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152, h o nephrolithiasis s p lithotripsy and h o left ureteropelvic junction stone 03 spontaneously passing by U S no evidence of right stone on most recent u s 5 months ago h o pyelo last episode in 03 MRSA in blood and urine SLE w h o pericarditis last flare couple years ago didn t flare w urosepsis Devic s disease Recurrent transverse myelitis with sequelae of paraplegia-exacerbation in 93 Recurrent bilateral optic neuritis with legal neurologist Dr. Heaton UMass Memorial Medical Center steroids increased to 40 qd in Renee for concern for recurrent optic neuritis which turned out to be capsular ossification blindness in right CMED CSRU . Bilateral knee arthritis Suspected glaucoma in left CMED CSRU turned out to be capsular ossification or a secondary cataract corrected w laser surgery 2014-11-03 Urostomy s p ileal loop conduit in 2007 for neurogenic bladder w persistent leak Steroid-induced hyperglycemia Hypothyroid Osteoporosis Hx of DVT in RLE 93 on coumadin for a couple years and then ASA until a couple months ago Social History Retired ICU nurse Thomas Haas x 15 yrs but maintains her certification . Lives at Lowell Home NH x 11 yrs due to chronic CMED issues Her doctor there is Dr. Gerald Jones . No h o tobacco alcohol or IVDA Wheelchair dependent requires Hoyer lift . UE strength intact but poor motor movements due to loss of sensation .,0
48, Colace 100 mg p.o. b.i.d. Folate 1 mg q.d. Artificial Tears 2 drops each eye b.i.d. and p.r.n. Serax 15 mg p.o. q6h hold if patient excessively sleepy Thiamine 100 mg p.o. q.d. MS Contin 30 mg p.o.b.i.d multivitamin q.d. MSIR 15 mg p.o. q3-4h p.r.n. pain and Axid 150 mg p.o. b.i.d. The patient is to undergo dry dressing changes and splint to his right arm q.d. DIET Regular . FOLLOWUP The patient is to be seen in the burn clinic two days after discharge . The patient was discharged in stable condition . Dictated By TELSHEY K. PAP M.D. IK06 Attending TELSHEY K. PAP M.D. BH2 MC084 4189 Batch 9441 Index No. YROINI4 PGM D 01 07 97 T 01 07 97 CC 1.,2
173, Atrial fibrillation secondary to hyperthyroidism initially diagnosed in 2005 Status post current cardioversion times four Hyperthyroidism status post radioactive iodine ablation . Status post carpal tunnel release Status post umbilical hernia repair . Hypertension MEDICATIONS AT HOME 1. Accupril 40 mg q.d. Aspirin 325 mg q.d Clonidine 0.1 mg b.i.d.,0
83, On admission in general the patient was in no acute distress comfortable . Vital signs showed temperature 96.3 pulse 64 blood pressure 170 70 respiratory rate 20 oxygen saturation 98 in room air . Head eyes ears nose and throat examination is normocephalic and atraumatic . Extraocular movements are intact . The pupils are equal round and reactive to light and accommodation . Anicteric . Throat is clear . The chest is clear to auscultation bilaterally . Neck was supple with no lymphadenopathy . Cardiovascular shows grade II VI systolic ejection murmur regular rate and rhythm . The abdomen is soft nontender nondistended with a small umbilical hernia . Extremities are warm noncyanotic and nonedematous times four . There is no peripheral edema .,1
26, Metastatic gallbladder cancer . Status post cholecystectomy . Status post transverse colectomy with anastomosis . G tube placement . Feeding jejunostomy . Hypothyroidism . Blood loss requiring transfusion .,2
165, As above . PAST SURGICAL HISTORY As above MEDICATIONS ON ADMISSION Percocet and Naprosyn . ALLERGIES Demerol,0
206, VITAL SIGNS Temp 98.5 heart rate 74 BP 140 90 respiratory rate 18 O2 sat 98 . GENERAL The patient was alert but in mild discomfort . HEENT PERRL EOMI oropharynx clear moist buccal mucosa . NECK No lymphadenopathy no JVD . LUNGS Bibasilar crackles . Breath sounds were of good intensity . HEART Regular rate and rhythm normal S1 S2 no murmurs rubs or gallops . ABDOMEN Soft non-distended . Tender to palpation at the left lower quadrant and especially at the epigastrium . There was no splenomegaly or hepatosplenomegaly . Bowel sounds were present . BACK Point tenderness at the left costovertebral angle . EXTREMITIES Warm to touch no clubbing cyanosis or edema . NEURO The patient was alert and oriented x3 . Deep tendon reflexes were equal and adequate in upper and lower extremities . Cerebellar function was intact . Sensation was intact to pain and light touch .,1
59, In Clinic his cervical spine examination was benign . Shoulder elevation is 170 degrees with 70 degrees of external rotation and internal rotation of the right shoulder to T9 vertebra versus T7 on the left . Rotator cuff measures 4-5 on the right and 5 out of 5 on the left . Mild pain with resistive test and his Pigott sign is mildly positive on the right negative on the left . There is 1 cm. sulcus sign bilaterally . Laxity is noted as well as markedly positive apprehension sign on the right . Biceps are normal . HOSPITAL COURSE AND TREATMENT The patient was admitted to the Hospital and was taken to the operating room for an open Bankart procedure with biceps tenodesis Please see the operative note for full details . Postoperatively the patient did very well and was neurovascularly intact . His wound was intact clean and dry and it was covered with perioperative antibiotics . He was discharged to home on Percocet . He was given strict instructions to limit his external rotation no more than 30 degrees . He was seen by physical therapy prior to discharge . FOLLOW UP He is to follow up with Dr. Rach Breutznedeaisscarvwierst in Clinic .,1
154, 1 Cardiovascular The patient was admitted for rule out myocardial infarction . She remained on telemetry for greater than 48 hours which demonstrated no dysrhythmia during this time . The patient underwent an echocardiogram which demonstrated a preserved ejection fraction with left ventricular hypertrophy and no significant valvular abnormalities . The patient was maintained on her aspirin and Lasix . The patient &aposs Diltiazem was stopped due to her increased blood pressure and was started on Labetalol which was gradually titrated up to a target blood pressure of 160-170 systolic in her right arm . The patient also underwent an Adenosine MIBI stress test which showed only mild lateral ischemia . At this time the patient &aposs presyncopal symptoms were not felt to be secondary to a cardiovascular etiology . 2 Neurological vascular The discrepancy in the patient &aposs pulses and blood pressure was felt to be consistent with a subclavian artery stenosis . The patient underwent MRI MRA of the head neck and upper chest which demonstrated a proximal left subclavian artery stenosis proximal to the take off of the left vertebral artery . The left vertebral artery had a decreased flow consistent with either native vessel disease or some degree of retrograde flow with subclavian steal phenomenon . The patient had patent carotids bilaterally on her neck MRA . MRI of the head demonstrated a small vessel disease and was likely an old right cerebellar infarct . The patient underwent non-invasive carotid ultrasounds which demonstrated no significant carotid disease . The patient was also noted to have antegrade flow in both of her vertebral arteries bilaterally . The results of these studies suggested that the patient &aposs symptoms were not due to subclavian steal phenomenon and therefore it was decided that the patient would not go further to angio and or surgical or percutaneous intervention . A Neurology consult was obtained and it was felt that the most valuable intervention that could be done for the patient &aposs intervascular disease would be adequate control of her blood pressure . 3 Orthopedic The patient suffered a fall at home with her initial event . Outside hip films were obtained but were not available for view . Repeat hip films demonstrated a right sided pubic rami fracture likely new . An Orthopedics consult was obtained and the patient was encouraged to weight bear as tolerated with Physical Therapy assistance . A bone scan was also obtained to rule out an occult hip fracture which was negative . At the time of this dictation the patient was able to bear weight with the assistance of Physical Therapy and a walker .Plan,0
69, Notable for sodium 141 potassium 4.2 chloride 109 bicarb 19.8 BUN 38 creatinine 1.2 and glucose 388 . She had a pneumonia of 31 calcium was 7.5 phosphorous 3.0 magnesium 1.3 . Her bilirubin was 1.4 total 0.2 direct . alkaline phosphatase 101 . SGPT 22 SGOT 41 amylase 31 lipase less than 1 . LDH was 38.9 CK was 66 her hematocrit was 27.4 white count was 8.0 and her platelets were 55 . PT was 14.5 PTT 25.5 . ,1
32, Percocet one to two tablets p.o. q.4-6h. p.r.n. Iron Sulfate 325 mg p.o. b.i.d Colace 100 mg b.i.d. and one Aspirin q.d. She is to follow-up with Dr. Para for follow-up . Dictated By RIMARVNAA D. KUSHDREPS M.D. AV94 Attending EARLLAMARG S. PARA M.D. FT99 OH475 4059 Batch 2446 Index No. LXAIB23C4 L D 06 07 93 T,2
21, Allergies include AMOXICILLIN and CODEINE . MEDICATIONS ON ADMISSION Insulin by sliding-scale NPH insulin 16 units in the morning and 6 units in the evening . Lipitor 20 mg p.o. q.d. Zoloft 50 mg p.o. t.i.d. 4. Reglan 10 mg p.o. t.i.d. Lopressor 50 mg p.o. b.i.d. Aspirin 81 mg p.o. q.d. Multivitamin 1 p.o. q.d. Remeron p.o. q.d. ,2
148,"1. GI Patient was transfused 2 units of packed red blood cells overnight the first night after admission and his hematocrit bumped up appropriately .', 'He remained hemodynamically stable throughout his admission . He was continued on a proton pump inhibitor and on iron sulfate and vitamin C .', 'His Coumadin was held at the time given the bleeding even though it was important to keep his INR 2.5-3.5 given his artificial valve it was felt that the risk of continued bleeding was to', 'great to continue the Coumadin . He was subsequently seen by the GI team who performed an upper endoscopy which demonstrated the following', 'In the esophagus there was a small hiatal hernia and in the stomach there is evidence of erosive gastritis of the body of the stomach and the antrum the mucous appeared edematous .', 'A small polyp was found in the fundus which stigmata of old bleeding an Endoclip was applied to this . Another polyp was found in the antrum and cold biopsies were obtained there .', 'In the duodenum a small AVM was noted in the second portion of the duodenum and was cauterized . The biopsy subsequently demonstrated a hyperplastic polyp with acute and chronic inflammation', 'and erosion and reactive epithelial changes but no dysplasia . Also of note prior to the upper endoscopy the patient received fresh frozen plasma to reverse his anticoagulation .', 'Patient remained hemodynamically stable during and after the upper endoscopy and his hematocrit remained above 30 following this until the point of discharge .', 'His last recorded hematocrit on discharge was 31.3 . His last BUN and creatinine were 42 and 1.5 with an INR of 2.5 . Consideration was given to performing a repeat colonoscopy .', 'This was discussed with the GI Service who felt that this was not necessary given the recent colonoscopy that he had had in 05 2003 . 2.', 'Cardiovascular A Ischemia Patient &aposs troponin bump was found to be likely to demand ischemia in the setting of his GI bleed it was not felt that he was having acute coronary syndrome .', 'On discharge he was continued on his aspirin simvastatin and his Lopressor which was initially held and subsequently restarted . B Rhythm Patient continued to be in A-fib.', 'throughout the admission and was restarted on his Coumadin concurrently with heparin . Heparin was subsequently DCd once his INR reached a therapeutic level between 2.5-3.5 .', 'His last reported INR on discharge was 2.5 . C Valves Patient had as noted above his anticoagulation was initially reversed despite his having artificial valves .', 'However his Coumadin was subsequently restarted and he achieved therapeutic INR levels before discharge . D Pump Patient during this hospital course', 'became hypervolemic likely due to his diuretics being held and due to his receiving blood products . He was diuresed initially with one dose of Lasix and subsequently with one dose of torsemide', 'after it was discovered that he developed thrombocytopenia on a prior admission in reaction to Lasix . He subsequently was diuresed to a euvolemic state . Of note he did not become', 'thrombocytopenic on this admission .",0
75,"Auditory hearing screening was performed with automated auditory brain stem responses and the infant passed both ears on his previous admission .', 'Hearing screens were repeated on 2018-05-13 and he passed both ears . PSYCHOSOCIAL Family is invested and involved .",1
162, As above and once transferred to the floor patient had fingersticks monitored every four hours with a sliding scale . Patient reached goal of fingersticks between 50 and 300 which is what she maintains at home . Sliding scale was adjusted as necessary . Patient was continued on intravenous fluids until taking good po . Infectious Disease The patient had an elevated white count upon admission however white count came down to 7.1 and prior to discharge patient was afebrile and no clear etiology for elevated white blood cell on admission questionably secondary to short gastrointestinal infection however patient is completely symptom free upon discharge . Fluid electrolytes and nutrition The patient s electrolytes were repleted as necessary . Potassium was given with her intravenous fluids and phosphate will be repleted as patient increases her po intake .,0
113, Atenolol 50 mg p.o. q.d. Lipitor 10 mg p.o. q.d. baby aspirin 81 mg p.o. q.d. iron sulfate 81 mg p.o. q.d Lasix 40 mg p.o. q.d. Accupril 40 mg p.o. q.d. hydrochlorothiazide 12.5 mg p.o. q.d. NPH insulin 18 units q.a.m. and 10 units q.p.m. Humalog sliding-scale q.a.m. and q.p.m.,3
153, 1 Bronchiolitis obliterans organizing pneumonia The video assisted thoracoscopic study at the outside hospital was consistent with bronchiolitis obliterans organizing pneumonia . The patient was continued on steroids throughout the course of her stay . This was changed to Solu-Medrol part way through the course due to her hematologic problems see below . By discharge she was returned to 40 mg of Prednisone q. day times one month to be followed by a slow taper . The patient &aposs bronchiolitis obliterans organizing pneumonia appeared to improve slowly throughout her hospital course however on July 12 1998 after starting dialysis see below the patient desaturated and required supplemental oxygen . Repeat chest x-rays and chest CT scans appeared consistent with pulmonary edema from volume overload given her renal failure and eventually the patient &aposs pulmonary status did improve after significant volume removal with dialysis for several weeks . At the time of her discharge the patient was still requiring two liters of supplemental oxygen to maintain her oxygen saturations in the mid 90 . 2 Thrombotic thrombocytopenic purpura The patient was initially admitted with platelet count of 28 hematocrit of 32 LDH of 496 with 2 schistocytes and 2 spherocytes on her smear . This was felt to be consistent with thrombotic thrombocytopenic purpura and on June 20 1998 she was started on daily plasma exchange which continued through July 27 1999 . She was also changed to intravenous Solu-Medrol 50 mg q. day which was changed back to 40 mg of Prednisone prior to discharge . Her platelet count initially rose to a maximum of 159 on July 3 1998 then they steadily fell to a low of 60 on July 20 1999 . Her LDH which peaked at 1255 decreased to the mid 200s but remained elevated . She continued to have a few schistocytes on her smear but it was much decreased . The patient also required red blood cell transfusions approximately two units every seven to ten days to maintain her hematocrit . Eventually her plasma exchange was tapered to a smaller and smaller dose each day and then discontinued altogether after July 27 1999 . After this the patient &aposs platelet count rose to a maximum of 177 on discharge . It is felt that the patient &aposs thrombotic thrombocytopenic purpura has resolved . She will continue on her Prednisone for one month as above for the bronchiolitis obliterans organizing pneumonia with a very slow taper . 3 Renal The patient presented in acute renal failure with a BUN of 101 and a creatinine of 3.7 . Throughout the month of June she had a rising Potassium phosphate and increasing volume overload with decreasing response to diuretics and she was finally initiated on dialysis with ultrafiltration on July 12 1998 . The opinion of the Renal consult was that this was permanent and non-reversible renal failure since it did not improve with dialysis and the patient will continue on dialysis three times per week . She required approximately five liters of ultrafiltration fluid removal at each dialysis session due to her significant volume overload . During the course of her dialysis she had a great improvement in her lower extremity edema and her oxygen saturation . 4 Infectious disease The patient had multiple line infections during her admission including a confirmed coag. negative Staphylococcus line infection with positive blood cultures on June 23 1998 July 4 1998 July 8 1998 and July 9 1998 . The patient eventually had a left subclavian Tesio catheter placed and a right brachial PICC line placed on July 10 1998 which remained patent and uninfected . She received a full three week course of Vancomycin and also received a three week course of Ceftazidime . In addition she had a fungal urinary tract infection treated with Amphojel bladder irrigation which was followed by a Klebsiella urinary tract infection for which she received Levofloxacin times fourteen days . She also received a fourteen day course of Acyclovir which was begun on June 21 1998 for perianal lesions consistent with herpes simplex virus . She was also on Fluconazole for some oral thrush which was inadvertently continued for a total of thirty days . The patient was also started on Bactrim one double strength tablet q.o.d. as prophylaxis for Pneumocystis carinii pneumonia while on her high dose steroids . 5 Rheumatology The patient was admitted with a question of lupus given her ANA of 1640 although her rheumatoid factor and ANCA were negative . Unfortunately throughout her admission we were unable to test any more titers since she was receiving daily plasma exchange . A repeat ANA rheumatoid factor and ANCA may be repeated as an outpatient . FOLLOW-UP 1 The patient will follow-up with her primary care physician Dr. Tamarg Study in Arvus after she is discharged from rehabilitation . 2 The patient is being discharged to A Hospital where she will receive onsite hemodialysis three times per week on Monday Wednesday and Friday . The nephrologist who will follow her there is Dr. Study . 3 The patient will continue to have her CBC LDH bilirubin chem-7 and magnesium and calcium checked with each dialysis and the results will be faxed to Dr. Ian Zineisfreierm the hematology attending at fax number 751-329-8840 . 4 The patient will eventually need a permanent dialysis fistula . The left subclavian Tesio which she has in place will last for several months in the mean time . She would like to arrange to have her fistula placed at Pre Health and the vascular surgeons there should be contacted regarding this . 5 The patient will need packed red blood cell transfusions with dialysis when her hematocrit falls below 26 . 6 The patient will continue her Prednisone at 40 mg p.o. q. day times one month this was started on July 27 1999 and then she will begin a slow taper as guided by Pulmonary . 7 The patient has a follow-up appointment in the Pulmonary Clinic with Dr. Cedwi Stone at 336-2931 on August 30 1999 at 140 PM . 8 The patient has a follow-up appointment with Dr. Ian Zineisfreierm at the We Erthunt Hospital at 180-0455 on August 15 1999 at 1230 PM . MEDICATIONS ON DISCHARGE 1 Calcitriol 0.25 mcg p.o. q. day . 2 TUMS 1250 mg p.o. t.i.d. 3 Premarin 0.625 mg p.o. q. day . 4 Colace 100 mg p.o. b.i.d. 5 Humulin sliding scale q.a.c. and q.h.s. 6 Labetalol 400 mg p.o. t.i.d. 7 Omeprazole 20 mg p.o. q. day . 8 Serax 15 mg p.o. q.h.s. p.r.n. insomnia . 9 Prednisone 40 mg p.o. q. day times thirty days beginning on July 27 1999 to be followed by a slow taper as directed by the pulmonologist . 10 Metamucil one packet p.o. q. day . 11 Amlodipine 10 mg p.o. q. day . 12 Bactrim Double Strength one tablet p.o. q.o.d. 13 Nephrocaps one tablet p.o. q. day . 14 Epogen 1 000 units subcutaneously three times per week . 15 Iron sulfate 300 mg p.o. t.i.d. Dictated By CHELA FYFENEIGH M.D. NY5 Attending LENNI E. NECESSARY M.D. BE1 IZ845 6789 Batch 7665 Index No. YQGKGG4LST D 08 01 98 T 08 01 98 CC CEDWI STONE MD BMH PULMONARY CLINIC TAMARG STUDY MD Port O,0
45, Toprol XL 100 mg daily Hydralazine 25 mg daily Lasix 40 mg twice a day digoxin 0.75 mg daily Lovenox 40 mg twice daily subcutaneously and albuterol p.r.n. Peter Richard MD Dictated By Michael O. Tucker M.D. MEDQUIST36 D 2016-01-29 090727 T 2016-01-29 094948 Job 72842 Signed electronically by DR.,2
60, In general confused white man in mild distress . Vital signs Temperature was 102 heart rate was 110 respiratory rate was 22 blood pressure was 113 63 . His head eyes ears nose throat was benign . His neck was supple . Lungs Rales at the right base bilateral decreased breath sounds at the bases . Cor Regular rate and rhythm S1 and S2 no extra heart sounds abdomen distended with an epigastric mass noted mildly tender to palpation no guarding . Bowel sounds were present . The neurological examination was nonfocal .,1
38, Stable . DISCHARGE DIAGNOSIS 1. Depression . Insulin-dependent diabetes mellitus . Asthma . Alcohol abuse . DISCHARGE MEDICATIONS 1. Insulin NPH 10 units q.a.m. 5 units q.p.m. Humalog sliding scale insulin for fingerstick blood glucose 151-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units greater than 400 12 units . Multivitamin . Fluticasone . Albuterol p.r.n. Pepcid 20 mg p.o. q.d. FOLLOW-UP PLANS The patient will be transferred to the Inpatient Psychiatry Unit on Springfield Municipal Hospital IV for further evaluation and treatment of his depression and possible suicidal ideation . He will follow-up with his primary care doctor Dr. Gillis after discharge Johannes for Diabetes management and Psychiatry for further management of his impulsive behaviors . Patty K. Wagner M.D. 01 -820 Dictated By Cora C. Haskett M.D. MEDQUIST36 D 2010-08-31 0908 T 2010-09-10 0823 JOB 34336 Signed electronically by DR. Elizabeth Gabriele on FRI 2010-09-10,2
64, Na 134 K 4.2 Cl 98 bicarb 26 BUN 11 creatinine 0.5 glucose 119 . CBC White count 7.5 hematocrit 28.5 platelets 452 . PT 16.2 PTT 34.7 INR 1.8 . LDH 254 amylase 727 lipase 8600 .,1
91, On admission weight 1515 grams 10th to 25th percentile head circumference 30 cm 25th to 50th percentile length 41 cm 10th to 25th percentile . Warm dry premature infant active with exam mild respiratory distress at rest . Overall appearance consistent with estimated gestational age . Thin warm dry pink no rashes . Fontanelle soft and flat . Ears normal . Palate intact . Nondysmorphic . Positive red reflex bilaterally . Neck supple no lesions . Chest moderately aerated . Mild grunting . Cardiovascular Regular rate and rhythm no murmur femoral pulses 2 . Abdomen soft no hepatosplenomegaly quiet bowel sounds 3 vessel cord . CMED CSRU Normal female anus patent . Hips stable . Back normal . No lesions . Appropriate tone and activity for gestational age .,1
125, Insulin 44 units NPH qam 8 units qpm Vasotec 2.5 qd Lasix 40 qd Mevacor 40 qd Cardizem CD 180 qd Ciprofloxacin for urinary tract infection aspirin .,3
14,"She remains very weak and will most likely benefit from some physical therapy andshe still has the bilateral edema . She is to go to the Necsoncardel Medical Center for more chronic care .', 'Follow-up is with Dr. Wedleung in the Hem Onc in two weeks . The appointment has already been made . The patient is very limited in how much she can do right now because of her pain primarily', 'and her difficulty breathing . Dictated By JEABRIHARL FIGEFREIERMFOTHGRENDCAJAQUE M.D. Attending LA INEMACISTIN PRONTMANDES M.D. HD45 SY882 1177 Batch 020 Index No. YJQI3J9VU6 D 01 25 94",2
189, Cardiology was consulted to evaluate this and felt that the changes seen on the EKG were not significant . The patient was also seen by Dr. Nusc from General Surgery for evaluation of micro calcifications in the right breast . The patient refused a biopsy for this admission and desires follow-up mammograms . She is to be followed up by General Surgery . The patient underwent a total vaginal hysterectomy on June 4 1993 which she tolerated without complications . Her post-operative course has been uncomplicated . She remained afebrile throughout her admission tolerating a regular diet by post-operative day two and was discharged on June 6 1993 with Percocet for pain . The Foley was discontinued and the patient was urinating on her own . DISPOSITION,0
194, Coronary artery disease Myocardial infarction x3 Coronary artery bypass graft Systemic lupus erythematosus in remission HOME MEDICATIONS 1. Coreg 6.25 mg po bid 2 Lasix 25 mg po qd 3 Imdur 30 mg po qd K-Dur 10 milliequivalents po qd Zestril 2.5 mg po bid Multivitamin Folate ALLERGIES He has no known drug allergies . ,0
205, Mother died at 51 metastatic BCA Father died at 36 aplastic anemia only child Physical Exam T 100.0 bp 109 56 CVP 11 hr 113 rr 16 O2 95 on 3L NC mixed Quinn 82 genrl in nad resting comfortably heent perrla 4->3 mm bilaterally blind in right visual field eomi dry mm ? thrush neck no bruits cv rrr no m r g faint s1 s2 pulm cta bilaterally abd midline scar from urostomy nabs soft appears distended but patient denies ostomy RLQ c d i NT to palpation back right flank urostomy tube c d i nt to palpation extr no Gardner neuro a ox3 wiggles toes bilaterally unable to lift LE 06-12 grip bilaterally w UE decrease sensation to soft touch in left UE and LE Pertinent Results 2014-11-29 0511PM WBC 23.5 RBC 3.81 HGB 9.4 HCT 29.2 MCV 77 MCH 24.6 MCHC 32.1 RDW 18.1 2014-11-29 0511PM NEUTS 93 BANDS 1 LYMPHS 0 MONOS 6 EOS 0 BASOS 0 ATYPS 0 METAS 0 MYELOS 0 2014-11-29 0511PM GLUCOSE 229 UREA N 25 CREAT 0.8 SODIUM 136 POTASSIUM 5.3 CHLORIDE 101 TOTAL CO2 17 ANION GAP 23 2014-11-29 0511PM LD LDH 214 2014-11-29 0641PM LACTATE 1.4 2014-11-29 0511PM URINE COLOR Straw APPEAR Hazy SP Thibodeaux 1.008 2014-11-29 0511PM URINE BLOOD LG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 9.0 LEUK SM 2014-11-29 0511PM URINE RBC 21-50 WBC 04-12 BACTERIA MANY YEAST NONE EPI 0-2 2014-11-29 0511PM URINE 3PHOSPHAT OCC 2014-11-29 CT CAP 1. An 8 x 7 x 7 mm stone in the proximal right ureter with associated right hydronephrosis and inflammatory perinephric stranding . Additional smaller non-obstructing right renal stones . 2. Left renal stones without evidence of hydronephrosis . Ileal conduit is not well evaluated . 3. Right breast calcification . Correlation with mammography is suggested . . 2014-11-29 CXR No evidence of pneumonia . . 2014-11-29 CT AP 2 with contrast 1. Eight mm right proximal ureteral stone with right-sided hydronephrosis and inflammatory stranding . Pyelonephritis of the left kidney without left sided hydronephrosis . No evidence of intraabdominal abscess or of diverticulitis . Bilateral round hypodense renal lesions too small to accurately characterize but likely representing cysts . 4. 1.4 cm hypodense lesion in right lobe of the liver is incompletely characterized . . 2014-11-30 CT CAP Nephrostomy tube in the right kidney with an 8 mm right ureteric stone . 6 mm nonobstructing calculus in the left kidney . Calcified focus and a small hypodense lesion in the right lobe of the liver incompletely characterized . Bibasilar and dependent atelectasis . . 2014-11-29 510 pm BLOOD CULTURE 2 . FINAL REPORT 2014-12-04 AEROBIC BOTTLE Final 2014-12-04 KLEBSIELLA PNEUMONIAE . IDENTIFICATION AND SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE . OF TWO COLONIAL MORPHOLOGIES . ANAEROBIC BOTTLE Final 2014-12-04 REPORTED BY PHONE TO Robert BURGER 2014-11-30 1035A . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim Sulfa sensitivity testing available on request . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim Sulfa sensitivity testing available on request . 2ND STRAIN . SENSITIVITIES MIC expressed in MCG ML KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN SULBACTAM- = >32 R = >32 R CEFAZOLIN =4 S =4 S CEFEPIME =1 S =1 S CEFTAZIDIME =1 S =1 S CEFTRIAXONE =1 S = 1 S CEFUROXIME 4 S 4 S CIPROFLOXACIN = >4 R = >4 R GENTAMICIN 8 I 8 I IMIPENEM = 1 S =1 S LEVOFLOXACIN = >8 R = >8 R MEROPENEM =0.25 S = 0.25 S PIPERACILLIN TAZO = 4 S =4 S TOBRAMYCIN 4 S 8 I . 2014-11-30 150 pm URINE KIDNEY PERC. NEPH. . FINAL REPORT 2014-12-03 FLUID CULTURE Final 2014-12-03 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 . STAPH AUREUS COAG . > 100 000 ORGANISMS ML. . OF TWO COLONIAL MORPHOLOGIES . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins cephalosporins carbacephems carbapenems and beta-lactamase inhibitor combinations . Rifampin should not be used alone for therapy . GRAM NEGATIVE ROD S . > 100 000 ORGANISMS ML. . OF TWO COLONIAL MORPHOLOGIES . SENSITIVITIES MIC expressed in MCG ML STAPH AUREUS COAG | GENTAMICIN = >16 R LEVOFLOXACIN = >8 R NITROFURANTOIN = 16 S OXACILLIN = >4 R PENICILLIN = >0.5 R TETRACYCLINE = >16 R VANCOMYCIN =1 S . 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE PENDING ANAEROBIC BOTTLE PENDING 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE PENDING ANAEROBIC BOTTLE PENDING 2014-12-02 URINE URINE CULTURE FINAL No Growth 2014-12-02 CATHETER TIP IV WOUND CULTURE FINAL No Growth 2014-12-02 BLOOD CULTURE AEROBIC BOTTLE PENDING ANAEROBIC BOTTLE PENDING Brief Hospital Course 47 yo F w h o steroid-induced hyperglycemia SLE w h o pericarditis transverse myelitis w paraplegia and neurogenic bladder s p urostomy w ileal conduit h o ureteropelvic stone and urosepsis and h o RLE DVT admitted 11-29 w left pyelo and right 8 mm proximal ureteral stone w right hydro s p perc urostomy tube to relieve right hydro . . GNR sepsis Upon admission pt was febrile to 101.2 with U A consistent with UTI . A CT abd showed 8mm obstructing stone hydro with stranding consistent with pylonephritis . Her presentation was thought likely due to urosepsis given h o foul smelling urine and in setting of stone w hydro pyelo by CT. The patient went to IR on 2014-11-30 given evidence of right hydronephrosis on imaging for decompression and drainage. Upon admission she was treated with Vancomycin and Gentamycin and Flagyl . She was started on the MUST protocol with high dose steroids as well and a goal SVO2 >70 . She was hypoxic requiring 3L nasal cannula O2 . She subsequently developed hypotension with SBP in the 70s . She was transferred to the CMED where the patient was continued on the MUST protocol with goais of CVP 10-12 SVO2 greater than 70 . The patient was bolused with NS and did not required pressors . On the day after admission to the CMED the patient was noted to have small oxygen requirement with 2L NC . Repeat imaging revealed evidence of mild pulmonary congestion which was thought to account for the patient s mild hypoxia . Given that the patient had been maintaining a MAP of 60 without fluids or pressors her goal CVP was decreased to >8 to avoid fluid overload . The patient was continued on Vancomycin and Gentamycin while speciation and sensitivities were pending . Ciprofloxacin was added on 2014-12-01 for synergy when surveillance cultures were found to be growing again GNR . Gent and Cipro were then discontinued and changed to meropenem when blood culture sensitivities became available revealing GNR sensitive to Jacoby but resistant to both Gent and Cipro . Additionaly surveillance cultures were drawn daily and the patient was transferred back to the floor with no subsequent pressor requirement . Blood cltures from 11-30 grew KLEBSIELLA PNEUMONIAE and 12-01 grew KLEBSIELLA PNEUMONIAE and PROTEUS MIRABILIS both sensitive to the Meropenam which she had already been receiving . Urine cultures from 11-30 grew STAPH AUREUS COAG and GRAM NEGATIVE RODS of two morphologies not further speciated . She defervesed by 12-02 and remained clinically stable with normal blood pressures until the day of discharge . At the time of discharge blood cultures from 12-02 and 12-03 have no growth to date . She received a midline on 12-04 with a goal of 16 days of further antibiotic treatment with Meropenam for a total of 3 weeks upon discharge back to the nursing home where she lives . . Right hydronephrosis Given right sided hydronephrosis and GNR bactermeia a percutaneous nephrostomy tube was placed by IR 2014-11-30 . The patient put out 1385 cc urine the day after placement 950 cc of which came from nephrostomy tube . The tube appeared to be functioning well draining urine with occasional clot passage . Urology was notified about the clots and occasional blood tinged urine but they did not make any further recommendations . Cultures from urine drawn from the nephrostomy tube are currently growing > 100K GNR possibly of two colony morphologies speciation and sensitivity pending . . Hct drop On admission to hospital patient had Hct of 29.2 . In the setting of Right sublavian line placement as well as nephrostomy tube placement the patient was noted to have a drifting Hct concerning for bleed with nadir of 22.8 on 2014-12-01 . A CT abdomen was performed which did not demonstrate any retroperitoneal bleed . Hct stabilized to 24 for three days prior to discharge . This can be followed as an outpatient . Anemia workup revealed a picture of anemia of chronic disease TIBC 225 B12 and Folate normal Hapto 397 Ferritin 51 TRF 173 Iron 35 . . Hypoxia The patient on admission was requiring 3 L NC in the setting of receiving 2L NS and chest film which demonstrated pulmonary congestion . The patient was not diuresed but allowed to auto-diurese any additional fluids and is currently with O2 sats 97-98 on room air . As her BP remained stable she did not receiving any standing fluids but was be bolused as appropriate for a MAP 60 or CVP 8 with careful monitoring of pulmonary status . Patient had an echocardiogram in 2012 which demonstrated an EF of 60-65 . her O2 requirement by discharge was 96 on room air with no SOB . . Steroid-induced hyperglycemia At home the patient received metformin and SSI . The patient s metformin was held and she has been maintained on SSI qid while in the CMED . As the patient appeared to be clinically stable her stress dose steroids were discontinued and the patient was changed back to her home dose of Prednisone 40mg PO qd for maintenance with anticipated decrease in her blood sugars . Her Metformin was re-added 2 days prior to discharge as well and fingerstick glucoses on the day of discharge were 93 and 156 respectively . . Hypothyroidism Repeat TSH and Free T4 were appropriate on current outpatient regimen. Patient was continued on Levothyroxine 75mcg po qd . . H o transverse myelitis optic neuritis On stress dose steroids originally given MUST protocol and sepsis as patient clinically stabilized she was changed back to home dose of Prednisone 40mg pO qd . . SLE Currently no sx of active disease . No manifestations of SLE during this admission . . Osteoporosis We continued actonel vit D Tums . Capsular ossification We continued CMED CSRU gtt . . FEN She had a low bicarb likely due to renal wasting but there is an anion gap present . Serum acetone was normal . We followed lactate while she was in the CMED which was normal . She was NPO periodically but maintained a normal diet prior to discharge . . PPX SQ Heparin during this admission PPI . Communication patient . Dispo To nursing home for follow up with Dr. Hipp urology this coming Monday 12-08 at 130pm and with her PCP at the nursing home Medications on Admission Home Meds Ascorbic Acid 500 TID Cranberry Extract 425 BID Bisacodyl 10mg Senna Dephenhydramine 50mg prn loperamide prn famotidine 20mg KCL 20mg QD Metformin 1000 qd tums 1500 bid MVI Timolol 1 Drop BID 0.5 L CMED CSRU Synthroid 75 QD Compro 25mg pr Citrucel Vitamin D 50k Qmondays Oxazepam 15mg qhs tizamidine 8mg qhs actonel 35 qwed Diovan 80 qd prednisone 40 qd bactrim ds qmwf baclofen pump 2-3yrs Insulin SS . Meds on transfer Actonel 35 mg Oral qwednesdays Ascorbic Acid 500 mg PO TID Sodium Polystyrene Sulfonate 15 gm PO ONCE 11-29 @ 2201 Famotidine 20 mg PO DAILY Sulfameth Trimethoprim DS 1 TAB PO QMOWEFR Gentamicin 80 mg IV Q8H Timolol Maleate 0.5 1 DROP OS BID Heparin 5000 UNIT SC TID Tizanidine HCl 8 mg PO QHS Hydrocortisone Na Succ. 100 mg IV Q8H 11-30 @ 0906 Valsartan 80 mg PO DAILY Insulin SC per Insulin Flowsheet Vancomycin HCl 1000 mg IV Q 12H Levothyroxine Sodium 75 mcg PO DAILY Vitamin D 50 000 UNIT PO QWEDNESDAYS Discharge Disposition Extended Care Discharge Diagnosis GNR Sepsis Steroid induced hyperglycemia Hydronephrosis SLE Discharge Condition Stable Discharge Instructions Pls take all meds as prescribed . Call your doctor immediately if any new symptoms develop including fevers rash increase in bloody urine in nephrostomy or urostomy bags etc . Follow up appointments listed below . Followup Instructions With Dr. Vivian Hansen UMass Memorial Medical Center 3rd floor Morris on Monday 12-08 at @ 130pm you also have an appointment scheduled with Dr. Hipp for 01-14 . . Provider Sheena Phone 361-438-6334 Date Time 2015-01-07 830 Colleen Thomas MD 80-548 Completed by Edward James MD 50-497 2014-12-05 @ 1042 Signed electronically by DR. Ronald Z. Thome on,0
128, Lorazepam 1 mg. PO q6 hours PRN and Timoptic 0.5 1 drop b.i.d.,3
56, Her admission physical revealed a birth weight of 901 gm 20th percentile length 34 cm 25th percentile head circumference 25 cm 25th percentile . Anterior fontanelle open soft and flat . Red reflex was difficult to appreciate bilaterally . Pupils were large but equal and reactive . Palate deferred due to oral intubation . No defect noted during procedure . Increased work of breathing prior to intubation but presently comfortable . Breath sounds slightly crackly symmetric equal air entry . Cardiovascular regular rate and rhythm without murmur . Peripheral pulses plus 2 and symmetric . Abdomen soft without hepatosplenomegaly . Three-vessel cord clamped . Normal female external genitalia . Normal back and hips . Skin was pink and well-perfused . Appropriate tone and activity .,1
85, On admission showed a gentleman in no acute distress afebrile . Chest was clear to auscultation bilaterally . Heart has a regular rate and rhythm . Abdomen is benign no mass . Extremities were well perfused and warm .,1
129, Methylprednisolone 4 mg q. a.m. and 2 mg p.o. q.h.s. spironolactone 50 mg p.o. q.d. metformin 1500 mg p.o. q.h.s. Pravastatin 10 mg p.o. q.h.s. lisinopril 20 mg p.o. q. a.m. Lasix 80 mg p.o. q. a.m. Tylenol as needed insulin regular 22 units in the morning and 12 units at night lispro regular .,3
181, Briefly this 68 year old male with a history of coronary artery disease diabetes mellitus peripheral vascular disease was admitted originally to the Podiatry Service for a left patellar mid-foot ulcer . He underwent angiogram on 2013-08-28 to evaluate his circulation and found at that time that the patient had a poor circulation to the left leg . The patient was transferred to the Vascular Surgery Service for bilateral iliac stenting at that time . The patient also at that time was followed by Cardiology and for preoperative evaluation had a stress test which was positive and he became diaphoretic but denied any chest pain . Atropine was given and heart rate returned to the 70s and his blood pressure returned to the 120s over 80s . The patient denied any orthopnea shortness of breath chest pain paroxysmal nocturnal dyspnea or cough . He had occasional leg swelling . PAST MEDICAL HISTORY 1 . Coronary artery disease status post myocardial infarction in 2006 and 1997 and status post percutaneous transluminal coronary angioplasty times two . Diabetes mellitus type 2 since age 25 now currently on insulin which is complicated by peripheral neuropathy nephropathy and Charcot s foot . Chronic renal insufficiency . Peripheral vascular disease status post left iliac stent and right femoral stent . Hypertension . High cholesterol . Question of tendonitis . MEDICATIONS ON ADMISSION 1. Insulin 70 30 40 units q. a.m. and 40 units q. p.m. 2. Diovan 160 mg p.o. q. day . Nortriptyline 25 mg p.o. q. h.s. Norvasc 10 mg p.o. q. day . 5. Metoprolol 50 mg p.o. twice a day . 6. Hydrochlorothiazide 15 mg p.o. q. day .,0
171, Atrial fibrillation on coumadin Coronary artery disease status post NQWMI 02-25 s p LAD angioplasty and stent 05-26 Known non-dominant 90 RCA lesion not intervened upon . Dementia Mild-moderate aortic stenosis Hyperlipidemia Colon cancer Obstructive sleep apnea Anxiety Diabetes mellitus on oral medications Social History Married Lives with wife . One son in area Social alcohol . No tobacco drug use,0
47, n a Discharge Condition n a Discharge Instructions n a Followup Instructions n a Ruby Eric MD 73-490 Completed by Verna Richard MD 01-822 2016-04-04 2005 Signed electronically by DR.,2
203, The patient was taken to the operating room on March 11 2002 and underwent an uncomplicated right total hip replacement . The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit and then to the floor in stable condition . On postoperative check he was doing well . He was afebrile and his vital signs were stable . He was neurovascularly intact . His hematocrit was 34.7 . He was started on Coumadin for DVT prophylaxis and Ancef for routine antimicrobial coverage . He was made partial weight-bearing for his right lower extremity . He was placed on posterior hip dislocation precautions and was out of bed with physical therapy and occupational therapy . On postoperative day one there were no active issues . He was afebrile . His vital signs were stable . He was neurovascularly intact . On postoperative day two he was afebrile vital signs were stable . His incision was clean dry and intact with no erythema . He remained neurovascularly intact . His hematocrit was 34.8 . On postoperative day three lower extremity noninvasive ultrasounds were performed which showed no evidence of deep venous thrombosis in the lower extremities . The remainder of his hospitalization was uncomplicated . CONDITION ON DISCHARGE Stable .,0
180, Breast cancer in multiple female relatives .,0
182, Brother and sister both have asthma . Brother has diabetes mellitus . There is no family history of coronary artery disease .,0
202, The patient has no known drug allergies . MEDICATIONS ON ADMISSION Tylenol Ciprofloxacin and Insulin about 16 units of NPH qa.m.,0
120, Dr. Lloyd van de Clark in approximately one month postoperative . Please call the office at 854 787-3243 for an appointment . The patient is also to follow up with his primary care physician for diabetes management . He is to follow up with Dr. East here at the Heart Failure Clinic to continue follow up with cardiac rehabilitation and heart failure management . Brown des Stone M.D. 07 -760 Dictated By Anthony O Carreno M.D. MEDQUIST36 D 2011-10-31 1025 T 2011-10-31 1045 JOB 02527 Signed electronically by DR.,3
86, On admission temperature was 96.2 blood pressure 150 80 heart rate 92 respiratory rate 16 . In general he was unarousible intubated not on any sedation . Head eyes ears nose and throat His pupils were equal and three millimeters . They were minimally reactive . His sclerae were anicteric . The cardiac examination was unremarkable without murmurs . The lungs were clear to auscultation bilaterally . His abdomen had normal bowel sounds soft and nontender . Extremities had multiple bilateral lower extremity excoriations . Neurologic examination he was unarousible and without sedation . He had no spontaneous movements . Flaccid . Extremities Babinski reflex was equivocal bilaterally .,1
4,Feeds at discharge Enfamil 20 p.o. ad lib . Medications none . Car seat positioning not yet done . State newborn screening sent . Immunizations received hepatitis B on 09-16 .,2
163, As above Myocardial infarction also in l983 and l988 congestive heart failure in l989 diverticulitis in l978 and spontaneous pneumothorax in l956 . He had a coronary artery bypass graft times three as mentioned above CURRENT MEDICATIONS He came in on Carafate Enteric Coated Aspirin Albuterol Inhaler Atrovent Inhaler Procan SR Mevacor and Digoxin,0
19, Lasix 40 mg po bid . Potassium Chloride 20 milliequivalents po bid . Colace 100 mg po bid . Zantac 150 mg po bid . Aspirin 325 mg po qd . Captopril 25 mg po tid . Digoxin 0.25 mg po q day . Atorvastatin 10 mg po q day . Toprol XL 100 mg po q day . 10. Bollin insulin 18 units subcutaneous q A.M. Richard insulin 14 units subcutaneous q P.M. 11. Sliding scale Humalog regular insulin for breakfast is blood glucose of 151 to 200 equal 4 units 201 to 250 equal 6 units 251 to 350 equal 12 units greater than 350 equals 15 units . For lunch blood glucose of 101 to 150 equals 4 units 151 to 200 equals 7 units 201 to 250 equals 8 units 251 to 350 equals 12 units greater than 350 equals 15 units . Dinner blood glucose 101 to 150 equals 2 units 151 to 200 equals 3 units 201 to 250 equals 6 units 251 to 350 equals 12 units greater than 350 equals 15 units .,2
3,'1. Prolonged Respiratory Transition . Hyaline Membrane Disease . Rule out sepsis without antibiotics . Kevin F Juliusson M.D. 04 -834 Dictated ByAnita X. Duffy M.D. MEDQUIST36 D 2015-09-17 1345 T 2015-09-17 1415 JOB 24313 Signed electronically by DR.,2
20, Lisinopril 5 mg p.o. q. day . Metoprolol 37.5 mg p.o. twice a day . 3. Lipitor 10 mg p.o. q. day . Pantoprazole 40 mg p.o. q. day . Levothyroxine 100 micrograms p.o. q. day . DISCHARGE INSTRUCTIONS The patient was to arrange his follow-up with his primary care physician Bryan Smith . To follow-up with his Cardiologist Dr. Delores Padilla within one to two weeks of discharge . Tammy Thompson M.D. 40-318 Dictated By Randolph Q Barber M.D. MEDQUIST36 D 2015-11-26 1515 T 2015-11-26 1610 JOB 90402 Signed electronically by DR.,2
185, By problems 1. Infectious Disease . The patient was started on Amphotericine at .6 mg kg for a total of 250 mg for positive blood cultures for candida . The passport in his left arm was pulled and will be replaced if needed after the Amphotericine is completed . The patient will continue on his antibiotics for pseudomonas pneumonia to complete the fourteen day course which was completed on 09 06 92 . The patient was continued on his admission medications . 2. Hematology . The patient was continued on his G-CSF with an increase in his white count to 8 from 1.8 . The patient required multiple blood transfusions for a low hematocrit . ,0
111, Aspirin 325 mgs PO q.d. Prilosec 20 mgs PO q.d. Azmacort 2 puffs q.i.d. PRN Atrovent 2 puffs q.i.d. PRN heparin 5 000 units subcu. b.i.d. Digoxin 0.125 mgs PO q.d. Wellbutrin 37.5 mgs PO b.i.d. Kaopectate PRN Betoptic 0.25 OU q.d. Ritalin 10 mgs PO q.a.m. and at noon time Norvasc 2.5 mgs PO q.d. The patient reported disorientation with Ambien and Halcyon .,3
101,Home with parents,3
174, BACTRIM SEVERE RASH GANCICLOVIR RASH HAS BEEN DESENSITIZED .,0
22,CONDITION OF DISCHARGE Good . DISCHARGE STATUS To home . DISCHARGE DIAGNOSES Diabetic ketoacidosis . Viral gastroenteritis .,2
142,"1. Metoprolol 100 mg b.i.d. Plavix 75 mg q.d. Advair 550 mcg two puffs b.i.d. 4. Neurontin 300 mg t.i.d. Protonix 40 mg q.d. Montelukast 10 mg q.d.', 'Bethanechol 25 mg b.i.d. Docusate sodium 100 mg b.i.d. Zetia 10 mg q.d. Estrogen 0.3 mg q.d. Fluoxetine 40 mg q.d. Vicodin 5 -500 mg tablets q.4-6h. as needed for pain . 13.', 'Cyclobenzaprine 10 mg tablet one tablet orally t.i.d. Atorvastatin 80 mg q.d. Valsartan 320 mg q.d. Aspirin one q.d. Benadryl as needed .The patient will follow up with her primary care physician Dr. Benson 845 253 6629 in two weeks by calling to schedule an appointment . DR. Luedeman Melissa 69-853 Dictated By', 'Andrew C Hoffman M.D. MEDQUIST36 D 2017-07-02 1135 T 2017-07-04 0514 JOB 19444 Signed electronically by DR. Andrew X .. Dale on FRI 2017-09-22'",3
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