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Admission Date: [**2192-2-1**] Discharge Date: [**2192-2-6**] Date of Birth: [**2136-2-3**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 55-year-old male who presents with atypical chest pain for several weeks. Has a history of known carotid disease, left 80-90%, right 70-80%, and he is scheduled for a left CEA on [**2192-2-1**], and has been undergoing a preoperative evaluation. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Bilateral carotid disease. 3. Hypertension. 4. Hyperlipidemia. 5. Left renal artery stenosis. PREOPERATIVE MEDICATIONS: 1. Norvasc 10 mg q day. 2. Lipitor 10 mg q day. 3. Folate 1 mg q day. 4. Toprol 25 mg q day. ALLERGIES: Mussels and shellfish. SOCIAL HISTORY: Positive smoker x40 years. PHYSICAL EXAMINATION: At the time of admission, vital signs are a heart rate 65 sinus rhythm, 130/67 blood pressure, respiratory rate 16, and 97% on room air sat. Alert and oriented times three. Extraocular movements are intact. Neck is supple. Lungs are clear to auscultation. Cardiovascular: Regular, rate, and rhythm, distant heart sounds. Abdomen positive bowel sounds, tender in the left upper quadrant. Extremities: No edema noted. LABORATORIES: On [**1-20**], BUN is 18, creatinine 1.0, white blood cells 8.0, hematocrit 41, platelets 244. PT 12.0, PTT 27.4, INR of 1.0. Urinalysis is negative. Total cholesterol 239, LDL 157, HDL 67, TGL 107. Homocysteine level 19.3. Vitamin B12 level 328. LFTs within normal limits. Enzymes were cycled and were flat. Troponin-I less than 0.3 and CPKs were 61. ELECTROCARDIOGRAM: Showed ectopic atrial rhythm in the 70s. On [**1-26**], an echocardiogram was done showed an ejection fraction of 44%, normal perfusion, and mild cavity enlargement. No anginal or ischemic electrocardiogram changes noted. On [**2-1**] cardiac catheterization was done: Left ventricular ejection fraction of 60%, and mitral regurgitation noted, LMCA 90% ostial to the left anterior descending artery, the left anterior descending artery mid vessel is 60% tubular, left circumflex 40-50% proximal, right coronary artery small vessel tortuous irregularities, 70% proximal disease. An AIBP was placed in the catheterization laboratory secondary to uncontrolled pain in order to assist the balloon pump insertion, a stent was placed in the right iliac artery. The patient was placed on Heparin and transferred to the CCU pain free. Cardiac Surgery was consulted. HOSPITAL COURSE: On [**2-1**], the patient was taken emergently to the operating room, where he had left CEA and a CABG x3, LIMA to the LAD, SVG to the distal RCA, SVG to the OM. IBP was discontinued in the operating room. No intraoperative complications. See the operative note for complete details. The patient was transferred to the Intensive Care Unit. Anesthesia was reversed and the patient was successfully weaned from the ventilator early on postoperative day #1. He remained in the Intensive Care Unit due to slow weaning from vasopressor, eventually discontinued on postoperative day #3. Chest tubes were also discontinued on postoperative day #3, and patient was transferred to the floor for continued cardiac rehabilitation and recovery. He received 1 unit of packed red blood cells on the floor for a low hematocrit. Physical Therapy was consulted, and assisted patient with rehabilitation and determined to be stable. Mr. [**Known lastname **] continues to do well, ambulating independently, tolerating po, full strength in all extremities. Neurologically intact and hematocrit stable. PHYSICAL EXAM AT TIME OF DISCHARGE: Alert and oriented times three. Pupils are equal, round, and reactive to light. Follows commands. Neck is supple. No bleeding, oozing noted at the incision site at the left neck. Lungs are decreased bilateral bases, but otherwise clear to auscultation. Cardiovascular: Regular, rate, and rhythm, S1, S2, no murmurs, rubs, or gallops. Abdomen is soft, nontender, and nondistended, and positive bowel sounds, [**1-1**] pulses bilateral radial and femorals, and +[**12-1**] dorsalis pedis and PT. Sternal incision is clean, dry, and intact. No drainage noted. The patient has full strength bilaterally. LABORATORIES AT TIME OF DISCHARGE: White count of 6.7, hematocrit 27.7, platelets 140. BUN 11, creatinine 0.9, calcium 7.5, phosphorus was 1.8. DISCHARGE MEDICATIONS: 1. Lasix 20 mg q day. 2. Potassium chloride 20 mEq q day. 3. Metoprolol 12.5 mg po bid. 4. Ranitidine 150 mg po bid. 5. Enteric coated aspirin 325 mg q day. 6. Plavix 75 mg q day. 7. Ibuprofen 400 mg q6 prn. 8. Percocet 1-2 tablets po q4-6 prn. 9. Tylenol 650 mg q4 prn. DISPOSITION: The patient is stable and discharged to home. FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 70**] in six weeks with a primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17399**] in [**12-1**] weeks and Vascular surgeon, Dr. [**Last Name (STitle) 1391**] in two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 17400**] MEDQUIST36 D: [**2192-2-6**] 10:18 T: [**2192-2-6**] 10:18 JOB#: [**Job Number 17401**]

41401,4111,43310,4439,4401,4019

Admission Date: [**2163-3-23**] Discharge Date: [**2163-3-26**] Date of Birth: [**2088-9-5**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 74-year-old male who was originally admitted to care for hypoxia, hypertension, and mental status changes. Reportedly, the patient had abrupt onset of dyspnea and was found to be hypoxic. At outside hospital, the gas on 100% FIO2 of 85, pCO2 30, pH 7.47 with a systolic blood pressure of 70. He denies other symptoms at that time. Chest x-ray revealed extensive bilateral pulmonary disease consistent with lymphangitic carcinomatosis and perhaps pulmonary edema. Electrocardiogram demonstrated inferior ST elevation and ST depression in V2 and Q waves in the inferior leads. He did have a history of an old inferior myocardial infarction. Troponin-I peak at 1.92, peak CK at 210. CT scan of the chest was negative for pulmonary embolus. Echocardiogram demonstrated ejection fraction of 50% with posterior wide hypokinesis, mild MR and mild TR. He was then transferred to the [**Hospital6 **], where he underwent catheterization revealing 90% lesion in the mid right coronary artery with thrombus. He was referred to [**Hospital1 188**] for PCI of the right coronary artery lesion. Catheterization here revealed 60-70% lesion in the mid circ and distal circ in addition to the right coronary artery lesion. The right coronary artery lesion was stented in two places with much difficulty. In the holding area, he was noted to have decreased mental status and increased confusion. O2 sat was found to be 70%. He was given Lasix, intravenous nitroglycerin, and placed on 100% nonrebreather at which time his oxygen saturation improved to 90-100%. He was then transferred to the CCU for further evaluation. PHYSICAL EXAMINATION: Vitals at that time included a heart rate of 58, blood pressure 132/61, respirations 19, and he was 96% on nonrebreather. He is a pleasant man in no acute distress. Pupils are small but reactive. Heart: He had a regular, rate, and rhythm with a II/VI crescendo systolic murmur. His lungs have bibasilar dry, rhonchorous, coarse throughout especially in the lower lobe. Abdomen was soft, nontender, nondistended with positive bowel sounds with no hepatosplenomegaly. He had no clubbing, cyanosis, or edema. PAST MEDICAL HISTORY: 1. Metastatic prostate cancer with bone metastases to the right humeral. 2. Coronary artery disease status post myocardial infarction six years ago treated with medical therapy. A recent ETT showed inferior fixed defects, ejection fraction of 50%. 3. Hypertension. 4. Zoster. 5. High cholesterol. 6. Status post appendectomy. HOME MEDICATIONS: 1. Atenolol 50. 2. Zocor. 3. Neurontin. 4. Vicodin. 5. Levaquin. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He lives with his daughter. [**Name (NI) **] positive alcohol 1-2 drinks. He quit smoking tobacco 50 years ago. HOSPITAL COURSE: Hospital course is relatively uncomplicated. He was admitted to CCU. He was gently diuresed with Lasix and intravenous nitroglycerin. He was gradually weaned. His oxygen was gradually weaned down to 2 liters nasal cannula, however, there was not much improvement following this intervention. It was thought that his O2 requirement could possible be due to a primary pulmonary process that could have been lymphangitic carcinomatosis or fibrosis, perhaps from her Taxotere therapy. Patient was transfused 1 unit of packed red blood cells to maintain his hematocrit above 30 with a recent coronary event. His laboratories on admission were 17.7, 32.4 hematocrit, platelets 189. Sodium 144, potassium 3.8, chloride 110, bicarb 21, BUN 42, creatinine 0.8, glucose 157, calcium 8.7, magnesium 2.0, phosphorus 3.9. Cardiovascular: He had two stents placed to his RCA. He was continued on Plavix, aspirin, beta blockers, and ACE inhibitor. He was kept on Integrilin for 18 hours. Reportedly at the outside hospital, the patient was found to have an atypical pneumonia. He was continued on Levaquin. His QTC was monitored because of the prepencity of Levaquin to lengthen QTC. Patient was seen by Physical Therapy who said that he was safe to be discharged home and recommended PT visit to maximize rehabilitation. He was discharged home in good condition after speaking with the patient's oncologist with close followup to further workup the primary lung process causing him to have a new oxygen requirement. The patient was discharged home with home O2. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg po q day x4 days. 2. Simvastatin 2 mg po q day. 3. Gabapentin 400 mg po bid. 4. Protonix 40 mg po q day. 5. Lasix 40 mg po q day. 6. Atenolol 50 mg q am, 25 mg q pm. 7. Aspirin 325 mg po q day. 8. Home O2 by 2 liters nasal cannula continuous. 9. Plavix 75 mg po q day. FOLLOW-UP INSTRUCTIONS: The patient was to followup with Dr. [**Last Name (STitle) 2912**] in two weeks. In addition, he has an appointment with his oncologist the following week. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2163-3-27**] 15:33 T: [**2163-3-29**] 08:00 JOB#: [**Job Number 45323**]

41071,486,1985,4280,41401,412,185,4019,2720

Admission Date: [**2109-12-16**] Discharge Date: [**2109-12-17**] Date of Birth: [**2109-12-16**] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 59511**] is 709 gm birth weight, a product of approximately 24 4/7 weeks gestation. The infant was born at 18:42 on [**2109-12-16**]. The exact gestation dates are uncertain because the mother was not aware that she was pregnant until approximately one month prior to delivery and had late onset of prenatal care. The mother is a 23 year old G1 P0, blood type B positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B negative, GC negative, Chlamydia negative, GBS unknown. Mother has a history of migraine headaches treated with nortriptyline. She is a Jehovah's witness. The pregnancy was complicated by anhydramnios of unclear duration and possible IUGR. The mother presented to [**Hospital3 **] for prenatal care. She was presumed to have ruptured membranes and transferred to [**Hospital1 69**]. Mother was started on ampicillin and erythromycin seven days prior to delivery. She had no fever, no signs of chorioamnionitis clinically. The infant was born by stat C-section on [**12-16**] because of non- reassuring fetal heart rate tracing and prolonged fetal tachycardia. The infant emerged in a breech position with flexed hips, specifically the right leg more hyperextended and externally rotated. The infant was intubated in the Delivery Room. Apgar scores were 6 and 7. She was admitted to the NICU. SUMMARY OF HOSPITAL COURSE: The infant was placed on high frequency ventilation. Over the course of the evening, she was stable on high frequency ventilation. However, as of approximately 12 hours of age, she had deterioration in her oxygenation. Her chest x-ray showed no air leak, consistent with respiratory insufficiency, ET tube in good position. The infant had very low oxygen saturations, at best in the 80's. At this point, I discussed with the mother and father that the child's prognosis was very poor. Upon receiving volume expansion, she transiently had oxygen saturations in the 90's, still on 100 percent FIO2 and mean airway pressures in the 11-12 range. The infant was also initiated on indomethacin and dopamine for treatment of a patent ductus arteriosus. The infant then had a repeat occurrence of progressive desaturations that were unresponsive to hand bagging, switching to mechanical ventilation. The infant had progressive deterioration in her cardiorespiratory status despite maximal ventilatory support. There was further discussion with the family regarding the futility of continuing treatment in an infant who is having no response to maximal ventilatory support in terms of oxygenation. The etiology of her respiratory failure is thought to be related to her extreme prematurity and potential pulmonary hypoplasia given the mother's several day interval of prolonged ruptured membranes and oligohydramnios. The infant had ventilatory support withheld as of 1400 hours on [**2109-12-17**]. The infant was pronounced dead by [**Doctor First Name **] Zacharini, neonatal nurse practitioner at 1532 hours. I discussed autopsy permission with the parents. They have signed permission by telephone consent for autopsy with no restrictions. That packet will be taken to the Admission Office. CONDITION ON DISCHARGE: Death. The infant will be cremated as per parents' wishes at [**Hospital1 188**]. Dr. [**Last Name (STitle) **], obstetrician, has been notified. DISCHARGE DIAGNOSIS: Cardiorespiratory failure secondary to extreme prematurity and possible pulmonary hypoplasia. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 50-ABP Dictated By:[**Last Name (NamePattern1) 56577**] MEDQUIST36 D: [**2109-12-17**] 19:48:22 T: [**2109-12-19**] 09:25:16 Job#: [**Job Number 59512**]

V3001,76502,769,7485,76522,7470,V290

Admission Date: [**2139-6-22**] Discharge Date: [**2139-7-1**] Date of Birth: [**2066-2-17**] Sex: M Service: CARD [**Doctor First Name 147**] CHIEF COMPLAINT: Fatigue. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73 year old gentleman who was transferred from an outside hospital for cardiac catheterization. He presented with fatigue at [**Hospital3 15174**] with inverted T waves in the precordial leads. Denies chest pain but ruled in for an acute myocardial infarction. Cardiac catheterization at [**Hospital1 188**] revealed LM 30%, left anterior descending 70%, obtuse marginal 1 70%, mid-circumflex 40%, right coronary artery 100%, and non-dominant. He had preserved left ventricular function. He was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: 1. Cerebrovascular accident in [**2127**] with residual left weakness. 2. Abdominal aortic aneurysm. 3. Status post right cerebrovascular accident in [**2127**]; status post left cerebrovascular accident in [**2136**]. 4. Cataract surgery. 5. Insulin dependent diabetes mellitus. 6. Hypertension. 7. Hyperlipidemia. 8. Chronic renal insufficiency. 9. Gastroesophageal reflux disease. SOCIAL HISTORY: Mr. [**Known lastname **] quit smoking in [**2127**]. ALLERGIES: Prednisone causes swelling. MEDICATIONS: 1. Atenolol 25 mg q. day. 2. Lasix 40 mg q. day. 3. Aspirin 81 mg q. day. 4. Plavix 75 mg q. day. 5. Nifedipine 60 mg q. day. 6. Protonix 30 mg q. day. 7. Terazosin 2 mg q. h.s. 8. NPH 44 units q. a.m., 20 units q. p.m. REVIEW OF SYSTEMS: Denies melena, orthopnea, dyspnea, edema, dizziness or palpitations. Positive for right hip pain. PHYSICAL EXAMINATION: Blood pressure 170/80; heart rate 84. His head is normocephalic, atraumatic. Neck is supple with left carotid bruit with incisional scars bilaterally. Heart is regular rate and rhythm with a systolic ejection murmur. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, with normoactive bowel sounds. Extremities are without cyanosis, clubbing or edema. HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the Operating Room on [**2139-6-26**] for a coronary artery bypass graft times two. Graft included a left internal mammary artery to left anterior descending and saphenous vein graft to obtuse marginal. The operation was performed without complication and Mr. [**Known lastname **] was then transferred to the Cardiac Surgical Intensive Care Unit. There he was extubated, weaned off drips and fluid resuscitated. His stay in the Intensive Care Unit was remarkable for elevated blood sugars. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was obtained who recommended NPH dosing changes as well as changes in the Humalog sliding scale. His blood sugar have been better controlled over the last several days. Otherwise, Mr. [**Known lastname **] continued to improve. He was transferred to the Floor where he tolerated an oral diet and his pain was controlled with oral medications. He was able to ambulate some with Physical Therapy and on [**2139-7-1**], he was felt stable for transfer to a rehabilitation facility. PHYSICAL EXAMINATION: On discharge, temperature 98.9 F.; pulse 78; blood pressure 143/67; respirations 20; O2 saturation 93% on three liters. Heart was regular rate and rhythm. Lungs were coarse at the left base, but he was moving air well. Abdomen was soft, nontender, nondistended, with normoactive bowel sounds. Extremities were without cyanosis, clubbing or edema. Incision was clean, dry and intact. DISCHARGE MEDICATIONS: 1. [**Last Name (LF) **], [**First Name3 (LF) **]-saccharide complex 150 mg q. day. 2. Terazosin 2 mg p.o. h.s. 3. Amlodipine 5 mg q. day. 4. Pantoprazole 40 mg q. day. 5. Aspirin 325 mg q. day. 6. Calcium carbonate 1000 mg twice a day. 7. Metoprolol 37.5 mg twice a day. 8. Docusate 100 mg twice a day p.r.n. 9. Ipratropium two puffs i.h. q. four to six hours p.r.n. 10. Acetaminophen 325 to 650 mg q. four to six hours p.r.n. 11. Albuterol one to two puffs i.h. q. six hours p.r.n. 12. NPH 45 units at breakfast, 22 units at bedtime. 13. Potassium chloride 20 mEq p.o. twice a day. 14. Furosemide 60 mg p.o. twice a day times two weeks, then 40 mg q. day. 15. Humalog sliding scale: For glucoses 0 to 100, give zero units at breakfast, lunch, dinner and bedtime; for 101 to 150, 4 at breakfast, zero at lunch, 4 at dinner, zero at bedtime; 151 to 200, 6 at breakfast, 2 at lunch, 6 at dinner, zero at bedtime; 201 to 250, 8 units at breakfast, 4 at lunch, 8 at dinner and 2 at bedtime; 251 to 300, 10 units at breakfast, 6 at lunch, 10 at dinner, 4 at bedtime; 301 to 350, 14 at breakfast and 8 at lunch, 14 at dinner, and 6 at bedtime, and greater than 350, 16 units at breakfast, 10 at lunch, 16 at dinner and 8 at bedtime. For glucose less than 60, give juice. DISCHARGE INSTRUCTIONS: 1. Mr. [**Known lastname **] should follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks. 2. He should follow-up with his primary care physician in three to four weeks. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged to rehabilitation facility. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times two. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 11235**] MEDQUIST36 D: [**2139-7-1**] 10:32 T: [**2139-7-1**] 13:40 JOB#: [**Job Number 22996**]

41091,25001,41401,4019,43820,53081

Admission Date: [**2138-1-5**] Discharge Date: [**2138-1-18**] HISTORY OF PRESENT ILLNESS: This is an 83-year-old Caucasian female with history of dementia, hypertension, chronic renal insufficiency, who was initially admitted to [**Hospital1 346**] on [**1-5**] for acute mental metabolic toxic encephalopathy from acute and chronic renal failure, questionable Tylenol overdose with transaminitis, and an untreated urinary tract infection superimposed on her underlying dementia. On the night of admission, the patient acutely decompensated with an increased heart rate, increased respiratory rate, requiring an immediate transfer to the Intensive Care Unit. There she was found to have multiple pulmonary emboli, and was started on a Heparin drip for adequate anticoagulation. Unfortunately, this resulted in a massive intracranial hemorrhage within the occipital horns and the patient has had severe cognitive decline ever since to the point of unresponsiveness. Her hospital course has been marked by worsening renal and hepatic dysfunction associated with multiple metabolic derangements requiring intubation, blood loss anemia requiring multiple transfusions, a renal mass suspicious for malignancy, and an acute myocardial infarction, event associated pneumonia. Since the patient was without friends or family, a legal guardian was appointed by the state and the patient's code status was changed to DNR/DNI. The patient was transferred out of the Intensive Care Unit on [**1-17**] once her code status was finalized, and passed away the next day ([**1-18**]) at 12:45 pm. An autopsy was granted by her guardian, Ms. [**First Name4 (NamePattern1) 8214**] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**First Name (STitle) 35062**] MEDQUIST36 D: [**2138-2-24**] 12:37 T: [**2138-2-25**] 07:30 JOB#: [**Job Number **]

5849,2765,78039,431,5990,41071,41519,51882,42731

Admission Date: [**2194-5-4**] Discharge Date: [**2194-5-4**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: asp pna, CVA, MI Major Surgical or Invasive Procedure: intubation History of Present Illness: [**Age over 90 **] yo M w/ hx prostate ca, s/p recent d/c from [**Hospital1 18**] in [**3-15**] s/p CVA, newly dx'ed AF, hyperchol, glucose intolerance and AS was doing well at home after a rehab stay, when his family came to see him the day of admission and found him unresponsive. . They had last talked to him at 930pm the night prior to admission when he reported feeling short of breath with a stuffy nose, which he attributed to seasonal allergies, as well as some "upset stomach," which he attributed to taking [**Doctor First Name 130**]. He then said he had to go to make dinner. He didn't report any F/C/N/V or have any other complaints. . The day of admission, his family became worried because they had not heard from him and his great nephew came over to his house and found him unresponsive, cold and w/ yellow-white sputum around his mouth. He called the ambulance and pt was brought in to [**Hospital 882**] Hospital. . At [**Name (NI) 882**], pt was found to have an elevated troponin, an elevated wbc and a NCHCT showed a new CVA w/out a bleed. His CXR showed a L consolidation. He received 600mg IV clinda and albuterol nebs and he was transferred to [**Hospital1 18**] for futher treatment and management. . On arrival to [**Hospital1 18**] ED, his BP was 150/59, HR 120s (AF), RR 30s-40s 82% NRB. He was found to be gurgling w/ audible wheezing and crackles in respiratory distress. He had a short trial of CPAP while his code status was being clarified. He also received 100mg IV lasix and put out ~ 200cc urine. . When it was determined that pt was not DNR/DNI, pt was intubated and received 20mg etomidate and 120mg succinate. He was started on a propofol gtt and a nitro gtt. His BP's subsequently dropped to SPB 40-50's and his nitro gtt was turned off and he received IVF (~ 3L total of IV NS). His pressure came back up (he was briefly on neosynephrine). In the ED he also received 500mg IV levofloxacin and a central line was placed. . On arrival to the [**Name (NI) 153**], pt was hypotensive to the 70s/40s with HR in 140s-160s in atrial fibrillation. EKG consistent with old LBBB. He was given 1L NS wide open, his propofol was stopped and his SBP increased to 120s. He was given 10mg IV Diltiazem with HR in the 90s-110s with SBP 90s. Past Medical History: 1. Prostate ca 2. s/p CVA L frontal lobe [**3-15**] 3. AF recently diagnosed [**3-15**] 4. AS 5. hypercholesterolemia 6. glucose intolerance 7. CHF: Echo ([**3-15**]) EF< 20%, mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mod-severe AS, PFO with left-to-right shunt, mild pulm HTN Social History: Lives alone at home, s/p recent stay at rehab after his CVA. Semi-retired carpenter, and still does odd jobs to help his family at home. He has 3 sisters and one brother in the area. He is a widower since [**2171**], no children. He never smoked, drinks wine with dinner, and has no hx of illicit drug use. Family History: sisters died of cancer (? type), father died of CVA, mother w/ [**Name2 (NI) 2320**] Physical Exam: 101.2 PR HR 126 (110-130's) BP 148/87 (50-140/P-80's) AC 600 x 16 (overbreathing to 18-30) PEEP 5 100% FIO2 96-100% sat; Gen: thin cauc M lying in stretcher, intubated, arousable, following commands HEENT: dry mucous membranes Neck: no JVD appreciated but difficult exam Heart: very distant HS, irreg irreg, no m/r/g appreciated Lungs: diffuse coarse crackles, expiratory wheezing Abd: S/NT/ND/no masses Ext; 2+ pitting edema b/l Neuro: 0/5 motor on LUE and LLE, 4+/5 RUE and RLE; Pertinent Results: LABS: lact 7.5 wbc 10 hct 43 trop T 0.48 INR 1.9 creat 1.9 AG 16 . OSH: wbc 17.7 creat 1.8 BUN 33 glu 149 hct 46.3 plt 290 INR 2.1 PTT 26 alb 3.4 ALT/AST 61/72 alk phos 167 CK 612 CK-MB 62.6 MBIndex 10 [ref <3.5] trop I 4.10 [ref < 0.10 ng/ml] U/A tr prot, o/w negative; RAD: CXR: LUL pna, no effusion NCHCT from OSH per report: R frontal infarct, no bleed; . EKG: AF @ 130bpm, LAD, LVH, LBBB qrs 120msec, c/w baseline [**2194-3-19**], no change; . Cards: [**2194-3-21**] TTE EF < 20%, + PFO and L->R shunt at rest across interatrial septum; mod-severe AS, severe mitral annular calcification; Brief Hospital Course: On arrival to the [**Hospital Unit Name 153**], the patient was hypotensive and tachycardic. In addition, he was in respiratory failure and therefore intubated and sedated. CXR revealed LUL infiltrate. He was put on vancomycin and levofloxacin for sepsis, and levophedrine to keep his blood pressure elevated. Multiple cultures were sent. He was given fluid boluses. Troponins were checked which were elevated, suggesting myocardial damage, so he was given aspirin and diltiazem and lopressor for rate control. He was ventilated on AC with 60% oxygen and stable O2 sats. The patient's status declined as he became dependent on increasing doses of pressors throughout the first day of admission. The patient's family visited the patient on the day after admission and made a joint decision that the patient would not have wanted aggressive measures to keep him alive. The decision was made to discontinue all treatment except comfort measures and to extubate him. The patient died within 2 hours of withdrawl of care at 4:00 pm on [**2194-5-4**] with his family at the bedside. Medications on Admission: lisinopril 2.5mg po q24h toprol 12.5mg po bid warfarin for goal INR [**3-13**] atorvastatin 40mg po q24h lasix 20mg po q24h tylenol prn colace senna Discharge Disposition: Expired Discharge Diagnosis: pneumonia respiratory failure sepsis stroke myocardial infarction/troponin leak glucose intolerance atrial fibrillation Discharge Condition: dead [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

0389,51881,78552,41071,43411,5070,4280,5849,4241,42731,2765,99592,V1046,2720,7455

Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**] Date of Birth: 04/[**Numeric Identifier 5590**] Sex: F Service: [**Hospital **] MEDICAL INTENSIVE CARE UNIT HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old female with multiple medical problems and a prolonged recent Intensive Care Unit stay. She was readmitted with prepped and draped. In [**Month (only) **] of this year, she had gallstone pancreatitis requiring open cholecystectomy, and her course congestive heart failure, atrial fibrillation, C-diff, respiratory failure followed by failure to wean, and because of this, she had a tracheostomy, the placement of which was complicated by tracheal tear requiring placement of a specialized trachea and urgent repair. Additionally, she has an unclear myopathic, neuropathic process resulting in generalized total body weakness. She was sent to [**Location (un) 511**] admission after respiratory distress and reported granulation tissue in her tracheal site. Plans were made for a bronchoscopy in the morning. She denied shortness of breath, chest pain, or cough. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Vent dependent believed to be secondary to myopathy neuropathy. 4. Recent C-diff. 5. Volume overload. 6. Malnutrition. 7. Status post tracheal perforation. 8. Goiter hypothyroid. 9. Right IJ clot. 10. Gastroesophageal reflux disease. 11. Status post cholecystectomy. 12. Status post intra-abdominal abscess. ALLERGIES: ASPIRIN, LEVOFLOXACIN, VANCOMYCIN, GENTAMICIN. MEDICATIONS ON ADMISSION: Synthroid 75 q.d., Metoprolol 25 b.i.d., Prilosec 40 q.d., Flagyl 500 t.i.d., Paxil 20 q.d., Vitamin C 500 b.i.d., Zinc 220 q.d., Trazodone 25 q.h.s., Zofran p.r.n., Coumadin, Lasix 20 q.d., Promote tube feeds 65 cc/hr. PHYSICAL EXAMINATION: Vital signs: Pulse 100, blood pressure 109/65, oxygen saturation 99% on room air. General: She was an elderly white female in no acute distress. HEENT: Unremarkable. Lungs: Coarse breath sounds throughout. Cardiovascular: Irregularly, irregular with normal S1 and S2. Abdomen: Benign. Extremities: There was 3+ diffuse pitting edema. Neurological: She was alert and oriented with intact motor exam but generalized weakness. LABORATORY DATA: Chest x-ray pending. Electrocardiogram revealed atrial fibrillation at 125. HOSPITAL COURSE: This was a 79-year-old female with multiple medical problems, with prolonged Intensive Care Unit stay, admitted with respiratory distress to the Medical Intensive Care Unit. 1. Pulmonary: The patient was admitted with worsening respiratory status, breathing through a tracheostomy ventilator dependence believed to be secondary to myopathic process. On hospital day #2, bronchoscopy was performed which was negative for obstruction or vocal cord dysfunction. She was noticed to have a redundant trachea, and her episode of shortness of breath at the skilled nursing facility was likely secondary to her trach hitting the back of her trachea. Interventional Pulmonary and Thoracic Surgery evaluated her airway, and they recommended not changing her trach at this time. They felt that the current trach was appropriate and more likely to obstruct than any other. On hospital day #3, Neurology was consulted to evaluate her neuropathic process. The result of this will be dictated subsequently. The patient was rested on AC mode with plans to start her on pressure support trials on hospital day #4. By her fifth hospital day, the patient was tolerating pressure support mode well. At this point, the consensus thinking was that all of her respiratory failure was due to her muscular weakness. Pressure support was weaned as tolerated. On [**10-8**], after consultation with the Interventional Pulmonology Service, it was deemed that the patient was a candidate for change to a new trach which would allow her to speak from time to time. This was successfully performed without incident on [**10-8**]. The patient tolerated the procedure well. Following this through the remainder of her hospital stay, the patient was kept in pressure support mode with periodic T-piece trials. On the day prior to discharge, she was able to tolerate a trache mask trial for approximately three hours. We will discharge her to [**Hospital3 4419**] where she can be continued on pressure support mode with trache mask trials as tolerated. Of note at the time of discharge, she had not required AC ventilation mode for greater than two weeks. At the time of discharge when on the ventilator, the patient was in IMV mode with pressure support with an FIO2 of 40%, a set tidal volume of 500, a set rate of 5. She was overbreathing at a rate of 17 total. Her PEEP was set at 5.0, and her pressure support was set at 5.0 as well. 2. Cardiovascular: The patient came in with chronic atrial fibrillation, therapeutic on Coumadin. Her anticoagulation was stopped. In order for her to have her bronchoscopy, she was subsequently put on Heparin and reloaded with Coumadin. At the time of discharge, her INR was 2.5 on a dose of 3 mg a day, and this will need to be adjusted at the outside hospital at an appropriate stable dose. Additionally she was maintained on her Digoxin. Multiple Digoxin levels were checked and were all 1.0 which was deemed acceptable. 3. GI: The patient was on tube feeds. At the time of discharge she was tolerating tube feeds at a rate of 40 cc/hr. Of note, on two separated occasions approximately one week before discharge, the patient had complaints of nausea and vomiting for which her tube feeds had to be stopped. CT scan was performed on the day prior to discharge which revealed no intra-abdominal abscesses or evidence of bowel obstruction; however, the patient did appeared to have a mild ileus, the exact etiology of which is unclear at this time, although we speculated it may be related to her neuromuscular process. She was tolerating tube feeds and able to move her bowels with laxatives. We recommend continuing this at this time. At the rehabilitation facility, low-dose Erythromycin can be considered as a GI motility [**Doctor Last Name 360**] if she continues to have problems tolerating tube feeds and with nausea and vomiting. 4. Neurology: The patient was seen by the Neuromuscular Team who recommended muscle biopsy which was subsequently performed, the results of which are still pending at the time of this dictation and her discharge. She has a follow-up appointment with the Neurology Service on Monday, [**11-6**], at 4 p.m. on the [**Location (un) 858**] of the [**Hospital Ward Name 23**] Building, [**Telephone/Fax (1) **]. At that time, results of the biopsy should be back. In the meantime, they recommended a four-week trial of Prednisone 60 mg a day, of which she is currently on. She will continue this until the end of the four weeks in late [**Month (only) 359**], or until she is directed to stop from the Neurology Service. 5. Infectious disease: The patient had a urine culture come back positive for pseudomonas sensitive to Bactrim. At the time of dictation, she is on her fifth day of Bactrim. She will need to complete a 14-day course. She should also have her urine tested for clearing of the bacteria at the outside facility. 6. Endocrine: The patient was placed on a regular Insulin sliding scale for control of her blood sugars while on Prednisone. 7. Psychiatric: In order to help with sleeping, the patient was given 40 mg Paxil q.h.s. which seemed to work well. 8. Prophylaxis: For prophylaxis, the patient was placed on Prevacid q.d. 9. Fluids: The patient was very edematous at the time of her admission. She was started on Captopril which was titrated up to 37.5 t.i.d. This seemed to greatly improve her urine output. Additionally she was initially given a Lasix drip and subsequently switched over to daily Lasix dose. Her current dose is 60 mg IV t.i.d. With this, she has been diuresing approximately 500 cc to 1 L per day. We recommend continuing to do this until she clinically shows no evidence of fluid overload. On exam at the time of discharge, she has approximately 1+ pitting edema in her lower extremities. 10. Communication: Dr. [**Last Name (STitle) **], the patient's primary care physician, [**Name10 (NameIs) **] [**Name (NI) 653**] routinely throughout the course of her care. There are plans to have follow-up discussions with the family, as course evolved. Additionally as mentioned above, she has a follow-up appointment with the Neuromuscular Service regarding her diffuse myopathy. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 1213**] MEDQUIST36 D: [**2183-10-15**] 10:52 T: [**2183-10-15**] 11:12 JOB#: [**Job Number 5591**]

51881,5601,42731,4821,5990,00845,4280,3599,V550

Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**] Service: HISTORY OF PRESENT ILLNESS: The following discharge summary will cover the time period from [**10-15**] through [**2183-10-28**]. Please see previous discharge summary for information on patient's admission diagnosis and medications. HOSPITAL COURSE: 1. Gastrointestinal. On [**10-16**] the patient developed nausea, vomiting and abdominal pain. Because of this she was not discharged to rehabilitation at [**Location (un) 511**] Center Hospital as had been previously planned. Due to her symptoms a CT scan was obtained which revealed the patient had an ileus. There were no abscesses or other processes that could be identified. The neurology service was consulted regarding possibility of this ileus being related to the patient's myopathy but felt this was unlikely since skeletal muscle myopathies typically do not also involve smooth muscle of the Gastrointestinal tract. A Gastrointestinal consult was obtained who had no additional thoughts on what could be causing the patient's ileus and recommended bowel rest. The patient was kept off tube feeds for two days after which time they were restarted at a low rate of 20 cc's an hour as compared to her goal rate of 65 cc's per hour. The patient appeared to tolerate this reasonably well and the tube feeds were increased. When they reached the rate of 30 cc's an hour however the patient developed nausea and vomiting a second time. Tube feeds were again stopped and her bowel was rested for several days. On [**10-24**] it was decided that because the patient was unable to tolerate tube feeds at a reasonable rate she would be started on TPN for nutrition. At the time of this dictation on [**10-27**] the patient was reporting decreased abdominal pain and no further nausea or vomiting. She additionally had been successful in moving her bowels and treated with Colace, Senokot and Fleet enemas. The suspicion of the team at this point in time is that her ileus is resolving however, very slowly. Her tube feeds will need to be started at a very slow rate, advanced extremely gently as tolerated with caution being taken because when the rate is increased to abruptly she does tend to develop nausea and vomiting. She will be discharged out on no tube feeds, they can be started when she arrives at [**Location (un) 511**] Center for rehabilitation. She will be discharged out on TPN which she can continue. Additionally we will maintain her on [**Doctor Last Name **] and Colace. 2. Pulmonary. The patient continued to do well on a trach mask and in fact tolerated trach mask ventilation for five days in a row with no support from mechanical ventilator. Because of this she was deemed safe to go to the floor something which the team and the patient's family were very happy with as it was thought this could be a trial preliminary to transferring her to rehabilitation home. On [**10-21**] she was transferred to the floor. Unfortunately however, on [**10-22**] she was found to be hypoxic to the low 80's on the floor. She was suctioned with thick tenacious dark secretions came out, her O2 sats increased to the mid-80's. Chest x-ray was consistent with a left sided opacity throughout which was new. She was transferred back to the Intensive Care Unit with ventilatory support and bronchoscopy was performed which revealed purulent drainage from the left mainstem, sample was sent. Chest x-ray after bronchoscopy revealed markedly improved air space. O2 saturations increased to 98% on only .4 FIO2. Following this episode the patient was rested in IMV for several days. At the time of this admission she was feeling better and feeling strong enough to try pressor support ventilation again. The teams thinking is that perhaps the patient needs to be rested each night in an MV mode letting her use only a trach mask for five days may have been to much to soon and in the future we will get her to tolerate pressor support and rest her on the night and possibly during the day allowing her to breath through the trach mask. Currently she is being weaned, this will need to be continued at [**Hospital1 **]. Per discussion with the family the pulmonary attending is planning to call the pulmonary attending at [**Hospital1 **] to communicate the patient's need regarding ventilatory management. 3. Infectious disease. On [**10-16**] the patient's urine grew out Enterobacter which was sensitive only to Mirpenum and one other [**Doctor Last Name 360**]. She was treated with Mirpenum for seven days. At approximate completion of the 7 days course the patient's BAL sample from her bronch grew out pseudomonas which was resistant to Mirpenum. Because of this switched to Zosyn which the pseudomonas was sensitive to. She will be discharged on this and need to complete a 10 to 14 day course. Additionally she was started on Flagyl for possible C. diff given that she was complaining of abdominal pain and was feeling extremely weak. Of note, she did not have diarrhea. She did seem to get better after starting the Flagyl so she will need to complete a 14 day course of this as well for empiric therapy for C. diff. Also of note the patient had one set of blood cultures positive for coag negative staph however, it was deemed that this was a contaminant and the decision was made not to treat after consultation with Infectious Disease service. 4. Neurological. The patient continued to show improvement in her strength while on 60 mg of Prednisone a day. The original plan had been for her to be treated for 4 weeks with 60 mg of Prednisone empirically and then follow-up with the neuromuscular service for a decision as to whether or not to continue this. However, after approximately 2-1/2 weeks of therapy the patient had issues with infectious disease as detailed above including urinary tract infection and pulmonary infection. Because of these issues, with highly resistant bacteria it was deemed that the best thing to do would be to taper the steroids. On approximately [**10-22**] the patient was cut from 60 to 40 mg of Prednisone a day and on [**10-27**] the day of this dictation the patient was cut to 20 mg a day. She will need to continue this slow taper until the steroids had been weaned to off. If her improvement in neurologic function continues even off the steroids then she can probably never start on steroids again however, if she shows a decline once she is off steroids this will further enforce the theory that the steroids are what has been treating her myopathy and once she is clear for infectious issues she should be restarted on steroids in the future. She will follow-up with the neuromuscular service as detailed in her previous discharge summary. 5. Psychiatric. On one occasion the patient during the night the patient became quite despondent and request that she did not wish to continue with this therapy as she was incredibly frustrated. However, the team had multiple discussions on their rounds and at the time of this dictation the patient's mood had significantly improved and her will to fight on actually seemed quite remarkable. She is continued on her Paxil and at the present time the team did not see any need for additional psychiatric intervention. 6. Communication. A family meeting was held on [**2183-10-27**] with the patient's two daughters, son and husband as well as the attending physician in the Intensive Care Unit Dr. [**First Name (STitle) **], Dr. [**First Name (STitle) **] the former Intensive Care Unit attending, myself Dr. [**First Name (STitle) 916**] and the patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Discussion was held as to the patient's status. We discussed the fact that the family had previously wished for the patient to have resolution of all her issues prior to going to rehabilitation. However, we explained that her issues seemed to be taking quite sometime the resolve and that we will have to accept the fact that her issues are stable and improving although not completely resolved. Additionally was discussed the fact that the patient was clearly ready for rehabilitation now and likely many of her problems including her pulmonary and gastrointestinal problems may benefit from getting her out of bed and having her go to rehabilitation. The family was open to this and grateful for our assistance. Tentative plans were made to arrange for discharge to [**Hospital1 5593**] on [**2183-10-29**]. An addendum to this discharge summary will be dictated following this detailing the events of the 15th and 16th. Please refer to that discharge summary for the exact meds at discharge and discharge diagnosis. DIAGNOSIS AT TIME OF THIS DICTATION: 1. Respiratory failure resulting in ventilatory dependence. 2. Myopathy of unclear etiology. 3. Ileus of unclear etiology. 4. Pseudomonas pneumonia. 5. Enterobacter urinary tract infection. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 1213**] MEDQUIST36 D: [**2183-10-27**] 20:51 T: [**2183-10-27**] 21:10 JOB#: [**Job Number 5594**]

51881,5601,42731,4821,5990,00845,4280,3599,V550

Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**] Service: DISCHARGE DIAGNOSES: 1. Ventilatory dependence. 2. Atrial fibrillation. 3. Neuropathy and weakness. 4. Hyperthyroidism. 5. Gastroesophageal reflux disease. 6. Status post gallbladder removal. KNOWN ALLERGIES AT THE TIME OF DISCHARGE: 1. Levofloxacin causes a rash. 2. Vancomycin causes hearing loss. 3. Aspirin, Celebrex and non-steroidal anti-inflammatory drugs the patient cannot tolerate. 4. Gentamycin cannot tolerate per the patient's son. MEDICATIONS ON DISCHARGE: 1. Vitamin C 500 q.d. 2. Paxil 40 mg q.h.s. 3. Bactrim double strength one tab b.i.d. until [**2183-10-21**]. 4. Prednisone 60 mg q.d. until [**2183-11-4**] per neurology request. 5. Coumadin 3 mg po q.h.s. adjust to goal INR of 2.0 to 3.0. 6. Regular insulin per sliding scale. 7. Captopril 37.5 mg t.i.d. 8. Colace 100 b.i.d. 9. Prevacid 30 mg q.d. 10. Senna two tabs b.i.d. 11. Digoxin 0.125 mg q.d. 12. Synthroid 75 micrograms q.d. 13. Trazodone 25 mg q.h.s. prn for sleep. NUTRITIONAL NEEDS: The patient is lactose intolerant. VENTILATORY SETTINGS: Mrs. [**Known lastname 5579**] has been attempted to use a ____________ daily for as long as she can tolerate usually one to four hours. She has not required a C mode for the past two weeks. When she gets fatigued she has been rested comfortably in IMV mode FI2 40%, PEEP of 5, pressure support of 5 with a set rate of 5. FOLLOW UP: Dr. [**Last Name (STitle) **] her primary care physician as arranged by Dr. [**Last Name (STitle) **] and the Neurology Service as dictated above. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**] Dictated By:[**Last Name (NamePattern1) 1213**] MEDQUIST36 D: [**2183-10-15**] 10:56 T: [**2183-10-15**] 11:32 JOB#: [**Job Number 5592**]

51881,5601,42731,4821,5990,00845,4280,3599,V550

Admission Date: [**2183-8-6**] Discharge Date: Service: ICU CHIEF COMPLAINT: Hypercarbic hypoxemic respiratory failure HISTORY OF PRESENT ILLNESS: 79-year-old white female with a history of chronic obstructive pulmonary disease, hypertension, paroxysmal atrial fibrillation, presents from rehabilitation facility following an episode of tachypnea, hypoxia and obtundation requiring endotracheal intubation. The patient is status post a recent prolonged hospitalization from [**7-4**] to [**7-25**] for gallstone pancreatitis requiring open cholecystectomy and choledochoduodenostomy on [**7-3**] by Dr. [**Last Name (STitle) 1305**] with a long hospitalization complicated by E. coli sepsis, a lower gastrointestinal bleed, with negative colonoscopy, volume overload, and a postoperative abdominal abscess, culture positive for vancomycin-resistant enterococcus requiring CT-guided drainage. The patient also suffered C. difficile colitis during this admission. Toward the end of her hospitalization, the patient was noted to have acute tachypnea, pH 7.27, CO2 70, which resolved with minimal intervention the following day. The patient was discharged to a skilled nursing facility on [**7-25**] on a plan for linezolid for four weeks for her VRE abscess, and Flagyl for two weeks for her C. difficile colitis. At the skilled nursing facility, the patient has done poorly, with continued lethargy, anorexia and depression. She was noted to have decreased sodium to 119 on [**8-3**], which was question of serum-inappropriate antidiuretic hormone. The patient developed cough on [**7-29**], for which she was started on Robitussin, and yesterday she was noted to have hypoxia with an oxygen saturation of 93% on 2 liters nasal cannula. This morning, shortly after breakfast, the patient was noted to become more tachypneic and somnolent, having an oxygen saturation in the 60s on 2 liters, improving to 97% on 100% non-rebreather. She became increasingly somnolent, and became completely unresponsive. The patient was bag mask ventilated and referred to [**Hospital1 188**] for further evaluation. In the Emergency Department, she was afebrile, with heart rate in the 80s, blood pressure 140/80, oxygen saturation 90% on 100% non-rebreather. She was unresponsive to voice and pain. The patient was subsequently intubated, with improvement in her mental status following intubation. A CTA of the chest was performed, without evidence of pulmonary embolism, with scattered ground-glass opacities, slightly increased right greater than left. Electrocardiogram was without significant change. A head CT was negative for acute bleed or cerebrovascular accident. After receiving 4 liters of normal saline, ceftriaxone, Flagyl and lasix, the patient was transferred to the Intensive Care Unit. Upon arrival to the Intensive Care Unit, the patient spiked a temperature to 101, and dropped her systolic blood pressure from 130s to the 80s. The patient received a 1 liter fluid bolus without significant change. She was subsequently started on dopamine. PAST MEDICAL HISTORY: 1. Hypertension 2. Chronic obstructive pulmonary disease, FEV-1 1.74 in [**2176**] 3. Atrial fibrillation 4. Congestive heart failure with an ejection fraction of 60%, basal septal hypertrophy, 1 to 2+ aortic regurgitation, and 1 to 2+ mitral regurgitation 5. History of gastrointestinal bleed on aspirin 6. Degenerative joint disease 7. Migraine headaches 8. Cataracts 9. Large substernal goiter and hypothyroidism ALLERGIES: Aspirin MEDICATIONS ON TRANSFER: Linezolid 200 mg twice a day, Flagyl 500 mg by mouth three times a day, Darvocet as needed, atenolol 100 mg by mouth once daily, Ranitidine 150 mg by mouth once daily, Levothyroxine 75 mcg by mouth once daily, lasix 40 mg by mouth once daily, amiodarone 200 mg by mouth once daily, Zoloft, Mycostatin, Florinef, and prednisone SOCIAL HISTORY: The patient is married and has her children very involved with her care. Her son, [**Name (NI) **], is a cardiologist in [**Name (NI) 5583**], [**State 350**]. She has a 20 pack year smoking history. PHYSICAL EXAMINATION: Temperature 101, heart rate 70s to 80s, blood pressure 170/48 on 16 mcg/kg/minute of dopamine. Skin: Dry, cool feet. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, pupils equal, round and reactive to light and accommodation, extraocular movements intact, oropharynx dry. Neck: Prominent external jugular vein. Lungs: Bilateral inspiratory and expiratory rhonchi. Cardiovascular: S1 and S2, no murmurs, gallops or rubs. Abdomen: Surgical scar healing well, hypoactive bowel sounds, soft, nontender, nondistended. Extremities: No edema, peripheral pulses intact. Neurological: Moving upper extremities and lower extremities. LABORATORY DATA: White blood count 17.3, hematocrit 33.5, platelets 187. INR 1.4, PTT 30. Sodium 130, potassium 3.7, chloride 94, bicarbonate 26, BUN 13, creatinine 0.3. CPK 75, troponin-i 0.3. Urinalysis was unremarkable. Chest x-ray revealed increasing left-sided effusion, consolidation at the left base, a large mediastinal mass without tracheal deviation that was unchanged from that on [**7-22**]. CT of the chest was negative for pulmonary embolism, moderate bilateral pleural effusion, slightly increased from [**7-23**]. Bilateral atelectasis, partial collapse adjacent to pleural effusions, large superior mediastinal mass with calcific density consistent with thyroid goiter. Deviated trachea and esophagus, deviated anterior and to the right. Calcification of the coronary arteries, ground-glass opacifications in both lungs, with central lobular emphysematous changes mostly at the bases. CT of the head: No acute bleed, chronic small vessel ischemic changes. HOSPITAL COURSE: 1. Pulmonary/thoracic: The patient was initially admitted with hypoxic and hypercarbic respiratory failure. As stated above, CTA showed no evidence for pulmonary embolism. The patient was gradually weaned from the ventilator. The patient's left-sided pleural effusion was tapped on [**8-7**], which revealed a 700 cc pleural effusion which was transudative and sterile. The patient was extubated on [**8-10**]. However, on [**8-15**], while receiving a bath, the patient again developed sudden acute hypoxia, respiratory acidosis, apnea, and generalized unresponsiveness, requiring emergent reintubation on [**8-15**]. On [**8-18**], the patient underwent a percutaneous tracheostomy, complicated by a tear of the posterior trachea. The patient was taken emergently to the operating room, and required open sternotomy with surgical repair of her trachea, along with placement of bilateral chest tubes and mediastinal tubes. Because of the tortuosity of her large substernal goiter, she had a partial thyroid resection. Following this procedure, the patient was managed on AC ventilation, with eventual removal of her chest and mediastinal tubes. The patient continued to wean from the ventilator on AC and, at the time of this dictation, is tolerating pressure support for approximately 12 hours per day. The patient was bronchoscoped on an almost daily regimen by Dr. [**First Name (STitle) **] [**Name (STitle) **] of Interventional Pulmonology both for secretion clearing and checking placement of the endotracheal tube. The endotracheal tube position was changed multiple times. At the time of this dictation, the patient is scheduled to undergo placement of a customized tracheostomy tube obtained by Dr. [**Last Name (STitle) **] on [**9-3**]. 2. Cardiovascular/hemodynamics: The patient was weaned off pressors by [**8-9**]. The patient's amiodarone was discontinued secondary to concerns for precipitating a myopathy. An echocardiogram in late [**Month (only) 205**] revealed basal septal left ventricular hypertrophy with ejection fraction greater than 55%, 2+ mitral regurgitation, 2+ tricuspid regurgitation, and moderate pulmonary hypertension. The patient was restarted on her outpatient doses of Captopril, on low doses of ACE inhibitors and beta blockers. In the second week of [**Month (only) 216**], the patient's blood pressure began to trend to the 90s, with heart rate in the 110s, along with poor urine output. There were no electrocardiogram changes, and the patient did not complain of chest pain or shortness of breath. The patient's poor urine output is currently being managed with aggressive fluid boluses and resuscitation. She remains otherwise hemodynamically stable. 3. Infectious Disease: The patient was initially covered with broad spectrum antibiotics, including ceftazidime, Flagyl, as well as linezolid. All blood cultures remained negative, though her sputum did grow Klebsiella pneumoniae, with urine showing pseudomonas. Her antibiotic therapy was tailored to Zosyn, for which she received a seven day course. The patient did develop a rash on Levaquin, which she was being treated for a urinary tract infection. Following the tear of her trachea, the patient was begun on a 14 day course of empiric vancomycin for coverage of her history of methicillin resistant staphylococcus aureus, as per Dr. [**Last Name (STitle) 952**], the Thoracic Surgery attending. 4. Neurological: The etiology of the patient's recurrent respiratory decompensations was unclear. [**Name2 (NI) 227**] the fact that her chronic obstructive pulmonary disease was not felt to be very severe, a diagnosis of a potential respiratory muscle myopathy was entertained. While CKs were negative, the patient was evaluated by Neurology. The patient had a negative tensilon test. An electromyogram was also consistent with a myopathic process with a moderate to severe axonal polyneuropathy noted. At the time of this dictation, the differential diagnosis includes critical care myopathy vs. drug-induced myopathy. Because of concern for drug-induced myopathy, linezolid and amiodarone were discontinued. All other medications were longstanding. The patient is currently scheduled to undergo a muscle biopsy by Dr. [**Last Name (STitle) 1338**] in a combined operating room procedure on [**9-3**]. 5. Gastroenterology: The patient has a history of lower gastrointestinal bleed during her last hospitalization, with a negative colonoscopy. The patient has remained OB negative during this hospitalization. She had multiple C. difficile screens, which have been negative. An abdominal CT done on [**8-26**] revealed no change in her abdominal fluid collection. 6. Hematology: The patient developed thrombocytopenia to the 100s during the early part of her hospitalization. The etiology was unclear, but was felt to either be drug-related vs. thrombocytopenia sepsis. It has since resolved. The patient required intermittent transfusions of several units of packed red blood cells. 7. Endocrine: The patient was continued on Synthroid. Given her periods of hypotension, an ACTH stimulation test was performed, which was negative. 8. Renal: The patient's creatinine remained well within normal limits. However, as stated in the cardiovascular section, her urine output continued to be poor through the second week of [**Month (only) 216**]. She was given aggressive fluid resuscitation with some improvement in her urine output but, at the time of this dictation, is currently receiving intravenous fluid boluses. A fractional excretion of sodium was calculated and was found to be 0.1 and negative of pre-renal insufficiency. 9. Fluids, electrolytes and nutrition: The patient was briefly on total parenteral nutrition at the time of her tracheal seal, but is currently now tolerating tube feeds. She will need to undergo placement of a percutaneous endoscopic gastrostomy tube either by Radiology or by Dr. [**Last Name (STitle) **]. An addendum will be completed for this hospitalization at the time of discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 5584**] MEDQUIST36 D: [**2183-8-29**] 20:53 T: [**2183-8-30**] 00:00 JOB#: [**Job Number 5585**]

51881,9982,5121,5180,496,42731,4280,5119,4820

Admission Date: [**2183-8-6**] Discharge Date: [**2183-9-15**] Service: PRIMARY DIAGNOSIS: 1. Volume overload anasarca. 2. Status post posterior trach perforation and repair. 3. Respiratory failure with ventilatory dependence. Mechanical ventilatory dependence. 4. Atrial fibrillation. 5. Clostridium difficile infection. 6. Malnourishment. 7. Sepsis. Status post treatment and resolution. 8. Pneumonia, ventilatory associated status post resolution and treatment. 9. Anemia. 10. Pleural effusions. 11. Goiter. 12. Hypothyroidism 13. Urinary tract infection, numerous including pseudomonas. 14. Questionable myopathy. 15. Yeast infection of the urinary tract. 16. Thrombocytopenia subsequent resolution. 17. Right internal jugular, non-occlusive clot. 18. Hyponatremia subsequently resolved. 19. Tracheostomy. 20. Hypothyroidism. 21. Gastroesophageal reflux disease. SECONDARY DIAGNOSIS: 1. Status post cholecystectomy and choledochoduodenostomy. 2. Vancomycin resistant enterococcus bacteremia in abscess. 3. History of lower gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname 5579**] is a 79-year-old female with chronic obstructive pulmonary disease, hypertension, paroxysmal atrial fibrillation, who presents from Shore House Rehabilitation following episodes of tachypnea, hypoxemia and obtundation requiring endotracheal intubation. The patient is status post recent hospitalization from [**7-4**] to [**2183-7-25**] for gallstone pancreatitis requiring open cholecystectomy and choledochoduodenostomy on [**2183-7-11**] by Dr. [**Last Name (STitle) 1305**] with hospitalization complicated by E. coli sepsis, volume overload and bilateral pleural effusion, atrial fibrillation and postop abdominal abscess which grew out Vancomycin Resistant Enterococcus. The patient subsequently had a gallbladder drainage by CT guidance on [**2183-7-18**]. The patient suffered C. diff colitis at prior hospitalization. Towards the end of hospitalization was noted to have acute tachypnea. She was subsequently discharged to Shore House on [**2183-7-25**] on antibiotics Linezolide for four week course for her Vancomycin resistant enterococcus abscess and Flagyl for 14 day course for C. diff colitis. At the Shore House however, the patient was doing poorly with continued lethargy, anorexia and depression. The patient was noted to develop hyponatremia. She apparently developed cough on [**7-29**] for which she was treated with Robitussin and the day prior to admission was noted to have hypoxemia with O2 saturations 90% on two liters nasal cannula. On the morning of presentation to [**Hospital1 190**] the patient shortly was noted to become more tachypneic and somnolent with oxygen saturation in the 60's and requiring 100% non-rebreather. The patient subsequently then became unresponsive and was subsequently started manual artificial respirations and was sent to [**Hospital1 190**] for further evaluation. In the Emergency Room she was afebrile, heart rate in the 80s and blood pressure 140/80, oxygen saturation 90% on 100% non-rebreather, unresponsive. The patient subsequently intubated at the Emergency Room at [**Hospital1 190**]. She was admitted to the Intensive Care Unit for further treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gastroesophageal reflux disease, FEV 1 of 1.74, 70% predicted. 3. Atrial fibrillation. 4. Congestive heart failure with ejection fraction of 60% Basal septal hypokinesis. 5. History of Gastrointestinal bleed secondary to aspirin. 6. Degenerative joint disease. 7. Migraine headaches. 8. Cataracts. 9. Substernal goiter with hypothyroidism status post biopsy. ALLERGIES: Aspirin which causes gastrointestinal bleed. MEDICATIONS ON PRESENTATION: 1. Linezolide 200 mg p.o. b.i.d. 2. Flagyl 500 mg p.o. q 8 hours. 3. Percocet 4. Atenolol 100 mg q day. 5. Ranitidine 150 mg p.o. q day. 6. Levoxyl 75 mcg q day. 7. Lasix 40 mg p.o. q day. 8. Amiodarone 200 mg p.o. q day. 9. Florinef 0.1 mg p.o. q day. 10. Prednisone 30 mg p.o. q day. PHYSICAL EXAMINATION: Upon presentation the patient was subsequently intubated, temperature 101, heart rate 70 to 80 and atrial fibrillation. Blood pressure 107/48 on Dopamine. Skin was dry. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Oropharynx dry. Neck: Prominent external jugular veins. Lungs: Bilaterally coarse breath sounds. Cardiac: Irregular rate and rhythm, no murmurs, rubs or gallops. Abdomen: Surgical site healing well. Hyperactive bowel sounds, soft, nontender to palpation. Extremities: No edema, peripheral pulses 2+. Neurological: Moving all extremities. On vent setting, assist control 500, tidal volume, respiratory rate of 17, FIO2 0.7, PEEP of 5. LABS ON PRESENTATION: White count 17,300, hematocrit 33.5, platelets 187,000. Prothrombin time of 14, PTT 30, sodium 130, potassium 2.7, chloride 94, bicarbonate 26, BUN 13, creatinine 0.3, glucose 81. Calcium 7.1, magnesium 1.2, albumin 2.2, CK 75, troponin less than 0.3. Chest x-ray revealed left effusion, questionable consolidation left base with mass with tracheal deviation which is unchanged from [**7-22**]. CT of the chest revealed no pulmonary embolism, moderate bilateral pleural effusions slightly increased from [**2183-7-23**]. Left sided atelectasis, partial collapse adjacent to pleural effusion. Superior mediastinal mass calcific densities consistent with right goiter with deviation of the trachea. Scattered ground glass opacities in both lungs. CT of the head revealed no bleeding. Chronic small vessels with ischemic changes. Fluid in the mastoid ear cells, right greater than left, right middle ear. IMPRESSION AND PLAN: The patient was subsequently admitted to the Medical Intensive Care Unit for further treatment. She is a 79-year-old person with chronic obstructive pulmonary disease, hypertension, congestive heart failure presents from rehabilitation on [**2183-8-6**] following episode of tachypnea, hypoxia, obtundation requiring intubation with presumed sepsis. The patient is status post recent hospitalization [**7-4**] to [**7-25**] for gallstone pancreatitis requiring open cholecystectomy and choledochoduodenostomy with hospitalization complicated by sepsis, volume overload and bilateral effusions, atrial fibrillation, C. diff colitis and postoperative intra-abdominal abscess at the port-a-hepatis requiring CT guidance drainage and extended therapeutic use of Linezolid. The patient had one episode of unexplained respiratory decompensation at hospitalization characterized by respiratory acidosis and hypoxemia. She had a negative CT angio of the chest and episode resolved on its own after treatment with high flow oxygen. The patient had been failing to thrive at rehabilitation with poor p.o. intake, unable to fully participate in rehabilitation activities. THE patient presented on [**2183-8-6**] in ventilatory failure and hypertension requiring volume resuscitation and temple posterior support. Sputum grew out Klebsiella and urine grew out pseudomonas. All blood cultures were surprisingly negative. The initial impression was that the patient may have aspirated however, further workup revealed a questionable myopathy and we suspected she is unable to effectively clear her secretions. She has since undergone a complicated tracheostomy requiring tracheal repair and open sternotomy. SUMMARY OF HOSPITAL COURSE BY SYSTEM AND PLAN: 1. Pulmonary. Infectious disease. The patient initially presented with hypoxemia, hypercarbia, respiratory failure requiring intubation. The patient originally spiked to 102.8 and developed leukocytosis to 37,000. Chest x-ray showed bilateral moderate effusions with ill defined opacification in the right lung. CT angio of the chest revealed no evidence of pulmonary embolism, scattered ground glass opacity, emphysematous changes and moderate bilateral effusions, slightly increased since last hospitalization. She also demonstrated a large substernal goiter which was unchanged. She was covered with broad spectrum antibiotics initially with Ceftazidime, Flagyl as well as Linazolid which she has been scheduled to be on through mid-[**Month (only) 216**] for intra-abdominal Vancomycin Resistant Enterococcus abscess. Her left sided effusion was subsequently tapped by interventional pulmonology which removed 700 cc's of fluid on [**8-7**] which was transudative and sterile. All blood cultures proved negative. Her sputum did show Klebsiella with urine showing pseudomonas. Her antibiotic therapy was changed to Zosyn, Piperacillin, Bactrim for which she received a 7 day course. The patient was weaned off chemical process on [**8-9**], extubated on [**8-10**]. She initially did well though developed sudden acute hypoxemia, respiratory acidosis, apnea and generalized unresponsiveness requiring emergent re-intubation on [**2183-8-15**]. This occurred while receiving a bath. The feeling is that she had an underlying questionable myopathic process which caused the patient to be unable to clear her secretions. The patient improved rapidly following re-intubation with excellent oxygenation though required chemical process transiently, Levophed. On [**2183-8-18**] the patient underwent percutaneous tracheostomy, which was complicated by tear of the posterior trachea. She was taken emergently to the operating room and required open sternotomy. She had a large substernal goiter making her airway tortuous. Bilateral thoracostomy tubes were placed which were eventually discontinued on [**2183-8-22**]. She had a mediastinal tube with drainage, was subsequently discontinued several days afterwards. During that period she required daily bronchoscopies to check placement of the endotracheal tube for suctioning. She was allowed to have a mild cuff leak so as not to produce tension on the suture line. On [**2183-9-8**] the patient underwent a tracheostomy change to a Bivoner tracheostomy flexible trach with a foam cuff. The patient tolerated the procedure well. The patient currently is being weaned off vents. The patient is currently requiring assist control 500, tidal volume, respiratory rate of 12, FIO2 of 0.4% and PEEP of 5 at night time. During the day the patient is able to tolerate pressure support of 8 and PEEP of 5 with FIO2 of 0.4% for extended periods of time. The patient was given multiple trials of pressure support. however, the longest that the patient is able to tolerate pressure support was approximately 36 hours before she subsequently had respiratory decompensation including low tidal volumes and decreased oxygen saturation. Ever since the tracheostomy changed to the Bivoner valve the patient is unable to tolerate trach mask trial. It is thought that the patient's respiratory failure to wean may be secondary to a myopathic process. Will be discussed later in Neurological component of this dictation. The patient will benefit from pulmonary rehabilitation for vent weaning. Ultimately once the patient is tolerating more pressure support on her Bivoner valve the patient will be changed over to Shiley which is fenestrated tracheostomy in transition to removal of trach. This trach change will be performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 5586**] at a later date. Dr. [**First Name (STitle) 5586**] telephone number is [**Telephone/Fax (1) 3020**]. Arrangements should be made once the patient is able to tolerate pressure support for extended periods of time. No passine valve should be placed on the Bivoner valve as her cuff is a foam cuff and does not display completely. 2. Cardiovascular. The patient has a history of paroxysmal atrial fibrillation since her last hospitalization. She has been on Amiodarone which has since subsequently discontinued given a question of contributing to her myopathy. She has required DC cardioversion for atrial fibrillation shortly after her initial presentation at [**Hospital1 190**] though subsequently reverted to constant atrial fibrillation. She is currently being rate controlled with Lopressor 25 mg p.o. b.i.d. She had an echo in Late [**2183-7-14**] which showed basilar septal left ventricular hypertrophy, ejection fraction of greater than 55% 2+ MR, 2+ TR, moderate pulmonary hypertension. She was also given a trial of low dose Captopril however, her blood pressures subsequently were to low systolically, 80's to 90's systolic so Captopril was subsequently discontinued. She required persistent diuresis with Lasix however, with aggressive diuresis the patient's bicarbonate increased to 40 and she developed contraction alkalosis and relatively oliguria. The patient was subsequently rebolused with intravenous fluids and her urine output improved and contraction alkalosis subsequently resolved. The patient's urine output subsequently began to pick up, 50 cc's an hour without aggressive Lasix diuretic treatment. 3. Renal. Her BUN and creatinine has remained stable throughout her hospitalization. Her 24 hour urine estimates for creatinine clearance approximately 50 to 60. In regards to urine output the patient was aggressively diuresed during hospital course however, subsequently became intravascularly dry and her urine output subsequently dropped to 5 to 10 cc's an hour which responded to intravenous fluid boluses. It is thought the patient would start to mobilize her extravascular space once her nutritional status improved. The patient may tolerate gentle diuresis at this point however, will run the risk of volume contraction alkalosis and intravascular depletion and anuria requiring further intravenous fluid boluses and further worsening of her anasarca. 4. Neurology. The patient was originally evaluated by Neurology, felt to have a myopathy with possible muscle weakness. The patient had a negative Tensilon test. An EEG was also consistent with mild pathic process, MR to severe axonal polyneuropathy was also noted. It is unclear what is the cause of her myopathy. Differential includes critical care myopathy versus dry induced myopathy. Potential offenders include Amiodarone and Lanazolide. She also had normal CK laboratory test. Her thyroid and renal functions have been measured and are normal. Originally there was a planned biopsy by Neurosurgery during the trach change in the operating room however, the biopsy of the muscle was not performed as Dr. [**Last Name (STitle) **] was unavailable for the muscle biopsy. However, given her recurrent status will defer muscle biopsy to a later date. Her prognosis is unclear at this point. It is unclear whether or not the patient will benefit from steroids. 5. Gastrointestinal. The patient has a history of lower gastrointestinal bleed with bright red blood per rectum during her last hospitalization which was a negative colonoscopy. She has been occult blood negative for most part during hospitalization. She did screens which have been negative. However, the most recent C. diff colitis screen was positive for C. diff colitis. The patient was started on Metronidazole per percutaneous endoscopic gastrostomy tube for treatment, complete a 14 day course. She had an abdominal CT without contrast done earlier in the hospital which showed basically resolution of her former abdominal abscess. Her Linazolide was discontinued on [**8-19**] with Infectious Disease's recommendations. She currently has a percutaneous endoscopic gastrostomy tube placed and was receiving tube feeds and most of her medications through the percutaneous endoscopic gastrostomy tube. 6. Genitourinary. The patient had multiple numerous urinary tract infections with bacteria and yeast and on [**2183-8-19**] Foley was subsequently changed. The patient received two days of Levofloxacin discontinued following development of a fine erythematous rash involving upper chest, back and thighs. The patient subsequently development of a urinary tract infection is being treated with Bactrim DS tablets p.o. b.i.d., will complete a 7 day course. The patient has subsequently had multiple yeast infections as well treated with Diflucan and Foley changes. 7. Heme. The patient developed thrombocytopenia with a drop in her platelets down to 100,000 during earlier part of her hospitalization the etiology was unclear. It is thought to be drug related verses thrombocytopenia with sepsis. Her Thrombocytopenia has subsequently resolved. She has required intermittent transfusions of packed red blood cells during hospitalization without clear source of bleeding. The patient may have anemia of chronic disease at this point. During the later part of her hospitalization the patient's hematocrit has subsequently stable around 30. The patient has been on Heparin during a portion of her hospitalization for catheter related thrombosis of the right anterior jugular, partial non-occlusive clot. The line was subsequently discontinued and was started on Heparin for earlier part of her hospitalization and subsequently held prior to her procedures of tracheostomy. Heparin was restarted during the later part of her hospital course and Coumadin was subsequently started. INR should be checked and Heparin should be discontinued once her INR is greater than 2.0. Goal INR is greater than 2, less than 3.0. The patient tolerating Coumadin 5 mg p.o. q h.s. 8. Endocrine. The patient was maintained on Synthroid throughout her entire hospital course. Random Cortisol during her hospital course revealed measurement of 20, the patient was not adrenal insufficient. The patient's hypothyroidism was subsequently treated with hormone replacement. 9. FEN. The patient had unexplained hyponatremia as an outpatient at the rehabilitation and upon presentation at [**Hospital1 69**] questionable whether or not the patient has inappropriate NIDH also, responded with intravenous fluid resuscitation. The hyponatremia subsequently resolved. The patient was briefly on total parenteral nutrition around the time of her tracheal repair. The patient was subsequently tolerating tube feeds and subsequently had percutaneous gastrostomy tube placed and performed by Interventional Radiology and has been receiving tube feeds Promod without fiber and subsequently been doing well. Currently at goal of 70 cc's per hour. During her entire hospital course the patient had episodes of hypocalcemia, hypokalemia which was subsequently repleted and with resolution. The patient received approximately 250 cc's of free water boluses through her percutaneous endoscopic gastrostomy tube b.i.d. 10. Prophylaxis. The patient currently on Pneumo boots, on Heparin GGT and is in the process of transition to Coumadin. The patient receives Prevacid through her percutaneous endoscopic gastrostomy tube. 11. Lines: The patient currently has a right single lumen PICC line for access. The patient has Foley and a Percutaneous endoscopic gastrostomy tube placed as well. DISCHARGE MEDICATION: 1. Lopressor 25 mg per G-tube b.i.d. 2. Synthroid 75 mcg per G-tube q day. 3. Prevacid suspension 30 mg per G-tube q day. 4. Paxil 20 mg per G-tube q day. 5. Heparin GGT. 6. Promod without fiber, goal of 70 cc's per hour through the percutaneous endoscopic gastrostomy tube. 7. Bactrim DS tablets p.o. b.i.d. times seven day course to finish on [**2183-9-17**]. 8. Metronidazole 500 mg per G-tube q 8 hours times 14 days to finish on [**2183-9-25**]. 9. Coumadin 5 mg per G-tube q h.s. 10. Lactulose 30 cc's per G-tube q day p.r.n. constipation. 11. Albuterol MDI 2 puffs q 4 to 6 hours p.r.n. shortness of breath and wheezing. 12. Atrovent MDI 2 puffs q 4 to 6 hours p.r.n. shortness of breath and wheezing. 13. Tylenol 650 mg p.o. G-tube/per rectum q 4 to 6 hours p.r.n. temperature. 14. Trazodone 25 to 50 mg per G-tube q h.s. p.r.n. insomnia. 15. Nystatin Powder applied to effected area p.r.n. 16. Promod without fiber via percutaneous endoscopic gastrostomy tube 70 cc's per hour at goal. DISCHARGE CONDITION: Stable. DISCHARGE ACTIVITIES: Bedrest and per physical therapy. Discharged to physical and pulmonary rehabilitation for vent weaning. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 5588**] MEDQUIST36 D: [**2183-9-15**] 18:50 T: [**2183-9-15**] 18:56 JOB#: [**Job Number 5589**] 1 1 1 R

51881,9982,5121,5180,496,42731,4280,5119,4820

Admission Date: [**2184-1-16**] Discharge Date: [**2184-1-20**] Service: [**Hospital1 212**] HISTORY OF PRESENT ILLNESS: This 79-year-old woman is admitted for respiratory distress, hyponatremia and hyperkalemia. This woman has had a complicated medical course over the past six months which has included several episodes of respiratory failure, difficulty to wean off a ventilator, tracheostomy placement complicated by tracheal tear (requiring open sternotomy), anasarca, atrial fibrillation, E.coli sepsis, pseudomonas urinary tract infection, VRE intraabdominal abscess and Clostridium difficile colitis. Her ventilatory difficulties were thought to be perhaps secondary to a myopathic process, although muscle biopsy results were inconclusive and not demonstrative of inflammatory changes. Patient was admitted to [**Hospital1 **] [**10-28**] through [**2183-12-18**] and successfully weaned from the ventilator there. She was transferred to [**Hospital1 5595**] [**2183-12-18**] where she was gradually reintroduced to p.o. feed and weaned from PEG feeds. She currently tolerates a pureed diet. Her atrial fibrillation has been managed via rate control as the Amiodarone she was previous on was felt to possibly contribute to her myopathy. She had been on Lasix (40 mg b.i.d.) on transfer from [**Hospital1 **] and nonetheless gained 12 pounds from [**12-28**] through [**1-15**]. Lasix was decreased to 20 mg q. day on [**1-12**] because her sodium was noted to be 129. On [**1-15**], the patient was noted to have increased dyspnea and tachypnea. She states she has had intermittent dry cough for several days. No subjective fevers or chills. She was transferred to [**Hospital1 69**] today with still more dyspnea / tachypnea, sodium of 126 and a potassium of 6.2. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Diastolic dysfunction (latest echo [**2183-9-30**] ejection fraction of 70 to 80% (2+ aortic regurgitation, moderate mitral regurgitation, moderate tricuspid regurgitation). 4. History of intubations, tracheal tear secondary to tracheostomy, myopathic contribution to respiratory difficulty. 5. E.coli sepsis. 6. VRE abscess. 7. Klebsiella pneumonia. 8. Pneumoniae pneumonia. 9. Clostridium difficile colitis. 10. Malnutrition. 11. PEG placement. 12. Gastroesophageal reflux disease. 13. Status post cholecystectomy. 14. Gallstone pancreatitis. 15. Hypothyroidism. 16. Retrosternal goiter. MEDICATIONS ON ADMISSION: 1. Vitamin C 500 mg q. day. 2. Wellbutrin SR 150 mg q. day. 3. Ambien. 4. Warfarin 5 mg q.h.s. 5. Captopril 25 mg q. eight hours. 6. Metoprolol 25 mg q. 12 hours. 7. Levothyroxine 75 mcg q. day. 8. Digoxin 0.125 mg q. day. 9. Colace 100 mg p.o. b.i.d. 10. Senokot one tab b.i.d. ALLERGIES: 1. Aspirin. 2. Gentamycin. 3. Vancomycin. SOCIAL HISTORY: Twenty pack year smoking history. Son, [**Name (NI) **], cardiologist in [**Location (un) 5583**]. REVIEW OF SYSTEMS: Positive for rash present since [**12-30**] at [**Hospital1 5595**]. PHYSICAL EXAMINATION: On admission temperature 97.4 F, heart rate 96, blood pressure 143/68, respirations 20 and oxygen saturation 88% on room air. Head, eyes, ears, nose and throat: Pupils 2 mm, light reactive. Sclerae anicteric. Oropharynx dry. Lungs: Bilateral end expiratory wheezes. Heart: Regular rate, irregularly irregular rhythm, II/VI holosystolic murmur at the apex to the axilla. Abdomen: Soft, mild diffuse tenderness, J tube site non-erythematous, positive bowel sounds. Extremities: 2 cm bilateral pitting edema to mid thigh bilaterally. Skin: Reticular erythematous blanching and rash bilaterally upper extremities and trunk. Neuro: Alert and appropriately interactive. LABORATORY DATA ON ADMISSION: White count 9.7, hematocrit 34.0, platelets 319. INR 3.3, PTT 41.1. Sodium 125, potassium 6.4, chloride 84, total CO2 31, BUN 25, creatinine 0.6, glucose 119. Arterial blood gas: 7.38 / 58 / 91. Chest x-ray: Dense left retrocardiac opacity, small bilateral pleural effusions. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient was admitted for treatment of pneumonia. This was felt to be the main etiology of her respiratory distress. She had a Levofloxacin allergy on my medical record, but per patient and daughter, she did not have an allergy. She was placed on Levofloxacin 500 mg p.o. q. day for a 10 day course. Her respiratory status subsequently improved and returned to her baseline level of saturating in the 90s on zero to two liters of oxygen per nasal cannula. She was monitored for additional rash and no rash appeared. Her previous rash symptomatically improved throughout admission. The patient had evidence of a urinary tract infection on urinalysis. A culture was performed which was contaminated. Additional culture and sensitivities are recommended if the patient has continued symptoms despite her course of Levofloxacin. 2. ELECTROLYTES: Aforementioned, the patient had hyponatremia and hyperkalemia on admission. She was noted to be extravascularly volume overloaded and intravascularly depleted by physical examination. Potential etiologies of this were felt to include diastolic cardiac dysfunction and malnutrition with hypoalbuminemia. The patient received one liter of normal saline at a slow rate. Thereafter, she was fluid restricted. Her sodium improved to a level of 129 on the day prior to discharge. The patient's potassium likewise improved to a level under 5. A cosyntropin stimulation test was performed to rule out adrenal insufficiency. The test was negative. 3. CARDIOVASCULAR: Aforementioned, the patient was noted to be in atrial fibrillation and possibly with diastolic dysfunction. Her Metoprolol was increased to 37.5 mg p.o. B.i.d. for improved rate control. Her Captopril was also increased to 37.5 mg p.o. t.i.d. She was continued on Digoxin as her son noted that the patient diuresis well in response to this drug. She remained in atrial fibrillation with good rate control throughout admission. 4. NUTRITION: The patient has a recent history of malnutrition. A nutrition consult was obtained for tube feed recommendations as the patient has had decreased p.o. intake of late. She received nocturnal tube feedings with encouraged p.o. intake throughout the day. It is recommended that her nutritional status be closely monitored at [**Hospital1 5595**] as this contributes to her general well-being. 5. ENDOCRINE: Patient has noted history of hypothyroidism. TSH was pending at time of this dictation. She was continued on her outpatient dose of Synthroid throughout admission. 6. PROPHYLAXIS: The patient was continued on Coumadin at admission for her atrial fibrillation. She had an elevated INR on day #1 of admission and her Coumadin was held. It is recommended that her INR be monitored in an outpatient setting with adjustments made to maintain an INR between 2 and 3. 7. PSYCH: Patient has apparent depression with depressed mood and neurovegetative symptoms. She was continued on Wellbutrin SR this admission. It is recommended that she have a trial of Ritalin once she returns to [**Hospital1 5595**] for activation and appetite stimulation. DISCHARGE DIAGNOSIS: 1. Pneumonia. 2. Atrial fibrillation. 3. Diastolic dysfunction. 4. Depression. 5. Malnutrition. 6. Hypothyroidism. 7. Retrosternal goiter. 8. History of respiratory failure and multiple difficult intubations. 9. History of tracheostomy complicated by tracheal tear. CONDITION ON DISCHARGE: Fair. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q. day through [**2184-1-25**]. 2. Metoprolol 37.5 mg p.o. b.i.d. 3. Captopril 37.5 mg p.o. t.i.d. 4. Digoxin 0.125 mg p.o. q. day. 5. Levothyroxine 75 mcg p.o. q. day. 6. Wellbutrin SR 150 mg p.o. q. day. 7. Coumadin 3 mg p.o. q.h.s. 8. Multivitamin one tab p.o. q. day. 9. Vitamin C 500 mg p.o. q. day. 10. Colace 100 mg p.o. b.i.d. 11. Senna one tab p.o. b.i.d. 12. Atrovent one neb INH q. six hours. DISCHARGE STATUS: To [**Hospital1 5595**]. FOLLOW UP: Patient is to be followed by her outpatient physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**Last Name (NamePattern1) 5596**] MEDQUIST36 D: [**2184-1-20**] 07:54 T: [**2184-1-20**] 09:56 JOB#: [**Job Number 5597**]

486,51881,5990,42731,2761,2767,2639,496,4019

Admission Date: [**2104-8-29**] Discharge Date: [**2104-9-11**] Date of Birth: [**2104-8-29**] Sex: M Service: NEONATOLOGY [**Known lastname **] [**Known lastname 12056**]-[**Known lastname 51321**], triplet number two, was born at 34 weeks gestation by cesarean section, for a triplet gestation and preterm labor. Mother is a 39-year-old G4, para 1, now 4, woman with previous obstetrical history remarkable for spontaneous abortion in [**2100**] and [**2102**], a 38 week spontaneous vaginal delivery in [**2097**], whose name is [**Name (NI) 6644**]. [**Name2 (NI) **] previous medical history is remarkable for depression. She is currently on fluoxetine, remote HSV (normal Pap smear, no active lesions). The mother's prenatal screens are blood type A+, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative, GC negative, Chlamydia negative and Group B Strep unknown. This pregnancy is remarkable for being a spontaneous triamniotic, trichorionic triplet gestation. This pregnancy was complicated by preterm contractions leading to admission one week prior to delivery with tocolysis and betamethasone given at that time. The elective cesarean section was performed without the progression of labor. Rupture of membranes occurred at the time of delivery with clear fluid. There were no antepartum stressors or risk factors. This infant emerged with good tone and spontaneous cry. Apgars were 8 at one minute and 8 at five minutes. Birth weight was 1,615 grams (20th percentile). Birth length was 42.5 cm (25th percentile) and birth head circumference 29.5 cm (25th percentile). PHYSICAL EXAMINATION ON ADMISSION: Baby's admission physical examination revealed a nondysmorphic vigorous preterm infant. Anterior fontanelle soft and flat. Intact palate. Comfortable respirations. Breath sounds clear and equal. Heart was regular rate and rhythm. Pink and well perfused. Femoral pulses normal. Abdomen soft, non-distended. Three vessel umbilical cord. No organomegaly. Patent anus. Normal preterm male genitalia with testes descended bilaterally. Appropriate for age central nervous system examination. Normal spine, hips and clavicles. HOSPITAL COURSE BY SYSTEM: 1. Respiratory status: Infant has remained in room air throughout his Neonatal Intensive Care Unit stay. He has never required any supplemental oxygen and he has never had any apnea of prematurity. On examination, his respirations are comfortable. Lung sounds are clear and equal. 2. Cardiovascular status: The infant has remained normotensive throughout his Neonatal Intensive Care Unit stay. There are no active cardiovascular issues. 3. Fluids, Electrolytes and Nutrition status: Enteral feeds were begun on the day of delivery and were advanced without difficulty to full volume feeding and calorie enhanced formula or breast milk of 24 calories per ounce. The infant is being discharged home on that nutrition plan eating approximately every three to four hours. At the time of discharge his weight is 1,810 grams, his length is 43 cm and his head circumference is 29.7 cm. 4. Gastrointestinal status: The infant was treated with phototherapy for hyperbilirubinemia of prematurity on day of life three until day of life number five. Peak bilirubin occurred on day of life three with total 8.2. Direct was 0.2. 5. Hematology status: The infant has received no blood product transfusions during his Neonatal Intensive Care Unit stay. He is receiving supplemental iron of 2 mg/kg/day of elemental iron. 6. Urology: The infant was circumcised [**2104-9-11**], without complication. 7. Infectious Disease status: The infant never required evaluation for sepsis and never received any antibiotics during his Neonatal Intensive Care Unit stay. 8. Neurology: Sensory: Hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. 9. Psychosocial: Parents have been very involved in the infant's care throughout the Neonatal Intensive Care Unit stay as has the 6-year-old brother, [**Name (NI) 6644**]. CONDITION AT DISCHARGE: The infant is discharged in good condition. DISCHARGE STATUS: The infant is discharged home with his parents. PRIMARY PEDIATRIC CARE: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital3 51322**], [**Hospital1 8**], [**Numeric Identifier 4293**], telephone [**Telephone/Fax (1) 43957**]. CARE AND RECOMMENDATIONS AFTER DISCHARGE: 1. Feedings: Enfamil or breast milk 24 calories per ounce made with Enfamil powder. 2. Medications: Iron sulfate (25 mg/mL 0.15 cc p.o. q. day). 3. The infant has passed the car seat position screening test. 4. State newborn screen was sent on [**2104-9-10**]. That is the only state screen that was sent. 5. Parents have declined hepatitis C vaccine at this time and will wait until all infants reach 2 kg of weight. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born at 32 to 35 weeks and plan for day care during RSV season, with smoker in the household or with preschool sibs or (3) With chronic lung disease. 2. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and the care givers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS: 1. The parents have a pediatrician appointment scheduled for [**9-15**]. 2. They will be followed by the Visiting Nurses of [**Location (un) 86**]. DISCHARGE DIAGNOSES: 1. Prematurity at 34 weeks gestation. 2. Triplet Number Two. 3. Status post hyperbilirubinemia of prematurity. 4. Status post circumcision. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2104-9-11**] 13:16 T: [**2104-9-11**] 14:07 JOB#: [**Job Number 51323**]

V3401,76527,76516,7746

Admission Date: [**2190-12-11**] Discharge Date: [**2190-12-13**] Date of Birth: [**2112-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: unresponsive at HD Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 77 yo man with h/o longstanding HTN c/b ESRD, several lacunar strokes, multivascular dementia with poor baseline cognitive function, limited verbal ability and comprehension, as well as poor memory, who presented with AMS today from his outpatient dialysis center. . Per pt's wife and Neurology resident, pt had some agitation last night, talking with his wife and pacing with walker. He finally fell asleep around 3AM, awoke at 4AM for dialysis at 6:30, slightly groggy but responding appropriately to his wife before HD. Her received his usual dose of 50mg benadryl before dialysis, and then slept through the entire dialysis, which is unusual for him (last known "awake" time was 6:30AM). Following dialysis, staff tried to wake him up with verbal and tactile stim and he was unresponsive. Staff tried applying cold packs to head, no response. BP was "high" and RR was 12 (other VS unavailable). Wife tried to move his head which felt heavy and stiff, and entire body looked stiff with no spontaneous mvmt. At one point, wife tried to move him and he slapped her hand away, thus wife thought he was "alright." However, was again unresponsive, eyes closed just after this. . When EMS arrived, he had his eyes open and was looking around initially, though unresponsive. In ER, still unresponsive, BG found to be 49 - given 1amp d50, with no return to BL, thus CODE STROKE called. Neuro arrival within 5 minutes, and initial NIHSS score high in every category as pt unresponsive; TPA not given as last well-time was 6:30AM (5.5 hrs ago) and not clear to be stroke. Per Neuro recommendation, pt underwent head CT followed by head MRI, both of which were unrevealing for etiology of his AMS. He initially had 1mg Ativan given for possible Sz, and when no response, he was loaded on IV dilaudid. Had bedside EEG in the ER that did not show definite Sz activity, but Neuro recommends continuing Dilantin. Also notable, pt had SBP in the 250s while in ED. . Per wife, the patient's baseline is: limited speech and comprehension, walks with walker, brushes teeth and feeds self but wife helps him with most other adls, including transfers. He has some urinary and bowel incontinence at baseline. He has complained of no (and wife has noticed no) f/c/cp/sob/uri sx/gi/gu sx; he has chronic LBP and as usual took vicodin this am. No visual, hearing, sp/sw problems, no new weakness/numbness; has fallen (falls occ. at BL) but no head trauma. Past Medical History: -ESRD related to HTN nephropathy -s/p avf in both arms, R arm is functional -HTN x >20 yrs -Multivascular dementia -BPH -Chronic LBP with DJD, spinal stenosis -Macrocytic anemia, unclear if from ESRD Social History: Retired plumber; no tob, etoh or drugs; lives with wife; has 2 children. Family History: No strokes or CAD Physical Exam: Vitals: T 97.0, HR 51, BP 151/84, RR 18, Sat 100% on 2LNC, UO 78cc/3h Gen: initially sleeping and intermittently apneic, aroused to touch, poorly responsive and not following commands, withdraws to pain HEENT: PERRL (5 to 3 mm), EOMI with approp tracking, mouth closed and not opening for exam Neck: turning head with no apparent discomfort; tunnelled line into L SCV CV: bradycardic, regular, +s4, no s3, no m/r Lungs: CTA Abd: thin, soft, NT (no grimace or withdrawal), ND, no HSM Ext: UE -- L pulsatile AVF without bruit or thrill, 2+ radial pulse; R AVF with overlying bandage, with thrill and bruit, 2+ radial pulse LE -- thin, no edema, cool bilaterally but with 2+ DP pulses bilaterally Neuro: a) MS: Unresponsive to verbal, opens eyes to tactile stim, withdraws to pain, not following commands, nonverbal b) CN: perrla 5->3; +blink to threat bilat; could not look in mouth or test gag as teeth clenched shut c) Sensorimotor: moving all 4 ext and neck, resisting extension of arm for ABG d) DTRs: 1+ biceps bilaterally, 1+ at knees bilaterally, toes upgoing with Babinski bilaterally Pertinent Results: [**2190-12-11**] 10:43PM POTASSIUM-6.1* [**2190-12-11**] 08:53PM GLUCOSE-81 UREA N-33* CREAT-8.8* SODIUM-138 POTASSIUM-6.5* CHLORIDE-99 TOTAL CO2-28 ANION GAP-18 [**2190-12-11**] 08:53PM ALT(SGPT)-19 AST(SGOT)-54* CK(CPK)-198* ALK PHOS-68 TOT BILI-0.4 [**2190-12-11**] 08:53PM CK-MB-7 cTropnT-0.22* [**2190-12-11**] 08:53PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.8 [**2190-12-11**] 08:53PM TSH-3.2 [**2190-12-11**] 08:53PM WBC-4.8 RBC-3.79* HGB-13.4* HCT-41.6 MCV-110* MCH-35.3* MCHC-32.1 RDW-17.0* [**2190-12-11**] 08:53PM PLT COUNT-148* [**2190-12-11**] 08:53PM PT-11.7 PTT-29.3 INR(PT)-1.0 . pCXR [**2190-12-11**]: 1. New retrocardiac opacity, which likely indicates pneumonia. Atelectasis is a less likely diagnostic consideration. 2. Hypertensive configuration of the heart and aorta. 3. Indwelling dialysis catheter as above. . Brain MRI: No evidence of acute infarct. MRA: Head MRA is somewhat limited by motion. There is no evidence of vascular occlusion seen. There is diminished flow signal intensity visualized in the intracranial arteries which appears artifactual. The basilar artery flow void as well as the basilar artery flow signal on source images is maintained. IMPRESSION: Somewhat limited normal MRA of the head . head CT: No acute intracranial hemorrhage or mass effect. No significant change from [**2190-9-27**]. . EEG: This is an abnormal EEG in the waking and sleeping states due to the low voltage slow posterior rhythm as well as bursts of bilateral frontal 4 Hz slowing. This suggests an encephalopathic pattern which may be seen with medications or toxic metabolic abnormalities. . pCXR: Mild CHF with left greater than right small pleural effusions. Brief Hospital Course: MICU course: - CT, MRI/MRA, EEG all negative for acute pathology. Etiology of altered mental status thought to be multifactorial - 1)By history patient took double of the usual dose of benadryl. 2)Patient found to be hypoglycemic. 3) Renal failure. 4)All superimposed on baseline that per family is altered. - Patient was intially started on dilantin but the etiology was ultimately deemed not to be seizure. The patient should see his behavioral neurologist, Dr. [**First Name (STitle) **], for whether he should restart this medication. - Plan to go to dialysis [**2190-12-13**] with possible removal of tunneled catheter if dialysis through fistula is successful. - Elevated potassium was treated with good effect with kayexalate, insulin and D-50. - Patient was incidentally found to have a retrocardiac opacity but was not treated because of lack of fever and normal white blood cell count. - Home were held on admission, but were subsequently restarted and the blood pressure remained stable. # AMS: unclear etiology although possible precipitants include hypoglycemia, seizure, altered BP; Neurology was consulted, EEG was performed and showed no seizure. Head CT and MRI/A were unremarkable. Benadryl/trazodone were held. Mental status improved to baseline per his family. Trazodone was held. He should try to avoid >25 mg at a time of benadryl. Blood sugars returned to [**Location 213**]. . # CV: Had slight TnT bump though with no change in ECG and known ESRD; ruled out for MI, no CP/SOB. # HTN: became very hypertensive to >200/100, not controlled on home meds, so patient was changed to labetalol 400 mg tid in addition to his norvasc for better BP control, his BP improved to 140/90. . # ESRD: Had elevated Cr, K on admit. Dialyzed with improved K. Will continue increased frequency of HD for a few days. Due for another HD session the day after d/c. His fistula has matured as was used for effective HD. He will need to follow up with Dr. [**Last Name (STitle) 816**] as an outpatient to have his tunnelled HD cath removed. Pt. did not want to stay in the hospital to have this removed. He was restarted on his sensipar, renal caps, and fosrenal. He will follow up with Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) **]. . # Thrombocytopenia: plt count mildly low at 141k (recent bl 167k-190k) Follow up as an outpatient. . Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lopressor 12.5 mg [**Hospital1 **] 3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)* Refills:*2* 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**] hours as needed for agitation. 6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. 7. Trazodone 50 mg hs. Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)* Refills:*2* 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-24**] hours as needed for agitation. 6. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Altered Mental Status Hypoglycemia End Stage Renal Failure Hypertensive Urgency Vascular Dementia Discharge Condition: stable Discharge Instructions: Please continue medications as listed below. Please follow up for dialysis tomorrow. Please also follow up with Dr. [**Last Name (STitle) 816**] to have your tunnelled catheter removed. Followup Instructions: 1. Please call Dr.[**Name (NI) 1381**] office tomorrow to schedule a follow up appointment to have your tunnelled catheter removed. 2. Please follow up with your nephrologist in the next week. 3. Please go for dialysis tomorrow. 4. Follow up with your PCP [**Last Name (NamePattern4) **] [**1-18**] weeks.

78097,40391,5856,4280,42830,2767,25080,29040,4370,2819,7245,4389

Admission Date: [**2190-11-5**] Discharge Date: [**2190-11-10**] Date of Birth: [**2112-3-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Thrombosed Access Hyperkalemia Major Surgical or Invasive Procedure: Right arm arterio-venous hemodialysis graft placement [**2190-11-9**] L tunneled cath placed under fluoroscopy. Placement right at the vena caval-atrial junction History of Present Illness: Patient is a known Hemodialysis patient, ESRD since [**2187**] who presented for thrombectomy of Left upper arm AVF. During pre-op evaluation, Labwork revealed hyperkalemia, with a K of 9.3. Femoral line placed for hemodialysis, admitted from the pre-op holding area to the SICU where emergent hemodialysis was performed. Past Medical History: ESRD on HD since [**5-19**] - Dr. [**Last Name (STitle) **], [**Hospital1 1426**] [**Location (un) 4265**] MWF Dementia Had transplant w/u and declined Hypertensive nephrosclerosis Hypertension x >20 years BPH MRSA Bacteremia Chronic low back pain [**2-18**] spinal stenosis on vicodin PRN Anemia in past with normal iron studies Social History: Pt. is right handed, a native of [**Doctor First Name 26692**], and has 15 years of education. He worked as a commercial plumber for many years before retiring ten years ago. He lives with wife and 2 children in [**Location (un) 686**] in family owned home. Retired plumber. His wife still works full time but she is primary caregiver. [**Name (NI) **] h/o ETOH or tobacco or elicit drug use. Family History: no h/o CAD Physical Exam: On Admission: VS: 96.1, 200/91, 61, 13, 97% RA General: Agitated, combative CV: RRR Lungs: CTA bilaterally Abd: + Bowel sounds, soft, non-distended, no rebound or guarding. Extr: feet warm, no edema, palpable DP and PT pulses Pertinent Results: [**2190-11-5**] 04:12PM GLUCOSE-146* UREA N-96* CREAT-15.9*# SODIUM-135 POTASSIUM-5.9* CHLORIDE-87* TOTAL CO2-27 ANION GAP-27* [**2190-11-5**] 04:12PM CALCIUM-9.6 PHOSPHATE-4.9*# MAGNESIUM-2.7* [**2190-11-5**] 04:12PM WBC-6.4 RBC-3.55* HGB-12.7* HCT-38.2* MCV-108* MCH-35.8* MCHC-33.3 RDW-17.6* [**2190-11-5**] 04:12PM PLT COUNT-174 [**2190-11-5**] 04:12PM PT-12.6 PTT-28.5 INR(PT)-1.1 [**2190-11-5**] 01:34PM K+-9.3* [**2190-11-5**] 02:34PM K+-7.5* Following HD:[**2190-11-5**] 07:17PM POTASSIUM-4.3 On D/C: Gluc 157* BUN: 62* Creat: 12.1 Na:134 K:4.9 Cl:95* CO2:21* Brief Hospital Course: 77 y/o male on hemodialysis T-TH-S with ESRD since [**2187**] presented for thrombectomy to Left AVF when he was found to have hyperkalemia on pre-op labs. K of 9.3 was treated with emergent placement of femoral line and transfer to SICU for emergent hemodialysis. Patient received HD on [**11-6**] and [**11-8**] as well through the femoral line. On [**11-9**] the patient had a Right brachiocephalic loop AV Graft placed which is + Bruit and thrill on assessment [**11-10**], as well as a tunnelled hemodialysis catheter in the left chest under fluoroscopy with placement right at the vena caval-atrial junction. HD performed on [**11-10**] using Left Catheter with consistent blood flows of 300. Next treatment will be at [**Location (un) **] [**Location (un) **] on Saturday. Medications on Admission: Lanthanum 1000''' with meals, cinacalcet 30', B complex-vit C-folic acid 1', amlodipine 2.5', metoprolol 25'', levothyroxine 12.5' Discharge Medications: 1. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 3. Amlodipine 2.5 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Lanthanum 250 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Right arm arterio-venous hemodialysis graft placement [**2190-11-9**] left tunnelled hemodialysis catheter placement ESRD hyperkalemia Discharge Condition: Stable Discharge Instructions: Please continue outpatient hemodialysis per your regular schedule. Continue medications at home as usual Renal diet as recommended by your hemodialysis caregivers Dialysis unit will change dressing to the chest dialysis catheter. Check the new left arm graft daily to make sure it has a thrill ("buzzing") If this is not present, please call [**Telephone/Fax (1) 673**] and ask for [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-12-2**] 8:30 Completed by:[**2190-11-10**]

99673,2767,5856,40391,E8782,2948,28521,60000

Admission Date: [**2192-3-31**] Discharge Date: [**2192-4-2**] Date of Birth: [**2112-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Abdominal distension Major Surgical or Invasive Procedure: None History of Present Illness: 80 y/o M w/ baseline dementia, ESRD on HD, recurrent E coli bacteremia of unclear source, recurrent prostatitis w/ possible abscess, who p/w altered mental status, recent swallowing difficulties, increasing abdominal distention, and brown thick discharge from his penis. . In the ED, Labs showed normal WBC w/ left shift and floridly positive U/A. ECG had question of lateral ST depressions. Tropinin was below normal baseline. He had a CT abdomen performed which showed distended stool loaded colon with fecalization of the distal small bowel. He received 1 dose of ceftriaxone. Also while in the ED, he became agitated and received 2 mg of haldol w/ improved agitation. While awaiting transport to the floor, he became hypertensive w/ SBPs in 190s and required IV hydralazine with improvement to 140s. . He has had a [**Hospital 96531**] medical course of late w/ recurrent hospital admissions for E coli bacteremia and prostatitis c/b recurrent foley trauma. He was intitially admitted in [**1-23**] after blood cultures drawn at HD grew E coli. During admission he was also noted to have penile discharge. Since that time he has had 3 subsequent admissions for recurrent penile discharge and bacteremia w/ E coli. He has undergone extensive work up for both including CT abdomen/pelvis showing possible prostatic abscess, TTE showing possible aortic valve vegetation(which was not seen on subsequent TTE and wife refused [**Name2 (NI) **]), normal colonscopy, CT cystogram negative for enterovesicular fistula, and retrograde uretogram showing a large hollowed out section of the prostate which may represent abscess or fistula. He has completed multiple prolonged courses of antibiotics under the guidance of ID and Urology consultations. Following his last admission for the above problems in [**5-23**], he completed a course of Zosyn in house and then followed up with Urology as an outpt after which he was placed on Macrodantin x 3 months. He was most recently admitted [**Date range (1) 96532**]/08 for recurrent seroma over dialysis access site in his R arm. He had recently underwent a revision of the graft secondary to a large seroma. He had excision of right upper arm arteriovenous graft [**2192-2-22**] and a temporary HD line was placed and was scheduled for permanent line placement by IR post-discharge. In addition, blood cultures from presentation grew clostridium species. However, subsequent blood cultures were negative. Wound cultures from seroma also grew vanco sensitive enterococcus. He competed a 14 day course of vanco and ceftazidime. Past Medical History: # ESRD related to HTN nephropathy s/p av graft in both arms, R arm was functional until the past 24h # HTN x >20 yrs # Multivascular dementia # BPH # Chronic LBP with DJD, spinal stenosis # Macrocytic anemia, unclear etiology # h/o Bacteremia: [**12-22**]- Ecoli,B. Fragilis; [**3-23**] - Ecoli; several Ecoli isolates w/ different sensitivities - [**2191-4-4**] TTE: no vegetation seen.([**Month/Day/Year **] again refused) - [**2191-3-26**] TTE: aortic valve echodensity is new and c/w possible vegetation (wife and pt refused [**Month/Day/Year **]) but completed 4 wks of ceftazidime - outpt colonoscopy normal [**1-23**] w/o evidence of infectious source - CT [**12-23**] w/ hypodensity in prostate . # Prostatitis - multiple admissions w/ penile discharge, UTI, prostatitis - readmission [**5-/2191**]: w/ penile discharge ---CT cysto gram neg for enterovesicular fistula ---Retrograde uretogram was performed and showed a large hollowed out section of the prostate which may represent abscess or fistula. --- tx'ed w/ Zosyn x 7 days - readmission [**Date range (1) 96533**]: hematuria - [**Date range (1) 96534**]/07: recurrent discharge w/ Ecoli bacteremia ---prostate MRI: cannot exclude abscess-> 4wks ceftazidime ---Daily bladder irrigation through the Foley with fluid containing Neomycin-Polymyxin --- cytoscopy w/ purlent drainage from bladder --- d/c on 4 wks ceftazidime - [**1-23**]: penile discharge noted following foley catheter removal - [**12-22**]: CT of prostate with hypodense area: per Urology, not concerning for abscess when compared to prior imaging -> 4 wk course of Cipro/Flagyl Social History: Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or drugs; Family History: NC Physical Exam: Admission PE: VS: 98.6, 136/72, 95, 98% RA Gen: Responds briefly to questions, directs eyes appropriately, moves to command occasionally HEENT: No conjunctival pallor. No icterus. MMM. Will not open mouth for OP exam. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB, good BS BL, No W/R/C ABD: Grossly distended, firm, tense, no tenderness to palpation throughout, hypoactive bowel sounds, tympanitic EXT: WWP, NO CCE. 2+ DP pulses BL SKIN: No rashes/lesions, ecchymoses. NEURO: Will not answer A&O questions. Will not cooperate with motor exam. States yes to sensation questions. . MICU transfer PE: T: 99.4 BP: 91/53 HR:74 RR: 30 O2 99% bipap Gen: elderly man, opens eyes to stimulus HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: Distant. RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB, good BS BL, No W/R/C ABD: Distended, firm, NT, no bowel sounds EXT: WWP, NO CCE. 2+ DP pulses BL, fistula s/p surgical removal SKIN: No rashes/lesions, ecchymoses. NEURO: Moves all fours, opens eyes, Gait assessment deferred Pertinent Results: CT abdomen/pelvis [**3-30**]: The lung bases are clear aside from mild bibasilar atelectasis. The heart is enlarged. A central venous catheter is partially visualized terminating in the cavoatrial junction. There are aortic valvular calcifications. Allowing for the limitations of a non-contrast study, the liver, pancreas, spleen, stomach, adrenal glands, and small bowel loops are normal. Multiple small layering stone/sludge present in an otherwise normal-appearing gallbladder. The kidneys are small and atrophic, containing multiple small probable cysts consistent with history of end-stage renal disease. There is no free air or free fluid. CT PELVIS WITH CONTRAST: The entire colon is markedly distended with stool including fecalization of the distal small bowel. The prostate is enlarged. The bladder appears normal. There is no free air, free fluid, or pathologic adenopathy. BONE WINDOWS: There are multilevel degenerative changes, but no suspicious lesions. IMPRESSION: Distended stool loaded colon with fecalization of the distal small bowel. . [**4-1**] KUB: The cecum and ascending colon are dilated, measuring up to 10.1 cm. Specks of radiodense material are present within the colon, which represent dense residual contrast from prior administration. Small bowel does not appear to be dilated. There is no supine evidence of free intraperitoneal air. Upper abdomen is excluded from the radiograph. The osseous structures are diffusely demineralized. IMPRESSION: Persistent colonic dilatation, unchanged from scout images of recent CT. . [**2192-3-31**] 09:20AM GLUCOSE-86 UREA N-47* CREAT-11.0* SODIUM-142 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-22* [**2192-3-31**] 09:20AM CK(CPK)-104 [**2192-3-31**] 09:20AM CK-MB-7 cTropnT-0.19* [**2192-3-31**] 09:20AM CALCIUM-9.8 PHOSPHATE-5.2* MAGNESIUM-2.3 [**2192-3-31**] 09:20AM WBC-6.6 RBC-3.33* HGB-11.9* HCT-39.0* MCV-117* MCH-35.7* MCHC-30.5* RDW-16.9* [**2192-3-31**] 09:20AM PLT COUNT-170 [**2192-3-31**] 01:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2192-3-31**] 01:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2192-3-31**] 01:30AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-<1 [**2192-3-31**] 01:30AM URINE AMORPH-MANY [**2192-3-31**] 01:30AM URINE MUCOUS-MANY [**2192-3-30**] 08:30PM GLUCOSE-119* UREA N-40* CREAT-10.3*# SODIUM-142 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-22* [**2192-3-30**] 08:30PM estGFR-Using this [**2192-3-30**] 08:30PM ALT(SGPT)-21 AST(SGOT)-48* LD(LDH)-239 TOT BILI-0.3 [**2192-3-30**] 08:30PM CK-MB-7 cTropnT-0.19* [**2192-3-30**] 08:30PM ALBUMIN-4.9* [**2192-3-30**] 08:30PM NEUTS-78.7* LYMPHS-13.0* MONOS-6.1 EOS-1.8 BASOS-0.3 [**2192-3-30**] 08:30PM PLT COUNT-193 [**2192-4-1**] 07:05AM BLOOD WBC-11.5*# RBC-3.45* Hgb-13.0* Hct-42.0 MCV-122* MCH-37.7* MCHC-31.0 RDW-16.7* Plt Ct-202 [**2192-4-1**] 05:47PM BLOOD WBC-9.1 RBC-3.24* Hgb-12.1* Hct-38.0* MCV-118* MCH-37.4* MCHC-31.8 RDW-16.9* Plt Ct-201 [**2192-4-2**] 01:43AM BLOOD WBC-7.8 RBC-3.12* Hgb-11.8* Hct-36.4* MCV-117* MCH-37.8* MCHC-32.4 RDW-17.0* Plt Ct-171 [**2192-4-1**] 07:05AM BLOOD Glucose-98 UreaN-45* Creat-9.5*# Na-146* K-4.1 Cl-98 HCO3-16* AnGap-36* [**2192-4-1**] 05:47PM BLOOD Glucose-143* UreaN-64* Creat-10.8*# Na-142 K-4.1 Cl-98 HCO3-20* AnGap-28* [**2192-4-2**] 01:43AM BLOOD Glucose-110* UreaN-72* Creat-11.0* Na-145 K-3.8 Cl-102 HCO3-17* AnGap-30* [**2192-4-1**] 05:47PM BLOOD ALT-91* AST-233* LD(LDH)-316* CK(CPK)-2695* AlkPhos-91 Amylase-119* TotBili-0.4 [**2192-4-2**] 01:43AM BLOOD ALT-107* AST-282* LD(LDH)-376* CK(CPK)-3502* AlkPhos-92 Amylase-104* TotBili-0.4 [**2192-4-2**] 10:07AM BLOOD CK(CPK)-3291* Brief Hospital Course: 80 M with dementia, HTN, ESRD on HD, recurrent Ecoli bacteremia, prostate abscess, admitted with confusion, abdominal distension, difficulty swallowing, copious purulent penile discharge. . Brief hospital course: Patient was initially admitted to the floor and placed on aggressive bowel regimen and urology was consulted. Plan was for protate US to look for prostatic ascess. On [**4-1**] while on the floor the patient developed hypotension and an acute change in mental status. Pt was non-verbal with verbal baseline. MICU evaluation revealed :ABG 7.23/54/82 with lactate 3.6. SBP was 84 with HR in the 70s. He appeared tachypneic. He received 500cc NS as well as vancomycin, flagyl, Zosyn. He was transferred to the MICU with a diagnosis of septic shock EKG was unchanged from prior. Labs returned with CK of 2600. Surgery was consulted. Of note patient was unable to complete dialysis (0.5L off) the day prior to transfer secondary to hypotension. Possible sources of infection included GU tract given purulent penile discharge on admission or abdominal source given distention and colonic dilitation seen on plain films. He was aggressively hydated with IVF and continued on broad spectrum antibiotics including Vanco, Zosyn, and Flagyl. Bladder irrigation with Neomycin-Polymyxin was also continued. A CVL was attemped x2 without ability to thread the wire and was aborted. Given the abdominal distention surgery was consulted for concern for ischemic colitis. An exploratory laparotomy was offered to the patient's wife who declined surgical intervention. An NG tube was placed for decompression. Over the course of the next 24 hours in the ICU the patient's condition continued to worsen with progressive hypotension and the patient became unresponsive. His critical and deteriorating condition was discussed with his family who did not want to continue aggressive intervention. The decision was made to make the patient CMO on the morning of [**4-2**]. Antibiotics were discontinued and the patient expired at 2:20pm on [**4-2**] with his family at the bedside. His wife declined a post-mortem exam. Medications on Admission: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO [**Hospital1 **] (2 times a day) as needed for back pain. Disp:*35 Tablet(s)* Refills:*0* 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DINNER . Medications on transfer to ICU: 1. IV access: Peripheral Order date: [**3-31**] @ 0643 9. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H Order date: [**4-1**] @ 1601 2. 500 mL NS Bolus 500 ml Over 20 mins Order date: [**4-1**] @ 1522 10. Piperacillin-Tazobactam Na 2.25 g IV Q12H *Awaiting ID Approval* Order date: [**4-1**] @ 1455 3. Amlodipine 7.5 mg PO DAILY Order date: [**3-31**] @ [**2190**] 11. Piperacillin-Tazobactam Na 2.25 g IV ONCE Duration: 1 Doses Start: [**2192-4-1**] Order date: [**4-1**] @ 1526 4. Cinacalcet HCl 30 mg PO Q DINNER Order date: [**3-31**] @ [**2190**] 12. Simethicone 120 mg PO QID Order date: [**3-31**] @ 2034 5. Fleet Phospho-Soda 45 ml NG ONCE Duration: 1 Doses Please give by rectum. Order date: [**3-31**] @ 2230 13. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN Peripheral IV - Inspect site every shift Order date: [**3-31**] @ 0643 6. Lanthanum 500 mg PO TID W/MEALS Order date: [**3-31**] @ [**2190**] 14. Vancomycin 1000 mg IV HD PROTOCOL ID Approval will be required for this order in 71 hours. Order date: [**4-1**] @ 1455 7. Lactulose 30 mL PO TID Order date: [**3-31**] @ 2034 15. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: [**4-1**] @ 1523 8. Metoprolol 12.5 mg PO BID Order date: [**3-31**] @ [**2190**] (Dinner). 6. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

0389,78552,6012,5990,5856,40391,51881,41091,5647,29041,V667,99592,4370

Admission Date: [**2191-4-2**] Discharge Date: [**2191-4-6**] Date of Birth: [**2112-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: hematuria, chills Major Surgical or Invasive Procedure: None History of Present Illness: 79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP p/w hematuria, chills. Pt was recently admitted [**Date range (1) 96389**] for penile discharge. [**Date range (1) 159**] was consulted and placed a foley which revealed purulent discharge. Pt was placed on daily irrigation with abx, though this was discontinued at the time of d/c with plans for out-pt f/u with [**Date range (1) **]. Also during that admission, multiple [**Date range (1) **] cxs grew out E coli. Pt was discharged with plans for tx with [**Date range (1) **] with HD X 4 weeks. Initially the pt felt well after discharge and had no complaints. However, yesterday pt noted mild "chills and sweats." This AM pt noted large amount of hematuria, but he and his wife decided to go to HD. Pt with worse chills and sweats at HD. Given persistent symptoms and worsening hematuria, pt's wife brought him to [**Hospital1 18**] [**Name (NI) **]. . In ED, vitals: 96.1, hr 70, 110/50, rr 18, 96% RA. Lactate 1.8. BUN 23, cr 5.6. Hct 35, baseline 41. CXR with patchy retrocardiac opacity, likely atelectasis. EKG: nsr@78 bpm, LAD, RBBB, TWF v2-3 (new). [**Name (NI) 159**] consulted and foley was palced. Renal called for HD and elected to hold on dialysis today. LIJ placed for access (white port not flushing). Pt given vanc 1 gram, gent 80 mg for ? endocarditis, flagyl 500 mg given for prior h/o b frag bacteremia (on admission [**12-22**]), [**Month/Year (2) **] given for prior e coli bacteremia, tylenol 325 mg. Home BP meds held. Pt started on labetalol gtt for elevated sbps to 270s, which were controlled. However, pt's sbps dropped to 70s. Drip turned off and pt bolused with sbp to 120s. Pt transferred to MICU for further management. . ROS: Denies chest pain, abdominal pain, nausea, vomiting, or shortness of breath Past Medical History: -ESRD related to HTN nephropathy s/p av graft in both arms, R arm was functional until the past 24h -HTN x >20 yrs -Multivascular dementia -BPH -Chronic LBP with DJD, spinal stenosis -Macrocytic anemia, unclear etiology -Bacteremia - [**12-22**]- Ecoli and B. Fragilis; [**3-23**] - Ecoli -Prostatitis - [**3-23**] - CT of prostate with hypodense area and Ecoli in penile discharge swab and [**Month/Year (2) **]. Daily bladder irrigation through the Foley with fluid containing Neomycin-Polymyxin was done. Pt discharged on 4 weeks of [**Month/Year (2) **] as endocarditis not ruled out on TEE. Social History: Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or drugs; No recent sexual activity. Family History: NC Physical Exam: Vitals- 98.4, 158/p, 78, 20, 100% RA Gen - Alert, no acute distress, but appears confused. HEENT - PERRL, extraocular motions intact, anicteric, MMM Neck - no JVD, no cervical lymphadenopathy, central line left neck without erythema Chest - Clear to auscultation bilaterally CV - irregularly irregular, nml s1,s2. No murmurs noted. Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - 2+ DP, PT pulses bilaterally, no edema or cyanosis, warm and well perfused. Skin - No rashes or petechiae noted. foley catheter in place. draining bright red [**Location (un) **]. Pertinent Results: [**2191-4-2**] 02:10PM PLT COUNT-255 [**2191-4-2**] 02:10PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+ [**2191-4-2**] 02:10PM NEUTS-75.6* LYMPHS-16.1* MONOS-3.9 EOS-2.9 BASOS-1.6 [**2191-4-2**] 02:10PM WBC-6.6# RBC-3.49* HGB-11.4* HCT-35.8* MCV-103* MCH-32.7* MCHC-31.9 RDW-17.2* [**2191-4-2**] 02:10PM CALCIUM-9.2 PHOSPHATE-3.8# MAGNESIUM-2.0 [**2191-4-2**] 02:10PM CK-MB-NotDone cTropnT-0.28* [**2191-4-2**] 02:10PM CK(CPK)-94 [**2191-4-2**] 02:10PM estGFR-Using this [**2191-4-2**] 02:10PM GLUCOSE-136* UREA N-23* CREAT-5.6*# SODIUM-142 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-36* ANION GAP-16 [**2191-4-2**] 02:27PM LACTATE-1.8 [**2191-4-2**] 02:27PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF [**2191-4-3**] 12:00AM HCT-28.9* . CHEST (PORTABLE AP) [**2191-4-2**] 2:33 PM UPRIGHT AP CHEST: Heart size is normal, though there is a left ventricular configuration. Mediastinal and hilar contours are unchanged. There is minimal patchy opacity in the retrocardiac area which likely reflects atelectasis. There is no definite consolidation. No evidence of failure. No pleural effusion or pneumothorax. Flecks of dense material are seen within the bowel, likely reflecting bits of retained barium from recent CT. -Minimal patchy opacity in the retrocardiac region likely reflects atelectasis. To better evaluate this area, a lateral view could be obtained. . EKG [**2191-4-2**] Baseline artifact. Sinus rhythm. Atrial ectopy. Left axis deviation with left anterior fascicular block. Right bundle-branch block. Compared to the previous tracing of [**2191-3-29**] no significant diagnostic change. . [**2191-4-4**]- TTE The left atrium is dilated. The right atrium is moderately dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2191-3-26**], there is sginificant change. No vegetation is seen on either study. Brief Hospital Course: 79 yo M h/o HTN, ESRD [**2-18**] to HTN nephropathy, dementia, BPH, LBP p/w hematuria, chills. . In MICU continued [**Month/Day (2) 21347**], flagyl and vanc dosed by levels. Foley with numerous clots, periodically flushed. Dialysis planned for Tuesday as per renal, with [**Month/Day (2) **] 2 grams IV to be given during hemodialysis. Stabilized BP on home meds. Question of vegetation on TTE [**3-26**] admission. . #Fever/chills: Question of endocarditis (especially given previous ECHO) vs. prostatic infection, abscess. Vanc and flagyl DC'd shortly after initiation. Continued [**Month/Year (2) 21347**] 2 gm per dialysis. TTE with no evidence of vegetation. Wife would not like TEE at this time. E-coli bacteremia noted. Frequent bouts of prostatis, but family not interested in TURP at this time. ~6 week course of [**Month/Year (2) **]. . #hematuria: ddx includes prostatitis v abscess v prior trauma from foley placement. foley in place by [**Month/Year (2) **]. Monitored crit which were stable. [**Month/Year (2) 159**] had replaced the 16F Coude catheter placed in ED, numerous clots irrigated from the bladder. As patient did not produce much urine, it was difficult to tell whether foley was clotted vs. his baseline anuria. Irrigated the foley regularly to clear out any residual clots. Clear urine at the time of discharge. Patient denied any pain. No white count or fever, hemodynamically stable. Transfused PRBC's last 2 units on [**2191-4-5**]. [**Date Range 159**] follow up. . ESRD: on HD as an out-pt. Dialysis as per renal during admission. Electrolytes stable. Continued sevelamer, nephrocaps, CaCo3, cinacalcet. . #HTN urgency: transient HTN, resolved with gtt and now stable on no meds. Transient hypotension, likely related to Labetolol drip. No evidence of sepsis. Continue amlodipine and metoprolol [**Hospital1 **]. Stable [**Hospital1 **] pressure on the floor up to discharge. . #elevated tpn: in setting of renal failure. Minimal non-specific EKG changes. Pt asymptomatic. Pt was ruled out. . #FEN: renal/HH diet, IVF as above #ppx: pneumo boots, po diet #Full Code Medications on Admission: Amlodipine 7.5 mg daily Metoprolol Tartrate 25 mg [**Hospital1 **] Levothyroxine 25 mcg daily Cinacalcet 30 mg daily nephrocaps Ceftazidime 2 gm QHD X 4 weeks ([**Date range (3) 96388**]). Sevelamer 800 mg tid Calcium Carbonate 500 mg tid . MEDS on transfer to the floor: Levothyroxine Sodium 25 mcg PO DAILY Amlodipine 7.5 mg PO DAILY Metoprolol 25 mg PO BID Calcium Carbonate 500 mg PO TID W/MEALS Nephrocaps 1 CAP PO DAILY CeftazIDIME 2 gm IV QHD Senna 1 TAB PO BID:PRN Cinacalcet HCl 30 mg PO DAILY Sevelamer 1600 mg PO TID Docusate Sodium 100 mg PO BID Discharge Medications: 1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Tablet(s) 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. CeftazIDIME 2 gm IV QHD Discharge Disposition: Home Discharge Diagnosis: Primary: E-coli bacteremia Prostatitis Hematuria Hypertension ESRD secondary to hypertensive nephropathy . Secondary: s/p av graft in both arms, R arm is functional Multivascular dementia BPH Chronic LBP with DJD, spinal stenosis Macrocytic anemia Discharge Condition: stable Discharge Instructions: You were admitted with fever, chills, bleeding from urethra with clots. Your [**Date range (3) **] pressure was also very elevated, and then dropped after being placed on a Labetolol drip. You were given dialysis, foley catheter placed and flushed. You were continued on [**Last Name (LF) 21347**], [**First Name3 (LF) **] antibiotic given to you at dialysis. A repeat TTE demonstrated no vegetation concerning for endocarditis, and your wife would not like a TEE at this time. -Please continue [**First Name3 (LF) 21347**] 2 grams every dialysis until ID follow up on [**2191-4-25**]. A decision will be made at that time to continue with [**Date Range 21347**] or to have course of cipro or bactrim. -You will have a 6 week course of [**Date Range **] for your e-coli bacteremia, prostatis. -You will need your LFT's and CBC checked weekly at dialysis. -Please maintain all appointments, with your [**Date Range 3390**], [**Name10 (NameIs) **] and kidney doctors. -Please return to the hospital if you are feverish, have bleeding through your urethra, altered mental status, severely elevated [**Name10 (NameIs) **] pressure, or any other symptoms concerning to you or your wife. . Changes to your medications: -Your Metoprolol was increased to 50 mg twice daily -Sevelamer was increased to 1600 three times a day Followup Instructions: Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD. Phone [**Telephone/Fax (1) 133**]: Date/Time [**2191-4-15**] 3:00 PM -Will follow up on pending [**Month/Day/Year **] culture results. . Please follow up with Dr. [**Last Name (STitle) **] tomorrow at Dialysis in [**Location (un) **]. Discussed with Mrs. [**Known lastname 24110**], and she will see Dr. . Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2191-4-13**] 10:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2191-4-25**] 9:30

6011,7907,5997,40391,5856,0414,29040,4589,2819

Admission Date: [**2101-8-5**] Discharge Date: [**2101-8-15**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1145**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization, intubation History of Present Illness: 86 yo F with h/o HTN, CAD s/p remote CABG, DM who presents from NH with acute SOB and diaphoresis, transferred here for NSTEMI, admitted to CCU s/p cath on IABP, pressors, and intubated. She received lasix and NTG at [**Hospital1 18**] [**Location (un) 620**] and was transferred here. Her ECG on arrival showed [**Street Address(2) 2051**] depressions in V4-V6, II, avF. Cardiac enzymes were positive with CK 827/105/12.7 and Trop 1.02. CXR showed edema and RUL infiltrate; she was given ceftriaxone 1g, azithromycin 500, and clindamycin 600 and lasix 40IV. She received ASA, plavix 600, and heparin bolus. She underwent catheterization, showing severely elevated left and right-sided filling pressures (mean PCWP 30, giant v-waves). Grafts from SVG-> LAD and SVG -> RCA were patent. LAD had diffuse proximal disease. No prior LCx graft was found; LCx had 90% proximal occlusion and mid 70% which were stented. ACT returned as 85 (later attributed to heparin infiltration in peripheral IV). The patient became hypotensive and went into respiratory distress. Her LCx was found to have a fresh thrombus, as well as new thrombus in the LMCA. She was intubated and placed on a balloon pump. Dopamine and levophed were started. Integrillin was started. The LCx was restented twice. . On arrival to the floor the patient was noted to be significantly oozing from the groin. Vascular surgery was consulted and applied Femstop to stop bleeding. She received 1 unit pRBCs. Integrillin gtt was stopped. dopa @ 5, levo @ 0.16 . Past Medical History: HTN CAD s/p CABG: 15 yrs prior. SVG-> LAD and SVG -> RCA DM hypercholesterolemia dementia syncope depression Social History: lives in [**Location **], has son who is HCP. Family History: unknown Physical Exam: Vitals: T: 97.3 P: 84 BP: 91/47 RR: 16 SaO2: 97% AC: 550/16/1.0/5 General: Intubated, sedated, NAD. exam limited by bedrest s/p cath HEENT: PERRL, sclera anicteric. MMM Neck: supple, no JVD or carotid bruits appreciated Pulm: lungs coarse Cardiac: RRR, nl S1/S2 Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted. Ext: 1+ edema b/t. L groin with FemStop in place. R groin c/d/i. Right leg with 1+ dp. Left leg with mottled skin and nl capillary refill, dopplerable dp. Neurologic: intubated, sedated, MAE spontaneously. Pertinent Results: Echo [**2101-8-6**]: 1. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Inferior, lateral, and apical akinesis with septal and anterior hypokinesis is present. LVEF 30% 2. The aortic root is moderately dilated. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. . Admission Labs: [**2101-8-5**] 09:42PM TYPE-MIX PH-7.32* [**2101-8-5**] 09:42PM LACTATE-2.6* [**2101-8-5**] 09:42PM O2 SAT-67 [**2101-8-5**] 09:42PM freeCa-1.00* [**2101-8-5**] 09:30PM TYPE-ART PO2-174* PCO2-40 PH-7.37 TOTAL CO2-24 BASE XS--1 [**2101-8-5**] 09:30PM O2 SAT-99 [**2101-8-5**] 09:12PM GLUCOSE-295* UREA N-24* CREAT-1.0 SODIUM-135 POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-16 [**2101-8-5**] 09:12PM CK(CPK)-1275* [**2101-8-5**] 09:12PM CK-MB-123* MB INDX-9.6* [**2101-8-5**] 09:12PM MAGNESIUM-1.8 [**2101-8-5**] 09:12PM WBC-24.4*# RBC-3.88* HGB-10.8* HCT-32.0* MCV-83 MCH-27.9 MCHC-33.7 RDW-14.9 [**2101-8-5**] 09:12PM PT-14.2* PTT-115.8* INR(PT)-1.3* [**2101-8-5**] 07:21PM TYPE-ART RATES-13/ TIDAL VOL-500 PEEP-5 PO2-179* PCO2-52* PH-7.21* TOTAL CO2-22 BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED [**2101-8-5**] 07:21PM O2 SAT-98 [**2101-8-5**] 05:38PM TYPE-ART RATES-/14 O2-99 O2 FLOW-15 PO2-198* PCO2-41 PH-7.45 TOTAL CO2-29 BASE XS-4 AADO2-492 REQ O2-80 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2101-8-5**] 05:38PM O2 SAT-98 [**2101-8-5**] 02:24PM LACTATE-2.2* [**2101-8-5**] 12:30PM GLUCOSE-161* UREA N-22* CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17 [**2101-8-5**] 12:30PM CK(CPK)-827* [**2101-8-5**] 12:30PM CK-MB-105* MB INDX-12.7* cTropnT-1.02* [**2101-8-5**] 12:30PM WBC-14.1* RBC-4.38 HGB-12.5 HCT-37.3 MCV-85 MCH-28.6 MCHC-33.6 RDW-14.8 [**2101-8-5**] 12:30PM NEUTS-87.4* BANDS-0 LYMPHS-7.7* MONOS-3.6 EOS-1.2 BASOS-0.1 [**2101-8-5**] 12:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2101-8-5**] 12:30PM PLT SMR-NORMAL PLT COUNT-316 [**2101-8-5**] 12:30PM PT-12.2 PTT-21.4* INR(PT)-1.1 . Labs at time of Expiration: [**2101-8-15**] 04:00AM BLOOD WBC-16.5* RBC-3.14* Hgb-9.1* Hct-27.0* MCV-86 MCH-29.1 MCHC-33.9 RDW-15.6* [**2101-8-15**] 04:00AM BLOOD Neuts-73* Bands-5 Lymphs-7* Monos-9 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-1* NRBC-2* [**2101-8-15**] 04:00AM BLOOD Plt Smr-UNABLE TO [**2101-8-15**] 04:00AM BLOOD Glucose-49* UreaN-46* Creat-0.8 Na-148* K-3.8 Cl-111* HCO3-31 AnGap-10 [**2101-8-15**] 04:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.6 [**2101-8-15**] 09:09AM BLOOD Type-ART Temp-37.6 pO2-89 pCO2-43 pH-7.48* calTCO2-33* Base XS-7 [**2101-8-15**] 04:35AM BLOOD Lactate-2.0 [**2101-8-15**] 09:09AM BLOOD O2 Sat-96 [**2101-8-15**] 04:35AM BLOOD freeCa-1.17 . Micro: Fungal Swab: FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. . Chest X Ray [**2101-8-15**]: Severe pulmonary edema has worsened again obscuring the cardiac silhouette which is not particularly large. There is more mediastinal vascular engorgement and at least small bilateral pleural effusions are presumed. No pneumothorax. ET tube and nasogastric tube in standard placements. Brief Hospital Course: <b>Assessment and Plan: 86 yo F with h/o HTN, CAD s/p remote CABG, DM who presents from NH with acute SOB and diaphoresis, transferred here for NSTEMI, admitted to CCU s/p cath on IABP, pressors, and intubated. . Cardiac: Pump: The patient developed cardiogenic shock while in the cath lab, requiring placement of IABP and support with pressors. CI and SVR gradually improved, allowing discontinuation of the IABP and pressors. The patient remained volume overloaded and was therefore diuresed with IV lasix and responded very well. However, she continuously dropped her BP and required intermittent fluid boluses to maintain her BP. Blood transufions were also given during her episodes of hypotension to encourage fluid mobilization and maintain her hematocrit. Her CXR initially improved. However, she did continue to have patchy infiltrates despite good duresis. At the time of her death, she did have diffuse course breath sounds. . Ischemia: She had an infero/anterolateral MI, was s/p cath for NSTEMI and LCx stenting. The patient was not treated with intergrillin due to bleeding/oozing from groin sites. She was continued on aspirin, and plavix. Atorvastatin 80 mg qday was held for 2 days post cath for concern of drug fever, however, as her fevers continued without the medication it was restarted. She was started on a betablocker despite transient hypotension. The CCU team stopped following her cardiac enzymes, and continued her medical regimen up until the time of her death. . Rhythym: The patient had an episode of SVT (afib vs aflutter) on [**2101-8-11**], which broke with metoprolol IV and PO. She was then continued on metoprolol. She was monitored on telemetry throughout her hospitalization. She maintained her rhythm up until her death, eventually ending in asystole. . Respiratory failure: The patient was intubated in the cath lab. She was thought to be in heart failure post cath, and so was diuresed with IV lasix, however, ARDS was also on the differential given her persistant high O2 requirement. The patient then developed persistant fevers with elevated WBC count, and so was treated empirically for pneumonia with Zosyn/Vanco. Sputum cultures were unremarkable. An A-line was placed for closer monitoring of ABG's. On the last day, Fluconazole was added for possible yeast infection, although the likelihood was low. She initially tolerated trials of pressure support. However, she persistently dropped her 02 sats into the 80s. Her 02 requirement increased to an Fi02 of 0.6. Her PEEP could not be lowered. She persistently failed her RSBIs. The decision was made that extubation would be very difficult and unlikely. With that in mind, the family decided to withdraw care. She was made CMO and extubated. She persisted for 4 hours, with 02 sats in the 70's. She was comfortable at the time of her death. . Fevers: Throughout admission, she continued to spike fevers to 101+. She was initially started on Levaquin/Flagyl for aspiration pneumonia. However, her regimen was changed to vancomycin/Zosyn for pseudomonal coverage. She continued to spike fevers. Culture data remained negative. On the last day, Fluconazole was added for yeast coverage. . Diabetes Mellitus: The patient had high insulin requirements on tube feeds, therefore she was maintained on an insulin gtt. Her home avandia was held. Thyroid: the patient was continued on her home dose synthroid. . Psych: The patient was continued on her home dose zoloft. . Prophylaxis: PPI, bowel regimen . FEN: She was maintained on tube feeds. Electrolytes were monitored and repleted PRN. . Code Status/Disposition: She was initially DNR/DNI. However, this was reversed for catheterization. However, once her condition worsened, the family decided to make her CMO, the patient was then extubated and comforted with morphine/ativan boluses. After 4 hours, the patient went into asystole. Pulses could not be felt and we could not appreciate spontaneous breaths or heart beats for over 2 minutes. She was pronounced dead at 6:10PM. Her son and daughter were present. They did not want an autopsy. Medications on Admission: lasix 20 PO QOD ASA 325 avandia 8 mg levothyroxine 100 mcg lipitor 40 mg zoloft 25 mg detrol LA 4 mg QD neurontin Vitamin B12 1000 Qmonth namenda Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Non-ST Elevation Myocardial Infarction complicated by cardiac arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

41071,4280,99672,78551,9971,4275,5185,41401,4019,25000,2720,2948,311,V4581,V667

Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**] Service: ADDENDUM TO PREVIOUS DISCHARGE SUMMARY Add to medication list: Lasix 40 mg p.o. q.d. In regard to patient's congestive heart failure management, patient apparently was on isosorbide dinitrate 10 mg p.o. t.i.d. as an outpatient. This medication was tried prior to discharge and patient experienced hypotension with a low dose of this medication. Subsequently this medication was discontinued. Patient did quite well with diuresis with 20 mg of intravenous Lasix and thus the patient was discharged on a dosage of 40 mg daily p.o. q day. Non-ST elevation myocardial infarction: The patient frequently had rapid rate in the 110 range but her blood pressure would not tolerate further increase in metoprolol as she was already on a large dose of 50 mg p.o. t.i.d. which should be continued as an outpatient and on further follow up with her primary care physician this metoprolol dosage could likely be changed to a q.d. dosing. This was not done further prior to discharge since further titration of her medications may be needed. Eye issues: The patient has right conjunctival erythema most likely secondary to Bell's palsy causing a droopy lower lid. Patient apparently was on gatifloxacin eye drops for an unknown reason and unknown duration of time per her ophthalmologist, Dr. [**Last Name (STitle) 106470**]. Since Dr. [**Last Name (STitle) 106470**] could not be reached, I suggested that patient's daughters follow up with her outpatient ophthalmologist to make a follow up appointment regarding further use of these eye drops, their indication for use and any further follow up appointments that area needed. Patient had no signs or symptoms of infection, conjunctivitis and her eye apparently appeared improved than one month ago per the patient and her family. DISCHARGE MEDICATIONS: Addended should read aspirin 325 mg p.o. q.d., atorvastatin 10 mg p.o. q.d., Lasix 40 mg p.o. q.d., Atrovent inhaler q 6 hours p.r.n., nitroglycerine sublingual 0.3 mg sublingual p.r.n., Protonix 40 mg p.o. q.d., metoprolol 50 mg p.o. t.i.d., levofloxacin 250 mg p.o. q.d. times six more days to complete a ten day course for community acquired pneumonia, and last warfarin 3 mg p.o. q.h.s. Patient should follow up with her primary care doctor regarding her Coumadin and INR levels. I also advised at the rehabilitation facility that patient should have her potassium checked as well as her INR checked at least every other day to ensure therapeutic level of her Coumadin dosing as well as electrolyte repletion for diuresis. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 10397**] MEDQUIST36 D: [**2103-5-24**] 12:23 T: [**2103-5-24**] 12:11 JOB#: [**Job Number 106471**]

4280,41091,486,42731,00845,2765,41401

Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**] Service: DISCHARGE SUMMARY ADDENDUM HOSPITAL COURSE: Congestive heart failure: The patient was placed on BiPAP temporarily overnight in the Intensive Care Unit for eight hours and maintained stable oxygenation and good O2 saturations. She showed good improvement with Lasix 20 mg intravenous and a nitro drip which was shortly discontinued. It was thought that her episode of acute pulmonary edema was most likely in the setting of hypertension and tachycardia which was stabilized in the Medicine Intensive Care Unit. Patient was restarted on her beta blocker for improved rate control and at the time of this dictation is currently at a dosage of metoprolol 50 mg p.o. t.i.d. For further afterload reduction, patient was also started briefly on an ACE inhibitor but did not tolerate a low dose of 6.25 mg secondary to hypotension. Patient was also diuresed with Lasix 20 mg intravenous as needed for goal fluid balance of negative 500 cc per day. At the time of this dictation, patient has been diuresing well to 20 mg of intravenous Lasix per day but her chest x-ray still indicates mild failure and bilateral pleural effusions. She could likely use more diuresis and will likely be discharged on a standing Lasix dose. In addition patient had a transthoracic echocardiogram performed on [**5-21**] which revealed diastolic dysfunction, ejection fraction greater than 55 percent with a dilated left atrium and right atrium, mild symmetric left ventricular hypertrophy, normal left ventricular cavity size and normal left ventricular function, mild atrial fibrillation, trace aortic regurgitation and mild to moderate 1 to 2 mitral regurgitation. There were no wall motion abnormalities. Coronary artery disease/Non-ST elevation myocardial infarction: The patient did have an episode of chest pain during her Medical Intensive Care Unit stay and described as "indigestion" substernal pain for 30 minutes unrelated to food with associated mild shortness of breath and light headedness. Her EKG showed no new T wave inversions and [**Street Address(2) 28585**] depressions in V4 to V6. She was given one sublingual nitroglycerine with relief of pain but her EKG remained unchanged with persistent T wave inversions and [**Street Address(2) 4793**] depressions in V4 to V6. Cardiology was called to ask whether further intervention would be needed and cardiology suggested that in this [**Age over 90 **] year-old woman with an elevated INR cardiac catheterization would not be indicated. They suggested medical management. Patient's cardiac enzymes trended upward through her stay with a peak CK of 79, MB fraction 11, troponin 0.17. Patient was continued on her aspirin and was started on a low dose heparin drip with no bolus given her history of GI bleed. Her metoprolol dose was titrated up to control her heart rate to allow better filling and better systolic blood pressures. Patient remained chest pain free throughout the rest of her hospital course and her enzymes trended downward. Her heparin drip was stopped the day after her episode of chest pain she had some mild hematuria and had no further indications for heparin drip. She was also started on a statin 10 mg q day. The patient's outpatient cardiologist, Dr. [**Last Name (STitle) **], was contact[**Name (NI) **] and patient has refused a cardiac stress test in the past. Patient's outpatient cardiologist agreed with starting low dose Captopril (patient did not tolerate this in the hospital and thus it was discontinued) and agreed also with titrating up patient's beta blocker. Pneumonia: Although patient initially did not show signs of an infiltrate on chest x-ray and it was thought that patient most likely had a bronchitis early on admission. Patient's white count was trending upward to a peak of 15,000 and had mild low grade fevers. In the Medical Intensive Care Unit patient was started on empiric coverage for community acquired pneumonia with levofloxacin and her white count has been trending downward and she has remained afebrile. Her chest x-ray shows a left basilar opacity which could be an infiltrate versus atelectasis versus pleural effusion. She should continue her Levaquin for a total ten day course. Sputum culture was obtained during this hospitalization which showed 3+ gram positive, 2+ gram positive cocci in pairs and clusters and 1+ budding yeast but respiratory culture showed only oropharyngeal flora and no specific organisms. Patient also incidentally had a urine culture drawn which showed no growth. Atrial fibrillation: Patient remained in atrial fibrillation with a rate of 90s to 100 throughout her hospital stay. Her beta blocker dose was increased to 50 mg p.o. b.i.d. to further control her rate. Patient was also briefly started on heparin drip for a non-ST elevation myocardial infarction and her Coumadin dose was held but at the time of this dictation patient has been restarted on her Coumadin home dose of 3 mg p.o. q.h.s. and patient will be discharged on this dose. Fluid, electrolytes and nutrition: Patient was maintained on a 2 gram sodium diet. She developed a contraction alkalosis likely secondary to diuresis but still appeared fluid overloaded on examination and by chest x-ray. Her electrolytes remained stable throughout her hospitalization. Prophylaxis: The patient is on Coumadin with a therapeutic INR and a PTI. CODE: Patient is a full code which was readdressed with her family. DISPOSITION: Patient was evaluated by Physical Therapy who felt that patient would benefit from rehabilitation. She will likely be discharged from the Intensive Care Unit itself or from a medicine floor as soon as a bed is available at rehabilitation. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE CONDITION: Stable with O2 saturations 96 to 98 percent on 2 liters nasal cannula. DISCHARGE MEDICATIONS: 1) Metoprolol 50 mg p.o. t.i.d., hold for SBP less than 100 and heart rate less than 55. 2) Coumadin 3 mg p.o. q.h.s. 3) Atorvastatin 10 mg p.o. q.d. 4) Levofloxacin 250 mg p.o. q day times six more days. 5) Protonix 40 mg p.o. q.d. 6) Aspirin 325 mg p.o. q.d., 7) Atrovent nebulizer inhaled q 6 hour p.r.n. wheezing. 8) nitroglycerine sublingual 0.3 mg p.r.n. chest pain. FOLLOW UP PLANS: 1) Patient should follow up with her primary care physician or primary cardiologist in one to two weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 10397**] MEDQUIST36 D: [**2103-5-23**] 15:20 T: [**2103-5-23**] 15:35 JOB#: [**Job Number 106469**] cc:[**Hospital3 26500**]

4280,41091,486,42731,00845,2765,41401

Admission Date: [**2103-5-20**] Discharge Date: [**2103-5-24**] Service: MEDICINE INTERIM SUMMARY - HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female, with a history of coronary artery disease without interventions, also with AFIB on Coumadin, who was brought to the Emergency Department by EMT for chief complaint of shortness of breath and chest pain. The patient had been feeling these symptoms for the entire day. She started to feel 5/10 chest pain, substernal in location, around the time of her shortness of breath which was also associated with dizziness. In the ambulance, blood pressure 200/100, heart rate 110, AFIB, with O2 sats 82% on room air. The patient was also tachypneic and had diffuse expiratory wheezes on exam. She was given oxygen, aspirin and Nitroglycerin x 3 without relief. In the Emergency Department, blood pressure was 184/128, heart rate 99, and in AFIB. She was still tachypneic with a respiratory rate of 35, 100% room air sats. Pedal edema was noted. The patient was given 1 Combivent neb for audible wheezing. A chest x-ray suggested failure, and the patient was treated with lasix and Nitro drip, but blood pressure decreased to the 90s, so Nitroglycerin drip was discontinued. Urine output after 20 of IV lasix was approximately 300 cc, and her symptoms improved. The patient was admitted to the medicine team for rule out MI and CHF therapy. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Coronary artery disease, EF not known. 3. History of peptic ulcer disease. 4. Status post bilateral cataract surgery. 5. History of GI bleed. 6. History of carotid stenosis. MEDICATIONS ON ADMISSION: 1. Propranolol 10 tid. 2. Lasix. 3. Coumadin 2 mg po q hs. 4. Albuterol prn. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Denies tobacco, alcohol or IV drug abuse. PHYSICAL EXAMINATION: Temperature afebrile, BP 159/76, heart rate 75, respirations 27, satting 97% on 3 liters. In general, the patient was an elderly female, sitting comfortably, in no apparent distress. HEENT: Extraocular movements intact. Pupils equal, round and reactive to light. Moist mucous membranes. NECK: Positive jugulovenous distention to jaw level, no bruits, no lymphadenopathy. PULMONARY: Diffuse crackles throughout and expiratory wheezes. CARDIOVASCULAR: Irregularly irregular. S1 and S2 normal. Positive systolic murmur at the apex. ABDOMEN: Soft, nontender, nondistended with good bowel sounds. EXTREMITIES: 2+ edema bilateral lower extremities, no clubbing or cyanosis, no calf tenderness. NEURO: Nonfocal. LABORATORIES ON ADMISSION: White blood cell count 12.8 with a differential of 76% neutrophils, 16% lymphocytes, 7% monocytes, 1% eosinophils, hematocrit 47, platelets 206. Chem-7 - sodium 133, potassium 4.5, chloride 93, bicarb 32, BUN 17, creatinine 0.9, glucose 166. Initial cardiac enzymes - CK 491, MB 1, troponin less than 0.01. INR 1.8, PTT 31.1. CHEST X-RAY (BY WET READ): Showed bilateral pleural effusions consistent with [**2102-4-1**]. EKG: AFIB, at a heart rate of 89, normal axis and intervals, poor R wave progression, no ST-T wave changes. ASSESSMENT: This is a [**Age over 90 **]-year-old female admitted initially for a CHF exacerbation, and with cardiac ischemia likely related to her CHF. HOSPITAL COURSE - 1) CONGESTIVE HEART FAILURE: The patient was initially admitted with shortness of breath likely secondary to CHF exacerbation. From a pulmonary standpoint, her breathing had improved after nebulizer treatment initially. On the day of admission and the day after admission, however, on [**5-21**] the patient had an acute episode of acute pulmonary edema. The patient's O2 saturation decreased to 84% on 2 liters. She appeared diaphoretic and dyspneic with audible wheezes. Initially, she was given albuterol nebs with minimal response. Vital signs were 170/100, heart rate 120s, respiratory rate 30. She was given lasix 20 mg IV x 1, nitropaste 0.5", morphine 0.5 mg x 1. After therapy, her blood pressure increased to 230/120 and a respiratory rate was in the 40s. She was given hydralazine 20 mg IV x 1, another 1 mg of morphine, and 2 sublingual Nitros which brought her blood pressure down slightly more to the 140s. The patient appeared lethargic and less short of breath. She maintained sats in the high-90s on 100% nonrebreather. EKG showed slight T wave inversions in V5 and V6 which were a subtle change from her prior EKG, and she was then transferred to the Fennard ICU for BiPAP and Nitro drip. A discharge summary addendum will accompany this discharge summary for further information on the [**Hospital 228**] hospital course. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 10397**] MEDQUIST36 D: [**2103-5-23**] 13:42 T: [**2103-5-23**] 13:51 JOB#: [**Job Number 106468**]

4280,41091,486,42731,00845,2765,41401

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

4280,41091,486,42731,00845,2765,41401

Admission Date: [**2150-4-10**] Discharge Date: [**2150-4-13**] Date of Birth: [**2074-7-30**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old gentleman who had had coronary artery bypass grafting x 4 in the past and aortic heart valve replacement, status post a GI bleed. He is preangioplasty for stent angioplasty for left internal carotid artery stenosis. PHYSICAL EXAMINATION: Vital signs were stable. He was afebrile. He was awake, alert and oriented x 3 in no distress. Pupils were equal, round and reactive to light, extraocular movements full. He was hard of hearing, and wore glasses. Lungs were clear to auscultation. He had a clean, dry and intact CABG incision. Cardiac was regular rate and rhythm, S1 and S2, no murmurs. Abdomen was soft, nontender, nondistended with positive bowel sounds. Extremities showed trace edema in the bilateral lower extremities. Neurologically cranial nerves two through 12 were intact. Smile was symmetric with no drift. Extraocular movements were full. Strength was [**4-20**] in all muscle groups. HOSPITAL COURSE: He underwent the left carotid stenting procedure on [**2150-4-10**] without complications. Postoperatively he was monitored in the surgical intensive care unit. He was awake, alert and oriented with extraocular movements full, smile symmetric, no drift, strength was intact. He was transferred to the regular floor on postprocedure day two. The patient was transferred to the floor on [**2150-4-12**]. He remained awake, alert and oriented x 3 with no drift. His strength was [**4-20**] in all muscle groups. He had a small groin hematoma. He had positive pedal pulses. He is going to have an ultrasound of his left internal carotid artery today and then will be discharged to home for work-up with Dr. [**Last Name (STitle) 1132**] in two weeks' time, on Plavix, aspirin and Aggrenox. DISCHARGE MEDICATIONS: 1. Venlafaxine 75 mg p.o. q.d. 2. Percocet 1-2 tablets p.o. q. 4 hours p.r.n. 3. Enteric-coated aspirin 325 p.o. q.d. 4. Simvastatin 20 mg p.o. q.d. 5. Protonix 40 mg q. day. 6. Metoprolol 25 mg p.o. b.i.d. 7. Aggrenox 1 capsule p.o. b.i.d. 8. Plavix 75 mg p.o. q. day. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2150-4-13**] 08:49 T: [**2150-4-13**] 09:26 JOB#: [**Job Number 49297**]

43310,41401,V4581,53081,311,V433

Admission Date: [**2177-4-2**] Discharge Date: [**2177-4-7**] Service: CCU HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman with a history of AFib that has been difficult to rate control, who is scheduled for elective pacemaker placement and AVJ ablation on day of admission. After completion of pacemaker placement, patient's blood pressure dropped to 50/palpable. Volume resuscitation was begun and echocardiogram showed a large effusion with tamponade. Emergent pericardiocentesis was 300 cc of frank blood and improved blood pressure. Blood pressure decreased again and another 400 cc blood was pulled off. Pacing wire was repositioned successfully in the right ventricle and pacer was set at DDD at 90. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. Hypercholesterolemia. 4. Atrial fibrillation. 5. Atrial flutter. 6. Status post right atrial isthmus ablation in summer of [**2175**]. Was on amiodarone, but discontinued secondary to nausea and headache. Status post several admissions with AFib with RVR with rates in the 160s. Referred for pacer and AVJ ablation. Stress echocardiogram in [**2175-4-17**] showed an ejection fraction of 65%, mild AS and AI, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. ALLERGIES: Amiodarone causes headache and nausea. MEDICATIONS ON ADMISSION: 1. Atenolol 25 b.i.d. 2. Univasc 15 mg q.d. 3. Lescol 80 mg p.o. q.d. 4. Cartia 120 mg p.o. b.i.d. 5. Coumadin. 6. Levoxyl 75 mg p.o. q.d. 7. Vitamin E. 8. Vitamin C. 9. Calcium. 10. Magnesium citrate. 11. Calcium citrate. FAMILY HISTORY: Negative for diabetes and otherwise noncontributory. SOCIAL HISTORY: Denies drugs, tobacco, and alcohol. Lives in [**Location **] with friend. PHYSICAL EXAM ON ADMISSION: Temperature 97.3, blood pressure 120/59, heart rate 90, respiratory rate 16, and sats 100% on room air. Height is 5'5.5", weight 128 pounds. HEENT was moist mucous membranes. Clear oropharynx. Neck was supple. Jugular venous pressure is 6 cm. Cardiovascularly: S1, S2 with a 2/6 systolic ejection murmur at the right upper sternal border, and pericardial drain that was clean, dry, and intact. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, and nondistended, positive bowel sounds. Extremities: No cyanosis, clubbing, or edema. Neurologic examination: Awake, alert, and oriented times three. Cranial nerves II through XII are grossly intact. Intact strength and motor function, normal sensation. Skin: No rashes or lesions. LABORATORIES ON ADMISSION: White count 16.1, hematocrit 30.4, platelets 222. Potassium 4.2, creatinine 0.7, INR 1.3, PTT 25.1. Echocardiogram at 11:18 on day of admission showed moderate-to-large sized pericardial effusion with RV diastolic collapse. This is impaired filling and tamponade physiology. At 11:21 a.m. status post pericardiocentesis, just trivial physiologic pericardial effusion. HOSPITAL COURSE: This was an 81-year-old woman with a history of atrial fibrillation, atrial flutter, status post right atrial isthmus ablation in the summer of [**2175**] admitted for pacer placement. Procedure complicated by RV perforation requiring pericardiocentesis with removal of 700 cc of blood. 1. Hemorrhagic pericardial effusion with tamponade: Patient's drain output continued to decline and patient's drain was eventually removed with good results. Patient remained hemodynamically stable. She got 2 units of packed red blood cells in the Cath Lab, but was otherwise stable. Patient had follow-up echocardiogram with no recurrence of the effusion even after Coumadin was removed. Plans were to stay off Coumadin for at least one month secondary to this bleed. Otherwise, patient was started on Ancef 1 gram q.8 initially and then titrated off. 2. Atrial fibrillation: Patient continued to have episodes of tachycardia. Patient was continued on her outpatient regimen eventually and titrated up as tolerated. Patient's diltiazem dose was titrated up to 180 b.i.d. at time of discharge. Her atenolol at her home b.i.d. dose regimen was titrated up to 50 mg b.i.d. Patient was started on aspirin to which she is to continue especially while she is off Coumadin. Otherwise, patient was doing well and was planned for EP study as an outpatient. Patient will follow up with [**Hospital **] Clinic, on [**4-9**] for Device Clinic and then will return on [**4-29**] for AVJ ablation. 3. Pneumothorax: Patient had a small pneumothorax after her pacer placement. Leads were in place and pneumothorax had resolved by the time of dischar ge on follow-up chest x-ray. 3. Hypothyroidism: The patient was continued on her home dose of Levoxyl. Patient's TSH was elevated, but her free T4 was in the normal range, and this was likely secondary to subacute hypothyroid picture. No changes were made during this acute setting. DISCHARGE DIAGNOSES: 1. Right ventricle perforation. 2. Atrial fibrillation. 3. Atrial flutter. 4. Hypertension. 5. Hypothyroidism. 6. Pericardial effusion and tamponade. 7. Pneumothorax. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. once a day. 2. Atenolol 50 mg p.o. b.i.d. 3. Diltiazem extended release 180 mg p.o. b.i.d. 4. Ascorbic acid 500 mg p.o. b.i.d. 5. Vitamin E 400 units p.o. q.d. 6. Levothyroxine 75 mcg p.o. q.d. DISCHARGE CONDITION: Good. Patient is ambulating without difficulty. Chest pain free at present, no oxygen requirement. DISCHARGE STATUS: Discharged to home with followup. FOLLOW-UP INSTRUCTIONS: The patient is to see her PCP [**Last Name (NamePattern4) **] [**1-17**] weeks. Patient is to followup in Device Clinic on [**4-9**] at 9:30 and then for return on [**2177-4-29**] for an AVJ ablation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2177-4-7**] 13:50 T: [**2177-4-8**] 08:58 JOB#: [**Job Number 26913**]

42731,9971,9982,5121,42732,4239,4019,2449,2720

Admission Date: [**2153-4-17**] Discharge Date: [**2153-4-27**] Date of Birth: [**2153-4-17**] Sex: M Service: Neonatology HISTORY: Baby [**Name (NI) **] [**Known lastname 5253**] is a term infant admitted with increasing head circumference and bruising. He was born to a 31-year-old G1 P0 now 1 mother with unremarkable prenatal screens as follows: O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, PREGNANCY HISTORY: Estimated date of delivery was [**2153-4-23**] for estimated gestational age of 39-1/7 weeks. Pregnancy was complicated by oligohydramnios with an AFI of 3.5 and by multiple evaluations for decreased fetal movement. There was spontaneous onset of labor progressing through vacuum assisted vaginal delivery under epidural anesthesia. clear amniotic fluid, no antepartum maternal fever or fetal tachycardia, no antepartum antibiotic prophylaxis. Baby was vigorous at delivery, was bulb suction, dried, and had free flow oxygen administered briefly. Apgars were nine and nine. In the Newborn Nursery, he initially had a caput which increased in the amount of swelling and bruising in the subsequent 24 hours. He was then referred to the NICU for assessment and management of the increased bleeding. PHYSICAL EXAMINATION UPON ADMISSION TO THE NICU: Birth weight was 3850 grams. Head circumference was 41 cm. HEENT was significant for swelling of the scalp tissue in generalized distribution with ecchymosis extending from the occiput to the posterior auricular area and dorsal aspect of the neck to the mid cervical level. Ears were displaced forward. Eyes were normal. Neck and mouth were normal. No nasal flaring. Chest: No retractions, good breath sounds bilaterally, no crackles. Cardiovascular: Regular, rate, and rhythm. Femoral pulses normal, S1, S2 were normal. There was a 1/6 systolic ejection murmur in the upper left sternal border without radiation. Abdomen was soft, nontender, no organomegaly, no masses. Bowel sounds are active and patent. CNS active, responsive to stimulation. Pupils are reactive to light. Tone is normal, moving all limbs symmetrically, irritable with palpation of the scalp. Suck, root, gag, grasp, and morrow were normal. Skin: Pale as above, nonicteric. Musculoskeletal: Normal spine, hip, clavicles, small mass at the site of previous right quadriceps intramuscular injection. An initial head CT scan had revealed extracranial soft tissue swelling most prominently at the right frontal-parietal-occipital area extending to the left and to the upper cervical region. Ventricles were symmetrical and not compressed. No gross intraparenchymal hemorrhage. But upon further radiology attending [**Location (un) 1131**], there was a small bilateral occipital subdural hemorrhage noted. The initial hematocrit was 21.2, platelets 186. PT was 14.6, PTT 77 with an INR of 1.4. Fibrinogen was 192. D-dimer was negative. ASSESSMENT: This is a term infant with significant subgaleal hematoma with apparent extension over the past six hours. There was also elevation of the PTT suggesting possible inborn coagulopathy. There is also critical anemia secondary to the subgaleal hemorrhage. He was admitted to the NICU for further management. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Patient has been on room air maintaining sats above 95%. No apnea or bradycardia. 2. Cardiovascular: There was an initial murmur on admission likely secondary to severe anemia which has since resolved. He remained hemodynamically stable throughout this admission. 3. FEN: Patient was restarted on po feeds as of day of life three after the bleeding had stabilized. He has been taking breast milk or Enfamil 20 po adlib. His admission weight was 3850 grams. His weight on discharge was 4055. 4. GI: Given the significant amount of bleeding, baby was started prophylactically on phototherapy. His bilirubin peaked on day of life three at 5.4 with a subsequent bilirubin of 4.6 at which time phototherapy was discontinued. 5. Hematology: Given the rapid extension of the subgaleal bleed, coagulopathy workup was initiated revealing an elevated PTT level of 77 as well as factor 8 level that was below detection in the presence of normal factors 5, 9, 10, and 11. He was started on a 50 units/kg bolus of factor 8 followed by continuous factor 8 infusions at 50 units/kg/day divided until hourly infusion rates at [**4-19**]. Subsequent factor 8 levels varied with an initial factor 8 level of 18 after the bolus with which he received another bolus of factor 8 of 50 units/kg and increased factor 8 infusion rate to 65 units/kg/day. As of [**4-26**], he was switched over to bolus infusion in preparation of continued home factor 8 administration. His peak level after a bolus of 75 units/kg of factor 8 was 131. A trough level at 20 hours after the bolus on day of discharge was 29. He will continue to receive factor 8 bolus q day for a total of [**3-12**] weeks in light of the intracranial hemorrhage, and will be followed by Hematology visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 49178**] level checks at home. Currently, the infusion of factor 8 are going through a jugular Broviac which was placed on [**4-24**] for administration of factor. His last PTT on [**4-25**] was 68.3. The last hematocrit was on [**4-25**] of 54.5. 6. Neurology: Baby [**Name (NI) **] [**Known lastname 5253**] initially presented with significant subgaleal bleed as well as a small subdural hemorrhage. A repeat head CT scan on [**4-24**] had shown the resolution of the subdural hematoma and significant improvement of the subgaleal bleed. His head ultrasound on [**4-23**] reveals no interventricular hemorrhage. He had remained neurologically stable. His head circumference on [**4-27**] was 36.5 cm with a maximum head circumference on admission of 40.5 cm. 7. Social: Both parents are very involved in the care of Baby [**Name (NI) **] [**Known lastname 5253**]. They have been informed up to date on his needs, discharge from the hospital. Teaching has been completed on the care of the Boviak as well as administration of factor 8. 8. Sensory: Audiology: Hearing screen was performed automated auditory brain stem responses and Baby [**Name (NI) **] [**Known lastname 5253**] passed bilaterally. CONDITION ON DISCHARGE: Baby [**Name (NI) **] [**Known lastname 5253**] had been stable with improvement of the subgaleal bleed and good peak and trough factor 8 levels after the bolus infusion. DISPOSITION: Baby [**Name (NI) **] [**Known lastname 5253**] is to be discharged home with parents with close Hematology VNA followup. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 43197**]. CARE AND RECOMMENDATIONS: 1. Feeds at discharge: Breast milk Enfamil 20 po adlib as tolerated. 2. Medications: Factor 8 boluses at 75 units/kg/day. 3. Car seat position screening passed. 4. State Newborn Screen sent. 5. Immunizations: Received hepatitis B vaccination on [**4-25**]. FOLLOW-UP APPOINTMENT: Scheduled for [**4-30**]. DISCHARGE DIAGNOSIS: 1. Factor 8 deficiency. 2. Subgaleal hemorrhage, resolved. 3. Small occipital subdural hemorrhage, resolved Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Name8 (MD) 47634**] MEDQUIST36 D: [**2153-4-27**] 13:58 T: [**2153-4-27**] 14:22 JOB#: [**Job Number 49179**]

V3000,2860,7670,7728,V053,7765,7746

Admission Date: [**2159-8-26**] Discharge Date: [**2159-9-1**] Date of Birth: [**2159-8-26**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 6692**] was born at 34 5/7 weeks gestation to a 37 year old gravida III, para 0, now I woman. The mother's prenatal screens are blood type B negative, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B strep unknown. The mother was diagnosed with antiphospholipid antibodies after having had two spontaneous losses. This pregnancy was conceived with Clomid and intrauterine insemination. She was treated with Lovenox daily during the pregnancy. She had spontaneous rupture of membranes and labor was induced with Pitocin. She had a spontaneous vaginal delivery. The Apgars were 8 at one minute and 9 at five minutes. The birth weight was 2,165 grams (30th percentile), the birth length 43 cm (25th percentile), and the head circumference 32 cm (50th percentile. ADMISSION PHYSICAL EXAMINATION: Revealed a preterm infant, anterior fontanelle soft, open and flat, positive bilateral red reflexes. Palate intact. Mild intercostal retractions. The breath sounds were clear and equal. Heart was regular rate and rhythm, no murmur. Abdomen benign. No hepatosplenomegaly. Three vessel umbilical cord. Normal back, stable hip examination. Normal male genitalia for gestational age with testes descended bilaterally. Appropriate tone and strength. NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS: Respiratory: The infant has always remained on room air. He had some initial tachypnea and retractions which resolved in the first few hours of life. He has had no episodes of apnea, bradycardia or desaturation. On examination his respirations are comfortable. Lung sounds are clear and equal. Cardiovascular: He has remained normotensive throughout his Neonatal Intensive Care Unit stay. There are no cardiovascular issues. Fluid, electrolyte and nutrition status: At the time of discharge his weight is [**2184**] grams. Enteral feeds were begun on the day of life number one and advanced without difficulty to full volume feeding. At the time of discharge he is eating breast feeding and supplementing with 20 calorie per ounce formula on an ad lib schedule. Gastrointestinal status: He never required any phototherapy. His peak bilirubin on day of life number four was total 11.4, direct 0.4. Hematology: His hematocrit at the time of admission was 48.5. He has never received any blood product transfusions. Infectious Disease Status: The infant was started on ampicillin and Gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures negative. Genitourinary: The infant was circumcised on [**2159-8-31**]. The area is healing nicely. SENSORY: Audiology screening: The hearing screening was performed with automated auditory brain stem responses. The infant passed in both areas. PSYCHOSOCIAL: The parents have been very involved in the infant's care during his Neonatal Intensive Care Unit stay. The infant is discharged in good condition. Primary pediatric care will be performed by Dr. [**Last Name (STitle) **] of [**Hospital 57574**] Pediatrics. Telephone number is [**Telephone/Fax (1) 43701**]. RECOMMENDATIONS AFTER DISCHARGE: Feedings: Feeding and moving toward exclusive breast-feeding is the mother's plan. The infant is discharged on no medications. The infant passed a car seat position screening test. A State Newborn Screen was sent on [**2159-9-1**]. The infant received his first hepatitis B vaccine on [**2159-8-26**]. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis to be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with two of the following: Day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings or 3) With chronic lung disease. 1. 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 live immunization against influenza is recommended for household contact and out of home care givers. DISCHARGE DIAGNOSES: 1. Prematurity at 34 5/7 weeks. 2. Sepsis ruled out. 3. Status post transitional respiratory distress. 4. Status post circumcision. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2159-9-3**] 01:55:21 T: [**2159-9-3**] 09:06:46 Job#: [**Job Number 57575**]

V3000,7742,V290,V502,V053,76518,76527,7706

Admission Date: [**2161-12-20**] Discharge Date: [**2161-12-23**] Date of Birth: [**2107-6-7**] Sex: M Service: MEDICINE Allergies: Motrin / Iodine; Iodine Containing / Naprosyn Attending:[**Last Name (NamePattern1) 7539**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization and primary stent to distal RCA History of Present Illness: 54yo man with pmh significant for CAD, h/o CABG [**2158**] (LIMA and SVG to LAD, SVG to OM, SVG to PDA) presented to the ED c/o midsternal chest pain radiating between shoulders. Pain [**7-28**], sudden onset lasting for 30 minutes prior to arrival at ED, associated with SOB, without N/V/diaphoresis/parasthesias/fever/chills. EMS administered NTG with subsequent BP drop. ECG revealed 1 mm STE inferiorly with hyperdynamic T waves. In cath lab, LMCA with mild disease, LAD totally occluded after second septal, graft to LAD not engaged, presumed occluded. Left cx widely patent, SVG occluded, RCA with patent proximal stent, total occlusion of mid RCA with left to right collaterals to PL. All SVG occluded (to OM) or presumed occluded (LAD, RCA). RCA was stented with cypher stent, PL was dilated with balloon. Pt transferred to unit for monitoring. Social History: Patient lives with his wife and two daughters. Physical Exam: T 98.9 BP 112/67 HR 76 RR 18 O2Sat 98% 2L; General appearance: no apparent distress. Head and neck is nonicteric, mucosa moist. No JVD. Lungs are clear to auscultation bilaterally. Cardiac examination: Distant heart sounds, regular rate and rhythm. Abdomen is obese, nontender, and nondistended. Extremities had no clubbing, cyanosis, or edema. Neurologic examination: Is alert and oriented times three, grossly nonfocal exam. Groin: cath site without hematoma or bruit. Pertinent Results: Cardiac Cath - COMMENTS: 1. Selective coronary angiography revealed a right dominant system with acute occlusion of the RCA. THe LMCA had mild diffuse disease. The LAD was totally occluded after the second septal. The composite SVG-LIMA graft to the LAD was not engaged or seen on aortography and is presumed occluded. The LCx had a widely patent stent in the native OM1 artery. The SVG to OM is stump occluded. THe RCA had a patent proximal stent and total occlusion of the mid RCA with left to right collaterals to the PL branch. The SVG to RCA is known occluded from prior cath. 2. Hemodynamics revealed significantly elevated left and right heart filling pressures, pulmonary hypertension and preserved cardiac index. 3. Left ventriculography was note performed. 4. Successful PCI of the RCA with a 3.5 x 33 mm Cypher DES, post-dilated with a 4.0 mm balloon. Successful balloon angioplasty of the RPL with a 2.5 x 15 mm balloon. FINAL DIAGNOSIS: 1. Acute inferior myocardial infarction, managed by primary PCI. 2. Elevated left and right heart pressures with preserved cardiac output. 3. Successful PCI of the RCA. . . Echo - Conclusions: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated with mild regional left ventricular systolic dysfunction including severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract well. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-20**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Left ventricular cavity enlargement with regional systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Milldly dilated ascending aorta. . . [**2161-12-20**] 10:51PM WBC-5.5 RBC-4.38* HGB-12.1* HCT-35.8* MCV-82 MCH-27.6 MCHC-33.8 RDW-13.0 Brief Hospital Course: Pt was admitted and was taken to the cardiac catheterization lab where he received a cypher stent to the RCA. His hospital course was significant only for demonstrating several episodes of junctional rhythm which responded to atropine. Routine post myocardial infarction echo demonstrated an ejection fraction of 40 %. He was discharged to home to continue care with his cardiologist on an outpatient basis. Medications on Admission: Aspirin 325 mg Atorvastatin Calcium 80 mg Metoprolol Tartrate 25 mg [**Hospital1 **] Zetia 10 mg Moexipril 7.5 mg [**Hospital1 **] Celebrex 100 mg [**Hospital1 **] Zoloft 100 mg Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Moexipril HCl 15 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: myocardial infarction hypertension hypercholesterolemia gastro esophageal reflux disease Discharge Condition: stable Discharge Instructions: Adhere to 2 gm sodium diet Followup Instructions: 1)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-12-28**] 9:40 2)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-1-5**] 1:20 3)Dr.[**Name (NI) 9388**] office will contact you to make an appointment with him within the next several weeks Completed by:[**2162-1-11**]

41071,V4581,4019,53081,311,7291

Admission Date: [**2165-5-24**] Discharge Date: [**2165-5-27**] Date of Birth: [**2107-12-9**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old right-handed woman who was evaluated by a neurologist for vertigo. She indicates she was in her usual state of good health until approximately five days prior to her evaluation when she had complaints of the acute onset of vertigo, a sensation of being off balance, and vomiting. She also reports associated blurry vision with no headache, tinnitus, sensory symptoms, or speech difficulties. Her daughter, however, who was present during the interview today indicates that her speech was somewhat slurred. She was taken to [**Hospital **] Hospital where a head computed tomography showed "an abnormality." She had a magnetic resonance imaging/magnetic resonance angiography of the brain which showed evidence of a right posterior communicating artery aneurysm. She was referred to Dr. [**Last Name (STitle) 1132**] for endovascular vs. surgical therapy. She was admitted on [**2165-5-24**] for a conventional angiogram and consideration for endovascular treatment. PHYSICAL EXAMINATION ON PRESENTATION: She was a well-developed woman who appeared in mild discomfort. Her blood pressure was 120/80, her pulse was 72, her respiratory rate was 12, and she was afebrile. She was alert, awake, and fully oriented. Speech and language function were intact. Judgment, memory, and calculations were intact. Affect was appropriate. There was no apraxia, agnosia, or neglect. Cranial nerve examination revealed visual acuity was normal. She had a slight anisocoria with the left pupil approximately 4 mm in diameter and the right 3 mm. Both were equal, round, and reactive to light. There was no Horner syndrome or ptosis. The visual fields were full. Extraocular movements were full in all directions. Facial movement was intact. There was decreased sensation to touch on the left side of the face. Hearing was intact to rub. The palate elevated symmetrically. Motor examination revealed normal tone and muscle strength throughout. Cerebellar function was normal except for subtle clumsiness of the finger-to-nose on the left side. She also had slight difficulty drawing a figure eight with the left foot compared to the right. Deep tendon reflexes were 2+ throughout. SUMMARY OF HOSPITAL COURSE: She was admitted for angiogram for coiling of the right posterior communicating artery aneurysm. There were no intraoperative complications. Postoperatively, she was monitored in the Intensive Care Unit for close neurologic observation. She was started on heparin. The patient was in the Intensive Care Unit recovering from the coiling when she had the onset of unresponsiveness and bilateral pinpoint pupils. Her blood pressure rose to greater than 180 for a few minutes and then she had slight twitching of her head. She was immediately intubated and sedated and brought to head computed tomography which showed no evidence of bleeding or stroke. She was loaded prophylactically with Dilantin and started on Decadron. Her blood pressure was kept at less than 140. On [**5-25**], the patient was alert, awake, and oriented times three. She had some double vision in the left lateral gaze. She had negative drift. She had a slight hematoma of the right leg. Her iliopsoas were [**6-19**]. Her pulses were intact. Her Decadron was decreased. She was continued on Dilantin. She was out of bed to chair. On [**5-26**], there was no seizure activity. She was alert, awake, and oriented times three and moving all extremities with good strength. No drift. She continued to have a left lateral gaze minimal diplopia. She was stable, and she was transferred to the regular floor. On [**5-27**], she continued to be neurologically stable without any evidence of seizures. Alert, awake, and oriented times three. Moving all extremities. Her speech was fluent. DISCHARGE DISPOSITION: She was discharged on [**5-27**] in stable condition with followup with Dr. [**Last Name (STitle) 1132**] in one week. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets by mouth q.4h. as needed. 2. Decadron 2 mg by mouth q.6h. (for three days). 3. Famotidine 20 mg by mouth twice per day. 4. Dilantin 100 mg by mouth three times per day. 5. Aspirin 325 mg by mouth once per day. CONDITION AT DISCHARGE: Stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2165-5-27**] 13:56 T: [**2165-5-29**] 14:13 JOB#: [**Job Number 54801**]

4373,99709,78039,3682,30000,E8788

Admission Date: [**2177-10-13**] Discharge Date: [**2177-11-17**] Date of Birth: [**2177-10-13**] Sex: M Service: NEONATOLOGY HISTORY: This is the 1.315 kg product of a 28 [**1-9**] week twin gestation, born to a 27-year-old GI P0-II mother. Prenatal screens notable for maternal blood type A positive, antibody surface antigen negative, group B strep unknown. This is a Ultrasound at 23 weeks showed size discordance, attributed to twin-twin transfusion syndrome. Subsequent ultrasound showed increasing oligohydramnios but good biophysical profiles. The mother completed steroid therapy. These patients were delivered by cesarean section. Twin I emerged apneic but minutes. 1. Respiratory: The child was intubated and given 2 doses of surfactant, and rapidly weaned to CPAP and then nasal cannula. Intermittently the child had to go back on CPAP for increased spelling. He was started on caffeine and subsequently weaned onto nasal cannula on DOL #16 and onto RA on DOL#34. He is currently on caffeine. He has occasional spells. 2. Fluids, electrolytes and nutrition: He was initially nil by mouth and started on intravenous fluids. His feeds were advanced as tolerated .He is currently tolerating 150 cc/kg of PE28 with ProMod po/pg. 3. Infectious Disease: The patient had started antibiotics. Culture were negative at 48 hours, and these were discontinued. When he had increased spells, repeat CBC and blood cultures were done, but no further antibiotics were started. He is currently off all antibiotic therapy. 4. Cardiovascular: He never required blood pressure support, although he did have a murmur and was given a course of indomethacin. His murmur persisted. An echocardiogram was performed, which showed that he had a mild biventricular outflow obstruction, probably secondary to hypovolemia, but no structural heart disease and no duct. Repeat ECHO on DOL#28 revealed improved but mild biventricular hypertrophy, which will need to be followed as an outpatient at the Cardiology Clinic. 5. Hematology: He received a blood transfusion of 50 cc/kg since his hematocrit was relatively low and his echocardiogram was consistent with hypovolemia. He did require phototherapy for hyperbilirubinemia, however, at this time, he is off of phototherapy, with normal bilirubin levels. 6. Neurology: HUS on [**10-15**] and [**10-23**] were within normal limits Follow up HUS on [**2177-11-13**] revealed caudothalamic groove cyst PHYSICAL EXAMINATION: He is 2.170kg, he is non-dysmorphic. His cardiac examination shows a II/VI systolic murmur, regular rate and rhythm. His lung examination is clear bilaterally. His abdomen is soft and nondistended. The rest of his physical examination is within normal limits. CONDITION AT THE TIME OF THIS SUMMARY: Stable. FOLLOW UP 1. Paediatric Cardiology in mid [**Month (only) **] to F/U biventricular hypertrophy- parents will need to call for appointment 2. ROP screen on [**2177-11-19**] MEDICATION Caffeine 15mg po/pg qd Vit E 5 IU po/pg qd Ferrinsol 0.15cc po/pg qd DIAGNOSIS LIST: 1. Prematurity 2. Status post twin-twin transfusion 3. Mild apnea of prematurity 4. Status post rule out sepsis 5. Mild biventricular hypertrophy 6. Right subependymal cysts with resolved bilateral germinal matrix haemorrhages DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477 Dictated By:[**Name8 (MD) 45197**] MEDQUIST36 D: [**2177-10-31**] 17:56 T: [**2177-11-1**] 00:00 U: [**2177-11-17**] 09:00 JOB#: [**Job Number 35882**]

V3101,76515,7742,77081,4293,74689

Admission Date: [**2136-12-21**] Discharge Date: [**2136-12-23**] Service: HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old man who presents with shortness of breath. He was recently admitted to [**Hospital1 **] with chest pain on [**2136-12-15**]. Patient ruled in for a myocardial infarction with peak CK of over [**2135**]. Cardiac catheterization was done which showed three-vessel disease with an ejection fraction around 30%. Decision was made to manage the patient medically. He was also made DNR/DNI. He was discharged to rehab on [**2136-12-18**]. Patient was sent back to the Emergency Department today because of difficulty breathing. Patient was only able to provide limited history, but states he is still short of breath and is having cough. He denies chest pain. PAST MEDICAL HISTORY: Hypertension, depression, three-vessel coronary artery disease with an ejection fraction of 30%. MEDICATIONS ON ADMISSION: Aspirin, Lopressor, captopril, Lipitor, Protonix, Colace, Serzone, and Tylenol. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Patient has a father with coronary artery disease. PHYSICAL EXAMINATION AT TIME OF ADMISSION: Vital signs: 96.6, pulse 100, blood pressure 100/50, respiratory rate 40, and sating 98% on 100% nonrebreather. Generally he was in respiratory distress on 100% nonrebreather. HEENT: Pupils are equal, round, and reactive to light. OP with dry mucous membranes. Neck: Positive jugular venous distention. CVP estimated around 10. Respirations: Diffuse rhonchi most prominent in the right lower posterior lung fields. Coronary examination: regular, rate, and rhythm, no murmurs, rubs, or gallops. Abdomen was soft and nontender with positive bowel sounds, mild diffuse tenderness. Extremities: He had trace edema. Neurologic: He was alert and oriented times three. LABORATORIES ON ADMISSION: He had a white count of 19.0, hematocrit of 32.0, platelets 407,000. Sodium 134, potassium 6.2, chloride 100, bicarb 18, BUN 63, creatinine 2.8. His electrocardiogram showed a left bundle branch block. Chest x-ray with a bilateral infiltrates right greater than left and bilateral pleural effusions. ASSESSMENT AND PLAN: This is an 80-year-old man recently admitted with large myocardial infarction and now presenting with shortness of breath and increased respiratory rate. Chest x-ray suggestive of pneumonia and possible congestive heart failure. 1. Pulmonary. Plan to treat pneumonia with ceftriaxone and azithromycin in this critically ill patient. Also plan to continue oxygen, culture sputum, make him NPO. Pulmonary edema may also be playing a role, but will hold on Lasix given his hypotension. 2. Cardiovascular. Three-vessel coronary artery disease holding his po medications. Will consider restarting aspirin overall amount for myocardial infarction. 3. Renal. Creatinine increased. Check urine, electrolytes, and Foley. 4. ID. Blood cultures times two. Urine cultures. Sputum cultures. Ceftriaxone and azithromycin for pneumonia as above. 5. Gastrointestinal. NPO. 6. Code status. DNR/DNI. 7. Communication. Discussed with son and told him the next 12-24 hours are critical. HISTORY OF HOSPITAL COURSE: The patient began to have evidence of a further myocardial infarction with CK of 278 and a troponin of over 50. Patient was made comfort measures only. He is not a candidate for an invasive intervention. The patient continued to do poorly and died at 1 pm on [**2136-12-23**] after extensive discussions with the family. It was decided to discontinue oxygen. CONDITION ON DISCHARGE: Deceased. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36903**], M.D. [**MD Number(1) 36904**] Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1201**], M.D. MEDQUIST36 D: [**2136-12-23**] 13:19 T: [**2136-12-27**] 06:06 JOB#: [**Job Number 32157**]

486,4280,41091,5849,51881,4019

Admission Date: [**2159-8-10**] Discharge Date: [**2159-8-27**] Date of Birth: [**2097-12-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2159-8-13**] Two vessel coronary artery bypass grafting utlizing the left internal mammary to left anterior descending with vein graft from left internal mammary to obtuse marginal. [**2159-8-10**] Cardiac catheterization with placement of IABP History of Present Illness: This is a 61 year old Portuguese speaking man with history of hypertension and hyperlipidemia was admitted for an elective catheterization after an increase in DOE and increasing CP with walking. At present he is able to walk only 2 blocks before he becomes short of breath. He was previously quite active and athletic until two years ago when he began to have significant dyspnea on exertion and fatigue. He has a long standing history of tobacco and alcohol abuse. In [**2158-6-27**] while having a doctor's appointment, he was found to be extremely hypertensive and was admitted to [**Hospital3 2737**]. Testing at that time included a Cardiolite ETT where he exercised 5 minutes 31 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, 87% max PHR, stopping due to leg pain. EKG was non diagnostic due to baseline ST abnormalities. He had no chest pain. Imaging did not reveal any definite evidence of inducible ischemia. EF was noted at 22%. Echo on [**2158-7-25**] revealed a dilated LV with an EF of 25% with severe global hypokinesis. Last month the patient was admitted to [**Hospital6 **] in [**Location (un) 5503**] for a syncopal event. This was witnessed by a family member. He apparently had lost consciousness for several minutes. He was ruled out for an MI and told that this was most likely due to dehydration as it was a very hot day. Per Dr. [**Name (NI) 63433**] notes, an echo suggested a regional wall motion abnormality and persantine ETT suggested some anterior apical infarct with some inferoposterior ischemia. Cardiac catheterization was recommended but the patient refused. His family has since been able to convince him to have angiography. His daughter reports that her father can look short of breath at rest and with any type of walking. Previously he was quite athletic and now he cannot even walk a of a mile. She states that he easily becomes lightheaded when involved in light exertion or on a hot day. She also reports that over the past few months he has been getting chest discomfort with walking. He does not use SL nitroglycerin. She is unclear if he has a history of orthopnea or PND. She reports that he does not have LE edema. He does complain of leg fatigue with minimal amounts of walking. She reports that he has smoked 2 packs a day for over forty years and he has recently cut back to a pack a day. She also states that he has been drinking for at least forty years, currently imbibing in several beers and several glasses of wine throughout the day. He is also very non compliant with medications. Past Medical History: Cardiomyopathy, History of Syncope, ? Prior MI, Hypertension, Hyperlipidemia Social History: Patient is widowed and currently lives with his mother. [**Name (NI) **] is Portuguese speaking. He previously worked in a warehouse until last year, stopping d/t his health. Daughter reports that he has smoked 2 packs a day for over forty years and he has recently cut back to a pack a day. She also states that he has been drinking for at least forty years, currently imbibing in several beers and several glasses of wine throughout the day. His daughter [**Name (NI) **] helps out with his care. Family History: Mother with several [**Name (NI) 5290**] and a CVA in her 70's. Physical Exam: Vit: 140-150's/80-90, 81 regular, 18 Gen: WDWN male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD CV: regular rate and rhythm, normal s1s2, no murmur or rub Pulm: clear bilaterally Abd: benign, no organomegaly Ext: warm, no edema Skin: no lesions Neuro: alert and oriented, mood appropriate, cranial nerves grossly intact, FROM, 5/5 strength, no focal deficits Pertinent Results: [**2159-8-25**] 06:40AM BLOOD WBC-11.0 RBC-3.51* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.6 MCHC-34.7 RDW-13.9 Plt Ct-696* [**2159-8-26**] 06:20AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-133 K-4.4 Cl-99 HCO3-24 AnGap-14 [**2159-8-24**] 07:05AM BLOOD Mg-1.9 [**2159-8-11**] 08:44AM BLOOD Triglyc-144 HDL-43 CHOL/HD-4.2 LDLcalc-108 [**2159-8-11**] 08:44AM BLOOD TSH-3.5 Brief Hospital Course: Mr. [**Known lastname 19688**] was admitted and underwent elective cardiac catheterization which was signficant for severe three vessel disease(including left main) and severely depressed left ventricular function. Angiography demonstrated a co-dominant system with an 80% distal left main lesion, a heavily calcified LAD with 80% mid stenosis, an 80% lesion in the first obtuse marginal and a proximal 60% lesion in the right coronary artery. Ventriculogram revealed 1+ mitral regurgitatin and an LVEF of 25%. Based on his critical coronary anatomy, an IABP was placed to augment diastolic filling. Of note, catheterization was complicated by vasovagal episode which responded well to IV fluids and Atropine. Cardiac surgery was subsequently consulted and further evaluation was performed. An echocardiogram on [**8-11**] was notable for normal left ventricular cavity size. The overall left ventricular systolic function was moderately-to-severely depressed (ejection fraction 30%) secondary to severe hypokinesis of the anterior septum, anterior free wall, and apex. There was only mild(1+) mitral regurgitation. Workup was otherwise unremarkable and he was cleared for surgery. He remained pain free on medical therapy. On [**8-13**], Dr. [**Last Name (STitle) **] performed two vessel coronary artery bypass grafting. Operative findings were notable for a heavily calcified aorta. A cross-clamp was not utilized. The heart was therefore on bypass beating and the Guidant CTS off-pump system was used to obtain exposure on a beating empty heart. His operative course was otherwise uneventful and he transferred to the CSRU for further invasive monitoring. Within 48 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics as he weaned from inotropic support. The IABP was removed without complication. He experienced intermittent fevers with negative workup - blood and urine cultures remained negative. On postoperative day four, he transferred to the SDU. He went on to experience some confusion/agitation which initially required Haldol. Narcotics were also withheld. His symptoms progressed to visual hallucinations, diplopia, left visual field cuts associated with mild left sided weakness and facial droop. Neurology was urgently consulted and a head MRI/MRA was obtained on [**8-20**]. Findings were suggestive of a large subacute right occipital lobe infarct, within posterior cerebral artery territory. No was no evidence of intracranial bleed. Aspirin therapy was continued. Over the remainder of his hospital stay, his neurologic/mental status gradually improved and nearly returned to baseline. He worked daily and continued to improve with physical and occupational therapies. At discharge, his confusion had resolved and he had normal motor function. Unfortunately, he continued to experience left visual field cuts. He had no more diplopia. Given his depressed LV function, he was maintained on an ACEI and Coreg. He remained in a normal sinus rhythm without atrial or ventricular dysrhythmias. He was concomitantly diuresed toward his preoperative weight. He responded well to Lasix and by discharge, was near his preoperative weight with oxygen saturations of 98% on room air. His renal function remained normal. Just prior to discharge, he was treated with a short course of intravenous antibiotics for a superficial phlebitis. He was eventually discharged to home on postoperative day 14. He will be tranisitioned to PO antibiotics and follow up with Dr. [**Last Name (STitle) **] in approximately 4 weeks. Medications on Admission: Metoprolol 50mg twice a day Lipitor 20mg daily Lisinopril 10mg daily HCTZ 12.5mg daily Digoxin 0.25mg daily Asa 325mg daily NTP (unknown dose) daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 1 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Southeastern MA Discharge Diagnosis: CAD - s/p CABG Rt occipital CVA(postop) Cardiomyopathy s/p MI HTN Hyperlipidemia Phlebitis Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 2 pounds in one day or five in one week. Call with temperature more than 101.5, redness or drainage from incision. No driving, no lifting more than 10 pounds until follow up with surgeon. Adhere to 2 gm sodium diet 2 quarts Fluid Restriction Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Local PCP 2 weeks Cardiologist Dr. [**Last Name (STitle) 8098**] in 2 weeks Completed by:[**2159-9-13**]

41401,4280,4111,4240,4254,30391,5997,99702,4538,4019,3051,45829,E8790,E8498,2724,E8782,E8497

Admission Date: [**2110-6-13**] Discharge Date: [**2110-6-14**] Date of Birth: [**2050-6-20**] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old lady with past medical history significant for irritable bowel syndrome, hypertension, and hypercholesterolemia, who presents with bright red blood per rectum. The patient had a routine screening colonoscopy on [**2110-6-12**] at 11:30 a.m. She was found to have a polyp, which was removed. The patient was also noted to have mild diverticulosis. Around 5:30 p.m., the patient started to pass bright red blood per rectum approximately 100 to 400 cc every hour. She denied fever, chills, nausea, vomiting, or abdominal pain. She went to an outside hospital ED, but was transferred to [**Hospital1 18**] since her doctor was Dr. [**Last Name (STitle) 1940**] who is associated with [**Hospital1 18**]. In the ED, her vital signs were temperature 98, blood pressure 149/78, heart rate 80, respiratory rate 17, and saturating 97 percent on room air. Two large bore IVs were placed and the patient was resuscitated with 2 liters of IV normal saline. Her hematocrit was noted to drop from 39 to 22. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Inflammatory bowel disease. MEDICATIONS: 1. Diovan. 2. Premarin. 3. Lipitor. 4. Hydrochlorothiazide. ALLERGIES: CODEINE CAUSING NAUSEA. PHYSICAL EXAMINATION: Afebrile, heart rate 80, blood pressure 100/65, respiratory rate 15, and saturating 100 percent on room air. General: Pale, diaphoretic, alert female. HEENT: Oropharynx clear. Sclerae anicteric, but pale. Cardiovascular: The patient is tachy without murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft and nontender, normoactive bowel sounds, positive bright red blood in bedpan. Extremities: No clubbing, cyanosis, or edema. Pulses were 1 plus bilaterally. LABORATORY DATA: Chem-7 was unremarkable. CBC was remarkable for anemia with hematocrit of 27. KUB showing no free air. HOSPITAL COURSE: The patient was admitted to the MICU. On presentation to the MICU, she had a single IV. Initially her heart rate was in the 80s and her systolic blood pressure was in the 120s. However, she became more unstable and her heart rate jumped to 112 to 115 and her systolic blood pressure fell to the mid 90s. At this time a second IV was placed. The patient was transfused with packed red blood cells through both IVs. She remained tachycardiac and producing large amounts of blood per rectum. The decision was made to place a central line to allow for aggressive volume resuscitation. During the placement of the central line, the patient was complaining of some back pain, however, the wire fed easily and a 3-lumen catheter was placed. On chest x- ray, the catheter appeared to leave the subclavian vein into an internal mammary vein. However, since the central line both flushed and true blood, it was left in place temporarily. However, after the transfusion of 3 units of packed red blood cells the patient was stable, producing less blood per rectum, non-tachycardiac, the base systolic blood pressure in the 120s. Thus the central line was discontinued. The patient was seen by Dr. [**Last Name (STitle) 1940**] and the GI fellow. They took the patient to Endoscopy where they found red blood in the transverse, left, sigmoid, and rectum. There was no blood in the right colon. The polypectomy site was identified opposite the valve. It had a red clot on it, but was not bleeding. The clot was washed off. No bleeding was noted. Then 10 cc of epinephrine was injected 1:10,000 dilution into and around the base of the polypectomy. After this, BL-CAP electrocautery was applied for hemostasis successfully. There was no bleeding at the conclusion of the procedure. After this procedure, the patient's hematocrit remained stable. She was advanced to a clear liquid diet without difficulty. She had no additional episodes of bright red blood per rectum. Her diet was further advanced. She was monitored overnight and remained hemodynamically stable. She was discharged home the following day with followup to see Dr. [**Last Name (STitle) 1940**]. No changes to her medications were made. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: Gastrointestinal bleed status post polypectomy. DISCHARGE MEDICATIONS: No changes were made to her outpatient regimen. FOLLOWUP PLANS: The patient was asked to follow up with Dr. [**Last Name (STitle) 1940**] on Monday. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 39096**] Dictated By:[**Doctor Last Name 2020**] MEDQUIST36 D: [**2110-6-16**] 05:32:08 T: [**2110-6-16**] 06:14:05 Job#: [**Job Number 20597**]

99811,2765,E8788,5641,4019,2720,27541,5789

Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-13**] Date of Birth: [**2122-8-20**] Sex: F Service: ACOVE HISTORY OF PRESENT ILLNESS: This is a 74-year-old woman with history of Alzheimer's disease and hypercholesterolemia who has had two to three months of 25 pound weight loss, anorexia and dysphagia. She also reports increased burping. This was thought initially to be a side effect of Aricept, which was started approximately six months ago, however, with persistence of these symptoms, she reported to her primary care physician's who initiated a malignancy work-up. She was found to have pulmonary nodules on chest x-ray suspicious for lung metastases, guaiac positive stools, anemia, increased LFTs and also a bone scan positive for metastatic disease. The primary site of cancer was unknown. She was scheduled for a barium swallow on [**4-7**] and it is unclear whether this was done or not. She had a negative mammogram in [**2196-12-27**]. She was scheduled for a colonoscopy and esophagogastroduodenoscopy as an outpatient on the morning of admission, however, earlier that morning, she had an episode of bright red blood, hematemesis/hemoptysis after taking her pills. It was only approximately one ounce in quantity. There were no clots and no sputum. She had no other associated symptoms of nausea, vomiting, chest pain, lightheadedness, melena, bright red blood per rectum or abdominal pain. Her husband also reports she had transient hematuria ten years ago. An intravenous pyelogram was done with tomography with finding of widened bladder neck, otherwise, normal. The patient was sent from the Emergency Room where her vital signs were stable to the Esophagogastroduodenoscopy Suite where it was revealed an abnormal mucosa in the esophagus from 30 cm to 22 cm distally with adherent clot and moderate oozing. Colonoscopy was not performed at that time secondary to active bleeding and she was transferred to the Medical Intensive Care Unit for one night for observation. PAST MEDICAL HISTORY: 1. Alzheimer's disease. 2. Weight loss, dysphagia, anorexia, pulmonary nodules on chest x-ray guaiac positive stools, metastatic bone lesion on bone scan, increased LFTs, 3. Hypercholesterolemia. MEDICATIONS AT HOME: Aricept 5 mg po q.d., Lipitor 10 mg po q.d., Prempro .625/2.5 mg q.d., Centrum multivitamin. FAMILY HISTORY: No coronary artery disease. Father with duodenal/stomach cancer. Mother with question of mass in chest. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with her husband. One son, two grandchildren. She smokes less than one pack per day times 35 years and has occasional alcohol use. REVIEW OF SYSTEMS: No fevers, chills, nausea, vomiting, shortness of breath or chest pain. PHYSICAL EXAMINATION: Vital signs: Temperature 99.1. Pulse 96. Blood pressure 113/54. Respiratory rate 14-18. O2 saturation 100% on two liters nasal cannula. In general in no acute distress, pleasant woman. Neck: No lymphadenopathy, no thyromegaly, no axillary lymphadenopathy. Head, eyes, ears, nose and throat: Anicteric sclerae, dry mucous membranes. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, question of palpable liver edge 2 cm below diaphragm. Extremities: No edema. Neurological: Cranial nerves intact. Left lower extremity greater than right lower extremity weakness, [**2-28**] on the left and [**4-30**] on the right. LABORATORY DATA ON ADMISSION: White blood cell count 12.5, hematocrit 26.8, platelets 361,000. Neutrophils 87%, lymphocytes 8%, monocytes 5%, INR 1.1, PT 12.7, PTT 24.9. Sodium 138, potassium 3.3, chloride 99, bicarbonate 26, BUN 23, creatinine .8, glucose 120. WORK-UP PRIOR TO ADMISSION ON [**3-23**]: Sedimentation rate 68, ALT 33, AST 71, alkaline phosphatase 296, T bilirubin .8, GGT 81, albumin 3.8, total protein 6.9, globulin 3.1, calcium 9.9, TSH 2.6, iron 3, total cholesterol 218, TIBC 280, B12 984, folate greater than 20, ferritin 245, TRF 215, HDL 65, cholesterol to HDL ratio 3.4, SPEP abnormal band in gamma region 2% of total protein, IgG 698, IgA 318, IGM 214, IFE monoclonal IgM cap was seen. 24 hour urine: PH 5, protein 15, volume 380 cc, UPEP no Bence [**Doctor Last Name **] proteins, only albumin. Urine culture on [**3-23**] negative. CT of the head without contrast [**2196-6-26**]: Moderate atrophy without significant abnormalities. Mammogram [**2196-12-27**]: No evidence of malignancy. Chest PA and lateral [**2197-2-24**]: Extensive pulmonary and right hilar metastases. Left hip x-ray [**2197-3-28**]: Normal pelvis and left hip. Bone scan [**2197-4-7**]: Positive for multiple foci of increased activity, most likely secondary to metastatic disease, particularly in the right iliac crest within parietal region of calvaria. Esophagogastroduodenoscopy [**2197-4-10**]: Normal stomach, normal duodenum, esophagus with abnormal mucosa with bleeding in esophagus from 30 cm where the TE junction is seen to 22 cm proximally, adherent clot, active bleeding and friability. Lumen narrowed with ulceration and irregular mucosa. No varices. Biopsy performed at lower [**12-29**] of esophagus and middle [**12-29**] of esophagus. IMPRESSION: This is a 74-year-old woman with metastatic cancer of unclear etiology, although esophagogastroduodenoscopy results reveal bleeding ulcerations along the esophagus suggesting primary adenocarcinoma of the esophagus. SUMMARY OF HOSPITAL COURSE: 1. Bleeding eosphageal ulcerations: Likely eosphageal cancer. Patient was in the Medical Intensive Care Unit for one night and supported with intravenous fluids and transfused two units. She remained hemodynamically stable and hematocrit also bumped up appropriately to above 30 with the transfusions and remained stable throughout her hospital stay. Two large bore IVs were placed. Patient had no more episodes of hematemesis or any other signs of active bleeding. She was transferred to the floor after one night in the Medical Intensive Care Unit and her diet was advanced with good toleration. Patient was placed on a Protonix drip in the unit and once she came to the floor was on Protonix 40 mg po b.i.d. On the second day of admission, she was noted to have increased coagulation factors. INR 1.5, PT 14.6, PTT 25.7. She was started on Vitamin K subcutaneous injections times three days and her coagulation laboratories normalized by the time of discharge. 2. Hematology/Oncology: Patient was seen in the hospital by Dr. [**Last Name (STitle) **] from Hematology/Oncology who had already seen her once as an outpatient. The biopsy taken during esophagogastroduodenoscopy was nondiagnostic as it was mainly clot and necrotic tissue. However, a CT scan was done of her torso showing mediastinal lymphadenopathy, right hilar adenopathy, dilation of esophagus with air fluid level in the distal esophagus and distal esophageal wall markedly thickened beyond TE junction suspicious for malignancy. Innumerable pulmonary metastatic lesions and metastatic liver lesions, little normal liver tissue left, right adrenal mass likely metastases, renal cyst bilaterally, no free fluid or free air in the peritoneal cavity or pelvic cavity, no lytic or blast lesions seen in the bone. Of note, cavitary metastatic lesions in lungs suggestive of squamous cell primary. Given this, result of her CT scan, as well as what was done prior with definite metastatic disease, the patient's husband was seen by the Home Hospice Service and choose this as the next route management. Dr. [**Last Name (STitle) **] and her oncologist also felt that were no aggressive therapeutic measures to be done at this point, however, at a later time, if she becomes more symptomatic in terms of her swallowing or breathing, there may be room for palliative radiation or stenting placement in her esophagus. The patient will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. She was discharged to Home Hospice. 3. Alzheimer's disease. Appears to be moderate. Patient's family very supportive, making decisions for her. Aricept was held given her esophageal ulcerations. CONDITION OF DISCHARGE: Stable. DISCHARGE STATUS: Home with home hospice. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po b.i.d. 2. Other medications the same except for her Aricept, which was discontinued. DISCHARGE DIAGNOSES: 1. Alzheimer's disease. 2. Hypercholesterolemia. 3. Metastatic cancer, possibly of eosphageal origin. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 7069**] MEDQUIST36 D: [**2197-4-14**] 00:01 T: [**2197-4-14**] 00:01 JOB#: [**Job Number 36353**]

1505,1977,1970,1985,1987,53082,28522,3310,2720

Admission Date: [**2176-6-27**] Discharge Date: [**2176-7-13**] Date of Birth: [**2108-1-1**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Avelox Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypotension to 70s Major Surgical or Invasive Procedure: -Tunnel catheter for HD -Blood and FFP transfusions -Hemodialysis History of Present Illness: 68 yo F with tracheobronchomalacia, on heparin gtt for AVR, who was transferred here from an OSH for IP evaluation and possible Y stent who is transferred to the MICU for hypotension. She was initially admitted here on [**6-27**] and had a CT of her airway done revealing tracheobronchomalacia. She was scheduled for the OR on Monday for rigid bronch. Her bp remained stable on admission, and was in the 130s-140s/70s-80s throughout the day on [**6-27**] and [**6-28**]. On [**6-29**], her bp was 100/80 at 8 am (pulse 92 from 82), 92/43 at noon, and 87/54 at 4 pm (pulse 104). Per thoracic surgery she was mentating throughout all of this. No UOP recorded as she was incontinent, but at 8:45 pm a Foley was placed and drained 250 cc urine. The MICU team was called at 9 pm for hypotension. [**Name8 (MD) **] RN notes her bp was 62/palp (75/p w/doppler), pulse 120, respirations 32, and 98% on 3L. They attempted to give a 500 cc bolus but her last peripheral IV stopped working. She was transferred to the MICU at this time for CVL placement and further monitoring. Of note, her INR was subtherapeutic on admission at 1.4, and she was begun on a heparin drip (due to AVR). Her PTT was greater than 150 since 6 pm last night, and despite adjustments in the heparin gtt it was last measured at 147.5. Her heparin gtt was shut off at the time of her MICU transfer. . Currently, she is awake but drowsy and is mentating appropriately. She is complaining of severe abdominal and back pain which she states has been going on since yesterday. She also feels very cold. . In terms of recent history, she was admitted to [**Hospital 28448**] Center on [**6-17**] with SOB and cough. Initial CXR was clear. They felt she had a COPD exacerbation and treated her with steroids, bronchodilators, and azithromycin. On [**6-20**], she became acutely SOB and CXR showed LUL infiltrate. She was begun on zosyn and cipro for possible pseudomonal pna (as had reportedly grown this in past). Swallow study was negative for aspiration. On [**6-27**] (day of transfer) she was on day 7 of cipro/zosyn. Per their notes her SOB and cough were much improved. Her creatinine fluctuated between 1.8 and 2, and was 3 on discharge from the OSH. Her lasix and enalapril were discontinued there, and she was begun on IVF (total 500 cc). Renal ultrasound showed R kidney 10.2 cm w/mult cysts, left normal, no hydro. She had a negative C diff there, blood cx negative x2, urine cx negative. ABG 7.40/40/77 on [**6-21**]. Past Medical History: PMH: 1. Tracheobronchomalacia, s/p prolonged intubation/trach in [**2164**] s/p CABG 2. Recurrent pneumonias, reported hx pseudomonas in sputum 3. Bronchiectasis 4. CAD s/p CABGX5 [**2165**] 5. COPD/restrictive lung disease FEV1 680 ml (39% pred) in [**2174**] unchanged from [**2168**], TLC 63% pred 6. PVD 7. CHF (mild per notes) 8. Bell's Palsy 9. HTN 10. Hyperlipidemia 11. s/p AVR [**2165**] 12. DM 13. CKD, felt [**1-4**] diabetes, baseline Cr 1.4 14. GERD w/hiatal hernia 15. Esophageal stricture s/p dilatation x2 [**85**]. s/p R CEA [**4-/2169**] Social History: She lives alone in an [**Hospital3 **] facility. She is formerly a suitcase manufacturer. She denies any alcohol use or ever smoking cigarettes. She denies any asbestos exposure. Family History: father died from MI at age 60, mother died from MI at age 70 Physical Exam: Physical Exam: Vitals: 96.5F HR 99 BP 94/31 RR 40 100%/4Ln.c. Gen: conversant, alert and oriented female, apppears pale and uncomfortable HEENT: anicteric, mucus membranes very dry Neck: supple CV: tachycardic, regular Pulm: CTA anteriorly Abd: obese, TTP RUQ/LUQ without rebound or guarding, +bs, guaiac negative Ext: [**1-5**]+ pitting edema bilaterally, skin cold, pulses 1+ bilaterally Pertinent Results: [**2176-6-27**] 09:21PM GLUCOSE-125* UREA N-70* CREAT-2.7* SODIUM-134 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18 [**2176-6-27**] 09:21PM CALCIUM-8.9 PHOSPHATE-5.3* MAGNESIUM-2.0 [**2176-6-27**] 09:21PM WBC-13.1* RBC-3.70* HGB-11.0* HCT-30.9* MCV-84 MCH-29.7 MCHC-35.5* RDW-13.6 [**2176-6-27**] 09:21PM PLT COUNT-263 [**2176-6-27**] 09:21PM PT-15.4* PTT-20.9* INR(PT)-1.4* . CT Trachea [**2176-6-28**] IMPRESSION: 1. Severe diffuse tracheobronchomalacia. 2. Cylindrical bronchiectasis, predominantly basal, and scattered nodular ground-glass opacities suggest chronic and ongoing aspiration. 3. Small bilateral pleural effusion. 4. Atherosclerosis, including coronaries. 5. Moderate size hiatus hernia. . CT Abd/Pelvix [**2176-6-30**] IMPRESSION: 1. Large right pelvic side wall hematoma measuring 11.7 x 9.1 cm, with extension into the right rectus muscle. There is no evidence of intraperitoneal extension of hemorrhage. The possibility of active extravasation is not optimally assessed without intravenous contrast. 2. There are again seen scattered areas of ill-defined ground glass opacity and bronchiectatic changes within the lungs bilaterally, which are not significantly changed in comparison to most recent study from two days prior. . . Echo [**2176-7-2**]: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). A mid-cavitary gradient is identified, consistent with mild flow obstruction at rest. The patient was unable to cooperate with the Valsalva maneuver. Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. IMPRESSION: Symmetric LVH with hyperdynamic systolic function, and no regional wall motion abnormalities. Mild resting mid-cavitary flow obstruction. Normally-functioning mechanical aortic valve prosthesis. . LENI [**2176-7-5**] CONCLUSION: No evidence of DVT. . CXR [**2176-7-4**]: IMPRESSION: 1. Newly inserted two right central lines with no evidence of complications. 2. Small new right pleural effusion. Brief Hospital Course: 68 yo woman with tracheobronchomalacia, on heparin gtt for [**Hospital 64315**] transferred to [**Hospital1 18**] from an OSH for IP evaluation and possible Y stent who was transferred to the MICU for hypotension, decreased Hct in the setting of retroperitoneal bleed. . 1. Retroperitoneal Bleed - Pt had bleed and was hypovolemic in setting of blood loss while supratherpeutic on heparin. She received aggressive fluid resuscitation and PRBC transfusions while in house as needed for bleeding. Her anticoagulation was reversed with FFP. She did not require pressors. On CT scan, she was found to have a large right pelvic side wall hematoma with extension into the right rectus muscle. There was no evidence of intraperitoneal extension of hemorrhage. We monitored her Hct closely during the acute episodes q4. Although her Hct stabilized, when we attempted to start anticoagulation with warfarin again at low doses, she subsequently developed a decreasing hematocrit which required further transfusions of FFP and Hct. While attempting slow increase of coumadin to reach therapeutic INR for her AVR, she began further dropping her HCT with increase of her INR to 1.8. We reversed this INR with Vit K. We decided that she was currently not a candidate for anticoagulation in the setting of her acute bleed and in the setting of increasing bleeds to even low levels of anticoagulation. . 2. ARF on CRI - After developing hypotension, she became anuric. The most likely explination is that she developed ATN. She has required hemodialysis/ultrafiltration during her stay in the hospital, and she had a tunnel catheter placed to facilitate this in the future. She was initially on CVVH. She was converted to hemodialysis. She did experience two transient episodes of desaturiation of hemodialysis. The diasylate was changed to asili. She tolerated two additional dialysis sessions without incident. . 3. Elevated WBC count - She was hypothermic and met criteria for SIRS but this is all likely explained by hypovolemic shock. She ultimately had a gram stain positive for gram positive cocci in her sputum (culture negative to date [**7-13**]), from [**2176-7-10**]. We subsequently treated her with Vancomycin. She began her course on [**2176-7-10**] and was dosed by level with a goal vancomycin trough >15. She will continue this course for 7 days total. She also had erythema on her right lower extremity. This was thought to be more consistent with venous stasis changes than cellulitis and did not change when vancomycin was started. . 4. Tracheobronchomalacia - Patient was originally transferred for stent placement for this problem. She and her family subsequently decided not to proceed with this procedure given the risk/benefit ratio and the complications she has had during her hospital stay. . 6. CV: pump - anti-hypertensives were held given hypotension. Volume resuscitation as above. ischemia - no evidence of active ischemia. she had one episode of transient right-sided chest pain. her cardiac enzymes were negative. she was continued on statin for secondary prevention. Aspirin was held given bleeding risk. Antihypertensives also held. . 7. Diabetes mellitus - She was treated with an insulin sliding scale while in the hospital to maintain glucoses <120. . 8. Prophylaxis - She was maintained on PPI and pneumoboots while in the hospital. We attempted to anticoagulate her, but stopped as described above. . 9. Access: She had a tunnel line and PICC placed under IR while in the hospital. Medications on Admission: cipro 250 mg po q12h simvastatin 80 mg daily insulin sliding scale pantoprazole 40 mg daily olanzapine 2.5 mg po qhs prednisone 10 mg tid ferrous sulfate 325 mg daily buspirone 10 mg daily ezetimibe 10 mg daily amlodipine 5 mg daily ipratropium nebs q6h fluticasone-salmeterol 250/50 [**Hospital1 **] zosyn albuterol nebs tylenol Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 3. Buspirone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed. 5. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 11. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for agitation/insomnia. 12. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous Dosing by level for 3 days. Discharge Disposition: Extended Care Discharge Diagnosis: Retroperitoneal hematoma Discharge Condition: -Good Discharge Instructions: Please call if become dizzy, weak, temp >101, chills, abdominal pain or abnormal bruising. Followup Instructions: You should follow up with your PCP within one week of discharge [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2176-7-13**]

4590,78559,570,5849,40391,2800,51882,2760,486,496,79092,25040,5191,1122,V433,41400,V4581

Admission Date: [**2115-6-20**] Discharge Date: [**2115-6-30**] Date of Birth: [**2115-6-20**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: This is a 34-week, first female twin, born to a 25-year-old, G8, P 2-0-5-2, who had received late prenatal care and did not realize she was having twins. The infants were born by emergency cesarean section for concerns of an abruption and for preterm labor with breech presentation of the second twin. The mother did not have fever. The GBS status was unknown and rupture of membranes were at delivery. The infant's birth weight was 1760 g and the fluid was foul smelling. The infant was active on delivery with spontaneous cry, was suctioned and given blow- by oxygen in the delivery room. The Apgars were 8 and 9. Prenatal labs on the mother were O positive, antibody screen negative, hepatitis B negative, RPR nonreactive, and rubella immune. The infant was admitted to the newborn ICU for prematurity and tachypnea on initial exam. SUMMARY OF HOSPITAL CARE: Respiratory: The infant has remained in room air since admission, never intubated, never placed on CPAP, and did quite well without any requirement for oxygen. Cardiovascular: There have been no issues. No murmur has ever been heard on this patient. She has had stable blood pressures throughout her hospitalization. Fluids, electrolytes, and nutrition: The infant was initially made n.p.o. on D10W at 80 cc/kg/day maintenance IV fluids. Enteral ad-lib feedings were started on [**2115-6-22**]. She quickly advanced to full p.o. feeding, taking easily her minimum by [**2115-6-24**] of 100 cc/kg/day and advanced to 150 cc/kg/day by [**2115-6-27**]. She was placed on NeoSure 22 on [**2115-6-26**] and advanced to NeoSure 24 on [**2115-6-27**] to increase her caloric intake. She POs well and has had no issues and is tolerating 24 kcal formula well. The infant's discharge weight was 1810 grams. Hematology: The infant has had mild hyperbilirubinemia and was placed on phototherapy on [**2115-6-23**] and the bilirubin then decreased spontaneously. Last bilirubin was 6.1/0.3 on [**6-24**], day 4 of life. and it has not been an issue since that time. Neurology: The infant, on admission, was noted to be quite jittery with strange movements of her head. The infant did have a urine toxicology screen, as did the mother on admission, both of which were negative. She has had increased tone on physical exam and is somewhat jittery, although this has improved throughout her hospitalization. She has been placed on an Early Intervention Program because of these concerns and because of her prematurity, and they can follow as an outpatient. She has not had any head ultrasounds or other screening exams. Hearing screen was performed with augmented auditory brain stem responses and the infant had passed. She did not fit criteria for an ophthalmology exam for retinopathy of prematurity. Social: [**Hospital1 18**] SOcial Work was involved with the family. They can be reached at [**Telephone/Fax (1) 8717**]. Infectious disease. This patient was initially ruled out for bacterial sepsis with a blood culture and with ampicillin and gentamicin for two days. When the blood culture returned negative and the infant looked well, the antibiotics were stopped after two days. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: To home. Primary pediatrician is Dr. [**Last Name (STitle) **] at [**Location (un) 669**] Comprehensive Health. CARE AND RECOMMENDATIONS: The infant was sent home on NeoSure 24 kcal per ounce. This should be continued until 6 to 9 months corrected age. MEDICATIONS: None. FOLLOW UP: Newborn screening has been performed, and the infant has received hepatitis B immunization. She should follow up with her general pediatrician on Monday, [**2115-7-1**], and will have early intervention and a nursing visit to her home. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Small for gestational age. 3. Hyperbilirubinemia. 4. Rule out sepsis. DR. [**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595 Dictated By:[**Last Name (NamePattern1) 57691**] MEDQUIST36 D: [**2115-6-27**] 15:43:13 T: [**2115-6-28**] 10:01:21 Job#: [**Job Number 57692**]

V3101,76517,7742,7793,7706,76527,76407,V290

Unit No: [**Numeric Identifier 61051**] Admission Date: [**2184-2-11**] Discharge Date: [**2184-3-1**] Date of Birth: [**2184-2-11**] Sex: M Service: NBB HISTORY: Baby [**Name (NI) **] [**Known lastname 61052**] is a 2.1 kg product of a 33 and [**3-4**] week twin gestation, born to a 36 year-old, Gravida VII, Para 0. Prenatal screens 0 positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B negative, GBS unknown. Mother has history of thyroid insufficiency secondary to Hashimoto's. She is on thyroid replacement. Asthma, treated with inhalers. Mom has normal chromosomes, is Parvo negative, CF non carrier, normal protein CF, and factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**]. This was an IVF triplet pregnancy, reduced to twins. The pregnancy was complicated by decreased fetal growth approximately 10th percentile. The biophysical profile was 8 out of 8 for this twin. Mother had [**Name2 (NI) **] with worsening thrombocytopenia, prompting delivery. She was betamethasone complete on [**1-29**]. Infant was delivered by Cesarean section. Apgars of 7 and 8. Infant transferred back from [**Hospital3 1810**] on day of life three. Hospital course from day of life three on. PHYSICAL EXAMINATION: Weight 2.1 kg, 50th percentile. Length 47 cm, 75th percentile. Head circumference 31 cm, 50th percentile. General: Active infant, looking stated gestational age. Normal cephalic bruise of the upper lip. Anterior fontanel open and flat, palate intact. Red reflex deferred. Nevus squamous on forehead. Neck supple. Lungs with intermittent audible grunting. Mild intercostal retractions. Cardiovascular: Regular rate and rhythm. No murmur. Femoral pulses 2 plus bilaterally. Abdomen soft with active bowel sounds, no masses or organomegaly. Normal premature male. Hips stable. Clavicles intact. Good tone, moves all extremities. HOSPITAL COURSE: Respiratory: Has been stable in room air throughout hospital course without any issues. Cardiovascular: Has been stable throughout hospital course. Fluids, electrolytes and nutrition: Birth weight 2.1 kg, readmission to [**Hospital1 69**] 2.015 kg, on 130 cc per kg per day on a combination of breast milk and D-10-W. Reached full enteral feedings by day of life number six. Is currently ad lib feedings, breast milk 24 calories, Similac 24 calories, taking an adequate amount. Gastrointestinal: Peak bilirubin was on day of life three. Infant received phototherapy for a total of four days and rebound bilirubin was within normal limits. Infectious disease: Infant was status post 40 hour sepsis rule out, has had no sepsis risk factors or sepsis issues during this hospital course. Neurology: Has been appropriate for gestational age. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant passed. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42126**]. CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk 24, Similac 24 calories. MEDICATIONS: Not applicable. CAR SEAT POSITION: STATE NEWBORN SCREENING: Has been sent per protocol and has been within normal limits. IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2184-1-28**]. DISCHARGE DIAGNOSES: 1. Preterm twin, 33 and [**5-4**] week gestation. 2. Hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2184-3-1**] 00:13:35 T: [**2184-3-1**] 04:48:15 Job#: [**Job Number 61055**]

7742,76527,7793,76518,V502,V053

Unit No: [**Numeric Identifier 61051**] Admission Date: [**2184-2-11**] Discharge Date: [**2184-3-1**] Date of Birth: [**2184-2-11**] Sex: M Service: Neonatology HISTORY: Baby [**Name (NI) **] [**Known lastname 61052**] is a 2.1 kg product of a 33 and [**3-4**] week twin gestation, born to a 36 year-old, Gravida VII, Para 0. Prenatal screens 0 positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B negative, GBS unknown. Mother has history of thyroid insufficiency secondary to Hashimoto's. She is on thyroid replacement. Asthma, treated with inhalers. Mom has normal chromosomes, is Parvo negative, CF non carrier, normal protein CF, and factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**]. This was an IVF triplet pregnancy, reduced to twins. The pregnancy was complicated by decreased fetal growth approximately 10th percentile. The biophysical profile was 8 out of 8 for this twin. Mother had [**Name2 (NI) **] with worsening thrombocytopenia, prompting delivery. She was betamethasone complete on [**1-29**]. Infant was delivered by Cesarean section. Apgars of 7 and 8. Infant transferred back from [**Hospital3 1810**] on day of life three. Hospital course from day of life three on. PHYSICAL EXAMINATION: Weight 2.1 kg, 50th percentile. Length 47 cm, 75th percentile. Head circumference 31 cm, 50th percentile. General: Active infant, looking stated gestational age. Normal cephalic bruise of the upper lip. Anterior fontanel open and flat, palate intact. Red reflex deferred. Nevus squamous on forehead. Neck supple. Lungs with intermittent audible grunting. Mild intercostal retractions. Cardiovascular: Regular rate and rhythm. No murmur. Femoral pulses 2 plus bilaterally. Abdomen soft with active bowel sounds, no masses or organomegaly. Normal premature male. Hips stable. Clavicles intact. Good tone, moves all extremities. HOSPITAL COURSE: Respiratory: Has been stable in room air throughout hospital course without any issues. Cardiovascular: Has been stable throughout hospital course. Fluids, electrolytes and nutrition: Birth weight 2.1 kg, readmission to [**Hospital1 69**] 2.015 kg, on 130 cc per kg per day on a combination of breast milk and D-10-W. Reached full enteral feedings by day of life number six. Is currently ad lib feedings, breast milk 24 calories, Similac 24 calories, taking an adequate amount. Gastrointestinal: Peak bilirubin was on day of life three. Infant received phototherapy for a total of four days and rebound bilirubin was within normal limits. Infectious disease: Infant was status post 40 hour sepsis rule out, has had no sepsis risk factors or sepsis issues during this hospital course. Neurology: Has been appropriate for gestational age. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant passed. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42126**]. CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk 24, Similac 24 calories. MEDICATIONS: Not applicable. CAR SEAT POSITION: passed STATE NEWBORN SCREENING: Has been sent per protocol and has been within normal limits. IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2184-1-28**]. DISCHARGE DIAGNOSES: 1. Preterm twin, 33 and [**5-4**] week gestation. 2. Hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2184-3-1**] 00:13:35 T: [**2184-3-1**] 04:48:15 Job#: [**Job Number 61055**]

7742,76527,7793,76518,V502,V053

Unit No: [**Numeric Identifier 61051**] Admission Date: [**2184-2-11**] Discharge Date: [**2184-2-11**] Date of Birth: [**2184-2-11**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 61052**] is the first born of twins of a 33-4/7-weeks gestation pregnancy born to a 36-year-old G7, P0 woman. Prenatal screens: Blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B Strep status unknown. Prior OB history is notable for spontaneous abortion times 6. This was an in-[**Last Name (un) 5153**] fertilization achieved pregnancy with an estimated date of confinement of [**2184-3-27**]. The mother has medical history significant for thyroid insufficiency secondary to Hashimoto thyroiditis. She is on thyroid replacement treatment. She also has asthma treated with an inhaler. There was normal chromosomes with this pregnancy. Mother is also parvovirus negative, cystic fibrosis noncarrier, normal protein-C, protein-S, and factor V Leiden. This was an in-[**Last Name (un) 5153**] fertilization triplet reduced to twins. Pregnancy was complicated by decreased fetal growth. Biophysical profile was [**7-5**] for this twin. The mother also had pregnancy-induced hypertension with worsening thrombocytopenia prompting delivery. Mother was a betamethasone complete on [**2184-1-29**]. The infant was born by cesarean section. Had Apgar scores of 7 at 1 minute and 8 at 5 minutes. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 2.1 kg (50th percentile), length 47 cm (75th percentile), head circumference 31 cm (50th percentile). General: Active infant consistent with stated gestational age. Head, eyes, ears, nose, and throat: Normocephalic, bruise on the upper lip, anterior fontanel open and flat, palate intact, nevus flammeus on forehead. Neck is supple without masses. Chest: Intermittent grunting, mild intercostal retractions. Cardiovascular: Regular rate and rhythm, no murmur. Femoral pulses 2+ bilaterally. Abdomen is soft with active bowel sounds, no masses or organomegaly. GU: Normal preterm male. Testes descending. Musculoskeletal: Hips stable. Clavicles intact. Neurological: Good tone. Moving all extremities. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: This infant required intubation and treatment with Surfactant for his respiratory distress. His ventilatory settings were a peak inspiratory pressure of 20 over a positive end expiratory pressure of 5, intermittent mandatory ventilatory rate of 30, and 30% oxygen. Chest x-ray was consistent with respiratory distress syndrome. Cardiovascular: Blood pressure was 53/28 with a mean of 36. Heart rate was 120s-140s with no murmurs. Fluid, electrolytes, and nutrition: The baby was maintained NPO and was on intravenous on D10W at 80 cc/kg/day. Infectious disease: Due to the unknown etiology of the respiratory distress, this baby was evaluated for sepsis. A complete blood count was obtained. White blood cell count was 11,600, platelet count of 267,000. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. Disposition: The infant was transferred to the Neonatal Intensive Care Unit at [**Hospital3 1810**] CONDITION AT DISCHARGE: Guarded. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] level III Neonatal Intensive Care Unit for further treatment. The primary pediatrician is Dr. [**Last Name (STitle) 61053**] in [**Location (un) 1887**], [**State 350**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: NPO. MEDICATIONS: Ampicillin 300 mg IV every 12 hours. Gentamicin 6.5 mg IV every 24 hours. CAR SEAT POSITION SCREENING: Recommended prior to discharge. STATE NEWBORN SCREEN: Was obtained prior to discharge. IMMUNIZATIONS: No immunizations administered. DISCHARGE DIAGNOSES: Prematurity at 33-4/7 weeks gestation. Twin #1 of twin gestation. Respiratory distress syndrome. Suspicion for sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2184-2-12**] 22:32:28 T: [**2184-2-13**] 04:25:05 Job#: [**Job Number 61054**]

V3101,769,76527,76518,V290

Admission Date: [**2194-7-16**] Discharge Date: [**2194-7-18**] Date of Birth: [**2139-1-31**] Sex: M Service: Mr. [**Known lastname 7474**] was in the hospital for 24 hours. He came from [**Hospital3 1196**] with a history of alcoholic hepatitis C, Child-C cirrhosis. He came into [**Location (un) **] [**Hospital **] Hospital with peritoneal signs, where he had a peritoneal tap. He was subsequently transferred to [**Hospital1 1444**] to GI service, where he underwent a tap which showed a fecalith aspirate. He had a CT scan showed which showed massive free air. Consent was obtained. He was taken to the operating room, where he is found to have a hostile abdomen and necrotic portion of terminal small bowel and cecum, which were resected. A decision was made with conjunction of the family to make comfort measures only. Patient expired at 3:20 pm on [**2194-7-18**]. Dictated By:[**Last Name (NamePattern1) 99839**] MEDQUIST36 D: [**2194-7-18**] 18:10 T: [**2194-7-22**] 11:26 JOB#: [**Job Number 99840**] cc:[**Name8 (MD) 99841**]

5570,56983,5672,07054,5711

Admission Date: [**2183-5-26**] Discharge Date: [**2183-5-30**] Date of Birth: [**2123-12-14**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2183-5-26**] Mitral Valve Repair utilizing a 28mm [**Doctor Last Name 405**] Band History of Present Illness: This is a 59 year old female with recent diagnosis of mitral regurgitation. Over the last several months, she has experienced worsening shortness of breath and cough. Also admits to orthopnea and dyspnea on exertion. She has no history of myocardial infarction. Echocardiogram in [**2183-3-27**] revealed severe mitral regurgitation with flail posterior leaflet, and normal LV function. In preperation for cardiac surgery, she underwent cardiac catheterization which showed normal coronary arteries. It confirmed 4+ mitral regurgitation and normal left ventricular function. She had moderate pulmonary hypertension with PAP 50/19 with a mean of 30 mmHg. She was admitted for mitral valve surgery. Past Medical History: Mitral regurgitation Gastroesophogeal Reflux Disease History of Hemoptysis History of postive PPD - s/p treatment Social History: Denies tobacco and ETOH. Married, works in a grocery store. Lives with husband. Family History: Father died at age 30 - unknown cause Physical Exam: Vitals: BP 132/86, HR 77, RR 18 General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 4/6 systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: cool, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2183-5-30**] 06:20AM BLOOD WBC-13.8* RBC-3.21* Hgb-9.6* Hct-28.5* MCV-89 MCH-30.0 MCHC-33.8 RDW-14.5 Plt Ct-292# [**2183-5-29**] 06:05AM BLOOD WBC-13.3* RBC-2.89* Hgb-8.6* Hct-25.4* MCV-88 MCH-29.7 MCHC-33.8 RDW-14.3 Plt Ct-179 [**2183-5-28**] 06:35AM BLOOD WBC-16.7* RBC-3.02* Hgb-9.0* Hct-26.1* MCV-87 MCH-29.7 MCHC-34.3 RDW-14.5 Plt Ct-148* [**2183-5-26**] 11:57PM BLOOD WBC-20.9*# RBC-3.55* Hgb-10.7* Hct-31.0* MCV-87 MCH-30.1 MCHC-34.5 RDW-14.5 Plt Ct-179 [**2183-5-26**] 03:06PM BLOOD WBC-13.9*# RBC-3.60* Hgb-10.8*# Hct-31.3* MCV-87 MCH-30.0 MCHC-34.5 RDW-14.1 Plt Ct-182 [**2183-5-30**] 06:20AM BLOOD Glucose-102 UreaN-11 Creat-0.8 Na-137 K-4.6 Cl-98 HCO3-28 AnGap-16 [**2183-5-29**] 06:05AM BLOOD Glucose-157* UreaN-14 Creat-0.7 Na-134 K-3.3 Cl-97 HCO3-31 AnGap-9 [**2183-5-28**] 06:35AM BLOOD Glucose-124* UreaN-16 Creat-0.6 Na-137 K-3.8 Cl-97 HCO3-35* AnGap-9 [**2183-5-26**] 11:57PM BLOOD Glucose-119* UreaN-14 Creat-0.6 Na-140 K-4.2 Cl-108 HCO3-26 AnGap-10 [**2183-5-30**] 06:20AM BLOOD Mg-3.1* [**2183-5-28**] 06:35AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3 [**2183-5-29**]: The central venous line was removed in the meantime interval. The heart size is normal. The bibasilar atelectasis are again demonstrated, the worse on the right with no significant change on the left. The bilateral pleural effusion is small. There is no pneumothorax. Brief Hospital Course: Mrs. [**Known lastname 13260**] was admitted and underwent mitral valve repair by Dr. [**Last Name (STitle) 1290**]. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. Her CSRU course was uneventful and she transferred to the SDU on postoperative day one. Chest tubes and wires were removed without complication. She tolerated low dose beta blockade and continued to improve with diuresis. Given persistent systolic blood pressures in the 90 - 100mmHg range, her preoperative ACE inhibitor was not resumed. Several self limiting bursts of paroxysmal were noted but she remained mostly in a normal sinus rhythm. She continued to make steady progress and was cleared for discharge to home on postoperative day four. At discharge, her oxygen saturations were 96% on room air and her chest x-rays showed only small bilateral pleural effusions. Her sternum was stable and all surgical incisions were clean, dry and intact. Medications on Admission: Omeprazole 20 qd, Lisinopril 5 qd, Hydroxyzine 25 qd, Singulair 10 qd, Albuterol MDI, Bromfenex Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-2**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Mitral regurgitation - s/p MV Repair Postop Anemia GERD History of positive PPD Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**5-1**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-1**] weeks, call for appt Completed by:[**2183-5-30**]

4240,42731,4111,53081,4169,2768

Admission Date: [**2187-11-13**] Discharge Date: [**2187-11-15**] Date of Birth: [**2120-10-20**] Sex: F Service: RADIOLOGY Allergies: Sulfa (Sulfonamides) / Amoxicillin / Percocet Attending:[**First Name3 (LF) 25590**] Chief Complaint: renal artery angioplasty complicated by thrombus Major Surgical or Invasive Procedure: angioplasty [**2187-11-13**] complicated by renal artery thrombosis, status post 24 hour ICU stay for thrombolysis with tPA and heparin. angioplasty re-attempt [**2187-11-14**], no intervention (procedure aborted secondary to suboptimal approach) History of Present Illness: Pt is a 67 yo female with DMII, HTN, renal artery stenosis, who is s/p angioplasty yesterday with resultant thombus in renal artery noted on angiogram, s/p tPA and heparin in MICU, observed overnight with Hct stable, VSS. She went back to IR again today for possible restenting, however, the approach was felt to be not adequate for stenting, procedure aborted. Plan by IR was to have pt watched overnight, discharged in AM, to follow up at a later date for re-stenting. . As far as her history of HTN and RAS, the pt reports she has always had elevated blood pressure. It was first noted when she was pregnant and over the years since her BP has consistently been elevated, up to 220/110 [**First Name8 (NamePattern2) **] [**Last Name (un) **] records. Until 10 years ago, BPs were in the 180s-190s/90s on a hefty medication regimen and more medications were subsequently added (not noted which [**First Name8 (NamePattern2) **] [**Last Name (un) **] records). BPs diastolic improved, but systolics remained elevated 160s-170s. . In [**2184**], pt underwent angioplasty without stenting of her right kidney as she was found to have renal artery stenosis, thought [**1-3**] FMD. BP improved to the 120s systolic, but this lasted only 1 month. Later, an angiogram in [**3-/2185**] showed no large vessel stenosis in renal aa. but right kidney was 9.1 cm and left one was 11.7 cm. She had an abdominal CT scan for eval of abd pain in [**4-/2186**] showing an atrophic right kidney (unclear the size). Repeat MRA at the end of [**Month (only) 359**] demonstrated beading and narrowing of right renal artery with extension in to the branches. Her serum creatinine has been in the range of 0.7-0.9. She has had no albuminuria on [**Last Name (un) **]. . Yesterday, around noon, a thrombus was noted on angiogram. Simultaneously, pt also had a vasovagal episode, was put in trendelenberg, given IVF, and give one mg of atropine. She was given [**2181**] units of intra-arterial heparin, and 11 mg of tPA in divided doses. . She was completely stable overnight, with hcts 28 to 30 the last 24 hours. Her VSS. She is being called out to the medical floor in stable condition. Her ROS is negative for: CP/SOB/palpitations. No nausea/vomiting/abd pain/constipation. No numbness or tingling in extremities or weakness. Has been in lying position since IR procedure, sheath removed at 1pm. Pt able to sit up to 30 degrees at 6pm. C/o intermittent low back pain from lying down for 'so many hours.' She is also c/o hunger, wants to eat. Past Medical History: Diabetes mellitus Hypertension s/p H pylori eradication (had allergy to amoxicillin then); repeat endoscopy cx showed gone s/p ovarian cyst removal at age 16 s/p hysterectomy at 30 s/p CCY in [**2177**]; ovarian pathology seen and s/p oophorectomy s/p fixation of hernia after laporotomy s/p melanoma in situ removed from left shoulder-two months ago Bilateral cataracts Social History: Married, four children. Lives in [**Location **], MA. Never smoked. No alcohol. No IVDA. Family History: Mother- DM, HTN, CHF, died in her 80s. Father-died in 60s with MI, DM. Brother died at age 39, MI and DM. Both paternal and maternal grandmothers had [**Name2 (NI) **]. Physical Exam: VS: Tm: 98.6 Tc: 98.6 BP: 138/43 RR: 16 O2sat: 95-99% RA. I/O [**Telephone/Fax (1) 43382**] for net negative 779. Gen: Well appearing CF in NAD. WNWD. AOX3, [**Location (un) 1131**] a book. Pleasant and cooperative. HEENT: PERRL, EOMI. No scleral icterus. MMM, OP clear. Neck: no lymphadenopathy, no JVP appreciated. CV: RRR S1 and S2 audible, no murmurs, rubs or gallops Lungs: CTAB anteriorly Abd: Soft, NT ND, obese, positive bowel sounds, no masses. No organomegaly. Midline lower scar present and RUQ scar present. Back: could not examine as patient must lie flat Ext: WWP, DP/radial/PT 2+ bilaterally, no edema, right groin with catheter removed, bandaid in place, minimal bleeding. No palpable hematoma. No bruits. Pertinent Results: [**2187-11-13**] 07:42AM WBC-5.2 RBC-3.96* Hgb-12.8 Hct-34.4* MCV-87 MCH-32.3* MCHC-37.1* RDW-13.8 Plt Ct-247 [**2187-11-13**] 03:09PM WBC-9.1# RBC-UNABLE TO Hgb-11.7* Hct-34* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt Ct-240 [**2187-11-13**] 05:39PM Hct-31.7* [**2187-11-13**] 08:00PM Hct-30.9* [**2187-11-14**] 05:57AM Hct-28.7* [**2187-11-14**] 11:04AM WBC-10.1 RBC-3.39* Hgb-11.0* Hct-28.8* MCV-85 MCH-32.3* MCHC-38.0* RDW-13.7 Plt Ct-235 [**2187-11-14**] 05:47PM WBC-9.7 RBC-3.46* Hgb-11.3* Hct-30.3* MCV-88 MCH-32.6* MCHC-37.2* RDW-13.8 Plt Ct-264 [**2187-11-15**] 05:30AM WBC-9.8 RBC-3.22* Hgb-10.6* Hct-28.4* MCV-88 MCH-32.7* MCHC-37.2* RDW-13.5 Plt Ct-233 [**2187-11-13**] Glucose-191* UreaN-14 Creat-0.7 Na-142 K-3.8 Cl-108 HCO3-25 AnGap-13 [**2187-11-15**] Glucose-125* UreaN-12 Creat-0.9 Na-140 K-4.4 Cl-106 HCO3-25 AnGap-13 . Radiology: MRA kidney with and without contrast [**2187-9-27**]- 1. Beaded appearance of the right main renal artery extending into two main branch vessels, suggestive of fibromuscular dysplasia. Greater than 50% stenosis is noted at the main branch point, which is approximately 2.5 cm from the aorta. 2. Patent left main and left lower pole accessory renal arteries. 3. Marked parenchymal tissue loss of the right lower pole, likely from prior ischemic insult. 4. 11-mm cystic lesion in the pancreatic head. Differential includes pseudocyst or possible intraductal papillary mucinous tumor (IPMT). A followup study in six months is recommended to ensure stability. 5. Narrowed celiac ostium is likely from expiratory compression and is of little concern in the absence of related symptoms; please correlate clinically. . Abd CT: right kidney with 2 x 2 cm lesion (Area of the right kidney with increased contrast accumulation and irregular cortex, which may represent an intraparenchymal hematoma or reperfusion injury. No other hematoma). . [**2187-11-14**] RENAL ANGIOGRAM REPORT IMPRESSION: Follow up angiography after overnight thrombolysis demonstrated good renal artery perfusion with no evidence of residual thrombus. There is beading of the distal main renal artery and its proximal branch vessels consistent with fibromuscular dysplasia as was demonstrated on the prior angiogram from yesterday. The patient should return to their antihypertensive regimen as was being taken prior to the procedure. Brief Hospital Course: Impression/Plan: Pt is a 67 yo female with DM, HTN, renal artery stenosis, who is s/p renal artery angioplasty complicated by right renal artery thrombus, also s/p re-attempt today at stenting, aborted procedure [**1-3**] suboptimal approach. Plan by IR is to discharge and take back for follow up appt for another attempt at stenting after the [**Holiday **] holidays (per pt preference). . 1. Renal artery thrombus- The patient was taken to the ICU for tPA and heparin thrombolysis of the renal artery thrombus that complicated her initial angioplasty on [**2187-11-13**]. The pt tolerated the heparin and tPA without complications. The following day, she was taken back to Interventional Radiology for a re-look with possible restenting/angiogram, and it was noted the thrombus was resolved, however the approach was technically suboptimal (see report), and the procedure was aborted. The plan is to have the pt return as an outpatient at her convenience to have the procedure attempted again. She was given the phone numbers for which to schedule an appt with IR. She is currently with normal renal function, no CKD, with a baseline creat of 0.7. Her right groin site was without hematoma, bleeding or bruit. The sheath was removed without complications. . 2. Low Back Pain- Her back pain was believed to be secondary to lying flat for several hours while her procedures was being done. Her pain was musculoskeletal in nature, improved with positional changes. Abdominal CT ruled out retroperitoneal bleed. H/o apendectomy and cholecystectomy in the past. Pain relieved with tylenol, and resolved by discharge. . 3. Diabetes mellitus: She was restarted on her outpt regimen of humalog 75/25 with 8 units at breakfast and 18 units at dinnertime. Her blood sugars were stable and she was tolerating po well. . 4. HTN- well controlled. Etiology: secondary to renal artery stenosis [**1-3**] FMD. We continued her atenolol 100mg po qd, and restarted her valsartan 320mg po qAM and 160mg po qPM, and her HCTZ 25mg po qd after her procedure. Essentially, she is on the same medications for blood pressure as she was on prior to procedure. Her first procedure was complicated by a thrombus, so no stenting. Her second procedure was a suboptimal approach, therefore aborted. . 5. Acute blood loss Anemia: The patient's Hct was stable the last 48 hours, ranging from 28 to 30. Most likely secondary to procedural blood loss. Her CT Abd was neg for RP bleed. Her vital signs have been completely stable. She has no symptoms and is ambulating well without complaints. . 6. pancreatic cyst: The pt was noted on imaging to have an 11mm pancreatic cyst, an incidental finding. Repeat imaging was recommended for 6 months from now. The patient was given a report of her imaging, and a copy of the report was given to her to bring to her PCP's office in 7 days (an appointment was scheduled for her). She was explained that it is important for her to follow up and have repeat imaging, as the lesion could possibly be benign, although a malignant lesion is a possibility as well. Her PCP's office was called and notified. She has an appointment in 1 week. . 7. Prophylaxis: She was placed on pneumoboots and her home PPI. ASA was held in the setting of tPA, but then restarted. . 8. Code Status: full code Medications on Admission: Atenolol 100 mg qday Humalog 75/25 [**Hospital1 **] up to 40 units Diovan 320 mg qday Diovan 160 mg qpm Lipitor 20 mg qday Promega 2 tid Protonix 40 mg qday MVI Flonase 50 mcg 2 sprays qday HCTZ 25 mg qday ASA 81 mg- held 4 days prior to procedure Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:*60 Tablet(s)* Refills:*2* 8. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Ten (10) units Subcutaneous qAM at breakfast: Inject 10 units subcutaneously qAM. . Disp:*qs 1 vial* Refills:*2* 9. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty (20) units Subcutaneous qHS at dinnertime: Inject 20 units humalog subcutaneously at dinnertime. . Disp:*qs 1 vial* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Renal artery stenosis secondary to fibromuscular dysplasia status post angioplasty complicated by thrombus status post alteplase 2. Acute blood loss anemia 3. Hypertension 4. Diabetes mellitus 5. Low back pain Discharge Condition: Stable Discharge Instructions: You need to have a follow up abdominal CT since the one you had here incidentally revealed an 11-mm cystic lesion in the pancreatic head. You should see your PCP regarding this, who can arrange for an outpatient Abd CT. If you experience any chest pain, shortness of breath, numbness, weakness in your right leg, bleeding from right groin site, please report to the emergency room immediately. Please take all of your medications. Please follow up with your Primary Care Physician (see info below). Followup Instructions: 1. You have an appointment with Dr. [**First Name (STitle) **] (Dr.[**Name (NI) 43383**] associate at the same office). Your appt is for 11:00 am on Monday, [**11-19**]. Her office number is: [**Telephone/Fax (1) 31979**]. 2. You should bring a copy of the CAT scan report to your doctor so that she can schedule a follow up Abd CT to evaluate the incidental finding of pancreatic mass seen on CT. Completed by:[**2187-11-17**]

4401,99772,2851,59381,4473,25050,36201,V5867,2724,7802,42789,V1082,45829,V643

Admission Date: [**2124-7-20**] Discharge Date: [**2124-7-28**] Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: This is a 79 year old female with a history of coronary artery disease, status post myocardial infarction in [**2121**] who presented to an outside hospital [**7-17**] with complaints of warmth and malaise. She had been in her usual state of health when these symptoms occurred which were reminiscent of her prior myocardial infarction. She also had palpitations and intermittent shortness of breath. Electrocardiogram then showed ST depressions in leads 1, V3 through V6 and she was thought to be in heart failure. CKs were cycled and found to be negative and she was diuresed but continued to have oxygen requirements of 4 liters by nasal cannula. She was transferred to [**Hospital6 256**] for cardiac catheterization with a diagnosis of unstable angina on a Heparin drip. Her transthoracic echocardiogram done at the outside hospital showed an ejection fraction of about 55% with questionable wall motion abnormalities. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2121**], no catheterization was done. 2. Hypertension. 3. Hypercholesterolemia. 4. Diabetes mellitus. 5. Peripheral vascular disease. 6. Peptic ulcer disease, status post gastrointestinal bleed requiring transfusion. 7. Status post bladder suspension. The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Heparin drip 2. Nitroglycerin drip 3. Lopressor 25 b.i.d. 4. Norvasc 10 mg q.d. 5. Pravachol 10 mg q.d. 6. Zantac 7. Univasc 7.5 mg q.d. 8. NPH 15 units q AM, 10 units q PM, 5 units of regular q. PM FAMILY HISTORY: Mother died at 60 of myocardial infarction, father with diabetes mellitus. SOCIAL HISTORY: She stopped tobacco use in [**2114**], 25 pack year history, occasional alcohol. PHYSICAL EXAMINATION: Physical examination on admission revealed vital signs of temperature 97, heartrate 62, blood pressure 142/64, respiratory rate 22, saturation 94% on 4 liters nasal cannula. General: An elderly female lying . Head, eyes, ears, nose and throat examination: Anicteric, no ocular lesion. Neck with jugulovenous distension about 6 cm, carotids 2+ bilaterally. Cardiovascular, regular rate and rhythm, II/VI systolic murmur, no S3 or S4. Lungs, crackles bilaterally. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities, 2+ dorsalis pedis pulse bilaterally, 1+ edema of the lower extremities to mid calf. Neurological: Cranial nerves II through XII intact, alert and oriented times three, nonfocal. LABORATORY DATA: White blood count 9.8, hematocrit 31.6, chemistries reveal sodium 139, potassium 3.9, chloride 103, carbon dioxide 22, BUN 20, creatinine 1.1, glucose 126. CKs were 48, troponin 2.1, MB negative. Studies revealed electrocardiogram results as listed above. Cardiac catheterization revealed three vessel coronary artery disease, presumptive left main coronary artery disease, normal ventricular function, elevated bilateral filling pressures, severe pulmonary hypertension, severe systemic systolic hypertension. HOSPITAL COURSE: The patient was admitted [**2124-7-20**] with a diagnosis of unstable angina and congestive heart failure to the Medicine Cardiology Service where she was treated with Aspirin, beta blockers, ACE inhibitors and Heparin drip. She was also diuresed with Lasix pending cardiac catheterization. Cardiac catheterization was performed with results as listed above. The patient tolerated the procedure well. Based on these results, it was felt that coronary artery bypass grafting would be necessary. She was further stabilized and diuresed with Lasix and continued on Nitroglycerin drip and Heparin. She was taken to the Operating Room on [**2124-7-24**] where she underwent three vessel coronary artery bypass graft with saphenous vein grafts to obtuse marginal 1, posterior left ventricular and left anterior descending respectively under general endotracheal anesthesia. There were no intraoperative complications and the patient was transferred to the Cardiac Recovery Room, intubated, being atrioventricularly based at 90 per minute. She was extubated on postoperative day #1 and she was weaned. She was started on Lopressor, Aspirin and Lasix and transferred to the regular floor that evening. That evening the patient was complaining of some increased belching and symptoms that were similar to her previous myocardial infarction. Electrocardiogram was obtained which showed no changes. She was given 1 mg of Morphine. On postoperative day #2 the patient exhibited some confusion which cleared over the course of the day. Her narcotics were held. On postoperative day #3 she went into atrial fibrillation with rates to 100s. She was given 2 mg of Magnesium Sulfate and 5 mg of Lopressor intravenously. Rate was controlled to the 70s, she was intravenously loaded with Amiodarone after which she converted to normal sinus rhythm and then was continued on oral Amiodarone. At this time the patient was in normal sinus rhythm on p.o. Amiodarone and Lopressor. She is ambulating with assistance, tolerating a regular diet and is deemed stable for discharge to a rehabilitation facility for further physical therapy and cardiopulmonary care. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft times three 2. Coronary artery disease, status post myocardial infarction in [**2121**] 3. Hypertension 4. Hypercholesterolemia 5. Insulin dependent diabetes mellitus 6. Peripheral vascular disease 7. Peptic ulcer disease status post gastrointestinal bleed 8. Status post bladder suspension DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. q.d. times one week 2. Lopressor 25 mg p.o. q. 12 hours 3. Colace 100 mg p.o. b.i.d. 4. Aspirin 81 mg q.d. 5. Lasix 20 mg q. 12 hours times one week 6. Protonix 40 mg q.d. 7. Reglan 10 mg q. 8 hours 8. Amiodarone 400 mg t.i.d. times 7 days beginning [**7-28**] and then Amiodarone 400 mg p.o. b.i.d. times 7 days and then Amiodarone 400 mg p.o. q.d. times 7 days 9. Milk of magnesia 30 cc p.o. q.h.s. prn 10. Dulcolax suppository one p.r. q.d. prn 11. Insulin NPH 5 units q AM, 10 units q. PM 12. Insulin regular 5 units q. PM 13. Insulin sliding scale 14. Tylenol #3 one to two p.o. q. 4 to 6 hours prn 15. Zantac 150 mg p.o. b.i.d. FO[**Last Name (STitle) 996**]P: The patient is to follow up with her primary care physician in one to two weeks and to follow up with Dr. [**Last Name (Prefixes) 411**] in clinic in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 2682**] MEDQUIST36 D: [**2124-7-28**] 08:17 T: [**2124-7-28**] 09:44 JOB#: [**Job Number 28041**]

41401,4111,9971,42731,4280,5990,25000,2720,4019

Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**] Service: SURGERY Allergies: Iodine Attending:[**First Name3 (LF) 2597**] Chief Complaint: bilateral claudication and rest pain Major Surgical or Invasive Procedure: [**2130-4-12**]: B femoral patch endarterectomy, B iliac stents (7 stents) History of Present Illness: This elderly lady well known to [**Month/Day/Year 1106**]/Dr. [**Last Name (STitle) **] and has developed severe disabling claudication progressively worsening to the point now where she will only walk a few steps without pain and probably a mild ischemic rest pain as well. She underwent an MRA because of renal insufficiency which showed extensive iliac disease bilaterally. There were high-grade stenoses at the origin of both common iliac arteries and diffuse disease throughout both external iliac arteries involving the common femoral arteries as well with occlusion of her superficial femoral arteries. Past Medical History: 1. Coronary artery disease: - s/p CABG [**2124**] (SVG to OM, SVG to PLV, SVG to LAD) - Cardiac cath on [**12-13**] showed patent grafts 2. Peripheral [**Month/Year (2) 1106**] disease 3. Diabetes mellitus, type II 4. Hypertension 5. Chronic renal insufficiency (baseline creatinine 1.6-1.9) 6. s/p Right CEA 7. Macular degeneration 8. h/o GI bleed 9. s/p bladder suspension Social History: Lives alone. husband died 2 months ago. daughter lives nearby. activity limited by severe PVD. Tob: smoked for 30yrs; quit 15yrs ago EtOH: none Illicits: none Family History: NC Physical Exam: VSS: 99.1, 130/80, 86 94%RA GEN: NAD CARD: RR, [**2-7**] STEM Lungs: [**Month/Day (4) **] EXT: no edema, incisions c/d/i steri-strip RT DP palp, PT dopp, LT DP/PT dopp Pertinent Results: [**2130-4-17**] 06:20AM BLOOD WBC-6.4 RBC-3.23* Hgb-9.5* Hct-27.8* MCV-86 MCH-29.5 MCHC-34.2 RDW-15.0 Plt Ct-136* [**2130-4-17**] 06:20AM BLOOD Plt Ct-136* [**2130-4-17**] 06:20AM BLOOD Glucose-106* UreaN-39* Creat-1.6* Na-138 K-4.3 Cl-103 HCO3-30 AnGap-9 [**2130-4-17**] 06:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.6 Brief Hospital Course: Underwent uneventful bilateral common femoral endarterectomies and distal external iliac endarterectomies with Dacron patch angioplasties and balloon angioplasty and stenting of both common and external iliac arteries. Extubated in OR and transferred to PACU. B/L DP/PT dopplerable. pain controlled. UO at 22 cc/hr. BP 125/43, off nitro gtt. POD1- Hypotension overnight BP 86/42 CVP 3-4. Fluid bolus given with improvement in BP to 114/48. Second event of hypotension to SBP 50 HCT 28.4. Received 2 units PRBCs. Non contrast CT negative for retroperitoneal bleed. Hypertensive meds held. Dopamine gtt started, 5% albumin given for support. Swan catheter placed. Denies chest pain, abdominal pain. ECG WNL, cardiac enzymes cycled. Cardiology consult obtained. POD2-Intermittent hypotensive events, BP 69-110/32-47. Off Dopamine. Troponins elevated, likely demand ischemia per cardiology. POD3-No overnight events. VSS On heparin gtt. RT DP palp, B/L DP/PT dop Cardiology following patient with acute MI:Troponin 0.23, peak CK 154 with pos MB. Exam negative for CHF. POD4- No overnight events. OOB to chair. diet advanced to regular. PA cath discontinued. POD5- VSS. No overnight events. Cr 1.6. Physical therapy consulted. transferred from VICU to [**Wardname **] floor bed. POD6- VSS. No overnight events. Physical therapy cleared for discharge home with PT/home safety eval. Patient will follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week. Medications on Admission: ASA 81', Imdur 30', lisinopril 20", zestoril', metoprolol 50", MVI' zocor 40, lantus 8hs with Humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Lantus 100 unit/mL Solution Sig: 8 units at bedtime Subcutaneous at bedtime: Follow normal Humalog sliding scale with meals. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: B/L claudication s/p B femoral patch endarterectomy, B iliac stents (7 stents) Elevated Troponin-demand ischemia PMH: CAD, PVD, IDDM, CRI, HTN, macular degeneration, h/o GI bleed PSH: CABG '[**24**] x3, cardiac cath [**12-7**] shows patent grafts, R CEA '[**27**], bladder suspension Discharge Condition: Good. VSS Cr 1.6 Discharge Instructions: Division of [**Year (2 digits) **] and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**2-4**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr.[**Initials (NamePattern4) 5695**] [**Last Name (NamePattern4) 28043**] at [**Telephone/Fax (1) 3121**] to schedule office visit to be seen next week. Call Dr. [**Last Name (STitle) **] (Cardiology) at ([**Telephone/Fax (1) 10085**] to schedule office visit to be seen next week. Completed by:[**2130-4-18**]

44022,41091,3968,5859,4401,4471,40390,4168,45829,43310,25000,41400,V5867,V4581

Admission Date: [**2119-5-20**] Discharge Date: [**2119-5-31**] Date of Birth: [**2076-5-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: motor vehicle crash: car vs tree Major Surgical or Invasive Procedure: interventional radiology embolization: arteriogram via celiac showed right posterior segmental branch with active extravasation- embolized History of Present Illness: 43 yo female s/p MVC vs tree. She was the restrained driver, single occupant with no LOC, complaining of left humeral pain and diffuse abdominal pain most severe in the right upper quadrant. Past Medical History: s/p cesarean section and appendectomy Social History: Married, lives with husband Family History: Noncontributory Physical Exam: In the ER BP 130's HR 80 RR 20 Sat 100% Gen: complaining of abominal and arm pain HEENT: laceration on dorsum of tongue, PERRL, EOMI, TM clear bilaterally, c-spine cleared by CT and clinically CV: RRR NTTP Lungs: CTA B Abd: diffusely tender to palpation Ext: left humeral deformity, 2+ radial pulse, nl sensation of hand and arm Neuro: alert and oriented Ext: left arm deformity with good pulses and cap refill of hand, sensation intact Pertinent Results: CT Abd/ pelvis: complex liver laceration involving all 4 segments of the right lobe of the liver with perihepatic hematoma and ACTIVE EXTRAVASATION of contrast. High density fluid in pelvis consistent with hemoperitoneum. left Humerus xray: Minimally comminuted mid shaft humerus fracture CXR: neg Pelvis: neg Head CT: neg C spine CT: neg Wrist: neg Elbow: neg [**5-20**] arteriogram via celiac shows right posterior segmental branch with active extrav. --> embo x3 with coils, cessation of flow. [**2119-5-20**] 07:20AM WBC-17.2* RBC-3.60* HGB-11.7* HCT-34.1* MCV-95 MCH-32.4* MCHC-34.2 RDW-12.4 [**2119-5-20**] 09:51AM HCT-26.2* [**2119-5-20**] 01:39PM HCT-33.4*# Brief Hospital Course: Patient was evaluated in the ER by CT scan and found to have a grade IV liver laceration with active bleeding. She was transferred to the T-SICU and then taken to IR for embolization. Her hematocrit was found to have significantly dropped associated with hypotension to the 80's so she was tranfused 2 units of PRBC's. After the transfusion and embolization her hematocrit stabilized and she was transferred to the floor. Her pain was initially controlled with pca dilaudid and switched to po pain medication once she was tolerating po's. Her pain was difficult to control and the acute pain service was consulted for input. In the end, she was discharged home with MS contin [**Hospital1 **] 15mg and dilaudid for breathrough pain only. Her left humeral fracture was evaluated by ortho on admission and thought to be stable and non-operativve. It was placed in a splint. Throughout her hospitalization repeat images were obtained and reviewed by orthopedics. They continued to feel she was non-operative and should be kept in the splint. She was noted to have continued abdominal discomfort with some distention and lack of bowel movements after the embolization. This was relieved with laxatives and improved over time. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for breakthrough pain only: only take this medication as needed every 4 hours. . Disp:*60 Tablet(s)* Refills:*0* 4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Grade IV liver laceration s/p embolization Left humeral fracture Discharge Condition: stable Discharge Instructions: You are being discharged home today after your motor vehicle crash. You had a laceration in your liver that was treated by interventional radiography embolization. You should call your PCP or return to the ER if you should develop any worsening abdominal pain, lightheadedness, nausea, vomiting, fever, chills, or any other concerns. You should take your pain medication and stool softener as prescribed. You should not drive while taking narcotics. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in his clinic in 2 weeks by calling [**Telephone/Fax (1) 6439**]. Follow up with orthopedics in 2 weeks by calling [**Telephone/Fax (1) 1228**].

86803,86405,E8160,80701,81221

Admission Date: [**2165-2-27**] Discharge Date: [**2165-3-4**] Date of Birth: [**2124-11-3**] Sex: F Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 40 year old female, who has no symptoms at this time, presented with right sided weakness. A neurologic workup revealed the presence of 2 strokes. Cardiology workup revealed a patent foramen ovale and the patient was referred to Dr. [**Last Name (Prefixes) **] for patent foramen ovale closure. The patient did not have cardiac catheterization. A transesophageal echocardiography showed a patent foramen ovale with left to right flow. PAST MEDICAL HISTORY: Patent foramen ovale. Depression. Cerebrovascular accident. PAST SURGICAL HISTORY: Cesarean section x2. MEDICATIONS ON ADMISSION: Medications at preoperative workup were as follows: 1. Celexa 20 mg p.o. once daily. 2. Coumadin 5 mg p.o. 4 times a week and 7.5 mg p.o. 3 times a week. ALLERGIES: She is allergic to Penicillin which caused hives. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lived with her husband and had no smoking or alcohol history and no use of recreational drugs. LABORATORY DATA: Preoperative laboratory work as follows: White count 7.2, hematocrit 39.0, platelet count 284,000. PT 16.8, PTT 37.2 with an INR of 1.8. This was all approximately a week and one half preoperatively when the patient was still on Coumadin. Her urinalysis showed some hematuria with a small amount of bacteria. Sodium 138, potassium 3.6, chloride 101, bicarbonate 30, BUN 9, creatinine 0.6, with a blood sugar of 76, ALT 41, AST 43, alkaline phosphatase 75, total bilirubin 0.4, total protein 7.8, albumin 4.4, globulin 3.4. HBA1C 5.4%. Chest x-ray showed no acute cardiopulmonary process. EKG showed sinus rhythm at 67 with nonspecific ST-T wave flattening. PHYSICAL EXAMINATION: On examination, she had a heart rate of 66 and sinus rhythm with a blood pressure of 120/61, height 5 feet five inches tall, weight 105 pounds. She was in no apparent distress. She had no obvious skin lesions. Her extraocular movements were intact. The pupils are equal, round and reactive to light and accommodation. Her neck was supple. Her lungs were clear bilaterally without any rhonchi or rales. The heart was regular rate and rhythm, with S1 and S2 tones and no murmurs, rubs or gallops. Her abdomen was soft, nontender, nondistended with positive bowel sounds. Her extremities are warm and dry with no cyanosis, clubbing or edema. She had no obvious varicosities. She was alert and oriented and grossly neurologically intact cranial nerves II through XII. She had 2+ bilateral femoral, DP, PT and radial pulses and no carotid bruits. HO[**Last Name (STitle) **] COURSE: The patient was admitted to the hospital on [**2165-2-27**], after stopping her Coumadin at home. On [**2165-2-27**], she underwent minimally invasive atrial septal defect repair through a mini right thoracotomy by Dr. [**Last Name (Prefixes) 411**] and was transferred to the Cardiothoracic ICU in stable condition on a Propofol drip. She had a small right [**Doctor Last Name 406**] drain for thoracotomy drainage. She was given Morphine and Toradol for good pain control. She was extubated overnight and remained on a Neo-Synephrine drip at 1 mcg/kg/minute. She had a good blood pressure of 88/53 and sinus rhythm at 75 and temperature maximum of 99.9 postoperatively. White count rose to 13.0, hematocrit 25.2, and platelet count 303,000. Potassium 4.0, BUN 10, creatinine 0.6. She had coarse breath sounds which were decreased on the right. Her Foley and her chest tubes remained in place. Diet was advanced. She had been extubated and her [**Doctor Last Name 406**] drain was placed to water seal and she remained on Neo-Synephrine drip overnight. This was weaned the following morning down to 0.25. Her hematocrit dropped slightly to 20.2, white count remained at 9.6. She finished her perioperative Vancomycin. Her creatinine was stable at 0.5. Her chest tube was discontinued. Repeat chest x-ray was done. She was hemodynamically stable in sinus rhythm with a pressure of 110/58 and was transferred out to the floor. Lasix diuresis was begun. On the floor, the patient was evaluated by physical therapy to begin ambulation and activity tolerance and was seen by case management also for evaluation. Her Foley was removed that afternoon. On postoperative day #3, she did complain of some sharp right inner thigh pain with some activity. She was alert and oriented, began her aspirin, vitamins, iron and was restarted on her Celexa as well as Zantac. She was given Vitamin B6 for neurologic pain. Her aspirin was increased to 325 mg p.o. once daily. She was hemodynamically stable. Her weight was 88.2 kilograms. She was saturating 96% in room air. Her white count dropped to 8.0, her hematocrit rose to 25.4 and her creatinine remained stable at 0.7. She continued to work with physical therapy. She did have some incisional pain under her right breast, the site of her mini thoracotomy. This was treated with p.o. Percocet. She had decreased breath sounds at the bases. She was tolerating her p.o. well and was medicated for pain control. On postoperative day #4, her right inner thigh tingling decreased. She put out almost 6 liters of urine. Her heart was regular rate and rhythm. Her lungs were clear bilaterally. Her abdomen was soft, nontender. She was doing very well. The patient complained of a visual field deficit from the right eye since surgery without prior history. On examination, appeared to be nontoxic. Her visual fields were intact. Her extraocular movements were intact. Cranial nerves II through XII were intact, and she had no neurologic deficit. Question was whether the patient had an embolic stroke at that time. A CT of the head was ordered. Neurology consultation was ordered and plans were for discharge were placed on hold, given the patient's complaint of right eye blurriness. An ophthalmology consultation was obtained. The diagnosis was a small right macular area hemorrhage. Per initial consultation ophthalmology, it was recommended that the patient have a follow-up at her ophthalmologist in [**Location (un) 3307**] or at the [**Hospital3 **] Eye Clinic in [**Hospital Ward Name 23**], fifth floor. Telephone number was given to the patient, [**Telephone/Fax (1) 10153**], to make an appointment on Monday after discharge. On postoperative day #5, neurology saw the patient on [**2165-3-3**], after ophthalmology consultation. At the time, this was also noted about the sensory changes of her right thigh in the distribution of the femoral nerve and lateral femoral cutaneous nerve. Neurology recommended a state CT of the pelvis with stat coagulation studies to assess for retroperitoneal bleed as well as MRA of the brain with a stroke protocol to evaluate for any infarctions, either water shed or embolic, given her various neurologic complaints. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], neurology attendings. Ophthalmology consultation was performed as previously noted. On postoperative day #5, the patient was then in sinus rhythm at 72, was stable hemodynamically, had trace peripheral edema. Her thoracotomy incision was clean, dry and intact. Her pacing wires had been removed. Her central venous line was out. MRI was performed, awaiting final result. The MR scan was negative per Dr. [**Last Name (STitle) **], and the patient was neurologically cleared. The patient was also evaluated to go home with VNA services by case management. The patient was instructed to follow-up with ophthalmologist and was discharged home with VNA services on [**2165-3-4**]. DISCHARGE DIAGNOSES: Status post minimally invasive atrial septal defect repair. Status post cerebrovascular accident. Right macular hemorrhage. Depression. Status post cesarean section x2. DISCHARGE INSTRUCTIONS: 1. To follow-up with Dr. [**First Name (STitle) **], her primary care physician in approximately 2-3 weeks postdischarge with specific instructions to follow-up with Dr. [**First Name (STitle) **] on the right kidney mass and left pelvic cyst that were both found on CT scan in the hospital. 2. The patient was also instructed to follow-up at the ophthalmology clinic here at [**Hospital1 10154**], [**Telephone/Fax (1) 10153**], or to see her own ophthalmologist in [**Location (un) 3307**] as discussed for follow-up of her right retinal hemorrhage. 3. The patient was also instructed to follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately 4 weeks for her postoperative surgical visit in the office. MEDICATIONS ON DISCHARGE: 1. Celexa 20 mg p.o. once daily. 2. Ferrous Sulfate 325 mg p.o. once daily. 3. Vitamin C 500 mg p.o. twice daily. 4. Pyridoxine Hydrochloride 50 mg p.o. once daily. 5. Enteric-coated aspirin 325 mg p.o. once daily. 6. Percocet 5/325 one tablet p.o. p.r.n. q.4hours for pain. 7. Ibuprofen 400 mg p.o. q.6hours p.r.n. for pain. DISCHARGE STATUS: The patient was discharged to home in stable condition with VNA services on [**2165-3-4**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2165-4-16**] 16:12:56 T: [**2165-4-16**] 19:43:38 Job#: [**Job Number 10155**]

7455,36281,7820,7935,V1259,V5861,2859,45829,42731

Admission Date: [**2102-5-4**] Discharge Date: [**2102-5-14**] Date of Birth: [**2034-6-10**] Sex: M Service: CT [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is a 67 year old male who was referred to [**Hospital1 69**] from a Stress Test Laboratory following elicitation of symptoms of hypotension and diffuse ST depressions upon exercise. The patient was reportedly referred to for stress testing by his primary care provider due to complaints of chest pain after exercising for approximately ten minutes. At baseline, the patient walks four miles daily. Approximately one month ago, the patient experienced the sudden onset of chest pain across his chest, after approximately [**2-14**] of a mile of walking. The patient had similar symptoms the following day. The patient subsequently discontinued his walking regimen, and [**Doctor First Name **] to a regularly scheduled appointment with his primary care physician for which he was subsequently referred for a stress test. On stress testing, the patient was noted to experience hypotension from systolic 140 to systolic 108, and diffuse ST depressions after approximately four minutes of exercise testing. The patient was reportedly asymptomatic during this time, but was subsequently referred to [**Hospital1 190**] for further evaluation and management. PAST MEDICAL HISTORY: 1. History of bleeding ulcers. 2. Question of hypercholesterolemia. 3. Gastroesophageal reflux disease status post fundoplication. 4. History of idiopathic transaminitis. MEDICATIONS AT HOME: Zantac. ALLERGIES: Morphine, which causes disorientation. Tensilon which elicits hives. SOCIAL HISTORY: The patient is divorced. The patient is retired and is a part time safety officer. The patient has no history of tobacco use. The patient has a significant history of alcohol abuse in the distant past but has been abstinent for approximately 20 years. HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**] Service on [**2102-5-4**] for further work-up of his cardiac symptoms . Admission EKG demonstrated left axis deviation with 1/[**Street Address(2) 2915**] depression in V3 to V5; on exercise per the patient's stress test, the patient's EKG demonstrated diffuse [**Street Address(2) 31707**] depressions in V2 to V6 and ST elevations in V3. Cardiac catheterization conducted on [**2102-5-5**], demonstrated a three vessel coronary artery disease with a focal 80% stenosis in the mid-proximal segment of the left anterior descending, a focal 90% stenosis in the mid major obtuse marginal branch of the left circumflex, and 100% occlusion of the right coronary artery in its mid segment. The patient's calculated ejection fraction was noted to be 45%. At this point, Cardiac Surgery was consulted and, following a discussion of the relative pros and consultation of surgery, the patient consented to undergo a coronary artery bypass graft procedure to take place on [**2102-5-10**]. In the interval, the patient was stabilized by the Medicine Team in preparation for surgery. On [**2102-5-10**], the patient underwent a quadruple coronary artery bypass graft procedure. Anastomoses included from the left internal mammary artery to the left anterior descending, saphenous vein graft to the diagonal, saphenous vein graft to the obtuse marginal, and saphenous vein graft to the diagonal. The patient's pericardium was left open. Lines placed included arterial, Swan-Ganz and central venous pressure catheters; both ventricular and atrial wires were placed; mediastinal, left and right pleural tubes were placed. The patient was subsequently transferred to the Cardiac Surgery Recovery Unit, intubated, for further evaluation and management. On transfer, the patient's main arterial pressure was 80; his central venous pressure was 14; his PAD was 17 and his [**Doctor First Name 1052**] was 26. The patient's heart rate on transfer was noted to be normal sinus rhythm at 84 beats per minute. On transfer, active drips included Phenylephrine and Propofol. Shortly following arrival in the CSRU, the patient was weaned and extubated without complication. The patient was subsequently advanced to oral intake without complication. On postoperative day number one, the patient's lines and chest tubes were removed without complication. The patient was subsequently cleared for transfer to the regular patient floor. The patient was subsequently admitted to the Cardiac Thoracic Service under the direction of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On the floor, the patient progressed well clinically through to the time of his discharge. The patient's Foley catheter was removed and he was subsequently noted to be independently productive of urine for the duration of his stay. Adequate pain control was provided via oral pain medications for the duration of his stay. Physical Therapy was consulted and the patient was subsequently cleared for discharge directly to home following resolution of his acute medical issues. The patient's pacer wires were removed without complication and on postoperative day number four, [**2102-5-14**], the patient was cleared for discharge to home with instructions for follow-up. DISCHARGE STATUS: The patient is to be discharged to home with instructions for follow-up. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 325 mg p.o. q. day. 2. Atenolol 26 mg p.o. q. day. 3. Atorvastatin 10 mg p.o. q. day. 4. Lasix 20 mg p.o. twice a day times ten days. 5. Potassium chloride 20 mEq p.o. [**Hospital1 **] times ten days. 6. Colace 100 mg p.o. twice a day. 7. Percocet one to two tablets p.o. q. four to six hours p.r.n. for pain. 8. Lopressor 12.5 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient is to maintain his incision clean and dry at all times. 2. The patient may shower but should pat-dry incisions afterwards; no bathing or swimming until further notice. 3. The patient has been instructed to resume a cardiac diet. 4. The patient has been advised to limit physical exercise; no heavy exertion. 5. No driving while taking prescription pain medications. 6. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**] in one to two weeks; the patient is to call [**Telephone/Fax (1) 19968**], to schedule an appointment. 7. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks; the patient is to call [**Telephone/Fax (1) 170**], to schedule an appointment. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By: [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) 31708**], M.D. MEDQUIST36 D: [**2102-5-13**] 16:20 T: [**2102-5-13**] 17:02 JOB#: [**Job Number 31709**]

41401,4111,2720,53081,V173

Admission Date: [**2128-11-29**] Discharge Date: [**2128-12-8**] Date of Birth: [**2079-12-7**] Sex: F Service: Surgery, Purple Team HISTORY OF PRESENT ILLNESS: This is a 49-year-old woman who was referred to Dr. [**Last Name (STitle) **] for diverticular disease for a sigmoid colectomy. The patient's last attack of diverticulitis was on [**11-14**] of this past year. PAST MEDICAL HISTORY: 1. Mild spina bifida without neurologic deficits. 2. History of bladder cancer, status post chemotherapy and radiation therapy. Follow-up cystoscopies demonstrated no evidence of recurrence. 3. The patient is postmenopausal. PAST SURGICAL HISTORY: 1. The patient had a colonoscopy. 2. Resection of bladder tumor in [**2107**] for bladder cancer. MEDICATIONS ON ADMISSION: The patient was on hormone replacement therapy which is Estratab one-half strength, Prometrium 100 mg p.o. q.h.s. ALLERGIES: SULFA causes hives as well as multiple environmental allergies. SOCIAL HISTORY: The patient admits to one alcoholic drink per day and denies any use or abuse of tobacco products. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were pulse of 83, blood pressure 129/79. General impression revealed a well-appearing, well-dressed woman in no apparent distress. Head, ears, nose, eyes and throat revealed the patient had scleral icterus. No lymphadenopathy, and no thyromegaly. Lungs were clear to auscultation bilaterally. Cardiovascular had a regular rate and rhythm. No murmurs. The abdomen was soft, nontender, and nondistended, and without bruits. Extremities had edema, and there were palpable dorsalis pedis pulses bilaterally. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2128-11-29**]. She went to the operating room and had a sigmoid colectomy with a #29 EEA anastomosis. The patient tolerated the procedure well and an air and water-tight anastomosis was obtained. Please see previously dictated Operative Notes for more details. The patient was extubated in the operating room and was transferred from the operating room to the Postanesthesia Care Unit. In the Postanesthesia Care Unit, the patient was very somnolent and in fact had periods of apnea during sleep. She received 10 mg of morphine sulfate in the operating room and 12 mg of morphine sulfate in the Postanesthesia Care Unit. Because of her somnolence and apneic episodes, the patient was transferred to the Intensive Care Unit for closer monitoring. Pain medications were switched from morphine to Toradol. The patient did not require intubation while in the Intensive Care Unit. The patient was transferred from the Intensive Care Unit to the patient care floor on postoperative day one. While on the patient care floor she was n.p.o. while awaiting bowel function. Her pain was controlled with Toradol and Dilaudid patient-controlled analgesia at a minimum setting. Her Foley was discontinued on the first day on the patient care floor. The patient's course after this point was uncomplicated. Her electrolytes were periodically checked, and she was given maintenance intravenous fluids while she was n.p.o. On postoperative day seven despite she did not have flatus, the patient was started on sips of clears. The patient tolerated sips without any problems and denied any nausea or vomiting. On postoperative day eight the patient had flatus. Her diet was advanced as tolerated, and she tolerated a regular diet without problems. She was switched over to p.o. pain medication which controlled her pain adequately. At this point she was comfortable and ready to be discharged to home. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Condition on discharge was stable. MEDICATIONS ON DISCHARGE: The patient was discharged to home on her previous medications which included Estratab and Prometrium. In addition, the patient had Dilaudid 1 mg one to two tablets p.o. q.4h. p.r.n. for pain and Colace 100 mg p.o. b.i.d. while on Dilaudid. DISCHARGE FOLLOWUP: The patient was to see Dr. [**Last Name (STitle) **] in her office. The patient should call for follow-up appointment. DISCHARGE DIAGNOSES: 1. Diverticulosis. 2. Status post sigmoid colectomy and primary anastomosis. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Last Name (NamePattern1) 6355**] MEDQUIST36 D: [**2128-12-7**] 12:37 T: [**2128-12-12**] 13:37 JOB#: [**Job Number 35983**]

56211,78603,V1051

Admission Date: [**2201-2-6**] Discharge Date: [**2201-2-10**] Date of Birth: [**2141-12-30**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old man with a history of known coronary artery disease of worsening symptomatology who was referred for cardiac catheterization. Cardiac catheterization revealed severe three-vessel disease and mildly depressed ejection fraction. The patient complained of shortness of breath after climbing two or more flights of stairs or walking two blocks at a brisk pace. His wife also reported that he also occasionally has chest discomfort but was not sure when this occurs. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Coronary artery disease. PAST SURGICAL HISTORY: None. ALLERGIES: SULFA. MEDICATIONS: Cardizem 240 mg p.o. q.d., Lescol 80 mg p.o. q.d., Aspirin 325 mg p.o. q.d., Multivitamin 1 p.o. q.d. LABORATORY DATA: White count 8, hematocrit 43, platelet count 177; CHEM7 139, 4.7, 105, 25, 17, 1.0, 95. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2201-2-6**], and underwent three-vessel coronary artery bypass graft. The patient had LIMA to the left anterior descending, saphenous vein graft to diagonal, and saphenous vein graft to PL. The patient did well postoperatively and was brought to the CSRU. On postoperative day #1, the patient was transferred to the floor. On postoperative day #2, the patient's chest tube and wires were removed. The patient's Foley catheter was also removed at that time. The patient was seen by Physical Therapy on postoperative day #2 who felt that he was at least level III ambulation at that time. The patient continued to do well, and on postoperative day #3, the patient was seen by Physical Therapy again. At this time he was felt to be at approximately level IV and would most likely be ready for discharge on postoperative day #4. The patient was discharged to home on postoperative day #4 in good condition. DISCHARGE MEDICATIONS: Percocet 5/325 [**11-26**] p.o. q.4-6 hour p.r.n., Ibuprofen 400 mg p.o. q.6 hours p.r.n., Aspirin 325 mg p.o. q.d., Colace 100 mg p.o. b.i.d., KCl 20 mEq p.o. b.i.d. x 7 days, Lasix 20 mg p.o. b.i.d. x 7 days, Metoprolol 12.5 mg p.o. b.i.d., Lescol 80 mg p.o. q.d. DISCHARGE DIAGNOSIS: The patient coronary artery bypass grafting times three. CONDITION ON DISCHARGE: Good. DISPOSITION: To home. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2201-2-9**] 09:59 T: [**2201-2-9**] 10:00 JOB#: [**Job Number 25608**]

41401,4019,2720

Admission Date: [**2120-4-25**] Discharge Date: [**2120-5-1**] Date of Birth: [**2064-3-25**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: IV TPA History of Present Illness: 56 yo man with hx angioplasty in [**2116**] for cad, hx afib prior to that (none documented since, on no anticoag), p/w fall to L at work and sudden onset L sided weakness (face, arm and leg) at 4:30PM; CODE STROKE activated. Pt had been in USOH prior to event, and fall was witnessed by colleagues - pt collapsed to L against a filing cabinet, noted by colleagues to be weak on the L with facial droop on L as well. EMS got call at 5PM and pt arrived in ER at 5:30PM. VS in field included BG 91, BP 116/68, HR 60. Neurology at bedside upon pt arrival. NIHSS score 6 for facial droop (2), motor/arm (1), mild dysarthria (1), and extinction to DSS (2). Pt himself initially denied L sided weakness and denied that anything was wrong either with strength of limbs or with speech. He had been noted by EMS to at times be unable to move his L arm, and at other times able to touch his nose with L hand. C/o no other sx except mild L temple headache. No visual or hearing changes, problems swallowing, hearing problems, or other sx except as above. Stat head CT showed hyperdense L MCA, and CTA showed clot at M1. TPA given at 6:30PM (bolus) and infusion to be run for 1hr after. Past Medical History: PMH: CAD s/p angio in [**2116**] Hx afib prior to angio/stent placement, not documented since Hx L diaphragm paralysis after neck surgery No hx htn, high chol, dm to pt's knowledge (though on lipitor) Social History: Social History: Lives with wife, has kids; no tob, few drinks etoh/nt, no drugs; works in office Family History: Family History: No strokes or heart attacks in family. Father with DM. Physical Exam: Admission Examination: afebrile 116/68 HR 56 99%RA 16 wt 200 lbs General appearance: white male, NAD HEENT: moist mucus membranes, clear oropharynx Neck: supple, no bruits Heart: regular rate and rhythm, no murmurs Lungs: clear to auscultation bilaterally Abdomen: soft, nontender +bs Extremities: warm, well-perfused Skull & Spine: Neck movements are full and not painful to palpation in the paraspinal soft tissues Rectal: nl, guaiac neg stool Mental Status: The patient is alert and attentive, could provide accurate history. Language is intact with no errors, normal [**Location (un) 1131**] and comprehension, repetition, naming. There is however anosagnosia, with pt repeatedly saying L side working fine; no hand agnosia. Cranial Nerves: The visual fields are full to confrontation, but there is extinction to DSS on L, and he has a R gaze preference, though no gaze palsy. The optic discs are normal in appearance. Eye movements are normal, with no nystagmus. Pupils react equally to light 3.5->2 bilat, both directly and consensually. Sensation on the face is intact to light touch, pin prick per pt, with no ext to DSS. Facial movements are notable for L droop. Hearing is intact to finger rub. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. Mild dysarthria for labial sounds. Motor System: There is 5-/5 strength at the left deltoid and tricep, 4+/5 at finger extensors on L, 5-/5 L hamstring, elsewhere mms are full stength. There is no tremor, or abnormal movements. There is L drift and vacillation. Reflexes: The tendon reflexes are mildly depressed on L [**Hospital1 **]/[**Last Name (un) **] compared to R. Knees and ankles equal. The L toe is up, R is down. Sensory: Sensation is intact to LT, position, but he has intermittent extinction to DSS on the left to tactile and visual stim, neglects L side. Coordination: L F->N Ataxia is not out of proportion to weakness or neglect, improves with looking at hand on L; no ataxia elsewhere. The R finger/nose test normal. Gait: deferred for now Pertinent Results: CT head [**2120-4-25**]: IMPRESSION: Relatively "hyperdense" proximal right MCA, raising the possibility of acute embolic or thrombotic occulsion of this vessel, with no definite evidence of acute major vascular territorial infarct on this non- contrast head CT. Please refer to concurrent CTA, including post-processed CT perfusion study for more complete assessment of this finding.2. No acute hemorrhage. CTA head and neck [**2120-4-25**]: IMPRESSION: Findings consistent ischemia within the right middle cerebral artery territory, due to embolic occlusive fragment seen near the origin of the right middle cerebral artery on CT angiography. CT head [**2120-4-26**]: New hypodense region within the right basal ganglia with associated slight edema and mass effect on the ventricular system suggests acute stroke; however, no complication including no intracranial hemorrhage is detected CTA chest [**2120-4-30**]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multifocal, patchy air space disease. Findings nonspecific but differential diagnosis includes infectious or inflammatory process, including cryptogenic organizing pneumonia. While this is an atypical distribution for aspiration, given the patient's clinical history, this would also be a consideration. TEE [**2120-5-1**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-26**]+) mitral regurgitation is seen. There is no pericardial effusion. No aortic atheroma. IMPRESSION: No cardiac source of embolism seen. Brief Hospital Course: Patient presented to ED with exam of NIHSS of 6 as per above. He has a hyperdense right MCA sign confirmed by cut off on CTA and decreased CBF on perfusion. Mechanism of stroke is likely cardioembolic from atrial fibrillation. Patient received IV tPA after risk of 6.4% risk of ICH discussed with family and patient . No complications after bolus and infusion and patient monitored in ICU 24 hours with no complications. He was transferred to Neurology floor where he was noted to have a normal neurological exam with only some very mild left pronator drift. The patient was on telemetry and no arrhythmias noted. He had an echocardiogram which was poor quality so had a transesophageal echocardiogram which showed no cardiac embolic source for stroke. Patinet complained of shortness of breath during his hospital stay that persisted for two days. He had nml cardiac enzymes, nml EKG and chest ct-with perfusion which showed some lung space disease and small pleural effusions. His shortness of breath improved with ambulation and incentive spirometry. Patient worked with Pt/OT who felt he did not need any inpatient or home PT/OT service. Medications on Admission: Meds: Digoxin 250mcg ASA 81 mg Nadolol unknown dose Lipitor 10 mg Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 4. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: please do NOT take medication till your PCP checks INR blood level and tells you to continue the medication. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: stroke Discharge Condition: stable Discharge Instructions: Take medications as instructed Followup Instructions: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] Neurology [**Hospital 4038**] Clinic Phone:[**Telephone/Fax (1) 44**] [**2120-5-29**] 4:30 pm [**Hospital 18**] [**Hospital 878**] Clinic [**Hospital Ward Name 23**] bldng [**Location (un) **]. YOU MUST CALL TO CONFIRM THIS APPOINTMENT

43491,5180,34280,42731,412,41401,V4582

Admission Date: [**2182-7-10**] Discharge Date: [**2182-7-30**] Date of Birth: [**2114-1-4**] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: This is a 68-year old female with a history of myelodysplastic syndrome transformed into acute myelogenous leukemia (type M6A) diagnosed one month ago who was initially admitted for treatment with low-dose Ara-C and Hydroxyurea. Her disease was initially diagnosed secondary to pancytopenia with circulating blast forms and a bone marrow in [**2182-5-9**]. She was initially treated with Procrit and weekly transfusions with packed red blood cells and Danazol from which she developed an allergic reaction. Over the last week prior to admission, she developed increased fatigue. Repeat bone marrow showed 7 percent to 10 percent myeloblasts. PAST MEDICAL HISTORY: As above, history of myelodysplastic syndrome transformed into acute myelogenous leukemia. No prior surgeries or prior hospitalizations. MEDICATIONS ON ADMISSION: Procrit 40,000 units every week and Tylenol as needed. ALLERGIES: DANAZOL (causes facial swelling and periorbital edema). SOCIAL HISTORY: A 70-pack-year smoking history; currently smokes half a pack per day. Three drinks of alcohol per night. She is a retired office manager. FAMILY HISTORY: Sister deceased from a central nervous system aneurysm. Brother deceased from coronary artery disease. She has one daughter and one son. SUMMARY OF HOSPITAL COURSE: 1. HEMATOLOGY/ONCOLOGY ISSUES: The patient was initially admitted on to the Bone Marrow Transplant Service. She was treated with 13 days of low-dose Ara-C as well as Hydroxyurea. She was treated initially with a one time dose of GM-CSF which was then discontinued secondary to fevers. the patient did not show any signs of tumor lysis by laboratories. Currently waiting for counts to recover. 1. FEBRILE NEUTROPENIA ISSUES: The patient had fevers up to 103 as well as neutropenia. She was originally started on cefepime, fluconazole, and vancomycin. The cefepime was discontinued and switched to aztreonam because of a diffuse rash. AmBisome was eventually started for continued fevers, but then discontinued secondary to acute renal failure and switched to voriconazole. Vancomycin levels have been very elevated and was being dosed by levels. The blood cultures have remained negative to date. A chest x-ray did not show any infiltrates. Urine cultures from [**7-28**] grew 10:100,000 enterococcus with sensitivities pending. The patient was empirically started on linezolid, and the vancomycin was discontinued. 1. GASTROINTESTINAL BLEED ISSUES: In the setting of thrombocytopenia, the patient developed melanotic stools on the Bone Marrow Transplant floor. She remained hemodynamically stable and was transferred the [**Hospital Ward Name 332**] Intensive Care Unit for better monitoring. Her platelets were kept above 50 and her hematocrit above 25. She continued to have a slow gastrointestinal bleed. Gastroenterology was consulted and is following, holding off on colonoscope at this time. She given vitamin K, as well as amicrobic acid, and Protonix twice per day. She requires HLA typed and matched platelets secondary to antibodies. 1. HYPOTENSION ISSUES: The patient developed hypotension with mean arterial pressures in the 40s; asymptomatic. She was given multiple boluses of intravenous fluids without significant improvement in her pressures. The differential diagnoses included sepsis, gastrointestinal bleed, excessive losses from fever and rash as well as capillary leak syndrome. She was started on low-dose dopamine for renal perfusion. 1. ACUTE RENAL FAILURE ISSUES: The patient developed acute renal failure with a creatinine of up to 3.2. The Renal Service was consulted. Urine sediment showed muddy brown casts. The likely insult was hypotension in the setting of a gastrointestinal bleed. The patient continues to oliguric with improvement in the urine output with a low- dose dopamine drip. Urine also showed eosinophils - possible acute interstitial nephritis from multiple drugs. The patient was started on a trial of prednisone. The patient was also started on Bicitra 30 twice per day. 1. PULMONARY ISSUES: The patient was continued on albuterol and Atrovent nebulizers for chronic obstructive pulmonary disease seen on computerized axial tomography with a longstanding history of smoking. 1. RASH ISSUES: The patient developed a diffuse erythematous blanching rash which was likely secondary to drug effect - cefepime versus vancomycin. The Dermatology Service was consulted, and a biopsy was consistent with hypersensitivity reaction. The patient was started clobetasol and bacitracin topically as well as Sarna lotion for pruritus. 1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was continued on a full liquid diet. Electrolytes were repleted once per day. She was maintained on maintenance fluids. 1. PROPHYLAXIS ISSUES: Proton pump inhibitor and bowel regimen. 1. ACCESS ISSUES: Hickman catheter and peripheral lines. 1. CONTACT ISSUES: Son and daughter. 1. CODE STATUS ISSUES: Do not resuscitate/do not intubate. The rest of the hospital course will be dictated by the next Intensive Care Unit intern. [**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**] Dictated By:[**Last Name (NamePattern1) 35922**] MEDQUIST36 D: [**2182-7-30**] 11:43:31 T: [**2182-7-30**] 12:29:50 Job#: [**Job Number 56334**]

V581,V581,20500,20500,2880,2880,5849,5849,5990,5990,5781,5781,496,496,4280,4280,42830,42830

Admission Date: [**2103-1-15**] Discharge Date: [**2103-1-23**] Date of Birth: [**2033-3-1**] Sex: F Service: NEUROLOGY Allergies: Sulfonamides / Novocain Attending:[**First Name3 (LF) 15373**] Chief Complaint: CC-unresponsive episode Major Surgical or Invasive Procedure: none History of Present Illness: 69 yo female with hx of Parkinsons s/p DBS, and dementia who presents with episode of unresponsiveness. Per the patients son [**Name (NI) 892**] she has had a steady clinical decline since last fall. She initially failed placement in [**Hospital3 **] and moved in with her daughter. The daughter was unable to care for her and she was again moved to a higher acuity [**Hospital3 **] arrangement at [**Location (un) 583**] Gardens [**2101-12-22**]. They also had difficulty managing the patient as she had frequent freezing episodes, parkinson's exacerbations and fall. She fell and had head trauma on [**1-5**] and was brought to the [**Hospital 620**] [**Hospital 4068**] hospital where head CT was negative, but there was no occult infection or other clear cause of her decline so she was transferred to [**Hospital 11851**] rehab. Over the past week she was becoming increasingly disoriented and more somnolent when seen by her family to the point that she didn't know her own name or recognize her family. This am while at PT she suddenly froze for 5 min in her wheelchair and then became unresponsive. No tonic clonic activity noted, no fecal or urinary incontinence,no tongue biting. Of note the only recent alteration of her medications included discontinuation of Mirapex 2 months ago and started Detrol 3 weeks ago. Pt initially brought to [**Hospital3 **] for altered mental. Head CT revealed no acute process but she was transferred to [**Hospital1 18**] for further workup. In the ED she was febrile to 101.2 and was only mildly responsive to sternal rub. UA was negative, CXR was clear, LP was normal. Neurology saw the patient in the emergency room and felt that this was due to occult infection and hypernatremia, but they plan to continue to follow the patient on the floor. Past Medical History: 1. Parkinson's disease-dx [**2080**] s/p DBS placement [**2097**], never had tremor only negative symptoms with severe freezing episodes 2. dementia -likely [**Last Name (un) 309**] Body 3. HTN 4. Osteoporosis 5. Hyperlipidemia 6. Panic attacks Social History: Has been living at rehab as above. Worked in the media dept for the city. Remote minimal smoking hx and no EtoH. Family History: No fam hx of CVA, DMII, or dementia Physical Exam: T 98.6 HR 89 BP 99/58 RR 12 O2Sat 99% 2l Gen-NAD, not responding to command, wincing to sternal rub HEENT-PERRL, no elev JVP, head contorted to the right, MM very dry Hrt-RRR nS1S2, [**2-17**] sm at RUSB, [**2-17**] SM at apex, [**1-20**] diastolic murmur at LLSB Lungs-CTA bilat, poor inspiratory effort Abd-soft, NT, ND, no HSM, NABS Extrem-2+ rad and dp pulses, no LE edema Neuro-withdrawing from painful stimuli, 2+ dtr at knees and biceps bilat, toes downgoing bilat, diffuse rigidity Skin-No rashes or lesions Pertinent Results: CSF Protein 23 Glucose 79 LD(LDH): 10 CSF WBC 0 RBC 0 Poly 0 Lymph 75 Mono 25 EOs . Lactate:1.2 Ammonia: 17 Chem 7 150 113 36 115 AGap=15 3.8 26 0.9 . WBC 13.4 Hgb 12.8 Plt 272 Hgb 36.7 N:83.3 L:12.1 M:4.2 E:0.3 Bas:0.1 PT: 13.7 PTT: 25.1 INR: 1.2 . Color Yellow Appear Clear SpecGr 1.024 pH 5.0 Urobil Neg Bili Neg Leuk Neg Bld Lg Nitr Neg Prot Tr Glu Neg Ket Tr RBC 0-2 WBC 0-2 Bact Many Yeast None Epi 0-2 . ECG-pnd . CXR-no acute process- . OSH head CT-no acute process . Brief Hospital Course: The patient was admitted to the neurology service after being stabilized on the medical service. Her sinemet was restarted, with improvement in her initial presentation, which was consistent with an akinetic state. She regained movement in her limbs, although still severely limited by her underlying parkinson's disease, with R>L rigidity and her course throughout each day interrupted by dyskinesias. She was evaluated by a neuro-behavior specialist who knows her, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who felt that she was near her baseline and would not benefit from any medication changes. She was followed closely throughout her stay by movement disorders specialists, who will see her as an outpatient. Chief among our concerns, as well as her son's, is that [**Known firstname **] find a facility that can meet her medical needs, most importantly her frequent medication dosing requirements. She occasionally refuses her medications but accepts them readily in ice cream or [**Last Name (un) 16320**]. She should be treated through dyskinesias and any dose changes will be addressed as an outpatient. Dyskinesias - as opposed to akinesia - must be dealt with over the long-term and not during an inpatient stay. It will require close follow-up with movement disorders. Any questions regarding her management should go to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1942**], or his NP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 16321**]. She is discharged to rehab, with the plan on transferring to a facility of the family's choosing in the coming week. Medications on Admission: Sinemet 25/100 q2h 6am-6pm Sinemet 50/200 8pm Mirapex 0.25 mg [**12-19**] tab TID Evista 60 mg qday Lipitor 10 mg q day Detrol LA 2 mg q day Ativan 0.5 mg po bid Sertraline 150 mg q day Tylenol Norvasc 5mg qd Metoprolol 25 mg [**Hospital1 **] Discharge Medications: 1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO Q8PM (). Disp:*240 Tablet(s)* Refills:*2* 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO X1 (ONE TIME) as needed for insomnia. 10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours): daily from 6am to 6pm. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital1 16322**] Discharge Diagnosis: Parkinson disease Dementia Discharge Condition: Improved Discharge Instructions: Please continue to take all medications as prescribed. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1942**] Date/Time:[**2103-1-29**] 3:00 Completed by:[**2103-1-23**]

3320,2760,27652,73300,4019,33182,29410,2724

Admission Date: [**2149-2-12**] Discharge Date: [**2149-2-18**] Date of Birth: [**2093-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic with +ETT and 3VD on Cath Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG-PDA, Ramus) [**2149-2-13**] History of Present Illness: Mr. [**Known lastname 64814**] is a pleasant 55 y/o male who has multpile cardiac risk factors who was asymptomatic and underwent a stress. ETT was positive and then referred for cardiac cath. Cath revealed severe 3 vessel disease. He has then been referred for surgical revascularization. Past Medical History: Hypertension Hypercholesterolemia Diabetes Mellitus s/p R. Arm Surgery after MVA [**2141**] Social History: Denies Tobacco. Rare ETOH Family History: +CAD FH Physical Exam: General: WDWN male in NAD HEENT: NC/AT, PERRL, EOMI Neck: Supple, FROM, -Lymphadenopathy, Carotids 2+ without Bruits Lungs: CTAB -w/r/r CV: RRR, +S1S2 -c/r/m/g Abd: Soft, NT/ND +BS Ext: -C/C/E, 2+ Pulses throughout Neuro: Non-focal Pertinent Results: CXR [**2-15**]: No PTX, and no significant interval change versus prior following removal of tubes. Echo [**2-13**]: PRE-BYPASS: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Cath [**2-12**]: 1. Three vessel coronary artery disease. 2. Normal ventricular function on limited study 3. Elevation of LVEDP consistent with diastolic dysfunction. Carotid U/S [**2-12**]: Minimal plaque with bilateral less than 40% carotid stenosis. [**2149-2-18**] 05:40AM BLOOD WBC-5.0 RBC-3.05* Hgb-8.7* Hct-25.0* MCV-82 MCH-28.6 MCHC-35.0 RDW-14.1 Plt Ct-176# [**2149-2-15**] 02:46AM BLOOD PT-13.4* PTT-29.7 INR(PT)-1.2* [**2149-2-16**] 05:45AM BLOOD Glucose-135* UreaN-16 Creat-1.1 Na-136 K-4.0 Cl-101 HCO3-28 AnGap-11 [**2149-2-18**] 05:40AM BLOOD UreaN-18 Creat-1.0 K-4.1 [**2149-2-18**] 05:40AM BLOOD Mg-1.7 [**2149-2-12**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, following the cardiac cath Mr. [**Known lastname 64814**] was consulted by cardiac surgery. Following routine pre-op work-up, he consented for surgery and was taken to the operating room on [**2149-2-13**]. He underwent a coronary artery bypass graft x 3. Please see op note for surgical details. Mr. [**Known lastname 64814**] was then transferred to the CSRU in stable conition. Later on op day sedation was weaned and he awoke neurologically intact. He was then extubated, but had to be reintubated secondary to respiratory distress with partial airway obstruction. Then on post-op day one he was again weaned from sedation and mechanical ventilation and extubated. Neo-Synephrine was weaned by post op day two and B-blockers and Diuretics were started. He was gently diuresed during his hospital stay towards his preoperative weight. Chest tubes were removed on post-op day two and he was transferred to the cardiac surgery step-down unit. Physical therapy followed Mr. [**Known lastname 64814**] during his entire post-op course for mobilty and conditioning. On post-op day three his epicardial pacing wires and Foley catheter were removed. He appeared to be doing well with no post-op complications and was discharged home with VNA services and appropriate follow-up appointments on post-op day five. Medications on Admission: Glucophage 1500 [**Hospital1 **]/500 at lunch, Glucotrol 20mg qd, Avandia 8mg qd, HCTZ 40mg qd, Atenolol 50mg qd, Lipitor 20mg qd, Humalog, Lantus 10units qhs, Prinivil 40mg [**Last Name (LF) **], [**First Name3 (LF) **] 325mg qd, Fish Oil Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Also take 500 mg at lunch. Disp:*150 Tablet(s)* Refills:*0* 9. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: Two (2) Tab, Sust Release Osmotic Push PO DAILY (Daily). Disp:*60 Tab, Sust Release Osmotic Push(s)* Refills:*0* 11. Prinivil 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. Disp:*3 bottles* Refills:*2* Discharge Disposition: Home With Service Facility: VNA [**State 2748**] SE Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x 3 Hypertension Hypercholesterolemia Diabetes Mellitus Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. You should shower daily, let water flow over wounds, pat dry with a towel. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 933**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks. Completed by:[**2149-2-18**]

41401,4111,25001,4019,2720

Admission Date: [**2102-4-18**] Discharge Date: [**2102-6-5**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: [**2102-4-18**] Whipple Procedure [**2102-4-21**] Exploratory-lapaorotomy with control of pancreaticojejunostomy bleeding, revision of hepaticojejunostomy, gastrostomy-jejunostomy tube placement, 8-french silastic biliary stent placement [**2102-5-1**] Tracheostomy [**2102-4-21**] EGD [**2102-5-18**] EGD [**2102-5-21**] Colonoscopy [**2102-5-10**] IR drainage of abscess History of Present Illness: This patient is an 82 year old gentleman who presents with a history of chronic-non-obstructing jaundice. His symptoms started a month ago with jaundice and weight loss and he was found to have an ampullary adenoma on endoscopy but it was too big for resection. He also had a 1.5 cm distal common bile duct obstruction with atypical cells on cytology brushings. On review of systems he reports jaundice, weight loss of 15 pounds in 3 months. He has had no itching, abdominal or back pain, flushing, ascites, steatorrhea, fever, or chills. Past Medical History: Chronic Atrial Fibrillation Hypertension Hypothyroidism Perforated Appendicitis s/p appendectomy 40 years ago complicated by peritonitis History of duodenal ulcers Social History: The patient is a retired postal worker who now works on his family farm. He does not smoke tobacco or drink alcohol. Family History: non-contributory. Physical Exam: On admission: Gen: elderly male, strong-appearing, no acute distress, appears stated age, jaundiced HEENT: mild icterus, EOMI, moist mucous membranes Neck: no cervical lymphadenopathy, trachea midline CV: irregular irregular rhythm and rate, no murmurs Pulm: chest clear to auscultation bilaterally Abdomen: soft, non-tender, non-distended, normoactive bowel sounds, no masses Extr: no edema, warm and well-perfused Pertinent Results: SEROLOGIES: [**2102-4-18**] 05:19PM BLOOD WBC-19.9*# RBC-3.87* Hgb-12.5* Hct-36.7* MCV-95 MCH-32.4* MCHC-34.2 RDW-13.5 Plt Ct-259 [**2102-4-18**] 05:19PM GLUCOSE-112* UREA N-12 CREAT-0.6 SODIUM-139 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-10 [**2102-4-18**] 05:19PM PT-14.1* INR(PT)-1.3 [**2102-4-22**] 09:53PM BLOOD HEPARIN DEPENDENT ANTIBODIES: negative MICROBIOLOGY [**2102-4-22**] Urine Cx: Negative [**2102-4-22**] Blood Cx: Negative [**2102-4-24**] VRE Swab: negative [**2102-4-24**] MRSA screen: Negative [**2101-4-29**] C. Diff: Negative [**2102-4-30**] C. Diff: Negative [**2102-5-1**] MRSA screen: MRSA + [**2102-5-4**] Peritoneal Fluid culture: MRSA, VRE [**2102-5-4**] Wound culture: MRSA [**2102-5-6**] Sputum culture: negative [**2102-5-13**] Blood Culture: negative [**2102-5-13**] Urine Cx: negative [**2102-5-14**] Pigtail catheter fluid: VRE [**2102-5-19**] C. Diff: negative [**2102-5-21**] C Diff B Screen: Negative [**2102-5-20**] Urine Cx: negative [**2102-5-24**] Urine Cx: Pseudomonas (pan-sensitive) [**2102-5-24**] Blood Cx: Klebsiella Pneumonia (sensitive to Levoquin) [**2102-5-28**] Urine Cx: negative RADIOLOGY: [**2102-4-21**] CXR: bilateral effusions [**2102-4-28**] Abd CT: Bilateral pleural effusions. Right and left lower lobe opacities, which may represent atelectasis or consolidations. 2. Scattered ill-defined hypodense liver lesions, which appear concerning for cholangitis with microabscesses. Given the patient's history of malignancy, follow up is recommended. 3. Moderate intraperitoneal free fluid without evidence of a drainable abscess. [**2102-5-8**] ABdominal CT Scan: (1) New 15 x 8cm fluid collection at the inferior aspect of the afferent loop, consistent with anastomotic breakdown. Findings conveyed verbally by Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] to covering surgical team. 2) Stable small bilateral pleural effusions. 3) Unchanged appearance of hypoattenuating region within segment 3 of the liver. The differential for this area includes detractor injury versus cholangitis with abscess. 4) Multiple other small hypoattenuating lesions throughout the liver, likely consistent with simple cysts versus hemangiomas. 5) Multiple drains at the surgical site. 6) Bilateral simple renal cysts, many of which are too small to characterize. 7) Stable appearance of multiple simple-appearing cysts at the residual tail of the pancreas. [**2102-5-17**] Video Swallow Eval: No evidence of penetration or aspiration. Mild residual within the vallecula and piriform sinuses, which was cleared after several attempts. Please see speech pathologist report for a more complete account [**2102-5-18**] Abdomninal CT Scan : 1. Stable bilateral pleural effusions and bibasilar atelectasis. 2. Resolution of subhepatic organized fluid collection. 3. Stable small amount of ascites without evidence of any new drainable organized fluid collection. [**2102-5-24**] CXR: Bilateral Pleural Effusions PATHOLOGY: [**2102-4-18**] Operative Specimens: I. Gallbladder, cholecystectomy (A): 1. Chronic cholecystitis. 2. Cholelithiasis, mixed-type. II. Pancreaticoduodenectomy, Whipple procedure (B-Z): 1. Adenocarcinoma of the ampulla, arising in an adenoma. See synoptic report. 2. Pancreas: a. Small intraductal papillary mucinous tumor, 0.9 cm, with low-grade dysplasia (slide O). b. Tiny foci of low-grade pancreatic intraepithelial neoplasia. c. Dilation of pancreatic duct and focal chronic inactive pancreatitis. d. Mild hyalinization of pancreatic islets. e. No tumor in the pancreas. 3. Chronic active inflammation of common bile duct with dilation, and of cholecystic duct. 4. Segment of duodenum, within normal limits. CARDIOLOGY: [**2102-4-21**] Echocardiogram: 1. The left atrium is moderately dilated. The right atrium is moderately dilated. 2. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. There is a trivial/physiologic pericardial effusion. GI: [**2102-4-21**] EGD: 1- There was thick sputum and debris in the retropharynx and piriform sinuses that was suctioned. 2- NG tube in the esophagus and associated ulcerations 3- Blood in the stomach. 4- Gastrojejunostomy. 5- Anastomotic ulceration (injection). [**2102-5-18**] EGD: 1- No blood in the visualized portions of the upper GI tract 2- Erythema in the stomach compatible with gastritis 3- Nonbleeding ulcer in the stomach body (beneath the balloon of the PEG) 4- PEG tube in the stomach body 5- The endoscope was passed to the hub in the left limb and approximately 20-30 cm in the right limb. There was no blood in either limb. 6- Bilious fluids in stomach 7- Nonbleeding erosion in the one of the jejunal limbs (left side ? efferent) 8- Gastric erosion (mild) at the anastomosis site [**2102-5-19**] Colonoscopy: 1- There was no blood seen in the colon or ileum. 2- Polyp in the sigmoid and transverse colon 3- There was an area in the colon at 35cm where the mucosa was edematous and the lumen somewhat collapsed. There appeared to be multiple diverticulum in that area but the mucosa appeared ok. This could be an area that was transiently ischemic or inflammed with diverticular disease 4- Diverticulosis of the descending colon Brief Hospital Course: This is an 82 year old gentleman who presented for a Whipple resection for an obstructing ampullary mass. His post-operative course was extensive and complicated by significant post-operative bleeding requiring emergent laparotomy, ventillatory dependence requiring tracheostomy, tube-feeding requirements, and urinary tract infections with bacteremia. A brief summary of his hospital course is as follows: . The patient was admitted for elective Whipple resection on [**2102-4-18**]. This went without any intraoperative complications (please see the operative report of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for full details). He progressed well in the initial post-operative period but on post-operative day 3 he was noted to have tachycardia with decreased urine output and a drop in hematocrit with bloody NGT output. He was transfused with blood and transferred to the ICU for close monitoring. Emergent endoscopy was performed revealed blood in the stomach and ulceration in the anastamosis. The patient subsequently became tachypnic with a decrease in arterial oxygen and was intubated. His transfusion requirements continued to increase and his abdomen became more distended and he was taken to the OR on [**2102-4-21**] for abdominal washout and control of bleeding from his anastamosis (please see the operative note of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for full details). A Swan-ganz catheter was placed for cardiovascular assessment and management. He was transferred back to the ICU post-operatively. The patient remained stable in his initial post-operative period with good cardiovascular dynamics and stable hematocrits. On post-op day 2 (from his abdominal washout) he was off pressors and trophic tube feeds were started via his J-tube. His platelets gradually dropped and an HIT panel was sent which was negative; this was assessed as being secondary to consumption coagulopathy. His Swan Ganz catheter was remoed on post-op day 3 and he was extubated. His tube-feeds were advanced to goal by post-op day 4. He was re-intubated on post-op day 4 when he had copious secretions not improved with nebulizer treatments, and was kept on CPAP with pressure support. His Atrial fibrillation was rate-controlled with Diltiazem and aggressive diuresis was performed for post-operative fluid re-spacing. A percutaneous tracheostomy was performed on [**2102-5-1**] for continued ventilatory dependence. He was weaned off his vent on [**2102-5-3**] and tolerated trach mas breathing. He had partial dehiscence around his abdominal wounds which required initiation of wet to dry dressing changes. On [**2102-5-8**] the patient had an abdominal CT scan which revealed a small fluid collection near the anastamosis. This was drained by interventional radiology on [**2102-5-10**] and a pigtail catheter was left in place; cultures from this fluid collection were negative. The patient failed a bedside speech and swallow evaluation on [**2102-5-11**] and was continued on tube feeding. On [**2102-5-14**] his J-G tube was noted to be broken at the external infusion port and the tube was removed and changed to a Foley catheter for tube feeding. His trach was downsized to a #7 portex with a Passe-Muir valve on [**2102-5-16**] and a video swallow evaluation on [**2102-5-17**] was passed, with a regular diet started in addition to tube feeding. On [**2102-5-18**] the patient was stable in appearance but was transferred to the ICU with a significant elevation in his WBC count and guaic positive stools with a drop in his hematocrit. He was transfused blood and serial hematocrits subsequently remained stable. Colonoscopy and EGD evaluation revealed no obvious bleeding source. Pan-cultures revealed no obvious source for the patient's WBC count but he was started on empiric treatment for presumed C-Diff colitis. His white count gradually declined and he was transferred back to the floor after several days. His tube feeds were restarted on [**2102-5-21**] and he was advanced to a regular diet with cycled tube feeds on [**2102-5-23**]. He did, however, have a fever to 102 on [**2102-5-24**] and work-up this time revealed Pseudomonas in his urine and Klebsiella in his blood. Infectious Disease consulation was obtained and he was started on Levoquin for treatment and follow-up urine cultures were negative and he remained afebrile. His remaining JP drain was removed on [**2102-5-25**]. His Foley catheter was removed on [**2102-5-26**] and he was able to void without it. Towards the end of [**Month (only) 116**], social services and case management were asked to assist with rehab placement. Plans were made to transfer him to rehab. On [**6-2**], his trach was decanulated. He tolerated this well and was breathing well, as well as clearing secretions well. Physical therapy worked with the patient to assist with ambulation. Anti-coagulation for his chronic atrial fibrillation was not started given the chronicity and his recent severe episodes of post-op bleeding. He has planned follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] in 2 weeks. All questions were answered to his satisfaction upon discharge. On [**6-5**] in the morning the patient was discharged home with physical therapy services in addition to visiting nursing services to manage his ongoing tube feeds. Toward the end of the [**Hospital 228**] hospital stay he was able to take in roughly 1900 cal, tube feeds will be used to supplement his nutition. Medications on Admission: Pepcid Synthroid 50 mcg oral daily Triamterene Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) ml Injection ASDIR (AS DIRECTED): BS 121-160: 4 units, 161-200: 8 units, 201-240: 12 units, 241-280: 16 units, 281-320: 20 units. 2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Lansoprazole 30 mg Tablet,Lingual Delayed Release Sig: One (1) Tablet,Lingual Delayed Release PO DAILY (Daily). Disp:*30 Tablet,Lingual Delayed Release(s)* Refills:*2* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: [**Hospital 40198**] Healthcare Center - Nursing and Rehab Discharge Diagnosis: Primary: Periampullary mass in pancreas Secondary: Atrial Fibrillation, post-operative bleeding, Post-op ventilatory dependence, urinary tract infection, Klebsiella bacteremia, Difficulty swallowing, Hypertension, hypothyroidism Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. You should continue your regular diet with twice/day tube feeding supplements as indicated. You should return to the ER or call the office with any worsening abdominal pain, bloody stools, fever > 101.5, nausea or inability to tolerate a regular diet, respiratory distress, drainage from your wound, or concerning laboratory values. Followup Instructions: You should follow-up in the office of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] in [**1-1**] weeks (call [**Telephone/Fax (1) 2835**] for an appointment)

1562,99811,5185,9974,99832,42731,5672,7907,57410,2869,56089,5990,0417,0413,4019,2449

Admission Date: [**2184-5-14**] Discharge Date: [**2184-5-22**] Date of Birth: [**2184-5-13**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [**Known lastname 1169**] [**Known lastname 61521**] was born at 33 6/7 weeks gestation to a 35 year old gravida 2, para 0, now 1 woman. The mother's prenatal screens were blood type B positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and Group B Strep unknown. He was delivered by cesarean section for worsening oligohydramnios in breech positioning. This mother's previous medical history is remarkable for lupus, partial thyroidectomy secondary to benign tumor, VP shunt secondary to pseudotumor cerebri. Mother was not on any medications during the pregnancy. Mother was followed by the maternal fetal medicine service and her primary obstetrician. A fetal echocardiogram and level 2 ultrasound secondary to the maternal lupus were normal. The pregnancy was complicated with oligohydramnios since [**06**] weeks gestation. The mother received a complete course of betamethasone at that time. She had been home on bedrest. The interval ultrasound had stable amniotic fluid levels and good growth. Her biophysical profiles remained [**8-23**]. Over the week prior to delivery the mother had diarrhea and the amniotic fluid index was decreased to 4 from the previous [**7-24**]. So, in light of this change in amniotic fluid volume the mother was delivered by cesarean section. The infant emerged with Apgar's of 9 at one minute and 9 at five minutes. He developed respiratory distress soon after delivery and was transferred to the special care nursery at [**Hospital3 38285**]. The infant's birth weight was 2640 gm, the birth length 46.5 cm and the birth head circumference 35 cm. The infant required intubation and surfactant administration, additionally required fluid resuscitation and pressor support at [**Hospital3 **] and so was transferred to [**Hospital6 1760**] by the [**Hospital3 1810**] Transport Team. He was transferred to [**Hospital6 649**] due to lack of available beds at [**Hospital3 18242**]. NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS: Respiratory - He received 2 doses of Surfactant. He weaned to a CPAP pharyngeal positive airway pressure on day of life #5, and then weaned to nasal cannula on day of life #7 where he remained at a flow of 13 cc of 100% oxygen. On exam his respirations are comfortable, 40-60 breaths per minute. Lung sounds are clear and equal. Cardiovascular - He required pressor support with Dopamine to a maximum of 20 mcg/kg/min, with weaning by day of life #3. He has remained normotensive since that time. He has an intermittent Grade 1/6 systolic ejection murmur at the left sternal border. He has had no further cardiology workup. Fluids, electrolytes and nutrition - His weight at discharge is 2,600 grams. Enteral feeds were begun on day of life #5 and advanced without difficulty to full volume feedings on day of life #9 the night before transfer to [**Hospital1 2436**]. He is getting formula 20 cal/oz Similac Special Care, total fluids of 120 ml/kg/day orally or by gavage. His last set of electrolytes on [**2184-5-19**] were a sodium 133, potassium 5.5, chloride 112, bicarbonate 18, and triglycerides 47. Gastrointestinal - He was treated with phototherapy for hyperbilirubinemia of prematurity on day of life #4 until day of life #7. His peak bilirubin occurred on day of life #4 and was total of 12.0, direct 0.3. His last bilirubin on [**2184-5-21**], was total of 5.2, direct 0.3. Hematology - He has not received any blood product transfusions during his NICU stay. His last hematocrit [**2184-5-15**] was 41.4. His platelets on [**2184-5-16**], were 186,000. Infectious disease - He was started on ampicillin and gentamicin at the time of admission to [**Hospital3 **] Special Care Nursery. He will complete a 10-day course of antibiotics for presumed sepsis. The date of transfer, [**2184-5-24**], is day #9 of 10 of antibiotic. His gentamicin levels on [**5-16**] were trough 1.2 and peak 6.2. His blood culture remained negative. His spinal tap on day of life #4 had a white blood cell count of 8, a red blood cell count of 2, total protein of 89 and glucose of 36. No blood glucose was done concomitantly with that spinal tap, however, his blood glucoses during that day were in the 60s. His CSF culture remains negative. Neurology - Audiology screening has not yet been performed and is recommended prior to discharge. Psychosocial - Parents have been involved in the infant's care throughout his NICU stay. The infant is discharged in good condition. He is transferred to [**Hospital3 **] Special Care Nursery for continuing care. The name of the primary pediatric care provider has not yet been identified. RECOMMENDATIONS AFTER DISCHARGE: Feeding - Special care 20 cal/oz formula, currently at 120 ml/kg/day, advancing as tolerated to a recommended goal of 150 cc/k/day. Medications - The infant has a heparin lock being flushed every 6 hours and as needed with heparin 10 units/ml, 1 ml IV. Ampicillin 400 mg IV every 12 hours, gentamicin 8 mg IV every 24 hours, Desitin ointment topically to his diaper area as needed. Screening tests - He has not yet had a carseat position screening test. His state newborn screen was sent on [**2184-5-16**]. Immunizations - He has not received any immunizations. DISCHARGE DIAGNOSIS: 1. Prematurity at 33 6/7 weeks gestation. 2. Resolving respiratory distress syndrome. 3. Resolving presumed sepsis. 4. Status post hypotension. 5. Status post hyperbilirubinemia of prematurity. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2184-5-22**] 00:28:31 T: [**2184-5-22**] 06:57:40 Job#: [**Job Number 61522**]

769,77181,7742,76519,76527

Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-9**] Date of Birth: [**2098-6-15**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2137-7-2**] - Minimally invasive MVR (St. [**Male First Name (un) 923**] mechanical valve) History of Present Illness: This is a 39-year-old female with a history of [**Male First Name (un) 15196**] heart disease, who presented in pulmonary edema after her pregnancy. She was found to have moderate to severe mitral regurgitation. It was recommended that she have a mitral valve replacement, and after the risks and benefits were explained to her, she agreed to proceed. Past Medical History: [**Male First Name (un) **] [**Male First Name (un) **] CHF MR HTN Social History: Homemaker. Smoked [**1-7**] ppd quitting in [**5-11**]. Drinks 6 beers per weekend. Family History: Father with [**Date Range 15196**] heart disease Physical Exam: Pulse 82 133/70 64" 134 lbs GEN: WDWN female in NAD Skin: Few mottled areas of LE's HEENT: Unremarkable NECK: Unremarkable LUNGS: Clear HEART: RRR, holosystolic murmur ABD: Benign EXT: Warm, well perfused, no edema NEURO: Alert, nonfocal Pertinent Results: [**2137-7-7**] 04:20AM BLOOD Hct-24.1* [**2137-7-6**] 09:50AM BLOOD WBC-8.4 RBC-2.75* Hgb-8.5* Hct-23.9*# MCV-87 MCH-30.9 MCHC-35.5* RDW-13.9 Plt Ct-220 [**2137-7-9**] 05:55AM BLOOD PT-22.3* INR(PT)-2.2* [**2137-7-7**] 04:20AM BLOOD K-5.1 [**2137-7-5**] CXR Small bilateral pleural effusions have accumulated since [**7-3**] following removal of the right apical pleural tube. There is no detectable pneumothorax. Bibasilar atelectasis has worsened and increased in caliber of the cardiac silhouette, still normal in volume, may reflect increasing intravascular volume. [**2137-7-2**] ECHO Prebypass: 1. The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. 3. Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are moderately thickened. The mitral valve shows characteristic [**Month/Day/Year 15196**] deformity. There is mild mitral stenosis. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation vena contracta is >=0.7cm. 6.The tricuspid valve leaflets are mildly thickened. 7. There is no pericardial effusion. Post Bypass: There is a well-seated mechanical valve in the mitral position. Trivial/normal washing jets seen. Preserved LV systolic fxn., on inotropic support. (epinephrine) Nl RV systolic fxn, preserved aortic contours Brief Hospital Course: Mrs. [**Known lastname 62538**] was admitted to the [**Hospital1 18**] on [**2137-7-2**] for elective surgical management of her mitral valve disease. She was taken to the operating room where she underwent a minimally invasive mitral valve replacement utilizing a 25mm St. [**Male First Name (un) 923**] mechanical heart valve. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mrs. [**Known lastname 62538**] had awoke neurologically intake and was extubated. She was transfused for postoperative anemia. Anticoagulation was started for her mechanical valve. Her drains and wires were removed per protocol. later on postoperative day one, Mrs. [**Known lastname 62538**] was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. NSAIDs were given for her minimally invasive approach. Slowly her INR came within therapeutic range and she was discharged home on postoperative day seven. She will follow-up with Dr. [**Last Name (Prefixes) **], her primary care physician and her cardiologist as an outpatient. Her coumadin will be dosed for a target INR of 3.0-3.5 (mechanical mitral valve). Her primary care physician will monitor her blood work for coumadin dosing. Medications on Admission: Bisoprolol 2.5mg QD Lisinopril 10mg QD Lasix 20mg QD OCP Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* 7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-11**] hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: No services Discharge Diagnosis: MR [**First Name (Titles) **] [**Last Name (Titles) **] HTN Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams lotions or powders to any incisions [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (Prefixes) **] in 4 weeks with Dr. [**Last Name (STitle) 6254**] in [**2-8**] weeks with Dr. [**Last Name (STitle) 62539**] in [**2-8**] weeks Completed by:[**2137-7-11**]

3941,39891,4019,2859,V5861,42789

Admission Date: [**2120-5-24**] Discharge Date: [**2120-5-27**] Date of Birth: [**2078-7-1**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Briefly, this is a 41-year-old male, with a long history of fibrosing mediastinitis, who has had multiple episodes of head discomfort and shortness of breath after leaning over. He had been worked-up extensively and was found to have thrombosed his right subclavian, right IJ and had developed multiple collaterals. Venography by Dr. [**First Name (STitle) **] showed that his left innominate vein was still patent, and it was decided that he would need a bypass of this area to his heart to return blood flow. PAST MEDICAL HISTORY: Depression, high cholesterol, hypertension, SVC syndrome, gastroesophageal reflux disease, a paralyzed right hemidiaphragm secondary to a thoracotomy, and the fibrosing mediastinitis. He is status post mediastinoscopy, right pleuracotomy, and multiple oral surgeries. ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Coumadin which he stopped prior to surgery. 2. Lovenox subcutaneous. 3. Robaxisal 40 mg p.o. once daily. 4. Zoloft 100 mg p.o. once daily. 5. Lipitor 10 mg p.o. once daily. PHYSICAL EXAM: He is afebrile with stable vitals. His lungs are clear. Heart was regular. When he leaned over he was noted to have increased venous congestion of his head, and also got short of breath. HOSPITAL COURSE: The patient was taken to the operating room on [**2120-5-24**], where a left innominate vein to right atrial bypass graft was done using an 8 mm [**Doctor Last Name 4726**]-Tex graft through a median sternotomy incision. Please see the operative report for further details. The patient was transferred to the CSRU postoperatively, and he did well. He was weaned and extubated. His chest tubes were removed. The patient was transferred to the floor which he tolerated, and then he was started on a p.o. diet. His pain was well- controlled, and his Foley was also removed. The patient continued to do well, and he was started on Lovenox and Coumadin again. Goal INR of around 3.0. He continued to ambulate and improve, and his pain was well-controlled, and on postoperative day #3 it was decided that the patient would be safe for discharge, and the patient was discharged home. PT was consulted prior to discharge to evaluate for any functional losses, and it was noted that the patient had none, and it would be safe for the patient to be discharged home. The patient was discharged on [**2120-5-27**] in stable condition on Lovenox and Coumadin, as well as 8 mg of Coumadin, as well as Lovenox as a bridge for therapeutic INR, as well as all of his home medications. The patient was discharged in stable condition. DISCHARGE DIAGNOSES: 1. Fibrosing mediastinitis, status post left innominate vein to right atrial bypass graft. 2. Superior vena cava syndrome. 3. Hypertension. 4. High cholesterol. 5. Gastroesophageal reflux disease. 6. Status post mediastinoscopy. 7. Status post right thoracotomy. 8. Status post oral surgery. 9. Status post left eye surgery [**25**]. Status post vasectomy. 11. Paralyzed right hemidiaphragm. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**] Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2120-5-27**] 13:23:19 T: [**2120-5-27**] 13:44:32 Job#: [**Job Number 56950**]

4592,5192,4019,2720,53081,311

Admission Date: [**2173-6-23**] Discharge Date: [**2173-6-30**] Date of Birth: [**2095-7-27**] Sex: M Service: OMED Allergies: Niacin Attending:[**Doctor First Name 18856**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 77M with h/o metastatic RCC with mets to lung, thyroid, COPD, diastoic CHF, sleep apnea, restrictive lung disease, remote MI, presents with acute onset resp failure; intubated in ED, became hypotensive following sedation requiring 6L NS boluses and levophed. WBC 21 with 9%bands. CT angio-> L infrahilar mass compressing L main bronchus and L pulm art but stable, interval increase in parenchymal nodes and masses, increased b/l pleural effusions, stable RLL ground glass opacity, no PE. [**Hospital Unit Name 153**] course: treated with steriods, nebs, Zosyn->Levoflox. Weaned off pressors and extubated [**6-25**]; presumed mucus plugging v COPD flare v RLL infiltrate (bronchitis). On arrival on floor (5S on [**6-26**]), experienced some tachycardia due to frequent PAC's and non-sustained A-tach, and was given IV Dilt, 10 mg and 30 po, with successful rate control response. Past Medical History: PMH: metastatic RCC, COPD, OSA, h/o prostate CA, CAD s/p MI, hyperlipidemia, Afib, 4+MR Social History: Lives at home with wife; works as a heavy equipment operator. Family History: Leukemia, brain cancer Physical Exam: PE: T 97; BP 151/58; P 111; R 16; Sat 99% on 4 lpm I/O +6155 LOS good UOP Gen - NAD Heent - PERRLA, EOMI, O/P clear Neck - 8-9 cm JVD Lungs - LLL crackles, no wheezes CV - Tachy, [**Last Name (un) **] [**Last Name (un) **] Abd - Soft, NT, + BS, mod. distension Ext - 2+ edema t/o Neuro - A + O, moves all extremities Pertinent Labs - Cr 1.8, up from 1.4 on admission; blood and urine cx. neg. Pertinent Results: [**2173-6-23**] 06:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+ [**2173-6-23**] 06:15PM NEUTS-60 BANDS-9* LYMPHS-25 MONOS-2 EOS-1 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 [**2173-6-23**] 06:15PM WBC-21.1* RBC-5.09 HGB-13.8* HCT-47.1 MCV-92 MCH-27.1 MCHC-29.3* RDW-14.5 [**2173-6-23**] 06:15PM TOT PROT-6.9 ALBUMIN-3.3* GLOBULIN-3.6 CALCIUM-7.2* PHOSPHATE-5.5*# MAGNESIUM-0.9* [**2173-6-23**] 06:15PM CK-MB-15* MB INDX-4.3 cTropnT-0.01 [**2173-6-23**] 06:15PM ALT(SGPT)-53* AST(SGOT)-50* CK(CPK)-348* ALK PHOS-143* AMYLASE-57 TOT BILI-0.4 [**2173-6-23**] 06:15PM GLUCOSE-166* UREA N-20 CREAT-1.5* SODIUM-142 POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-23 ANION GAP-19 [**2173-6-23**] 06:25PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2173-6-23**] 06:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2173-6-23**] 06:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2173-6-23**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2173-6-23**] 07:00PM ALBUMIN-3.1* CALCIUM-6.8* PHOSPHATE-6.6* MAGNESIUM-0.8* [**2173-6-23**] 07:00PM CK-MB-15* MB INDX-4.2 cTropnT-0.03* [**2173-6-23**] 07:00PM ALT(SGPT)-50* AST(SGOT)-50* CK(CPK)-357* ALK PHOS-136* AMYLASE-62 TOT BILI-0.4 [**2173-6-23**] 07:00PM GLUCOSE-175* UREA N-20 CREAT-1.6* SODIUM-144 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-26 ANION GAP-17 [**2173-6-23**] 08:56PM HGB-11.0* calcHCT-33 [**2173-6-23**] 08:56PM LACTATE-1.0 K+-5.3 [**2173-6-23**] 08:56PM TYPE-ART PO2-378* PCO2-52* PH-7.21* TOTAL CO2-22 BASE XS--7 [**2173-6-23**] 10:03PM PT-14.3* PTT-24.4 INR(PT)-1.4 [**2173-6-23**] 10:28PM TYPE-ART PO2-229* PCO2-41 PH-7.28* TOTAL CO2-20* BASE XS--6 Brief Hospital Course: Mr. [**Known lastname 32090**] was transfered to the OMED service from the [**Hospital Unit Name 153**] after a one day stay which had required intubation. Initially, he required 4 LPM O2 via nasal cannula, and on arrival on the floor, he experienced and episode of irregularly irregular tachycardia, with rates b/t 100 and 150. An EKG was ordered, an interpreted as MFAT vs. ATACH with occasional PVC's. Mr. [**Known lastname 32090**] remained stable throughout this episode, and was asymptomatic. He was given 10 mg of Diltiazem, IVP, with immediate rate control to the 70's. He was followed with 30 of Dilt PO, and then put on a regular schedule of 90 mg Dilt tid. He was monitored on telemetry while on the floor. He was diuresed with Lasix IV 20 mg 1-2 doses/day, with occasional need for K, Ca, and Mg repletion. His SOB continued to improve through this interval, with lessening O2 requirements, finally needing only 2 lpm via NC. On [**6-29**], after walking to the bathroom without assistance, he was noted to have another episode of atach with RVR with rates of approx 100-150. He was again asymptomatic and stable during this episode. No Afib was noted. He was managed at this time with rest and an additional po dose of Dilt, 30mg. Later in the day of the 29th, his rhythm was stable, and he completed a video swallow study. The recommendations of the SLP were for no gulping, and sitting bolt upright for any po. He was d/c'd on the following day with F/U in heme/onc clinic, home O2, and home PT. His Dilt was prescribed in ER form, at one 240 mg capsule qd. Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*6 Tablet(s)* Refills:*0* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed for as instructed doses: Take five tablets once a day for three days, then 4 tablets once a day for three days, then 3 tablets once a day for three days, then 2 tablets once a day for three days, then one tablet once a day for three days. Disp:*45 Tablet(s)* Refills:*0* Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*6 Tablet(s)* Refills:*0* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed for as instructed doses: Take five tablets once a day for three days, then 4 tablets once a day for three days, then 3 tablets once a day for three days, then 2 tablets once a day for three days, then one tablet once a day for three days. Disp:*45 Tablet(s)* Refills:*0* 7. Diltiazem ER 240 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Bronchitic pneumonia/COPD flare. Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Followup Instructions: Heme/onc clinic. Please call Dr.[**Name (NI) 47540**] office to schedule [**Name6 (MD) 6337**] [**Name8 (MD) **] MD [**MD Number(1) 6342**]

51881,49121,1970,42832,4280,19889,V1052,4169,4019

Admission Date: [**2133-3-17**] Discharge Date: [**2133-3-19**] Date of Birth: [**2133-3-17**] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby Girl [**Name2 (NI) 40351**] is a term female infant, born by cesarean section for maternal indications, who is ready to transfer to the newborn nursery. The infant was born to a 29 year old, primigravida woman. Her prenatal screens were blood type 0 positive, antibody negative, Rubella immune; RPR nonreactive; hepatitis B surface antigen negative and group B strep unknown. This pregnancy was uncomplicated until [**2133-3-13**], four days prior to delivery when the mother noted malaise and shortness of breath. The symptoms persisted and on [**2133-3-15**], she developed productive cough and fever. On [**3-16**], she was started on Zithromax, Claritin and Albuterol as an outpatient. On the day of delivery, she presented to the [**Hospital1 2436**] Emergency Room with increasing shortness of breath, dyspnea, tachycardia and hypotension, with an oxygen saturation in room air of 77%. A chest x-ray showed bilateral pleural effusions and an echo showed cardiomyopathy. Her ejection fraction was only 30%. She was started on Digoxin, Labetalol and Lasix and transferred to [**Hospital1 69**]. Mother's previous medical history is significant for a history of kidney stones. The maternal family history is significant for a brother with a brain tumor. At [**Hospital1 69**], the mother was diagnosed with severe pre-eclampsia. She was started on magnesium sulfate and the decision was made to deliver by cesarean section. Rupture of membranes occurred at delivery. There was thick meconium stained amniotic fluid. The maternal fever for the four preceding days is as described above. The infant required just routine suctioning and blow-by oxygen and then was admitted to the Newborn Intensive Care Unit for persistent oxygen requirement. The birth weight was 4,295 grams. The birth length was 20 inches and the head circumference was 35 cms. The admission physical examination revealed a well appearing, non dysmorphic term female. Anterior fontanel was soft, open and flat. Red reflexes were present bilaterally. Palate was intact. Breath sounds were fairly clear with slightly diminished air entry. Symmetric. Mild intercostal retractions. No grunting or flaring. Regular rate and rhythm and heart without murmur. 2+ peripheral pulses including femorals. Abdomen benign without hepatosplenomegaly, masses. Normal female external genitalia. Normal back and extremities with stable hips. Mild erythema toxicum rash. Appropriate tone and responsitivity. HOSPITAL COURSE: Neonatal Intensive Care Unit course by systems: Respiratory: At the time of admission, her respirtory rate was in the mid 70's with an oxygen saturation of 87% on room air and 98% in blow by oxygen. She required small amount of oxygen. She weaned to room air by 09:00 on [**2133-3-18**]. Her respirations are comfortable. Lung sounds are clear and equal. Cardiovascular: Remained normotensive throughout her Neonatal Intensive Care Unit stay. There are no issues. Fluids, electrolytes and nutrition: She has been eating Enfamil 20 calories per ounce on an ad lib schedule, taking 30 to 70 cc on a q. three to four hour schedule. She has remained euglycemic throughout her Neonatal Intensive Care Unit stay. Her capillary blood glucose levels have been in the 60's. Her weight at the time of transfer is 4,285 grams. Gastrointestinal: There are no issues. Hematology: The patient's hematocrit at the time of admission was 51. The infant has received no blood products during her Neonatal Intensive Care Unit stay. Infectious disease: The infant was started on Ampicillin and Gentamycin at the time of admission for sepsis suspicion. She continues on those antibiotics at the time of transfer. The plan is to discontinue them at 48 hours if blood cultures remain negative. Her white blood count at the time of admission was 16,000 with a differential of 49 polys and 1 band and 25 nucleated red blood cells. Her platelet count was 267,000 and her blood culture remains negative to date. Neurology: There are no issues. Sensory: Audiology: Hearing screening has not yet been done but is recommended prior to discharge. Psychosocial: The mother was transferred back to the [**Hospital Ward Name 8559**] of [**Hospital1 69**] on [**2133-3-18**] and has been up to the Neonatal Intensive Care Unit to see the infant. The infant is being transferred in good condition to the newborn nursery. A primary pediatric care provider has not yet been identified by the family. CARE AND RECOMMENDATIONS: Feeding Enfamil 20 calories per ounce on the ad lib schedule. MEDICATIONS: Ampicillin 500 mg intravenous q. 12 hours. Gentamycin 17 mg intravenous q. 24 hours. Normal saline flush 1 cc intravenous every six hours prn to keep her peripheral intravenous patent. State newborn screen has not yet been set. The infant has received no immunizations prior to transfer. She will need hepatitis B vaccine. DISCHARGE DIAGNOSES: Term female newborn. Large for gestational age. Sepsis being ruled out. Status post respiratory distress due to retained fetal lung fluid. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**] Dictated By:[**Last Name (NamePattern1) 36864**] MEDQUIST36 D: [**2133-3-17**] 02:55 T: [**2133-3-19**] 04:45 JOB#: [**Job Number **]

V3001,7706,7661,V053,V290

Admission Date: [**2135-5-11**] Service: neonatal Sex: Male Date of Birth: [**2135-5-11**] Didcharge Date: [**2135-5-28**] GA: 34wk Discharge day of life:17 and PMA: 36 3/7wk BW:1650 gm Discharge wt: 1900 gm HISTORY: This is a 17-day-old baby boy who was born at 34 weeks gestation to a 33-year-old primigravida woman via C- section due to preeclampsia, IUGR with absent diastolic flow. The mother received betamethasone prior to delivery. Normal prenatal screen (B+, antibody negative, RPR NR, RI, GBS unknown, hepatitis B surface antigen negative. At delivery, the baby emerged vigorous. Apgar's were 8 and 9. He was brought to the NICU. HOSPITAL COURSE: Birth weight was 1.650 kilograms, birth length was 42 cm, head circumference 30.5. Respiratory: Respiratory distress syndrome. At birth, baby was grunting and flaring requiring nasal cannula for 6 days of life. Never required mechanical ventilation and was on room air for the rest of his hospitalization. He had no problems with apnea of prematurity. Cardiovascular: The baby was cardiovascularly stable, had normal blood pressures throughout his hospitalization. He has a murmur consistent with peripheral pulmonary stenosis which is heard intermittently. Fluids, electrolytes, nutrition: The baby was on IV fluids until day of life 2 at which time he began to take milk via NG tube. He has had good weight gain and will be discharged feeding breast milk made to 24 calorie/oz with addition of Similac powder and breast feeding. Medications at discharge: iron and multivitamin GI: Hyperbilirubinemia. Max Total Bili= 8.5/0.3. Rx phototherapy for 7 days and discontinued on [**2135-5-17**]. Hematology: The CBC at birth: white count 7.1k, hematocrit 45%, platelets 161,000, normal differential. Blood culture was no growth. No indication for further CBCs. Infectious disease: Patient had one evaluation for possible sepsis immediately after birth. Evaluation was negative. He did not receive antibiotic treatment. Neurology: Stable neurological exam, no indication for cranial ultrasound. Hearing test ([**2135-5-26**]) passed bilaterlly. Ophthalmology: The patient has a positive red reflex bilaterally. A formal eye exam was not indicated. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone number [**Telephone/Fax (1) 72821**]. FEEDINGS AT DISCHARGE: Breast milk, 24 calorie with Similac powder. MEDICATIONS: Iron and multivitamins. CAR SEAT SCREENING: passed. STATE NEWBORN SCREEN: Normal on [**2135-5-14**]. VACCINATIONS: Hepatitis B vaccine received on [**2135-5-27**]. IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxi should be considered from [**Month (only) **] through [**Month (only) 958**] for infant's who meet any of the following 4 criteria. 1. Born at less than 32 weeks. 2. Born between 32-35 weeks with 2 of the following: Daycare during RC season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congestive heart 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 life, immunization against influenza is recommended for household contacts and out of home caregivers. The infant has not receive Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks old but few than 12 weeks of age. FOLLOW UP APPOINTMENTS SCHEDULED: DISCHARGE DIAGNOSES: 1. Prematurity. 2. Sepsis ruled out. 3. PPS murmur. 4. Respiratory distress syndrome, resolved. 5. Hyperbilirubinemia treated with phototherapy. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Last Name (NamePattern1) 63980**] MEDQUIST36 D: [**2135-5-27**] 18:22:27 T: [**2135-5-28**] 07:17:34 Job#: [**Job Number 72822**]

V3001,769,7473,7742,76496,76527,V053,V290,V502,7706

Admission Date: [**2147-2-7**] Discharge Date: Date of Birth: [**2076-4-27**] Sex: M Service: The patient is a 70-year-old man with Type 2 diabetes mellitus who presented with new onset chest pain, non-Q wave inferior myocardial infarction with ST elevations. He was on Nitroglycerin and Heparin, no history of transient ischemic attack, no hypertension, hemodynamically stable. His clinical exam showed lungs were clear, no jugular venous distention. Heart was regular rate and rhythm. Abdomen was scaphoid. His EF was 60% and catheterization showed 100% occlusion of the RSV and 70% of the left main. The patient went to the operating room on [**2147-2-8**]. The patient's past medical history is significant for no coronary artery disease, no hypertension, only diabetes mellitus for 10 years. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lopressor. SOCIAL HISTORY: Tobacco: Smoking for a total of 50 pack years, no intravenous drug use. The patient was Spanish Speaking, communication was questionable at best. Please see the operative note for the [**2147-2-8**] operative note in detail. Postoperatively the patient was transferred to the Cardiothoracic Intensive Care Unit where he was progressing well. He was transferred to the floor on the next day after extubation on [**2147-2-8**], the day of the operation. He remained in the Intensive Care Unit [**2-9**] and was then transferred to the floor on the evening of [**2-9**]. The patient's heart rate was somewhat elevated on this day, he was given Lopressor to no effect and during the course of his stay Lopressor was increased to 35 mg p.o. b.i.d. which brought his heart rate down. He showed some evidence of trigeminy, his electrolytes were corrected and he was hemodynamically stable. Discharged on Keflex 500 mg q.i.d. for suspected sternal drainage which eventually towards the end of his admission turned out to be inconsequential by physical examination and CBC white count. Drainage was noted to be more serous then infected or erythema or cellulitis noted. On [**2-10**] his chest tube was discontinued and post chest x-ray showed no pneumothorax. His wires were discontinued on [**2147-2-12**] without any event. Postoperatively the patient was doing well and he was hemodynamically stable. Lytes were replaced as needed during his hospital stay. [**Female First Name (un) 3408**] was called in on [**2-12**] because the patient's blood sugars were initially on the outside, there was questionable control of his blood sugars. Glucophage was increased from his home dose of q day 500 mg to b.i.d. 500 mg and upon discharge on [**2-13**] [**Female First Name (un) 3408**] was contact[**Name (NI) **] to help him with insulin sliding scale and help managing his sugars which was started post [**Female First Name (un) 3408**] seeing him and giving him instructions and follow-up, he was deemed save for discharge. The patient was discharged home on [**2147-2-13**]. On physical examination his lungs were clear, he had no jugular venous distention, no pleural rub and his heart was regular rate and rhythm. His sternum had no discharge and no erythema. His leg harvest site showed no signs of infection. His discharge medications included Keflex 500 mg p.o. b.i.d. times seven days, insulin sliding scale, Lasix 20 mg b.i.d. times one week, KCL 20 mEq b.i.d. while on the Lasix, Glucophage 500 mg b.i.d., Glucotrol 10 mg p.o. q day, Lopressor 75 mg p.o. b.i.d., Percocet one to two tabs p.r.n. for pain. The patient is to take Colace as instructed. Rehabilitation upon discharge concurred with our assessment that the patient was physically fit for discharge and safe to go home. The patient is to follow-up with Dr. [**Last Name (STitle) **]. [**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2147-2-13**] 18:03 T: [**2147-2-13**] 18:47 JOB#: [**Job Number 39079**]

41071,41401,25000,3051

Admission Date: [**2156-10-18**] Discharge Date: [**2156-10-26**] Date of Birth: [**2076-4-27**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: nausea, vomiting, dysequilibrium Major Surgical or Invasive Procedure: [**10-20**] Right Craniotomy for Tumor resection History of Present Illness: This is an 80 year old right handed man with a 3week hisotry of n/v/HA/gait anomalies. This worsened in the 24 hours prior to presentation. He was taken to [**Hospital3 3383**] hospital where a CT showed a right cerebellar mass. He was transfered to [**Hospital1 **] for further evaulation. Past Medical History: DM, HTN, bypass surgery [**55**] years ago, appendectomy, cataract surgery Social History: Tob: 1ppd for his "entire life", recently down to 2 cigarettes a day. EtOH 1 glass of wine with dinner Family History: NC Physical Exam: On Admission: O: T: 98.1 BP: 148/78 HR: 71 R: 18 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**3-10**], IOLs OU EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place. Language: Speech slow with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-13**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Normal bilaterally Toes downgoing bilaterally Coordination: dysmetria, mild dysdiadochokinesis, normal heel to shin Handedness: Right Physical Exam upon discharge: awake, alert. oriented to self/hospital PERRL, EOMI face symmetric, tongue midline MAE's with good strengths following all commands incision- C/D/I Pertinent Results: [**2156-10-18**] MRI head with and without contrast: There is confirmation of an ovoid, irregularly rim-enhancing mass measuring 23 x 32 mm within the right cerebellar hemisphere. There is extensive surrounding edema, including compression of the fourth ventricle. No other areas of pathological enhancement are identified. The lesion exhibits very low diffusion, which would argue against an inflammatory process such as an abscess. The motion degraded FLAIR images suggest a very minor degree of T2 hyperintensity within the white matter of both cerebral hemispheres, becoming confluent in the periatrial regions bilaterally. Given the patient's age, chronic small vessel infarction would appear the most likely diagnosis. [**2156-10-18**] CTA head: No definite hypervascularity is seen in relationship to the cerebellar mass. [**2156-10-18**] CT chest/abd pelvis: IMPRESSION: 1. No primary tumor identified to account for metastasis. 2. There is interstitial lung disease with a basilar predominance and subpleural cysts consistent with interstitiell lung disease. Centrilobular emphysema is present. A nodule within the lingula measures 7 mm and is non- specific. Follow- up in 3 months is recommended, alternatively this could be compared to prior studies to ensure stability 3. A 3-mm nodule within the left lobe of the thyroid is noted 4. Diverticulosis without evidence of diverticulitis. CT HEAD W/O CONTRAST [**2156-10-21**] Status post resection of right cerebellar mass, with expected postoperative changes, and no evidence of large hematoma,increased mass effect, or larger vascular territorial infarction [**2156-10-22**]: MRI brain with and without contrast: minimal amount of blood product within the postoperative bed. No overt evidence of residual mass. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the neurosurgery service for work up of a right cerebellar lesion. He was started on antiemetics and steroids which improved his symptoms of nausea and vomiting. MRI was obtained to better evaluate the lesion. CT Torso was performed for metastatic workup but was negative for obvious signs of primary disease. After discussion with the patient and the patient's son and Healthcare proxy, [**Name (NI) **], the decision was made to proceed with resection of the mass. A pre-op work up was done. He required >400 units of Insulin twice during the day of [**10-20**] and his RISS was adjusted. He was made NPO at midnight in anticipation of surgery. MRI wand study was ordered for surgical planning. On [**10-21**] the patient underwent a right suboccipital craniotomy for resection of right cerebellar tumor. Post operatively patient remained stable on examination. Post op head CT showed post surgical changes, no acute hemorrhage, mass effect or acute infarct. On [**10-22**], he was transferred to the floor and his diet advanced. MRI Brain demonstrated no acute infarct. He was seen and evaluated by physical therapy and occupational therapy who fet that he would benefit from acute rehab. On [**10-24**] and [**10-25**] the patient's Serum Na dropped to 130 and BUN bumped, trending up to 36. The hyponatremia responded to NS fluid boluses and Serum Na improved to 133. Labs were followed closely. On [**10-26**] Na and K were WNL. BUN was improving. He was neurologically stable and cleared for discharge. Medications on Admission: unknown Discharge Medications: 1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/fever. 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right Cerebellar mass Intersitial Lung Disease Emphysema Thyroid nodule Diverticulosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair 3 days after your surgery. Your wound closure uses dissolvable sutures and the suture material will fall out on its own - do not pull the sutures or scrub the incision. Do not leave wet bandages or wet towels on the incision. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Continue to take your Keppra (Levetiracetam) as prescribed. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2156-11-8**] at 10:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. **** You must call registration before [**11-5**] at noon in order to be seen in clinic to update your insurance information and referral. The phone number for registration is [**Telephone/Fax (1) 10676**]. You should call them as soon as possible, do not wait until [**11-5**]. **** There were several abnormal findings on the CT scan we did of your chest. You must see your PCP within the month to discuss the findings of emphysema, thyroid nodule and diverticulosis. You need to have the CT chest repeated in 3 months. You should get a copy all your medical records to bring to your PCP. Completed by:[**2156-10-26**]

1983,3484,2761,515,4928,25000,V4581,1991,4019,41400,56210,3051,2410

Admission Date: [**2167-6-2**] Discharge Date: [**2167-6-5**] Date of Birth: [**2089-8-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo female with history of COPD, IPF, pulmonary hypertension (60-67) on 5 L by NC home O2 who presented to her PCP on the day of admission with a 1 week h/o increased dyspnea on exertion, generalized fatigue. She went to her PCP and CXR ordered; showed RLL pneumonia and PCP told pt to go to ED. In ED sats in low 90's on 5 L but had desats into the 80's, pO2 of 49 on ABG. . She admits to having a nonproductive, chronic cough with no recent change. She also has had intermittent left upper back and chest wall pain at the site of old rib fractures. No fevers, dizziness, abdominal pain, N/V, diarrhea, dysuria, edema. Past Medical History: COPD Idiopathic pulmonary fibrosis Pulmonary hypertension CAD s/p MI and stent to LCx Hypertension Osteoporosis Renal Artery Stenosis s/p stent to R renal artery CHF Hyperlipidemia GERD Fe deficiency Anemia s/p lap chole hx MRSA pna mesenteric ischemia s/p L shoulder hemiarthroplasty h/o fall with rib fractures patent foramen ovale Social History: currently living in a [**Hospital3 **] facility. +tobacco in past and quit 20 years ago; no drugs; occasional ETOH; retired homemaker. Widowed. Family History: twin sister with IPF. Physical Exam: VS- 98.2 82 152/55 20 92% Bipap 5/0 Gen - AOX3, speaking full sentences, comfortable HEENT - PERLA, cataracts bilaterally, anicteric Heart - RRR, 3/6 M TR Lungs - Dry hoarse crackles bilaterally, no wheezes Abdomen - Soft, NT, ND + BS Ext - No C/C/E, +2 d. pedis RLE, +1 d. pedis LLE Skin - Multiple ecchymoses, easy bruising Neuro - Grossly intact Pertinent Results: [**2167-6-2**] WBC-10.0 HGB-10.8* HCT-33.0* MCV-70* RDW-16.7* PLT-119 [**2167-6-2**] NEUTS-84.2* LYMPHS-9.7* MONOS-1.9* EOS-3.9 BASOS-0.2 [**2167-6-2**] GLUCOSE-135* UREA N-36* CREAT-1.8* SODIUM-137 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 Cardiac enzymes: negative . [**2167-6-2**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2167-6-2**] URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 . ECG: sinus, 90 bpm, normal axis, <[**Known lastname 4793**] depressions V5-V6. Qwave II, aVF. . CXR ([**6-2**]): right lower lobe pneumonia, old emphysematous changes . rib XR ([**6-2**]): At the site of the patient's maximal tenderness, there are multiple deformities of the ribs that correlate with rib fractures seen on the prior chest CT of [**2167-2-5**]. Brief Hospital Course: Assessment and Plan: Ms. [**Known lastname **]. [**Known lastname **] is a 77 yo female with severe baseline lung disease (COPD and IPF) requiring home O2, presenting with respiratory distress and pneumonia. . # COPD/IPF exacerbation: She has a history of COPD, IPF, pulmonary hypertension, PFO. She has baseline DOE on 5L oxygen at home ([**Hospital3 **]). Because of hypoxemia to 80%, she was admitted to MICU. She was placed on bipap and was never intubated. She eventually required CPAP only at night with 5-7 L by NC during the day. She received steroids (IV to PO) and nebulizer treatments. The patient stated her wishes to be DNR/DNI. She will be discharged on a prednisone taper. A bipap machine for home was also arranged for the patient where she will use at setting of [**4-10**]. Nasal saline also helped the patient with dryness and bleeding from her nose due to oxygen flow. She will continue her regular medications and inhalers at home. She was also prescribed low dose fentanyl lozenges for use as outpatient when preparing for exertion to decrease pain and exertion. She will followup with Dr. [**Last Name (STitle) 217**] regarding the effectiveness of these. . # Community acquired pneumonia: She was initially placed on vancomycin and levofloxacin. Only levofloxacin was continued for a total course of 10 days. This was renally dosed (750 mg every other day). . # Acute on chronic renal failure: Creatinine 1.8 on admission; this decreased to baseline of 1.3 by discharge. Acute component was most likely prerenal/dehydration. Medications were renally dosed. . # Blood cultures: 1/4 bottles positive for GPCs in clusters which were later identified as coag negative staph. Due to only having 1/4 bottles and that it was SCN, it was treated as a contaminant, and vancomycin was discontinued. . # Hypertension: She remained on Coreg, diltiazem, imdur. Lasix initally held with ARF but then restarted. . # Back and chest wall pain: reproducible at site of previous rib fractures. It seemed unlikely to be cardiac in origin and enzymes were negative; ECG did not show ischemic changes. A lidoderm patch was used in house and will be prescribed for the patient as an outpatient, as it provided significant relief. . # CAD: ASA, Imdur, Vytorin, Coreg were continued. Acute MI was ruled out. Medications on Admission: Alprazolam 0.25 mg ASA 81 mg Boniva 150 mg PO Qmonth Coreg 3.125 mg PO BID Diltiazem ER 180 mg PO QD Colace Lasix 40 mg PO Sun/Tues/Thurs/Sat Imdur 60 mg PO QD MVI Nexium 40 mg PO QD Zoloft 150 mg PO QD Trazadone 50 mg PO QD Vitamin D 50,000 units Vytorin 10/40 mg PO QD Discharge Medications: 1. Sleep oximetry Overnight continuous O2 saturation monitoring for one night 2. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once a day for 10 days: Sat [**6-6**]: take 4 pills. Sun [**6-7**] through Tues [**6-9**]: take 3 pills daily. Wed [**6-10**] through Fri [**6-12**]: take 2 pills daily. Sat [**6-13**] through Mon [**6-15**]: take one pill daily. Disp:*22 Tablet(s)* Refills:*0* 3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO every other day for 3 doses: Take first pill Sat, [**6-6**]; then take one pill every other day. Disp:*3 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 10. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Bipap Diagnosis: COPD Settings [**4-10**] 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY PRN () as needed for back pain: Place on painful area for 12 hours out of every day as needed for pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1* 15. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal Q3H (every 3 hours) as needed for nasal dryness. Disp:*1 bottle* Refills:*1* 19. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 20. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-9**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 21. Fentanyl Citrate 200 mcg Lozenge on a Handle Sig: One (1) Buccal three times a day as needed for pain or in preparation for exercise. Disp:*30 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Pneumonia Chronic obstructive pulmonary disease Idiopathic Pulmonary Fibrosis Hypoxemia Discharge Condition: Stable Discharge Instructions: You were admitted for difficulty brathing and pneumonia. We treated you with oxygen and antibiotics. . Use oxygen at home, 5-6 liters per minute during rest and during exercise. You can use your humidifier as needed. . At nighttime you will be using your new bipap machine. This is only for use during sleep. You will be instructed on how to operate this machine. . You may resume your regular activity at your [**Hospital3 **] facility, including walking to meals. . Please return to the hospital if you are having trouble breathing or chest pain, or any new symptoms that you are concerned about. . Please take all of your medications and keep all of your appointments with your doctors. Followup Instructions: Please see you PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 7 to 10 days. Please call ([**Telephone/Fax (1) 33678**] to make an appointment. . Other upcoming appointments: . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2167-7-21**] 1:00 . Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2167-11-10**] 10:30 . Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2167-11-10**] 10:30 . You also have an appointment with Dr. [**Last Name (STitle) 217**] on [**2167-11-10**] following your PFTs. Please call ([**Telephone/Fax (1) 96590**] if you would like to see him sooner. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

486,49121,5849,27651,79902,515,4280,42832,4168,7455,53081,41401,V4582,412,4019,73300,4401,2724

Admission Date: [**2167-12-21**] Discharge Date: [**2167-12-23**] Date of Birth: [**2089-8-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: # Left hip fracture s/p fall # Hypoxia Major Surgical or Invasive Procedure: # Arterial line placement # Right internal jugular central venous line placement # Endotracheal intubation History of Present Illness: 78F h/o COPD, presumed idiopathic pulmonary fibrosis on home O2, CAD s/p MI, CHF and Afib, presented with L hip fracture s/p fall [**1-9**] lightheadedness after transitioning from sitting to standing while doing laundry on the day of admission. Pt reported no LOC or seizure activity, and had fallen to the floor without striking furniture or head, remaining down approximately 30-40 minutes until a nursing assistant found her. Pt was unable to walk and needed to be lifted to bed, then was brought by EMS to [**Hospital1 18**]. Pt stated that she also had noticed increased DOE and SOB x 1 week with yellow sputum, occasionally blood-streaked with recent epistaxis [**1-9**] nasal drying due to home O2 NC. Pt denied fever, chills, diarrhea, decreased PO intake, or N/V; she did report constipation at baseline. Pt had her flu vaccine this year and confirmed annual pneumonia vaccinations for the last 3 years. . In the [**Name (NI) **], pt was hypoxic to the mid 80s with venti mask 50%, 12 L; she was placed on 100% NRB with O2 sats rising to 100% (at baseline, pt is 90% on 5L O2 NC). Pt was also noted to have STD in lateral leads, notably different from baseline. Pt reported a sensation of midsternum "heartburn" which quickly resolved, and stated that her pain during her past MI felt more like pressure and was different than this sensation. Pt received 2L NS, fentanyl & morphine for pain, as well as aspirin. Ortho was consulted about her L hip fracture as seen on x-ray and recommended ORIF as soon as medically stable. Pt was therefore admitted for further work-up of hypoxic respiratory distress, EKG changes, and consideration for surgical repair of her L hip fracture. Past Medical History: # Cardiovascular --Diastolic heart failure: EF 60% --Atrial fibrillation --MR [**Name13 (STitle) 109519**] --CAD: h/o LCx stenosis on prior cardiac cath --PFO --HTN --Hyperlipidemia --Mesenteric ischemia --Renal artery stenosis s/p R renal artery stent --PVD --Pulmonary hypertension --CVA . # Pulmonary --Home oxygen 5L --COPD --Presumed idiopathic pulmonary fibrosis stable RML lung nodule and anterior mediastinal soft tissue density . # Musculoskeletal --Osteoporosis --h/o fall with rib fractures . # Gastrointestinal --GERD . # Hematological --Fe deficiency anemia Social History: # Personal: Widowed. Lives in [**Hospital3 **] facility. # Tobacco: 35 pack years of smoking, quit ~[**2146**]. # Alcohol: Occasional. # Recreational drugs: None. Family History: # Mother: Rheumatic heart disease # Siblings: Twin sister died, 78. # Children: Two sons with MI, age 40s. Physical Exam: VS: Temp 96.8, BP 116/41, HR 70/NSR, RR 18/O2sat 96% GEN: Pleasant, NAD; speaking in full sentences with face mask, with decreased O2 sats with prolonged narration. HEENT: PERRL, EOMI, anicteric, MM mildly dry NECK: ?JVP = 10cm RESP: CTAB anteriorly, faint crackles as bases posteriorly CV: RR, S1 and S2 WNL, holosystolic murmur througout the precordium, loudest at apex ABD: Soft, ND, NT, BS+, no masses or hepatosplenomegaly EXT: No c/c/e, warm, good pulses SKIN: No rashes/no jaundice; 3cm skin tear on L distal shin NEURO: AAOx3. No sensory deficits to light touch. Pertinent Results: Admission labs: . [**2167-12-21**] 06:24PM WBC-10.6# RBC-3.88* HGB-8.7* HCT-28.9* MCV-75* MCH-22.4* MCHC-30.1* RDW-16.7* [**2167-12-21**] 06:24PM NEUTS-85.4* LYMPHS-8.8* MONOS-2.3 EOS-3.2 BASOS-0.3 [**2167-12-21**] 06:24PM CK(CPK)-67 [**2167-12-21**] 06:24PM cTropnT-0.02* [**2167-12-21**] 06:24PM GLUCOSE-127* UREA N-45* CREAT-1.6* SODIUM-139 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 . Imaging: . PELVIS (AP ONLY) [**2167-12-21**] 7:55 PM Extensively comminuted intertrochanteric fracture of the left proximal femur, with marked varus angulation, as described. . CHEST (PORTABLE AP) [**2167-12-21**] 6:54 PM Probable mild pulmonary vascular congestion, superimposed on chronic, diffuse interstitial process which (according to previous reports) represents known idiopathic pulmonary fibrosis. There is no definite new airspace process. . TEE (Complete) Done [**2167-12-22**] at 2:49:50 PM Emergency TEE performed in the operating room after cardiac arrest. The right atrium is dilated. A patent foramen ovale with flow across it is seen by color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are simple atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. No thrombus/embolus is seen in the pulmonary artery. Brief Hospital Course: 78F h/o COPD, idiopathic pulmonary fibrosis, CAD s/p MI, admitted to MICU with hypoxia and L intertrochanteric femur fracture. . # PEA arrest: Pt was noted to enter into PEA arrest while undergoing induction in the OR for ORIF. Pt was intubated and received 20min CPR, after which she was placed on epinephrine and norepinephrine gtt; per verbal report to this author, pt had also received NS fluid resuscitation. Emergency TTE performed in the OR demonstrated severe global free wall hypokinesis at the dilated right ventricular cavity. Pt was returned to the MICU, during which time she was ultimately placed on four pressors (norepinephrine, phenylephrine, dobutamine, and vasopressin), as well as NS boluses for hemodynamic support, and increased FiO2 for respiratory support. Given her poor prognosis, family members decided to withdraw care; pt expired within minutes of withdrawing pressor and ventilatory support. . # L femur fracture: Orthopedics was consulted in the ED and recommended ORIF after pt was deemed medically stable. Given h/o pulmonary disease and cardiac disease, MICU team discussed with the patient about risks associated with surgical repair, specifically perioperative MI and difficult post-op extubation. Pt stated her understanding of this risk, but that her quality of life would be very diminished if she did not undergo surgical repair. During a family meeting on [**12-22**] AM, all family members present concurred that surgical repair was desired, and stated their understanding of pt's high perioperative risk. Pt reversed her DNR/DNI status in order to undergo surgery, and in prepartion for surgery, received 2units PRBC given her low hematocrit. During induction, pt entered into pulseless electrical activity while on the OR table and underwent 20min of CPR. Surgery was aborted and pt was returned to the MICU. . # CAD s/p MI: Lateral [**Known lastname **] depressions on admission EKG resolved on repeat EKGs with troponin T elevated to 0.10, possibly indicating some cardiac demand. Pt reported "heartburn" but no chest pressure. Prior cardiac catheterizations demonstrated LCx involvement, and given this constellation of data, pt was considered a high peri-operative risk for MI. During induction, pt did enter into PEA arrest. . # Hypoxia: Pt was noted to have increased O2 requirement from baseline of 90% on 5L O2 NC, with DDx including PE (thrombotic vs fat in the setting of fracture), COPD flare, worsening idiopathic pulmonary fibrosis, infection, or worsening heart failure with associated pulmonary congestion. Pt improved rapidly overnight, indicating possible reversible cardiac etiology as also evidenced on EKG changes. Based on the considerations for her quality of life, pt's chronic pulmonary pathologies were not considered obstacles to ORIF per communication with her pulmonologist Dr. [**Last Name (STitle) 217**]. . # Code status: Pt was initially DNR/DNI, but after deciding to proceed with hip fracture repair, reversed her status to full code. After coding during induction for surgery, pt was intubated and received CPR. Pt's status was changed back to DNR, and she was later made CMO after her family decided to withdraw care based on her poor prognosis. Pt expired minutes after pressors and ventilatory support were withdrawn. Discharge Disposition: Expired Discharge Diagnosis: Left hip fracture Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2167-12-23**]

82021,5849,7455,42832,4275,496,515,4019,4401,4168,V1254,73300,41401,42731,4280,412,53081,E8859

Admission Date: [**2164-11-23**] Discharge Date: [**2164-12-10**] Date of Birth: [**2089-8-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: 75 yo female with multiple medical problems including CAD, hypertension, osteoporosis, CHF who presents with 2-3 days of woresning back pain to the point that it has become very difficult for her to walk and ambulate. She denies any numbness, tingling sensation, or other associate symptoms like fever, chills. Just complaining of pain and diffculty ambulating secondary to pain. No dysuria, urinary or bowel incontinence. Was seen by Dr. [**Last Name (STitle) 18068**] who gave her Percocet and she was taking [**12-11**] tablet every night and pain did not improve. Came in to the ED for further evaluation. Had imaging in the ED that did not show any evidence of acute fracture or any misalignment. Being admitted for pain control and possible rehab placement. Past Medical History: 1. CAD s/p MI and stent to LCx 2. Hypertension 3. Osteoporosis 4. Renal Artery Stenosis s/p stent to R renal artery 5. CHF 6. Hyperlipidemia 7. GERD 8. Fe deficiency Anemia 9. COPD 10. s/p lap chole 11. s/p L shoulder hemiarhtroplasty Social History: Lives at home with good social support; denies any EtOH, tobacco use or an IV drug or recreational drug use Family History: Non contributory Physical Exam: VS: T 97.6, pulse 71, BP 109/72, RR 92% room air Gen: moderately discomfort secondary to pain HEENT: PERRLA, EOMI, OP clear Neck: supple, no JVD Heart: S1, S2, RRR, no murmurs, rubs, gallops Abd: soft, ND, NT, no HSM Extrem: paraspinal tenderness, no rashes Neuro: AAO x 3, good sensation and [**4-11**] motor strength, decrease range of motion mainly secondary to pain Pertinent Results: [**2164-11-23**] 03:00PM PT-13.5 PTT-38.0* INR(PT)-1.1 [**2164-11-23**] 03:00PM WBC-8.1 RBC-5.25# HGB-11.6*# HCT-37.0# MCV-71* MCH-22.0* MCHC-31.3 RDW-16.9* [**2164-11-23**] 03:00PM GLUCOSE-119* UREA N-40* CREAT-1.7* SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 [**2164-11-23**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2164-11-23**] 03:00PM URINE RBC-0-2 WBC-[**10-27**]* BACTERIA-RARE YEAST-NONE EPI-[**5-17**] RENAL EPI-0-2 Brief Hospital Course: 75 yo female with multiple medical problems who presents with back pain and difficulty ambulating but no evidence of any fractures. Hospital course was complicated be hypotension and hypoxia leading to mesenteric ischemic colitis and MRSA pneumonia. 1. MRSA Pneumonia - patient was diagnosed with MRSA pneumonia and so was started on Vancomycin 1000mg IV daily. She had a PICC line placed, and will need an additional 2 weeks of total antibiotics. In addition, given her history of COPD, she will need aggressive pulmonary toilet / chest physical therapy as she is at an increased risk of mucous plugging if she does not clear well. 2. Mesenteric Ischemia - this was diagnosed on CT abdomen. This was likely secondary to her being hypotensive for a long period of time but throughout the hospital course, her diet was advanced and she tolerated it well. Her abdominal exam was benign. 3. Hypertension - her BP has been labile for most of the hospital course, but we finally were able to reach a regimen that was well tolerated by her. Given her history of renal artery stents, our goal is to keep her SBP around 140s and so she is currently on Diltiazem, and Isosorbide Dintrate. 4. CAD - she should continue her Aspirin, Plavix, and Simvastatin 5. Back Pain - likey secondary to her osteoporosis with possible compression fractures; she had plain films of her lumbar and thoracic areas that showed no evidence of fractures or misalignment. However, given her extent of pain, there was concern for compression fracture but an MRI could not be obtain due to her recent shoulder surgery and her history of renal artery stents. At that time, it was decided to obtain a CT of her lumbar and thoracic area that also did nto show any fractures - only some foramenal narrowing. Her pain was initially controlled with Ultram, Oxycodone, and Valium but she had an episode of becoming hypotensive and so her pain medications were switched around to Tylenol around the clock, with Calcitonin nasal spray. 6. Renal - she is s/p stent to the R renal artery from stenosis; she was seen by the Renal team who agreed with our current medication plans. Her baseline Creat is between 1.4 and 1.7 and she is well below her baseline at this the time of discharge. Medications on Admission: 1. Imdur 120mg po daily 2. Aspirin 325 mg po daily 3. Zocor 80mg po daily 4. Toprol XL 100mg po daily 5. Plavix 75mg po daily 6. Fosamax 70mg po q week 7. Zetia 10mg po daily 8. Norvasc 10mg po daily 9. Trazadone 50mg po qhs 10. Atrovent 2 puffs qid 11. Uniretic 15-25mg po daily 12. Percocet [**12-11**] tablet prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg Intravenous Q24H (every 24 hours) for 14 days. 18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb treatment Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 21. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) inhaler Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. MRSA Pneumonia 2. Back Pain 3. Hypertension 4. Renal Artery Stenosis s/p renal artery stents Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed. Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**12-9**] weeks. Please take your blood pressure medications with caution as we would like your blood pressure around 140 systolic. Please hold medications if SBP less than 140. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2164-12-18**] 2:00

73313,48241,5570,42832,51882,5990,585,496,4280,7197,73300,45829,V090,4019

Admission Date: [**2142-7-20**] Discharge Date: [**2142-7-28**] Date of Birth: [**2080-6-12**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: Initially presented to [**Hospital Unit Name 196**] for atrial flutter ablation. Transferred to ICU for hypotension. Major Surgical or Invasive Procedure: EP mapping History of Present Illness: 61 yo male with CAD s/p inferior and anteroseptal MI '[**30**] s/p 3V CABG (LIMA to LAD, SVG to OM, SVG to DM) and AVR (bovine) in [**2-24**], CHF (EF40%, mod pulm htn, apical aneurysm), HTN, AF dx'd [**6-6**] and failed CV on sotalol and amio, s/p DDD PM [**6-14**] for post-CV bradycardia. Presented to [**Hospital **] hospital with hypotension and atrial fibrillation -> Aflutter. Amio started [**7-9**] and dig there and CV [**2142-7-10**]. Converted to Aflutter [**7-14**]. [**7-18**] had VT/VF in setting of K 6.6 and transferred to [**Hospital1 18**]. [**Hospital1 18**] Course: TEE/CV [**7-19**], pacer DDDR 70 with mode-switch, dig stopped. Got 3 doses Coumadin (last [**7-22**]), and INR up to 5.1 [**7-25**], wbc climbing with lymphopenia. Waiting for INR to come down (received 3 doses coumadin after amio started and INR went to 21) before flutter ablation. Over the past several days, BP noted to be trending down. [**7-27**] hypotensive d/t ??infxn. Transferred to MICU service for mgt of hypotension. Past Medical History: 1. CAD -Coronary artery disease status post inferior and anteroseptal MI in [**2130**] -status post three vessel CABG(LIMA to LAD, SVG to OM, SVG to DM) and AVR (bovine) in [**2141-2-21**]. -ETT MIBI [**4-26**] on 8 min mod-[**Doctor First Name **] (7METS)57% PMHR-severe fixed defect dital inf wall and septum 2. CHF 3. Hypertension. 4. Hypercholesterolemia. 5. Hypothyroidism. 6. Melanoma on left shoulder in [**2140-10-23**]. 7. Erectile dysfunction. 8. History of erythema nodosum. 9. Community acquired pneumonia in [**2140-6-23**]. 10.light chain multiple myeloma. 12. Multifactorial renal failure. 13. DM 14. Light chain nephropathy/proteinuria. 15. Restless leg syndrome. 16. Hypercholesterolemia. 17. Hypocalcemia. Social History: The patient is divorced and lives alone in [**Location (un) 6691**], [**State 350**] in the Berkshires. He has two children. He was working in produce at a market but had to stop a week prior to admission because of shortness of breath and edema. He smoked one cigar per day for 30 years. He denies alcohol use. Family History: The patient's father had coronary artery disease and was an alcoholic. The patient's mother had diabetes mellitus and coronary artery disease. The patient's sister has coronary artery disease and atrial fibrillation. Physical Exam: T96.7 BP110/72 P76 97%RA Gen-very pleasant HEENT-anicteric, no conjunctival pallor, no nasal findings, no oral findings, neck supple, no LAD, infroorbital ecchymoses on right eye, laceration on left forehead. CVS-nl S1/S2, no S3/S4, 2/6 SEm at USB, no pedal edema, DP 1+ bilaterally, JVP 7cm. resp-CTAB, no wheezes, no crackles GI-nl BS, no tenderness neuro-A+O X 3, move all 4 limbs Pertinent Results: [**2142-7-20**] 03:40AM GLUCOSE-120* UREA N-43* CREAT-4.8* SODIUM-140 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18 [**2142-7-20**] 03:40AM CALCIUM-8.5 PHOSPHATE-6.3*# MAGNESIUM-1.8 [**2142-7-20**] 03:40AM DIGOXIN-1.2 [**2142-7-20**] 03:40AM WBC-16.9*# RBC-4.28*# HGB-13.5*# HCT-41.1# MCV-96 MCH-31.5 MCHC-32.8 RDW-16.4* [**2142-7-20**] 03:40AM PLT COUNT-169# [**2142-7-20**] 03:40AM PT-12.7 PTT-26.4 INR(PT)-1.0 [**2142-7-21**] 06:35AM BLOOD WBC-10.6 RBC-4.15* Hgb-13.2* Hct-40.4 MCV-97 MCH-31.9 MCHC-32.7 RDW-16.2* Plt Ct-166 [**2142-7-22**] 08:20AM BLOOD WBC-10.5 RBC-4.23* Hgb-13.6* Hct-40.4 MCV-96 MCH-32.1* MCHC-33.7 RDW-16.1* Plt Ct-162 [**2142-7-23**] 06:10AM BLOOD WBC-12.1* RBC-4.31* Hgb-13.8* Hct-41.0 MCV-95 MCH-32.0 MCHC-33.7 RDW-16.2* Plt Ct-170 [**2142-7-24**] 04:00AM BLOOD WBC-16.7* RBC-4.50* Hgb-14.2 Hct-42.1 MCV-94 MCH-31.6 MCHC-33.9 RDW-16.2* Plt Ct-190 [**2142-7-24**] 09:21AM BLOOD WBC-17.0* RBC-4.49* Hgb-14.2 Hct-42.6 MCV-95 MCH-31.6 MCHC-33.3 RDW-16.3* Plt Ct-191 [**2142-7-25**] 06:20AM BLOOD WBC-12.7* RBC-4.24* Hgb-13.4* Hct-41.0 MCV-97 MCH-31.5 MCHC-32.6 RDW-15.9* Plt Ct-169 [**2142-7-26**] 06:35AM BLOOD WBC-16.7* RBC-4.35* Hgb-13.6* Hct-41.4 MCV-95 MCH-31.3 MCHC-32.8 RDW-16.1* Plt Ct-180 [**2142-7-26**] 08:20AM BLOOD WBC-15.0* RBC-4.09* Hgb-13.3* Hct-39.0* MCV-95 MCH-32.4* MCHC-34.0 RDW-16.1* Plt Ct-173 [**2142-7-27**] 07:25AM BLOOD WBC-11.5* RBC-3.07* Hgb-9.7*# Hct-29.6* MCV-97 MCH-31.6 MCHC-32.8 RDW-16.1* Plt Ct-145* [**2142-7-27**] 11:06AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.8* Hct-28.2* MCV-98 MCH-30.6 MCHC-31.3 RDW-16.0* Plt Ct-155 [**2142-7-27**] 02:15PM BLOOD WBC-16.4*# RBC-3.47* Hgb-10.8* Hct-33.5* MCV-96 MCH-31.1 MCHC-32.3 RDW-15.8* Plt Ct-189 [**2142-7-28**] 12:14AM BLOOD WBC-16.4* RBC-2.85* Hgb-9.1* Hct-26.8* MCV-94 MCH-32.0 MCHC-34.0 RDW-15.9* Plt Ct-193 [**2142-7-24**] 04:00AM BLOOD Neuts-95.0* Bands-0 Lymphs-1.9* Monos-3.0 Eos-0.1 Baso-0 [**2142-7-27**] 11:06AM BLOOD PT-17.1* PTT-37.2* INR(PT)-1.8 [**2142-7-25**] 02:45PM BLOOD PT-29.1* PTT-43.1* INR(PT)-5.3 [**2142-7-24**] 09:40AM BLOOD PT-37.5* INR(PT)-8.9 [**2142-7-25**] 02:45PM BLOOD Fibrino-329 D-Dimer-995* [**2142-7-20**] 03:40AM BLOOD Glucose-120* UreaN-43* Creat-4.8* Na-140 K-4.9 Cl-104 HCO3-23 AnGap-18 [**2142-7-21**] 06:35AM BLOOD Glucose-99 UreaN-61* Creat-5.9*# Na-138 K-5.3* Cl-102 HCO3-21* AnGap-20 [**2142-7-22**] 08:20AM BLOOD Glucose-119* UreaN-49* Creat-5.2* Na-138 K-5.0 Cl-101 HCO3-26 AnGap-16 [**2142-7-23**] 06:10AM BLOOD Glucose-152* UreaN-62* Creat-6.3*# Na-136 K-5.3* Cl-99 HCO3-22 AnGap-20 [**2142-7-24**] 04:00AM BLOOD UreaN-79* Creat-7.1* Na-137 K-5.6* Cl-98 HCO3-19* AnGap-26* [**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137 K-6.1* Cl-98 HCO3-19* AnGap-26* [**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137 K-6.1* Cl-98 HCO3-19* AnGap-26* [**2142-7-25**] 06:20AM BLOOD Glucose-107* UreaN-62* Creat-5.8*# Na-139 K-5.6* Cl-101 HCO3-23 AnGap-21* [**2142-7-26**] 06:35AM BLOOD Glucose-105 UreaN-86* Creat-6.9*# Na-138 K-6.0* Cl-98 HCO3-24 AnGap-22* [**2142-7-26**] 08:20AM BLOOD Glucose-102 UreaN-85* Creat-7.1* Na-137 K-6.1* Cl-97 HCO3-25 AnGap-21* [**2142-7-27**] 07:25AM BLOOD Glucose-111* UreaN-90* Creat-4.9*# Na-138 K-5.7* Cl-102 HCO3-23 AnGap-19 [**2142-7-27**] 11:06AM BLOOD Glucose-171* UreaN-66* Creat-3.2*# Na-141 K-3.7 Cl-114* HCO3-19* AnGap-12 [**2142-7-27**] 07:55PM BLOOD Creat-5.3*# K-6.2* [**2142-7-28**] 12:14AM BLOOD Glucose-207* UreaN-116* Creat-5.5* Na-137 K-6.4* Cl-100 HCO3-23 AnGap-20 [**2142-7-24**] 09:21AM BLOOD ALT-16 AST-28 AlkPhos-99 TotBili-0.2 [**2142-7-27**] 11:06AM BLOOD LD(LDH)-243 CK(CPK)-43 [**2142-7-27**] 05:33PM BLOOD CK(CPK)-72 [**2142-7-27**] 09:32PM BLOOD CK(CPK)-66 [**2142-7-27**] 11:02PM BLOOD LD(LDH)-402* TotBili-0.2 [**2142-7-28**] 12:14AM BLOOD ALT-20 AST-26 [**2142-7-27**] 11:06AM BLOOD CK-MB-NotDone cTropnT-0.49* [**2142-7-27**] 05:33PM BLOOD CK-MB-NotDone cTropnT-0.81* [**2142-7-27**] 09:32PM BLOOD CK-MB-NotDone cTropnT-0.87* [**2142-7-20**] 03:40AM BLOOD Calcium-8.5 Phos-6.3*# Mg-1.8 [**2142-7-21**] 06:35AM BLOOD Mg-2.1 [**2142-7-22**] 08:20AM BLOOD Mg-1.9 [**2142-7-23**] 06:10AM BLOOD Mg-2.6 [**2142-7-24**] 04:00AM BLOOD Mg-2.7* [**2142-7-24**] 09:21AM BLOOD Albumin-3.0* Calcium-10.3* Phos-7.9*# Mg-3.3* [**2142-7-25**] 06:20AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.4 [**2142-7-26**] 06:35AM BLOOD Calcium-9.4 Phos-7.2*# Mg-2.9* [**2142-7-26**] 08:20AM BLOOD Phos-7.2* Mg-2.7* [**2142-7-27**] 07:25AM BLOOD Calcium-8.2* Phos-5.1*# Mg-2.2 [**2142-7-27**] 11:06AM BLOOD Calcium-4.8* Phos-3.1# Mg-1.5* [**2142-7-27**] 02:15PM BLOOD Calcium-8.6 [**2142-7-28**] 12:14AM BLOOD Calcium-8.2* Phos-6.5*# Mg-3.1* [**2142-7-27**] 11:02PM BLOOD Hapto-241* [**2142-7-27**] 05:33PM BLOOD TSH-6.4* [**2142-7-27**] 05:33PM BLOOD T3-26* Free T4-0.6* [**2142-7-24**] 04:00AM BLOOD PTH-43 [**2142-7-27**] 11:02PM BLOOD Cortsol-29.3* [**2142-7-27**] 09:32PM BLOOD Cortsol-25.5* [**2142-7-27**] 07:55PM BLOOD Cortsol-22.9* [**2142-7-20**] 03:40AM BLOOD Digoxin-1.2 [**2142-7-28**] 12:29AM BLOOD Type-ART pO2-175* pCO2-39 pH-7.38 calHCO3-24 Base XS--1 Intubat-NOT INTUBA [**2142-7-27**] 08:04PM BLOOD Type-ART pO2-125* pCO2-45 pH-7.34* calHCO3-25 Base XS--1 Intubat-NOT INTUBA [**2142-7-27**] 06:16PM BLOOD Type-[**Last Name (un) **] pH-7.31* [**2142-7-27**] 11:10AM BLOOD Lactate-2.1* [**2142-7-27**] 06:16PM BLOOD Lactate-1.8 [**2142-7-27**] 08:04PM BLOOD Lactate-1.3 [**2142-7-28**] 12:29AM BLOOD Glucose-208* Lactate-1.4 K-6.0* [**2142-7-27**] 06:16PM BLOOD freeCa-1.14 [**2142-7-27**] 08:04PM BLOOD freeCa-1.12 [**2142-7-28**] 12:29AM BLOOD freeCa-1.07* [**7-27**] on transfer to the ICU: EKG: Atrial paced rhythm Right bundle branch block Inferior infarct, age indeterminate Anterior myocardial infarct, age indeterminate Diffuse ST-T wave abnormalities - cannot exclude in part ischemia CXR: Worsening left retrocardiac opacity with adjacent moderate sized pleural effusion. Pneumonia cannot be excluded. CT abd/pelvis: 1. No evidence of retroperitoneal hematoma. 2. Standing in the subcutaneous tissues and small amount of free fluid noted in the presacral space consistent with edema. 3. Moderate-sized bilateral pleural effusion with associated atelectasis. Brief Hospital Course: 61 yo M with MM, ESRD, CAD s/p V-tach arrest, CHF, a-fib/flutter, awaiting INR to trend down for elective ablation, when he subsequently became increasingly hypotensive and confused/disoriented, so he was transferred to the ICU for further management of ?sepsis vs.adrenal insufficiency. He was under the care of the ICU team for only several hours before he went into v-fib arrest, coded and was not able to be resuscitated. 1)Hypotension: Likely sepsis vs adrenal insufficiency. BCXs/fungal cx were sent in light of the recent steroid use. Vanc and cefepime (for gram neg coverage) were started empirically. As line infection was of high likelihood, the plan was to d/c HD line when possible. He was started on IV stress dose steroids Q8hrs empirically and cortisol stim test was sent. Pressors were initiated with neo and levophed to maintain MAP>60, and IVF boluses were given as needed. He was transfused to HCT >30 and H/H chakcs proceeded Q6hours. CT was negative for retroperitoneal bleed. 2) Renal: He was HD dependent and had been dialyzed the day prior to transfer to the ICU. 3) Cor: He was on ASA and a statin, BP meds were held given hypotension. On transfer to the ICU, EKG showed possible new ischemia and cardiac markers trended upwards. However, in the setting of his renal insuffuciency, level of elevation was not clear. His potassium level was slowly creeping up. Kayexalate was given and K followed. Prior to his subsequent K level at 6.4 and the third set of markers coming back, Mr.N went into v-fib arrest. Code was called and CPR initiated. Despite 30 minutes resus efforts, Mr.N was not able to be revived, code was stopped and he was pronounced. His family was notified and they declined autopsy. [4) Thyroid: There was a question as to whether this was the source of afib/flutter; however, TFT were normal. He was kept on synthroid. 5) A-flutter: He was to undergo elective ablation after stabilization of BP. 6) Heme: H/O multiple myeloma. Cont thalidomide, monitor HCT. 7) FEN: NPO 8) Code: FULL] Medications on Admission: 1. Toprol-XL 50 mg po qd. 2. Trazodone 100 mg po qd. 3. Isosorbide mononitrate 30 mg ER qd. 4. Sinemet 10/100 mg qhs, prn, restless leg syndrome. 5. Lipitor 20 mg qd. 6. Synthroid 175 mcg qd. 7. Wellbutrin 100 mg [**Hospital1 **]. 8. Aspirin 81 mg qd. 9. Glargine 20 units qhs. 10. Humalog sliding scale. 11. Calcium carbonate 500 mg tid. 12. Pamidronate 30 mg times one. 13. Zantac 300 mg qhs. 14. amiodarone 200mg [**Hospital1 **] 15. digoxin 0.125 QD 16. prednisone 50 on taper 17. clonasepam 2mg QHS 17. Thalidomide 400 [**Hospital1 **] 18. calcium acetate 1334 Discharge Medications: None Discharge Disposition: Home with Service Discharge Diagnosis: 1. Deceased 2. hyperkalemia 3. Atrial flutter 4. coronary artery disease post MI and CABG 5. CHF 6. Hypotension. 7. Hypothyroidism. 8.light chain multiple myeloma. 9.renal failure requiring hemodialysis 10. DM Discharge Condition: Deceased Discharge Instructions: None--deceased Followup Instructions: None-deceased

4589,40391,4275,20300,4280,2767,42731,V433,V4581

Admission Date: [**2141-3-13**] Discharge Date: [**2141-3-24**] Date of Birth: [**2080-6-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 60 year old white male has a known murmur since childhood. He is status post inferior myocardial infarction and anteroseptal myocardial infarction in [**2130**] and status post angioplasty at that time. Since [**2140-9-23**] he has had increased dyspnea on exertion and an echocardiogram in [**2140-12-24**], revealed an aortic stenosis with an 80 mm gradient and ejection fraction of 40% with apical akinesis. He had a cardiac catheterization in [**2140-12-24**] which revealed an ejection fraction of 40%, 1+ mitral regurgitation with moderate MAC, left anterior descending is 90% mid 90% lesion, diagonal 1 70% lesion and the right coronary artery had a mid occlusion. He is now admitted for aortic valve replacement and coronary artery bypass graft. PAST MEDICAL HISTORY: Significant for history of skin cancer of the left shoulder, history of hypothyroidism, history of hypercholesterolemia and history of hypertension and history of coronary artery disease, status post angioplasty in [**2130**], status post inferior myocardial infarction and anteroseptal myocardial infarction in [**2130**]. MEDICATIONS ON ADMISSION: Prozac 20 mg p.o. q. day; Synthroid .125 mEq; Pravachol 80 mg p.o. q. day; Toprol XL 100 mg p.o. q. day; Altace 5 mg p.o. q. day; Aspirin 325 mg p.o. q. day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: He smokes cigars occasionally and drinks alcohol occasionally. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: He is a well developed, well nourished male in no apparent distress. Vital signs are stable, afebrile. Head, eyes, ears, nose and throat examination, normocephalic, atraumatic, extraocular movements intact. Oropharynx was benign. Neck supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs, clear to auscultation and percussion. Cardiovascular examination, regular rate and rhythm, III/VI blowing murmur. Abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without cyanosis, clubbing or edema. Neurological examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. HOSPITAL COURSE: He was admitted to the unit for heart failure workup. He was in stable condition on the unit and on [**2141-3-15**] he underwent aortic valve replacement, 24 mm [**Last Name (un) 3843**]-[**Doctor Last Name **], and coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to obtuse marginal 1 and diagonal. Crossclamp time was 93 minutes, total bypass time 131 minutes. He was transferred to the Cardiothoracic Surgery Recovery Unit in stable condition. He was extubated. He was started on an ACE inhibitor. Chest tubes were discontinued on postoperative day #2. He was transferred to the floor on postoperative day #2. He continued to have a stable postoperative course. He went into rapid atrial fibrillation and had to be anticoagulated and converted back to sinus rhythm. Electrophysiology was following him and wanted him to be seen in follow up on [**4-18**] at 2 PM, Tuesday with Dr. [**Last Name (STitle) **]. He was on Amiodarone and he had an increased TSH to 46 with a decrease T3 and free T4, so he was discontinued from the Amiodarone and his Levoxyl was increased to .150 mg. He needs his pulmonary function tests checked in two to three weeks. So, he was discharged to home on postoperative day #9 in stable condition. His laboratory data on discharge revealed hematocrit 33.1, white count 8,700, platelets 164. Sodium 135, potassium 4.2, chloride 98, carbon dioxide 27, BUN 16, creatinine 0.6 and blood sugar 104. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. Percocet 1 to 2 p.o. q. 4-6 hours prn pain 3. Ecotrin 81 mg p.o. q. day 4. Coumadin 5 mg p.o. q.h.s. 5. Prozac 20 mg p.o. q. day 6. Levoxyl 150 mcg p.o. q. day 7. Atenolol 25 mg p.o. q. day 8. Altace 5 mg p.o. q. day 9. Lipitor 10 mg p.o. q. day FO[**Last Name (STitle) 996**]P: He will be followed by Dr. [**Last Name (STitle) 46214**] in one to two weeks and Dr. [**Last Name (Prefixes) **] in four weeks and Dr. [**Last Name (STitle) **] on [**4-18**]. Also the visiting nurses will check his coagulation screens on Monday, Wednesday and Friday and call them to Dr. [**Last Name (STitle) 46214**] and he is aware of that. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2141-3-24**] 16:04 T: [**2141-3-24**] 17:02 JOB#: [**Job Number 46215**]

4241,4280,2767,2765,9971,42732,41401,412,V4582

Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-26**] Date of Birth: [**2067-5-16**] Sex: M Service: SURGERY Allergies: Vicodin Attending:[**First Name3 (LF) 371**] Chief Complaint: high speed MVC, unrestrained driver-drove off a median Major Surgical or Invasive Procedure: [**2143-3-3**]: Thoracic stent graft repair of thoracic aorta; femoral to axillary bypass graft with ringed PTFE; bilateral pelvic angiography and thoracic angiography. [**2143-3-7**]: Status post PEG (percutaneous endoscopic gastrostomy tube) placement and open tracheostomy. [**2143-3-21**]: Halo placement RSC CVL ETT History of Present Illness: 75 M (General Surgeon) w/ CAD sp CABG X 4 sp high speed MVC, unrestrained driver-drove off a median. Transferred vis [**Location (un) **] HD stable w/ GCS 15. Injuries: aortic dissection (take off of L SC), C2 burst fx, C7 TP/SP fx, T4/5 vertebral body burst fractures w/ increased kyphotic angulation, T3 inf endplate fx, w/ compression deformities at T4/T5, Mild retropulsion of T4/T5, multiple high, B rib fx, sm SDH, nasal sinus fx, lg post scalp lac. Past Medical History: 1. CAD sp CABG X 4 [**2124**] 2. ? h/o spinal shock syndrome (denies h/o spinal fx) Social History: General surgeon quit tobacco in [**2104**] no ETOH has 1 son and 7 daughters Family History: NC Physical Exam: 98.8 82 115/82 NAD, A&O x 3, GCS 15 PERRLA 7cm R posterior scalp laceration R orbit edema/ecchymosis RRR CTA B + BS, NT, ND rectal tone wnl, guiac negative moves all extremities. 5/5 strength +2 PT, DP B TLS no stepoffs/ deformities Pertinent Results: [**2143-3-3**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2143-3-3**] 06:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->=1.035 [**2143-3-3**] 06:00AM FIBRINOGE-274 [**2143-3-3**] 06:00AM PT-13.0 PTT-23.2 INR(PT)-1.1 [**2143-3-3**] 06:00AM PLT COUNT-152 [**2143-3-3**] 06:00AM WBC-12.5* RBC-3.86* HGB-10.7* HCT-30.9* MCV-80* MCH-27.8 MCHC-34.7 RDW-14.4 [**2143-3-3**] 06:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2143-3-3**] 06:00AM URINE HOURS-RANDOM [**2143-3-3**] 06:00AM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2143-3-3**] 06:00AM AMYLASE-56 [**2143-3-3**] 06:00AM UREA N-25* CREAT-1.2 [**2143-3-3**] 06:19AM freeCa-1.11* [**2143-3-3**] 06:19AM HGB-11.4* calcHCT-34 O2 SAT-57 CARBOXYHB-1 MET HGB-0.4 [**2143-3-3**] 06:19AM GLUCOSE-155* LACTATE-2.2* NA+-140 K+-3.8 CL--106 TCO2-26 [**2143-3-3**] 06:19AM PH-7.29* COMMENTS-TRAUMA GRE [**2143-3-3**] 09:36AM freeCa-1.11* [**2143-3-3**] 09:36AM HGB-7.2* calcHCT-22 [**2143-3-3**] 09:36AM GLUCOSE-147* NA+-136 K+-3.9 [**2143-3-3**] 09:36AM GLUCOSE-147* NA+-136 K+-3.9 [**2143-3-3**] 09:36AM TYPE-ART PO2-345* PCO2-42 PH-7.35 TOTAL CO2-24 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED RADIOLOGY Final Report C-SPINE (PORTABLE) IN O.R. [**2143-3-21**] 9:21 PM C-SPINE (PORTABLE) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOG Reason: INTRA OP CK HALO PLACEMENT INDICATION: Intraoperative check of halo placement. Single intraoperative fluoroscopic spot view of the lateral C-spine was obtained without radiologist present. Limited view of C1 through C5 is seen without overlying instrumentation. For complete details, please see the surgical note. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Approved: FRI [**2143-3-22**] 8:12 PM Cardiology Report ECG Study Date of [**2143-3-10**] 7:46:24 PM Sinus rhythm. Occasional ventricular premature beats. Left atrial abnormality. Incomplete right bundle-branch block. Probable old anterior wall myocardial infarction. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2143-3-8**] ventricular premature beats are new. Otherwise, no significant diagnostic change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 88 160 110 396/441.57 67 79 68 RADIOLOGY Final Report UNILAT LOWER EXT VEINS LEFT PORT [**2143-3-12**] 6:01 PM UNILAT LOWER EXT VEINS LEFT PO Reason: SWELLING LEFT LEG [**Hospital 93**] MEDICAL CONDITION: 75 year old man with Left ax fem bypass, now with increased LLE swelling REASON FOR THIS EXAMINATION: R/O left lower extremity DVT - portable please HISTORY: 75-year-old man with left ax-fem bypass, now with increased left lower extremity swelling. FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. Intraluminal thrombus is not identified. IMPRESSION: No evidence of DVT. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: WED [**2143-3-13**] 8:51 AM Cardiology Report ECHO Study Date of [**2143-3-11**] PATIENT/TEST INFORMATION: Indication: H/O cardiac surgerywith distant CABG . Left ventricular function. Height: (in) 67 Weight (lb): 190 BSA (m2): 1.98 m2 BP (mm Hg): 113/45 HR (bpm): 88 Status: Inpatient Date/Time: [**2143-3-11**] at 13:42 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 224 msec TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderately depressed LVEF. No resting LVOT gradient. Cannot exclude LV mass/thrombus. AORTA: Mildly dilated aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed with septal and apical akinesis. The lateral wall moves best. A left ventricular mass/thrombus cannot be excluded. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2143-3-11**] 16:49. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] ([**Numeric Identifier 65363**]) RADIOLOGY Final Report CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2143-3-6**] 9:17 AM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: facial bone fx [**Hospital 93**] MEDICAL CONDITION: 75 year old man with major trauma s/p MVC, multiple facial ecchymoses and known nasal fx REASON FOR THIS EXAMINATION: facial bone fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: MVC. Multiple facial ecchymoses. [**Hospital **] facial fractures. TECHNIQUE: Contiguous axial images of the facial bones were obtained with coronally reformatted images. FINDINGS: The patient is intubated, with an OG tube present. Findings relating to comminuted C2 cervical spine fracture have been previously described. Aside from the previously described comminuted and mildly displaced nasal bone fracture, no other facial fractures are identified. Fluid levels, with some component of mild mucosal thickening, are seen within the frontal, maxillary, and sphenoid sinuses, with near confluent opacification of the ethmoid air cells as well. The mastoid air cells are aerated. The orbits appear intact, including the lamina papyracea as well as the orbital floors. There is a moderate left-sided nasal septal spur. Note is also made of diffuse soft tissue thickening of the face and neck, probably a combination of hemorrhage and edema. A 1 cm area of increased density in the frontal subcutaneous soft tissues probably represents a hematoma. IMPRESSION: 1. Nasal fracture. No other facial fractures identified. 2. Fluid levels are seen within the frontal, maxillary, sphenoid, and ethmoid sinuses, either post-traumatic or relating to intubation. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Approved: [**Doctor First Name **] [**2143-3-7**] 12:47 PM RADIOLOGY Final Report MRA BRAIN W/O CONTRAST [**2143-3-5**] 8:25 AM MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST Reason: possible intraspinal hematoma, carotid dissection [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p MVC with multiple spine fractures, thoracic aortic stenting. REASON FOR THIS EXAMINATION: possible intraspinal hematoma, carotid dissection MRI OF THE BRAIN AND MRA OF THE CIRCLE OF [**Location (un) **] AND UPPER CERVICAL VASCULATURE INDICATION: Trauma with cervical spine fracture and aortic dissection. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed. Diffusion-weighted images are included. 3D Time-of-Flight MR angiography of the circle of [**Location (un) 431**] was performed. Multiplanar reformatted images and source image data are reviewed. 2D Time-of-Flight MR angiography of the superior cervical vasculature was also obtained. Comparison is made with the CT scan of the brain from [**3-4**], [**2143**] and with CT angiographic images from [**2143-3-3**]. FINDINGS: On diffusion-weighted images, two foci of increased signal intensity are observed within the inferior left occipital lobe, and also two within the cerebellum, one in each hemisphere. These are suspicious for areas of acute infarction, or shear injury. There is no susceptibility artifact identified in these locations. Tiny foci of T2 signal hyperintensity are visualized where the diffusion signal abnormalities are observed. On FLAIR images, there are additional small foci of increased signal intensity in the subcortical and periventricular white matter of the cerebral hemispheres. These may reflect chronic areas of microvascular infarction. There is evidence of a small amount of intraventricular blood, as noted on the CT scan. Subarachnoid blood is not well seen on MR imaging, though there is a small amount visible as increased signal within a few of the posterior cerebral sulci on the FLAIR images. The ventricles are not dilated. No subdural hematomas are visualized. MR angiography of the circle of [**Location (un) 431**] demonstrates flow within both intracranial vertebral arteries, within the basilar artery, and within the proximal portions of the posterior cerebral arteries. The internal carotid arteries, anterior and middle cerebral arteries, and posterior communicating arteries, also demonstrate flow signal. Some flow signal is also observed within the posterior inferior cerebellar arteries. The CTA of [**3-3**] demonstrated atherosclerotic narrowing of the left carotid siphon, but this is difficult to appreciate on the MRA. MRA of the upper cervical vasculature is somewhat limited by motion artifact. In particular, signal within the vertebral arteries at the craniocervical junction is blurred. However, there does appear to be continuous signal throughout the superior cervical right vertebral artery and into the intracranial portion of this vessel. On the left, there is a segment of the vertebral artery, at the level of C1, where no flow is seen. This vessel was better visualized on the CT angiographic portion of the examination of [**2143-3-3**]. IMPRESSION: 1. MRI of the brain demonstrates a few small foci of diffusion signal abnormality in the cerebellum and inferior left occipital lobe, which are suspicious for infarctions or areas of axonal shear injury. Otherwise, the brain is stable in appearance, compared to the [**2143-3-4**] CT. 2. MRA of the circle of [**Location (un) 431**] demonstrates flow in the anterior and posterior circulations. 3. MR angiography of the upper cervical vasculature shows poor signal in the distal segment of the left vertebral artery, at the skull base. This segment of the left vertebral artery was better visualized on the CT of [**2143-3-3**]. Poor visualization of signal in this location on the MRA may be due to technical factors. Small sites of non-occlusive arterial injury may not be apparent on this exam. Otherwise, the superior segments of the cervical internal carotid arteries and vertebral arteries, and their proximal intracranial components, demonstrate flow signal. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**] Approved: [**First Name8 (NamePattern2) **] [**2143-3-5**] 2:16 PM RADIOLOGY Final Report MR CERVICAL SPINE [**2143-3-5**] 8:25 AM MR CERVICAL SPINE; MR THORACIC SPINE Reason: Eval C2 burst fx [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p MVC with multiple spine fractures, thoracic aortic stenting. REASON FOR THIS EXAMINATION: Eval C2 burst fx INDICATION: Status post MVC, multiple spine fractures and thoracic aortic stenting. [**Hospital **] C2 burst fracture. TECHNIQUE: Multiplanar T1 and T2 weighted scans of the cervical and thoracic spine were obtained. Correlation is made to CT of the cervical spine performed [**2143-3-3**]. PLEASE NOTE: This examination was performed and originally dictated [**2143-3-5**]. However, the dictation has been lost, and it has been presented to us for reinterpretation, and is being dictated on [**2143-3-6**]. FINDINGS: MR OF THE CERVICAL SPINE: The actual fracture lines in C2 seen on the prior CT are not clearly visualized on this examination. Evaluation of the vertebral bodies demonstrate elevated STIR signal within the C2 vertebral body, representing edema associated with the fractures in that bone. In addition, the fracture line of the C7 spinal process is seen, with mild distraction at the fracture site. Diffuse high signal is seen on the STIR images in the tissues posterior to the C2- C6 levels, as well as at the paraspinal muscles at and below the C6 level. No evidence of focal distortion at the cervical extent of the spinal cord is noted. MRA OF THE VERTEBRAL ARTERIES: Limited 3D imaging of the C1/2 region was performed. No gross abnormalities are seen along the course of the vertebral arteries. There is arterial flow seen through the region of the foramen transversarium fractures. MRI THORACIC SPINE: Increased T2 and STIR signal is seen within the T3, T4, and T5 vertebral bodies, with compression deformities of the T4 and T5 vertebral bodies. Although on the prior CT, no definite retropulsion was seen, there appears to be a small mid- vertebral focus of retropulsion of less than 5 mm arising from both the T4 and T5 vertebral bodies posteriorly. Examination of the spinal cord demonstrates focal widening of the spinal cord diameter in the AP direction at the T4 and T5 levels, and corresponding narrowing in the transverse dimension. To the right of the spinal cord, there is a 9-mm region which demonstrates decreased STIR signal, and appears to have elevated T2-weighted signal (series 14, image 324, series 18, image 394). This may represent an epidural hematoma, as it appears that the thecal sac is compressed from the lateral direction, resulting in the elongation in the AP dimension. We cannot definitively determine whether or not there is any spinal cord edema at this level, although the physical distortion of the cord itself is evident. Note is also made of increased prevertebral soft tissue signal and thickness at this level, also likely resulting from hematoma. The left side of the superior T6 vertebral body also demonstrates elevated STIR signal, probably representing focal contusion. Note is also made of bilateral pleural effusions. Elevated paravertebral STIR signal is seen, extending from the lower cervical to the upper thoracic (approximately T8) levels, representing soft tissue injury. The remainder of the lower thoracic and visualized upper lumbar spine appear otherwise unremarkable. IMPRESSION: 1. C2 vertebral body and C7 spinous process fractures with bone marrow edema. 2. Diffuse soft tissue edema/inflammation in the region of the interspinous ligaments. 3. No evidence of spinal cord abnormalities in the cervical region. 4. Patent appearance of the vertebral arteries with appropriate vascular flow at the C1/2 region. 5. Marrow edema involving the T3-T6 vertebral body levels, with compression deformities at T4 and T5. 6. Mild retropulsion of T4 and T5 vertebral bodies, not clearly deforming the spinal cord. However, there appears to be mass effect upon the thecal sac at this site, probably from a right epidural hematoma, causing slight elongation of the spinal cord in the AP dimension. We cannot assess on this examination for cord edema. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] on [**2143-3-6**], 3 o'clock p.m. The orthopedic spine service is also following this patient, and have reviewed the images from this examination. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Approved: WED [**2143-3-6**] 8:21 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2143-3-4**] 11:11 AM CT HEAD W/O CONTRAST Reason: eval sdh [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p mva w/sdh REASON FOR THIS EXAMINATION: eval sdh CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post MVA, subdural hemorrhage. [**Hospital **] interval change. TECHNIQUE: Non-contrast CT of the head was performed in comparison with examination performed [**2143-3-3**]. FINDINGS: The tiny foci of increased attenuation seen on the prior examinations in the frontal and parietal sulci are slightly more diffuse on this examination, without evidence of new hemorrhage. A trace amount of dependent blood is seen within both atria of the lateral ventricles, likely post-traumatic. The extra-axial spaces are preserved. The [**Doctor Last Name 352**] white matter differentiation remains preserved as well. There is no appreciable mass effect. Note is again made of the large subgaleal soft tissue hematomas, which in conjunction with diffuse edema appears significantly worse than on the prior study. In addition, there is an increased amount of fluid within the sphenoid sinuses as well as in the nasopharynx and minimally within the ethmoid air cells. The mastoid air cells remain aerated. There appears to be a nasal bone fracture. In addition, there is a moderate amount of radiopaque debris on the skin surface at the right vertex, in the regions of skin irregularity probably representing laceration. IMPRESSION: 1) Tiny foci of subarachnoid blood are unchanged. No mass effect or hydrocephalus. 2) High attenuation fluid within the sphenoid sinus as well as in the nasopharynx, consistent with blood and secretions. 3) Nasal bone fracture. 4) Enlarging frontal/parietal subgaleal hematomas. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: MON [**2143-3-4**] 9:05 PM RADIOLOGY Final Report (Revised) CT C-SPINE W/O CONTRAST [**2143-3-3**] 6:57 AM CT C-SPINE W/O CONTRAST Reason: MVC, ? FX [**Hospital 93**] MEDICAL CONDITION: 75 year old man sp MVC, ? SDH, C2c7 fx REASON FOR THIS EXAMINATION: eval fx CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 75-year-old man status post MVC. TECHNIQUE: Multidetector axial images of the cervical spine were obtained without contrast. Coronal and sagittal reformatted images were obtained. FINDINGS: There coronally oriented fractures of the C2 body with widening of the fragments. The posterior longitudinal ligament appears intact at this level and there is no impingement on the thecal sac. In addition there are multiple fractures of C7 involving the spinous process and both transverse processes. The ring appears to remain intact. There are also bilateral first and second rib fractures. Opacities at the lung apices may represent contusions. Overall the alignment of the cervical vertebral bodies remains intact. There is mild prevertebral soft tissue swelling and significant posterior soft tissue swelling. In addition there are degenerative changes of the cervical spine most prominent at C5-6 with posterior disc bulge and osteophyte formation. There may be mild canal stenosis at this level. CT is limited in its ability to [**Hospital 4656**] intrathecal detail however the remainder of the visualized outline of the thecal sac is unremarkable. IMPRESSION: 1. C2 burst fracture. 2. Multiple C7 fractures however the pedicles and lamina remain intact. 3. Bilateral first and second rib fractures. 4. No traumatic cord compression identified on this scan. NOTE ADDED AT ATTENDING REVIEW: The C2 fractures extend to invovle the transverse foramina bilaterally. This raises a concern of vertebral artery injury. There is also a fracture of the right lamina, just to the right of midline. I do not believe there is CT evidence that reassures me about the posterior longitudinal ligament. In fact, the fracture of the C7 spinous process suggests a tear of the interspinous ligaments, which would also indicate compromised integrity. Further, there is prevertebral soft tissue space widening, worrisome for an anterior longitudinal ligament tear. There is high density in the spinal canal that may represent thin subdural or epidural hematoma. There are two small fragments adjacent to the anterior inferior endplate of C2, which may represent avulsion fractures, and may be acute or chronic. There is fusion, apparently congenital, of the facets bilaterally at C7- T1. These additional findings indicate the need for a cervical spine MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] the ligaments and possible intraspinal hematoma. There is also concern for injury to the vertebral arteries, and this may be evaluated with MR, including axial fat saturated T1 weighted images on the [**Company 14672**] instrument, and an MRA. The CTA examination is not a substitute for the MR. These findings were discussed with Dr. [**Last Name (STitle) **] at 11:15 am on [**2143-3-4**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: MON [**2143-3-4**] 11:46 AM RADIOLOGY Final Report CTA NECK W&W/OC & RECONS [**2143-3-3**] 7:10 AM CTA NECK W&W/OC & RECONS; CTA CHEST W&W/O C &RECONS Reason: MCV, C2, C7, RIB FX. ? CAROTID/AORTIC INJURIES Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: [**Hospital **] carotid injury CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 75-year-old man status post high-speed motor vehicle accident. TECHNIQUE: Multidetector axial images of the neck, chest, abdomen and pelvis were obtained using a CTA protocol with 100 cc Optiray. Multiplanar reformatted images were obtained. CT NECK WITH IV CONTRAST: As described on the preceding C-spine CT, there is a burst fracture of C2 as well as multiple C7 fractures. The carotid and vertebral arteries are patent. As the right vertebral artery passes the C2 fracture, there may be a small raised intimal flap. This is nonocclusive. Fluid is observed in the sphenoid sinuses. A nasal bone fracture is also observed which is slightly deviated to the right. Overlying soft tissue swelling is also noted. Multiple lymph nodes are observed but do not meet CT criteria for pathologic enlargement. CT CHEST WITH IV CONTRAST: At the level of the ligamentum arteriosum, there is a defect in the aortic wall with apparent pseudoaneurysm. An associated periaortic hematoma is observed. The patient is status post CABG. A penetrating ulcer is also observed in the ascending aorta. There is moderate cardiomegaly. No axillary, mediastinal, or hilar lymphadenopathy is identified. There are diffusely increased interstitial markings as well as bibasilar atelectasis. Opacity at the lung apices may represent small contusions. There are bilateral first and second rib fractures. In addition there are compression burst fractures of T4 and T5. Inferior endplate changes of T3 are also noted. There is increased kyphotic angulation of the thoracic spine at these levels. CT ABDOMEN WITH IV CONTRAST: Just inferior to the takeoff of the inferior mesenteric artery, there is a short segment of aortic dissection which is non- flow limiting. A similar short segment of non-flow-limiting dissection is observed at the proximal left common iliac artery. The external iliac and common femoral arteries are patent bilaterally. The liver, gallbladder, pancreas, adrenal glands, and kidneys are unremarkable. Small focus of hypodensity in the spleen may represent a cyst. There is a small hiatal hernia. The stomach and bowel loops are otherwise unremarkable. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS: Foley catheter and air are observed in the bladder. The bladder wall appears mildly thickened. Calcifications are observed in the enlarged prostate gland. The sigmoid colon and rectum are unremarkable. There is no free fluid and no pelvic or inguinal lymphadenopathy. Bone islands are observed in the left superior acetabulum and sacrum. IMPRESSION: 1. Acute traumatic aortic injury at the level of the ligamentum arteriosum with associated mediastinal hematoma. The site of injury is approximately 2 cm from the origin of the left subclavian artery. 2. Short segment non-flow-limiting dissections of the infrarenal aorta and left common iliac artery. Possible raised intimal flap in the right vertebral artery at the C2 level. 3. Redemonstration of C2, C7, and bilateral first and second rib fractures. Additional findings of T4 and 5 vertebral body burst fractures with increased kyphotic angulation of the thoracic spine at this level. There may be a T3 inferior endplate fracture as well. 4. Redemonstration of fluid within the sphenoid sinuses and large right frontal and parietal subgaleal hematomas. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**] Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 1:55 PM RADIOLOGY Final Report CTA ABD W&W/O C & RECONS [**2143-3-3**] 7:10 AM CTA NECK W&W/OC & RECONS; CTA CHEST W&W/O C &RECONS Reason: MCV, C2, C7, RIB FX. ? CAROTID/AORTIC INJURIES Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 75 year old man with REASON FOR THIS EXAMINATION: [**Hospital **] carotid injury CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 75-year-old man status post high-speed motor vehicle accident. TECHNIQUE: Multidetector axial images of the neck, chest, abdomen and pelvis were obtained using a CTA protocol with 100 cc Optiray. Multiplanar reformatted images were obtained. CT NECK WITH IV CONTRAST: As described on the preceding C-spine CT, there is a burst fracture of C2 as well as multiple C7 fractures. The carotid and vertebral arteries are patent. As the right vertebral artery passes the C2 fracture, there may be a small raised intimal flap. This is nonocclusive. Fluid is observed in the sphenoid sinuses. A nasal bone fracture is also observed which is slightly deviated to the right. Overlying soft tissue swelling is also noted. Multiple lymph nodes are observed but do not meet CT criteria for pathologic enlargement. CT CHEST WITH IV CONTRAST: At the level of the ligamentum arteriosum, there is a defect in the aortic wall with apparent pseudoaneurysm. An associated periaortic hematoma is observed. The patient is status post CABG. A penetrating ulcer is also observed in the ascending aorta. There is moderate cardiomegaly. No axillary, mediastinal, or hilar lymphadenopathy is identified. There are diffusely increased interstitial markings as well as bibasilar atelectasis. Opacity at the lung apices may represent small contusions. There are bilateral first and second rib fractures. In addition there are compression burst fractures of T4 and T5. Inferior endplate changes of T3 are also noted. There is increased kyphotic angulation of the thoracic spine at these levels. CT ABDOMEN WITH IV CONTRAST: Just inferior to the takeoff of the inferior mesenteric artery, there is a short segment of aortic dissection which is non- flow limiting. A similar short segment of non-flow-limiting dissection is observed at the proximal left common iliac artery. The external iliac and common femoral arteries are patent bilaterally. The liver, gallbladder, pancreas, adrenal glands, and kidneys are unremarkable. Small focus of hypodensity in the spleen may represent a cyst. There is a small hiatal hernia. The stomach and bowel loops are otherwise unremarkable. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS: Foley catheter and air are observed in the bladder. The bladder wall appears mildly thickened. Calcifications are observed in the enlarged prostate gland. The sigmoid colon and rectum are unremarkable. There is no free fluid and no pelvic or inguinal lymphadenopathy. Bone islands are observed in the left superior acetabulum and sacrum. IMPRESSION: 1. Acute traumatic aortic injury at the level of the ligamentum arteriosum with associated mediastinal hematoma. The site of injury is approximately 2 cm from the origin of the left subclavian artery. 2. Short segment non-flow-limiting dissections of the infrarenal aorta and left common iliac artery. Possible raised intimal flap in the right vertebral artery at the C2 level. 3. Redemonstration of C2, C7, and bilateral first and second rib fractures. Additional findings of T4 and 5 vertebral body burst fractures with increased kyphotic angulation of the thoracic spine at this level. There may be a T3 inferior endplate fracture as well. 4. Redemonstration of fluid within the sphenoid sinuses and large right frontal and parietal subgaleal hematomas. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**] Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 1:55 PM RADIOLOGY Final Report -76 BY SAME PHYSICIAN [**2143-3-3**] 5:28 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN Reason: please assess for bleeding, mediastinal widening [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p repair of dissected aorta REASON FOR THIS EXAMINATION: please assess for bleeding, mediastinal widening HISTORY: Aortic dissection. A single portable chest radiograph demonstrates interval placement of an aortic endograft at the level of the aortic knob and descending aorta, new when compared to the radiographs obtained earlier the same day. There is a right subclavian Swan-Ganz catheter with its tip in the left main pulmonary artery. There is an endotracheal tube with its tip at the level of the clavicular heads. Surgical skin staples are new and project over the superior left hemithorax. Sternotomy wires and surgical clips overlying the cardiomediastinal silhouette remain unchanged. There is no right-sided effusion. There is a moderate left-sided pleural effusion. Of note, lucency about the distal aspect of the endotracheal tube may represent overinflation of the cuff balloon. IMPRESSION: Interval placement of aortic endograft. Support lines as described. The endotracheal cuff balloon may be overinflated and clinical correlation is requested. Interval development of left-sided pleural effusion. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**] Approved: [**First Name8 (NamePattern2) **] [**2143-3-3**] 10:36 PM Brief Hospital Course: Pt was taken to the trauma bay by EMS. Pt was evaluated in the ED and admitted to the trauma service. Neurologically: 1. meds: tylenol, motrin, roxicet, olanzypine, ativan. 2. C2 burst fracture. 3. Multiple C7 fractures however the pedicles and lamina remain intact. 4. Bilateral first and second rib fractures. 5. T4 and T5 thoracic burst fractures with increased kyphotic angulation of the thoracic spine at this level. 6. Pt now has a halo on placed by Dr. [**Last Name (STitle) 363**] on [**2143-3-21**]. Pt can ambulate. Respiratory: 1. Open Tracheostomy 2. meds: albuterol, ipratropium bromide, tessalon pearls. CV: 1. Thoracic stent graft repair of thoracic aorta; femoral to axillary bypass graft with ringed PTFE; bilateral pelvic angiography and thoracic angiography. 2. Meds: lopressor, [**Last Name (LF) 17339**], [**First Name3 (LF) **], lisinopril. 3. Pt had cardiac contusion vs MI with enzyme leak while in ICU, echo done [**3-11**] shows EF 30-35% GI: 1. Status post PEG (percutaneous endoscopic gastrostomy tube) placement 2. meds: colace, dulcolax, milk of magnesia. FEN: 1. Cardiac healthy diet. 2. Tubefeeding: Start After midnight; Promote w/ fiber Full strength; Starting rate: 85 ml/hr; Do not advance rate Goal rate: 85 ml/hr Cycle?: Yes, starting now Cycle start: 1900 Cycle end: 0700 Residual Check: q4h Hold feeding for residual >= : 150 ml Flush w/ 100 ml water q8h Other instructions: Please hold TF for today until 7 pm. You can start them at 7 pm on [**3-24**] and stop at 7 a.m. on [**3-25**]. Please check a calorie count during the day 3. Calorie count (for dates: [**3-26**], [**3-27**], [**3-28**]). Endocrine: placed on sliding scale insulin. Blood sugars in 120s. Activity: ambulate. Halo to remain on at all times. Medications on Admission: Tenormin Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Artificial Tear Ointment 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1) Appl Ophthalmic PRN (as needed). 3. Enoxaparin 40 mg/0.4 mL Syringe [**Month/Year (2) **]: One (1) Subcutaneous DAILY (Daily). 4. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 6. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2) Puff Inhalation QID (4 times a day). 8. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: One (1) Injection ASDIR (AS DIRECTED). 10. Docusate Sodium 150 mg/15 mL Liquid [**Month/Year (2) **]: One Hundred (100) mg PO BID (2 times a day). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Year (2) **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 12. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 13. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for agitation. 14. Nystatin 100,000 unit/mL Suspension [**Month/Year (2) **]: Five (5) ML PO QID (4 times a day) as needed. 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 16. Olanzapine 7.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 17. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 19. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 20. Benzonatate 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3 times a day) as needed for cough. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: MVC 1. Partial transection of thoracic aorta. 2. C2 burst fracture. 3. Multiple C7 fractures however the pedicles and lamina remain intact. 4. Bilateral first and second rib fractures. 5. Respiratory failure status post trauma, nutritional needs. 6. Nasal bone fracture 7. T4 and T5 thoracic burst fractures with increased kyphotic angulation of the thoracic spine at this level. Discharge Condition: stable Discharge Instructions: Please follow-up with Dr. [**Last Name (STitle) 363**] in 2 weeks. You will also have xrays of your C-spine and T-spine that day. Please follow-up with the trauma clinic in 2 weeks. Please follow-up in vascular clininc in 1 month with Dr. [**Last Name (STitle) **]. Followup Instructions: Please call [**Telephone/Fax (1) 3573**] to schedule an appointment with Dr. [**Last Name (STitle) 363**]. Please see him in 2 weeks. Please call [**Telephone/Fax (1) 6439**] to schedule an appointment with the trauma clinic. Please be seen in the office in 2 weeks. Please call [**Telephone/Fax (1) 1237**] to schedule an appointment with Dr. [**Last Name (STitle) **]. Please see him in 4 weeks. Completed by:[**2143-3-26**]

9010,80502,8052,5185,8602,85222,41071,E8160,80507,80704,486,2851,4280,5601,8730,8020,V4581

Admission Date: [**2117-6-2**] Discharge Date: [**2117-6-8**] Date of Birth: [**2068-6-25**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1055**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 48 yr old male with hx of type A aortic dissection s/p re-do repair in [**12/2116**], AVR who present with worsening SSCP x 5 days. Pt states that the pain is on-and-off, described as "ripping" from his chest radiating into his back, assoc with mild SOB, no n/v. Pain is not exertional and resolves on its own. Pt presented to [**Location (un) 620**] where a CT was performed and showed "new leakage and a large hematoma" so he was transferred to [**Hospital1 18**]. Here, a CTA was performed and showed a type A dissection with no leakage but a fluid collection around the ascending aorta, likely [**12-30**] post-op changes. CT surgery evaluated the patient and disagreed with radiology stating that he could not have a type A dissection given that his ascending aorta has been replaced. They diagnosed him with a chronic type B with a residual hematoma. He was admitted to the MICU for rule out MI, BP control and close observation. Pt is currently pain free. . Pt initially presented in [**2111**] with chest pain radiating to his neck and a CT scan revealed a type I aortic dissection. At that time, he had a tube graft replacement of the ascending aorta. That hospital course was complicated by a left MCA CVA. In [**12/2116**], pt again presented to the hospital with chest pain radiating to his neck and CT scan showed Type 1 aortic dissecting aneurysm involving thoracic and abdominal aorta, extending to the proximal aspect of left iliac artery. He was brought to the operating room where he underwent a Redo Ascending Aortic replacement (and Bentall procedure) w/ a #28 Gel weave graft along with an AVR w/ a #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]. Past Medical History: PMH: 1. Type A Aortic dissection dx in [**2111**] - [**2111**]: s/p repair with tube graft(thoracic/abd) - [**12/2116**]: redo ascending aortic replacement with AVR 2. CVA of left MCA, residual right-sided hemiparesis, dysarthria 3. Hypertension 4. Hypercholesterolemia 5. GERD 6. Anemia Social History: Social Hx: Lives in [**Location 620**] with family. Currently not working. Quit smoking 5 yrs ago after 15 yr pk hx. no etoh Family History: Non-contributory Physical Exam: Exam: temp, BP 182/120-->99/65 on Nipride gtt, HR 75, R 14, O2 97% 2L Gen: NAD, resting comfortably HEENT: PERRL, EOMI, MMM Neck: no JVD appreciated CV: RRR, 3/6 systolic murmur heard best at RUSB, loud S2 click Chest: clear Abd: +BS, soft, NT Ext: warm, no edema, 2+ DP Neuro: CN 2-12 intact; left facial droop; +dysarthria; [**12-2**] strength in RUE/RLE; [**4-1**] in LUE/LLE PE on acceptance to floor: Vitals: T97.0 / 56 / 18 / 120/62 / No O2 sat taken Gen: A&Ox3, aphasic HEENT: No JVD, no LAD, R facial drop, R face decreased sensation, no erythema/edema/exudates in throat Lungs: CTA B Heart: 3/6 systolic murmur radiating to the carotids and USBs, loud S1/S2, no r/g Abdomen: Soft, mild RUQ tenderness, +BS, ND Extr: R distal UE 0/5 motor (R hand paralysis), R leg [**4-1**] motor (but much weaker than L leg), no c/c/e Neuro: Aphasia, neuro findings noted above Pertinent Results: [**2117-6-1**] 07:00PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-141 POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2117-6-1**] 07:00PM CK-MB-3 cTropnT-<0.01 [**2117-6-1**] 07:00PM CALCIUM-9.2 MAGNESIUM-2.0 [**2117-6-1**] 07:00PM WBC-5.6# RBC-5.03# HGB-10.9*# HCT-36.7*# MCV-73*# MCH-21.7*# MCHC-29.7* RDW-15.0 [**2117-6-1**] 07:00PM NEUTS-51.9 LYMPHS-41.8 MONOS-4.9 EOS-0.9 BASOS-0.5 [**2117-6-1**] 07:00PM HYPOCHROM-3+ MICROCYT-3+ [**2117-6-1**] 07:00PM PLT COUNT-246# EKG: NSR at 67, LAD (new); LVH by voltage; no ST-T wave changes . CT of abd at [**Location (un) 620**], [**2118-6-1**]: OLD DISSECTION OF UNCHANGED APPEARANCE EXTENDING WELL INTO THE LUMBAR AORTA. ALSO EVIDENCE OF INTERVAL AORTIC VALVE REPAIR AND CHANGES COMPATIBLE WITH A NEW LEAKAGE AROUND THE AORTIC ROOT WHERE THERE IS A LARGE HEMATOMA EXTENDING CRANIALLY ENDING JUST PRIOR TO THE TAKE OFF OF THE CRANIAL VESSELS. NO INVOLVEMENT OF THE PERICARDIUM. . CTA at [**Hospital1 18**]: 1. Extensive type 1 aortic dissection extending superiorly into the brachiocephalic and left common carotid artery, and extending inferiorly into the left iliac artery. All major aortic vascular branches, with the exception of the left renal artery originating off the true lumen. There is no evidence of major organ infarction. 2. Small low-attenuation fluid collection around the ascending aorta, at the area of the prior aneurysm graft repair. This is likely postoperative in nature. There is no evidence to suggest leak. 3. Small hiatal hernia. 4. Small low-attenuation lesion in the left lobe of the liver likely representing a small cyst versus hemangioma, but not definitively characterized on this study. 5. Bibasilar atelectasis. . Echo, [**3-2**]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The aortic prosthesis is well functioning. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: 1. Chest Pain: Given the patient's initial presentation with chest pain, the immediate concern was leakage or worsening dissection. However, given the CTA performed at [**Hospital1 18**], it was found that the changes that were initially so concerning at the OSH were in fact more consistent with post-surgical changes than with new dissection. There were no signs of leakage on the CTA. CT surgery was consulted, and were in full agreement that there did not appear to be any worsening of the patient's prior surgical site, and that the patient's dissection was stable. Cardiac enzymes were obtained that ruled the patient out for new MI. EKG remained stable and convergent with previous EKGs on file. . 2. Chronic Type I Aortic Dissection: As noted above, the initial workup revealed that the cause of the patient's chest pain was not compatible with new aortic dissection or furthering of the patient's previous dissection. It was immediately obvious that the patient's BP was not being adequately controlled, and so on arrival the patient was transferred to the MICU for observation and management of hypertension. A Nipride drip was started, then transitioned to captopril and metoprolol, with a goal BP of 100-120 systolic. The patient had HR in the 50s for the majority of his hospitalization, but was reasonably active with no subjective side effects of his bradycardia. Because of initial concern at the OSH, the patient's warfarin was held, and on arrival to [**Hospital1 18**], once it was clear that this was not an evolution of his dissection, a heparin gtt was begun, with eventual bridging to resumption of warfarin therapy. The patient was eventually titrated to an adequate INR, with a goal of 2.5-3. . 3. Hypertension: As noted above, the patient was noted to be hypertensive on arrival, and so he was initially given nipride gtt, then onto metoprolol and captopril. This achieved the target SBP with no adverse side effects other than an asymptomatic bradycardia. He was instructed to continue this regimen as an outpatient. . 4. Hypercholesterolemia: The patient was continued on his outpatient doses of pravachol and gemfibrozil. A FLP was checked during his hospitalization that was found to be satisfactory. Medications on Admission: coumadin 2mg qhs protonix 40mg qd pravachol 20mg qd gemfibrozil 600mg [**Hospital1 **] percocet metoprolol 50mg [**Hospital1 **] Discharge Medications: 1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 6. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSAT (every Saturday). 7. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSUN (every Sunday). 8. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTUES (every Tuesday). 9. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTHUR (every Thursday). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Type I aortic dissection Aortic Valve Repair, St. [**Male First Name (un) 923**] Mechanical valve. INR goal 2.5-3 Hypertension, SBP goal of 100-120 SBP Hypercholesterolemia Discharge Condition: Stable, ambulating well without assist. Discharge Instructions: If you experience chest pain, shortness of breath, fevers, chills, nausea, vomiting, or any other concerning symptoms, contact your physician or return to the emergency room. Followup Instructions: Please report for an INR check on THURSDAY of this week at your regular location. Then, call your primary care physician for an appointment on FRIDAY of this week. An INR was drawn before you left on Tuesday and should be available to your primary doctor during your appointment on friday. Also, in the next week, please call Dr. [**Last Name (STitle) 31068**] (your cardiologist) for an outpatient appointment. Please make this appointment for sometime in the next 1-2 weeks. Completed by:[**2117-6-15**]

44103,99812,E8788,42789,43820,V433,53081,V5861,2720,4019

Admission Date: [**2117-1-8**] Discharge Date: [**2117-1-22**] Date of Birth: [**2068-6-25**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Bental/Asc Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] History of Present Illness: 48 y/o male who presented in [**10-1**] with acute onset of chest pain radiating to back of neck with N&V. CT scan showed Type 1 aortic dissecting aneurysm involving thoracic and abd. aortas, exteding to prox. aspect of left iliac artery. Previous hx is relevant for thoracic/abd aorta replacement in 03. He presented on [**12-16**] with DOE since [**10-1**] and back pain. The cardiac cath showed an aneurysmal dilatation of the proximal third of the aorta, below the previous graft, along with significant root dilatation and aortic regurgitation. The pt. was then scheduled for an aortic valve and root replacement. Past Medical History: Type A Aortic dissection [**2111**] & repair w/tube graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04 CVA w/ residual rt sided hemiparesis HTN ^chol GERD anemia Social History: Lives in [**Location 620**] with family. Currently not working. Quit smoking 5 yrs ago after 15 yr pk hx. Pt. denies ETOH drinking. Family History: Non-contributory Physical Exam: VS: Ht.: 6'2" Wt.: 216 BP: 108/85 HR: 58 General: Sitting in bed in NAD Resp: CTAB CV: RRR, S1S2 with 3/6 SEM and radiation to carotids GI: Soft, flat, NT/ND +BS Neuro: A&O x 3, appropriate with R hemiparesis Ext: warm, well-perfuses, - edema, - varicosities Pulses: 1+ throughout Brief Hospital Course: Pt. was scheduled to be a same day admit following his surgery but was found to have an elevated INR and had to be admitted and delayed until a lower INR. On [**2117-1-10**] pt. was given one dose of Vitamin K and scheduled for the OR the next day. On [**2117-1-11**] pt. had a stable INR and was brought to the operating room where he underwent a Redo Ascending Ao replacement (and Bentall procedure) w/ a #28 Gel weave graft. Along with an AVR w/ a #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]. Please see surgical note for full details. Pt. tolerated the procedure well. Total CPB time was 210 minutes with a XCT of 142 minutes. Pt. was brought to the CSRU in stable condition with a MAP 80, CVP 12, PAD 15, [**Doctor First Name 1052**] 22, and a HR of 80 NSR. He was being titrated on Nitro, Epi, and propofol when transferred. On Post-Op day #1, propofol was weaned. NMB reversed and pt. was weaned off ventilation. After extubation, pt was awake, alert and oriented and had no new deficits(r-sided hemiparesis pre-op). Pt. was now on Nipride and that was planned to be weaned. POD #2 pt. had no new events but was still being titrated on Nipride. Anticoagulation started today. POD #3, pt. was transfused 1 unit of PRBC due to low HCT (25). Still in CSRU secondary to not being able to titrate off Nipride. Chest tubes were removed and Foley replaced. POD #4, HCT increased to 29.1. Pt. had increased DOE though the day with a transient drop in SBP after Lopressor (80's). Neo was started. An echo was performed which showed a small pericardial effusion. CXR showed L. pleural effusion. Suture over CT site due to bleeding. POD #5 Neo was weaned. POD # 6 pt. had PO2 in 90's and was receiving O2 via open face tent. POD #7, repeat CXR performed yesterday revealed increased L pleural effusion. A pigtail catheter was placed over guidewire into left chest which immediately drained 550 cc. Weaned mask to nasal cannula since oxygenation improved. POD #8, CT d/c'd. Later that night pt. was oozing from l. chest tube sight with resolution after stitch placement. Pt. was transferred to telemetry floor. POD #9 & 10: Hemodynamically stable. Pt. is now awaiting INR to increase and still needs an increase and strength and activity before being discharged home. Cont. to receive Coumadin. POD #11, pt doing well and was d/c'd home with VNA services and INR will be checked on [**1-23**] and [**1-25**] with results sent to Dr. [**Last Name (STitle) 30197**]. D/C PE: VS: 99.5 75 SR 120/60 22 Neuro: alert, oriented with r-side hemiparesis Pulm: CTAB Cardiac: RRR Sternum: + Bledding from pacer site, -Erythema Abd: soft, NT/ND +BS Ext: warm, -c/c/e Medications on Admission: 1. Lopressor 25mg [**Hospital1 **] 2. Diovan 160mg [**Hospital1 **] 3. Enalapril 20mg qd 4. HCTZ 25mg qd 5. Nifedical 30mg [**Hospital1 **] 6. Protonix 40mg qd 7. Pravachol 20mg qd 8. Tizanidine 4mg qd 9. Gemfibrizol 600mg [**Hospital1 **] 10. FeSO4 325mg qd Discharge Medications: 1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once a day: goal INR 2.5-3 pt to take 5 mg Sat and Sun then inr check and as directed. Disp:*100 Tablet(s)* Refills:*0* 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: pt may resume after d/c. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: S/P Redo Asc. & Bentall Ao replacement #28 Gelweave/AVR #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Type A Aortic dissection [**2111**] s/p repair w/tube graft(thoracic/abd) [**3-30**]; s/p emergent asc. aorta repair 04 CVA (stroke) w/ residual rt sided hemiparesis Hypertension Hypercholesterolemia GERD/Acid reflux Anemia Discharge Condition: good Discharge Instructions: KEEP WOUNDS CLEAN AND DRY. OK TO SHOWER, NO BATHING OR SWIMMING. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. [**Last Name (NamePattern4) 2138**]p Instructions: wound clinic in 1 week Dr [**Last Name (STitle) 30197**] in [**12-31**] weeks and for INR checks as directed Dr [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2117-3-15**]

4241,44101,99671,E8781,2809,4019,79092

Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-20**] Date of Birth: [**2179-4-14**] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [**Known lastname **] was born at 37 6/7 weeks gestation by spontaneous vaginal delivery after an induction for intrauterine growth restriction and a non-reassuring fetal heart rate pattern. She was born to a 23-year-old gravida IV, para I now II woman, whose prenatal screens are blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, group B strep unknown. Rupture of membranes occurred four and a half hours prior to delivery, with clear fluid. There was no intrapartum fever or sepsis risk factors. The second stage of labor lasted only six minutes. The infant emerged vigorous. Apgars were 8 at one minute and 9 at five minutes. She went to the Newborn Nursery, where she was noted to be grunting at the time of admission and, at five hours of age, she was transferred to the Newborn Intensive Care Unit for persistent respiratory distress. Her birth weight was 3100 grams (75th percentile for gestational age), her birth length was 49.5 cm (75th percentile), and her head circumference 35 cm (90th percentile). PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic, term-appearing infant. Anterior fontanel open and flat, sutures approximated. A small unilateral cleft lip, palate intact. Mild grunting, however, intermittently quiet. Breath sounds equal with quiet. No flaring, some head bobbing. Pink and well perfused. Normal S1, S2 heart sounds, no murmur. Femoral and brachial pulses +2 and equal. Abdomen soft. Clavicles intact. Normal spine examination, normal extremity examination. Term female external genitalia, and tone slightly decreased generally. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant required nasal cannula oxygen until day of life three, when she weaned to room air, and has remained there since that time. Her chest x-ray was consistent with retained fetal lung fluid. On examination, her respirations are comfortable, and her lung sounds are clear and equal. 2. Cardiovascular: She has remained normotensive throughout her Newborn Intensive Care Unit stay. She has normal S1, S2 heart sounds, no murmur. She is pink and well perfused. 3. Fluids, electrolytes and nutrition: Enteral feeds were begun at the time of delivery. She is breast feeding. She did have some trouble with latching on, and is currently bottle feeding, and she has tried a variety of nipples, but is now taking adequate volume with a well-coordinated suck and swallow. She has been taking breastmilk ad lib volumes by bottle - up to 75-80cc. Mother plans on trying to breastfeeding again at home. Her weight at the time of discharge is 2960 grams. She was evaluated by Plastic Surgery nurse, [**First Name8 (NamePattern2) 40699**] [**Last Name (NamePattern1) **] from [**Hospital3 1810**] Plastic Surgery team. The plan is for her to be seen at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40701**] at one month of age, and surgery for repair of the cleft lip at approximately three months of age. 4. Gastrointestinal: She has been treated with phototherapy for physiologic hyperbilirubinemia. Her peak bilirubin on [**2179-4-17**] was total 16.0, direct 0.3. Her bilirubin on the day of discharge was 5. Hematology: Her hematocrit at the time of admission was 54, platelets 389,000. She has received no blood products during this Newborn Intensive Care Unit stay. 6. Infectious Disease: Ampicillin and gentamicin were begun at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the blood cultures remained negative and the infant was clinically well. The patient was found to be positive for vancomycin resistant enterococcus on surveillance cultures done in the NICU 2 days ago. The parents were informed of these results and informed of the implications of this including the very low risk of any clinical infection in their baby but the need to inform other healthcare providers regarding the colonization status. It is anticipated that this organism will most likely be cleared from the GI tract over the next several months. 7. Sensory: Hearing screen was performed with automated auditory brain stem responses, and the infant passed in both ears. 8. Psychosocial: Mother has been very involved in the infant's care throughout the Newborn Intensive Care Unit stay. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The infant is being discharged home with her parents. PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 2312**] Pediatrics, address [**Apartment Address(1) 41118**], [**Location (un) 538**], [**Numeric Identifier 41119**], telephone number [**Telephone/Fax (1) 37109**]. CARE RECOMMENDATIONS: 1. Feedings: On an ad lib schedule, breast feeding or Enfamil 20 calories/ounce. 2. Medications: The infant is discharged on no medications. 3. A state newborn screen was sent on [**2179-4-19**]. 4. Immunizations received: The infant has received hepatitis B vaccine on [**2179-4-19**]. 5. Immunizations recommended: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 958**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks gestation; (2) Born between 32 and 35 weeks, with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; or (3) With chronic lung disease. Influenza immunization should be considered annually in the fall for pre-term infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. 6. Follow-up appointments: a. Follow up with primary pediatric care provider within one week of discharge. b. Follow up with the Plastic Surgery team at [**Hospital1 **], telephone number [**Telephone/Fax (1) 41120**], at one month of age. DISCHARGE DIAGNOSIS: 1. Term female newborn 2. Status post transient tachypnea of the newborn due to retained fetal lung fluid 3. Sepsis ruled out 4. Minor left cleft lip 5. Hyperbilirubinemia [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2179-4-20**] 00:42 T: [**2179-4-20**] 00:59 JOB#: [**Job Number 41121**]

V3000,7706,74912,7746,V289,V053

Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-22**] Date of Birth: [**2179-4-14**] Sex: F Service: Neonatology ADDENDUM: This is an addendum to Discharge Summary signed on [**4-22**]. Additional information revealed the bilirubin on the day of discharge was 12.9 with a direct component of 0.3 after receiving double phototherapy overnight. A follow-up bilirubin will be checked on [**4-22**] at [**Hospital1 190**] in the Neonatal Intensive Care Unit at 10 a.m. in the morning. The parents are aware of the need for this follow-up bilirubin off of phototherapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**] Dictated By:[**Last Name (NamePattern4) 41252**] MEDQUIST36 D: [**2179-4-21**] 16:10 T: [**2179-4-21**] 15:23 JOB#: [**Job Number 41253**]

V3000,7706,74912,7746,V289,V053

Admission Date: [**2108-10-28**] Discharge Date: [**2108-11-5**] Date of Birth: [**2066-7-8**] Sex: F Service: TRANSPLANT SURGERY CHIEF COMPLAINT: Fever, nausea and vomiting. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 28926**] is a 42 year-old female approximately seven weeks status post cadaveric renal transplant with a postoperative course complicated by a ureteral leak requiring nephrostomy tube placement and V.A.C. care to wound as well as a line associated SVC syndrome requiring Coumadinization. The patient subsequently was discharged to a rehabilitation center, but now returned to [**Hospital1 69**] on [**2108-10-28**] with several day history of fevers, nausea, vomiting. Her fevers were as high as 101.5. She also reported decrease in her urine output for one week. Her wound care continued with no notable signs of infection. The patient continued to have bowel movements without any evidence of diarrhea. She was without any abdominal pain, chest pain, shortness of breath or any respiratory symptoms. At presentation in the Emergency Department her systolic blood pressure was noted to be in the 90s requiring intravenous boluses. PAST MEDICAL HISTORY: 1. Diabetes mellitus insulin dependent. 2. End stage renal disease. 3. Hypertension. 4. Hypothyroidism. 5. Left line associated SVC syndrome requiring thrombolectomy and Coumadinization. PAST SURGICAL HISTORY: 1. Status post cadaveric renal transplant on [**2108-9-8**]. 2. Status post Perm-A-Cath in the right IJ. 3. Status post AV fistula times three. 4. Status post stenting of the right brachiocephalic and SVC. 5. Status post SVC thrombectomy on [**9-17**] and [**9-18**]. ALLERGIES: Floxins and Vancomycin. SOCIAL HISTORY: She is divorced on disability. She denies any ethanol or tobacco use. MEDICATIONS ON ADMISSION: 1. Bactrim SS one tab po q day. 2. CellCept 1 gram po b.i.d. 3. Neurontin 100 mg po t.i.d. 4. Lansoprazole 30 mg po q day. 5. Valcyte 350 mg po q.o.d. 6. NPH 22 b.i.d. 7. Zinc 220 mg po q.d. 8. Coumadin 4 mg po q day. 9. Dulcolax 10 mg po b.i.d. 10. Prograf 2 mg po b.i.d. 11. Levoxyl 75 micrograms po q day. 12. Celexa 20 mg po q day. 13. Lipitor 10 mg po q day. 14. Percocet one to two tabs po q 4 to 6 hours prn pain. 15. Lopressor 75 mg po b.i.d. 16. Lasix 40 mg po q day. 17. Vitamin C 500 mg b.i.d. 18. Prednisone 0.5 mg po q day. PHYSICAL EXAMINATION: Temperature 98.9. Blood pressure 131/46. Heart rate 91. Respiratory rate 17. She was 100% on 4 liters nasal cannula. General, she was well developed, well nourished lady in no acute distress. Head, eyes, ears, nose and throat normocephalic, atraumatic. Anicteric. Oropharynx without any lesions. They were moist. Neck was supple. Heart regular rate and rhythm. Respirations clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Packed right lower quadrant wound. The wound was without any purulent drainage on removal of the V.A.C. Extremities there was noted for some left ankle skin ulcer. LABORATORIES ON ADMISSION: White blood cell count 3.5, hematocrit 37.1, platelets 155, sodium 136, potassium 5.0, chloride 107, bicarb 18, BUN 42, creatinine 3.1, glucose 83. [**Name (NI) 2591**] PT 20.8, PTT 37, INR 2.9. Her urinalysis was notable for moderate amounts of leukocyte esterase, negative nitrite, 21 to 50 white blood cell and moderate bacteria. Chest x-ray was negative. Renal ultrasound was obtained, which was negative for hydro. There was no fluid collection. There is normal arterial wave forms and normal resistive indices. HOSPITAL COURSE: The patient is a 42 year-old female status post cadaveric renal transplant on [**2108-9-8**] for end stage renal disease secondary to diabetes mellitus who had a postoperative course complicated by a ureteral leak requiring nephrostomy as well as a V.A.C. to the wound. During that hospital stay had a line associated SVC syndrome requiring thrombolectomy. She returned from rehab on [**2108-10-28**] to [**Hospital1 69**] with fevers and nausea and vomiting as well as decreased urine output. She was noted to have a positive urinalysis. Urine culture was sent. She was initially kept in the Intensive Care Unit for close monitoring for urosepsis. She was bolused and provided with intravenous hydration and her blood pressure responded appropriately. Her urine output improved. She was placed initially on Zosyn for appropriate antimicrobial coverage. Her urine culture was followed up, which indicated Enterobacter cloacae, which was actually resistant to Zosyn and sensitive to Levofloxacin. At that point she was switched over to a 14 day course of Levofloxacin. The patient continued with complaints of nausea and voting. Her Prograf was discontinued and the patient was switched onto Imuran and by the time of discharge she was on a 150 mg po q day. Additionally, since admission the patient's Coumadin dose had been held secondary to elevated INR, but by the time of discharge the patient was placed on a Coumadin dose of 0.5 mg po q day and to have a regular biweekly laboratory blood work drawn including close monitoring of her coagulation. The patient underwent a nephrostogram, which indicated a small anastomotic leak. It was thought that it would be best to keep the nephrostomy tube open for another four weeks and to repeat the study at that time. Renal function, however, was improving and was noted to make adequate amount of urine through the nephrostomy tube. By the time of discharge on hospital day nine the patient was tolerating a regular diet. Her nausea and vomiting had resolved and she continued to make excellent urine output. She was on a immunosuppressant regimen of Prednisone 5 mg po q day, Tacrolimus 1 mg po b.i.d. as well as Imuran 150 mg po q day. DISCHARGE STATUS: To rehabilitation center. DISCHARGE DIAGNOSES: 1. Urosepsis/urinary tract infection. 2. Hydration. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg po q day. 2. Bactrim SS one tab po q day. 3. Celexa 20 mg po q day. 4. Colace 100 mg po b.i.d. 5. Valcyte 450 mg po q day. 6. Synthroid 75 micrograms one tab po q day. 7. Vitamin C 500 mg po b.i.d. 8. Zinc sulfate 220 mg one tab po q day. 9. Tylenol one to two tabs po q 4 to 6 hours prn. 10. Sulfa 500 mg one tab po b.i.d. 11. Prednisone 5 mg one tab po q day. 12. Albuterol one to two puffs inhalation q 6 hours prn. 13. Robitussin 5 to 10 ml po q 6 hours prn. 14. Reglan 10 mg one tab po t.i.d. 15. Levofloxacin 250 mg one tab po q day for eight more days for a total of 14 days treatment. 16. Famotidine 200 mg one tab po q day. 17. Imuran 150 mg po q day. 18. Tequin one tab po b.i.d. 19. Percocet one to two tabs po q 4 to 6 hours prn. 20. Zofran 2 mg intravenously q 4 to 6 hours prn nausea and vomiting. 21. Benadryl 150 mg intravenously q 6 hours prn. 22. Coumadin 0.5 mg one tab po q day. 23. Insulin sliding scale. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on Monday [**2108-11-12**] at the Transplant Center, telephone number [**Telephone/Fax (1) 673**] at 2:40 p.m. She is additionally to call the Transplant Center for follow up appointments with Dr. [**Last Name (STitle) **] as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She is additionally to have laboratories biweekly including CBC, chem 10, [**Last Name (NamePattern1) **], liver function tests, amylase, lipase as well as Tacrolimus levels in the a.m. before the a.m. dose is given. She is to continue to have V.A.C. treatment as well as nephrostomy care at the rehabiltiatino center. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (STitle) 28927**] MEDQUIST36 D: [**2108-11-5**] 11:28 T: [**2108-11-5**] 11:32 JOB#: [**Job Number 28928**]

99681,70713,99674,5990,E8780,V5861,25000,4019,2449

Admission Date: [**2108-9-16**] Discharge Date: [**2108-10-12**] Date of Birth: [**2066-7-8**] Sex: F Service: ADMITTING DIAGNOSIS: Superior vena cava syndrome. DISCHARGE DIAGNOSES: 1. Status post cadaveric renal transplant on [**2108-9-8**]. 2. Superior vena caval syndrome. 3. Distal ureter necrosis. 4. Status post revision of ureter bladder anastomosis. HISTORY OF PRESENT ILLNESS: At the time of admission the patient is a 42 year old female with a history of diabetes mellitus type 1, end-stage renal disease who was on hemodialysis prior to cadaveric renal transplant done on [**2108-9-8**]. The patient also has a history of hypertension, hypothyroidism, and a left lower extremity deep vein thrombosis. The patient has a history of a Perma-Cath and three arteriovenous fistulae. The patient also was found out to have a history of a right brachiocephalic and superior vena caval venous stent. The patient presented to the [**Hospital1 188**] in the Emergency Department on [**2108-9-16**], with demonstrable edema of the bilateral upper extremities and her head and neck. The patient was without other complaints. The patient was highly concerning for superior vena caval syndrome. The patient was admitted to the Surgical Service. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. History of end-stage renal disease. 3. Status post cadaveric renal transplant on [**2108-9-8**]. 4. Hypertension. 5. Hypothyroidism. 6. History of left lower extremity deep vein thrombosis. 7. Status post Perma-Cath placement. 8. History of arteriovenous fistulae times three. 9. It is unclear when it was placed but patient also had a history of a right brachiocephalic and a superior vena caval stent. 10. The patient at the time of admission had a right IJ Perma-Cath which was placed in the superior vena cava. PAST SURGICAL HISTORY: 1. Right internal jugular Perma-Cath. 2. History of arteriovenous fistula times three. 3. Status post cadaveric renal transplant, as stated on [**2108-9-8**]. HOSPITAL COURSE: The patient was admitted to the hospital and at the time of admission, the patient was afebrile; blood pressure was 143/53. The patient's admission laboratory examination revealed a white blood cell count of 14.0, hematocrit of 33, platelets of 151. Sodium 136, potassium 4.4, chloride 104, carbon dioxide of 16, BUN of 102, creatinine of 5.1 which is down from a creatinine of 5.5 at the time of discharge from her cadaveric renal transplant. Glucose was well controlled at 56. The patient underwent an ultrasound which showed dilation of both of her internal jugular veins. The patient had an MRV which demonstrated left IJ and bilateral brachiocephalic vein and a superior vena caval thrombus. The patient also, on chest x-ray, demonstrated a stent within her right brachiocephalic and superior vena cava. It is unclear when these were placed. The [**Hospital 228**] hospital course included angiogram done on the 20th with thrombectomy. This did not completely remove all of the clot. The patient was treated with repeat angiogram on the 21st with stenting and thrombectomy of the clot from the superior vena cava, brachiocephalic and internal jugular with modest return of flow and removal of her Perma-Cath. A few days later the patient was taken back down to angiogram where the patient had recanalization of all of her central veins in her neck with good return of flow, and the patient had a dramatic clinical response with resolution of her upper extremity swelling and edema. The patient was treated with heparin and then Coumadinized. The patient was also noted on her hospital stay to have a large amount of fluid coming from her wound. The wound was opened down to the level of the fascia. Creatinine in the fluid was consistent with a urine leak. The patient was taken down to Interventional Radiology where she had a nephrostomy tube placed which demonstrated stricturing of the distal ureter. Of note, it should be stated at the time of the kidney transplant, it was noted that the Transplant Team had transsected a lower polar artery that was probably supplying the bladder which was probably supplying the ureter and this was the reason for the necrosis of the distal end of the ureter. Interventional Radiology had a stent placed through the distal stricture and into the bladder. The patient was taken to the Operating Room on the [**9-26**] for a upper ureteral bladder anastomosis. At the time of the operation, the previous ureteral anastomosis of the bladder was identified. This was taken down sharply. Previously, the necrotic and ischemic ureter was transsected. A new ureter to bladder anastomosis was performed in good fashion. The patient, postoperatively, did well. The large wound was treated with a wound VAC which was changed every two to three days. The [**Location (un) 1661**]-[**Location (un) 1662**] which was placed at the time of the surgery decreased in output and once there was no further evidence of leak, the [**Location (un) 1661**]-[**Location (un) 1662**] creatinine was normal. The [**Location (un) 1661**]-[**Location (un) 1662**] was removed. The patient was seen and evaluated by Physical Therapy. The patient was ambulatory but could not meet reasonable goals and therefore was felt to an adequate candidate for further rehabilitation work at rehabilitation hospital. The patient was tolerating a regular diet. The wound was cleaning up nicely with a wound VAC. The patient was on Coumadin, and the patient was placed back on therapeutic levels of her immunosuppressants. At the time of discharge, the patient had a repeat renal duplex on the [**2108-10-8**]. Resistant indices at 0.7 with normal flow already in the veins. The patient's creatinine which had risen, at the time of discharge was down to 3.7, which is the lowest point it had been so far. Therefore, discharge diagnosis included the following. DISCHARGE DIAGNOSES: 1. Status post cadaveric renal transplant on the [**2108-9-8**]. 2. Severe vena caval syndrome secondary to occlusion, secondary to a Perma-Cath in the superior vena cava and stent. 3. Status post angiographic thrombectomy of the central veins of the neck. 4. Distal ureteral necrosis. 5. Status post revision of ureteral bladder anastomosis. 6. Opening of transplant wound treated with wound VAC. DISCHARGE MEDICATIONS: 1. Coumadin 2 mg p.o. q. h.s. 2. Lanosolid 600 mg p.o. q. 12. 3. Zinc sulfate 220 mg p.o. q. day. 4. Lasix 40 mg p.o. twice a day. 5. Insulin sliding scale. 6. Metoprolol 75 mg p.o. twice a day. 7. Fancyclovir 450 mg p.o. q.o.d. 8. Pantoprazole 30 mg p.o. q. day. 9. Atorvastatin 10 mg p.o. q. day. 10. Gabapentin 100 mg p.o. three times a day. 11. Artificial tears o.u. p.r.n. 12. Synthroid 75 micrograms p.o. q. day. 13. Single strength Bactrim one tablet p.o. q. day. 14. Her immunosuppressant medications which include Prednisone 10 mg p.o. q. day; Mycophenolate mofetil 100 mg p.o. twice a day and Prograf 4 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. Wound therapy q. day. Dressings include a wound VAC which should be changed every two days to the right lower quadrant wound incision. 2. The patient's follow-up will include an appointment with Dr. [**Last Name (STitle) 28924**] in the Transplant Office on Tuesday, the 18th. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 14369**] MEDQUIST36 D: [**2108-10-12**] 15:45 T: [**2108-10-12**] 17:58 JOB#: [**Job Number 28925**]

99674,99681,5849,25001,5990,E8798,4592,E8781,E8780

Admission Date: [**2194-6-28**] Discharge Date: [**2194-7-16**] Date of Birth: [**2176-9-4**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5883**] Chief Complaint: Traumatic amputation left foot Major Surgical or Invasive Procedure: 1. Left anterior lateral thigh free fasciocutaneous flap to the left dorsal foot. 2. Debridement of skin and muscle of the left foot. 3. Neurorrhaphy of the superior and median perforator nerves from the anterolateral thigh to the superficial peroneal nerve of the foot. 4. Local advancement flap closure of anterior thigh defect. 5. Local advancement flap elevation of left foot plantar skin. History of Present Illness: 17 yo M transferred from an outside hospital on [**2194-6-28**] after a traumatic amputation of his left foot by a lawnmower. After initial debridement of the wound in NH, Mr. [**Known lastname 67756**] was sent to [**Hospital3 **] for additional deep debridement and flap coverage of his wound. Past Medical History: Otherwise healthy Social History: Occ. ETOH. Recently quit smoking. Occasional marijuana prior to admission. No IVDU. Lives with girlfriend's parents in NH. High school student. Family History: Non-contributory. Physical Exam: GEN: A&O, NAD, pleasant HEENT: Visual acuity equal and intact bilat., EOMI, PERRLA CV: RRR PULM: CTA bilat. ABD: soft, nt/nd EXT: L extremity splinted, elevated. Flap wwp, cap refill <2sec, strong doppler. Wound edges c/d/i. Graft site healing well. Pertinent Results: [**2194-6-28**] 07:20PM PLT SMR-VERY HIGH PLT COUNT-646* Brief Hospital Course: 17 yo M transferred from an outside hospital on [**2194-6-28**] after a traumatic amputation of his left foot by a lawn mower. After initial debridement of the wound in NH, Mr. [**Known lastname 67756**] was sent to [**Hospital3 **] for additional deep debridement and flap coverage of his wound. He underwent debridement with orthopedics on [**6-30**] without complication. He was returned to the OR for definitive flap coverage on [**2194-7-2**] and transferred to the plastic surgery service. He was noted to have a corneal abrasion post-operatively and was treated to resolution by ophthalmology. Mr. [**Known lastname 67756**] did well post-operatively with no evidence of flap failure and was discharged home with services after PT/OT evaluation and patient education on flap dangle protocol. Medications on Admission: None. Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 2. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-10**] hours as needed for Pain for 10 days. Disp:*40 Tablet(s)* Refills:*0* 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. Disp:*20 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*80 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Name6 (MD) 67757**] [**Name8 (MD) **] RN ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67758**]) to set up Discharge Diagnosis: Traumatic amputation of left foot Status post flap repair of wound. Discharge Condition: Stable. Discharge Instructions: Please resume your home medications. Call or return to the hospital if you experience: fever > 100.8F, increasing or foul smelling drainage from your wound, significant color or temperature change to your flap, increasing pain any significant change in your medical condition. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week.

8961,E9200,9181,E9289,3536

Admission Date: [**2145-4-30**] Discharge Date: [**2145-5-6**] Service: NEUROLOGY Allergies: Sulfonamides Attending:[**First Name3 (LF) 6075**] Chief Complaint: confusion, aphasia, right facial droop Major Surgical or Invasive Procedure: CT/CTA head and neck iv-tPA History of Present Illness: Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with a history of Afib (not on coumadin), prior strokes ([**2131**], [**2133**]) details of which are unknown, HTN and recent right arm fracture and osteotomy who developed "confusion", decreased verbal output and right facial droop this AM at her NH. She was well this AM until she went to the bathroom at the NH just before 8:00AM. At that time, she was noted to have decreased verbal output (which is unusual for her) completely non-verbal with a right facial droop. EMS was called and she arrived in the ER at 9:50AM. She was initially evaluated by the stroke fellow who found her to be awake, non- verbal, following simple commands, with right facial droop and right hemiparesis. Her initial NIHSS was 12. She had a CT Scan at which showed no evidence of hemorrhage or infarction. CTA showed no large branch occlusions in the intracranil circulation. She was given IV t-PA at 11:00 AM, 3 hours after symptom onset. Past Medical History: PAF not on anticoagulation Tachy-Brady Syndrome HTN dyslipidemia h/o CVA ('[**31**], '[**33**]) Urinary incontinence Diastolic CHF (EF >60% 9/04) Social History: Lives alone in own Sr. apartment. Does own housework, but decreased function lately. Has VNA home care. Never married. No HCP. Family History: Non-contributory Physical Exam: Admission Exam: T 98.0 BP 134/71 HR 120irreg RR20 O2 Sat 90% Gen: Resting on ED stretcher, appears somewhat agitated Neck: supple, no carotid bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: +left basilar crackles, decreased BS at right base aBd: +BS soft, nontender ext: + 1 pedal edema Neurologic examination: Mental status: Awake and alert, unable to state name, follows simple, one step midline and appendicular commands. Practically non-verbal, though tries to initiate speech; occasionally able to say yes or no. Unable to repeat single words or name any items. Does not appear to understand complex commands or questions. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2mm bilaterally. Visual fields appear full to threat (could not comply with confrontation testing). Extraocular movements intact bilaterally without nystagmus. Sensation to noxious appears intact V1-V3. Right facial droop. Tongue deviated to right (? due to facial). Tongue midline without fasciculations, intact movements Motor: Normal bulk bilaterally. Tone slightly increased in right LE. No adventitious movements. Unable to comply with formal motor testing, but could hold left arm and leg antigravity and right leg antigravity for >10 seconds. Moved Right UE on the bed (at least [**1-23**]). Sensation: Withdraws to pinch in all 4 extremities. Reflexes: B T Br Pa Ach Right 2 2 * 2 2 Left 2 2 2 2 2 Rflxs slightly more brisk on the right Toes were downgoing bilaterally Coordination: Unable to assess (pt doesn't appear to understand task) Pertinent Results: MRA BRAIN W/O CONTRAST [**2145-5-2**] 11:12 AM FINDINGS: Abnormal diffusion is noted in the posterior left frontal lobe in the precentral gyrus region, consistent with acute stroke. Subacute/chronic infarct is noted in the right cerebellar region as evidenced by abnormal signal on T2 and FLAIR images with shine through artifact on diffusion-weighted images. Patchy areas of hyperintensity are noted in the periventricular deep white matter consistent with a small vessel disease. A punctate area of susceptibility abnormality is noted in the right cerebellum, may represent tiny calcification versus tiny punctate hemorrhage. IMPRESSION: 1) Acute infarct is noted in the left posterior frontal lobe. 2) Subacute/chronic infarct noted in the right cerebellum. CTA HEAD W&W/O C & RECONS [**2145-4-30**] 10:30 AM COMPARISON: [**2145-3-25**]. FINDINGS: There is no intracranial hemorrhage, shift of normally midline structures, or hydrocephalus. The ventricles and sulci remain enlarged, consistent with atrophy. There is low attenuation of the periventricular white matter consistent with chronic microvascular infarction. The [**Doctor Last Name 352**]-white matter differentiation remains intact. There is no evidence of a new major vascular territorial infarct. The osseous structures are normal. There are several right maxillary sinus mucosal retention cysts versus polyps. IMPRESSION: No intracranial hemorrhage or change in the appearance of the brain. Please note that an MRI with diffusion-weighted imaging is more sensitive for detection of an acute infarct. [**2145-4-30**] 10:15AM GLUCOSE-119* UREA N-26* CREAT-1.0 SODIUM-140 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-33* ANION GAP-16 [**2145-4-30**] 10:15AM CK(CPK)-19* [**2145-4-30**] 10:15AM CK-MB-2 cTropnT-<0.01 [**2145-4-30**] 10:15AM CHOLEST-222* [**2145-4-30**] 10:15AM %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE [**2145-4-30**] 10:15AM TRIGLYCER-138 HDL CHOL-63 CHOL/HDL-3.5 LDL(CALC)-131* [**2145-4-30**] 10:15AM WBC-10.7 RBC-4.58 HGB-13.4 HCT-39.5 MCV-86 MCH-29.1 MCHC-33.9 RDW-14.4 [**2145-4-30**] 10:15AM PLT COUNT-219 [**2145-4-30**] 10:15AM PT-12.9 PTT-25.7 INR(PT)-1.1 Brief Hospital Course: After IV-tPA administration Pt was observied in the Neurological ICU x48 hours during which time there was limited improvement in her presenting symptoms. She was transferred to the general Inpatient Stroke Service where bedside swallowing evaluation proved her incompetent to handle PO but unfortunately would not allow for NG-tube placement. In addition, prior to discharge she was evaluated by Speech Pathology. After some discussion with the family and medical care team, the decision was made to transfer to an extened care facility for further care. Medications on Admission: Lasix 60mg qd Plavix 75 qd Diltiazem 180mg qd Colace 100mg [**Hospital1 **] Toprol 100mg qd Lisinopril 2.5mg qd Zaroxolyn 2.5mg qd 30min prior to lasix Discharge Medications: Lasix 60mg qd Plavix 75 qd Diltiazem 180mg qd Colace 100mg [**Hospital1 **] Toprol 100mg qd Lisinopril 2.5mg qd Zaroxolyn 2.5mg qd 30min prior to lasix Discharge Disposition: Extended Care Discharge Diagnosis: left MCA infarct pulmonary effusion Discharge Condition: guarded Discharge Instructions: Take all medications as prescribed. Follow-up with all appoinments as directed. Followup Instructions: Follow-up with your primary care physician on discharge. Completed by:[**2146-8-2**]

43411,51881,42831,5119,42731,5070,4019,43811

Admission Date: [**2186-9-16**] Discharge Date: [**2186-10-6**] Date of Birth: [**2127-6-21**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1556**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: none History of Present Illness: 60 F car vs tree with unstable T4 fx involving all 3 columns with compression, T7 fracture, sternal fracture s/p transfer to the ICU with intubation for worsening sats and collapse of lower lobes on chest CT Past Medical History: asthma, COPD Social History: Smoker, no drugs, occasional EtOH Family History: non-contributory Physical Exam: upon arrival in ER: 96 85 105/64 18 95%on 3L HEENT: R lateral canthus laceration NEck: C-collar in place Chest: CTAB, RRR Abd: Sort, NT, ND Pelvis: stable GU: Guiac neg Ext: [**5-4**] stregnth b/l LE's, no deformities or ecchymosis Pertinent Results: [**2186-9-16**] 06:40AM NEUTS-84.2* BANDS-0 LYMPHS-12.1* MONOS-2.5 EOS-0.9 BASOS-0.3 [**2186-9-16**] 06:40AM WBC-12.8* RBC-3.66* HGB-12.3 HCT-36.2 MCV-99* MCH-33.6* MCHC-34.0 RDW-13.6 [**2186-9-16**] 06:40AM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-1.6 [**2186-9-16**] 06:40AM LIPASE-54 [**2186-9-16**] 06:40AM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-66 AMYLASE-34 TOT BILI-0.4 [**2186-9-16**] 06:40AM GLUCOSE-112* UREA N-7 CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [**2186-9-16**] 08:20PM HCT-36.7 RADIOLOGY Final Report CT RECONSTRUCTION [**2186-9-16**] 7:15 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: high speed [**Month/Day/Year 39447**] with sternal fracture and T4 fracture. Would Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with REASON FOR THIS EXAMINATION: high speed [**Hospital 39447**] with sternal fracture and T4 fracture. Would like to evaluate chest and abdomen with IV contrast. NO PO contrast. CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE CHEST, ABDOMEN AND PELVIS WITH CONTRAST DATED [**2186-9-16**]. CLINICAL HISTORY: Status post high speed [**Month/Day/Year 39447**] with sternal fracture and T4 fracture. Please evaluate chest and abdomen with IV contrast. TECHNIQUE: CT scan evaluation of the chest, abdomen and pelvis was performed with IV contrast using 5 mm collimation. Images were reformatted and evaluated in both the coronal and sagittal planes. COMPARISON: Comparison is made to prior CT scans of the cervical, thoracic and lumbar spines. FINDINGS: There is a nondisplaced fracture through the manubrium. A small amount of retromanubrial hematoma is identified. As seen in the recent CT examination, there is a complex fracture involving the T4 vertebral body. There is approximately 80% compression of this vertebral body and 25 degrees of kyphosis at this level. Bilateral pars fractures are also identified at T4, representing posterior column injury. Moderate canal narrowing and angulation is noted at this level. A small amount of paraspinal hematoma is noted. There is also a compression fracture involving the T7 vertebral body with approximately 30% loss of vertebral body height. The fracture does not appear to extend to the posterior column. No significant canal narrowing is identified at this level. There is no evidence for mediastinal hematoma. The aorta is normal in contour and there is no evidence for contrast extravasation. Heart and great vessels are unremarkable. There are small bibasilar consolidations and small bilateral effusions. No significant lymphadenopathy is identified within the chest. The liver, gallbladder, pancreas, spleen and adrenal glands are unremarkable. Both kidneys enhance symmetrically and are otherwise unremarkable. There is no free fluid or significant lymphadenopathy within the abdomen or pelvis. A Foley catheter is noted within the bladder. IMPRESSION: 1. Nondisplaced fracture through the manubrium. 2. Complex fracture involving the T4 vertebral body with involvement of the posterior column and 25 degrees of kyphosis. This results in moderate narrowing and angulation of the spinal canal at this level. 3. Compression fracture involving the T7 vertebral body with loss of approximately 30% of vertebral body height. 4. No evidence for aortic injury. 5. No evidence for free fluid in the abdomen or pelvis. Findings were discussed with Dr. [**Last Name (STitle) 62533**] at the time of the examination. The study and the report were reviewed by the staff radiologist. DR. [**Known lastname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 62534**] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SUN [**2186-9-17**] 8:35 AM RADIOLOGY Final Report CT T-SPINE W/O CONTRAST [**2186-9-16**] 7:18 AM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: evaluate known T4 fx [**Hospital 93**] MEDICAL CONDITION: 59 year old woman s/p MVA REASON FOR THIS EXAMINATION: evaluate known T4 fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old female status post MVA with T4 acute fracture. COMPARISONS: No comparisons are available. TECHNIQUE: Multiple CT axial images of the thoracic spine were obtained without IV contrast. Coronal and sagittal reformations were performed. Coronal and sagittal reformations of the sternum were also performed. FINDINGS: There is compression fracture of T4 with retropulsion of the superior corner of the body into the spinal canal. There are bilateral fractures at the bases of the pedicles, pars interarticularis and transverse processes and the left lamina. There is approximately 25% narrowing of the canal. There is 30 degrees of kyphosis. There is also a mild compression fracture of the T7 vertebral body. No other thoracic spine fractures were identified. The spinal canal contents are not well evaluated. There are small paraspinal hematomas associated with the above- described fractures. IMPRESSION: 1. Unstable fracture of T4 with features as discussed above. 2. Compression fracture of T7 3. Subjacent to the xiphoid process of the sternum is a small density, probably a vein, but there could be a small hematoma. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**] DR. [**First Name (STitle) 23303**] [**Doctor Last Name **] Approved: MON [**2186-9-18**] 8:25 AM RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [**2186-9-18**] 5:14 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: HYPOXIA, EVAL FOR PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with h/o asthma, COPD; admitted to hosp following [**Last Name (LF) 39447**], [**First Name3 (LF) **] spine fracture now with hypoxia and left pulmonary artery fullness on CXR. REASON FOR THIS EXAMINATION: PE? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old female with asthma admitted status post [**First Name3 (LF) 39447**] now presenting with hypoxia, left pulmonary artery fullness on the chest x-ray. COMPARISON: Comparison is made to [**2186-9-16**]. TECHNIQUE: MDCT axial images of the chest were obtained without and with IV contrast. Nonionic IV contrast was used as a rapid bolus as necessary for this study. 100 cc of Optiray 250 were used. Multiplanar reconstructions were performed. CT OF THE CHEST: There are no significant axillary lymph nodes. There are multiple small AP window lymph nodes that do not meet CT criteria for pathology. There is no pericardial effusion. The heart is mildly enlarged. The aorta appears to be intact. The pulmonary artery is slightly enlarged measuring 2 cm, which may represent chronic pulmonary artery hypertension. Clinical correlation is recommended. This is unchanged to [**2186-9-16**]. The pulmonary artery branches are patent. There are no filling defects which suggest pulmonary embolism. There are mild calcifications of the coronary arteries. The suggestion of enlargement of the left pulmonary artery as seen in the chest radiograph is likely due to atelectasis of left upper lobe posteriorly and superior segment of left lower lobe. The appearance of the pulmonary artery is unchanged compared to the prior study. Examination of the lung windows again demonstrate paraseptal emphysema with multiple subpleural blebs. There is interval worsening of the atelectasis of the posterior aspect of the bilateral upper lobes and lower lobes. There is basically complete atelectasis of the bilateral lower lobes. Most of the segmental branches, however, are patent with the exception of the superior segment of the left lower lobe where you can see an abrupt cut off.. There are very small bilateral pleural effusions. There are minimal atelectasis in the right middle lobe. Limited images of the upper abdomen do not demonstrate significant abnormality. BONE WINDOWS: Again noted complex unstable fracture of T4 which is unchanged in appearance when compared to the prior study. The degree of angulation also appears to be unchanged. As is the narrowing of the spinal canal. Note that this fracture involves the anterior, medial and posterior columns as described in detail in the CT of the thoracic spine. Also the appearance of the compression fracture of T7 is also unchanged when compared to the prior study. No definite sternal fracture can be seen. Multiplanar reconstructions were important to better evaluate the bone alignment. IMPRESSION: 1. No evidence of pulmonary embolism. 2. The apparent enlargement of the left pulmonary artery is secondary to the overlapping of the atelectasis of the posterior aspect of the left upper lobe and superior segment of the left lower lobe. 3. Interval worsening of bilateral atelectasis involving the posterior aspect of the upper lobes and the bilateral lower lobes. This is described above in detail. 4. Unchanged appearance of fractures of the thoracic spine. 5. The aorta is intact. 6. Mildly enlarged main [**MD Number(3) 62535**] be secondary to pulmonary artery hypertention. It is unchanged when compared to the prior study. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: TUE [**2186-9-19**] 10:10 AM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2186-9-26**] 11:19 AM CHEST (PORTABLE AP) Reason: consolidation? [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with hypoxia and productive cough REASON FOR THIS EXAMINATION: consolidation? INDICATION: Hypoxia, cough. COMPARISON: Chest x-ray from [**2186-9-19**]. SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: There is persistent left lower lobe collapse with an associated small left pleural effusion. There is right lower lobe atelectasis with a small right pleural effusion. There is no pneumothorax. The cardiac and mediastinal contours are within normal limits. Spinal stabilization device obscures the midline chest. IMPRESSION: Persistent lower lobe atelectasis, left worse than right with associated small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2186-9-26**] 8:51 PM Brief Hospital Course: 60 F car vs tree transferred to [**Hospital1 18**] ER from OSH. Pt. was immediately evaluated by the Emergency Medicine and Trauma Surgery teams. CT scans during initial evaluation revealed an unstable T4 fx involving all 3 columns with compression, T7 fracture, and a manubrium fracture. The pt. was kept immobilized and put on log roll precautions, and orthopedics-spine service was consulted. The pt. was admitted to the step down unit for decreased O2 sats due to COPD,asthma, started on CIWA protocol, given asthma meds and aggressive pulmonary toilet. Pt. was subsequently intubated for decreasing O2 sats and increasing O2 demand and sent to TSICU for management. Pulmonary service was consulted who recommended continued chest PT and steroid administration. Ortho-spine service changed plan at this time from operative to non-operative management of unstable T-spine fractures considering pt's pulmonary status. Pt. to remain in TLSO brace at all times. Pt had repeated pulm eval including a CTA that was negative for thrombus, but showed bilateral collapse of lower lobes with effusions. Pt.'s respiratory status slowly improved over course with eventual uneventful extubation and transfer to step down and then to floor with increasing saturations and decreasing O2 demand. She was treated with Levofloxacin for a presumed pneumonia and developed diarrhea at the end of this 7 day course. Stool specimen x3 for C-diff were obtained and sent; thus far 2 cultures have come back as negative; the 3rd specimen pending at time of this report. Imodium has been started after 2nd negative report came back. Pt. also became delirious over length of hospital stay, but with increased O2 status, mental status has slowly improved. Pt. has been on regular floor for a number of days off any O2, satting well, clear mental status, and has been receiving daily PT. Pt. ready for d/c to rehab facility for continuation of PT and respiratory therapy. Pt. to follow up with ortho-spine and orthopedics after her discharge. Her home regimen of Wellbutrin, Spiriva, Singulair, Advair and prn Albuterol MDI were restarted prior to her discharge. Medications on Admission: albuterol Spiriva Advair Singulair Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. Disp:*1 1* Refills:*0* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Wellbutrin 100 mg Tablet Sig: 1 [**1-1**] Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 26478**] - [**Location (un) 1157**] Discharge Diagnosis: s/p Motor vehicle crash T4 compression fracture T7 fracture Sternal fracture Discharge Condition: Stable Discharge Instructions: Keep your brace on at all times! Followup Instructions: 1) Please make an appointment to follow up with the ortho-spine service in clinic in 3 weeks: [**Telephone/Fax (1) 3573**] 2) Please make an appointment to follow up with the trauma surgery service in clinic in 3 weeks: [**Telephone/Fax (1) 6439**] 3) Follow up with your primary doctor, Dr. [**Last Name (STitle) 37133**] after your dicharge; you will need to have an evaluation by a Pulmonologist; this referral will need to be made by your PCP. 4) Follow up with your primary Allergists after your discharge. Completed by:[**2186-10-6**]

8072,8052,5185,486,49320,30500,2763,8509,E8150,3051,3079,78791,V1079

Admission Date: [**2137-11-26**] Discharge Date: [**2137-12-1**] Date of Birth: [**2084-9-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25342**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Endoscopic Gastroduodenoscopy with Biopsy Temporary Dialysis catheter placement in Right Femoral Vein PICC line placement History of Present Illness: Patient is a 52yo F with HIV/HCV coinfection (not on Haart, CD4 250s, VL 4K), ESRD on HD - admitted with fever to 104.9. She did not have any pain or cough or urinary/bowel sx. HD stopped early today due to fevers, given vanco there. Here in ED given levo/flagyl/vanco, also recieved gent. Patient has tunnel cath-- recent stripping at [**Hospital1 2177**] 1 wk ago. Patient had a recent admission for esophagitis and [**Doctor First Name 329**] [**Doctor Last Name **] tear for which she was treated with fluc. and acyclovir (d/c'd [**11-15**]). In ed, cxr was neg, blood cx were taken, patient rec'd vanc,levo,flagyl, gent x 1. Also rec'd vanc at dialysis. Past Medical History: HIV: Diagnosed approximately 6 years ago. Never been on antiretroviral therapy. No history of opportunistic infections. No other HIV associated complications. Hepatitis C Hepatitis B Hypertension End-stage renal disease: hypertensive nephrosclerosis. Gets hemodialysis on Tuesday, Thursday, and Saturdays. Has previously been on peritoneal dialysis but that was changed to hemodialysis approximately 1-2 years ago, secondary to complications of peritonitis. Status post burn injury to lower anterior abdomen. Sigmoid colon polyp: Status post polypectomy on [**2136-4-30**], pathology showing adenoma with high-grade dysplasia. No evidence of invasive carcinoma. Social History: Hx of tobacco, denies alcohol or IVDU. Pt says she contracted HIV after being raped several years ago. Family History: No history of diabetes, coronary artery disease, kidney disease, or liver disease. History of colon cancer in her father who died when she was very young. Physical Exam: Temperature 97.7 HR 60 BP 110/66 (113-137)/(66-74) P 56-62 o2 100% RA I/O= 90/0 GENERAL: NAD HEENT: Oropharynx is clear without blood or petechia. No thrush. No scleral icterus. NECK: Supple. tunneled IJ CARDIOVASCULAR: Normal S1, S2. Regular rate and rhythm. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft/nontender/nondistended. No rebound/guarding. No masses. No peritoneal signs. No organomegaly. Positive bowel sounds. EXTREMITIES: Warm and well perfused. +2 bilateral radial and DP pulses. Symmetric pulses. SKIN: No rashes or other lesions noted. NEUROLOGIC: Alert, awake, oriented x3. Motor and sensory grossly nonfocal. Pertinent Results: MICRO: [**2137-11-26**] 1:30 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2137-11-30**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2137-11-27**] AT 9:25AM. PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. PSEUDOMONAS AERUGINOSA. 2ND MORPHOLOGY. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ 2 S 2 S IMIPENEM-------------- 2 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S ANAEROBIC BOTTLE (Pending): . [**2137-11-26**] 2:00 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2137-11-29**]): PSEUDOMONAS AERUGINOSA. SENSITIVITIES PERFORMED ON CULTURE # 221-4221M [**2137-11-26**]. ANAEROBIC BOTTLE (Pending): . [**2137-12-1**] 6:45 am SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST (Pending): . Cardiology Report ECHO Study Date of [**2137-11-30**] PATIENT/TEST INFORMATION: Indication: ? Endocarditis. Height: (in) 65 Weight (lb): 122 BSA (m2): 1.60 m2 BP (mm Hg): 140/90 HR (bpm): 63 Status: Inpatient Date/Time: [**2137-11-30**] at 11:40 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6 Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 243 msec TR Gradient (+ RA = PASP): <= 20 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 0.8 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter with >50% decrease collapse during respiration (estimated RAP 5-10 mmHg). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions: The left atrium is normal in size. The estimated right atrial pressure [**4-17**] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened with a 5mm non-mobile echodensity suggested on the LVOT side of the non-coronary leaflet c/w a possible vegetation. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. There is trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Possible vegetation on the aortic valve without evidence for aortic regurgitation. If clinically indicated, a TEE would be better able to define the aortic valve morphology. CLINICAL IMPLICATIONS: Based on [**2127**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2137-11-30**] 14:00. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J. . DISCHARGE LABS: [**2137-12-1**] 06:45AM BLOOD WBC-2.5* RBC-3.52* Hgb-11.2* Hct-33.3* MCV-95 MCH-31.9 MCHC-33.7 RDW-14.7 Plt Ct-219 [**2137-12-1**] 06:45AM BLOOD Neuts-45* Bands-0 Lymphs-32 Monos-18* Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2137-12-1**] 06:45AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Schisto-OCCASIONAL Burr-OCCASIONAL [**2137-12-1**] 06:45AM BLOOD PT-12.2 PTT-32.0 INR(PT)-1.0 [**2137-12-1**] 06:45AM BLOOD Gran Ct-1020* [**2137-12-1**] 06:45AM BLOOD Glucose-85 UreaN-27* Creat-11.7*# Na-135 K-4.0 Cl-96 HCO3-26 AnGap-17 [**2137-12-1**] 06:45AM BLOOD Albumin-3.5 Calcium-10.7* Phos-4.2 Mg-2.3 [**2137-12-1**] 06:55AM BLOOD Genta-2.5* Brief Hospital Course: 53 y/o female with HIV, Hep B, Hep C, HTN, ESRD on HD, with pseudomonal bacteremia, blood cultures quickly cleared, on gent and ceftaz, with evidence of possible aortic valve vegitation on TTE. . 1. Pseudomonal Bacteremia: Blood cultures positive on [**2137-11-26**]. Cleared the next day. Remained clear for several more days. Discharged on gentamycin and ceftazapime. TTE showed possible aortic valve vegitation. She will need TEE on Tuesday [**2137-12-3**] and course of antibiotics (to be given with HD) to be determined by result of TEE. Likely will need at least six weeks. . 2. ESRD: Temporary dialysis line placed Sunday by surgery. Dialysed sunday. Line removed before discharge. Next dialysis should be Tuesday [**2137-12-3**]. She is scheduled for a tunneled line, to be done Tuesday [**2137-12-3**] by IR. Her nephrologist is [**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**]. . 3. HTN: Controled on 5 mg Lisinopril. Metoprolol XL 100 mg QD was held initially because of hypotension and restarted on discharge. . 4. HIV: Last CD4 248. Not on HAART. Needs follow up with [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**]. . 5. Hep B/Hep C: Stable. Needs to follow upo with [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**]. . 6. Leukopenia: Trending down. Monocytosis. Not neutropenic (ANC>1000). Needs CBC checked to ensure trend of WBC count. . 7. Anemia: Newly anemic this admission. She is iron deficient, but has a high ferritin and low TIBC consistant with ACD. Needs CBC to trend Hct. . 8. Esophagitis on EGD: Continued on [**Hospital1 **] Pantoprazole. H. pylori serology positive on [**2137-11-11**]. Had H. pylori serology resent and needs to be followed up. Needs esophageal biopsy results followed up. Medications on Admission: Medications at home: Lisinopril 5mg QD Nephrocaps Renalgel/Sevelamer 800 mg Tablet Sig Metoprolol XL 100 mg po qd . Discharged [**2137-11-15**] additionally on: Pantoprazole 40mg [**Hospital1 **] Carbamide Peroxide 6.5 % Drops Acyclovir 200 mg Capsule Capsule PO Q24H Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q48H Discharge Medications: 1. Gentamicin in Normal Saline 60 mg/50 mL Piggyback Sig: Sixty (60) mg Intravenous QHD (each hemodialysis) for 6 weeks. 2. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous QHD (each hemodialysis) for 6 weeks. 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): please check with gastrointestinal doctor before stopping. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pseudomonal Bacteremia secondary to Dialysis Line Infection Aortic Valve Endocarditis Leukopenia Anemia Esophagitis Secondary Diagnosis: End Stage Renal Disease Hypertension HIV Hepatitis C Hepatitis B Discharge Condition: Afebrile. O2 saturation of 100%. Dialysed Sunday [**2137-12-1**]. Ambulatory. Discharge Instructions: You had an infection in your blood which may have caused bacteria to attach to your heart valve. If you notice fever or chills, please call your doctor or come to the emergency room for evaluation. Please come back to [**Hospital1 18**] on Tuesday [**2137-12-3**] at 9:00AM to the [**Hospital Unit Name **]-Fourth Floor Cardiology Department on the [**Hospital Ward Name 12837**] in order to get the ultrasound of your heart. You should not have anything to eat or drink starting Monday night at midnight until after the procedure on Tuesday. You will then go to the Interventional Radiology Department on the [**Hospital Ward Name 517**] in the Clinical Center-[**Location (un) **] to have a new dialysis line placed. Please ask to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You will then get dialysis here at [**Hospital1 18**] that day. Please be sure to folow up with Dr. [**Last Name (STitle) 1057**] of the Infectious Disease Clinic for evaluation of your HIV infection and Hepatitis. You can call ([**Telephone/Fax (1) 1300**] to make an appointment. This is very important. Followup Instructions: TEE on Tuesday [**2137-12-3**] to evaluate aortic valve for vegitation IR to place tunneled dialysis line Tuesday [**2137-12-3**] for dialysis H. Pylori results form EGD/Biopsy CBC to evaluate trend of leukopenia Needs to consider starting HAART therapy for HIV infection Completed by:[**2137-12-2**]

99662,03843,4210,5856,07054,07032,40391,V08,53019,28521,28850

Admission Date: [**2142-10-11**] Discharge Date: [**2142-10-12**] Date of Birth: [**2084-9-7**] Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending:[**First Name3 (LF) 2763**] Chief Complaint: Hypertension Major Surgical or Invasive Procedure: HD History of Present Illness: 58 y/o anuric HD dependent female with HIV on HAART (last CD4 94), CKD stage V on HD ([**1-10**] HTN, dialyzed MWF via L CVL), RUE AVG (ligation and subsequent excision ([**2142-9-15**]), HCV with liver biopsy [**3-/2137**] (grade II inflammation) who p/w RUQ pain and vomiting starting at 4 pm today after HD. . Of note, pt recently admitted from [**Date range (1) 100888**] on surgery service for right arm arteriovenous graft infection. She underwent excision right arteriovenous graft. GPC bacteremia on blood cultures [**2142-9-13**]. Graft cultures speciated as enterobacter. She completed vancomycin for 2 weeks at [**Year (4 digits) 2286**], and ciprofloxacin PO daily for 2 weeks. . Pt reports RUQ pain, intermittent, +chills. Denies fevers. No diarrhea, constipation, cough/cold sx. Reports vomiting, non-bloody. No HA, visual changes. Reports she missed her BP pills yesterday and today due to nausea/vomiting. Of note, pt does not make urine. . In ED, initial VS - initial VS were: 8, 98.6, 53, 226/101, 18, 100%. EKG showing sinus brady 48, NA, Qtc 461. Lactate wnl. Alk phos slightly above baseline. RUQ US showing stones, no cholycystitis. CXR showing no acute process. Transplant surgery notified, and they are aware and recommend MICU admission. CT A/P negative for acute process. Overall, "no SBO. Distal colonic wall thickening is more likely related to underdistension than colitis, but clinical correlation recommended. Polycystic kidneys. High density streaks in peritoneum unchanged since [**2137**], could be related to a barium spill. CT head showed no acute proces. . Pt started to develop worsening SOB, and there was a ? of mild pulmonary edema. SBP was 240s at this time. Nitro gtt started at 0.2 mcg. . Vitals on transfer - BP 215/117, HR 72, RR 18, 100% 2L NC. Access - 20G, HD line, R EJ. . On arrival to the MICU, mental status is alert. . Review of systems: (+) Per HPI. (+) HA (-) Denies fever, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HIV on HAART CKD stage V on HD ([**1-10**] HTN) RUE AVG, ligated [**2142-6-15**] Hep C: Liver biopsy [**3-/2137**] showed focal mild-to-moderate portal chronic inflammation with focal periportal extension (grade II). HTN Diverticulosis High-grade adenomatous polyp Social History: no current IV drug use, no current etoh or smoking Family History: non-contributory Physical Exam: Vitals: 97.6, 222/120, 72, 18, 100 RA General: Alert, but somewhat sleepy, oriented, mild distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1, prominent S2, grade III holodystolic murmur heard best at LSB Lungs: mild crackles at bases, no wheezes, rales, ronchi Abdomen: soft, minimally tender RUQ, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on Admission: [**2142-10-11**] 12:35AM BLOOD WBC-3.5* RBC-3.99* Hgb-11.9* Hct-39.0 MCV-98 MCH-29.9 MCHC-30.5* RDW-17.3* Plt Ct-148* [**2142-10-11**] 12:35AM BLOOD Neuts-66.3 Lymphs-26.5 Monos-4.9 Eos-1.4 Baso-0.9 [**2142-10-11**] 12:35AM BLOOD Plt Ct-148* [**2142-10-11**] 01:41PM BLOOD WBC-3.2* Lymph-25 Abs [**Last Name (un) **]-800 CD3%-56 Abs CD3-449* CD4%-25 Abs CD4-200* CD8%-31 Abs CD8-246 CD4/CD8-0.8* [**2142-10-11**] 12:35AM BLOOD Glucose-110* UreaN-27* Creat-5.9* Na-137 K-4.2 Cl-93* HCO3-29 AnGap-19 [**2142-10-11**] 12:35AM BLOOD ALT-18 AST-39 CK(CPK)-52 AlkPhos-490* TotBili-0.7 [**2142-10-11**] 12:35AM BLOOD Lipase-39 [**2142-10-11**] 12:35AM BLOOD CK-MB-2 cTropnT-0.02* [**2142-10-11**] 12:35AM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1 [**2142-10-11**] 01:41PM BLOOD PTH-2913* [**2142-10-11**] 12:48AM BLOOD Lactate-1.8 . Labs on Discharge: [**2142-10-12**] 03:29AM BLOOD WBC-3.3* RBC-3.63* Hgb-10.7* Hct-34.7* MCV-96 MCH-29.6 MCHC-30.9* RDW-17.1* Plt Ct-137* [**2142-10-12**] 03:29AM BLOOD Neuts-56 Bands-0 Lymphs-40 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2142-10-12**] 03:29AM BLOOD Plt Ct-137* [**2142-10-12**] 03:29AM BLOOD Glucose-87 UreaN-41* Creat-8.1*# Na-136 K-4.3 Cl-94* HCO3-30 AnGap-16 [**2142-10-12**] 03:29AM BLOOD ALT-20 AST-34 LD(LDH)-174 AlkPhos-415* TotBili-1.1 [**2142-10-11**] 01:41PM BLOOD GGT-62* [**2142-10-12**] 03:29AM BLOOD Albumin-4.2 Calcium-10.0 Phos-4.8* Mg-2.0 [**2142-10-11**] 01:41PM BLOOD PTH-2913* . CT head without contrast [**10-11**]: IMPRESSION: 1. No acute intracranial process. 2. Opacification of the left mastoid air cells may be due to inflammatory or infectious process. . CT abd/pelvis without contrast: IMPRESSION: 1. No evidence of bowel obstruction, diverticulitis or renal stones. 2. Left and sigmoid colonic wall thickening with mild stranding along the medial wall of the descending colon is most likely undersitension and chronic abnormality rather than mild colitis, though clinical correlation is needed. 3. Polycystic kidneys with some new intermediate density lesions and some increased in size and a septated left cystic lesion. Outpatient MRI is recommended in no more than 6 months to assess further. 4. Cholelithiasis without CT evidence of cholecystitis. 5. 4 mm right middle lobe nodule needs no follow- up if patient is low risk for malignancy. 12 month f/u chest CT if patient is high risk for a malignancy. . CXR PA and lateral: IMPRESSION: Vascular engorgement and early pulmonary edema, due to volume overload, and/or cardiac insufficiency. . Liver/gallbladder US [**2142-10-11**]: IMPRESSION: Cholelithiasis without evidence of cholecystitis. Polycystic kidneys are partially imaged and not completely evaluated, though no overtly concerning lesion is seen in their visualized portions. Brief Hospital Course: 58 y/o anuric HD dependent female with HIV on HAART, HCV, CKD stage V on HD, RUE AVG ligation and subsequent excision ([**2142-9-15**]), who p/w RUQ pain, nausea, and vomiting, and is admitted to MICU for hypertensive emergency. . # HTN emergency: pt presented with SBP in 230s and evidence of vascular engorgement and early pulmonary edema with volume overload, classifying her HTN as HTN emergency. Head CT was wnl. No EKG evidence of strain or ischemia was seen. Etiology of elevated BP was likely related to nausea/vomiting/missing BP pills at home, along with pain. Baseline SBP 140-160 per review of clinic notes. Of note, mental status was alert. She was started on nitro gtt with goal SBP 180 but was d/ced in the PM after normalization of her pressures. We continued home lisinopril and home metoprolol. Pain control was achieved with IV morphine. Patient tolerated HD performed in the ICU and was discharged after overnight stay. . # RUQ pain: RUQ US showed cholelithiasis without cholecystitis. CT A/P showed no SBO. Distal colonic wall thickening is more likely related to underdistension than colitis. No fever or jaundice, or evidence for cholecystitis. Elevated alk phos may suggest infiltrative disease. Recommend repeating outpatient LFTs and w/u with possible MRCP if alk phos remains elevated. Consider outpt cholecystectomy for biliary colic, now resolved. . # CKD stage V on HD ([**1-10**] HTN): gets dialyzed on MWF. Renal team performed UF on hospital day 1, and HD on Friday (hospital day 2). Continued sevelamer, nephrocaps. Of note, patient's PTH returned as 2913. Pt will start IV zemplar at HD for ? secondary vs. tertiary hyperparathyroidism. . # HIV: on HAART. Last CD4 94 (22%) and VL 71 copies/ml. We continued atazanavir, raltegravir, ritonavir, lamivudine. On discharge, CD4 count pending. Pt may require bactrim ppx depending on CD4 count. Pt was set up with ID appt on discharge. . # HCV: liver biopsy [**3-/2137**] showed focal mild-to-moderate portal chronic inflammation with focal periportal extension (grade II). . # Hx of right arm arteriovenous graft infection/excision right arteriovenous graft: GPC bacteremia on blood cultures [**2142-9-13**]. Graft cultures speciated as enterobacter. She completed vancomycin for 2 weeks at [**Year (4 digits) 2286**], and ciprofloxacin PO daily for 2 weeks. No signs of infection locally or systemically. Bcx pending on d/c. . # 4 mm right middle lobe nodule: per radiology, needs no follow-up if patient is low risk for malignancy. 12 month f/u chest CT if patient is high risk for a malignancy. Communicated above with oupt PCP. . # Transitional issues: - follow up CD4 count, and start bactrim prophylaxis depending on result. - Started IV zemplar at HD (Dr [**Last Name (STitle) 7473**] [**Name (STitle) 82414**]) given high PTH values (2913). - 4 mm RML nodule, which requires repeat evaluation and possible CT if high risk for malignancy - ID appt re: HIV care as outpt Medications on Admission: 1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap PO DAILY (Daily). 3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY (Daily). 4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: 25 mg PO DAILY (Daily). 7. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1) PO DAILY (Daily). 11. heparin (porcine) 1,000 unit/mL Solution [**Name (STitle) **]: One (1) Injection PRN (as needed) as needed for line flush. 12. aspirin 81 mg Tablet, Chewable [**Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 13. acetaminophen 325 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 14. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 15. metoprolol succinate 100 mg Tablet Extended Release 24 hr [**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 16. oxycodone 5 mg Tablet [**Name (STitle) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Medications: 1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap PO DAILY (Daily). 3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY (Daily). 4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: Twenty Five (25) mg PO DAILY (Daily). 7. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1) packet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr [**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 14. oxycodone 5 mg Capsule [**Name (STitle) **]: [**12-10**] Capsules PO every four (4) hours as needed for pain. 15. zemplar qhd Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - hypertensive emergency . SECONDARY: - end stage renal disease, on HD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you in the hospital. You were admitted to the intensive care unit due to very high blood pressures, likely a result of nausea/vomiting, inability to take your home pills, and a shortened [**Known lastname 2286**] session the day before. . While you were here, we controlled your blood pressure with IV medications. Your blood pressure responded nicely. You are being discharged on your home blood pressure regimen of metoprolol and lisinopril. . While you were here, we also checked some blood tests related to your kidneys. Your PTH levels were high and the kidney team will add a new IV medication called zemplar with your [**Known lastname 2286**]. . MEDICATION CHANGES - addition of IV zemplar with [**Known lastname 2286**] . No other changes were made to your medications. Please follow-up with your outpatient appointments below. Please seek medical attention for any concerns. Followup Instructions: Appointments: 1) Department: [**Hospital3 249**] When: THURSDAY [**2142-10-18**] at 3:50 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] linical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . 2) Department: INFECTIOUS DISEASE When: TUESDAY [**2142-10-30**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2142-10-12**]

40391,5856,042,V4511,07054,78701,57420,56210,51889,V1272

Admission Date: [**2142-11-25**] Discharge Date: [**2142-11-26**] Date of Birth: [**2084-9-7**] Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending:[**First Name3 (LF) 2297**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 58 year-old woman with HCV, HIV CD4 200, ESRD on HD last HD [**11-23**] and 9 prior admissions this year for abdominal pain and HD access issues last discharge [**10-18**] presenting with epigastric pain. She reports epigastric pain that began this morning and is associated with nausea and non-bloody non-bilious vomiting. She also reports mild dyspnea and orthopnea with nonproductive cough. She denies any chest pain or pressure. In the ED, initial VS were 100.1 76 221/110 16 97%RA. Labs in the ED were notable for TropT 0.01, K 7, Cr 9.4, BUN 69, WBC 4.6 and BNP 30K. She received 2mg of zofran and 10mg of morphine IV for nausea and abdominal pain in the ED. She also received 2g calcium gluconate IV, 1 amp D50 and 10units of insulin and admitted to the MICU for emergent treatment of her hyperkalemia. Vitals on transfer were 99.6 76 189/96 99% on RA. On arrival to the MICU, patient appears comforatable and is without additional complaints. Past Medical History: - HIV/AIDS on HAART CD4 200 [**10-11**] - CKD stage V on HD ([**1-10**] HTN) - RUE AVG, ligated [**2142-6-15**] - Hep C: Liver biopsy [**3-/2137**] showed focal mild-to-moderate portal - chronic inflammation with focal periportal extension (grade II) - HTN - Diverticulosis - High-grade adenomatous polyp Social History: No current IV drug use, No current etoh or Smoking Family History: non-contributory Physical Exam: VS: T: 97, P: 87, BP: 142/74, RR: 15, O2 sat 100% on RA General: Alert, oriented, no acute distress HEENT: Swollen face, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated to 12cm H2O, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to ausculation bialreally, no wheezes, rales or ronchi Abdomen: Obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally. Discharge: VS: T: 97, P: 60, BP: 135/71, 95% on RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no JVD, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to ausculation bialreally, no wheezes, rales or ronchi Abdomen: Obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: 1+ nonpitting edema bilat LE, 1+ DP pulses bilaterally. Pertinent Results: Hematology: [**2142-11-26**] 06:08AM BLOOD WBC-3.5* RBC-3.79* Hgb-11.4* Hct-35.4* MCV-93 MCH-30.1 MCHC-32.3 RDW-17.8* Plt Ct-124* [**2142-11-25**] 07:49PM BLOOD WBC-4.6# RBC-4.16* Hgb-12.0 Hct-39.4 MCV-95 MCH-28.8 MCHC-30.4* RDW-18.2* Plt Ct-160 [**2142-11-25**] 07:49PM BLOOD Neuts-70.8* Lymphs-25.1 Monos-3.2 Eos-0.5 Baso-0.5 [**2142-11-26**] 06:08AM BLOOD PT-11.2 PTT-34.8 INR(PT)-1.0 [**2142-11-25**] 07:49PM BLOOD PT-10.8 PTT-35.1 INR(PT)-1.0 Chemistries: [**2142-11-26**] 06:08AM BLOOD Glucose-95 UreaN-40* Creat-6.6*# Na-134 K-4.9 Cl-93* HCO3-33* AnGap-13 [**2142-11-25**] 07:49PM BLOOD Glucose-95 UreaN-69* Creat-9.4*# Na-138 K-7.0* Cl-94* HCO3-28 AnGap-23* [**2142-11-26**] 06:08AM BLOOD ALT-19 AST-27 CK(CPK)-40 TotBili-0.9 [**2142-11-25**] 07:49PM BLOOD ALT-20 AST-29 CK(CPK)-55 AlkPhos-604* TotBili-1.2 [**2142-11-26**] 06:08AM BLOOD Albumin-4.3 Calcium-10.4* Phos-4.4 Mg-2.2 [**2142-11-25**] 07:49PM BLOOD Calcium-10.3 Phos-4.1 Mg-2.4 [**2142-11-26**] 01:43AM BLOOD Lactate-1.2 [**2142-11-25**] 08:10PM BLOOD Lactate-2.6* K-6.5* [**2142-11-25**] CXR IMPRESSION: No evidence of congestive heart failure. Brief Hospital Course: 58 year-old woman with poorly controlled HTN, HIV(last CD4 200 on [**10-11**]), ESRD on HD presents with acute onset of abodminal pain and is found to have hyperkalemia. . #. Hyperkalemia: Patient was found to be hyperkalemic to 7.0 in the ED and was treated with calcium gluconate, D50 and insulin with follow-up value of 6.5. Patient has a recent baseline potassium 4.3-5 thus this represents an acute increase in her potassium level. She denies missing any HD sessions. Her hyperkalemia may have been related to dietary indiscretion. She underwent emergent hemodialysis and her hyperkalemia corrected. # Abdominal pain: Patient presents after acute onset of nausea, vomiting and abdominal pain. There was no sign if infectious etiology- no leukocytosis, no fever. Her nausea was liked related to her uremia and all her symptoms improved with HD. She was able to tolerate a diet at the time of discharge. # ESRD: CKD Stage V due to HTN. On HD MWF. Patient last received [**Month/Day (4) 2286**] on 2 days prior to admission. She underwent emergent HD on admission and then had her regularly scheduled [**Month/Day (4) 2286**] in the morning. She was continued on Sevelemer and Nephrocaps. # HIV/AIDS: On HARRT, last CD4 200 on [**2142-10-11**]. Continued on atazanavir, raltegravir, ritonavir, lamivudine. # HTN: Patient has poorly contolled HTN with prior admissions for hypertensive emergency, she presented hypertensive again today to the ED. Vitals on admission were slightly improved after her nausea and pain were contolled. She was continued on her home lisinopril, metoprolol and amlodipine. # Shoulder arthritis: Extensive workup as outpatient for shoulder pain, thought to be musculoskeletal. Patient was continued on PO oxycodone as needed for control of symptoms. #CODE: Full Code (confirmed with patient) Medications on Admission: - Sevelamer carbonate 800 mg TID QAC - B complex-vitamin C-folic acid 1 mg daily - atazanavir 300 mg daily - raltegravir 400 mg [**Hospital1 **] - ritonavir 100 mg daily - lamivudine 10 mg/mL daily - senna 8.6 mg [**Hospital1 **]:PRN - docusate sodium 100 mg [**Hospital1 **] - lactulose 10 gram/15 mL daily - polyethylene glycol 3350 17 gram/dose daily - aspirin 81 mg daily - lisinopril 40 mg daily - metoprolol succinate 100 mg daily - oxycodone 5 mg Q4H - amlodipine 2.5 mg daily Discharge Medications: 1. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 3. atazanavir 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day. 4. raltegravir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 6. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 8. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO DAILY (Daily). 9. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 11. lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 12. lamivudine Oral 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr [**Hospital1 **]: One (1) Tablet Extended Release 24 hr PO once a day. 14. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperkalemia, ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital with abdominal pain. We found that your potassium was very high and you were admitted to the intensive care unit for [**Known lastname 2286**]. Your potassium improved after [**Known lastname 2286**]. Your abdominal pain also improved and you were discharged home. No changes were made to your medications. Followup Instructions: Please call your primary care doctor at [**Telephone/Fax (1) 250**] to follow-up in [**12-10**] weeks. Please keep the following appointments: Department: [**Hospital3 249**] When: TUESDAY [**2143-1-15**] at 2:10 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: OBSTETRICS AND GYNECOLOGY When: THURSDAY [**2143-2-14**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71322**], MD [**Telephone/Fax (1) 2664**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2143-4-2**] at 10:15 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

2767,5856,042,40391,27669,V4511,07054,28521,78900,71691

Admission Date: [**2187-9-4**] Discharge Date: [**2187-9-15**] Service: CCU ADMISSION DIAGNOSIS: Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 79 year old female with CRF, DM, HTN, remote tobacco use who was in her usual state of health until [**9-3**] when she presented to an outside hospital with non-ST elevation MI with peak CK equal to 1500. The patient was treated medically with Lovenox, Integrilin, aspirin, dopamine, nitropaste. On [**9-4**] recurrent angina and transferred to [**Hospital1 18**] for cardiac catheterization showing three vessel disease with elevated left and right sided filling pressures. IVC was placed. Dobutamine and nitroglycerin drips and 40 of IV Lasix given. The patient was transferred to the CCU in stable condition. PAST MEDICAL HISTORY: Coronary artery disease status post cath. Diabetes. Hypertension. A-fib. Remote history of small CVA. ALLERGIES: No known drug allergies. MEDICATIONS: Fluoxetine, guaifenesin, nifedipine, glyburide, lovastatin, Toprol XL, lisinopril, Protonix, isosorbide dinitrate, metformin, KCl, hydrochlorothiazide. PHYSICAL EXAMINATION: Afebrile, blood pressure 110/69, heart rate 91, respiratory rate 18, O2 96 percent on 2 liters nasal cannula. In general, elderly female in no apparent distress. HEENT dry mucous membranes. Chest clear to auscultation bilaterally. CV irregular, no rubs or gallops, IABP sounds. Abdomen soft, nondistended, nontender, good bowel sounds. Extremities full pulses. LABORATORY DATA: CK 626, CKMB 24, troponin T 6.4. HOSPITAL COURSE: 1. Cardiovascular. The patient is status post non-ST elevation MI with three vessel disease and needs CABG in the future. The patient was cathed on admission and showed three vessel disease with elevated left and right filling pressures. The patient was taken off IABP and pressors slowly as tolerated and medications were optimized throughout hospitalization for better control of blood pressure and cardiac risk factors. Please see updated list of medications. CT surgery was also consulted for surgery for CABG and because of complicating mental status changes and rising creatinine, recommended outpatient rehab, then follow up with CT surgery for elective CABG. 2. Diabetes type 2. Well controlled throughout her hospitalization. 3. Psych. The patient had ICU psychosis, but when all her antianxiety, antipsychosis medications were held, she remained awake, alert and oriented times three for 48 hours before discharge. Vital signs were stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. Anterior myocardial infarction. 2. Subendocardial hypertension. 3. Coronary artery disease. DISCHARGE MEDICATIONS: 1. Tylenol 325 one to two tablets q.4 to 6h. 2. Multivitamin one tablet q.day. 3. Atorvastatin 40 mg p.o. q.day. 4. Fluoxetine 20 mg p.o. q.day. 5. Folic acid 1 mg p.o. q.day. 6. Cyanocobalamin 25 mcg p.o. q.day. 7. Thiamine 100 mg p.o. q.day. 8. Docusate one tab p.o. b.i.d. 9. Albuterol ipratropium one two puffs p.r.n. 10. Albuterol one inhalation p.r.n. 11. Ipratropium one inhalation q.6h. p.r.n. 12. Aspirin 325 a day. 13. Pantoprazole 40 q.day. 14. Diltiazem 60 p.o. q.i.d. 15. Levofloxacin 250 p.o. q.o.d. 16. Warfarin 5 mg p.o. q.h.s. 17. Lisinopril 5 mg p.o. q.day. 18. Glyburide 5 mg p.o. q.day. 19. Regular insulin sliding scale. 20. Toprol XL 25 mg p.o. q.day. FOLLOWUP: Follow up with Dr. [**Last Name (STitle) 70**], cardiothoracic surgery, on [**10-3**]. The patient is also to follow up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50479**], in one to two weeks. Appointments are made on discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2187-9-15**] 13:41 T: [**2187-9-15**] 14:09 JOB#: [**Job Number 50480**]

41071,42731,4271,5849,40391,78551,5990,00845,41401

Admission Date: [**2187-9-4**] Discharge Date: [**2187-9-18**] Service: CCU-MEDICINE ADMITTING DIAGNOSIS: Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 79 year old female with chronic renal failure, diabetes mellitus, hypertension, remote tobacco use, who was in her usual state of health until [**2187-9-3**], where she presented to an outside hospital with non ST elevation myocardial infarction with peaked CK of 1500. The patient was treated medically with Lovenox, Integrilin, Aspirin, Dopamine, Nitroglycerin, and Aspirin. On [**2187-9-3**], she had recurrent angina and was transferred to [**Hospital1 69**] for cardiac catheterization which showed three vessel disease with elevated left and right filling pressures. An IAVP was placed and Dobutamine and Nitroglycerin drips were started and intravenous Lasix was given. The patient was then transferred to the CCU in stable condition. PAST MEDICAL HISTORY: 1. Coronary artery disease with catheterization. 2. Diabetes mellitus. 3. Hypertension. 4. Atrial fibrillation. 5. Remote small cerebrovascular accident ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Fluoxetine. 2. Guaifenesin. 3. Nifedipine. 4. Glyburide. 5. Toprol XL. 6. Lovastatin. 7. Lisinopril. 8. Protonix. 9. Isosorbide Dinitrate. 10. Metformin. 11. Potassium Chloride. 12. Hydrochlorothiazide. PHYSICAL EXAMINATION: On admission, the patient was afebrile, blood pressure 110/69, heart rate 91, respiratory rate 18, oxygen saturation 96% on two liters nasal cannula. In general, the patient is an elderly female in no apparent distress. Head, eyes, ears, nose and throat - Dry mucous membranes. Chest is clear to auscultation bilaterally. Cardiovascular is irregularly irregular, no rubs or gallops. IAVP sounds. The abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities - palpable pulses. LABORATORY DATA: On admission, CK was 626, CK MB 24.0, troponin T 6.4. Otherwise Chem7 and complete blood count were stable. HOSPITAL COURSE: 1. Cardiovascular - The patient assessed non ST elevation myocardial infarction with three vessel disease and need for coronary artery bypass graft in the future. The patient's catheterization on admission showed three vessel disease with elevated left and right filling pressures. In the CCU, the patient was taken off IAVP and pressors were slowly weaned as tolerated and medications were optimized throughout hospitalization for better blood pressure control and control of her cardiac risk factors. Please see updated list of discharge medications. Cardiothoracic Surgery was also consulted for surgery for coronary artery bypass graft and because of complicating mental status changes and rising creatinine, it was recommended to follow-up with Cardiothoracic Surgery as an outpatient for an elective coronary artery bypass graft. The patient also has a history of atrial fibrillation and was placed on a Diltiazem drip while being NPO. Once able to take p.o., the patient's rate was well controlled with p.o. Diltiazem which was titrated to keep her heart rate less than 100, and the patient was kept on a Heparin drip and converted to p.o. Warfarin with goal INR of 2.0 to 3.0. The patient will need frequent INR checks at rehabilitation to titrate Coumadin dose. The patient also had a few episodes of nonsustained ventricular tachycardia during this hospitalization and her Toprol XL was titrated upwards for this. 2. Diabetes mellitus type 2 - The patient was well controlled throughout hospitalization with a regular insulin sliding scale and p.o. Glyburide. 3. Psychiatry - The patient had Intensive Care Unit psychosis for a short period of time while on Haldol and Ativan. Once all her antianxiety medications were held, her mental status began to clear and the patient remained awake, alert and oriented times three times 48 hours before discharge. Psychiatry was also consulted and agreed with her mental status being back to baseline 48 hours before discharge. 4. Infectious disease - The patient had increasing white blood cell count during hospitalization and was found to be Clostridium difficile positive. The patient also had a chest CT for concern of a lung process but was found to have congestive heart failure, mediastinal lymphadenopathy which needs to be followed up with a chest CT in three months, and an indeterminate adrenal mass will need to be followed up with a magnetic resonance scan in three months. The patient was also started on Flagyl for a ten day course for Clostridium difficile. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to rehabilitation. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction, subendocardial, initial episode. 2. Hypertension, benign and essential. 3. Coronary artery disease, native. MEDICATIONS ON DISCHARGE: 1. Tylenol one to two tablets p.o. q4-6hours p.r.n. 2. Multivitamin one tablet p.o. once daily. 3. Atorvastatin 40 mg p.o. once daily. 4. Fluoxetine 20 mg p.o. once daily. 5. Folic Acid 1 mg p.o. once daily. 6. Cyanocobalamin 50 mcg p.o. once daily. 7. Thiamine HCl 100 mg p.o. once daily. 8. Regular insulin sliding scale. 9. Docusate 100 mg p.o. twice a day. 10. Albuterol Ipratropium one to two puffs inhaled q4hours p.r.n. 11. Albuterol nebulizer one nebulizer inhaled q4hours p.r.n. 12. Ipratropium Bromide one nebulizer inhaled q6hours p.r.n. 13. Aspirin 325 mg once daily. 14. Lisinopril 5 mg p.o. once daily. 15. Glyburide 5 mg p.o. twice a day. 16. Diltiazem 60 mg p.o. four times a day. 17. Metoprolol XL 100 mg p.o. once daily. 18. Warfarin 2 mg p.o. q.h.s. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 70**], cardiothoracic surgery, [**2187-10-3**], at 1:30 p.m. The patient is to follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50481**] in one to two weeks. The patient will also need a follow-up chest CT in three months with a follow-up magnetic resonance scan in three months for adrenal mass. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern4) 50356**] MEDQUIST36 D: [**2187-9-19**] 17:01 T: [**2187-9-19**] 18:48 JOB#: [**Job Number 50482**]

41071,42731,4271,5849,40391,78551,5990,00845,41401

Admission Date: [**2143-2-15**] Discharge Date: [**2143-2-18**] Service: PRINCIPLE DIAGNOSIS AT DISCHARGE: Right caudate thalamic hemorrhage secondary to hypertension. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 46608**] is a 60-year-old man with past medical history of hypertension and coronary artery disease. Has been having fevers over the last three days. On the night prior to admission he began to complain that "something is happening to me." According to his wife at baseline he ambulates with a walker because of "back problems." [**Name2 (NI) **] has had a fever since [**2143-2-12**] with a dry cough but no other localizing symptoms and he was being empirically treated with antibiotics by his primary care physician. [**Name10 (NameIs) **] night prior to admission he got up to urinate and was unable to take off his pants or later to put them back on. He also developed a left sided throbbing headache at that time. However, he went back to sleep in the morning. He had the sense that something was wrong and his wife brought him to [**Name (NI) 16843**] Hospital where a Head CT was obtained that showed a right caudate hemorrhage without extension into the ventricles. He was then transferred to [**Hospital1 190**] for further evaluation and treatment. REVIEW OF SYSTEMS: He has had fevers without change in urination. He has had decreased hearing and he wears a hearing aid in the right ear. he complains of chronic left hip pain and back pain. The patient denied any problems with sore throat, nausea, vomiting, visual changes, difficulty swallowing, chest pain, palpitations, short of breath, abdominal pain or change in bowel and bladder habits. PAST MEDICAL HISTORY: 1. Hypertension. 2. Left hip replacement [**2141**]. 3. Coronary artery disease. Status post three vessel Coronary artery bypass graft in [**2130**]. Angioplasty in [**2131**]. 4. Hypercholesterolemia. 5. Gout. 6. Prostate cancer [**2128**]. 7. Colon surgery for gastrointestinal bleed/diverticulosis in [**2138**]. 8. Cholecystectomy in [**2138**]. 9. Bladder sphincter surgery in [**2135**]. 10. Ear surgery times three. 11. Hernia repair times three. 12. Bilateral cataract surgery. ALLERGIES: Sulfa gives him a rash. Penicillin gives a rash. Demerol and Ambien with unknown reaction. MEDICATIONS: 1. Aspirin 325 mg p.o. q day. 2. KCL 10 mg p.o. twice a day. 3. Hydralazine 15 mg p.o. three times a day. 4. Flomax 64 mg p.o. q day. 5. Aciphex 20 mg p.o. q day. 6. Zocor 40 mg p.o. q day. 7. Allopurinol 100 mg p.o. q day. 8. Norvasc 5 mg q day. 9. Lasix 20 mg p.o. q day. 10. Iron 325 mg p.o. q day. 11. Hydrocodone twice a day p.r.n. SOCIAL HISTORY: Originally from [**State 9512**], worked as an Air Force plane mechanic. Married with children. Positive smoking history PHYSICAL EXAMINATION: At presentation his temperature was 97.1, blood pressure is 177/76, heart rate was 87. Respiratory rate was 24. He was sating 100% on two liters. In general the patient appeared his stated age lying in bed in no acute distress. His head was normocephalic and atraumatic. Eyes: Nonicteric. Oropharynx was clear without lesions. Mucous membranes were moist. Neck was supple with no jugular venous distention or bruits. Lungs were clear to auscultation bilaterally. Cardiac exam revealed a normal S1 and S2. 2/6 systolic ejection murmur heard best at the upper sternal border. Abdomen was soft, nontender, nondistended with normal bowel sounds. Extremities were warm with no clubbing or cyanosis. He had mild pitting edema at the ankles. Neurologic: He was awake, alert, cooperative, appeared grossly oriented. He was able to provide some detail of recent and remote events. Serial 3's were intact. His object naming was intact. Registration intact with four attempts. Recall [**3-5**] items in three minutes. He followed simple commands. Speech: Normal voice quality and articulation. Comprehension is coherent. He was fluent without paresthesias. He was able to say no if's, and's and but's intact. Cranial nerve exam: The patient with left lower facial droop without trismus. His extraocular movements intact without nystagmus. His visual fields intact with confrontation. His funduscopic exam revealed normal vasculature with sharp optic discs. Pupils were reactive to light directly and consensually, 3 mm to 2 mm, palate was symmetric and tongue was midline. Hearing was decreased to finger rub bilaterally. His neck and shoulder shrug however, were normal. On motor examination his legs were adducted at rest with increased tone. There is no upper extremity cogwheeling rigidity. There is no pronator drift. His interphalangeal testing was limited by pain. Strength exam was symmetric with 5- strength in the deltoids, 5 in the biceps, 5 in the wrist flexors and extensors, 5 in the finger flexors, 5- in the finger extensors. 4 on the hip flexors, 5 in the knee flexors, 4+ in the knee extensors, 5- in the ankle flexors, 4+ in the ankle extensors, 5 in the toe reflexes, 4+ in the toe extensors. Reflexes were 2+ and symmetric in the biceps, triceps and brachioradialis. Lower extremity they were 4+ in the patella on the left and 3+ on the right. Achilles jerks were absent and toes were upgoing bilaterally. There is no ankle clonus. Sensory: Pinprick is decreased on the left face, arm and leg. Vibration is decreased in the toes. Proprioception intact in the fingers. Coordination finger-to-nose intact with mild action tremor. Heel-to-shin was intact. Rapid alternating movements intact. Toe tap was intact. Gait was very unsteady with retropulsion, normal base but short step and stride. HOSPITAL COURSE: Mr. [**Known lastname 46608**] was admitted to the neurological Intensive Care Unit for further evaluation and treatment of his right caudate hemorrhage. An magnetic resonance scan of his head was done with Gadalidium to look for additional reasons for sensory changes such as an ischemic stroke and none were found. There was no evidence of enhancement underneath the hemorrhage to suggest a lesion which later bled. Systolic blood pressure was maintained between 120 to 140 and his aspirin was held and will continue to be so for the next 10 days. The following day Mr. [**Known lastname 46608**] was transferred to the floor. However, on the 16th he was found to be much less responsive and to have fevers and the source of his fevers were eventually found however, over the next day Mr. [**Known lastname 46608**] was no longer febrile and was back to his baseline. On the 17th Mr. [**Known lastname 46608**] was observed to ambulate well with his walker avoiding obstacles and was able to transfer in and out of his bed with minimal assistance. DISCHARGE INSTRUCTIONS: Mr. [**Known lastname 46608**] was discharged to home on [**2143-2-18**]. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. q day. 2. Amlodipine 5 mg p.o. q day. 3. Allopurinol 100 mg p.o. q day. 4. Zocor 40 mg p.o. q day. 5. Hydralazine 50 mg p.o. three times a day. 6. KCL 10 mEq p.o. twice a day. 7. Slow-Mag 64 mg p.o. q day. 8. Aciphex 20 mg p.o. q day. 9. Iron 325 mg p.o. q day. 10. Hydrocodone one tab twice a day p.r.n. He is to hold his aspirin for one further week and then may resume all pre-admission medications. DIET: Low sodium, low cholesterol. He has been asked to return for follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**2143-3-12**], [**Telephone/Fax (1) 46609**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**MD Number(1) 2107**] Dictated By:[**Last Name (NamePattern1) 660**] MEDQUIST36 D: [**2143-2-18**] 20:29 T: [**2143-2-18**] 20:09 JOB#: [**Job Number **]

431,2720,4019,V1046,2749

Admission Date: [**2101-12-1**] Discharge Date: [**2101-12-5**] Date of Birth: [**2055-5-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Alcohol intoxication, Suicidal ideation Major Surgical or Invasive Procedure: None History of Present Illness: 46 M with PMHx significant for nephrectomy, and prior admissions for alcohol intoxication, who presents with suicidal ideation. Patient has prior history of ED visits with both of these presentations. Patient reports that he has been on a drinking binge (vodka & listerine) for the past 2 months, with his last drink 2 days prior to admission. Patient denies ever having EtOH withdrawal seizures and just reports having "shakes". Since stopping alcohol on day prior to admission, he has been feeling anxiety, depression, nausea with nonbloody bilious emesis, headache, chills, & tremors. he also reports lightheadedess and dizziness. He denies any methanol or ethylene glycol ingestions, fevers, abdominal pain, diarrhea. He does reports that his last meal was 3 days prior to admission, and he has consumed essentially nothing but alcohol since. Patient reports that he's been feeling suicidal for the past couple days after stopping alcohol. he reports that he has significant financial, occupational and familial stressors. He called 911 this am and was brought to the ED. . . . ROS: Positive: chest rash Negative: change in vision, oral ulcerations, neck stiffness, chest pain, abdominal pain, diarrhea, constipation In the ED, vitals signs were T:96.7, HR:130, BP: 72/44. The patient was also found to have a significant ETOH intoxication, as well as an AG acidosis (anion gap 35)and ARF. Tox screen was positive for only EtOH and LFTs were mildly elevated. he was given Ativan, 2L fluids, phenergan for nausea, one dose of ceftriaxone and sent to the floor. Past Medical History: 1. Alcohol abuse. 2. Right nephrectomy for a mass in his kidney. 3. HTN 4. Dyslipidemia Social History: Patient reports that he drinks 1 quart of vodka or listerine per day. Has been doing this lately for 2 months. Long-standing drinking history. Patient has had prior visits to [**Hospital1 18**] ED for suicide attempt and EtOH intoxication. Patient reports smoking 1 pack per week, denies any other illicit drugs. Family History: No family history of cancer, no bleeding diathesis Father - deceased - MI age 70 Mother - recent CVA Physical Exam: Physical Exam: Vitals - T: 100.3 BP: 100/62 HR: 123 RR: 12 02 sat:96RA Gen: NAD, anxious, cooperative SKIN: redness to face and upper chest, no excoriations or lesions HEENT: AT/NC, bilateral scleral injection without exudate, pink conjunctiva, PERRL, EOMI, dry MM, poor dentition, no evidence of oral ulceration Neck: no masses, no LAD, no JVD, no carotid bruit CV: tachycardic, S1/S2, flow murmur @ RUSB, nondisplaced PMI Chest: cta b/l, no crackles or wheezes. Abd: soft, nd, +bs, no organomegaly, no rebound, no guarding Extr: no cyanosis, no clubbing; no edema, 2+ pulses b/l. Neuro: awake, alert, a&ox3, cn ii-xii intact; strength 4/5 bilaterally Pertinent Results: [**2101-12-1**] 02:01PM WBC-6.5 RBC-4.65 HGB-15.9 HCT-46.0 MCV-99*# MCH-34.2* MCHC-34.6 RDW-16.0* [**2101-12-1**] 02:01PM NEUTS-74.4* LYMPHS-14.3* MONOS-10.9 EOS-0.1 BASOS-0.3 [**2101-12-1**] 02:01PM ASA-NEG ETHANOL-296* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2101-12-1**] 02:01PM CALCIUM-7.8* PHOSPHATE-7.5*# MAGNESIUM-2.1 [**2101-12-1**] 02:01PM CK-MB-21* MB INDX-3.1 cTropnT-<0.01 [**2101-12-1**] 02:01PM LIPASE-71* [**2101-12-1**] 02:01PM ALT(SGPT)-99* AST(SGOT)-156* CK(CPK)-688* ALK PHOS-122* AMYLASE-92 TOT BILI-0.4 [**2101-12-1**] 02:01PM GLUCOSE-118* UREA N-37* CREAT-2.1* SODIUM-141 POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-15* ANION GAP-40* . [**2101-12-1**] CXR: IMPRESSION: No acute pulmonary process. . CT HEAD: IMPRESSION: No intracranial hemorrhage or fracture. No mass effect. Brief Hospital Course: Patient is a 46 M with suicidal ideation, EtOH withdrawal, hypotension, elevated lactate, ARF, metabolic acidosis, & tachycardia. . # EtOH Withdrawal: Patient ceased drinking approximately 24 hours prior to admission. Load with Valium 10mg until confortable, then Q1hprn per CIWA > 10. the patient initially required high doses. MVI/Thiamine/Folate were also given. . # Hypotension: due to volume depletion in the context of poor po intake, responded well to fluids. . # Tachycardia - Likely due to a combination of etoh withdrawal hypovolemia. Patient's HR has decreased with fluid challenge. Fluid hydration. . # Fevers - Likely in the setting of alcohol withdrawal. Cultures negative. . # ARF- Cr on admission to 2.0. Baseline is 0.8. Likely pre-renal renal failure, responded well to fluids. No evidence of secondary ingestions. Renal was consulted to help with management. . # Metabolic Acidosis: Patient with metabolic acidosis. Likely due to alcoholic and starvation ketoacidosis as well as renal failure. Lactate minimally elevated. No evidence of seconday ingestion. Resolved with IVF hydration. . # Suicide attempt- patient currently with 1:1 sitter. Consulted Psychiatry. Recommended inpatient psychiatry admission. . FULL CODE Medications on Admission: Paxil Lipitor 20 Norvasc 20 "Something to stop Alcohol cravings" Discharge Disposition: Extended Care Facility: [**Hospital3 8063**] - [**Location (un) **] Discharge Diagnosis: EtOH withdrawal Suicide Attempt Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you experience shortness of breath, chest pain, fevers/chills. . Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 3 weeks of discharge. On this admission, it was noted that you have a small amount of red blood cells in your urine. This will need to be followed up with your primary care physician upon discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

29181,5849,2762,30391,4019,V1052,V600

Admission Date: [**2105-9-26**] Discharge Date: [**2105-9-29**] Date of Birth: [**2055-5-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 50 y/o male with PMHx EtOH abuse with withdrawal symptoms and DTs, depression, HTN who presents to the ED with suicidal ideations after an episode of binge drinking, called EMS on self with SI. Did not actually harm himself. Was recently admitted to dual diagnosis center for ~1 week starting on [**9-16**], after discharge began drinking 1 pint of vodka nightly and reports he drank [**1-3**] gallon of vodka today. . In the ED, initial vs were: Temp:99.3 HR:124 BP:135/88 Resp:16 Sat:95 Patient received thiamine, folate, multivitamin, 2L fluid and was started on CIWA scale with valium and received a total of 80mg PO with 2mg Ativan due to withdrawal symptoms - agitation, tachycardia, and tremulousness that resolved with treatment. Psych was consulted and did not feel that a section 12 was necessary at this time. . Of note, patient does admit to an admission at [**Hospital1 2025**] where he experienced seizures and self reports a diagnosis of delirium tremens. . On the floor, the patient feels shaky, anxious and tremulous. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: (from OMR, confirmed with patient) PAST MEDICAL HISTORY: - PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49342**] at [**Hospital **] Medical Associates in [**Location (un) 5110**], MA - s/p R nephectomy in [**2096**] [**2-3**] renal mass, HTN, dyslipidemia PAST PSYCHIATRIC HISTORY: (from OMR, confirmed with patient) - Unclear psychiatric diagnosis separate from his alcoholism. Historical diagnosis of MDD, anxiety, bipolar disorder. - Multiple past dual diagnosis hospitalizations, two at [**Hospital1 1680**] JP in the past month. - Medication trials include prozac, seroquel and benzos. - Pt reports one prior SA/SBI by stabbing himself once in [**2099**] in the RLQ, sought medical treatment at [**Hospital1 2025**]. Patient has scar on RLQ, but appears to be surgical incision, possibly from nephrectomy. Social History: - Tobacco: 1 pack/week - Alcohol: 1 qt of vodka daily, reportedly [**1-3**] gallon today; multiple in/outpatient detoxes; self-reported h/o withdrawal seizure at [**Hospital1 2025**] ([**2100**]), self-reported DT's (tremors and VHs, no ICU stays), and blackouts. Longest period of sobriety for three months ending a couple months ago (similar to past evaluations, patient vague about time frame.) - Illicits: denies IVDU, remote h/o benzo and cocaine abuse Family History: Father died of MI at age 70. Physical Exam: Vitals: T: 98.0 BP: 142/794 P:70 R: 16 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, 2x2 erythematous scaly patch on right thigh since last hospitalization Skin: Diffuse erythematous macules on back and chest, some excoriated, blanching. Erythematous face. Neuro: AAOx3, 5/5 strength all extremities, +tremor, no nystagmus Pertinent Results: Labs on Admission: [**2105-9-26**] 02:55PM BLOOD WBC-7.8 RBC-4.60 Hgb-14.8 Hct-42.5 MCV-92 MCH-32.3* MCHC-35.0 RDW-14.4 Plt Ct-313 [**2105-9-26**] 02:55PM BLOOD Neuts-59.3 Lymphs-31.9 Monos-5.6 Eos-1.2 Baso-2.0 [**2105-9-26**] 02:55PM BLOOD Glucose-147* UreaN-15 Creat-1.1 Na-144 K-3.8 Cl-102 HCO3-23 AnGap-23* [**2105-9-26**] 02:55PM BLOOD ALT-52* AST-60* LD(LDH)-197 AlkPhos-105 TotBili-0.5 [**2105-9-26**] 02:55PM BLOOD Albumin-4.3 Calcium-9.2 Phos-1.3*# Mg-1.9 [**2105-9-26**] 02:55PM BLOOD ASA-NEG Ethanol-277* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG . Labs on Discharge: [**2105-9-29**] 08:50AM BLOOD WBC-4.9 RBC-4.34* Hgb-13.6* Hct-40.7 MCV-94 MCH-31.3 MCHC-33.4 RDW-14.0 Plt Ct-209 [**2105-9-29**] 08:50AM BLOOD Glucose-94 UreaN-9 Creat-1.0 Na-140 K-4.5 Cl-104 HCO3-28 AnGap-13 [**2105-9-29**] 08:50AM BLOOD UricAcd-4.8 Brief Hospital Course: In the MICU [**Date range (3) 49343**]: 50 y/o male with known history of EtOH withdrawal and DTs who presents after SI while intoxicated, now with EtOH withdrawal symptoms. In the [**Name (NI) **], Pt received diazepam 80mg PO with lorazepam 2mg and a banana bag and another 20mg of diazepam with 1mg lorazepam overnight in the CCU. He felt better the following morning and was transferred to the medical floor. Psych did not recommend section 12. Pt also had an anion gap acidosis - (Gap of 19 on admission) that had closed by morning. . Called out to the medical floor, [**9-27**] - [**9-29**]: . # ETOH withdrawal, dependence - On folate, thiamine, CIWA. Continued to receive Valium through day 2 on medical floor for CIWA > 10. When patient's symptoms of withdrawal had resolved, he was discharged home with instructions for close follow-up. . # gout - Patient developed pain in right toe on the medical floor. Presentation consistent with acute gout. Started on naproxen and colchicine with significant improvement. . # depression with suicidality - Suicidal ideation resolved by the time of discharge. Patient was seen by psych who recommended dual diagnosis, however the patient refused. . # hepatitis, NOS - Mild elevation in ALT, AST. Most likely fatty liver vs. alcohol induced. . # follow-up: Consider HIV testing and would vaccinate for HAV and HBV. Medications on Admission: Zoloft Trazodone Norvasc "Cholesterol medication" Discharge Medications: 1. Outpatient Meds Patient does not know doses of home medications. Please continue taking trazodone and amlodipine as you have been directed. 2. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days: Please take for five days following discarge. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital with alcohol intoxication and withdrawal. You were given medication for your symptoms of withdrawal. By the time of discharge, your symptoms had resolved. Please do not drink alcohol. . You were also treated for pain that you experienced in your toe. We believe this was related to a condition called gout. Please take the Naprosyn (naproxen) 500 mg every twelve hours for the next five days for this pain in your toe. Followup Instructions: Please follow-up at the following time/place: . Department: [**Hospital3 249**] When: FRIDAY [**2105-10-16**] at 2:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ******PLEASE NOTE: YOU HAVE A MANAGED CARE INSURANCE PLAN AND YOU MUST CALL YOUR INSURANCE TO TELL THEM WHO YOUR PRIMARY CARE DOCTOR IS. DR [**Last Name (STitle) **] WORKS CLOSELY WITH DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PLEASE LIST DR [**First Name (STitle) **] AS YOUR PCP WITH YOUR INS. QUESTIONS PLEASE CALL NUMBER ABOVE.

29181,V6284,30301,311,4019,2749,5733,7821

Admission Date: [**2101-8-18**] Discharge Date: [**2101-8-24**] Date of Birth: [**2030-12-10**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman has had symptoms of shortness of breath and fatigue for approximately one year prior to admission. He underwent a cardiac echocardiogram on [**2101-5-5**] revealing a moderately enlarged left atrium with a torn chordae of the anterior mitral valve leaflet. There was also [**4-7**]+ mitral regurgitation, mild to moderate pulmonary hypertension. The patient was admitted to the [**Hospital1 188**] on [**2101-8-18**] for a cardiac catheterization. This revealed normal left ventricular ejection fraction of 65 percent as well as normal coronary arteries. It also showed moderate pulmonary hypertension with pulmonary artery pressures of 45/16 and the patient was referred for mitral valve repair versus replacement with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Mitral regurgitation. 3. Esophageal donut placed approximately 15 years ago. 4. Rectal fissure repair. 5. Back surgery in [**2056**]. ALLERGIES: The patient states allergies to Klonopin and all antidepressant medications which resulted in nausea and fatigue. PREOPERATIVE MEDICATIONS: 1. Lasix 20 mg p.o. q.d. 2. Potassium 10 mEq p.o. q.d. 3. Aspirin 81 mg p.o. q.d. LABORATORY DATA: The laboratory values preoperatively were unremarkable. PHYSICAL EXAMINATION: The patient's physical examination was unremarkable. SOCIAL HISTORY: The patient denied alcohol intake and was a cigar smoker for 20 years but quit three months prior to admission. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2101-8-19**] with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he underwent a mitral valve repair with a #28 CE anuloplasty band. Postoperatively, the patient was on a nitroglycerin drip and transported to the Cardiac Surgery Recovery Unit in good condition. The patient was successfully weaned from mechanical ventilation and extubated the night of surgery. He was in normal sinus rhythm with stable hemodynamic parameters. On postoperative day number one, beta blockers were initiated. His Swan-Ganz catheter was removed. On postoperative day number two, diuresis was initiated. The patient remained hemodynamically stable and was ready to be transferred to the telemetry floor. The patient, on postoperative day number three, had a number of hours of atrial fibrillation, was treated with increasing beta blockers as well as Amiodarone and before the following morning had converted to sinus rhythm with no further episodes of atrial fibrillation. Today, postoperative day number five, he remains hemodynamically stable and ready to be discharged home. Condition today: Neurologically, he was grossly intact with no apparent deficits. The pulmonary examination revealed that his lungs were clear to auscultation bilaterally. Coronary examination revealed a regular rate and rhythm. Sternal incision was clean with Steri-Strips clean, dry, and intact. His abdomen was benign. His extremities were warm without edema. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. b.i.d. for one week and then 200 mg p.o. q.d. for three weeks or until discontinued by Dr. [**Last Name (STitle) **]. 2. Lopressor 25 mg p.o. b.i.d. 3. Aspirin 325 mg p.o. q.d. 4. Zantac 150 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Dilaudid 2 mg p.o. q. 4-6 hours p.r.n. pain. 7. Lasix 20 mg p.o. b.i.d. times seven days. 8. Potassium chloride 20 mEq p.o. b.i.d. times seven days. DISCHARGE DIAGNOSIS: Mitral regurgitation, status post mitral valve repair. CONDITION ON DISCHARGE: Good. FOLLOW UP: The patient is to follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in one to two weeks, his cardiologist. He is also to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**], in one to two weeks. He is to follow-up with his cardiac surgeon, Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], in three to four weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 5664**] MEDQUIST36 D: [**2101-8-24**] 16:59:55 T: [**2101-8-24**] 17:46:57 Job#: [**Job Number 58312**]

4240,9971,42731,4295,2720,4169,E8789

Admission Date: [**2167-8-23**] Discharge Date: [**2167-9-10**] Service: SURGERY Allergies: Pronestyl / Clindamycin / Coumadin Attending:[**First Name3 (LF) 1481**] Chief Complaint: "I need a colonoscopy" Major Surgical or Invasive Procedure: [**8-24**] Colonoscopy [**8-25**] EGD with push enteroscopy [**8-25**] Exploratory laparotomy with right hemicolectomy History of Present Illness: [**Age over 90 **] yo female with a h/o CHF and anemia, who presents for bowel prep for a colonoscopy tomorrow AM. She reportedly has guaiac positive stools, but colonoscopy has not been completed [**1-29**] pt vomiting contrast material. She notes that she can eat solids and liquids, but the rate at which she can swallow is her limiting factor. Unclear what her baseline Hct is, but she has recently been hospitalized for CHF/PNA/"severe" anemia in [**Month (only) 404**] and again [**2167-1-28**] at [**Hospital3 **] Hospital. She states that she does get "dizzy" with standing abruptly, and has fallen multiple times, but mostly [**1-29**] decreased vision as opposed to orthostasis. She has had DOE for years, stable, able to walk half a mile or 1 flight of stairs before getting short of breath. No chest pain or pedal edema. On ROS, no constipation/diarrhea/melena/BRBPR/fever/chills/night sweats/PND/orthopnea/incontinence or other urinary symptoms. Past Medical History: Pacemake placed >25 years ago L Carotid stent placed 5-10 years ago Open heart surgery in 50s for VSD Has "lazy valve" per report Gout in [**2167**] resolved with ibuprofen Social History: Pt lives with her daughter in [**Name (NI) **] in [**Hospital3 **] on the weekends, and in [**Last Name (un) **] on the weekends at home. Has 2 cats and 1 dog. Drinks 1.5 cups of whiskey+soda daily, no smoking/IVDU Family History: No family h/o CA, DM, heart disease Physical Exam: T 98.5 BP 170/70 P 72 RR 20 93% O2 Sats RA Gen: Pleasant woman in NAD, appears younger than stated age HEENT: Clear OP, MMM, L surgical pupil, R pupil reactive at 1 cm, vision impaired bilaterally; can detect light and large objects. NECK: Supple, No LAD, JVP at 8-10 cm, No bruits CV: RR, NL rate. NL S1, S2. Early diastolic murmur loudest over apex LUNGS: bibasilar fine crackles ABD: Soft, NT, mild epigastric tenderness to deep palpation. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: [**2167-8-23**] 03:45PM WBC-10.5 RBC-3.96* HGB-11.2* HCT-34.1* MCV-86 MCH-28.2 MCHC-32.7 RDW-15.4 [**2167-8-23**] 03:45PM PLT COUNT-310 [**2167-8-23**] 03:45PM PT-12.6 PTT-26.6 INR(PT)-1.1 [**2167-8-23**] 05:10PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.8 [**2167-8-23**] 05:10PM LIPASE-29 [**2167-8-23**] 05:10PM ALT(SGPT)-35 AST(SGOT)-48* ALK PHOS-91 AMYLASE-77 TOT BILI-0.5 [**2167-8-23**] 05:10PM GLUCOSE-546* UREA N-23* CREAT-0.8 SODIUM-134 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12 [**2167-8-23**] 05:10PM BLOOD Lipase-29 [**2167-8-23**] 05:10PM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.8 Mg-1.8 Pre-operative Labs: [**2167-8-25**] 10:37PM BLOOD WBC-12.7* RBC-3.60* Hgb-10.3* Hct-31.1* MCV-87 MCH-28.6 MCHC-33.1 RDW-15.4 Plt Ct-301 [**2167-8-25**] 03:50PM BLOOD Neuts-85* Bands-5 Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2167-8-25**] 10:37PM BLOOD PT-13.3* PTT-26.8 INR(PT)-1.2* [**2167-8-25**] 10:37PM BLOOD Glucose-91 UreaN-30* Creat-1.4* Na-142 K-3.6 Cl-101 HCO3-25 AnGap-20 [**2167-8-25**] 10:37PM BLOOD CK(CPK)-59 [**2167-8-25**] 10:37PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2167-8-25**] 10:37PM BLOOD Calcium-8.3* Phos-4.8*# Mg-1.5* Discharge Labs: [**2167-9-8**] 03:15AM BLOOD WBC-14.5* RBC-2.69* Hgb-8.0* Hct-23.6* MCV-87 MCH-29.6 MCHC-33.9 RDW-17.3* Plt Ct-444* [**2167-9-8**] 03:15AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.1 [**2167-9-8**] 03:15AM BLOOD Plt Ct-444* [**2167-9-8**] 03:15AM BLOOD Glucose-57* UreaN-27* Creat-1.0 Na-142 K-3.6 Cl-105 HCO3-28 AnGap-13 [**2167-9-8**] 03:15AM BLOOD Phos-3.1 Mg-1.7 [**2167-9-8**] 03:26AM BLOOD Type-[**Last Name (un) **] pH-7.36 Comment-GREEN TOP [**2167-9-8**] 03:26AM BLOOD freeCa-1.11* Microbiology: [**2167-8-25**] 5:50 pm SWAB Site: PERITONEAL REC'D AT 11:30 PM. GRAM STAIN (Final [**2167-8-27**]): [**2167-8-26**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1052**] [**Last Name (NamePattern1) 5259**] AT 4:00 AM. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). aureus and beta streptococcus). GRAM NEGATIVE ROD(S). MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. PROBABLE ENTEROCOCCUS. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. [**2167-8-31**] 9:52 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2167-9-3**]** MRSA SCREEN (Final [**2167-9-3**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin sensitivity performed by agar screen. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | OXACILLIN------------- R [**2167-8-31**] 9:49 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2167-9-3**]** GRAM STAIN (Final [**2167-8-31**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2167-9-3**]): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. [**2167-9-7**] 3:49 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): [**2167-9-7**] 3:49 pm SWAB Site: RECTAL R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary): No VRE isolated. CT CHEST W/CONTRAST [**2167-8-25**] 4:33 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: please evaluate for perforation Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with severe abdominal pain s/p colonoscopy. REASON FOR THIS EXAMINATION: please evaluate for perforation CONTRAINDICATIONS for IV CONTRAST: None. EXAMINATION: CT abdomen. INDICATION: Severe abdominal pain post-EGD. FINDINGS: A CT of chest and abdomen was performed with axial images taken from the lung apices to the symphysis pubis. IV contrast only was administered. On the CT of thorax there is some soft tissue in the apices bilaterally which may represent apical scarring. This patient has a pacemaker with two leads in situ. The pulmonary arteries are very large and the left atrium is also prominent. The appearances may be consistent with pulmonary hypertension. The patient has cardiomegaly. On the lung windows there is emphysematous change in the lungs and some scattered scarring. Anterior to the distal esophagus there is some free air. Below the diaphragm air is seen to extend along the posterior part of the caudate lobe and along the falciform ligament. Free air is also seen anterior to the left lobe of the liver. More inferiorly free air is seen posterior to the tip of the right lobe of the liver. There is intrahepatic bile duct dilatation. The common bile duct measures 1 cm. The appearances may be consistent with the patient's age. The spleen is normal. The adrenals and kidneys are unremarkable. The bowel where visualized is normal. CT PELVIS: Some free fluid is seen in the pelvis and extending to the right side of the rectum. Several diverticula are seen in the sigmoid colon. BONY WINDOWS: Degenerative changes noted throughout the spine. There is a high-density medium in the spinal canal which may represent previous Thorotrast examination. IMPRESSION: Status post perforation from recent examination most likely secondary to EGD. Free air seen extending into the mediastinum from the inferior esophagus and extending down into the abdomen around the liver and into the falciform ligament. Bilateral pleural effusions and atelectasis. Biapical scarring and emphysema. Cardiomegaly and enlarged pulmonary arteries which may be secondary to pulmonary hypertension. Diverticula in the sigmoid colon. Free fluid in the pelvis. Degenerative change in the spine. Intra- and extra-hepatic bile duct dilatation. Possible Thorotrast exposure in the spinal canal. Cardiology Report ECHO Study Date of [**2167-8-27**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Valvular heart disease. Height: (in) 62 Weight (lb): 104 BSA (m2): 1.45 m2 BP (mm Hg): 108/35 HR (bpm): 60 Status: Inpatient Date/Time: [**2167-8-27**] at 09:19 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.51 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 65% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: *3.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) Mitral Valve - Mean Gradient: 6 mm Hg Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - E Wave Deceleration Time: 566 msec TR Gradient (+ RA = PASP): *50 to 60 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: *1.2 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Normal regional LV systolic function. RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. Moderate thickening of mitral valve chordae. Moderate MS. Mild to moderate ([**12-29**]+) MR. TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Left pleural effusion. Conclusions: 1. The left atrium is moderately dilated. The right atrium is moderately dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The right ventricular cavity is moderately dilated. There is severe global right ventricular free wall hypokinesis. 4. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is moderate thickening of the mitral valve chordae. There is moderate mitral stenosis. Mild to moderate ([**12-29**]+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. OPERATIVE REPORT Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 66760**] Service: Date: [**2167-8-25**] Surgeon: [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD 2205 PREOPERATIVE DIAGNOSIS: Perforated viscus. POSTOPERATIVE DIAGNOSIS: Perforation of the right colon. SURGICAL PROCEDURE: Laparotomy, right colectomy and abdominal washout. ASSISTANT: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD (RES) ANESTHESIA: General. INDICATIONS: This elderly woman has undergone 2 endoscopic procedures with therapy in 2 days. These have included a colonoscopy with BICAP of angiodysplastic lesions in the cecum, as well as removal of a sigmoid polyp. On the following day, she had a push enteroscopy with BICAP of several lesions in her stomach. She originally did well, but then developed the sudden onset of abdominal pain and had free air under the diaphragm, confirmed both by upright chest x-ray and CT scan. She is complaining of abdominal pain with tenderness and has been given the option of surgical treatment. At [**Age over 90 **] years old, she does wish to undergo surgery, as there is a reasonable chance of fixing the problem. PREPARATION: In operating room, the patient was given a general endotracheal anesthetic. Intravenous antibiotics were given, 2 grams of heparin and boots. The abdomen was prepared with Betadine solution and draped in the usual fashion. INCISION: A midline incision was made incorporating a portion of the old lower midline incision with another upward extension part way up between the umbilicus and the xiphoid. The abdomen then opened and explored. FINDINGS: There was a pneumoperitoneum. There were some adhesions from her old surgery in the midline. There were also adhesions from her cholecystectomy to the liver. There was purulent fluid in the abdomen, a small but modest amount. There was a small amount of free stool spillage from a tiny perforation of the right colon. There was another perforation which was even smaller, a centimeter or two away, in the right colon. There were no other perforations that we could see. PROCEDURE IN DETAIL: The abdomen was opened. The adhesions were lysed. We were able to suck out purulent fluid and find the perforation in the cecum, which was closed over with silk suture. The abdomen was then irrigated copiously after control of the spill was accomplished. We also ran the bowel and found several small diverticula of the small bowel which were totally intact. There was no injury to the small bowel. There did not appear to be any problem with the stomach. The sigmoid colon also appeared to be normal, although there were some adhesions down to the pelvis. It was my feeling that the best therapy here would be a right colectomy, in that the patient had a diseased right colon to begin with, and the cause of the bleeding most likely. It also appeared to be relatively thin walled and I was worried that if I had oversewn the 2 areas where there were perforations present now, that some of the other treated areas, of which there were approximately 10, might become problem[**Name (NI) 115**] in the next several days. Therefore, we mobilized the right colon at the white line of Toldt. The hepatic flexure was taken down. The omentum was taken off the transverse colon. We selected our resection margin, taking only approximately 3 or 4 inches of terminal ileum. We then extended our resection down well around to the mid transverse colon, in order to ensure that we had gotten all of the areas of vascular malformation seen in the descending and ascending colon. Bowel was cleaned off and [**Female First Name (un) 3224**] stapler was applied across both the ileum and the colon. Mesentery was then taken between clamp with 2-0 silk ties. The specimen was sent off the field. Due to the lateness of the hour, it was not open. We then oversewed the staple line with interrupted sutures of 3-0 silk. A side-to-side anastomosis was then created using interrupted 3-0 silk in a single layer. The posterior row was placed of sutures of 3-0 silk and then tied down. The colon and ileum were then opened and the anterior row was placed. The neck of the anastomosis was quite wide and spacious. There was no evidence of leak. It was noted that gas and liquid stool would pass without problem. The mesentery was then closed with the 3-0 silk. The areas were inspected and were dry. CLOSURE: The fascia was closed with a running suture of #1 PDS. The skin was closed with a stapling device. Dry sterile dressings were applied. The patient was then extubated and sent to the recovery area in satisfactory condition, having tolerated the procedure well. DRAINS: None. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal. Brief Hospital Course: Ms. [**Known lastname 4427**] had been admitted to [**Hospital1 18**] on [**8-23**] under the medical service for a colonoscopy secondary to her inability to tolerate the oral contrast and a history of congestive heart failure and anemia, along with her age of [**Age over 90 **] years. The colonoscopy demonstrated multiple diverticula and angioectasias which were cauterized. It was recommended that she undergo an enteroscopy and be placed on iron replacement therapy. The small bowel enteroscopy was performed on [**8-25**] which showed gastric angioectasias that were cauterized and duodenal diverticula. She developed acute abdominal pain with peritoneal signs after her small bowel enteroscopy. An abdominal x-ray showed free air under the diaphragm. An abdominal and pelvic CT scan was done which showed free intraperitoneal air and perforation. The surgical service was consulted and she was taken to the operating room under the care of Dr. [**Last Name (STitle) **] for an exploratory laparotomy and right hemicolectomy on [**8-25**]. She was started on intravenous Zosyn and Flagyl pre-operatively and gram negative rods were found on a peritoneal swab intra-operatively and continued for a total of fourteen days. Ampicillin was added on POD 4 after a nasal swab confirmed Staph Aureus Coag + and was completed after four days of treatment and a repeat culture showing no growth. Post-operatively she developed low urine output and hypotension and was admitted to the surgical intensive care unit. Her creatinine was found to be elevated at 1.7 which was thought to be related to the CT scan contrast. On POD 2 a Levophed drip was started to maintain her systolic blood pressure greater than 110 and a renal consultation was initiated. The renal service recommended more intravenous resuscitation and then challenging with Lasix. An echocardiogram was also done in the setting of her history of congestive heart failure, her central venous pressures of 16 and low urine output. This showed her systolic function to be >55% along with mild pulmonary hypertension, tricuspid, and mitral regurgitation. On POD 3 her respiratory status deteriorated and she was not tolerating continous positive airway pressure via a face mask. An arterial blood gas demonstrated respiratory and metabolic acidosis. A chest x-ray confirmed pulmonary edema. She had persistent anuria after Lasix, Bumex, and intravenous fluids. Hemodialysis was also started on POD 3 by the renal service after her persistent anuria and a creatinine of 3.7. After discussion with her family, the patient's advanced orders of not intubating were rescinded but the order of no resuscitation with chest compressions was maintained, she was intubated and mechanically ventilated on POD 3. A Dobbhoff feeding tube was placed on POD 5 and tube feeds were started. On POD 6 the dialysis was stopped secondary to an increase in urine output but was resumed on POD 7 after her weight was noted to have increased, she was anuric, and pulmonary failure was noted on chest x-ray. The Levophed drip continued along with mechanical ventilation. On POD 6 and 7 she was transfused a total of two units of packed red blood cells for a hematocrit of 24 and 21 with no active signs of bleeding, with a good response in her hematocrit. On POD 9 the Levophed was discontinued and hemodialysis was stopped secondary to improvement in her renal function; her serum creatinine was 0.7, and her urine output was satisfactory. On POD 10 she was successfully extubated. POD 12 a diet was resumed, she remained afebrile, and her central venous catheter was removed secondary to an increased white blood cell count of 15.5k; the tip was cultured with no growth found. Diuresis continued with daily Lasix with a good response in her urine output. On HD 13 her Dobbhoff was removed and she was tolerating a regular diet. At the time of discharge she was afebrile, oxygenating well on 3 liters nasal cannula, tolerating a regular diet with +bowel movements and +flatus. She had completed her antibiotic course and her white blood cell count was stable at 12.9k. On HD18, she had an episode of hypoglycemia (40 mg/dl). Her insulin was held, she was given glucose, and she recovered without incident. The Lasix was continued daily with the dose decreased from 40mg to 20mg, her BUN was 29 with a creatinine of 0.9. She was hemodynamically stable at the time of discharge with a hematocrit of 25.2. She was transferred to [**Hospital1 599**] of [**Hospital 23638**] rehabilitation facility for further strength and mobility training. Medications on Admission: Lorazepam 0.5 mg PO HS:PRN anxiety Multivitamins 1 CAP PO DAILY Atorvastatin 10 mg PO HS Digoxin 0.125 mg PO DAILY Furosemide 40 mg PO DAILY Trandolapril 8 mg PO DAILY Occuvite Nexium 40 Plavix 75 (held) Calcium qd Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Other Sig: Zero (0) every six (6) hours: Fingersticks to be done every 6 hours with Regular Insulin Sliding Scale. 9. Lasix 20mg Tablet Sig: One (1) Tablet PO once a day. 10. Acetaminophen 500 mg/5 mL Liquid Sig: One (1) PO every six (6) hours as needed for pain: Dose should equal 650mg or 6.5ml. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Lorazepam 0.5 mg PO QHS for insomnia Discharge Disposition: Extended Care Facility: Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**] Discharge Diagnosis: Anemia Perforated bowel Discharge Condition: Good Discharge Instructions: Notify your MD or return to the emergency department if you experience: *Increased or persistent pain *Fever > 101.5 *Nausea or vomiting *Inability to pass gas or stool *If incision appears red, is warm, or if there is drainage *Any other symptoms concerning to you Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, call ([**Telephone/Fax (1) 8818**] for an appointment

56985,4928,39891,3963,3970,9982,2762,5849,2851,42731,53782,2113,V4501,E8788

Admission Date: [**2130-9-28**] Discharge Date: [**2130-10-6**] Date of Birth: [**2130-9-28**] Sex: F Service: Neonatology HISTORY: Baby Girl [**Known lastname 62319**] is the [**2080**] gram product of a 34- [**4-17**] week gestation born to a 35 year old G2 P0 now 1 mother. Prenatal screens were O positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Maternal history of uterine fibroids and recurrent abdominal pain during this pregnancy. Previous evaluations consistent with left fibroid pain and left ovarian cyst. Mother presented at [**Hospital1 190**] on [**9-26**] with right abdominal pain. Admitted to antepartum floor. On ultrasound on the day of delivery, had features consistent with right ovarian torsion. Mother's maximum temperature was 100.4. The decision was made to deliver the infant by cesarean section. Of note, recent fetal scan was suggestive of horseshoe kidney. No other anomalies identified. Maternal medications included Dilaudid and non steroidal anti- inflammatories. SOCIAL HISTORY: The father is involved and is a physician at [**Hospital6 33**]. The infant emerged with good tone and grimace. Routine bulb suctioning. Dried, stimulated, and responded well, with spontaneous cry and improved color. Apgars were 8 and 9. PHYSICAL EXAMINATION ON ADMISSION: Weight [**2080**] grams (25th percentile), length 43.25 cm (25th percentile), head circumference 32.25 cm (50th percentile). Pink, comfortable, eyes open, looking around. Non dysmorphic. Palate intact. Red reflex x 2. Ears normal set without anomalies. Neck supple with no masses. Clavicles intact. Lungs clear to apex, fair to good aeration. Positive subcostal retractions, but no flaring or grunting. Cardiovascular - Regular rate and rhythm. No murmur. 2+ femoral pulses. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. Three vessel cord. Genitourinary - Normal preterm female. Patent anus. Stable hips. No sacral anomalies. Extremities pink, well perfused, except for mild acrocyanosis. Good grasp, plantar reflex, symmetric Moro. HOSPITAL COURSE: 1. RESPIRATORY. [**Doctor First Name 21212**] has been stable in room air throughout hospital course. 2. CARDIOVASCULAR. Has had no issues. 3. FLUID AND ELECTROLYTES. Birth weight was [**2080**] grams. Discharge weight is 1890 gms. She was initially started on 60 cc/kg/day of D10W. Enteral feedings were started at 24 hours of age. Infant is currently ad lib feeding breast milk or Enfamil 24 calorie, taking in good amounts. 4. GASTROINTESTINAL. Peak bilirubin was on day of life 3 of 11.2/0.3. She received phototherapy, and the issue has resolved. 5. HEMATOLOGY. Hematocrit on admission is 54. She has not required any blood transfusions. 6. INFECTIOUS DISEASE. A CBC and blood culture were obtained on admission. CBC was benign, and blood culture remained negative at 48 hours, at which time ampicillin and gentamicin were discontinued. 7. NEUROLOGIC has been appropriate for gestational age. 8. SENSORY. Audiology - Hearing screen was performed with automated auditory brainstem responses. Infant passed bilerally. 9. GENITOURINARY. A renal ultrasound was done on [**10-2**], revealing a horseshoe kidney. There was no hydronephrosis evident. CONDITION ON DISCHARGE: Stable. DISPOSITION: To home. VNA arranged for [**10-7**]. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Telephone/Fax (1) 51822**]. Appointment scheduled for [**10-9**]. CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk 24 calorie, Enfamil 24 calorie, or ad lib breast feeding. MEDICATIONS: Not applicable. CAR SEAT POSITION SCREENING: Was performed, and the infant passed. STATE NEWBORN SCREENING: Screens have been sent per protocol, and have been within normal limits. The infant received hepatitis B vaccine on [**10-5**]. DISCHARGE DIAGNOSES: 1. Premature infant born at 34-3/7 weeks. 2. Rule out sepsis, with antibiotics. 3. Horseshoe kidney. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2130-10-5**] 20:50:49 T: [**2130-10-5**] 23:19:22 Job#: [**Job Number 62320**]

V3001,7533,7742,7608,76527,76517,V290,V053

Unit No: [**Numeric Identifier 57244**] Admission Date: [**2132-12-8**] Discharge Date: [**2133-3-13**] Date of Birth: [**2132-10-16**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is a 696 gram product of a 24 and [**1-19**] week twin gestation with estimated date of confinement of [**2133-2-3**], born to a 28-year- old gravida 3, para 0, mom with prenatal screens - blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group beta strep status unknown. This pregnancy was complicated by prenatal neural tube defect in the sibling of this infant. This infant subsequently died on [**10-31**], secondary to complications from the neural tube defect. Pregnancy otherwise uncomplicated until mom went into unstoppable preterm labor. She had spontaneous rupture of membranes and was treated with antibiotics prior to delivery. This infant was delivered by cesarean section because of transverse lie. She had Apgar scores of 6 at 1 minute, and 7 at 5 minutes of age. She was dried and received bulb suctioning and was intubated in the delivery room. She was always active and vigorous. She was transported to the newborn intensive care unit for management of prematurity. PHYSICAL EXAMINATION: Weight 696 grams (25th to 50th percentile), head circumference 23 cm (10th percentile), length 32.5 cm (10th to 25th percentile). VITAL SIGNS: Temperature 92.9 rectally, heart rate 148, respiratory rate 64, blood pressure 34/16 with a mean arterial pressure of 22, blood glucose 77. HEENT: Anterior fontanel open and flat. Lips, gums and palate intact. Skin bruising noted on arms and legs and head. Neck supple. LUNGS: Intercostal retractions and coarse breath sounds noted. HEART: Regular rate and rhythm. No murmurs. 2+ femoral pulses bilaterally. ABDOMEN: Soft. No active bowel sounds. EXTREMITIES: Capillary refill brisk. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 57245**] was admitted to the newborn intensive care unit and placed on conventional mandatory ventilation shortly after admission. She received 3 doses of surfactant. She was switched to hi-fi ventilation on day of life 1 for worsening ventilation and oxygenation. She received several doses of bicarb in the first week of life for a persistent metabolic acidosis. She remained on hi-fi oscillatory ventilation until day of life 25 when she was switched back to conventional mandatory ventilation. She was started on Combivent on day of life 21 and Flovent on day of life 25. Flovent was weaned off by day of life 43. Caffeine citrate was started on day of life 34 for apnea of prematurity. This was subsequently discontinued on day of life 88. Diuril was started on day of life 36 for chronic lung disease and Aldactone was started on day of life 75 also for chronic lung disease. She was extubated to continuous positive airway pressure on day of life 82. She required reintubation on day of life 111 secondary to complications from eye drops and eye examination. She was placed back on CPAP on day of life 117. She transitioned to vapotherm (high flow humidified oxygen) on day of life 25, and then finally to nasal cannula oxygen 200 cc, 100% by day of life 141 ([**3-6**]). She remains on Diuril and Aldactone. She also has been receiving Lasix twice a week. Gas on day of discharge is: 7.35/61 Of note, infant had elevated pancreatic enzymes noted on newborn screen that decreased with sample post blood transfusion. The newborn screen was negative for CF mutations BUT given that there are other potential mutations and pancreatic enzymes were very elevated, newborn screening program recommended obtaining a sweat test at~2 months of age. CARDIOVASCULAR: [**Known lastname 57245**] received multiple fluid boluses and was started on dopamine for hypotension on the date of delivery. Dopamine was weaned off on day of life 2. She was treated with 2 courses of indomethacin for patent ductus arteriosus. The second course of indomethacin ended on day of life 5. A follow up echo on [**10-22**] showed a persistent patent ductus arteriosus. She was transferred to [**Hospital3 **] at 7 days of age for patent ductus arteriosus ligation. Dopamine was restarted on day of life 6 for continued hypotension. She remained on dopamine through day of life 15 with maximum dose reaching 25 mcg per kg per minute. Dopamine requirement likely related to presumed sepsis going on at this time although she did receive 2 doses of hydrocortisone, the first on [**10-27**] and the second on [**12-3**], for presumed adrenal insufficiency which subsequently helped her to wean off of the dopamine. She continues to have a soft murmur. Last echo on [**10-30**] showed good bilateral ventricular function. She will receive a baseline echocardiogram prior to her discharge. FLUIDS, ELECTROLYTES AND NUTRITION/ GASTROINTESTINAL: Upon admission to the newborn intensive care unit, umbilical arterial catheter and umbilical venous catheters were placed. Intravenous fluids of D5W were started at 100 cc per kg per day. Her maximum fluid volume reached 180 cc per kg per day by day of life 5. [**Known lastname 57245**] had an acute episode on [**10-27**] with hypotension and abdominal distention. Although there were no corresponding radiographic signs this was presumed to be necrotizing enterocolitis. She was started on antibiotics at that time and watched clinically for progressing signs of acute peritonitis. After this episode on [**10-27**], the patient had progressive worsening of abdominal distention. A contrast enema was performed on [**11-26**] which was within normal limits revealing no structural defects and no overt colonic obstruction. Upper gastrointestinal was performed on [**12-1**] which showed delayed contrast into the jejunal junction. Trophic feeds of breast milk at 20 calories per ounce were started on [**11-17**] and held on [**11-20**] secondary to repeated biliary aspirates and worsening abdominal distention. This prompted the above two studies, the contrast enema and upper gastrointestinal. [**Known lastname 57245**] has also had issues with indirect hyperbilirubinemia. On [**11-5**], the bilirubin was total 4.2 with an indirect of 2.3. On [**12-1**], her bilirubin was 4.8 with an indirect of 3.3. This indirect hyperbilirubinemia was likely due to a total parenteral nutrition cholestasis. The trace elements were removed from her parenteral nutrition. In addition carnitine was added to her daily parenteral nutrition. Liver function tests were normal on [**11-7**]. On [**11-25**] they were mildly elevated with the following values: ALT of 158, AST of 242, and alkaline phosphatase of 533. [**Known lastname 57245**] had a right middle quadrant, right lower quadrant abdominal mass discovered on ultrasound on [**2132-11-5**]. This abdominal mass was of unknown etiology despite repeated serial abdominal ultrasounds on [**11-12**], [**11-24**] and [**12-1**]. In addition the patient received a noncontrast abdominal CT on [**11-7**]. This abdominal mass has been confirmed to be extraluminal, and not within the parenchyma of the liver. Abdominal ultrasound on [**11-24**], revealed evolving calcifications within this mass as well. Contrast enema on [**11-26**] revealed that this mass is not likely to be causing any colonic obstruction. In addition upper gastrointestinal series on [**12-1**] revealed that this mass is not likely to be causing any small bowel obstruction as well. The patient had several meconium stools after the barium enema on [**11-26**]. On [**12-3**], the patient was taken for an exploratory laparotomy at [**Hospital1 57246**] hospital to assess the abdominal mass No. 1 and No. 2 to assess the patient's lower colonic small bowel strictures. The exploratory laparotomy revealed multiple ileal perforations and adhesions. The perforations were oversewn and the procedure was tolerated well. [**Known lastname 57245**] returned to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**12-8**]. She remained NPO until do 62 at which time trophic feeds were started. She was advanced over to full volume feeds by day of life 76. Caloric density was increased to maximum of 33 calories per ounce breast milk with ProMod. Reglan was started on day of life 63. A rectal tube was placed on day of life 62 to administer normal saline enemas on a regular basis to promote stool passage. This was discontinued on day of life 73. She is currently received PO, PG feeds of NeoSure or breast milk concentrated to 28 calories per ounce. Her weight at the time of transfer is 3.9 kg. Her last electrolytes on [**3-10**] were sodium of 140, potassium 4.3, chloride 94 and bicarb of 39. On [**3-6**], her calcium was 10.9, alkaline phosphatase 483. HEMATOLOGY: [**Known lastname 57245**]'s blood type is O positive, direct antibody test negative. She has received a total of 14 packed red blood cells transfusions and one platelet transfusion during her newborn intensive care unit hospitalization. Her last hematocrit on [**3-10**] was 34.7 with a reticulocyte count of 2.2. INFECTIOUS DISEASE: Upon admission to the newborn intensive care unit, CBC and blood cultures were drawn and the infant was placed on ampicillin and gentamycin. Blood culture at this time was negative. CBC was remarkable for initial white blood cell count of 5.3. She remained on ampicillin and gentamycin for 7 days at which time they ampicillin and gentamycin were discontinued. Vancomycin and gentamycin were restarted on day of life 6 for presumed episode of necrotizing enterocolitis. The patient was also put on clindamycin at that time. On [**11-7**], the antibiotic regimen was changed to vancomycin, meropenem, and amphotericin secondary to this abdominal mass of unknown etiology. The patient remained on this regimen for 2 weeks at which time only meropenem was continued secondary to the unresolving abdominal mass. On [**12-1**], vancomycin was added to the regimen for the presence of a low grade temperature. This was discontinued on [**12-3**] once blood cultures showed no growth at 48 hours. The patient has had no positive blood cultures throughout her hospital course. The meropenem was discontinued postoperatively after the exploratory lap. Vancomycin and gentamycin were restarted on day of life 62 for increased abdominal distention. Blood culture was negative at that time and vancomycin and gentamycin were discontinued after 48 hours. Vancomycin and gentamycin were again restarted on day of life 112 for an acute respiratory decompensation and presumed pneumonia. Vancomycin was discontinued and presumed pneumonia was ultimately treated for 7 days with gentamycin, Zosyn and oxacillin. She had thrush which was treated with nystatin from day of life 120 to 134. NEUROLOGY: [**Known lastname 57245**] had normal head ultrasounds on [**10-17**], [**10-20**], [**10-24**], [**10-27**], [**11-19**], and [**1-8**]. Head ultrasound on [**3-4**] showed asymmetry of the lateral ventricles, the left being larger than the right with increased echogenicity lateral to the left lateral ventricle. A follow up MRI on [**3-5**] was normal. [**Known lastname 57245**] was on Fentanyl infusions and boluses on and off for the first 2 months of age. SENSORY: 1. Audiology: [**Known lastname 57245**] has not yet had a hearing screening. 2. Ophthalmology: [**Known lastname 57245**]'s last examination was on [**3-9**] which showed regressing ROP, stage 2, zone 2. She is to get a follow up ophthalmology examination in 2 weeks. PSYCHOSOCIAL. [**Known lastname 57245**] has involved in loving parents. [**Doctor First Name **]- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] social work is involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) **]. CONDITION AT THE TIME OF TRANSFER: [**Known lastname 57245**] is stable on nasal cannula oxygen 200 cc, 100%. DISCHARGE DISPOSITION: To [**Hospital3 1810**] via ambulance for G-tube placement. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1787**] [**Last Name (NamePattern1) **], at [**Hospital3 1810**]. Phone: [**Telephone/Fax (1) 38541**]. CARE RECOMMENDATIONS: [**Known lastname 57245**] has been NPO since 4 a.m. Intravenous fluids of D10W with 2 mEq of sodium chloride and 1 mEq of potassium chloride infusing at 100 cc per kg per day. MEDICATIONS: On hold for now. CAR SEAT POSITION SCREEN: Pending. THE STATE NEWBORN SCREEN: The last State Newborn Screen was sent on [**1-2**]. No abnormal results have been reported. IMMUNIZATIONS RECEIVED: [**Known lastname 57245**] received Hepatitis B vaccine on [**12-17**] and [**1-30**]. DTAP vaccine on [**12-17**], and [**2-19**], HIB vaccine [**12-16**] and [**2-19**], IPV vaccine on [**12-17**], and [**2-19**]. Prevenar vaccine on [**12-15**], and [**2-19**], and Synagis vaccine on [**3-5**]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria. A. Born within 32 weeks. B. Born between 32 and 35 weeks with two of the following: 2. daycare during the RSV season. 3. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 4. with chronic lung disease. 1. 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. Follow up appointments with infant include: A sweat test is recommended for [**Known lastname 57245**] when age appropriate. [**Known lastname 57245**] will be followed by pulmonology, the name is [**Name (NI) 4468**] [**Name (NI) 37305**] at [**Hospital3 **]. [**Known lastname 57245**] will also be followed by care group VNA ([**Hospital6 **]). Tel No. [**Telephone/Fax (1) 57247**]. Fax No [**Telephone/Fax (1) 57248**]. [**Known lastname 57245**] will be getting her G-tube supplies, formula, oxygen and home monitor through [**Location (un) 511**] Home Therapy. Phone No. 1-[**Telephone/Fax (1) 33819**]. DISCHARGE DIAGNOSIS: 1. Prematurity at 24 and 2/7 weeks. 2. Respiratory distress syndrome. 3. Presumed sepsis. 4. Patent ductus arteriosus status post patent ductus arteriosus ligation. 5. Necrotizing enterocolitis. 6. Ileal perforations status post exploratory lap and oversew. 7. Direct hyperbilirubinemia. 8. Physiologic jaundice. 9. Apnea of prematurity. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2133-3-12**] 22:12:31 T: [**2133-3-13**] 00:10:46 Job#: [**Job Number 57249**]

7707,7742,7775,7793,78341,769,77081,36221,7766

Unit No: [**Numeric Identifier 57244**] Admission Date: [**2133-3-13**] Discharge Date: [**2133-3-19**] Date of Birth: [**2132-10-16**] Sex: F Service: Neonatology ADDENDUM: Please see previously detailed discharge summary for hospital course by systems. This dictation covers the period from [**3-13**] through [**2133-3-19**], postoperatively from gastrostomy tube placement. System number one: Respiratory. [**Known lastname 57245**] is stable on nasal cannula oxygen, 200 cc flow, 100 percent. Her baseline respiratory rate is 40 to 60 breaths per minute. She is being discharged on oxygen and diuretics, Diuril and Aldactone. She will be seen in pulmonary clinic with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] at [**Hospital3 1810**]. As noted in the previous discharge summary Myelia had elevated pancreatic enzymes noted on initial newborn screen that decreased with sample post blood transfusion. The newborn screen wa negative for CF mutations BUT given that there are other potential mutations and pancreatic enzymes were very elevated, newborn screen program recommended obtaining a sweat test at ~2 months of age. Baseline ABG obtained [**3-19**]: 7.35/61/64 on RA System number two: Cardiovascular. A murmur remains audible at the time of discharge. A recent echocardiogram on [**2133-3-6**] showed a patent foramen ovale with left to right flow and a slightly dilated right ventricle with good function. Recent blood pressure is 80/44 with a mean of 67. Baseline heart rate is 120 to 150 beats per minute. System number three: Fluids, electrolytes and nutrition. [**Known lastname 57245**] is allowed to p.o. feed ad lib from 6 a.m. to 6 p.m. during the day. At night, her total volume is adjusted to deliver 130 cc/kg per day via the gastrostomy tube and pump. Her formula is either breast milk or Similac, both fortified to 30 calories per ounce. The formula is four scoops of unpacked powdered formula to 185 cc of water. The breast milk is 1.5 tsp of Similac formula powder to 70 cc of breast milk. An additional four calories per ounce is added by 0.5 cc of corn oil. Weight on the day of discharge is 3.99 kg with a length of 54 cm and a head circumference of 38 cm. lytes on [**3-19**]: 134/5.1/94/34 System number four: Gastrointestinal. [**Known lastname 57245**] had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] gastrostomy tube placed on [**2133-3-13**] for postoperative recovery. This has been uneventful. System number five: Sensory. Audiology: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname 57245**] passed in both ears. Ophthalmology: Most recent eye examination was on [**2133-3-9**], showing regressing stage II retinopathy of prematurity. Follow up is recommended with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 1810**]. System number six: Psychosocial. The patient's name, after discharge, will be Wornum. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 56128**] [**Last Name (NamePattern1) **], [**Hospital3 1810**], [**Hospital1 9796**], [**Location (un) 86**], [**Numeric Identifier **]. Phone number [**Telephone/Fax (1) 57250**]. Fax number [**Telephone/Fax (1) 38542**]. CARE AND RECOMMENDATIONS: 1. Feeding: Feeding to be by p.o. or by gastrostomy tube feeding for a total of 130 cc/kg per day of breast milk or Similac, 30 calories per ounce. 2. Medications: Diuril 80 mg p.o. twice a day. Aldactone 12 mg p.o. once daily. Lasix 8 mg twice weekly on Monday and Thursday p.o.. Ferrous sulfate 25 mg/ml dilution, 0.3 ml p.o. once daily. Prilosec 4 mg p.o. once daily. Potassium chloride supplement, 6 meq twice a day. Reglan 0.4 mg p.o. three times daily, one-half hour before feeding. 1. Car seat position screening was performed. [**Known lastname 57245**] was observed for 90 minutes in her car seat without any episodes of oxygen desaturation or bradycardia. 2. No new additional state screens have been sent. Last was on [**2133-1-2**], with normal results. 3. No further immunizations have been administered. Synagis was given on [**2133-3-5**]. 4. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born between 32 and 35 weeks with two of the following: Daycare during RSV season , a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for house hold contacts and out of home caregivers. FOLLOW UP: Scheduled or recommended: 1. Dr. [**First Name8 (NamePattern2) 56128**] [**Last Name (NamePattern1) **], primary pediatrician, Friday, [**3-20**] at 2:15 p.m. 2. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], pediatric pulmonology, phone number [**Telephone/Fax (1) 57251**]. Appointment scheduled for [**3-31**] at 11 a.m. A sweat test is scheduled and an appointment at 12:30 with Dr. [**Last Name (STitle) 37305**]. 3. Dr. [**Last Name (STitle) **], pediatric ophthalmology, phone number [**Telephone/Fax (1) 57252**]. An appointment is needed the week of [**2133-3-23**]. 4. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5715**], pediatric surgery, phone number [**Telephone/Fax (1) 57253**]. Appointment scheduled for [**4-13**] at 10:30 a.m. 5. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 1557**], pediatric feeding team, phone number [**Telephone/Fax (1) 57254**]. Appointment to be scheduled. 6. Would also recommend family contacting state registry motor vehicles to obtain a handicapped plackard in setting of Myelia's oxygen need. DISCHARGE DIAGNOSES: 1. Former premature infant at 24 and 2/7 weeks gestation. 2. Chronic lung disease. 3. Patent foramen ovale. 4. Retinopathy of prematurity. 5. Status post gastrostomy tube placement. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 43886**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2133-3-19**] 04:24:33 T: [**2133-3-19**] 05:40:57 Job#: [**Job Number 57255**]

7707,7742,7775,7793,78341,769,77081,36221,7766

Admission Date: [**2132-10-16**] Discharge Date: [**2132-12-3**] Date of Birth: [**2132-10-16**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is a 24 [**1-19**] week gestational age twin girl born to a 28 year old gravida III, para 0 mother with the following prenatal laboratories: Blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, GBS unknown. Of note was a prenatal diagnosis of twin boy number 1 with a known neural tube defect discovered on prenatal ultrasound. This patient, twin girl 2 had no prenatally diagnosed congenital formations on ultrasound. The patient was born via cesarean section secondary to unstoppable preterm labor. The patient was delivered in transverse lie, vigorous at birth with spontaneous respirations. Heart rate at 100. Patient was given bag mas ventilation times one minute and promptly intubated in the delivery room. Apgars 6 and 7 at one and five minutes. The patient was subsequently transferred to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION ON PRESENTATION: Birth weight is 696 grams, length was 32.5 cm, head circumference was 23 cm. Vital signs on admission: Heart rate 140 to 150, blood pressure means ranging from 24 to 36, respirations on mechanical ventilation 25 breaths per minute, temperature 98.7. General: Preterm female on mechanical ventilation in radiant warmer. Head, eyes, ears, nose and throat: Anterior fontanelle open and flat, oropharynx clear, palate intact, endotracheal tube in place, no dysmorphic features. Eyes fused. Neck supple, no crepitus. Respiratory: Mechanical breath sounds equal bilaterally, good air exchange, mild intermittent retractions. Cardiac: Regular rate and rhythm, S1, S2 normal, II/VI systolic ejection murmur with radiation to the left axilla, femoral pulses 2 plus bilaterally. Abdomen: Soft, nondistended, bowel sounds, no hepatosplenomegaly noted, anus patent. Extremities: Well perfused, no cyanosis or edema. Spine intact, no dimpling. No Ortolani or Barlow sign present. Neurologic: Spontaneous MAE, appropriate tone on examination. Palmar and plantar reflexes intact. PHYSICAL EXAM AT TIME OF TRANSFER: alert, active, AFOF, coarse breath sounds, mild-moderate ic/sc retx. abdomen extremely distended, decreased bowel sounds, ext well perfused. tone aga. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: The patient was intubated in the delivery room and brought down to the Neonatal Intensive Care Unit for further management. Patient received a total of three doses of surfactant. Patient was ventilated on synchronous intermittent mandatory ventilation for 24 hours and then transitioned to high frequency ventilation on day of life number 2. Patient remained on high frequency ventilation until [**2132-11-11**] at which point she was transitioned back to conventional ventilation. At the time of this summary, the patient is on conventional ventilation with current settings of 21/5, respiratory rate of 24 and FIO2 of 28 percent oxygen. At approximately one week of life patient showed radiographic signs of pulmonary interstitial emphysema bilaterally and showed persistent signs until two weeks of life at which point this resolved. During the 2nd week of [**Month (only) 1096**], cysts were noted in the right lower base and mean airway pressures were minimized as low as 19/5. On the most recent films, these cysts have resolved. For persistent pulmonary insufficiency patient was trialed on Flovent MDI starting [**2132-11-11**] and was continued on this medication for two weeks at which point it was weaned off. She was also trialed on Combivent 2 puffs q 6 starting on [**2132-11-11**] and remains on this medicine at time of this summary. Patient was also started on Diuril on [**2132-11-17**] and weaned to a maximum intravenous dose. Patient has been on caffeine since [**2132-11-20**] and remains on caffeine at time at thissummary. 2. CARDIAC: Cardiac murmur was detected on day of life number two consistent with a patent ductus arteriosus. On [**2132-10-20**] a course of indomethacin was started. Patient received two full doses of indomethacin with no resolution signs of a patent ductus arteriosus including murmur, widened pulse pressures and palmar pulses. Cardiac echocardiogram on [**2132-10-20**] revealed a large unidirectional patent ductus arteriosus with no other structural defects of the heart. On [**2132-10-23**] patient was taken to [**Hospital3 1810**] for ligation of the patent ductus arteriosus. The operation was well tolerated with no problems afterwards. The patient had intermittent periods of hypotension throughout her hospital course. Dopamine was started on day of life number 2. Patient continued on dopamine for hypotension until [**2132-10-31**] at which time it was discontinued. The patient did receive stress doses of hydrocortisone on [**10-27**] as well as [**12-3**] for presumed adrenal insufficiency prior to abdominal surgery. GASTROINTESTINAL: Patient had an acute episode on [**2132-10-27**] with hypotension and abdominal distention. This episode was presumed to be necrotizing enterocolitis although there were no corresponding radiographic signs. The patient was started on antibiotics at that time and watched clinically for progressing signs of acute peritonitis. After this episode on [**10-27**] the patient had progressive worsening of abdominal distention. A contrast enema was performed on [**2132-11-26**] which was within normal limits revealing no structural defects and no overt colonic obstruction. Upper gastrointestinal was performed on [**2132-12-1**] which showed delayed contrast into the jejunal junction. Trophic feeds of breast milk 20 calories per ounce was started on [**2132-11-17**] and held on [**2132-11-20**] secondary to repeated biliary aspirates and worsening abdominal distention. This prompted the above two studies--contrast enema and UGI. Patient also had a problem of indirect hyperbilirubinemia. On [**11-5**] the bilirubin was total of 4.2, indirect 2.3. On [**12-1**] bilirubin 4.8 with indirect of 3.3. This indirect hyperbilirubinemia was likely due to total parenteral nutrition cholestasis. The trace elements have been removed from her parenteral nutrition. In addition Carnitine has been added to her daily parenteral nutrition. Liver function tests were normal on [**2132-11-7**]. On [**2132-11-25**] they were mildly elevated with the following values, ALT 158, AST 242, alkaline phosphatase 533. Patient has had a right middle quadrant/right lower quadrant abdominal mass discovered on ultrasound on [**2132-11-5**]. This abdominal mass is of unknown etiology despite repeated serial abdominal ultrasounds on [**2132-11-12**], [**2132-11-24**] and [**2132-12-1**]. In addition, the patient received a noncontrast abdominal CT on [**2132-11-7**]. This abdominal mass has been confirmed to be extraluminal, and not within the parenchyma of the liver. Abdominal ultrasound on [**2132-11-24**] revealed evolving calcifications within this mass as well. Contrast enema on [**2132-11-26**] revealed that this mas is not likely to be causing any colonic obstruction. In addition, upper gastrointestinal series on [**2132-12-1**] revealed that this mass is not likely to be causing any small bowel obstruction as well. Patient has had several meconium stools after the barium enema on [**2132-11-26**]. On [**2132-12-3**] the patient was taken for an exploratory laparotomy at the [**Hospital3 1810**] to assess the abdominal mass number one, and number two to assess the patient's lower colonic/small bowel strictures. 1. FLUID, ELECTROLYTES AND NUTRITION: The patient has been placed on parenteral nutrition on day of life number one and is continued on parenteral nutrition at the time of discharge suddenly. Patient has been given interlipids which have been stopped intermittently for increased triglycerides. 1. HEMATOLOGY: The patient has had anemia secondary to her prematurity and frequent phlebotomy. She has received packed cell transfusions on [**2132-10-20**], [**2132-10-27**], [**2132-10-30**], [**2132-11-4**], [**2132-11-12**], [**2132-11-19**]. 12/20/2204 and [**2132-12-3**]. Patient has had direct hyperbilirubinemia for which she has received phototherapy times two courses in her hospital course. 1. INFECTIOUS DISEASE: The patient was initially placed on Vancomycin and Gentamycin for a seven day course at which time this was discontinued. On [**2132-10-27**] secondary to a presumed episode of necrotizing enterocolitis. The patient was placed on Vancomycin, Gentamicin, Clindamycin. On [**2132-11-7**] the antibiotic regimen was changed to Vancomycin, meropenem, M amphotericin secondary to this abdominal mass of unknown etiology. The patient remained on this antibiotic regimen for two weeks at which time only meropenem was continued secondary to the nonresolving abdominal mass. On [**2132-12-1**] Vancomycin was added to the regimen for the presence of a low grade temperature. This was discontinued on [**2132-12-1**] once blood cultures were no growth to date from [**2132-12-1**] times 48 hours. The patient has had no positive blood cultures throughout her hospital course. The plan was to discontinue meropenem post- operatively if an abscess was not found. 1. NEUROLOGIC: Patient has been on a Fentanyl drip throughout her hospital course for agitation and lability. Head ultrasounds on [**2132-10-20**], [**2132-10-27**], [**2132-11-4**] and [**2132-11-19**] have all been within normal limits revealing no structural defects as well as no intraventricular hemorrhage. 1. EYE EXAMINATIONS: On [**2132-11-11**] revealed immature retinas zone 1. Eye examination on [**2132-12-2**] showed immature retinas, stage 1, zone 2. Follow up recommended in two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) 56760**] MEDQUIST36 D: [**2132-12-3**] 10:23:35 T: [**2132-12-3**] 12:18:58 Job#: [**Job Number 57243**]

V3101,76502,769,7775,7742,7707,7793,77181,7757,76522,7470,7766,36221,4589,78933,2554

Admission Date: [**2132-10-16**] Discharge Date: [**2132-12-3**] Date of Birth: [**2132-10-16**] Sex: M Service: NB ADDENDUM FROM [**2132-12-3**] FEEDS: No feeds at time of discharge. MEDICATIONS: 1. Meropenem (to be discontinued if no abscess found) 2. Fentanyl 2.5 mcg/kg/min. 3. Combivent 2 puffs MDI q 6 h. 4. Diuril 20 mg/kg/day IMMUNIZATIONS: None administered through hospital course. CONDITION ON DISCHARGE: Critical. DISCHARGE DISPOSITION: To [**Hospital3 1810**] for further management. DISCHARGE DIAGNOSES: 1. Prematurity at 24-2/7 weeks gestational age. 2. Respiratory distress. 3. Chronic lung disease. 4. Patent ductus arteriosus, status post ligation. 5. Hypotension, resolved. 6. Necrotizing enterocolitis. 7. Abdominal distention. 8. Abdominal mass, unknown etiology. 9. Indirect hyperbilirubinemia. 10. Anemia. 11. Presumed sepsis. 12. Retinopathy of prematurity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 43886**] Dictated By:[**Last Name (NamePattern1) 57241**] MEDQUIST36 D: [**2132-12-3**] 10:26:17 T: [**2132-12-3**] 11:50:32 Job#: [**Job Number 57242**]

V3101,76502,769,7775,7742,7707,7793,77181,7757,76522,7470,7766,36221,4589,78933,2554

Admission Date: [**2197-11-7**] Discharge Date: [**2197-11-15**] Date of Birth: [**2152-10-15**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 6483**] is a 44 year-old female who was evaluated by the Transplant Center for a right donor hepatectomy for her sister [**Name (NI) **] [**Name (NI) 41841**]. Ms. [**Known lastname 6483**] is otherwise in excellent health. She presented to [**Hospital1 69**] for a donor liver transplant. Preoperative risks and complications were reviewed prior. PAST MEDICAL HISTORY: Migraines. Otherwise there is no cardiac or pulmonary disease noted. PAST MEDICAL HISTORY: Status post left knee arthroscopy times two. ALLERGIES: Percocet and Codeine, which gives the patient gastrointestinal upset. MEDICATIONS: 1. Zoloft 50 mg po q.d. 2. Multivitamin. 3. Trazodone prn at bedtime. PHYSICAL EXAMINATION: Temperature 97.8. Blood pressure 107/50. Pulse 64. Respiratory rate 18. Satting 97% on room air. Height 5'5", weight 150 pounds. General, alert and oriented times three. Well developed, well nourished female in no acute distress. Head, eyes, ears, nose and throat pupils are equal, round and reactive to light. Normocephalic, atraumatic. Extraocular movements intact. Oropharynx was clear. Respirations lungs were clear to auscultation bilaterally. Cardiac regular rate and rhythm. No murmurs, rubs or gallops. Abdomen soft, nontender, nondistended. Extremities no clubbing, cyanosis or edema. Moving all extremities times four. LABORATORY DATA COLLECTED PREOPERATIVELY: Normal white blood cell count, hemoglobin, platelets, liver function tests and albumin of 4.4. Her hepatitis A antibody was negative. Her hepatitis B surface antigen, surface antibody and core antibody were negative. Hepatitis C antibody was negative as well. The patient underwent the normal preoperative imaging and tests required for a donor hepatectomy. HOSPITAL COURSE: Ms. [**Known lastname 6483**] is a 45 year-old female in otherwise good health. She presented to [**Hospital1 346**] on [**2197-11-17**] for a right donor hepatectomy for her sister [**Name (NI) **] [**Name (NI) 41841**]. The operation went without any complications. She had an estimated blood loss of about 1800, which was replaced with 1000 Cell [**Doctor Last Name 10105**]. Epidural was placed initially for pain control and was placed on a short course of Unasyn perioperatively. From the recovery room she was transferred to the Intensive Care Unit for close monitoring. She had some respiratory insufficiency with a combination of respiratory metabolic acidosis. She required some fluid. Arterial blood gases were continually checked and her acidosis eventually resolved. However, on postoperative day two she was markedly around 12 liters positive for overall fluid balance. The patient went into a rapid atrial fibrillation. She was placed on a Diltiazem drip and she received Amiodarone as well at which time she converted to normal sinus rhythm. Her liver function tests continually trended downward. She maintained good urine output throughout her postoperative course. She had a postoperative liver duplex ultrasound, which was a normal study with normal wave forms. A bilirubin was checked within her JP drain, which revealed 7.5. All her cardiac enzymes were negative times three. She was noted to have a left hand thrombophlebitis for which she was started on Unasyn. The patient was transferred to the floor on postoperative day four wherein she remained in stable condition. Her diet was advanced slowly, which was tolerated. Our goal at that point was to continue with diuresis at around 2 liters negative per day, which is achieved using Lasix. Her lateral JP drain was removed on postoperative day nine. It was felt that the patient was stable for discharge on postoperative day nine. Her pain was well controlled. Her liver function tests had trended downward within normal limits. She was to be discharged with a one week course of Augmentin for a left hand thrombophlebitis. She additionally is to follow up with Dr. [**Last Name (STitle) **] at the Transplant Center. CONDITION ON DISCHARGE: Home. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: 1. Status post right donor hepatic lobectomy. 2. Status post left hand thrombophlebitis. 3. Short course postoperative atrial fibrillation. DISCHARGE MEDICATIONS: 1. Sertraline 50 mg one tab po q day. 2. Trazodone 25 mg po q.h.s. prn insomnia. 3. Augmentin 875 mg one tab po b.i.d. for seven days total. 4. Percocet one to two tabs po q 4 to 6 hours prn pain. 5. Colace 100 mg one tab po b.i.d. FOLLOW UP PLANS: The patient is to follow up at the Transplant Center, telephone number [**Telephone/Fax (1) 673**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Monday [**2197-11-20**] at 1:50 p.m. She is additionally to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the Transplant Center on [**2197-11-29**] at 10:00 a.m. She is to be discharged with her medial JP drain in place to be removed in clinic. At that time she is to undergo additional laboratory work. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 12360**] MEDQUIST36 D: [**2197-11-15**] 03:32 T: [**2197-11-20**] 06:15 JOB#: [**Job Number 50945**]

V596,2762,462

Admission Date: [**2124-12-12**] Discharge Date: [**2124-12-22**] Date of Birth: [**2050-4-17**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Stroke (right sided weakness and dysarthria) Major Surgical or Invasive Procedure: PEG placement [**2124-12-21**] History of Present Illness: This is a 74 year-old female with a history of diabetes, hypertension, hyperlipidemia, with known CAD by cath in [**2120**], and diastolic dysfunction transferred from [**Hospital3 46817**] for cardiac catheterization for NSTEMI and found to have a new stroke. Per husband, she had sustained slip and fall(unwitnessed) [**2124-12-11**], found down by her husband and son helped her into bed and she was unsteady on her feet. They brought pt to [**Hospital6 8283**] where CT head was negative but troponins were elevated, TNI 2.21. She was heparinized overnight and transferred on the first boat to [**Hospital1 18**] this AM. Per report at [**Hospital6 8283**], Stroke score 0, verbal w/o focal abnormalities, heparin IV, ASA, plavix for TNI 0.02 came w/new facial droop, slow speech, lethargic, picking at herself. She was transferred here for further evaluation. CT head negative here, MRI/MRA w/acute MCA stroke. Neuro consulted, said no TPA because were unsure of chronicity. TNI here 0.09, EKG w/STD in 1 V5-V6 TWI in III, avF. Cardiology was concerned about NSTEMI. exam also significant for dysarthria (pt's son said started [**12-11**]), right arm drift and diffuse weakness/asthenia. MRI-small b/l strokes. . In the ED, initial vitals were Tm: 98.0 HR: 102 BP: 195-94 RR: 17 O2Sat: 96% on 4L. There, she was found to be somnolent, have a facial droop and right pronator drift. She had a non-contrast head CT which was negative, but the MRI showed acute MCA stroke, L striatocapsular stroke w/ additional small R striatocapsular stroke per Neurology. No evolution of neuro exam. For management of her elevated blood pressures, she received 10mg IV labetalol, hydralazine and metoprolol 5mg IV. The patient was admitted for further evaluation and management. Unable to perform ROS as pt aphasic. Past Medical History: CAD, 3 vessel disease found on cardiac cath [**2120-7-23**]; s/p cabg Diastolic Dysfunction Diabetes Dyslipidemia Hypertension Atrophic Kidney Hx of R retinal artery embolus [**2123-10-18**], when she had presented with visual illusion of a purple flower, started on Plavix at that time in addition to her full ASA 325. Work-up at the time included negative TTE and carotid U/s. Residual decrease VA in that eye. MEDICATIONS: -Metformin 750 Qday -Glyburide [**Hospital1 **] -ASA 325 -Plavix 75 -Candesartan 16 Qday -Fluticasone nasal spray -Lipitor 20 -Metorpolol 50 [**Hospital1 **] Social History: Retired, lives in [**Hospital3 4298**] with husband, helps out at family's flower shop, no hx tobacco, social EtOH, has 2 children, functionally independent at baseline, drives. Daughter [**Name (NI) 402**] [**Telephone/Fax (1) 56188**] Son [**Name (NI) **] and husband [**Name (NI) **] [**Telephone/Fax (1) 56189**] Family History: Non contributory Physical Exam: T 98 HR 86 BP 210/110 [**Month (only) **] to SBP 175 after 10 mg Hydral RR 16 sO2 98% on 2 L nc GEN: looks unwell but no acute distress HEENT: mmm NECK: no LAD; no carotid bruits; no meningismus, limited ROM at neck LUNGS: Clear to auscultation bilaterally HEART: Nitro patch, regular rate and rhythm, normal S1 and S2, no murmurs ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date, person. Attention: DOWbw. Language: fluent; repetition: intact; Naming intact; Comprehension intact; moderate dysarthria and hypophonic speech, no paraphasic errors. Prosody: normal. No Apraxia. No Neglect. CRANIAL NERVES: II: Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 3-->2 mm bilaterally. III, IV, VI: Extraocular movements intact without nystagmus. No ptosis. V: Facial sensation intact to light touch. VII: R facial droop VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious movements, no tremor, no asterixis. RUE pronator drift with deltoid and triceps 5-, bilat [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] more prominent on IP/hamstrings/dorsiflexion but symmetric bilat. REFLEXES: 1+ throughout, plantar response mute bilat SENSORY SYSTEM: Sensation intact to light touch without extinction to DSS. COORDINATION: Difficulty with FNF in RUE. GAIT: too weak to stand Pertinent Results: [**2124-12-12**] 10:50AM FIBRINOGE-459* PT-13.7* PTT-37.0* INR(PT)-1.2* PLT COUNT-284 NEUTS-78.2* LYMPHS-15.7* MONOS-4.0 EOS-1.5 BASOS-0.6 WBC-9.7 RBC-4.58 HGB-13.6 HCT-39.2 MCV-86 MCH-29.7 MCHC-34.8 RDW-13.6 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.5* GLUCOSE-187* UREA N-13 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 [**2124-12-12**] 11:20AM URINE MUCOUS-RARE HYALINE-0-2 RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ECG: Sinus rhythm at 101 bpm, <1mm STD in 1 V5-V6 TWI in III, avF new compared to old dated [**2120-7-26**]. [**2124-12-12**] 10:50AM CK-MB-11* MB INDX-2.3 [**2124-12-12**] 10:50AM cTropnT-0.09* [**2124-12-12**] 10:50AM CK(CPK)-475* [**2124-12-12**] 08:38PM CK-MB-8 cTropnT-0.07* CT HEAD W/O CONTRAST Study Date of [**2124-12-12**] 10:33 AM IMPRESSION: No evidence of acute intracranial hemorrhage or large vascular territory ischemia. However, if acute stroke is suspected, MRI is recommended. CHEST (PORTABLE AP) Study Date of [**2124-12-12**] 11:59 AM IMPRESSION: Stable cardiomegaly with no signs of failure or acute pneumonia. Density in the aorticopulmonary window may represent clips from prior surgical procedure (closure of PDA). Study Date of [**2124-12-12**] 12:43 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST; MR 3D RENDERING W/POST PROCESS 1. Acute infarction of the left corona radiata and the left posterior aspect of the putamen. Focal area of infarction in the right parietal lobe. This distribution is indicative of a central source of emboli-like a cardiac source. 2. Changes consistent with chronic small vessel ischemic disease and old lacunar infarctions. 3. Stenosis of the right M1 segment. TTE (Complete) Done [**2124-12-13**] at 11:01:15 AM IMPRESSION: No cardiac source of embolism identified. Preserved global and regional biventricular systolic function. Mild aortic regurgitation. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the report of the prior study (images unavailable for review) of [**2120-7-23**], there is now symmetric LVH. The degrees of mitral and aortic regurgitation are slightly less on the current study. TTE (Focused views) Done [**2124-12-13**] at 3:48:37 PM IMPRESSION: Suboptimal image quality. No premature passage of microbubbles into the left heart is seen at rest or with maneuvers. HIP 1 VIEW Study Date of [**2124-12-13**] 7:32 AM Single bedside frontal radiograph of the right hip is normal. No fracture identified and normal appearing right hip CT C-SPINE W/O CONTRAST Study Date of [**2124-12-13**] 9:30 AM IMPRESSION: 1. No fracture or malalignment. 2. Multilevel spondylosis. Mild spinal canal stenosis at C5/6. Brief Hospital Course: This 74 yo woman was admitted with simultaneous NSTEMI (max trop 0.09) and stroke affecting her left corona radiata and posterior putamen resulting in right face, arm, and leg weakness, and dysphagia. The etiology was thought to be more small vessel, but in the context of these events on anti-platelet agents, it was felt she would ultimately benefit from anticoagulation. In the short term, a joint decision between neurology and cardiology was made to hold off on anticoagulation out of fear for hemorrhagic conversion and to continue her aspirin and plavix. Her echo showed preserved EF, no evidence of embolic source and no PFO. Her HgbA1C was 7.2. Her blood sugars were difficult to control in the context of having her home metformin and glyburide held. These were re-started on discharge. Her blood pressures were also difficult to control and after a period of 3 days during which most of her BP meds were held in an attempt to allow her BP to autoregulate in the aftermath of her stroke, she was restarted on her home regimen, and her lisinopril was increased to 10 mg daily. Her lipid panel showed elevated lipids including an LDL of 113, and so her lipitor was increased from 20 to 80 mg daily and zetia 10 mg daily was added. She failed her S/S eval and she subsequently received meds and tube feeds through an NG tube. She was originally scheduled for PEG placement [**2124-12-18**], but this was postponted until [**12-21**] as she was quite hypertensive immediately before the initially scheduled PEG placement. In the meantime, her plavix was DC'd and she was kept on aspirin as the only blood thinnner. After PEG placement [**12-21**], aspirin was DC'd and coumadin was started with a lovenox bridge. On discharge, her neurological exam was significant for right arm and leg weakness in the 4/5 range, dysphagia, and dysarthria with language output limited to stating name and answering simple yes/no questions. Medications on Admission: -Metformin 750 Qday -Glyburide [**Hospital1 **] -ASA 325 -Plavix 75 -Candesartan 16 Qday -Fluticasone nasal spray -Lipitor 20 -Metorpolol 50 [**Hospital1 **] Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 160 mg/5 mL Solution Sig: [**1-19**] PO Q6H (every 6 hours) as needed for fever,ha,pain. 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Candesartan 16 mg Tablet Sig: One (1) Tablet PO Qday (). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous twice a day. 10. Insulin Lispro 100 unit/mL Cartridge Sig: 6-16 Units Subcutaneous three times a day: Per Insulin sliding scale. . 11. Metformin 750 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours): Can DC Lovenox when INR is > 2.0. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: stroke and NSTEMI Secondary diagnoses: CAD HTN DM Hyperlipidemia Discharge Condition: Stable right arm and leg weakness in the 4/5 range, dysphagia, and dysarthria with language output limited to stating name and answering simple yes/no questions. Discharge Instructions: You have had a stroke and simultaneous type of heart attack call an NSTEMI. You will need to continue to control your risk factors including your blood pressure, blood sugars, and cholesterol. Your speech has been slowly improving and you should continue to work with speech therapy, as well as physical therapy for your weakness. You should see a nutritionist at rehab to help control your diabetes, especially in the context of having to be on liquid feeds through your PEG tube. Please return to the ER if you experience any sudden weakness, change in sensation, vision, or language, develop any severe headaches, vertigo, seizures, or anything else that concerns you seriously. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of Neurology [**2125-2-6**], 2pm at the [**Hospital Ward Name 23**] Clinical Center. Call to change or cancel: [**Telephone/Fax (1) 2574**]. Please follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 29822**], especially for having your blood INR followed Completed by:[**2124-12-22**]

43411,41071,V4581,25000,41401

Admission Date: [**2120-7-26**] Discharge Date: [**2120-8-1**] Date of Birth: [**2050-4-17**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 70-year-old female with no known history of coronary artery disease. She had one previous episode of chest tightness with exertion upon a routine physical examination with her primary care physician. [**Name10 (NameIs) **] had electrocardiogram changes with ST depression, fatigue and chest tightness. On Myoview she had a large zone of distal anterior apical ischemia with preserved systolic and diastolic function. She was referred for cardiac catheterization. Cardiac catheterization on [**2120-7-23**] showed an ejection fraction of 60 percent, 100 percent right PDA, 90 percent mid LAD, 90 percent distal circumflex, 80 percent OM2, 80 percent OM3 with normal wall motion. PAST MEDICAL HISTORY: Significant for hypertension, elevated cholesterol, anxiety, allergic rhinitis, osteopenia, microscopic proteinuria, status post hamstring repair in [**2112**], status post partial hysterectomy, status post rectocele, cystocele repair, diabetes type 2. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Lipitor 20 once a day. 2. Atacand 16 once a day. 3. Atenolol 50 once a day. 4. Glucovance 2.5/100 once a day. 5. Zyrtec 10 once a day. 6. Glyburide 5 once a day. 7. Catapres 2 every week. 8. Aspirin 325 once a day. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs: Pulse 58, sinus bradycardia, blood pressure 132/56, respiratory rate 14, room air SPO2 95 percent. General: Awake, pleasant. Neurological: Alert and oriented times three. Grip strength equal bilaterally. Plantar flexion equal bilaterally. Pupils equal, round and reactive to light. Extraocular movements intact. Cardiovascular: Regular rate and rhythm. No murmur, rub or gallop. Respiratory: Clear to auscultation. Gastrointestinal: Obese. Abdomen: Softly distended, nontender. Extremities: Cool, no varicosities, equal bilaterally. Pulses: Femoral 2 plus right and left, popliteal 2 plus right and left. DP, PT 2 plus right and left. Radial 2 plus right and left. Carotids: No bruit. HOSPITAL COURSE: Mrs. [**Known lastname **] was admitted the morning of [**2120-7-26**] to go to the Operating Room. She underwent a coronary artery bypass graft times 3 with LIMA to the LAD, saphenous vein graft to the PDA and saphenous vein grafts to the OM. She was under general anesthesia and cardiopulmonary bypass. Endoscopic vein harvest of the right thigh and open vein harvest of the upper right calf were the saphenous vein graft sites. She was transferred out of the Operating Room, intubated on small amounts of Neo and Propofol, a-paced with an underlying rhythm of 50 in sinus bradycardia. The evening of postoperative day 1, she was extubated. On postoperative day 2, she was transfused one unit of packed red blood cells for a hematocrit of 24 with a low blood pressure. Her chest tubes were also removed on postoperative day 2. On postoperative day 3, she was transferred to the inpatient floor, F2, and her atrial and ventricular pacing wires were removed. She was followed throughout her hospital course by physical therapists and she was cleared by Physical Therapy, found to be safe for home, on [**2120-7-30**]. She progressed well throughout her hospital course, staying in a normal sinus rhythm with stable vital signs. She was ambulating three times a day with strict pulmonary toilet throughout her stay and was ambulating independently by [**2120-7-31**]. CONDITION ON DISCHARGE: Vital signs: Temperature 99.6 degrees, pulse 94 in sinus rhythm, blood pressure 140/67. Respiratory rate 16. Room air SPO2 94 percent. Labs on [**2120-8-1**], white count 11.2, hematocrit 33.2, platelets 222, potassium 4.5, BUN 14, creatinine 0.6. Weight 71 kg, down from 72 kg preoperatively. PHYSICAL EXAMINATION: Neurological: Awake, alert and oriented times three, nonfocal. Respiratory: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. No rub or murmur. Incision: Clean, dry and intact. Sternum stable with no click. Right leg vein harvest site clean, dry and intact, open to air. Gastrointestinal: Abdomen soft, nontender, nondistended with positive bowel sounds. Extremities: 1 to 2 plus edema bilaterally. DISCHARGE STATUS: Home with visiting nurse. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass graft. Type 2 diabetes. Hypertension. DISCHARGE MEDICATIONS: 1. Colace 100 mg twice a day. 2. Zantac 150 mg twice a day. 3. Aspirin 325 mg once a day. 4. Plavix 75 mg once a day. 5. Glyburide 5 mg once a day. 6. Glucovance 5/500 once a day. 7. Lipitor 20 mg once a day. 8. Vicodin 5/500 one to two tablets p.o. q.4-6h. p.r.n. 9. Lasix 20 mg once a day for 7 days. 10. Lopressor 75 mg twice a day. 11. Atacand 8 mg once a day. FOLLOW-UP PLAN: The patient is discharged with visiting nurse to follow. Follow-up with Dr. [**Last Name (STitle) 19751**] in one to two weeks, with Dr. [**Last Name (STitle) **] in one to two weeks, and Dr. [**Last Name (STitle) 70**] in 5 to 6 weeks. She will also follow-up in the Outpatient [**Hospital 409**] Clinic in [**1-19**] weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) 28068**] MEDQUIST36 D: [**2120-8-1**] 10:55:42 T: [**2120-8-1**] 11:29:46 Job#: [**Job Number 56187**]

41401,25000,4019

Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-28**] Service: MICU CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman with a history of tracheobronchiomalacia and chronic respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital. The patient originally had her respiratory failure following an episode of aspiration pneumonia back in [**Month (only) 404**], at which time she had failed attempts at stenting of her tracheobronchiomalacia and required tracheostomy and PEG tube placement for her chronic respiratory failure. She has been at [**Hospital3 672**] Hospital since that time and has been unable to wean from the ventilator. Her usual vent settings are SIMV, respiratory rate of 8, tidal volume of 500, pressure support of 15, PEEP of 5, FIO2 of 0.3. The patient had been doing well and had been gradually weaned off the ventilator until the day of admission. At that time she was noted to be in respiratory distress. She was tachypneic and short of breath. Two saturations decreased to 90%. She went from CPAP back to IMV. Arterial blood gas was 7.23/70/123/30/96%. Breath sounds were noted to be distant and chest x-ray could not be obtained for a significant period so she was sent to [**Hospital1 188**] for further evaluation. In the Emergency Department the patient was bagged and suctioned. No obvious mucous plugs were removed and Lasix 60 mg IV x 1 was given. The patient's symptoms improved and she was transferred to the medical intensive care unit for further evaluation. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Hypertension. 3. Tracheobronchiomalacia as above. 4. Anemia. 5. Moderate to severe mitral regurgitation. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Ritalin 5 mg p.o. q.d. 3. Zoloft 50 mg p.o. q.d. 4. Albuterol p.r.n. 5. Subcutaneous heparin 5,000 mg subcutaneous b.i.d. 6. Ativan 0.25 mg p.o. q. 8 hours p.r.n. 7. Lasix 40 mg p.o. q.d. on hold x 1 week. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient is currently a resident at [**Hospital3 672**] Hospital. She has some family members who are involved in her care. She has no known history of tobacco or drug use. PHYSICAL EXAMINATION: Vital signs were 98.8, heart rate 82, blood pressure 92/47, respiratory rate 18, 100% bagged. In general she was an obese, confused woman who was in no acute distress at the time of the medical intensive care unit evaluation. HEENT: Left eye cataract with some ptosis. Oropharynx was noted to have thrush, otherwise dry. Neck: No jugular venous distension, no lymphadenopathy. Tracheostomy in place. Cardiac: Regular rate and rhythm, no murmurs, gallops, or rubs. Lungs: Rhonchi noted diffusely with decreased breath sounds at the bases bilaterally, occasional expiratory wheezes. Abdomen: Soft, nontender, distended abdomen, positive bowel sounds. PEG in place with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp. Extremities: No cyanosis, clubbing or edema, warm with good pulses, no calf tenderness, no palpable cord. Neurological: The patient was able to move all extremities, decreased hearing and unable to communicate or take p.o. LABORATORY DATA: White blood count 18.2, hematocrit 36.4, platelet count 425, and 87.5, no bands. Sodium 132, BUN 49, creatinine 1.1, glucose 231. Urinalysis had large blood, greater than 50 white blood cells, [**12-5**] red blood cells, nitrite negative, leukocyte esterase moderate. HOSPITAL COURSE: 1. Pulmonary: The patient was admitted with respiratory distress of unclear etiology. She was given Lasix initially for congestive heart failure, although this was unlikely to be congestive heart failure. The patient was thought to have a mucous plug given the rapid improvement of her symptoms after suctioning. The patient had follow-up chest x-ray which demonstrated right middle lobe pneumonia and question of pneumonia at the left base. The patient was initially started on ceftriaxone and azithromycin in the Emergency Department, but was then changed to vancomycin and Zosyn to cover a ventilator-associated pneumonia. The patient was then put back on her [**Hospital3 672**] Hospital ventilator settings and her white count decreased. She continued to have low-grade temperatures which were thought to be due to her lack of adequate antibiotics. Sputum culture showed greater than 25 polys, less than 10 epithelial cells with mixed flora and final culture is pending at the time of this dictation. 2. Cardiac: The patient was treated empirically in the Emergency Department for congestive heart failure. She underwent transthoracic echocardiogram to evaluate her ejection fraction given possible congestive heart failure. This demonstrated left atrium with moderate dilatation, right atrium with moderate dilatation, mild left ventricular hypertrophy, minimal aortic stenosis, 1+ aortic regurgitation, mild to moderate mitral regurgitation, impaired ventricular relaxation. It was not clear if the patient was in any congestive heart failure and she was not given Lasix. This can be restarted should her symptoms worsen. 3. Weakness: On hospital day number one the patient was noted to have some left-sided weakness. It is unclear exactly what her baseline is. She was able to move all four extremities, however she had some flaccidity and hyperreflexia in the left upper and lower extremities. She underwent CT scan of the head which demonstrated no acute changes but chronic microvascular changes and atherosclerosis of the internal carotid and vertebral arteries. Given the patient's condition and unclear age of her findings, no additional work-up was undertaken. 4. Endocrine: The patient was maintained on fingersticks q.i.d. and a Regular Insulin sliding scale for her diabetes mellitus. This should be maintained at her discharge for optimal blood sugar control during her time of infection. 5. Anemia: The patient's blood counts decreased from admission of 36 down to 26 on hospital day number two. Some of this was thought to be dilution as the patient did receive some intravenous fluids during her admission. She was guaiac negative and did not have any signs of active bleeding. Blood count is stable at the time of her discharge. She did not have a history of coronary artery disease so no packed cells were given. Should her hematocrit decreased to less than 24, blood transfusion may be of benefit to her. 6. Access: The patient had a PICC line placed for intravenous antibiotics to complete a 14-day course of vancomycin and Zosyn. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged back to [**Hospital3 **] Hospital for continued weaning and intravenous antibiotic therapy. DISCHARGE DIAGNOSES: 1. Ventilator-associated pneumonia. 2. Cerebrovascular accident of unclear duration. 3. Mitral regurgitation. 4. Anemia. 5. Diabetes mellitus. 6. Urinary tract infection: Positive urinary tract infection with Gram-negative rods and beta streptococcus. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram q. 48 hours started on [**2199-5-27**] to receive a 14-day course. 2. Zosyn 2.25 grams IV q. 6 hours started on [**2199-5-27**] to complete a 14-day course. 3. Sertraline 50 mg p.o. q.d. 4. Methylphenidate 5 mg p.o. b.i.d. 5. Albuterol nebulizer inhaled q. 6 hours p.r.n. 6. Atrovent 2 puffs inhaled q.i.d. 7. Heparin 5,000 mg subcutaneous b.i.d. 8. Fluticasone 110, 2 puffs inhaled b.i.d. 9. Regular Insulin sliding scale. 10. Fluconazole 100 mg p.o. q. 24 hours for thrush to complete four additional doses. 11. Lansoprazole 30 mg via nasogastric tube q.d. 12. Ativan 0.25 mg p.o./IV t.i.d. p.r.n. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 17420**] MEDQUIST36 D: [**2199-5-28**] 10:50 T: [**2199-5-28**] 11:03 JOB#: [**Job Number 46668**]

486,51882,3968,5990,2765,43311,E8798,04119,5191

Admission Date: [**2201-10-19**] Discharge Date: [**2201-10-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7934**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: HPI: 86 year old female with tracheobronchiomalacia and chronic respitory distress vent dependent, h/o UTI, h/o aspiration PNA, DM type2, MR who presents from OSH after difficulty with ventilation and found to have rapid atrial fibrillation. Patient found at OSH to be in severe respitory distress with minimal. EKG done which showed afib with RVR of 140-170. Patient given solumedral 125mg and lasix 20mg at OSH for concern of CHF. Patient transferred to ED were found to be in rapid afib, hypotensive to SBP 60s and hypoxic with O2Sat in 80s. Patient was cardioverted in the ED and returned to sinus rhythm, decrease in HR and increase in BP. Patient given 4L IVF in the ED with minimal urine output. Patient was also found to be febrile with temp 104. Given flagyl,vanco,ceftriaxone in the ED. On CXR in ED found that there was an overdistension of tracheostomy cuff which was reduced in the ED. Past Medical History: 1. Diabetes mellitus type 2. 2. Hypertension. 3. Tracheobronchiomalacia 4. Anemia. 5. Moderate to severe mitral regurgitation. 6. PAF 7. COPD 8. CVA 9. C. diff being treated at OSH with flagyl and aztreonam Social History: Unknown Family History: The patient is currently a resident at [**Hospital3 672**] Hospital. No known tobacco or drug use Physical Exam: T 104.2 HR 90-107 BP 96-100/34 RR 27 O2Sat 100% on vent. CMV Vt450x RR 26 PEEP 6 FiO2 40% Gen: Patient attached to vent via tracheostomy. Spontaneously moving LE B/L. Patient responds to painful stimuli. Heent: Pupils pinpoint, unable to get movement, MMM Lungs: Course BS ant/lat, good airway entry Cardiac: RRR S1/S2 hol Abd: distended, decreased BS Ext: no edema Neuro: repsonsive to painful stimuli Pertinent Results: [**2201-10-19**] 08:20PM O2 SAT-99 [**2201-10-19**] 08:20PM freeCa-1.11* [**2201-10-19**] 08:20PM TYPE-ART PO2-194* PCO2-36 PH-7.36 TOTAL CO2-21 BASE XS--4 [**2201-10-19**] 08:20PM LACTATE-1.4 [**2201-10-19**] 04:15PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2201-10-19**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2201-10-19**] 04:15PM URINE RBC->50 WBC-[**12-6**]* BACTERIA-MANY YEAST-MANY EPI-[**6-26**] TRANS EPI-[**6-26**] [**2201-10-19**] 04:15PM URINE GRANULAR-0-2 FINE GRANULAR CASTS [**2201-10-19**] 02:58PM TYPE-ART TEMP-40.0 RATES-/24 TIDAL VOL-600 O2-98 PO2-609* PCO2-74* PH-7.11* TOTAL CO2-25 BASE XS--7 AADO2-42 REQ O2-19 -ASSIST/CON INTUBATED-INTUBATED [**2201-10-19**] 01:57PM LACTATE-1.4 [**2201-10-19**] 01:30PM GLUCOSE-237* UREA N-78* CREAT-1.6* SODIUM-134 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12 [**2201-10-19**] 01:30PM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-50 ALK PHOS-83 TOT BILI-0.2 [**2201-10-19**] 01:30PM cTropnT-0.08* [**2201-10-19**] 01:30PM CK-MB-NotDone [**2201-10-19**] 01:30PM TOT PROT-7.5 CALCIUM-7.9* PHOSPHATE-5.0* MAGNESIUM-2.4 [**2201-10-19**] 01:30PM WBC-22.8*# RBC-2.99* HGB-9.0* HCT-29.9* MCV-100*# MCH-30.0 MCHC-30.0*# RDW-14.3 [**2201-10-19**] 01:30PM NEUTS-90* BANDS-3 LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2201-10-19**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+ [**2201-10-19**] 01:30PM PLT COUNT-447* [**2201-10-19**] 01:30PM PT-15.2* PTT-88.5* INR(PT)-1.6 . EKG: on arrival; atrial fibrillation @ RVR of 140, nl axis, no ST changes . CXR: Marked overdistention of tracheostomy tube cuff, placing the trachea at risk for perforation and fistula formation. Probable pleural and parenchymal scarring at the lung bases, although it is difficult to fully exclude a pneumonia at the left lung base. . CXR [**10-21**] 1. Persistent tracheostomy cuff distention. 2. Worsening mild congestive heart failure with mild cardiomegaly and small bilateral pleural effusions. . [**2201-10-20**] 12:23 am SPUTUM Site: ENDOTRACHEAL GRAM STAIN (Final [**2201-10-20**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). NOTE: Culture data pending at time of discharge. . [**2201-10-20**] 12:30AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2201-10-20**] 12:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2201-10-20**] 12:30AM URINE RBC-21-50* WBC-[**12-6**]* Bacteri-MOD Yeast-MOD Epi-[**3-21**] . Brief Hospital Course: A/P: 86 y/o female with PMHx significant for tracheobronchiomalacia and chronic respitory distress with tracheostomy on chronic vent who presents from [**Hospital3 672**] in severe respitory distress, afib with RVR, hypotension and febrile. . 1. Sepsis: PNA vs Cdiff. Pt came in with Positive Cdiff cultures from OSH. Cultures sent from [**Hospital1 18**] were subsequently negative. Will continue flagyl for complete course. In addition, gram stain revealed gram neg rods, gram + cocci in pairs and cocci and gram + rods. Speciation pending at time of discharge. - Will continue to keep patient on current vent setting and titrate back to baseline as tolerated. - Will conitnue vanco/zosyn/flagyl which could cover possible VAP or aspiration PNA and CDIFF. Should complete full course of antibiotics at [**Hospital3 672**]. Vanco and zosyn started [**10-20**] and flagyl started at OSH should continue until [**10-27**]. - Continue albuterol/atrovent nebs prn - Patient with resp acidosis, would check daily ABG to make sure correcting on current vent settings - [**10-15**] Cdiff positive from [**10-15**] sample drawn at OSH. Cdiff negative at [**Hospital1 18**] [**10-20**]. . 2. Yeast infection- From urine cx. Pulled foley on [**10-21**]. Should recheck U/A at [**Hospital3 672**] on [**10-23**] for persistent fungal UTI. . 3. PAF - Patient currently in sinus rhythm, atrial fibrillation could have been exacerabted by infectious cause. - Will hold off on BBlocker at this time as BP low. - Consider repeat cardiovesion if returns back to atrial fib. - Pt needs to be anticoagulated with Warfarin. This was communicated with physician at [**Hospital3 672**] on [**10-21**]. . 4. Acute Renal Failure - Patient with Cre 1.3, last Cre was 1.1 in [**2199**]. Could be ATN secondary to hypotensive episode. Patient with minimal urine output. Would continue to monitor BUN/Cre and K+. Trending down. Probably [**2-18**] infection. . 5. DM RISS . 6. Anemia: HCT improved but some guiaic + stool on last day of admission in setting of heparin. D/C'd heparin on final night of admission. Can reconsider anticoagulation at [**Hospital1 1099**]. . 7. Access: Femoral line . 8. FEN: Continue IVF to maintain BP and UOP . 9. PPx: Heparin SC, PPI, bowel regimine . 10. Code: Full . 11. Comm with daughter . 12. Disp: To rehab Medications on Admission: 1) Lopressor 12.5 [**Hospital1 **] 2) Protonix 40mg qd 3) Modafonil 200mg qd 4) Albuterol 2puff q6 prn 5) Atrovent 2puff q6 prn 6) Heparin SC 5000units [**Hospital1 **] 7) Zoloft 75mg qd 8) Aranesp 25 mcg/qweek 9) Flagyl 500mg tid 10) Aztreonam 1g IV q12 11) Ferrlecit 62.5mg x3/week Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Respiratory Distress/Pneumonia Discharge Condition: Stable Discharge Instructions: Pls administer all meds as indicated and call with any ?s. Pt to complete course of antibiotics with vanco, flagyl and zosyn through newly place ([**10-21**]) PICC line. Followup Instructions: At OSH

0389,51884,486,5849,42731,00845,496,4240,99592,5191,V440,1122,4019

Admission Date: [**2199-1-27**] Discharge Date: Service: MICU This is a dictation summary from admission until [**2199-2-10**]. The rest will be completed by next intern. CHIEF COMPLAINT: Respiratory distress. admitted with decreased responsiveness and respiratory distress. Patient's past history of present illness is not well known except that the patient has been noted to have increasing dyspnea over the past month or two, most notable with exertion. An exact number cannot be known. The patient gets short of breath after a block or so. The family of the patient also said that the patient had been coughing for a unresponsiveness and very short of breath. She was not noted to have any fevers, chills, nausea, vomiting, abdominal pain, diarrhea or constipation, rhinorrhea or sore throat prior to admission. EMS was called and the patient was brought to the Emergency Department. In the Emergency Department, she had a chest x-ray which demonstrated right middle lobe pneumonia. Arterial blood gas revealed 7.11/93/300. Patient was placed on BiPAP with minimal improvement in her gas. Patient was then intubated. A thick sputum was also suctioned from her. She also received Solu-Medrol and nebulizers in the Emergency Department for a question of a chronic obstructive pulmonary disease flare. Patient's blood pressure was systolic 120s to 140s and briefly dropped to 50/20. Patient was started on dopamine, however, increased to 190s. Dopamine was changed to Neo with improvement of the patient's rate and pressure. She received Ceftriaxone and Flagyl and 1400 cc of intravenous fluid and sent to the Medical Intensive Care Unit for further evaluation. PAST MEDICAL HISTORY: 1. Diabetes. No further information available. 2. Hypertension. 3. Arthritis. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Hydrochlorothiazide 25 mg po q.d. 2. Lisinopril 40 mg po q.d. 3. Tolazamide 250 mg po q.d. 4. Naprosyn 500 mg po b.i.d. SOCIAL HISTORY: The patient drinks approximately one drink per day, usually to help her sleep. She denies any history of tobacco or drug use per the family. The patient lives with her daughter and her family is very involved in her care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 46665**]. PHYSICAL EXAMINATION: Temperature 101.8, 104. Blood pressure 120/40. General: The patient is vented, sedated in no acute distress. Head, eyes, ears, nose and throat: Pinpoint pupils, but received morphine in the Emergency Department. Normocephalic, atraumatic. No icterus. Small hemorrhage in left conjunctivae. Neck supple. Heart: Regular rate and rhythm, no murmurs, rubs or gallops. Lungs: Coarse rhonchi bilaterally. Inspiratory and expiratory wheeze with increased expiratory time. Abdomen: Soft, nontender, nondistended with positive bowel sounds. Extremities: Cool, no edema. LABORATORIES: White blood cell count 22, hematocrit 47, creatinine of 2.1. Toxicology screen negative. Electrocardiogram: Sinus tachycardia at 132 with normal axis, normal intervals, Qs in III and aVF. Chest x-ray with right middle lobe pneumonia. HOSPITAL COURSE: 1. Pulmonary: The patient was admitted with possible aspiration pneumonia given the questionable history of alcohol use, although, upon further questioning, his history of alcohol was less substantial. Patient was started on levofloxacin, Flagyl and vancomycin. She was also started on Combivent nebulizers and Solu-Medrol for question of chronic obstructive pulmonary disease exacerbation given the patient's wheezing on physical examination. Patient remained afebrile after a couple of days and the vancomycin was discontinued. As there appeared to be no indication of flora, the patient was be treated for 14 days with levofloxacin and Flagyl for a probable aspiration pneumonia. Because the patient was noted to be noted to have severe wheezing and also had an effusion on chest x-ray, CT was performed of the chest which showed no change in her pneumonia. It did note small bilateral pleural effusions. Patient was attempted several times to be weaned to pressure support from AC ventilation, however, she did tolerate this and she became very agitated and desynchronous with the ventilator. On hospital day six, the patient had a bronchoscopy to further examine her wheezing as she had no history of chronic obstructive pulmonary disease, smoking, and no clear reason for her wheezing. Bronchoscopy demonstrated very severe tracheomalacia with 80-90% distal tracheal collapse, also severe malacia of her RMST/RBI with complete obstruction of the bassilar segments of the right lower lobe, moderate collapse of her left main stem bronchus. At this point, the patient's steroids were discontinued and in house, the following day, the patient was brought to the OR by Interventional Pulmonary for stenting of her distal trachea and left mainstem were performed. Patient's wheezing did not improve and she remained difficult to wean. The plan was then to remove the stents and to perform a tracheostomy, to wean her off her AC and ventilatory support. On hospital day ten, the patient's temperature spiked and grew gram positive cocci in her sputum. The vancomycin was restarted and awaiting final respiratory cultures. 2. Cardiovascular: The patient was initially brought to the floor on Neo after her failure with dopamine. Patient's blood pressure remained somewhat tenuous and the patient's Neo was changed to a vasopressin with good improvement. She remained on this for approximately two hospital day and then was able to wean off her pressures altogether. She underwent cardiac echocardiogram which demonstrated normal ejection fraction, moderate to severe mitral regurgitation. Patient remained off her blood pressure medications with minor fluctuations in her blood pressure. Patient became increasingly total volume overloaded during her admission, up to 20 liters positive. However, her intervascular space remained volume depleted. She was then tried to be diuresed with Lasix, although, this tended to dry her out. On hospital day 12, the patient received 20 of Lasix intravenously and dropped her pressures to the 70s. She was restarted on vasopressin which provided only some improvement in her blood pressure. On hospital day 14, the patient was started on dopamine with the hope of improving her profusion to her kidneys in hope of auto-diuresis. 3. Renal: Patient was admitted with acute renal failure with a creatinine of 2.0. She was noted to have normal renal function prior to admission. Patient was treated with intravenous fluids in the Emergency Department. This slowly resolved over several days until she came to a creatinine of 0.8 which was felt to be her baseline. 4. Infectious Disease: Patient was started on antibiotics for her pneumonia as listed in the pulmonary section. On hospital day 14, the patient remained to have low grade temperature spikes. Patient will have CT of the sinuses to rule out sinusitis. She will be changed from Levaquin to vancomycin and ceftazidime for a presumed sinusitis until the CT scan results have returned. 5. Nutrition: Patient was started on tube feeds upon admission. Promote with fiber. Patient tolerated these well through her nasogastric or OT tube. Due to patient's inability to wean off the ventilator, the option of percutaneous endoscopic gastrostomy was discussed with the patient's family. The agreed that percutaneous endoscopic gastrostomy was wanted should the patient still have some chance of recovery. Gastrointestinal came to evaluate the percutaneous endoscopic gastrostomy and once the patient is off pressors, they will perform this procedure. 6. Fluid and electrolytes: The patient became increasingly volume overloaded during the length of her stay up to 20 liters positive. The reasoning for her inability to secrete this fluid is not clear. Should have normal renal function. Patient does have a low abdomen which is likely contributing to this problem. >.....<pressors with diuresis may be wanted. 7. Prophylaxis: The patient will remain on H2 blocker due to lack of intravenous PPI availability. Pneumoboots and heparin subcutaneously. 8. Code status: Patient is full code. Should the patient's prognosis worsen, this should be readjusted with the family. 9. Endocrine: Patient was maintained on an insulin drip, taken off her oral hypoglycemic. Increase fingersticks as well once the patient is off pressors and is doing better, she will be returned to insulin or oral hypoglycemics. DICTATION WILL BE CONTINUED BY INTERN TAKING OVER THIS SERVICE. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**First Name3 (LF) 46666**] MEDQUIST36 D: [**2199-2-10**] 01:23 T: [**2199-2-10**] 13:30 JOB#: [**Job Number 46667**]

5070,51884,5849,2766,7070,0389,5191,4589,25000

Unit No: [**Numeric Identifier 67511**] Admission Date: [**2101-5-30**] Discharge Date: [**2101-5-30**] Date of Birth: [**2101-5-30**] Sex: M Service: NB ADMISSION DIAGNOSES: 1. Antenatally diagnosed hypoplastic left heart syndrome. 2. Antenatally diagnosed bilateral pyelatelectasis DISCHARGE DIAGNOSES: 1. Antenatally diagnosed hypoplastic left heart syndrome. 2. Antenatally diagnosed bilateral pyelatelectasis HISTORY: This infant was delivered at 38-6/7 weeks to a 38- year-old gravida 2 para 1 now 2 woman with a past obstetric history notable for a term spontaneous vaginal delivery in [**2097**]; this child is alive and well. PAST MEDICAL HISTORY: Noncontributory. PRENATAL SCREENS: Blood group A+; direct antibody test negative; hepatitis B surface antigen negative; RPR nonreactive; rubella immune; gonococcus negative; Chlamydia negative; HIV negative; quadruple-AFP normal/low risk; cystic fibrosis negative. Last menstrual period was [**2100-9-8**], for an estimated date of delivery of [**2101-6-7**], and an estimated gestational age of 38-6/7 weeks at delivery today, [**2101-5-30**], at 14:30. Pregnancy was complicated by ventricular size discrepancy noted on fetal survey with subsequent echo showing the following: hypoplastic left heart syndrome with probable aortic and mitral valve atresia, mild tricuspid regurgitation, adequate pulmonary artery, good right ventricular systolic function, large PDA, small left atrium, moderate nonrestrictive atrial septal defect. The fetal survey also showed bilateral pyelectasis. Parents declined amniocentesis. Elective cesarean section was undertaken, without prior labor, for fetal indications. Ruptpure of membranes occurred at delivery, yielding clear amniotic fluid. There was no fever or other clinical evidence of chorioamnionitis. The mother received spinal anesthesia. The infant was vigorous at delivery. He was orally and nasally bulb suctioned and dried. Infant was mildly cyanotic initially but attained good color over 1-2 minutes. No oxygen was required. Apgars were 9 at 1 minute and 9 at 5 minutes. Infant was transferred uneventfully to the NICU on room air. PHYSICAL EXAMINATION: Term infant in no distress. Right arm blood pressure is 79/37 [mean 52], left arm 63/28 [43], right leg 61/27 [40], left leg 72/28 [41], SaO2 is 90% in room air [postductal], heart rate 164, respiratory rate 40- 60. HEENT: Anterior fontanel is soft and flat. Facies nondysmorphic. Palate intact. Neck/mouth normal. No nasal flaring. CHEST: No retractions. Good breath sounds bilaterally. No adventitious sounds. CVS: Well perfused [capillary refill 3 seconds], regular rate and rhythm; femoral pulses normal; II/VI systolic ejection murmur at the left sternal border radiating across the chest and into both axilla. ABD: Soft, nondistended, no organomegaly. Bowel sounds active. Anus appears patent. A 3- vessel umbilical cord is noted. GU: Infant has a normal penis with bilaterally descended testes. INTEG: Normal. MSK: Infant has a shallow sacral dimple with an easily visualized base. There is a normal spine, limbs, hips and clavicles. CNS: The infant is active and responsive to mild stimulation. Tone is normal and symmetrical. He is moving all extremities symmetrically. Suck, root, gag are intact; facies are symmetrical; extraocular movements are normal; pupils are equal and reactive to light. INVESTIGATIONS: D-stick 47. IMPRESSION: This term infant presents with antenatally diagnosed hypoplastic left heart syndrome, currently stable in room air, and antenatally diagnosed bilateral pyelatelectasis. PLAN: The infant is to be transferred to [**Hospital3 1810**] for definitive management. Two peripheral IVs have been started, and prostaglandin has been initiated at 0.01 mcg/kg per minute. We will continue to monitor perfusion and postductal oxygen saturation closely on the transport. We will target oxygen saturations of 70%-85% and mean blood pressures above 40 mmHg. The infant has no sepsis risk factors. We will therefore defer antibiotic coverage for now but consider this if cardiorespiratory symptoms develop. Respiratory drive appears well maintained with the start of the prostaglandin infusion. We will, therefore, defer intubation unless apnea is noted. Enteral feeds will be deferred given the likelihood of cardiorespiratory compromise. In the interim, maintenance IV D10W has been started with the usual attention to fluid and metabolic issues. The infant will require postnatal abdominal ultrasound in followup of the antenatally diagnosed renal dilatation. The parents have been updated through an interpreter. CONDITION ON DISCHARGE: Guarded. DISCHARGE DISPOSITION: Transferred to [**Hospital3 1810**] Cardiac Intensive Care Unit. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 2427**] [[**Hospital1 1474**]]. DISCHARGE MEDICATIONS: 1. Prostaglandin 0.01 mcg/kg per minutes through peripheral IV. 2. D10W at 80 ml/kg per minute through peripheral IV. A state screen has been sent. The infant has not received a hearing screen or hepatitis B immunization. Vitamin K and ophthalmic erythromycin prophylaxis have been administrated. Reviewed By: DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-622 Dictated By:[**Last Name (NamePattern4) 55784**] MEDQUIST36 D: [**2101-5-30**] 16:26:19 T: [**2101-5-30**] 17:41:45 Job#: [**Job Number 67512**]

V3001,7705,7467

Admission Date: [**2179-8-9**] Discharge Date: [**2179-8-17**] Date of Birth: [**2133-5-8**] Sex: M Service: MEDICINE Allergies: E-Mycin Attending:[**First Name3 (LF) 3507**] Chief Complaint: RLE Cellulitis/Code Sepsis Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: 46 yo M with HTN, DM2, who presents to the ED with 1 day of right lower extremity warmness. Pt and wife say that yesterday he was feeling fatigued and "achy" all over. +Fevers (did not take with thermometer), +chills. +Nausea. No vomiting. +sweating. Last night he was walking and hit his right leg on the corner of the dishwasher which called attention to his RLE. He noticed that it was warm and slightly duskier than usual (has normal status changes). No cough. No dysuria. . In the ED, VS on arrival were: T: 105.3; HR: 120; BP: 125/82, RR: 20; O2: 94 RA. He received Vancomycin 1 g IV x 1, ceftriaxone 1 g IV x 1, dolansterone mesylate 12.5 mg IV x 1, Ketolorac 30 mg, Tylenol 1 g IV x 1. BP noted to be 70s systolic and pt received 5-6 L NS. He was put on the code sepsis protocol and a RIJ was placed. Past Medical History: 1. Type 2 diabetes mellitus. 2. Hypertension. 3. h/o b/l DVT 94' in setting ARDS (see below). Since then, RLE swollen and with venous stasis changes. 4. High cholesterol. 5. Anal fissure. 6. Thalassemia. 7. h/o ARDS with Enterococcus and coag- negative Staphylococcus in [**2168**]. Social History: Married with four children. Financial risk analyst at Fidelity. No smoking. Occasional EtOH. No drugs. Family History: Family History: M: DM, HTn; F: HTN. No CAD. No clotting disorders in family. Physical Exam: VS: T: 103.4; HR: 118; BP: 108/54; RR:22; O2: 100 2L Gen: Speaking in full sentences, in NAD HEENT: MMM, sclera anicteric. OP clear Neck: JVD difficult to see [**3-11**] neck girth. No LAD. RIJ in place without erythema or bleeding. CV: RRR S1S2. No M/R/G Lungs: CTA b/l with slightly diminished air flow at bases. Abd: NABS. SOft, NT, ND Back: No spinal, paraspinal, CVA tenderness Ext: RLE: swollen >>L. Non pitting edema 2+. DP 2+ b/l. +venous stasus changes mid calf down. +slight erythema/duskiness above that to knee. +warmth in that area (marked with pen). +right lower inguinal lymph nodes palpable and painful. No streaks or cords Neuro: MS [**6-11**] LE. A&O x 3 Pertinent Results: [**2179-8-9**] 11:20AM WBC-8.4 RBC-6.06 HGB-12.3* HCT-36.4* MCV-60* MCH-20.3* MCHC-33.8 RDW-16.1* [**2179-8-9**] 11:20AM NEUTS-87.5* LYMPHS-8.3* MONOS-3.6 EOS-0.2 BASOS-0.3 [**2179-8-9**] 11:38AM LACTATE-3.0* Brief Hospital Course: #) Sepsis/RLE cellulitis: source appeared to be the cellulitis. Surgery was consulted and felt that clincially, pt did not have Nec Fasc or compartment syndrome. All Micro data from admission negative. Initial CT scan or RLE (without contrast) showed: Low-density region within the inferior aspect of the medial head of the gastrocnemius muscle suggests pyomyositis, particularly given the patient's clinical history. Several areas of low density may reflect developing loculated fluid collections, although at this time, no single loculated fluid collection is identified that might be amenable to drainage. Extensive and circumferential edema of the subcutaneous fat is nonspecific, likely reflecting a combination of venous stasis and cellulitis. No specific evidence of osteomyelitis. As there was evidence for ? fluid collection on initial CT scan, a repeat CT scan the day before discharge showed diffuse subcutaneous soft tissue edema. The differential diagnosis includes changes related to cellulitis. However, there is no evidence for phlegmon or abscess on this examination. The patient was started in the ICU on broad spectrum abx (Vanc/Unasyn-->Vanc/Zosyn) and the patient will complete a total of 14 d of Vanc/Zosyn for treatment of the cellulitis. #) DM2: Restarted metformin, 1000mg [**Hospital1 **] and Actos, 45mg QD. As patient had recent CT with IV contrast, will hold Metformin for 48 hours and pt to restart as outpt. . #) HTN: given recent Hypotension, ICU team started short acting BB. Pt's Blood pressure was stable on the floor; eventually switched back to Atenolol 100 mg qhs with plans to reinstitute Lisinopril 5 mg as outpt. . #) Anemia: Likely [**3-11**] aggressive fluid repletion in setting of anemia, inflammation, and thalasemmia. Pts HCT on admission was 36.4 which dropped to a nadir of 25.9 during the hospitalization. HCT on discharge was 27.5, pt was guiac (-). Medications on Admission: Metformin 1000 mg [**Hospital1 **] Atenolol 100 mg qpm Lisinopril 5 mg qpm Lipitor 10 mg qhs Actos 45 mg qday ASA 81 mg qday Ibuprofen 600 mg prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*12 Tablet(s)* Refills:*0* 5. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gm Recon Solns Intravenous Q8H (every 8 hours) for 10 days: course to finish on [**8-27**]. Disp:*qs Recon Soln(s)* Refills:*0* 6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 8H (Every 8 Hours) for 10 days: Course to finish on [**8-27**]. Disp:*qs gm* Refills:*0* 9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: DO NOT take until the evening of [**8-18**]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary Diagnosis: Right Lower Extremity Cellulitis Secondary Diagnoses: Type 2 DM Hypertension Thalassemia/Anemia Venous insufficiency secondary to h/o DVT Hypercholesterolemia Discharge Condition: stable; cellulitis improving Discharge Instructions: Please contact your primary contact doctor should you have any fevers, chills, night seats, worsening leg pain or swelling, or any other complaints. Because you recently had a CT scan, DO NOT take your Metformin until the evening of [**8-18**]. Followup Instructions: Please make an appointment to follow up with Dr. [**Last Name (STitle) 58**] next week.

0389,78552,6826,28249,99592,45981,25000,4019,28529,2720

Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-26**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old male with a past medical history of diabetes, hypertension, and deep venous thrombosis presenting with a fever and lower extremity pain times one day. In the Emergency Department, the patient was noted to have a fever and hypotension. He received 6 liters of intravenous fluids, Ancef, and Unasyn and was transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Hypertension. 3. Bilateral deep venous thrombosis. 4. High cholesterol. 5. Anal fissure. 6. Thalassemia. MEDICATIONS ON ADMISSION: Actos, Glucophage, atenolol, aspirin, and Lipitor. ALLERGIES: ERYTHROMYCIN. SOCIAL HISTORY: No alcohol. No tobacco. No drug use. FAMILY HISTORY: Mother with diabetes. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient had a temperature of 103.5, his heart rate was 112, his blood pressure was 109/50, his respiratory rate was 20, and his oxygen saturation was 100% on 2 liters. In general, he was alert and oriented times three. In no acute distress. Head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric. The oropharynx was clear. No neck stiffness. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities revealed right lower extremity venous changes. Pain the medial thigh to the calf. No rash. Neurologic examination revealed cranial nerves II through XII were intact. Sensation and strength were [**6-10**]. Distal pulses were 2+ distally. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 12.8. His hematocrit was 37.1. Chemistries were within normal limits. Urinalysis was normal. Lactate was 3.3. PERTINENT RADIOLOGY/IMAGING: A computed tomography angiogram was negative for a pulmonary embolism. A chest x-ray was normal. A right lower extremity ultrasound revealed no deep venous thrombosis. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. INFECTIOUS DISEASE ISSUES: The patient presented with fevers, hypotension, right lower extremity pain, and septic physiology responsive to intravenous fluids. The patient had a negative ultrasound of his right lower extremity for deep venous thrombosis and a negative computed tomography angiogram for a pulmonary embolism. Urinalysis was normal. No murmur was heard on cardiac examination, and a transthoracic echocardiogram was negative for endocarditis. It was thought that the source of his infection was a right lower extremity cellulitis. He was initially started on Unasyn, as the patient is a diabetic, and gentamicin was added to cover Pseudomonas. A right lower extremity magnetic resonance imaging was performed which showed soft tissue edema. No focal fluid collection, and no signs of fasciitis. General Surgery was consulted, and vancomycin was added to the regimen for his cellulitis. The patient developed a headache without neck stiffness. A lumbar puncture was attempted but was unsuccessful. The patient's cellulitis continued to improve. Another line was placed prior to discharge. He will be discharged on seven days of Unasyn and then by mouth Augmentin for seven days. He was instructed to use compression stockings to reduce the swelling and improve circulation. 2. HEADACHE ISSUES: The patient's headache improved during his hospital course. He did not have any associated photophobia or neck stiffness. It was thought that this may have been secondary to discontinuation of his beta blocker because of his low blood pressures. DISCHARGE STATUS: Discharge status was to home. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient to follow up with Dr. [**Last Name (STitle) 58**] on Wednesday, [**11-27**]. MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: Mid line placement on [**2176-11-25**]. MEDICATIONS ON DISCHARGE: 1. Unasyn 3 gram intravenously q.6h. (times seven days). 2. Augmentin 500/125 one tablet by mouth three times per day (times seven days); starting in one week. 3. Normal saline flushes 10 cc before and after each Unasyn dose. 3. Heparin flushes 2 cc after each Unasyn dose. DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988 Dictated By:[**Last Name (NamePattern1) 3476**] MEDQUIST36 D: [**2177-3-19**] 12:03 T: [**2177-3-19**] 12:52 JOB#: [**Job Number 6061**]

6826,5990,28249,4019,25000,4589,7856,04100,7840