate/MVI; and switched to po's once taking po's. SW was consulted and assisted the medical team in obtaining a shelter for him to be discharged to. . # ?Adrenal insufficiency - The patient was unsure of history, noted to be on hydrocortisone, which was confirmed with his pharmacy. On contacting his PCP (Dr. [**MD Number(4) 75518**] last saw him in [**Month (only) 359**]), the diagnosis began on a prolonged ICU stay at [**Hospital3 **] a year ago. At times he does not take the steroids and his blood pressure maintains SBP 100's. He initially had been on hydrocortisone but upon learning this a prednisone taper was initiated. . # Communication - Mother [**First Name8 (NamePattern2) 1439**] [**Name (NI) 53917**]) home - [**Telephone/Fax (1) 75519**]; cell - [**Telephone/Fax (1) 75520**] . Medications on Admission: Pantoprazole 40 mg IV bid Ondansetron 4 mg IV q8 hrs prn Lorazepam 2 mg IV Q2H PRN CIWA>10 Thiamine 100 mg IV daily FoLIC Acid 1 mg IV daily HYDROmorphone (Dilaudid) 1-2 mg IV q4 hrs prn Insulin SC Trazadone 75 mg qhs Seroquel 200 mg [**Hospital1 **] Hydrocortisone 10 mg q8 Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*120 Cap(s)* Refills:*2* 8. Prednisone 2.5 mg Tablet Sig: Four (4) Tablet PO once a day for 5 days: please take 4 tablets a day for 5 days, then take 3 tablets a day for the next 7 days, take two tablets a day for the next 7 days and then one tablet a day for 7 days. Disp:*65 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Quetiapine 200 mg Tablet Sig: 0.5 Tablet PO QHS PRN (). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: gastric ulcer, esophagitis ----------------- alcohol cirrhosis chronic pleural effusions Discharge Condition: stable, afebrile, ambulatory Discharge Instructions: You were admitted to the hospital with hematemesis (vomiting blood). You had an EGD (scope) to evaluate your esophagus and stomach, where an ulcer was found. You received medications to treat this and your symptoms improved. You should take your medications as prescribed. You will be taking prednisone 10mg a day and the dose will be decreased over time. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 26647**] Thursday [**4-13**] at 1:15pm Completed by:[**2130-4-5**]

Admission Date: [**2134-5-23**] Discharge Date: [**2134-5-28**] Date of Birth: [**2056-9-12**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Acute stroke Major Surgical or Invasive Procedure: IV-TPA History of Present Illness: Reason for consult: Code Stroke History of Present Illness: 76 year old right handed woman with history of CAD s/p CABG in [**2117**]'s, htn, hyperchol, who was feeling well until 11 a.m. today when she told her husband she was going out shopping but her speech sounded slurred. She walked upstairs and about 15 minutes later her husband heard a thump. He found her lying on the bathroom floor, mumbling incoherently, with her right leg crossed over her left. He called his daughter who came over to the house, then she called EMS. Husband reports no recent systemic illness, followed by Dr. [**Last Name (STitle) 16958**] for cardiology, told everything was fine recently. Husband not aware of any prior history of arrhythmia, no prior stroke. Review of systems: No known recent fever, weight loss, cough, rhinorrhea, chest pain, palpitations, vomiting, diarrhea, or rash. She does sometimes feel short of breath with exertion. Past Medical History: Past Medical History: Hypertension CAD s/p CABG in [**2117**] Hypercholesterolemia Social History: Social History: Lives with husband. Family History: Family History: Non contributory Physical Exam: Examination: T 95.4 HR 96, irregular BP 128/68 RR 18 Pulse Ox 100% on RA initially General appearance: 76 year old woman in C-spine collar lying quietly in bed in NAD, with eyes open HEENT: NC/AT, wearing C-spine collar CV: Iregular rate rhythm without audible murmurs, rubs or gallops. No carotid bruits audible. Lungs: Crackles at bases Abdomen: Soft, nontender, nondistended, no hsm or masses palpated Extremities: no clubbing, cyanosis or edema Mental Status: Awake and alert, with eyes open. Mute, does not produce any sound or speech. Does not reliably follow any commands, does not mimic commands. Cranial Nerves: Left pupil is round and reactive to light, right is surgical. Blinks to threat bilaterally. Optic disc margins are sharp on funduscopic exam. Extraocular movements are full without gaze preference initially, then after 20-30 minutes she developed a left gaze preference. There is no nystagmus. +corneals. Right UMN facial droop. +gag. Motor System: Initially no movement of right arm, occasional flexion of right leg to noxious stimuli on either side. Moves left arm and leg vigorously antigravity. Normal tone. Reflexes: Deep tendon reflexes are 2+ and symmetric. Plantar response extensor on right initially, later mute. Sensory: Responds more vigorously to noxious stimuli on the left, readily but less vigorously in right leg, no response to pinprick in right arm. Coordination, Gait: Could not assess Pertinent Results: [**2134-5-27**] 06:00AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.6* Hct-34.0* MCV-90 MCH-30.6 MCHC-34.0 RDW-14.2 Plt Ct-139* [**2134-5-23**] 01:40PM BLOOD Neuts-78.1* Bands-0 Lymphs-14.5* Monos-4.3 Eos-2.2 Baso-0.9 [**2134-5-27**] 06:00AM BLOOD Glucose-109* UreaN-11 Creat-0.6 Na-141 K-3.5 Cl-104 HCO3-29 AnGap-12 [**2134-5-24**] 02:47AM BLOOD ALT-17 AST-23 LD(LDH)-185 CK(CPK)-34 AlkPhos-48 TotBili-0.5 [**2134-5-27**] 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9 [**2134-5-23**] 05:47PM BLOOD %HbA1c-5.7 [**2134-5-23**] 05:47PM BLOOD Triglyc-86 HDL-43 CHOL/HD-3.0 LDLcalc-68 LDLmeas-75 CTA [**2134-5-23**]: CONCLUSION: No evidence of infarction on the non-contrast CT scan. Profound prolongation of mean transit time throughout the left middle cerebral artery distribution. The blood volume appears largely preserved, although somewhat decreased in the anterior temporal lobe. Occlusion of the left middle cerebral artery during its M1 course, just distal to the origin of an anterior temporal branch. CT head [**2134-5-24**]: FINDINGS: There is mild prominence of the ventricles and sulci in an atrophic pattern. There is no evidence of hemorrhage or acute infarction. There is a tiny focal hypodensity in the left putamen, suggesting an old lacunar infarction. There have been no significant changes since the head CT of [**2134-5-23**]. CXR [**2134-5-27**]: There is significant improvement in previously demonstrated severe pulmonary edema being now of a mild degree. Bilateral pleural effusions are again noted. The heart size is markedly enlarged but stable and the patient is after CABG. CONCLUSION: No evidence of hemorrhage or recent infarction. CT C-spine [**2134-5-24**]: FINDINGS: Alignment is normal. No fractures are identified. There are mild degenerative changes in the cervical spine that cause mild narrowing of the spinal canal but no suggestion of spinal cord compression. Noncontrast CT has limited intraspinal soft tissue resolution and cannot evaluate the possibility of disc, hematoma, or other soft tissue abnormalities inside the spinal canal. There are large bilateral pleural effusions, incompletely evaluated on this study. CONCLUSION: No evidence of fracture or subluxation Echocardiogram [**2134-5-24**]: The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] 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 to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate to severe mitral regurgitation. Preserved global and regional biventricular systolic function. Moderate pulmonary artery systolic hypertension. No left atrial mass/thrombus seen. Right knee x-ray [**2134-5-27**]: Degenerative changes of the right knee including medial compartment joint space narrowing. No definite fracture is seen; previous finding reflected a projecting osteophyte. Chondrocalcinosis. Brief Hospital Course: Hospital Course: 1. Neurology: Patient received IV TPA in ED for NIHSS of 15 and admitted to Neurology ICU for observation and post-IV TPA protocol. Patient was noted to have no neurological deficits within 24 hours. She was noted to have atrial fibrillation on admission and stroke was thought to be cardioembolic in etiology. The patient was started on heparin and coumadin. Once INR was therapeutic heparin discontinued and patient continued on Coumadin 3 mg po qday. She was transferred to the floor once medically stable. Lipid panel TG 86, HDL 43, and LDL 75, Hgb A1c 5.7%. She worked with PT/OT once her knee pain improved. 2. CV: Echocardiogram done and showed moderate to severe mitral regurgitation and moderate pulmonary hypertension. She was treated with Lasix as needed for moderate to severe pulmonary edema which improved to mild pulmonary edema on repeat CXR. She was ruled out for MI with cardiac enzymes x 3. 3. Respiratory: Patient was on oxygen nasal cannula during the duration of hospitalization which was thought to be related to pulmonary edema. She was treated with intermittent Lasix. 4. FEN/GI: Tolerated regular diet. 5. MSK: Patient had a fall after stroke. She had C-spine CT which was read as no evidence of fracture. She complained of right knee pain. X-rays showed that there was DJD but no evidence of fracture. She was placed in knee immobilizer and worked with PT/OT. 6. Rehab: Given's patient's deconditioning during this hospital stay, it was though she would benefit from inpatient rehabilitation. Medications on Admission: Medications: Simvastatin 40 mg daily Welchol 625 mg daily Norvasc 5 mg daily Atenolol 100 mg daily Semprex D 8,60 mg daily Isosorbide dinitrate 20 mg daily Zetia 10 mg daily Evista 60 mg Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): titrate based on INR goal [**2-6**]. Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: stroke Discharge Condition: stable Discharge Instructions: Follow up with appointments as below. Take all medications as instructed. Followup Instructions: Neurology [**Hospital 4038**] Clinic. [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 18**]. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2134-6-29**] 11:00 AM. Please call to confirm appointment Call your PCP after discharge from rehabilitation and make an appointment to follow up with them. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Admission Date: [**2173-2-27**] Discharge Date: [**2173-3-4**] Date of Birth: Sex: F Service: NEUROSURG HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female with a history of a fall in the morning of admission who was taken to the [**Hospital 8**] Hospital at that time and was noted to be somnolent but arousable and moving all four extremities. She had an episode of emesis times two and was therefore intubated. She was then transferred to the [**Hospital1 346**] and was found on arrival to the [**Hospital1 1444**] to be unresponsive with pupils 5 mm bilaterally and minimally reactive. She was moving her bilateral lower extremities slightly and on CT scan was found to have a large left-sided subdural hematoma with midline shift and was taken urgently to the Operating Room for evacuation. PAST MEDICAL HISTORY: 1. History of hypertension. 2. Depression. 3. She is hard of hearing. MEDICATIONS: 1. Verapamil. 2. Hydrochlorothiazide. 3. Zestril. 4. Zoloft. 5. Ativan. 6. Enteric coated aspirin. ALLERGIES: She has no known drug allergies. PHYSICAL EXAMINATION: At the time of admission, she had pupils that were 5 mm and minimally reactive in the Emergency Room. Lungs were clear to percussion and auscultation. Heart rate was regular in rate and rhythm. Abdominal examination was soft, nontender with no organomegaly. The extremities showed a right foot to be slightly cyanotic with no evidence of Doppler pulses in the dorsalis pedis or posterior tibials. There was a scar on the leg from previous surgery and there was eschar at the heel. The left foot was warm. The remainder of the physical examination was rather limited due to the condition of the patient's unresponsiveness and the urgency of taking the patient to the Operating Room. LABORATORY: Preoperatively, her hematocrit was 33. Chem-7 was stable. Coagulation studies were considered stable with a PT of 12.9 and PTT of 21.6. INR 1.2. The urinalysis was negative. Urine cultures were obtained. Lactate was 1.7, glucose 218. HOSPITAL COURSE: Due to the clinical findings, the patient was taken urgently to the Operating Room where, under general endotracheal anesthesia, the patient underwent a left sided craniotomy with evacuation of subdural hematoma. The patient tolerated the procedure well and went to the Neurology Intensive Care Unit in stable condition, but remained essentially intubated and unresponsive to all but noxious stimuli, for which she showed occasional withdrawal of the extremities. During the [**Hospital 228**] hospital course, she showed at several occasions throughout the remainder of the hospitalization, the pupils were noted to be 3 mm and reactive to 2 mm with brisk withdrawal of the right arm and spontaneous movement of the bilateral lower extremities and a flicker of movement of the left arm. She did not open eyes spontaneously to command; occasionally would open eyes to sternal rub, but did not follow commands. Due to the clinical findings and the gravity of the situation, a discussion was held with the family and a decision was made to provide no heroic measures. The patient was subsequently extubated and transferred to the Hospital Floor on the [**2173-3-3**], and later on the 30th, the family decided to continue with comfort measures only. The patient never regained evidence of neurologic function beyond that described previously. Her examination continued to show limited spontaneous movement with the patient never opening her eyes to noxious stimuli. She developed mild tachycardia early on the [**3-4**] with decreased breath sounds in the right side and remained comatose until approximately 08:57 a.m. on the [**2173-3-4**], when the patient was found to have expired. CONDITION AT DISCHARGE: Deceased. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Doctor Last Name 7239**] MEDQUIST36 D: [**2173-5-24**] 18:55 T: [**2173-5-25**] 10:33 JOB#: [**Job Number 107188**]

Admission Date: [**2117-2-24**] Discharge Date: [**2117-3-6**] Date of Birth: [**2092-5-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4358**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: rigid bronschoscopy x 2 broncholith resection and biopsy lymph node biopsy History of Present Illness: 24 year old F with no significant past pulmonary history who was admitted to [**Hospital1 18**] on [**2117-2-24**] with increasing hemoptysis. She was recently admitted to [**Hospital1 18**] with fevers, neck stiffness, chest pain, and headache. She underwent an extensive work-and treated empirically for CAP. She was thought to have had a viral infection. . Since she has left the hospital, she has continued to have fever, night sweats, and has had 8lbs weight loss. She has also in the last week developed hemopysis. She first noted one episode one week ago. She had recurrent episodes three days, every night this week. Episodes occurred at night so she was unable to quanititate the amount of blood loss, until the day of admission when she had two episodes of approximately [**11-25**] cup of bright red blood. Patient reports today that the volume of blood did not change over the course of the week, and was more concerned about the increasing frequency of symptoms. However, per [**Company 191**] note on [**2-23**] patient as reporting one tablespoon of hemoptysis prior to recent outpatient visit. Patient denies any chest pain, shortness of breath. She denies , nausea, vomiting, hematemesis, or blood in stools. . Of note, patient's recent evaluation for fevers, chest pain, headache and neck stiffness eventually attributed for viral syndrome included the following workup. She underwent extensive workup including rule out for ACS, CHF, PE, and pericardial effusion. She also had an extensive infectious workup with head and neck imaging, EGD, fiberoptic endoscopy, LP which were overall unrevealing. CT chest showed evidence calcified lymph nodes near the airways suggestive of prior histoplasmosis. Patient as treated for CAP with ceftriaxone and azithromycin. She was followed by the ID team. . In the ED, initial VS were stable. She was initially admitted to the medical floor. She was evaluated by pulmonology, however given increasing volume of hemoptysis, patient was transferred to the MICU for monitoring. . On arrival to the MICU, patient appeared well, complained of a headache and mild nausea without emesis. Bedside basin with three to four quarter sized block clots from hemoptysis. She was shortly after taken away for CT Chest. . Review of systems: (+) Per HPI (-) Denies sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: - Duodenitis - Tonsillectomy at age 6 Social History: From [**State 4260**] - In [**Location (un) 86**] for 3.5 years now as a student at Berkelee - She is a musician - Drinks 2-3 glasses of wine every other day - Used to smoke 3 cigarettes daily, quit 3 years ago - Used cocaine in past for a few weeks, but none since 6 years ago - Not currently sexually active, checked for STIs [**2111**], all negative Family History: - Schizophrenia - No heart disease - No lung disease - No cancer - unknown if vasculitis. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation DISCHARGE EXAM: afebrile, SBP 110s/70s, HR 70-80s, 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2117-2-24**] 07:50PM BLOOD WBC-11.0 RBC-3.66* Hgb-10.8* Hct-33.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.3 Plt Ct-362 [**2117-2-24**] 07:50PM BLOOD Neuts-83.4* Lymphs-11.0* Monos-4.8 Eos-0.5 Baso-0.3 [**2117-2-24**] 07:50PM BLOOD PT-13.7* PTT-31.6 INR(PT)-1.3* [**2117-2-24**] 07:50PM BLOOD Glucose-97 UreaN-15 Creat-0.7 Na-136 K-3.8 Cl-103 HCO3-23 AnGap-14 [**2117-2-24**] 07:50PM BLOOD ALT-10 AST-15 LD(LDH)-167 AlkPhos-67 TotBili-0.3 [**2117-2-25**] 07:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7 [**2117-2-24**] 10:57PM BLOOD ANCA-POSITIVE * [**2117-2-24**] 10:57PM BLOOD [**Doctor First Name **]-NEGATIVE [**2117-2-24**] 08:00PM BLOOD Lactate-0.8 CXR [**2117-2-24**]: IMPRESSION: Findings suggestive of right lower lobe pneumonia. CT TORSO [**2117-2-25**]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Increase in size of partly calcified subcarinal lymph node, new partly Preliminary Reportcalcified right hilar lymph node and right infrahilar lymph node. 3. New consolidation involving the anterior basal segment of the right lower Preliminary Reportlobe. 4. Multiple peribronchial opacities and multiple tree-in-[**Male First Name (un) 239**] opacities Preliminary Reportthroughout the right lobe which is a nonspecific finding which has a wide differential including infection. 5. Multiple areas of ground-glass opacity diffusely throughout the right lung. 6. Interval decrease in size of right pleural effusion. RIGID BRONCH [**2117-2-26**]: 24 yo female with likely fibrosing mediastinitis and submassive hemoptysis underwent Rigid bronchoscopy, flexible bronchoscopy, showing Splayed main and right main carinas. At the distal [**Hospital1 **], there was a rounded area of mucosal extrinsic compression that bled easily to light bronchoscopic contact. Evaluation of all airways to subsegmental level and with application of suction did not show evidence of parenchymal origin of hemoptysis. There was no evidence of a broncholith and no endobronchial lesions or thrombus. EBUS showed a large calcified station 7 node, not sampled. Station 11R enlarged lymph node underwent EBUS TBNA with minimal bleeding. Argon plasma coagulation to the mucosa at the [**Hospital1 **] that was bleeding was used to control bleeding with complete hemostasis. MRI HEAD: Normal brain MRI. No evidence of infection or mass. FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, 2, 3, 4, 5, 7, 8, 10, 16, 19, 20, 23, 45 and 56. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. T cells comprise 90% of lymphoid gated events. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see S12-16115N) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. RIGHT BRONCH INTERMEDIUS BX: Right bronchus intermedius endobronchial lesion, biopsy: - Bronchial mucosa with ulceration and squamous metaplasia of the respiratory epithelium; see note. EBUS-TBNA, Lymph node 11R: NEGATIVE FOR MALIGNANT CELLS. Polymorphous lymphocytes, consistent with lymph node sampling. Bronchial cells. DISCHARGE LABS: [**2117-3-5**] 07:00AM BLOOD WBC-6.6 RBC-3.52* Hgb-10.3* Hct-32.9* MCV-94 MCH-29.3 MCHC-31.3 RDW-13.7 Plt Ct-391 [**2117-3-2**] 06:45AM BLOOD Neuts-64.6 Lymphs-27.2 Monos-5.0 Eos-2.6 Baso-0.6 [**2117-3-5**] 07:00AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 [**2117-3-5**] 07:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0 OTHER TESTS: [**2117-3-2**] 06:45AM BLOOD HCG-<5 [**2117-3-5**] 07:00AM BLOOD ANCA-PND [**2117-2-24**] 10:57PM BLOOD ANCA-POSITIVE * [**2117-3-2**] 06:45AM BLOOD AFP-1.8 [**2117-2-24**] 10:57PM BLOOD [**Doctor First Name **]-NEGATIVE MICRO: [**2117-2-25**] 11:53AM URINE HISTOPLASMA ANTIGEN-NEG [**2117-3-2**] 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR FUNGI-PND [**2117-3-2**] 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND [**2117-3-2**] 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND [**2117-3-2**] 3:10 pm TISSUE (R) BRONDUS INTERMEDIUS ENDOBRONCHIAL LESION SUSPECTED HYSTO. GRAM STAIN (Final [**2117-3-2**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2117-3-5**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2117-3-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final [**2117-3-3**]): TEST CANCELLED, PATIENT CREDITED. Log In error TEST NOT ON REQUISITION. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Time Taken Not Noted Log-In Date/Time: [**2117-2-26**] 11:19 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2117-2-26**] 6:44 pm TISSUE IIR EBUS TBNA. GRAM STAIN (Final [**2117-2-26**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2117-3-1**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2117-3-4**]): NO GROWTH. ACID FAST SMEAR (Final [**2117-2-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2117-2-26**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NEG [**2117-2-24**] BLOOD CULTURE Blood Culture, Routine- NEG [**2117-2-24**] BLOOD CULTURE Blood Culture, Routine-NEG Brief Hospital Course: 24 year old female with calcified pulmonary lumph nodes and moderate hemoptysis concerning for chronic histoplasmosis # Hemoptysis: Pt presented with hemoptysis, and transferred to the MICU for monitoring shortly after arrival. She subsequently underwent CT torso on [**2-25**] which showed increase in size of partly calcified subcarinal lymph node, as well as a new partly calcified right hilar lymph node and right infrahilar lymph node. It was generally thought that this could be a presentation of histoplasmosis, perhaps on some spectrum of fibrosing mediastinitis vs mediastinal granuloma as opposed to active pulmonary histo. She underwent bronchoscopy on [**2-25**] which revealed a rounded area of mucosal extrinsic compression in the distal bronchus intermedius that bled easily to light bronchoscopic contact. This could also be seen on the CT and was consistent with a broncholith extruding from the calcified subcarinal lymph node. Evaluation of all airways to subsegmental level and with application of suction did not show evidence of parenchymal origin of hemoptysis. She underwent biopsy of a station 11R enlarged lymph node with minimal bleeding. She underwent Argon plasma coagulation to the mucosa at the bronchus intermedius with hemostasis. Biopsies were taken and showd normal lymph node tissue. She was transferred to the floor after this procedure where she remained stable and her hemoptysis had decreased to scant amounts. Consults were obtained from ID, pulm, IP, and CT surgery and extensive discussions were held regarding the likely underlying etiology of the mediastinal process and the risk of bleeding if broncholith was fully resected. Since the area had only been cauterized as a temporizing measure, it was considered likely that bleeding would recur due to the continued presence of the broncholith underlying the eroded airway. IP returned for second bronchoscopy on [**2117-3-2**] in an effort to resect the broncholith in the most minimally invasive approach. Broncholith was removed and sent for path and the underlying subcarinal node was biopsied. The area was cauterized. Her hemoptysis resolved after this measure. The path report on the biopsy was unremarkable, showing ulcerated mucosa, extensive granulation tissue but no granulomas, and no evidence of viral inclusions. It was sent for special stains and universal PCR on viruses, bacteria, and fungus which were pending at the time of discharge. Extensive discussion was held with ID (involving outside consultation to specialist in histoplasmosis) and determination was made that this was most likely a form of mediastinal granuloma secondary to histoplasmosis. Work up had been negative for malignancy, including bHCG, AFP, and LDH to r/o germ cell tumor. PPD neg x 2. While the histoplasma ab and ag tests were negative except for one mildly positive yeast phase antibody during her first hospitalization, these tests lack sensitivity and numerous ID physicians agreed that a floridly positive serology panel was not required to make the diagnosis of histoplasma. Due to the calcifications, the process seemed to be rather long-standing, however, her presentation was relatively acute (past 2 months) and had, in fact, developed new calcifications over the course of a few weeks on CT. Therefore, it is difficult to say if this was entirely acute or something acute on top of a chronic process. She grew up in [**State 4260**] so could have been exposed to histo decades ago. One possible explanation proposed was that the calcified subcarinal node was chronic, but had enlarged and ruptured, leading to acute inflammation, fevers, chest pain, and protrusion of and subsequent growth of the broncholith into the airway that led to her hemoptysis. After extensive discussion, decision was made to treat with itraconazole empirically despite the negative serologies for the reasons above. Per ID, some people with mediastinal granuloma will respond to the therapy and experience shrinkage of the nodes. She was started on itraconazole and counseled on proper use and potential interactions. She will follow up with her PCP, [**Name10 (NameIs) **] for repeat bronchi in 6 weeks, CT [**Doctor First Name **] in 3 weeks, and ID for routine blood tests on itraconazole. She felt well at the time of discharge. # PNA: due to fevers and new ground glass opacities and consolidations on CT, pt was suspected to have a post-obstructive PNA in the setting of compressive hilar lymphadenopathy. She was given a 5 day course of levofloxacin. Her fevers had resolved and she felt better. # Coagulopathy: pt had slight elevation of INR in house, thought to be nutritional deficiency [**12-24**] prolonged illness. She was vitamin K in the MICU and her INR normalized. # Headache: pt complained of chronic HA while in house. She states the HA began about 2 months ago and was present before the first hospitalization. At that time she had a CT sinus that was negative and an LP which was negative. Due to the chronic nature of her [**Last Name (LF) **], [**First Name3 (LF) **] MRI was obtained during this hospitalization to rule out CNS disease and was normal. She variably described it as a facial pain on the right vs bifrontal ache. She was tried on gabapentin due to suspicion for trigeminal neuralgia for the right facial pain but this did not improve her symptoms. She had also tried tylenol, NSAIDs, fiorecet, and oxycodone throughout her hospitalization to little effect. Ultimately no cause was identified and it was thought that this may be [**12-24**] chronic illness/inflammatory state with a possible rebound component in the setting of frequent analgesic use. TRANSITIONAL ISSUES: - follow up final pathology special stains and universal PCR for bacteria, fungus, and virus on biopsy specimen - cont itraconazole for 4-6 months per ID with routine blood work per their recs - follow up with CT surgery in 3 weeks - follow up with IP for repeat bronchoscopy in 6 weeks (may [**2116**]) - repeat CT chest in 3 months ([**2117-5-23**]) - repeat echocardiogram in 6 months ([**2117-8-23**]) - follow up for improvement of HA and consider withdrawal of all pain medication if suspect rebound HA Medications on Admission: - Omeprazole 20mg daily - Motrin prn Discharge Medications: 1. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO as directed for 6 months: Take 2 tabs three times a day until the evening of [**2117-3-7**]. Take 2 tabs twice daily after that. Disp:*120 Capsule(s)* Refills:*0* 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*21 Tablet(s)* Refills:*0* 3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*30 Powder in Packet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Mediastinal Granuloma secondary to Histoplasmosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you were coughing up blood. You were evaluated with bronchoscopy and found to have a calcified mass eroding into your bronchus, causing the bleeding. This was removed and the area was cauterized to prevent further bleeding. The tissue was sent to pathology and was unremarkable. It was also sent for special studies to evaluate for infection, which are pending. It is most likely that this was caused by histoplasmosis, so you were started on itraconazole to treat this. You should always take this medication with something acidic, such as coke AND [**Location (un) 2452**] juice (alternatively you could drink orangina), to improve the absorption. You should avoid alcohol while on this medication, because it can be toxic to your liver. Do not start ANY other medications while you are on itraconazole without talking to your doctor due to the high risk of medication interactions on this. Your new medication list is attached. Please note that omeprazole has been stopped. Followup Instructions: Please follow up with your primary care doctor in one week. Please follow up in the Interventional Pulmonary clinic for repeat bronchoscopy in 6 weeks. Please follow up with Dr. [**Last Name (STitle) 7343**] in CT surgery in [**12-25**] weeks. Please repeat CT chest in 3 months and repeat echocardiogram in 6 months. Please follow up with infectious disease as listed below. Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 3373**] (Interventional Pulmonology): [**Telephone/Fax (1) 3020**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7343**] (Cardiothoracic Surgery): [**Telephone/Fax (1) 87085**] Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] ([**Hospital3 **]): [**Telephone/Fax (1) 2010**] The following appointments have already been made for you: Department: INFECTIOUS DISEASE When: FRIDAY [**2117-3-19**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2117-4-15**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**] (PULMONARY) Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Unit No: [**Numeric Identifier 75189**] Admission Date: [**2175-8-29**] Discharge Date: [**2175-10-11**] Date of Birth: [**2175-8-29**] Sex: M Service: NB [**Known lastname **] was born at 30 5/7 weeks gestation to a mother with pregnancy-induced hypertension and intrauterine growth retardation, for which she was induced. MATERNAL HISTORY: Mother is a 39-year-old, gravida 2, para 0 now 1. Expected date of delivery was [**2175-11-2**]. Maternal prenatal screens were as follows: Blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Mother has history of hypertension and gastroesophageal reflux. She had a Nissen fundoplication done. Baby had prenatal diagnosis of intrauterine growth retardation at 10- 15 percentile, AFI and BPP within normal limits. This was an IVF pregnancy. Mother had a complete course of betamethasone prior to delivery. She delivered via induced vaginal delivery for pregnancy induced hypertension and IUGR. Mother received intrapartum antibiotics, and artificial rupture of membranes was done 30 minutes before delivery, yielding clear amniotic fluid. Infant had nuchal cord x2. Infant was initially hypotonic, cyanotic. He had some respiratory effort. Heart rate was more than 100. He was warmed, dry, suctioned, stimulated and facial CPAP was applied for 1 minute with FIO2 60%-70%. Color improved. Respiratory effort improved but infant still had respiratory distress with retractions. Infant was intubated in delivery room with 2.5 ET tube. Tone and color improved, and oxygen requirement decreased to 30%. Apgars were 6 and 8 at one and five minutes. He was then admitted to the NICU without problems. At admission to the NICU his birth weight was 1,220 grams, this is in the 50 percentile; and 40.5 cm, this is in the 50 percentile; and head circumference was , this is in the 25th percentile. PHYSICAL EXAMINATION AT DISCHARGE: Weight on [**10-17**] is 2,345 grams. Baby appears well, no apparent distress, active. Vitals are stable. HEENT: He is normocephalic, no dysmorphic features. Anterior fontanelle soft, flat. Ears normal. Palate intact. Eyes have minimal mucoid discharge. Neck: No masses. Chest is symmetric, no respiratory distress, good air entry and breath sounds clear bilaterally. Cardiovascular: Normal heart sounds, intermittent systolic soft murmur. Pulses: Peripheral pulses normal. Abdomen: Soft, nondistended, no organomegaly or masses. GU: Normal male genitalia status post circumcision. Skin: Pale, pink, well perfused. Extremities: Intact. Neurologic: Normal neuromuscular tone, normal symmetric reflexes and activity. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. Respiratory: Initially after intubation, the patient received 1 dose of surfactant. Then on the same day he was extubated to CPAP with pressure of 8 on which he stayed for 2 days. He then required nasal cannula O2 for 3 days before successfully weaning to room air. On day 2 he was started on caffeine for apnea of prematurity. Caffeine was discontinued at the corrected gestational age of 35 weeks as his spells were resolving. He continued to have intermittent apnea/bradycardia, but his last episode was on [**10-12**], five days prior to discharge. 2. Cardiovascular: He was hemodynamically stable throughout his stay with normal blood pressure and heart rate. 3. Fluids, electrolytes, nutrition: He was initially started on D10 IVF by peripheral line, then parenteral nutrition. NG feeds were started concurrently and slowly advanced to full enteral volumes by day of life 8. When he reached full feeds, he was started on iron and vitamin E. He was started on breast milk and Premature Enfamil 20 and advanced to a caloric density of 28 calories/ounce. Prior to discharge, his calories were lowered back to 26 calories/ounce. He had some feeding intolerance manifested by occasional spitting up which has now resolved. Currently he is feeding p.o. ad lib breast milk or Enfamil 26 and breastfeeding with a minimal volume of 140 mL/kg/day, and he is on additional iron and multivitamin. 4. GI: Maximal bilirubin was on day 2 of life 6.5 total and 0.3 direct. He was on phototherapy for 3 days. Last bilirubin level was 3.1 total, 0.3 direct on day 9 of life. 5. Infectious disease: He was started on empiric Ampicillin and Gentamicin on admission to the NICU due to prematurity, respiratory distress, and unknown maternal GBS status. The antibiotics were discontinued after 48 hours due to negative blood culture. 6. Hematology: Initial hematocrit at admission was 37%. He did not require any blood transfusion. Most recent hematocrit was 25.2% with 3.5% reticulocytes on [**10-10**]. 7. Neurology: His first head son[**Name (NI) **] done on [**9-5**] in the first week of life and was normal. Repeat head son[**Name (NI) **] on [**9-29**] at 1 month was also normal. Neurological exam was normal throughout his stay. 8. Audiology: Hearing screening was performed with automatic auditory brainstem responses and he passed bilaterally. 9. Ophthalmology: Eyes were examined most recently on [**2175-10-10**], and the result was mature retinas bilaterally. Follow-up was recommended in 9 months. CONDITION AT DISCHARGE: Stable. [**Known lastname **] will be discharged home in a car seat with his parents. His pediatrician is [**First Name5 (NamePattern1) 12584**] [**Last Name (NamePattern1) 63994**] and the telephone number is [**Telephone/Fax (1) 75190**]. RECOMMENDATIONS AT DISCHARGE: [**Known lastname **] will be discharged home on breast milk or Enfamil 26kcal/oz and breastfeeding ad lib on iron and multivitamin supplements. He had a car-seat test done and passed. Newborn Screen repeat was done on [**9-15**]. He received a hepatitis B vaccine on [**9-30**]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria: Born at less than 32 weeks, born between 32 and 35 weeks with 2 of he following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, chronic lung disease or hemodynamically significant CHT. 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 again influenza is recommended for household contacts and out of home caregivers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but few than 12 weeks of age. FOLLOWUP: Followup appointments recommended are with his PMD, Dr. [**First Name8 (NamePattern2) 12584**] [**Last Name (NamePattern1) 363**], phone number [**Telephone/Fax (1) 63996**], 2-3 days after discharge and with the ophthalmologist in 9 months. DISCHARGE DIAGNOSES: 1. Prematurity 30 5/7 weeks. 2. Rule out sepsis - resolved. 3. Respiratory distress syndrome - resolved. 4. Hyperbilirubinemia - resolved. 5. Apnea of prematurity - resolved. 6. Anemia of prematurity. 7. Bilateral nasolacrimal duct obstruction. [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 72747**] Dictated By:[**Name8 (MD) 72748**] MEDQUIST36 D: [**2175-10-10**] 16:46:57 T: [**2175-10-11**] 10:46:15 Job#: [**Job Number 75191**]

Admission Date: [**2130-9-5**] Discharge Date: [**2130-9-21**] Date of Birth: [**2081-3-4**] Sex: F Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: End Stage Renal Disease Secondary to FSGS, s/p two prior renal transplants. Major Surgical or Invasive Procedure: 1) s/p Living Unrelated Renal Transplant 2) s/p Exploratory Laparotomy for delayed graft function 3) s/p Transplant Nephrectomy following hyperacute rejection 4) s/p Attempted Right Upper Extremity AV Graft placement History of Present Illness: Ms. [**Known lastname **] is a 49 year old female with end-stage renal disease secondary to FSGS. She previously received 2 transplants. The first transplant was performed in [**2110**] and lasted approximately 10 years before it was lost secondary to allograft nephropathy. Her second transplant occured in [**2122**] and failed 7 years later secondary to chronic allograft nephropathy. She has been on dialysis since [**2129-4-26**]. She reports no prior problems with [**Name2 (NI) 102836**]. Both of her renal transplants are still in place. She presented with an ABO-incompatible donor (her husband), and under a live donor swap program, presents now for a living donor transplant from a compatible donor at another institution. Past Medical History: Thalassemia minor. S/p MI in [**2129**] requiring PTCA with stents placed S/p parathyroidectomy ([**2129-12-26**]) Avascular necrosis of the both hips requiring surgery. H/o atrial fibrillation Hypertension S/P C-section CAD; s/p MIl; PTCA of Mid RCA ([**2122**]) c.b stenosis s/p re-angioplasty, [**12/2129**]; s/p LAD stent placement Social History: The patient was born and raised in [**Location (un) 2624**], MA. She has been married for 25 years and has one 23-year-old daughter. She lives in [**State 1727**]. She does not drink alcohol and does not use any illicit drugs and never has. She has not smoked since high school. Physical Exam: General: Well nourished, well developed female in no apparent distress. Temp: 99.2, P83, R16, 02Sat: 97% BP: 95/65. Lungs: Clear to auscultation. Heart: Regular rate and rhythm. Abdomen: Soft, non-tender, non-distended. Both transplants are present in both the right and left lower quadrant. There is no evidence of graft tenderness or swelling. Vascular: Femoral pulses are 2+ equal bilaterally Ex: No peripheral edema. Pertinent Results: [**2130-9-5**] 09:35AM BLOOD PT-14.3* PTT-27.8 INR(PT)-1.3 [**2130-9-5**] 09:38AM BLOOD Glucose-163* Lactate-1.9 Na-138 K-4.7 Cl-103 [**2130-9-5**] 09:38AM BLOOD Hgb-10.8* calcHCT-32 Brief Hospital Course: The patient presented with an ABO-incompatible donor, and under a live donor swap program, the patient was taken to the operating room for live donor transplant from an ABO- compatible donor from another institution on [**2130-9-5**]. Pre-Op class II antigen was weekly positive so the patient was given IvIG in addition the usual thymogloblin, cellcept, and solumedrol prior to implantation. The operative course was significant for a warm ischemia time of <1 hours. 6 L fluids intraop, 300 cc EBL. 35 cc urine made on table. Immediately following arrival the the PACU the patient was noted to be oliguric, a renal transplant ultrasound was obtained showing a normal-appearing transplant kidney. There was reversal of diastolic flow in keeping with high organ resistance, concerning for acutre rejection. The patient was therefore taken back to the operating room approximately 8 hours following her arrival the the PACU where she underwent an exploratory laparotomy, renal vein thrombectomy, and renal transplant core biopsy. Frozen section revealed a dense eosinophilic material consistent with thrombi within glomerular capillaries, neutrophils within glomerular capillaries, and a neutrophilic infiltrate within interstitium with no acute interstitial hemorrhage or arteritis seen. Since these finndings were worrisome for hyperacute rejection, the patient was plasmapheresed immediately post-op, treated with IV IG, ATG, and Solumedrol. Over the ensuing days she received plasmapheresis, IVIG for a total of 5 days, thymoglobulin, and one dose of rituximab. Daily ultrasounds demonstrated persistently elevated RIs, with flow to the kidney. The patient required multiple runs of dialysis secondary to volume overload. On POD3 she developed atrial fibrillation during dialysis run secondary to fluid shifts. She was treated with Amiodarone and subsequently converted to NSR. On POD#7 a renal biopsy was obtained showing renal parenchyma with near-total hemorrhagic coagulative necrosis. Foci of acute inflammation / organization were noted. Several small arteries showed significant intimal fibroplasia. Given the biopsy findings, and failure of the kidney to produce urine, the patient was taken back to the OR on POD9 for an exploratory laparotomy with transplant nephrectomy. The kidney appeared firm but dusk, and histologic evaluation revealed almost no viable tissue. Over the ensuuing days, the patient recovered from the operation, and continued HD. On [**2130-9-20**] a right arm AV graft was attempted, but aborted secondary to extensive arterial disease. On the night prior to discharge, the patient was found to be febrile in the dialysis unit. She also complained of swelling and pain at the site of her PIC line in the left arm. This was therefore removed and the patient defervescred and she remained afebrile for the remainder of her time here. She was therefore discharged in the evening on HD#17 Medications on Admission: Neurontin, Allopurinol, Synthroid, Lipitor, Protonix, aspirin, Plavix, Venopril, Renagel, Discharge Medications: 1. 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* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD (every other day) for 3 months. Disp:*45 Tablet(s)* Refills:*0* 6. Synarel 2 mg/mL Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (). Disp:*60 Spray* Refills:*2* 7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours) for 2 weeks. Disp:*10 Patch 72HR(s)* Refills:*0* 9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*12 Injectors* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every four (4) hours: ; 500 mg with each meal, 1000 mg imbetween meals (total 6 times/day) . Disp:*180 Tablet, Chewable(s)* Refills:*2* 13. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Living unrelated renal transplant Hyperacute rejection of renal transplant Nephrectomy of transplanted kidney End stage renal disease secondary to focal segmental glomerular sclerosis Thrombocytopenia secondary to immunosupression Hypocalcemia Coranary Artery Disease Post-Operative Atrial Fibrillation Thallasemia Minor combined with Blood Loss anemia requiring multiple blood transfusion Discharge Condition: Excellent Discharge Instructions: 1. Please monitor for the following: fever, chills, nausea, vomiting, inabilitity to tolerate food/drink. If any of these occur, please contact your physician [**Name Initial (PRE) 2227**]. 2. Do not drive while taking narcotics. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] (TRANSPLANT) TRANSPLANT CENTER (NHB) Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2130-9-28**] 2:20 Provider: [**Name10 (NameIs) 970**],[**Name11 (NameIs) 971**] TRANSPLANT CENTER (NHB) Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2130-10-3**] 2:40

Admission Date: [**2187-7-25**] Discharge Date: [**2187-7-30**] Date of Birth: [**2130-6-17**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 57 year old male patient with known history of coronary artery disease, who underwent a previous angioplasty with stent to the left anterior descending in [**2183**]. He has had a recent increase of shortness of breath and fatigue and his cardiac catheterization on [**2187-7-25**], revealed a 70% left main occlusion with normal left ventricular function. He is referred for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Coronary artery disease with previous percutaneous transluminal coronary angioplasty. 2. Atrial fibrillation times five years. 3. 70 to 100 pack year smoking history, quit two years ago. 4. Asthma. 5. Chronic obstructive pulmonary disease. 6. Daily ETOH intake of two to six beers per day. PREOPERATIVE MEDICATIONS: 1. Coumadin 5 mg p.o. once daily. 2. Ramipril 10 mg p.o. once daily. 3. Inderal 20 mg p.o. twice a day. 4. Lipitor 10 mg p.o. once daily. 5. Aspirin 81 mg p.o. once daily. 6. Coenzyme Q10, 60 mg p.o. once daily. ALLERGIES: The patient states no known drug allergies but has had previous intolerable side effects from beta blockers, which include insomnia, fatigue and impotence. LABORATORY DATA: Preoperative laboratory values were unremarkable with the exception of baseline INR of 1.5. Preoperative chest x-ray revealed chronic obstructive pulmonary disease with bullous changes. Preoperative electrocardiogram showed atrial fibrillation with no acute ischemia. PHYSICAL EXAMINATION: Preoperatively, his physical examination was unremarkable. HOSPITAL COURSE: The patient was taken to the operating room on [**2187-7-26**], where he underwent an off pump coronary artery bypass graft times two with left internal mammary artery to the left anterior descending and saphenous vein to the obtuse marginal. Postoperatively, he was on Neo-Synephrine, Nitroglycerin and Propofol intravenous drip. He was transported from the operating room to the Cardiac Surgery Recovery Unit in good condition. On the day of surgery, the patient was weaned from mechanical ventilation and extubated. The patient had some ventricular arrhythmias through the course of the night of surgery felt to be related to his pulmonary artery catheter. Once this was removed, he had no further ventricular arrhythmia. The patient remained on Neo-Synephrine drip for a few hours the following day postoperative day one, but ultimately that was weaned off with blood pressure above 90 systolic and the patient was asymptomatic tolerating that well. The patient had his chest tubes removed on peripheral pulses day one and begun beta blockers and diuretic. The patient began cardiac rehabilitation on postoperative day two, began to ambulate on the telemetry floor, was placed on intravenous Heparin drip due to his chronic atrial fibrillation and Coumadin was initiated the evening of postoperative day two. The patient progressed with cardiac rehabilitation over the next couple of days and has remained hemodynamically stable in atrial fibrillation with a resting heart rate of about 100. His beta blocker was increased. His Coumadin was given at his preoperative dose of 5 mg p.o. once daily His INR had not yet bumped. After discussion with Dr. [**Last Name (STitle) 1537**] and the patient, it was felt appropriate for the patient to have his Heparin discontinued and allow him to be discharged home on his preoperative Coumadin dose. CONDITION ON DISCHARGE: Neurologically, the patient is intact with no apparent neurologic deficits. On pulmonary examination, his lungs are clear to auscultation bilaterally. Cardiac examination is irregular rate and rhythm. His abdomen is obese, soft, benign. His sternal incision is clean and dry with no erythema and no sternal drainage. He does, however, have a small amount of serosanguinous drainage oozing from his chest tube site. MEDICATIONS ON DISCHARGE: 1. Lopressor 50 mg p.o. twice a day. 2. Aspirin 81 mg p.o. once daily. 3. Percocet one to two tablets q4-6hours p.r.n. pain. 4. Ibuprofen 400 mg p.o. q6hours p.r.n. pain. 5. Lasix 20 mg p.o. twice a day times seven days. 6. Potassium Chloride 20 meq twice a day times seven days. 7. Lipitor 10 mg p.o. once daily. 8. Coumadin 5 mg p.o. today, [**2187-7-30**], tomorrow [**2187-7-31**], and then he is to have an INR checked and the results are to be called to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**], whose office will dose continued Coumadin. They have been contact[**Name (NI) **] and have agreed to do this and the patient has the appropriate information regarding Coumadin dosing to be done by his primary care physician. DISCHARGE STATUS: The patient is discharged in good condition. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass graft. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2187-7-30**] 14:20 T: [**2187-7-30**] 17:54 JOB#: [**Job Number 17678**]

Admission Date: [**2115-5-30**] Discharge Date: [**2115-6-4**] Date of Birth: [**2061-3-22**] Sex: F Service: ADMISSION DIAGNOSIS: Breast cancer. DISCHARGE DIAGNOSES: 1. Breast cancer. 2. Status post [**Last Name (un) 5884**] on the right, mastectomy. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman who had a recent diagnosis of right breast cancer. Core biopsy returned as invasive carcinoma. The patient had a lumpectomy and sentinel node biopsy which were negative but with positive margins. Patient went back for re-excision and again had positive margins. The patient is now consulted for a right mastectomy with [**Last Name (un) 5884**], free flap reconstruction. The patient understands all surgical alternatives, and has agreed to this decision. PAST MEDICAL HISTORY: 1. Mitral valve prolapse. 2. Status post C section. 3. Status post right breast biopsy. 4. Status post right lumpectomy with sentinel node. ALLERGIES: Penicillin and sulfa. MEDICATIONS: 1. Vitamins. 2. Calcium. 3. Antioxidant. PHYSICAL EXAMINATION ON ADMISSION: Vital signs stable, afebrile. General: Is in no acute distress. Chest was clear to auscultation bilaterally. Cardiovascular is regular, rate, and rhythm without murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended with no masses or organomegaly. Extremities are warm, noncyanotic, nonedematous x4. Neurologic is grossly intact. HOSPITAL COURSE: The patient was admitted for semielective mastectomy with [**Last Name (un) 5884**] on the right reconstruction. The patient was taken to the operating room on [**2115-5-30**], and had the procedure performed as outlined above. The patient tolerated the procedure well without complication in the postoperative course, she was immediately placed in the Intensive Care Unit for close monitoring. The patient had flap checks per protocol q 30 minutes for the first 12 to 24 hours followed by q1 hour followed by q2 hour checks. The flap seemed to be doing well, and a Doppler probe was left close to the venous outflow postoperatively. Flap was seen to be doing very well, and the patient was transferred to the floor on postoperative day #3. Subsequent to this, the patient had an unremarkable hospital stay, and the Doppler probe was removed on postoperative day #4, the patient subsequently discharged to home. DISCHARGE CONDITION: Good. DISPOSITION: Home. DIET: Adlib. MEDICATIONS: Resume all home medications. 1. Magnesium hydroxide. 2. Milk of magnesia prn. 3. Percocet 5/325 [**1-24**] q4-6h prn. 4. Colace 100 mg [**Hospital1 **]. 5. Clindamycin 300 mg q6 x7 days. 6. Enteric coated aspirin 81 mg q day. DISCHARGE INSTRUCTIONS: The patient is to followup with Dr. [**First Name (STitle) **] in his clinic within one week. No heavy lifting. Patient should return if any problems with either incision sites or any signs of cellulitis or infection. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2115-6-3**] 09:28 T: [**2115-6-3**] 11:56 JOB#: [**Job Number 49686**]

Admission Date: [**2158-2-1**] Discharge Date: [**2158-2-7**] Date of Birth: [**2158-2-1**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 30106**] #1, ([**Known lastname 4489**]) is a 1665 gram baby girl, [**Name2 (NI) **] at 31 and 6/7 weeks gestational age to a 36 year old, Gravida I, Para 0 to 1 mother with prenatal screens blood type B positive, antibody negative, group B strep positive, hepatitis B surface antigen negative, RPR nonreactive. [**Hospital 37544**] medical history was notable for myomectomy for fibroids. There was a normal amniocentesis for both twins. Twin #2 had a prenatal ultrasound suggestive of club foot. The prenatal course was remarkable for spontaneous di/di twinning with concordant growth and diet controlled gestational diabetes. Prior preterm labor was treated with Magnesium Sulfate and bed rest and the mother was betamethasone complete on [**2158-1-3**]. There was premature rupture of membranes nine hours prior to delivery. Mother received two doses of Terbutaline and was started on intrapartum Penicillin. A Cesarean section was performed for malpresentation and changing cervix. This twin emerged with strong cry and had Apgars of seven and eight at one and five minutes. PHYSICAL EXAMINATION: Notable for a weight of 1665 grams (50th percentile); length 42 cm (50th percentile); head circumference 30 cm (50th percentile). Examination was remarkable for a preterm infant in mild to moderate respiratory distress. Pink color. Soft, anterior fontanel, normal facies, intact palate. Mild retractions. Coarse breath sounds with fair air entry. No murmur. Femoral pulses present. Flat, soft, nontender abdomen without hepatosplenomegaly. Normal external genitalia. Normal perfusion. Normal tone and activity. HOSPITAL COURSE: 1.) Respiratory: Baby had initial respiratory distress, likely retained lung fluid versus surfactant deficiency. She was placed on C-Pap of six and weaned to room air by 24 hours of life. Subsequently, she has been comfortable in room air, saturating greater than 95 to 97%. She has not had significant apnea of prematurity and is not on caffeine. 2.) Cardiovascular: [**Known lastname 4489**] has been stable from a cardiovascular standpoint from admission. No murmurs have been noted. 3.) Fluids, electrolytes and nutrition: [**Known lastname 4489**] was initially npo and received D-10 at 80 cc per kg per day and was transitioned to peripheral parenteral nutrition. She was started on enteral feeds at around 24 hours of life and has advanced easily to full enteral feeds at 150 cc per kg per day. She has been advanced from premature Enfamil 20 to 22 calories per ounce. All her feeds are p.g. At discharge, her weight was 1,615 grams (down from birth weight of 1665 grams). 4.) Gastrointestinal: No active issues. 5.) Hematology: Maternal blood type was B positive; antibody negative. Baby's blood type has not been recorded. Maximum bilirubin was on [**2158-2-4**] at 7.1. No phototherapy was initiated and the bilirubin was decreased to 6.1 on [**2158-2-6**]. 6.) Infectious disease: Initial CBC showed a white count of 12.6 with 5% polys, 85% lymphocytes, 7% monocytes, 0 bands. Hematocrit was 51. Platelets were 381. Baby was started on ampicillin and gentamicin which were discontinued at 48 hours, with negative blood cultures. There have been no other active infectious disease issues. 7.) Neurology: Cranial ultrasound has not yet been performed but should be done in the next week. 8.) Sensory: Hearing screening has not yet been performed. Ophthalmology examination has also not yet been performed and given the gestational age at 31 and 6/7 weeks, this should be considered in [**3-2**] weeks. 9.) Routine health care maintenance: Newborn state screen was sent on [**2158-2-4**] with results pending. No immunizations have been given. CONDITION AT TRANSFER: Stable. DISCHARGE DISPOSITION: [**Hospital **] Hospital, Level II Neonatal Intensive Care Unit. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 52636**] at HVAMPBD. CARE/RECOMMENDATIONS: 1. Feeds at discharge are premature Enfamil at 22 calories per ounce, currently advancing on caloric density. 2. Medications: None at this time. 3. Car seat testing has not yet been done but should be done prior to discharge. 4. State newborn results are pending. 5. Synagis-RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1.) [**Month (only) **] at less than 32 weeks. 2.) [**Month (only) **] between 32 and 35 weeks with two of three of the following: Day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, school age siblings. 3.) 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. FOLLOW-UP APPOINTMENTS: No follow-up appointments have yet been scheduled. DISCHARGE DIAGNOSES: 1. Prematurity at 31 and 6/7 weeks gestational age. 2. Mild hyperbilirubinemia. 3. Immature feeding. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**] Dictated By:[**Name8 (MD) 52637**] MEDQUIST36 D: [**2158-2-7**] 08:22 T: [**2158-2-7**] 08:55 JOB#: [**Job Number 52638**]

Admission Date: [**2181-7-12**] Discharge Date: [**2181-7-17**] Date of Birth: [**2126-6-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: right flank pain Major Surgical or Invasive Procedure: right sided thoracocentesis (-2200 mL fluid) History of Present Illness: 55 YO female with metastatic adenocarcinoma with unknown primary on C2D1 gemcitabine/irinotecan and with malignant pleural effusions presented to [**Hospital1 18**] ED with severe R flank pain, radiating to chest. Patient reports pain was [**9-19**] in severity. She was otherwise asymptomatic, denying shortness of breath or coughing at presentation. She experienced R flank pain previously for which she had applied a fentanyl patch with adequate pain control. Of note, she has known lytic bone lesions to the R pelvis. She reports that she had not applied the fentanyl patch to the R flank recently as pain control had improved. . The patient's cancer initially presented as syncope and further work-up revealed pericardial/pleural effusion [**2181-5-10**]. The pleural fluid revealed metastatic adenocarcinoma and the pericardial fluid a well-differentiated mucinous adenocarcinoma. The patient has had 3 recent admissions: on [**5-16**] for dyspnea and [**6-6**] and [**6-14**] for dizziness/syncope. On admission [**6-6**], the patient had pericardiocentesis and balloon pericardiotomy with removal of 520 cc of bloody fluid. [**Month/Year (2) **] on [**6-4**] showed stable loculated pericardial effusion. [**Month/Year (2) **] [**6-11**] (EF>55%) suggestive of pericardial constriction, although unchanged in size since prior admission. . During admission on [**6-14**], cardiology team saw the patient and recommended trial of low dose beta blocker for rate control; a pericardial window was not performed because the effusion was determined to be stable and symptoms thought to be related to dehydration and tachycardia. Subsequent CT of the torso did not reveal a primary source but did reveal bony lytic lesions in the right ischium and bilateral ilia concerning for metastatic disease. She also underwent an upper and lower endoscopy without evidence of a primary lesion. Considering pericardial and pleural fluid pathology, a subtle gastric or pancreatico/biliary tumor was suspected and the patient was started on gemcitabine/irinotecan. Her last dose of chemotherapy was yesterday 8/2 per patient. Chemotherapy was begun on [**2181-6-15**]. . Pt. presented to ED with tachycardia above baseline in 130s to 140s. Patient has h/o resting tachycardia 115-120. Electrocardiogram in the ED showed sinus tachycardia unchanged from prior. Radiography showed reaccumulation of pulmonary edema and CT of the chest showed no acute changes. A therapeutic thoracentesis was performed of 2200 mL of dark maroon right pleural fluid. In addition, after the procedure, the patient complained of increased shortness of breath increased from baseline, patient's O2 saturation was in the 90s. The patient was administered Lasix (40 mg X1) in the ED with subsequent improvement of respiratory function. In ED patient was administered vancomycin 1 g, ondasetron 2 mg twice, and 4 doses of morphine sulfate 4 mg. Patient was admitt-ed to ICU for pain control and management of tachycardia in setting of pleural effusions. Past Medical History: - Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in [**2162**]. - GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age 50, normal pap's per patient - Hypertension. - History of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/[**2178**]. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral DVT - adenocarcinoma of unclear primary Social History: She works as a nursing assistant. Lives with her husband, who keeps very early hours, working at the [**Location (un) **] food market. Children are 18 and 19. Family History: Her father died of stomach cancer at age 72. Mother died of colon cancer at age 63. She is the 10th of 13 children. She has lost 3 siblings to motor vehicle accidents. Physical Exam: Gen: NAD HEENT: Sclera anicteric. PERRL, EOMI. No oral lesions Neck: Supple CV: Tachycardic, regular, no M/R/G. Chest: Bilaterally decreased LL BS L>R to [**12-13**] way up. R sided ronchi. ABD: Soft, NND. No HSM or tenderness. Soft subcutaneous firm mobile nodule in midepigastrium (at site of Lovenox injection sites per patient). Ext: No cyanosis or edema Neuro: non-focal, CN II-XII grossly intact, moves all extremities well Skin: no rash or petechiae noted Pertinent Results: [**2181-7-11**] 11:40AM GRAN CT-1260* [**2181-7-11**] 11:40AM PLT COUNT-521* [**2181-7-11**] 11:40AM WBC-2.7* RBC-4.04* HGB-13.2 HCT-37.9 MCV-94 MCH-32.5* MCHC-34.7 RDW-17.4* [**2181-7-12**] 12:17PM LACTATE-1.7 [**2181-7-12**] 12:22PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2181-7-12**] 12:22PM ALT(SGPT)-98* AST(SGOT)-52* CK(CPK)-63 ALK PHOS-148* AMYLASE-30 TOT BILI-0.8 [**2181-7-12**] 12:22PM LIPASE-74* [**2181-7-12**] 12:22PM GLUCOSE-119* UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 . C.dif - negative Blood and urine cx: no growth . CXR ([**7-11**]): IMPRESSION: Increased size of now large right pleural effusion and minimally increased now moderate left pleural effusion. . Chest CT ([**7-12**]) IMPRESSION: 1. Diffuse peribronchovascular opacity with air bronchograms involving the right middle and right lower lobes post thoracentesis. Given the rapid evolution of this process, findings likely represent pulmonary edema. Pulmonary hemorrhage or multifocal pneumonia is less likely. Close interval radiographic follow up recommended. 2. Large left pleural effusion with adjacent compressive atelectasis. 3. Minimal pericardial fluid. 4. No pneumothorax or reaccumulation of the right pleural effusion. CXR ([**7-15**]): IMPRESSION: 1. Unchanged moderate left-sided pleural effusion. 2. Patchy opacities at the right lung base have cleared since the prior examination, likely representing pulmonary edema given its rapid improvement; mild persistent residual pulmonary edema. Brief Hospital Course: The patient is a 55 y/o woman with metastatic adenocarcinoma of unknown primary (likely discrete gastric or pancreaticobiliary ca) admitted with tachycardia in the setting of malignant pericardial effusions and uncontrolled pain. . # Malignant Effusion - The patient presented for outpatient therapeutic thoracocentesis [**7-12**] (done for worsening SOB) with removal of 2200 mL R sided fluid, followed by excruciating pain at thoracotomy site. The dyspnea after her procedure was likely a result of reexpansion edema, which was reflected on her chest X-ray. She was initially treated in the intensive care unit with oxygen therapy as well as IV Lasix and closely monitored. No infectious etiology was identified. It was decided that thoracentesis was not warranted as her pleural effusion was significantly smaller after the procedure. Her respiratory distress rapidly improved with diuresis and she was soon back to baseline (requires home O2). . # Mucinous adenocarcinoma of unknown primary: The patient began chemotherapy on [**2181-6-15**] with Gemzar and CPT-11 for metastatic disease. She did not experience significant nausea during hospitalization, but continued to have diarrhea related to her chemotherapy which was treated with Lomotil. . # DVT/PE - She is s/p IVC filter placement on [**2181-5-30**] s/p DVT of common femoral. She was continued on lovenox therapy. . # Pain - Patient had known lytic lesions, with high risk of pathologic fracture. Bilateral hip xray on [**6-12**] demonstrated no progression of known metastatic lesions. Orthopedics were consulted on prior admisson and believe chemotherapy should proceed prior to any radiation therapy to the hip. Also with pain at site of thoracentesis. She was treated with home fentanyl 25mcg patch for pain control, home lidocaine patch with morphine for breakthrough pain Medications on Admission: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every 6-8 hours as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Nausea. 7. Megace Oral 40 mg/mL Suspension Sig: Ten (10) mL PO once a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every [**3-16**] hours as needed for diarrhea. 11. Nebulizer for home use Please provide one nebulizer and associated equipment. 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer treatment Inhalation every six (6) hours. Disp:*120 mL* Refills:*2* 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation every six (6) hours. Disp:*120 mL* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: 1.) Malignant pleural effusion 2.) Mucinous adenocarcinoma of unknown primary Discharge Condition: fair Discharge Instructions: You were in the hospital because of pain and difficulty breathing after your thoracocentesis (or pleural fluid drainage). You were given medications to help get fluid off of your lungs and pain medications. When you leave the hospital, continue to take all medications as prescribed and keep all health care appointments. If you feel worsening shortness of breath, chest pain, fever, chills, abdominal pain or if your condition worsens in any way, seek immediate medical attention. Followup Instructions: You have the following appointments with Dr.[**Name (NI) 8949**] office on [**7-25**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13145**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 10:00

Admission Date: [**2133-10-22**] Discharge Date: [**2133-10-29**] Service: CCU CHIEF COMPLAINT: The patient was med flighted to [**Hospital1 346**] for cardiac catheterization. HISTORY OF PRESENT ILLNESS: The patient is an 88 year-old female with a history of coronary artery disease status post inferior myocardial infarction in [**2125**], history of hypertension and history of hypercholesterolemia who presented to [**Hospital3 1280**] with complaint of shortness of breath and substernal chest pain that had lasted for two days. She presented on [**2133-10-22**]. She describes this as a burning sensation such as "breathing in cold air." There were no associated symptoms of nausea, vomiting, diaphoresis or palpitations. The pain was worse while lying down. She had no history of angina. There is a question of myocardial infarction versus myopericarditis at [**Hospital3 1280**]. Her CK was found to be 92, which elevated to 137 then 142 with troponin elevations from 1.84 to 3.7 to 4.02. Cardiac catheterization at the outside hospital showed three vessel disease with 90% occlusion of the left anterior descending coronary artery and total occlusion of the right coronary artery. At this time the patient was med flighted to [**Hospital1 188**] and no further intervention was performed. The patient had a cardiac catheterization in [**2128-3-16**], which showed diffuse 50% obtuse marginal one stenosis at the stented site. The area was patent by angiography and IVUF. PAST MEDICAL HISTORY: Coronary artery disease status post inferior myocardial infarction, also with percutaneous transluminal coronary angioplasty and stent of the obtuse marginal one. The patient had a myocardial infarction in 11/96 and she was found to have a residual EF of 60%. She had question of congestive heart failure in the past and history of hypertension, history of hypothyroidism, history of hypercholesterolemia and diabetes. The patient also had a history of osteoarthritis status post left knee replacement. MEDICATIONS ON TRANSFER: Lopressor 50 mg po b.i.d., aspirin 325 mg po q.d., Lipitor 10 mg po q day, Levoxyl 150 mcg po q.d., Protonix 40 mg po q day, Colace prn and she was also on an intravenous nitroglycerin drip and intravenous heparin drip. ALLERGIES: Codeine. FAMILY HISTORY: The patient's sister died at 69 of a myocardial infarction. SOCIAL HISTORY: The patient had quit smoking thirty five years ago, but use to smoke one pack a day for approximately twenty four years. She had no history of alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs 95.0, 91, and blood pressure of 88/51 with an intraaortic balloon pump in place. General appearance, tired ill appearing female without much movement and in no acute distress. HEENT pupils are equal, round, and reactive to light and accommodation. Dry mucous membranes. No scleral icterus. Neck no JVD. No carotid bruits. Cardiac regular rate and rhythm. No murmurs appreciated. Distant heart sounds. Pulmonary distant breath sounds. Patient with very little air movement. Abdomen positive bowel sounds, soft, nontender, nondistended. Extremities no clubbing, cyanosis or edema. Very faint dorsalis pedis pulse and posterior tibial pulses. LABORATORIES ON ADMISSION: White blood cell count 12.6, hematocrit 30.4 and platelets 396. Coagulation studies showed an INR of 1.6 and PTT of 81.3. Electrolytes showed sodium 137, potassium 4.4, chloride 103, bicarbonate 22, BUN 45 and creatinine 1.9 with a glucose of 197. Cardiac enzymes drawn in the Coronary Care Unit showed a CK of 319, MB of 32 and troponin greater then 50. Electrocardiogram showed question of idioventricular rhythm, ST depressions in AVL, retrograde T waves and left bundaloid morphology. Cardiac catheterization showed elevated wedge pressure of 37 and otherwise findings of markedly increased filling pressures, left main with 30% diffuse disease. Left anterior descending coronary artery with 90% proximal occlusion with TIMI two flow after the balloon was inserted, 3.8 by 8 mm hepacoach sent, ramus to intermedius had the ability to rescue it. Renal function has minimization of contrast used. The patient has a diagnosis of cardiogenic shock with a PA saturation of 42%. Therefore an intraaortic balloon pump was placed. Th[**Last Name (STitle) 15937**]ssment and recommendations from the cardiac catheterization included anterior myocardial infarction with cardiogenic shock, aspirin and Plavix for thirty days at least, ace inhibitor when the creatinine stabilized, heparin half dose while on Integrilin for 24 hours and an intraaortic balloon pump. Dr. [**Last Name (Prefixes) **] of Cardiothoracic Surgery was also consulted. HOSPITAL COURSE: Given the above the patient was diagnosed with a large anterior myocardial infarction and cardiogenic shock. 1. Cardiac: Pump, the patient was continued on an intravenous nitroglycerin drip. She was continued on a lower dose of Metoprolol, which subsequently was discontinued. She was maintained on an intraaortic balloon pump for a day. She was prepared for a coronary artery bypass graft, however, this was not performed. Subsequently she was diuresed with Lasix for presumed congestive heart failure. She was started on ianatrops for one day, however, this was discontinued secondary to abnormal and occasional supraventricular tachycardias on telemetry. For ischemia she was continued on Plavix, aspirin and her heparin drip. The Integrilin drip was discontinued one day after catheterization. 2. Pulmonary: The patient had periods of apnea on her monitor prior to the catheterization. Subsequently she was sating about 95% on room air. 3. Endocrine: The patient had a question of diabetes mellitus and a history of hypothyroidism. Therefore she was maintained on an regular insulin sliding scale and continued on her Synthroid. The patient was also continued on Protonix and her heparin drip. Given the above the patient had some difficulty being weaned off the intraaortic balloon pump, however, this was achieved after days. The patient's Captopril dose was increased upwards. She was started on Hydralazine and that was titrated upwards. She was also put on Isordil and that was titrated upwards. However, the patient continued to experience significant congestive heart failure and it was the families decision given the severity of her congestive heart failure and her frequent episodes of supraventricular tachycardia and apnea that she be made comfort measures only. Therefore the patient was maintained on morphine. She was given multiple medications for her major complaint, which was cough and this very pleasant female died probably of supraventricular tachycardia on [**2133-10-29**] at 11:20 a.m. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Doctor First Name 15938**] MEDQUIST36 D: [**2133-11-26**] 11:07 T: [**2133-11-30**] 07:33 JOB#: [**Job Number 15939**]

Admission Date: [**2181-10-4**] Discharge Date: [**2181-10-9**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old woman with known aortic stenosis followed by echocardiogram for the past three years now with a narrowed aortic valve area of 0.6 cm square with a peak gradient of 111 and a mean gradient of 70. She had a cardiac catheterization done in [**Month (only) **] of this year, which showed severe AS, mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] pulmonary hypertension and clean coronary arteries with an aortic valve at 0.6 cm squared and a mean gradient of 54 with an EF of 75% now presents in preoperative area for aortic valve replacement. PAST MEDICAL HISTORY: 1. Aortic stenosis. 2. Sleep apnea, uses BiPAP at home. 3. Scarlet fever. 4. Appendectomy. 5. Tonsillectomy and adenoidectomy. MEDICATIONS PREOPERATIVELY: Aspirin 81 mg q.d. and Claritin 10 mg prn. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother died at age [**Age over 90 **] of natural causes and father died at age [**Age over 90 **] also of natural causes. SOCIAL HISTORY: She lives with her husband who also suffers from [**Name (NI) 2481**] disease. Tobacco use is positive. Seven cigarettes per day times 46 years and alcohol use is positive for three to four drinks per day. No other drug use. PHYSICAL EXAMINATION: Height is 5'7". Weight 183 pounds. Heart rate is 72 sinus rhythm. Blood pressure 169/74. Respiratory rate 20. General examination, healthy appearing elder woman in no acute distress. She reports that she is very active. She denies any history of chest discomfort or significant shortness of breath. Only mild dyspnea on exertion over the past year. Skin is intact with no lesions. HEENT pupils are equal, round and reactive to light with extraocular movements intact. Anicteric. Noninjected. Mucous membranes are moist with no lesions. Neck is supple with no JVD and no lymphadenopathy. Chest is clear to auscultation bilaterally. Heart sounds regular rate and rhythm with a 4 out of 6 blowing murmur radiating to the carotids. Abdomen is soft, nontender, nondistended. Positive bowel sounds. No hepatosplenomegaly. Extremities are warm and well profuse with no clubbing, cyanosis or edema. No varicosities. Neurologically is a nonfocal examination. She is alert and oriented times three. She moves all extremities. She follows commands. Cranial nerves II through XII are grossly intact. Positive sensation in all dermatomes and strength is 5 out of 5 in both upper and lower extremities. 2+ pulses bilaterally femorally. 1+ pulse bilaterally dorsalis pedis and posterior tibial, 2+ pulses in the radial bilaterally. A radiating murmur to the carotids both right and left. LABORATORY DATA PRIOR TO ADMISSION: White count 6.3, hematocrit 38.5, sodium 137, potassium 4.4, chloride 100, CO2 31, BUN 23, creatinine 0.8, glucose 164, INR 1.02. Electrocardiogram shows a sinus rhythm with a rate of 70. Normal intervals, .16, .8 and .38 with biphasic Ts in leads V2 and V3. HOSPITAL COURSE: On [**10-4**] the patient was a direct admit to the Operating Room where she underwent an aortic valve replacement. Please see the operating report for full details. In summary, she had an aortic valve replacement with a #21 [**Location (un) **] pericardial. The tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer she had an arteriole line, a Swan-Ganz catheter, ventricular and atrial pacing wires and mediastinal chest tubes. Her mean arterial pressure was 61. Her CVP was 9. She had a heart rate of 82 and a normal sinus rhythm. She was transferred on propofol infusion at 30 mcg per kilogram per minute. She did well in the immediate postoperative period. She was weaned from her propofol. Her anesthesia was reversed. She was then weaned from the ventilator and extubated shortly after arrival to the Cardiothoracic Intensive Care Unit. She remained hemodynamically stable overnight with a little bit of nitroglycerin for blood pressure control. On the morning of postoperative day one she was weaned from the nitroglycerin. Her chest tubes were removed and she was transferred to Far Six for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient remained hemodynamically stable and progressed nicely and her activity level so that on postoperative day four she was ambulating 500 feet and able to climb a flight of stairs. The decision was made at that time that she was stable and ready to be discharged to home on the following morning. During this postoperative course she did have one episode of rapid atrial fibrillation with a ventricular response rate of 130 to 150. She was given IV Lopressor for rate control and started on Amiodarone. She converted back to a normal sinus rhythm with a rate in the 60s following an oral load of Amiodarone and the intravenous Lopressor. On postoperative day five she was discharged to home. At the time of discharge her condition was stable. Physical examination on discharge, vital signs temperature 97.4. Heart rate 68 sinus rhythm. Blood pressure 112/76. Respiratory rate 20. O2 sat 94% on room air. Alert and oriented times three. Moves all extremities. Follows commands. Respiratory clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2 with a 2/6 systolic ejection murmur. Her sternum is stable. Incision is clean and dry, open to air with staples. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well profuse with no clubbing, cyanosis or edema. Weight preoperatively was 84.2 kilograms. At discharge it is 86.6 kilograms. Laboratory data, white count 8.8, hematocrit 26.4, platelets 233, sodium 134, potassium 4.2, chloride 101, CO2 30, BUN 33, creatinine 0.8,glucose 147. MEDICATIONS ON DISCHARGE: Lasix 20 mg q.d. times ten days, potassium chloride 20 milliequivalents q.d. times ten days, aspirin 81 mg q.d., Lopresor 50 mg b.i.d., Amiodarone 400 mg t.i.d. through [**10-13**] and then b.i.d. times seven days and then q.d., Captopril 12.5 mg t.i.d. Prn medications include Tylenol 650 mg q 6 hours, Percocet one to two tabs q 4 hours and Motrin 400 mg q 6 hours. DISCHARGE DIAGNOSES: 1. Aortic stenosis status post AVR with a #21 [**Location (un) **] valve. 2. Sleep apnea. 3. Scarlet fever. 4. Status post appendectomy. 5. Status post tonsillectomy and adenoidectomy. The patient is to have follow up with Dr. [**Last Name (STitle) **] in three to four weeks and follow up in the [**Hospital 409**] Clinic in two weeks. She also is to have follow up with her primary care physician in three to four weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2181-10-8**] 18:50 T: [**2181-10-12**] 07:23 JOB#: [**Job Number 15341**]

Admission Date: [**2140-2-29**] Discharge Date: [**2140-3-4**] Date of Birth: [**2140-2-29**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: The patient is a 1.83-kg product of a 32-5/7 gestation born to a 29-year-old gravida 2, para 0 to 2 mother. Serologies: A+, ab neg, hep neg, RPR NR, RI, GBS positive from previous pregnancy. This pregnancy was complicated by several admissions to [**Hospital **] Hospital between 24 and 26 weeks with several cervical shortenings. She received a complete course of betamethasone at 24 weeks. She was transferred to [**Hospital1 69**] at 26 weeks with preterm labor which was treated with another course of betamethasone and tocolysis. Onset of labor began again on the morning of delivery, and due to breech/breech presentation the patient was born via cesarean section. This twin emerged with decreased tone and poor respiratory effort. She required positive pressure ventilation with a good response in color and improved respiratory effort. PHYSICAL EXAMINATION ON PRESENTATION: Her examination on admission revealed she was active and pink. Head, ears, nose, eyes and throat revealed she had an anterior fontanel which was normal and flat. She had an oropharynx which was clear. No cleft, and no neck masses. Cardiovascular examination showed a normal first heart sound and second heart sound, and no murmurs. Lungs had coarse but equal breath sounds bilaterally. She had mild-to-moderate grunting and increased work of breathing. Her abdomen was soft with no hepatosplenomegaly, and no masses. Neurologic examination was nonfocal and age appropriate. Genitalia showed a normal premie female. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: Shortly after arrival in the Neonatal Intensive Care Unit she was placed on CPAP due to increased work of breathing. Her initial arterial blood gas showed mild CO2 retention, however, and the patient was then intubated. She received surfactant times one and was able to wean quickly on her ventilator settings. She was extubated by the following morning to room air. She has apnea of prematurity requiring caffeine citrate therapy (started on [**3-3**]). Current maintenance dose is 11 mg pg qday. 2. CARDIOVASCULAR: She had good blood pressures during her stay here and has had no cardiovascular issues. 3. FLUIDS/ELECTROLYTES/NUTRITION: She was initially made n.p.o. but after extubating feeds were started. She has been advancing on her feeds successfully and is currently at 120 cc/kg per day via PG-tube of breast milk or PE-20. Feeds have been going very well. Plan is to reach a goal volume of 150 cc/k/day. 4. HEMATOLOGY: Her complete blood count on admission showed a white blood cell count of 15.8, a hematocrit of 57.5, and a platelet count of 252. She had 24 neutrophils and 0 bands. 5. INFECTIOUS DISEASE: She was started on ampicillin and gentamicin for a 48-hour rule out sepsis. Her blood cultures remained negative throughout her stay, and the antibiotics were discontinued after 48 hours. She has had no further infectious issues. 6. GASTROINTESTINAL: The patient was started on phototherapy on day of life two for a maximum bilirubin of 8.8. She continued on phototherapy today. Today's bilirubin on [**3-4**] is 8.3 (down from 9.1 on [**3-2**]). 7. NEUROLOGY: The patient has had no neurologic issues during her stay. 8. SENSORY: Hearing screen was not performed yet. DISCHARGE STATUS: The patient was to be transferred to [**Hospital 487**] Hospital on [**3-4**]. CONDITION AT DISCHARGE: She was discharged in good condition. MEDICATIONS ON DISCHARGE: Caffeine Citrate 11 mg pg qd. SCREENING: State newborn screening was pending. IMMUNIZATIONS RECEIVED: None. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 958**] 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 plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; and/or (3) 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 care givers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Respiratory distress syndrome, resolved. 3. Rule out sepsis, resolved. 4. Hyperbilirubinemia. 5. Apnea of prematurity. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **] M.D. [**MD Number(1) 37201**] Dictated By:[**Name8 (MD) 36241**] MEDQUIST36 D: [**2140-3-3**] 16:03 T: [**2140-3-3**] 15:08 JOB#: [**Job Number 39002**]

Unit No: [**Numeric Identifier 69007**] Admission Date: [**2171-10-2**] Discharge Date: [**2171-10-28**] Date of Birth: [**2171-10-2**] Sex: F Service: NB REASON FOR ADMISSION: 1. Prematurity (32-6/7 weeks gestation) due to respiratory distress syndrome. 2. Maternal history. HISTORY OF PRESENT ILLNESS: [**Known firstname 402**] [**Known lastname **] is a 32-year-old G1, P0 woman with past medical history notable for unexplained infertility. Her prenatal screens were as follows: O negative (status post RhoGAM), DAT negative, HBS antigen negative, RPR NR, rubella immune, GBS unknown. FAMILY HISTORY: Noncontributory. HOSPITAL COURSE: Her [**Last Name (un) **] was [**2171-11-21**]. Her current pregnancy was complicated by increasing transaminases and pruritus consistent with cholelithiasis of pregnancy for which she received Actigall. Mother received full course of betamethasone which was completed on [**2171-10-1**]. She proceeded for cesarean section for maternal indications under spinal anesthesia. Rupture of membranes occurred at delivery and yielded clear amniotic fluid. There was no antepartum fever or clinical evidence of chorioamnionitis. Delivery by elective C-section. Infant was vigorous at delivery. Apgars were 8 and 9 at one and five minutes, respectively. She was admitted to NICU in view of prematurity. PHYSICAL EXAMINATION ON ADMISSION: Preterm infant with examination consistent with 33-week gestation. Heart rate 156, respiratory rate 50-70, temperature 98.8, blood pressure 64/30 (42), saturations 94% and 21% FI02 on CPAP. Birth weight [**2079**] grams, head circumference 32.5 cm, length 45 cm. HEENT: Anterior fontanel soft and flat, nondysmorphic. Palate intact. Normocephalic. Neck and mouth normal. Red reflex present bilaterally. Chest: Mild intercostal retractions on CPAP, fair breath sounds bilaterally, no adventitious sounds. CVS: Well perfused. Regular rate and rhythm. Femoral pulses normal. S1, S2 normal. No murmur. Abdomen: Soft, nontender. Liver 1 cm. No splenomegaly. No masses. Bowel sounds active. Anus patent. Three-vessel umbilical cord. GU: Normal female genitalia. CNS: Reactive, responsive to stimulation. Tone appropriate and symmetrical. Suck and gag intact. Facies symmetrical. Spine, hips and limbs: Normal. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: She received CPAP soon after birth in view of intercostal retractions suggestive of respiratory distress syndrome. She rapidly transitioned and came off CPAP on day of life #1. She had minimal episodes of apnea and bradycardia. At the time of discharge she has been free of spells for more than 5 days prior to discharge. Cardiovascular: No concerns. In particular, there was no clinical evidence of PDA. Fluids, electrolytes, nutrition: She was NPO for the 1st 34 hours of life and received parenteral nutrition for the 1st few days of life. Feeds were gradually introduced on day of life #2 and advanced to a maximum of 150 ml/kg per day of breast milk 24 calories per ounce by day of life #9. At the time of discharge she is on ad lib. p.o. feeds of breast milk 24 calories made by Similac powder along with 3-4 breast feeds. Weight at discharge is 2615 grams. GI: No complications. She received phototherapy for physiological jaundice exaggerated by prematurity with a maximum bilirubin of 8.9/0.3 on day of life #3. Hematology: No complications. Infectious disease: She received IV antibiotics for 1st 48 hours for sepsis rule-out. She did not have any episodes of suspected or proven sepsis. NEUROLOGY: No clinical concerns. She does not fit the criteria for routine cranial ultrasound scan screen. SENSORY: 1. Audiology: Passed newborn hearing screen. 2. Ophthalmology: Does not fit the criteria for routine ROP screen. PSYCHOSOCIAL: No concerns. CONDITION ON DISCHARGE: Well. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone [**Telephone/Fax (1) 37376**]. CARE RECOMMENDATIONS: Feeds at discharge: Ad lib. p.o. feeds of breast milk 24 made with Similac powder along with breast feeds. MEDICATIONS: Ferrous sulfate. STATE NEWBORN SCREENING: Initial results unremarkable. Full report awaited. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2171-10-15**]. IMMUNIZATIONS RECOMMENDED: 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 RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings, or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: 1. Primary care pediatrician 2-3 days following discharge. 2. VNA appointment 1-2 days following discharge. DISCHARGE DIAGNOSES: 1. Prematurity (32-6/7 weeks gestation). 2. Mild respiratory distress syndrome. Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**] Dictated By:[**Name (STitle) 66431**] MEDQUIST36 D: [**2171-10-29**] 13:14:59 T: [**2171-10-29**] 14:24:34 Job#: [**Job Number 69008**]

Admission Date: [**2197-2-16**] Discharge Date: [**2197-3-9**] Date of Birth: [**2197-2-16**] Sex: F Service: Neonatology HISTORY: Baby Girl [**Known lastname **] Twin A was a 33-6/7 week gestation female Twin A delivered preterm by cesarean section due to preterm labor and transverse lie. Mother is a 42-year-old G2 P0 now 2 with prenatal screens O positive, antibody negative, and RPR nonreactive, rubella immune, hepatitis B surface OB HISTORY: Notable for previous birth at term delivered at [**Hospital3 **]. This pregnancy was conceived on Clomid with estimated delivery date of [**2197-3-31**], complicated by PIH. On the day of delivery, mom was noted to be in preterm labor Rupture of membrane at delivery, no perinatal risk factors for sepsis. Twin A emerged with spontaneous cry and required only blow-by O2 and routine care in the Delivery Room. Apgars were eight and eight. She was transferred to the NICU on blow-by O2. ADMISSION PHYSICAL EXAMINATION: Weight 2205 grams (50th percentile), length 46 cm (60th percentile), head circumference 32 cm (60th percentile). Nondysmorphic baby with overall appearance consistent with estimated gestational age. Anterior fontanel is soft and open and flat. Red reflex present bilaterally. Palate intact. Grunting with subcostal retractions. Breath sounds diminished bilaterally. Symmetric regular, rate, and rhythm without murmur. Abdomen is benign without hepatosplenomegaly or masses. Three vessel cord. Normal female external genitalia for gestational age. Normal back and extremities with stable hips. Skin pink except for acrocyanosis, appropriate tone, strength, and activity. Initial D-sticks was 109. Baby Girl [**Known lastname **] was admitted to the NICU with moderate respiratory distress. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Moderate respiratory distress secondary to retained fetal lung fluid. She was placed on CPAP of 5 with resolution of respiratory distress. She was weaned off CPAP to on room air on day of life one. Since then she has been stable on room air maintaining sats above 94%. No spells. 2. Cardiovascular: The patient has been hemodynamically stable throughout her admission in the NICU. 3. FEN: Patient has been tolerating full feeds since day of life five, and has been taking enteral feeds and po since day of life 18. She is currently taking breast milk, Enfamil 24 and tolerating that well. Her birth weight was 2205 grams. Her weight prior to discharge was 2735. She is currently on iron supplement. 4. GI: Baby Girl [**Known lastname 48934**] bilirubin peaked on day of life four at 8.8. No phototherapy was started. 5. Hematology: Patient's initial hematocrit was 57. No transfusion during this admission. 6. Infectious Disease: Patient had an initial sepsis evaluation with benign complete blood count and differential. She was on ampicillin and gentamicin for 48 hours. Blood culture remained negative and the antibiotics were discontinued. 7. Audiology: Hearing screen was performed with automated auditory brain stem responses and patient passed bilateral ears. 8. Psychosocial: The [**Hospital1 69**] social worker was involved with the family. CONDITION ON DISCHARGE: Stable, tolerating full feeds. DISPOSITION: Baby Girl [**Known lastname **] was discharged to the Newborn Nursery. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 9063**] at [**Location (un) 12670**], telephone [**Telephone/Fax (1) 48935**]. CARE AND RECOMMENDATION: 1. Feeds at discharge: Full po feeds, breast milk or Enfamil 24. 2. Medication: Iron 0.2 cc, ferrous sulfate 25 mg/cc po q day. 3. The patient passed car seat position screening. 4. State newborn screens were sent. 5. The patient received hepatitis B #1. Synagis RSV 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 plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) 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. FOLLOW-UP APPOINTMENT: Recommended two days after discharging from the hospital. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Mild respiratory distress. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2197-3-9**] 12:30 T: [**2197-3-9**] 12:36 JOB#: [**Job Number 48936**]

Admission Date: [**2184-9-30**] Discharge Date: [**2184-10-5**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: HPI: [**Age over 90 **] y/o female fell down 3 stairs at the post office. Had LOC at scene but was awake and GSC 14 at [**Hospital 26380**] Hospital (lost point for orientation.) She was found to have a traumatic SAH was given Dilantin then transferred here for further care. She was transferred here via ambulance and was found to an acute change on arrival. Past Medical History: Motorcycle accident 30 years ago, had craniotomy, extensive left arm surgery due to trauma causing weakness and zygomatic fracture. HTN Social History: Prior Marine, lives alone independently, DNR at baseline, nonsmoker, no alcohol Family History: nc Physical Exam: Pt in process of being intubated when examined. Patient is in collar has right occipital hematoma Eyes open, awake, trying to mouth words, trying to sit up moving uppers symmetrically. Questionably moving lowers to commands. Appears to be full strength in upper extremities. Moving left leg less than right. Pupil right surgical left [**3-9**]; Patient was quickly intubated for airway protection had vomitted. PHYSICAL EXAM: O: T: BP:158/80 HR: 94 R 20 O2Sats 100% Exam upon discharge: alert and oriented x3, motor full, no pronator drift Pertinent Results: CT/MRI: prior left frontal craniotomy site noted. Small bilateral traumatic sah at convexity Labs:PT: 17.5 PTT: 30.4 INR: 1.6 [**2184-10-1**] Head CT: IMPRESSION: Overall, no significant change in appearance of convexity subarachnoid blood compared to the previous CT of [**2184-9-30**]. Brief Hospital Course: Pt was admitted to neurosurgery and monitored closely. She remained neurologically stable. repeat Ct was stable. She was transferred to the floor. Diet and activity were advanced. She was evaluated by PT and felt suitable for discharge home with services. Medications on Admission: Norvasc and OTC Discharge Medications: 1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 14663**] Discharge Diagnosis: traumatic brain injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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, or Ibuprofen etc. for one week. Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2184-10-3**]

Admission Date: [**2127-7-12**] Discharge Date: [**2127-7-14**] Date of Birth: [**2060-9-26**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 66 year old female admitted on [**2127-7-11**], mid afternoon, four days after discharge from the Thrombus Service where she had had a right pneumothorax and right-sided rib fractures due to a motor vehicle accident. At that time she had been discharged to a rehabilitation facility, primarily due to her social situation where she was considered to a fall risk and she lives at home alone without any social support. One day prior to admission, staff at the skilled nursing facility noticed increased drainage from the chest tube wound sight and today the patient was noted to have a temperature of 101.6. The patient has also noticed worsening shortness of breath. She was transported back to [**Hospital6 649**] and admitted back to the Trauma Service. PAST MEDICAL HISTORY: Status post motor vehicle crash ten days prior with multiple right rib fractures, status post right-sided chest tube, glaucoma, chronic neuritic pain, depression and otherwise nonspecified psychiatric history, most likely a paranoid personality disorder. PAST SURGICAL HISTORY: Status post left open reduction and internal fixation of the tibial plateau and status post bilateral hip replacement. MEDICATIONS ON ADMISSION: Timolol, eye drops for glaucoma, Nortriptyline 75 mg q.d., Neurontin 600 mg t.i.d., Colace, Celexa 10 mg q.d., Percocet prn and Ibuprofen. ALLERGIES: The patient has stated allergies to Effexor, Penicillin and Topamax, none of which were related to rash or shortness of breath by her history. PHYSICAL EXAMINATION: Physical examination on arrival showed temperature 97.6, heartrate 98, blood pressure 145/37 and respiratory rate 18. Oxygen saturations were 82% on room air and 99% on nonrebreather. The patient was awake and alert in no acute distress, not tachypneic. There was a right-sided chest crepitus palpated and auscultated. Left side of the lung, decreased breathsounds as well at the base. There was no jugulovenous distension. Heart had a regular rate. The abdomen was soft, nontender, and had good bowel sounds. The left knee had an area of ecchymosis but was not tender to palpation nor warm to the touch. Left eye also had some ecchymosis from a prior hematoma on the left anterior portion of her scalp. LABORATORY DATA: Initial laboratory data were significant for a white count of 19.8, hematocrit 28, the patient having a baseline hematocrit at discharge between 28 and 30. Urinalysis with numerous white blood cells. Initial radiology, chest x-ray was obtained showing left lower lobe and right lower lobe consolidation, as well as a right lower lobe effusion. Electrocardiogram was performed which showed no acute change from her prior electrocardiogram. HOSPITAL COURSE: The patient was admitted to the floor for possible empyema versus pneumonia versus urinary tract infection and started on Vancomycin and Ceftriaxone. It was difficult to maintain the patient's oxygenation due to her pain. A chest tube was attempted to be placed but was placed in the chest wall and not in the intrapleural space. Said chest tube was discontinued and upon thoracic surgery consultation was not felt to be needed. The chest computerized tomographic angiography was required to rule out pulmonary embolism which showed the patient to be without emboli. Chest computerized tomography scan did reveal a small right apical pneumothorax as well as a small right hydropneumothorax near the pulmonary artery and atelectasis versus pneumonia at the right middle lobe. Aggressive chest physical therapy and antibiotics gradually improved the patient's oxygenation until she was sating well on simple nasal cannula. Antibiotics were switched over to Levaquin and as her condition has improved, she is stable for transfer back to the rehabilitation facility where it is crucial that she use incentive spirometry, has gotten out of bed as often as possible and that her pain is managed well to prevent relapse of possible pneumonia. She should follow up at the Trauma Clinic in one to two weeks and should have an outpatient colonoscopy scheduled as she has a persistent anemia with heme positive stools. After she is done completing her course of Fluoroquinolones it is recommended that she be started on iron therapy but not prior to finishing her Levaquin as Fluoroquinolone levels are reduced in the face of concurrent iron therapy. At this time the patient is discharged with the following diagnoses. DISCHARGE DIAGNOSIS: 1. Right rib fractures from prior motor vehicle accident status post second chest tube insertion 2. Urinary tract infection 3. Pneumonia 4. Loculated hydropneumothoraces on the right times two 5. Anemia DISCHARGE MEDICATIONS: 1. Nortriptyline 75 mg h.s. 2. Neurontin 600 mg t.i.d. 3. Docusate 100 mg b.i.d. 4. Celexa 10 mg q.d. 5. Dilaudid 2 to 4 mg p.o. q. 6 hours prn for ten days 6. Levaquin 500 mg q.d. for nine days DISCHARGE INSTRUCTIONS: Chest physiotherapy one to two times per day as well as physical therapy for general strengthening and gait safety. It is expected that as her condition improves she will be safe to be discharged back home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 4791**] MEDQUIST36 D: [**2127-7-14**] 19:19 T: [**2127-7-14**] 19:34 JOB#: [**Job Number 98696**]

Admission Date: [**2122-5-28**] Discharge Date: [**2122-6-8**] Date of Birth: [**2047-4-9**] Sex: M Service: MEDICINE Allergies: Diovan Attending:[**First Name3 (LF) 3984**] Chief Complaint: Fever and malaise Major Surgical or Invasive Procedure: bronchoscopy [**5-29**] History of Present Illness: Mr. [**Known lastname 50155**] is a very pleasant 75 year old man with past medical history significant for MDS-RAEB2 with AML features, wegener's granulomatosis (in remission), CKD stage V on HD. He has recently been on Revlimid therapy but stopped recently due to rash, fatigue, and thrombocytopenia. He presented to outpatient clinic today with one week of increasing fatigue, intermittent fevers, cough with brown sputum, mild frontal headache, left-sided rib pain with coughing, and anorexia. CT chest showed marked increase in previously described areas of consolidation. He was referred for inpatient management. . He reports chronic DOE related to anemia, he has poor PO intake but increased gas. His rash has resolved, his lower extremity edema has resolved with hemodialysis. He denies orthopnea, abdominal pain, diarrhea, constipation, change in urine, bleeding, increased bruising. Past Medical History: Past Medical History: - MDS RAEB-2/AML overlap initiated treatment with lenalidomide [**2122-3-5**] - Essential Thrombocytosis with Jak2V617F mutation - ANCA + Vascultitis/Wegener's granulomatosis - Stage IV CKD re: GN; treated with Cytoxan. - Pulmonary artery hypertension - PFO/ASD with right-to-left shunting - Hyperparathyroidism s/p resection - HTN - Gout. - Glaucoma. - Osteopenia. Social History: married, lives with his wife. [**Name (NI) **] has 3 children (2 daughters and one son). He currently works part time in an antique shop, and used to work as a land surveyor. He served in the Korean war.Prior smoker, quit over 20 yrs ago. No drinking, illicits. Family History: Father: heart disease, CVA, died from liver cancer Mother: died from heart attack in 80s Physical Exam: . GEN: Comfortable VITALS: 102.5, 140/80 80 92% RA -> 98% when encourage to breath. HEENT: Edentulous maxilla, poor dentition with caries mandible. Soft, no LADts COR: S1 and S2, no murmurs. CHEST: Clear to auscultation bilaterally. Musical rhonchi on inspiration. tenderness over 5th ribs in mid-axillary line. ABD: Soft, non-tender, + spleen tip EXT: No edema, mild atrophy. SKIN: Warm, dry. NEURO: Alert, oriented, normal attention. . Pertinent Results: [**2122-5-28**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2122-5-28**] 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2122-5-28**] 06:00PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [**2122-5-28**] 06:00PM URINE MUCOUS-RARE [**2122-5-28**] 04:31PM UREA N-62* CREAT-4.8* SODIUM-136 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-25 ANION GAP-20 [**2122-5-28**] 04:31PM ALT(SGPT)-19 AST(SGOT)-30 LD(LDH)-311* ALK PHOS-121 TOT BILI-0.3 [**2122-5-28**] 04:31PM CALCIUM-7.2* PHOSPHATE-3.4 MAGNESIUM-1.8 [**2122-5-28**] 04:31PM WBC-3.5* RBC-2.44* HGB-7.3* HCT-20.7* MCV-85 MCH-30.1 MCHC-35.5* RDW-15.2 [**2122-5-28**] 04:31PM NEUTS-80* BANDS-0 LYMPHS-12* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-5-28**] 04:31PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2122-5-28**] 04:31PM PLT SMR-VERY LOW PLT COUNT-22* [**2122-5-27**] 11:00AM UREA N-56* CREAT-4.6* [**2122-5-27**] 11:00AM estGFR-Using this [**2122-5-27**] 11:00AM WBC-3.1* RBC-2.68* HGB-8.2* HCT-22.8* MCV-85 MCH-30.5 MCHC-35.9* RDW-15.1 [**2122-5-27**] 11:00AM NEUTS-76* BANDS-1 LYMPHS-14* MONOS-5 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2122-5-27**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2122-5-27**] 11:00AM PLT SMR-VERY LOW PLT COUNT-30* [**2122-5-27**] 11:00AM GRAN CT-2387 [**2122-5-27**] CT CHEST IMPRESSION: 1. Multiple pulmonary consolidations as described, most of them are either new or significantly increased since [**2122-3-18**]. Similar, but smaller areas of consolidation have been seen back in [**2115-9-22**]. The differential diagnosis would include recurrence of known Wegener vasculitis, in particular given the presence of areas of ground-glass surrounding the areas of consolidation that might be consistent with hemorrhage. The septal thickening surrounding the areas of consolidation might be consistent with clearance of the hemorrhage by the lymphatic system and lymphatic engourgment. The other consideration would include opportunistic infection such as invasive aspergillosis given the known immunosuppressed status of the patient. 2. Splenomegaly, unchanged. Vascular calcifications. Partially imaged horseshoe kidney. 3. Extensive degenerative changes of the thoracic spine. Asymmetric sclerosis within the medial head of the left clavicle most likely consistent with degenerative disease or arthritis or SAPHO. 4. Dilated pulmonary arteries, consistent with pulmonary hypertension, unchanged since [**2122-3-18**], and slightly progressed since [**2115-9-22**] (4.5 cm). 5. Upper chest/lower neck calcifications, 5:19, most likely representing prior surgery and given the known parathyroid adenoma most likely related to that reason. [**2122-6-6**] CT Chest 1. Progression of dominant expansile consolidative opacity since the prior CT in the left upper lobe with some residual areas that remain partly aerated, evolving substantially over two weeks, referring to radiographs. Major differential considerations include an expansile consolidation associated with pyogenic infection or hemorrhage. Given immunosuppresion, atypical sources of infection including fungal etiologies could also be considered. The density is intermediate, so while hemorrhage may represent a substantial component, specific areas of hematoma are not definable. 2. Progression of left upper lobe opacity noted in the background of resolving mass-like opacities in the right lung and left lower lobe. 2. New interval moderate pericardial effusion. 3. Moderate stable cardiomegaly. 4. Enlarged pulmonary artery consistent with pulmonary hypertension. Brief Hospital Course: Course on the Onc Floor: Mr [**Known lastname 50155**] was on [**2122-5-27**] admitted patient with history of Wegener's granulomatosis, MDS/AML, recently on Revlimid therapy, pancytopenia, and poor functional status, presented on with malaise, fever, and acute on chronic changes to his chest CT with increased size and number of areas of consolidation. Given complex history, the differential was broad, and included regular and opportunistic infections, recurrent vasculititis, malignancy, and/or hemorrhage. The case was discussed his oncologist, Dr. [**Last Name (STitle) 6944**], who has also been in contact with his pulmonologist, Dr. [**Last Name (STitle) 2168**]. The plan was to begin broad spectrum antibiotic coverage and to check blood, sputum, and urine cultures. His hemodialysis was continued M, W, F. On [**2122-6-4**] pt developed increasing respiratory distress, progressive CXR consolidation and had continued hemoptysis. ICU Course: Mr. [**Known lastname 50155**] was admitted to the [**Hospital Ward Name 332**] ICU on [**2122-6-4**] for worsening respiratory status and increased oxygen requirements. At admission, patient had been desaturating on low flow NC to mid 80s at times. He was placed on shovel mask and then 70% FM today with sats recovering to high 90s. Etiology was thought to be worse underlying infectious process in lungs with some additional edema as CXR showed worse LUL infiltrate and effusions. Pt was started on broad spectrum antibiotics with vanco, cefepime (later changed to zosyn), voriconazole, and levaquin. For his stage IV CKD secondary to WG pt was continued MWF hemodialysis. He was making very small amounts of urine at baseline # MDS: Pt was transfusion dependent with ongoing thrombocytopenias and severe anemia. He has known AML transformation with last bone marrow just few months ago with 15% blasts. He also had an older history of essential throbocytosis as well. CBCs were followed [**Hospital1 **]. Platelet transfusions were given for platelet counts <50 and PRBCs were given for HCT <21. . #Wegener's: Unclear whether patient was having a wegener's flare. He had been in remission for WG since [**2114**], although he has advancing stage IV renal disease felt to be from WG. His immunosuppression also made a WG flare less likely. On [**6-6**] a repeat CT showed large lung lesions compressing mediastinum with a large pericardial effusion, left pleural effusion, large heart thought to be due to infection vs wegeners w/ hemorrhage. On [**6-7**], Mr. [**Known lastname 50155**] was coded and was intubated and on pressors. Interventional pulmonary, CT surgery and interventional radiology were contact[**Name (NI) **] about a biopsy of the lung mass. Given his thrombocytopenia, risk of bleeding and poor functional status, it was felt that a biopsy carried a high risk of morbidity and mortality. The procedure and the patient's prognosis was explained to the family and they decided to withdraw care. Mr. [**Known lastname 50155**] was extubated on [**2122-6-8**] and passed away at 3:45 pm. His family was comforted and consoled. They declined a autopsy but agreed to a post-mortem bronchoscopy to biopsy the lung mass found on CT. Medications on Admission: Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **] [**5-28**] @ [**2045**] View Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety [**5-28**] @ [**2045**] View Citalopram Hydrobromide 10 mg PO/NG DAILY [**5-28**] @ [**2045**] View Calcitriol 0.25 mcg PO DAILY [**5-28**] @ [**2045**] View Allopurinol 100 mg PO/NG EVERY OTHER DAY [**5-28**] @ [**2045**] View Vitamin B Complex -- TAKES INTERMITTENTLY Calcium Citrate 1500 mg PO DAILY Sodium Bicarbonate 650 mg PO BID Nifedipine SR 60 mg PO QD Discharge Medications: patient deceased Discharge Disposition: Expired Discharge Diagnosis: patient deceased Discharge Condition: patient deceased Discharge Instructions: patient deceased Followup Instructions: patient deceased [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Admission Date: [**2152-8-27**] Discharge Date: [**2152-8-30**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 106**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. cardiac catheterization and stenting History of Present Illness: 88F without previous cardiac history p/w acute onset of light-headedness and SOB. Pt was with son at home eating dinner. At roughly 8pm she got up to go to the bathroom. On returning from the bathroom, the son noted that she was SOB and lightheaded so that she had to sit down. The pt was less alert than usual and so the son [**Name (NI) 47658**] her flat on the ground and called 911. She was diaphoretic though never mentioned any chest pain, The ambulance arrived and found her hypotensive by report and she was taken to the ED. Past Medical History: Arthritis gallstones ?spastic bladder Social History: Lives with son for the summer in [**Name (NI) 86**]. Normally lives with another son in [**State 5887**]. She is a retired seamstress. Smoked for 5-10 years, though quit over 50 years ago. Drinks wine with dinner. Needs cane to walk, feeds, dresses self, but doesn't cook for self. Family History: Mother died in 80s after a hip frx Father: died in 50s from coal miner's lung Physical Exam: VS: T 99.8, BP 150/66, HR 93, RR 19, O2 100% on 4L Gen: Elderly female in NAD, resp or otherwise. Oriented x1. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8cm. CV: PMI located in 5th intercostal space, midclavicular line. SEM RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No L femoral bruit, R leg in brace Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Leg brace, 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2152-8-27**] 09:10PM WBC-14.4* RBC-3.19* HGB-9.3* HCT-29.4* MCV-92 MCH-29.3 MCHC-31.7 RDW-14.8 [**2152-8-27**] 09:10PM NEUTS-77.8* LYMPHS-17.0* MONOS-4.3 EOS-0.7 BASOS-0.2 [**2152-8-27**] 09:10PM PLT COUNT-217 [**2152-8-27**] 09:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2152-8-27**] 09:10PM ALBUMIN-3.6 CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-2.7* [**2152-8-27**] 09:10PM CK-MB-27* MB INDX-4.9 [**2152-8-27**] 09:10PM cTropnT-6.34* [**2152-8-27**] 09:10PM LIPASE-41 [**2152-8-27**] 09:10PM ALT(SGPT)-28 AST(SGOT)-93* CK(CPK)-548* ALK PHOS-109 AMYLASE-45 TOT BILI-0.3 [**2152-8-27**] 09:10PM GLUCOSE-198* UREA N-40* CREAT-1.6* SODIUM-140 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-19* ANION GAP-20 [**2152-8-27**] 09:46PM TYPE-ART PO2-145* PCO2-27* PH-7.44 TOTAL CO2-19* BASE XS--3 INTUBATED-NOT INTUBA [**2152-8-27**] 09:46PM LACTATE-2.7* K+-4.3 CL--113* LIPID/CHOLESTEROL Cholest 117 Triglyc 59 HDL 51 CHOL/HD 2.3 LDLcalc 54 [**8-30**] B12 396, Folate 17.3, Iron 37, calcTIBC 285, Ferritin 119, TRF 219 Retic 1.1% . EKG [**8-27**]: complete heart block with junctional escape at [**Street Address(2) 74118**] elevations II, III, aVF, LAD, PRWP, PR . Cardiac Cath [**8-27**] 1. Coronary angiography in this right dominant system demonstrated single vessel disease. The LMCA and LCx had no angiographically apparent flow limiting epicardial disease. The LAD had minimal disease. The mid-RCA had an 80% lesion and mid/distal total occlusion. 2. Resting hemodynamics revealed elevated right sided filling pressures with an RVEDP of 17 mmHg and PCWP = 16 mm Hg consistent with RV infarct physiology. There was moderate pulmonary systolic hypertension with a PASP of 46 mmHg. There was mild systemic arterial systolic hypertension with an SBP of 148 mmHg. 3. Successful stenting of the distal and mid RCA lesions with 2.5 X 28 mm Minivision and 3.0 X 16 mm Liberte bare metal stents with no residual stenosis (see PTCA comments for detail). 4. Successful treatment of inferior MI with thrombectomy and primary PTCA. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Acute inferior myocardial infarction, managed by acute export thrombectomy and dilation and stenting of mid and distal RCA lesions. 3. Moderate pulmonary artery hypertension and Right ventricular dysfunction. 4. Mild systemic arterial hypertension. 5. Successful stenting of the distal and mid RCA with bare metal stents. . TTE [**8-29**] The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal akinesis of the basal inferior and inferolateral walls and hypokinesis of the basal to mid inferior walls. The remaining segments contract normally (LVEF = 50 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is mildly dilated. There is moderate global right ventricular free wall hypokinesis with apical dyskinesis. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional left and right ventricular dysfunction consistent with inferior/inferolateral myocardial infarction with right ventricular involvement. Severe mitral regurgitation. Borderline elevated pulmonary artery systolic pressures. . CXR [**8-30**]: IMPRESSION: No fluid overload or heart failure. No acute cardiopulmonary disease. Brief Hospital Course: 1. STEMI: Symptoms started at roughly 8pm and pt arrived in the ED at 8:30pm. In the ED, her vitals were: Pulse 50, BP 99/65, Respiratory Rate 22, O2 saturation 97% on 4L nasal canula. Initial ECG showed ST elevations inferiorly and complete heart block with a junctional escape. Pt was given asa, plavix 600mg x1, heparin gtt, integrilin and transferred to the cath lab. At cath, she was found to have a 80% mid total occlusion of the RCA which was opened and treated with a bare metal stent. There was no hemodynamic instability, though pacing was transiently required during the cath for heart rate in 40s. The patient was admitted to CCU for overnight monitoring, arriving in stable condition with pulse in 90s BP 120/80. In the CCU, she had an uneventful course with no further ischemic symptoms or evidence of heart block, and was discharged on aspirin, clopidogrel, atorvastatin, metoprolol, lasix, and lisinopril. She will follow up her primary care physician and cardiologist upon her return to [**State 5887**] in two weeks. Her lipid panel should be repeated as an outpatient. . 2. Mitral Regurgitation: The patient's [**8-29**] echocardiogram was notable for severe (4+) mitral regurgitation. She should have a cardiac MRI in [**3-31**] weeks for further evaluation, with consideration for possible valve repair. . 3. Renal insufficiency: Per the patient's primary care physician, [**Name10 (NameIs) **] last recorded creatinine was 1.0 on 7/[**2149**]. Her creatinine was somewhat elevated from this at 1.6 on admission, and trended back down following rehydration. She will need a repeat creatinine and potassium measurement as she has started an ACE inhibitor in hospital. . 4. Anemia: The patient was found to have a normocytic anemia at admission with hematocrit nadir of 23 in hospital, and consequently was transfused 2 units of PRBCs She did not have any gross GI bleeding, but did have some heme positive stools. She denies ever having a colonoscopy. Her anemia should be worked up further as an outpatient. Her iron studies, folate and B12 levels were normal when checked [**8-30**]. Chronic renal insufficiency may be a contributing factor to her anemia, although low level GI bleeding should be excluded. . 5. Health maintenance The patient received the pneumovax vaccine prior to discharge Medications on Admission: detrol Discharge Medications: 1. Aspirin 325 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* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Detrol Oral Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. STEMI 2. complete heart block, resolved Discharge Condition: good Discharge Instructions: You came to the hospital with shortness of breath. Your symptoms were due to a heart attack. You had a stent placed in one of the arteries supplying the heart. You were started on some new medicines to protect your heart. It is very important that you do not stop any of these medicines without first talking to a physician. Please call your doctor and seek medical attention at once if you develop: ** recurrent shortness of breath, chest discomfort, dizziness or faintness, abdominal pain, black or bloody stools, or other symptoms that worry you Followup Instructions: Please follow up with your primary care doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 74119**] at [**Telephone/Fax (1) 74120**] on Monday [**9-18**] at 1:30pm. You will also need to follow up with cardiology [**2157-9-20**]:45pm with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 74121**] Heartcare Group ([**Location 74122**], PA) at [**Telephone/Fax (1) 74123**].

Admission Date: [**2166-2-25**] [**Year/Month/Day **] Date: [**2166-3-14**] Date of Birth: [**2125-12-1**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4533**] Chief Complaint: continued intubation/monitoring s/p R radical nephrectomy Major Surgical or Invasive Procedure: R radical nephrectomy and s/p intubation History of Present Illness: 40yo man with h/o ascending aortic dissection in [**2160**] s/p repair and St. Jude's valve placement on coumadin ([**2160**]), s/p recent R perinephric bleed requiring IR embolization([**11/2165**]), CRI with h/o ATN requiring CVVH post procedure, HTN, who was admitted to [**Hospital Unit Name 153**] for monitoring after R radical nephrectomy and removal of large renal mass. . The patient was admitted to the OR with urology service for R radical nephrectomy and removal of large renal mass (13cm) suspicious for malignancy today. The procedure was difficult but without complications, and 150cc 250% albumin. Specimen sent for pathology. Patient was bridged with heparin prior to procedure. Given history of prior history of ATN and fluid overload requiring CVVH during last admission ([**Month (only) **]-[**Month (only) **]/[**2165**]), patient was brought to [**Hospital Unit Name 153**] for continued intubation, monitoring of volume status and UOP post procedure. . On arrival to ICU, patient was intubated and sedated on propofol. Vitals stable, oxygenating well, family at bedside. Past Medical History: -Large ascending aortic dissection in [**2160**] s/p Dacron graft placement and St. Jude's valve placement (on coumadin goal INR 2.5-3.5) -R perinephric bleed s/p IR embolization of R kidney ([**2165-12-15**]) -R renal mass -Hypertension -Hypercholesterolemia -Mild chronic kidney disease (baseline Cr 1.1-1.3) Social History: married, has 3 children. occasional EtOH, denies tobacco Family History: Mother, father with hypertension, sister with CVA Physical Exam: VITALS ?????? 98.7, 165/49, 77 GENERAL - intubated, sedated HEENT - PERRLA NECK - supple, no thyromegaly, JVP=10 LUNGS - CTA anteriorly HEART - +mechanical SEM in across precordium, no rubs ABDOMEN - dressings over large right flank incision site, c/d/i, soft, trace bowel sounds EXTREMITIES - WWP, no LE edema Brief Hospital Course: Patient was admitted post-operatively to the [**Hospital Ward Name 332**] ICU under Dr.[**Name (NI) 24219**] Urology service. He remained intubated overnight due to the length of the case, but did well overnight, weaning on vent settings appropriately and he was extubated without difficulty on POD 1. His heparin anticoagulation was restarted approximately 8 hours after surgery at 1 am on [**2166-2-28**]. On POD 1, his PTT ranged from 65.7-94.3. In late POD 1, early POD 2, he was noted to have a decreasing hct, for which he received a transfusion of 2u pRBCs. However, after transfusion, his hct did not change. His UOP decreased and his creatinine increased from 1.8 immediately postoperatively to 4.1 on early POD 2. Of note, he was given two doses of lasix 40 mg IV on POD 1. A CT scan of the abdomen/pelvis without contrast was performed, which demonstrated a large R retroperitoneal hematoma. Heparin gtt was stopped and the patient was transfused as necessary to keep his hct > 25. He received a total of 7u of pRBCs, after which his hct stabilized off anticoagulation. Cardiology was consulted regarding the safety of stopping anticoagulation with a St. [**Male First Name (un) 1525**] mechanical valve present. They concluded that the risk of restarting anticoagulation would clearly have to be weighed against the risk of bleeding, but that 3-4 days off anticoagulation would not lead to excessive risk. The patient's heparin was restarted in the evening of his third day off anticoagulation, and the pt had no evidence of bleeding for the rest of his hospital stay. Renal was consulted regarding the patient's acute renal failure, which was thought to be secondary to acute tubular necrosis as a consequence of transient hypoperfusion of the remaining kidney either intraoperatively or postoperatively during his bleeding episode. The patient's creatinine peaked at 5.3 on [**2166-3-2**], after which his urine output improved significantly and his renal function began to improve, settling out at 1.8 on [**Date Range **]. He did not require dialysis during this hospitalization. After heparin was restarted and the patient's hct was noted to be stable with a therapeutic PTT, the pt was transferred from the ICU to the floor. The remainder of his hospital course was uncomplicated, and involved restarting coumadin to reach a therapeutic INR of 2.5-3.5. This required coumadin doses of 7.5 mg PO qhs to eventually reach an INR of 2.5 upon [**Date Range **]. The patient's primary care physician was [**Name (NI) 653**], who recommended discharging the patient on his home coumadin dose (3.0) with a plan to follow-up with the pt's PCP three days later for an INR check and coumadin dose adjustment. Of note, one day before [**Name (NI) **], the pt was noted to have small openings in his R flank wound in its medialmost- and lateralmost edges. This breakdown was probed, and was noted to be purely superficial, < 1 cm in depth and approximately 1-2 cm in width. Steri strips with benzoin were applied and dry gauze was applied. The patient was asked to call Dr. [**First Name (STitle) **] if his wound drainage worsened or if the wound opened up further. Before he was [**First Name (STitle) **], new steri strips were applied to the extent of his wound. He was discharged in stable condition, voiding without difficulty, ambulating without difficulty, and tolerating a regular diet. He will call Dr. [**First Name (STitle) **] for a follow-up appointment. Medications on Admission: Home meds confirmed with family -Fenofibrate 145 mg PO daily -Carvedilol 50 mg PO bid -Amlodipine 10 mg PO daily -Lisinopril 5 mg PO daily -Colchicine 0.6 mg PO daily -Coumadin 3 mg PO daily [**First Name (STitle) **] Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: Please follow up with your PCP [**Last Name (NamePattern4) **] [**2166-3-17**] for an INR check to keep your INR between 2.5-3.5. Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take to prevent constipation while taking percocet. [**Month (only) 116**] stop if not taking percocet. Disp:*60 Capsule(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 7. Fenofibrate 150 mg Capsule Sig: One (1) Capsule PO once a day. [**Month (only) **] Disposition: Home [**Month (only) **] Diagnosis: Right renal cell carcinoma [**Month (only) **] Condition: Stable [**Month (only) **] Instructions: -Do not lift anything heavier than a phone book (10 pounds) until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Your medications have changed. Please take your medications as instructed in the [**Month (only) **] instructions sheet. Please avoid all NSAIDs (motrin, advil, aleve, ibuprofen) -Call your Urologist's office today to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or [**Month (only) **] from your incision, call your doctor or go to the nearest ER. -There are small areas of breakdown on the ends of your wounds. Expect some mild drainage from these areas. If you notice that the drainage is increasing or that the wounds are getting larger, please call Dr. [**First Name (STitle) **] immediately. -Take your original coumadin dose of 3 mg daily. Please follow-up with your PCP on [**Name9 (PRE) 766**] [**2166-3-17**] for an INR check. Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to set up follow-up appointment and if you have any urological questions. Followup Instructions: Please call Dr.[**Name (NI) 24219**] office to arrange a follow-up appointment. Please follow-up with your primary care physician on MONDAY [**2166-3-17**] for an INR check. Your INR checks will need to be more frequent in the first two weeks because your coumadin doses have been different. You will resume your original coumadin dose of 3 mg daily Completed by:[**2166-3-15**]

Admission Date: [**2127-10-15**] Discharge Date: [**2127-10-25**] Date of Birth: [**2083-10-2**] Sex: M Service: NEUROLOGY Allergies: Penicillins / lisinopril Attending:[**First Name3 (LF) 2569**] Chief Complaint: Transferred from OSH, intubated/sedated, stroke care Major Surgical or Invasive Procedure: Angiographically guided clot retrieval procedure, insertion of central venous catheter, arterial line procedure History of Present Illness: The pt is a 44 year-old right-handed man with a past medical history significant for HLD, depression who presents as an OSH transfer with a basilar occlusion. History derived from wife who was at bedside. Patient noted the onset of nausea and vomiting on Monday. Wife thinks the patient woke up with this sensation. He denied any sensation of vertigo, he apparently had a mild headache. In addition to the severe nausea and vomiting he felt unsteady and kept veering to the right when he was walking. This sensation had been improving over the last two days but was still present so he made an appointment with his PCP. [**Name10 (NameIs) **] was able to drive and get to his PCP on his own power this morning. Besides the above symptoms his wife stated that he didn't have any facial asymmetry, no obvious weakness, no problems with vision, no difficulty with language. At the PCP's office he was by report feeling worse and disoriented. We have not been able to contact the PCP [**Name Initial (PRE) **]. He then reportedly collapsed at the office with a question of seizure like activity, and possible left eye deviation. EMS arrived and he was intubated and transferred to a local hospital then [**Hospital1 **]. At the OSH they got a head CT which apparently was normal and then a CTA which showed an occlusion of the right vertebral artery, and an occlusion in the top of the basilar artery. There endovascular service was not available and he was transferred to [**Hospital1 18**] for endovascular intervention. Past Medical History: - HLD - Depression - Insomnia Social History: Lives at home with his wife and three children. He is a sales representative. No history of smoking. No drug use. Uses EtOH on social occasions. Family History: Both his mother and father had CAD, he had a grandmother with a stroke. Migraine history in his family but he does not have any headaches. No history that wife is aware of bleeding or clotting disorders. Physical Exam: Physical Exam on Admission: Vitals: T:98 P: 84 R: 16 BP:159/99 SaO2:100 intubated General: intubated, propofol off for about 2-3 minutes HEENT: NC/AT, intuabed, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Grimacing to pain, not opening eyes to pain. Not responding to commands. Withdraws right side purposefully away from pain. Not responding to any commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. Some roving eye movements, no clear ocular bobbing. Unable to test visual fields. III, IV, VI: has dolls eyes in horizontal and vertical directions V: corneals intact, ? of less on left VII: unclear but with grimace little less movement of left face IX, X: Gag intact -Motor: Normal bulk, tone throughout. With stimulation withdraws to pain on the right arm and leg purposefully, the left leg is externally rotated and withdraws less than the left, he extensor postures the left arm. -Sensory: Withdraws to pain as above -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: not assessed -Gait: not assessed Pertinent Results: Labs on Admission: [**2127-10-15**] 01:55PM BLOOD WBC-9.2 RBC-4.37* Hgb-15.1 Hct-41.6 MCV-95 MCH-34.5* MCHC-36.3* RDW-12.6 Plt Ct-203 [**2127-10-15**] 01:55PM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1 [**2127-10-15**] 01:55PM BLOOD Lupus-PND AT-101 ProtCFn-129* ProtSAg-113 ACA IgG-2.3 ACA IgM-3.2 [**2127-10-15**] 01:55PM BLOOD ESR-3 [**2127-10-15**] 01:55PM BLOOD Fibrino-302 [**2127-10-16**] 05:10AM BLOOD Glucose-129* UreaN-9 Creat-0.6 Na-139 K-3.7 Cl-105 HCO3-23 AnGap-15 [**2127-10-16**] 05:10AM BLOOD ALT-43* AST-23 [**2127-10-16**] 05:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2127-10-16**] 05:10AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.1 Cholest-202* [**2127-10-16**] 05:10AM BLOOD Triglyc-102 HDL-48 CHOL/HD-4.2 LDLcalc-134* [**2127-10-16**] 05:10AM BLOOD %HbA1c-5.5 eAG-111 [**2127-10-16**] 05:10AM BLOOD TSH-0.60 [**2127-10-15**] 01:55PM BLOOD b2micro-1.3 [**2127-10-15**] 01:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2127-10-15**] 05:54PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [**2127-10-15**] 05:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2127-10-15**] 05:54PM URINE RBC-6* WBC-29* Bacteri-FEW Yeast-NONE Epi-<1 [**2127-10-15**] 05:54PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Cultures: MRSA Screen [**2127-10-20**]: Negative Sputum [**2127-10-18**]: Pneumococcus (Sensitivities pending) Urine culture [**2127-10-18**]: No growth C diff Toxin [**2127-10-20**], [**2127-10-22**]: Negative Stool O/P: pending Stool Cultures: pending EKG [**2127-10-15**]: Sinus bradycardia. Q-T interval prolongation. No previous tracing available for comparison. CXR [**2127-10-15**]: Appropriately positioned ET and NG tubes. Mild retrocardiac atelectasis. ECHO [**2127-10-18**]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. MRI/MRA ([**2127-10-16**]): 1. Complete occlusion of the basilar artery with multiple acute infarcts in the right cerebellum, right vermis, and bilateral paramedian pons. Top of the basilar artery, including bilateral posterior cerebrals and superior cerebellar arteries appear patent. Complete occlusion of the right vertebral artery with intrinsic high T1 signal may represent occlusion secondary to dissection. MRI/MRA ([**2127-10-19**]): Extensive acute infarctions in the bilateral pons, right superior vermis, and right superior and inferior cerebellum, and small acute infarction in the inferior left cerebellar hemisphere, with expected temporal evolution. New small acute infarction more superiorly in the left cerebellar hemisphere. Minimal effacement of the right lateral wall of the superior fourth ventricle, new since the prior exam. Partially improved flow through the distal basilar artery, which was previously occluded. Persistent occlusion of the right superior cerebellar artery. Persistent abnormal irregularity and narrowing of the intracranial right vertebral artery. Persistent nonvisualization of the right posterior inferior cerebellar artery. Brief Hospital Course: For two days prior to seeking medical attention, he was experiencing symptoms of nausea, vomitting and headaches. He did not receive TPA at the outside hospital. Mr. [**Known lastname **] was admitted to the ICU following an interventional procedure which recanalized occluded vessels in the posterior circulation (right vertebral artery and top of the basilar artery). He was intubated on arrival and remained intubated for this procedure. He was transferred to the ICU following this procedure. - He has remained hemodynamically stable during his course in the ICU and has not required IV pressors. He was initiated on IV anticoagulation with heparin and received his first dose of warfarin on [**2127-10-22**]. His heparin drip was discontinued on discharge and should receive his first dose of lovenox at his rehab facility. - He was plavix loaded in the interventional suite and while he was receiving both plavix and heparin, he was noted to have some oropharyngeal bleeding that was formally addressed by a bronchoscopic evaluation showing the presence of a traumatic lesion in the soft pharynx. This was treated with packing and has subsequently remained bleeding-free; additionally his plavix was discontinued. - On the days following his admission, we have noticed an improvement in his overall neurological examination. Today, he is able to move his eyes conjugately in all four directions as well as possesses significant neck movement. He has started to regain some chewing movements of his mouth but cannot volitionally open his mouth or protrude his tongue. He does have some very slight volitional movement of his upper extremities along the plane of gravity but this comes with a prolonged reaction time. - He received a tracheostomy and PEG tube on [**2127-10-21**] and has subsequently done well on trach collar. His tube feeds were reinitiated overnight, and they are currently at goal. He has remained on trach collar for >2 days. - He had a repeat MRI on [**2127-10-19**] which showed completion of his stroke with extensive areas of infarcts in the region of the midbrain and right cerebellum as well as partial recanalization of his right vertebral and basilar artery - His family has remained at his bedside throughout his stay. We had a family meeting on [**2127-10-17**] where we discussed his prognosis and likely prolonged rehabilitation. - He has been seen by and worked with speech therapy to develop a system of YES (looking up) and NO (looking down). In addition, his therapist provided some communication boards to help improve his communication skills. With PT's help, he has also been able to sit up in chair during much of the day time. - He did spike some fevers during his ICU course associated with a slight elevation in WBC and foul smelling sputum. Cultures have eventually grown out Coag positive staph aureus for which he is currently receiving IV vancomycin and ciprofloxacin. He is also receiving aztreonam so as to cover for coag negative staph bacteremia. - Prior to his discharge, he received a PICC line. His INR remained subtherapeutic in spite of three days of 5mg of warfarin QHS, and his dose was increased prior to discharge. Physical Examination on Discharge: Vitals: T 37.6-37.9, 59-65, 142-158/68-78, 16-24, 96-100%, 4.5L/2.8L GEN: Young, NAD, intermittently extends arms and legs, makes good eye contact, diaphoretic. CV: Regular heart sounds, without murmurs or rubs Pulm: Clear to auscultation bilaterally Abd: Soft without tenderness or distention Extremities: Without edema or clubbing Neurological Examination: Mental Status: Eyes are open at baseline. Can shake/nod head slowly. Intermittently will follow commands. Variably responds correctly by looking up/down. Cranial Nerves: PERRL, Able to provide conjugate gaze in all four directions but has difficulty tracking objects. There is no apparent facial droop or ptosis. There are no corneal reflexes, and no gag, although he does have a cough. There is no VOR. Cannot open his mouth and show his teeth or protrude tongue. Motor: Extensor posturing to pain in both upper extremities. Some right sided volitional movement along the plane of gravity but is slow. Lower extremities spontaneously extensor posture, also occasional triple flexion on painful stimulation of the lower extremities. He occasionally withdraws to pain. Reflexes are normal throughout, toes are up bilaterally Sensory: Difficult to assess Coordination/Gait: Not tested Transitional Issues: - Please keep Mr. [**Known lastname **] [**Last Name (Titles) 90846**] on warfarin (he needs this for the indefinite future). He can be on a lovenox bridge to a goal INR of 2.0 to 3.0. Please check coags daily especially while his antibiotics are being discontinued. - Please have Mr. [**Known lastname **] follow up with Dr. [**Last Name (STitle) **] of the Division of Vascular Neurology on [**Month (only) **] the 16th, [**2127**] at 10AM. - He requires a total of 14 days of IV antibiotics. His vancomycin, aztreonam and ciprofloxacin can be safely discontinued on [**2127-11-3**]. These are designed to treat a coag positive staph pneumonia and coag negative staph bacteremia. - Mr. [**Known lastname **] is an extremely motivated individual with a highly supportive family. Please provide aggressive phyiscal therapy and occupational therapy for him. - Continue to titrate his antihypertensives to maintain his SBP<130 Medications on Admission: Citalopram 20mg qd Trazadone 50mg qd Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. insulin regular human 100 unit/mL Solution Sig: As directed Injection every six (6) hours. 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. heparin (porcine) in D5W 25,000 unit/500 mL Parenteral Solution Sig: 1700U/hr Intravenous Continuous infusion: Until INR reaches a goal of 2.0-3.0. 7. aztreonam in dextrose(iso-osm) 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for Until [**2127-11-3**] days. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for Until [**2127-11-3**] days. 10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for Until [**2127-11-3**] days. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 15. labetalol 5 mg/mL Solution Sig: One (1) Intravenous Q4H (every 4 hours) as needed for SBP>160. 16. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Ischemic Stroke of the Posterior Circulation, Pontine/Midbrain infarct Hypercholesterolemia Depression Discharge Condition: Mental Status: Follows commands, responds by eye movements (Yes - look up, NO- look down) Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname **], you received treatment at the Intensive Care Unit of the [**Hospital1 69**] for a stroke in the back portion of your brain. This caused your symptoms of nausea and vomiting for two days, followed by your collapse at your physician's office. Our neurointerventional team were able to fix the blockage in the blood vessels of your brain, but there was still a large portion of tissue that did not receive oxygen and nutrients for a long period of time. The region of your brain infarcted is called the brainstem, which can control a variety of functions including swallowing, breathing and has passing through connections that control movement. - Initially, you were placed on a breathing machine to help maintain regular breathing. This was switched over to a "tracheostomy", which is an artificial breathing tube that connects directly to your trachea. This is a reversible procedure, that may be able to come out in the future. - Since you have significant swallowing dysfunction, you received a PEG tube that inserts directly into your stomach. You can receive tube feeds and water through this tube to provide you vital nutrients that you need to recover. - It is important that you try your best to participate as much as possible in rehabilitation exercises to help improve your strength over time. - We initiated you on a medication called IV heparin to keep your blood thin and [**Hospital1 90846**] and prevent future clots. This will be transitioned to a pill called WARFARIN or COUMADIN, which will do the same to your blood (blood thinner). - You will receive antibiotics for a limited period of time to treat a blood stream infection as well as a pneumonia that you developed while in the ICU. - We have scheduled an appointment for you to see one of our stroke specialists on the [**10-24**] at 1:00PM. Your day-to day care will be under the physician at your acute rehabilitation facility. - In addition to these, you will continue to take CITALOPRAM for depression WARFARIN for blood thinning LISINOPRIL for hypertension SIMVASTATIN for high cholesterol INSULIN as needed for high blood sugars FAMOTIDINE twice daily to prevent stress ulcers in your stomach Followup Instructions: [**Hospital Ward Name 23**] Building [**Location (un) **] [**Location (un) 830**], [**Location (un) **], [**Numeric Identifier 718**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2127-12-24**] 1:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2127-10-25**]

Admission Date: [**2131-10-14**] Discharge Date: [**2131-10-15**] Date of Birth: [**2104-5-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: found down. Major Surgical or Invasive Procedure: None History of Present Illness: patient is a 27-year-old man with history of obsessive-compulsive disorder and depression who presents from home after being found down by his friend's girlfriend. According to Friend, [**Name (NI) **] (see below) they were "partying hard" at a friend's house and then woke up the next morning to find [**Doctor Last Name **] as well as another friend unable to wake up. [**Doctor First Name **] believes that [**Doctor Last Name **] took too many "opiates", because "this is what opiate overdose looks to me." Everyone was worried about [**Doctor Last Name **] so they called Police and the ambulance which took [**Doctor Last Name **] to the Emergency Room. . In the ED, initial vs were: T afebrile, P 114, BP 113/86, R 14, O2 sat 94%RA. An EKG showed sinus tachycardia with normal intervals and no ischemic changes. Patient was given 2mg IN Narcan in the field, 2mg IM narcan in ED and then got 2nd mg IV Narcan - as he appeared to be protecting his airway adequately, he was not intubated. He was however started on Narcan drip prior to admission for concern of persistent somnolence. He also received 1L of intravenous fluids. . On the floor, he feels sleepy and tired. He does not recall what happened. He would prefer to have his brother [**Name (NI) 653**] and when asked, he agrees for us to contact his outpatient psychiatrist. He endorses a friend named [**Name (NI) **] ([**Telephone/Fax (1) 40783**]. . As per his outpatient psychiatrists (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - former pediatric psychiatrist, and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - current psychiatrist with whom patient has only met for a couple of sessions), patient has a history of "disabling" obsessive-compulsive disorder, complicated by mild depression. Patient has no history of suicide attempts or intentional drug overdose. . Review of systems: patient states that he feels sleepy, denies coughing, fevers, chills, recent illness . 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: --obsessive-compulsive disorder (diagnosed years ago) --depression with history of psychiatric hospital admissions (per psychiatric note from [**2130-3-29**]) Social History: Social History: Lives by himself. ?On Disability due to psych ilness. Started smoking about 6 months ago and smokes a pack every 2 days. Drinks socially but in large amounts. Family History: (As per OMR) Extensive OCD FH - eldest brother (controlled on multiple meds), another brother (present at interview) had a "brief stint" with OCD that resolved, father (undiagnosed, except by children). Physical Exam: Vitals: T: 98.4 BP: 92/67 P: 103 R: 12 O2: 96%RA General: Patient is alert to name, address, president, and hospital. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic, 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 SKIN: large scar on right shin (old burn), and scar on forehead, well healed. Pertinent Results: [**2131-10-15**] 01:00PM BLOOD WBC-6.4 RBC-3.95* Hgb-11.7* Hct-33.7* MCV-85 MCH-29.5 MCHC-34.6 RDW-12.7 Plt Ct-174 [**2131-10-14**] 02:00PM BLOOD WBC-16.9* RBC-4.85 Hgb-14.3 Hct-41.2 MCV-85 MCH-29.4 MCHC-34.6 RDW-12.7 Plt Ct-265 [**2131-10-14**] 05:38PM BLOOD PT-13.3 PTT-31.7 INR(PT)-1.1 [**2131-10-15**] 03:25AM BLOOD Glucose-72 UreaN-19 Creat-0.8 Na-141 K-4.5 Cl-108 HCO3-27 AnGap-11 [**2131-10-14**] 02:00PM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-143 K-5.9* Cl-104 HCO3-29 AnGap-16 [**2131-10-14**] 05:38PM BLOOD ALT-21 AST-28 AlkPhos-45 Amylase-28 TotBili-0.4 [**2131-10-14**] 05:38PM BLOOD Lipase-16 [**2131-10-15**] 03:25AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.8 [**2131-10-14**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2131-10-14**] 02:10PM BLOOD Glucose-94 Lactate-3.5* K-5.7* [**2131-10-15**] 03:55AM BLOOD Lactate-1.1 Benzodiazepine Screen, Urine NEG Barbiturate Screen, Urine NEG Opiate Screen, Urine NEG Cocaine, Urine POS Amphetamine Screen, Urine POS Methadone, Urine POS Brief Hospital Course: # Overdose/Somnolence - No evidence of trauma on exam. Urine toxicology was positive for methadone, cocaine, and amphetamines. Amphetamine likely positive in setting of prescribed Adderall. He does not have medication patches on his body or needle track marks. Patient responded to Narcan and was on Narcan Drip in ED. His alertness waxed and waned the morning of admission. His respiratory rate remained normal and he did not require Narcan after admission. He received 4L IVF. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale was maintained. Psychiatry was consulted in the morning; they did not believe there was any element of suicidality in the presentation. Outpatient psychiatrists [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 40784**], and [**First Name8 (NamePattern2) 40785**] [**Last Name (NamePattern1) **] (former Psychiatrist) have been [**Last Name (NamePattern1) 653**] and are aware of admission; both agree with involving the inpatient psychiatric consult team. Throughout the day, the patient's mental status returned to an appropriate baseline; he continued to deny opiod ingestion, but he does state that he was unaware of what he was consuming at the shindig. # Hypotension - likely related to opiate overdose. Differential in a person who overdosed in his age group would include GI bleed; his HCT did trend down from 41-33 but his other cell lines decreased and he was not noted to have diarrhea. He received 4L IVF. . #Leukocytosis - Initial leukocytosis quickly resolved after admission. Unclear etiology. Medications on Admission: Medications: --Adderall 15 mg [**Hospital1 **] --Abilify 10 mg QD --citalopram 60 mg QAM --clonazepam 0.5 mg [**Hospital1 **] PRN Discharge Disposition: Home Discharge Diagnosis: Overdose Discharge Condition: Good, stable Discharge Instructions: You were evaluated in the ED and the ICU for increased sedation after "a night of partying." Although you do not know what specifically you ingested, your lab results demonstrate that you ingested opiods. This would explain your increased sedation, decreased drive to breath, and decreased blood pressure; these symptoms reversed when we used an [**Doctor Last Name 360**] that targets opiods. You were observed throughout the day and improved to a normal mental status. Stop using drugs. Continue to see your psychiatrist. See below instructions for danger signs that would suggest that you return to the ED. Followup Instructions: Followup with your outpatient psychiatrist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 3 days. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2199-5-17**] Discharge Date: [**2199-5-27**] Date of Birth: [**2138-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: epinephrine Attending:[**First Name3 (LF) 165**] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: Coronary artery bypass (LIMA>LAD, SVG>Diag, SVG>Ramus, SVG>OM, SVG>OM, SVG>PDA) [**5-21**] History of Present Illness: Mr. [**Known lastname 43681**] is a 60 year old male with coronary artery disease as documented by catheterization at the [**Hospital6 13185**] in [**2189**]. Recently he developed exertional chest discomfort, for which he was sent for an exercise echo on [**2199-5-7**]. This test showed ST depression. During a stress mibi on [**2199-5-15**] he developed 3 episodes of NSVT and 1/10 chest pain. Perfusion images showed a small area of ischemia in the basal-mid inferolateral wall, LCx/OM territory. After he completed the stress test he went home and developed a recurrence of chest pain. Initially a work-up at [**Hospital **] Hospital was negative for MI but he was referred to [**Hospital1 18**] for cardiac catheterization. This test revealed multi-vessel coronary artery disease. Past Medical History: Coronary Artery Disease Sleep apnea Hypertension Hyperlipidemia Gout Social History: Mr. [**Known lastname 43681**] is a former smoker, having quit in [**2189**]. He is an occasional drinker, stating that he has a couple drinks with friends. [**Name (NI) **] denies illicit drugs. Family History: Mr. [**Known lastname 112247**] mother has heart disease, s/p a coronary artery bypass grafting in her late 60s, early 70s. His maternal uncle has a history of heart uncle. Physical Exam: Admission physical exam: VS: T 98.2, BP 128/65, HR 56, RR 18, SpO2 96% on RA WEIGHT: 107kg GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: 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 abdominial bruits. EXTREMITIES: No c/c/e. RIght wrist with TR band in place. 2+ radial pulses bilaterally. Hair loss of the lower extremities bilaterally. NEURO: CN II-XII tested and [**Known lastname 5235**], strength 5/5 throughout, sensation grossly normal. Gait not tested. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Date/Time: [**2199-5-21**] Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. [**Year (4 digits) **]: Normal ascending [**Year (4 digits) 5236**] diameter. Simple atheroma in descending [**Year (4 digits) 5236**]. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. There are simple atheroma in the descending thoracic [**Year (4 digits) 5236**]. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic fxn. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2199-5-27**] 05:07AM BLOOD Hct-30.7* [**2199-5-26**] 05:10AM BLOOD WBC-6.5 RBC-2.95* Hgb-9.1* Hct-26.5* MCV-90 MCH-30.9 MCHC-34.4 RDW-12.7 Plt Ct-219 [**2199-5-27**] 05:07AM BLOOD PT-12.4 INR(PT)-1.1 [**2199-5-27**] 05:07AM BLOOD UreaN-41* Creat-1.6* Na-133 K-5.2* Cl-94* HCO3-27 AnGap-17 [**2199-5-27**] 05:07AM BLOOD Mg-2.4 [**5-26**] PA&Lat: The right IJ line tip is in the mid SVC. There is volume loss in the retrocardiac region but the effusions are much smaller. A small left lower lobe retrocardiac infiltrate could be present versus volume loss. Overall, the aeration of the left lung is improved. Brief Hospital Course: Patient is a 60 yo male with PMHx of CAD by cath at the [**Hospital1 112**] in [**2189**], HTN, HLD, and OSA (does not use CPAP regularly) recently with chest pain and oupatient ETT revealing significant ST depression admitted last night with chest pain at OSH and transferred to [**Hospital1 18**] for cardiac catheterization found to have extensive 3-vessel CAD referred to cardiac surgery for CABG. The patient was brought to the Operating Room on [**2199-5-21**] where the patient underwent a coronary artery bypass grafting times six (LIMA>LAD, SVG>Diag, SVG>Ramus, SVG>OM, SVG>OM, SVG>PDA). 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 [**Date Range 5235**] and hemodynamically stable. Beta blocker was initiated and the patient was diuresed towards the preoperative weight.Baseline creat 1.4-1.6. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. On the morning of post-operative day three Mr. [**Known lastname 43681**] had intermittent rapid atrial fibrillation 150-160's which converted to sinus rhythm with increased beta blockers and was bolused with amiodarone and placed on taper. Anticoagulation was started, goal INR [**1-4**] to be managed by [**Hospital 6435**] [**Hospital3 **]. At discharge his creat was 1.6 and potassium sightly elevated. He has been aggressively diursed and is being discharged on low dose lasix and no potassium supplement. He will need to have chem 7 checked over the next couple of days and diuretics/potassium adjusted as needed. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, his wounds were healing well and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. VNA Allcare network to f/u with him at home. Medications on Admission: --ASA 81mg daily --Pravastatin 20mg daily --Atenolol 25mg daily --Linsopril 20mg daily --Fenofibrate 200mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 2. Pravastatin 20 mg PO DAILY RX *pravastatin 10 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 3. Acetaminophen 650 mg PO Q4H:PRN pain/fever 4. Amiodarone 400 mg PO BID Duration: 3 Days then decrease 200mg [**Hospital1 **] x 1 week then decrease to 200mg daily RX *amiodarone 200 mg 2 Tablet(s) by mouth twice daily for 3 days Disp #*90 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID Duration: 1 Months 6. Furosemide 40 mg PO DAILY Duration: 1 Weeks RX *furosemide 40 mg 1 Tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX *hydromorphone 2 mg [**12-3**] Tablet(s) by mouth every 4 hrs Disp #*40 Tablet Refills:*0 8. Metoprolol Tartrate 37.5 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg [**10-4**] Tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*2 9. Ranitidine 150 mg PO DAILY Duration: 1 Months RX *ranitidine HCl 150 mg 1 Capsule(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Warfarin MD to order daily dose PO DAILY RX *warfarin 5 mg as directed Tablet(s) by mouth daily as directed Disp #*90 Tablet Refills:*0 11. fenofibrate *NF* 200 mg Oral daily 12. Potassium 20meq tabs po to be taken as directed Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage +1 lower ext edema 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: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**2199-6-4**] at 11 am [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-6-25**] 1:30 Cardiologist Dr. [**Last Name (STitle) **] (Dr.[**Name (NI) 112248**] office will call patient to arrange) Please call to schedule the following: Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69482**] ([**Telephone/Fax (1) 112249**] in [**3-7**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2199-5-27**]

Admission Date: [**2160-4-27**] Discharge Date: [**2160-5-15**] Service: SURGERY Allergies: Demerol / Lidocaine Attending:[**First Name3 (LF) 5880**] Chief Complaint: 81 F s/p AAA and ventral hernia repair with component separation [**2160-2-18**] p/w fever to 102.4 Major Surgical or Invasive Procedure: Percutaneous cholecystostomy tube History of Present Illness: 81 F s/p AAA repair and ventral hernia repair presenting with fever of unknown etiology admitted to the surgical service for blood cultures, CT of the abdomen, IV hydration, and r/o SBO. Past Medical History: Includes rheumatoid arthritis, prednisone dependent and on methotrexate; ischemic heart disease with a myocardial infarction in [**2155**], stress test done on [**2159-11-18**] was without ischemic changes, no perfusion deficits, ejection fraction was 72% with no wall motion abnormalities; also history of GERD; history of urinary tract infections, treated; history of skin cancer; history of MRSA infections; history of UTI sepsis with hypotension. Social History: non-contributory Family History: non-contributory Physical Exam: 101.8 103 105/48 25 99%2LNC Lethargic Lungs with mild expiratory wheeze bilaterally soft, non-distended, mild RUQ tenderness to deep palpation, midline wound healing well with granulation- minimal fibrinous exudate, soft swelling in RLQ without erythema or induration 1+ edema bilaterally pulses 2+ Pertinent Results: [**2160-4-27**] 12:15AM BLOOD WBC-25.7*# RBC-3.51* Hgb-9.9* Hct-31.3* MCV-89 MCH-28.1 MCHC-31.5 RDW-19.4* Plt Ct-531* [**2160-4-27**] 09:50AM BLOOD WBC-24.8* RBC-3.21* Hgb-9.2* Hct-28.9* MCV-90 MCH-28.5 MCHC-31.7 RDW-19.3* Plt Ct-493* [**2160-4-28**] 05:50AM BLOOD WBC-17.9* RBC-2.89* Hgb-8.3* Hct-25.5* MCV-88 MCH-28.6 MCHC-32.4 RDW-19.8* Plt Ct-474* [**2160-4-29**] 10:00AM BLOOD WBC-14.3* RBC-2.49* Hgb-7.2* Hct-22.3* MCV-89 MCH-28.7 MCHC-32.1 RDW-19.4* Plt Ct-434 [**2160-4-29**] 10:29PM BLOOD WBC-13.6* RBC-2.77* Hgb-8.0* Hct-24.6* MCV-89 MCH-28.9 MCHC-32.4 RDW-18.4* Plt Ct-411 [**2160-4-30**] 03:31AM BLOOD WBC-13.5* RBC-3.17* Hgb-9.1* Hct-27.6* MCV-87 MCH-28.9 MCHC-33.1 RDW-18.5* Plt Ct-417 [**2160-4-30**] 12:10PM BLOOD WBC-13.6* RBC-3.17* Hgb-9.2* Hct-27.8* MCV-88 MCH-28.9 MCHC-33.0 RDW-18.8* Plt Ct-434 [**2160-5-1**] 02:19AM BLOOD WBC-16.8* RBC-2.98* Hgb-8.7* Hct-26.3* MCV-88 MCH-29.2 MCHC-33.1 RDW-18.5* Plt Ct-426 [**2160-5-2**] 04:35AM BLOOD WBC-18.1* RBC-3.21* Hgb-9.2* Hct-28.6* MCV-89 MCH-28.5 MCHC-32.0 RDW-18.6* Plt Ct-504* [**2160-5-3**] 04:23AM BLOOD WBC-11.3* RBC-3.20* Hgb-9.2* Hct-28.7* MCV-90 MCH-28.8 MCHC-32.2 RDW-18.5* Plt Ct-478* [**2160-5-4**] 05:15AM BLOOD WBC-12.2* RBC-3.59* Hgb-10.4* Hct-32.9* MCV-92 MCH-29.1 MCHC-31.8 RDW-18.5* Plt Ct-506* [**2160-4-27**] 12:15AM BLOOD Glucose-55* UreaN-39* Creat-1.0 Na-143 K-5.0 Cl-105 HCO3-28 AnGap-15 [**2160-4-27**] 09:50AM BLOOD Glucose-83 UreaN-33* Creat-0.9 Na-137 K-4.9 Cl-102 HCO3-25 AnGap-15 [**2160-4-28**] 05:50AM BLOOD Glucose-59* UreaN-20 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-27 AnGap-15 [**2160-4-29**] 10:00AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-140 K-3.8 Cl-102 HCO3-28 AnGap-14 [**2160-4-29**] 10:29PM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-139 K-3.2* Cl-101 HCO3-28 AnGap-13 [**2160-4-30**] 03:31AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 [**2160-4-30**] 12:10PM BLOOD Glucose-175* UreaN-15 Creat-1.0 Na-139 K-3.7 Cl-100 HCO3-26 AnGap-17 [**2160-5-1**] 02:19AM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-141 K-3.3 Cl-102 HCO3-25 AnGap-17 [**2160-5-2**] 04:35AM BLOOD Glucose-176* UreaN-33* Creat-1.0 Na-142 K-3.6 Cl-106 HCO3-26 AnGap-14 [**2160-5-2**] 04:37PM BLOOD Glucose-294* UreaN-36* Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-25 AnGap-13 [**2160-5-3**] 04:23AM BLOOD Glucose-334* UreaN-39* Creat-0.9 Na-139 K-4.3 Cl-106 HCO3-25 AnGap-12 [**2160-5-4**] 05:15AM BLOOD Glucose-137* UreaN-39* Creat-0.8 Na-143 K-3.3 Cl-109* HCO3-26 AnGap-11 ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST CT CHEST WITH CONTRAST: The pulmonary arteries opacify without evidence for filling defects. The appearance of the aorta is stable from [**2160-3-11**]. The mediastinal lymph nodes are unchanged, none meeting pathologic criteria. NG tube is present within the stomach. The bronchi are patent to the subsegmental level. There is new right lower lobe atelectasis compared to [**2160-3-11**]. Right upper lobe pleural thickening measuring 2 x 1 cm is unchanged. There is a left upper lobe pulmonary nodule, unchanged from [**2160-3-11**]. CT ABDOMEN WITH CONTRAST: The liver enhances without focal lesions. There is new pericholecystic fluid and inflammatory change that is present between the gallbladder and head of the pancreas. This is new from [**2160-3-11**]. Given the predominance of inflammation adjacent to the pancreas, this is more likely a sequela of pancreatitis. However, cholecystitis cannot be entirely excluded and clinical correlation is recommended. The pancreas enhances homogeneously. The common bile duct is not dilated. Below the body of the pancreas is a fluid collection measuring 5 x 4.5 cm that is smaller than [**3-11**], [**2159**]. The spleen, adrenals, and small bowel are normal. Multiple air- fluid levels in the small bowel are present but within normal limits. The small bowel is not distended. Along the midline upper abdominal wall is a 3 cm fat-containing defect. More inferiorly, there is a large abdominal wall defect. Patient is status post closure of abdominal wall surgery by secondary intention. Within the subcutaneous tissues of the right anterior abdominal wall is a 10 x 2.4 cm fluid structure. It demonstrates minimal rim enhancement. This likely represents a seroma, but liquefying hematoma or abscess cannot be excluded. CT PELVIS WITH CONTRAST: The rectum and sigmoid are unchanged with marked sigmoid diverticulosis. There is marked atherosclerotic calcification of the abdominal aorta and its major branches, and surgical clips are present indicating abdominal surgery. Multiple hypodense lesions in both kidneys are unchanged and likely represent simple cysts. The distal ureters and bladder appear normal. A Foley is present within a compressed bladder. The remaining large bowel is normal caliber. There is no free fluid in the pelvis. A healed left inferior pubic ramus fracture is unchanged. Otherwise the osseous structures are only remarkable for degenerative disease throughout the osseous skeleton. IMPRESSION: 1. New pericholecystic fluid/inflammatory change is most predominant between the gallbladder and pancreas. This is likely be the sequela of pancreatitis, but cholecystitis cannot be entirely excluded. Clinical correlation is advised. 2. Persistent but improving 5 cm peripancreatic fluid collection below the body of the pancreas. 3. New 10 x 2.4 cm right abdominal wall fluid collection that likely represents seroma, but hematoma or abscess cannot be excluded. These findings were discussed with the Emergency Department house staff caring for the patient at 4 a.m. on [**4-27**], [**2159**]. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2160-4-28**] 7:14 PM IMPRESSION: Moderately distended gallbladder with wall thickening and edema. No stones or definite sludge seen within the gallbladder. Findings are nonspecific in the setting of ascites and clinical correlation is recommended. Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 10:20 p.m. on [**2160-4-28**]. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ GALLBLADDER SCAN [**2160-4-28**] IMPRESSION: Nonvisualization of gallbladder after 2.5 hours. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ GUIDANCE PERC TRANS BIL DRAINAGE US [**2160-4-29**] 3:31 PM PROCEDURE: Preprocedure consent was obtained from the patient's two daughters, one of whom is the healthcare proxy. Abnormal INR was corrected preprocedure with 3 units of fresh frozen plasma. Preprocedure confirmation of patient identity and nature of procedure was performed. Initial ultrasound images show moderately distended gallbladder. Following aseptic technique using a right lateral intercostal approach and following local and intravenous analgesia (because of a history of lidocaine allergy, a different [**Doctor Last Name 360**] without reported crossover was used). An 8.2-French [**Last Name (un) 2823**] catheter was placed within the distended gallbladder body. The pigtail tip was formed within the gallbladder body, aspiration yielded 80 cc of dark bile. Sample has been sent for microbiological analysis as requested. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CHEST (PORTABLE AP) [**2160-5-5**] 5:06 PM IMPRESSION: 1. Continued moderate left pleural effusion and left lower lobe atelectasis and/or pneumonia. 2. Mild congestive heart failure. Brief Hospital Course: Patient was admitted to the surgical service on [**2160-4-26**] after a CT scan of the abdomen was performed from the emergency room showing fluid and stranding around the pancreas and gallbladder in addition to an abdominal wall seroma. Her PICC line was discontinued as it was purulent appearing. A NG tube was placed in the emergency department for decompression. She was started on vancomycin/levofloxacin/flagyl and blood cultures were sent. Her NGT was discontinued on [**2160-4-28**]. On [**2160-4-29**] she continued to be febrile to 103.2 with rigors annd tachycardia. She was maintained on IV lopressor for heart rate control and started on TPN. An ultrasound showed a moderately distended gallbladder with wall thickening and edema. On the ultrasound no stones or definite sludge seen within the gallbladder. A HIDA scan was performed due to further evaluate for cholecystitis and was suspicious for cholecystitis as there was no tracer uptake in the gallbladder on delayed images. . She was taken to interventional radiology for a percutaneous cholecystostomy tube placement and drainage. She was continued on antibiotics and fluconazole was added to her regimen. Blood cultures and the biliary cultures had no growth, however antibiotics had been initiated at an early stage. She was observed in the ICU following percutaneous tube placement due to tachycardia and mild hypotension. She was noted to be in rapid atrial fibrillation on the first evening in the ICU and she was rate controlled with medication then spontaneously reverted back to sinus rhythm within 12 hours. She continued in the SICU and recovered well with stable hemodynamics following this. She was out of bed and working with physical therapy. Her diet was slowly advanced. She was transferred to the floor on post-procedure day 2. She had an uneventful course on the floor. She worked with physical therapy and nursing for increasing activity. She remained afebrile and antibiotics were discontinued. She and was monitored by nutrition for PO intake. Calorie counts for [**Date range (1) 16935**] was 1162/1292/1227 and 44/59/51gm of protein. Per inpatient nutritionist caloric goal is 1250 calories per day. She will continue on boost supplements and needs encouragement and aid with meals. She was transferred to rehab on [**2160-5-9**] where she will continue [**Hospital1 **] dressing changes and physical therapy. The drain will remain in place and she will follow-up with Dr. [**Last Name (STitle) **]. Medications on Admission: Actonel Atenolol 50 Lipitor 40 Folic Acid Methotrexate 15 po qFri Prednisone [**4-29**] ASA 81 MVI Protonix Vitamin D Colace Calcium Ativan Atrovent ?diltiazem 30qid wellbutrin 75 Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 12. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital6 **] TCU - [**Location (un) 86**] Discharge Diagnosis: cholestasis Discharge Condition: good Discharge Instructions: [**Name8 (MD) **] M.D. or go to the emergency room for fevers, chills, abdominal pain, breakdown or drainage from wound, redness around wound, nausea/vomitting, questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 week in the general surgery clinic. Please call clinic to schedule/confirm ([**Telephone/Fax (1) 6449**]. Follow-up with your rheumatologist about restarting methotrexate. Follow-up with primary care physician.

Admission Date: [**2104-8-15**] Discharge Date: [**2104-9-9**] Service: VSURG Allergies: Penicillins / Cephalosporins / Carbapenem / Aztreonam Attending:[**First Name3 (LF) 1781**] Chief Complaint: Fevers and confusion, new Major Surgical or Invasive Procedure: Right foot debridment [**2104-8-27**] History of Present Illness: Patient recently discharged form our hospital areturn to ER with fever,chill and confusion. Vascular consulted during ER evaluation. Patient now admitted to vascular service for continued care(.Note on physical exam in ER. rt. leg cellulitis and foot color changes.Patient's PCP and vascular [**Name9 (PRE) 19670**] opted for conserative treatment. He was started on Ceftriaxone and flagyl ) Past Medical History: Diabetes type one, insulin dependant COPD CAD, s/p MI [**2094**] pneumonia, recent treated PVD esophgitis hypercholestremia history of CVA right sided s/p CABGsx4 s/p rt. toe amputations #3&4 Social History: not avaible Family History: unknown Physical Exam: Vital signs: 100.7-89-16 92/52 oxygen saturation on 6liter/nasal cannula 98% General: oriented x2. No acute distress Heart: irregular irregular rythmn Lungs: corase crackles LLL ABD: bengin EXT: right foot: large dorsal foot ersovie ulcer, not gangrenous with erthyema, warm to palpation and toe blanching Pulses: radial and femoral pulses palpable bilaterally, popliteal biphasic signal bilaterally. right pedal pulses moophasic signal. Left pedal pulses biphasic signal. Neuro Ox2, grossly intact Pertinent Results: [**2104-8-14**] 10:21PM LACTATE-2.0 [**2104-8-14**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2104-8-14**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2104-8-14**] 10:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2104-8-14**] 10:00PM GLUCOSE-65* UREA N-19 CREAT-0.7 SODIUM-137 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-32* ANION GAP-12 [**2104-8-14**] 10:00PM CK(CPK)-26* [**2104-8-14**] 10:00PM CK-MB-2 cTropnT-<0.01 [**2104-8-14**] 10:00PM WBC-20.0* RBC-4.19* HGB-13.1* HCT-38.4*# MCV-92 MCH-31.2 MCHC-34.0 RDW-13.8 [**2104-8-14**] 10:00PM NEUTS-83.3* LYMPHS-10.9* MONOS-5.4 EOS-0.3 BASOS-0.2 [**2104-8-14**] 10:00PM PLT COUNT-228 [**2104-8-14**] 10:00PM PT-12.5 PTT-30.1 INR(PT)-1.0 Brief Hospital Course: [**2104-8-15**] admitted vascular surgical service.right foot infection continued on Cefriaxone and flagyl.Now with fever of 102.5 and mental status changes in last twentfour hours. admitting chest xray left lower pneumonia antibiotics were changed to vancomycin,levofloxcin and flagyl IV. The night of admission patient became more confused, hypoglycemic with ? seizures VS. rigors and hypotension. He was transfered to ICU for hemodynamic monitering. right internal jugular line was placed withut pneumo thorax.Patient blood pressure responded to 2 liters of fluid bolus. Patient remained with low grade fever 100.5 but was hemodynamically stable. Total WBC 21.A D10 IV drip was instuted for his hypoglycemia. [**2104-8-16**] [**Last Name (un) **] service was consulted for glycemic control.Podiatry recommended continued current managment. Consider radical soft tissue debridment of right foot. [**2104-8-17**] patient 's WBC showed improvement. 14.4 Digoxin level was 0.6 and his digoxin was restarted.Blood cultures positive gram positive cocci.along with wound culture. cardology consulted. P mibi recommended 7/26/04abnormal P mibi. Echo obtained to asses left ventricular function.EF 30% with multiple reginol wall motion abnormalities.Patient at considerable cardiac risk. This was discussed with Dr. [**Last Name (STitle) **] by DR. [**Last Name (STitle) **] [**Name (STitle) 19671**] consultant. [**2104-8-19**] transfered to VICU [**2104-8-25**] angiogram with angioplasty and stenting of right TPT. [**2104-8-27**] debridment of right TMa VAC dressing application. [**2104-8-28**] urine c/s and urinalysis sent for mucous in urine. urinalysis was positive. Foley was removed. patient continued on antibiocs. wound c/s and bone c/s postive for MRSA. [**2104-9-2**] right TMA. Infectious disease consulted. Lenght of antibiotic for MRSA six weeks since bone culture positive. [**2104-9-3**] inital dressing removed. skin edges well approximated. no erythema.no drainage. ambulation strict nonweight bearing. Seen by physical theraphy who recommends rehab at discharge prior returning home. [**Last Name (un) **] continued to follow patient and adjust insluin dosing. [**2104-9-5**] levofloxcin discontinued. [**9-6**] flagyl dicontinued anerobic cultures no growth. [**2104-9-9**] PICC line placed. wbc 10.0 bun/cr. 18/0.6. 8/.17/04 discharged afebrile and stable Medications on Admission: medrol 4mgm qd surfate 240mgm qbid magoxide 400mgm [**Hospital1 **] insulin Humelin N 100 u [**Hospital1 **] insulin Humellin R [**Hospital1 **] pravachol 40mgm HS rinitidine 150mgm [**Hospital1 **] ASA 81 mgm qd lanoxin 125mgm qd atrovent MDI prn enalapril 5mgm dq fosmax 70mgm q week combivent MDI Flovent MDI Imdur 20mgm qd lasix 20mgm qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Methylprednisolone 4 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal QID (4 times a day) as needed. 10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 11. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. 14. Sodium Chloride 0.9% Flush 3 ml IV QD:PRN Peripheral IV - Inspect site every shift 15. Vancomycin HCl 1000 mg IV Q18H Previously approved by ID. 16. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: Humalog breakfast/dinner: glucose < 80/ no insulin glucose 81-120/3u glucose 121-160/5u glucose 161-200/10u glucose 201-240/12u glucose 241-280/14u glucoses 281-320/16u glucose 321-360/18u glucose 361-400/20u glucose > 400/ [**Name8 (MD) 138**] MD. Lunch: glucoses <160/ no insulin glucoses 161-200/2u glucose 201-240/6u glucose 241-280/8u glucose 281-320/10u glucose 321-360/12u glucose 361-400/14u HS: glucoses<240/no insulin glucose 241-280/2u glucose 281-320/4u glucose 321-360/6u glucose 361-400/8u glucose > 400 [**Name8 (MD) 138**] MD. . Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: osteomylitis rt. foot s/p Right TMA MRSA wound infection Discharge Condition: stable Discharge Instructions: Moniter ESR while on antibiotics. trough level q week. contiune antibiotic for 6 weeks from [**2104-9-2**] finger glucoses qid Followup Instructions: 2 weeks Dr.[**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 1784**] Completed by:[**2104-9-9**]

Admission Date: [**2147-1-27**] [**Year/Month/Day **] Date: [**2147-2-12**] Date of Birth: [**2090-7-16**] Sex: M Service: MEDICINE Allergies: Cefepime / Cipro Cystitis Attending:[**First Name3 (LF) 3913**] Chief Complaint: Cough, malaise, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 56 year old man with a h/o AML s/p allo SCT in [**2143-6-16**] c/b chronic skin and pulmonary GVHD treated with prednisone 10mg daily. He reports 5-6 days of URI symptoms, myalgias, cough productive of yellow sputum, decreased appetite, and poor PO intake. No fevers, though he has been taking tylenol. He presented to heme/onc clinic today and reported headache and nausea with improved after 1L NS. He was afebrile but hypoxic to 90% on RA, which improved to 94% on 2L. Nasal swab and blood cultures were sent. CXR was negative. He was given vancomycin/aztreonam (due to cefepime allergy) and admitted for further workup. . O2 sats were in the mid-80s on RA so he was placed on nasal cannula and then shovel mask. 6pm ABG was: 7.46/37/69. Lactate 1.1. . Overnight pt became more hypoxic and tachypnic. Febrile to 101.8. Azithro was added to his abx. Chest CT [**First Name9 (NamePattern2) 5692**] [**Last Name (un) 22975**] tree [**Male First Name (un) 239**] opacities and concern for brochiolitis/pneuonitis. BMT wanted to give IVIG due to low IgG, but pt was too hypoxic. Eventually 86% on NRB. [**Hospital Unit Name 153**] was called. Pt given albuterol x 1, and CXR taken. Pt c/o resp fatigue. Transfered to ICU. . ROS: (+) As noted above. (-) No current chest pain, palpitations, SOB, abdominal pain, N/V/D. Past Medical History: # Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on warfarin # Acute myeloid leukemia: - [**3-/2143**]: diagnosed - [**6-/2143**]: underwent a matched unrelated allogeneic stem cell transplant. - post-transplant course c/b bx-proven GVHD of the liver and an intermittent skin rash, s/p management with cyclosporine, mycophenolate, rituximab, and currently, steroids. # type 2 DM: steroid-induced # hyperlipidemia # bilateral hip AVN # HTN # nephrolithiasis: s/p lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage # BCC s/p excision # SCC left cheek, s/p Mohs' [**5-/2144**] # multiple back surgeries: L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware) # anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [**2-/2144**] # chronic numbness, neuropathic pain in left upper extremity # multilevel compression fractures T11, T12, L1 and mild compression L3 and L4 # OSA: refused biPAP at home Social History: Lives with his wife, and son. [**Name (NI) **] is retired, worked as a [**Company 22957**] technician Tobacco - 40 pk year hx, quit 5 yrs ago. EtOH - denies Drug use - denies. Family History: Mother died suddenly in her 70s. Father died of unknown cancer. One sister has thyroid cancer. One brother has diabetes. One sister has [**Name (NI) 5895**]. Physical Exam: Admission physical exam Vitals: 101.8 132/88 109 24 91% NRB FS 127 General: A&Ox3 but appears SOB, speaking full sentences HEENT: dry MMM, clear OP, no scleral icterus Neck: Supple, no masses Lungs: Coarse breath sounds througout, no wheezes. CV: Regular, nml S1/S2, no murmurs. Abdomen: Soft, NT, ND, +BS Extrem: Hands and feet warm and well perfused, no cyanosis, 2+ pedal pulses, no edema. Neuro: CN grossly intact, strength and sensation grossly intact. [**Name (NI) **] physical Exam: Please refer to daily progress note. Pertinent Results: ICU Admission Labs: pH 7.45, pCO2 38, pO2 50 HCO3 27 from clotted sample pH 7.42 pCO2 40 pO2 75 HCO3 27, on face mask 100% Lactate:1.4 Ca: 8.7 Mg: 2.0 P: 2.7 ALT: 22 AP: 94 Tbili: 0.3 AST: 25 LDH: 292 MCV 108 wbc 3.1 plts 158 hct 41.9 N:79 Band:3 L:9 M:8 E:0 Bas:1 MB: 2 Trop-T: <0.01 ================================================================ Pertinent Labs: [**2147-1-27**] 11:15AM BLOOD IgG-61* IgA-19* IgM-15* [**2147-1-27**] 11:15AM BLOOD CK-MB-2 cTropnT-<0.01 [**2147-1-27**] 09:57PM BLOOD CK-MB-2 cTropnT-<0.01 [**2147-1-28**] 06:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2147-1-28**] 11:30AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-223* [**2147-1-28**] 10:50AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1 [**2147-1-28**] 10:50AM BLOOD B-GLUCAN- <31 pg/mL [**2147-1-29**] 04:30AM BLOOD PT-37.8* PTT-40.1* INR(PT)-3.9* [**2147-1-30**] 04:04AM BLOOD PT-44.7* PTT-39.4* INR(PT)-4.8* [**2147-2-5**] 02:58AM BLOOD IgG-523* [**2147-2-9**] 05:54AM BLOOD Gran Ct-5040 [**2147-2-10**] 06:30AM BLOOD LD(LDH)-240 ================================================================ Labs on [**Month/Day/Year **]: [**2147-2-12**] 06:00AM BLOOD WBC-6.0 RBC-2.76* Hgb-10.0* Hct-29.4* MCV-106* MCH-36.3* MCHC-34.1 RDW-16.5* Plt Ct-215 [**2147-2-12**] 06:00AM BLOOD PT-19.6* PTT-25.7 INR(PT)-1.8* [**2147-2-12**] 06:00AM BLOOD Glucose-167* UreaN-14 Creat-1.0 Na-140 K-3.8 Cl-99 HCO3-34* AnGap-11 [**2147-2-12**] 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9 ================================================================ Microbiology: [**2147-1-27**] 12:00 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [**2147-1-30**]** Respiratory Viral Culture (Final [**2147-1-30**]): TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final [**2147-1-30**]): THIS IS A CORRECTED REPORT. Positive for Respiratory viral antigens. PREVIOUSLY REPORTED AS. Negative for Respiratory Viral Antigen [**2147-1-28**]. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. REPORTED BY PHONE TO [**Doctor Last Name **] FOREST AT 1135 [**2147-1-30**]. Respiratory Virus Identification (Final [**2147-1-30**]): REPORTED BY PHONE TO S. FOREST 11.35A [**2147-1-30**]. POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. Viral antigen identified by immunofluorescence [**2147-1-28**] 11:17 am CMV Viral Load (Final [**2147-1-31**]): CMV DNA not detected. [**2147-2-3**] 4:07 am URINE Legionella Urinary Antigen (Final [**2147-2-3**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2147-2-5**] 6:10 pm SPUTUM Source: Induced. GRAM STAIN (Final [**2147-2-5**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN CLUSTERS. RESPIRATORY CULTURE (Final [**2147-2-7**]): HEAVY GROWTH Commensal Respiratory Flora. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2147-2-6**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST. [**2147-2-6**] 8:21 am Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2147-2-6**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2147-2-6**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2147-2-6**]): Negative for Influenza B. ================================================================ Imaging CTA chest [**1-28**] 1. Bibasilar bronchiectasis, unchanged compared with yesterdays examination with mulktilobar peribronchovascular ground-glass opacity with a tree-in-[**Male First Name (un) 239**] configuration. This pattern is nonspecific infectious or inflammatory, and consistent with small airways infection, atypical infections including fungal infection such as aspergillosis. 2. There is no pulmonary embolism. Echocardiography [**1-30**]: Poor image quality. 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 global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 56M with h/o AML s/p allo SCT c/b chronic skin/pulmonary GVHD, who presented to clinic with URI symptoms, myalgias, and decreased PO intake and was found to be hypoxic, admitted on [**2147-1-27**] and discharged on [**2147-2-12**]. # Hypoxia: On admission was hypoxic to 90% on RA, febrile and w/o leukocytosis then rapidly developed more profound hypoxia on the floor. On transfer to the ICU required 100% non rebreather mask. Underwent CTA which demonstrated multifocal tree-[**Male First Name (un) 239**] opacities consistent with bronchiolitis and ruled out PE. Nasal swab DFA Was positive for influenza. His high oxygen demand was thought to be multifactorial with viral bronchiolitis/pneumonitis and possibly exacerbation of underlying chronic pulmonary GVH. Other contributing mechanisms were atelectasis, under-recruitment and sleep apnea as evidenced by his improved oxygenation with non-invasive positive pressure ventilation. Significant Heart Failure was ruled out per [**Male First Name (un) 72257**] and normal echocardiography. Patient was treated with Tamiflu 150mg [**Hospital1 **] and will complete 10 days of treatment on day of ICU [**Hospital1 **] (this increased dose and prolonged dose is as per recent guidelines for Flu treatment in BMT patients). D/t to his high risk of superinfection as well as possible LLL infiltrate he was also covered with Abx: Vanco+Aztereonem+Azithro were started on [**1-27**], on [**2-2**] aztreonem was changed to meropenem for more wide spectrum coverage. Azithromycine was intially given [**Date range (1) 72263**] and then restarted on [**2-2**] and continued untill [**2-5**] when urine legionella returned neg. On day of ICU [**Month/Year (2) **] patient is thus on day 11 of Vanco and day 5 of Meropenem. Patient's home prednsione dose of 10mg daily was increased to 40mg daily for suspected Acute on chronic pulmonary GVHD, this was reduced back to home dose a day prior to ICU [**Month/Year (2) **]. IVIG was given on [**1-30**] for hypogammaglobulinemia and influenza infection without complications. Acyclovir and Bactrim prophylaxis were continued. Patient continued to require 60-80% of Oxygen throughout most of his ICU stay which we were able to wean to 50% on non-invasive ventilation, but patient did not tolerated this due to discomfort from the mask. Over the final 24h of his ICU stay his oxygemnation improved remarkably and on ICU discharged O2 requirement is down to 4L through nasal canula with Saturations >92%. He was then transferred to the floor with gradual improvement of his oxygenation as he completed the antiviral ([**2-9**], 10 day course) and antibiotics ([**2-11**], 10 day course). He declined CPAP on the floor. His O2Sat remained stable and he was discharged with home oxygen. He was instructed to have follow up appointment with his doctor to determine further need for oxygen requirement as his pneumonia improves. # AML: s/p SCT ([**6-/2143**]), c/b chronic GVHD of skin/lungs. Patient was on higher dose of prednisone while in the ICU which was tapered back to home dose of 10 mg by the time of transfer from ICU to floor. He remained on home prednisone and ID prophylaxis with acyclovir and Bactrim. # Hypogammaglobulinemia. He received 0.4g/kg of IVIG on [**1-30**]. IgG on [**2-5**] improved to 523. No additional IVIG was given. His level can be monitored in the outpatient setting. # H/o PE: Patient was intially supertheraputic d/t azithromycin therapy, recieved vitamin K and warfarine was held. He then became undertheraputic and was bridged with Lovenox. Warfarin was restarted on [**2-3**] at 5mg daily, INR is 2.1 on day of ICU [**Month/Year (2) **] and Lovenox was discontinued. He continued with 5 mg warfarin with INR beteween 2.0-2.3 until [**2147-2-11**] when INR level dropped to 1.8 and he received a total of 7 mg warfarin on the evening of [**2147-2-11**] with INR still at 1.8. He was instructed to take 7.5 mg of warfarin on Sunday and 5 mg of warfarin on [**Year (4 digits) 766**] with lab on Tuesday in the outpatient setting, so that his INR can be followed up by his doctor. Adjustment of his warfarin is likely given recent discontinuation of antibiotics. # Type 2 DM. Because of his poor po intake initially, NPH was held. As his appetite improved, his insulin was readjusted to 10 unit NPH [**Hospital1 **] and then to 12 unit NPH [**Hospital1 **] with insulin sliding scale. Patient reports that his home dose insulin is 12 units and not 10 units [**Hospital1 **]. He was discharged on home dose NPH. # Hypertension. He continued with home metoprolol tartrate 12.5 mg [**Hospital1 **] as at home. # Hyperlipidemia. He continued with home atorvastatin 20 mg daily. # Previous EKG changes: Early in ICU course patient noted to have transient lateral/posterior ST depressions in V4-V6, I and AvL. With CE x 3 neg. and No CP. This was likely demand ischemia in this patient with multiple coronary risk factors but no known CAD. He continued statin and beta blocker. Consider outpatient stress test. # FEN. Patient refused a diabetic diet and preferred regular diet while on the floor. # Access: PICC while in the hospital. # Code status: Full Code, ICU consent done with wife/HCP [**Name (NI) 4457**], h [**Telephone/Fax (1) 72264**], c-[**Telephone/Fax (1) 72265**] Medications on Admission: MEDICATIONS: - Acyclovir 400mg PO TID - Atorvastatin 20mg daily - Budesonide 3mg TID - Folic acid 1mg daily - Gabapentin 300mg QHS - Oxycodone ER 40mg Q8h - Hydromorphone 4mg; 0.5-1 tablet daily prn - NPH 10units [**Hospital1 **] - Humalog SS - Metoprolol tartrate 12.5mg [**Hospital1 **] - Pantoprazole 40mg [**Hospital1 **] - Prednisone 10mg daily - Bactrim 400mg-80mg Tablet daily - Warfarin 2.5mg alternating with 5mg daily - Calcium carbonate 648mg TID - Cholecalciferol 1000unit daily . ALLERGIES: - Cefepime - Cipro [**Hospital1 **] Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM: Please take 1.5 tablets (7.5 mg) on Sunday and then take 1 tablet (5 mg) daily until your INR is above 2. Further dosage adjustment per your healthcare provider. 10. calcium carbonate 648 mg Tablet Sig: One (1) Tablet PO three times a day. 11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO three times a day. 13. Insulin Sliding Scale Use Humalog insulin sliding scale as you have been at home. Dosage per your healthcare [**Provider Number 72266**]. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 15. hydromorphone 4 mg Tablet Sig: 0.5-1 Tablet PO once a day as needed for pain. 16. vitamin B12 Injection per month, dosage per your healthcare [**Provider Number 72267**]. Insulin NPH 10-12 units twice a day. Dosage adjustment per your healthcare [**Provider Number 72268**]. Home Oxygen Continuous oxygen 2-3L flow per minute via nasal cannula. Pulse dose for portability. For pnuemonia. 19. Outpatient Lab Work Please have a PT and INR checked on Tuesday, [**2147-2-14**], and have the results faxed or called in to your PCP's office (Dr. [**Last Name (STitle) 1683**]. Phone [**Telephone/Fax (1) 22609**], Fax [**Telephone/Fax (1) 22611**]. [**Telephone/Fax (1) **] Disposition: Home With Service Facility: [**Location (un) **] oxygen [**Location (un) **] Diagnosis: Primary diagnosis: - Influenza A pneumonia Secondary diagnoses: - Chronic graft versus host disease- Lung and Skin - Type 2 Diabetes - History of pulmonary embolism [**Location (un) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Location (un) **] Instructions: Dear Mr. [**Known lastname 47367**], It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital for cough and increased trouble with breathing. In the hospital, it was found that you have influenza pneumonia. Because of your increased oxygen use, you were transferred to the intensive care unit for close monitoring. You were treated with an antiviral for the flu as well as antibiotics for possible bacterial pneumonia as well. You completed the course of the antiviral and antibiotics while in the hospital. Please note the following changes in your medications: - Please START supplemental oxygen at 2-3L/min, continuously, until your pneumonia and shortness of breath have resolved. Your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] when you can stop using oxygen. You will need to have your INR level checked on Tuesday, [**2147-2-14**], and have the results faxed to your PCP who manages your coumadin. It will be important for you to follow up with your doctors [**First Name (Titles) 3**] [**Name5 (PTitle) 57228**] below. Followup Instructions: Department: HEMATOLOGY/BMT When: THURSDAY [**2147-2-16**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2147-2-16**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: [**Hospital Ward Name **] [**2147-4-14**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2147-2-12**]

Admission Date: [**2201-6-12**] Discharge Date: [**2201-6-24**] Date of Birth: [**2116-12-7**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Dicloxacillin Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2201-6-19**] Aortic valve replacement (19 mm CE Magna Pericardial) and Aortic Endarectomy [**2201-6-15**] Cardiac catheterization History of Present Illness: 84 year old female with a history of severe Aortic stenosis, HTN, rheumatic fever, breast and renal cell cancer, who presents with shortness of breath. She was recently admitted to [**Hospital1 18**] for hyponatremia and flash pulmonary edema and was treated with fluid restriction and IV lasix with improvement. She was sent home and had the impression that she should consume more salty foods to increase her sodium level. She has been eating high salt foods for a few days and yesterday noted SOB. No chest pain. She did report feeling diapharetic. She called her lifeline and then came to the ED. No pleuritic chest pain. Past Medical History: 1. Breast cancer status post mastectomy 2. Renal cell cancer status post left nephrectomy 3. History of rheumatic fever 4. Moderate-to-severe aortic stenosis - followed by Dr. [**Last Name (STitle) **]. 5. Recurrent cellulitis of the right arm 6. Falls 7. Hyponatremia 8. Hyperkalemia 9. Hypertension 10. Eczema 11. Urinary incontinence 12. Osteoporosis 13. GERD - Patient is asymptomatic at this time. 14. diverticulosis - seen on [**Last Name (un) **] [**1-4**] 15. Internal hemorrhoids, grade I, seen on [**Last Name (un) **] [**1-4**] PAST SURGICAL HISTORY: 1. Status post right mastectomy 2. Status post left nephrectomy 3. Status post bunionectomy 4. Status post medial sesamoidectomy, fifth metatarsal osteotomy, and left Akin procedure - Fall of [**2196**]. 5. Status post hysterectomy for uterine prolapse 6. Status post surgery for bladder prolapse Social History: The patient is widowed and currently lives alone in [**Location (un) 16824**]. No stairs. She has four children who are very involved. No alcohol use. She quit smoking in [**2150**]. She does not utilize an assistive device. She manages her medications and finances without difficulty. No [**Hospital 24262**] home health aides. Family History: The patient's father died of colon cancer at age 69. Her mother developed breast cancer at age 48 and died five years later of pneumonia. Unfortunately, her sister recently died at age 87 secondary to Alzheimer's disease. Physical Exam: ADMISSION EXAM: VS: T 98.2, BP 164/80, HR 100 RR 20, 98%2L, Wt 47.5Kg. GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm. CARDIAC: systolic murmur right sternal border, radiates to carotids. LUNGS: decreased breath sounds in lower bases bilateraly ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. no pedal edema 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+ Pertinent Results: [**2201-6-23**] 04:52AM BLOOD WBC-12.6* RBC-3.62* Hgb-10.6* Hct-32.0* MCV-89 MCH-29.2 MCHC-33.0 RDW-15.3 Plt Ct-320 [**2201-6-12**] 03:25AM BLOOD WBC-11.7* RBC-3.78* Hgb-11.4* Hct-34.2* MCV-90 MCH-30.2 MCHC-33.4 RDW-14.5 Plt Ct-570* [**2201-6-12**] 03:25AM BLOOD Neuts-81.0* Lymphs-10.2* Monos-6.1 Eos-1.6 Baso-1.2 [**2201-6-23**] 04:52AM BLOOD Plt Ct-320 [**2201-6-19**] 12:07PM BLOOD PT-16.2* PTT-66.9* INR(PT)-1.4* [**2201-6-12**] 03:25AM BLOOD Plt Ct-570* [**2201-6-19**] 10:19AM BLOOD Fibrino-291 [**2201-6-23**] 04:52AM BLOOD Glucose-90 UreaN-24* Creat-0.7 Na-133 K-4.2 Cl-97 HCO3-27 AnGap-13 [**2201-6-12**] 03:25AM BLOOD Glucose-101* UreaN-14 Creat-0.7 Na-127* K-6.2* Cl-91* HCO3-25 AnGap-17 [**2201-6-12**] 04:45PM BLOOD Glucose-175* UreaN-15 Creat-0.6 Na-131* K-4.6 Cl-95* HCO3-26 AnGap-15 [**2201-6-16**] 06:10AM BLOOD ALT-24 AST-27 AlkPhos-97 TotBili-0.5 [**2201-6-13**] 04:20AM BLOOD CK-MB-4 cTropnT-0.06* [**2201-6-12**] 03:25AM BLOOD cTropnT-0.04* proBNP-8905* [**2201-6-16**] 04:00PM BLOOD %HbA1c-5.6 eAG-114 [**2201-6-13**] 04:20AM BLOOD TSH-8.8* [**2201-6-16**] 06:10AM BLOOD T3-83 Free T4-1.7 [**6-12**] CXR: IMPRESSION: Congestive heart failure and moderate pulmonary edema, persistent or recurrent over six days, progressively decompensated over ten days. [**6-13**] CXR: Persistent cardiomegaly. Worsening pulmonary vascular congestion accompanied by diffuse interstitial edema as well as more confluent perihilar and basilar opacities likely representing alveolar edema as well. Small to moderate pleural effusions are unchanged. New opacity in right mid lung adjacent to the minor fissure may reflect loculated fluid in the fissure with adjacent atelectasis, but attention to this region on followup radiographs would be helpful to exclude a developing pneumonia or other acute process in this region. [**6-13**] echo: The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**12-28**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Critical aortic valve stenosis. Mild-moderate aortic regurgitation. Symmetric left ventricular hypertrophy with preserved regional and global systolic function. Pulmonary artery hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2197-7-12**], the severity of aortic stenosis, mitral regurgitation, and pulmonary artery hypertension have increased. Bilateral pleural effusions are now present. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on [**2195**] ACC/AHA Valvular Heart Disease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a surgical candidate, surgical intervention has been shown to improve survival. [**6-15**] Cardiac Cath: pending Carotid US: 1. Mild to moderate plaque with bilateral less than 40% carotid stenosis, unchanged from [**2196-2-24**]. 2. Complete thrombosis of the left external jugular vein. The deep veins are patent without evidence of thrombosis. CT chest: IMPRESSION: 1. Known aortic valve calcifications consistent with known aortic stenosis. 2. Bilateral moderate pleural effusions, most likely layering. 3. Evidence of minimal interstitial pulmonary edema, significantly improved since [**2201-6-13**]. 4. Essential sparing of ascending aorta from coarse calcifications but evidence of minimal may be intimal calcifications present. 5. No left kidney seen in orthotopic location, resected ?. Brief Hospital Course: Presented to emergency room in pulmonary edema treated with intravenous lasix and morphine with improvement. She was admitted and started on lasix drip for diuresis with improvement in pulmonary status and then transitioned to bolus dosing. Additionally she had echocardiogram that revealed severe aortic stenosis and surgery was consulted to evaluated for surgical intervention. Her preoperative workup included cardiac catheterization that revealed 40 % mid vessel stenosis. Her preoperative urine revealed ecsherichia coli treated with nitrofurantoin and repeat urine culture [**6-17**] had no growth. Her hyponatremia related to heart failure was monitored with improved slowly. On [**2201-6-19**] she was taken to the operating room for aortic valve replacement and aortic endarectomy. See operative report for further details. She received vancomycin for perioperative antibiotics and was transferred to the intensive care unit for post operative management on epinephrine and neosynephrine. On post operative day one she was weaned from sedation, was slow to wake and was extubated that evening without complications. Additionally she was weaned off all inotropes and pressors and started on lasix for diuresis and betablockers for heart rate management. She continued to slowly progress on post operative day two she had atrial fibrillation treated with amiodarone and betablockers. She converted back to sinus rhythm. Amiodarone drip was completed due to intermittent burst of atrial fibrillation and transitioned to oral amiodarone. She was not started on coumadin due to limit time frame of atrial fibrillation. She remained in the intensive care unit for hemodynamic monitoring. On post operative day three she was transferred to the floor. Physical therapy worked with her on strength and mobility. On post operative day five she was ready for discharge to rehab - [**Hospital **] center [**Location (un) **]. Medications on Admission: Simvastatin 10 daily Calcium Carbonate 200mg (500mg) tablet, 2 tabs qhs Vit D3 800 qhs Lidoderm patch for bilateral flanks Tylenol 650mg q 4-6hrs prn pain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp. 4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): decrease to 200mg daily on [**2157-5-5**]. 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days: d/c when pedal edema resolved. 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal QID (4 times a day). 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days: while on lasix. 16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for back rash. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: Acute on chronic diastolic heart failure Aortic Stenosis s/p AVR (tissue) Breast cancer Renal cell cancer status post left nephrectomy rheumatic fever Recurrent cellulitis of the right arm Falls Hyponatremia Hyperkalemia Hypertension Eczema Urinary incontinence Osteoporosis Gastric esophageal reflux disease Diverticulosis hemorrhoids Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram as needed Incisions: Sternal - healing well, no erythema or drainage Edema 1+ edema bilateral lower extremities Left groin cath site ozzing serous drainage 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 [**First Name (STitle) **] on [**7-20**] at 1:15pm [**Doctor First Name 102445**] [**Hospital Unit Name **] Cardiologist: Dr [**Last Name (STitle) **] ([**Location (un) 620**] office) on [**7-27**] at 3pm BONE DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2201-7-6**] 11:40 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2201-7-8**] 9:30 [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2202-3-2**] 1:30 Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **] in [**3-31**] weeks [**Telephone/Fax (1) 719**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2201-6-24**]

Admission Date: [**2117-5-6**] Discharge Date: [**2117-5-12**] Date of Birth: [**2052-5-20**] Sex: M Service: MEDICINE Allergies: Penicillins / gemfibrozil / ibuprofen Attending:[**First Name3 (LF) 602**] Chief Complaint: dyspnea, stable [**First Name3 (LF) 8813**] dissection Major Surgical or Invasive Procedure: Endotracheal intubation and mechanical ventilation History of Present Illness: History of Present Illness: Mr. [**Known lastname 7474**] is a 64M with a history of active prostate cancer s/p completion of radiation tx yesterday, who presented to [**Hospital3 **] with dyspnea on exertion. [**First Name8 (NamePattern2) **] [**Hospital1 **] documentation, he was walking upstairs to do laundry, and when he came back down he had persistent shortness of breath. He has had some intermittent DOE for the last several months, but is usually able to catch his breath with rest whereas today he felt persistently SOB. According to his wife, he was told that his grandson (to whom he is very attached) was in a MVA, and after that he became very anxious and SOB. She thinks anxiety may play a large role in his SOB. At [**Hospital1 **], he had O2 sat 92% on 4L by NC. Labs were notable for WBC of 7.0 with 15% bandemia, Hct of 24.9, creatinine of 4.0, and lactate of 0.8. He underwent chest x-ray that showed enlarged aorta, and subsequent CT (noncontrast given renal failure) that showed dissection extending from arch to beyond the level of the renal arteries. At that time, it was not known that he has a history of [**Hospital1 8813**] dissection, and this was felt to be acute. He was started on BIPAP for his SOB and an esmolol gtt to control blood pressures. He received levofloxacin for possible pneumonia and was transferred to [**Hospital1 18**] for further management of the dissection. In transit to the ED, he removed BIPAP so he was placed on NRB. In the ED, initial VS were Pulse: 113, RR: 22, BP: 149/91, O2Sat: 100, O2Flow: 100NRB. While in the ED, he developed a temperature to 102.4 rectal. He received 1 g of vancomycin, 4.5 g Zosyn, and acetaminophen for fever/infection. He was continued on esmolol gtt and started on nitroprusside gtt. At the time of arrival to ED, chronicity of patient's [**Hospital1 8813**] dissection was unknown. He was intubated for planned TEE and MRI prior to purported surgical intervention. He was sedated with propofol but BP dropped so changed to fentanyl/versed. . On arrival to the MICU, he is intubated and sedated. Has drool coming from mouth, so suctioned which causes patient to wince/appear uncomfortable. Otherwise minimally responsive to Qs. Past Medical History: - Prostate cancer: [**Doctor Last Name **] Grade is 4+3. He is followed by radiation oncology Dr. [**Last Name (STitle) 12354**] undergoing radiation treatment. - [**Last Name (STitle) **] dissection: First noted in [**2114**]. Most recent assessment [**3-/2116**] in Atrius records: Type B [**Year (4 digits) 8813**] dissection with proximal descending thoracic aorta measuring five centimeters and dimension. The dissection flap extends into the left common iliac artery. The celiac, SMA, and right renal artery arise from the true lumen while the left renal artery arises from the false lumen. - Hypertension - Gout - Claustrophobia - CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min (recent baseline creatinine 2.5-3.0) - Spinal stenosis (lumbar region) - Chronic back pain - Arthritis (? RA) - Hypertriglyceridemia - Positive PPD - Bilateral total knee replacements Social History: Lives with his wife and her two sons ages 17 and 18 (they were 2 and 3 when he was married, so he treats them as his own children). Has an infant grandson to whom he is very attached. Mows lawns in his neighborhood for money, otherwise no income. Was in jail for 23 years. - Tobacco: Smoke [**2-1**] pack per day since age 30, quit [**2116**] but recently sneaking cigarettes per wife. - Alcohol: None - Illicits: None (wife concerned too much oxycodone) Family History: father with htn, passed away at age 75 mother 82 healthy Physical Exam: Admission Exam: ED vital signs: 113, RR: 22, BP: 149/91, O2Sat: 100, O2Flow: 100NRB. Exam in MICU: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM Neck: Supple, JVP not visibly elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated though referred ventillator sounds somewhat obscure heart sounds Lungs: Referred upper airway sounds from ventillator but no clear rales or wheeze Abdomen: Soft, non-distended, bowel sounds present, no organomegaly GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Toes misshapen possibly [**3-4**] gout Neuro: Moving all extremities; remainder of exam deferred Discharge Exam: Vitals: 98.4, hr 73, 132/84 19 rr 97% RA. Physical Exam: Gen: AAOx3, NAD, pleasant conversant gentleman. Neck: supple, no JVD. Heart: nl s1 s2, no mrg Lungs: CTA BL Abdomen: Soft, nt, nd. No rebound or guarding. Extremities: 2+ pulses, no lower extremity edema, deformed right knee from s/p several knee replacements, dry atrophic skin changes b/l. Neuro: AAOx3, conversant. CN 2-12 grossly intact Motor: [**6-5**] u/e and le sensation grossly intact. Pertinent Results: I) Admission Labs: COMPLETE BLOOD COUNT: [**2117-5-6**] 06:50PM BLOOD WBC-7.8 RBC-2.66* Hgb-8.1* Hct-26.4* MCV-99* MCH-30.5 MCHC-30.8* RDW-14.2 Plt Ct-204 [**2117-5-6**] 06:50PM BLOOD Neuts-88.7* Lymphs-6.1* Monos-4.0 Eos-1.0 Baso-0.1 BASIC COAGULATION (PT, PTT, PLT, INR [**2117-5-6**] 06:50PM BLOOD PT-13.3* PTT-28.0 INR(PT)-1.2* RENAL & GLUCOSE [**2117-5-6**] 06:50PM BLOOD Glucose-166* UreaN-65* Creat-3.9* Na-137 K-3.8 Cl-105 HCO3-19* AnGap-17 Enzymes: [**2117-5-6**] 06:50PM BLOOD ALT-28 AST-33 AlkPhos-133* TotBili-0.3 [**2117-5-6**] 06:50PM BLOOD cTropnT-0.03* ABG: [**2117-5-6**] 07:02PM BLOOD Type-ART pO2-267* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 Intubat-NOT INTUBA [**2117-5-7**] 01:11AM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5 FiO2-80 pO2-170* pCO2-40 pH-7.33* calTCO2-22 Base XS--4 AADO2-353 REQ O2-64 -ASSIST/CON Intubat-INTUBATED UA: [**2117-5-6**] 07:55PM URINE RBC-2 WBC-50* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 [**2117-5-6**] 07:55PM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD II) Micro: URINE CULTURE (Final [**2117-5-7**]): NO GROWTH. Blood Culture, Routine (Final [**2117-5-12**]): NO GROWTH. MRSA SCREEN (Final [**2117-5-9**]): No MRSA isolated. GRAM STAIN (Final [**2117-5-8**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. III) Imaging: CT Chest/Abdomen without Contrast: IMPRESSION 1. Limited non-contrast CT of the chest and abdomen demonstrating a type B [**Year/Month/Day 8813**] dissection extending to the level of the infrarenal aorta, inferior aspect not included on the images. The distal extent is not assessed in this study. Allowing for differences in technique, this has not significantly changed since the earlier study of [**2115-7-18**]. Assessment of the false and true lumens and the visceral branches is limited in this study. 2. New since the prior study are small simple bilateral pleural effusions with bibasilar atelectasis. 3. Moderate centrilobular emphysema, apical predominant. 4. 3.8 cm left renal cyst is not characterized in this study, a non-emergent renal ultrasound can be performed for further assessment if not already obtained. Renal Doppler US: IMPRESSION: 1. Normal bilateral main renal artery waveforms and resistive indices. 2. Left main renal artery cannot followed back to the aorta due to technical reasons. 3. Abdominal [**Year (4 digits) 8813**] dissection. MRA TORSO: IMPRESSION: 1. Redemonstration of type B [**Year (4 digits) 8813**] dissection with slight interval increase in size of the aorta. 2. Moderate-sized pleural effusions with adjacent compressive atelectasis bilaterally. IV) Studies: Renal Ultrasound: FINDINGS: The right kidney measures 10.7, the left kidney measures 11.9 cm without evidence of hydronephrosis or stones. There is a 1 cm left upper pole kidney cyst and a 5-mm right lower pole hyperechoic lesion, likely representing AML (angiomyolipoma). There is normal perfusion of both kidneys. Both renal arteries show normal waveforms, RIs and flow velocities. The right main renal artery can be followed to the aorta and demonstrates normal waveform. The right renal vein is patent. There is a normal resistive indix at the right main renal artery (0.65). At the left kidney, the main renal artery and vein demonstrate normal waveforms. The left renal artery cannot be followed to the aorta due to technical reasons. The resistive index of the left main renal artery is 0.61. TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The [**Year (4 digits) 8813**] root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. No dissection flap is seen (best assessed by thoracic/chest MRI/CT or TEE). The [**Year (4 digits) 8813**] valve leaflets are mildly thickened (?#). There is no [**Year (4 digits) 8813**] valve stenosis. No [**Year (4 digits) 8813**] regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated thoraic aorta. Pulmonary artery hypertension. Mild mitral regurgitation. Pulmonary artery hypertension. If clinically indicated, a thoracic/chest MRI/CT or TEE is suggested to better characterize an [**Year (4 digits) 8813**] dissection. V) Discharge Labs: CBC: [**2117-5-12**] 06:41AM BLOOD WBC-5.1 RBC-2.61* Hgb-7.9* Hct-26.3* MCV-101* MCH-30.1 MCHC-29.9* RDW-14.4 Plt Ct-287 CHEM: [**2117-5-12**] 06:41AM BLOOD Glucose-105* UreaN-33* Creat-2.3* Na-141 K-4.2 Cl-110* HCO3-23 AnGap-12 [**2117-5-12**] 06:41AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 Urine: [**2117-5-10**] 06:49PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-<1 [**2117-5-10**] 06:49PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG VI) Studies Pending at Discharge: None. Brief Hospital Course: 64 year old man with a past medical history signficant for chronic kidney disease, hypertension, prostate cancer s/p XRT, and type [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] [**Last Name (NamePattern4) 8813**] dissection (dxed [**2114**]) transferred from outside hospital for hypoxemic respiratory failure. Hospital course notable for finding of stable type B [**Year (4 digits) 8813**] dissection, acute on chronic diastolic heart failure due to malignant uncontrolled hypertension, and acute on chronic renal failure. #Acute on chronic diastolic heart failure/Malignant Hypertension: Patient presented to [**Hospital3 **] with shortness of breath and hypoxia requiring high flow oxygen. He had a chest CT which showed type B [**Hospital3 8813**] dissection (old, but not clear at OSH). Transferred to [**Hospital1 18**] for management of [**Hospital1 8813**] dissection (see below). Upon transfer patient required escalating oxygen support and was intubated for both hypoxia and to facilitate workup of dissection. Patient admitted initially to the ICU and was diuresed and blood pressure controlled. Following extubation patient was transferred to the medical floor where he required intensive titration of blood pressure medications to maintain goal SBP <130 although BPs on the floor were 120-160. Patient was euvolemic on discharge and it was felt that initial hypoxia was due to malignant hypertension. Medications were uptitrated and patient was discharged on a regimen of max dose labetalol, clonidine 0.2 mg TID, amlodipine 10, and hydralazine 75mg TID. A TTE prior to discharge showed a preserved EF with mild symmetric LVH. Patient was euvolemic breathing on RA prior to discharge. On follow up could consider uptitratring clonidine or hydral or starting diltiazem for better BP control if needed. Goal SBP <130. Lasix 20mg po daily was started for chronic diastolic CHF as well. Home VNA was arranged to help keep BP within goal. #Acute On Chronic Renal Failure: The patient presented to [**Hospital1 **] with a creatinine of 4. His best creatinine on record was from [**Hospital1 **] in [**2115**] at 1.7. Recently his baseline has been approximately 2.5. His elevated creatinine was felt to be related to malignant hypertension and improved with treatment of blood pressure and CHF. Renal doppler ultrasound did not show renal artery stenosis, however, it is possible that his [**Year (4 digits) 8813**] dissection partly into the renal artery may be creating RAS physiology. That said, an ACEI/[**Last Name (un) **] was not started due to ARF. Addition, of these medications could be considered in the future once renal function returns to baseline. #Chronic [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Dissection: MRA showed no interval progression in the size of his [**Last Name (NamePattern4) 8813**] dissection. The patient was seen by Vascular Surgery and blood pressure was treated aggressively as stated above. He is scheduled for follow up with vascular surgery in 6 months with a screening MRA to monitor for progression of his [**Last Name (NamePattern4) 8813**] dissection. #Presumed UTI/PNA: While on the floor the patient lacked any signs or symptoms of a UTI or pneumonia. After verifying with [**Hospital1 **] that his cultures were negative. His antibiotics which were empirically started in the ED (Rocephin/Azithromycin) were discontinued. His cultures at [**Hospital1 **] were also negative. Medication Changes: -Increased labetalol to 800mg TID -Increased Amlodipine to 10mg QD -Started Lasix 20mg PO QD -Held allopurinol in the setting of his acute renal failure. -Stopped nifedipine xl (as the patient was already taking amlodipine) Transitional Issues: 1. Blood pressure control. Home VNA has been arranged for the patient to help with his medications and blood pressure measurements. Ideally, his blood pressure should be in the 130's or less. His blood pressure medication will likely require titration in the future to achieve these goals. 2. Monitoring [**Hospital1 **] Disease: The patient has follow up with vascular surgery in 6 months. There has been no progression in his [**Hospital1 8813**] dissection when compared to films from the last year. 3. Since the patient was started on lasix during this hospitalization, we recommend drawing a chem 10 in one week to check for electrolyte abnormalities and renal function. Medications on Admission: Medications: Per Atrius records. - Oxycodone 15 mg PO Q6H PRN pain - Clonidine 0.3 mg PO TID - Amlodipine 5 mg PO daily - Labetalol 300 mg PO TID - Zoladex administered monthly in urology - Fluoxetine 40 mg PO daily - Allopurinol 300 mg PO daily - Nifedepine ER 30 mg PO daily - Colchicine 0.3 mg PO daily for gout pain - Hydralazine 75 mg PO TID Discharge Medications: 1. labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*1* 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 months. Disp:*60 Tablet(s)* Refills:*1* 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. oxycodone 15 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 6. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a day. 7. colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO once a day as needed for pain. 8. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. Chronic [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Dissection 2. Hypertension 3. Compensated acute heart failure with a preserved ejection fraction of 55%. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 7474**], You were admitted to the hospital with acute shortness of breath and pulmonary edema. We believe that this is due to something called congestive heart failure. Your congestive heart failure which has now resolved was most likely caused by your high blood pressure and excess fluid and salt retention. We resolved this condition by controlling your blood pressure and starting you on a water pill to help keep your lungs from becoming congested. You have something called a TYPE B [**Known lastname **] DISSECTION. Your Aorta (the biggest blood vessel in your body) has a small tear in it. You have had this [**Known lastname 8813**] dissection for more than two years. Type B [**Known lastname 8813**] dissections are treated medically with very good blood pressure control. Your blood pressure should be around 120/80 or slightly lower if possible. If your blood pressure gets too high, the tear in your aorta can increase in side and your dissection could get worse which is a LIFE THREATENING CONDITION. 1. IT IS INCREDIBLY IMPORTANT THAT YOU TAKE YOUR BLOOD PRESSURE MEDICATION AS DIRECTED. 2. IT IS INCREDIBLY IMPORTANT THAT YOU FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR ON A FREQUENT BASIS. We have made some changes to your home medications to help control your blood pressure. We have also arranged for you to have a visting home nurse to help you with your blood pressure medications and helping you to take your blood pressure every day. It is a good habit to weigh yourself every day. If you weight goes up more than three pounds in one day, call your PCP. [**Name10 (NameIs) **] you find that you are becoming short of breath, please call your PCP. [**Name10 (NameIs) 2172**] visiting nurse will help you arrange your medications that you are supposed to take which are listed on the included sheet. You may resume any other medication that is not listed below. 1. We have increased your labetalol to 800mg by mouth 3 times per day ( take four 200mg tablets by mouth three times per day) . 2. We have increased your amlodipine to 10mg by mouth once a day (take two 5mg tablets by mouth once a day) 3. We have started you on a diuretic called lasix 20mg (furosemide) by mouth once a day. 4. We have STOPPED your nifedipine. 5. We have held your allopurinol. Please talk to your PCP about resuming this medications. IF YOU HAVE ANY QUESTIONS ABOUT YOUR MEDICATIONS PLEASE CALL THE OFFICE OF DR. [**First Name (STitle) **] [**First Name (STitle) 38274**]. If you experience any of the danger signs listed below please call your doctor or go to the emergency department. PCP: [**Name10 (NameIs) 38274**],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 3530**] Followup Instructions: Name: [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 38279**], NP Specialty: Primary Care When: Friday [**5-14**] at 10:30 Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**] Phone: [**Telephone/Fax (1) 3530**] Department: VASCULAR SURGERY When: WEDNESDAY [**2117-11-10**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone: [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: WEDNESDAY [**2117-11-10**] at 3:00 PM With: XMR [**Telephone/Fax (1) 327**] Building: CC [**Location (un) 591**] [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

Admission Date: [**2187-8-23**] Discharge Date: [**2187-8-26**] Date of Birth: [**2141-5-14**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Biaxin / Vancomycin / Haldol / Heparin Agents Attending:[**First Name3 (LF) 898**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: 1. hemodialysis 2. cauterization of bleeding from tooth extraction site History of Present Illness: 46 yo AA woman with h/o SLE, ESRD on hemodialysis, htn, hyperlipidemia, and cardiomyopathy, CHF, and recent immunosuppression with tacrolimius/cellcept/IVIG in an attempted preparation for receiving a kidney transplant from her sister presented initially on [**8-23**] with atypical chest pain. She had no ischemic EKG changes, and her initial set of cardiac enzymes was flat. She also complained of epigastric/RUQ pain. Finally, she had subacute complaints of subjective fever and bronchitis symptoms. In the ED, her vitals were T = 97.5, (T@ dialysis = 99.2), BP = 191/97, HR = 70, RR = 20 and 100% RA. . She had severe hyperkalemia to 8.1, and underwent urgent hemodialysis. In hemodialysis, she developed significant bleeding from a site of recent tooth extraction, and then arterial bleeding from her AV fistula site when the HD line was disconnected. She was managed with DDAVP 15mcg IV x i, 10units of cryoprecipitate; additionally, ENT stopped the oral bleeding with Ag local tx, and AV fistula bleeding stopped after 55min of continuous pressure. The working suspicion is that she was suffering from uremic platelet dysfunction. . She was admitted to MICU after she had developed persistent bleeding from the site of her recent tooth extraction as well as arterial bleeding from her AV fistula site. The bleeding from her tooth extraction site stopped after she was seen by ENT and this was treated with local Ag therapy. The bleeding from her AV fistula site stopped after continuous pressure for 55min, and DDAVP. . Overnight, several events took place. First, she remained chest pain free, but her troponin trended from 0.06 to 0.26 and then back down to 0.06 with the only EKG changes of new TWI in V6 and borderline Twave flattening in lead I. Her CK and MB remained flat throughout. Secondly, she was ruled out for AAA and PE by CTangiogram. Next, she had a Tmax of 101.6, and repeat blood cultures were drawn. She additionally underwent CTangiogram of torso: No evidence of PE; no aortic aneurysm/dissection; no pathologic LAD; non-specific thickening of the pylorus. Also, her labs were significant for the following: . - evidence of hemolysis with hapto < 20, elevated LDH - no evidence of TTP, no schistocytes on peripheral smear, and no evidence of DIC (nl coags, fibrinogen elevated) . - platelets remained stable in 50's range - DIC Ab returned positive; heme/onc consulted re: anticoagulation strategy in setting of recent significant bleeding . - transaminitis trending downward - elevated amylase/lipase - now trending downward. . Past Medical History: PMHx: 1) End-Stage Renal Disease on hemodialysis Tues, Thurs, Sat; L dialysis fistula 2) SLE: dx [**2173**], h/o lupus cerebri, membranous glomerulonephritis, BOOP [**9-/2179**], Raynaud's, DIP arthritis 3) HTN 4) Dyslipidemia 5) Cardiomyopathy & CHF: normal cath in [**2183**]; TTE in [**9-9**] showed EF 45%, 1+ MR, mild global left ventricular hypokinesis, LVH; Exercise MIBI in [**9-9**] showed EF 62% 6) History of salmonella bacteremia 7) Gastritis: dx by EGD [**10/2185**] 8) Anemia: ? thallesemia, autoimmune hemolytic anemia 9) TTP/HUS 10) Thrombocytopenia/ITP 11) HSV [**2184-10-5**] 12) Cervical dysplasia LGSIL [**2180**]-[**2181**] 13) Breast DCIS 14) Uterine Prolapse 15) Fibroids s/p TVH 16) Adrenal crisis [**2184**] (was on chronic prednisone- finished in [**8-9**]) 17) Osteoporosis 18) Hypothyroidism 19) Cataracts 20) Seizures 21) S/p hysterectomy for dysfunction uterine bleeding of [**Last Name (un) 6722**] etiolgoy. 22) Pancreatitis [**2-7**] pancreatic divisum 23) status post cholecstectomy in [**2184-7-5**], 24) adrenal crisis in [**2184-6-5**] . . PSHx: 1) CCY [**2184**] 2) D&C/HSC [**2186**] 3) Breast excision x 3, [**2186**] 4) TVH [**5-/2187**] . Social History: Currently on disability. Denies any alcohol nor tobacco use. Supportive contacts / friends in area. Family History: She reports a family history of lupus and autoimmune diseases. Physical Exam: PE Tm 101.6, Tc 100.1, 130-170/60-80, 78-98, 100% RA . gen: a/o, no acute distress; overall appears well, pleasant heent: no scleral icterus, perrla; no OP lesions/ulcers. Last molar tooth on left with no evidence of active bleeding after treatment by ENT neck: supple, full range of motion cv: RRR, [**3-11**] holosystolic murmur throughout precordium (unchanged since admission) resp: CTA bilaterally throughout abd: soft, NABS, minimal epigastric tenderness; no peritoneal signs extr: -few scattered dark, pigmented 2x2cm nodular lesions in bilateral proximal lower extremities -No evidence of conjunctival/palatal petechiae, Oslers/[**Last Name (un) 1003**], or splinter hemorrhages neuro: no focal deficits appreciated Pertinent Results: [**2187-8-23**] 11:00PM PT-12.7 PTT-27.7 INR(PT)-1.1 [**2187-8-23**] 08:54PM GLUCOSE-98 UREA N-23* CREAT-6.2*# SODIUM-142 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-14 [**2187-8-23**] 08:54PM ALT(SGPT)-305* AST(SGOT)-286* LD(LDH)-431* CK(CPK)-41 ALK PHOS-381* AMYLASE-321* TOT BILI-0.5 [**2187-8-23**] 08:54PM LIPASE-251* [**2187-8-23**] 08:54PM CK-MB-NotDone cTropnT-0.25* [**2187-8-23**] 08:54PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.6 [**2187-8-23**] 08:54PM WBC-2.4* RBC-3.66* HGB-10.7* HCT-33.6* MCV-92 MCH-29.2 MCHC-31.8 RDW-22.6* [**2187-8-23**] 08:54PM PLT COUNT-51* LPLT-3+ [**2187-8-23**] 11:20AM POTASSIUM-2.2* [**2187-8-23**] 11:20AM ALT(SGPT)-246* AST(SGOT)-451* LD(LDH)-488* ALK PHOS-376* AMYLASE-276* TOT BILI-0.8 DIR BILI-0.5* INDIR BIL-0.3 [**2187-8-23**] 11:20AM LIPASE-712* [**2187-8-23**] 11:20AM ALBUMIN-3.4 [**2187-8-23**] 11:20AM HAPTOGLOB-<20* [**2187-8-23**] 11:10AM POTASSIUM-5.0 [**2187-8-23**] 09:17AM K+-8.1* [**2187-8-23**] 07:58AM GLUCOSE-84 [**2187-8-23**] 07:45AM GLUCOSE-88 UREA N-80* CREAT-12.4*# SODIUM-134 POTASSIUM-7.2* CHLORIDE-95* TOTAL CO2-24 ANION GAP-22* [**2187-8-23**] 07:45AM CK(CPK)-74 [**2187-8-23**] 07:45AM CK(CPK)-74 [**2187-8-23**] 07:45AM cTropnT-0.06* [**2187-8-23**] 07:45AM CK-MB-NotDone [**2187-8-23**] 07:45AM WBC-3.4* RBC-4.21 HGB-12.5 HCT-39.1 MCV-93# MCH-29.6# MCHC-31.9 RDW-22.4* [**2187-8-23**] 07:45AM NEUTS-48* BANDS-1 LYMPHS-45* MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2* [**2187-8-23**] 07:45AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ [**2187-8-23**] 07:45AM PLT SMR-VERY LOW PLT COUNT-50*# [**2187-8-23**] 07:45AM PT-11.8 PTT-28.8 INR(PT)-0.9 [**2187-8-23**] 07:45AM FIBRINOGE-443* [**2187-8-23**] 07:45AM RET AUT-3.4* Brief Hospital Course: A/P: 46 yo AA woman with h/o SLE, ESRD on hemodialysis, htn, hyperlipidemia, and cardiomyopathy, CHF, recent immunosuppresion presented with atypical chest pain, abdominal pain, and severe hyperkalemia; now stable from MICU after uremic bleeding. . 1. Chest Pain: Presentation was atypical for angina, and she ruled out for acute MI. Over her MICU course, there was concern for aortic dissection or other etiology for her chest pain, and she underwent a CTangiogram of the torso. This showed no evidence of any aortic dissection, aneurysm, or a pulmonary embolism. Her chest pain resolved. . 2. Abdominal Pain/Diarrhea: This was a non-specific abdominal pain. On review, it turns out that this is a chronic complaint. Her abdominal CT did not demonstrate any acute pathology. She does have chronically elevated amylase/lipase and LFT's that date back several years. It may be that this is related to her SLE or potentially autoimmune hepatitis. Her abdominal pain had resolved by time of discharge. She will need to f/u with her PCP and nephrologist for further management. . 3. Fever: She defervesced over her hospital course, and her infectious workup was unrevealing. She had no evidence of any pulmonary infiltrates, and her blood cultures remained no growth to date. No empiric abx coverage was initiated and she remained well throughout. . 4. Hyperkalemia/ESRD: On presentation, she had an elevated Creatinine at 12, and a markedly elevated K at 8.1. She underwent urgent hemodialysis, with her hyperkalemia and uremia improving. She did have peaked T waves on admission EKG, but no other worrisome findings. She did have what was suspected to be uremic bleeding on day of admission with bleeding from her AV fistula site, as well as oral mucosal bleeding from the site of her recent tooth extraction. This resolved with DDAVP, pressure, and an ENT procedure. She had no further bleeding. . 5. Heme: She has chronic pancytopenia, but on admission her platelets had dropped from a baseline of 100's to 50's. She had no evidence of DIC. Given her history of TTP, this was considered as a potential etiology. Heme/Onc and transfusion medicine were involved. There was no definitive evidence of TTP, as there were not pathologic levels of schistocytes on her peripheral smear. Her HIT Ab did come back positive, but this was felt to be a low titer and of questionable significance. She has potentially received heparin in low quantity in her hemodialysis sessions. However, it was felt that this Ab positivity may be the result of her recent IVIG treatment. Given her recently controlled uremic bleeding, it was decided that she would be anticoagulated with argatroban only if she developed a thrombotic complication. She remained stable and required no anticoagulation. . 6. CHF/Cardiomyopathy: TTE in [**9-9**] showed EF 45%, 1+ MR, mild global left ventricular hypokinesis, LVH. Monitored her volume status closely; there was no evidence of CHF. . 7. Hypertension: Continued her home regimen; bp improved after hemodialysis. Held her ace-i in setting of hyperkalemia. . Medications on Admission: Meds: ativan .5mg 1-2x/day prn serax 15mg qhs prn fosamax 35mg qweek nifedipine 90mg qd atenolol 100mg qd zestril 40mg qd nephrocap 1 cap qd folic acid 1 tab qd ***Immunosuppression (tacrolimus, cellcept, IVIG) recently stopped . All: biaxin, sulfa, vancomycin, haldol Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*10 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). Discharge Disposition: Home Discharge Diagnosis: 1. SLE 2. ESRD, hemodialysis dependent 3. Hyperkalemia 4. uremic bleeding, s/p DDAVP treatment 5. chest pain - ruled out for ACS 6. pancytopenia 7. worsening thrombocytopenia, HIT Ab positive 8. hypertension 9. h/o TTP 10. s/p immunosuppression in preparation for kidney transplant Discharge Condition: fair Discharge Instructions: 1. Continue to take your usual medications 2. Call your Nephrologist to schedule a follow up appointment within the next week 3. Call your doctor or return to the emergency room for any further chest pain, shortness of breath, fever, chills, nausea/vomiting, or any other concerning symptoms. 4. If you have any bleeding you should call your PCP and return to the closest ED. 5. You are scheduled for HD next Tuesday [**2187-8-28**] at the Kidney Center. Followup Instructions: Call your Nephrologist, Dr [**Last Name (STitle) 1860**], to schedule a follow up appointment within the next week Please call your PCP and make [**Name Initial (PRE) **] follow up appointment for [**1-7**] weeks. Appointment Reminders: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2187-8-28**] 2:20 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-8-29**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2187-9-21**] 2:00

Admission Date: [**2165-5-2**] Discharge Date: [**2165-5-6**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old gentleman with a history of left subdural hematoma, who was admitted on [**2165-3-30**] to [**Hospital1 188**] status post a fall down a flight of stairs while on Coumadin for previous cerebrovascular accident. At the time, the patient has also had a hemothorax on the right side, and was admitted to the Trauma Intensive Care Unit with a chest tube in place. He was awake, alert, and oriented times three with 5/5 muscle strength in all muscle groups at the time of admission. On the second or third day hospital stay, the patient developed electrocardiogram changes and had ruled in for a myocardial infarction. An echocardiogram later revealed an ejection fraction of 25%. The patient developed right sided weakness also at this time. He was intubated, sedated, and eventually awoke, but continued to have the right sided weakness. Serial head CT scans showed no change in the size of the subdural hematoma, and it was decided that patient would not undergo drainage of the subdural hematoma. The patient eventually got trached and PEG and was transferred to rehabilitation. While at rehab, the patient had a worsening examination. Apparently, he had regained some tone on the right side, which was then gone and was brought to [**Hospital1 190**] where a CT scan showed an increase in the size of the left subdural hematoma. Patient had 12 mm of midline shift with a 30 mm subdural hematoma which was chronic in appearance. The patient was drained at the bedside. Was kept in the Recovery Room overnight. Neurologically would open his eyes. Began following simple commands. Would stick out his tongue, would state his name, had increased tone on the right side, where as before it was flaccid. Patient improved neurologically, was seen by physical therapy and occupational therapy and found to require acute rehabilitation prior to discharge to home. He was stable from a cardiac standpoint throughout his hospital stay. He was awake, alert, moving the left side spontaneously. The right side had increased tone and did move to pain. He was in stable condition at the time of discharge. Medications at time of discharge: Zantac 150 mg/G tube [**Hospital1 **], digoxin 0.125/G tube q day, nystatin oral suspension 5 cc po qid, Lipitor 20 mg/G tube q day, lisinopril 20 mg/G tube q day, metoprolol 75 mg/G tube tid, insulin was on per sliding scale, Glipizide 10 mg po q day. At the time of discharge, will be transferred to rehabilitation. Will follow up with Dr. [**Last Name (STitle) 1327**] with repeat head CT scan in two weeks' time. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2165-5-6**] 11:08 T: [**2165-5-6**] 11:14 JOB#: [**Job Number 36867**]

Admission Date: [**2118-7-14**] Discharge Date: [**2118-7-20**] Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1835**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Posterior Fossa Decompression for tumor removal History of Present Illness: The patient is a elderly woman who is known to have metastatic carcinoma. She was recently diagnosed with a left-sided, large, posterior fossa lesion that is not amenable to radiosurgical treatment. The patient has mass effect on the surrounding tissue and is showing neurological decline with extrapyramidal signs. She is, hence, in need of surgical decompression for prolonged survival. The patient was extensively counseled. She is taken electively to the operating room. Past Medical History: Colon CA with mets to lung and brain Social History: The patient lives in [**Hospital3 **] in [**Hospital1 1559**] area. She has a niece who is nearby. No drinking and no smoking. Family History: Father- unknown type of malignancy. Brother- prostate cancer, brother-meningioma. Physical Exam: Physical exam on admission: In general, the patient is alert, oriented, and in no apparent distress. She understands conversation perfectly well. Her speech is fluent. Her Karnofsky performance status is 80. The HEENT examination reveals pupils equal, round, and reactive to light. The extraocular muscles are intact. The oropharynx is clear without exudate or lesion. There is no lymphadenopathy in the cervical, infraclavicular, supraclavicular, or axillary lymph node chains bilaterally. Lungs show mild crackles over the right lobe in both upper and lower lobe lung fields. The abdomen is soft, nontender, and nondistended. The extremities are without cyanosis, clubbing, or edema. NEUROLOGIC EXAMINATION: Cranial nerves II through XII are grossly intact. Strength is [**4-27**] in all muscle groups in the upper and lower extremities. There is no focal weakness. There is no focal sensory deficit. There is no pronator drift. The patient has intact gait. It is somewhat slow, but intact. The patient has mild difficulty with tandem walk. Exam on discharge: Alert and oriented x3, EOM's full, PERRL 3-2.5, full motor strength. Speech is clear, Comprehension intact, no pronator. Follows complex commands. Pertinent Results: Labs on admission: [**2118-7-15**] 02:00AM BLOOD WBC-13.3* RBC-3.71* Hgb-11.5* Hct-34.1* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.0 Plt Ct-183 [**2118-7-15**] 02:00AM BLOOD Glucose-223* UreaN-18 Creat-0.6 Na-135 K-3.8 Cl-100 HCO3-26 AnGap-13 Labs on discharge: [**2118-7-20**] 06:50AM BLOOD WBC-12.1* RBC-4.24 Hgb-13.0 Hct-39.6 MCV-94 MCH-30.7 MCHC-32.8 RDW-14.8 Plt Ct-227 [**2118-7-20**] 06:50AM BLOOD Plt Ct-227 [**2118-7-20**] 06:50AM BLOOD PT-11.9 PTT-30.4 INR(PT)-1.0 [**2118-7-20**] 06:50AM BLOOD Glucose-151* UreaN-27* Creat-0.7 Na-137 K-3.5 Cl-97 HCO3-26 AnGap-18 [**2118-7-20**] 06:50AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3 Brief Hospital Course: [**7-14**]: Pt went to the OR as an elective admission for resection of posterior fossa mass via suboccipital craniotomy. The patient tolerated this procedure very well with no complications. Post operatively she was transfered to the ICU for further care including q1 neuro checks and strict SBP control to less than 140. Upon post op exam the patient remained at her neurological baseline without defecit. Her incision was C/D/I with no active drainage and her pain was well controlled. She remained in the ICU overnight with no medical issues. [**7-15**]: Pt was seen in A.M rounds and was doing well. No new defecits and was AOx3. She underwent post operative head ct that showed no acute infarct or intracranial hemorrhage. The patient did require a nipride iv drip for blood pressure control and this was effectively weaned in the evening with new blood pressure requirements of less than 160. MRI head was consistent with post operative changes and no acute pathology. [**2034-7-15**]: Pt did well upon arrival to the floor but did develop some mental status changes over the weekend and become more agitated. She was somewhat disoriented in the evenings and a geriatric medicine consult was called. They felt her changes were likely due to her decadron and hospital stay. Some medications changes were made and her decadron was tapered to 2mg twice daily. She did have some difficulty swallowing on the 25th and the speech and swallow team saw her on the 26th. She was deemed unsafe for PO intake on the 26th and was made NPO. A dobhoff tube was attempted but the patient was uncooperative and she did remove it on her own. [**7-19**]: Speech and Swallow consulted patient and recommended NPO. [**7-20**]: Patient was cleared for soft solids by Speech and Swallow. Pt was cleared and discharged to rehab. Medications on Admission: OSTEO [**Hospital1 **] FLEX - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC CALCIUM CARBONATE-VIT D3-MIN [CALCIUM 600 + MINERALS] - (Prescribed by Other Provider) - Dosage uncertain NAPROXEN SODIUM [ALEVE] - (Prescribed by Other Provider) - Dosage uncertain VITAMIN B COMP & C NO.3 - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Famotidine 20 mg IV Q12H 5. Dexamethasone 2 mg IV Q8H Duration: 2 Days Start: [**7-20**] AM 6. Dexamethasone 2 mg IV Q12H Start: [**7-22**] AM 7. Metoprolol Tartrate 5 mg IV Q6H hold for HR<60 8. Insulin Sliding Scale While on Decadron only. Discharge Disposition: Extended Care Facility: [**Hospital 1294**] Healthcare Center - [**Location (un) 1294**] Discharge Diagnosis: Prelim Diganosis: Colon CA metastasis to brain 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: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your [**Location (un) 2729**] are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your surgery, you may safely resume taking this at the time of your follow up appointment. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office in 10 days (from your date of surgery) for removal of your staples/[**Location (un) 2729**] and a wound check. Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be sure to point out any incisions, which may be covered by clothing at the time of suture/staple removal. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**8-1**] at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a multi-disciplinary appointment. 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 with/ or without gadolinium contrast. Completed by:[**2118-7-20**]

Admission Date: [**2192-5-17**] Discharge Date: [**2192-6-12**] Service: ADMITTING DIAGNOSIS: Electrocardiogram changes HISTORY OF PRESENT ILLNESS: This is an 83-year-old Russian speaking male with a history of coronary artery disease, status post myocardial infarction in [**2188**] and congestive heart failure who was admitted approximately two weeks prior to his [**5-17**] admission for changes in mental status and lethargy. At that time, he was found to have a calcium of 14.9 and treated with pamidronate, calcitonin, Lasix and intravenous fluids. He subsequently had a polymorphic ventricular tachycardia arrest on [**5-10**]. At that time, he was resuscitated, intubated and transferred to the CCU where he was quickly extubated and seen by EPS who thought the patient had a long QT syndrome and metabolic process versus ischemia. At the time, they recommended amiodarone. The patient was later found to have hyperparathyroidism and was treated with improvement in mental status and sent to [**Hospital3 7**] on [**5-16**]. However, on [**5-16**], the patient's electrocardiogram showed ST depressions in leads V2 and V3. For this reason, the patient was sent to the Emergency Room to be ruled out for myocardial infarction or ischemia. At the time of admission, the patient denied chest pain, although he complained of a constant throat tightness with atypical symptoms. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2188**] 2. Congestive heart failure 3. Hypertension 4. Polymorphic ventricular tachycardia arrest 5. Liver mass 6. Hyperparathyroidism 7. Chronic renal insufficiency ADMISSION MEDICATIONS: 1. Lisinopril 15 mg po bid 2. Ciprofloxacin 250 mg po bid 3. Heparin subcutaneous 4. Prilosec 20 mg po qd 5. Enteric coated aspirin 225 mg po qd 6. Lopressor 12.5 mg po bid 7. Vancomycin SOCIAL HISTORY: Sixty plus pack year smoker, denies alcohol use. FAMILY HISTORY: Noncontributory ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: He was with a stable blood pressure in the 130s/60s, heart rate in the 70s, respiratory rate in the 18 to 20 range and 100% on room air. NECK: No jugular venous distention. He had bilateral carotid bruits. CARDIAC: S1, S2, regular rate and rhythm, no murmurs, rubs or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Without any evidence of edema. ADMISSION LABORATORIES: Hematocrit of 33, platelet count 221. Chem-7 with a BUN of 27, creatinine of 1.4, troponin of 1.1, CPK of 88, calcium of 8.9. IMAGING: His electrocardiogram on the 18th showed a normal sinus rhythm with a normal axis and Q-waves in 2, 3 and AVF. ASSESSMENT: At this time, it was felt that this was an 83-year-old male with a history cardiac disease and electrocardiogram changes plus troponin which would be consistent with infarction in the inferior wall of his myocardium. The patient refused cardiac catheterization at the time of admission and was treated with aspirin, heparin, Lopressor and lisinopril. The patient's CKs were cycled. Of note, the patient did have an elevated troponin of 14.3 on [**5-10**] during his ventricular tachycardia arrest. HOSPITAL COURSE: The patient was admitted. He was treated with aspirin, Lopressor, lisinopril and his CKs were cycled. Attempts were made to obtain a consent for cardiac catheterization, however, the family repeatedly refused to give consent until [**5-22**] when the patient finally underwent a cardiac catheterization that demonstrated the following: Left main and three vessel disease in the right dominant system. The left main was calcified and had 90% ostial stenosis. The LAD had a 70% proximal stenosis. The D1 had moderate diffuse disease. The circumflex was totally occluded proximally with left to left collaterals. The RCA was totally occluded proximally with left to right collaterals. The ejection fraction was calculated to be 44% with severe anterior lateral hypokinesis. The patient did well post catheterization and at this point, cardiothoracic surgery was consulted for potential coronary revascularization. Post catheterization, the patient was restarted on the heparin on which he had been maintained throughout the hospital admission and coronary artery bypass grafting was planned for [**5-24**]. At the time, the patient was in stable condition. He had an uneventful next couple of days and was stable with a heart rate in the 60s and blood pressure in the 120s to 140s/60s to 80s and was awaiting coronary artery bypass graft which was finally performed on [**5-29**] by Dr. [**Last Name (STitle) **]. He had the following: Left ventricular aneurysmectomy, as well as a left internal mammary artery to diagonal, saphenous vein graft to LAD, saphenous vein graft to OM and saphenous vein graft to PDA. The cardiopulmonary bypass time was 76 minutes with a crossclamp time of 62 minutes. The last cardiac output prior to transfer to the Cardiothoracic Intensive Care Unit was 4.0 liters per minute. The patient was transferred to the Cardiothoracic Intensive Care Unit where he required some Neo-Synephrine for blood pressure support. However, he was quickly weaned from both pressors and his sedation and extubated on the 30th and on the 31st, began complaining of chest pain. He had, on physical exam, a rapid pulse of approximately 100 and a blood pressure of 162/72. HEART: Difficult to hear, secondary to his breath sounds, but he did have a definitive rub that was easily auscultatable. An electrocardiogram obtained on the 31st showed diffuse ST elevations in all leads, as well as T-wave depression in leads V4 through V6, 1 and AVL. A cardiology consult was obtained, as well as a bed side echocardiogram which showed inferior posterior akinesis was old and anterior wall motion that was preserved with an ejection fraction of 35% to 40%. Cardiology consult at this point felt that this was consistent with pericarditis and he was started on Indomethacin, as well as some diuresis with Lasix. He was transferred to the floor with his chest tubes out and doing well when he developed an irregularly irregular rhythm on postoperative day #3. He was found to be in atrial fibrillation and a discussion with EPS occurred between cardiothoracic surgery and it was felt that he would benefit from being studied and having an automated implantable cardiac defibrillator placed given his history of ventricular tachycardia arrest. He was not treated with procainamide or amiodarone. Instead, he was anticoagulated and rate controlled with Lopressor. At this time, it was felt the patient merited an implantable defibrillator and several discussions took place over the next couple of days with the wife and daughter of the patient who felt that the patient, who was otherwise very stable, was took weak to undergo the procedure. They were frequently preventing the patient from receiving physical therapy, from being mobilized from ambulating and they did not consent for EPS to study the patient or place AV fibrillator until [**6-6**]. On [**6-6**], the patient was taken to the [**Hospital1 **] [**Last Name (Titles) 516**] where an internal cardiac defibrillator was placed. The patient tolerated the procedure without complication and had the pacer interrogated. The EPS fellow came by to see the patient post procedure frequently to assure the family that the patient was stable post procedure and ready for discharge. The patient had laboratory values checked on the 7th which were significant for a white count of 8.2, hematocrit 31.7, platelets 261 with a BUN of 38 and a creatinine of 1.9. Otherwise, his chemistries were normal. His ionized calcium throughout the admission had remained within normal limits. The patient was stable from discharge. At this point he was, on physical exam, in a regular rhythm. He was making good urine output with 700 cc per day. He was clear to auscultation bilaterally. Regular rate and rhythm with a well healed sternotomy incision, as were his vein harvest sites and he awaited placement until [**6-11**], at which time a rehabilitation bed was found. He was discharged on [**6-12**] with the following medications: 1. Colace 100 mg po bid 2. Zantac 150 mg po qd 3. Aspirin 81 mg po qd 4. Indocin 25 mg po tid with food 5. Lopressor 25 mg po bid 6. Zestril 10 mg po qd 7. Tylenol 650 mg po q 4 to 6 hours prn 8. Albuterol/Atrovent nebulizers prn 9. Lasix 20 mg po bid 10. Potassium chloride 20 milliequivalents po bid DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post myocardial infarction 2. Polymorphic ventricular tachycardia arrest 3. Hyperparathyroidism 4. Chronic renal insufficiency 5. Status post coronary artery bypass graft x4 on [**2192-5-29**] 6. Status post AICD placement on [**6-6**] of [**2192**] DIET: Regular DISCHARGE INSTRUCTIONS: Follow up with EPS, as well as cardiothoracic surgery. Call to schedule an appointment. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1112**] W. 02-229 Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2192-6-12**] 10:53 T: [**2192-6-12**] 12:45 JOB#: [**Job Number 8855**]

Admission Date: [**2141-4-23**] Discharge Date: [**2141-5-7**] Date of Birth: [**2141-4-23**] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] was born at 34 and 5/7 weeks gestation by cesarean section for nonreassuring fetal heart rate to a 35 year-old gravida 5 para 2 now 3 woman. Prenatal screens are blood type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B strep unknown. This pregnancy was complicated by an abnormal alpha fetoprotein study with a normal amniocentesis. The antepartum course was otherwise uncomplicated until rupture of membranes on the day of delivery. Mother presented in spontaneous labor, which was augmented with pitocin. She had an antepartum fever of 100.4. The infant emerged with spontaneous cry. Apgars were 8 at one minute and 8 at five minutes. The birth weight was 2175 grams. The birth length 47 cm and the birth head circumference 29 cm. ADMISSION PHYSICAL EXAMINATION: Active premature infant. Anterior fontanel soft and flat. Positive bilateral red reflex. Breath sounds course that were slightly diminished on admission, but improving. Heart was regular rate and rhythm. No murmur. Abdomen soft. Distended testes bilaterally. Mongolian spot over sacrum. Stable hip examination. Symmetric tone and reflex. HOSPITAL COURSE: Respiratory status: The infant required oxygen by nasal cannula until day of life number two when he weaned to room air where he has remained. He has not ever had an apnea or bradycardia. On examination his respirations are comfortable. His lung sounds are clear and equal. Cardiovascular status: He has been normotensive throughout his Neonatal Intensive Care Unit stay. there are no cardiovascular issues. Fluid, electrolyte and nutrition status: Enteral feeds were begun on day of life number one and advanced without difficulty to full volume feeding by day of life number four. At the time of discharge he is feeding breast milk or Enfamil 20 calorie per ounce. The mother has visited only a few times during his Neonatal Intensive Care Unit stay and so has had limited experience with breast feeding the infant. At the time of discharge the weight is 2400 grams, the length is 47 cm and the head circumference 32 cm. Gastrointestinal status: The last bilirubin done on day of life number three was 5.7 total at direct 0.3. The infant never required any phototherapy. Hematological status: The infant never received any blood product transfusions. His hematocrit at the time of admission was 45.7. Infectious disease status: [**Known lastname **] was started on Ampicillin and Gentamycin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours. Blood cultures were negative and the infant was clinically well. Sensory: Audiology, hearing screen was performed with automated and auditory brain stem responses and the infant passed in both ears. Psycho/social: Parents speak Mandarin and we have communicated with them with a interpreter during their Neonatal Intensive Care Unit stay. The infant is discharged home in good condition. Primary pediatric care will be provided by [**Hospital3 **] Community Center, [**Location (un) 48869**]in Quinsy, [**State 350**]. Parents plan to call on Monday the 14th to schedule an appointment. CARE/RECOMMENDATIONS: Feedings, breast feeding or formula 24 calorie per ounce on an ad lib schedule. Medications, iron sulfate (25 mg per ml elemental iron) 0.2 cc po q day. The infant passed a car seat position screening test. The last state newborn screen was sent on [**2140-5-7**]. The infant received his first hepatitis B vaccine on [**2141-4-30**]. DISCHARGE DIAGNOSES: 1. Status post prematurity at 34 and 5/7 weeks. 2. Status post transitional respiratory distress. 3. Sepsis ruled out. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**First Name3 (LF) 48870**] MEDQUIST36 D: [**2141-5-7**] 11:28 T: [**2141-5-8**] 05:57 JOB#: [**Job Number 48871**]

Admission Date: [**2158-1-18**] Discharge Date: [**2158-1-24**] Date of Birth: [**2089-7-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Patient admitted with R sided abdominal pain s/p diverting loop colostomy. Major Surgical or Invasive Procedure: None History of Present Illness: 68 F presents to the ED today on POD 16 from a diverting loop colostomy that was performed for an obstructing sigmoid lesion. She was discharged on [**2158-1-9**] and was doing well. She was in her usual state of health until 48 hrs ago when she started feeling very weak, almost unable to walk up a flight of stars. She also complains of right sided abdominal pain, unrelated to po intake, that has worsened over the past 48 hrs as well. She denies any fevers, nausea, or vomiting. She does report chills, decreased urine output, as well as more liquid ostomy output than usual. The output has now started thickening up again. Of not, Ms. [**Known lastname 84080**] had a colonoscopy on [**12-30**] that showed an applecore lesion in the sigmoid colon at 30cm, and a stent was placed. No biopsy taken. Past Medical History: polycystic kidney disease, HTN Social History: quit Tob 1y ago, formerly 1-2ppd x30y. + EtOH, 1-2 drinks nightly. Lives at home with her eldest son. Family History: not applicable Physical Exam: PE: 97.6 80 87/59 --> (105/60 1L bolus) 16 100% RA A&O x 3, NAD PERRL, EOMI, anicteric sclera Lips and tongue dry Neck supple, no masses RRR CTAB Abdomen soft, nondistended, gas and yellow stool in ostomy bag. She is tender to palpation in the RUQ with guarding. Normal bowel sounds, negative [**Doctor Last Name 515**]. Midline incision well healed with old steri-strips in place. Ostomy digitalized without difficulty or pain. Guiac negative. LE warm, no edema Pertinent Results: [**2158-1-18**] 11:50AM BLOOD WBC-11.8* RBC-3.80* Hgb-11.9* Hct-37.1 MCV-98 MCH-31.3 MCHC-32.0 RDW-13.6 Plt Ct-563*# [**2158-1-18**] 11:50AM BLOOD Glucose-104* UreaN-34* Creat-2.1* Na-141 K-3.4 Cl-104 HCO3-22 AnGap-18 [**2158-1-20**] 02:45AM BLOOD Glucose-102* UreaN-22* Creat-1.6* Na-139 K-3.3 Cl-112* HCO3-19* AnGap-11 [**2158-1-23**] 06:58AM BLOOD Glucose-110* UreaN-10 Creat-1.1 Na-136 K-3.6 Cl-108 HCO3-21* AnGap-11 [**2158-1-23**] 06:58AM BLOOD Calcium-7.1* Phos-2.3* Mg-1.6 [**2158-1-18**] 11:56AM BLOOD Lactate-2.6* K-2.9* Ct Scan [**2158-1-18**] 1. Mid lower abdomen small fluid collection with locule of gas concerning for abscess. 2. Diffuse bowel wall thickening of the large bowel, as well as involvement of several loops of small bowel, with mesenteric stranding. Findings raise concern for an infectious or inflammatory process. 3. Status post diverting colostomy and stent placement in the rectosigmoid colon with narrowing of the mid stent likely related to known rectal mass. 4. Unchanged fusiform aneurysmal dilatation of the infrarenal aorta up to 3.3 cm. 5. Diverticulosis without evidence of acute diverticulitis. Brief Hospital Course: Patient Admitted with R sided abdominal pain s/p loop colostomy. CT scan was done showing possible abscess. Iintravenous antibiotics started as well as intravenous fluids. Labs were obtained and monitored. Initial labwork showed elevated bun/cre. confirming acute renal failure. Also white count was elevated. Throughout hospital course patient's pain resolved and her acute renal failure resolved. We will send her home today with one week of cipro/flagyl. We also will have her follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Percocet prn, Protonix 40', Atenolol 50', Nifedipine 60', Lasix 20' 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. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*7 Tablet(s)* Refills:*0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute renal failure and abdominal pain Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - Please call [**Telephone/Fax (1) 2723**] to make an appointment two weeks after discharge. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2158-3-2**] 8:00 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2158-3-2**] 8:00 Completed by:[**2158-1-24**]

Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-13**] Date of Birth: [**2126-3-23**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest Pain/NSTEMI Major Surgical or Invasive Procedure: Aortic valve replacement (23mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical Regent) History of Present Illness: This is a 22yoM with a history of hepatitis C and polysubstance abuse, who was transferred from [**Hospital3 **] for further management of a NSTEMI thought to be secondary to aortic valve vegetation embolism. He first presented on [**2148-10-26**] with fevers and lightheadedness. He was found to have strep viridans endocartiditis with large vegetation on his noncoronary cusp, as well as posterior root seen on TEE. He was treated with penicillin and Gentamicin and transferred to [**Hospital1 **] State on [**11-14**], at which point he was transitioned to high dose ceftriaxone. He completed four weeks of antibiotics on [**2148-11-23**], and has been without fevers, chills, malaise, weakness, sensory deficits, vision abnormalities since that time. He presented to [**Hospital6 3105**] 3 days ago with anterior chest pain radiating to the left side, which started on [**11-30**]. Troponin was found to be elevated at 2.09, and though there were no acute EKG changes per report, he was treated for NSTEMI with Lovenox and Plavix (ASA allergy). A TTE demonstrated persistentce of a large aortic valve vegetation, along with moderate-severe aortic regurgitation. An embolic vegetation is suspected as the source of the NSTEMI. . Past Medical History: Viridans strep aortic valve endocarditis NSTEMI Depression IV drug use (heroin) hepatitis C marijuana use migraines Social History: Lives w/ his wife in [**Name (NI) 487**]. Has four kids 12, 8,6,2. 1PPD for 7 years, quit Hx of polysubstance abuse, particularly heroin, but claims to be clean since d/c from [**Hospital1 **] state hospital, utox was + for MJ at admission to LGH. Had tried cocaine 5 times in the months prior to initial admission [**10-26**], but none since. Not currently working, applying for SSI. Family History: Mom had 2CVA with hemiparesis. Dad with DM2, four living siblings are healthy, one murdered. Physical Exam: Admission Physical Exam: VS: T= 98 BP= 100/58 HR= 93 RR= 18 O2 sat= 100RA GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP flat, positive carotid thrill CARDIAC: RRR, III/VI pan-diastolic murmur loudest at RUSB 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. No [**Last Name (un) **] lesions or splinter hemorrhages. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Multiple tatoos. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ NEURO: Walking w/o difficulty, normal gait, CNII-XII intact, strength 5/5 throughout Pertinent Results: Admission labs: [**2148-12-3**] 11:10AM BLOOD WBC-7.7 RBC-3.95* Hgb-11.3* Hct-33.0* MCV-84 MCH-28.6 MCHC-34.3 RDW-15.9* Plt Ct-321 [**2148-12-3**] 02:37AM BLOOD PT-13.2 PTT-30.6 INR(PT)-1.1 [**2148-12-3**] 11:10AM BLOOD Glucose-109* UreaN-25* Creat-0.9 Na-139 K-4.5 Cl-103 HCO3-25 AnGap-16 [**2148-12-4**] 08:45AM BLOOD ALT-244* AST-127* LD(LDH)-255* AlkPhos-120 TotBili-0.5 [**2148-12-3**] 08:50AM BLOOD CK-MB-3 cTropnT-0.23* [**2148-12-3**] 11:10AM BLOOD Calcium-9.7 Phos-4.0 Mg-1.8 [**2148-12-4**] 08:45AM BLOOD calTIBC-309 Ferritn-413* TRF-238 [**2148-12-4**] 08:45AM BLOOD %HbA1c-5.0 eAG-97 [**2148-12-4**] 08:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2148-12-4**] 08:45AM BLOOD HCV Ab-POSITIVE* BLOOD CULTURES [**2148-12-3**] No growth CT HEAD [**2148-12-3**]: FINDINGS: There is no intracranial hemorrhage. The [**Doctor Last Name 352**]-white matterdifferentiation is preserved. There is no edema, mass or mass effect. The ventricles and sulci are normal in size and configuration. The mastoid air cells and paranasal sinuses are clear. There is no fracture. IMPRESSION: No acute intracranial process. CORONARY CT [**2148-12-4**]: IMPRESSION: 1. Suboptimal cardiac gating due to high heart rate and inability to proceed with large dose of IV beta-blockers due to patient's low blood pressure. 2. No central obstructing filling defect demonstrated in right coronary artery, left main, left circumflex artery. Normal anatomic origin of the coronary arteries. 3. Large vegetation of a known bicuspid valve accompanied by calcifications. 4. Thickening of the aortic valve apparatus versus (less likely) papillary muscle hypertrophy. TEE [**12-5**] PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= XX %). Right ventricular chamber size is normal. with borderline normal free wall function. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The aortic valve leaflets are severely thickened/deformed. There is a large vegetation on the aortic valve. No aortic valve abscess is seen. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POST: 1. Mechanical valve in aortic position 2. Well seated and good leaflet excursion with expected washing jets. Peak gradient = 35 mm hg. 3. RV and LV have unchanged systolic function Radiology Report CHEST (PORTABLE AP) Study Date of [**2148-12-9**] 7:19 AM [**Hospital 93**] MEDICAL CONDITION: 22 year old man with s/p avr Final Report: The patient is status post median sternotomy and aortic valvular surgery, with stable post-operative appearance of the cardiomediastinal contours. Minimal area of atelectasis is again demonstrated in the right lower lobe, with otherwise clear lungs. Extreme left lung base has been excluded from the radiograph, precluding assessment for small left effusion or peripheral basilar left lung abnormality. Brief Hospital Course: Patient was transferred to [**Hospital1 18**] after ruling in for NSTEMI at [**Hospital6 3105**], has had been treated prior to that admission for aortic valve endocarditis. An echo prior to transferred revealed severe aortic regurgitation. Following admission he remained stable. Cardiac catheterization was not performed due to risk of embolization of the vegetation. Cardiac surgical consultation was requested. On [**12-5**] he went to the Operating Room after the usual preoperative workup, please see operative report for details. In summary he had: Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] mechanical valve, reference number [**Serial Number 88070**]. His bypass time was 101 minutes, with a crossclamp time of 84 minutes. He tolerated the operation well and post-operatively was transferred to the cardiac surgery ICU in stable condition. He remained hemodynamically stable, awoke intact was weaned from the ventilator and extubated. All tubes lines and drains were removed per cardiac surgery protocols. He was started on Bblockers, diuretics and anticoagulation the day following surgery. He transferred to the stepdown floor on POD 1. Physical Therapy saw him for strength and mobility. His Methadone was resumed, he received opiates and Toradol for surgical pain. The remainder of his hospital course was uneventful, he continued to make good progress and was cleared for discharge to home on POD eight. His INR is to be followed by [**Company 191**] coumadin clinic starting on [**2147-12-17**]. His first INR check is the day after discharge with results to cardiac surgery oncall staff at [**Hospital1 18**] before [**12-17**] or [**Company 191**] coumadin clinic if after [**12-17**]. All follow-up appointments were advised. Medications on Admission: Methadone 75mg daily lorazepam 0.5mg daily/PRN tylenol colace omeprazole 20mg daily senna simethicone bisacodyl Discharge Medications: 1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 4. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3-4 hrs as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 6. methadone 5 mg/5 mL Solution Sig: Seventy Five (75) mg PO DAILY (Daily). 7. warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: take 8mg daily until otherwise directed by the [**Hospital 191**] clinic target INR 2.5-3.5. Disp:*150 Tablet(s)* Refills:*2* 8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. Disp:*30 * Refills:*1* 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Outpatient Lab Work INR to be drawn on [**2148-12-14**] with results sent called to the [**Hospital1 18**] answering service [**Telephone/Fax (1) 170**]. INR should then be drawn again on [**12-17**] with results on that day and thereafter sent to the [**Hospital 191**] clinic at [**Hospital1 18**] [**Telephone/Fax (1) 2173**], fax [**Telephone/Fax (1) 3534**]. Discharge Disposition: Home Discharge Diagnosis: aortic insufficiency s/p mechanical AVR h/o aortic valve endocarditis hepatitis C h/o Intravenous drug abuse polysubstance abuse depression Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid and Motrin Incisions: Sternal - healing well, no erythema or drainage edema-none 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**] **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) **] [**2148-1-2**] at 1:15 pm Cardiologist:Dr. [**Last Name (STitle) 29070**] [**2147-12-25**] at 3:45 pm PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 88071**] [**Name (STitle) **] @ [**Hospital6 733**] [**2148-12-20**] @ 1:45 PM **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve Goal INR 2.5-3.5 First draw day after discharge and [**12-17**] Results to: [**Company 191**] coumadin clinic t(they will follow starting [**2147-12-17**] phone ([**Telephone/Fax (1) 10844**] fax ([**Telephone/Fax (1) 23341**] Confirmed with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 88072**] Completed by:[**2148-12-13**]

Admission Date: [**2117-1-12**] Discharge Date: [**2117-1-16**] Date of Birth: [**2070-2-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: VF arrest Major Surgical or Invasive Procedure: Cardiac catheterization with placement of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 87853**] intubation History of Present Illness: A 46 yom with PMH HTN, Hyperlipidemia presented is transfered to [**Hospital1 18**] s/p VF arrest. According to the report, patient presented to [**Hospital3 **] ED clutching his chest, and collapsed in triage. CPR was initiated, initial rhythm was VF he was cardioverted and received Epinephrine 1mg, atropine 1mg and lidocaine 250mg (100/50/150), and his rhythm converted to VT and then Sinus Tach. He was intubated and sedated and transfered to [**Hospital1 18**] for evaluation for cooling protocol and cath. . On arrival to [**Hospital1 18**], he was taken for cardiac cath which showed 40% stenosis of the RCA and an occluding thrombus in the Left Circumflex artery, which was stented with a DES. After stenting, patient again had VF arrest, CPR was performed for 10 seconds and he was cardioverted into sinus rhythm and admitted BP: 102/60, HR:75 RR:20 SOa2 100% on 100% FiO2, assist control at 5 peep and vt 550 frequency of 20. . Review of systems is not possible as patient is intubated and sedated. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: No prior - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Hypertension - Hyperlipidemia - Obesity Social History: - Employed in flower delivery - Tobacco history: 20 pack year history, currently smoking 1-1.5 PPD - ETOH: Rarely, <1 drink/week - Illicit drugs: wife denies Family History: - Mother: CAD s/p stent at age 75 - Father deceased cirrhosis, lung CA - Brother alive and well - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Physical Exam: On admission: VS: T:97.6 BP:117/73, HR:74 RR:20 SaO2:100% on 100% FiO2 GENERAL: Middle aged overweight male intubated, eyes open to sternal rub. HEENT: NCAT, Pupils 3mm and poorly reactive to light. NECK: JVP non elevated CARDIAC: normal S1, S2. regular rate/ rhythm. No MRG. No thrills, lifts. No S3 or S4. LUNGS: Coarse transmitted inspiratory breath sounds, otherwise CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Overweight, soft, non distended, No HSM, bowel sounds hypoactive EXTREMITIES: Moving all extremities, No edema. Right arterial line in place, at cath site, no erythemia, no eccyhmosis. Dorsalis pedis/posterior tibial pulses 2+ BL Neuro: 2+ patellar and achilles DTRs. Squeezes and releases hands on command, follows command to wiggle toes BL. On discharge: same as above except: GENERAL: breathing spontaneously on RA, awake, alert and oriented, following commands. HEENT: PERRL LUNGS: CTAB ABDOMEN: Normoactive BS EXTREMITIES: No arterial line in place NEURO: Follows all commands, interactive Pertinent Results: [**2117-1-12**] 05:40PM PT-13.6* PTT-94.9* INR(PT)-1.2* [**2117-1-12**] 05:40PM PLT COUNT-234 [**2117-1-12**] 05:40PM WBC-32.6* RBC-4.31* HGB-13.6* HCT-38.0* MCV-88 MCH-31.5 MCHC-35.7* RDW-13.5 [**2117-1-12**] 05:40PM %HbA1c-5.6 eAG-114 [**2117-1-12**] 05:40PM ALBUMIN-3.8 MAGNESIUM-2.0 [**2117-1-12**] 05:40PM ALT(SGPT)-47* AST(SGOT)-41* TOT BILI-0.2 [**2117-1-12**] 05:40PM estGFR-Using this [**2117-1-12**] 05:40PM GLUCOSE-251* UREA N-20 CREAT-1.0 SODIUM-138 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14 [**2117-1-12**] 05:47PM freeCa-1.11* [**2117-1-12**] 05:47PM HGB-14.3 calcHCT-43 O2 SAT-97 [**2117-1-12**] 05:47PM GLUCOSE-236* LACTATE-1.5 NA+-136 K+-4.1 CL--105 [**2117-1-12**] 05:47PM TYPE-ART RATES-/16 TIDAL VOL-550 PO2-209* PCO2-56* PH-7.24* TOTAL CO2-25 BASE XS--4 -ASSIST/CON INTUBATED-INTUBATED [**2117-1-12**] 07:17PM PT-12.4 PTT-31.8 INR(PT)-1.0 [**2117-1-12**] 07:17PM ALBUMIN-4.1 CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-2.2 CHOLEST-171 [**2117-1-12**] 07:17PM CK-MB-33* MB INDX-4.9 [**2117-1-12**] 09:22PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ECHO [**1-13**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. EF 45-50%. CXR (While intubated): Endotracheal tube tip is at the upper clavicular level, approximately 6 cm above the carina. Nasogastric tube extends into the stomach with the side port in the lower esophagus. Respiratory motion somewhat degrades the image. There are atelectatic changes at the left base in the retrocardiac area, though no gross evidence of pneumonia or pulmonary vascular congestion. CATH REPORT: 1. Selective coronary angiography of this right dominant system demonstrated 1 vessel coronary artery disease. The LMCA and LAD had no angiographically apparent flow-limiting disease. The LCx had total occlusion mid-vessel. The RCA had 40% mid-vessel stenosis. 2. Limited resting hemodynamics revealed normal systemic arterial pressures. Left ventricular end diastolic pressure was mildly elevated at 24 mmHg. There was no aortic stenosis on pullback from the LV to the aorta. Inpatient Labs: [**2117-1-12**] 07:17PM BLOOD %HbA1c-5.6 eAG-114 [**2117-1-13**] 03:37AM BLOOD Triglyc-146 HDL-44 CHOL/HD-3.7 LDLcalc-88 [**2117-1-12**] 07:17PM BLOOD TSH-1.6 [**2117-1-12**] 05:47PM BLOOD Type-ART Rates-/16 Tidal V-550 pO2-209* pCO2-56* pH-7.24* calTCO2-25 Base XS--4 -ASSIST/CON Intubat-INTUBATED [**2117-1-13**] 01:31PM BLOOD Type-ART pO2-94 pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Intubat-INTUBATED [**2117-1-13**] 03:47AM BLOOD Lactate-0.8 [**2117-1-12**] 05:40PM BLOOD ALT-47* AST-41* TotBili-0.2 [**2117-1-12**] 07:17PM BLOOD ALT-49* AST-53* LD(LDH)-221 CK(CPK)-674* AlkPhos-71 TotBili-0.3 [**2117-1-12**] 07:17PM BLOOD CK-MB-33* MB Indx-4.9 [**2117-1-13**] 03:37AM BLOOD CK(CPK)-[**2064**]* [**2117-1-13**] 03:37AM BLOOD CK-MB-125* MB Indx-6.4* cTropnT-1.13* [**2117-1-13**] 01:18PM BLOOD CK(CPK)-2692* [**2117-1-13**] 01:18PM BLOOD CK-MB-104* MB Indx-3.9 cTropnT-1.06* [**2117-1-14**] 04:30AM BLOOD CK(CPK)-[**2040**]* [**2117-1-14**] 04:30AM BLOOD CK-MB-31* MB Indx-1.6 cTropnT-0.94* Discharge Labs: [**2117-1-16**] 08:45AM BLOOD WBC-11.5* RBC-4.42* Hgb-14.0 Hct-38.5* MCV-87 MCH-31.6 MCHC-36.2* RDW-13.4 Plt Ct-234 [**2117-1-14**] 04:30AM BLOOD PT-12.8 PTT-25.7 INR(PT)-1.1 [**2117-1-16**] 08:45AM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-24 AnGap-15 [**2117-1-16**] 08:45AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1 Urine: [**2117-1-12**] 09:22PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]->=1.035 [**2117-1-12**] 09:22PM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2117-1-12**] 09:22PM URINE RBC-[**1-2**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [**2117-1-12**] 09:22PM URINE AmorphX-MANY CaOxalX-FEW [**2117-1-12**] 09:22PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: 46 yoM with hypertension/hyperlipidemia admitted s/p Ventricular fibrillation arrest with cath showing 40% stenosis RCA, and DES to L circ and second arrest on cardiac cath table with successful resuscitation. . # VENTRICULAR FIBRILLATION ARREST: Related to poor perfusion of myocardium. S/P successful resuscitation and DES (see below). Second episode of VF in the cath lab was likely related to reperfusion injury. Urine tox negative. Remained in sinus throughout rest of admission. Started on amiodarone load at OSH, not continued at time of discharge. . # CORONARIES:Patient was found to have 1V disease and is s/p DES to LCx and cath showed 40% stenosis of RCA. Initially placed on Prasugrel 10 mg daily post-cath and transitioned to clopidogrel 75mg daily at time of discharge for minimum 12 months. ASA 325 was started and continued at discharge. Atorvastatin 80mg was started and transitioned to simvastatin 80mg at discharge. Integrillin drip initially on post-cath, stopped per protocol. Metoprolol succinate was titrated up to 75mg daily. Pt. was recommended for outpt. cardiac rehab. . # PUMP: LVEF unknown from previous, post-cath TTE showed mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis and LVEF 45-50%. Management as above. . # VENTILATION: Patient intubated at admission for airway protection, ABG showed respiratory acidosis. Will adjust vent settings to increase ventillation frequency to 20 and decrease FiO2 to 60%. Patient received on fentanyl and versed, transition to propofol, and successfully extubated without complication. NG tube to suction while intubated. . # Transitional Issues: 1. Pt was found to have flat/depressed affect throughout admission but pt's wife reports this as baseline. Consider f/u with PCP [**Last Name (NamePattern4) **]: depressive sx. 2. Pt was recommended for cardiac rehab. He was instructed to call PCP on weekday to schedule appt. and to seek out local cardiologist from PCP [**Name Initial (PRE) 28085**]. Medications on Admission: Lipitor 10mg daily Simvastatin 20mg daily Metoprolol XL 25mg daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*31 Tablet(s)* Refills:*2* 2. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*31 Tablet(s)* Refills:*11* 4. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*31 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. ST elevation myocardial infarction 2. Cardiac arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 87854**], You were admitted to our hospital after you were transferred from the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in order to undergo cardiac catherization. You had a major heart attack. You had stents placed in the arteries that supply blood to the heart. Your heart also went into a dangerous rhythm and stopped temporarily. You were temporarily on a ventilator to help you breathe. You were able to breathe on your own and had no further chest pain. . Some of your medications were changed during this admission: START aspirin 325mg daily indefinitely START clopidogrel (Plavix) 75mg daily for at least one year INCREASE simvastatin to 80mg daily INCREASE metoprolol succinate (Toprol XL) to 75mg daily . Only your cardiologist can tell you to stop taking aspirin or Plavix (clopidogrel). You must take these medications every day to prevent another heart attack. . You will need outpatient cardiac rehab. Dr. [**Last Name (STitle) 7047**] discussed this with you. Followup Instructions: You should call Dr.[**Name (NI) 72943**] office at [**Telephone/Fax (1) 18325**] on Monday to schedule an appointment with him within the next 1-2 weeks and also ask him to refer you to a local cardiologist who you should make an appointment with within the next 2 weeks as well. . You should go to cardiac rehab as you discussed with Dr. [**Last Name (STitle) 7047**].

Admission Date: [**2200-9-5**] Discharge Date: [**2200-9-28**] Date of Birth: [**2127-2-9**] Sex: F Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female who originally presented with a persistent cough. At the time, a chest x-ray was performed, which showed an abnormal mediastinum. A suspicion was raised about a possible ascending aortic aneurysm. A follow-up CT scan was performed, which showed a 5.2 x 5.4 cm in diameter aneurysm that appeared to taper at the level of the innominate artery. The patient's echocardiogram showed good left ventricular function with mild left ventricular hypertrophy. In addition, the patient was noted to have a moderately dilated aortic root and 2+ aortic insufficiency with mild aortic stenosis, mitral regurgitation, and tricuspid regurgitation. In addition, the patient underwent cardiac catheterization preoperatively, which showed two vessel disease with disease in the left anterior descending artery, first diagonal, and a large obtuse marginal. The patient presented to Cardiac Surgery for a possible surgical intervention. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Hypertension 3. Peptic ulcer disease 4. Depression 5. Valvular disease ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Zestril 40 mg by mouth once daily 2. Imipramine 100 mg once daily 3. Trazodone 100 mg daily at bedtime 4. Atenolol 25 mg once daily 5. Nexium as needed LABORATORY DATA: Hematocrit 30.8, white blood cell count 9.1, platelets 72. Glucose 110, BUN 23, creatinine 1.4, sodium 137, potassium 4.5. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery service. Given the history of ascending aortic aneurysm and coronary artery disease, the patient underwent: 1. Resection and repair of ascending aortic and proximal aortic arch aneurysm 2. Coronary artery bypass graft x 1 3. Aortic valve replacement The patient tolerated the procedure well, which was performed on [**2200-9-5**]. There were no complications. The resection and repair of the ascending and proximal arch aortic aneurysm was performed with hemi-arch-type repair using 26 mm gel-weave Dacron tube graft. The aortic valve replacement was done with a 21 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial bioprosthesis. The patient remained intubated and was transferred to the Intensive Care Unit in stable condition. She remained intubated. The patient was diuresed appropriately. The patient was started on several medications to maintain her systolic blood pressure at 120 or below. On postoperative day one, the patient was noted to have decreased bowel sounds and dark-colored drainage from the mouth. Vancomycin and levofloxacin were added empirically. The patient was continued on nitro drip to help maintain her pressures. She was also continued on Lopressor and Hydralazine, as well as labetalol. The patient was extubated on [**2200-9-9**]. She tolerated extubation well, without any complications. The patient was noted to have periods of confusion. Of note is that the patient had to go back to the operating room for a chest evacuation of a hematoma and suturing of a bleeding vessel. Cardiology was consulted to assist with blood pressure control. Cardiology recommendation was to initiate more aggressive diuresis, to continue labetalol, Captopril and Hydralazine. Her antidepressant medication (imipramine) was discontinued. The patient was transferred to the regular floor in stable condition. On [**2200-9-14**], the patient appeared to be in increased respiratory distress. She had crackles on examination bilaterally. She was thought to be fluid overloaded. A chest x-ray done at the time showed bilateral pleural effusions, left significantly greater than right, with associated left lower lobe collapse/consolidation. The patient was diuresed more. An electrocardiogram was obtained, which showed no change. In addition, left thoracentesis was performed, with significant amount of fluid drained. In addition, a pigtail catheter was placed by bedside and fluid was drained with suction. A follow-up chest x-ray obtained on the following day showed significant improvement in the amount of fluid present in the lungs. Consequently, the pigtail catheter was removed on [**2200-9-17**]. The other issue was the patient's decreased appetite, which has been going on for the last week or so. The patient was restarted on her outpatient dose of imipramine. She was encouraged to eat and also to ambulate. Physical Therapy was following her during the hospitalization course. The patient remained afebrile. She was improving her oxygenation. The patient was discharged to a rehabilitation facility in stable condition. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Ascending aortic aneurysm status post resection and repair of the ascending aortic and proximal aortic arch aneurysm 2. Coronary artery disease status post coronary artery bypass graft x 1 3. Aortic valve replacement 4. Hypertension 5. Depression DI[**Last Name (STitle) 408**]E INSTRUCTIONS: 1. The patient is to follow up with her surgeon, Dr. [**Last Name (Prefixes) 411**] in approximately four weeks. 2. The patient is to follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in approximately one to two weeks. 3. The patient is to follow up with the cardiologist in approximately three to four weeks. DISCHARGE MEDICATIONS: Will be dictated separately. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 10097**] MEDQUIST36 D: [**2200-9-18**] 02:35 T: [**2200-9-18**] 03:13 JOB#: [**Job Number 10098**]

Admission Date: [**2144-10-22**] [**Month/Day/Year **] Date: [**2144-10-26**] Date of Birth: [**2099-1-29**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 4654**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 45M with history of alcoholism and pericarditis who presents to the ED with 2 days of chest pain consistent with his pain associated with pericarditis. Pt states that he has flairs every 3-4 months treated with ibuprofen. In the ED, vitals 96.5 132 129/87 12 98% RA. Patient noted diaphoresis, pain worse with inspiration, vomiting after eating. Not associated with change in position, radiation. Also dry cough, chills (no fevers). Pt states that this pain is similar to pain that he has had in the past with pericarditis. Pt is also a heavy drinker. Last alcohol consumed evening of [**10-21**]. Normal consumption [**2-5**] pints of vodka daily. Patient does have a history of seizures with withdrawal. Is in active withdrawal requiring hourly valium. Tox screen in ED significant for alcohol level 334. The tox screen was also positive for benzos, however, the patient had concurrent dosing of valium for his alcohol withdrawal and [**Month/Day (2) **] benzo use. . Pt also notes that he has had right arm numbness for the last 2 weeks. He states that he had a fall and since them his arms and hand have been numb with pins and needle sensation. Arm is notable for swelling but full ROM. Past Medical History: Chronic heavy etoh abuse x 20 years (hx of withdrawal seizures, last 4 weeks ago) Hx of pericarditis (s/p window; few years ago) s/p bilateral shoulder dislocataions in setting of seizures Depression Social History: Homeless, divorced. One daughter. Drinks [**2-5**] pints of vodka daily. Does not smoke. Remote history of smoking 1ppw x 8 years. No illicit drug use. Family History: Mother - healthy. Father - unknown. Aunts and uncles with alcoholism Physical Exam: General Appearance: Well nourished, No acute distress, Thin, Diaphoretic Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Purposeful, Tone: Not assessed Pertinent Results: [**2144-10-22**] 09:15AM BLOOD WBC-4.5 RBC-4.09* Hgb-13.5* Hct-39.0* MCV-96 MCH-33.0* MCHC-34.5 RDW-14.8 Plt Ct-135* [**2144-10-22**] 09:15AM BLOOD Neuts-43.9* Lymphs-51.0* Monos-3.6 Eos-1.1 Baso-0.5 [**2144-10-22**] 09:15AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.1 [**2144-10-22**] 09:15AM BLOOD Plt Ct-135* [**2144-10-22**] 09:15AM BLOOD Glucose-101 UreaN-6 Creat-0.6 Na-145 K-3.8 Cl-102 HCO3-26 AnGap-21* [**2144-10-22**] 09:15AM BLOOD ALT-42* AST-106* LD(LDH)-266* CK(CPK)-230* AlkPhos-89 TotBili-0.7 [**2144-10-22**] 09:15AM BLOOD Lipase-38 [**2144-10-22**] 09:15AM BLOOD cTropnT-<0.01 [**2144-10-23**] 05:10AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.4 Mg-1.5* [**2144-10-22**] 09:15AM BLOOD [**Month/Day/Year **]-NEG Ethanol-334* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG chest x-ray - IMPRESSION: No acute intrathoracic process. CTA chest - IMPRESSION: 1. No pulmonary embolism, aortic dissection or pericardial effusion 2. Fatty infiltration of the liver. upper extremity ultrasound - PRELIM read - No son[**Name (NI) 493**] evidence of compartment syndrome. Normal examination of the forearm. forearm x-ray Two views of the right forearm are obtained. An intravenous catheter is present. No fracture or dislocation is identified. Brief Hospital Course: A&P: 45M with history of alcoholism and pericarditis admitted to initially to ICU for alcohol withdrawal and later transferred to medicine service. <br> Alcohol withdrawl - Pt has history of seizures during wihdrawal. Has been drinking [**2-5**] pints of vodka daily. Last drink 10pm [**10-21**]. Patient was monitored on CIWA scale and received a significant amount of valium. He was also seen by the addiction consult. At time of [**Month/Year (2) **], patient was walking comfortably without any clinical evidence of active ETOH withdrawal. Given mild tremors and that pt sx mildly worsened [**10-25**] of original anticipated d/c - pt will be d/c with tail of end librium taper (given 50mg today and tomorrow, and 25mg next 2 days). Pt has already Rx by Dr. [**Last Name (STitle) **] yesterday diazepam for breath through tremors/anxiety. PCP otherwise to [**Name Initial (PRE) **]/u on pt and assess progress. <br> Pericarditis - History of flairs every 3-4 months. Per report, had pericardial window 10 years ago at the [**Hospital1 756**]. Symptoms responded well to ibuprofen. No evidence of pericardial effusion on CT. D/C with ibruprofen. <br> Right Arm Numbness - Pt describes numbness and tingling in arm and hand. Right arm swollen and tight distal to elbow. Full range of motion. No tenderness to palpation. Had trauma to arm two weeks ago. X-rays and U/S were unremarkable, no evidence of fracture, nerve entrapment or compartment syndrome. <b> Anemia, nos - pt with all cell counts mildly low - chronic and consistant with etoh marrow suppression. PCP to [**Name Initial (PRE) **]/u as indicated - etoh cessation d/w pt along with S.W. consult as above. Medications on Admission: Seroquel 50mg qhs [**Name Initial (PRE) **] Medications: 1. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2* 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*2* 6. Diazepam 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for tremulousness. [**Name Initial (PRE) **]:*4 Tablet(s)* Refills:*0* 7. Chlordiazepoxide HCl 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): TAKE 2 TABS FOR NEXT TWO DAYS EVERY MORNING, THEN TAKE ONLY 1 TAB EVERY MORNING FOR NEXT 3 DAYS (THEN YOU WILL BE DONE). [**Name Initial (PRE) **]:*7 Capsule(s)* Refills:*0* [**Name Initial (PRE) **] Disposition: Home [**Name Initial (PRE) **] Diagnosis: ETOH Withdrawal Pericarditis Depression Anxiety Right Arm Numbness [**Name Initial (PRE) **] Condition: Vital Signs Stable, ambulating without difficulty. [**Name Initial (PRE) **] Instructions: Return to ED if having worsening tremulousness, worsening signs of ETOH withdrawal. DO NOT DRINK ANY ALCOHOL Use motrin as needed for pericarditis pain. <br> Do not plan to operate any heavy machinery or drive for atleast next 1 week. If your tremulousness gets worse, first take one of your as needed diazepam medications (only take if you need it), if that does not settle your symptoms call your PCP or return to ED as above. The librium prescription is intended so you won't need the diazepam medication. Followup Instructions: 1. PCP f/u with Dr. [**First Name (STitle) **], [**First Name3 (LF) **] on [**2144-11-9**] at 10:30am. ([**Location (un) **], [**Telephone/Fax (1) 4326**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2144-10-26**]

Admission Date: [**2166-3-4**] Discharge Date: [**2166-3-18**] Date of Birth: [**2105-2-4**] Sex: F Service: CARDIOTHORACIC Allergies: Hmg-Coa Reductase Inhibitors (Statins) / Compazine / Oxycodone Hcl/Acetaminophen / Morphine Attending:[**First Name3 (LF) 1283**] Chief Complaint: exertioanl angina, DOE, fatigue Major Surgical or Invasive Procedure: [**3-10**] AVR (19mm St-[**Male First Name (un) 923**]) History of Present Illness: 61 yo F with known AS and recent increase in symptoms. Past Medical History: MS, R breast CA-s/p lumpectomy/XRT-completed [**1-11**], glucose intollerance, dyslipidemia, Hashimoto Thyroiditis, AS. Social History: works in OR booking at [**Hospital6 **] no tobacco rare etoh Family History: NC Physical Exam: HR 62 RR 14 BP 123/68 Well appearing F in NAD Lungs CTAB Heart RRR 3/6 SEM radiation to carotids Abdomen benign Extrem warm, no edema, 2+ pulses t/o No varicosities Pertinent Results: [**2166-3-18**] 04:20AM BLOOD WBC-5.4 RBC-2.75* Hgb-8.6* Hct-26.1* MCV-95 MCH-31.5 MCHC-33.1 RDW-14.2 Plt Ct-394 [**2166-3-18**] 04:20AM BLOOD PT-24.9* INR(PT)-2.4* [**2166-3-17**] 10:25AM BLOOD PT-24.6* PTT-32.9 INR(PT)-2.4* [**2166-3-16**] 06:25AM BLOOD PT-22.7* PTT-89.8* INR(PT)-2.2* [**2166-3-15**] 12:14AM BLOOD PT-14.5* PTT-57.7* INR(PT)-1.3* [**2166-3-14**] 04:00PM BLOOD PT-12.8 PTT-40.9* INR(PT)-1.1 [**2166-3-18**] 04:20AM BLOOD Plt Ct-394 [**2166-3-18**] 04:20AM BLOOD Glucose-101 UreaN-13 Creat-0.8 Na-133 K-3.9 Cl-98 HCO3-31 AnGap-8 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76619**] (Complete) Done [**2166-3-10**] at 9:19:46 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2105-2-4**] Age (years): 61 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: avr ICD-9 Codes: 786.05, 440.0, 424.1, 424.0 Test Information Date/Time: [**2166-3-10**] at 09:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: [**Pager number **] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *56 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 51 mm Hg Aortic Valve - LVOT pk vel: 0.74 m/sec Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mild [1+] 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. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. 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 severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Before final separation from bypass, the tissue valve was tested and found to have unacceptably high regurgitation associated with the right cusp. The aorta was re-clamped and the valve inspected. Tried to wean again, and again too much AI at the right cusp. Finally re-clamped and placed a mechanical valve. Post-CPB: A mechanical aortic valve is in place. No AI, no peri-valvular leak. Mean gradient = 11. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 66799**]r systolic fxn. Aorta intact. Other parameters as pre-bypass. Brief Hospital Course: She was transferred from MWMC to cardiac surgery. She was cleared for surgery by dental. She was taken to the operating room on [**3-10**] where she underwent an AVR. She was transferred to the ICU in stable condition. She was extubated later that same day. She was given 48 hours of vancomycin since she was in the hospital preoperatively. She was started on coumadin for her mechanical valve.She was transfused 1 unit for HCT 24 with oliguria and hypotension. She continued to require a neo gtt. Her chest tubes had air leaks and were dc'd on POD #3. She was weaned from her neo and transferred to the floor. She had SVT and was seen by electrophysiology. She was started on amiodarone. Her INR was therapeutic and she was ready for discharge home. Pre-discharge xray showed a moderate left effusion. Thoracentesis for 500 cc bloody fluid was performed. Post-tap xray was improved and she was ready for discharge home. Coumadin will be followed by the [**Hospital1 **] heart center coumadin clinic. Medications on Admission: Arimidex1, atenolol 50 hs, ASA 81', trazadone prn, rhinocort, zetia 10', protonix 40', HCTZ, niaspan 1500', norvasc 5', meloxican 15', mirapex 0.25', diasynenide, lipitor 5', ambien prn. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 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:*0* 3. 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:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily (). 6. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*0* 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO ONCE (Once) for 2 days: 3 mg [**3-18**] and [**3-19**] and then check INR [**3-20**] with results to MWMC coumadin clinic. Disp:*60 Tablet(s)* Refills:*0* 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: AS now s/p AVR MS, R breast CA-s/p lumpectomy/XRT-completed [**1-11**], glucose intolerance, dyslipidemia, Hashimoto Thyroiditis Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions,creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) 5448**] 2 weeks Dr. [**Last Name (STitle) 32255**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2166-3-18**]

Admission Date: [**2159-6-12**] Discharge Date: [**2159-6-27**] Date of Birth: [**2114-1-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: Non healing left heal ulcer Major Surgical or Invasive Procedure: L fem-DP bpg L heel debridement Past Medical History: HTN IDDM with neuropathy Renal failure with peritoneal dialysis MWF MI in [**12-9**] Gallbladder removal '[**34**] Amps of L4 and L5 '[**49**] Left foot debridement sub 4th and 5th met heads '[**58**] Amp of Right 2nd [**2157**]. Social History: She used to smoke, however, has quit. Denies alcohol use. Family History: Medical problems significant for diabetes. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg [**Name2 (NI) **] HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2159-6-12**] 5:33 PM CHEST (PORTABLE AP) Reason: eval for cvl placement PORTABLE SUPINE FRONTAL RADIOGRAPH: FINDINGS: Lung volumes are reduced. Allowing for this and technique, cardiac and mediastinal contours are within normal limits. There is a right-sided IJ central venous catheter with its tip in the mid SVC. The patient is intubated with ET tube terminating above the level of the clavicles. An NG tube terminates within the stomach. No pneumothorax is seen on this supine radiograph. There is a small amount of atelectasis in the retrocardiac region. IMPRESSION: Reduced lung volumes with left retrocardiac atelectasis. Central venous catheter with its tip in the mid SVC [**2159-6-13**] LEFT HEEL, 2 VIEWS: The ulcer over the heel is noted. Some irregularity of the underlying portion of the calcaneus is within the range of normal. No focal bone destruction or periosteal new bone formation to confirm the presence of osteomyelitis is identified. No reactive sclerosis is detected. No fracture is identified. Vascular calcification and surgical clips noted. IMPRESSION: Ulceration. No osteomyelitis identified. [**2159-6-25**] Source: left heel. **FINAL REPORT [**2159-6-29**]** GRAM STAIN (Final [**2159-6-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2159-6-28**]): 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). GRAM NEGATIVE ROD(S). MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [**2159-6-29**]): NO ANAEROBES ISOLATED [**2159-6-12**] 05:36PM WBC-12.7* RBC-3.26* HGB-9.2* HCT-27.7* MCV-85 MCH-28.3 MCHC-33.1 RDW-15.0 Brief Hospital Course: Pt admitted [**2159-6-12**] for ischemic foot. Pt pre-op'd cleared for surgery. IV Antibiotics started. Cx taken. Podiatry consulted / plastics / renal consulted. Pt recieved PD M/W/F. Pt underwent a Left common femoral artery to dorsalis pedis artery bypass graft in situ using greater saphenous vein, angioscopy and valve lysis, revision of distal anastomosis, and intraoperative arteriogram. Pt tolerated th procedure well. There were no complications. Pt acidotic transfered to the SICU in stable condition. Intubated. It was thought that the pt was in metabolic acidosis secondary to untreated renal failure, likely secondary to non compliance PD. [**2159-6-14**] - [**2159-6-17**] Pt extubated. Podiatry to debride wound. Pt remained in SICU. [**2159-6-18**] Pt underwent a debridement of left heel. Pt tolerated th procedure well. There were no complications. Pt extubted in the OR. Transfered to the PACU in stable condition. Once reccoperated from anesthesia pt transfered to the VICU in stable condition. Pt had VAC after the procedure. Pt recieved PRBC's [**2159-6-19**] - [**2159-6-25**] PT consult. Pt allowed OOB to chair. NWB left foot. Awaiting cx and sensitivities / vac in place. Foley DC'd. [**2159-6-26**] Vac removed. Wound improved. Plastics see pt. Want to see on f/u as out pt. Vac replaced. PICC placed at bedside for AB therapy. Pt dc'd in stable condition. Taking PO / ambulating with ASST, pos BM, pos urination. Medications on Admission: insulin 70/30 40 qam, 40 qpm, lasix 80 [**Hospital1 **], renagel 1200 [**Hospital1 **], zestril 40 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:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 months. Disp:*15 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous as needed per level < 15 for 1 months: blood levels should be checked every third day and dosed only if level < 15; dosing to be reviewed by peritoneal dialysis coordinator -- [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 60552**] Fax [**Telephone/Fax (1) 60553**] for any changes during therapy. Disp:*10 doses* Refills:*0* 9. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: One (1) flush Intravenous per ccs protocol. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: homehealth vna Discharge Diagnosis: HTN IDDM ESRD Heel ulcer Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea,vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. 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. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise indicated at follow up with PCP. Followup Instructions: F/U with [**Doctor Last Name **] in [**1-7**] wks. F/U with Nephrology as per routine F/U with PCP soon after discharge to review medications and events Completed by:[**2159-8-21**]

Admission Date: [**2165-3-7**] Discharge Date: [**2165-3-12**] Date of Birth: [**2098-1-30**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 348**] Chief Complaint: Hematemesis and fevers Major Surgical or Invasive Procedure: none History of Present Illness: 67 yo M with history of COPD, CVA with residual left sided weakness, history of aspiration, hypertension. Was admitted to the MICU due to concerns for upper GI bleed, fevers, and hypotension. Patient was at his [**Hospital3 **] facility when discovered to have temp of 102 and was vomiting "blood and coffee grounds". Patient reports multiple sick contacts in his nursing home. Could not be more specific. He corraborates ED and EMT story of coffee ground emesis; however, cannot further elaborate. Denies current nausea or abdominal pain and denies seeing blood in his stool. . Upon arrival to the ED, patient's vitals were T 100.8, BP 106/60, HR 70, RR 18, O2sat 91% RA. Received total of 2 L NS due to blood pressures transiently to 90s systolic on several occasions. Pressures were minimally fluid responsive and systolics were never above 110. Had one rectal temp of 103 in ED. Was given Vancomycin and Zosyn in ED due to question of pneumonia. Blood cultures were sent prior to initiation of anitbiotics. Had UA sent, which was positive by dipstick, no culture was sent. Also received ondansetron and pantoprazole. Stools were noted to be dark brown and guaiac positive. NG lavage in the ED with small coffee ground specs, but otherwise clear. Type and screen was sent, two 18G IVs were placed. GI was made aware of the patient; however, did not officially consult in the ED. . ROS: (+)ve: coffee ground emesis, cough, fevers (-)ve: chest pain, dyspnea, orthopnea, hematochezia, abdominal pain, nausea, sputum production, constipation, diarrhea Past Medical History: COPD HTN CVA with residual left sided weakness Dysphagia and aspiration pneumonitis h/o ETOH abuse Social History: Pt is a resident at [**Hospital3 2558**] nursing home. He is a former heavy smoker, prior alcoholic who has been abstinent for 5 yrs. Family History: Reviewed and non-contributory Physical Exam: VS: T 98.7, BP 99/40, HR 61, RR 18, O2sat 95% 2L NC GEN: NAD HEENT: PERRL, EOMI, oral mucosa moist NECK: Supple, no LAD, JVP at ~8 cm PULM: Inpiratory squeaks bilaterally anterior, decreased breath sounds throughout CARD: RR, nl S1, nl S2, no M/R/G ABD: BS hyperactive, soft, non-tender, non-distended, no organomegaly EXT: No C/C/E NEURO: Oriented to "hospital", date, year, current president SKIN: stage I on sacrum - skin is erythematous, boggy, no area of ulceration noted. Pertinent Results: [**2165-3-7**] 07:51PM HCT-30.5* [**2165-3-7**] 12:37PM LACTATE-1.3 [**2165-3-7**] 12:17PM HCT-31.6* [**2165-3-7**] 07:59AM LACTATE-1.3 [**2165-3-7**] 05:00AM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-135 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14 [**2165-3-7**] 05:00AM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.0 [**2165-3-7**] 05:00AM WBC-10.1 RBC-3.70* HGB-10.5* HCT-32.8* MCV-89 MCH-28.4 MCHC-32.0 RDW-13.2 [**2165-3-7**] 05:00AM NEUTS-76.5* LYMPHS-18.9 MONOS-4.2 EOS-0.2 BASOS-0.2 [**2165-3-7**] 05:00AM PLT COUNT-246 [**2165-3-7**] 05:00AM PT-14.1* PTT-28.2 INR(PT)-1.2* [**2165-3-7**] 12:55AM URINE HOURS-RANDOM [**2165-3-7**] 12:55AM URINE GR HOLD-HOLD [**2165-3-7**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2165-3-7**] 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2165-3-7**] 12:30AM URINE RBC-[**5-1**]* WBC-[**10-11**]* BACTERIA-OCC YEAST-NONE EPI-0 [**2165-3-6**] 10:28PM LACTATE-1.0 [**2165-3-6**] 09:20PM GLUCOSE-112* UREA N-31* CREAT-1.0 SODIUM-133 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14 [**2165-3-6**] 09:20PM estGFR-Using this [**2165-3-6**] 09:20PM ALT(SGPT)-15 AST(SGOT)-18 CK(CPK)-27* ALK PHOS-66 TOT BILI-0.3 [**2165-3-6**] 09:20PM LIPASE-27 [**2165-3-6**] 09:20PM cTropnT-<0.01 [**2165-3-6**] 09:20PM CK-MB-NotDone [**2165-3-6**] 09:20PM ALBUMIN-3.4 CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2165-3-6**] 09:20PM ACETONE-NEGATIVE OSMOLAL-289 [**2165-3-6**] 09:20PM WBC-13.4*# RBC-3.88* HGB-11.3* HCT-33.7* MCV-87 MCH-29.2 MCHC-33.6 RDW-13.2 [**2165-3-6**] 09:20PM NEUTS-86.7* LYMPHS-9.2* MONOS-4.0 EOS-0 BASOS-0.1 [**2165-3-6**] 09:20PM PLT COUNT-285 [**2165-3-6**] 09:20PM PT-13.9* PTT-24.8 INR(PT)-1.2* [**2165-3-6**] 09:20PM SED RATE-43* Imaging: CXR [**3-6**]: IMPRESSION: 1. Limited evaluation with suggestion of new right mid lung opacity. Recommend dedicated PA and lateral radiographs for further evaluation when clinically feasible. 2. No pneumoperitoneum. . CT abd/pelvis [**3-6**]: IMPRESSION: 1. Peribronchial cuffing with airspace opacification proximally suggests a pneumonitis that may be infectious or secondary to aspiration. Age- indeterminate given lack of prior. 2. Simple cyst in the left lower renal pole. 3. Small axial hiatal hernia. 4. Atherosclerosis of the SMA origin. 5. No intra-abdominal abscess. No diverticulitis. 6. Likely dilatation of the thoracic ascending aorta for which further imaging is needed. . Radiology Report CHEST (PA & LAT) Study Date of [**2165-3-9**] 1:31 PM Impression: Continue improvement with almost complete resolution of right upper lobe opacity. Opacities in the lower lobes medially are unchanged, likely atelectasis. There is no pneumothorax or enlarging pleural effusions. If any, there is a small left pleural effusion. Moderate degenerative changes are in the thoracic spine. . [**2165-3-12**] EGD: Impression: Medium hiatal hernia Slightly tortuous esophagus no rings or strictures. No lesions, no old or fresh blood in stomach Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up with referring physician as needed Observe in hospital setting . Brief Hospital Course: Assessment and Plan 67 yo M with history of COPD, CVA with residual left sided weakness, history of aspiration, hypertension. Was admitted to the MICU due to concerns for upper GI bleed, fevers, and hypotension. # Fevers / Leukocytosis: Pulmonary source thought initially to be most likely given that patient had CXR opacity in RUL and new cough. Lactate at presentation was 1.0. Patient thought to have had an aspiration pneumonia as he already has a history of this. Legionella was negative, levofloxacin which was initially started was then discontinued once legionella negative. UA in the ED was positive for bacteria, WBCs, and leuk est however UCx not sent before antibiotics started. Patient treated with zosyn and vancomycin for presumed UTI and PNA. Decreased to zosyn on floor. Patient had 1x fever to 101 rectally while on floor on zosyn which corresponded to R PIV site being red, warm, painful. After R arm PIV pulled, he had no further fever, R arm no longer red - this 1x fever likely due to thrombophlebitis. Abx changed to PO cipro on [**3-12**]. Foley d/c for infection risk. . # Hypotension: Likely initially sepsis physiology given fever, elevated WBC. Fluid responsive. Unlikely cardiac etiology. Patient with unchanged EKG in the ED from baseline and no complaints of chest pain. Cardiac enzymes were negative. Patient with several episodes of asymptomatic hypotension at night with SBPs in high 80s which resolved w/waking patient, and were fluid responsive (when fluids given). Patient not tachycardic during these episodes. . # GI bleed: Both coffee ground emesis and guaiac, but no grossly positive stools point to upper GI bleed. HCT at presentation was 33.7 and his baseline appears to be mid to upper 30s by review of medical record. Patient with history of gastritis diagnosed on [**2160**] EGD. Has recently been discontinued from ranitidine. He was restarted on protonix [**Hospital1 **] through his hospital course. Evaluated for GI. EGD negative for gastritis, PUD. Should have outpatient colonoscopy in future. . # Nutrition: As per S&S recommendations; Continue baseline diet of nectar thick liquids and ground solids, pills crushed with puree, swallow with chin tucked to chest, 1:1 supervision during meals . # Sacral decub: a small area of erythema and boggy skin was noted on the patient's sacrum upon presentation. We treated the area with barrier cream and frequent turns while the patient was here. This regimen will need to be continued when the patient is at his [**Hospital1 1501**] to prevent further deterioration of the skin in this area. . # Prophylaxis: Heparin subcutaneous . # Code status: FULL - d/w patient. Medications on Admission: 1. Aspirin 325 mg daily 2. Multivitamin daily 3. Folic Acid 1 mg daily 5. Mirtazapine 45 mg at bedtime 6. Calcium Carbonate 500 mg chewable twice daily 7. Cholecalciferol 400 unit tab, two daily 8. Alendronate 70 mg PO every Tuesday 9. Docusate Sodium 100 mg twice daily 10. Simvastatin 10 mg daily 11. Psyllium one packet daily Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: urinary tract infection superficial thrombophlebitis Discharge Condition: vital signs stable, tolerating PO. Discharge Instructions: You were admitted for fever and low blood pressure. We think this was likely due to a urinary tract infection which we treated with antibiotics and your fever improved. It is also possible that you had a small amount of aspiration into your lungs. Please be sure to adhere to the diet restrictions made by our speach and swallow team when you return to your nursing facility. . We removed your foley catheter because of your urinary tract infection. Please try to avoid using a catheter in the future because of the increased risk of infection that it provides. . While you were in the hospital you were noted to have a red area on your sacrum which can signal the start of a pressure ulcer. We treated it with barrier cream and frequent turning. Please be sure to stay as active as possible and get out of bed as much as you can. When you are in bed, you need to be sure to turn frequently so that you do not further develop ulcers on your back or bottom. . Please return to the ED if you develop any of the following symptoms: high fever, shortness of breath, chest pain, diarrhea or vomiting such that you cannot keep down food or your medicines. Followup Instructions: Please have your nursing home help you to contact your primary care provider, [**Name10 (NameIs) **] [**Last Name (STitle) 4321**], to determine when you will need to follow up with her.

Admission Date: [**2109-11-28**] Discharge Date: [**2109-12-8**] Date of Birth: [**2050-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 10593**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Right knee arthrocentesis History of Present Illness: Mr. [**Known lastname **] is a 59yo male with history of insulin dependent DM, on albuterol inhaler at home, who presented to ED with 3 day history of fever, dyspnea, and non-productive cough. Patient had called EMS tonight for increased coughing, and was brought to [**Hospital1 18**] for further evaluation. Patient reports receiving a flu vaccine on Thursday prior to admission. After receiving the flu shot, patient reports developing subjective fever without chills. For the past 3 days, the patient has noticed cough with white sputum production. In the past day or two, he reports muscle aches making him unable to bend down to tie his shoes. He denies DOE or dyspnea at rest. He has not noticed rashes. He denies sick contacts. [**Name (NI) **] has had poor appetite the past 2 days. He denies nausea, vomiting, and abdominal pain. . In the ED, initial VS were: 100.1 96 173/84 24 100% 15L, though his respiratory rate decreased with talking (to 30s). Patient denied any CP. Exam notable for tachypnea and rhonchi. Labs notable for leukocytosis with WBC 12.9 with 78% N, 15.9% L. In the ED, the patient was started on ceftriaxone and azithromycin. He also received albuterol/ipratropium nebs times 2 in the ED and was started on IV methylprednisolone. Blood and urine cultures were drawn as well; UA from the ED was not concerning for UTI. CXR was limited secondary to body habitus, though there was no appreciable consolidations or effusions. . VS prior to transfer: 98 159/61 100% CPAP RR 45, when talking RR 30s. . On arrival to the MICU, patient has CPAP in place; VS upon arrival to the MICU: T 100.0 (Ax) HR 97 BP 125/77 RR 31 (RR decreased to 20s w/ conversation) O2 Sat 96% via FM at 8L. Patient reports that he feels better since arrival in the ED. He is currently receiving nebulizer treatment via FM. . Of note, the patient has never formally been diagnosed with asthma, though he uses his albuterol inhaler twice daily. He is currently not using CPAP at home as insurance is no longer covering this. Patient had ECHO in [**4-/2109**] that did not show evidence of pulmonary HTN. PFTs have been variable in the past and show a restrictive pattern. . Review of systems: (+) For urinary frequency. (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies rashes or skin changes. Past Medical History: -- DM, insulin dependent; complicated by retinopathy and renal insufficiency -- HTN with ECHO ([**4-/2109**]) evidence of LV Hypertrophy -- HLD -- Obesity -- Hypercalcemia -- Sleep Apnea on CPAP -- renal insufficiency [**2-6**] poorly controlled DM -- retinopathy [**2-6**] poorly controlled DM -- glaucoma -- Restrictive lung disease on PFTs, which was thought to be due to his obesity. Of note, PFTshave been somewhat unreliable due to inadequate test performance. Suspicion for parenchymal lung disease is minimal on pulmonary note from [**12-14**]. Social History: Lives in [**Location 686**]. Unemployed (former merchant marine). Married with 7 year-old boy. - Tobacco: Denies tobacco (never smoked) - Alcohol: Rare EtOH - Illicits: No IVDA or illicits Family History: Father, sister, brothers: Diabetes. Mother: asthma Physical Exam: ADMISSION EXAM Vitals: T: 100.0 (Ax) BP: 125/77 P: 97 R: 31 O2: 97% via FM at 8L General: Alert & oriented to person, place and time. Labored breathing, but able to complete full sentences. 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: Elevated RR. Labored breathing, but able to compelte full sentences. Wheezing present diffusely bilaterally. No crackles. Abdomen: soft, non-tender, distended, bowel sounds present, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, clubbing +. no cyanosis. 2+ pitting edema of the LE bilaterally. LUE w/ significant swelling when compared w/ RUE (patient attributes this to h/o gout) Neuro: CN II-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE EXAM Vitals: 99.4 112/70 86 20 97%RA General: obese, NAD 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: Able to complete full sentences. Resp unlabored. Distant breath sounds, grossly clear to auscultation, no wheezes Abdomen: soft, obese, non-tender, distended (at baseline) Ext: warm, well perfused, 2+ pulses, clubbing +. no cyanosis. 2+ pitting edema of the LE bilaterally. Swelling of right knee and right ankle, mildly warmer to touch than left; right calf larger than left Pertinent Results: On admission: [**2109-11-28**] 02:20AM BLOOD WBC-12.9* RBC-3.82* Hgb-12.0* Hct-37.7* MCV-99* MCH-31.4 MCHC-31.9 RDW-14.0 Plt Ct-280 [**2109-11-28**] 02:20AM BLOOD Neuts-78.0* Lymphs-15.9* Monos-4.8 Eos-1.0 Baso-0.2 [**2109-11-28**] 02:20AM BLOOD Glucose-249* UreaN-59* Creat-1.6* Na-142 K-5.4* Cl-100 HCO3-29 AnGap-18 [**2109-11-28**] 02:20AM BLOOD CK(CPK)-885* [**2109-11-28**] 02:20AM BLOOD CK-MB-12* MB Indx-1.4 proBNP-52 [**2109-11-28**] 02:20AM BLOOD cTropnT-0.21* [**2109-11-28**] 02:20AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.5 [**2109-12-3**] 08:45AM BLOOD VitB12-902* Folate-11.6 [**2109-11-28**] 02:52AM BLOOD Type-ART Tidal V-530 FiO2-50 pO2-132* pCO2-58* pH-7.32* calTCO2-31* Base XS-2 Intubat-NOT INTUBA Vent-SPONTANEOU [**2109-11-28**] 02:28AM BLOOD Lactate-1.2 On discharge: [**2109-12-8**] 06:40AM BLOOD WBC-14.0* RBC-4.15* Hgb-13.0* Hct-42.0 MCV-101* MCH-31.2 MCHC-30.9* RDW-13.7 Plt Ct-577* [**2109-12-8**] 06:40AM BLOOD Glucose-56* UreaN-67* Creat-1.5* Na-139 K-5.2* Cl-96 HCO3-30 AnGap-18 [**2109-12-7**] 08:00AM BLOOD CK(CPK)-221 [**2109-12-1**] 07:45AM BLOOD CK-MB-7 cTropnT-0.14* [**2109-12-8**] 06:40AM BLOOD Calcium-10.2 Phos-4.7* Mg-2.4 Urine: [**2109-11-28**] 02:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2109-11-28**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2109-11-28**] 02:30AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [**2109-11-28**] 02:30AM URINE CastHy-16* [**2109-12-7**] 03:02AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2109-12-7**] 03:02AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2109-12-7**] 03:02AM URINE RBC->182* WBC-3 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2109-12-7**] 04:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011 [**2109-12-7**] 04:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2109-12-7**] 04:00PM URINE RBC-35* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 Micro: Blood Culture, Routine (Final [**2109-12-4**]): NO GROWTH. Blood Culture, Routine (Final [**2109-12-4**]): NO GROWTH. URINE CULTURE (Final [**2109-11-29**]): NO GROWTH. URINE CULTURE (Final [**2109-12-1**]): NO GROWTH. URINE CULTURE ([**2109-12-7**] Pending): DIRECT INFLUENZA A ANTIGEN TEST (Final [**2109-11-28**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2109-11-28**]): Negative for Influenza B. Right knee arthrocentesis fluid: GRAM STAIN (Final [**2109-12-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2109-12-7**]): NO GROWTH. [**2109-12-4**] 12:00PM JOINT FLUID WBC-9000* RBC-[**Numeric Identifier 54848**]* Polys-100* Lymphs-0 Monos-0 [**2109-12-4**] 12:00PM JOINT FLUID Crystal-MANY Shape-NEEDLE Locatio-I/E Birefri-NEG Comment-c/w monosodium urate crystals ECG [**2109-11-28**]: Sinus tachycardia suggested. Compared to the previous tracing of [**2108-2-3**] the rate has increased. Portable CXR [**2109-11-28**]: PORTABLE AP CHEST RADIOGRAPH: Limited study due to patient body habitus with underpenetration of x-ray. Bilateral low lung volumes are noted with crowding of bronchovascular markings. Cardiac silhouette appears similar in size compared to [**9-4**], [**2109**]. Lung bases cannot be completely evaluated due to limitations of the study. A repeat chest xray should be obtained. Findings were discussed with Dr. [**Last Name (STitle) 17321**] at 3:00 a.m. on [**2109-11-28**] via telephone. Portable abdomen [**2109-11-28**]: PORTABLE ABDOMINAL RADIOGRAPH: No comparisons available. Study is limited by patient body habitus and inadequate penetration, as well as motion. Within this limitation, there appears to be gastric distention; however, bowel loops appear nonobstructive, although there is a paucity of bowel loops particularly within the right abdomen. Free air under the diaphragms can't be excluded in the setting of motion artifact. Portable CXR [**2109-11-28**]: PORTABLE AP CHEST RADIOGRAPH: Comparison made to portable AP chest radiograph obtained 30 minutes earlier. Study is limited by body habitus and decreased penetration. Again noted are decreased lung volumes with crowding of bronchovascular markings. Focal consolidation or pleural effusion cannot be completely evaluated at the lung bases making this study relatively nondiagnostic. Cardiac silhouette appears unchanged. TTE [**2109-11-29**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) 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. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2109-4-16**], the findings are grossly similar, but the technically suboptimal nature of both studies precludes definitive comparison. Right LE ultrasound [**2109-12-1**]: FINDINGS: There is normal grayscale appearance with compressibility, color Doppler flow, and pulse wave Doppler waveforms with augmentation of the right common femoral, superficial femoral and popliteal veins. IMPRESSION: NO DVT in the right lower extremity. IR guided right knee arthrocentesis [**2109-12-4**]: IMPRESSION: 1. Successful fluoroscopic guided right knee joint aspiration of approximately 30 mL of serosanguineous nonpurulent fluid. The fluid was sent to the laboratory for culture, gram stain, cell count and crystal analysis. 2. Imaging demonstrates changes of a prior right knee moderate joint effusion. Right knee x-ray [**2109-12-4**]: There is air within the suprapatellar recess, presumably accounted for by arthrocentesis peformed earlier the same day. There are mild degenerative changes, with small marginal spurs in all three compartments. Otherwise, right knee x-ray examination within normal limits. The cortical surfaces about the joint appear intact and the joint spaces are grossly preserved. Brief Hospital Course: Mr. [**Known lastname **] is a 59yo male with history of insulin dependent DM, on albuterol inhaler at home, who presented to ED with 3 day history of fever, dyspnea, and cough productive of white phlegm. . # Hypoxemia: Pt presented with fever, leukocytosis, cough, and hypoxia. Clinical symptoms consistent with pneumonia. Several chest x-rays were performed but difficult to interpret given body habitus. He was initially hypoxic requiring 15L oxygen and was transferred to MICU with positive pressure ventilation. He was diuresed with IV lasix and was weaned to 2-3L oxygen prior to transfer to floor. He was treated for CAP with a 5 day course of levofloxacin. Additionally, pt has wheezes on exam with questionable hx of asthma. He was put on standing nebulizers. Pt also has OSA but has not been able to get CPAP at home which may have exacerbated symptoms. He was given CPAP to use at night during his hospital stay. He was weaned to room air and afebrile for several days prior to discharge home. He should follow up with outpatient pulmonary for repeat PFTs. He should also obtain CPAP for his OSA. Unfortunately, however, he did not have insurance and could not afford CPAP. He was transitioned to his home lasix dose. Of note, TTE showed normal EF with no significant changes. . # Gout, acute: Pt had low grade temps on [**2109-11-30**] to 100.5 and complained of pain in both elbows and right knee/ankle. His right knee and right ankle were swollen. Lower extremity was obtained because the right calf was larger than the left; this was negative for DVT. Given his kidney disease, he was treated for his gout with a 5 day course of prednisone. He was given small doses of oxycodone and tramadol for additional pain control. He underwent bedside right knee arthrocentesis on [**2109-12-3**] which was unsuccessful. He was then sent to IR for IR guided right knee arthrocentesis which was consistent with gout, showing monosodium urate crystals. He was told to follow up with his PCP regarding initiation of allopurinol to prevent future gout attacks. Gram stain and culture of the right knee tap did not show any organisms. He had difficulties ambulating due to pain and swelling of the right knee. Physical therapy evaluated him and initially recommended discharge to rehab. However, given pt's insurance, rehab options were limited and he was not accepted. He worked with PT in the hospital and was able to ambulate, including walk up the stairs, by the time of discharge. He was provided with a walker for additional assistance. . # Hematuria: Pt complaining of pain with urination. UA showing RBCs and large blood. UA did not indicate urinary tract infection. Hematuria may be due to kidney stone. He was told to follow up with his PCP for repeat [**Name9 (PRE) 71617**]. . # Elevated troponin: Trop elevated to 0.21 initially, downtrended to 0.13. Likely due to demand ischemia as well as component of worsening renal function. ACS was unlikely as pt was not complaining of chest pain, EKG did not show ischemic changes, and CK-MB was flat. CKs downtrended to normal by time of discharge. . # Hyperkalemia: Pt presented w/ hyperkalemia and K peaked at 5.8. Potassium normalized after one dose of kayexalate. Lisinopril was held during hospital stay given hyperkalemia. BPs remained within target range. Potassium was 5.2 at time of discharge; he was told to continue to hold his lisinopril and follow up with his PCP for repeat electrolyte check. . # CKD, stage 2: Baseline 1.5-1.7. Presented with worsening renal function with Cr of 2. Cr downtrended to baseline and was 1.5 by time of discharge. . # Lower extremity edema: Patient on chronic furosemide at home for LE edema. LENI of right LE negative for DVT. He was initially diuresed with iv lasix in the ICU for his hypoxia and transitioned to home po lasix. . # Distended abdomen: Per patient, this is his baseline. KUB in the emergency department was not remarkable for any acute process. . # Diabetes mellitus, uncontrolled, with complications: Patient with poorly controlled DM (insulin dependent). He was on a regimen of 100units NPH [**Hospital1 **] and 70 units regular insulin [**Hospital1 **]. His morning fingersticks were low in the 50s to 70s. His nighttime NPH was progressively reduced. He was maintained on a humalog sliding scale while in hospital. [**Last Name (un) **] diabetes consult was initiated and it was recommended that he reduce his NPH regimen to 80units QAM and 50units QPM. He was also told to discuss his short acting insulin regimen with his PCP. [**Name10 (NameIs) **] awaiting his next PCP appointment, he was told to check his morning fingersticks. If fingersticks reach 200s, he should begin to give himself 10 units of regular insulin with meals. . # Anemia: Stable at patient's baseline HCT in the high 30s. Macrocytic; B12 and folate were within normal limits. . # HTN, benign: He was continued on his home diltiazem. Lisinopril was held due to hyperkalemia. BPs remained within target range. . # HLD: Continued home gemfibrozil . # Tinea Pedis: he was started on clotrimazole cream for his tinea pedis. Medications on Admission: - albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. - CPAP - diltiazem HCl 120 mg Capsule, Extended Release PO daily - furosemide 40 mg PO BID - gemfibrozil 600 mg PO BID - lisinopril 40 mg Tablet - aspirin 325 mg PO daily - prednisone 10 mg Tablet Sig: Taper As Described Below PO once a day: Take two tablets for two days, take one tablet for two days, take [**1-6**] tablet for two days, then stop. Disp:*10 Tablet(s)* Refills:*2* - Vitamin D-3 1,000 unit Tablet 1 tablet PO daily - Vitamin A Oral - NPH Insulin: 100 units in morning and 100 units at dinner - Regular Insulin 70 units twice daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 7. vitamin A Oral 8. NPH insulin human recomb 100 unit/mL Suspension Sig: Eighty (80) units Subcutaneous every morning. Disp:*3 bottle* Refills:*0* 9. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifty (50) units Subcutaneous at bedtime. Disp:*3 bottle* Refills:*0* 10. Humulin R 100 unit/mL Solution Sig: Ten (10) units Injection three times a day with meals as needed for fingerstick above 200. Disp:*3 bottle* Refills:*0* 11. Clotrimazole Foot 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to feet. Disp:*1 tube* Refills:*0* 12. Outpatient Lab Work Please check CBC, electrolytes (chem 7), and urinanalysis and send results to Dr[**Name (NI) 52622**] office (Phone: [**Telephone/Fax (1) 7976**]; Fax [**Telephone/Fax (1) 13238**]) by [**2109-12-18**] Discharge Disposition: Home Discharge Diagnosis: Primary: Community Acquired Pneumonia Asthma Obstructive Sleep Apnea Gout flare Tinea pedis Secondary: Insulin-dependent diabetes Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with shortness of breath, fever, and cough. You were treated for pneumonia with antibiotics. You also developed a gout flare of your right knee and you were treated with steroids. Your right knee was drained and was consistent with gout. Please speak with your primary care doctor with regard to starting a medication that will prevent future gout attacks. You had low blood sugars in the morning. You should decrease your night-time NPH to 80 units in the morning and 50 units at night. You should follow-up with your primary care doctor regarding your insulin regimen. Until you see your doctor, please continue to check your fingersticks. If your morning sugars are in the 200s, please start giving yourself 10 units of Regular insulin with your meals. It is important that you have a CPAP machine at home for your obstructive sleep apnea. Unfortunately, you do not have insurance to pay for this. Please talk to your doctor about alternative ways to obtain the breathing machine at night. You should have your doctor arrange for you to see a lung specialist and repeat tests that look at your lung function. While you were in the hospital, you had pain with urination and had blood in the urine. This may be due to a kidney stone. Please have your doctor [**Month/Day/Year 19697**] your urine when you see him. Your doctor [**First Name (Titles) 4801**] [**Last Name (Titles) 19697**] your potassium level because it was high during this hospital stay (your lisinopril was stopped because of this). He should also [**Last Name (Titles) 19697**] your blood counts (platelets, white blood count) because these numbers were high during your hospital stay. The following changes were made to your medications: 1) DECREASE your NPH to 80 units in the morning and 50 units at night. Please check your sugars and if the morning sugars rise to the 200s, please start giving yourself ONLY 10 units of Regular insulin with your meals until you see your doctor 2) Your lisinopril was held because your potassium was high. Please discuss with your primary care doctor when you should restart your lisinopril. 3) Please start using clotrimazole cream for a fungal infection in your feet. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] W. Location: [**Location **] Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 1265**] Phone: [**Telephone/Fax (1) 7976**] *Please call your primary care physician and book [**Name Initial (PRE) **] follow up appointment for your hospitalization within 1 week of discharge. Completed by:[**2109-12-8**]

Admission Date: [**2110-3-17**] Discharge Date: [**2110-3-21**] Date of Birth: [**2070-11-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2110-3-17**] Coronary artery bypas graft x 5(LIMA-KAD,SVG-PLV,SVG-PDA,SVG-dg1,SVG-dg2) History of Present Illness: This 39 year old male hAShadexertional angina for past 3 years. He had anabnormal stress test and was referred for catheterization which revealed severe triple vessel disease. He was referred for surgery. Past Medical History: Hypertension Hypercholesterolemia Childhood concussions Childhood seizure ( on med for 5 years) Remote Fx R clavicle s/p Tonsillectomy Social History: Race:Hispanic Last Dental Exam:[**2107**] Lives with:divorced, one daughter in [**Name (NI) 4194**] Occupation:driver Tobacco:smokes [**11-24**] ppd ETOH:bottle of wine on wkds Family History: Mother with MI at 59 Physical Exam: admission: Pulse:61 Resp: O2 sat: 98% B/P Right: 150/97 Left: 137/98 Height:5'7" Weight:197 General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI []R eye lower lid with minimal swelling/erythema improved since prior visit/Rx Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] non-tender [x ] bowel sounds + [x]; no HSM Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x];healed R dorsal foot scar and L ventral foot scar Neuro: Grossly intact, nonfocal exam; MAE [**3-27**] strengths Pulses: Femoral Right:2+ (ecchymosis post cath) Left:2+ DP Right:NP Left:NP PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89458**] (Complete) Done [**2110-3-17**] at 2:06:32 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-11-16**] Age (years): 39 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 424.1 Test Information Date/Time: [**2110-3-17**] at 14:06 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW2-: Machine: U/S 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.3 cm Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic function. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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. 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 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. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size is normal. with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. 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. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS There is normal right ventricular systolic function. The left ventricle has improved function from pre-bypass - now with an ejection fraction of 50 to 55%. The thoracic aorta is intact after decannulation. There are no other significant changes from the pre-bypass study. Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and underwent coronary artery bypass graft x 5 on [**2110-3-17**]. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from surgery, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Later on this day he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He worked with physical therapy for strength and mobility during his post-op course. He was discharged to home. All follow-up appointments were advised. Medications on Admission: HCTZ 25 mg daily Simvastatin 80 mg daily atenolol 25 mg daily lisinopril 40 mg daily ASA 81 mg daily SL NTG prn Discharge Medications: 1. 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* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 5 Hypertension Hypercholesterolemia Childhood concussions Childhood seizure ( on med for 5 years) s/p Tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema none 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**] **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) **] ([**Telephone/Fax (1) 170**]) on [**4-3**] at [**Hospital1 **] at 9:00am Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**4-17**] at 1:30pm Wound check on [**3-26**] at 10:15am Please call to schedule appointments with: Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-25**] 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** Completed by:[**2110-3-26**]

Admission Date: [**2142-4-2**] Discharge Date: [**2142-5-8**] Date of Birth: [**2099-7-23**] Sex: M Service: NEUROLOGY Allergies: Nifedipine Attending:[**First Name3 (LF) 2569**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: [**2142-4-4**] intubation suboccipital craniectomy and R venticulostomy - [**2142-4-6**] ventriculostomy - VP shunt- [**2142-4-16**] trach and PEG History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 2 minutes Time (and date) the patient was last known well: 12:30 on [**4-2**] NIH Stroke Scale Score: 10 t-[**MD Number(3) 6360**]: --- Yes Time t-PA was given ------:------ (24h clock) -X- No Reason t-PA was not given or considered: out of window I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score was 0: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 1 3. Visual fields: 0 4. Facial palsy: 2 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 2 7. Limb Ataxia: 0 8. Sensory: 2 9. Language: 0 10. Dysarthria: 2 11. Extinction and Neglect: 0 HPI: Mr. [**Known lastname 110219**] is a 42 yo Portuguese-speaking man with h/o DM2, HTN, HL who presents with L facial droop, R sided numbness, and slurred speech. History is somewhat limited due to language barrier and acute code stroke setting. The patient developed nausea/vomiting at 12:30 am today. Over the next several hours, he worsened, developing difficulty with balance and right sided numbness and weakness. At 4:00pm, wife noticed L facial droop. Patient was brought to [**Hospital 4199**] Hospital. NCHCT was interpreted as normal. [**Hospital1 2025**] neurology was consulted over the phone. NIHSS 8. Received IV labetalol 20 mg total, Zofran and ASA 325 mg. He was transferred to [**Hospital1 18**] without any thrombolysis (unclear if [**Name (NI) 2025**] on-call stroke line thought he was out of window). In [**Hospital1 18**], patient had NIHSS 9. BP was elevated at 254/125. He was started on nicardipine drip for BP control. According to patient's wife, he has been stable to slightly improving over past few hours. He was quite restless because he is bothered by the absence of sensation on his right side. He has no pain or headache. No nausea. No diplopia in primary gaze, and no vertigo. On limited ROS, no fever, cough, SOB, chest pain. Past Medical History: DM2 HTN HL Social History: married, no tobacco. Speaks Portuguese. Understands very limited English Family History: h/o CAD Physical Exam: ADMISSION EXAM Physical Exam: Vitals: T: afeb P:100 R: 16 BP:215/135 SaO2:96/ra General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Attentive and cooperative. Language is fluent with intact naming and comprehension. Speech was moderately dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: R pupil 6mm, L pupil 4mm, both briskly reactive both direct and consensual responses. VFF to confrontation with blink to threat. III, IV, VI: In primary gaze, L eye deviated inward. Complete L gaze palsy b/l. On R gaze there is horizontal nystagmus. Vertical gaze and convergence intact. V: Facial sensation intact to light touch. VII: Upper and lower facial musculature weakness. VIII: Hearing intact to voice grossly. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii. XII: Tongue protrudes in midline. -Motor: Normal bulk. Decreased tone in right side. R pronator drift present. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 3 4- 4- 4 4- -Sensory: Decreased light touch and pinch on right upper and lower extremities (now intact on face though previously right face numb). No extinction to DSS. -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 on left, extensor on right. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: deferred [**2142-5-1**] On transfer out of ICU: Spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L gaze palsy, R eye abducens weakness (R beating nystagmus when looking R). No blink to threat. No corneals. L upper/lower face weakness. +gag. +cough. LUE/LLE 4+ to 5/5 strength. RUE/RLE hemiplegia but R fingers/wrist/elbow extending/flexing now and R quad contracts (almost antigravity). Inconsistent with R side depending on exhaustion level. R toe up. DISCHARGE EXAM: Spontaneously awake, follows commands, shows thumbs-up for yes and shakes pointer finger for no. Pupils R 2.5->1.5, L 2->1.5. L gaze palsy, R eye abducens weakness (R beating nystagmus when looking R). L upper/lower face weakness. LUE/LLE 5/5 strength. RUE/RLE hemiplegia but R fingers/wrist/elbow extending/flexing now, can move R quad anti-gravity and dorsi/plantar flex foot with good strength. R toe upgoing. Pertinent Results: [**2142-4-2**] 07:15PM WBC-11.6* RBC-5.87 HGB-17.8 HCT-52.3* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.0 [**2142-4-2**] 07:15PM PLT COUNT-278 [**2142-4-2**] 07:15PM PT-9.8 PTT-26.9 INR(PT)-0.9 [**2142-4-2**] 07:15PM UREA N-16 [**2142-4-2**] 07:26PM GLUCOSE-353* NA+-141 K+-4.1 CL--100 TCO2-23 [**2142-4-2**] 08:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2142-4-2**] 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2142-4-2**] 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2142-4-2**] 10:58PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2142-4-2**] 10:58PM CK-MB-3 [**2142-4-2**] 10:58PM CK(CPK)-171 [**2142-4-2**] 10:58PM GLUCOSE-313* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [**2142-4-4**] 3:41 pm BRONCHOALVEOLAR LAVAGE LEFT LUNG. **FINAL REPORT [**2142-4-20**]** GRAM STAIN (Final [**2142-4-4**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [**2142-4-8**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110220**] FROM [**2142-4-4**]. FUNGAL CULTURE (Final [**2142-4-20**]): NO FUNGUS ISOLATED. [**2142-4-24**] 7:48 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2142-4-29**]** GRAM STAIN (Final [**2142-4-24**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2142-4-29**]): SPARSE GROWTH Commensal Respiratory Flora. GARDNERELLA VAGINALIS. MODERATE GROWTH. [**2142-4-24**] 10:01 pm Mini-BAL BRONCHIAL LAVAGE. **FINAL REPORT [**2142-4-27**]** GRAM STAIN (Final [**2142-4-24**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2142-4-27**]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. YEAST. 10,000-100,000 ORGANISMS/ML.. [**2142-4-25**] 2:16 pm Blood (Toxo) Source: Venipuncture. **FINAL REPORT [**2142-4-27**]** TOXOPLASMA IgG ANTIBODY (Final [**2142-4-27**]): POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 53 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [**2142-4-27**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with Toxoplasma once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [**2-16**] weeks. ECG [**4-2**] Normal sinus rhythm. Q waves in leads III and aVF consistent with prior inferior myocardial infarction. No previous tracing available for comparison. CTA Head/Neck [**4-2**] IMPRESSION: 1. Unremarkable head CT without evidence of infarct or hemorrhage. MRI is suggested if clinically warranted. 2. Hypoplastic right vertebral and small left vertebral arteries, likely developmental. Both vertebral arteries end as PICA with reconstitution of the right vertebral artery from the right superior cerebellar. [**4-3**] CXR IMPRESSION: 1. Unremarkable head CT without evidence of infarct or hemorrhage. MRI is suggested if clinically warranted. 2. Hypoplastic right vertebral and small left vertebral arteries, likely developmental. Both vertebral arteries end as PICA with reconstitution of the right vertebral artery from the right superior cerebellar. [**4-4**] CXR As compared to the previous radiograph, there is no relevant change. Minimal atelectasis at the right lung base. Borderline size of the cardiac silhouette. No pneumonia, no pulmonary edema. The nasogastric tube is in constant position. [**4-6**] MRI/A Brain FINDINGS: There is an acute infarct with hemorrhagic conversion identified in the left cerebellum in the region of posterior inferior and anterior inferior cerebellar arteries extending to the left side of the pons. There is mass effect on the fourth ventricle. There has been a craniectomy identified in the region for decompression. There is mild indentation of the lateral ventricles and there is presence of a right frontal approach ventricular drain with the tip in the region of left lateral ventricle. The temporal horns are mildly dilated indicating some degree of obstructive hydrocephalus. There is signal change within the anterior portion of corpus callosum related to the tract of the ventricular drain. The flow void of the distal left vertebral artery is not well visualized. On the MRA of the head no abnormalities are seen in the anterior circulation. Both vertebral arteries are not visualized beyond posterior arch of C1. Subtle flow signal is identified in the distal basilar artery but flow signal is not seen in the proximal basal artery nor the distal vertebral arteries. There are fluid levels within the left maxillary sinus which could be related to intubation. IMPRESSION: Postoperative changes for decompression secondary to hemorrhagic left cerebellar infarct. There remains mass effect on the fourth ventricle and some dilatation of the lateral ventricle. A ventricular drain is in position. Both vertebral arteries are not visualized distal to the posterior arch of C1 level. The proximal basal artery is not visualized as well. There abnormalities on the anterior circulation on MRA. [**4-7**] NCHCT IMPRESSION: 1. Known left cerebellar infarct with hemorrhage, with mass effect on the 4th ventricle and basal cisterns, stable in appearance since the earlier study of [**2142-4-6**]. 2. Stable positioning of the ventricular drain, coursing through the frontal [**Doctor Last Name 534**] of the left lateral ventricle, terminating at its lateral margin. Minimal interval increase in the ventricular size since [**2142-4-5**] CT study. [**4-8**] NCHCT IMPRESSION: 1. Interval repositioning of the right external ventricular drain with tip now projecting anterior to the frontal [**Doctor Last Name 534**] of the right lateral ventricle adjacent to the falx, outside the ventricular system. 2. Otherwise similar exam with left cerebellar infarct with hemorrhagic conversion, adjacent mass effect, and stable ventricular size. [**4-9**] NCHCT IMPRESSION: 1. Interval repositioning of right frontal external ventricular drain, now terminating in the left putamen or internal capsule. Ventricles have decreased in size since the prior exam. 2. Left cerebellar infarction with stable posterior fossa mass effect and hypodensity extending into the pons. [**4-10**] NCHCT IMPRESSION: 1. Significant interval decrease in size of left lateral ventricle is likely related to over shunting through the right frontal approach EVD, as there is no associated sulcal effacement or new edema. Correlate with catheter function and close f/u. Assessment of the position of the tip of the catheter is difficult due to the significant decompression of the ventricle- it is either outside the ventricular margin or within. Pl. review the images to decide on further management. 2. Left cerebellar infarct with stable posterior fossa mass effect and suboccipital craniectomy. [**4-13**] NCHCT IMPRESSION: 1. Right frontal approach EVD terminates in the left lateral ventricle. Left lateral ventricle has increased in size since the prior exam, with ventricles and sulci now similar in size and configuration to [**2142-4-2**]. 2. Status post suboccipital craniectomy with unchanged posterior low-density fluid collection. Left cerebellar infarction and pontine infarction are stable. Slight improvement in effacement of fourth ventricle. [**2142-4-15**] R Lower Ext - Doppler US: FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. There is normal compressibility, flow and augmentation. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. [**2142-4-16**] NCHCT IMPRESSION: 1. Repositioning of the EVD with the tip in the third ventricle. 2. Continued effacement of the fourth ventricle by mass effect in the left cerebellar hemisphere. Status post suboccipital craniectomy. [**2142-4-17**] Renal Son[**Name (NI) **]: RENAL SON[**Name (NI) **]: The right kidney measures 12.8 cm, and the left kidney measures 13.6 cm. There is no hydronephrosis, stones, or mass. Bladder is collapsed with a Foley in place. IMPRESSION: Normal renal son[**Name (NI) **]. [**2142-4-23**] TEE: Conclusions 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest x 4 injections (central line x 2; peripheral line x 2). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch (clip [**Clip Number (Radiology) **]) and the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetation, intracardiac mass/thrombus seen. No evidence for an atrial septal defect or patent foramen ovale by color flow Doppler or saline injection at rest. Simple thoracic atheroma. Brief Hospital Course: 42yo M with h/o DM2, HTN who presented with L lower face weakness, dysarthria, R sided sensory loss and hemiparesis, nausea/emesis, found to have L vertebral and proximal basilar artery occlusion resulting in L cerebellar / L pontine infarct. . [] Acute Ischemic Stroke, Vertebrobasilar Occlusion - The patient was found to have a clinical syndrome consistent with a brainstem stroke and was found on imaging to have stenosis of both vertebral arteries and the proximal basilar artery. He arrived at the hospital outside the window for intravenous tPA or intra-arterial therapies. He has two fetal PCAs coming from his anterior circulation which would preclude him from being able to have a mechanical thrombectomy. He was started on a Heparin infusion with goal PTT 60-80 to aid the dissolution of the thrombus. After hemorrhagic conversion was found on a repeat MRI, this was switched to Aspirin 81 mg daily. A TTE was performed which was unrevealing for thrombus, wall motion abnormalities, or intracardiac shunt, but the suspicion for venous hypercoagulability causing paradoxical embolism remained high given the history of a brother of similar age with bilateral lower extremity DVTs. Hypercoagulability labs (except for genetic studies) were obtained and were normal. A TEE was obtained that failed to show an intracardiac shunt and showed only aortic arch simple atheroma. The patient will have genetic hypercoagulability studies as an outpatient. . He was transferred to the stroke step-down unit on [**2142-5-1**] and remained stable. His exam has continued to improve, as he is more alert and following commands well. He has begun to use a Passy-Muir valve to speak and is tolerating this well. His right hemiparesis is also improving, and he is currently able to lift his R arm over his head, can extend his leg anti-gravity, and dorsi/plantarflex his foot. . [] Increased Intracranial Pressure - On [**2142-4-4**], he transiently developed worsening neurologic deficits including losing his corneal, cough and gag reflexes. A repeat NCHCT showed worsening infarction of the left cerebellum and compression of the fourth ventricle. He was taken to the OR by Neurosurgery for emergent decompression/occipital craniectomy and placement of a ventriculostomy. The ventriculostomy was revised/replaced twice for improved placement. Due to mildly elevated ICP and CSF drainage, this was converted to a ventriculoperitoneal shunt on [**2142-4-16**]. He had no complications and no further signs of increased ICP after the procedure. . [] Pulmonary Edema/Volume Overload - In the setting of receiving IVF, he became net positive in his fluid balance, tachypneic, and hypoxic. Furosemide did not sufficiently improve his respiratory status. He was also noted to have worsening leukocytosis and extensive secretions concerning for infection. He subsequently was electively intubated to provide further respirator support. He was unable to wean from the ventilator and failed an extubation trial. An endotracheal tube was placed on [**2142-4-20**]. He succeeded in tolerating the trach mask for 36-48 hours on [**2142-5-1**] and was subsequently transferred to the stroke step-down unit. His secretions have improved with a scopolamine patch. He continues to have intermittent tachypnea of unclear etiology without desaturation or any compromise of his respiratory status. . [] Pneumonia - He had recurrent fevers shortly after admission. Cultures were obtained and revealed MSSA in the sputum. He was treated with IV antibiotics for 10 days for this. He also had proprionobacterium acnes in the blood. Later he again began having fevers and increased sputum production. He underwent bronchoscopy again on [**2142-4-24**] and was treated with VAP protocol (Cefepime, Cipro, and Vanc) from [**Date range (1) 92895**], during which time his fever curve and sputum improved. He had transient low grade fevers to 99.8 axillary on [**5-3**]; repeat infectious work-up including UA/UCx/Blood cultures/CXR as well as LENI's was negative. He subsequently remeained afebrile with no signs of infection. . [] Diabetes - His HgbA1c was 11.9, and his blood sugars were initially difficult to control. He was placed on an insulin GTT and then transferred to long acting insulin. Blood sugars remained well-controlled on this regimen. . [] Hyperlipidemia - Initial LDL was 109. He was restarted on statin therapy and this improved to 59. He will continue on atorvastatin 20mg daily for his hyperlipidemia. . [] Nutrition - He was maintained on tube feeds. Due to the likelihood of an inability to swallow based on the area of his stroke, a gastrostomy was placed on [**2142-4-20**]. Our speech/swallow team continue to follow for progress. His phos has been running a little high; please check a chem-10 in the next week to re-evaluate. . . TRANSITIONAL CARE ISSUES: [ ] He will need intensive PT, OT, and speech therapy. [ ] Please check chem-10 at least once in next week to re-evaluate his bun/creatinine and phos. [ ] Hypercoagulability - Prothrombin and Factor V Leiden gene mutation tests should be obtained as an outpatient. [ ] He has a follow-up appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in our stroke clinic on [**2142-6-26**]. He also has an appointment to establish care with a new PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on [**2142-5-18**]. Medications on Admission: asa 81 atenolol 50 mg daily chlorthalidone 10 mg daily HCTZ 25 mg daily lisinopril 40 mg daily amlodipine 10 mg daily pravastatin 40 mg daily metformin 1000 mg daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. erythromycin 5 mg/gram (0.5 %) Ointment Sig: see instructions Ophthalmic QID (4 times a day): apply to both eyes QID. 12. labetalol 100 mg Tablet Sig: Five (5) Tablet PO Q6H (every 6 hours). 13. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35) unit Subcutaneous twice a day: 35u with breakfast and dinner. 14. insulin aspart 100 unit/mL Solution Sig: as instructed Subcutaneous ACHS: Give ACHS as per insulin sliding scale. 15. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 17. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day): Left eye. 18. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day). 19. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q 3 DAYS (): for increased secretions. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Left cerebellar/pontine stroke Occlusion of the left vertebral and basilar arteries Hypertension Hyperlipidemia Diabetes type II 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: Dear Mr. [**Known lastname 110219**], You were admitted to [**Hospital1 69**] on [**2142-4-2**] due to nausea/vomiting, right sided weakness, and a left facial droop. You were found to have a stroke in the left side of your cerebellum as well as part of your brainstem. This stroke likely resulted from a clot in your vertebral artery in your neck. This may be related to your high blood pressure, high cholesterol, and diabetes. You had tests to look at your heart as well as to look for any disorders of blood clotting and these were normal. You had tracheostomy and gastrostomy tubes placed while in the intensive care unit. You will need intensive physical therapy to help regain your strength. You were started on some new medications to better control your blood pressure and cholesterol. We made the following changes to your medications: Increased amlodipine to 20mg daily Started clonidine 0.3mg 3 times a day and labetalol 500mg 4 times a day to help control your bloood pressure Held atenolol 50mg daily and HCTZ 25mg daily Continued lisinopril 40mg daily Changed from pravastatin to atorvastatin 20mg daily to help control your cholesterol Changed from metformin to lantus 35mg twice a day in addition to insulin sliding scale injections to better control your diabetes If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: You have the following appointment scheduled with a new primary care physician at [**Hospital1 69**]: Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2142-5-18**] 2:15 You also have the following appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in stroke clinic: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2142-6-26**] 3:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Admission Date: [**2129-3-31**] Discharge Date: [**2129-4-13**] Service: Medicine ADMISSION DIAGNOSIS: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man with a history of fever, chills, shortness of breath x one week. The patient reports having shortness of breath for three to four months. He has also experienced recent night sweats and weight loss, approximately 15 pounds, cough and dyspnea on exertion. Over the past week the patient has reported fevers to 102 as well as shaking chills. In addition he reports mildly productive cough, yellow sputum, no blood, and worsening dyspnea on exertion. The patient has a history of tuberculosis exposure in his youth, however he reports being tested during his time in the navy. The patient also noted some slight decrease in appetite and increased obstipation over the past month, which was evaluated by colonoscopy. The patient was originally evaluated for shortness of breath by Dr. [**Last Name (STitle) 217**] in pulmonary clinic on [**2129-1-26**]. A CT at that time revealed honeycombing, ground glass opacification, septal line thickening, traction, bronchiectasis and bronchiolectasis in predominantly mid lungs and distribution to a lesser extent in the upper lung zone and with relative sparing of the lower lung zone. Pulmonary function tests at the time also represented a slightly restrictive pattern with an FVC of 83%, an FEV of 105% and a FVC/FEV ratio of 1:27% with a DL/VA of 67% predicted. At that time a biopsy to evaluate this interstitial lung disease was broached and the patient declined at that time. The patient notes that this last episode of shortness of breath was more acute in nature over the last week with general malaise the day prior to admission and the family asked him to present for evaluation. PHYSICAL EXAMINATION: Vital signs showed a temperature of 100.6, heart rate 86, blood pressure 146/74, respiratory rate 18, 93% on three liters. General: African-American male lying in bed in no acute distress. HEENT: Anicteric sclerae, pupils were equal, round, and reactive to light, extraocular movements intact, nasopharynx clear. Neck: Soft, supple with no jugular venous distension, no cervical lymphadenopathy. Heart: Regular rate and rhythm, split S2. Lungs: Crackles at the bases bilaterally. Abdomen: Soft, nontender, nondistended. Extremities: No cyanosis or edema. Neurologic: Alert and oriented x 3. Cranial nerves two through 12 were intact. Strength was grossly intact. He had symmetric reflexes intact and symmetric. PAST MEDICAL HISTORY: 1. High cholesterol. 2. Status post appendectomy. 3. Pulmonary disease under evaluation, room air saturations resting 95%, on room air 91% with ambulation. 4. History of bifascicular block with occasional ventricular ectopy. 6. Pulmonary function tests in [**12-31**] showed a restrictive pattern. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Aspirin. SOCIAL HISTORY: The patient is retired, he worked in the navy for many years. He uses social alcohol. He has a son in [**Name (NI) 86**]. The patient lives in [**Location 7188**], RI and worked for 21 years as an environmental specialist in the navy in pest control, wore a mask, no birds at home, smoked two packs per day x 55 years, he quit four months ago. FAMILY HISTORY: His father is deceased of coronary artery disease. His mother is deceased of unknown cause, with diabetes. LABORATORY DATA: White blood cell count 8.4, hematocrit 37.5, platelet count 337, MCV 84, neutrophils 73, lymphocytes 19, monocytes 6. Sodium 137, potassium 4.2, chloride 110, BUN 26, ALT 58, AST 68, alkaline phosphatase 86, LDH 410, total bilirubin 0.2, albumin 3.3. Blood cultures were negative. Urine cultures were negative. EKG was normal sinus rhythm at 80 beats per minute, normal axis, normal intervals. Right bundle branch block with nonspecific ST changes, no T wave inversions, unchanged from [**2128-12-3**]. Chest x-ray showed a complex interstitial opacities bilaterally with worsening in the right upper lobe. HOSPITAL COURSE: 1. Pulmonary: The patient represents with acute on chronic shortness of breath. Previous CT was notable for interstitial lung pattern. In house a repeat chest CT was obtained which showed a segmental pulmonary embolism to the posterior basal segment of the left lower lobe, progression of interstitial lung disease particularly in the right lobe with interval development of numerous cytologic and large hilar lymph nodes, new adenopathy nonspecific, and extensive coronary artery calcifications. Given the patient's evidence of a PE the patient was initially started on CT. Pulmonary was consulted and a biopsy was planned. However three days into the admission the patient experienced some additional increasing O2 requirements as well as demonstration of a troponin leak. On [**2129-4-4**] a repeat CT was obtained. The repeat CT on [**4-4**] showed pulmonary embolism in the left lower lobe had decreased in size but interval progression of interstitial lung disease particularly in the upper lobes with hilar adenopathy. The patient was placed on levofloxacin, vancomycin, Bactrim and a BAL was performed. The cell count was predominantly polys with a Gram stain negative. CT surgery was also consulted and biopsy was not indicated at this time. As a result, the patient was empirically placed on prednisone, Solu-Medrol 30 mg IV q. 8 and prednisone 60 mg p.o. q.d. the patient's respiratory status improved with the Solu-Medrol and the patient was transferred back to the floor on [**2129-4-7**]. The patient will be discharged on his prednisone dose. The patient was placed initially on Bactrim prophylaxis given prednisone use, however the patient developed slightly elevated liver function tests and given this result the Bactrim was discontinued. The patient was also provided with supplemental vitamin D and calcium given prednisone use. The patient will be monitored as an outpatient by Dr. [**Last Name (STitle) 217**], his pulmonologist. Of note the patient's interstitial lung disease could be due to a variety of ideologies given its pattern as well as its both fibrotic and cystic components. The hilar adenopathy suggested a possible sarcoidosis picture. However the dense interstitial fibrotic as well as the cystic component suggested chronic interstitial pneumonitis. The patient has risk factors for multiple exposures given his previous occupational history. Biopsy will be needed to further evaluate the etiology of his interstitial lung disease. 2. Infectious disease: The patient came in with a low-grade temperature with a picture of worsening right upper lobe interstitial lung disease as well as shaking chills. The patient was initially ruled out for tuberculosis with sputum and a negative PPD was placed. The patient was started on levofloxacin for the possibility of pneumonia noted on CT. Blood cultures were subsequently negative. BAL was performed and it was nondiagnostic. Of note, Legionella was negative. When the patient was first admitted he did have several nights of evening fevers. These fevers resolved with the initiation of prednisone. The patient was afebrile prior to discharge. 3. Cardiac: The patient had a history of right bundle branch block, with risk factor of high cholesterol and smoking history. On [**4-3**] the patient experienced a troponin leak in the setting of increased shortness of breath and pleuritic chest pain. Cardiology was consulted and they felt that troponin would likely be a result of strain rather than acute myocardial infarction. In addition, the patient was placed on heparin for PE at that time. It was suggested that we follow and the patient's CKs and troponins subsequently declined. An echocardiogram obtained at the time showed an ejection fraction of greater than 60%, TASP of greater than 42 mmHg with a conclusion of overall left ventricular systolic function normal with a right ventricular cavity dilated; right ventricular systolic function appeared depressed with normal septal motion, mild MR [**First Name (Titles) 151**] [**Last Name (Titles) 39707**] tricuspid valve with no effusion. This in comparison to his last report of [**2129-1-25**] showed his right ventricular free wall motion was now depressed. 4. Liver: The patient had a slight bump in his liver function tests prior to his discharge with an ALT of 256. As a result a right upper quadrant was obtained prior to is discharge to evaluate for acute causes. A hepatitis panel was performed in house and was negative. This should be followed up as an outpatient. 5. Hematology: With a history of anemia, anemia work-up was nonrevealing. The patient was transitioned from heparin to Coumadin for PE. The patient was discharged with a therapeutic INR between 2 and 3. The patient will need outpatient Coumadin monitoring. 6. Endocrine: The patient had a history of prednisone use in house. His glucose was controlled with sliding scale. The patient will be discharged to rehabilitation on sliding scale and should be transitioned to oral [**Doctor Last Name 360**]. 7. Code status: Full. The patient was evaluated by physical therapy in house to plan for discharge to rehabilitation center. 8. GI: The patient was placed on proton pump inhibitor in house given steroid use. DISCHARGE STATUS: To rehabilitation. DISCHARGE MEDICATIONS: 1. Calcium carbonate 500 mg p.o. t.i.d. 2. Vitamin D 400 units p.o. q.d. 3. Warfarin 3 mg p.o. h.s. 4. Prednisone 50 mg p.o. q.d. 5. Senna 1 tablet p.o. b.i.d. 6. Bisacodyl 10 mg p.o./p.r. q.d. 7. Insulin sliding scale. 8. Enteric-coated aspirin 81 mg p.o. q.d. 9. Sublingual nitroglycerin 0.3 mg p.r.n. 10. Pantoprazole 40 mg p.o. q.d. 11. Docusate sodium 100 mg p.o. q.d. 12. Multivitamins 1 p.o. q.d. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Interstitial lung disease, PE. 2. Pneumonia. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 45699**] Dictated By:[**Last Name (NamePattern1) 201**] MEDQUIST36 D: [**2129-4-13**] 11:17 T: [**2129-4-13**] 11:57 JOB#: [**Job Number 46711**]

Admission Date: [**2160-5-14**] Discharge Date: [**2160-5-26**] Date of Birth: [**2160-5-14**] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 54667**] was born at 31 and 3/7 weeks gestation to a 23 year-old gravida 6 para 3 now 4 woman. The mother's prenatal screens are blood type A positive, antibody negative, Rubella unknown, RPR nonreactive, hepatitis surface antigen negative, group B strep unknown. This pregnancy was complicated by a history of intrauterine growth restriction, chronic maternal hypertension and history of oligohydramnios. The mother received a complete course of betamethasone prior to delivery. She did have a fever of 100.1 on the day of delivery and a decreasing amniotic fluid volume index. These are the reasons for a cesarean section. The infant emerged vigorous. Apgars were 8 at one minute and 8 at five minutes. ADMISSION PHYSICAL EXAMINATION: Active alert preterm infant. Anterior fontanel open and flat, positive bilateral red reflex, palate intact, mild to moderate subcostal retractions and grunting, diminished breath sounds bilaterally. Heart was regular rate and rhythm. Present femoral pulses. Three vessel umbilical cord. No hepatosplenomegaly. Normal preterm female genitalia, patent anus, intact spine, stable hip examination and tone and reflexes appropriate for gestational age and a small bruise on her lower lip. Her birth weight was 1450 grams. Her birth length was 38 cm and her birth head circumference was 29 cm. NEONATAL INTENSIVE CARE UNIT COURSE: 1. Respiratory status: She required nasopharyngeal continuous positive airway pressure from the time of admission until day of life number five at which time she transitioned to room air where she has remained. On examination her respirations are comfortable, lung sounds are clear and equal. She was started on caffeine citrate on day of life number three for apnea of prematurity. She has 0 to 2 episodes of apnea in each 24 hour period. 2. Cardiovascular status: She has remained normotensive throughout her Neonatal Intensive Care Unit stay. Her heart has a regular rate and rhythm. No murmur. There are no cardiovascular issues. 3. Fluid, electrolyte and nutrition status: Her weight at the time of transfer is 1375 grams, length is 40 cm and her head circumference is 27 cm. Enteral feeds were begun on day of life number one and advanced without difficulty to full volume feeding by day of life number seven. At the time of transfer she is feeding breast milk 26 calories per ounce all by gavage. Her total fluids are 150 cc per kilogram per day. Her last electrolytes on [**2160-5-17**] were sodium 141, potassium 4.3, chloride 107, and bicarbonate of 22. 4. Gastrointestinal status: She was treated with phototherapy for hyperbilirubinemia of prematurity from day of life number one until day of life number seven. Her peak bilirubin on day of life number one was total 7.1, direct 0.3. Her last bilirubin level on [**2160-5-24**] was total 5.4, direct 0.2. 5. Hematology: She has never received any blood product transfusions during her Neonatal Intensive Care Unit stay. Her hematocrit on [**2160-5-16**] was 45.5. She did have some initial thrombocytopenia felt to be due to her mother's chronic hypertension. Her platelets at the time of admission were 114,000. The nadir of those on [**2160-5-16**] were 112,000 and a repeat on [**2160-5-20**] was 139,000. 6. Infectious disease status: [**Known lastname **] was started on Ampicillin and Gentamicin at the time of admission for sepsis risk factors. Her antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures were negative. 7. Neurology: She had a head ultrasound on [**2160-5-21**] that was completely within normal limits. 8. Sensory: Audiology, hearing screen is recommended prior to discharge. Ophthalmology, the eyes have not yet been examined and she is due for her first examination at three weeks of age. 9. Psycho/social: The parents have been very involved in the infant's care throughout her Neonatal Intensive Care Unit stay. DISCHARGE CONDITION: The infant is discharged in good condition. DISCHARGE STATUS: The infant is discharged to [**Hospital 1474**] Hospital level two nursery for continued care. PRIMARY PEDIATRIC CARE: To be provided by [**Hospital 1475**] Pediatrics. RECOMMENDATIONS AFTER DISCHARGE: Feedings, total fluids of 150 cc per kilogram per day, 26 calorie per ounce expressed breast milk made with 4 calories per ounce of human milk fortifier, 2 calories per ounce of medium chain triglyceride oil and ProMod [**2-15**] teaspoon per 100 cc of breast milk or 90 cc of formula. MEDICATIONS: 1. Caffeine citrate 10 mg by gavage daily. 2. Supplemental iron of 2 mg per kilogram per day, which would be 0.1 cc po daily. 3. Vitamin E 5 international units pg daily. She has not yet had a car seat position screening test. This is recommended by the time of discharge. A state newborn screen was sent on [**2160-5-18**]. She has not yet received any immunizations. Recommended immunizations, Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria, one born at less then 32 weeks, two born between 32 and 35 weeks with two of the following; day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school aged siblings or with chronic lung disease. Influenza immunizations is 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), immunizations against influenza is recommended for household contact and out of home caregivers. DISCHARGE DIAGNOSES: 1. Prematurity at 31 and 3/7 weeks gestation. 2. Status post intrauterine growth restriction. 3. Status post respiratory distress syndrome. 4. Sepsis ruled out. 5. Resolving thrombocytopenia. 6. Apnea of prematurity. 7. Status post hyperbilirubinemia of prematurity. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2160-5-26**] 08:43 T: [**2160-5-26**] 08:56 JOB#: [**Job Number 54668**]

Admission Date: [**2160-5-4**] Discharge Date: [**2160-5-21**] Date of Birth: [**2108-8-25**] Sex: F Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 30**] Chief Complaint: hypoxia, seizure Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: 51 y/o F with h/o Hep C, COPD, and sz disorder presents from home w/ hypoxia and ?seizure. Recent MICU admit [**Date range (2) 98617**] with respiratory failure requiring intubation and subsequent tracheostomy attributed to ARDS (suspected viral etiology). She was treated w/ broad spectrum antibiotics and steroids. Course c/b VAP due to Klebsiella and Serratia ([**Last Name (un) 36**] meropenem; res cephalosporins), coag (-) staph line infection (s/p vanco X 14 days). Pt was discharged to rehab [**2160-4-7**]; trach removed and pt d/c home [**2160-4-25**]. She initially went to in-laws with husband for 4-5 hours, the three of whom were recently diagnosed with bronchitis. She then went to stay with her sister and mother for 1 week were she received VNA services. On [**2160-5-2**], she went to her home with her husband, who she had not been exposed to in 1 week. On [**5-3**], she c/o being tired. On day of admission, [**5-4**]. per family, pt awoke feeling "[**Last Name (un) 98618**]" and short of breath. Because she felt like she was going to have a seizure, she presented to OSH, where she was noted to be hypoxic 84% RA -> 90s on 100% NRB. An x-ray shwed bilateral infiltrates, and she received levofloxacin 500 mg IV X 1 and was transferred to [**Hospital1 18**] for further management. In [**Name (NI) **] pt 96% 100% NRB, sbp 80s-90s. She was initially conversant, however then she had episodes where her eyes rolled up in her head, and she began posturing her upper extremities. Each episode lasted 10-15 seconds, occurring every 1-2 minutes for a total of 20 minutes. She received 2 mg IV Ativan for suspected seizure, after which she was somnolent. Neuro was consulted, who was concerned for status epilepticus and pt received 20 mg/kg IV Fosphenytoin. Further history/ROS could not be obtained [**3-5**] patient's mental status. . She had a course in the MICU which was complicated by failed extubation on [**5-5**] and [**5-13**]. and had bronchoscopy which on microbiology but not pathology showed viral cytopathic changes, possibly c/w CMV pneumoitis, but no immunostains had been done. She has had a history in the past of klebsiella and serratia VAP (pan-sensitive) and one [**2-6**] Klebs blood cx which was ESBL, but on this admission has not had any positive cultures for blood, sputum, BAL, CSF, urine, c diff tox, flu, or legionella. TTE has shown diastolic dysfunction with EF 60% and 1+ MR and mild-mod pulmonary artery HTN. BB have been controlling her rate well. . She has been on moerately high doses of benzodiazepines for sedation. and on prednisone for stress dosing, and has been weaning off of both. She also recently had her NGT removed and with a (+) gag reflex was started on a nectar thick diet until video swallow assessment could be made. In the meantime, her glargine has been held due to low oral intake. . Her subclavian and arterial lines have been removed and she is maintained by peripheral iv's. Past Medical History: 1) COPD 2) Hepatitis C 3) Seizure disorder 4) Depression 5) Recent admission w/ ARDS c/b VAP and line infection (see above) 6) Percutaneous tracheostomy ([**2160-3-11**]) 7) EGD with PEG placement ([**2160-3-11**]) Social History: + Tob, 1.5 ppy X many years, no EtOH, lives with husband though recently stayed with mother and sister after rehab, has a 25yo son Physical Exam: ADMISSION PHYSICAL EXAM: PE: Tc 99.7 (rectal), pc 94, bpc 91/53, resp 16, 100% NRB Gen: middle-aged female, initially somnelent, not responsive to sternal rub, then opens eyes and answers simple questions (oriented only to self), follows simple commands HEENT: PERRL, EOMI, anicteric, pale conjunctiva, OMM slightly dry, OP clear, neck supple, no LAD, no JVD Cardiac: RRR, II/VI SM at RUSB, no R/G Pulm: crackles at bases bilaterally. Occasional upper-airway ronchi Abd: NABS, soft, NT/ND, no masses Ext: 1+ pedal edema Neuro: PERRL, EOMI, face symmetrical, (+) gag, moves all 4 extremities in response to painful stimuli. 2+ DTR [**Name (NI) **] bilaterally, 3+ DTR LE bilaterally. Pertinent Results: [**2160-5-4**] 12:55PM PT-14.6* PTT-33.2 INR(PT)-1.3 [**2160-5-4**] 12:55PM PLT COUNT-175 [**2160-5-4**] 12:55PM HYPOCHROM-3+ POIKILOCY-1+ [**2160-5-4**] 12:55PM NEUTS-82.1* LYMPHS-13.8* MONOS-3.8 EOS-0.2 BASOS-0.2 [**2160-5-4**] 12:55PM WBC-25.9*# RBC-3.59* HGB-9.6* HCT-31.4* MCV-88 MCH-26.8*# MCHC-30.6* RDW-14.0 [**2160-5-4**] 12:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2160-5-4**] 12:55PM TSH-0.75 [**2160-5-4**] 12:55PM VIT B12-780 FOLATE-7.0 [**2160-5-4**] 12:55PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.6 [**2160-5-4**] 12:55PM CK-MB-9 cTropnT-0.05* proBNP-585* [**2160-5-4**] 12:55PM LIPASE-11 [**2160-5-4**] 12:55PM ALT(SGPT)-50* AST(SGOT)-77* CK(CPK)-225* ALK PHOS-100 AMYLASE-21 TOT BILI-0.3 [**2160-5-4**] 12:55PM GLUCOSE-127* UREA N-11 CREAT-0.4 SODIUM-142 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-32* ANION GAP-8 [**2160-5-4**] 01:02PM LACTATE-1.4 [**2160-5-4**] 01:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2160-5-4**] 01:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2160-5-4**] 01:27PM URINE GR HOLD-HOLD [**2160-5-4**] 01:27PM URINE HOURS-RANDOM [**2160-5-4**] 02:40PM TYPE-ART PO2-139* PCO2-76* PH-7.24* TOTAL CO2-34* BASE XS-2 [**2160-5-4**] 02:10PM AMMONIA-83* [**2160-5-4**] 04:10PM PO2-80* PCO2-80* PH-7.22* TOTAL CO2-34* BASE XS-1 [**2160-5-4**] 04:10PM LACTATE-1.0 [**2160-5-4**] 04:10PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2160-5-4**] 04:30PM PHENYTOIN-24.1* [**2160-5-4**] 09:05PM TYPE-ART TEMP-37.2 PO2-172* PCO2-60* PH-7.29* TOTAL CO2-30 BASE XS-1 INTUBATED-INTUBATED [**2160-5-4**] 10:00PM CORTISOL-13.2 [**2160-5-4**] 10:00PM CALCIUM-8.1* PHOSPHATE-2.3* MAGNESIUM-1.4* [**2160-5-4**] 10:00PM CK-MB-6 cTropnT-0.04* [**2160-5-4**] 10:00PM GLUCOSE-115* UREA N-10 CREAT-0.3* SODIUM-142 POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-31* ANION GAP-7* [**2160-5-4**] 10:35PM CORTISOL-16.1 [**2160-5-4**] 11:05PM CORTISOL-16.5 Brief Hospital Course: NOTE: THE PATIENT WAS DISCHARGED AGAINST MEDICAL ADVICE. PLEASE SEE THE SECTION "DISPOSITION" FOR THE RELEVANT DETAILS. THE HOSPITAL COURSE UP TO THIS POINT IS SUMMARIZED FIRST: A/P: 51 yoF w/ h/o COPD, seizure disorder recent admit w/ ARDS presents w/ leukocytosis, hypoxia, and episodes concerning for seizure. Intubated with ARDS of unclear etiology, failed extubation x2 ([**5-5**] and [**5-13**]) with hypoxic resp failure of unclear etiology. * 1) Hypoxic/Hypercarbic respiratory failure and ARDS: Unclear cause. All cultures were negative, including blood, sputum, BAL, CSF, urine, c dif, flu, legionella. Intubated in ED with ABG of 7.26/76/139. On nebs, flovent. Pt was covered for 1 week with meropenum, azithro, vanco until [**5-10**] (pt has h/o klebsiella/serretia VAP and ESBL Klebs bacteremia). Second attempt at extubation was attempted [**5-13**], and the patient did well initially, but then acutely desaturated and was reintubated. Aspiration vs. flash pulm edema were considered as factors complicating extubation. . Pt was beta-blocked and a Swan-Ganz catheter was in place before the third extubation attempt on [**5-16**] in order to diagnose and manage acute manifestations of heart failure upon extubation. BAL microbiology but not pathology showed cytopathic changes but viral and bacterial cultures as well as CMV immunology were negative. . 2) Seizure: Pt has a h/o seizure disorder, the precipitant of which may be proximate to inadequate treatment on a single [**Doctor Last Name 360**] (dilantin) in the setting of fever and hypoxia. Head CT and urine tox were neg. An EEG showed diffuse encephalopathy without status epilepticus. Additional history obtained from outpt neurologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 98619**] showed that the pt presented to [**Location (un) 5871**] Regional with generalized tonic-clonic seizure on [**4-30**] with Dilantin level of 22, started on Zonegran because she failed a single [**Doctor Last Name 360**], and was discharged on HD#2 with normal mental status. At the [**Hospital1 18**], she required successive reloading of Dilantin [**5-14**]-20, before the patient left against medical advice. Despite leaving against medical advise before a therapeutic serum level of dilantin could be achieved, the patient was nevertheless scheduled with her primary care physician for dilantin dose adjustment. She was also scheduled in seizure clinic at the [**Hospital1 18**] for follow-up of her seizure disorder. Zonegran was increased to 300mg qd (on [**4-26**]) after 2 weeks of 200mg. * 3) Leukocytosis and Fever: Pulmonary source was initially suspected (ddx: HAP, aspiration pneumonia/pneumonitis) given the patient's hypoxia and bilateral infiltrates. U/A negative, BCx NGTD, CSF neg, BAL and sputum neg. C Dif neg x 4. Empiric oral vanco d/c'd [**5-8**]. Covered w/ meropenem/azithro empirically to cover HAP/aspiration pneumonia x 1 week until [**5-10**]. Spiked on [**5-14**] to 101 and re-cultured without any growth in culture. * 4) Sepsis/Hypotension/Adrenal Insufficiency: Pt was initially on levophed, weaned off after fluid resusitation. Minor troponin leak to 0.05. EF by ECHO [**5-6**] 60% with 1+MR. Pt was on steroids for ARDS during last recent admission, and was started on hydrocortixone for a positive cortisol stim test, which showed adrenal insufficiency with a maximal cortisol of 16-17. Her hypotension did resolve with stress-dose steroids in a few days. She has been on a prednisone taper, receiving 7.5 mg on [**5-19**], and due to receive 5 mg on [**5-20**]. Because of the adrenal insufficiency documented by absolute value as well as a relative value, the patient was scheduled for follow-up in endocrinology clinic within 1 month from discharge. She was discharged on prednisone 10mg until this appointment. * 5) Pulm Edema: EF 60%. Pt with pulm edema on [**5-5**] after extubation resulting in reintubation. [**Month (only) 116**] have been due to post-negative pressure pulm edema or flashing due to possible diastolic dysfunction. Diuresed but again showed signs of CHF after fluid resusitation. Swan placed [**5-7**] with mixed picture before diuresis. Decreased SVR and high CI supported a septic physiology, but a high CVP supportive of CHF. Pt developed upper and lower extremity edema that started to resolve with gradual diruesis. She has been euvolemic on exam for over 4 days preceding discharge. * 5) Anemia of Chronic Disease: The paient's baseline 26-28 from prior admission. Vit B12 and folate WNL. Transfused 2 Units [**5-8**] but otherwise has not required any blood products. Hct remained stable and >28 without additional transfusions. . 6) Thrombocytopenia: HIT negative, LFTs unchanged. Platelets improved with improvement of acute illness. * 7) Borderline Type II DM: HBA1C = 6.0. Pt was temporarily on an insulin drip while on TPN and hydrocortisone, transitioned to insulin glargine with sliding scale, but since the patient had poor oral intake, she had glargine held x 5 days and did not require dosing in the hospital. The patient was instructed to hold any additional insulin and covered with RISS until 1 day prior to admission when the patient's glood sugar. She began taking better oral intake before discharge. * 8) NSVT: Documented on evening of [**2160-5-11**]. Multiple 3-4 beat runs over a minute with sinus beats in between. Likely due to concurrent medical illness, resolveing The etiology was not clear. Electrolytes were normal. Pt was asymptomatic without further events. * 9) Diastolic dysfunction: EF 60% with 1+ MR, mild-mod pulmonary artery HTN. BB has been controlling her rate well. * 10)Hepatitis C: mild transaminitis, not significantly changed from prior admission * 11)Depression: Will restart prozac [**2160-5-20**]. 12)F/E/N: Tube feeds by nasogastric tube started [**5-6**]. -Once the NG tube was removed, the pt was noted to have a (+) gag reflex and was advanced to nectar thickened diet until video swallowing study could confirm that she could safely swallow. The patient was seen on the video study to have aspiration with thin liquids. She nevertheless refused to maintain a diet of thickened liquids, despite numerous conversations informing her that this diet may only be for a limited time until her swallow improved and informing her of the risks of swallowing thin liquids such as recurrent aspiration, pneumonia, intubation, or death. - electrolytes monitored and repleted as needed * 13)Ppx: Heparin SQ, pneumoboots, IV Lansoprazole. * 14)Access: Left Subclavian and right a-line d/c'd after patient transferred to the medical floor from the ICU. Afterwards, the patient was maintained with PIVs. * 15)Code: FULL CODE, confirmed by sister. * 16)Comm: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 9973**] [**Telephone/Fax (1) 98620**] (home), [**Telephone/Fax (1) 98621**] (his mother's home where he is staying), Sister [**Name (NI) 2048**] [**Name (NI) **] [**Telephone/Fax (1) 98622**] (home), [**Telephone/Fax (1) 98623**] (work). . 17)Dispo: The patient was seen by PT who, along with the medical and nursing staff, felt that the patient was not safe for independent discharge because of weakness, imbalance, and because of low dilantin level which would require further loading with dilantin. The patient refused discharge to rehabilitation, stating that she had spent too much time already in the hospital and rehabilitation hospital. Multiple conversations informed her of the risks of aspiration, seizure, fall, head injury, and death, but the patient nevertheless demanded to sign out of the hospital against medical advice and left in this manner despite recruiting the patient's husband and daughter to convince the patient. Mrs. [**Known lastname 9485**] was discharge against medical advice on [**2160-5-21**], and refused to wait until services could be set up for the patient, noting that she would set them up herself. Medications on Admission: Prozac 20 [**Hospital1 **] Oxybutynin Patch Monday and Thursday Protonix 40 qd Dilantin 450 qd Combivent two puffs qid Albuterol 1 prn Tylenol prn an anti-epileptic started recently starting with "Z", ?Zonergan Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q2H PRN (). Disp:*1 inhaler* Refills:*2* 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. Disp:*25 nebulizer treatment* Refills:*0* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours). Disp:*50 nebulizer treatment* Refills:*2* 6. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache. Disp:*50 Tablet(s)* Refills:*0* 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Because you left the hospital AMA, you are not yet at the correct blood level of this medication. You should be mointored on it. Disp:*90 Capsule(s)* Refills:*2* 11. 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* 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: You should not stop this medication until you are tested in the endocrine clinic. Disp:*30 Tablet(s)* Refills:*2* 13. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 14. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Recurrent Respiratory Failure. 2. Seizure. 3. Hospital Acquired Pneumonia. 4. Diastolic Heart Failure. 5. Adrenal Insufficiency. 6. Non-Sustained Ventricular Tachycardia. 7. Non-Immune Mediated Thrombocytopenia. 8. Diarrhea NOS. 9. Aspiration with thin liquids Secondary/Past Medical History: 1. COPD. 2. Hepatitis C. 3. Seizure Disorder. 4. Adult Respiratory Distress Syndrome. 5. Ventilator Associated Pneumonia. 6. Coagulase Negative Line Sepsis. 7. Diabetes Mellitis Type II. 8. Percutaneous Gastrostomy Tube. Discharge Condition: Fair. Discharge Instructions: Patient is leaving against medical advice. We have explained to her in detail our recommendations for inpatient rehabilitation, but she refuses. We have also made clear that she is at increased risk for morbidity, rehospitalization, or mortality. She was lucid and understood the implications of her decision. INSTRUCTIONS TO PATIENT: Continue taking prednisone for adrenal insufficiency until instructed otherwise by your physician. [**Name10 (NameIs) **] loperamide for diarrhea. Follow-up on Friday (the next available appointment) with Dr. [**First Name (STitle) **] for adjustment of your seizure medicine--because you left the hospital early against medical advice, you have not reach the correct blood levels of the medicine and are at risk for seizure because you cannot be appropriately monitored and have your medications appropriately adjusted. Followup Instructions: You must see your physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on FRIDAY at 12:45pm, the next available appointment, to have your dilantin level checked. It is low and you are at risk of seizure by leaving the hospital with a low level despite increasing the dose. Additionally, you have been made a follow-up in neurology clinic on Friday [**6-13**] at 9am for an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] of the Neurology Department Seizure Division. You need to call [**Telephone/Fax (1) 876**] to give your registration information. Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 32084**] Date/Time:[**2160-6-13**] 9:00 Finally, please follow-up in endocrine clinic to determine whether you have adrenal insufficiency. Do not stop taking prednisone until you are instructed otherwise. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 44382**] [**Name (STitle) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2160-5-27**] 10:00

Admission Date: [**2144-9-9**] Discharge Date: [**2144-9-16**] Date of Birth: [**2089-9-20**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male with known coronary artery disease who was admitted to [**Hospital6 2910**] on [**2144-9-9**], for elective cardiac catheterization. Past medical history is significant for coronary artery disease status post percutaneous transluminal coronary angioplasty with stent of the left anterior descending coronary artery in [**2138**]. Upon arrival to the [**Hospital6 2910**], the patient reported constant four out of ten chest pain with radiation to his jaw since the previous evening, [**2144-9-8**]. He received morphine prior to catheterization. Catheterization demonstrated a tight LAD lesion, 70% proximal, 90% mid LAD, resulting in an inability to see his previous LAD stent. The patient continued to have chest pain status post catheterization with no electrocardiogram changes evident. Left ventriculogram during catheterization showed normal size and good contraction of all wall segments. He was started on a nitroglycerin intravenous drip at 80 mcg/minute, Aggrastat and heparin. This resulted in a decrease in his chest pain to one to two out of ten in severity. Labs drawn at [**Hospital6 14475**] showed a hematocrit of 39.0, creatinine kinase of 126, troponin 0.06. The patient was transferred to [**Hospital1 69**] for therapeutic catheterization. Upon arrival vital signs were 97.8, blood pressure 140 to 160 over 90 to 100, heart rate in the 60's with normal sinus rhythm, oxygen saturation 98 to 100% on two liters nasal cannula oxygen. Prior to catheterization at [**Hospital1 69**], patient received fentanyl 25 mcg for his discomfort and Versed. Therapeutic catheterization at [**Hospital1 190**] showed left main coronary artery disease with mid ostial disease, left anterior descending with 60% ostial lesion, moderate 50% mid disease prior to stent, 95% tight focal lesion in old stent prior to first major diagonal branch. A Cypher stent was deployed in the proximal/middle LAD. Status post catheterization, the patient had serosanguinous blood discharge and ooze from around sheaths upon arrival to the floor. Tunnel sheaths were pulled with systolic blood pressures in the range of 140's to 150's. Cardiac fellow applied pressure. The patient complained of recurrent pain so additional doses of morphine were given. At this time then his right groin developed a large hematoma. Subsequently, nitroglycerin and Aggrastat were discontinued. Intravenous fluids were started with aggressive fluid hydration. Stat hematocrit value was drawn with a value of 34.9. The patient's hematoma continued to expand and he continued to complain of pain. As the hematoma and groin continued to ooze bloody discharge, a vascular groin C-clamp was applied. The patient was transferred to the Coronary Care Unit for further hemodynamic monitoring. Upon arrival to the CCU, he complained of severe pain, greater than ten out of ten in severity. Upon arrival he then received another 10 mg of morphine, 1 mg of Versed, 50 mcg of fentanyl and Phenergan 25 mg IV. PAST MEDICAL HISTORY: 1. Coronary artery disease status post percutaneous transluminal coronary angioplasty and stent to left anterior descending artery in [**2138**]. 2. Hypothyroidism. 3. Hypertension. 4. Chronic back pain status post multiple surgeries (times eight). 5. Non-Hodgkin's lymphoma status post chemotherapy and radiation therapy. 6. Prostate cancer status post radical prostatectomy. 7. Status post cholecystectomy. 8. Nephrolithiasis. 9. Status post right salivary gland removal. ALLERGIES: Patient with no known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o. q. day. 2. Levoxyl 25 mcg p.o. q. day. 3. Catapres patch q. week. 4. Accupril 40 mg p.o. q. day. 5. Lasix 80 mg p.o. b.i.d. 6. Plavix 75 mg p.o. q. day. 7. Wellbutrin SR 150 mg p.o. b.i.d. 8. Zoloft 150 mg p.o. q. day. 9. Potassium chloride 20 mEq p.o. q. day. 10. Nitroglycerin sublingual 0.4 mg p.r.n. chest pain. 11. Ditropan XL 10 mg p.o. q. day. 12. Salagen 5 mg p.o. t.i.d. 13. DDAVP 2 mcg p.o. q. day. 14. Lipitor 10 mg p.o. q. day. 15. Neurontin 300 mg p.o. q.i.d. 16. Folic acid 400 mcg p.o. q. day. PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.0, blood pressure 106/60, respiratory rate 15, heart rate 77, oxygen saturation 99% on three liters nasal cannula. General appearance: Well-developed, obese male, lying flat, lethargic, no apparent distress. HEENT: Normocephalic, atraumatic. Neck: Supple, no masses or lymphadenopathy. No jugular venous distention. Lungs: Clear to auscultation bilaterally. No rhonchi, rales, wheezes. Cardiovascular: Regular rate and rhythm. S1, S2 heart sounds auscultated. No murmurs, rubs or gallops. Abdomen: Soft, mildly tender diffusely, non-distended. Decreased bowel sounds. Groin: Right femoral area with large tense hematoma, markedly expanding, very tender to palpation. Extremities: Cool, 2+ dorsalis pedis pulses bilaterally, 1+ posterior tibial pulses bilaterally. No clubbing, cyanosis or edema. PERTINENT LABORATORIES, X-RAYS AND OTHER STUDIES: Laboratories drawn on the morning of [**2144-9-9**] at [**Hospital6 11896**] showed sodium 132, potassium 3.1, chloride 96, bicarbonate 26, BUN 14, creatinine 0.9, glucose 114, calcium 7.7, magnesium 2.0, creatinine kinase 126, troponin 0.06. The latest coagulation profile from [**2144-9-2**] showed PT 9.9, PTT 26, INR 1.0. The latest hematocrit value from [**2144-8-12**] was 39.0. ELECTROCARDIOGRAM: Dipyridamole EKG ([**2144-8-25**]): Normal sinus rhythm, left atrial enlargement, incomplete right bundle branch block, left anterior hemiblock but inconclusive dipyridamole exercise EKG. No chest pain or diagnostic ST segment changes to heart rate of 101. CARDIOLITE STRESS TEST ([**2144-8-25**]): Normal left ventricular size and function. Ejection fraction 58%. Anterior wall thinning consistent with prior non-transmural myocardial infarction. Inferior basal wall ischemia. ELECTROCARDIOGRAM [**2144-9-9**] AT [**Hospital6 **]: Showed normal sinus rhythm at 60 beats per minute. Left axis deviation. Borderline PR interval. Right bundle branch block. Left anterior fascicular block. Poor R-wave progression. Poor voltage in limb leads. CORONARY CATHETERIZATION ([**2144-9-9**]): Demonstrated selective left-sided coronary angiography in this left dominant circulation demonstrated one vessel coronary artery disease. The left main coronary artery had a 30% ostial lesion. The left anterior descending had serial lesions, with a tubular 60% proximal, 50% mid prior to the old stent, mild in-stent re-stenosis leading into a 95% lesion at the distal end of the stent. The left circumflex had mild luminal irregularity and gave off an OM1 with moderate diffuse disease. The right coronary artery was not engaged. Successful stenting of the main left anterior descending was performed with a 3.5 x 18 mm Cypher (drug alluding stent). ECHOCARDIOGRAM ([**2144-9-10**]): Left ventricular ejection fraction 60%. The left atrium is normal in size. Left ventricular cavity size and systolic function are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (three) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is no 2-D echocardiographic findings of tamponade, but a complete Doppler assessment was not possible. ARTERIAL DOPPLERS OF THE RIGHT LOWER EXTREMITY ([**2144-9-10**]). Duplex evaluation performed of the right lower extremity arterial and venous systems with concentration on the inguinal region. Impression was that of a large right groin hematoma. There was no evidence of obvious pseudo-aneurysm or arteriovenous fistula. REPEAT RIGHT VASCULAR ULTRASOUND OF THE LOWER EXTREMITY ([**2144-9-4**]): Again, there was a large right femoral hematoma which demonstrates heterogeneous echotexture. The right common femoral artery and vein are patent demonstrating normal vascular flow. There is no evidence of pseudo-aneurysm or arteriovenous fistula formation. BRIEF SUMMARY OF HOSPITAL COURSE: 1. Coronary artery disease: Patient with known history of coronary artery disease status post coronary catheterization times two on [**2144-9-9**], status post stent placement in the proximal/mid left anterior descending artery. Plan was made to continue aspirin, Plavix, Lipitor and folate. It was unclear originally why the patient was not on a beta blocker. Therefore, once his blood pressure was able to tolerate additional antihypertensives, a low dose beta blocker was added to his medication regimen. We started him on metoprolol, titrating up the dose to desired effect. Initially many of the patient's antihypertensive medications including Catapres and Accupril were held secondary to the questionable hemodynamic instability resulting from his right groin hematoma and blood loss anemia. After stabilization of his intravascular volume status post multiple transfusions, and several days of monitoring, the patient was restarted on metoprolol and captopril. After several days of monitoring, the patient continued to be hypertensive with blood pressures ranging 160 to 180 over 90's to 100. Therefore the doses of the captopril and metoprolol were titrated up. The captopril was switched to longer acting lisinopril. At the time of discharge the patient's blood pressure was controlled on metoprolol 100 b.i.d., lisinopril 40 q. day and hydrochlorothiazide 25 q. day. The patient continued to be monitored on telemetry with no evidence of acute conduction abnormalities. After the complaint of chest pain on the first day of admission with no demonstrable electrocardiographic changes, the patient remained chest pain free for the remainder of this admission. 2. Right groin hematoma resulting in blood loss anemia: Vascular Surgery consultation was obtained status post coronary catheterization and development of large right groin hematoma. Vascular Surgery recommended a lower extremity ultrasound with results as above, namely, ultrasound demonstrated a large right groin hematoma, no evidence of pseudo-aneurysm or arteriovenous fistula formation. In the Coronary Care Unit, serial hematocrits were obtained, patient's blood pressure and hemodynamics were checked serially and peripheral pulse checks were done q. one hour. Due to anemia secondary to blood loss, the patient required multiple blood transfusions for stabilization of his blood volume and maintenance of hematocrit greater than 30. All told he received five units of blood. Initially also he was kept on bed rest with Foley catheter in place and his right leg immobilized. His pain was treated with morphine, fentanyl and Versed initially. After several days it was switched over to Vicodin as the patient uses Vicodin at home for control of his lower back pain. Repeat ultrasound was obtained on [**2144-9-4**], with no evidence of hematoma expansion, no evidence of pseudo-aneurysm or arteriovenous fistula formation. Upon discharge, the patient's hematoma size was stabilized. Serial hematocrits had been stable above 33 to 36 for several days. As the patient's hematoma resolved within a prolonged period of immobilization, it was felt that discharge to a rehabilitation facility where he could work on functional mobility and increasing gait and balance was warranted. CONDITION AT DISCHARGE: Fair. Right groin hematoma size stable. Hematocrit stabilized. Unable to demonstrate full pre-hospital functionality, so discharge to rehab. DISCHARGE STATUS: Patient discharge to extended care facility, rehab program. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Blood loss anemia. 3. Status post cardiac catheterization with stent. 4. Right groin hematoma. 5. Unstable angina. 6. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. 3. Folic acid 400 mcg p.o. q. day. 4. Lipitor 10 mg p.o. q. day. 5. Levoxyl 25 mcg p.o. q. day. 6. Sertraline 50 mg three tablets p.o. q. day. 7. Pantoprazole 40 mg p.o. q. day. 8. Salagen 5 mg one tablet p.o. t.i.d. 9. Oxybutynin 10 mg p.o. q. day. 10. Colace 100 mg p.o. b.i.d. 11. Senna one tablet p.o. b.i.d. as needed for constipation. 12. Dulcolax 5 mg two tablets p.o. q. day as needed for constipation. 13. Zolpidem 5 mg one to two tablets p.o. q. hs. p.r.n. insomnia. 14. Neurontin 300 mg one p.o. q.i.d. 15. Tramadol 50 mg one tablet p.o. q. 4-6h. as needed for pain. 16. Hydrocodone/acetaminophen 5/500 mg one to two tablets p.o. q. 4h. as needed for pain, not to exceed eight tablets daily. 17. Milk of magnesia 30 cc q. 6h. as needed for dyspepsia. 18. Metoprolol 100 mg one p.o. b.i.d. 19. Wellbutrin 150 mg two tablets p.o. q. a.m. 20. Lisinopril 20 mg two tablets p.o. q. day. 21. Hydrochlorothiazide 25 mg one p.o. q. day. 22. Augmentin 500/125 mg one tablet p.o. b.i.d., continue for nine days for a total of a ten day course. 23. Potassium chloride 20 mEq one tablet p.o. q. day. FOLLOW-UP PLANS: Patient is being discharged to a rehabilitation program for gait, stair, transfer training with goal of increased functional mobility. He is instructed to please follow up with Dr. [**Last Name (STitle) 2912**] one to two weeks after discharge from the rehabilitation program. He can call [**Telephone/Fax (1) 25832**] for an appointment and was given this information. Additionally, he was told to call Dr.[**Name (NI) 5452**] for a follow-up appointment at [**Telephone/Fax (1) 2394**] within the following two to three weeks. The patient was instructed that we have changed several of his pre-hospital medications, particularly those controlling his blood pressure. He was instructed to discard his Catapres patch, Lasix and Accupril prescriptions. He was instructed that we have added metoprolol, lisinopril and hydrochlorothiazide to his blood pressure regimen. He is instructed to take them as directed. Additionally, he was instructed that he must take daily aspirin and Plavix for the next nine months. He was instructed that if he misses any doses, the risk of his coronary stents occluding dramatically increases. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Last Name (NamePattern1) 257**] MEDQUIST36 D: [**2144-9-15**] 20:42 T: [**2144-9-15**] 20:39 JOB#: [**Job Number 27867**] cc:[**Last Name (NamePattern4) 27868**]

Admission Date: [**2132-9-6**] Discharge Date: [**2132-9-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4891**] Chief Complaint: hypoxia, mental status changes Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 2866**] is a [**Age over 90 **]-year-old man with a history of Parkinson's disease, dementia, hypertension, and recent aspiration pneumonia who presents with altered mental status and is admitted to the [**Hospital Unit Name 153**] with hypoxic respiratory failure. She was recently admitted in [**2132-6-26**] for delirium and gradually worsening mental status and was found to have aspiration PNA and treated with antibiotics. This admission was notable for a speech and swallow evaluation concluding in the recommendation for aspiration precautions, and a discussion about goals of care with his daughter and subsequent change in his code status to DNI/DNR. He was discharged to rehab and then transferred to [**Hospital1 **] nursing home for long term care. He was doing well until the day prior to admission when his daughter noted that he was less oriented than usual (he is A/0 to person and sometimes place or time at baseline) and having a productive cough with difficulty managing his oral secreations. He was transferred to the ED for further evaluation. ROS is notably negative for fevers, nausea, vomiting, diarrhea, dysuria, and rash. EMS reports he was 92%ra. In the ED, initial VS: 99.2 74 126/107 24 98%NRB. He was tachypneic to the 40s with copious oral secretions. O2 sats fell to the high 80s and he was put on a NRB with improvement in his hypoxia. He was given 500cc NS initially because it was felt she was dry, and then lasix 10iv x 1 because of concern for volume overload. She also received morphine for dyspnea. CXR showed mew LLL infiltrate and resolution of prior RLL pneumonia and she was treated with vanc/levoflox. He also had a negative head CT. He was initially admitted to the ICU for stabilization. Past Medical History: 1. Parkinson's disease 2. Memory loss 3. Urinary incontinence 4. Hypertension 5. Hearing impairment 6. Depression 7. Anemia 8. Chronic kidney disease 9. Colon cancer s/p resection 10. Cholecystectomy [**32**]. Pacemaker 12. Leg injury in World War II 13. Amblyopia, left eye, due to childhood injury Social History: Pt born in NY, has one daughter who lives in [**Name (NI) 7349**]. Wife has AD and lives in [**Hospital1 **] of [**Location (un) 55**]. He is an artist who owned an industrial cleaning company. Until recently, he had been living at CCB with 45 hours/week of private assistance. No tobacco use. No current etoh use. Family History: Non-Contributory Physical Exam: ON ADMISSION: 99.2 74 126/107 24 98%NRB General: agitated HEENT: Sclera anicteric, mucous membranes dry Neck: supple, JVP elevated Lungs: rales on left > right CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present Ext: warm, trace lower extremity edema Psych: not able to answer questions; responded to verbal stimuli Pertinent Results: [**2132-9-6**] 08:20PM BLOOD WBC-16.0*# RBC-3.48* Hgb-10.6* Hct-32.2* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.7 Plt Ct-284 [**2132-9-7**] 04:26AM BLOOD WBC-16.4* RBC-3.09* Hgb-9.2* Hct-28.8* MCV-93 MCH-29.8 MCHC-32.0 RDW-13.2 Plt Ct-235 [**2132-9-6**] 08:30PM BLOOD Glucose-113* UreaN-41* Creat-1.6* Na-147* K-5.2* Cl-111* HCO3-26 AnGap-15 IMAGING: [**9-6**] CXR: Left basilar opacity concerning for infection with small left pleural effusion. Prominent hila bilaterally. [**9-6**] CXR: There has been little change compared to the prior study. Again noted is a left basilar airspace opacity concerning for infection. Small left pleural effusion persists. There is a patchy opacity as well on the right lung base which could represent an atelectasis. Both hila remain prominent, and underlying lymphadenopathy may be present. The cardiac and mediastinal contours are unchanged. Pulmonary vascularity is not engorged. Hemithorax. Left-sided dual-chamber pacemaker leads terminating in right atrium and right ventricle are again noted. [**9-7**] CT Head w/o Contrast: Essentially unchanged study from [**2132-7-6**]. No acute intracranial process. Similar global atrophy, particularly bifrontal, and unchanged cystic encephalomalacia in the left cerebellar hemisphere. Brief Hospital Course: Mr. [**Known lastname 2866**] is a [**Age over 90 **]yo male w a history of Parkinson's disease, dementia, hypertension, and recent aspiration pneumonia who presents with altered mental status and is admitted to the [**Hospital Unit Name 153**] with hypoxia and tachypnea. # Pulmonary Process: Patient with recent admission for PNA in [**Month (only) 205**], admitted with elevated WCC, AMS, CXR with new L basilar opacity concerning for infection with small left pleural effusion. At this time it was believed this was secondary to a recurrent aspiration pneumonia, however heart failure, PE and atelectasis were also considered within the differential. A urine legionella antigen was negative. He was started on vancomycin, levofloxacin and cefepime to cover for hospital and community acquired PNA, but then switched to vancomycin, cipro and cefepime for better pseudomonal coverage. Given the concern for aspiration, he was ordered for a speech and swallow evaluation, who has evaluated him previously for a similar condition. Once he was stabilized, he was transitioned to the medicine HMED service, and he was gradually transitioned to PO antibiotics with cipro and flagyl to avoid the need for a PICC line. # Dysphagia: Attributed to his underlying parkinson's and dementia. Appears stable, per speech and swallow evaluation. A ground diet with thin liquids was recommended., with aspiration precautions, with special consideration made for the days that his mental status is poor, to consider reassessing before offering him food. Per discussions with his daughter/HCP [**Name (NI) **], the decision was made for him to eat for comfort and not pursue invasive measures related to the dysphagia. # Acute kidney injury: On admission the patient's creatinine was elevated to 1.6 from a baseline of 0.9. This was believed to be secondary to hypovolemic hypoperfusion. In the ED, the patient had received both a fluid bolus and a one-time dose of IV lasix 10mg. On arrival in the [**Hospital Unit Name 153**], the patient received an additional fluid bolus. His serum Cr stabilized at 1.5 and this may be a new baseline. He did not appear intravascularly contracted or overloaded at the time of discharge. # Goals of care: Extensive discussion with his HCP/daughter, including a geriatrics inpatient consult, was helpful in clarifying the patient's goals of care. The daughter expressed interest in discussing goals of care and potential transition to inpatient hospice in the near future. We discussed avoiding IV antibiotics, as they would require a PICC line that he might find uncomfortable, but did choose to have him remain on PO antibiotics at this time. His prognosis due to the recurrent aspirations is poor, and his daughter understands that the point may arise when she no longer wishes for him to be readmitted to the hospital. She will discuss the goals of care further with Dr [**Last Name (STitle) **], at [**Hospital1 **]. Dr [**Last Name (STitle) **] was updated by the writer on the day prior to discharge. Medications on Admission: Doxazosin 1mg PO qhs Omeprazole 20mg qd MVI PO qd ASA 81mg PO qd Amlodipine 5mg PO qd Carbidopa-Levodopa 25-100 PO qid Cholecalciferol Vitamin D3 400unit PO qd Calcium carbonate 500mg [**Hospital1 **] Cyanocobalamin 100mcg PO qd Sertraline 25mg PO qd Folic acid 1mg PO qd DuoNeb nebulizer INH tid prn Aricept 10mg PO qd Namdena 5mg PO qd Discharge Medications: 1. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-29**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for Constipation. 12. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation three times a day as needed for shortness of breath or wheezing. 13. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Please continue this to complete aspiration pneumonia course, through [**2132-9-13**]. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days: Please continue for aspiration pneumonia until [**2132-9-13**]. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Aspiration pneumonia Dementia/Parkinson's disease Discharge Condition: Discharge condition: stable Mental status: alert and oriented at times, to person. Not oriented to place or date. Conversation is usually tangiential, delirious at times but not agitated. Ambulatory status: with assistance, patient able to ambulate. Discharge Instructions: Mr [**Known lastname 2866**], It was a pleasure to take care of you during your admission. You were treated for aspiration pneumonia, and your cough improved. We spoke to your daughter during your time here and updated her daily. We are talking to your daughter about controlling your symptoms and considering hospice, and we have spoken to Dr [**Last Name (STitle) **] about this, but we have not yet started this plan. We will be discharging you on PO antibiotics, with a foley catheter due to hematuria (or blood in your urine). Followup Instructions: Dr [**Last Name (STitle) **] was updated today [**9-10**] about the discussions and plans for your care. She will resume caring for you when you return to [**Hospital1 **]. We held sertraline, namenda and aricept while he was in the hospital. We restarted sertraline on [**9-10**]. The namenda and aricept can be restarted once his delirium improves to some degree.

Admission Date: [**2183-11-19**] Discharge Date: [**2183-11-26**] Date of Birth: [**2102-8-19**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / Codeine / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: left main coronary artery disease Major Surgical or Invasive Procedure: Coronary artery bypass grafts x2 (LIMA-LAD,SVG-OM) [**2183-11-21**] History of Present Illness: This 81 year old white female was visiting her sister at a nursing home when she developed 5/10 chest pain. Staff there called 911 and she was transferred to the ER at an outside hospital. She relates a similar episode last week with pain lasting 5-10 minutes. Catheterization there demonstrated a 90% left main lesion and she was transferred for surgery. Past Medical History: coronary artery disease hypertension hyperlipidemia peripheral vascular disease gastroesophageal reflux Social History: Lives with: her sister but she is currently in nursing home Tobacco: no-quit many years ago ETOH: one drink every few nights Family History: father died at 61 of a stroke. Sister has congestive heart failure Physical Exam: admission: Temp: 99 Pulse:98 Resp: 18 O2 sat: 98&-RA B/P Right: 165/63 Left: Height: 62 in Weight: 128 Lbs/ 58 Kg General: NAD Skin: Dry [x] intact [n]dry skin with superficial dermatitis LT ankle HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Gr. 3/6 SEM base to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm x[], well-perfused [x] Edema Varicosities: s/p B vv stripping- faint scars B upper thighs Neuro: Grossly intact Pulses: Femoral Right: Left:P DP Right: Dop Left: Dop PT [**Name (NI) 167**]: Dop Left: Dop Radial Right: Left: Carotid Bruit Right:trans Murmur Left:trans murmur Pertinent Results: [**2183-11-24**] 05:45AM BLOOD WBC-9.3 RBC-3.60* Hgb-10.3* Hct-30.6* MCV-85 MCH-28.6 MCHC-33.7 RDW-15.5 Plt Ct-186 [**2183-11-25**] 05:40AM BLOOD UreaN-21* Creat-0.8 K-4.2 [**2183-11-24**] 05:45AM BLOOD Glucose-103 UreaN-18 Creat-1.0 Na-137 K-4.4 Cl-103 HCO3-27 AnGap-11 Brief Hospital Course: Following transfer she remained pain free and was begun on a Heparin infusion. On [**11-21**] she was taken to the Operating Room where revascularization was performed. See operative note for details. She tolerated the operation well and weaned from bypass on neosynephrine and propofol in stable condition. She was weaned from pressors and extubated without difficulty. CTs were removed on POD 1 and pacing wires on day 3. Beta blockade was resumed and she was diuresed towards her preoperative weight. She transferred to the floor and was seen by Physical Therapy for mobility and strength. Wounds were healing well at discharge. Restrictions, medications and follow up were discussed with her. A rehabilitation facility was utilized at discharge to further allow her recovery before returning home. Medications on Admission: Simvastatin 20mg/D, Norvasc 5mg/D, Aldactone 25mg [**Hospital1 **], Celexa 20mg/D, Ambien 10mg/D Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 4 weeks. 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 4 weeks. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 8. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: Maples Nursing & Retirement Center - [**Location (un) 6151**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts hypertension hyperlipidemia peripheral vascular disease gastroesophageal reflex Discharge Condition: good Discharge Instructions: Call if any redness of, or drainage from incisions. Report any fever greater then 100.5. Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. No lotions, creams or powders to incision. Shower daily, pat the wounds dry. No baths or swimming for 1 month. No lifting greater then 10 pounds for 10 weeks from date of surgery. No driving for 1 month or while taking narcotics for pain. Call with any questions or concerns. Take all medications as directed. Followup Instructions: Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 13350**]in [**3-18**] weeks. Dr. [**Last Name (STitle) 8579**] in [**3-18**] weeks. please call for appointments [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks Completed by:[**2183-11-26**]

Admission Date: [**2152-10-23**] Discharge Date: [**2152-10-28**] Date of Birth: [**2106-5-30**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male without significant past medical history admitted to [**Hospital 1474**] Hospital on [**2152-10-22**] with new onset chest pain. There he had recurrent pain with electrocardiogram changes and hypotension. He was transferred to [**Hospital1 69**] in the am of [**2152-10-23**] for cardiac catheterization which revealed critical left main and three vessel disease. Intra-aortic balloon pump was placed for anatomy and ongoing pain. The Cardiothoracic Surgery team was consulted for emergent revascularization. PAST MEDICAL HISTORY: Hypercholesterolemia. MEDICATIONS: None at home. ALLERGIES: No known drug allergies. HOSPITAL COURSE: Following transfer from [**Hospital 1474**] Hospital, the patient underwent cardiac catheterization on [**2152-10-23**] which revealed 80% hazy proximal stenosis of the LMCA and total occlusion of the left circumflex proximally. The left anterior descending artery and right coronary artery had minimal luminal irregularities. During the procedure, the patient developed 6/10 chest pain and Cardiothoracic Surgery team was contact[**Name (NI) **] for urgent surgical revascularization. The patient became pain free following placement of an intra-aortic balloon pump as well as IV Fentanyl and high-flow oxygen. Patient was taken to the operating room on the same day, and had a two vessel coronary artery bypass graft with a left internal mammary being grafted to the left anterior descending artery and saphenous vein graft to the OM. The patient was thereafter transferred to the SICU for continued management. The patient's intra-aortic balloon pump was discontinued on postoperative day #1. Patient had labile blood pressures and required Neo-Synephrine until postoperative day #2. Patient also received two units of packed red blood cells for a hematocrit of 22. Patient was transferred to the Cardiothoracic Surgery floor on postoperative day #3. Patient had an uneventful recovery on the Cardiothoracic Surgery floor. Physical therapy was initiated, and by the time of discharge, the patient had achieved level five activity with physical therapy. Patient's pain was well controlled on Percocet. Patient remained in normal sinus rhythm. The patient was on a nicotine patch for heavy tobacco use prior to admission. The patient was deemed stable for discharge on postoperative day #5. The patient's blood glucose was noted to be as high as 240 one time in the unit, and the patient may need outpatient evaluation for diabetes. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po bid. 2. Potassium 20 mEq po bid. 3. Colace 100 mg po bid. 4. Enteric coated aspirin 325 mg po q day. 5. Metoprolol 75 mg po bid. 6. Percocet 1-2 tablets po q4-6h prn for pain. 7. Motrin 400 mg po q6-8h prn. FOLLOWUP: Patient is to followup with Dr. [**Last Name (STitle) 70**] six weeks following discharge. The patient is to followup with primary care physician 2-4 weeks following discharge. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2152-10-29**] 13:31 T: [**2152-11-1**] 07:53 JOB#: [**Job Number 35287**]

Admission Date: [**2175-9-7**] Discharge Date: [**2175-9-16**] Date of Birth: [**2154-9-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2108**] Chief Complaint: preeclampsia Major Surgical or Invasive Procedure: intubation History of Present Illness: 20 yo F G1P0 at 26 weeks acute onset SOB, tachycardia, hypertension (191/115), periorbital edema transferred from [**Hospital6 39405**] for management of preeclampsia. Given VS derangment and dyspnea, she had a STAT ECHO there which showed a normal EF. She rec'd 10mg IV labetalol which brought her BP to 170/100s. Upon arrival here she had a CTA which showed large bilateral pleural effusions with bibasilar atlectesis, but no pulmonary embolism. She was also found to have very low TSH 0.02 and endocrine was consulted for hyperthyroidism. She was started on Magnesium drip. She was brought for emergent C-section at 5am this morning. In OR she received a total of 90mg esmolol, 5mg metoprolol, 200mcg Fentanyl, 15mg IV morphine. CS was done under general anesthesia - she rec;d - no epidural. +orthopnea. 800cc EBL. 20units pitocin. There was brief uterine atony intraop. Endocrine consulted - do not feel that this is [**Hospital6 **] storm, recommend treatment with b-blocker and methimazole. Past Medical History: - None (no hx of [**Hospital6 **] disease) - wisdom tooth extraction [**9-1**] Social History: - Tobacco: None - etOH: None - Illicits: reported ecstacy prior to pregnancy Family History: non contributory Physical Exam: GEN: NAD VS: AF HR 100 BP 130/90 (up to SBP 200 transiently) 100% on 100% fiO2 HEENT: PERRL, ET tube in place with some bloody oral secretions, no OP lesions, no cervical LAD. Mild periorbital edema CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, mildly distended, lower abd incision dressing c/d/i LIMBS: 1+ LE edema to knee SKIN: No rashes or skin breakdown NEURO: paralyzed, sedated - does not respond to voice Pertinent Results: Cardiac MR [**Last Name (Titles) 87107**]: 1. Mildly increased left ventricular cavity size with moderately increased LVvolume, mildly increased LV mass, and global left ventricular hypokinesis. TheLVEF was moderately decreased at 39%. The effective forward LVEF was severelydecreased at 33%. 2. No CMR evidence of focal myocardial edema, inflammation or scarring/infarction. 3. Mildly increased right ventricular cavity size. The RVEF was mildly decreased at 48%. 4. Moderate mitral and tricuspid regurgitation. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 6. Mild biatrial enlargement. 7. Normal coronary artery origins. 8. Small pericardial effusion. 9. Bilateral pleural effusions and pulmonary consolidations, which are better appreciated on chest CT from [**2175-9-11**]. [**9-12**] CTA CHest IMPRESSION: 1. No evidence of pulmonary embolism. 2. Worsening alveolar pulmonary edema. 3. New bronchopneumonia is likely [**2175-9-15**] 07:20AM BLOOD WBC-9.5 RBC-4.90 Hgb-12.3 Hct-36.5 MCV-74* MCH-25.1* MCHC-33.8 RDW-16.7* Plt Ct-413 [**2175-9-7**] 01:01AM BLOOD WBC-11.9* RBC-5.18 Hgb-11.5* Hct-35.4* MCV-68* MCH-22.1* MCHC-32.3 RDW-15.9* Plt Ct-209 [**2175-9-12**] 04:32AM BLOOD Neuts-69.7 Lymphs-21.0 Monos-5.8 Eos-3.2 Baso-0.3 [**2175-9-12**] 04:32AM BLOOD PT-11.6 PTT-31.5 INR(PT)-1.0 [**2175-9-15**] 07:20AM BLOOD Glucose-79 UreaN-16 Creat-0.4 Na-138 K-4.5 Cl-104 HCO3-24 AnGap-15 [**2175-9-7**] 01:01AM BLOOD Glucose-99 UreaN-9 Creat-0.4 Na-141 K-3.6 Cl-109* HCO3-18* AnGap-18 [**2175-9-14**] 02:53AM BLOOD ALT-22 AST-22 LD(LDH)-194 AlkPhos-85 [**2175-9-11**] 09:10AM BLOOD cTropnT-<0.01 proBNP-1325* [**2175-9-12**] 04:32AM BLOOD CK-MB-1 cTropnT-<0.01 [**2175-9-15**] 07:20AM BLOOD Albumin-3.5 Calcium-9.4 Phos-4.7* Mg-1.8 [**2175-9-14**] 02:00PM BLOOD calTIBC-369 Ferritn-77 TRF-284 [**2175-9-14**] 02:53AM BLOOD TSH-<0.02* [**2175-9-13**] 05:55AM BLOOD TSH-<0.02* [**2175-9-12**] 04:32AM BLOOD TSH-<0.02* [**2175-9-9**] 04:40AM BLOOD TSH-<0.02* [**2175-9-7**] 07:35AM BLOOD TSH-0.033* [**2175-9-7**] 01:01AM BLOOD TSH-<0.02* [**2175-9-15**] 07:20AM BLOOD T4-8.8 calcTBG-1.14 TUptake-0.88 T4Index-7.7 [**2175-9-7**] 07:35AM BLOOD T4-18.9* T3-363* calcTBG-0.66* TUptake-1.52* T4Index-28.7* Free T4-3.9* [**2175-9-7**] 07:35AM BLOOD Anti-Tg-LESS THAN antiTPO-LESS THAN Brief Hospital Course: 20 yo F presented with severe preeclampsia at 26 weeks, transferred from [**Hospital3 2568**], taken for stat s/p C-section, found to have thyrotoxicosis and cardiomyopathy. Respiratory failure due to cardiomyopathy: Intubated prior to her C-section with general anesthesia. Found to have bilateral pleural effusions; TTE showed an of EF 45% and new MR/TR. This is indicative of peripartum cardiomyopathy. Optimal treatment with neurohormonal blockade was initiated with beta blockers and ACE inhibitors. She was able to tolerate lisinopril 40mg daily and labetalol 600mg po tid. She was diuresed with IV lasix (20mg IV bid) and upon discharge she was transitioned to 20mg po daily. She was euvolemic upon discharge. On the day prior to discharge she underwent a repeat echocardiogram, EF was 50% and there was 1+ MR. She was advised to avoid further pregnancy at least until her ejection fraction returns to normal. She was set up for follow up with Dr. [**First Name (STitle) 449**] Change from the Advanced Heart Failure Clinic at [**Hospital1 18**]. Severe Preeclampsia: With hypertension and significant proteinuria. Treated with stat C section and 24 hours of magnesium drip. She was followed by maternal fetal medicine throughout her hospitalization. Thyrotoxicosis: likely [**Doctor Last Name 933**] disease with exopthalmos, tremor, tachycardia, cardiomyopathy. She was started on methimazole which was titrated down to 20mg po daily. The patient will follow up with Dr. [**Last Name (STitle) **] on [**9-25**]. Post-op Cesarian delivery: Stable with average post-op bleeding and vaginal bleeding. She was given rectal misoprostol to help stop her bleeding. Her Hct remained stable. Her baby girl was admitted to the NICU upon delivery and was doing well at the time of her mother's discharge. Medications on Admission: Prenatal vitamins Discharge Medications: 1. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Methimazole 10 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: please weigh yourself every day, call your physician if you gain or lose 3 pounds. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Severe preeclampsia THyrotoxicosis due to [**Doctor Last Name 933**] disease Peripartum cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with severe preecclampsia, thyrotoxicosis and cardiomyopathy. Your baby was delivered by emergency [**Name (NI) **]. You were seen by the endocrine doctors for your [**Name5 (PTitle) **] and the cardiologists for your heart. It is very important for you to continue to take all the medications we have prescribed and to keep your follow up appointments. ** If you develop any signs of illness -- fever, sore throat, etc -- STOP your Methimazole, call Dr [**Last Name (STitle) **], and come in for a CBC (blood test). If it is the weekend -- go to the emergency room. Followup Instructions: ** If you develop any signs of illness -- fever, sore throat, etc -- STOP your Methimazole, call Dr [**Last Name (STitle) **], and come in for a CBC (blood test). If it is the weekend -- go to the emergency room. Name:[**Doctor First Name 177**] [**Last Name (NamePattern4) 87108**],MD Specialty: Primary Care When: Thursday, [**9-28**] at 10:30am Location: [**Hospital3 **] MEDICAL ASSOCIATES Address: [**Hospital3 **], [**Location (un) 87109**],[**Numeric Identifier 40498**] Phone: [**Telephone/Fax (1) 87110**] Department: CARDIAC SERVICES When: MONDAY [**2175-10-9**] at 11:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are working on a follow up appt in the Endocrine department in the next week. You will be called at home with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 1803**].

Admission Date: [**2154-8-30**] Discharge Date: [**2154-9-1**] Date of Birth: [**2081-12-11**] Sex: F Service: MEDICINE Allergies: Optiray 320 Attending:[**First Name3 (LF) 2290**] Chief Complaint: Post-operative hypoxia Major Surgical or Invasive Procedure: Debridement of tracheal nodule with interventional pulmonology History of Present Illness: 72 yo F with poorly differentiated squamous cell carcinoma of the lung who underwent rigid bronch [**2154-8-30**] (Friday) in the CDC for debridement of a nodule partially occluding the trachea (CT 09/[**2153**]). Patient was apneic post-operatively attributed to paralytics, for which she was intubated and placed on AC until the paralytic wore off. She was then weaned to CPAP and extubated to high flow facemask without difficulty. She was later switched to high flow face tent and then nasal canula 4L->2L and was comfortable sating 92%. On the floor, the patient was comfortable on 2L nasal cannula, sating 94%. Complains of coughing when taking deep breaths, but otherwise stable. She denies CP, N/V/D/C, dysuria, HA, vision changes, or depressed mood. Past Medical History: Poorly differentiated SCC of lung: - s/p right upper lobectomy and chemotherapy [**2148**] - left lower lobe nodule 1.4cm, non-diagnostic CT-guided biopsy, s/p CyberKnife CAD s/p Coronary angioplasty [**2139**], [**2151**], CABG x 3v [**2151**] H/o Infectious colitis [**2152**] HTN IDDM Hypercholesterolemia Bladder surgery [**2123**] Hernia repair [**2147**], S/p Cholecystectomy [**2147**] Social History: Former smoker, 80 pack year history. No EtOH or drugs. Married. Family History: Father with lung/bone cancer, mother relatively healthy until later yrs. Physical Exam: VS: 97.9 96.9 102/60 20 96%2LNC GEN: Pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM RESP: Wheezing throughout with Rhonchorous breath sounds CV: RR, S1 and S2 wnl, no m/r/g ABD: Soft, NT, ND, +BS, no masses or hepatosplenomegaly EXT: Trace edema in bilateral lower extremities SKIN: No rashes, fairly dry skin, surfaces intact NEURO: AOx3. CNII-XII, sensory, and motor grossly intact. Pertinent Results: [**2154-9-1**] 07:10AM BLOOD WBC-5.9 RBC-4.15* Hgb-12.1 Hct-35.8* MCV-86 MCH-29.1 MCHC-33.7 RDW-15.4 Plt Ct-170 [**2154-8-30**] 11:05AM BLOOD WBC-8.8 RBC-5.04 Hgb-14.4 Hct-44.7 MCV-89 MCH-28.5 MCHC-32.2 RDW-15.2 Plt Ct-230 [**2154-9-1**] 07:10AM BLOOD Plt Ct-170 [**2154-8-30**] 11:05AM BLOOD Plt Ct-230 [**2154-8-30**] 11:05AM BLOOD Glucose-269* UreaN-14 Creat-0.7 Na-142 K-4.3 Cl-104 HCO3-33* AnGap-9 [**2154-8-31**] 04:08AM BLOOD Glucose-136* UreaN-10 Creat-0.6 Na-141 K-3.7 Cl-105 HCO3-29 AnGap-11 [**2154-8-31**] 04:08AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8 [**2154-8-30**] 11:05AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1 [**2154-8-30**] 02:09PM BLOOD Type-ART pO2-97 pCO2-49* pH-7.37 calTCO2-29 Base XS-1 [**2154-8-30**] 10:26AM BLOOD Type-ART pO2-66* pCO2-55* pH-7.33* calTCO2-30 Base XS-0 Intubat-INTUBATED [**2154-8-30**] 10:26AM BLOOD Glucose-239* Lactate-2.2* Na-141 K-4.4 Cl-102 [**2154-8-30**] 10:26AM BLOOD Hgb-14.4 calcHCT-43 O2 Sat-89 COHgb-2.0 MetHgb-0 [**2154-8-30**] 10:26AM BLOOD freeCa-1.13 [**2154-8-30**] MRSA SCREEN MRSA SCREEN-PENDING [**2154-8-31**] Radiology CHEST (PORTABLE AP) Right upper, right perihilar, right lower lobe opacities consistent with improving hemorrhage or aspiration are unchanged. A left lung is grossly clear. There is no evident pneumothorax. Right lung peripheral opacities better evaluated in prior CT [**8-5**] and are unchanged. [**2154-8-31**] Radiology CHEST (PORTABLE AP) There has been markedly improved in right upper, right perihilar and right lower lobe opacities consistent with improving hemorrhage or aspiration. Cardiomediastinal contours are unchanged with mild-to-moderate cardiomegaly. There is no evident pneumothorax. Of note, the lateral aspect of the left hemithorax was not included on the film. There are no increasing right pleural effusions. Sternal wires are aligned with fracture of the first wire. [**2154-8-30**] Radiology CHEST (PORTABLE AP) FINDINGS: In comparison with the earlier study of this date, the endotracheal tube has been removed. The diffuse area of opacification involving the perihilar region extending into both the apical and lower zone on the right is again seen. Again, this could well represent post-procedure hemorrhage, though supervening pneumonia cannot be excluded. [**2154-8-30**] Radiology CHEST (PORTABLE AP) IMPRESSIONS: Extensive right central and upper lung airspace opacity, which may reflect hemorrhage from the recent procedure, or asymmetric pulmonary edema. [**2154-8-30**] Pathology Tissue: Tracheal tumor Distal , [**2154-8-30**] [**Last Name (LF) 829**],[**First Name3 (LF) 828**] C. Not Finalized Brief Hospital Course: # Apnea/Hypoxia: The patient experienced apnea in the immediate post-operative period following debridement of a tracheal nodule. The apnea was thought to be attributed to paralytics, which warranted intubation. When the paralytic agents wore off, the patient was extubated, but remained hypoxia. The prolonged hypoxia post-operatively was attributed to aspiration pneumonitis likely with an element of post-operative inflammation from the procedure itself. The patient remained rhoncorous with course upper airway breath sounds throughout the hospitalization. CXR ruled out PNA as a potentialy source of hypoxia, and the patient did not produce significant volumes of concentration of blood in the sputum concerning for tracheal bleed. Other possibilities include worsening of underlying lung cancer which is unlikely to explain acute hypoxia. The patient was eventually transitioned to high flow face mask, followed by high-flow face tent, followed by nasal cannular on 4L. The patient was weaned without event from 4L to 2L nasal cannula and transferred to the inpatient medical floor, where she continued sat'ing ~94% on 2L. Nebs were administered on an as needed basis throughout the duration of hospitalization, and were found to be helpful in terms of coughing up phlegm. The patient was taken off supplemental oxygen the following day and sat'ed within her normal baseline range 88-92% on room air without any problems at rest. However, patient desaturated with physical therapy during activity. They recommended home oxygen (2L with activity)when ambulating with a walker. The patient will be discharged with home oxygen as well as VNA services. . # Hct Drop: The patient presented with a Hct 44.7 and found to have a Hct of 33.1 post-operatively. The low Hct is most likely attributable to fluids received during procedure and minimal blood loss, however given the 12 point drop, her lab values were followed and the Hct level was stable and began to rise without event or concern for chonic blood loss. Hct 34.0->35.8 this AM. . # Non-Small Cell Lung CA: A new tracheal mass identified on CT in [**Month (only) **] was highly concerning for metastasis and likely to grow to occlude airway the airway, so surgical debridement was warranted with interventional pulmonology without intraoperative complications outside of apnea/hypoxia as elaborated on above. The patient is now POD#2 s/p debridment by IP. Biopsy results are pending. She is followed by interventional pulmonology for continued management. . # Goals of Care: Discussed code status with patient, daughter and sons. [**Name (NI) **] quite clearly does not desire intubation or heroic measures. Daughter is having a difficult time with this but understands and respects her mother's wishes. The DNR/DNI status was confirmed with the patient and her health care proxy. . # IDDM: Continued home glargine and home meds. . # HTN: Continued amlodipine, lopressor and ASA. . # Hyperlipidemia: Continued home statin. Medications on Admission: AMLODIPINE 5 mg daily ESOMEPRAZOLE 40mg qd GLARGINE 8 units daily @ night LORAZEPAM 1mg [**Hospital1 **] METOPROLOL 150 mg [**Hospital1 **] REPAGLINIDE 0.5 mg tid SIMVASTATIN 40 mg qd ASPIRIN 81 mg daily FAMOTIDINE qd Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. insulin glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 4. lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for insomnia. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-24**] puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 IH* Refills:*2* 11. Oxygen 2L nasal canula with ambulation 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary: Aspiration-induced hypoxia Secondary: Poorly differentiated SCC of lung: - right upper lobectomy and chemotherapy [**2148**] - left lower lobe nodule 1.4cm, non-diagnostic CT-guided biopsy, s/p CyberKnife Coronary artery disease: Coronary angioplasty [**2139**], [**2151**], CABG x 3v [**2151**] Infectious colitis [**2152**] Hypertension Insulin-dependent diabetes mellitus Hypercholesterolemia Bladder surgery [**2123**] Hernia repair [**2147**] Cholecystectomy [**2147**] Tracheal nodule debridement [**8-/2154**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) and supplemental oxygen. Discharge Instructions: You were admitted to the [**Hospital 18**] hospital for surgical debridement of a tracheal nodule that was contributing to your difficulty breathing. You underwent this procedure with the interventional pulmonologists. After surgery you were found to have difficulty breathing and decreased oxygen levels that were thought to be a result of both the paralytic [**Doctor Last Name 360**] used during surgery as well as the possibility that you aspirated fluids into your trachea/lungs during surgery. As such, you were intubated and transferred to the medical intensive care unit (MICU) for respiratory care and support. In the MICU, your blood oxygen levels improved over the course of a day on supplemental oxygen and you were transitioned from a face-mask to a face-tent to a nasal cannula on supplementary oxygen. When your oxygen levels stabilized, you were transferred to the inpatient floor, where you were eventually weaned off of supplementary oxygen. You were breathing stable at your baseline blood oxygen levels on the inpatient floor at rest, but were found to be significantly short of breath with activity. As such, physical therapy has recommended home oxygen, as well as instructed you to walk with a walker. We have set up visiting nursing to assist you with your home oxygen, as well as evaluating you for home safety and continued physical therapy. The following changes were made to your at-home medications: 1) Added Home oxygen. 2) Added Albuterol-Ipratropium inhaler. Please take 1-2 PUFFs every 4-6 hours as needed for shortness of breath or wheezing. No other changes were made to your at-home medications. Please continue taking them as instructed. 3) Decreased your metoprolol to 50 mg twice a day from 150 mg Followup Instructions: Please follow-up with your primary care physician 7-10 days following discharge. Completed by:[**2154-9-1**]

Admission Date: [**2113-7-29**] Discharge Date: [**2113-7-30**] Date of Birth: [**2089-1-7**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 425**] Chief Complaint: presyncope Major Surgical or Invasive Procedure: None. History of Present Illness: 24 yom with no PMH who 2 days ago while swimming became "dizzy," resolving with rest. Sensation was intermittent and he thought it was possibly due to his childhood asthma. He tried inhalers without relief. On the day of admission he was bending down to pick things up at the pool and noted tat he got lightheaded every time he stood back up. He describes an associated "throbby" feeling in his chest, however denies CP or overt palpitations. He experienced mild SOB with episodes. Denies any orhopnea, PND, LE edema. On ROS, pt. describes being in his usual state of health until 2 days ago. He denies fevers or chills, uri symptoms, constipation or skin changes. One episode of diarrea a few days ago. At baseline, pateitn swims laps, is not limited by SOB or CP or any activities. No history of syncope. In the ED, patient found to have hr in 180s. Initially, rate too rapid to identify type of tachycardia on EKG (appeared to be supraventricular), and patient received adenosine which decreased rate and unmasked atrial fibrillation. He was given 10 mg IV diltiazem + 30 mg PO diltiazem, which decreased HR 110s. HR increased again however and he was started on diltiazem drip and sent to CCU. Past Medical History: childhood asthma, no intubations, no allergies Social History: lives alone, no smoking, occasional etoh, none since [**Hospital1 **] day, no illicit drugs Family History: Mother: htn and recent "heart murmur". No cardiac history Physical Exam: Vitals: (post atrial fibrillation conversion) P 67, BP 118/65, 98% Gen: Obese HEENT: mmm Neck: No thyromegaly CV: No JVD, nl S1, S2, no m/r/g Lungs: cta bilaterally Abd: soft, nontender, NABS LE: no edema, 2+ pulses bilaterally Pertinent Results: EKG [**2113-7-29**] Atrial fibrillation with a rapid ventricular response. No previous tracing available for comparison. [**2113-7-29**] 02:30PM GLUCOSE-101 UREA N-15 CREAT-1.2 SODIUM-143 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15 [**2113-7-29**] 02:30PM CALCIUM-10.5* PHOSPHATE-2.6* MAGNESIUM-2.0 [**2113-7-29**] 02:30PM WBC-7.6 RBC-6.26* HGB-17.7 HCT-49.4 MCV-79* MCH-28.2 MCHC-35.8* RDW-12.8 [**2113-7-29**] 02:30PM PLT COUNT-300 [**2113-7-29**] 02:30PM PT-13.1 PTT-24.2 INR(PT)-1.1 Brief Hospital Course: The patient was brought to the cardiac critical care unit with continued atrial fibrillation while on a diltiazem IV drip. He was subsequently cardioverted with 2 rounds of 1 mg ibutilide given IV. He remained in normal sinus rhythm thereafter. The cause of his atrial fibrillation was considered to be a benign response to vagal trigger. Given the patient's age and lack of other cardiac medical history, anticoagulation and antiarrhythmic medications are not necessary at this time. The patient was scheduled for an outpatient echocardiogram to evaluate for occult structural disease and also will follow-up with a cardiologist as an outpatient. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Discharge Condition: Improved, no orthostasis, back in normal sinus rhythm. Discharge Instructions: You had an episode of atrial fibrillation, which is an abnormal heart rhythm that was terminated with medication in the hospital. In the future, if you have these events and are feeling poorly, please return to the hospital. Otherwise, provided you feel generally well, you should try lying down and relaxing; this heart rhythm frequently terminates on its own. You should make the follow up appointments as listed below. You will need to have an echocardiogram of your heart (see phone number below) within the week. We advise continuing your efforts to lose weight as this will benefit your overall health, and may help to prevent further episodes of this heart rhythm. Followup Instructions: Please call [**Telephone/Fax (1) 3312**] or [**Telephone/Fax (1) 69442**] to schedule an echocardiogram within the week. Please call [**Telephone/Fax (1) 285**] to schedule an appointment with Dr. [**Last Name (STitle) **] (cardiologist) within the next 1-2 months. Please establish care with a primary care doctor who can help with routine health monitoring and may be able to help you with weight loss. Completed by:[**2113-8-15**]

Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-24**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypotension, Right hip and knee pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 2026**] is a 61M w/ ESRD on dialysis with PMH seizure disorder, nonischemic cardiomyopathy EF 50%, ESRD on HD (T/Th/Sat, last session on saturday), hepatitis B, CAD, CVA, recent admission for MRSA bacteremia [**1-25**] line infection on Vancomycin (planned last day [**2120-2-27**]), who presents from dialysis for increased right hip pain and hypotension (70/50) prior to dialysis. Currently blood pressure 101/70. He was asymptomatic on arrival. No weakness or dizziness. discharged [**1-25**] for line sepsis. Has left chest tunneled line now. no pain at the site. He denies CP, abd pain, SOB, cough, fever. He feels well and does not want to be here. PR complains of R leg pain which he states is chronic since CVA in [**2116**], denies any changes in baseline. . In the ED, initial VS were: T 98.8 88 101/70 16 95%. Exam notable for mentating well, but was refusing to take off his pants. Labs were notable for WBC 12.3 with 82.3% PMN's, Hct 36.5, K 6.5, which improved to 6.1, and lactate of 1.9. Trop of 0.11 (elevated previously to 0.16 on last admission). ECG showed peaked T waves. He was given Calcium gluconate, insulin, glucose, and kayexalate. Renal was contact[**Name (NI) **] from [**Name (NI) **]. A central line was placed - attempted R IJ but unable to place and placed L fem line. Cultures were sent and pt was given a dose of Vanc and Cefepime. He was given 1200L fluid 81/46. Mentating well, even in BP in lows 70s. VS prior to transfer 81/46 HR 72 RR 12 O2 sat 95% RA. He was been afebrile since admission. For access pt has 20g in left arm, L femoral line. . On arrival to the MICU, . 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: - CKD stage V, on hemodialysis [**1-25**] HTN - Seizure disorder since mid [**2097**]'s after starting dialysis - [**11/2119**] staph epidermidis bacteremia and CONS bacteremia - [**9-/2119**]: MSSA and VRE bacteremia - MSSA [**12/2117**] and [**4-/2118**] - MSSA HD line infection with septic lung emboli [**9-1**] - Graft excision for infected thigh graft [**2117-5-26**] - Multiple thrombectomies in LUE and R thigh AV fistula - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy - MI [**2086**] per pt - CVA [**2086**] per pt (residual LE weakness) - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] Social History: Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died few years ago ("was shot to death"). Family History: Father with DM, mother died at age 41 of renal failure Physical Exam: Vitals: T: 98.2 BP 91/45 leg cuff: P: 76 R:15 O2: 98% General: Alert, oriented, no acute distress, patient annoyed by frequent questions. HEENT: Sclera anicteric, EOMI Neck: supple, NO JVD. Lungs: CTA BL Chest: HD port in place on left, but is non-tender, non-erythematous, witn no pus, fluctuance, or induration noted CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: no cyanosis or edema, chronic atrophic skin changes in LE bilaterally, swollen right knee, atrophic muscles in calfs. Multiple scars from prior vascular access in arms b/l. Neuro: CN 2-12 intact, sensation throughout, [**4-27**] stregnth throughout, small pinpoint pupils, EOM intact, A+O x3. Attention intact, [**2-24**] recall at 5 minutes. Mild dysarthria. Subtle right sided facial droop. Wears corrective eyeware. Pertinent Results: HIP MRI: [**2119-2-22**] RESULT PENDING. Right Knee HIP XR: INDICATION: Right knee pain. COMPARISON: Right knee radiograph on [**2120-1-17**]. CT-Torso on [**2117-11-15**]. Single AP view of the pelvis. Additional view of the right hip and two views of the right knee. RIGHT HIP: There is a deformity of the right acetabulum, suggesting an old fracture. Heterotopic ossification is seen in bilateral hips. The SI joints are not visible and probably fused. There is compression deformity of the right femoral head with joint space narrowing and subchondral sclerosis of the acetabulum, not seen on prior CT-Torso on [**2117-11-15**]. This finding is suggestive of avascular necrosis. RIGHT KNEE: Marked muscle wasting is seen in the right lower extremity with marked demineralization. The large spur on the inferior aspect of the patella is unchanged from [**2120-1-17**]. There is no acute fracture or dislocation in the right knee. Impression: Probable old fracture of the right acetabulum along with marked muscle wasting (suggestng paraplegia). Probably fusion of the SI joints may reflect spondyloarthropathy or relate to ? paraplegia. Probable AVN rightfemoral head. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 251**] [**Name (STitle) 20492**] DR. [**First Name (STitle) **] M. [**Doctor Last Name **] Approved: WED [**2120-2-21**] 6:43 PM Knee Aspiratre: NO growth. Blood Cultures: No growth [**2120-2-24**] 05:09AM BLOOD WBC-5.3 RBC-2.95* Hgb-8.3* Hct-25.1* MCV-85 MCH-28.1 MCHC-33.1 RDW-17.4* Plt Ct-259 [**2120-2-23**] 06:19AM BLOOD WBC-5.0 RBC-3.22* Hgb-8.7* Hct-28.5* MCV-88 MCH-27.1 MCHC-30.7* RDW-17.2* Plt Ct-305 [**2120-2-22**] 01:02AM BLOOD WBC-5.0 RBC-3.15* Hgb-8.4* Hct-26.8* MCV-85 MCH-26.6* MCHC-31.3 RDW-18.0* Plt Ct-241 [**2120-2-21**] 04:00AM BLOOD WBC-6.5 RBC-3.58* Hgb-9.7* Hct-31.8* MCV-89 MCH-27.2 MCHC-30.6* RDW-17.3* Plt Ct-343 [**2120-2-20**] 04:31PM BLOOD WBC-10.4 RBC-3.71* Hgb-10.3* Hct-32.6* MCV-88 MCH-27.7 MCHC-31.5 RDW-17.0* Plt Ct-387 [**2120-2-20**] 09:20AM BLOOD WBC-12.3*# RBC-4.13*# Hgb-11.8*# Hct-36.5*# MCV-88 MCH-28.5 MCHC-32.3 RDW-17.1* Plt Ct-451* [**2120-2-20**] 04:31PM BLOOD Neuts-82.0* Lymphs-11.0* Monos-3.5 Eos-2.9 Baso-0.6 [**2120-2-20**] 09:20AM BLOOD Neuts-82.3* Lymphs-12.1* Monos-3.0 Eos-1.9 Baso-0.6 [**2120-2-24**] 05:09AM BLOOD PT-12.0 PTT-32.5 INR(PT)-1.1 [**2120-2-22**] 01:02AM BLOOD PT-12.8* PTT-37.7* INR(PT)-1.2* [**2120-2-20**] 04:31PM BLOOD PT-12.8* PTT-39.3* INR(PT)-1.2* [**2120-2-20**] 04:31PM BLOOD ESR-60* [**2120-2-24**] 05:09AM BLOOD Glucose-85 UreaN-22* Creat-5.4*# Na-145 K-4.4 Cl-104 HCO3-30 AnGap-15 [**2120-2-23**] 06:19AM BLOOD Glucose-103* UreaN-40* Creat-8.3*# Na-138 K-4.0 Cl-99 HCO3-25 AnGap-18 [**2120-2-22**] 01:02AM BLOOD Glucose-86 UreaN-29* Creat-6.0*# Na-138 K-3.7 Cl-100 HCO3-26 AnGap-16 [**2120-2-21**] 04:00AM BLOOD Glucose-81 UreaN-69* Creat-11.1* Na-140 K-4.9 Cl-102 HCO3-16* AnGap-27* [**2120-2-20**] 07:21PM BLOOD Glucose-93 UreaN-64* Creat-10.5* Na-138 K-4.9 Cl-102 HCO3-18* AnGap-23* [**2120-2-20**] 04:31PM BLOOD Glucose-89 UreaN-63* Creat-10.7* Na-138 K-5.1 Cl-100 HCO3-18* AnGap-25* [**2120-2-20**] 09:20AM BLOOD Glucose-108* UreaN-63* Creat-10.5*# Na-138 K-6.5* Cl-98 HCO3-19* AnGap-28* [**2120-2-24**] 05:09AM BLOOD Calcium-8.9 Phos-3.8# Mg-2.0 [**2120-2-20**] 04:31PM BLOOD Cortsol-22.0* [**2120-2-20**] 04:31PM BLOOD CRP-38.7* [**2120-2-24**] 06:26AM BLOOD Vanco-22.3* [**2120-2-23**] 06:20AM BLOOD Vanco-33.8* [**2120-2-21**] 09:13AM BLOOD Vanco-24.7* [**2120-2-20**] 09:20AM BLOOD Vanco-21.4* [**2120-2-20**] 09:33AM BLOOD Lactate-1.9 K-6.1* [**2120-2-20**] 07:50PM BLOOD Lactate-1.1 Brief Hospital Course: Dr. [**Known lastname 2026**] is the 61-year-old male with a past medical history significant for end-stage renal disease who receives hemodialysis on Tuesday Thursday Saturday, non-ischemic cardiomyopathy with an ejection fraction of 40-50%, hepatitis B, coronary artery disease, CVA, MRSA bacteremia secondary to a presumed dialysis line infection (line was subsequently replaced) [**2120-1-25**] on vancomycin until [**2120-2-27**] who presented to the emergency department with a chief complaint of right hip and knee pain as well as asymptomatic hypotension at dialysis (70/50s). During his admission in the MICU, he was hypotensive to the 90??????s/45, however, per report that this is the patients baseline. Furthermore, when the patient receives HD, his blood pressure tends to drop 10-20 points. He reports no symptoms then either. He was treated with meropenem in addition to his vancomycin in the MICU. However, per recommendations of ID, his meropenem was held. There were no acute events in the MICU and he has remained afebrile. His presenting complaint to the emergency department was for his right hip and knee pain. Xrays reveal an acetabular fracture as well as avascular necrosis of the femoral head. The patient notes that he is bound to a scooter at home. Upon review of systems, he denies chest pain, SOB, denies fevers, chills, change in bowel or bladder habits, cough. Patient endorses chronic right/hip and knee pain. He was subsequent transferred to the floor. 1. Hypotension Hypotension: Per record patient has a baseline blood pressure in the low 100s to 90s. This problem seems to be exacerbated by the fluid removal in hemodialysis secondary to his ESRD. Notably the patient does not complain of any sequelae from his hypotension. He has undergone and extensive workup and is being appropriately treated with vancomycin. He is afebrile and without white count. His blood cultures have shown no growth to date. - Vanc dose per HD until [**2120-2-27**]. -Less fluid removal at hemodialysis -Midodrine maintains SBP during HD . 2.ESRD: Patient has long standing history of ESRD. -Electrolyte management per renal -Low phos diet -Nephrocaps 3. Right knee and hip pain: He has been hemodynamically stable but continues to report right knee pain, for which he refused arthrocentesis while in MICU. He agreed to it on [**2-23**], as we expressed concern about possible septic arthritis. Orthopedic Surgery was consulted, and arthrocentesis was performed. They also recommended CT of hip to further evaluate AVN as well as look for fluid collection, though unlikely. Radiology recommended MRI instead, and he had MRI [**2120-2-23**] Currently denies hip pain, states knee feels better. Knee aspirate showed no growth. Will follow up with Ortho oupatient for possible hip replacement. 4. Seizure disorder: Stable and controlled. -Keppra -Oxycarbazepine Medications on Admission: Medications: discharge meds from [**2120-1-25**], confirmed with pt 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day. 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS (). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY (). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous with HD for 1 doses: To be dosed based on trough and given on hemodialysis days. (Duration 6 weeks, last day [**2120-2-28**]). Disp:*qS * Refills:*0* 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. . Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QHD (each hemodialysis). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) application Topical once a day. 16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 17. midodrine 5 mg Tablet Sig: 1.5 Tablets PO WITH DIALYSIS (). Disp:*22 Tablet(s)* Refills:*2* 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Final Day [**2-28**]. 19. Outpatient Lab Work Please have your CBC (white blood count, hematocrit, platelets) drawn on [**2-27**] and have faxed to PCP [**Name Initial (PRE) **] [**Telephone/Fax (1) 3382**] and dialysis [**Telephone/Fax (1) 12142**] Discharge Disposition: Home With Service Facility: [**Hospital3 20493**] Discharge Diagnosis: Primary: Hypotension secondary to hypovolemia, avascular necrosis of R hip, R knee effusion likely secondary to OA Secondary: CKD stage V on HD, recent MRSA line infection, seizure disorder, s/p distant CVA with residual RLE weakness 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: Mr [**Known lastname 2026**], You were admitted to the hospital with low blood pressure which was likely due to hemodialysis. You were admitted to the ICU out of concern for infection, however we do not think that you had a new infection and continued to treat your known bloodstream infection. The orthopedic and renal (dialysis) consultants aided us in our management. You had pain in your right knee, and a sample was drawn from that. You also had imaging of your hip which showed some degeneration of your right hip, which demonstrated some degeneration. If you have worsening pain in your right hip or knee, you should call [**Telephone/Fax (1) 1228**] to schedule an urgen orthopedics appointment. You should follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**] at [**Telephone/Fax (1) 1228**] within 1-2 weeks to further evaluate your hip. The following changes have been made to your medications: -START 7.5 mg midodrine prior to dialysis on dialysis days -You will continue antibiotics until [**2120-2-28**], given during dialysis. Because of your heart failure, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Because you were discharged on the weekend, we were unable to schedule you a follow up appointment with your PCP. [**Name10 (NameIs) 357**] call [**Telephone/Fax (1) 250**] to schedule an appointment with Dr [**Last Name (STitle) **]. You should have CBC labs drawn on Tuesday [**2-27**]. If you have worsening pain in your right hip or knee, you should call [**Telephone/Fax (1) 1228**] to schedule an urgen orthopedics appointment. You should follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**] at [**Telephone/Fax (1) 1228**] within 1-2 weeks to further evaluate your hip. Department: INFECTIOUS DISEASE When: TUESDAY [**2120-2-27**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2156-8-16**] Discharge Date: [**2156-9-6**] Date of Birth: [**2099-8-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Fall from ladder with head bleed Major Surgical or Invasive Procedure: Placement of [**Last Name (un) **] Bolt ACDF C3-C4 Endotracheal intubation History of Present Illness: Mr. [**Known lastname **]. [**Known lastname **] is a 56 year old man with no known past medical history who fell from a 8-10 feet ladder while at work. He struck his head against a dumpster while falling. Patient lost conciousness, was intubated and sedated and arrived to [**Hospital1 18**] via Med flight on [**2156-8-16**]. GCS of 8 on arrival. Patient had subsequent occipital bone basilar skull fracture, subdural hematoma, subarachnoid hematoma and contra-coup brain injury. His initial presentation was notable for left arm weakness found to be due to traumatic C3-C4 cervical disc herniation with resultant cord compression. He had an ICP Bolt monitor placed on [**8-16**] (removed [**2156-8-17**]). Past Medical History: Unknown Social History: long-term girl friend, at least 2 daughters, otherwise unknown Family History: Unknown Physical Exam: VS: T:97.8 BP: 110 / 57(70) HR: 77 R14 O2Sats 100% Gen: Sedated, intubated. NAD. HEENT: Pupils: 1.5mm pinpoint. EOMs:UTA Neck: Supple. Rigid collar in place Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: GCS 7V. Intubated, sedated. + Corneal, + Blink, + Gag with ETT stimulation. Localizes deep pain and withdrawal to upper right arm only, left upper arm flaccid. Localizes deep pain and withdrawal to lower leg extermity bilaterally. + point tenderness along posterior spine at level of approx. T6/7. Toes are upgoing bilaterally. Speech not assessed. No tremors or fasciculations. . Cranial Nerves: I: Not tested II: Pupils 1.5mm fixed. III, IV, VI: not tested. V, VII: not tested. VIII: Unable to ascertain IX, X: ETT patent [**Doctor First Name 81**]: NT XII: NT Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. No clonus. Toes upgoing bilaterally. Pertinent Results: [**2156-8-24**] WBC-14.4* RBC-4.02* Hgb-12.7* Hct-38.0* MCV-95 MCH-31.7 MCHC-33.5 RDW-12.9 Plt Ct-413 [**2156-8-24**] PT-20.3* PTT-33.6 INR(PT)-1.9* [**2156-8-24**] Glucose-152* UreaN-20 Creat-0.7 Na-150* K-3.7 Cl-114* HCO3-25 AnGap-15 [**2156-8-24**] ALT-24 AST-33 AlkPhos-73 Amylase-55 TotBili-0.4 [**2156-8-24**] TotProt-6.4 Albumin-3.7 Globuln-2.7 Calcium-8.9 Phos-3.7 Mg-2.4 [**2156-8-16**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2156-8-20**] freeCa-1.20 . MRI on admission: 1. Multiple cerebral contusions which are seen to have progressed when compared to the previous study of earlier today. 2. Subarachnoid hemorrhage bilaterally. 3. Multiple fractures seen in the left occipital bone and in the left side of the base of the skull traveling through the jugular foramen and the carotid canal. 4. Possible left signmoijd sinus and jugular venous thrombosis. Would suggest MRV if clinically indicated. Brief Hospital Course: 56 year old male s/p fall from ladder head injury [**8-16**] and consequent occipital bone basilar skull fracture, subdural hematoma, subarachnoid hematoma, contra-coup injury and traumatic C3 disk herniation. . [**2156-8-16**] - [**2156-8-20**]: Head injury and loss of consciousness. Suffered an occipital bone basilar skull fracture, subdural hematoma, subarachnoid hematoma and contra-coup injury. He was intubated prior to arrival at [**Hospital1 18**] and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bolt insertion on [**2156-8-16**]. His ICPs remained normal for 24 hours and his bolt was removed. He moved all extremities except his left arm, plain films of the arm were negative. CT imaging of his neck showed a large disc herniation at C3-C4 causing cord compression and he underwent anterior cervical discectomy and fusion on [**2156-8-20**]. Patient receiving tube feeds through NG tube, patient is unable to eat. He was transferred out of the Trauma ICU on [**8-20**] at that time he started having significant fevers. . [**2156-8-20**] - [**2156-8-27**]: The patient started to have a fever on [**8-20**], although, did have low grade temperatures (100-100.4) intermittently during the hospitalization. Blood cultures were drawn (presumed from the line, not labeled) [**1-2**] Coagulase negative Staphylococcus, two morphologies, was reported on [**2156-8-22**]. He was started on vancomycin and surveillance cultures were drawn. He remained febrile through [**8-24**] when he developed tachypnea and snoring respirations. He was scanned from his neck to pelvis and no obvious source of infection was found. He was transferred to the MICU service on [**8-24**] for treatment of his fevers and concerning respiratory status. Upon arrival to the MICU, pt had difficulty protecting his airway - most likely secondary to both tongue obstruction as well as post op prevertebral soft tissue edema with subsequent narrowing of the airway. Patient was treated with Vancomycin/Zosyn for Aspiration Pneumonia. Pt was electively intubated on [**8-24**]. While intubated, pt only required pressure support and he was successfully extubated on [**8-27**]. . [**8-28**] - [**2156-9-6**]: Patient transferred to general medicine floor. Patient continued on IV antibiotics (Vancomycin and Zosyn) for aspiration pneumonia until [**2156-8-30**]. [**2156-9-2**] patient developed fever of 100.3. Blood culture, urine culture, CXR negative. X-ray of hardware in cervical spine no overt sign of infection. Patient's fever eventually resolved. Nutritional status on [**Last Name **] problem. [**Name (NI) **] failed bed-side speech evaluation and video study. PEG tube was placed [**2156-9-1**] for nutritional status, currently on tube feeds. Patient requires rehab for neurologic dysfunction. Patient awake and alert, but oriented only to name. Left upper extremity is completely flaccid. Patient unable to eat, dress, wash or perform any basic activities on his own. Unable to follow simple directions. Patient is only able to answer yes/no to very simple questions, unable to follow more complex questions. Medications on Admission: Unknown Discharge Disposition: Extended Care Facility: [**Hospital3 12564**] Discharge Diagnosis: Primary Status post-fall with traumatic brain injury Basilar skull fracture Subdural hematoma Subarachnoid hematoma Contra-coup brain injury C3-C4 disk herniation Discharge Condition: Stable Discharge Instructions: You were seen at the [**Hospital1 18**] after you fell from a ladder. You fractured your skull and had intracraneal bleed. You also had an herniated disk that compressed your cervical spine that required surgery. You were intubated and required multiple days in the intensive care unit. During this time you developed a pneumonia that was treated with the antibiotics suggested by the infectious disease doctors. You required a tube that went to your stomach placed to feed you, since you were unable to eat due to poor muscle control in your throat. Followup Instructions: Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment in [**5-5**] days.

Admission Date: [**2126-3-11**] Discharge Date: [**2126-3-26**] Date of Birth: [**2058-1-29**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Vancomycin / Codeine Attending:[**First Name3 (LF) 2474**] Chief Complaint: Dysuria, abdominal pain Major Surgical or Invasive Procedure: Percutaneous CT scan guided drainage of abdominal fluid. History of Present Illness: Patient is a 68 yo F, h/o cervical CA, radiation cystitis, radiation colitis, frequent line infections, recurrent UTIs who presented after developing acute on chronic severe abdominal pain. Four days prior to admission, patient woke with severe abdominal pain that was worsened with movement. She had some dysuria in the days prior. She also complained of nausea and vomiting. Her abdominal pain was worsened by movement. She denied fevers or chills. . She was brought by ambulance to an outside hospital. There she had a CT of her abdomen which was notable for mild ascites, but no acute process. She was mildly hypotensive to SBP of 90s and was given 3 L NS. Given levofloxacin/flagyl. She was transferred to the [**Hospital1 18**] ED. On arrival T 100.8, hr 107, bp 100/71. Soon thereafter SBP dropped to the 70s and she was bolused a total 5L NS. Her ostomy output was heme negative. U/A showed gross blood and + WBC. She was given one dose of meropenem 500mg IV, as this is what she was discharged on previously. Her pain was also treated with tylenol and dilaudid. She became mildly hypotensive with dilaudid. Pt was then transfer to the MICU her VS were T 98, 120/51, 15, 99/ra. . On arrival to the ICU, she again become hypotensive and required levophed. She also recieved one unit of PRBCs for HCT of 22. She was continued on meropenem for presumed urosepsis, and had received a total of 8L of IV fluids while in the ICU. She was then transferred to the floor after she stabilized on [**3-13**]. . The morning of [**3-14**], she was noted to be in marked respiratory distress. Her oxygen saturation at times dropped to 80% on non-rebreather, and was noted to be hypertensive into the 160s systolic. She was given 20mg lasix x 2, her usual dose of dilaudid and hydralazine without marked improvement, and the MICU resident was called. Examination demonstrated bilateral crackles and JVP elevated to the angle of the mandible. CXR demonstrated marked pulmonary edema. She was given nitroglycerin SL and transferred to the ICU for possible initiation of BIPAP. . When she arrived in the ICU, her respiratory status had markedly improved and she denied any shortness of breath or chest pain. She continued however to have abdominal pain. Past Medical History: 1. Cervical CA s/p TAH/XRT s/p hysterectomy [**2096**] with recurrence in [**2097**] 2. Radiation cystitis 3. Urinary Retention; straight catheterization ~8x per day 4. R ureteral stricture -- c/b recurrent infections -- s/p right nephrectomy ([**2123**]) 5. Recurrent UTIs: (Klebsiella (amp resistant) and Enterococcus (Levo resistant) 6. Short gut syndrome since [**2109**] s/p colostomy from radiation enteritis. 7. Osteoporosis 8. Hypothyroidism 9. Migraine HA 10. Depression 11. Fibromyalgia 12. Chronic abdominal pain syndrome 13. Multiple admits for enterococcus, klebsiella, [**Female First Name (un) **] infections 14. DVT / thrombophlebitis from indwelling central access 15. Lumbar radiculopathy 16. Multiple Prior PICC line / Hickman infections -- See multiple surgical notes [**2115**] to date 17. H/O SBO followed by surgery [**33**]. H/O STEMI [**2-20**] Takotsubo CM, with clean coronaries on cath in [**4-27**]. EF down to 20% in setting of illness, but EF recovered to 55-60%, in setting of klebsiella PNA. 19. Hyponatremia: previously attributed to hctz use Social History: She lives with her husband in an [**Hospital3 4634**] [**Last Name (un) **]. She reports a 80 PY smoking history but quit 18 years ago. Denies alcohol or drugs. She walks with a walker but has a history of frequent falls. Independent of ADLS. Family History: Father with ETOH abuse, CAD. [**Last Name (un) **] with renal ca, CAD. 3 healthy children. Physical Exam: Admission Exam: 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 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 SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. . Discharge Exam: VS: T 98.8 , BP 120/56 , P 81 , RR 16 , O2 99 % on RA, Gen: Thin woman in NAD HEENT: Normocephalic, anicteric, OP benign, MM appear dry CV: RRR, no M/R/G; there is no jugular venous distension appreciated, DP pulses 2+ bilaterally Pulm: Expansion equal bilaterally, but overall decreased air movement, worst at right lung field Abd: Soft, ND, BS+, ostomy bag in place. Mild tenderness to palpation Extrem: Warm and well perfused, no C/C/E Neuro: A and Ox3, strength 3/5 in lower extremities, [**4-23**] in upper extremities Psych: Pleasant, cooperative. Pertinent Results: ADMISSION LABS: [**2126-3-11**] 08:45PM BLOOD WBC-7.6# RBC-3.20* Hgb-9.4* Hct-28.5* MCV-89 MCH-29.2 MCHC-32.9 RDW-13.1 Plt Ct-175 [**2126-3-11**] 08:45PM BLOOD Neuts-93.8* Lymphs-3.5* Monos-2.6 Eos-0 Baso-0.1 [**2126-3-11**] 08:45PM BLOOD Glucose-93 UreaN-17 Creat-1.4* Na-134 K-5.2* Cl-106 HCO3-17* AnGap-16 [**2126-3-11**] 08:45PM BLOOD ALT-16 AST-26 LD(LDH)-145 CK(CPK)-203* AlkPhos-81 TotBili-0.2 [**2126-3-11**] 08:45PM BLOOD Lipase-27 [**2126-3-11**] 08:57PM BLOOD Lactate-3.2* . ICU LABS: [**2126-3-15**] 04:00PM BLOOD CK-MB-4 cTropnT-<0.01 [**2126-3-16**] 04:28AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2468* [**2126-3-17**] 02:23PM BLOOD ANCA-NEGATIVE B [**2126-3-17**] 02:23PM BLOOD [**Doctor First Name **]-NEGATIVE [**2126-3-17**] 02:23PM BLOOD CRP-188.2* [**2126-3-17**] 02:23PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [**2126-3-17**] 02:23PM BLOOD B-GLUCAN-PND . DISCHARGE LABS: [**2126-3-26**] 06:00AM BLOOD WBC-3.6* Hgb-7.4* Hct-22.5* MCV-87 MCH-28.6 MCHC-32.8 RDW-13.2 Plt Ct-565 [**2126-3-26**] 06:00AM Reticulocyte Count, Manual 1.7* [**2126-3-26**] 06:00AM LDH 119 T.Bili 0.1 Direc Bili 0.1 Indirect bili 0.0 [**2126-3-26**] 05:44AM BLOOD Glucose-86 UreaN-36 Creat-1.2 Na-136 K-4.5 Cl-105 HCO3-22 [**2126-3-26**] 05:44AM BLOOD Calcium-9.6* Phos-4.8 Mg-2.1 . MICROBIOLOGY: [**2126-3-11**] Blood Cx: negative [**2126-3-11**] Urine Cx: 10,000-100,000 ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [**2126-3-12**] Stool Cx: negative [**2126-3-12**] Blood Cx: negative [**2126-3-16**] Urine Legionella Ag: negative [**2126-3-18**] Influenza swab: negative . IMAGING: [**2126-3-11**] CXR: In comparison with the study of [**2-11**], there is some increased opacification at the left base, which does not silhouette the hemidiaphragm or left heart border. Although this could conceivably represent a region of pneumonia, it more likely reflects artifact of soft tissues pressed against the cassette. No evidence of vascular congestion or pleural effusion. Tip of the central catheter again lies in the mid-to-lower portion of the SVC. . [**2126-3-12**] CT Abdomen/Pelvis w/ con: 1. New moderate ascites and small bilateral pleural effusions. No evidence of abscess or pyelonephritis. 2. Unchanged fullness of the left renal pelvis, likely due to UPJ obstruction. 3. Stable moderate common bile duct dilation in this patient who is post-cholecystectomy. . [**2126-3-16**] CT Chest w/o con: 1. Extensive fibrotic changes and ground-glass opacity suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity or NSIP. 2. No evidence of edema or pneumonia. . [**2126-3-18**] ECHO: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2125-10-30**], mild mitral regurgitation is now seen. . [**2126-3-19**] chest x-ray: In comparison with the study of [**3-18**], there has been decrease in the diffuse bilateral pulmonary opacifications, consistent with improving pulmonary edema or hemorrhage. Blunting of the costophrenic angle on the right persists consistent with a small effusion. Increasing opacification at the left base is consistent with pleural effusion and some volume loss. Central catheter remains in place. . [**2126-3-21**] KUB: Dilated loops of bowel in the left mid abdomen up to 4.8 cm which raise concern for small-bowel obstruction. CT provides more specific information if clinical concern remains. . [**2126-3-21**] KUB: Supine and upright abdominal radiographs were obtained. A dilated loop of bowel in the left lower quadrant measures 4.8 cm and is essentially unchanged in four hours. Surgical clips project over the mid abdomen and pelvis. A calcified right breast implant is seen. Dilated bowel loop remains concerning for small-bowel obstruction. . [**2126-3-22**] CT abdomen:1. Multiple intra-abdominal fluid collections, with rim enhancement and pockets of air, highly suspicious for abscess. 2. Interval development of marked left hydronephrosis. 3. Status post right nephrectomy. Appearance of fluid-filled tubular structure at the expected location and course of the right ureter. If the patient did not have right ureteral resection, this could represent a urine-filled right ureteral stump. Recommend clinical correlations. 4. Thickened, diffuse bladder wall, likely radiation change such as radiation cystitis. 5. No bowel obstruction. Oral contrast has reached the RLQ ileostomy bag. . [**2126-3-25**] Abd US:1. A small subhepatic fluid collection measuring 4.5 cm. Previously seen right paracolic gutter and pelvic fluid collections are not well visualized. Please note that ultrasound is less sensitive for detecting loculated intra-abdominal fluid collections. 2. Stable appearance of the mild intra- and extra-hepatic biliary dilatation. 3. Moderate left hydroureteronephrosis, slightly improved since the prior study. . At time of discharge, intraabdominal fluid culture pending (prelim result no growth to date). Brief Hospital Course: MICU Course: [**Date range (1) 70244**] # Sepsis of likely urinary origin: Upon presentation to [**Hospital1 18**] on [**3-11**], had blood pressure drop to 70s sytolic. She was given 5L IVF in ED and transferred to MICU. CXR was unrevealing. U/A showed increased leuks and WBC on urine micro. Was empirically started on meropenem in MICU given that patient had recently been on carbapenems for a UTI in end of 1/[**2126**]. In MICU her BP was intially stable and then fell and patient was started on norepinephrine, which she remained on for approximately 17 hours on [**3-12**]. Given patient's severe abdominal pain, received a CT abd/pelvis in the ED which showed moderate ascites, though no other acute changes. Surgery consult was called and felt that there was no acute surgical intervention indicated and followed the patient's course in the MICU. We also trended patient's lactate level, which was 3.2 at presentation and trended down to 1.3 with fluid resuscitation. Checked cdiff toxin, which was negative. IV team was called to assist in managment of patient's tunneled double lumen catheter and they suggested ethanol dwells between TPN infusions in order to prevent line infection. Blood cultures from [**3-11**] and [**3-12**] were negative. . # Abdominal pain: Pain with severe abdominal pain upon presentation. We reassured after ruling out acute intra-abdominal process with CT scan and serial exams. Given frequent (Q1hour) IV dilaudid requirements on morning of [**3-13**], pain service consult was called; however, prior to pain service seeing patient her pain improved to point that dilaudid could be given less frequently. Was felt that we had been behind on pain control after sleeping overnight, possible due to held doses of gabapentin. She was continued on methadone, dilaudid, and gabapentin. . # Anemia: HCT was found to be 22, pt was transfused 1 unit of PRBCs. Post-transfusion HCT was 26.9. . Medicine Floor Course: [**Date range (1) 32116**]: Patient was called out from the MICU on [**2126-3-13**] after she had been normotensive for 24 hours without pressors. She had a new oxygen requirement (94% on 4L) thought [**2-20**] volume overload (8 L + for LOS). Overnight, she was hypertensive to 188/80. In the morning she was found to be hypoxic to 81% on 4L. She was put on a non-rebreather with intermittent improvement of her oxygen sats to low 90s but would then drop to low 80s. She was also given iv lasix 20 mg x 2 and she put out 2 L in 2 hours. Her blood pressure was treated with hydralazine 20 mg iv x1 and SL nitro. Despite these interventions she was still hypoxic in the 80s on a non-rebreather and was transferred back to the MICU for positive pressure ventilation and aggressive diuresis. . MICU Course: [**Date range (1) 97780**]: CXR was c/w volume overload, likely from fluid resuscitation she received in the MICU. She was diuresed with IV lasix and started on azithromycin for atypical pneumonia coverage. CT chest performed later revealed extensive fibrotic changes and ground-glass opacities suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity, or NSIP. Pneumonitis workup was initiated. ESR =83, CRP = 188.2, [**Doctor First Name **], ANCA, Beta-glucan, and galactomannan were all negative. She was stable and was transferred to the floor for further evaluation. . Medicine Floor Course: [**Date range (1) 20494**]: Pt was stable and continued to improved. Active issues: . # Hypoxemia/Pulmonary infiltrates: Oxygenation gradually improved and pt was weaned off oxygen supplement gradually. Etiology of infiltrates was unclear, possibilities included [**Name (NI) **] and medication-induced lung toxicity. Pt received 1 course of azithromycin for possible atypical pneumonia. Her flu and legionella screenings were negative. She was weaned off O2 and mantained 95%+ saturation on room air at the time of discharge. . # Urosepsis: Pt remained hemodynamically stable on the floor. She received meropenem for total of 7 days ([**Date range (1) 28666**]). She remained without urinary complaints. Pt was given Hyoscyamine for bladder spasm pain. . #Anemia: The patients hematocrit trended down throughout her hospitalization from around 27 to a low of 22. Her baseline over the last few months has been 25-28. This was attributed to her ongoing inflammation secondary to her radiation enteritis and cystitis, although the precise etiology remains unclear, and infection and myelodysplasia should be considered as well. Her manual reticulocyte count was found to be 1.7 (corrected 0.53), indicating insufficient marrow response. Her ostomy output was found to be guiac negative and her C+ CT scan of the abdomen and pelvis demonstrated no evidence of active bleeding. Hemolysis labs demonstrated no evidence of ongoing hemolytic process, however corrected retic count was low. This can be due to illness or medication suppression. Recent iron studies were all within normal limits. Pt was instructed to follow up with primary care physician about this issue, with repeat Hct/reticulocyte count and further workup as needed. . # Abdominal pain/fluid collections: The patient had known chronic abdominal pain related to cervical cancer and radiation complications. C. diff was been negative. We continued her home medication (methadone and oxycodone), and added dilaudid. Pt was able to eat and drink, and did not have any vomiting. She was evaluated with KUB for possible obstruction, which showed dilated loops of bowel. CT of abdomen demonstrated multiple fluid collections, enlarged fluid filled bladder, L hydronephrosis, and a dilated fluid filled ureteral stump. Urology was consulted, and a foley was placed for decompression. When the patient was taken for CT-guided drainage of the collections, the collections had almost completely disappeared, potentially related to decompression from the foley catheter. Fluid from the remaining collection was sampled and sent for culture and analysis, which demonstrated no bacteria and a creatinine of 1.8 (not consistent with urinoma). Repeat ultrasound demonstrated interval resolution of the previoulsy noted hydronephrosis and stable appearance of the fluid collections compared to the most recent CT scan. . Chronic issues: . # CKD: Pt Cr remained at her her baseline, and no new acute issues. . # Short Gut Syndrome: We continued pt's TPN and she was also followed by the nutritionist while she was in the hospital. . # Anxiety/depression: We continued pt's home meds (alprazolam, fluoxetine). . # Chronic Pain/Fibromyalgia: We continued the pt's home meds (gabapentin, methadone). . # Hypothyroidism: We continued the pt's home med (levothyroxine). . # Osteoporosis: We continued the pt's home med (vitamin D, calcium). . #HTN: We restarted pt's Lisinopril on [**3-19**] after her blood pressure returned to its chronically high level. Medications on Admission: 1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 5X/WEEK (MO,TU,WE,TH,FR). 3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 9. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 6 days. [**Month/Day (4) **]:*7 grams* Refills:*0* 11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Pyridium 100 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 13. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Day (4) **]:*30 Tablet(s)* Refills:*2* 15. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection Injection once a month. 16. darifenacin 15 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 17. hyoscyamine sulfate 0.125 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO four times a day as needed for bladder spasm. 18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 19. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal semiweekly. 20. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache. 21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 22. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three times a day as needed for headache. 23. optics mini drops Sig: 1-2 drops once a day. 24. Metrogel 1 % Gel Sig: One (1) Topical twice a day. 25. Ethanol 70% Catheter DWELL (Tunneled Access Line) Sig: Two (2) mL once a day: 2 mL DWELL DAILY Not for IV use. To be instilled into central catheter port (both ports) for local dwell. For 2 hour dwell following TPN. Aspirate and follow with normal flushing. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 8. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for bladder spasm. 10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Maalox Advanced Oral 13. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal 2XWEEK (). 14. Salagen 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 17. ethanol (ethyl alcohol) 98 % Solution Sig: Two (2) ML Injection DAILY (Daily). 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. [**Month/Day (4) **]:*30 Tablet(s)* Refills:*0* 20. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Urosepsis, anemia, pulmonary infiltrates, hydronephrosis, abdominal fluid collections Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assistance. Discharge Instructions: Dear Ms. [**Known lastname 13275**], . It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for a severe infection of the urinary tract, anemia, low blood pressure and shortness of breath. . -For your urinary tract infection, you were given a course of IV antibiotics and your infection resolved. . -For your low blood pressure, you were given IV fluids and medications to help maintain your blood pressure initially. Your low blood pressure was related to your urinary tract infection and improved as this issue improved. After you returned to your baseline blood pressure (high), we restarted your blood pressure medication. . -For your anemia, you were transfused 1 unit of packed red blood cells. You should follow up regarding this issue with your primary care doctor as an outpatient. . -For your shortness of breath, you were given oral antibiotics, supplementary oxygen and diuretics, and you improved. We think that your shortness of breath may have been related to an adverse reaction to a blood transfusion that you received. You will follow up as outpatient at the pulmonary clinic (see below). . -For your abdominal pain, we obtained a CT scan which initially showed multiple fluid collections in your abdominal cavity. These collections resolved spontaneously following placement of a foley catheter, and so we suspect that they were related to your bladder. We took you to interventional radiology to sample fluid from one of these collections, and found no evidecne of infection. You were also followed by urology, who recommended keeping the foley in place until you have an appointment with them in 2 weeks. . We made the following changes to your medications: CHANGED Oxycodone 5mg 1-2 tablets by mouth every 6 hours to PO Dilaudid 2mg 1-2 tablets every 4 hours as needed for pain. . STARTED Hyocyamine 0.125mg SL every 6 hours as needed for bladder spasm STARTED Clotrimazole 1 troc by mouth 4 times a day. Followup Instructions: Name: [**Last Name (LF) 6692**], [**Name8 (MD) 41356**] NP Specialty: Urology Address: [**Street Address(2) **], Ste#58 [**Location (un) 538**], [**Numeric Identifier 7023**] Phone: [**Telephone/Fax (1) 16240**] Appointment: Thursday [**4-11**] at 1:30PM Radiology Department: WEDNESDAY [**2126-4-17**] at 11:45 AM Building: [**Hospital6 29**] [**Location (un) 861**], [**Telephone/Fax (1) 327**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ** An order has been placed for you to have a chest x-ray prior to your Pulmonary appointments Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2126-4-17**] at 12:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2126-4-17**] at 1 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2126-4-17**] at 1 PM Please call your primary care physician when you leave rehab for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**] Completed by:[**2126-3-27**]

Admission Date: [**2129-7-14**] Discharge Date: [**2129-7-19**] Date of Birth: [**2063-7-21**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine / Steri-Strip / Adhesive Attending:[**First Name3 (LF) 5790**] Chief Complaint: Recurrent Right pleural Effusion Major Surgical or Invasive Procedure: [**2129-7-19**] Right VATS total pulmonary decortication and parietal pleurectomy. History of Present Illness: Mrs. [**Known lastname 28673**] is a 65-year-old woman with a previous history of Hodgkin lymphoma, who was noted to have dyspnea and found to have a large, slightly loculated right pleural effusion. This was incompletely drained. s/p Right video-assisted thoracoscopic surgery drainage of pleural effusion, pleural biopsy, lysis of adhesions and removal of clotted hemothorax on [**2129-6-24**]. She still feels short of breath and using home O2 1 L. She also complains of night sweat, intermittent cough, no hemoptysis. Pathology of pleura biopsy no evidence of malignancy. She is being admitted for right decortication and parietal pleurectomy. Past Medical History: Coronary artery disease - MI in [**2122**] s/p stents X3 CABG w/ mitral valve repair in [**2127-3-2**] Insulin-dependent Type 2 DM Hypothyroidism GERD w/ Barrett's esophagitis Hodgkin's disease s/p XRT Splenectomy in [**2093**] Social History: Lives at home alone - divorced, independent ADLs, works as a software trainer. Daughter lives nearby Denies tobacco, alcohol or drugs. Family History: Sister with coronary artery dises (MI/CABG) and Type 2 Diabetes Mellitus Physical Exam: VS: T: 98.7 HR: 99 SBP: 108/71 Sats: 95% RA 89-92 w/ambulation Genera: 65 year-old female in no apparent distress HEENT: mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds throughout GI: benign Extre: warm no edema Incision: Right VATS site clean no drainage Skin: multiple tape burns Neuro: non-focal Pertinent Results: [**2129-7-19**] WBC-11.2* RBC-3.33* Hgb-8.8* Hct-28.0 Plt Ct-376 [**2129-7-18**] WBC-12.7* RBC-3.19* Hgb-8.7* Hct-27.3 Plt Ct-346 [**2129-7-14**] WBC-15.6*# RBC-4.17* Hgb-11.1* Hct-33.3 Plt Ct-432 [**2129-7-19**] Glucose-176* UreaN-13 Creat-0.7 Na-137 K-4.2 Cl-101 HCO3-31 [**2129-7-14**] Glucose-198* UreaN-19 Creat-0.8 Na-135 K-5.8* Cl-105 HCO3-23 [**2129-7-14**] Glucose-136* CXR: [**2129-7-19**] There is no pneumothorax. Unchanged bilateral pleural effusions and associated bibasilar atelectasis. [**2129-7-18**] the right-sided chest tube has been removed. A second basal right-sided chest tube is in unchanged position. There might be a minimal right upper air inclusion. The large pneumothorax is not seen. Unchanged pleural fluid accumulation in the right hemithorax. The left lung shows a slightly improved ventilation. The right-sided central venous access line is unchanged in course and position. 08/16/09The more lateral right-sided chest tube has been removed. There remains a right apical chest tube. No appreciable pneumothorax is seen. There remain pleural effusions bilaterally. There is mild atelectasis within the right mid lung zone. [**2129-7-15**] Appearances are stable with remaining small loculated right pneumothorax and bibasilar pleural effusions. Brief Hospital Course: Mrs. [**Known lastname 28673**] was admitted on [**2129-7-14**] for Right VATS total pulmonary decortication and parietal pleurectomy. She was transferred to SICU intubated. A bedside echocardiogram revealed low cardiac output. A central line was placed to monitor volume status. She was transfused 1 unit of PRBC for HCT of 26. and administered a fluid challenge with a good response. On [**2129-7-15**] she was extubated. On [**2129-7-17**] she transferred to the floor. Respiratory: Once extubated her oxygen saturations were in the high 90's on nasal cannula. Aggressive pulmonary toilet & IS were continued. Her RA oxygen saturations at rest were 94-96%, on ambulation 89-92%. She was discharged to home on 1 Liter nasal cannula with ambulation as needed. Chest tubes; Once the chest tube air-leak resolved the chest tubes were removed on: [**2129-7-16**] Apical ant chest tube removed, [**2129-7-18**] Post Apical Chest tube removed. The [**2129-7-19**] the basilar chest tube was removed. She was followed by serial chest films. The right pneumothorax resolved. Small bilateral lower lobe effusion and atelectasis remain. Cardiac: She was in sinus rhythm throughout. Her cardiac medications were restarted immediately. Plavix was restarted on [**2129-7-17**]. GI: no issues. Endocrine: She continued on insulin throughout her hospital stay. The metformin was restarted once her PO intake improved. FEN: Her lytes were repleted as needed. Tolerated a diabetic diet. Pain: An epidural was placed preoperative and managed my the acute pain service. Immediately postoperatively the epidural was stopped secondary to hypotension. She converted to a Dilaudid PCA with good control then to PO pain meds. Disposition: She was seen by physical therapy who deemed her safe for home. She was discharged with VNA and home oxygen 1 Liter nasal cannula with ambulation. Medications on Admission: Levothyroxine 150 mcg daily, metoprolol succinate 25 mg daily, clopidogrel 75 mg daily, folic acid 1 mg daily, metformin 1000mg [**Hospital1 **],niaspan 500mg hs, omeprazole 20 mg [**Hospital1 **], aspirin 81 mg daily, calcium citrate daily, thiamine 100 mg daily, crestor 40 mg daily, insulin NPH & SS Discharge Medications: 1. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Calcium Citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO twice a day. 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed Subcutaneous twice a day. 13. Insulin Lispro sliding scale continue 14. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: take with food and water. Disp:*90 Tablet(s)* Refills:*0* 15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Recurrent Right lower lobe effusion Discharge Condition: stable Discharge Instructions: Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased cough, shortness of breath, or chest pain. -Incision develops drainage -Chest tube dressing remove tomorrow and cover site with a bandaid until healed -You may shower tomorrow. No tub bathing or swimming for 3 weeks -No driving while taking narcotics -Take motrin with food and water for pain. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on [**8-2**] 9:30 am in the Chest Disease Center, [**Hospital Ward Name 121**] Building [**Hospital1 **] I. Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 9347**] Completed by:[**2129-7-20**]

Admission Date: [**2124-6-26**] Discharge Date: [**2124-6-29**] Date of Birth: [**2061-9-22**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Codeine / Morphine / Rifaximin / Linezolid / Vancomycin / Dilaudid Attending:[**First Name3 (LF) 8388**] Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) History of Present Illness: 62yoF with alcoholic cirrhosis, varices, s/p TIPS in [**2123**], ischemic bowel [**2120**] s/p R colectomy, and ileostomy reversal who presents from [**Location (un) 620**] with LGIB. Pt has a 15 year hx of alcohol abuse, and relapsed with alcohol 1 month ago. 3 days ago, pt developed black bloody stools with 4 large bloody bowel movements last night. Pt had 3 more this morning filling the toilet bowl w/ BRBB + black stool which improved this morning. Pt has had some nausea, but no vomiting or hematemesis. At [**Name (NI) 31237**], pt had dark red blood on rectal exam. NG lavage was negative but there was poor return of fluid. HCT 20 down from her baseline of 31. She was started on pantroprazole, octreotide and given 1 unit of blood prior to transfer. Vitals were stable on transfer. On arrival to [**Hospital1 18**], patient reported feeling nauseous and anxious, and was afraid of withdrawing from EtOH. She did have 1 more large bloody BM in the ED. Her initial VS were 99.8 95 108/76 18 98%. She was given 4mg IV zofran. She was receiving 2nd unit pRBC. Hepatology recommended transfer to MICU for emergent EGD for suspicion of UGIB. On arrival to the MICU, pt was stable and received a 2nd unit of blood. Vitals 99.8 97 107/74 18 99%. In MICU, pt received emergent EGD which showed a 1 cm non-bleeding ulcer with fresh clot in the stomach at the gastro-jejunal anastomosis and grade 1 distal esophageal varices. Past Medical History: 1. EtOH abuse x15 yrs: last drink was [**2122-6-23**] 2. Cirrhosis: c/b ascites, esophageal varices w/o hemorrhage 3. Last EGD [**2122-5-6**] - showed 1 cord of Grade II varicies 4. Exploratory laparotomy for SBO with lysis of adhesions ([**8-/2122**]), right colectomy, end ileostomy ([**2122-7-10**]) 5. Asthma 6. Gastric ulcers 7. Hypothyroidism 8. Loose ostomy output - has been treated with mesalamine in past without relief 9. Depression 10. h.o. Gastric bypass 14 years ago 11. s/p hysterectomy for endometriosis and "abnormal looking cells" 12. Malnutrition on tube feeds 13. Multiple incisional hernia operations complicated by exposed mesh from prior ventral hernia repair 14. h.o. SBP on Ciprofloxacin - patient states she thinks she had VRE Social History: Quit smoking [**2105**]. Denies illicit drug use. 15 year history of alcohol abuse, recent relapse 1 month ago. Lives with husband (who is s/p renal transplant from daughter) and her daughter and 1 [**Name2 (NI) 12496**]. (1 year old is now with father) Currently unemployed and has not seen a social worker/counselor for depression. Pt worked in billing and collections for a surgeon in the past. Family History: Father, brother and uncle have [**Name (NI) 3729**]. Father died of lung CA. Mother died of brain CA. Sister died of MS. Brother with [**Name (NI) 4522**] disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 99.8 BP:107/74 P:97 R:18 18 O2: 99% on RA General: Alert, oriented, in mild distress, very anxious with tremors of upper extremities HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no bulging flanks, negative fluid wave, several serpigenous erythematous escoriating lesions with central clearing across lower abdomen and lower extremities Rectal: Deferred. GI only noted skin tags and minor external hemorrhoids with not active source of bleeding or fissures. GU: no foley Ext: warm, well perfused, 2+ pulses, no edema Neuro: no focal deficits Physical exam on discharge: hemodynamically stable, afebrile no abd pain excoriating rash on LEs, chest wall Pertinent Results: Admission: [**2124-6-26**] 11:58PM HCT-21.0* [**2124-6-26**] 07:00PM GLUCOSE-100 UREA N-23* CREAT-0.9 SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-17* ANION GAP-21* [**2124-6-26**] 07:00PM ALT(SGPT)-30 AST(SGOT)-100* ALK PHOS-75 TOT BILI-2.6* [**2124-6-26**] 07:00PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-3.6 [**Month/Day/Year 31238**]-1.4* [**2124-6-26**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2124-6-26**] 07:00PM WBC-7.4 RBC-2.67* HGB-7.7* HCT-23.2* MCV-87 MCH-28.7 MCHC-33.0 RDW-16.2* [**2124-6-26**] 07:00PM PLT SMR-LOW PLT COUNT-92* [**2124-6-26**] 07:00PM PT-15.5* PTT-37.5* INR(PT)-1.5* LIVER/GALLBLADDER US WITH DOPPLERS ([**2124-6-27**]): 1. Patent TIPS. No ascites. 2. Borderline splenomegaly. 3. Limited assessment of the liver, but it is coarsened in echotexture compatible with known cirrhosis. EGD ([**2124-6-26**], prelim): -Esophagus: 2 cords of grade I varices were seen in the lower third of the esophagus. The varices were not bleeding. -Stomach: A marginal ulcer was seen on the jejunal side of the gastro-jejunal anastamosis. The ulcer was 1cm in diameter. There was some exudate that was washed off. There were a few pigmented spots but no visible vessel or clot. There was some minimal contact bleeding from the tissue at the edge of the ulcer, but no active bleeding noted from the ulcer and no blood seen in the stomach pouch or intestine. -Duodenum: Normal duodenum. -Other findings: Normal Roux-en-Y gastric bypass anatomy noted consistent with known history -IMPRESSION: Varices at the lower third of the esophagus. A marginal ulcer was seen on the jejunal side of the gastro-jejunal anastamosis. The ulcer was 1cm in diameter. There was some exudate that was washed off. There were a few pigmented spots but no visible vessel or clot. There was some minimal contact bleeding from the tissue at the edge of the ulcer, but no active bleeding noted from the ulcer and no blood seen in the stomach pouch or intestine. Normal Roux-en-Y gastric bypass anatomy noted consistent with known history. Otherwise normal EGD to third part of the duodenum -RECOMMENDATIONS: Prilosec 40mg [**Hospital1 **]. Check H. pylori antibody. Take Carafate suspension 2 grams twice a day. The source of bleeding was from the marginal ulcer. Given its endoscopic appearance it is a low risk to re-bleed. Avoid alcohol and smoking. RUQ u/s [**6-27**]: 1. Patent TIPS. No ascites. 2. Borderline splenomegaly. 3. Limited assessment of the liver, but it is coarsened in echotexture compatible with known cirrhosis. Labs on Discharge: [**2124-6-29**] 01:05PM BLOOD WBC-7.9# RBC-3.50* Hgb-10.3* Hct-31.4* MCV-90 MCH-29.6 MCHC-33.0 RDW-17.4* Plt Ct-119* [**2124-6-29**] 06:05AM BLOOD Glucose-105* UreaN-20 Creat-0.9 Na-138 K-3.6 Cl-107 HCO3-25 AnGap-10 [**2124-6-29**] 06:05AM BLOOD ALT-28 AST-73* AlkPhos-96 TotBili-1.5 [**2124-6-29**] 06:05AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.0 Mg-1.8 Brief Hospital Course: 62 yo F with h/o EtOH cirrhosis c/b portal HTN and bleeding varices, s/p TIPS ([**2123**]) and h/o ischemic bowel s/p right colectomy and ileostomy reversal ([**2120**]), who recently relapsed with drinking who presented with upper GI bleed. #GI BLEED: Ms. [**Known lastname 2643**] was admitted to the MICU where she had an emergent EGD for suspicion of upper GI bleed. EGD showed a 1cm non-bleeding marginal ulcer at the site of the gastro-jejunal anastomasis from her prior Roux-en-Y gastric bypass as the most likely cause of her GI bleed. Given h/o portal hypertensive gastropathy and variceal bleeds, she had RUQ abdominal ultrasound which showed that TIPS was patent with no ascites/splenomegaly. She received 4 units of blood total, and her HCT bumped from 20 to 26 following transfusion. She had one more episode of black stool and large BRBPR while in the MICU on HD #2, no further episodes after this. She initially received Octreotide on admission, this was DC'd once lower suspicion for variceal bleed. EGD showed nonbleeding ulcer at GJ anastomosis which was likely source of bleed. She was initially on pantoprazole gtt, later switched to pantoprazole 40mg IV BID and Carafate susp 2gm [**Hospital1 **]. She also received 3-day course of Ceftriaxone for SBP prophylaxis. Her home spironolactone and Lasix were held in MICU in setting of GI bleed. Heparin prophylaxis was held in MICU given recent GI bleed. Patient was then transferred to the floor where her hct remained stable. On discharge, she will take 3 days of Cipro 500mg [**Hospital1 **] for SBP prophylaxis, will continue carafate, increase her home PPI dose from qd to [**Hospital1 **]. She will have labs re-checked and faxed to liver clinic on [**2124-7-3**] to assure her hct remains stable. . # ALCOHOLIC CIRRHOSIS: The patient's home furosemide, spironolactone were held in setting of GI bleed. Her lactulose was held in MICU per her preference. . #ALCOHOL WITHDRAWAL: At admission to the MICU, the patient reported a fear of going into alcohol withdrawal even though her last drink was just on the morning of her admission. The patient did not score per CIWA while in MICU, so it was discontinued. She received her home folate, multivitamins, and thiamine. Patient was interested in outpt program to stop drinking. Spoke with social work. . #THROMBOCYTOPENIA: The patient's platelet count at admission was 92 and decreased to 58 on [**2124-6-28**]. The thrombocytopenia could be secondary to decreased production by a hypocellular bone marrow as seen in cirrhosis, but is most likely dilutional given the patient's transfusion with several units of pRBCs. . #ACID-BASE DISTURBANCE: The patient had an initial AG of 21. Her AG metabolic acidosis could be secondary to alcoholic or starvation ketoacidosis. Based on her initial blood gas, the patient also had a primary respiratory alkalosis, likely secondary to hyperventilation from her anxiety. She also had a primary metabolic alkalosis, likely secondary to volume contraction alkalosis given her GI bleed. Her AG closed over the course of her hospitalization. . #ANXIETY: Ms. [**Known lastname 2643**] received Lorazepam prn for her anxiety. . #RASH: The patient's rash was serpiginous in appearance, most c/w tinea corporis (with many overlying excoriations). She received Clotrimazole cream and oral fluconazole for treatment of her rash. Will need outpatient derm follow up given severity and chronicity of rash. Wanted to see derm in clinic in [**Location (un) 55**], provided contact information. . #DEPRESSION: The patient was continued on her home gabapentin. . #HYPOTHYROIDISM: The patient was continued on her home levothyroxine sodium. . TRANSITIONS OF CARE: -will have cbc/chem10/coags/LFTs checked on [**7-3**] and faxed to liver clinic -wil be seen in liver clinic as outpt -will take Cipro 500mg PO bid x3 days -changed PPI dosing from qd to [**Hospital1 **], will need to be changed back to qd as outpt -started carafate, may need to be d/c'ed as outpatient Medications on Admission: Levothyroxine 50 mcg PO QD Lansoprazole 30 mg DR [**Last Name (STitle) **] oxide 400 mg PO QD Furosemide 40 mg PO QD Spironolactone 25 mg 2 tablets PO QD Folic acid 1 mg PO QD B complex vitamin 1 cap PO QD Senna 8.6 mg 1 tab PO BID Docusate sodium 100 mg PO BID Gabapentin 300 mg cap PO TID Oxycodone 5 mg 1-2 tablets PO Q3H Lactulose 10 gm/15 ml syrup, 30 ml PO QID Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Senna 1 TAB PO BID:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Gabapentin 300 mg PO Q8H 5. Sucralfate 1 gm PO BID Please give separately from other meds so do not affect absorption RX *Carafate 1 gram twice a day Disp #*30 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg once a day Disp #*30 Tablet Refills:*2 7. FoLIC Acid 1 mg PO DAILY 8. Bacitracin Ointment 1 Appl TP QID RX *bacitracin zinc 500 unit/gram four times a day Disp #*1 Tube Refills:*2 9. Clotrimazole Cream 1 Appl TP [**Hospital1 **] RX *Antifungal (clotrimazole) 1 % twice a day Disp #*1 Tube Refills:*2 10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX *lansoprazole 30 mg twice a day Disp #*60 Tablet Refills:*2 11. [**Hospital1 **] Oxide 400 mg PO DAILY 12. Furosemide 40 mg PO DAILY 13. Spironolactone 50 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain take 1-2 tabs for pain as needed 15. Vitamin B Complex 1 CAP PO DAILY 16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX *Cipro 500 mg twice a day Disp #*6 Tablet Refills:*0 17. Outpatient Lab Work Please check CBC, Chem10, LFTs, coags on [**2124-7-3**] and fax results to: Liver clinic Fax: [**Telephone/Fax (1) 24156**] Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleed Discharge Condition: Patient's physical examination is unchanged at time of transfer to floor. Discharge Instructions: Dear Mrs. [**Known lastname 2643**], It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted on [**2124-6-26**] because you had several bloody bowel movements suggesting that you had bleeding of your gastrointestinal tract. You received an esophagogastroduodenoscopy which showed a small ulcer in your stomach as the most likely source of your bleed. You were treated with several units of blood, and your red blood cell count has increased in response to your transfusion. We also treated your chronic rash, most likely ringworm, with an antifungal cream, Clotrimazole. As we discussed, please call the dermatology clinic in [**Location (un) 55**], information is below. . Please attend the follow up appointments listed below. . We have made the following changes to your medications: START -Ciprofloxacin 500mg twice per day for 3 days -Sulfacrate 1g twice per day until your doctor tels you to stop -Thiamine 100mg daily -Clotrimazole cream twice per day, apply to rash -Bacitracin cream 4 times per day, apply to scratches on legs until healed CHANGE Lansoprazole from 30mg daily to twice per day; take at this frequency until your doctor tells you to stop. Please have your labs checked this [**Last Name (LF) 766**], [**7-3**] and the results will be faxed to the transplant clinic. Followup Instructions: Department: Liver Center With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: [**7-14**] at 12:20pm Phone: [**Telephone/Fax (1) 24157**] Department: DERMATOLOGY [**Country **] Dermatology and Laser Center [**Location (un) **] # 104 [**Location (un) 55**] ([**Telephone/Fax (1) 31239**] Please call to schedule an appointment Department: DERMATOLOGY When: WEDNESDAY [**2124-8-2**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11937**], PA [**Telephone/Fax (1) 3965**] Building: None [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: ORTHOPEDICS When: FRIDAY [**2124-8-25**] at 9:40 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: SPINE CENTER When: FRIDAY [**2124-8-25**] at 10:00 AM With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8603**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2124-6-29**]

Admission Date: [**2147-1-5**] Discharge Date: [**2147-1-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8684**] Chief Complaint: Difficulty Breathing Major Surgical or Invasive Procedure: Cardiac cath trans-esophageal echo Dual chamber biv pacemaker placement ICD placement intubation History of Present Illness: 81 year old male with a history of hypertension, hypothyroidism, and a pacemaker x 5 years for complete heart block; presents with sudden onset of shortness of breath this morning ([**2147-1-5**]) at 5am. He was awakened out of sleep with difficulty breathing that improved when he sat up. He called his son on the phone, then called the fire department and was subsequently taken to the [**Hospital1 18**] Emergency Department. . He admits to having orthopnea and PND. He denies chest pain, dizziness, syncope, headaches, cough, fevers/chills, or nausea,vomiting,or diarrhea. The patient states that he has experienced some exertional dyspnea in the past. He admits that he has a limited activity level due in part to dyspnea, but he mainly complains of bilateral lower extremity pain with walking, that improves with rest. He describes this pain as arthritis in his knees and hips, but also has pain in both calves as well. . On admission he stated that he feels a lot better since being in the hospital on oxygen. Past Medical History: Hypertension Hypothyroidism Pacemaker (biventricular) x 5 years Complete heart block Social History: A retired car salesman and WWII vet. He states that he drinks alcohol socially, he smokes [**1-2**] pack per day for 60 years. He lives alone, his wife passed in [**Month (only) 116**]. He has 2 sons and 3 daughters all of whom live nearby. Family History: No known cardiac disease Physical Exam: On admission: vitals: T 98.9, HR 65 paced, BP 144/61, O2sat 96%ra, 98%2L General appearance: Elderly man, comfortable alert and oriented x 3, in no apparent distress. HEENT: AT-NC, CN II-XII grossly intact, EOM-intact, no facial asymmetry Neck: supple, no masses, no tenderness, carotid pulses 2+ bilaterally, no carotid bruits, no JVP Pulm: clear to auscultation, no crackles, no wheezes CV: occasional early beats, no S3, no murmurs, no extra heart sounds appreciated Abdomen: Obese, soft non-tender, non-distended, no organomegaly, no masses or bulges. Ext: 2+ bilateral lower extremity edema. Weak dp pulses bilaterally, no pt pulses. Dry flaky skin on dorsal tibial surface, no chronic venostasis changes. Pertinent Results: [**2147-1-5**] 07:45AM GLUCOSE-116* UREA N-22* CREAT-1.3* SODIUM-141 POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-24 ANION GAP-17 [**2147-1-5**] 07:45AM PHOSPHATE-3.9 MAGNESIUM-1.8 [**2147-1-5**] 07:45AM WBC-5.4 RBC-4.59* HGB-14.1 HCT-41.1 MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 [**2147-1-5**] 07:45AM NEUTS-70.6* LYMPHS-22.5 MONOS-6.0 EOS-0.7 BASOS-0.1 [**2147-1-5**] 07:45AM PLT COUNT-159 [**2147-1-5**] 07:45AM PT-14.8* PTT-26.0 INR(PT)-1.5 [**2147-1-5**] 07:45AM CK(CPK)-193* [**2147-1-5**] 07:45AM cTropnT-0.05* [**2147-1-5**] 07:45AM CK-MB-6 [**2147-1-5**] 02:30PM CK(CPK)-132 [**2147-1-5**] 02:30PM cTropnT-0.05* [**2147-1-5**] 02:30PM CK-MB-5 proBNP-2746* [**2147-1-5**] 02:30PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-71 TOT BILI-1.1 [**2147-1-5**] 02:30PM POTASSIUM-4.5 [**2147-1-5**] 02:55PM K+-4.6 [**2147-1-5**] 07:45AM D-DIMER-1240* . Brief Hospital Course: 81 yo male, initially admitted for SOB/CHF exacerbation; hospital course discussed by problem. # Dyspnea- he had been ruled out for a PE by CTA done in the ED. The patient appeared to fluid overloaded in likely CHF exacerbation by exam and by CXR. The patient was diuresed effectively with IV Lasix. He also had a troponin leak up to .06, peak CK in 300's. An echo was done which showed global hypokinesis and an EF of 15%. Cardiology was consulted, and the patient underwent a P-MIBI, which revealed LV enlargement and a mild, fixed defect of inferior wall. Cardiac cath was discussed with and subsequently performed on the patient, which demonstrated no CAD, but severely depressed LVEF. The patient's ACE was increased, and a statin, low-dose beta-blocker, and Lasix were initiated, with an improvement in his symptoms. Given the patient's low EF, a EP consult was obtained for possible ICD placement. Prior to pacer/ICD placement, the patient underwent a TEE to evaluate for possible atrial thrombus, none was found. . On [**1-11**], the patient had a [**Hospital1 **]-ventricular pacemaker and ICD placed, but EP studies on [**1-13**] showed that the RV lead was not in the correct position. The patient had been started on anticoagulation for Afib/flutter, so FFP was given to reverse his INR in preparation for EP re-positioning of RV lead. However, the patient became acutely SOB and hypertensive while in EP lab. The patient was intubated and given 40 mg IV Lasix, and nitroglycerin and the EP procedure was completed. He was then transferred from to the CCU for CHF and ventilator management. . While in the CCU, the patient the patient became tachy and hypotensive, required dopamine for 24 hours to maintain pressure. Cardiac enzymes were repeated, and an echo was repeated to rule out tamponade. The patient improved with aggressive diuresis, was successfully weaned off pressors and extubated. Although the patient had one temperature spike during the CCU, no infectious source was found, and he received 48 hours of empiric antibiotics following the EP procedure. The patient was transferred back to the medicine floor and remained hemodynamically stable and afebrile, with no further episodes of chest pain or shortness of breath. . # CHB- his pacemaker was upgraded to dual chamber [**Hospital1 **]-ventricular pacer along with the ICD. He will be followed in the device clinic, with his first appointment on [**2147-1-20**]. . # h/o a-fib/aflutter- He was rate controlled with Lopressor, titrated up to a dose of 25 mg [**Hospital1 **], given that his blood pressure tolerates this. He was also started on Coumadin, initially mg, titrated down to 2.5 mg every evening. INR monitoring will be required on a daily basis to ensure correct dosing for a target range of 2.0-3.0 . # L upper extremity edema- Following his stay in the CCU, the patient's LUE was noted to be edematous and an ultrasound was obtained which confirmed a DVT. The patient was already on Coumadin, but a heparin drip was started as his INR at that time was subtherapuetic. . # hypothyroidism- He was continued on his current dose of Levoxyl, and thyroid studies were done which showed an elevated TSH and low free T3, however no medication changes were made during this acute exacerbation of CHF. . # Hypertension- The patient's blood pressure remained well controlled following the procedure and his stay in the CCU. A number of new medications (beta blocker, Lasix, ACE increase) were started to help optimize his cardiac health, however, these may need to be tailored to prevent hypotension. The patient was ruled out for both tamponade and infection as potential causes of hypotension. . # FEN- The patient was placed on fluid restriction of 1.5L per day and tolerated a low sodium/cardiac diet well. His electrolytes were carefully monitored in the setting of diuresis, with occasional K+/Mg repletion. . The patient was evaluated by physical therapy, who recommended the patient be admitted to a rehab facility. This was discussed with both the patient and his family, including his HCP; and he was subsequently discharged to [**Hospital 100**] Rehab for further rehabilitation. The patient will need follow-up with the EP/device clinic as described above. Medications on Admission: aspirin 325 mg PO daily Lisinopril 5 mg PO daily Levothyroxine 112 mcg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*0* 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: CHF, both diastolic and systolic dysfunction complete heart block atrial fibrillation hypertension hypothyroidism Discharge Condition: good Discharge Instructions: You have been started on three new medications that are listed below. Please take these and all of your medications as instructed. Please DO NOT start taking the warfarin until tomorrow night. Warfarin is a medication that keeps your blood thin and to prevent blood clots. However, you have an increased risk of bleeding while on this medication, particularly after any type of fall or injury. Please call your doctor if you develop any chest pain, shortness of breath, fevers, chills, or vomiting. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2147-1-20**] 11:00 . You will need to make a follow-up appointment with Dr. [**Last Name (STitle) **] after your discharge. Please call [**Telephone/Fax (1) 12483**] for an appointment.

Admission Date: [**2173-12-13**] Discharge Date: [**2173-12-20**] Date of Birth: [**2173-12-13**] Sex: M Service: Neonatology HISTORY: This is a 30 2/7 weeks' gestational age male delivered pre term due to pregnancy-induced hypertension and early HELLP. Mom is a 26-year-old G2, P now 2. Prenatal screens: Blood type A negative, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, GBS status unknown. EDC was [**2173-2-18**]. Obstetrical history notable for previous pre-term delivery at 33 weeks. Mom had a C-section for pregnancy-induced hypertension with that pregnancy. This pregnancy was also complicated by pregnancy-induced hypertension which was progressive despite multiple antihypertensive agents. Was admitted to [**Hospital6 3872**] on [**12-13**] with left lower quadrant and epigastric pain, blood pressure 180/114, and elevated LFTs with an AST of 169 and an ALT of 58 and 3 plus proteinuria. Platelets normal at 327. On ultrasound there was a biophysical profile of [**8-1**] and an amniotic fluid index of 13, estimated fetal weight of 1280 grams, which was the 10th percentile. Mom was given labetalol and magnesium, betamethasone and was transferred to [**Hospital1 69**]. Here, the patient was sectioned due to probable early HELLP syndrome. Infant emerged with spontaneous cry, required only blow-by O2, and routine care in the Operating Room. Apgars were 7 at 1 minute and 8 at 5 minutes. Was transferred to the NICU secondary to prematurity. PHYSICAL EXAMINATION ON ADMISSION: Weight 1430 (55th percentile), length 42 cm (75th percentile), head circumference 27 cm (30th percentile). General: Patient was a non-dysmorphic male infant with overall appearance consistent with gestational age. Anterior fontanel open and flat. Palate intact. Red reflex was present bilaterally. Patient was grunting, flaring, and retracting with breath sounds slightly diminished bilaterally but symmetric. Heart: Regular rate and rhythm; no murmur. Normal peripheral pulses, including femoral pulses. Abdominal exam: Benign without hepatosplenomegaly or masses; three vessel cord. Normal male genitalia for gestational age. Back: Normal. Extremities: Unremarkable. Hip exam: Deferred. Skin: Pink and well perfused; good tone and strength for gestational age. NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS: 1. Respiratory: Patient was intubated for progressive respiratory distress. Received 1 dose of surfactant, was extubated on day of life 2 to C-PAP, and was off C-PAP to room air by day of life 3. Subsequently has been breathing comfortably in room air. 2. Cardiovascular: Patient has been cardiovascularly stable throughout admission with normal blood pressures. Patient has had no episodes of apnea and bradycardia of prematurity and therefore has never been started on caffeine. 3. FEN: Patient initially NPO and started on IV fluids at 80 cc/kg per day. Enteral feeds of Special Care 20 initiated on day of life 2 and tolerated well. Feeds were slowly advanced as tolerated, and patient reached full feeds of 150 cc/kg per day of Special Care 20 on the evening of [**2173-12-19**]. Calories were increased on [**2173-12-20**] to 22 calories an ounce. Electrolytes have remained within normal limits. Last set of electrolytes on [**2173-12-17**] with a sodium of 145, potassium of 5.6, chloride of 116, and bicarbonate of 19. Patient's weight at birth 1430 grams, patient's weight at time of transfer on [**2173-12-20**] was 1395 grams. 4. GI: Bilirubin levels were followed. Patient's bilirubin peaked at 10.3/0.3 on day of life 3, and single phototherapy was initiated. Phototherapy was discontinued on [**2173-12-18**] with rebound bilirubin level on [**2173-12-19**] of 6.6/0.4. Bilirubin checked again in [**2173-12-20**] was 6.8/0.3. 5. Hematology: CBC sent on admission with a hematocrit of 54 percent and platelets of 227. CBC was repeated on day of life 2 with a hematocrit of 49 percent and a platelet count of 189. Patient required no blood products during this hospitalization. Mom's blood type A negative. Baby's blood type A positive, Coombs negative. 6. Neurology: Patient had a head ultrasound performed on [**2173-12-20**] which was unremarkable. 7. ID: Patient had a CBC and blood culture sent on admission. Initially had a low white count of 3.7 with 47 polys and no bands. CBC was repeated on day of life 2 and the white count was up to 4.4 with 63 polys and 1 band. Patient was treated with ampicillin and gentamicin. Blood cultures with no growth at 48 hours, and antibiotics were discontinued. 8. Sensory: Audiology hearing screen not yet performed. Ophthalmology exam not yet performed. 9. Psychosocial: [**Hospital1 18**] social worker involved with the family throughout hospitalization. Social worker can be reached at [**Telephone/Fax (1) 8717**]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Patient transferred to Level 2 NICU at [**Hospital3 1280**]. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 60010**], [**Telephone/Fax (1) 46247**] CARE AND RECOMMENDATIONS: Feeds at discharge: Total fluids are to 150 cc/kg per day of Special Care 22 by gavage tube. MEDICATIONS: None. Patient will need a car seat test prior to discharge home. Newborn State screens sent and pending at time of discharge. Patient has not received any immunizations during this hospitalization. Patient will require RSV prophylaxis upon discharge home. DISCHARGE DIAGNOSES: 1. Prematurity at 30 weeks gestational age 2. Respiratory distress syndrome 3. Rule out sepsis 4. Hyperbilirubinemia [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2173-12-20**] 11:47:27 T: [**2173-12-20**] 12:22:59 Job#: [**Job Number 60011**]

Admission Date: [**2109-2-16**] Discharge Date: [**2109-2-19**] Service: MICU CHIEF COMPLAINT: Choking. HISTORY OF PRESENT ILLNESS: This is a 78-year-old female with severe Parkinson's disease found unconscious and unresponsive with agonal breathing. Family reports the patient choked on some chicken. They proceeded to do CPR and the Heimlich and retrieved some chicken with fingers. Patient emergently was intubated at the scene, and afterwards her vitals were a pulse of 161, blood pressure 150/88. Pulse came down to 100 and she was 98% on 100% O2. Patient received a 500 cc bolus of normal saline. In the Emergency Department, patient's vitals were pulse 118, blood pressure 171/64, respiratory rate 17, and 100% O2. Of note, the family thinks the patient was choking on chicken for about three minutes and was totally nonresponsive without palpable pulse for about two minutes. Also of note, the patient is on her 6th day of treatment for urinary tract infection with Cipro. Family states that the patient was slightly more fatigued, but otherwise at her baseline with severe Parkinson's disease, and not oriented. Patient had good po intake, no other localizing signs. There is a question of a transient ischemic attack 2-3 weeks ago. In the MICU, patient was found to have right lateral gaze and deviation, and was sent for head CT scan. PAST MEDICAL HISTORY: 1. Parkinson's disease. 2. History of multiple falls, status post subarachnoid hemorrhage in [**2104-3-5**], status post right pelvic fracture in [**2103**]. 3. Dementia. 4. Coronary artery disease, echocardiogram in [**2104-3-5**] showed an ejection fraction of 40% with anteroseptal hypokinesis. 5. History of deep venous thrombosis, pulmonary embolus, not currently on anticoagulation. 6. Depression. 7. Status post IVC filter placement in [**2104-5-5**]. 8. History of urinary tract infections with mental status changes. MEDICATIONS: 1. Aspirin 325 mg po q day. 2. BuSpar 10 mg po qid. 3. Lactulose. 4. Multivitamin. 5. Prilosec 20 mg po q hs. 6. Remeron 30 mg po q hs. 7. Seroquel 25 mg po prn. 8. Sinemet 25/100 one tablet po tid. 9. Trazodone 50 mg po tid. 10. Tylenol prn. 11. Cipro day six. 12. Premarin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient lives with her daughter. There is no history of tobacco or alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vitals: Pulse 124, blood pressure 147/64, respiratory rate 14, and O2 saturation 100%, vent set at SIMV respiratory rate of 12, tidal volume of 500, PEEP of 5, and FIO2 of 100%. In general, the patient is awake, but intubated. Lungs are clear to auscultation bilaterally anteriorly. Cardiovascular: Tachycardic, no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, normoactive bowel sounds. Extremities: 2+ pedal pulses, no clubbing, cyanosis, or edema. Neurologic: Right lateral gaze deviation, no movement past midline, pupils are equal, round, and reactive to light and accommodation. Moves both upper extremities spontaneously, increased rigidity diffusely, Babinski upgoing bilaterally. LABORATORIES: White count 18.5, hematocrit 38.2, platelets 505. Sodium 140, potassium 4.1, chloride 101, bicarb 21, BUN 22, creatinine 1.0, glucose 149. Arterial blood gas: 7.36, 41, 233. CHEST X-RAY: Rotated, ETT in good position, no cardiopulmonary infiltrates. HEAD CT SCAN: No hemorrhage. ELECTROCARDIOGRAM: Normal sinus rhythm at 118 beats per minute, left axis deviation, normal intervals, Q waves in V1 through V2, no change from [**2103**]. Echocardiogram from [**2104-4-4**]: Ejection fraction of 40%, mild-to-moderate hypokinesis in the anteroseptal and apical walls, RV normal. EGD from [**2108-3-5**]: Hiatal hernia, grade II esophagitis, Barrett's. C-scope from [**2108-3-5**] shows grade I internal hemorrhoids. HOSPITAL COURSE: In short, this is a 78-year-old female with a history of severe Parkinson's, multiple falls, who presents status post choking. Patient most likely had temporary-complete airway obstruction and possible pulseless electrical activity. The patient was emergently intubated and required no defibrillation. 1. Pulmonary: The patient has no known lung disease. Because of her episode and fear of any residual foreign objects, the patient was bronched. This revealed no evidence of upper airway obstruction. Patient's vent was changed from SIMV to CPAP with pressure support. She was taking good ventilations with very little sedation. The patient was noted to have very thigh secretions on suctioning. There was a question of aspiration pneumonia especially given elevated white count. Discussion took place with the daughter, who is the proxy. Decision was made to extubate the patient despite the large volume of secretions. The daughter was well aware of the risks, benefits. If the patient remained intubated, she would be much more likely to develop vent-acquired pneumonia. If she was extubated, there was a significant risk of drowning in secretions. The patient's daughter chose the latter choice, according to her what she thought her mother would want. There was no plan to reintubate once extubated. Patient was extubated on [**2109-2-19**]. Following extubation, the patient became tachypneic and uncomfortable. Patient's comfort was maximized with Morphine drip. Because of the revised goals, the patient was transferred to the floor. The following day, she was transferred to hospice care. 2. Heme: The patient was noted to have a hematocrit drop from 38.2 to 30.3. She was also having coffee-grounds suctioned. Her hematocrit further decreased to 25. The patient was treated with 2 units of packed red blood cells. Her hematocrit came up to 32. The patient had no further coffee-grounds, and he hematocrit stabilized. No nasogastric lavage was performed. Hematocrit came up to 32 and remains stable. 3. Infectious Disease: The patient developed a fever, although her white count came down. Fever was up to 101.3. Blood cultures and urine cultures were negative. Chest x-ray showed no sign of infiltrate. No antibiotics were initiated. 4. Neurologic: Patient has known severe Parkinson's on Sinemet. Although despite the lateral gaze deviation, the patient's head CT scan was negative. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Carbidopa/levodopa 25/100, one tablet po tid. 2. Morphine prn. 3. Lansoprazole. DISCHARGE INSTRUCTIONS: The patient is discharged to hospice care. She is to followup with Dr. [**Last Name (STitle) 1266**] as needed. Patient's other medications can be restarted according to the wishes of the family and PCP. DISCHARGE DIAGNOSES: 1. Respiratory arrest status post foreign object removal. 2. Possible pulseless electrical arrest secondary to complete airway obstruction. 3. Upper gastrointestinal bleed, status post 2 units of packed red blood cells. 4. Parkinson's. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**] Dictated By:[**Name8 (MD) 4990**] MEDQUIST36 D: [**2109-6-10**] 14:46 T: [**2109-6-13**] 12:38 JOB#: [**Job Number 21553**]

Admission Date: [**2102-6-5**] Discharge Date: [**2102-6-17**] Service: MEDICINE Allergies: Quinidine Attending:[**First Name3 (LF) 905**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Left hemi arthroplasty, removal of internal medullary nail from femur which was placed 5 months ago History of Present Illness: Mr. [**Known lastname 19434**] is a 89 year old male with CAD, CHF, COPD, Afib, CRI, L femur fracture [**1-11**]; presents following fall with pain in L hip. He was at a golf course today, standing and watching when he said he slipped and/or his leg gave out from under him, causing him to fall. He immediately felt pain in his left hip. Denies LOC, denies hitting head or neck. Was feeling fine earlier in the day. Fall witnessed by others. He fractured his L midshaft femur in [**1-11**] with nail placement. . Pt has extensive history of CAD with CHF and CRI. CABG in [**2074**]'s; last cath [**2085**]. Believes he has not had an MI since CABG but prior have "5 or 6". Ambulates around his house and the length of a few houses, but does not do stairs at home. Also with h/o COPD and says O2 sats are in the low 90's at best when checked. Past Medical History: # CAD, history of inferior and apical wall MI, s/p CABG [**2074**], Cath [**2085**]: 3VD, SVG's to the OM1 and LAD are widely patent; Occluded SVG to the PDA # CHF, last ECHO EF <30% [**2101-6-4**] at Dr.[**Name (NI) 5765**] office # Atrial fibrillation s/p DCCV in [**2089**] on amio since [**2090**] # Atrial flutter secondary to quinidine, s/p ablation [**2090**] # Severe tricuspid regurgitation w/ moderate PHTN # Pleural fibrosis s/p pleurectomy [**2077**] # COPD, PFTs [**2099**]: FEV1 60% FVC 71% FEV1/FVC1 119% # Peripheral vascular disease # CRI: baseline creatinine 2.0 # Hypothyroidism [**1-6**] amiodarone # Psoriasis # Distal abdominal aorta anuerysm # Basal and squamous cell carcinomas Social History: Patient lives with wife in [**Name (NI) **]. He is a former furniture and carpet salesman. He used to be in the army and was an instructor for the airforce. He has a 138 pack year history, quit in [**2074**] prior to CABG. Ocassional glass of wine socially. Family History: Father-MI Physical Exam: PE and vitals on admission V: 97.1 140/70 85 20 94% 4L NC Gen: very pleasant, lying in bed in NAD HEENT: NC/AT. EOM: full range of motion. Tonsils are non-erythematous. Neck: soft, no lymphadenopathy. CV: nl S1/S2. with 2/6 systolic murmur throughout precordium Pulm: no crackles appreciated. Diffuse wheezes and rhonchi throughout Abd: soft and non-tender, ND, +BS Ext: Both UE and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to palpation. LLE- Able to wiggle toes and has full sensation to light touch. bilateral 1+ edema, L>R. R anterior thigh with dressings [**1-6**] recent "skin cancer removal" Neuro: A&Ox3 . Vitals and exam on discharge: 97.3 110/60 91 20 93% on 2L 240/incontinent Exam mostly unchanged. See following. CVS: irregularly irregular Pulm: scattered rhonchi with diffuse wheezes, good air movement Abd: soft, NTND, +bs Ext: upper and lower extremities warm, dressings on LLE c/d/i, no erythema or warmth. dressing on RLE c/d/i. bilateral +1 edema Pertinent Results: [**2102-6-5**] 02:50PM GLUCOSE-102 UREA N-45* CREAT-2.3* SODIUM-147* POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-29 ANION GAP-14 [**2102-6-5**] 02:50PM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-2.7* [**2102-6-5**] 02:50PM WBC-6.3 RBC-4.10* HGB-12.2* HCT-38.8* MCV-95 MCH-29.6 MCHC-31.3 RDW-15.2 [**2102-6-5**] 02:50PM NEUTS-71.2* LYMPHS-22.4 MONOS-3.8 EOS-1.8 BASOS-0.8 [**2102-6-5**] 02:50PM PLT COUNT-162 [**2102-6-5**] 02:50PM PT-24.5* PTT-35.8* INR(PT)-2.5* . L hip/pelvis XRay: There is an intramedullary rod in the left femur with a single proximal screw. There is also varus angulation and deformity seen of the femoral head and neck and due to difficulty in positioning patient, this area is not fully evaluated; however, there is likely a fracture involving the femoral neck on the left side. Dystrophic calcifications are identified. There are degenerative changes and joint calcifications involving the right hip. Degenerative changes of the lower lumbar spine are identified. . L femur Xray: 1. As seen earlier today, there is an acute fracture of the left femoral neck. 2. The spiral fracture of the left femoral shaft is evaluated, and there is no change in fracture fragment position or hardware appearance compared to [**2102-4-20**]. There remains some angulation of the mid aspect of the more proximal to distal interlocking screws. . ECHO [**2102-6-12**] The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Low normal left ventricular systolic function without definite regional dysfunction. Mild mitral regurgitation. Pulmonary artery systolic hypertension. . CT HEAD done on [**2102-6-14**] for acute delirium There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. Surrounding osseous structures are unremarkable. The imaged portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No intracranial hemorrhage. . CXR ([**2102-6-16**]): PA and lateral views of the chest are obtained. Midline sternotomy wires are again noted. There is volume loss in the right lung, with apical pleural thickening. Linear atelectasis versus scar is noted in the right mid lung. Retrocardiac atelectasis is noted, which appears slightly increased from prior study. The heart is enlarged. There is no pneumothorax. Brief Hospital Course: # Hip fracture: pt had removal of previous hardware and plating/hemiarthroplasty - involved procedure. He has been evaluated by PT and progressed to functional mobility. . #Hypotension: after surgery pt had some episodes of hypotension, likely secondary to blood loss during surgery and agressive diuresis. We held his diuretic, gave his blood transfusions and his blood pressures have been stable in the 90's systolic. . #CHF: ECHO revealed LVEF 50% His lungs always sounded wet on auscultation. His BP dropped after surgery due to aggressive diuresis and blood loss. His lasix has been held, with no evidence of worsening CHF on chest x-ray ([**2102-6-16**]). He is maintaining his sats on 2L. He is very sensitive to the lasix as he drops his pressure. His rate was better controlled after starting the Amiodarone. This also helped his blood pressure. . # CAD: extensive history but stable during this hospitalization. Continued ASA, beta blocker, statin. . # COPD: former smoker, on inhalers at home without home O2 currently. Has been 80's to low 90's here. We continued his nebulizer treatments and albuterol while in the hospital. We titrated his O2 as needed, with a goal of O2 sat 90-93%. He has been maintaining this O2 on 2L nasal cannula. . #Afib: Afib has been stable over this hospitalization. Pt has a hx of being difficult to convert. His rate has been well controlled on amiodarone and metoprolol. . # Agitation, delirium: Initially a problem in the immediate post-surgical period, at which time it was controlled with pain management and Haloperidol PRN. Behavior however improved drastically and patient is very cooperative and pleasant without any intervention. . # Blood Loss: Baseline Hct near 28. He has some bleeding in the postoperative period from his surgical wound. He got blood transfusion. His HCT was stable for more than a week prior to discharge. Surgical wound was well healed and no blood is seen on bandage. . #Hypothyroidism: We continued the pt on his synthroid. . #Prophylaxis: He has been maintained on 30 lovenox daily (secondary to his kidney function) and was recently restarted on his home dose of Coumadin. His INR has been responding. Will need to stop lovenox after INR between [**1-7**]. His INR needs to be monitored closely due to the interaction with Amiodarone. Medications on Admission: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-6**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Atrovent 0.02 % Solution Sig: [**12-6**] puffa Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Aerochamber Inhaler Sig: One (1) Miscellaneous use with inhalers. 13. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal TID (3 times a day) as needed. 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Morphine Sulfate 1-2 mg IV Q4H:PRN 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours): Please stop when INR reaches 2 to 3. . 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12 () as needed for pain. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Left femoral neck fracture Secondary: Anemia, atrial fibrillation, Hypotension, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral vascular disease Discharge Condition: Stable Discharge Instructions: Please take all your medications and follow up with your appointments. Please do not hesitate to go to the emergency room or call your doctor if you have any worsening shortness of breath, nausea, vomiting, leg pain, dizziness or any other concerns. . Please monitor your INR every other day until it is between 2 and 3. Please stop Lovenox as soon as INR reaches 2. Please continue to take your coumadin and check your INR two times a week. Your coumadin may need to be adjusted because you are on Amiodarone. . Please check electrolytes frequently. If potassium is above 5.0 please give 30 mg of Kayexalate. . We have stopped your lasix for low blood pressures and renal failure while on the lasix. Please evaluate patient before re-starting lasix. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-6-22**] 8:10 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-6-22**] 8:30 . Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2102-9-28**] 9:00 . Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**6-13**] days from the day of discharge from the hospital. . Please make an appointment to follow up with Dr. [**Last Name (STitle) 1005**] in orthopedics in two weeks. Please call to make the appointment. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Admission Date: [**2203-8-3**] Discharge Date: [**2203-8-29**] Date of Birth: [**2140-12-30**] Sex: M Service: CARDIOTHORACIC Allergies: Anacin Attending:[**First Name3 (LF) 5790**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**2203-8-3**] Right thoracotomy and tracheoplasty with mesh, right mainstem bronchus and bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. [**2203-8-15**] - tracheostomy [**2203-8-25**] Flexible bronchoscopy with bronchoalveolar lavage. History of Present Illness: The patient is a 62-year-old gentleman who has severe COPD was found have severe diffuse tracheobronchomalacia. He had marked improvement in dyspnea with a silicone Y-stent, and presents for tracheobronchoplasty. He is using inhalers as prescribed with some sx improvement and using oxygen at night. Without O2 he is satting about 88-90%. He had a mild URI several months ago and fully recovered from it. He is able to walk several blocks w/o stopping; he is OK going up one flight of stairs but usually needs a break at the end. He presents now for surgery. Past Medical History: # Diabetes mellitus type 2 -- followed at [**Last Name (un) **], on Insulin and Victoza -- last HgbA1c 9.2% on [**2202-12-14**] # COPD -- former heavy smoker -- good functional capacity # Tracheobronchomalacia -- severe on CT and bronchoscopy ([**8-/2202**]) -- excellent results with stent trial -- considering tracheobronchoplasty # Diastolic CHF -- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology -- last echo ([**2200-9-19**]) with LVEF > 60% -- stable on Furosemide 60 mg PO daily -- mild lower extremity edema # Osteoarthritis -- stable symptoms # Narcotics Contract -- stable Percocet regimen -- last renewed on [**2202-3-3**] # Hypertension -- recently added Hydralazine # GERD -- no symptoms recently # Chronic kidney disease stage III -- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] -- stable creatinine around 1.5 -- Calcitriol for elevated PTH Social History: # Diet: He has had difficulty improving his diet. His weight has remained fairly stable. # Exercise: Walks approximately one mile each day and is fairly physically active given his medical issues. # Smoking: Quit approximately six years ago and previously smoked 0.5-1 pack per day since the age of 12. # Alcohol: No alcohol in 15 years, stopped after getting sick from drinking too much wine at a party. # Drugs: None Family History: # Mother -- died at age 58 from DM complications # Father -- died at age 73 from "[**Last Name **] problem" but not MI Physical Exam: BP: 171/70. Heart Rate: 63. Weight: 251.8. BMI: 35.4. Temperature: 95.7. O2 Saturation%: 90. Alwake alert oriented lungs clear w/o wheezing heart regular abd soft, not distended Pertinent Results: [**2203-8-3**] 11:20AM HGB-15.1 calcHCT-45 [**2203-8-3**] 01:17PM HGB-14.6 calcHCT-44 O2 SAT-97 MET HGB-0 [**2203-8-3**] 01:17PM GLUCOSE-119* LACTATE-1.4 NA+-140 K+-3.7 CL--104 TCO2-27 [**2203-8-3**] 05:27PM WBC-16.1*# RBC-5.43 HGB-14.5 HCT-45.6 MCV-84 MCH-26.6* MCHC-31.7 RDW-16.3* [**2203-8-3**] 05:27PM CALCIUM-7.9* PHOSPHATE-4.9*# MAGNESIUM-1.5* [**2203-8-3**] 05:27PM CK-MB-14* MB INDX-0.8 [**2203-8-3**] 05:27PM CK(CPK)-1719* [**2203-8-3**] 05:27PM GLUCOSE-136* UREA N-18 CREAT-1.6* SODIUM-141 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-27 ANION GAP-11 [**2203-8-14**] Chest CT : 1. Status post tracheobronchoplasty. ET tube in place with fluid within the distal trachea. Persistent narrowing of the central airways. 2. Since [**2203-8-1**], new large right, and moderate left loculated pleural effusions. 3. New diffuse bilateral ground glass opacities with prominent pulmonary vasculature, likely edema. 4. Bilateral lower lobe opacities, likely atelectasis, cannot exclude infection. 5. Emphysema. 6. Prior granulomatous disease. [**2203-8-18**] Bilat lower ext duplex : No evidence of deep vein thrombosis in either leg. [**2203-8-23**] Chest CT : 1. Extensive bilateral diffuse ground-glass opacities with associated bibasilar severe atelectasis and small pleural effusions along with the severe tracheobronchial stenosis suggest that a combination of upper airway obstruction, pulmonary edema, atelectasis, and likely a concurrent infectious process might be contributing to the patient's difficulty to wean off the vent. 2. Enlarged mediastinal lymph nodes, not significantly changed compared with prior studies. [**2203-8-29**] CXR : In comparison with the study of [**8-27**], the monitoring and support devices remain in place. Continued enlargement of the cardiac silhouette with indistinct pulmonary vessels and bilateral areas of pulmonary opacification, consistent with pulmonary edema and multifocal pneumonia. [**2203-8-12**] 4:20 pm SPUTUM SPUTUM. **FINAL REPORT [**2203-8-15**]** GRAM STAIN (Final [**2203-8-12**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2203-8-15**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SERRATIA MARCESCENS. 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. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | SERRATIA MARCESCENS | | CEFEPIME-------------- 2 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S 4 S TRIMETHOPRIM/SULFA---- <=1 S [**2203-8-18**] 11:42 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2203-8-22**]** GRAM STAIN (Final [**2203-8-18**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2203-8-22**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | SERRATIA MARCESCENS | | CEFEPIME-------------- 4 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 I <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM------------- 1 S <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S 8 I TRIMETHOPRIM/SULFA---- <=1 S [**2203-8-25**] 12:37 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2203-8-25**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2203-8-27**]): Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). ~[**2191**]/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. FUNGAL CULTURE (Preliminary): YEAST. Brief Hospital Course: Mr. [**Known lastname 108993**] is a 62 year old admitted for tracheobronchomalacia on whom we performed tracheobronchoplasty with posterior splinting on [**2203-8-3**]. The procedure went without complications. Post-operatively in the PACU he failed to extubate and was transferred to the trauma ICU. A chest xray at the time showed that the endotracheal tube ended 3.9cm above carina. The right chest tube was in place. There was only mild pulmonary edema, no pneumothorax, and bibasilar atelectasis. At the time he developed low urine output and received a 500 mL bolus. He was found to have persistent metabolic acidosis. On POD1, his chest tube was set to waterseal. A second attempt was made to extubate. He became hypoxic with oxygen saturations at 88%, so he was placed to CPAP. Due to respiratory distress, however, he required reintubation. At the time, a chest xray revealed subcutaneous emphysema tracking along the anterior chest wall and a pneumothorax. The chest tube was placed back onto -20 cm H2O suction. On POD2, his creatinine was elevated to 2.6. A FeNa was 0.2% and FeUrea was 31.8%. The patient was on furosemide at the time, so intrinsic renal failure was suspected given the FeUrea as FeNa is unreliable in patients on furosemide. He was put on D5 normal saline, and tube feeds were started via an orogastric tube. A chest xray at the time reveals a stable pneumothorax. A PICC line was placed for additional access. On POD3, the pleurovac was found to have a systems leak and was replaced. Tube feeds were advanced every 6 hours. FeUrea was 43.3, a non-diagnostic value. Creatinine was stable at 2. A sputum culture from POD1 grew our rare gram negative rods. On POD4, to optimize respiratory status, furosemide was continued and a 60mg IV dose administered. Mr. [**Known lastname 108993**] was started on levofloxacin and piperacillin/tazobactam at this time too because of the cultures. He was also having hypertension, and his metoprolol was increased from twice daily to thrice daily. We felt at this time the chest tube was working against the patient's ability to exhale efficiently, so we removed the chest tube. He developed a fever or 102.7 and so cultures were drawn. On POD5, the sputum cultures grew out pansensitive pseudomonas aeruginosa. Because of persistent hypertension with systolic blood pressures reaching the 190s, a labetalol drip was started and hydralazine started, which achieved better control. His FiO2 was increased from 40% to 60% due to low saturations of 80%. On POD6, he pass a spontaneous breathing trial on 0 and 5 inspiratory pressure support settings; however, after an extubation trial he became hypoxic at 5 minutes, desatting to 70%. He also became tachypnic and so he was reintubated. To optimize his ventilatory status, a fluid deficit was desired. To achieve it, his drips were concentrated. His cumulative balance that day was -500 mL. On POD7, a new left subclavian line was placed to begin a furosemide drip. Inhaled steroids were also added in an effort to optimize respiratory status. On POD8, sensitivities came back on the pseudomonas cultures, and vancomycin was discontinued. Ciprofloxacin was changed to PO. Fluid balance was -1.6L. On POD9, copious secretions were noted and repeat sputum cultures obtained. Fluid balance was -2.4L. On POD10, he developed a WBC of 18 and low grade temperatures, so he was pan-cultured. To double cover pseudomonas, piperacillin/tazobactam was started. The U/A was not conclusive for infection. On POD 11, WBC continued to rise to 21. A CT of the chest was performed to search a source that was potentially drainable. A large right pleural effusion was found as well as a smaller, left-sided loculated effusion. His PICC was draining purulent materal, and a PICC culture was sent but ultimately grew out nothing (final). His bronchoalveolar lavage culture was 2+PMNs, and grew out pseudomonas again. On POD12/0, a tracheostomy was performed in the OR. The operation went without complications, and post-operatively the patient was transferred directly to the trauma ICU. A Dobhoff tube was placed, and a thoracentesis of the pleural effusion was performed with cultures sent. No organisms were isolated. On POD13/1, loose stools prompted a C. diff toxin assay, which was negative. He had increased hypertension, so labetalol IV was given. His sedation medication, lorazepam, was switched to propofol in an effort to reduce his hypertension. A blood gas revealed respiratory alkalosis. On POD14/2, patient was foudn to have increased abdominal distention, and a KUB showed ileus. NGT was placed to low continuous suction, tube feeds held. Methylnaltrexone, a mu-opioid antagonist, was trialed with no effect. He was found also on CXR to have a R>L pleural effusion, for which interventional pulmonology was consulted for pigtail placement. He continued to be diuresed, receiving 40 mg furosemide IV. He was also febrile to 101.3 and so he was pan-cultured. Although the urine, pleural fluid, and blood cultures were negative, the sputum culture grew out serratia marcesens and pseudomonal aeruginosa. On POD15/3, bronchoscopy was performed for respiratory secretions. He was hypertensive and started on a labetalol drip. Based on ID recommendations, he was switched to cefepime. At this time, the source of leukocytosis was unclear but it was suggested the mesh may be colonized with pseudomonas aeruginosa. The pulmonology team, who had been consulted for failure to extubate, felt a wise course would be to permit lung rest on the ventilator and allow the pneumonia to pass prior to subsequent extubation attempts. So, he remained on the ventilator on POD16/4, and that day was otherwise unremarkable. On POD17/5, the pigtail catheter was removed; however, due to high PEEP requirements, the trauma ICU was unable to attempt trach mask. In an effort for further diuresis, on POD18/6 the tube feeds were concentrated. Also he was switched to D5 1/2NS for hypernatremia. Despite having been found to have persistent copious secretions, Mr. [**Known lastname 108993**] was able to be weaned to CPAP [**1-16**]. He self-discontinued his arterial line, which was replaced. On POD19/7, his mental status continued to improve, and bowel sounds were noted. Tube feeds were continued at goal. On POD20/8, his mental status continued to improve and he was able to answer questions. Despite SaO2>95%, he was having episodes of agitation, which improved with lorazepam. He was started on inhaled tobramycin for double-coverage of pseudomonas. A repeat CT chest did not show an appreciable drainable effusion. He was switched back to assist control for increased tachypnea despite normal oxygen saturations. On POD21/9 he had a J tube placed and tube feedings were continued which were well tolerated. His insulin requirements were graduaklly decreasing as his infection was controlled and his insulin was adjusted appropriately. Over the last few days his WBC had decreased nicely to the 14 range and he remains afebrile on Cefepine ( started [**2203-8-19**]) and inhaled Tobra (started [**2203-8-23**]). His antibiotics should continue thru [**2203-9-14**]. His secretions have decreased since his last bronchoscopy on [**2203-8-25**]. There was no exposed mesh or purulence noted. He has been weaning better with good CPAP trials and remains on O2 at 50% with IPS and PEEP both at 8 cm. He also has been evaluated by the Physical Therapy service closely and he needs continued encouragement and maximum assistance to increase his mobility and evantually be more independent. After a long, complicated course, he was discharged to rehab of [**2203-8-29**] and will follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Lisinopril 40 mg PO DAILY 2. Allopurinol 100 mg PO BID 3. Atenolol 50 mg PO BID 4. Amlodipine 10 mg PO DAILY 5. HydrALAzine 50 mg PO BID 6. Atorvastatin 80 mg PO DAILY 7. Humalog 75/25 80 Units Breakfast Humalog 75/25 40 Units Lunch Humalog 75/25 70 Units Dinner 8. Furosemide 60 mg PO DAILY 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 11. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours Hold for K > 12. Aspirin 81 mg PO DAILY 13. Tamsulosin 0.4 mg PO HS 14. Ipratropium Bromide MDI 2 PUFF IH QID 15. Calcitriol 0.25 mcg PO EVERY OTHER DAY 16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Furosemide 40 mg PO DAILY 2. NPH 35 Units Breakfast NPH 25 Units Bedtime Insulin SC Sliding Scale using REG Insulin 3. HydrALAzine 50 mg PO BID 4. Albuterol Inhaler 6 PUFF IH Q2H:PRN Wheeze 5. Albuterol-Ipratropium 6 PUFFS IH Q6H 6. Bisacodyl 10 mg PO/PR [**Hospital1 **] 7. CefePIME 2 g IV Q8H thru [**2203-9-14**] 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **] Use only if patient is on mechanical ventilation. 9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. Docusate Sodium 100 mg PO BID 12. Famotidine 20 mg PO BID 13. Fluconazole 100 mg PO Q24H Duration: 7 Days thru [**2203-9-5**] 14. Heparin 5000 UNIT SC TID 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q3H:PRN pain 17. Labetalol 300 mg PO TID HTN Hold for SBP<120, HR<50. 18. Lorazepam 1-2 mg IV Q4H:PRN agitation 19. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO TID:PRN mouth sores 20. Metoclopramide 5 mg PO QIDACHS 21. Ondansetron 4 mg IV Q8H:PRN nausea 22. Senna 1 TAB PO BID 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 24. Tobramycin Inhalation Soln 300 mg NEB [**Hospital1 **] thru [**2203-9-14**] 25. Atorvastatin 80 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Tracheobronchomalacia Pseudomonas and serratia pneumonia Respiratory insufficiency Thrush 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 for surgery to improve your airway. Unfortunately you had difficulty breathing on your own and you required a tracheostomy along with help from a respirator. * You are slowly improving and will need time to get stronger and totally wean from the respirator. * You are4 being fed through a feeding tube in your stomach but in time you should be able to swallow and eat regular food. * You will need to participate in Physical Therapy to get strong and begin to walk again. * Dr. [**Last Name (STitle) **] will continue to follow you in the Clinic. Followup Instructions: You will need to be seen by Dr. [**Last Name (STitle) **] in the Thoracic Surgery Clinic on [**2203-9-13**]. His secretary will call the rehab to arrange a time. ([**Telephone/Fax (1) 16996**]) Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) 470**] of the [**Location (un) 40900**] for a chest xray. Completed by:[**2203-8-29**]

Admission Date: [**2106-6-26**] Discharge Date: [**2106-7-2**] Date of Birth: [**2071-7-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Fever / Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Briefly patient is a 34 yo male with PMH of HTN is admitted for fevers, myalgias, diarrhea, nausea, vomiting, dizziness, cough ("[**Location (un) 2452**]" sputum), diminished appetite, weight loss that began about 10 days ago. Reports his niece had the flu recently, but has had no other sick contacts. Pt is not a health care worker and has recent travel history. He was seen at the [**Hospital **] clinic and had a viral swab sent, which showed he was negative for influenza. He was then seen in the [**Hospital1 18**] ED on [**2106-6-24**], where he received IV fluids and supportive care and discharged home with diagnosis of viral syndrome. He continued to have symptoms, including sudden hearing loss (now resolved), and re-presented to the ED on [**2106-6-26**]. . In the ED, he was febrile to 102.7F. His other VS- HR 102, BP 143/94, SaO2 90% RA --> 95% 3L NC. CXR was described as RML infiltrate, for which he received Lovoflox x1 and 2L NS. He was admitted to the floor and treated initially with Ceftriaxone and Azithromycin. He continued to have low-grade temps, and coverage was broadened to include Vancomycin given concern for post-influenza pneumonia. He was also having episodes of tachycardia and hypotension, for which he received approximately 3.5L of IVF in total. The RN was called overnight for lightheadedness and he was found to be satting in the mid-80s on 3L NC, which improved to mid-90s on NRB. ABG was 7.46/33/72. He began to cough pink frothy sputum and was transferred to MICU. . In the MICU, pt was placed on nonrebreather mask and IV antibiotics were continued. A trial of lasix was administered which helped improve some of the symptoms. Patient received an echocardiogram which showed normal cardiac function. Pt was weaned off of the mask and was saturating 96% on 6L of oxygen. Pt was found to be negative for influenza A and B, C diff, PCP, O&P, campylobacter, and legionella. Also negative for HIV. . Currently, patient is able to breathe with relative ease at 2L O2. Had some dyspnea on exertion yesterday. Denies any DOE today. Tolerating food and able to sit up without discomfort. No complaints at present. Says he feels "better" Past Medical History: Hypertension Dental work several years ago Social History: Lives with girlfriend, brother, his brother's wife, and his brother's children. He works as an orthopedic/prosthetic technician. No tobacco use, no etoh use (none at all), no drug use. From El [**Country 19118**] originally, came to the US 18-19 years ago. Family History: Sister had a "heart attack" at age 14, still living. Details not known. Patinet has 1 other sister and 2 brothers, healthy. [**Name2 (NI) 6961**] living, father with recent ex-lap for perforated viscous [**2-1**] colon cancer. Physical Exam: T- 98 BP- 122/84 HR- 78 R- 34 94%3L General: ill appearing, in distress HEENT: dry mucus membranes CV: RRR s1, s2, no M/G/R Respiratory: Bilateral crackles, though left greater than right Abdomen: soft, NT/ND, small pimple-like lesions in differnet stages (some only hyperpigmented scars) around abdomen Extremities: positive pulses, no edema Neuro- AAOx3 Pertinent Results: [**2106-6-26**] 10:00PM WBC-9.1 RBC-4.98 HGB-14.1 HCT-38.6* MCV-78* MCH-28.4 MCHC-36.6* RDW-13.5 PLT COUNT-230 NEUTS-80.7* LYMPHS-16.6* MONOS-2.1 EOS-0.1 BASOS-0.5 GLUCOSE-139* UREA N-13 CREAT-0.9 SODIUM-125* POTASSIUM-3.4 CHLORIDE-88* TOTAL CO2-29 ANION GAP-11 ALT(SGPT)-81* AST(SGOT)-156* LD(LDH)-1256* ALK PHOS-73 TOT BILI-0.6 LACTATE-1.4 [**2106-6-28**] 04:36AM ABG: pO2-72* pCO2-33* pH-7.46* calTCO2-24 Base XS-0 [**2106-6-28**] 06:04AM ABG: pO2-122* pCO2-34* pH-7.47* calTCO2-25 Base XS-2 [**2106-6-28**] 05:45PM ABG: pO2-114* pCO2-35 pH-7.44 calTCO2-25 Base XS-0 [**2106-6-28**] 05:47PM VBG: pO2-32* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Microbiology Data: - Rapid Respiratory Viral Antigen Test (Preliminary): Respiratory viral antigens not detected. - DIRECT INFLUENZA ANTIGEN TEST: Negative for Influenza A and B viral antigens. - Legionella urinary antigen negative. [**2106-6-30**] 06:03AM BLOOD WBC-10.0 RBC-4.61 Hgb-12.9* Hct-37.9* MCV-82 MCH-27.9 MCHC-33.9 RDW-13.1 Plt Ct-499* [**2106-7-1**] 05:50AM BLOOD WBC-9.8 RBC-4.85 Hgb-13.3* Hct-39.3* MCV-81* MCH-27.4 MCHC-33.8 RDW-13.5 Plt Ct-553* [**2106-7-2**] 06:05AM BLOOD WBC-10.6 RBC-4.81 Hgb-13.4* Hct-39.3* MCV-82 MCH-27.8 MCHC-34.0 RDW-13.6 Plt Ct-598* [**2106-7-1**] 05:50AM BLOOD Plt Ct-553* [**2106-7-2**] 06:05AM BLOOD PT-14.2* PTT-26.0 INR(PT)-1.2* [**2106-7-2**] 06:05AM BLOOD Plt Ct-598* [**2106-6-30**] 06:03AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-138 K-4.4 Cl-103 HCO3-26 AnGap-13 [**2106-7-1**] 05:50AM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-137 K-4.5 Cl-103 HCO3-25 AnGap-14 [**2106-7-2**] 06:05AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-134 K-4.5 Cl-101 HCO3-24 AnGap-14 [**2106-6-28**] 03:00PM BLOOD ALT-116* AST-139* LD(LDH)-1115* CK(CPK)-4307* [**2106-7-1**] 05:50AM BLOOD ALT-190* AST-172* LD(LDH)-836* CK(CPK)-958* [**2106-7-2**] 06:05AM BLOOD ALT-185* AST-117* LD(LDH)-747* AlkPhos-119* TotBili-0.7 [**2106-6-29**] 03:54AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.7* [**2106-6-30**] 06:03AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.5 [**2106-7-2**] 06:05AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.5 [**2106-6-27**] 08:00PM BLOOD HIV Ab-NEGATIVE [**2106-6-28**] 04:36AM BLOOD Lactate-1.1 [**2106-6-28**] 06:04AM BLOOD Lactate-1.0 [**2106-6-28**] 04:36AM BLOOD O2 Sat-94 Chest X-ray ([**6-26**])- IMPRESSION: Ill-defined bibasilar opacities concerning for pneumonia Chest X-ray ([**6-28**])- IMPRESSION: Worsening bibasilar pneumonia Chest X-ray ([**6-29**])- IMPRESSION: Mildly improved bibasilar consolidations. ECHO ([**6-28**])- Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. [**2106-6-30**] 06:03AM BLOOD WBC-10.0 RBC-4.61 Hgb-12.9* Hct-37.9* MCV-82 MCH-27.9 MCHC-33.9 RDW-13.1 Plt Ct-499* [**2106-7-1**] 05:50AM BLOOD WBC-9.8 RBC-4.85 Hgb-13.3* Hct-39.3* MCV-81* MCH-27.4 MCHC-33.8 RDW-13.5 Plt Ct-553* [**2106-7-2**] 06:05AM BLOOD WBC-10.6 RBC-4.81 Hgb-13.4* Hct-39.3* MCV-82 MCH-27.8 MCHC-34.0 RDW-13.6 Plt Ct-598* [**2106-6-29**] 03:54AM BLOOD PT-14.5* PTT-29.1 INR(PT)-1.3* [**2106-6-29**] 03:54AM BLOOD Plt Ct-407 [**2106-6-30**] 06:03AM BLOOD PT-14.2* PTT-27.8 INR(PT)-1.2* [**2106-6-30**] 06:03AM BLOOD Plt Ct-499* [**2106-7-1**] 05:50AM BLOOD Plt Ct-553* [**2106-7-2**] 06:05AM BLOOD PT-14.2* PTT-26.0 INR(PT)-1.2* [**2106-7-2**] 06:05AM BLOOD Plt Ct-598* [**2106-6-29**] 03:54AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-135 K-4.1 Cl-101 HCO3-22 AnGap-16 [**2106-6-30**] 06:03AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-138 K-4.4 Cl-103 HCO3-26 AnGap-13 [**2106-7-1**] 05:50AM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-137 K-4.5 Cl-103 HCO3-25 AnGap-14 [**2106-7-2**] 06:05AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-134 K-4.5 Cl-101 HCO3-24 AnGap-14 [**2106-7-1**] 05:50AM BLOOD ALT-190* AST-172* LD(LDH)-836* CK(CPK)-958* [**2106-7-2**] 06:05AM BLOOD ALT-185* AST-117* LD(LDH)-747* AlkPhos-119* TotBili-0.7 [**2106-6-29**] 03:54AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.7* [**2106-6-30**] 06:03AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.5 [**2106-7-2**] 06:05AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.5 [**2106-6-27**] 08:00PM BLOOD HIV Ab-NEGATIVE Respiratory Viral Culture (Final [**2106-7-2**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus. Brief Hospital Course: 1. Respiratory Distress - Initially, the patient was admitted with the differential diagnosis of bacterial pneumonia versus bacterial supreinfection of a viral respiratory infection. He was admitted to the floor and treated initially with Ceftriaxone and Azithromycin. He continued to have low-grade temps, and was broadened to include Vancomycin given concern for post-influenza pneumonia. He was also having episodes of tachycardia and hypotension, for which he received approximately 3.5L of IVF in total. The RN was called overnight for lightheadedness and he was found to be satting in the mid-80s on 3L NC, which improved to mid-90s on NRB. ABG was 7.46/33/72. He began to cough pink frothy sputum. At that point, he was transferred to the MICU. In the MICU, it was felt that the patient's CXR was consistent with ARDs or volume overload. It was felt that the patient's presentation was concerning for staph pneumonia after a viral infection, compounded by volume overload/capillary leak. HIV testing was done and was negative. Also, the legionella urinary antigen and the DFA for influenza A and B were both negative. The patient was continued on broad spectrum coverage, including vancomycin, ceftriaxone, and levofloxacin for community acquired pneumonia. He was also given lasix IV. The patient's dyspnea improved over two days in the ICU. Also, his O2 requirements were able to be weaned down slowly while maintaining his O2 sats. Prior to the patient's discharge from the MICU, a rapid respiratory viral screen/culture was sent- negative for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus. On transfer back to medicine floor, patient remained stable. He was weaned off oxygen and denied any shortness of breath or dyspnea on exertion. He remained afebrile and reported good PO intake and increasing energy level. No longer complained of fatigue. He was sent home with a script for levofloxacin and linezolid . However, his insurance did not cover the levoquin so we substituted cefpodoxime 200mg PO BID and azithromycin 250mg PO daily x 2 days for levoquin to finish his abx course. 2. Hyponatremia - It was felt that this was likely hypovolemic hyponatremia from dehydration, as his urine Na was <10 and he was hypovolemic on exam. Additionally, he was on a thiazide diuretic at home. His HCTZ was held. His hyponatremia resolved after he was given fluids. Hyponatremia was not an issue upon discharge from the medicine floor. 3. Hypertension - The patient had a history of hypertension. The patient's HCTZ was held. Additionally, his EKG was consistent with RVH. An echo was ordered and was within normal limits. Patient was restarted on his HCTZ upon discharge. Medications on Admission: Hydrochlorothiazide 12.5mg po qday Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 5 doses. Disp:*5 Tablet(s)* Refills:*0* 2. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 3. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* *****Pharmacy called, his insurance does not cover Levaquin, substituted for cefpodoxime 200 [**Hospital1 **] x 2 days and azithromycin 250 daily x 2 days Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia Acute Respiratory Distress Syndrome Secondary: Hypertension Discharge Condition: Good. Vital signs stable. Discharge Instructions: You were admitted to the hospital on [**6-26**] with fevers, body aches, diarrhea, nausea, vomiting, dizziness, cough diminished appetite, weight loss and shortness of breath. While here you required oxygen therapy to keep your levels high. You were transferred to the ICU for management of your low oxygen levels and fevers. You received some diuretics to clear some fluid off your lungs and antibiotics for your infection. You were stabilized in the ICU and transferred back to the floor on [**7-1**]. Since you were on the floor, you did not have any fevers and eventually were oxygenating very well on room air (without any supplemental oxygen). On discharge, you were comfortable and stable. The following medication changes were made: 1. Your blood pressure medicine hydrochrolothiazide was held because you had several low blood pressure measurements. We are restarting you on a reduced dosage: Hydrochlorothiazide 12.5 mg, by mouth, daily. 2. Continue your levaquin and linezolid through Sunday [**2106-7-4**] Follow up with your primary care physician ([**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 250**]) in [**1-1**] weeks. If you experience any high fevers, shortness of breath, deep chest pain, uncontrollable nausea/vomiting/diarrhea, or any other medically concerning symptoms, please contact your doctor or come to the emergency department. Followup Instructions: Follow up with your primary care physician ([**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 250**]) in [**1-1**] weeks. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2106-7-12**]

Name: [**Known lastname 441**],[**Known firstname 121**] Unit No: [**Numeric Identifier 14003**] Admission Date: [**2181-12-13**] Discharge Date: [**2181-12-27**] Date of Birth: [**2159-2-18**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14004**] Addendum: Please review additions to discharge summary. Chief Complaint: 22 y/o male, right hand dominant, s/p motor vehicle accident at 1pm on [**2181-12-13**] in [**State 4488**], with severe left volar forearm injury. Surgeon in [**State 4488**] repaired radial and ulnar artery with cephalic vein graft. the patient was then transferred to [**Hospital1 **] for definitive management of his left arm injury. Major Surgical or Invasive Procedure: PROCEDURE [**2181-12-15**]: 1. Irrigation and debridement left hand and forearm wound. 2. Open reduction and internal fixation left proximal radius fracture. 3. Over reduction internal fixation left distal ulna fracture. 4. Adjustment external fixator. 5. VAC dressing change. . PROCEDURE [**2181-12-19**]: 1. Extensive debridement, associated with an open fracture of left forearm and hand. 2. Reconstruction left ulnar nerve gap with multi cable sural nerve graft, approximately 9 cm. 3. Partial coverage of left forearm and hand wound with anterolateral thigh flap from the right side with microvascular anastomosis. 4. Split-thickness skin grafting of remaining left forearm wound, greater than 100 cm2. 5. Split-thickness skin grafting less than 100 cm2 of right thigh donor site. History of Present Illness: 22-year-old male who was transported from an outside hospital in [**State 4488**] after a motor vehicle crash. This unfortunate male had a traumatic injury to his left arm after his car hit a telephone pole. He had a degloving injury of part of his left forearm. He was taken directly to an operating room in [**State 4488**] for grafting of his forearm artery secondary to arterial injury. He was transferred here for the remainder of traumatic workup and further care of his arm injury. Past Medical History: Denies . PSH: ORIF R ankle fracture three years ago Social History: 1ppd x 5 yrs, 1 drink EtOH/wk, denies IVDU, + marijuana, admits to using methadone (not prescribed by a clinic). Works driving heavy equipment for a logging company. Family History: N/C Physical Exam: PE [**2181-12-13**]: HR 154 BP 160/100 98%RA left hand with visible deformity at proximal forearm and wrist open surgical wound with ?alloderm on radial/volar aspect of left wrist 2+ nonpitting edema and echymosis throughout left hand. left hand cool to touch sensation intact to pinprick left thumb, insensate other four digits dopplerable radial pulse, ulnar pulse not dopplerable pulse ox wave forms absent in all five digits. Pertinent Results: ADMISSION LABS: [**2181-12-12**] 11:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2181-12-12**] 11:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2181-12-12**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 418**]-1.014 [**2181-12-12**] 11:00PM FIBRINOGE-225 [**2181-12-12**] 11:00PM PT-13.5* PTT-24.0 INR(PT)-1.5* [**2181-12-12**] 11:00PM PLT COUNT-249 [**2181-12-12**] 11:00PM WBC-18.0* RBC-3.32* HGB-10.7* HCT-29.4* MCV-89 MCH-32.3* MCHC-36.5* RDW-13.2 [**2181-12-12**] 11:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [**2181-12-12**] 11:00PM URINE HOURS-RANDOM [**2181-12-12**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2181-12-12**] 11:00PM LIPASE-15 [**2181-12-12**] 11:00PM UREA N-14 CREAT-1.0 [**2181-12-12**] 11:17PM freeCa-1.06* [**2181-12-12**] 11:17PM GLUCOSE-114* LACTATE-2.1* NA+-140 K+-4.4 CL--109 TCO2-23 [**2181-12-12**] 11:17PM PH-7.35 COMMENTS-GREEN TOP [**2181-12-13**] 03:50AM FIBRINOGE-209 [**2181-12-13**] 03:50AM PT-14.7* PTT-29.1 INR(PT)-1.3* [**2181-12-13**] 03:50AM PLT COUNT-201 [**2181-12-13**] 03:55AM freeCa-1.03* [**2181-12-13**] 03:55AM HGB-7.9* calcHCT-24 O2 SAT-99 [**2181-12-13**] 03:55AM HGB-7.9* calcHCT-24 O2 SAT-99 [**2181-12-13**] 03:55AM GLUCOSE-108* LACTATE-1.8 NA+-137 K+-3.7 CL--112 [**2181-12-13**] 03:55AM TYPE-ART PO2-147* PCO2-32* PH-7.43 TOTAL CO2-22 BASE XS--1 [**2181-12-13**] 05:03AM freeCa-1.25 [**2181-12-13**] 05:03AM HGB-10.1* calcHCT-30 [**2181-12-13**] 05:03AM GLUCOSE-121* LACTATE-2.0 NA+-143 K+-4.3 CL--113* [**2181-12-13**] 05:03AM TYPE-ART PO2-170* PCO2-34* PH-7.44 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED [**2181-12-13**] 06:06AM freeCa-1.16 [**2181-12-13**] 06:06AM HGB-10.1* calcHCT-30 [**2181-12-13**] 06:06AM GLUCOSE-125* LACTATE-2.9* NA+-140 K+-4.3 CL--112 [**2181-12-13**] 06:06AM TYPE-ART PO2-198* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED [**2181-12-13**] 10:10AM PTT-26.4 [**2181-12-13**] 10:10AM PLT COUNT-247 [**2181-12-13**] 10:10AM WBC-15.9* RBC-3.28* HGB-10.2* HCT-29.4* MCV-90 MCH-31.2 MCHC-34.8 RDW-13.7 [**2181-12-13**] 10:10AM CALCIUM-8.3* PHOSPHATE-2.8 MAGNESIUM-1.7 [**2181-12-13**] 10:10AM GLUCOSE-159* UREA N-12 CREAT-1.0 SODIUM-144 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-21* ANION GAP-14 [**2181-12-13**] 04:08PM PTT-35.7* [**2181-12-13**] 10:00PM PTT-32.9 . RADIOLOGY: Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of [**2181-12-12**] 11:05P IMPRESSION: No lung contusion. No pneumothorax. No displaced rib fracture. . Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2181-12-12**] 11:26 PM IMPRESSION: No fracture. . Radiology Report CT HEAD W/O CONTRAST Study Date of [**2181-12-12**] 11:26 PM IMPRESSION: No acute intracranial process. . Radiology Report CT TORSO W/CONTRAST Study Date of [**2181-12-12**] 11:27 PM IMPRESSION: No evidence of trauma to the torso on CT. . Radiology Report HAND (AP, LAT & OBLIQUE) LEFT Study Date of [**2181-12-12**] 11:39 PM IMPRESSION: Proximal radial shaft, distal radius and distal ulnar fractures in addition to fractures at the second and third metacarpal bases. . Radiology Report CT UP EXT W/O C Study Date of [**2181-12-16**] 8:24 AM IMPRESSION: 1. Proximal radial and distal ulnar shaft fractures transfixed with plate and screws. 2. Severe comminuted intraarticular fracture of distal radius with impaction. 3. Volar subluxation of the ulna at distal radioulnar joint. 4. Nondisplaced comminuted triquetral fracture. 5. Interarticular fracture through the base of the second metacarpal and possible fracture along the lateral aspect of the base of the third metacarpal bone. 6. Trapezium fracture. 7. Edema and degloving injury over the volar aapect of the forearm. . MICROBIOLOGY: [**2181-12-17**] 2:29 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2181-12-20**]** MRSA SCREEN (Final [**2181-12-20**]): No MRSA isolated. Brief Hospital Course: This patient was admitted to the Plastic Surgery service after sustaining a traumatic left arm injury when involved in a motor vehicle accident in [**State 4488**] on [**2181-12-12**]. . Hospital day #1~[**2181-12-12**] Patient was admitted to the Emergency Department and underwent emergent body imaging upon arrival. . Hospital day #2~[**2181-12-13**] Patient to the operating room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81**] for irrigation and debridement of degloving wound left forearm, wound exploration of left forearm, revision and repair laceration, left radial artery, revision and repair laceration left ulnar artery with interposition vein graft left foot, open repair of flexor digitorum superficialis left ring finger, open repair of flexor digitorum superficiality left small finger, open carpal tunnel release, wound VAC dressing placement and external fixation left ulna and radial fractures. Pt was admitted to ICU for close monitoring and to check left hand pulses by pulse oximetry. A heparin drip was started and patient was started on aspirin to maintain patency of blood flow to left upper extremity. Patient was started on gentamicin and unasyn for broad empiric coverage. He was started on dilaudid PCA for pain control but this provided insufficient pain control for the patient so the Acute Pain Service (APS) was consulted and a left axillary block was provided. . Hospital day #3~[**2181-12-14**] Patient received 2units of PRBCs today for a hematocrit drop to 17.9 (29.4 on admission). Pain control continued to be an issue so the axillary block and the PCA doses were increased by APS. Neurontin was also added to pain regimen and ativan was given PRN for periods of anxiety. Patient had symptoms of oral thrush and was given Nystatin swish and swallow. . Hospital day #4~[**2181-12-15**] Patient had a planned procedure in the Operating room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81**] for left forearm wound excision & debridement, Open reduction and internal fixation left proximal radius fracture, Over reduction internal fixation left distal ulna fracture, Adjustment of external fixator, and wound VAC dressing change. Patient continued on the dilaudid PCA, left axillary block and neurontin for pain control. He continued with heparin drip and daily aspirin to maintain patency of blood supply to left upper extremity. Patient continued on unasyn. . Hospital day #5 [**2181-12-16**]: Patient having increased difficulty with pain today so APS service added a Ketamine infusion, discontinued the axillary block and started a lumbar plexus infusion with Ropivacaine instead. Patient's pain came under good control. . Hospital day #6 [**2181-12-17**] Wound VAC therapy to left forearm continued. Patient was Transferred from ICU to floor today. . Hospital day #7 [**2181-12-18**] Pain management regimen continued guided by APS. Patient reported diminished relief of pain with dilaudid PCA so he was changed to Morphine PCA and his Ketamine dose was increased. Patient was prepped for operating room in the morning for closure of his left arm wounds. . Hospital day #8 [**2181-12-19**] Patient to operating room today with Dr. [**Last Name (STitle) 81**] for open reduction and internal fixation of comminuted multi-fragment fracture left distal radius, open reduction internal fixation of left proximal ulnar shaft fracture, closed reduction and percutaneous pin fixation of left distal radial ulnar joint, removal of external fixator left forearm and irrigation and debridement of wound left forearm. After this procedure, Dr. [**First Name (STitle) **] [**Name (STitle) 11867**] began the final procedure, this admission, for reconstruction of the left forearm; Extensive debridement, reconstruction left ulnar nerve gap with multi cable sural nerve graft (approximately 9 cm), partial coverage of left forearm and hand wound with anterolateral thigh flap from the right side with microvascular anastomosis, split-thickness skin grafting of remaining left forearm wound (greater than 100 cm2), and split-thickness skin grafting less than 100 cm2 of right thigh donor site. Patient tolerated the procedure well and was transferred to Post Anesthesia Care Unit for recovery. A wound VAC was applied to skin graft sites and flap checks were done, per protocol, to left forearm flap site. Patient was continued on Morphine PCA, ketamine drip, and neurontin post-procedure with good pain control noted. Patient was continued on aspirin therapy. Patient was transferred to the floor when recovery criteria were met. . Hospital day #9 [**2181-12-20**] Patient had PICC placement to right arm today for ongoing IV medications. APS recommended the discontinuation of morphine PCA and restarted dilaudid PCA. Ketamine drip was continued and patient was started on PO methadone. Neurontin was continued. Unasyn was continued. Patient was started on clear liquids. . Hospital day #10 [**2181-12-21**] Patient had his foley catheter discontinued and his diet was advanced to regular today. Flap checks continued. . Hospital day #11 [**2181-12-22**] Patient's IV fluids and dilaudid PCA were discontinued today. Patient was started on PO dilaudid 4-8 mg PO Q3h prn and methadone 40mg PO TID continued. Flap checks continued. Patient continued on Unasyn. . Hospital day #12 [**2181-12-23**] Flap checks were switched to q4. . Hospital day #13 [**2181-12-24**] Patient's skin graft dressings and VAC were taken down today and 100% take of skin grafts was noted. Graft sites were dressed with xeroform, fluffs, with kerlix wrap. Patient had a dorsal orthoplast splint fashioned by Occupational Therapy today that he will wear continuously. Patient had a Psych consult for substance abuse counseling today. . Hospital day #14 [**2181-12-25**] All dressings changed once a day and graft sites and flap remain healthy and patent. Occupational Therapy working with patient on range of motion and strengthening exercises for left upper extremity. Patient was also working with OT on ambulation. . Hospital day #15 [**2181-12-26**] Patient increasing ambulation about the unit, doing well. Father of patient assisting patient with ambulation around the unit multiple times today and learning dressing changes for home. Pain medication management discussed with Psych liaison RN who can assist with future pain medication weaning ([**Location (un) 7749**], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 14005**]). She is happy to help with advising about weaning pain meds/methadone when it is time. . Hospital day #16 [**2181-12-27**] Patient prepared for discharge home today. The patient and his father were provided discharge instructions and prescriptions. They provided detailed follow up instructions. Patient's right thigh flap donor site with skin graft reconstruction to remaining defect appeared pink and healthy. Patient's left thigh donor site continued to dry out and was open to air with old drying xeroform intact. Left lower extremity ankle/foot incisions clean/dry/intact with steri-strips in place and no signs of infection. Left arm flap pink and healthy with strong doppler signal. Left forearm skin graft sites remained pink and healthy. PICC line was discontinued. Medications on Admission: Methadone (not clinic prescribed) Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 30 days. Disp:*180 Capsule(s)* Refills:*1* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Max 12/day. Do not exceed 4gms/4000mgs of Tylenol per day. 4. hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for 14 days. Disp:*224 Tablet(s)* Refills:*0* 5. methadone 10 mg Tablet Sig: Four (4) Tablet PO Q8H (every 8 hours) for 14 days. Disp:*168 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: 1. Crush injury with degloving injury left forearm, with associated radius and ulna fractures. 2. Left proximal radius fracture. 3. Left ulnar fracture. 4. Left forearm and hand wound. 5. Left forearm injury with open wound as well as an ulnar nerve gap, status post revascularization and partial reconstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please change your skin graft sites (left arm and right thigh) dressings once a day. Dressing changes are as follows: 1) place fresh xeroforms over skin graft sites. 2) place 'fluffed up' gauze over the xeroform 3) Wrap sites with kerlix gauze wrap -Leave left thigh donor site open to air and do not cover with dressing. Let area continue to dry out. -Leave left foot/ankle incisions open to air and leave steri strips in place until they fall off. -Elevate you left arm as much as possible and maintain in your splint. -Practice your left arm range of motion and strenghtening exercises as taught to you by Occupational Therapy. -You MUST walk around at least 4 times or more a day. . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * You will need to be weaned off of your pain medications and Plastic Surgery and/or your PCP may not be comfortable managing this alone. The Psych Nurse Liaison that you met with in hospital, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14006**], RN, would be happy to help assist with this process and can be reached at : ([**Telephone/Fax (1) 14005**]. She has kindly volunteered to help with advising about weaning of your pain meds/methadone when it is time. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Physical Therapy: Per discharge plan. Treatments Frequency: Per discharge plan. Followup Instructions: Please follow up in our HAND CLINIC in two weeks time. Hand Clinic: ([**Telephone/Fax (1) 14007**] [**Hospital Ward Name 600**], [**Hospital Ward Name **] Building, [**Location (un) 457**] Please follow up in the Hand Clinic on Tuesday, [**2182-1-8**]. You must call ([**Telephone/Fax (1) 14007**] to make an appointment. The clinic is open from 8-12pm most Tuesdays. The clinic is located on the [**Hospital Ward Name **], [**Hospital Ward Name **] Building, [**Location (un) 457**]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14008**] office during the week of [**2-11**] (6 weeks from now). [**Telephone/Fax (1) 14009**] office -[**Hospital1 6925**]. Please ask them how you should arrange for follow up xrays for the appointment since you are coming from [**State 4488**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14010**] MD [**Last Name (un) 14011**] Completed by:[**2181-12-27**]

Admission Date: [**2179-6-9**] Discharge Date: [**2179-7-3**] Date of Birth: [**2106-7-21**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Inferior myocardial infarctin, ventricular septal defect, cardiogenic shock Major Surgical or Invasive Procedure: [**6-12**] Ventricular septal defect repair History of Present Illness: Ms. [**Known lastname 732**] is a 72 year old woman with no known cardiac history, who presented from an outside hospital with hypotension and chest pain after a flight from [**Location (un) **]. A bedside echo revealed a ventricular septal defect and she therefore was transferred to [**Hospital1 69**]. Past Medical History: GERD, Arthitis (?Rheumatoid), s/p Left Hip Replacement Social History: Ms. [**Known lastname 732**] has a very remote tobacco history. She drink alcohol only occasionally. Family History: Unable to obtain Physical Exam: Admission Exam VS: T [**Age over 90 **]F P52 SBP 102 Vent: AC 450x24 PEEP 10 FI02 100% GENERAL: Intubated, Sedated HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: flat. No JVP. CARDIAC: Cannot appreciate heart sounds LUNGS: Good airmovement anteriorly. ABDOMEN: Soft, NTND. EXTREMITIES: Tandem heart lines in left groin. Femoral line in right groin. No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: No palpable pulses. Pertinent Results: Admission [**2179-6-9**] 12:21PM PTT-87.8* [**2179-6-9**] 12:21PM PLT SMR-NORMAL PLT COUNT-288 [**2179-6-9**] 12:21PM WBC-16.0* RBC-3.07* HGB-10.1* HCT-30.0* MCV-98 MCH-32.8* MCHC-33.6 RDW-15.1 [**2179-6-9**] 12:21PM %HbA1c-5.3 eAG-105 [**2179-6-9**] 12:21PM ALBUMIN-2.9* [**2179-6-9**] 12:21PM CK-MB-18* MB INDX-7.7* cTropnT-3.31* [**2179-6-9**] 12:21PM ALT(SGPT)-57* AST(SGOT)-69* CK(CPK)-235* ALK PHOS-126* AMYLASE-24 TOT BILI-1.4 [**2179-6-9**] 12:21PM GLUCOSE-160* UREA N-27* CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-17* ANION GAP-19 [**2179-6-9**] 12:39PM TYPE-ART RATES-/20 TIDAL VOL-450 O2-100 PO2-298* PCO2-29* PH-7.32* TOTAL CO2-16* BASE XS--9 AADO2-386 REQ O2-68 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-CATH LAB Last Day Hospitalized [**2179-7-3**] 01:55AM BLOOD WBC-15.6* RBC-2.56* Hgb-8.8* Hct-25.3* MCV-99* MCH-34.3* MCHC-34.6 RDW-27.7* Plt Ct-90* [**2179-7-3**] 01:55AM BLOOD Plt Ct-90* [**2179-7-3**] 01:55AM BLOOD PT-29.8* PTT-33.9 INR(PT)-2.9* [**2179-7-3**] 01:55AM BLOOD Glucose-171* UreaN-116* Creat-2.7* Na-141 K-3.0* Cl-94* HCO3-29 AnGap-21* [**2179-7-3**] 01:55AM BLOOD ALT-145* AST-214* LD(LDH)-655* AlkPhos-179* Amylase-182* TotBili-29.3* [**2179-7-2**] 02:04AM BLOOD ALT-139* AST-189* LD(LDH)-590* AlkPhos-112* Amylase-155* TotBili-27.2* [**2179-7-3**] 01:55AM BLOOD Lipase-200* [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% >= 55% Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Moderate global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions 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. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. RV systolic function: mild to moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. The aortic valve was not opening in the prebypass period in the setting of tandem heart. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results before cardiopulmonary byoass. The venous cannula for the tandem heart seen at the IVC RA junction. Impression: In the prebypass period, a large VSD (2cm x 1 cm) seen in the basal to mid inferoseptal wall. The tandem heart is functioning well as shown by the lack of aortic valve opening with 4.2L/min flows. Post bypass: Patient is on 0.2 mcg/kg/min or milrinone. LVEF is 45%. RV is mild global hypokinesis. Loading conditions alters the dysfunction. Normal three aortic cusps, no aortic stenosis with peak velocity at 1m/sec. No AI. A 0.3cm x 1mm free floating homeogenous structure was seen in the LVOT, (ventricular side of the aortic valve, ? Ruptured chordae). The VSD patch is seen on the LV side with no identifiable leaks. The discontinuity between the inferior septum is still seen on the RV side consistent with the surgical repair. The mitral valve leaflets are normal, no papillary muscle dysfunction or rutpure. Mild central MR> The tricuspid leaflets are normal, with mild TR. Minimal PI. Intact thoracic aorta. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician Radiology Report CHEST (PORTABLE AP) Study Date of [**2179-7-2**] 3:04 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 88734**] Final Report Multifocal consolidations within the lungs, with only right apex spearing appears to be unchanged. The ET tube tip, left subclavian line, feeding tube are unchanged. The right midline is unchanged. Overall, no substantial change since the prior examination obtained a day ago is demonstrated. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Brief Hospital Course: Ms. [**Known lastname 732**] was transferred from an outside hospital presenting with a myocardial infarction secondary to a large ventricular septal defect. A Tandem heart was placed on arrival. Closure of the lesion was unsucessfully attempted with a ventricular septal defect closure device as the lesion was larger than the device. An oxygenator was added to the tandem device in the setting of worsening oxygenation. During transition to oxygenation the patient's systolic blood pressure dropped to 10-40mmHg. The cardiology team tried to percutaneously close the VSD but was unsuccesful. On [**6-12**] she underwent open closure of her ventricular septal defect. Please see the operative note for details. In summary she had: 1. Repair of postinfarct ventricular septal defect with a pericardial onlay patch from the left ventricular side. Patch is PeriGuard reference #[**Serial Number 88735**], lot #[**Telephone/Fax (5) 88736**]. 2. Removal of patient from extracorporeal membrane oxygenation continuous circulatory support. 3. Open repair of right common femoral artery. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit on multiple pressors and inotropes. The patient was kept sedated to allow for diuresis in the immediate post-op period. She was weaned from her pressors and diuresed over several days and ultimately extubated, but her respiratory status remained tenuous. Over the next several days she continued to show slow improvement however on [**6-23**] the patient developed became acutely hypotensive again requiring pressors she also became anuric and required reintubation. A repeat echo showed failure of the surgical VSD closure nad she was brought to the cath lab for percutaneous closure attempt-this time successfully. The patient continued to have acute renal failure ultimately requiring dialysis. She also developed a component of liver failure w/elevated LFT's and TBili. An ultrasound showed a distende gallbladder and a chole tube was placed by general surgery on [**6-29**]. The patient remined intubated and critically ill and the family decided to make the patient comfort measures only, on [**7-3**] she expired at 9:35PM Medications on Admission: Naproxen 250mg tablets Methotrexate 2.5mg Lansoprazole 30mg "Bone Density Drink" Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: ventricular septal defect Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2179-7-7**]

Admission Date: [**2105-2-7**] Discharge Date: [**2105-2-13**] Date of Birth: [**2045-7-12**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy Laparoscopic sigmoid colectomy History of Present Illness: The patient is a 59F who hasn't seen a doctor in a number of years and no known significant PMH who presents with BRBPR starting this am. She reports feeling completely at her baseline yesterday, with no blood noted in stool, no nausea/vomiting, no lightheadedness, DOE, SOB, syncope. This am she took some Metamucil, which she has been taking for the past few weeks for mild constipation, and later in the morning felt an urge or sensation as though she was going to have diarrhea. Her bowel movement was very watery and bright red, but she did not have lightheadedness, shortness of breath at this time. No abd pain associated with this. She had another episode at home after which she presented to the ED. . In the ED her vital signs included a BP of 162/86 and HR 82. She had another episode of BRBPR. Rectal exam showed bright red blood but no rectal fissures, masses, or external hemorrhoids. NG lavage was negative. Her initial Hct was 30 but dropped to 22 after fluid resuscitation and the bloody bowel movement. She was given 1U PRBC. Coags and LFTs were normal. GI was called and recommended admitting to MICU for observation given the brisk nature of the bleed and to do colonoscopy on Monday if she remained stable. If she rebleeds, they recommeneded proceeding to tagged red blood cell scan. Shortly after this she had another bloody bowel movement and was thus sent to radiology for a tagged RBC scan before coming to the MICU. . On review of systems, she has had no fevers or chills, abdominal pain, nausea/vomiting, loss of appetite, weight loss, lightheadedness, shortness of breath, dyspnea on exertion, presyncope/syncope. She has never had a colonoscopy before. Her sister was diagnosed with [**First Name3 (LF) 499**] cancer in her 40s and was treated with no recurrence to date (now in her 60s). Past Medical History: lactose intolerance Social History: Lives with her son. [**Name (NI) 1403**] as a desktop publisher for [**Doctor Last Name 14323**] Education. No smoking, EtOH. Family History: --sister with [**Name2 (NI) 499**] cancer diagnosed in her 40s -- father with diabetes -- mother with "heart problems" Physical Exam: Admission VS: 97.9, 80, 152/84, 15, 98% on RA Last 24hr: Tm/c 99.3, 83 (60-80s), 178/83 (140-180/60-80s), 19, 99% RA Gen: alert, interactive, pleasant woman in NAD lying comfortably in bed HEENT: PERRL, EOMI, OP clear, MMM Neck: no lymphadenopathy, no carotid bruits, no masses, no JVD Lungs: CTAB CV: RRR, nl S1S2, II/VI systolic flow murmur RUSB Abd: +BS, S/NT/ND, no masses Ext: no c/c/e Labs: see below Pertinent Results: [**2105-2-7**] 11:00PM HCT-24.3* [**2105-2-7**] 06:00PM HGB-7.2* calcHCT-22 [**2105-2-7**] 05:56PM PT-12.3 PTT-26.2 INR(PT)-1.0 [**2105-2-7**] 03:30PM GLUCOSE-165* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 [**2105-2-7**] 03:30PM estGFR-Using this [**2105-2-7**] 03:30PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-147 ALK PHOS-84 TOT BILI-0.5 [**2105-2-7**] 03:30PM WBC-11.1* RBC-4.51 HGB-8.3* HCT-30.2* MCV-67* MCH-18.4* MCHC-27.4* RDW-16.7* [**2105-2-7**] 03:30PM NEUTS-84.1* LYMPHS-10.9* MONOS-3.8 EOS-0.9 BASOS-0.4 [**2105-2-7**] 03:30PM PLT COUNT-399 . [**2105-2-13**] 06:20AM BLOOD WBC-7.5 RBC-3.71* Hgb-7.7* Hct-26.9* MCV-73* MCH-20.9* MCHC-28.8* RDW-19.4* Plt Ct-263 [**2105-2-11**] 06:10AM BLOOD Glucose-106* UreaN-10 Creat-0.6 Na-141 K-3.9 Cl-103 HCO3-28 AnGap-14 [**2105-2-7**] 03:30PM BLOOD ALT-11 AST-17 LD(LDH)-147 AlkPhos-84 TotBili-0.5 [**2105-2-11**] 06:10AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8 . GI BLEEDING STUDY [**2105-2-7**] INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images show normal opacification of the aorta and iliac vessels Dynamic blood pool images show no evidence for uptake within the bowel to suggest active bleeding. IMPRESSION: No evidence for GI bleeding during the time of the study. . CT HEAD W/ & W/O CONTRAST [**2105-2-9**] 3:31 PM IMPRESSION: 1. No evidence of metastatic disease. 2. Mild chronic mucosal sinus disease in the right maxillary sinus, and left sphenoid air cells. . CT ABD W&W/O C [**2105-2-9**] 3:30 PM INDICATION: 59-year-old female admitted for gastrointestinal bleeding with colonoscopy demonstrating a large 5-cm circumferential sigmoid mass at the distal sigmoid [**Month/Day/Year 499**]. Please evaluate for metastasis. CT CHEST WITH CONTRAST: Within the right lobe of the thyroid, there is a 1.3 x 1.1 cm hypoattenuating nodule. No nodules are identified within the left lobe. Aside from minor hypoventilatory changes at the dependent portions of the lungs, no nodule, opacity, or effusions are present. The heart is grossly unremarkable without pericardial effusion. No axillary, mediastinal, or hilar adenopathy is present. The major airways are patent down to the subsegmental level. CT ABDOMEN WITH CONTRAST: There is cholelithiasis without evidence of acute cholecystitis. No lesions are detected within the liver. The spleen, stomach, pancreas, adrenal glands are unremarkable. There is a 1.6-cm hypoattenuating lesion within the interpolar region of the left kidney. No free fluid or free air is present within the abdomen. The abdominal large and small bowel is grossly unremarkable. CT PELVIS WITH CONTRAST: There is focal annular thickening within the distal sigmoid [**Month/Day/Year 499**] with several regions of projectile soft tissue masses suggesting extramural extension. A focal region of hyperinhancement is detected centrally suggesing a central ulceration. There are small lymph nodes within the adjacent mesentery and along the [**Female First Name (un) 899**] the largest measuring 8 x 5 mm. Smaller lymph nodes are also detected along the left para- aortic chain. At the level of the lower pole of the right kidney there is a midline mesenteric lymph node (3:86) measuring 8 x 4 mm. IMPRESSION: 1. Annular mass within the distal sigmoid [**Female First Name (un) 499**] with irregular margin suggesting extramural extension. Several small (sub cm) but suspicious lymph nodes surrounding and extending along the [**Female First Name (un) 899**]. PET-CT could provide more accurate nodal evaluation. 2. 1.3 cm hypoattenuating nodule in the right lobe of the thyroid. This finding should be further evaluated with ultrasound. 3. Fibroid uterus. 4. Cholelithiasis. 5. Degenerative change at the L5-S1 level with intervertebral body disc space narrowing and degeneration . SPECIMEN SUBMITTED: GI BX'S, 2 JARS. Procedure date Tissue received Report Date Diagnosed by [**2105-2-9**] [**2105-2-9**] [**2105-2-10**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mrr?????? DIAGNOSIS: A. Sigmoid [**Doctor Last Name 499**] mass, mucosal biopsy: Adenocarcinoma. There is no submucosal tissue to evaluate the degree of invasion. B. [**Doctor Last Name **] polyp at 20 cm, polypectomy: Hyperplastic polyp. . Brief Hospital Course: Pt presented to the MICU after having three episodes of painless bleeding per rectum. She received one unit of PRBC's in the ED. She received a tagged red blood cell study which failed to demonstrate an active site of bleeding, and then she was admitted to the MICU for observation. Her MICU course was uncomplicated. Her vital signs were stable and she had no further episodes of bleeding. She began her golytely prep and was scoped by GI. The colonoscopy revealed...A single pedunculated 1 cm non-bleeding polyp of benign appearance was found in the sigmoid [**Doctor Last Name 499**] at 20cm. A single-piece polypectomy was performed using a hot snare. The polyp was completely removed.There was scant bleeding post polypectomy that was controlled by thermal cauterization. A single pedunculated 8 mm non-bleeding polyp of benign appearance was found in the rectum. A single-piece polypectomy was performed using a hot snare. The polyp was completely removed but could not be retrieved. An ulcerated , indurated and infiltrative circumferential mass of malignant appearance measuring about 5cm was found at the distal sigmoid [**Doctor Last Name 499**]. The mass caused a partial obstruction. The scope could not traverse the lesion and the examination was interrupted. Cold forceps biopsies were performed for histology at the sigmoid [**Doctor Last Name 499**] mass. Impression: Mass in the distal sigmoid [**Doctor Last Name 499**] (biopsy) Polyp in the sigmoid [**Doctor Last Name 499**] at 20cm (polypectomy) Polyp in the rectum (polypectomy) She then went to the OR on [**2105-2-10**] for a Laparoscopic sigmoid colectomy. Post-op she did well without complications. She was started on sips on POD 1 and her diet was advanced along slowly. She was tolerating a regular diet at time of discharge. She reported +flatus and + small BM. She had good pain control. Her lap sites were C/D/I, abdomen soft. She went home on POD 3. Hypertension: She was started on HCTZ 12.5mg qd for BP management. She will follow-up with her PCP for further management. Medications on Admission: Lactaid occasional Advil and Excedrin, although none recently Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 4. Lactulose 10 gram Packet Sig: One (1) PO once a day. 5. Motrin 600 mg Tablet Sig: One (1) Tablet PO three times a day for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* 6. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed [**Date Range **] mass Discharge Condition: Good Discharge Instructions: Discharge Instructions: -It is Ok to shower and wash incision. No baths or swimming. -Keep incision clean and dry. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily. * No heavy lifting (>[**9-30**] lbs) until your follow up appointment. Followup Instructions: Follow up with your primary care doctor. Call to schedule. Please follow-up with Dr. [**First Name (STitle) **] on [**2105-2-18**] at 9:00am in [**Hospital Ward Name 23**] [**Location (un) **]. Call ([**Telephone/Fax (1) 6347**] with questions or concerns. Completed by:[**2105-2-13**]

Admission Date: [**2168-7-9**] Discharge Date: [**2168-7-29**] Date of Birth: [**2127-7-23**] Sex: F Service: SURGERY Allergies: Codeine / Demerol Attending:[**First Name3 (LF) 3223**] Chief Complaint: 30 foot fall onto tree stump Major Surgical or Invasive Procedure: ORIF of right tibial fracture Halo vest application under fluoroscopic control History of Present Illness: This is a 40 year-old woman who was brought to the ED by [**Location (un) 1110**] EMS after a 30ft fall onto a tree stump. Initially there were concerns that the fall had been a suicide attempt. There was a failed intubation atttempt by EMS (for GCS=7 on scene) and a needle decompression of the left chest by EMS for decreased breath sounds on that side. Past Medical History: Medical: h/o pyelonephritis h/o blackouts and head trauma h/o kidney stones while pregnant h/o alleged rape Psychiatric: long h/o EtOH abuse with bings & blackouts h/o self-cutting h/o threatening violence to others, once cut husband superficially [**Name (NI) **] in [**2159**] >6 suicide attempts (cutting, attempted hanging, EtOH ingestion) Social History: EtOH: long h/o EtOH abuse, with multiple hospitalizations at detox/rehabs and 6-month period of sobriety in [**2161**] drinking since age 14 h/o cocaine and marijuana, last used in [**2151**] daily cigarettes Family History: alcoholism in father, mother, 2 siblings, mother's maternal grandfather Physical Exam: On discharege: T97.3 P90s/60s P76 R16 95% RA Gen: Alert and awake, pleasant. HEENT: Halo in place. Pin sites have no erythema, redness or swelling. Chest: Clear to auscultation bilaterally. CV: Regular rate and rhythm. Abd: Soft, nontender. Ext: Right LE surgical incision clean, dry and intact with no signs of infection. Extremities warm and well-perfused. Pertinent Results: [**2168-7-9**] 07:40PM URINE HOURS-RANDOM [**2168-7-9**] 07:40PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2168-7-9**] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2168-7-9**] 07:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2168-7-9**] 07:40PM URINE RBC-[**5-6**]* WBC-[**10-16**]* BACTERIA-OCC YEAST-NONE EPI-0-2 [**2168-7-9**] 07:40PM URINE WBCCLUMP-OCC [**2168-7-9**] 07:29PM UREA N-5* CREAT-0.5 [**2168-7-9**] 07:29PM AMYLASE-101* [**2168-7-9**] 07:29PM ASA-NEG ETHANOL-197* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2168-7-9**] 07:29PM TYPE-[**Last Name (un) **] PH-7.27* [**2168-7-9**] 07:29PM GLUCOSE-100 LACTATE-3.2* NA+-143 K+-3.0* CL--110 TCO2-24 [**2168-7-9**] 07:29PM freeCa-1.00* [**2168-7-9**] 07:29PM HGB-11.5* calcHCT-35 [**2168-7-9**] 07:29PM WBC-8.1 RBC-3.30* HGB-11.3* HCT-32.3* MCV-98 MCH-34.3* MCHC-35.0 RDW-13.4 [**2168-7-9**] 07:29PM PT-12.6 PTT-24.2 INR(PT)-1.0 [**2168-7-9**] 07:29PM FIBRINOGE-327 Brief Hospital Course: On arrival at [**Hospital1 18**] the patient was moving all extremities and opened eyes to commands. Her initial clinical and radiographic evaluation revealed the following injuries: Fractures of C1, C8-C10 (transverse processes), T6 and T10 (vertebral bodies), multiple ribs bilaterally and right tibia (closed). Grade 2 liver laceration in segment V of the liver, with intraperitoneal hematoma in gallbladder fossa and inferior edge of the liver. Fluid in the mesentery, anterior to the pancreas, surrounding the SMV, concerning for mesenteric injury. Bilateral pneumothoraces. Small amount of pneumomediastinum. She was intubated and bilateral chest tubes were placed, and she was taken to the OR by Dr. [**Last Name (STitle) 363**] for placement of a halo vest. She was admitted to the trauma ICU and followed by Dr. [**Last Name (STitle) 2719**], who repaired her tibia fracture with an ORIF. She was monitored for alcohol withdrawal on a CIWA protocol and was watched by a sitter until there were no concerns for suicidality. She was followed by psychiatry while hospitalized and continued to deny memory of the jumping event but denied recent feelings of depression or suicidality. Ultimately it was felt that her major psychiatric issue was alcohol dependence and she was encouraged to join AA upon discharge, which she agreed to do. She was cleared psychiatrically for rehab, with no immediate concern for suicidality. She was also followed by Physical Therapy, Social Work and a case manager while hospitalized. Medications on Admission: ativan fluoxetine omeprazole dilantin Discharge Medications: 1. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*0* 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*0* 3. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO QPM (once a day (in the evening)). Disp:*90 Tablet, Chewable(s)* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*35 Tablet(s)* Refills:*0* 5. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*10 Tablet Sustained Release 12HR(s)* Refills:*0* 6. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 7. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily) for 4 weeks. Disp:*QS mg * Refills:*0* 8. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed. Disp:*90 Tablet(s)* Refills:*0* 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Disp:*30 Capsule(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cervical and thoracic spine fractures Multiple rib fractures Right tibia fracture (closed) Discharge Condition: Good Discharge Instructions: You should call a physician or come to ER if you have worsening pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds or pin sites, or if you have any questions or concerns. You should not drive or operate heavy machinery while on any narcotic pain medication such as percocet as it can be sedating. You may take colace to soften the stool as needed for constipation, which can be cause by narcotic pain medication. The halo should remain in place until your follow-up visit in 3 weeks. You may bear partial weight as tolerated on your right leg. Followup Instructions: Call for an appointment with Dr. [**Last Name (STitle) 363**] in 3 weeks. You will need a repeat CT scan of your C-spine at that time. Call for an appointment with Dr. [**Last Name (STitle) 2719**] (Orthopedics) in 4 weeks ([**Telephone/Fax (1) 1228**]). We encourage you to join Alcoholics Anonymous ([**Telephone/Fax (1) 6003**]) for help with staying sober. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Admission Date: [**2120-3-28**] Discharge Date: [**2120-4-21**] Date of Birth: [**2039-6-5**] Sex: F Service: SURGERY Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 668**] Chief Complaint: Common Bile Duct Injury Major Surgical or Invasive Procedure: Exploratory laparotomy Roux-en-Y hepaticojejunostomy. History of Present Illness: 80-year-old female who underwent an open cholecystectomy that was complicated by development of a complete transection of the common bile duct. At the time, the injury was recognized intraoperatively and the distal bile duct was tied off as well as the proximal bile duct and a T tube was placed in the proximal portion of the biliary tree in communication with the liver. The patient was allowed to recover from this surgery and was in the process of being referred for definitive evaluation when she presented with a malpositioned T tube and abdominal pain. She was sent to our facility for further evaluation. She underwent complete work-up including placement of a percutaneous transhepatic cholangiogram in the distal bile duct and now presents for definitive repair. Past Medical History: DM II HTN hypercholesterolemia obesity Social History: Retired bank teller. Lives alone in Falmoth, daughter lives in [**Name (NI) 15739**]. Denies tobacco and EtOH use. Family History: non-contributory Physical Exam: On Discharge NAD, A&0x3 RRR CTAB soft, NT/ND wound- c/d/i t-tube in place no LE edema Pertinent Results: [**2120-3-29**] 12:10AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.2* Hct-30.8* MCV-85 MCH-28.3 MCHC-33.2 RDW-15.1 Plt Ct-253 [**2120-3-29**] 05:50AM BLOOD WBC-13.9* RBC-3.57* Hgb-10.2* Hct-30.4* MCV-85 MCH-28.5 MCHC-33.4 RDW-15.2 Plt Ct-248 [**2120-4-14**] 06:00AM BLOOD WBC-6.1 RBC-3.17* Hgb-8.9* Hct-26.8* MCV-85 MCH-28.0 MCHC-33.1 RDW-15.4 Plt Ct-302 [**2120-4-15**] 05:00AM BLOOD WBC-6.0 RBC-3.27* Hgb-9.1* Hct-27.2* MCV-83 MCH-27.9 MCHC-33.5 RDW-15.4 Plt Ct-308 [**2120-3-29**] 12:10AM BLOOD PT-16.8* PTT-27.3 INR(PT)-1.5* [**2120-3-29**] 12:10AM BLOOD Plt Ct-253 [**2120-3-29**] 05:50AM BLOOD Plt Ct-248 [**2120-3-29**] 09:05AM BLOOD PT-17.4* PTT-28.3 INR(PT)-1.6* [**2120-4-13**] 05:00AM BLOOD PT-13.3* PTT-27.2 INR(PT)-1.2* [**2120-4-14**] 06:00AM BLOOD Plt Ct-302 [**2120-4-15**] 05:00AM BLOOD Plt Ct-308 [**2120-3-29**] 12:10AM BLOOD Glucose-254* UreaN-17 Creat-1.4* Na-139 K-4.3 Cl-108 HCO3-19* AnGap-16 [**2120-3-29**] 05:50AM BLOOD Glucose-259* UreaN-17 Creat-1.4* Na-135 K-4.1 Cl-102 HCO3-19* AnGap-18 [**2120-4-14**] 06:00AM BLOOD Glucose-98 UreaN-14 Creat-1.2* Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 [**2120-4-15**] 05:00AM BLOOD Glucose-102 UreaN-13 Creat-1.1 Na-139 K-3.3 Cl-102 HCO3-28 AnGap-12 [**2120-3-29**] 12:10AM BLOOD ALT-235* AST-237* AlkPhos-401* Amylase-36 TotBili-3.2* [**2120-3-29**] 05:50AM BLOOD ALT-209* AST-193* AlkPhos-383* Amylase-31 TotBili-3.4* [**2120-3-30**] 07:35AM BLOOD ALT-121* AST-66* AlkPhos-276* TotBili-1.6* [**2120-3-31**] 10:23AM BLOOD ALT-78* AST-30 AlkPhos-260* Amylase-28 TotBili-1.0 [**2120-4-1**] 05:45AM BLOOD ALT-53* AST-25 LD(LDH)-177 AlkPhos-250* Amylase-33 TotBili-0.8 [**2120-4-2**] 05:35AM BLOOD ALT-42* AST-34 AlkPhos-291* Amylase-44 TotBili-0.7 [**2120-4-3**] 05:05AM BLOOD ALT-37 AST-44* AlkPhos-385* TotBili-0.8 [**2120-4-12**] 05:15AM BLOOD ALT-23 AST-22 AlkPhos-134* Amylase-17 TotBili-0.6 [**2120-4-13**] 05:00AM BLOOD ALT-17 AST-19 AlkPhos-178* Amylase-19 TotBili-0.6 [**2120-4-14**] 06:00AM BLOOD ALT-16 AST-23 AlkPhos-205* Amylase-22 TotBili-0.6 [**2120-4-15**] 05:00AM BLOOD ALT-20 AST-29 AlkPhos-251* Amylase-24 TotBili-0.5 [**2120-3-29**] 12:10AM BLOOD Lipase-47 [**2120-3-29**] 05:50AM BLOOD Lipase-35 [**2120-3-31**] 10:23AM BLOOD Lipase-38 [**2120-4-13**] 05:00AM BLOOD Lipase-20 [**2120-4-14**] 06:00AM BLOOD Lipase-23 [**2120-4-15**] 05:00AM BLOOD Lipase-32 [**2120-3-29**] 12:10AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.1 Mg-1.3* [**2120-3-29**] 05:50AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.9 Mg-1.2* [**2120-3-30**] 07:35AM BLOOD Albumin-2.8* [**2120-4-13**] 05:00AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.4* [**2120-4-14**] 06:00AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.7 Mg-1.5* [**2120-4-15**] 05:00AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.6 Brief Hospital Course: Pt was admitted to Surgical service for management of CBD injury. Percutaneous transhepatic cholangiogram demonstrated dilated intrahepatic biliary duct and obstructed common hepatic duct with contrast extravasation into a contained collection. No opacification of common bile duct. An 8 French external drainage catheter was placed and connected with a bag. She was started on vanco, levo and flagyl. Blood cultures on admission grew pan-sensitive ENTEROCOCCUS FAECALIS. She received IV levaquin and po linezolid. A cardiac echo was done that did not demonstrated vegetations. Pt was managed conservatively until operation. She remained in the hospital until surgery. Cardiology was consultation for preop eval. A p-mibi stress test was done. Recommendations included improved bp control for which lopresor was increased and norvasc was started. ASA was recommended as well as reinstituting zocor. CT A/P 1. Interval improvement in intrahepatic biliary dilatation, status post catheter placement. 2. Significant improvement in perihepatic inflammatory process centered in the hepatic flexure region. 3. Imaging findings are at least concerning for transection of common bile duct. . P MIBI: Normal myocardial perfusion. Normal left ventricular cavity size and systolic function. . Echo: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. . Pre-Op CXR: Moderate enlargement of the cardiac silhouette is slightly more severe consistent with mild cardiomegaly and/or pericardial effusion. There is no pulmonary edema or congestion of vessels in the lung or mediastinum to indicate clinically significant cardiac decompensation. New linear opacities in the left lower lung are due to atelectasis. Lungs are otherwise clear. There is no pleural effusion or evidence of central adenopathy. Thoracic aorta particularly at the arch, shows calcification but no dilatation. . On [**2120-4-9**] she was taken to the OR by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for exploratory laparotomy, Roux-en-Y hepaticojejunostomy. She was in satisfactory condition and was kept in the PACU for low UOP. Pt was moved to the floor and low UOP continued. Pt was moved to the SICU for closer hemodynamic monitoring (eg CVP) for post-op hypovolemia. Pt was awake and oriented throughout. Pt was transfused one unit pRBC. Pt responded to fluid boluses and UOP improved. POD 3 pt was moved back to the medical-surgical unit. Diet was started, and supplements added. She complained on persistent nausea, no appetite and vomiting after eating. Metformin, actos and glyburide were held for possibility etiology of nausea, vomiting and fluid retention. Insulin sliding scale was used and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained. An EGD was performed that demonstrated gastritis. Zantac was d/c'd and protonix was increased to [**Hospital1 **] and maalox was administered with improvement in appetite and dietary tolerance. Actos and glyburide were restarted POD 5 pt had cholangiogram: contrast in the common hepatic duct, right and left hepatic ducts and multiple intrahepatic divisions as well as contrast in the jejunum. No obstruction or stricture identified. No extraluminal contrast. An abdominal CT was done on [**2120-4-18**] that demonstrated the following: Stable appearance of the perihepatic inflammatory process, involving the surgical bed, hepatic flexure, and omentum. No organized abscess/fluid collection. 2) Interval decrease in size in the small fluid collection adjacent to the pancreatic tail. 3) No evidence of bowel obstruction. 4) Right adrenal adenoma. 5) Probable tiny left lower lobe pulmonary nodule. She required increased lopressor, hctz and ntg tp for bp control for sbp's in range of 170/80-160/70. BP decreased on these meds to range of 127/70. She was discharged home in stable condition, tolerating a regular diet and ambulating independently. Medications on Admission: metformin 500" actos 30 glyburide 5" zantac 150" Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: common bile duct injury s/p lap chole at OSH DM II HTN hyperlipidemia Discharge Condition: stable Discharge Instructions: Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take medications, incision redness, bleeding or pus, drainage from insertion site at capped bile tube site, abdominal pain or any questions Labs weekly for cbc, chem 10, ast, alt, alk phos, t.bili, albumin with results fax'd to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 697**] [**Month (only) 116**] shower No heavy lifting Followup Instructions: call [**Telephone/Fax (1) 673**] to schedule follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-11**] weeks Completed by:[**2120-4-30**]

Admission Date: [**2152-10-18**] Discharge Date: [**2152-10-25**] Date of Birth: [**2091-3-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right lower lobe Efusion Major Surgical or Invasive Procedure: [**2152-10-20**]: Flexible bronchoscopy with bronchoalveolar lavage and active brushings and right video-assisted thoracoscopic surgery total pulmonary decortication. [**2152-10-19**]: Thoracic ultrasound. Thoracentesis on the right side. History of Present Illness: Mr [**Known lastname 22703**] is a 61M with a PMHx of AFib and non-ischemic cardiomyopathy who has been transfered from [**Hospital1 18**]-[**Location (un) 620**] for evaluation and management of his ongoing pulmonary issues. He initially presented there in [**8-30**] with a cough productive of yellow sputum and fevers to 101.5. He was treated for PNA and discharged to home on a course of cefpodoxime and azithromycin. On that admission he was found to be supratherapeutic on his coumadin to an INR of 3.1 secondary to the antibiotics and adjustments to his regimen were made for the duration of the course. The patient states that he never really felt any better and continued to have a productive cough, intermittent hemoptysis and fatigue, though he did return to work. On [**10-16**] he saw his PCP, [**Name10 (NameIs) 1023**] felt that there was radiographic improvement, but prescribed a course of clarithromycin and steroids for persistent cough. Over the course of the night the patient states that his cough was much worse and he went to the [**Location (un) 620**] ED. He was admitted and started on Vanc and Zosyn. CT showed a large loculated R pleural effusion as well as a new nodule on the left (comp CCT [**3-29**]). Thoracentesis was performed [**10-18**] and 200cc of bloody fluid was drawn and sent for analysis. The decision was made to transfer him to our service for possible surgical management. The patient reports no history of trauma, no sick contacts, no recent travel history, no history of exposure to tuberculosis (last PPD 20 years ago--neg). Past Medical History: Right pleural effusion. Nonischemic cardiomyopathy with an EF of 40% Obesity Atrial Fibrillation on coumadin status post total knee replacement status post MVA Social History: Single lives with mother. [**Name (NI) 4084**] smoked. Does not drink Family History: Mother--alive & healthy Father--[**Month (only) **]. prostate cancer Physical Exam: VS: T 97.8 HR: 54 SB BP: 108/60 Sats: 96% 1L Weight: 43.8 Kg General: 61 year-old male in no apparent distress HEENT: normocephalic, mucus membrane moist Neck: supple no lymphadenopathy Card: RRR Resp: decrease breath sounds on right occasional rhonchi, otherwise clear GI: obese, bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm right trace edema, left none Incision: Right VATs site clean dry intact w/steri-strips. Neuro: non-focal Pertinent Results: [**2152-10-25**] WBC-13.8 [**2152-10-24**] WBC-14.0* RBC-3.48* Hgb-10.8* Hct-31.8* Plt Ct-357 [**2152-10-23**] WBC-15.9* RBC-3.49* Hgb-10.9* Hct-31.9* Plt Ct-352 [**2152-10-20**] WBC-16.9* RBC-4.04* Hgb-12.7* Hct-36.3* Plt Ct-345 [**2152-10-18**] WBC-27.9* RBC-3.98* Hgb-12.7* Hct-35.8* Plt Ct-308 [**2152-10-24**] Glucose-81 UreaN-14 Creat-0.6 Na-135 K-4.1 Cl-96 HCO3-33* [**2152-10-18**] Glucose-196* UreaN-23* Creat-0.8 Na-133 K-4.9 Cl-95* HCO3-28 [**2152-10-24**] Calcium-7.8* Phos-3.1 Mg-2.3 [**2152-10-20**] 12:30 pm TISSUE Site: PLEURAL RIGHT PLEURAL DEBRIS. GRAM STAIN (Final [**2152-10-20**]): 1+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2152-10-24**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2152-10-24**]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2152-10-23**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2152-10-23**]): NO FUNGAL ELEMENTS SEEN. [**2152-10-20**] 12:23 pm PLEURAL FLUID RIGHT. GRAM STAIN (Final [**2152-10-20**]): 4+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2152-10-23**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2152-10-20**] 11:31 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2152-10-20**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2152-10-22**]): ~[**2143**]/ML OROPHARYNGEAL FLORA. YEAST. 10,000-100,000 ORGANISMS/ML.. ACID FAST SMEAR (Final [**2152-10-23**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST CULTURE (Pending): [**2152-10-19**] 11:41 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [**2152-10-19**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2152-10-22**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2152-10-25**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2152-10-20**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): CXR: [**2152-10-24**] IMPRESSION: Interval removal of two of three right-sided chest tubes. No pneumothorax. Persistent right-sided pleural effusion and bibasilar atelectasis. Chest CT w/contrast [**2152-10-19**]: FINDINGS: There is a loculated right pleural effusion with resulting right lower lobe and right middle lobe collapse. Minimal atelectasis in the left lower lobe and linear atelectasis in the left upper lobe. There is an 11 mm x 9 mm nodule in the left upper lobe (image 14, series 2). There is an additional nodule in the left upper lobe measuring 10 mm x 6 mm (image 18, series 2). There is a right hilar mass 4.5 cm x 2.7 cm x 2 cm. There is resulting narrowing of the bronchus intermedius and right middle lobe bronchus. There is thickening of the posterior wall of the bronchus intermedius. There is a subcarinal lymph node measuring 8 mm x 13 mm. There are right hilar lymph nodes measuring 15 mm x 18 mm. Brief Hospital Course: Mr. [**Known lastname 22703**] was admitted on [**2152-10-18**] for a persistent right lower lobe effusion. He was continued on his antibiotics Vancomycin, Zosyn and prednisone. On [**2152-10-19**] he had Thoracic ultrasound showed a moderate-sized pleural effusion which was visualized mostly at the posterior back of the hemothorax just at the paraspinal area. The fusion seems loculated and not free-flowing as the anterior part of the hemothorax very tiny effusion could be visualized, which was drained for 200 mL of serosanguineous effusion. A chest CT w/contrast revealed a loculated right pleural effusion with resulting right lower lobe and right middle lobe collapse. On [**2152-10-20**] he was taken to the operating room for successful Flexible bronchoscopy with bronchoalveolar lavage and active brushings and right video-assisted thoracoscopic surgery total pulmonary decortication. He was extubated in the operating room, monitored in the PACU prior to transfer to the floor. The 3 chest-tubes remained on suction x 48 hrs, a foley to gravity and Dilaudid PCA for pain. On POD1-2 his diet was restarted, the foley was removed and he voided without difficulty. Aggressive pulmonary toilet and nebs were continued. Chest film showed Significant decrease in right pleural effusion with residual atelectasis. Right-sided chest tubes with no evidence for pneumothorax. He was continued on Vancomycin until the culture data back. On POD3 the chest-tube were placed to water seal, chest film showed Patchy opacification of the right mid and lower lobes with small-to-moderate right-sided pleural effusion. The right anterior apical chest-tube was removed. On POD4 the posterior apical chest tube was remove and the basilar was placed to pneumostat. On POD5 the vancomycin and zosyn was changed to amoxicillin x 14 days for STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. His coumadin will be restarted. He was followed by physical therapy and was discharged to [**Location (un) 582**] at [**Location (un) 620**]. Medications on Admission: Amiodarone 200mg PO daily, Carvedilol 6.25mg PO BID, Lasix 80mg PO daily, lisinopril 5mg PO daily, Coumadin regular dose 7.5mg PO daily except 3.75mg PO Wednesdays--down to 5mg PO daily since starting anibiotic therapy for pneumonia [**8-30**] Discharge Medications: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): wean to off 30 x 2 days, 20 x 2 days, 10 x 2 days, 5 x 2 days then off. 4. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 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. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. 13. Regular Insulin Sliding Scale Fingerstick QIDInsulin SC Sliding Scale 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: please dose to maintain Goal INR 2.0-3.0. 18. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 19. Ipratropium Bromide 0.02 % Solution Sig: Two (2) ml Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Right pleural effusion. Nonischemic cardiomyopathy with an EF of 40% Obesity Atrial Fibrillation on coumadin status post total knee replacement status post MVA Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased cough, or chest pain -Incision develops drainage -Chest Tube site remove dressing Thursday cover with a bandaid. Should site begin to drain cover with a clean dressing and change as needed to keep site clean and dry. -Pneumostat: empty with a syringe. Keep a log of drainage. Site keep clean and apply dry clean dressing daily. Should tube fall out please call. This tube will be removed slowly to allow track to close. -Restart coumadin 5 mg goal INR 2.0-3.0 -Daily weights Followup Instructions: Follow-up with Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**2152-10-31**] 10:30 in the [**Hospital Ward Name 121**] Building Chest Disease Center, [**Hospital1 **] I Report to the [**Location (un) 591**], [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[**2152-10-26**]

Admission Date: [**2189-2-28**] Discharge Date: [**2189-3-11**] Date of Birth: [**2144-11-9**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Zomig Attending:[**Male First Name (un) 5282**] Chief Complaint: fevers, nausea, vomiting Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: 44yF with autoimmune hepatitis s/p transplant in [**2176**] with multiple complications (including recurrent AIH, chronic rejection, chronic portal vein thrombosis, and chronic LLE) presenting one day after discharge for IR dilatation of IVC stricture with nausea, vomiting, syncope, and fever. Was admitted [**Date range (1) 60486**] for planned IR balloon dilatation of IVC for treatment of chronic lower extremity edema. On the drive home from the hospital yesterday she felt nauseated and vomited six times (non-bloody, non-bilious). Each time she pulled over and passed out briefly after vomiting. Awoke at 3am with continued nausea and fever to 101.7, diffuse myalgias, but no syncopal episodes. She presented to [**Hospital3 15402**], where she was hypotensive to 80s and labs revealed a WBC of 22 and 26% bandemia. She was given a 500cc NS bolus, vancomycin (1gm) and zosyn (3.375mg) at 1:30/12:30pm. On transfer to the [**Hospital1 **] ED, vitals were T 98.9, HR 105, BP 113/54, RR 18, 98% on RA. WBC 23, 26% bands, and lactate of 6.6. Sepsis line was placed. Given 4L NS and CVP was 10, ScvO2 79, and making 50cc/hr urine. Was hypoglycemic to 60s and given 2 amps. Ultrasound of groin showed no evidence of aneurysm. RUQ ultrasound showed patent IVC. Liver consulted with nothing to add. On transfer to floor, vitals were T 97.5, HR 105, BP 121/58, RR 19, 96% on RA. Patient appeared well but complained of diffuse body pain, worse on right leg. Review of Systems: + worsening lower extremity pain and edema + myalgias + lower back pain/soreness x1 days + HA, relieved with morphine Otherwise, denies rash, chest pain, cough, shortness of breath, diarrhea, constipation, dysuria, hematuria, frequency, urgency, oliguria. Past Medical History: 1. Autoimmune hepatitis, s/p orthotopic liver transplant in UAB in 2/98, known recurrent AIH treated with prednisone and azathioprine. not cirrhotic. Most recent bilirubin is down to 4.2 from a peak of 30.7 in [**Month (only) 359**] c/b encephalopathy 2. Chronic portal vein thrombosis 3. Chronic lymphedema, s/p liver transplant 4. Psorasis 5. Allergic rhinitis 6. Dysfunctional uterine bleeding s/p partial hysterectomy 7. s/p CCY 8. Depression 9. ? extrahepatic bile duct obstruction. Social History: Pt moved to [**Location (un) 86**] in [**10-19**]. Pt lives with her daughter and grandson. Pt is disabled. No tobacco use. Has alcohol only on special occasions (birthdays, holidays). Last drink in [**10-20**]. No recreational drugs. Family History: Notable for heart disease and diabetes in multiple members. No history of auto-immune hepatitis or liver failure. Physical Exam: Vitals:BP 99/59, HR 95 SpO2 100% on RA General: In no distress, still some generalized pain Neuro: Alert, Oriented x3, no asterixis CV: RRR Lungs: Clear x 2 Abdomen: S, NT, Distended but not tense, no perceivable organomegaly, Chevron scar Extemities: Massive dependednt edema, hard to compression Pertinent Results: LABS ON ADMISSION: [**2189-2-27**] 06:15AM BLOOD WBC-7.2 RBC-3.76* Hgb-12.1 Hct-37.4 MCV-100* MCH-32.2* MCHC-32.3 RDW-16.4* Plt Ct-113* [**2189-2-28**] 02:55PM BLOOD Neuts-70 Bands-18* Lymphs-6* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2189-2-28**] 02:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL [**2189-2-27**] 06:15AM BLOOD PT-17.8* PTT-42.3* INR(PT)-1.6* [**2189-2-27**] 06:15AM BLOOD Glucose-112* UreaN-17 Creat-1.2* Na-134 K-3.2* Cl-102 HCO3-25 AnGap-10 [**2189-2-27**] 06:15AM BLOOD ALT-98* AST-157* LD(LDH)-212 CK(CPK)-59 AlkPhos-137* TotBili-3.1* [**2189-2-28**] 02:55PM BLOOD Lipase-12 [**2189-2-27**] 06:15AM BLOOD CK-MB-1 cTropnT-<0.01 [**2189-2-27**] 06:15AM BLOOD Calcium-7.5* Phos-4.1 Mg-1.5* [**2189-2-28**] 02:55PM BLOOD Ammonia-49 [**2189-2-28**] 02:55PM BLOOD Cortsol-13.9 [**2189-2-28**] 02:55PM BLOOD CRP-50.4* [**2189-3-1**] 04:13AM BLOOD Vanco-6.5* [**2189-2-28**] 09:47PM BLOOD Type-MIX pO2-42* pCO2-38 pH-7.37 calTCO2-23 [**2189-2-28**] 03:03PM BLOOD Lactate-6.6* . Micro: Coag neg staph at the OSH blood culture. Sensitive to Vanc. . [**2189-2-28**] Urine Culture ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML. AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S . [**2189-3-2**] URINE CULTURE (Final [**2189-3-3**]): YEAST. 10,000-100,000 ORGANISMS/ML. . Imaging: [**2189-2-27**] IMPRESSION: No right lower extremity DVT. . [**2189-2-28**] CXR IMPRESSION: No acute intrathoracic process. Right IJ CV line in appropriate position. . [**2189-2-28**] Left groin ultrasound FINDINGS: Direct ultrasound examination was performed on the left groin area at the site of prior catheterization. The left common femoral artery and vein are patent with normal waveform without evidence of aneurysm. There is no DVT or hematoma. . [**2189-2-28**] RUQ Ultrasound IMPRESSION: Limited Doppler exam detailed above with patency of IVC demonstrated. . [**2189-3-4**] Pelvic Ultrasound IMPRESSION: Near resolution of previously seen ovarian cysts, with one simple residual cyst on the right, measuring 2.3 cm. Focal calcifications within both ovaries, of uncertain significance. No evidence of malignancy. . [**2189-3-4**] Abdominal Ultrasound IMPRESSION: Portal veins were not able to be seen. However, this is unchanged since multiple prior ultrasounds and the CT of the abdomen and pelvis of [**2188-10-12**]. No large volume ascites. . [**2189-3-5**] KUB IMPRESSION: No evidence of bowel obstruction or free intraperitoneal air. . [**2189-3-6**] Abdomen and Pelvis CT IMPRESSION: 1. Diffuse anasarca. 2. Bilateral pleural effusion, right greater than left with adjacent compressive atelectasis in the right lung base. 3. Nonobstructive left kidney stones, the largest measures 5mm,however no hydronephrosis. 4. Splenorenal shunt and venous collaterals. Unable to assess presence of portal vein thrombus in this non-contrast study. . [**2189-3-8**] CXR IMPRESSION: 1. Patchy right infrahilar opacity, which may be due to atelectasis or pneumonia. 2. Interstitial edema and small pleural effusions, left greater than right. 3. Enlarged main pulmonary artery suggestive of pulmonary arterial hypertension. . WBC [**3-7**]: 7.5 WBC [**3-9**]: 13.6 WBC [**3-11**]: 10.9 . Labs on discharge: WBC 10.9 Hct 26.9 Plt 141 INR 1.7 Cr 1.0 TBili 2.9 Brief Hospital Course: Ms. [**Known lastname 108169**] is a 43 year old woman with a history of auto-immune hepatitis, s/p liver transplant with recurrent AIH. She recently underwent balloon dilation of the IVC. Two days following the procedure she presented with hypotension, syncope, emesis, and bandemia. She has positive blood cultures from an outside hospital. . #) Sepsis: She presented with hypotension and fevers. A central line was placed and she was given Zosyn and Vancomycin in addition to approximately 5 L of IV fluids. The blood cultures from the outside hospital eventually grew. coag neg staph. Her antibiotics were narrowed to vancomycin. She completed a seven day course. She remained afebrile and hemodynamically stable on the floor. The infection was thought to have occurred as a result of instrumentation following the IVC dilation. . #) Elevated WBC: Her WBC began to increase one day after stopping antibiotics. Obtained urine, blood, and CXR. Afebrile, cultures did not show evidence for infection, and patient was feeling well. As such, antibiotics were held and another course was not re-started. WBC then downtrended. . #) UTI: She had a urinary infection with enterococcus suscepible to vancomycin. She received a total of seven days treatment. . #) HRS: Following fluid resucitation she developed HRS. This was treated with midodrine, albumin, and octreotide. Her creatinine began to improve after several days. She maintained a good urine output. With improved creatinine, she was transitioned back to her home diuretic regimen and she put out multiple liters to this over the first 2 days, then diuresis volumes tapered down. . #) Volume Status: Ms. [**Known lastname 108169**] [**Last Name (Titles) 108171**] has 4+ LE edema. She underwent an IVC dilation to see if it would improve her edema. She also had a pelvic ultrasound while admitted to see if a cystic structure noted on previous imaging could be contributing to her edema. However, this structure had resolved. Her diuretics were held given hypotension and HRS. They were restarted on [**3-7**]. She had 4-5 L negative daily over the first two days. The increased edema caused much discomfort in her abdomen and legs. With diuresis, discomfort improved and ambulation became easier. . # Autoimmune hepatitis s/p liver transplant with recurrence--stable. Continued immunosuppression with Azathioprine, Cellcept, Tacrolimus and Prednisone. Levels of tacrolimus were within the therapeutic range. She met with social work during the admission because she was having difficulty paying for medications. They were able to provide her with a temporary supply while applying for alternate health care coverage. . #) Depression: Continued home meds. She met with social work while an inpatient. Cheerful on discharge. Discharged with SW f/u and services at home (nursing, home safety eval, PT, social work). Medications on Admission: Azothiaprine 50mg [**Hospital1 **] Mycophenolate Mofetil 1000mg [**Hospital1 **] Prednisone 15mg PO QD Tacrolimus 1mg [**Hospital1 **] Spironolactone 150mg PO QD Torsemide 40mg PO QD Omeprazole 20mg PO QD Ursodiol 600mg PO QD Kristalose 10ml QD Singulair 10mg PO QD Nasonex 50mcg 2 sprays QD Cholecalciferol 400U PO QD Calcium Carbonate 500mg PO QID Magnesium Oxide 2000mg PO QD Clobetasol 0.05% one application topically [**Hospital1 **] Lactobacillus acidophilus one capsule TID Potassium chloride 1 capsule QD Vitamin K (not taking due to expense) Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO Q 24H (Every 24 Hours). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 10. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Magnesium Oxide 400 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 17. Kristalose 10 gram Packet Sig: One (1) PO once a day. 18. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2) sprays Nasal once a day. 19. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule PO three times a day. 20. Potassium Chloride Oral Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary Diagnosis: Bacteremia Chronic Lower Extremity Edema Hepatorenal Syndrome Sepsis Urinary Tract Infection . Secondary Diagnosis: Autoimmune Hepatitis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital after having fevers and passing out. Tests showed you had bacteria in your blood stream. You were treated with antibiotics for this infection. In the course of being treated your kidneys were not working as well as they should be. You were given medical treatment and your kidneys returned back to normal. Followup Instructions: Previously-scheduled appointments: . Provider: [**Name10 (NameIs) 278**] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2189-4-10**] 10:15 . Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD (Hepatology)Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-4-10**] 11:40 Completed by:[**2189-3-11**]