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Toprol . Lasix . Digoxin . Coumadin . Flovent . Albuterol . Lisinopril .

Of note Na 133 K 4 WBC 8.82 hematocrit 35.1 platelets 229 . PT 13.8 with an INR of 1.3 PTT 25.5 total protein was 6.2 albumin 3.4 globulin of 2.8 calcium of 9.1 phos 2.7 mag 2.1 urea 3.7 . ALT was elevated at 240 AST 85 LDH 305 alk phos 85 total bilirubin was 1.3 direct bili was .8 . Cholesterol 188 triglyceride was 127 . UA trace protein trace ketones positive for bilirubin and nitrogen and also 4 to 6 wbcs with 1 bacteria . Chest x-ray Showed a left paratracheal adenopathy and small left pleural effusion with no evidence of pneumonia . In summary the patient is a 49 year old woman with metastatic breast cell CA status post chemotherapy with CMSAP and PVSC and XRT who presented with fever four days of diarrhea nausea and vomiting and had been on Keflex for an erythema on her left chest wall . The Keflex was stopped when she developed the diarrhea . When she arrived the plan was to go ahead and treat here rythematous induration and possible cellulitis with IV antibiotics . So she was put on dicloxicillin and we did local wound care with an agent called Santyl which is a collagenace ondebrided which worked very well for her . Also at the time of admission we were also considering palliative Taxol chemotherapy which the patient declined . She refused the Taxol therapy so that was not done . Another major issue with this patient was pain control . She had been in a whole lot of pain from her left arm lesion . So pain control was a big issue so she was on MS Contin and MSIR at home she thought that clouded her thinking so we tried different things for pain management . One of them was to do a subarachnoid neurologic block at C6-C7 interface on 1-6-94 . After that the patient had minimal relief of pain . However she declined further blocks which were offered to her . So accepted to be on dilaudid p.o. which was started at a dosage of 2-4 meg but since then we have tapered it up . She is now getting dilaudid 8 mg q2h and in addition she has been on fentanyl patch . She is now getting 75 micrograms per hour of the fentanyl patch which is changed every 72 hours . We can go up by 25 mg on the fentanyl patch as needed to control her pain and we can always go up on the dilaudid because she is still in considerable amount of pain . Other things that happened during this admission we obtained ahead CT for her on the 8th of January because of her clouded thinking and altered mental status which was probably due to the morphine that she was taking . We went ahead and got a head CT scanand it showed no enhancing lesions . In addition her liver transaminases were elevated we thought about doing further work-up but that was deferred because the patient wanted to wait on that . That has been stable . The patient on January 13 became hyponatremic . Her sodium went down to 121 and before that on admission she was 133 . A renal consult was obtained and their assessment was that this was probably a mixture of hypovolemia as well as SIADH . We proceeded to do for her hyponatremia we gave her some fluid and her urine sodium became higher than her serum sodium we stopped it . We had given her some normal saline and then we proceeded to just do fluid restriction . In addition we gave her a sodium chloride one gram per day and that also helped so that now at the time of discharge the patient &aposs sodium is between 126 and 129 prior to that it had gone down to as low 116. So that has really improved . We suggest continuing increased salt intake in her diet and also continuing with the fluid restriction of free water intake to one liter per day . On the 14th of January the patient developed increased shortness of breath and chest x-ray was taken showed a wedge shaped infiltrate in the right upper lobe which was consistent with Hampton &aposs hump . Also a VQ scan obtained the next day showed high probability for PE . So we proceeded to put her on heparin for anticoagulation and then when she was therapeutic on heparin we went ahead and started her on coumadin and she is currently on coumadin at 2.5 mg q.h.s. Her INR is 2.3 . We want her INR to remain between 2 and 3 . So if it goes much lower than 2 then we would consider increasing it to perhaps coumadin 2.5 and 5 alternating every other night . However we would leave it at 2.5 for now . Other major issues As a result of all the things happened and with her hyponatremia and also the other problems her blood pressure was elevated also . We put her on nifedipine IR SL and that was not enough to control her blood pressure which was in the 200s in the systolic so we had started her on atenolol . So on discharge she is on atenolol 100 . If needed to you can give her some nifedipine SL to decrease her blood pressure . The patient also has significant edema in both arms now and also some mild edema in the lower extremities so I think that fluid restriction should help with that . She is also a little dry . The patient is on oxygen . Ever since the pulmonary embolus she has been on oxygen . She was on 4 liters now she is on 5 liters sating 94 to 96 on 5 liters . We would like for her to remain on the oxygen as well . The complications that I have listed include the hyponatremia pulmonary embolus and also the elevatd blood pressure .

Feedings at discharge Similac 22 calories per ounce by mouth ad lib with a goal of decreasing to 20 calories per ounce for dextrose sticks of greater than 60 . Medications None .', 'A state newborn screen was sent on day of life three the results are pending . Received hepatitis B vaccine on 2012-09-30 .

Pentamidine 300 mg IV q. 36 hours Pentamidine nasal wash 60 mg per 6 ml of sterile water q.d. voriconazole 200 mg p.o. b.i.d. acyclovir 400 mg p.o. b.i.d. cyclosporine 50 mg p.o. b.i.d. prednisone 60 mg p.o. q.d. GCSF 480 mcg IV q.d. Epogen 40 000 units subcu q. week Protonix 40 mg q.d. Simethicone 80 mg p.o. q. 8 nitroglycerin paste 1 &quot q. 4 h. p.r.n. flunisolide nasal inhaler 2 puffs q. 8 OxyCodone 10 -15 mg p.o. q. 6 p.r.n. Sudafed 30 mg q. 6 p.o. p.r.n. Fluconazole 2 cream b.i.d. to erythematous skin lesions Ditropan 5 mg p.o. b.i.d. Tylenol 650 mg p.o. q. 4 h. p.r.n. Ambien 5 -10 mg p.o. q. h.s. p.r.n. Neurontin 100 mg q. a.m. 200 mg q. p.m. Aquaphor cream b.i.d. p.r.n. Lotrimin 1 cream b.i.d. to feet Dulcolax 5 -10 mg p.o. q.d. p.r.n. Phoslo 667 mg p.o. t.i.d. Peridex 0.12 15 ml p.o. b.i.d. mouthwash Benadryl 25-50 mg q. 4 -6 h. p.r.n. pruritus Sarna cream q.d. p.r.n. pruritus Nystatin 5 ml p.o. q.i.d. swish and ! spit folate 1 mg p.o. q.d. vitamin E 400 units p.o. q.d. Haldol 2 mg IV q. 6 p.r.n. agitation Colace 100 mg b.i.d. Senna 2 tablets p.o. b.i.d.

Atazanavir 300 mg q.d. Ritonavir 100 mg q.d. Tenofovir 300 mg q.d. Didanosine 250 mg q.d.

Continue ad lib feeding . Follow up with pediatrician at SCCHC on Tuesday 2018-05-15 . Medications Not applicable . Car seat positioning screen Not applicable .', 'State newborn screens were sent on 2018-05-09 and results are pending . On his previous admission', 'Terrance received hepatitis B vaccine on 2018-05-09 . 6. Immunization recommended Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age .', 'Before this age and for the first 24 months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers .

HISTORY OF PRESENT ILLNESS Date of birth 10 4 88 . This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9 5 93 at 2116 hours with a 2-3 day history of chills fevers cough vomiting and weakness unable to walk . At Noughwell Entanbon Health her temperature was 101 pulse 135 blood pressure 94 74 respiratory rate 20 . Positive findings of physical examination include chicken pox lesions on thorax sunken eyes thick nasal discharge dry lips tongue and mucous membranes red tonsils . The remainder of the physical examination was considered within normal limits . Admission diagnosis at Ni Hospital &aposs vomiting and dehydration hypokalemia hyponatremia tonsillitis . A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted . Oral cyanosis and shallow respirations were noted on 9 7 93 at 245 a.m. Therefore the patient was intubated at 345 a.m. on 9 7 93 . Chest x-ray was unremarkable . Cardiovascular stable significant hypertension was noted on 9 7 93 at 510 a.m. and therefore 10 cc&aposs per kilo albumin was given . The patient was admitted was started on clear fluids tolerated with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc &aposs per hour for 9 hours . 100 cc&aposs per kilo . Sodium and potassium at this time were 128 1.5 . At Labor Day 930 a.m. the fluids were increased to 100 cc&aposs per hour 200 cc&aposs per kilo for 5 hours . Electrolytes at this point were sodium 132 potassium 1.8 . At 9 6 93 230 p.m. fluids were decreased to 75 cc&aposs per hour 150 cc&aposs per kilo 40 mEq of K phosphate added to the intravenous fluids . Electrolytes at this point were a sodium of 143 and potassium 1.7 . On 9 6 93 2200 fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc &aposs per hour . This rate was maintained for 11 hours . Electrolytes at this time were a sodium of 148 potassium 1.7 . At 9 7 93 100 a.m. intravenous fluids rate was decreased to 50 cc&aposs per hour total fluids given during the first 24 hours were 140 to 150 cc&aposs per kilo per day . At this time sodium was 147 potassium 2.6 total sodium given during the first 24 hours 20 mEq per kilo per day . On 9 7 93 at 400 a.m. albumin bolus 5 10 cc&aposs per kilo was given a total of 120 cc&aposs electrolytes were sodium 155 potassium 3.1 . At 9 7 93 at 500 a.m. sodium bicarbonate given 60 mEq calcium bolus 10 cc&aposs given . On 9 7 530 a.m. D5 quarter normal saline and 40 of K phosphate at 100 cc&aposs per hour was given . The patient was taking PO initially until 9 6 93 at 1745 . There were no abnormal findings in abdominal exam . On 9 5 93 hematocrit 48 white blood count 11.2 neutrophiles 67 bands 14 lymphs 11 monos 6 meta 2 platelets 220 000 . Copious urine output BUN 1.0 creatinine .8 . Normal neurologic exam on admission then lethargic on 9 6 93 at 1745 then patient became unresponsive areflexic and limp at 9 6 93 at 1745 to 2200 . Patient was having seizures twitching of face and rapid movements of eyes . Pupils dilated and sluggish . Valium was given at 9 7 93 0002 . IV ampicillin chloramphenicol ceftriaxone and culture were sent . Finally Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9 7 93 630 a.m. and on arrival patient was seizing with rhythmic eye movement to left . The patient was unresponsive poor perfusion . Temperature was 101.8 . A second intravenous was started and given normal saline bolus change in intravenous fluids to D5 water with 80 mEq of bicarbonate plus 40 mEq of KCL at 45 cc&aposs per hour bicarbonate given 2 mEq per kilo attempted to start dopa for poor perfusion but worsening perfusion . Therefore dopa was stopped . Total volume given as bolus 50 cc&aposs per kilo sodium bicarbonate at 2 mEq per kilo was given . Last ABG there was 6.98 31 171 bicarbonate of 7 . Phenobarbital and Dilantin given for seizure control . Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176 potassium 2.5 chloride 140 bicarbonate 14 calcium 7.2 magnesium 2.7 . Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9 7 93 1115 a.m. Lines placed were a right femoral triple lumen endotracheal tube 4.0 arterial line right radial line Foley placed peripheral intravenous line nasogastric tube . On admission to Fairm of Ijordcompmac Hospital temperature 100.2 pulse 149 respiratory rate 50 blood pressure 98 66 mean arterial pressure of 73 weight 12 kilos .

Prednisone 60 mg daily for 4 days . Continue inhalers as prescribed . Disposition Follow up and Instructions to Patient Call Dr. Linketerf tomorrow and make an appointment for follow-up on the lung nodule . THIS IS VERY IMPORTANT .

Cardiac arrest His arrest was of unknown etiology at the time of admission . No further history was ever gained about his cardiac arrest throughout his hospitalization . CT angiogram had been negative for pulmonary embolism . The patient had an echocardiogram on 2013-04-26 which showed a normal ejection fraction and trivial mitral regurgitation otherwise no obvious abnormalities were seen . Given the patient had an out of hospital arrest remained unresponsive despite hemodynamic stability he was treated with induced hypothermia and with cold packs and a cooling blanket were placed with goals of reducing his core body temperature to 32 degrees Celsius for a period of twelve hours at which point he would be rewarmed over the subsequent six hours . This was done however as in problem number two below we were not successful in any neurologic recovery . Neurology The patient remained unresponsive after the induced hypothermia the patient was noticed to develop myoclonic jerks and occasional fluttering of his eyelids . Electroencephalogram revealed the patient was experiencing persistent seizure activity . Neurology was consulted and the patient was treated very aggressively loaded with multiple drugs including Ativan and Propofol drips . The patient continued to demonstrate seizure activity despite this . He was loaded with Dilantin and ultimately was treated with a Pentobarb coma . After multiple attempts of weaning the Pentobarb the patient was continually reverting to status epilepticus which was never able to be suppressed . Infectious disease Over the course of his hospital stay the patient s white blood cell count rose to a peak of 17 . Multiple cultures were done and the patient was ultimately found to have methicillin resistant Staphylococcus aureus bacteremia pneumonia and urinary tract infection . For all these infections the patient was treated with Vancomycin and he was also on Levofloxacin and Flagyl for presumed aspiration pneumonia at the time of his admission . Blood cultures cleared by 2013-05-03 . Sputum culture as late as 2013-05-10 however was still positive for coagulase positive Staphylococcus which was methicillin resistant Staphylococcus aureus . The patient remained gravely ill throughout his hospital stay and had multiple meetings were held with his family with his son being his next of kin . Ultimately it was decided that the patient s wishes would be to not be maintained in a vegetative state and given his poor prognosis ultimately the decision was made to pursue comfort measures only . With these goals of care the patient expired on 2013-05-11 . The family did consent to a postmortem examination . DISCHARGE DIAGNOSES Cardiac arrest . Anoxic brain injury Status epilepticus Methicillin resistant Staphylococcus aureus pneumonia . MRSA urinary tract infection . MRSA Bacteremia . Steven Welch Montana 61528 Dictated By Julie DD George M.D. MEDQUIST36 D 2013-12-24 135505 T 2013-12-24 204707 Job 52892 Signed electronically by DR. Patricia Henley on Maxine 2014-01-02 1045 AM

Severe blunt abdominal trauma with rupture of liver left renal vein pancreas and transverse mesocolon . SPECIAL PROCEDURES AND OPERATIONS 1. 7-2-93 emergency room exploratory laparotomy repair of liver laceration repair of torn transverse mesocolon repair of serosal tear of transverse colon ligation and division of ruptured left renal vein exploration of pancreas 2. 7-4-93 exploratory laparotomy irrigation and debridement pancreatic drainage placement gastrostomy tube jejunostomy cholecystostomy placement of right subclavian Quinton catheter 3. 7-10-93 abdominal irrigation and debridement and packing of pancreas 4. 7-12-93 7-14 7-20 7-22 and 7-24 were the same as 7-10-93 and 7-17 was the same with the addition of tracheostomy were same as 7-10 COMPLICATIONS Severe necrotizing pancreatitis and diffuse peritonitis . MEDICATIONS ON DISCHARGE N A. DOCTORS DISCHARGE ORDERS N A. ESTIMATED DISABILITY AND PROBABLE DURATION N A. DISPOSITION Mason Street . RISSPA BREATH M.D. TR un bmot DD 08-07-93 TD

The patient is to be transferred to the Cambridge Hospital Hospital Special Care Nursery .',

He is healthy looking . The general physical examination did not reveal any abnormality . Heart chest and abdominal examinations were normal . The right knee examination showed some effusion . The range of motion was 15 to 120 degree on the right side and on the left side it was zero to 135 . There was normal muscle power . The peripheral pulses were palpable .

Continue breast feeding with post-feed supplemental EBM . Follow-up bilirubin in 1 day f u with PMD in 1-3 days . Medications Not applicable . Car seat position and screening', 'Not applicable . State newborn screens were sent on 2018-12-31 and the results are pending . Immunizations received Hepatitis B vaccine on 12-31 2006 .', 'Immunization recommended Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the child s life', 'immunization against influenza is recommended for all household contacts and out of home caregivers .

All systems were reviewed and were negative except as given above . MEDICATIONS Metformin Zocor and analgesics . ALLERGIES None .

Notable for a white blood cell of 9.5 ANC 7.7 hematocrit 26 platelets of 248 BUN and creatinine 12. and 1.2 respectively magnesium 1.1 calcium 8.7 .

Prilosec 20 mg p.o. q.d. Percocet 1-2 tabs p.o. q.6-8h. x5 days MVI 1 tab p.o. q.d. DISCHARGE FOLLOW-UP The patient was advised to follow-up with Dr. Edwards in clinic in one week . CONDITION ON DISCHARGE Stable condition . DISCHARGE DISPOSITION The patient was discharged to home . Dictated By SON RHALT SUBINTERN . Attending MOPAIGEIT S. SOLID M.D. KP91 KX681 6848 Batch 52108 Index No. GAEHS07465 D 03 01 00 T 03 01 00 CC 1.

Dyazide one p.o. q.d. Propanolol 5 mg. p.o. t.i.d. Isordil 5 mg. p.o. t.i.d. Glaucoma drops .

Atrial fibrillation 2 s p MVR mechanical 3 CHF EF 15 4 HTN 5 multiple CVA s last 1998 6 Hypercholesterolemia 7 Type II DM 8 Multiple prior UTI Social History Lives in Danvers with wife denies Timothy or alcohol

1 Lasix 20 mg. PO q.d. 2 Sinemet 25 100 1 t.i.d. 3 Cogentin 0.5 mg. 1 tabs PO q.a.m. and 1 q.noon as well as 1 q.h.s. 4 Eldepryl 5 mg. PO b.i.d. 5 Enteric coated aspirin 325 mg. PO q.d. 6 Potassium chloride 10 mEq. PO q.d.

Term 37 and 1 7 weeks appropriate for gestational age male neonate . Exaggerated physiologic hyperbilirubinemia responsive to phototherapy .', 'Nicole Monica MD 48-041 Dictated By Michelle A Sweeney M.D. MEDQUIST36 D 2019-01-02 121610 T 2019-01-02 130035 Job 38170 Signed electronically by DR. Victoria Cox on FRI 2019-01-04 1125 AM'

ON ADMISSION On presentation temperature 99.3 degrees F other vital signs were within normal limits . He was in no acute distress non-toxic . Cardiovascular Regular rate and rhythm . Pulmonary Clear to auscultation bilaterally . Abdomen soft and there was wound erythema with three areas of dehiscence draining foul-smelling purulent fluid . The fascia appeared intact by probing . The stoma was pink and functional . The wound was a midline incision for his radical cystoprostatectomy .

Notable for a BUN and creatinine of 78 1.7 for a sodium potassium 139 and 3.6 chloride and bicarb 108 21 . White count 7 hematocrit 24.2 platelet count was 183 . His INR was also 3.4 . PTT was 55 . His EKG was notable for right bundle branch block left axis deviation but was in sinus rhythm . His UA had 10-17 white blood cells trace leukocyte esterase hyaline casts numbering 60-70 . His chest x-ray was notable for clear lungs with no edema or infiltrates and small bilateral effusions . OTHER NOTALBE LABS Patient was found to have a troponin of 0.71 on admission with a CK of 46 and CKMB of 3.4 .

Stable . DISCHARGE STATUS Leona Wheeler is to be transferred on 2015-07-17 to a rehabilitation facility . DISCHARGE DIAGNOSIS 1. Status post CABG times four . Meghan G. Bardin M.D. 43 -132 Dictated By Louise B. Robertson M.D. MEDQUIST36 D 2015-07-17 0839 T 2015-07-22 1029 JOB 72575 Signed electronically by DR. Derek Vildosola on WED 2015-07-29 115 PM

Alcohol abuse in the past Chronic obstructive pulmonary disease . Chronic pleural effusions Chronic renal insufficiency with baseline creatinine 1.8-2 . 5 Ischemic bowel status post SMA Percutaneous Transluminal Coronary Angioplasty . 6 Serratiaurosepsis . Positive PPD . 8 Status post total hip replacement . 9 Right bundle branch block with left anterior hemiblock on electrocardiogram Allergies to penicillin sulfa codeine morphine sulfate .Medications on transfer included thiamine multivitamin Pepcid ceftizoxime 1 gm intravenously q. eight hours Flagyl 500 mg intravenously q. eight hours gentamicin 80 mg IV q. 24 hours Ventolin inhaler Lotrimin cream sliding scale nitro paste pyridium Vancomycin 125 mg p.o. q.i.d. and calcium carbonate . Habits Positive for cigarettes of 40 pack years quit in 1990. Positive alcohol abuse in the distant past Family history is positive for tuberculosis hypertension and alcoholism . Social history Former Vermont blacksmith He has one son and lives in a nursing home .

ON ADMISSION Birth weight 1455 grams 50th percentile head circumference 29.25 cm 50th percentile length 41.5 cm 50th percentile . Nondysmorphic with overall appearance consistent with gestational age . Anterior fontanel soft open flat red reflex present bilaterally palate intact . Intermittent grunting moderate intercostal retractions diminished air entry regular rate and rhythm without murmur 2 femoral pulses . Abdomen benign with no hepatosplenomegaly or masses . No external female genitalia . Normal back and extremities with stable hips appropriate tone skin pink with fair perfusion .

PHYSICAL EXAM VITAL SIGNS He was afebrile with stable vital signs HEART Regular rate and rhythm with a 2 out of 6 systolic ejection murmur heard loudest at the apex . LUNGS Clear to auscultation . ABDOMEN Soft nontender nondistended . EXTREMITIES No cyanosis clubbing or edema . Palpable DP s bilaterally PERTINENT LABS His hematocrit was 44 White count was 8 . Potassium was 3.9 BUN and creatinine was 18 and 0.9 . His troponin was 29.7

Significant for sodium 140 potassium 3 BUN 35 creatinine 3.6 liver function tests within normal limits calcium 6.6 albumin 2 magnesium1.4 PT 14 white count 30.1 with 77 polys 13 bands 5 lymphs and 5 monos . Urine sodium is 75 urine creatinine 143 urine osmose 392 . Pleural fluid pH is 7.29 glucose 91 total protein3.1 LDH 296 70 white blood cells 50 red blood cells . HOSPITAL COURSE 1. Colitis . The patient has a history of ischemic bowel status post SMA Percutaneous Transluminal Coronary Angioplasty with recent admission for gram negative rod urosepsis complicated by C. difficile colitis . The patient received a full course of Flagyl and was C. difficile toxin negative times three prior to transfer . He now returns with fever rising white count diarrhea and dehydration . Initially treated with intravenous ceftizoxime gentamicin and Flagyl for presumed sepsis either with urine or bowel source . He was also started on p.o. Vancomycin . Blood cultures and urine cultures came back negative . Stool for C. difficile returned positive . The diagnosis therefore was relapsed C. difficile colitis . Intravenous antibiotics were discontinued and the patient was continued on p.o. Vancomycin . He improved clinically with defervescence decreased white blood cell count to 10 000 with resolution of left shift and some decrease in abdominal distention on exam . An abdominal CAT scan revealed thickened bowel wall and thumb printing primarily involving the cecum and right colon greater than the left consistent with C. difficile colitis . The diagnosis of recurrent bowel ischemia however was not ruled out and this will continue to be a concern in the future . The patient was initially n.p.o. and was then advanced to clear liquids which he tolerated . He will be advanced to soft solids prior to discharge . 2. Azotemia . The patient has chronic renal insufficiency with baseline creatinine 1.8-2 . Creatinine had risen to 4.3 on admission presumed secondary to sepsis and dehydration . With intravenous hydration the BUN and creatinine fell to 12 1.9 which is within normal limits for this patient . The abdominal CAT scan showed no evidence of hydronephrosis orrenal abscess . 3. Mental status . The patient was alert and oriented throughout the admission however by personality he is somewhat cantankerous and demanding of the nurses . He was written for Haldol 1 mg p.o.b.i.d. p.r.n. to help with this problem . DISCHARGE DISPOSITION Medications on transfer include multivitamin 1 tablet p.o. q.d. Pepcid 20 mg p.o. b.i.d. Ventolin inhaler two puffs q.i.d. Vancomycin 125 mg p.o. q.i.d. times seven days calcium carbonate 1250 mg p.o. b.i.d. Lotrimin cream to groin b.i.d. p.r.n. O2 at four liters per minute and Haldol 1 mg p.o. b.i.d. p.r.n. Dictated By CA NA SHUFF M.D. SO92 VX072 9578 TRANGCA CHIRDSTEN M.D. ZO84 D 07 17 91 T 07 17 91 Batch

Notable on admission were BUN and creatinine of 8.0 and 0.7 . Sodium 134 ALT 18 AST 27 LDH 221 white count 2.05 hematocrit 23 platelet count 137 000 . The differential showed 45 polys 6 bands 8 lymphs 32 monos . Urinalysis was negative . Sputum gram stain showed no polys and no bacteria . AFB stain was negative . Chest X-ray was consistent with an old chest X-ray on 08 08 92 showing a resolving left lower lobe and lingular infiltrate and resolution of the right mid lung infiltrate .

Tylenol 650 mg p.o. q. 4 -6h p.r.n. headache or pain acyclovir 400 mg p.o. t.i.d. acyclovir topical t.i.d. to be applied to lesion on corner of mouth Peridex 15 ml p.o. b.i.d. Mycelex 1 troche p.o. t.i.d. g-csf 404 mcg subcu q.d. folic acid 1 mg p.o. q.d. lorazepam 1-2 mg p.o. q. 4 -6h p.r.n. nausea and vomiting Miracle Cream topical q.d. p.r.n. perianal irritation Eucerin Cream topical b.i.d. Zantac 150 mg p.o. b.i.d. Restoril 15 -30 mg p.o. q. h.s. p.r.n. insomnia multivitamin 1 tablet p.o. q.d. viscous lidocaine 15 ml p.o. q. 3h can be applied to corner of mouth or lips p.r.n. pain control . CONDITION UPON DISCHARGE Stable . FOLLOWUP Follow up appointment with Die Anoort and Tomedankell Care on 11 18 00 at 930 a.m. one day after discharge . The patient knows to go to Sper Medical Center every day for line care blood draws and monitoring . Dictated By CONRELLIE KOTERUDES M.D. VJ31 Attending SUOT CARE M.D. OB89 RL958 5760 Batch 24769 Index No. GFNC2Z5N8Q D 11 22 00 T 11 22 00 CC 1.

ON admission physical examination reveals a non dysmorphic infant well saturated and perfused with multiple bruises noted over the upper legs left arm and chest . No bony abnormalities or petechiae noted . She was moving all joints and extremities well . HEENT Within normal limits . CV Normal S1 and S2 without a murmur . Lungs were clear . Abdomen was benign . Genitalia normal . Premature female . Neuro Non focal and age appropriate . Hips normal held in the breech position . Anus patent . Spine intact .

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

Hydrochlorothiazide 50 mg p.o. q day atenolol 50 mg p.o. q day dicloxacillin started on December 29 2002 Naproxen 500 mg p.o. t.i.d. aspirin 81 mg p.o. q day Tylenol p.r.n. SOCIAL HISTORY Widowed since 1972 no tobacco no alcohol lives alone . Smoked 3 packs per day x 17 years .

On admission . GENERAL He was well-appearing and in no apparent distress . Performance status was 0 . VITAL SIGNS Weight 70.4 kilograms temperature 96.5 respiratory rate 20 blood pressure 105 60 pulse 76 . SKIN Unremarkable without rashes or lesions . HEENT Sclerae anicteric . Pupils equal round and reactive to light . Oropharynx lips teeth and gums were without lesions and without evidence of mucositis . NECK Supple with a normal thyroid gland . No cervical supraclavicular or axillary adenopathy . CHEST Clear . HEART Heart sounds normal . ABDOMEN Soft nontender without any masses and without any hepatosplenomegaly . GU Normal testes and penis . EXTREMITIES Without clubbing cyanosis or edema . NEURO Normal with intact cranial nerves deep tendon reflexes and normal motor sensory exam .

As above . PAST SURGICAL HISTORY 02 90 total abdominal hysterectomy complicated by ureteral transection with right ureteral tube placed for six weeks stent tube placed in left ureter six weeks prior to admission for a hydronephrosis post in 03 91 bilateral salpingo-oophorectomy and appendectomy CURRENT MEDICATIONS Prednisone 20 mg p.o. q.a.m with 10 mg p.o. q.p.m. Uniphyl 400 mg p.o. q.d. Augmentin 250 p.o. t.i.d. Estrase 2 mg p.o. q.d. MS Contin 30 mg q.12h. and Morphine p.r.n.

Notable for a sodium of 145 potassium 3.6 BUN 23 creatinine 1.3 glucose 104 hematocrit 42 white count 8.7 platelet count 235 and a PT of 12.9 seconds . The urinalysis was negative . The Troponin I was less than .4 and the creatine kinase was 114 . Chest x-ray revealed moderate cardiomegaly with no clear interstitial or alveolar pulmonary edema and chronic atelectasis and or scarring at both lung bases . The electrocardiogram revealed normal sinus rhythm with premature atrial complexes and right bundle branch block with left anterior hemiblock and old anterior myocardial infarction .

Initial white count 19.4 thousand 64 polys 3 bands hematocrit 35.8 platelets 281 000 . Chest x-ray revealed streaky lung fields of normal situs no consolidation consistent with retained fetal lung fluid .

Acetaminophen 325 mg Tablet Sig Two 2 Tablet PO Q4-6H every 4 to 6 hours as needed for fever or pain . Albuterol-Ipratropium 103-18 mcg Actuation Aerosol Sig 06 -17 Puffs Inhalation Q2-4H every 2 to 4 hours as needed . Calcium Acetate 667 mg Capsule Sig Two 2 Capsule PO TID W MEALS 3 TIMES A DAY WITH MEALS . Fentanyl Citrate PF 0.05 mg mL Solution Sig 25-100 mcg Injection Q2H every 2 hours as needed for comfort . Insulin Regular Human 100 unit mL Solution Sig 2-10 units Injection ASDIR AS DIRECTED per sliding scale for blood sugars > 150mg dl . 6. Midazolam 1 mg mL Solution Sig 1-2 mg Injection Q2H every 2 hours as needed for comfort . 7. Phenytoin Sodium 50 mg mL Solution Sig One 95y 150 mg Intravenous Q8H every 8 hours . 8. Ranitidine HCl 15 mg mL Syrup Sig One 95y 150 mg PO DAILY Daily . 9. Polyvinyl Alcohol-Povidone 1.4-0.6 Dropperette Sig 01-12 Drops Ophthalmic QID 4 times a day . Discharge Disposition Extended Care Discharge Diagnosis Hypoxic brain injury Cranial hemorrages sub arachnoid and parenchemal Pseudomonal sepsis completed antibiotic course Metastatic Squamous cell carcinoma of unknown primary . Thrombocytopenia Blood loss anemia Discharge Condition Intubated stable Discharge Instructions You are being transferred to another hospital intubated with the plan to extubate upon arrival to Women s and Infants hosptial and initiation of palliative care . . Your antibiotics were stopped 2016-05-15 Vancomycin 1000mg q24 and Aztreonam 1000mg q8 as your micorbiology data has been negative and your course for pseudomonal sepsis has been completed . If you continue to have fevers blood cultures should be repeated . Followup Instructions As directed . Jacque John MD 40-836 Completed by Marcy Caroline Latham MD 51-251 2016-05-31 1628 Signed electronically by DR. Richard Ronald Lockett on MON 2016-08-01

ON ADMISSION General The patient was in no acute distress well developed . Vital signs Stable afebrile . HEENT Normocephalic atraumatic . PERRL anicteric EOMI . The throat was clear . Neck Supple midline without masses or lymphadenopathy . No bruit or JVD . Cardiovascular Irregularly irregular without murmurs rubs or gallops . Chest Clear to auscultation bilaterally . Abdomen Soft nontender nondistended without masses or organomegaly . Extremities Warm noncyanotic nonedematous times four . Neurological Grossly intact . ADMISSION LABORATORY DATA CBC 11.3 15.7 44.6 183 . PT 14 INR 1.3 PTT 115 . Chemistries 137 4.3 104 22 14 0.7 155 . ALT 27 AST 21 alkaline phosphatase 72 total bilirubin 1.2 amylase 47 . The U A was negative .

On admission includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent white blood cell count 4500 PT and PTT normal . Sodium 140 potassium 4.2 chloride 105 carbon dioxide 30 BUN 24 creatinine 1.0 . HOSPITAL COURSE AND TREATMENT The patient was admitted to the Cardiac Catheterization Laboratory . There her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44 17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20 under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm. which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase KS . ACHASTHA N. GRAFT M.D. TR hfr DD 08 22 1998 TD 08 27 1998 356 P cc ACHASTHA NICEMAEN GRAFT M.D. GITTETUMN DARNNAMAN

DISPOSITION MEDICATIONS at the time of discharge are G-CSF 300 micrograms subcu q. day Acyclovir 200 mg p.o. b.i.d. Erythromycin 500 mg p.o. b.i.d. Dapsone 50 mg p.o. Monday Wednesday and Friday Imodium 1-2 tablets p.o. q. 6 hours p.r.n. Nystatin 5 cc swish and swallow q.i.d Serax 50 mg p.o. q. 6 hours p.r.n. and Kay-Ceil 40 mEq p.o. b.i.d. The patient needs to have his blood drawn the day after discharge to check a potassium and magnesium which he has been wasting secondary to Amphotericine . He will probably need potassium and magnesium replacement . He will need follow up lytes drawn throughout the week . CR887 2594 TRANGCA FERCI CHIRDSTEN M.D. UO2 D 09 07 92 Batch 5346 Report P4722W3 T 09 09 92 Dicatated

Discharge medications Baclofen 10 p.o. t.i.d. MVI one tablet p.o. q.d. Mycostatin powder TP q.d. to be applied to the rash in her left groin area also dilaudid 8 mg p.o. q2h Colace 100 mg p.o. b.i.d.', 'coumadin 2.5 mg p.o. q.h.s. fentanyl patch 75 micrograms per hour topical q72 hours atenolol 100 mg p.o. q.d.

Good . DISCHARGE DIAGNOSES Community-acquired pneumonia . Acute respiratory distress syndrome . Iron-deficiency anemia . Hypothyroidism .

PHYSICAL EXAMINATION ON PRESENTATION The patient had a temperature of 100.9 . He had a blood pressure of 148 to 162 45 to 54 . He had a heart rate of 85 to 87 breathing at 17 to 23 satting 100 on room air . In general he was alert and in no acute distress . His neck was supple without any jugular venous distention . HEENT examination revealed his pupils were equal round and reactive to light . His extraocular movements were intact . His sclerae were anicteric . His mucous membranes were moist . His oropharynx was benign . Cardiovascular revealed a regular rate and rhythm heart sounds muffled no murmurs . Respiratory revealed bibasilar rales . Abdomen was soft nontender and nondistended positive bowel sounds . Extremities revealed trace lower extremity edema right greater than left 2 dorsalis pedis and posterior tibialis pulses . He had 2 femoral pulses bilaterally . No hematomas were noted but a soft right femoral bruit was heard . LABORATORY DATA ON PRESENTATION The patient had a white blood cell count of 9.5 a hematocrit of 34.5 a platelet count of 194 . His Chem-7 revealed sodium of 132 potassium of 43 chloride of 97 bicarbonate of 28 BUN of 25 creatinine of 1.3 glucose of 220 . He had an INR of 1.1 . A calcium of 8.4 phosphate of 2.5 magnesium of 1.9 . Pericardial fluid analysis was consistent with an exudative etiology . RADIOLOGY IMAGING The patient had an electrocardiogram with normal sinus rhythm at 70 normal axis normal intervals low voltage in the limb leads . Chest x-ray on admission revealed a large left pleural effusion . The patient had an echocardiogram on 11-10 which revealed the following Global left ventricular systolic function appeared grossly preserved . Due to technical quality a focal wall motion abnormality could not be fully excluded . The aortic valve leaflets were mildly thickened . The mitral valve leaflets were mildly thickened . There was a large pericardial effusion up to greater than 6 cm wide anterior to the right ventricle . The right ventricle was compressed .

Coumadin 5 mg po q d Tagamet 400 mg po q d Amoxicillin which was started on Labor Day for a sore throat and Ativan 1 mg po prn nausea anxiety .

On admission the Baby Lucas is well appearing no jaundice . He has bilateral breath sounds that are clear and equal . The heart rate is regular without murmur . Pulses are 2 and symmetrical . The abdomen is soft and nontender with no hepatosplenomegaly . His weight is 3.160 kilograms 7 pounds 3 ounces at birth . He is circumcised with testes descended bilaterally . His hips are stable . His tone is normal . Normal neonatal reflexes . He is tolerating his feedings well .

Neurontin Keppra Lamictal decadron multivitamin Murray Calcium Discharge Medications 1. Heparin Sodium Porcine 5 000 unit mL Solution Sig One 1 Injection TID 3 times a day . 2. Diphenhydramine HCl 25 mg Capsule Sig One 1 Capsule PO Q6H every 6 hours as needed . 3. Albuterol Ipratropium 103-18 mcg Actuation Aerosol Sig 03-04 Puffs Inhalation Q4H every 4 hours as needed . Acetaminophen 325 mg Tablet Sig 1-2 Tablets PO Q4-6H every 4 to 6 hours as needed . Fluticasone Salmeterol 250-50 mcg Dose Disk with Device Sig One 1 Disk with Device Inhalation BID 2 times a day . Lamotrigine 100 mg Tablet Sig 1.5 Tablets PO BID 2 times a day . Levetiracetam 500 mg Tablet Sig Three 3 Tablet PO BID 2 times a day . Ibuprofen 400 mg Tablet Sig Two 2 Tablet PO Q8H every 8 hours as needed . 9. Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day . 10. Pantoprazole Sodium 40 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO Q24H every 24 hours . 11. Ciprofloxacin 500 mg Tablet Sig One 1 Tablet PO Q12H every 12 hours for 2 weeks. Tablet s Metoprolol Tartrate 25 mg Tablet Sig 0.5 Tablet PO BID 2 times a day . Lorazepam 1 mg Tablet Sig One 1 Tablet PO HS at bedtime as needed . 14. Dexamethasone 2 mg Tablet Sig One 1 Tablet PO Q12H every 12 hours . 15. Insulin Regular Human 100 unit mL Solution Sig One 1 Injection ASDIR AS DIRECTED 51-150 0 Units 151-200 2 Units 201-250 4 Units 251-300 6 Units 301-350 8 Units 351-400 10 Units > 400 Bessie MD 16. Hydralazine HCl 20 mg mL Solution Sig 0.5 syringe Injection Q4HR as needed for sbp > 150 . Disp qs syringe Refills 0 Discharge Disposition Extended Care Discharge Diagnosis Cerebrospinal fluid leak Chronic steroid use wound infection Perforated sigmoid diverticulum status post exploratory laparotomy Status post sigmoid colectomy hartmans pouch and washout Post operative fever fever status post Reveision Right craniotomy and revsion of bone flap change in mental status Seizure Conant palsy with Left sided weakness Respiratory failure requiring intubation Methicillin resistant staph aureus infection of central nervous system Pelvic abscess oligodendroglioma Asthma S p craniotomy x 3 Hernia Surgery x 3 Discharge Condition Good Discharge Instructions Call with any spiking fevers leakage from your head wound increase in headaches confusion blurry vision severe neck stiffness redness swelling or discharge around your wound site Call your general surgeon if you experience increased abdominal pain vomiting decreased or increased ostomy output . Followup Instructions 1. Dr. Martha Lopez or Dr. Henson in infectious disese in 2 weeks . Call for an appointment 724 875 5043 2. Dr Fisher in General surgery 1 week call his office for an appointment . 515-3442 3. Follow up in 1 week at brain tumor clinic . Call for an appointment 908-6508 Cherrie Celeste MD 44-924 Completed by Angie Irene MD 36-512 2012-06-19 0950 Signed electronically by DR. Charles Mcwilliams on

Included a white blood count of 140 000 7 polys 1 bands 3 lymphs 1 monos 2 basos 4 blasts 76 pearl monocytes 6 meta &aposs 3 nucleated red blood cells . There were some oval tear drop cells and target cells with a few schistocytes . The platelet count was 9 000 hematocrit was 26.5 with an mean corpuscular volume of about 73 . His prothrombin time and partial thromboplastin time were normal . His uric acid was up at 97 his total bilirubin was up at 1.8 his LDH was 428 his phosphorus was 1.2 calcium 8.6 Digoxin level was 1.0 potassium on admission was 2.9 sodium 135 BUN and creatinine 13 1.6 and sugar of 267 . A computerized tomography scan of his head showed no signs of an acute bleed a chest X-ray showed no new infiltrates or masses . There was cardiomegaly with prominent vascularity but no effusions . An electrocardiogram was consistent with atrial fibrillation .

ON ADMISSION On admission Thomas was well-appearing though slightly sleepy with jaundice . He had bilateral breath sounds that were clear and equal . The heart rate was regular without murmur and pulses were 2 and symmetrical . The abdomen was soft and nontender with no hepatosplenomegaly . His weight was 3.505 7 pounds 12 ounces on readmission . He had normal male genitalia with bilaterally descended testes . His hips were stable . His tone was normal with normal neonatal reflexes . He is tolerating his feedings well . SUMMARY OF HOSPITAL COURSE RESPIRATORY Without issues on this admission . Breath sounds are clear and equal . CARDIOVASCULAR Without issues on this admission . He had a regular heart rate and rhythm no murmur and pulses were 2 and symmetric . FLUIDS ELECTROLYTES AND NUTRITION Alleyne birth weight was 3.710 kg 8 pounds 3 ounces . His weight on this admission was 3.505 kg 7 pounds 12 ounces . Linda is breast feeding every 3 hours and supplementing with expressed breast milk . He is feeding well . His discharge weight is 3585 grams 7 pounds 13 ounces . GASTROINTESTINAL Alleyne bilirubin on 2018-05-09 was 10.4 at which time he was discharged to home . At the primary pediatrician s office on 2018-05-12 his bilirubin had been 23 at which time he was readmitted to the HealthSouth Rehab Hospital of Western Mass. and double phototherapy was started . His bilirubin on 05-13 was 18.4 and on 05-14 it was 14.7 . Phototherapy was discontinued on 2018-05-14 and a rebound bilirubin will be checked in the pediatrician s office . HEMATOLOGY The hematocrit on 05-12 was 48.7 with a reticulocyte count of 1.9 and his blood type is O Coombs negative . INFECTIOUS DISEASE No issues on this admission . NEUROLOGICAL The infant has been appropriate for gestational age .

He had mild elevation of the WBC intermittently grossly bloody urine . No cultures were positive but the chest x-ray showed bilateral densities more on the left than the right compatible with aspiration pneumonia . There were no radiographic indications of congestive heart failure . HOSPITAL COURSE AND TREATMENT The patient was started on Clindamycin intravenous and Cefuroxime intravenous with clearing of his fever but persistence of cough choking and intermittently many coarse rales in his base with no clearing by x-ray . His ambulation was minimal and always with assistance but he had a transurethral resection of the prostate on 09 14 96 . He is transferred to Louline Mauikings Medical Center for future rehabilitation and hopeful return home with considerable support and assistance .

He was a chronically ill appearing elderly man with a respiratory rate of 30 temperature 99.6 pulse 100 and irregularly irregular blood pressure 148 71 . He had some petechiae on his extremities as well as in his mucosal membranes with some hemorrhagic bullae . There were bibasilar rales with some wheezing . He had no cardiac murmur . His abdomen was distended with massive hepatosplenomegaly which was somewhat tender . The neurological examination aside from the blind right eye was unremarkable .

PHYSICAL EXAMINATION Emaciated white female in mild respiratory distress . Temperature was 98.1 heart rate 116 blood pressure 120 68 and room air O2 saturation was 93 HEENT Dry mucous membranes and myotic pupils NECK No lymphadenopathy CHEST Few inspiratory wheezes and no rhonchi HEART Regular rate and rhythm with tachycardia and no rubs or murmur ABDOMEN Well healed Pfannenstiel scars and no masses PELVIC No masses RECTAL No masses and guaiac negative EXTREMITIES No edema or cyanosis LABORATORY EXAMINATION Hematocrit was 40 white count was 21 and platelet count of 723 000 PT and PTT were 12 and 26 . Electrolytes were within normal limits liver function tests within normal limits and EKG showed a heart rate of 128 axis 73 and possible ectopic P

Lopressor 25 mg p.o. b.i.d. Lasix 20 mg p.o. q. 12 hours times seven days . 3. Potassium chloride 20 mEq p.o. q. 12 hours times seven days . Colace 100 mg p.o. b.i.d. Metformin 500 mg p.o. b.i.d. Percocet 5 325 one to two tablets p.o. q. four to six hours p.r.n. Celexa 20 mg p.o. q.d. Lipitor 20 mg p.o. q.d. Warfarin 5 mg p.o. q.d. times four days after which point the patient s dosage schedule is to be coordinated by his PCP Dr. Jerold Esqueda . DISCHARGE INSTRUCTIONS The patient is to maintain his incisions clean and dry at all times . The patient may shower but should pat dry incisions afterwards no bathing or swimming until further notice . The patient may resume a Heart Healthy Diet . The patient had been advised to limit his physical exercise no heavy exertion . No driving while taking prescription pain medications . The patient is to have his Coumadin managed by his primary care provider Dr. Jerold Esqueda for a target INR of 2.5 . The patient is to report to Dr. Jones office on 2010-06-14 for an initial blood draw and subsequent Coumadin titration Coumadin levels are to be monitored per his PCP David . The patient is to follow-up with Dr. Leanne Larimore in Cardiology within two to three weeks following discharge . The patient is to follow-up with Dr. Brenda Hummer four weeks following discharge . The patient is to call to schedule all appointments . Tracy X. Carmen M.D. 76-050 Dictated By Gerald R. Quiroz M.D. MEDQUIST36 D 2010-06-12 0200 T 2010 -06-12 1421 JOB 47222 Signed electronically by DR. Tiffany D. Picklesimer on WED 2010-07-28

Coronary artery disease . DISCHARGE DIAGNOSES Coronary artery disease . Status post off pump coronary artery bypass graft times three .

Metoprolol 50 mg PO b.i.d. Isordil 20 mg PO t.i.d. Ecotrin aspirin q.day .

1.Respiratory . Without issues on this admission . Breath sounds are clear and equal . 2. Cardiovascular . Without issues on this admission . He had a regular heart rate and rhythm no murmur', 'pulses were 2 and symmetric . 3. Fluids electrolytes and nutrition . The baby s weight was 3.160 kilograms 7 pounds 3 ounces . He is breast and bottle feeding every 3 hours with expressed breast milk', 'and or Enfamil . He is feeding well . His discharge weight is 3025 gm and has been stable for past 2 days . 4. Gastrointestinal . The baby s bilirubin on 2018-12-31 was 15.5', '0.5 at which time double phototherapy was started . On 01-01 his bilirubin was 17.3 0.4 at which time triple phototherapy was started and then his subsequent bilirubins are 16.5', '0.4 on 2019-01-01 and 16.2 0.5 on 2019-01-02 . Phototherapy was discontinued on 2019-01-04 for a bilirubin of 12.1 and a rebound bilirubin will be checked on 01-05 . 5. Hematology .', 'The hematocrit on 01-02 was 61 with a reticulocyte of 2.6 . His blood type is A Coombs negative . 6. Infectious disease . No issues on this admission . 7. Neurological .', 'The baby has been appropriate for gestational age with normal newborn reflexes . 8.', 'Sensory Auditory hearing screening was performed with automated brainstem responses . The infant passed both ears on 2018-12-30 . 9. Psychosocial . The family is invested and involved .'

1. cerebrovascular accident . The patient suffered some mild weakness which was attributed to stenosis of the distal right internal carotid artery . This was determined by head CT head MRI head MRA carotid noninvasive studies transcranial Dopplers . The possibility of a cardiac origin was evaluated by echocardiogram and Holter monitor . Her echocardiogram curiously showed a normal left ventricular size and systolic function a patent foramen ovale with a trace right to left shunt as determined by bubble study trace MR was present . Previous echoes have shown MVP at the Ona Hospital . Her Holter showed up to 12 beats of SVT but was otherwise unremarkable . The patient had a normal B12 negative syphilis serologies and normal thyroid function during this hospitalization . She was anticoagulated with heparin and after several days Coumadin was started . Her exact Coumadin dose is undetermined at this point however it looks like it will be something around 5 mg a day . Her pro time and PTT have normalized at the time of discharge . She needs to be given 5 mg of Coumadin tonight 5 22 92 . In addition heparin should be started to drip on arrival at 400 units an hour . It is discontinued at the time of transport . The patient has received physical therapy and occupational therapy and her recovery is near complete . During evaluation of her neurologic status it was determined that for several months prior to admission the patient has been too unsteady to ambulate . On our exam she is found to have a significant amount of ataxia especially in the midline and the exact cause of this is unknown . There are multiple possible contributions and this is where her need for careful internal medical evaluation has arisen . At the time we were to embark on this evaluation the patient &aposs family strongly requested that she be transferred to the Sas General Hospital . What follows is a summary of her medical problems and their possible relationship to her ataxia . Her ataxia is likely due to some cerebellar function though this is not certain . Moreover her MRI did not show any discrete cerebellar lesions . Our leading theory at this point is that her cerebellar dysfunction relates to perineoplastic syndrome relating to her history of breast Ca . As I mentioned above her evaluation was limited by her cardiologic status at the time . While mammogram and CA-15.3 and breast exam are all normal the idea of a perineoplastic syndrome with or without concomitant breast Ca has reared its head . Two possible markers are anti-Hu syndrome and anti-Yo antibody . These tests were sent on the 18th and are pending at the time of discharge . The results can be obtained by paging me Do A. Joasscchird M.D. at 834-364-2251 . I will be happy to furnish the results . The patient has a history of MI in 1989 . Echocardiogram no longer shows wall motion abnormalities . EKG when the patient goes out of left bundle branch block transiently shows an anterolateral Q wave inversion . We would like to discontinue her Isordil to improve upon some orthostatic hypotension but we are not certain whether her heart will tolerate this . Persantine thallium is scheduled at this time but is yet to be performed . The patient has a history of orthostatic hypotension x many years . It has been evaluated in the past without success . During her hospitalization we confirmed the presence of this even when she was hydrated with saline to a fractional excretion of sodium of 2 . Studies of her autonomic system did not document any dysautonomia . Studies of skin galvanic conduction were normal and her RR interval evaluation was not abnormal . This is a chronic problem but may be contributing to her current weakness and inability to walk . Florinef is to be considered however stopping the Isordil is one goal . The patient has a history of bronchiectasis from a childhood pneumonia . In addition there is a distant history of M. kansasaii infection . This has been evaluated by Dr. Screen at Sas General Hospital and probably relates to her lung xray . CT at the Ona Hospital in 1989 showed similar findings . A chest CT was to be performed and may be yielding . A PPD was placed and is to be read on Saturday 4 26th . The left volar forearm has the PPD just proximal to the wrist crease and a candida albicans placed just distal to the antecubital fossa . The patient has a history of deep venous thrombosis in 1990 for which she received 6 months of Coumadin . Dopplers of her lower extremities were negative on this admission . It is doubtful that she has chronic PE but this is one consideration . It is likely that she has pulmonary hypertension from her lung disease and so this is a consideration . The patient had mild hyponatremia during this hospitalization with a sodium as low as 131 . We think this is likely due to an SIADH as she is euvolemic . This can be evaluated further and is not a problem at this time . The patient has glaucoma . Her medications are as listed below . Her ophthalmologist is aware of transfer . His name is Ettrent Can and he can be reached at 678-233-5033 b 549 . DOCTORS DISCHARGE ORDERS Propanolol 5 mg. p.o. t.i.d. hold for SBP less than 110 Isosorbide 5 mg. p.o. t.i.d. hold for SBP less than 110 Colace 100 mg. p.o. b.i.d. Pilocarpine 4 one drop q.i.d. O.D. Pilocarpine 2 one drop b.i.d. O.S. Betasan 0.5 one drop b.i.d. O.D. . Bacitracin ointment one drop O.D. q.h.s. Ciprofloxacin 500 mg. one p.o. b.i.d. x four more days until 5 25 92 for recently discovered siderobacter UTI . Coumadin 5 mg. p.o. q.h.s. She needs her dose on 5 22 92 . Heparin i.v. drip at 400 units per hour on her arrival . In addition the patient requires occupational therapy and physical therapy .

Pulmonary On admission the infant required CPAP 6 cm of water 30 oxygen . Initial capillary blood gas was pH 7.29 CO2 47 . Infant was intubated on day of life two for increased respiratory distress', 'and received one dose of surfactant . Infant was extubated on day of life four to CPAP and transitioned to room air on day of life six . The infant has remained in room air throughout the hospitalization .', 'Caffeine citrate was started on day of life six and was discontinued on 05-23 day of life 18 . The last apnea and bradycardia was on 06-10 . 2. Cardiovascular The infant has remained hemodynamically', 'stable throughout this hospitalization no murmur . Heart rate 150 to 160 mean blood pressure 40 to 54 . 3.', 'Fluid electrolytes and nutrition Infant was initially nothing by mouth receiving 80 cc per kilogram per day of D10W intravenously .', 'Infant was started on enteral feedings on day of life four and advanced to full volume feedings of 150 cc per kilogram per day by day of life seven .', 'During feeding advancement infant was given parenteral nutrition and intralipids . The infant tolerated feeding advancement without difficulty .', 'Infant was advanced to maximum caloric density of breast milk or premature Enfamil 26 calories per ounce with ProMod by day of life 11 .', 'Infant is currently on breast milk or Enfamil 24 calories per ounce po minimum 140 cc per kilogram per day . The most recent weight is 2525 g.', 'Head circumference 24.5 cm length 45.5 cm . The most recent electrolytes on day of life five were sodium 145 chloride 115 potassium 4 TCO2 of 21 .', 'On day of life 25 calcium 10.1 phosphorus 6.9 alkaline phosphatase 341 . 4. Gastrointestinal Infant was started on double phototherapy on day of life two for a maximum bilirubin level of 8.1 with', 'a direct of 0.3 . Infant decreased to single phototherapy and phototherapy was discontinued on day of life six . Rebound bilirubin level on day of life seven was 5.3 with a direct of 0.3 . 5.', 'Hematology The infant did not receive any blood transfusions this hospitalization . The most recent hematocrit on day of life two was 47 . CBC on admission white blood cell count 8.9 hematocrit 47', 'platelets 243 000 6 neutrophils 0 bands . Repeat CBC on day of life two showed a white blood cell count of 8.4 platelets 95 41 neutrophils 0 bands . Repeat platelet count on day of life three', 'was 229 . 6. Infectious disease The infant received 48 hours of ampicillin and gentamicin for rule out sepsis . Blood cultures remained negative to date . Infant has not had any issues with sepsis this', 'hospitalization . 7. Neurology Head ultrasound on day of life seven showed no intraventricular hemorrhage . A repeat head ultrasound on day of life 33 06-07 showed a slight increase of echogenicity', 'in the caudothalamic groove which may represent tiny bilateral germinal matrix hemorrhages no periventricular leukomalacia . A repeat head ultrasound is recommended in one month .', 'Normal neurological examination . Sensory hearing screening was performed with automated auditory brain stem responses . Infant passed both ears . Ophthalmology', 'eyes examined most recently on 05-30 revealing immaturity of the retinal vessels but no ROP as of yet . A follow up examination should be scheduled for the week of 06-20 .', 'Ophthalmologist is Dr. Cruea Franklin . 8. Psycho social Parents involved . Triplet number one is still in the Neonatal Intensive Care Unit and triplet number three is home with family', 'and there is also a 2 year-old sibling .', 'CONDITION ON DISCHARGE', 'Stable on room air .

BY SYSTEM Respiratory The baby was intubated in the Delivery Room received two doses of surfactant . Radiograph revealed bilateral diffuse granular pattern consistent with surfactant deficiency . Maximum mechanical ventilation PIP 26 PEEP 6 rate of 25 maximum FIO2 35 percent . Mychelia was extubated to a CPAP of 6 cm on day of life two where she remained until day of life 20 . On day of life two she was also loaded with caffeine and continues on caffeine at time of transfer . She was transitioned to a nasal cannula on day of life 20 and remains on nasal cannula O2 100 percent at 13 cc flow . She averaged 2-3 apnea episodes a day with bradycardia and desaturations . She has a comfortable respiratory rate and good air exchange . Cardiovascular She received a normal saline bolus times one initially for poor perfusion and was started on dopamine with a maximum infusion rate of 6 mcg per kg per hour . This was discontinued on day of life two to maintain a mean arterial pressure of greater than 33 . She has remained hemodynamically stable during the remainder of her hospitalization here . Fluids electrolytes nutrition Initially maintained NPO . UAC and UVC lines were placed upon admission to the CMED . The UAC was left in place until day of life two and was removed after wean from dopamine . UVC remained in place through day of life six and was utilized to administer parenteral nutrition . Electrolytes and glucose remained in the normal range throughout the first week . She was started on enteral feeds on day of life six with a slow advance secondary to increased abdominal girth which was felt to be due to CPAP . She passed meconium . She achieved full feeds on day of life 13 . Calories were gradually increased to breast milk 30 calories with ProMod consisting of four of human milk fortifier four of MCT and two of Polycose with a 12-28 teaspoon of ProMod per 50 ml of breast milk or 60 ml of formula . On day of life six due to concerns for hyperglycemia and abdominal distention sepsis evaluation was obtained . She was noted at this time to have hyperglycemia requiring two subcutaneous doses of insulin and a decreased glucose infusion rate to achieve euglycemia . This resolved that same day . Urine output was always noted to be of sufficient quantity . Gastrointestinal Mychelia demonstrated slow gastrointestinal motility and abdominal distention felt to be due to CPAP . She was slow to advance on enteral feeds and gradually attained full enteral volume on day of life 13 . On day of life 15 she was made NPO for a distended abdomen and a bilious spit . Serial KUBs revealed nonspecific changes with dilated loops . No pneumatosis or free air was seen . She was noted to have bluish discoloration thought to perhaps be a bruise on her left lower quadrant . There was no radiographic correlation with this . Feeds were restarted . Again she was advanced to full volume but was made NPO on day of life 20 for abdominal distention . This NPO was temporary for that day and she then resumed feedings and has been tolerating full enteral feeds well improved since off of CPAP passing normal stools guaiac negative . Mychelia was also treated for physiologic jaundice . She was started under phototherapy on day of life one through day of life three with a peak serum bilirubin of 4.7 0.3 . This issue resolved . Hematologic and Infectious Disease Initial CBC was notable for a white count of 5.5 with 49 polys 1 band and 47 lymphs . Initial hematocrit was 46.3 percent and platelets 320 000 . Her initial blood culture remained negative and she received 48 hours of ampicillin and gentamicin . As previously noted on day of life six with hyperglycemia abdominal distention a CBC and blood culture were again obtained revealing a white count of 9.1 with 30 polys 0 bands and 58 lymphs . Hematocrit at that time was noted to be 31 and platelets 370 000 . Blood culture grew staph coagulase negative and the baby received seven days of vancomycin and gentamicin . A lumbar puncture was also performed to rule out meningitis . This culture remained negative with normal cell counts and chemistries . Antibiotic levels were monitored and doses adjusted accordingly . Mychelia required two transfusions during her hospital stay . On day of life 15 for a hematocrit of 29 she received 20 cc of packed red blood cells . She started on iron and vitamin E supplements on day of life 25 and continues on that at this time of transfer . However on day of life 34 12-04 she was noted to be pale and less stress tolerant mottling easily with care . A hematocrit and reticulocyte count showed a hematocrit of 23 percent and a reticulocyte count of 1.9 percent . Therefore with blood available from the first aliquot a second 20 cc per kg of packed red blood cells were infused without incident . Neurological Initial head ultrasound on day of life seven was normal . At one month of age on 12-03 she was noted to have an absent septum pellucidum . An MRI obtained and reviewed by the Hallmark Health System Radiology Department revealed focal gyral morphology consistent with prematurity normal midline structures normal myelination no lesions no signal abnormalities or extracerebral collections . The cortical ribbon is intact . The major vascular structures at the skull base are normal . The septal leaflets may be partially absent but there are no coronal images provided for confirmation and the pituitary stalk is present . An Ophthalmology consult was obtained to determine the presence of optic nerves . These were both determined to be present and intact . Endocrine was also consulted . Several labs were ordered . Electrolytes and thyroid studies were noted to be in the normal range with serum sodium of 136 potassium 4.7 chloride 98 and CO2 34 . She had a calcium of 10.3 a phosphorus of 4.8 and alkaline phosphatase of 440 . Thyroid function studies revealed a TSH of 2.2 T4 of 5.7 T3 of 101 and a cortisol level of 43 all within the normal range . A growth hormone was sent and the results were pending at time of transfer . In addition an FSH and LH were obtained on 12-10 and results are pending at time of transfer . Please contact lab control at Mattapan Community Health Center for results 409 238-8236 . The baby s neurologic examination is appropriate for corrected gestational age which is 33 and 6 7 weeks on day of transfer . By mother s report a maternal cousin also has an absent septum pellucidum . Given normal pituitary tests thus far and normal optic nerve no evidence of septic optic dysplasia . Pediatrician should have low threshold for endocrinology reconsult if any signs of pituitary problems . Sensory Audiology hearing has not yet been obtained . This is recommended prior to discharge from hospital to home . Ophthalmology Initial ROP screen was done on 12-02 and revealed immature retinas to zone 2 bilaterally . They recommended follow-up examination due on the week of 12 20 . Psychosocial Gardner State Hospital social worker has assisted in working with this family . The contact may be reached at 754 791 7976 . Parents have been very involved and appropriate with infant and have eagerly learned to care for their baby . Condition at time of transfer is good . Discharge disposition is to level 2 nursery at Jordan Hospital Hospital . Name of primary pediatrician is Ashley Daley of Village Pediatrics in Stockbridge . Feedings at the time of transfer include breast milk 30 with ProMod at 150 cc per kg per day all gavage given over one hour . Medications include Fer-In-Norman vitamin E 5 international units each day and caffeine citrate once a day . Car seat positioning screening has not been obtained . Newborn state screens have been sent per protocol . Results have been in the normal range . IMMUNIZATIONS RECEIVED Mychelia received hepatitis B vaccine on 11-02 due to unknown maternal hepatitis B surface antigen status . She also received hepatitis B immune globulin on 11-02 . On 12-06 she received her second hepatitis B vaccine . Her two month immunizations have not yet been given . IMMUNIZATIONS RECOMMENDED Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following three criteria 1 born at less than 32 weeks 2 born at 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 infants 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 first 24 months of the infant s life immunization against influenza is recommended for household contacts and out of home caregivers . Follow-up appointments recommended with the primary pediatrician Dr. Marilyn Daley of Stockbridge Village Pediatrics Dr. Lynn Warren of Neurology from Emerson Hospital and Ophthalmology to follow her ophthalmology status . DISCHARGE DIAGNOSES Prematurity at 28-2 7 weeks . Surfactant deficiency . Hypotension . Sepsis suspect . Physiologic jaundice . Coagulase negative bacteremia . Anemia of prematurity . Apnea of prematurity . Absent septum pellucidum . Rosalie Gloria North Dakota 67177 Dictated By George D Gregory M.D. MEDQUIST36 D 2013-12-10 124122 T 2013-12-10 140332 Job

On admission the patient s birth weight was 1.705 kilograms which is 50th percentile . Length was 40 cm 50th percentile . Head circumference was 30 cm 50th percentile . The patient was born at 32 and 4 7 weeks gestation and brought directly to the CMED CSRU .

She is a half to one pack per day smoker for 10 years who quit approximately one week prior to her admission . She denies alcohol use .

Her temperature is 97.9 blood pressure 160 80 heart rate 92 her HEENT examination reveals anicteric sclerae and her left eye has slightly relaxed inferoorbital wall . Her chest is clear to auscultation . Her heart has regular rate and rhythm with I VI systolic ejection murmur at the base . Abdomen is obese soft non-tender and without palpable masses . Extremities two plus pulses bilaterally and nonpitting edema up to the knees in both legs . Neurologic examination is unremarkable . LABORATORY DATA sodium 142 potassium 3.3 chloride 98 bicarbonate 34 BUN and creatinine 14 0.9 . Her alkaline phosphatase is 77 white blood count 12.5 hematocrit 42.6 platelet count 268 . IN SUMMARY This is a patient with recurrence of a mixed mesodermal cancer at the vaginal apex who presents for local excision .

discharge disposition 'Home .

Coumadin 2.5 mg. five times a week Ativan and Lomotil prn . ADVERSE DRUG REACTIONS no known drug allergies but has shellfish allergy and question of an Iodine allergy .

On admission chest x-ray with no acute cardiopulmonary process . Electrocardiogram notable for sinus tachycardia with a rate of 104 beats per minute normal axis normal intervals new T wave inversion in III and old T wave inversions in aVL and V1 . This was not significantly changed from comparison with 2016-03-17 . On admission white blood cell count 7.3 73 percent neutrophils 15 percent bands 6 percent lymphocytes hematocrit 30.4 platelet count 228 000 . Sodium 136 potassium 3.5 chloride 98 bicarbonate 23 blood urea nitrogen 16 creatinine 0.8 glucose 142 .

celexa premarin trazodone 6-MP Prednisone Discharge Medications 1. Phenytoin Sodium Extended 100 mg Capsule Sig One 1 Capsule PO TID 3 times a day for 1 months . Disp 90 Capsule s Refills 0 2. Acetaminophen Caff Butalbital 504-61-78 mg Capsule Sig 01-28 Tablets PO Q4-6H every 4 to 6 hours as needed for 1 months . Disp 60 Tablet s Refills 0 3. Citalopram 20 mg Tablet Sig One 1 Tablet PO DAILY Daily . 4. Metoprolol Tartrate 25 mg Tablet Sig One 1 Tablet PO BID 2 times a day . 5. Hydromorphone 2 mg Tablet Sig 1-2 Tablets PO Q4H every 4 hours as needed for pain . Disp 40 Tablet s Refills 0 6. Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day Use while taking narcotics . 7. Phenytoin Sodium Extended 100 mg Capsule Sig One 1 Capsule PO TID 3 times a day . Disp 90 Capsule s Refills 0 Discharge Disposition Extended Care Facility St. Annes Hospital Burlington Discharge Diagnosis Head trauma with subarachnoid hemorrhage C7 fracture Discharge Condition neurologically stable Discharge Instructions Call for severe headache or any other problems . Please take Fioricet as directed for headaches . Please do not drive while on this medication . Please continue to wear your C-collar at all times . Please continue Dilantin as directed for seizure prophylaxis . Followup Instructions Follow up with Dr. Kelley in 4 weeks with head CT call 716 3268 Please also follow-up with Dr. Obrecht of CMED CCU spine in 2 weeks for flexion extension X-rays 228 411-7660 Please follow-up with your PCP N 6-12 months reguading the right thyroid nodule and the bilateral small lung nodules seen on your chest CT . Vernia Diana MD 76-016 Completed by Sonya Ramona NP 80-AKY 2013-04-01 1453 Signed electronically by DR.

Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs prn . Rice S.F. Thrash M.D. 15-419 Dictated By Brett E.X. Im M.D. MEDQUIST36 D 2012-06-29 0115 T 2012-06-29 0547 JOB 44693 Signed electronically by DR. Vicki Baker on TUE 2012-07-03 823 AM

As described above the patient was transfused an additional 2 units in the Intensive Care Unit and the patient also received an upper endoscopy study and her varices were banded .', 'On transfer to the Lemgarson Hospital service her hematocrit was 31.2 white count 11.1 and a platelet count 80 . Her PT was 13.1 PTT 26.7 . The rest of her labs were unremarkable .', 'She was watched very closely while on the floor . She was on GI bleed precautions at all times was too large for IV . She had a clot at the blood bank and she had BID hematocrits checked .', 'She was kept NPO until January 26 when she began to feel hungry . At that time clear liquids were started . All of her stools were guaiaced . She also began Nadolol 40 mg QD to reduce her portal', 'hypertension . The GI consult team continued to follow her . We also tried to contact her physician at Va Sit Namar Healthcare and was unsuccessful . Therefore we decided to work up her cirrhosis .', 'She was described as having cirrhosis and we decided that we wanted to try to figure out the etiology .', 'Her ferritin and iron studies did not reveal any evidence of hemochromatosis and her hep serologies were all negative . She also had negative antimitochondrial antibody and she also had no evidence', 'of ceruloplasmin . Over the course of her admission were also sent an alpha-1-antitrypsin which was negative .', 'She did very well over the course of her admission with no evidence of further bleeding .', 'Her hematocrit stayed stable at approximately 32 . We also did an ultrasound guided paracentesis .', 'The peritoneal fluid showed a glucose of 244 total protein 0.8 and a albumin of 0.5 globulin 0.3 amylase 16 LDH of 51 . The serum albumin gradient was 1.8 consistent with portal hypertension .', 'The cell count showed a white blood cell count of 160 with 16 polys . She therefore criteria for a spontaneous bacterial peritonitis .', 'Her platelet count stayed persistently low and we decided that it might be due to Cimetidine . Therefore we switched her Cimetidine to Prilosec .', 'By the 2th the patient was feeling very well and desired to transfer or discharge to home . She wanted to be closer to North Dakota .', 'After discussion with her private physician Dr. Joasscchird tel. 090-249-6079 at Va Sit Namar Healthcare and Dr. Acrookesjo at Do Of Hospital', 'the patient was judged to be fit for discharge and she was sent home with AH and physical therapy . She was quite able to climb stairs on her own in the hospital .', 'She is to follow up with Dr. Acrookesjo in one week and Dr. Work the gastrointestinal fellow here at PUOMC in 2 weeks . She may require a repeat upper endoscopy study to see if she needs any rebanding .', 'The patient however complained of a persistent wheeze with beta blocker therefore it was agreed that we would stop the beta blocker until the patient was followed up as an outpatient .

Assessment was continued with laboratory studies which showed the patient to have a white blood cell count of 9 hematocrit 39 and platelets 470 . The patient had a normal amylase and lipase and a normal basic metabolic panel . The patient had KUB that showed multiple dilated loops of small bowel and was admitted for a partial small bowel obstruction . An nasogastric tube was placed and had an H2 blocker started and was admitted for bowel rest and decompression . The patient tolerated the nasogastric tube well . The nasogastric tube was removed on hsp day 3 . The pain improved quickly and the patient was started on a clear liquid diet which was advanced as tolerated . On 7 9 99 the patient was tolerating a house diet . The patient had some minimal back pain that occurred after food but with negative urinalysis and negative fever spikes over the entire course of this stay . The patient will be discharged home on Zantac Simethicone and preoperative medications with follow-up with Dr. Ur in two weeks . Dictated By NISTE BLOCKER M.D. AQ36 Attending STIE FYFE M.D. BW3 BL436 5666 Batch 85114 Index No. FNQXCX58 EM D 07 09 99 T

Spironolactone 50 mg p.o. b.i.d. 2 Advil p.r.n. 3 Topical steroids for eczema p.r.n. ALLERGIES The patient had no known drug allergies .

Levoxine 0.125 mg PO q.day Vasotec 10 mg PO b.i.d. Maxzide 75 50 30 mg PO q.day .

Thromboembolus to the right profunda femoris and right superficial femoral artery . MA JAMTLANDBRANTESSLIGH M.D. DICTATING FOR COR TLAND M.D. TR qa bmot DD 07 02 92 TD

On admission the patient s birth weight was 1.705 kilograms which is 50th percentile . Length was 40 cm 50th percentile . Head circumference was 30 cm 50th percentile . The patient was born at 32 and 4 7 weeks gestation and brought directly to the CMED CSRU .

Cigarette smoking Insulin dependent diabetes mellitus . Proteinuria Aortic stenosis . Cellulitis Gangrene of his left second toe in 2010-06-06 followed by an amputation . Left common femoral dorsalis pedis bypass graft Right leg bypass graft in 1999 . Right below the knee amputation in 2008

Coronary artery disease status post coronary artery bypass graft four vessels . Congestive heart failure . Klebsiella pneumonia . Failed swallow study status post percutaneous endoscopic gastrostomy tube placement . Central line culture positive for coagulase negative Staphylococcus aureus status post a 14 day treatment with vancomycin and removal of the line .

ON ADMISSION This is a gentleman who is intubated comfortable with minimal sedation . He was afebrile with a temperature of 99.1 . His pulse was in the 70s blood pressure 119 58 . He was breathing 12 per minute and saturating 98 . His CVP is ranging from 07-27 . He was intubated and has a nasogastric tube . His neck has a well-healed right carotid endarterectomy scar . There is also a well-healing tracheostomy scar . The lungs were clear to auscultation bilaterally . The heart was regular with an S1 and S2 . The abdomen was soft nontender nondistended with normoactive bowel sounds . The extremities were without edema . The left arm was in a cast .

On admission the sodium was 136 potassium 3.0 chloride 98 CO2 20 BUN 8 creatinine 0.8 and glucose 94 ALT 5 AST 10 LDH 166 alkaline phosphatase 81 total bili 0.6 direct bili .3 albumin 3.3 calcium 8.8 and uric acid 3.1 . She had CA-125 which was pending at the time of discharge . Her hematocrit was 31.1 WBC 11.6 and 151 000 platelets .

Brothers with William cancer and a MI . Father with emphysema . Mother with lung cancer .

ON ADMISSION Physical examination at the time of admission revealed she was in no acute distress . Blood pressure was 150 79 a pulse of 81 . She is legally blind . She was without any adenopathy . Her chest was clear to auscultation . Heart had a normal S1 and S2 with no murmurs gallops or rubs . Her abdomen was soft with well-healed incisions . There was no organomegaly . Extremities were without edema . She had a functioning arteriovenous fistula with a thrill and a bruit in her left arm .

Stable DISCHARGE DIAGNOSES Coronary artery disease Mitral valve regurgitation status post coronary artery bypass graft x2 and mitral valve annuloplasty SECONDARY DIAGNOSES 1. Coronary artery disease Myocardial infarction x3 Coronary artery bypass graft DISCHARGE MEDICATIONS 1. Lopressor 25 mg po bid 2. Amiodarone taper 400 mg po tid x4 days then bid x7 days qd x7 days then 200 mg po qd 3. Lasix 20 mg po qd K-Dur 20 milliequivalents po qd Aspirin 81 mg po qd 6. Percocet 1 to 2 po q 4 to 6 hours prn 7. Colace 100 mg po bid Percocet Protonix 20 mg po qd DIGrimmE INSTRUCTIONS The patient should follow up with Dr. von Diamond in approximately three weeks . The patient should also follow up with his primary care doctor Dr. Beals in approximately three weeks . Briley von der Ross M.D. 67 -576 Dictated By Julie H. Bullock M.D. MEDQUIST36 D 2013-08-15 0755 T 2013-08-15 0901 JOB 15357 Signed electronically by DR. Santos von der Ross on WED 2013-08-21

Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition Extended Care Discharge Diagnosis benzodiazipine overdose Discharge Condition stable Discharge Instructions please take your medications and call your doctor if you experience chest pain abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else . Followup Instructions please call your primary doctor Edmund Starke once your are discharge from the hospital Clemmie Shawn MD 65-948 Completed by Michael Melvin Kinzer MD 51-991 2012-03-26 1709 Signed electronically by DR.

Satisfactory TO DO PLAN 1 Follow-up esophageal biopsy results 2 Schedule GI follow-up if biopsy results abnormal or if continued bleeding . 3 Consider oncology follow-up if biopsies suggestive of malignancy 4 Omeprazole 40 mg po bid x6 wks . No dictated summary ENTERED BY ZISKFUSCJALK ACRI M.D.

82 119 60 22 and 99 on room air . Well appearing in no apparent distress . Pupils are equal round and reactive to light . Moist mucous membranes . No JVD . Regular rate and rhythm .', 'Positive tenderness to sternum . Chest was clear to auscultation bilaterally . Abdomen Obese soft . Extremities show no edema 2 dorsalis pedis 1 femoral pulses .'Troponin-T less than 0.01. EKG Sinus 84 normal axis QTc 430 Q s in III and aVF no ST changes as compared to 2017-05-01 EKG .

DISCHARGE DISPOSITION To home .

Physical examination revealed that the vital signs were stable . Lungs were clear to auscultation bilaterally . Heart was irregular with no murmurs palpated . Abdomen was benign . Pulses were 2 throughout .

Coumadin Lipitor Toprol XL ASA Zoloft Glucophage Aricept Namenda Artificial Tears Discharge Medications Not applicable . Discharge Disposition Extended Care Facility Patient deceased . Discharge Diagnosis Not applicable patient deceased . Discharge Condition Not applicable . Discharge Instructions Not applicable . Followup Instructions Not applicable . William William MD PHD 13-279 Completed by Barbara Josephine MD 21-547 2013-11-15 1413 Signed electronically by DR. Exie Culbreath on MON 2013-11-18 1006 AM

1 Enteric coated aspirin 325 mg p.o. q. day . 2 Capoten 25 mg p.o. t.i.d. 3 Lanoxin 0.25 mg p.o. q. day . 4 Cardizem 125 mg p.o. q. day . 5 Glucotrol XL 10 mg p.o. b.i.d. 6 Glucophage 500 mg p.o. q. day . 7 Amaryl 2 mg p.o. q.h.s.

Augmentin 500 mg t.i.d. Senokot one q.h.s. Sertraline 75 mg q.day . Aspirin 81 mg q.day . Vitamin B12 100 mcg IM q.month . Urecholine 25 mg t.i.d. Colace .

Cefuroxime 1.5 grams intravenously q8h Solu-Medrol 62.5 mg intravenously q8h Ventolin metered dose inhaler 2 puffs PO q.i.d. Pepcid 20 mg intravenously b.i.d.

Timolol .5 Discharge Disposition Extended Care Discharge Diagnosis Right lower extremity necrosing fascitis history of prostate cancer s p TURP glaucoma Discharge Condition Fair Discharge Instructions If you have any fevers chills nausea vomiting chest pain foot pain please seek medical attention . Followup Instructions Please follow up with Dr. Mallard in one week call 421-3721 for an appointment . Follow up with Dr. Adner in 2 weeks call 763-9180 for an appointment . Mark William MD 19-081 Completed by Shane Gabrielle MD 73-971 2016-04-01 0836 Signed electronically by DR. Robert Howell on WED 2016-05-18

His meds on transfer to FIH were Levophed Dopamine and Ceftriaxone .

BY SYSTEM 1. NEUROLOGY Mr. Roach was transported to Intensive Care Unit from the trauma bay . Upon arrival Neurosurgery promptly placed V. Holtzen bolt . This allowed continuous monitoring of intracranial pressure . Notably intracranial pressure was 17 when the bolt was placed . During his hospitalization his intracranial pressure was monitored very closely and maintained to a level of less than 20 . To do this mannitol 25 mg q. 6h. was used . While using mannitol his serum osmolalities were followed closely . In addition to monitoring his intracranial pressure his systemic blood pressures were maintained in such a manner that his cerebral perfusion pressure was maintained at 70 mmHg . A parameter monitor for his neurologic status PaCO2 which was maintained between 35 and 40 during his hospitalization . Mr. Roach was kept sedated with propofol and was given Fentanyl and or morphine boluses for pain . Neurologic checks were followed initially every one hour and then every two hours to monitor for change in neurologic examination . During his hospitalization two subsequent CAT scans were obtained one on hospital day two . This CAT scan revealed possible worsening and was read as epidural versus subdural bleed . After a discussion with both Radiology and Neurosurgery the decision was made that the worsening did not appear significant and this was not accompanied by a change in his clinical condition . His intracranial pressure remained stable and his clinical examination was unchanged . An additional CT scan was obtained on hospital day three . This examination was unchanged from the previous examination . Again his intracranial pressure and neurologic examination remained the same and conservative treatment was opted for . CARDIOVASCULAR As described in previous section Neo-Synephrine and eventually Levophed were used to maintain a coronary perfusion pressure of greater than 70 . A pulmonary artery catheter was placed on hospital day four . This catheter was placed when the patient started to demonstrate septic physiology and for increasing pressor support . Please see Infectious Disease section for more details . 3. GASTROINTESTINAL Mr. Roach was n.p.o. from the time of his admission . A orogastric tube was passed . Initially during admission carafate was given down the orogastric tube . However on a routine chest x-ray shot on hospital day three a mediastinum was noted . This raised the question of potential esophageal rupture . Gastroenterology was consulted for this . Gastroenterology was consulted to assist in creating the most appropriate diagnostic rhythm given his intubated and sedated status . At this point his carafate was switched to intravenous Protonix and he was strictly n.p.o. 4. HEMATOLOGY Throughout Mr. Richard admission his hematocrit remained stable in the low 30s . As will be discussed in the Infectious Disease section he developed an episode of what appeared to be sepsis and his white blood cell count peaked at 23 . Mr. Roach was on Pneumo boots spontaneous compression devices for deep venous thrombosis prophylaxis . He was not a candidate for subcutaneous heparin as we were concerned of an intracranial hemorrhage . An inferior vena cava filter was considered but was deferred as it was felt that Mr. Roach was too unstable to undergo the procedure . 5. ENDOCRINE Mr. Marian blood sugar was maintained under tight control from 100 to 130 using a regular insulin sliding-scale . 6. INFECTIOUS DISEASE Mr. Roach had a spike in white blood cell count and developed fevers . His blood urine and sputum were all cultured . Blood cultures were pertinent for one bottle of gram positive coagulase negative Staphylococcus which grew from 08-25 . His preliminary cultures including sputum from 08-25 grew Escherichia coli . Sputum from 08-27 grew gram-negative rods not yet speciated and from 08-27 a bronchoalveolar lavage grew 1 gram-negative rods and 4 polymorphonuclear lymphocytes . Throughout this time Mr. Richard temperature continued to increase and was such that on hospital day four his temperature maximum was 42.2 degrees centigrade . During his hospitalization his was treated with vancomycin for his gram-negative rods imipenem and Flagyl . Initially he had been placed on clindamycin to cover his drain but his cultures became positive and his white blood cell count increased . He was switched from clindamycin to the imipenem and Flagyl . Vancomycin was added when we had the positive blood culture . With a fever of 102 up to 42 degrees centigrade aggressive measures including cooling blankets alcohol swabs and fans were used in an attempt to bring his body temperature down . Hypercarbia would result and increase in cerebral perfusion paralysis was initiated to decrease genesis of carbon dioxide secreted during shivering . 7. PULMONARY As discussed in the Infectious Disease section Mr. Roach developed a pneumonia likely from gram-negative organisms but most likely from Escherichia coli . For this pneumonia he was placed empirically on imipenem vancomycin and Flagyl . On hospital day three Mr. Roach had developed an episode of tachycardia and tachypnea . For this a CT angiogram was obtained which demonstrated no pulmonary embolism . On hospital day four a routine chest x-ray revealed a left-sided pneumothorax . For this a left 34 Caucasian chest tube was placed . On the evening of hospital day four Mr. Roach had an acute episode whereby his central venous pressure rose sharply and immediately followed by a period of asystole . Urgent resuscitation measures were initiated . The measures included attempts at pacing . Epinephrine and atropine were administered as were bicarbonate and calcium . He had a differential diagnosis of asystole preceded by an acute rise in central venous pressure included attention pneumothorax cardiac tamponade and pulmonary embolism . During the resuscitation afterwards it was noted that a patent left chest tube was present in the left chest so initially neo-decompression was attempted in the right chest . There was no sign of attention pneumothorax with decompression and a right chest tube was placed . During this time a needle aspiration of what was felt to be the pericardium was performed revealing bloody fluid coming back . A left anterior thoracotomy was made by the Cardiac Surgery fellow who was present . After 30 minutes of active resuscitation including internal cardiac massage there was no evidence of return of vital signs or electric activity to the heart as noted on electrocardiogram monitors . Resuscitation was terminated at 1914 on 08-27 . After the termination of resuscitation both the anesthesia Intensive Care Unit attending and the surgical attending were present to discuss the proceedings events with the patient s family members including his next of kin his mother . Permission for a postmortem examination was granted . Matthew M. Barnett M.D. 78 -102 Dictated By Mark D. Eng M.D. MEDQUIST36 D 2013 08-28 0021 T 2013-09-03 1111 JOB 24887 Signed electronically by DR. Katherin Toth on MON 2013

Toprol 75 mg po bid Furosemide 20 mg po bid times one week potassium chloride 20 mEq po bid while on Lasix Colace 100 mg po bid while on Percocet enteric coated Aspirin 325 mg po q day Indocin 25 mg po bid Sarna cream applied to affected area prn Percocet 1-2 tabs po q 4-6 hours prn Ibuprofen 400 mg po q 6 hours prn Tylenol 650 mg po q 4-6 hours prn Ativan 0.5 mg po q 8 hours prn . FOAnterP The patient will follow-up in the wound care clinic in two weeks . The patient will also follow-up with Dr. Fairchild her primary care physician in three weeks . The patient will follow-up with Dr. vel Diaz in 3-4 weeks . Briley von der Ross M.D. 67 -576 Dictated By Emily O Ennis M.D. MEDQUIST36 D 2013-01-08 1646 T 2013-01 -08 1708 JOB 67252 Signed electronically by DR.

Atenolol 25 mg p.o. q. day . Lasix 20 mg p.o. q. day times seven days . 3. Potassium chloride 20 mEq p.o. q. day times seven days . 4. Niferex 150 mg p.o. q. day times one month . 5. Vitamin C 500 mg p.o. twice a day times one month . 6. Multivitamin one p.o. q. day times one month . Ambien 5 mg p.o. q. h.s. p.r.n. Colace 100 mg p.o. twice a day . Avandia 4 mg p.o. q. day . Glucophage 500 mg p.o. twice a day . Lipitor 20 mg p.o. q. day . Zantac 150 mg p.o. twice a day . 13. Niaspan 500 mg p.o. q. day . 14. Percocet 5 325 one to two p.o. q. four to six hours p.r.n. DISPOSITION The patient is to be discharged to home . CONDITION ON DISCHARGE Stable condition . DISCHARGE INSTRUCTIONS The patient is to follow-up with Dr. Neri in one to two weeks . The patient is to follow-up with Dr. Rota in three to four weeks . The patient is to return to Smith on or about 05-17 to have his staples removed . Gabriela E. D. Castillo M.D. 05-025 Dictated By Julia Q Mcafee M.D. MEDQUIST36 D 2017-05-01 1506 T 2017-05-01 1537 JOB 59432 Signed electronically by DR. Kathy Brendel on TUE 2017-05-02 808 AM

Intravenous chemotherapy for lung cancer . DOCTORS DISCHARGE ORDERS Slo-Mag one tab p.o. b.i.d. Stelazine 2 mg. p.o. q.d. Ativan 1 mg p.o. or s.l. q. 4 -6 hr. p.r.n. nausea . WORK DISABILITY AND PROBABLE DURATION COMPLETE . Followup will be with Dr. Guabenfranda Day in his office . CA SHUFF M.D. TR ds bmot DD 6-2 93 TD

At that time it was felt that the patient was likely having a repeat GI bleed and while he was hemodynamically stable he had evidently lost a substantial amount of blood .

Lopressor 100 mg po three times a day . Captopril 75 mg po three times a day . Prilosec 20 mg po per day . Hydralazine 12.5 mg four times per day . Reglan 10 mg po three times a day .

Cerebrovascular accident Atrial fibrillation on Coumadin . Diabetes mellitus type 2 Hypothyroidism . Mild dementia Proteinuria . Nephropathy Anemia . Hearing impaired PAST SURGICAL HISTORY Laparoscopic cholecystectomy as above Total hip replacement in 2002 . Appendectomy Diskectomy . MEDICATIONS ON ADMISSION 1 Digoxin .125 mg qod .25 mg qod . Colace 100 mg po tid Levoxyl 100 ugm po qd Prinivil 20 mg po qd . Zantac 150 mg po bid Aspirin 325 mg qd Aricept 5 mg po qd . Glyburide 1.25 mg po qam Oxybutynin 5 mg po bid . Coumadin 7.5 mg on Sun Tues Wed Fri and Sat 5 mg on Mon and Thurs . ALLERGIES Fluoroquinolones

Include Librax 1 PO before meals Pancrease 2 tabs before meals Synthroid 0.125 mg PO qd . Tenormin 50 mg bid Valium 5 mg bid to tid Premarin 0.625 mg qd Provera 2.5 mg qod Desyrel 50 mg qhs .

Sandostatin 100 mcg subcu. b.i.d. Percocet 1-2 tabs q.3 -4h. p.r.n. pain Axid 150 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. DISCHARGE FOLLOW-UP The patient has been instructed to follow-up with Dr. Red in one week and in the Urology Clinic in three weeks . DISCHARGE DISPOSITION The patient is discharged to home on 7 10 98 . CONDITION ON DISCHARGE Stable condition . Dictated By MALICHARLEAR KROENER M.D. EB85 Attending LEAND L. KROENER M.D. QW18 FO508 6558 Batch 54270 Index No. YCCYST5DG2 D 07 10 98 T 07 12 98 CC 1.