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allergies: codeine / penicillins / zinc oxide attending: chief complaint: transferred to for possible endocarditis, transfer to et for work up of cirrhosis major surgical or invasive procedure: transesophageal echocardiogram history of present illness: patient is a 60 yo m with hcv, cirrhosis, h/o poly substance abuse currently on a methadone program, trasnfusion dependent anemia, chronic renal isufficiency, cad, h/o cardiac arrest s/p icd who was initially transferred to ccu for enterococcus bacteremia and concern for endocarditis given new murmur and persistant bacteremia. he was initially treated with vancomycin and gentamicin but gent discontinued for . tee and tte negative for vegetation but given high pre-test probability and possible infected pacer wires id has consulted on patient and recommended cipro and vancomycin for prolonged course. patient has never had an outpatient work up for cirrhosis in the past and his meld was >20 and so patient transferred to - for further management of his acute on chronic kidney injury in addition to work up for cirrhosis and initiation of transplant evaluation. . review of systems: patient is somnolent, is arousable and oriented so ros is unable to be completed. past medical history: -?cirrhosis -hepatitis c -polysubstance abuse - ivdu, now on methadone, etoh, mja -hld -htn -icd/dual chamber pacemaker -, 70% -cad distant mi -recurrent vt, vf arrest s/p guidant icd prolonged qt -gerd s/p partial gastrectomy in for gastric ulcer -hypothyroidism -peripheral vascular disease -right hip fracture s/p multiple surgical revisions -chronic pain (hip and back) -appendectomy in social history: the patient is on disability. - ivdu with heroin (last use "years ago"). - mja use - he formerly drank a 6 packs/day and now cut back to beers/day. - he is currently on methadone. - he is married and lives with his wife. family history: sister died from "blood clot" with sudden death. had not been hospitalized or with recent trauma/surgery. no other family history of blood clots/bleeding disorders. no family history of heart problems, or cancer. physical exam: admission exam: vitals: av paced at 80bpm, 110/47 16 95%ra general: patient is somnolent but arousable, he is when aroused he is aox3 but he quickly closes eyes and has to be rearoused. he is chronically ill appearing. nad. does not appear grossly jaundiced heent: normocephalic, atraumatic, no scleral icterus neck: supple, nt, no : s1 s2 clear and of good quality, 2/6 systolic murmur rusb lungs: patient unable to take deep breaths for exam but clear to asucultation on anterior exam abdomen: soft, obese, ecchymoses, nttp, distended, palpable hepatosplenomegaly. extremities: bilateral 3+ up to thigh with also scrotal edema present. chronic le skin changes hyperpigmentation of skin without evidence of cellulitis. diminished pulses but also with severe edema neurological: somnolent but arousable, ox3 when aroused discharge exam: general: patient is alert and oriented x3, chronically ill appearing. nad. does not appear grossly jaundiced, wanting to go home, does not want further treatment heent: normocephalic, atraumatic, no scleral icterus neck: supple, nt, no : s1 s2 clear and of good quality, 2/6 systolic murmur lusb lungs: patient clear to asucultation on anterior exam abdomen: soft, obese, ecchymoses, nttp, distended. extremities: bilateral 3+ up to hips also with scrotal edema present. chronic le skin changes c/w venous stasis. pertinent results: admission: 07:48pm blood wbc-21.0*# rbc-2.52*# hgb-7.9*# hct-23.5*# mcv-93 mch-31.4 mchc-33.7# rdw-19.2* plt ct-58* 07:48pm blood neuts-77* bands-13* lymphs-5* monos-2 eos-3 baso-0 atyps-0 metas-0 myelos-0 07:48pm blood pt-17.0* ptt-40.2* inr(pt)-1.5* 07:48pm blood fibrino-133* 07:48pm blood esr-81* 07:48pm blood ret aut-1.8 07:48pm blood glucose-97 urean-61* creat-3.2*# na-139 k-3.3 cl-109* hco3-24 angap-9 07:48pm blood albumin-1.4* calcium-7.7* phos-3.8 mg-2.2 07:48pm blood alt-33 ast-128* ld(ldh)-335* alkphos-46 totbili-2.0* dirbili-0.9* indbili-1.1 07:48pm blood hapto-<5* 08:00pm blood hapto-<5* 07:48pm blood crp-55.9* 08:08pm blood type- temp-35.6 po2-59* pco2-39 ph-7.43 caltco2-27 base xs-1 08:08pm blood lactate-2.6* 08:08pm blood freeca-1.11* hemolysis work up: 07:48pm blood hapto-<5* 08:00pm blood hapto-<5* 04:11am blood caltibc-146 ferritn-906* trf-112* 07:48pm blood ret aut-1.8 07:48pm blood fibrino-133* 08:00pm blood fibrino-113* 03:45am blood fibrino-77* 04:30am blood fibrino-117*# 04:30am blood fdp-40-80* 03:00pm blood fibrino-101* 07:48pm blood pt-17.0* ptt-40.2* inr(pt)-1.5* 07:48pm blood plt smr-very low plt ct-58* difficult cross match: diagnosis, assessment and recommendations: mr. has a new diagnosis of an anti-k (prior diagnosis of anti-c, anti-e and anti-sda at ). k is a member of the blood group system. anti-k is clinically significant and is capable of causing hemolytic transfusion reactions. in the future, mr. should receive k, c and e antigen negative products for all red cell transfusions. approximately 13% of abo compatible blood will be k, c and e antigen negative. in addition, mr. has an anti-sda. although usually not considered clinically significant these antibodies can complicate blood bank workups. therefore, please notify the blood bank as soon as possible if transfusion is being considered. reports: tee : the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no masses or vegetations are seen on the mitral valve. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. ct head impression: no ct evidence for acute intracranial hemorrhage or mass effect. correlate clinically to decide on the need for further workup/followup. ruq us 1. coarsened heterogeneous hepatic echotexture without focal lesion. small volume of ascites and borderline splenomegaly noted. 2. bilateral pleural effusions. 3. prominent cbd at 8 mm. cxr right picc tip is in the right atrium, can be withdrawn approximately 4 cm for more standard position. there are low lung volumes. moderate cardiomegaly is stable. left transvenous pacemaker leads are in a standard position. moderate pulmonary edema has minimally increased. small left pleural effusion has increased. left lower lobe retrocardiac atelectasis has worsened. micro: hcv viral load (final ): 192,129 iu/ml. bcx x6 negative c.diff negative ucx negative x 1, gnrs ~5000/ml x1 catheter tip cx negative brief hospital course: patient is a 60yo m with ivdu, polysubstance abuse on methadone, hcv, ?cirrhosis based on biopsy per report who was initially admitted to ccu for ?endocarditis/pacemaker wire infection, transferred to et for management of cirrhosis and acute kidney injury. # goals of care: it is clear thats patient's goal is to be discharged home regardless of prognosis. he is aware that his liver will continue to deteriorate and he does not want to continue aggressive measures to improve his hepatic function. he is a not a transplant candidate, both from pre-hospitalization etoh intake and because patient not interested in evaluation, without a transplant his prognosis is poor. palliative care consulted. after in depth discussion between patient, his wife, and with pal care team the decision was made to transition patient to home hospice care. patient's icd was turned off and a home hospital bed was delivered to patient's home. he was discharged in stable condition to home hospice care with minimal medications. # hepatitis c: end stage liver dysfunction possibly complicated by cirrhosis, ascites and hepatic encephalopathy though cirrhosis not confirmed. this has been untreated as an outpatient and has not seen a hepatologist. lfts began improving in the ccu and continued to during et admission but albumin remained <1.5 and inr 1.5. meld=22 on et transfer. he was encephalopathic on transfer. transplant work up was initiated though not completed as patient expressed his desire to not be treated. /ama negative, hbsab+ but hbsag-, hcv load 192,000. his cirrhosis was treated with lactulose and rifaximin. he continued to refuse his lactulose yet his mental status improved in clarity, hepatic encephalopathy likey the result of bacteremia. he was treated with spironolactone: 50mg for anasarca and hypokalemia and furosemide 20mg daily. creatinine remained stable at new baseline of 1.4 despite diuretics. # acute kidney injury: acute on chronic renal insufficiency. feurea was 48% and urinalysis showed muddy brown casts suggesting atn. episode of hypotension may have precipitated atn in addition to gentamicin related nephrotoxicity. creatinine continued to improve during admission with clearing of bacteremia, improvement in lfts and with avoiding hypotension and gentamicin. renal initially consulted, did not feel it was hrs but rather atn. lasix did not exacerbate renal function # bacteremia: at osh, he had bcx positive for enterobacter and enterococcus. all bcx drawn at were negative. he was treated with vanc and gent at the osh, which was changed to vanc and cipro after consult with id at . patient with prior enterococcal uti/bacteremia without definitive evidence of endocarditis found on tee. he was treated for endocarditis despite negative tee given high suspicion and pacer wire high risk infection. he was treated with iv vanco and cipro for a 6 week course. a tte and tee showed no vegetations and no sign of infection on the pacer/icd wire. the lead was not removed per id recommendations. #anemia - he has a known history of anemia which is transfusion dependent. the etiology is thought to be hemolytic given low haptoglobin, elevated ldh and tbili. repeat work-up here showed anti-c, anti-e, anti-sda and anti- antibodies. heme/onc was consulted did not feel this was dic but rather transfusion hemolysis. however, after bacteremia was treated hct remained relatively stable with uptrending platelets. inr remained elevated and continued to rise somewhat in the setting of low fibrinogen and elevated fdps. upper and lower endoscopies were deferred given goals of care discussion with patient and his wife. did require multiple prbc transfusions, he remained hd stable during hct drops without e/o bleeding. #thrombocytopenia and concern for dic - thrombocytopenia was thought to be primarily from liver disease. there was initially some concern for dic. fibrinogen was low, fibrin split products were elevated, and inr was somewhat elevated (which may have been partially from liver disease). he did not receive any blood products in the ccu and there was no evidence of bleeding. heme/onc was following and thought that if there were e/o bleeding then we could consider ffp or cryoprecipitate. platelets continued to rise after bacteremia treated. anemia treatment as above with prbcs #h/o substance abuse - continued on home methadone dose, it was divided into 3 doses at one point to treat pain and patient tolerated this dosing regimen well. discharged on pre-hospitalization 140mg daily #chronic venous stasis - no s/s infection, chronic, stable. transitional issues: - patient discharged to home hospice care medications on admission: medications: unclear home medications but based on transfer list: -methadone -epoetin -oxazepam 15 mg daily -digoxin 0.125 -folic acid -levothyroxine 0.088 -phytonadione 2.5 mg dily discharge medications: 1. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*90 doses* refills:*0* 2. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 4. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. methadone 40 mg tablet, soluble sig: 3.5 tablet, solubles po once a day. disp:*105 tablet, soluble(s)* refills:*0* 6. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: 5-20 mg po q2hrs as needed for pain or sob. disp:*30 ml* refills:*0* 7. hyoscyamine sulfate 0.125 mg/ml drops sig: one (1) ml po every four (4) hours as needed for upper respiratory congestion. disp:*15 ml* refills:*0* 8. lorazepam 0.5 mg tablet sig: 0.5-2 mg po every four (4) hours as needed for anxiety. disp:*30 tabs* refills:*0* 9. oxycodone 5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: old colony hospice discharge diagnosis: active: - end stage liver disease - hepatitis c - alcohol - polysubstance abuse now on methadone chronic: -hld -htn -icd/dual chamber pacemaker -, 70% -cad distant mi -recurrent vt, vf arrest s/p guidant icd prolonged qt -gerd s/p partial gastrectomy in for gastric ulcer -hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: lethargic but arousable. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: mr. , it was a pleasure treating you during this hospitalization. you were transferred to with bacteria in your blood and the concern that you developed an infection on one of your heart valves. you had an echocardiogram completed of your heart which did not show infection on your heart valve. you were treated with iv antibiotics. you were also found to have dropping blood levels requiring multiple transfusions. your kidneys were damaged when you were admitted but began improving after your blood pressure was improved and an antibiotic called gentamicin was stopped. your kidney, liver and blood counts all improved and you were discharged in improved condition. your liver disease is end stage and after discussion it was clear you did not want to be evaluated for a transplant. in keeping with your goals of care and after discussion with your wife, , it was decided to send you home with hospice care. prior to your discharge the implanted icd was turned off. it was a pleasure treating you at . the following changes to your home medications were made: - start lactulose 30ml three times per day - start rifaximin 550mg twice daily - start pantoprazole 40mg daily - pain and breathing control with morphine, ativan and oxycodone. - no other changes to your home medications were made, please continue as previously prescribed followup instructions: none md Procedure: Diagnostic ultrasound of heart Central venous catheter placement with guidance Diagnoses: Thrombocytopenia, unspecified Other chronic pain Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Chronic hepatitis C with hepatic coma Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Peripheral vascular disease, unspecified Hypopotassemia Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Hypotension, unspecified Bacteremia Old myocardial infarction Pain in joint, pelvic region and thigh Acute and subacute bacterial endocarditis Other ascites Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Encounter for palliative care Backache, unspecified Other specified antibiotics causing adverse effects in therapeutic use Opioid abuse, unspecified Chronic diastolic heart failure Ulcer of heel and midfoot Venous (peripheral) insufficiency, unspecified Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Infection and inflammatory reaction due to cardiac device, implant, and graft Chronic viral hepatitis B with hepatic coma without hepatitis delta Ulcer of thigh Chronic ulcer of other specified sites Cannabis abuse, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: referred after ct head done in am; headaches for 2-3 months major surgical or invasive procedure: bilateral craniotomies with evacuation of subdural hematomas history of present illness: this is a 66 year old who was referred by his pcp for head ct the morning of admission on the of . the history is as per the interpreter (pt only speaks cantonese). the patient describes a bilateral headache of months duration, partially relieved by pain medication (tylenol). he does not recall any incident of trauma or any falls, but does describe a routine daily chinese exercise where he shakes his head to either side. the headache has been constant, and last night, increased in intensity and the patient describes a feeling of loss of balance (ataxia). he has has no visual field disturbances, loc, or other neurological symptoms of note. past medical history: - hypertension - recent gastric biopsy for abdominal discomfort social history: - pt is with very little english - he is married - he has 4 children - he is currently retired - he does not smoke or drink alcohol family history: noncontributory. physical exam: ------physical exam: gen: wd/wn, comfortable, nad. heent: pupils: 4 to 2 mm bilaterally. eoms intact. neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. no c/c/e. . neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. . cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2mm 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 finger rub bilaterally. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. . motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift . sensation: intact to light touch bilaterally. . toes downgoing bilaterally . gait not assessed on discharge: unchanged pertinent results: admission labs: 11:50am blood wbc-8.8 rbc-4.77 hgb-12.8* hct-36.1* mcv-76* mch-26.8* mchc-35.4* rdw-12.9 plt ct-323 11:50am blood neuts-80.2* lymphs-14.1* monos-3.5 eos-1.7 baso-0.5 11:50am blood pt-11.5 ptt-28.6 inr(pt)-1.0 11:50am blood glucose-182* urean-8 creat-1.1 na-140 k-4.1 cl-102 hco3-27 angap-15 11:50am blood alt-23 ast-16 alkphos-71 amylase-93 totbili-0.2 11:50am blood albumin-4.4 calcium-9.2 phos-2.8 mg-2.5 hct : there are moderate sized bilateral frontoparietal convexity subdural hematomas. the right subdural hematoma measures 2.3 cm from the inner table whereas the left subdural hematoma measures 1.7 cm from the inner table. the subdural hematomas have areas of hyperdensity interspersed by lower density areas. these findings likely represent acute on chronic hematomas. there is minimal shift of the midline structures to the left by 4 mm. there is mass effect upon the ipsilateral lateral ventricle. in addition, there appears to be trapping of the temporal of the right lateral ventricle as it is dilated out of proportion to the remainder of the ventricular system. the suprasellar cistern is patent but has some minimal mass effect upon it. the quadrigeminal plate cistern is patent as well as the basal cisterns. there is atherosclerotic calcification. the -white matter differentiation is preserved. incidental note is made of a chronic left tripod fracture. impression: acute on chronic bilateral subdural hematomas, right greater than left with mild mass effect. there appears to trapping of the temporal of the right lateral ventricle. mri 10/706: there are bilateral mixed signal intensities with predominant hyperintense t1 signal subdural hematomas identified extending from frontal to the parietal region. the hematoma on the right measures 2.5 cm in the maximum width and the hematoma on the left side measures 2 cm in the maximum width. there is indentation on the adjacent brain with compression of both lateral ventricles. there is no significant midline shift seen. the basal cisterns are patent. there is mild prominence of both temporal horns identified. small amount of blood is also seen along the tentorium on the right side. following gadolinium, no abnormal parenchymal or vascular enhancement seen. there is mild meningeal enhancement identified bilaterally. at the craniocervical junction, no abnormalities are seen. specifically, no evidence of tonsillar herniation is seen. impression: bilateral mixed signal intensity subdural hematomas with hyperintense t1 signal indicating acute/subacute subdurals. the left-sided subdural measures 2 cm and the right-sided subdural measures 2.5 cm in maximum width. no evidence of herniation is seen. mass effect is seen on both cerebral hemispheres and the ventricles. no evidence of acute infarct. hct : the patient is status post bilateral parietal craniotomies. there is small amount of hemorrhage at the postoperative site, and small bilateral subdural fluid collections with layering hematocrit posteriorly. there is a small amount of intracranial air. the bilateral subdural collections are greatly decreased in size from and no longer demonstrate a heterogeneous pattern. there is no shift of midline structures, but there is compression of both lateral ventricles that appear relatively unchanged. there is distortion of the suprasellar cistern, unchanged indicating some mild downward pressure, but the quadrigeminal plate and basal cisterns are relatively intact. the right temporal is dilated indicating some entrapment, slightly improved. impression: status post bilateral craniectomies with smaller bilateral subdural collections and unchanged mass effect. path: #1, right subdural collection: acute hematoma. #2, right subdural membrane and clot: chronic, organizing hematoma with features of chronic subdural hematoma. ekg : normal sinus rhythm. ecg is within normal limits and unchanged compared to the previous tracing of . intervals axes rate pr qrs qt/qtc p qrs t 83 170 92 358/397.71 76 60 54 cxr : no evidence of acute cardiopulmonary abnormality. brief hospital course: mr. is a 66yo who has had ataxia and multiple falls, as well as several weeks of headache, who was admitted to the hospital from the ed due to bilateral subdural hematomas found on ct. the ct an mri showed bilateral acute on chronic and subacute subdural hematomas with multiple membranes in between them and mass effect. he was admitted for observation, and then he was taken to the or for bilateral craniotomies for evacuation on . he was prepared and consented as per standard. his post-operative exam was stable. he had frequent neuro checks and his blood pressure was closely controlled. in the icu, he had one episode of left pupil dilatation, but his hct at the time remained stable and the dilatation resolved spontaneously. it was thought to be secondary to irritation from hemorrhage. he was transferred out of the icu on . he was seen by speech and swallow on , who did not have any reccomendations as they felt his speech and swallowing was intact. he was evaluated by pt and required further treatment. they continued to work with him until his gait had improved and he was cleared for discharge. hospital course was otherwise notable for chest pain, with a normal ekg and negative cardiac enzymes, and an asymptomatic positive blood culture (gpc, ) thought to be a contaminant. medications on admission: medications prior to admission: - antihypertensive (unable to indicate the tablet name) - chinese herbal medicine discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*30 tablet(s)* refills:*0* 2. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): take while taking percocet. disp:*60 capsule(s)* refills:*0* 4. senna 8.6 mg tablet sig: one (1) tablet po twice a day: take while taking percocet. disp:*60 tablet(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 for constipation. disp:*60 tablet, delayed release (e.c.)(s)* refills:*0* discharge disposition: home with service facility: unsure discharge diagnosis: bilateral subdural hematoma discharge condition: neurologically stable discharge instructions: call for severe headache, change in consciousness, visual changes, or any problems. followup instructions: follow up in 4 weeks with head ct with dr. - call for appt. talk to your primary care doctor about your blood sugar levels. md Procedure: Incision of cerebral meninges Diagnoses: Unspecified essential hypertension Subdural hemorrhage

discharge condition: stable at the time of discharge. his discharge date was . dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Excision of intervertebral disc Dorsal and dorsolumbar fusion of the posterior column, posterior technique Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Diagnoses: Unspecified schizophrenia, unspecified Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Closed fracture of sacrum and coccyx without mention of spinal cord injury Accidental fall from or out of building or other structure Closed fracture of pubis Closed fracture of acetabulum Closed fracture of lumbar spine with spinal cord injury

history of present illness: the patient is a 26-year-old gentleman who fell, actually witnessed jumping 30 feet. was intubated in the emergency room, agitated. injuries include a l1 burst fracture with posterior cord involvement as well as pelvic fractures. past psychiatric history: the patient has a psychiatric history with bipolar disorder and schizophrenia. he was evaluated in the ed on after being found intoxicated on his fire escape. he was d/c'd from the emergency room after being found to be in no risk to himself or others. allergies: the patient has no known allergies. physical examination: on physical exam, blood pressure was 124/84, heart rate 106. patient was afebrile. heent: pupils are equal, round, and reactive to light. lungs are clear to auscultation. he has got some superficial abrasions on his back. his abdomen is soft and nontender. extremities: no gross deformities. superficial laceration of the right leg. neurologically, he was intubated and sedated, but able to follow commands. his coma score was 11 on admission. he was moving all extremities with good strength. he was admitted to the trauma sicu for close monitoring. he was followed by the ortho service for his pelvic fractures and also the neurosurgery service for a spinal fracture. pelvic fractures including a right inferior rami fracture, question of an acetabular fracture on the right, sacral ........ fracture, right inferior rami fracture, and a right acetabular fracture. he was also followed very closely by the psychiatry service. the patient remained from a psychiatric perspective during his hospitalization. he did require an operative procedure by neurosurgery service. he underwent l1 vertebrectomy, t12 to l2 arthrodesis with titanium cage, plate, and screw, and that procedure was done on . postoperatively, he remained neurologically intact, moving all extremities with good strength. full strength and full sensation. he was fitted for a tlso brace. he was out of bed on postoperative day #3 in his tlso brace. he was complaining of severe amount of pain. receiving 8 mg of dilaudid q.4h. for pain. his incision remains clean, dry, and intact. his drains were d/c'd on postoperative day one and postoperative day two. his mental status remains stable and he was stable from a psychiatric point. he continued to be followed by the ortho service for his pelvic fractures, who felt they were nonoperative, and the patient was allowed touchdown weightbearing on the right side for these pelvic fractures. he was seen by physical therapy and occupational therapy and will require acute rehab stay as well as close psychiatric followup. discharge medications: 1. abilifi 15 mg p.o. q.d. 2. hydromorphone 2-8 mg p.o. q.4-6h. prn. 3. pantoprazole 40 mg p.o. q.d. 4. heparin 5,000 units subq q.12h. condition on discharge: stable. follow-up instructions: he will follow up in two weeks for staple removal with dr. . follow up with dr. for his pelvic fractures in clinic in weeks' time. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Excision of intervertebral disc Dorsal and dorsolumbar fusion of the posterior column, posterior technique Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Diagnoses: Unspecified schizophrenia, unspecified Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Closed fracture of sacrum and coccyx without mention of spinal cord injury Accidental fall from or out of building or other structure Closed fracture of pubis Closed fracture of acetabulum Closed fracture of lumbar spine with spinal cord injury

allergies: lamictal attending: addendum: patient ultimately not discharged to inpatient psychiatric unit from icu but transferred to floor as no inpatient psychiatric bed availability. . spiked fever on transfer to the floor to 102.3 on evening. blood, urine cultures and cxr obtained u/a with pyuria. started on cipro. urine culture ultimately showed e. coli (sensitive to cipro). additionally, small right antecubital phlebitis i and d'ed on . patient had fever on night of and was placed on empiric vancomycin. he received two doses of vancomycin. this was subsequently stopped since phlebitis was not clearly source of fevers. it was thought that the haldol the patient was on was contributing to the fevers. this was stopped on . the patient subsequently remained afebrile and his leukocytosis resolved. it is still unclear if fevers and leukocytosis were secondary to haldol vs. the uti. he will need to remain on the cipro for his uti until (2-week total course given this was catheter-associated). . psychiatry continued to follow. valium added to standing regimen. haldol was stopped as described above. patient became more and more paranoid and agitated. was first given ativan, which worked well. seroquel was later added per psychiatry's recommendation. this was first given as a prn, and later made as a standing medication. the patient remained quite paranoid and was agitated at times. 1:1 security sitter maintained. to be transferred to inpatient psychiatry facility. for the time being, haldol should be avoided. pertinent results: chest (portable ap) 8:33 pm chest (portable ap) reason: query aspiriation pneumonia medical condition: 30 year old man with fever and cough reason for this examination: query aspiriation pneumonia procedure: chest portable ap on . comparison: . history: 30-year-old man with fever and cough, rule out acute aspiration pneumonia. findings: the lung volumes are low with associated bibasilar minimal atelectasis. no pneumonia or aspiration induced abnormality is noted. the heart size is normal. there is no pleural effusion. metallic hardware are seen projected over the lumbar spine. the stomach is persistently dilated with air. ============================================================= 06:45am blood wbc-6.1 rbc-4.45* hgb-13.4* hct-38.0* mcv-85 mch-30.1 mchc-35.4* rdw-12.8 plt ct-277 07:30am blood wbc-10.3 rbc-4.84 hgb-14.0 hct-41.4 mcv-86 mch-28.9 mchc-33.7 rdw-12.6 plt ct-245 08:00am blood wbc-12.3* rbc-4.76 hgb-13.6* hct-40.2 mcv-84 mch-28.4 mchc-33.8 rdw-12.5 plt ct-234 07:25am blood wbc-14.0* rbc-5.00 hgb-15.0 hct-43.7 mcv-87 mch-30.0 mchc-34.3 rdw-13.1 plt ct-214 12:55am urine color-yellow appear-hazy sp -1.011 12:55am urine blood-neg nitrite-pos protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 12:55am urine rbc-1 wbc-88* bacteri-none yeast-none epi-0 . micro: : blood cx x 2: ngtd : blood cx x 2: ngtd : blood cx x 2: ngtd 12:55 am urine source: cvs. escherichia coli. >100,000 organisms/ml.. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- 32 i piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s discharge medications: 1. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. hexavitamin tablet sig: one (1) cap po daily (daily). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily): will need taper of this (to 14mg, then 7mg). started on . each patch should be used for 2 weeks, and then completely off (6 week total taper) . 7. diazepam 5 mg tablet sig: one (1) tablet po bid (2 times a day). 8. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, fever, headache. 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 9 days: last dose on . 10. quetiapine 25 mg tablet sig: two (2) tablet po bid (2 times a day). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. discharge disposition: extended care facility: hospital - discharge diagnosis: anticholinergic toxicity robitussin (with dextromethorphan) overdose altered mental status depression schizophrenia fever uti phlebitis discharge condition: stable, cleared from medical perspective followup instructions: patient transferred to inpatient psychiatry . after discharge from the inpatient psychiatric facility, you can call to schedule a primary care appointment in the practice (you have not followed up there in over a year) md Procedure: Alcohol detoxification Diagnoses: Esophageal reflux Tobacco use disorder Urinary tract infection, site not specified Depressive disorder, not elsewhere classified Opioid type dependence, continuous Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cellulitis and abscess of upper arm and forearm Other and unspecified special symptoms or syndromes, not elsewhere classified Altered mental status Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Phlebitis and thrombophlebitis of superficial veins of upper extremities Accidents occurring in residential institution Alcohol abuse, continuous Tachycardia, unspecified Leukocytosis, unspecified Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted Infection and inflammatory reaction due to indwelling urinary catheter Schizoaffective disorder, unspecified Poisoning by antitussives Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics Infection following other infusion, injection, transfusion, or vaccination

allergies: lamictal attending: chief complaint: cc: major surgical or invasive procedure: none history of present illness: 30 yo m with pmh of schizoaffective disorder who was found in the street with altered mental status. ems brought him into the ed. the patient reports that he drank 3 bottles of robitussin to "get high" and had no intention of hurting himself. he does not remember much after that but was told he passed out and ems brought him to the ed. prior to this, he denies feeling sick, denies having headaches, fevers, chills, dysuria, diarrhea. . in the ed, he was reportedly combative, irritating to staff. his vitals initially were t 99.8, hr 120, bp 188/107, rr 20, o2 sat 97% ra. finger stick was 100. minimal history was obtained. he was found to have large pupils, dry skin and " " eyes. the ed staff recognized him from a prior visit a few weeks ago and remembered that he overdoses on cough syrup. a screen and consult were obtained and he was treated as a anticholinergic overdose with 1mg physostigmine. he calmed down with this treatment although had some occasional agitation per report. given the occassional agitation, he was given 5mg diazepam and placed in 4 pt restraints. he was given 3l ns. his ekg showed sinus tach with nl axis and q waves in ii, iii, avf and small q in v5 and 6. twf in iii and avf but poor baseline. qrs is narrow. . currently, he is calm, speaking in slow full sentences. he feels thirsty with dry mouth and hungry. denies headache, fevers, chills, shortness of breath, chest pain, nausea or vomiting, dysuria, hematuria, diarrhea, constipation. denies suicidal ideations, denies homicidal ideations. denies feeling depressed. past medical history: 1) hx gerd 2) icu admission (') for fall off of a fire escape ?sa in context of dxm abuse; he was treated for rhabdo, vertebral fracture. 3) h/o schizoaffective disorder versus bipolar disorder (') with multiple od's on dxm per prior psych consult note: multiple psych inpatient admissions from - - , , c/l, for agitation (including multiple assaults of hospital staff requiring chemical & physical restraints), delirium. sa by od in ' with notable periods of depression and suicidal urges. h/o of avh, ior, paranoia, per omr. medication trials include: tegretol, effexor, depakote, lithium. prior psychiatrist: dr. (). therapist: (). however, pt now states that he sees a new psychiatrist at , has seen her once recently social history: per prior omr psych note : born and lived in ct. adopted at age 5 months. good relations with adopted parents. no family abuse history. completed year of college. hx incarceration for assault and battery while using dxm. multiple incarcerations since for vagrancy. longstanding h/o dxm abuse starting at age 17 (upwards of bottles on occasion); +substance abuse treatment @ s/p hospitalization at . dxm makes him feel "high and dissociated." he has used ketamine, lsd, mushrooms, while in college. no problems with etoh. no detoxes, sz, dt's. 1 ppd cigarette smoker. the longest period of being drug-free occurred from -, during which time he felt bored and was cycling. currently - denies smoking. endorses previous marijuana and amphetamines po and im. drinks 4-5 beers every 2 days. no iv drugs. uses cough medicine to get high family history: + for depression and thought disorders. physical exam: vitals: t hr 87, bp 154/85, o2 sat 95% on ra general: disheveled male in nad speaking slowly. in four point leather restraints skin: dry palms, flushed face. nail polish on nails. heent: face flushed, very dry mm and lips, dilated pupils about 10mm responded to light with constriction equally to 4mm. eomi. mildly injected conjunctiva. no lad. full rom neck cv: rrr no m/r/g lungs: decreased bs at bilateral bases. abdomen: no bowel sounds appreciated, soft ntnd ext: no e/c/c. dp 2+ symmetric. neuro: cniii- xii in tact. pupils dilated as described above. constrict to light. did not test strength given restraints. sensation in tact to light touch. pertinent results: frontal chest radiograph: cardiac and mediastinal contours are unremarkable. there is mild vascular congestion without frank pulmonary edema. there are no focal consolidations or large pleural effusion. the right costophrenic angle is excluded from the image. multiple clips and fusion hardware are seen within the lower thoracic and within the lumbar spine. impression: no evidence of acute cardiopulmonary process 03:43pm blood wbc-17.5*# rbc-4.81 hgb-14.8 hct-42.5 mcv-88 mch-30.7 mchc-34.7 rdw-13.1 plt ct-243 05:24am blood wbc-11.9* rbc-5.52 hgb-16.3 hct-47.3 mcv-86 mch-29.6 mchc-34.6 rdw-12.5 plt ct-241 05:24am blood glucose-96 urean-8 creat-0.9 na-138 k-3.3 cl-102 hco3-27 angap-12 05:24am blood calcium-9.3 phos-3.8 mg-2.3 02:20am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg brief hospital course: 30 yo m with pmh of schizoaffective disorder who presents after drinking 3 bottles of robitussin to "get high." he has a presumed anticholinergic overdose given his clinical picture of low fever, dry axilla, tachycardia, agitation, dilated pupils. in addition, he was given physostigmine in the ed with reported good response. the half life of physostigmine is 15 mins. this medication can be repeated x1 if needed. ddx also includes infection, uremia, head trauma. he has no signs of infection with a negative u/a and clear cxr. meningitis is always on the ddx but given the history of ingestion, lack of headache or neck stiffness, overdose is more likely. . # anticholinergic toxicity: no ectopy on telemetry, and no qrs widening - qt prolongation on ekg on initial admit, has resolved. received one dose of physostigmine in the emergency room. rest of screens were negative including acetaminophen and salicylates which are common co-ingestions. patient was followed by toxicology consult with no further reccomendations. ciwa scale was within normal limits throughout hospital course. patient is cleared from a medical standpoint and has no further medical issues other than his psychiatric issues. #psych: the patient became increasingly agitated and attemtped to leave the hospital, for which a code purple was called and a section 12 ordered with psychiatric input. the psychiatric consult service was concerned for possible bipolar disorder, schizoaffective disorder, or psychosis and felt that the patient would benefit from an inpatient psychiatric stay. he was discharged from the icu to an inpatient psychiatric facility, after being cleared from a medical standpoint in regards to his anticholinergic toxicity. . #leukocytosis: likely leukemoid reaction to stress. no localizing source of infection and wbc count is within normal limits today. no concern for any underlying infection, patient is cleared from a medical standpoint. . # tobacco abuse: smoking cessation counselling as outpatient medications on admission: mvi discharge disposition: extended care facility: hospital - discharge diagnosis: anticholinergic toxicity discharge condition: stable, cleared from medical perspective discharge instructions: you were admitted for anticholinergic toxicity. your toxicity resolved and you were transfereed to inpatient psychiatry. followup instructions: inpatient psychiatry Procedure: Alcohol detoxification Diagnoses: Esophageal reflux Tobacco use disorder Urinary tract infection, site not specified Depressive disorder, not elsewhere classified Opioid type dependence, continuous Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cellulitis and abscess of upper arm and forearm Other and unspecified special symptoms or syndromes, not elsewhere classified Altered mental status Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Phlebitis and thrombophlebitis of superficial veins of upper extremities Accidents occurring in residential institution Alcohol abuse, continuous Tachycardia, unspecified Leukocytosis, unspecified Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted Infection and inflammatory reaction due to indwelling urinary catheter Schizoaffective disorder, unspecified Poisoning by antitussives Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics Infection following other infusion, injection, transfusion, or vaccination

reason for admission: the patient is a 60 year old white male with a past medical history of chronic myelogenous monocytic leukemia diagnosed in , chronic anemia, and hypertension. the patient presented to the hospital with several days of fevers as high as 102, night sweats, and cough for three weeks. this is also associated with rigors. the patient also reported decreased p.o. intake and symptoms consistent with orthopnea. on review of systems, the patient also complained of bilateral ankle and knee pain which began on the morning of admission. positive nausea, no emesis, positive chronic headaches, no abdominal pain or diarrhea, positive constipation and positive chronic low back pain. he had a three pound weight loss in the prior two weeks. past medical history: 1. chronic myelogenous monocytic leukemia diagnosed . 2. myelodysplastic syndrome diagnosed by bone marrow biopsy . 3. chronic fevers. 4. anemia. 5. hypertension. 6. history of right ankle fusion in . 7. gastroesophageal reflux disease. 8. history of cellulitis. medications on admission: 1. protonix 40 mg once daily. 2. celebrex 200 mg once daily. 3. colace 100 mg twice a day. 4. prednisone 10 mg twice a day. 5. hydroxyurea 500 twice a day. 6. fentanyl patch 75 mcg transdermally q2-3days. 7. oxycodone p.r.n. 8. allopurinol 100 mg once daily. 9. diovan 80 mg once daily. allergies: no known drug allergies. social history: the patient is married. forty pack year smoking history. he quit in . no current alcohol or drug use. physical examination: on presentation, the patient's vital signs are temperature of 98.2, blood pressure 130/70, pulse 82, respiratory rate 20. generally, the patient was in significant pain with movement. his oropharynx was clear. mucous membranes are dry. his neck had no lymphadenopathy. the heart was regular rate and rhythm without murmur, gallop or rub. the lungs were clear to auscultation bilaterally with no wheezes. the abdomen was soft, nontender, nondistended. extremities - the patient's knees were swollen and had effusion bilaterally. there was no erythema or warmth. his ankles were swollen bilaterally and tender to palpation, also without warmth or erythema. laboratory data: white blood cell count was 14.0, hematocrit 27.1, platelet count 282,000. he had 36% neutrophils and 27% bands and 39% lymphocytes. sodium was 130, potassium 3.9, chloride 92, co2 26, blood urea nitrogen 18, creatinine 1.4, glucose 176. coagulation studies were within normal limits. chest x-ray showed no active cardiopulmonary process. assessment: fever of unknown etiology. hospital course: the patient was admitted to the bone marrow transplant service for workup including pancultures and prophylactic antibiotics. the patient had an arthrocentesis of his right knee on , and it was sent for gram stain and culture. this showed no polys and no organisms. culture was pending. on hospital day two, the patient's steroids were increased. he was also seen by the rheumatology in consultation and they recommended continuing the current dose of prednisone as well as avoiding increasing the allopurinol dose. the patient was also evaluated by physical therapy on hospital day three and treatment was instituted. nursing note on , noted the patient's abdomen as being distended and firm, however, the patient's baseline. his abdomen was not tender on examination at this time. also the patient was transfused two units of packed red blood cells for a hematocrit of 22.8 which brought his hematocrit up to 27.0. on , the patient had his left knee tapped. this was also sent for gram stain and culture. this showed 6500 white blood cells and 13,000 red blood cells, 41% polys, 27% lymphocytes and 24% monocytes. his blood cultures were still no growth and pending at this point and his urine culture from , showed less than 10,000 organisms. his joint culture initially from the right knee showed no growth. on , the patient was seen by radiation oncology to evaluate his malignant knee effusion as cytology had confirmed this from prior arthrocenteses. on , the patient was started on low dose ara-c for palliation. the patient also noted on , increased swelling and pain involving the right elbow which was new. the patient was continued on this palliative chemotherapy with some symptomatic improvement. he underwent repeat bilateral arthrocentesis of both knees on . on , per the nursing note, the patient's abdomen was firmly distended with bowel sounds present. he was complaining of nausea which was treated with phenergan. poor p.o. intake due to nausea but otherwise his gastrointestinal assessment was unchanged from the patient's baseline. on , a surgery consultation was obtained due to abdominal pain. the patient began complaining of lower abdominal pain that morning. he described it as sharp and diffuse, nonradiating, associated with nausea and vomiting. the patient had no fever or chills. on examination, the patient was afebrile and his vital signs were stable. his abdomen was distended with guarding. he had diffuse tenderness to palpation although worse in the lower abdomen with positive rebound and peritoneal signs. his rectal examination was guaiac negative. chest x-ray upright showed no free air in the diaphragm and kub showed a few mildly dilated loops of bowel and no free air. the recommendations were to keep the patient npo, to start him on imipenem, to obtain a ct. assessment by the surgical attending, the patient has a surgical abdomen and he was deteriorating rapidly with a heart rate in the 160s, respiratory rate 32 on nonrebreather with oxygen saturation 90%. he was deemed too unstable to undergo a ct scan and taken to the operating room for emergency exploratory laparotomy. at the time, the patient was taken to the operating room he was on multiple pressors and nitroglycerin for hemodynamic instability. additionally, he had fluids going wide open. the family was advised of his grave prognosis and the patient was taken to the operating room where a perforated sigmoid colon was found. the patient underwent a sigmoid colectomy and sigmoid colostomy and mobilization of the splenic flexure and pouch. he had diffuse peritonitis and was hemodynamically unstable throughout the case. he had five liters of crystalloid and two units of packed red blood cells during the case. estimated blood loss was less than 400cc. the patient was transferred to the for a higher degree of intensive care unit care. at that point, he was on neo-synephrine drip, levophed drip, hydrocortisone 100 q8hours, ampicillin one q6hours, levaquin 500 mg once daily, flagyl 500 mg three times a day, acyclovir 400 mg three times a day. on postoperative day one, the patient was on dopamine 2 mcg/kg/ml, levophed 0.3 mcg/kg/minute, neo-synephrine 2.5 mcg/kg/minute. cardiac index was 3.5. his arterial blood gases showed acidosis of 7.29, pco2 39, po2 107 and base access of 6.0. his white blood cell count was 17.6 and hematocrit was 36.6. inr was 1.4. creatinine 0.9. lactate was 3.5. on examination, the patient's ostomy was dusky and had no output. later that day the patient showed deterioration with a base access of a nadir 10 and a blood pressure of 30. he was taken back to the operating room emergently for a decompressive laparotomy and lavage. the patient's hematology/oncologist was contact and advised 100 mg to control his likely cytokine release from his recent chemotherapy. the patient was decompressed and taken back to the intensive care unit in critical condition. on postoperative day two and one, the patient was on levophed 0.175, vasopressin 0.04, also on cefepime, flagyl, levaquin, ampicillin and acyclovir for his antibiotics. his white blood cell count at this point was 3.9, hematocrit 29.3, inr 1.6 and his creatinine was 0.7. the patient's abdomen was left open with a bag type dressing for closure. at this point, the patient was also developing multiorgan system failure with adult respiratory distress syndrome, and the patient was put on low protective ventilation. he was also in septic shock with a cvp of 22 and hyperdynamic with an index of 5.8 and svr of 400. later that day after discussion with the patient's oncologist as well as his family, we were all at the bedside, the patient's prognosis was felt to be nonsurvival given this catastrophic abdominal event in the setting of his recent chemotherapy and large cytokine response. it was felt that aggressive measures would be unable to salvage the situation and the decision was made with the family to change the patient's code status to comfort measures only. he was made comfortable with narcotics and his pressors were discontinued. the patient was pronounced dead at 1541 on . the patient was pronounced by dr. and the patient's family was at the bedside. report to medical examiner which waived the case. additionally, the patient's family was approached about a postmortem examination and they were inclined to do so at that point. discharge diagnoses/cause of death: 1. overwhelming sepsis secondary to chronic myelogenous monocytic leukemia. 2. gastroesophageal reflux disease. 3. hypertension. 4. anemia. 5. malignant joint effusions. , m.d. dictated by: medquist36 Procedure: Colostomy, not otherwise specified Pulmonary artery wedge monitoring Arthrocentesis Arthrocentesis Open and other sigmoidectomy Other laparotomy Injection or infusion of cancer chemotherapeutic substance Diagnoses: Acidosis Unspecified septicemia Perforation of intestine Septic shock Retention of urine, unspecified Chronic lymphoid leukemia, without mention of having achieved remission Unspecified peritonitis Arthropathy associated with hematological disorders

history of present illness: mr. is a 77-year-old male with a history of hypertension, alcoholism, and tobacco abuse who presented to the emergency department on the afternoon of admission complaining of dyspnea earlier in the day. he had a feeling of indigestion accompanied by diaphoresis, chills, and nausea. he became progressively dyspneic throughout the afternoon and presented to the emergency room. in the emergency department, he was initially treated with lasix and antibiotics. despite these measures he remained tachypneic and was intubated for distress and worsening hypoxia. he received 3 liters of fluid in the emergency department over roughly six hours with no urine output. at the time of intubation, his blood pressure had dropped to a systolic of 80, and he was started on dopamine. there was a report of weight loss over the past three months along with malaise. there was no history of chest pain. no recent history of gastrointestinal illnesses. past medical history: 1. hypertension. 2. depression. 3. alcoholism. 4. tobacco use of one pack per day times 50 years. 5. gout. 6. peripheral vascular disease. 7. non-insulin-dependent diabetes mellitus. 8. chronic obstructive pulmonary disease. medications on admission: 1. micardis 20 mg p.o. q.d. 2. lasix 20 mg p.o. q.d. 3. effexor. social history: the patient is married and retired. family history: non-insulin-dependent diabetes in multiple family members. physical examination on presentation: admission physical examination with vital signs which revealed a temperature of 99.7, heart rate of 115, blood pressure of 96/41, ventilator setting of fvc of 500 x 14, fio2 of 50%, positive end-expiratory pressure of 5. in general, intubated but alert. answered questions. head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. extraocular movements were intact. neck revealed elevated jugular venous pressure. no bruits. lungs revealed rhonchorous breath sounds throughout. scattered bibasilar end-expiratory crackles. abdomen was soft, nontender, and nondistended. normal active bowel sounds. extremities were thin, hairless, good pulses, no edema, cool. skin revealed no rash. neurologically, moved all extremities. pertinent laboratory data on presentation: admission laboratories with a white blood cell count of 15.1 (85% neutrophils and no bands), hematocrit of 33.7, platelets of 309, mean cell volume of 111. sma-7 revealed a sodium of 145, potassium of 5, chloride of 108, bicarbonate of 26, blood urea nitrogen of 20, creatinine of 1.6, and glucose of 259. calcium of 8.5, phosphorous of 7.5, magnesium of 2.1. creatine kinase of 43, troponin of 2. arterial blood gas status post intubation was 7.23/56/238 on 50% fio2 and 5 of positive end-expiratory pressure. hepatic enzymes revealed alt of 17, ast of 42, alkaline phosphatase of 161, total bilirubin of 0.4, amylase of 113. radiology/imaging: chest x-ray revealed small right pleural effusion, diffuse interstitial alveolar infiltrates bilaterally (left greater than right); new compared to . electrocardiogram revealed sinus tachycardia with a rate into the 120s, normal intervals, normal axis, q waves in v2 and v3, poor r wave progression, st elevations in v2 to v4 noted along with 1.5-mm st depressions in v5 to v6. these changes were new compared to electrocardiogram. hospital course: the patient was originally admitted to the medical intensive care unit for management of respiratory distress thought to be secondary to pneumonia. over the course of the first 24 hours the patient started ruling in for a myocardial infarction, and he was emergently transferred to the to undergo cardiac catheterization. the patient did undergo cardiac catheterization which revealed the following vascular abnormalities: the left main was calcified but okay, the left anterior descending artery had a 99% focal clot in the proximal region, and the left circumflex had a 95% large second obtuse marginal and a 70% distal circumflex lesion in the av groove. the right coronary artery had a 90% middle and a diffusely diseased posterior descending artery. stents were placed to the left anterior descending artery and large second obtuse marginal. the patient had elevations of his pulmonary capillary wedge pressure, and pulmonary artery pressure, along with borderline hypotension on high-dose levophed; so an intra-aortic balloon pump was placed. the patient was then transferred to the coronary care unit for further care. at the time of presentation, the patient had also been anuric for the first 24 hours of his admission. over the next 72 hours, the patient continued to have progressive oliguria becoming increasingly refractory to diuretics. his creatinine was rising, and he became fluid overloaded. though we were able to wean pressors and intra-aortic balloon pump was off for cardiac support, the fluid overload secondary to his worsening renal failure was refractory to medical therapy. hemodialysis was initiated on . prior to hemodialysis, the patient had multiple weaning trials which he had failed felt secondary to fluid overload in his lungs. despite several rounds of hemodialysis, which the patient tolerated well, his weaning mechanics were still noted to be quite poor. after 16 days of intubation, the goals of the patient's care were revised and advance support was withdrawn. the patient was extubated on after getting his fourth round of dialysis; and over the next 18 hours, he was made comfortable as his cardiopulmonary parameters decompensated. the patient was pronounced dead at 6:20 a.m. on the morning of . diagnosis at death: 1. intraseptal myocardial infarction leading to cardiogenic shock with subsequent multiorgan failure. 2. inability to wean off ventilator despite successful diuresis. note: the patient was notified of the patient's death, and voluntary postmortem examination was refused, and funeral home was to make arrangements. dr., 12-463 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of endotracheal tube Implant of pulsation balloon Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Other pulmonary insufficiency, not elsewhere classified Acute myocardial infarction of other anterior wall, initial episode of care Chronic airway obstruction, not elsewhere classified Cardiogenic shock

allergies: penicillins / aspirin / levofloxacin / bactrim attending: chief complaint: nausea/ vomiting major surgical or invasive procedure: placement of external ventriclar device. history of present illness: ms. is a 56f with history of lupus, renal insufficiency, and hypertension who presents to the ed with nausea and vomiting for several hours. while in triage, patient became unresponsive and was noted to only have movement in her bilateral upper extremities. patient was emergently intubated and taken to ct scan. per family, patient has been in usual health and felt ill this afternoon. her lupus has been well controlled, though she has been hypertensive in office visits. she does not use any anti-coagulation. past medical history: #type iv lupus nephritis x 8 years - on prednisone, cellcept (s/p cytoxan in past) - baseline cr - 1.9-2.0 #htn #h/o klebsiella esbl uti #h/o asymptomatic bacturia #h/o necrotizing fasciitis #h/o ards #h/o anemia social history: cantonese speaker who is a homemaker and lives with husband and 2 children. family history: fh: sister with lupus and mother with htn. no cad, ca physical exam: deceased pertinent results: 10:29pm pt-9.9 ptt-25.6 inr(pt)-0.9 10:13pm glucose-161* lactate-2.0 na+-144 k+-3.6 cl--118* tco2-19* 10:13pm hgb-9.7* calchct-29 10:00pm glucose-171* urea n-43* creat-1.8* sodium-145 potassium-3.9 chloride-115* total co2-19* anion gap-15 10:00pm estgfr-using this 10:00pm calcium-8.4 phosphate-3.8 magnesium-1.9 10:00pm wbc-14.4*# rbc-3.18* hgb-9.7* hct-30.3* mcv-95 mch-30.7 mchc-32.2 rdw-12.8 10:00pm neuts-63.3 lymphs-31.9 monos-3.6 eos-0.9 basos-0.3 10:00pm plt count-239 brief hospital course: ms. is a 56f with history of lupus, renal insufficiency, and hypertension who presents to the ed with nausea and vomiting for several hours. while in triage, patient became unresponsive and was noted to only have movement in her bilateral upper extremities. patient was emergently intubated and taken to ct scan. the ct showed an aca aneurysm with very high intracranial pressure. emergent evd placed in icu with elevated icps in the 30s. she was admitted to the neurointensive care unit for aggressive critical care. given patient's poor prognosis, the patient's family withdrew care. she was extubated and passed shortly. medications on admission: medications prior to admission: plaquenil 200 mg every other day calcitriol 0.25 mcg daily lisinopril 10 mg daily discharge medications: none discharge disposition: expired discharge diagnosis: subarachnoid hemorrhage secondary to aneurysm rupture intracranial hemorrhage coma respiratory failure discharge condition: deceased discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Insertion or replacement of external ventricular drain [EVD] Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Obstructive hydrocephalus Long-term (current) use of steroids Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Subarachnoid hemorrhage Chronic kidney disease, unspecified Compression of brain Cerebral edema Do not resuscitate status

allergies: penicillins / aspirin attending: chief complaint: as noted before major surgical or invasive procedure: as noted before brief hospital course: pt is being discharged on cipro for minor pseudomonal infection of graft site final sensitivities are not yet available; please contact to obtain final sensitivities to tailor antibiosis discharge disposition: extended care facility: - discharge diagnosis: as noted before discharge condition: as noted before md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Temporary tracheostomy Other skin graft to other sites Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Transfusion of packed cells Closed biopsy of skin and subcutaneous tissue Transfusion of other serum Transfusion of platelets Infusion of drotrecogin alfa (activated) Diagnoses: Systemic lupus erythematosus Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified essential hypertension Long-term (current) use of steroids Acute posthemorrhagic anemia Paralytic ileus Other and unspecified coagulation defects Cytomegaloviral disease Traumatic shock Pneumonia due to Klebsiella pneumoniae Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft Full-thickness skin loss [third degree NOS] of thigh [any part] Posttraumatic wound infection not elsewhere classified Varicella (hemorrhagic) pneumonitis Unspecified diseases of blood and blood-forming organs Burn [any degree] involving less than 10 percent of body surface with third degree burn, less than 10 percent or unspecified Accident caused by caustic and corrosive substances

allergies: penicillins / aspirin attending: chief complaint: left leg wound major surgical or invasive procedure: multiple debridements of left thigh (, , , ) tracheostomy () split thickness skin graft () history of present illness: 48yo chinese f presented to ed with extensive necrotic l thigh wound. pain & rash started 2wks prior to admission as red dots on leg. pt treated with a topical compound made up from centipedes & cow gallbladder. leg subsequently became more painful, edematous & weeping fluid. pt very dizzy & orthostatic, +chills. past medical history: type iv lupus nephritis htn anemia social history: social history: cantonese speaker who is a homemaker and lives with husband and 2 children of 9 and 14 years. she denies cigarrettes, drugs, alcohol. family history: fh: sister with lupus and mother with htn. no cad, ca physical exam: vs - bp 61/36, hr 77, rr 22, sat 88% ra thin, pale, toxic-appearing, asian female, oriented x 3, limited english-speaking heent - perrla/eomi, facial rash chest - decreased breath sounds throughout cv - tachy, rr, no murmur abd - soft, nt, nd ext - l thigh with sloughed skin & tense/weeping bullae, foul odor, 1+ femoral pulse, 2+ peripheral edema, dp pulse non-palpable but biphasic on u/s pertinent results: 01:56pm blood wbc-4.6 rbc-2.06*# hgb-6.1*# hct-17.5*# mcv-85 mch-29.3 mchc-34.6 rdw-16.7* plt ct-83*# 01:56pm blood neuts-74* bands-23* lymphs-2* monos-0 eos-0 baso-0 atyps-0 metas-1* myelos-0 01:56pm blood pt-11.8 ptt-89.1* inr(pt)-0.9 04:50pm blood fibrino-104*# 01:56pm blood esr-13 01:56pm blood glucose-128* urean-115* creat-5.9*# na-113* k-6.7* cl-91* hco3-12* angap-17 01:56pm blood alt-14 ast-13 ck(cpk)-53 alkphos-43 amylase-80 totbili-0.4 01:56pm blood lipase-137* 05:49pm blood ck-mb-3 ctropnt-<0.01 01:56pm blood albumin-1.9* calcium-9.7 phos-7.2*# mg-2.5 04:37pm blood type-art po2-216* pco2-34* ph-7.03* calhco3-10* base xs--21 05:01pm blood glucose-153* lactate-4.5* na-129* k-4.9 cl-105 02:00pm urine color-yellow appear-clear sp -1.013 02:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg brief hospital course: pt admitted to via ed for sepsis & suspected necrotizing fasciitis, taken to ed for debridement, transferred to sicu intubated & on pressors. consults placed to dermatology/hematology/nephrology. diagnosed with zoster & started on acyclovir. multiple antibiotics for superinfection of l thigh wound. pt was extubated on , but reintubated on for worsening respiratory distress & hypoxia. pt developing thrombocytopenia (requiring platelet transfusions), anemia (requiring multiple transfusions), acute renal failure, melena. tee performed on - no vegetations. transferred to micu service on . pt underwent repeat debridement & tracheostomy on , after which she returned to sicu. pt diagnosed with cmv viremia on & started on ganciclovir. pt started on gcsf for leukopenia. plastics consulted regarding future skin grafting of wound & took pt to or for debridement of wound and placement of vac dressing. ophthamology consulted & noted no evidence of retinitis. transferred from sicu to floor on . pt taken to or on for planned split-thickness skin graft, but decided intraoperatively that tissue was not ready for grafting; debrided wound & placed vac drain. pt transferred back to sicu on due to profound anemia due to blood loss from thigh with a confirmed hct of 8.4, hypotension - received transfusion of 9 units prbc plus ffp & platelets. pt started on amicar upon recommendation of heme for ? bleeding dyscrasia, although extensive work-up has failed to demonstrate a known bleeding disorder - pt responded to amicar with significantly decreased bleeding from wounds. pt stabilized & returned to floor. chronic pain service consulted for l leg pain. pt developed a lll pneumonia (klebsiella) & ileus on , tx'd with antibiotics. pt noted to have significant metabolic acidosis on , transferred back to sicu for monitoring - placed on bicarb. work-up resulted in diagnosis of renal tubular acidosis, pt stabilized on bicarb infusion & transitioned to po bicitrate, returned to the floor on . pt to or on for a split thickness skin graft to her left thigh from donor sites on right thigh & abdomen - surgery went well w/o complication. pt noted to have a uti post-operatively & tx'd with course of antibiotics. trach d/c'd on . pt's stsg with 70-80% take, continue dressing changes, cultures sent from wound with ? of colonization - no signs of cellulitis or systemic infection. pt to rehab for continuing wound care until fully healed & pt/ot to treat her severe deconditioning following a 2 month hospitalization with multiple stays in the icu. d/c to rehab on . medications on admission: nifedipine, atenolol, mvi, lasix, phoslo, ferosol, prednisone, cellcept, zaroxylyn, feosol discharge medications: 1. tizanidine hcl 2 mg tablet sig: 1-2 tablets po tid (3 times a day) as needed for muscle spasms. disp:*60 tablet(s)* refills:*0* 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 3. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 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. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). disp:*1 vial* refills:*2* 7. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 9. sodium citrate-citric acid 500-334 mg/5 ml solution sig: thirty (30) ml po bid (2 times a day). disp:*1800 ml(s)* refills:*2* 10. aminocaproic acid 500 mg tablet sig: eight (8) tablet po q4h (every 4 hours). discharge disposition: extended care facility: - discharge diagnosis: chemical burn left thigh, s/p multiple debridements & skin graft. renal tubular acidosis. lupus nephritis. urinary tract infection. bleeding dyscrasia, unspecified. blood loss anemia. disseminated varicella zoster. cmv viremia. hypertension. discharge condition: good, stable. discharge instructions: - dressing changes -daily physical therapy -medications per attached sheet -follow-up with trauma clnic in 2 weeks -follow-up with nephrology in 2 weeks -needs electrolytes drawn at least twice weekly followup instructions: follow-up in the trauma clinic in weeks, call ( for appointment & directions. follow-up with nephrology, dr. , in 2 weeks, call ( for appointment. if any questions regarding hematology issues, please call dr. @ (. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Temporary tracheostomy Other skin graft to other sites Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Transfusion of packed cells Closed biopsy of skin and subcutaneous tissue Transfusion of other serum Transfusion of platelets Infusion of drotrecogin alfa (activated) Diagnoses: Systemic lupus erythematosus Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified essential hypertension Long-term (current) use of steroids Acute posthemorrhagic anemia Paralytic ileus Other and unspecified coagulation defects Cytomegaloviral disease Traumatic shock Pneumonia due to Klebsiella pneumoniae Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft Full-thickness skin loss [third degree NOS] of thigh [any part] Posttraumatic wound infection not elsewhere classified Varicella (hemorrhagic) pneumonitis Unspecified diseases of blood and blood-forming organs Burn [any degree] involving less than 10 percent of body surface with third degree burn, less than 10 percent or unspecified Accident caused by caustic and corrosive substances

allergies: penicillins / codeine attending: chief complaint: acute aortic occlusion with bilateral lower extremity ischemia. major surgical or invasive procedure: 1. right axillobifemoral bypass with ring ptfe graft history of present illness: this 82-year-old lady who is demented was transferred here from the hospital with acute limb ischemia. both legs were mottled to the hips. the patient was in respiratory failure and had evidence of recent myocardial infarction. a ct scan was done because she was complaining abdominal pain and this showed the aorta was thrombosed distal to the renal arteries. because of the urgent nature of the situation and after careful discussion with the family, she was taken emergently to the operating room for an attempt at salvaging of her limbs. past medical history: pshx: pacemaker ', ccy, cardiac cath with angioplasty/stent, tah, appy, c-section social history: no smoking no alcohol family history: non contributary physical exam: neg resp neg pulse neg hr neg corneal reflex pertinent results: echo measurements: left atrium - long axis dimension: *5.6 cm (nl <= 4.0 cm) left atrium - four chamber length: *7.1 cm (nl <= 5.2 cm) right atrium - four chamber length: *6.6 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.7 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 30% to 40% (nl >=55%) aorta - valve level: 3.0 cm (nl <= 3.6 cm) aorta - ascending: 3.3 cm (nl <= 3.4 cm) aortic valve - peak velocity: *3.4 m/sec (nl <= 2.0 m/sec) aortic valve - peak gradient: 50 mm hg aortic valve - mean gradient: 20 mm hg aortic valve - lvot peak vel: 0. m/sec aortic valve - lvot diam: 2.0 cm mitral valve - e wave: 1.2 m/sec tr gradient (+ ra = pasp): *33 mm hg (nl <= 25 mm hg) pulmonic valve - peak velocity: *1.1 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: normal lv wall thicknesses and cavity size. moderate regional lv systolic dysfunction. tvi e/e' >15, suggesting pcwp>18mmhg. lv wall motion: regional lv wall motion abnormalities include: mid anterior - akinetic; basal inferior - akinetic; anterior apex - akinetic; right ventricle: normal rv chamber size. mild global rv free wall hypokinesis. aorta: normal aortic root diameter. focal calcifications in aortic root. normal ascending aorta diameter. aortic valve: mildly thickened aortic valve leaflets. aortic valve mass. no ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild thickening of mitral valve chordae. trivial mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. general comments: based on aha endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. conclusions: the left and right atrium is moderately dilated. left ventricular wall thickness and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with focal akinesis of the basal inferior wall and the distal half of the anterior wall. the remaining segments contract well. right ventricular chamber size is normal with mild global free wall hypokinesis. the aortic valve leaflets are mildly thickened. there is mild-moderate aortic valve stenosis. a 6mm, mobile, echodensity is seen on the aortic side of the aortic valve, attached to the non-coronary leaflet c/w vegetation/thrombus/tumor. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mobile aortic valve echodensity c/w thrombus vs vegetation vs. ??. regional left ventriuclar systolic dysfunction c/w cad. mild-moderate aortic valve stenosis. chest (portable ap) reason: eval effusion, consolidation indication: 82-year-old woman status post axillary bifemoral bypass occlusion. comments: portable supine ap radiograph of the chest is reviewed, and compared with the previous study of yesterday. the tip of the endotracheal tube is identified at the thoracic inlet. the right jugular swan-ganz catheter terminates in the right main pa. the previously identified mild congestive heart failure has been slightly improving. there is continued left lower lobe patchy atelectasis. no pneumothorax is identified. the pacemaker leads remain in place. impression: improving mild congestive heart failure with cardiomegaly. continued left lower lobe patchy atelectasis. radiology final report cta chest w&w/o c &recons 11:04 am cta chest w&w/o c &recons; cta abd w&w/o c & recons reason: cta: rule out dissection/pe. has a elevated cr. but is field of view: 36 contrast: optiray medical condition: 82 year old woman with chest pain, neck pain and leg pain in setting of htn reason for this examination: cta: rule out dissection/pe. has a elevated cr. but is being pretreated. contraindications for iv contrast: none. indication: chest pain, neck pain, and leg pain, in setting of hypertension. evaluate for dissection or pulmonary embolism. technique: cta chest, abdomen, and pelvis, with images obtained before and after the administration of iv contrast. comparisons: none. findings: cta: there is no evidence of pulmonary embolism. no evidence of dissection involving the thoracic aorta. evaluation of the abdominal aorta shows occlusion of the distal aorta, with filling defect seen beginning at the level of the takeoff of the smas, resulting in total occlusion of the distal abdominal aorta. there is also filling defect seen extending into the iliac arteries. on the delayed scan of the abdomen and pelvis, there appears to be slight filling within the left external iliac artery, although this is incompletely evaluated. marked atherosclerotic calcifications are seen involving the infrarenal aorta. there is aneurysmal dilatation of the infrarenal aorta measuring up to 3.7 x 3.2 cm in its infrarenal portion. no definite dissection is seen. no dominant collateral vessels are seen bypassing the area of aortic occlusion. note is also made that during the smart prep images obtained for contrast timing evaluation, there was marked delay in the time for contrast passage from the svc to the pulmonary arteries and to the ascending aorta, suggesting heart failure or markedly decreased cardiac output. ct of the chest without and with contrast: there is pulmonary vascular engorgement. there are patchy ground-glass opacities seen throughout the lungs, with interstitial thickening as well as engorgement of pulmonary venules. no consolidation, or significant pleural effusion. coronary artery calcifications are seen, and there is a pacemaker present in the setting of marked cardiomegaly. in addition, calcifications of the left ventricle are seen, suggesting prior rheumatic disease. ct of the abdomen with contrast: the liver has a nodular surface appearance, suggesting cirrhosis. the gallbladder wall appears slightly thickened, although the gallbladder is not totally distended, likely related to congestive failure/fluid overload. the spleen, adrenal glands, pancreas, stomach, and small bowel are unremarkable. there is a renal cyst seen in the interpolar portion of the right kidney, and several other cortical low-density foci seen within both kidneys, more on the right than on the left, which might represent small renal cysts, but are too small to characterize on this study. the kidneys enhance symmetrically. ct of the pelvis with contrast: there are diverticula of the sigmoid colon. large bowel and bladder otherwise appear unremarkable. the bladder is decompressed. examination of osseous structures shows degenerative changes and suggests short pedicles of the lower lumbar spine. multiple healed rib fractures are seen both on the right and on the left. no lytic or sclerotic lesions suspicious for malignancy are present. coronally and sagittally reformatted images, as well as multiple obliquely reformatted images were also obtained. in addition, volume rendered images as well as mip images were created at the workstation to better depict the involvement of thrombosis. mpr value: 3. impression: 1. thrombosis of the distal aorta, and extending into the iliac arteries. there are no significant collateral vessels to suggest chronic changes. there may be some flow seen in the left external iliac artery on the delayed images. 2. no evidence of pulmonary embolism. 3. pulmonary edema and marked cardiomegaly, with delayed transit of contrast from the svc to the aorta. findings were discussed in person with the emergency department team taking care of the patient immediately after the completion of this examination, and a wet read report was placed on emergency department dashboard subsequently. brief hospital course: pt admitted on underwent a right axillobifemoral bypass with ring ptfe graft for acute aortic rupture / pt critical. sent to the sicu in critical condition. pt intubated. pt found to have multi sytem failure s/p acute aortic occlussion. all attempts to resusitate were made. multiple tests were obtained. bp control very labile / multiple drips were used pt family contact pt made dnr / dni / cmo pt expired medications on admission: : asa 81', lipitor 10', digoxin 0.125', lasix 120', glucophage 650', isordil 5", zoloft 25', lopressor 50", prilosec 20", diovan 80', premarin 0.625', riss, mvi' discharge medications: n/a discharge disposition: expired discharge diagnosis: acute aortic disection b/l extremity occlusion mi dementie cri discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other (peripheral) vascular shunt or bypass Infusion of vasopressor agent Diagnoses: Subendocardial infarction, initial episode of care Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Atherosclerosis of aorta Atrial fibrillation Aortic valve disorders Other specified forms of chronic ischemic heart disease Acute respiratory failure Volume depletion, unspecified

history of present illness: the patient is a 76-year-old female transferred from with suspected subarachnoid hemorrhage. the patient reports that the night before admission, while watching a sox game, he had a sudden onset of whole headache. the headache, the patient states, radiated down the posterior aspect of the neck bilaterally into the shoulders and arms, but further states left-sided, and some numbness in the hands. the patient was unable to move the entire left side x 45 minutes. the patient was transferred to where a head ct was negative. she had an lp, which showed stable amount of blood in all 4 tubes. the patient further states that now she just has posterior neck discomfort bilaterally. denies current nausea, visual changes, shortness of breath, fever, headache or stiff neck. past medical history: giant cell arteritis. polymyalgia rheumatica. breast cancer with right lumpectomy. hypothyroidism. left cochlear implant. allergies: 1. morphine. 2. sulfa. 3. amoxicillin. 4. codeine. physical examination: she is awake, alert and oriented x 3. vital signs are stable. visual fields are intact bilaterally. cardiovascular: regular rate and rhythm. no murmurs, rubs or gallops. lungs are clear to auscultation. neck: nontender to palpation. abdomen: soft, nontender, nondistended. positive bowel sounds. neurologic: moving all extremities with good strength 5/5. sensation is intact to light touch. proprioception is intact. she has no drift. naming is intact. repetition intact. cranial nerves ii through xii grossly intact. her face is symmetric. lips are full bilateral. tongue midline. deep tendon reflexes are full and symmetric. toes are downgoing. again, head ct was negative. lp showed 630 white cells and ,000 red cells. hospital course: the patient was admitted to the icu for close neurologic observation. she underwent an angiogram, which showed a 1.5-mm right pcomm infundibulum, which required no intervention and most likely is not the source of her subarachnoid hemorrhage. she remained neurologically stable, was transferred to the regular floor, had a ct myelogram to rule out spinal avm, which was ruled out. was seen by physical therapy and occupational therapy and was felt to be safe for discharge to home with follow-up with dr. in 2 weeks. the patient's condition was stable at the time of discharge. medications on discharge: 1. levothyroxine 88 mcg p.o. q.d. 2. divalproex sodium 250 mg 1 p.o. q.8h. 3. hydrochlorothiazide 50 q.d. 4. valsartan 100 mg p.o. q.d. 5. alendronate sodium 70 p.o. q.sunday. 6. prednisone 15 mg p.o. q.d. condition on discharge: stable. follow up: she will follow up with dr. in 2 weeks. , Procedure: Arteriography of cerebral arteries Transfusion of packed cells Contrast myelogram Diagnoses: Anemia, unspecified Polymyalgia rheumatica Unspecified essential hypertension Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Subarachnoid hemorrhage Cerebral aneurysm, nonruptured Displacement of cervical intervertebral disc without myelopathy First degree atrioventricular block Cervical spondylosis without myelopathy Giant cell arteritis

history of the present illness: mr. was a 22-year-old gentleman who had no significant past medical history who was involved in a motor vehicle accident at high speed after losing control of his vehicle involving a prolonged extrication from the accident site with agonal respirations and transport via to the emergency room where he arrived as a trauma plus. during the transport, he was intubated and the airway was secured and his vital signs were stabilized. upon arrival to the er, he was further resuscitated and standard atls protocol was instituted with all supporting services informed and neurosurgery present. upon arrival, his gcs was 3 as it was at the scene and his initial examination findings were significant for a right pupil 2 mm and a left pupil of 6 mm, right facial swelling and ecchymosis with obvious facial fractures, multiple. the chest and pelvis demonstrated no obvious signs of injury or deformity; however, he had an obvious right arm deformity. after the patient was stabilized, ct scans and radiology imaging demonstrated a left subdural hematoma, subarachnoid mass, subarachnoid hemorrhage, and intraventricular blood as well as left mandibular fracture, multiple right orbital fractures, zygomatic fractures, sphenoid and maxillary sinus fractures. a ct of the c spine demonstrated no fracture of the neck and chest ct was negative except for pulmonary contusions and a small left pneumothorax which was followed by chest x-ray and found not to be progressing and neither was it evident on chest x-rays. there was no evidence of abdominal injuries and workup of his humerus fracture showed a displaced midshaft humeral fracture with no evidence of vascular compromise in that extremity. upon evaluation, the neurosurgical team felt that the patient was unsalvagable. they did not place a ventriculostomy drain for two reasons; first, the ventricle was not accessible for adequate drainage of csf and that any drainage of csf would be of no utility. we then instituted optimal medical management to minimize secondary brain injury from the trauma and we did place a komino icp monitor. at the insertion site, the icp was 60. we instituted standard protocols including increasing the systolic blood pressure to maintain cerebral perfusion pressure as best as we could as close to 70 and we ensured adequate volume resuscitation through central monitoring. upon arrival into the trauma intensive care unit, under the full supervision of multiple senior residents and with constant contact with the attending surgeons as well as all consult services, it was noted that the patient was bradycardiac and the pressure fell to 68/24. he was again resuscitated to a pressure of 130/140 with an adequate heart rate of initially 140, stabilized to 80-90, cvp of 13 at that time. we continued maintaining his systemic blood pressure with an epinephrine drip which was then added to a levophed drip. eventually, a pitressin drip after the epinephrine was stopped. this was done in an attempt to maximize cerebral perfusion; however, his icp continued to increase despite all of our medical management efforts and his icp peaked out at 138. it was noted that between the hours of 8:00 and 9:00 a.m. on , the patient's urine output had increased significantly and it was most likely diabetes insipidus. we conducted replacement of all fluid losses and continued to best support him as we could. at this point, the clinical examination demonstrated fixed and dilated pupils on both sides indicating severe brain injury and there was no gag reflex. the patient had a gcs of 3 and no oculovestibular reflex. there was no evidence of any kind of neurological activity with regards to the neuromotor system. the organ bank had been informed earlier during the hospital stay and were involved in approaching the family during the course of this admission. neurology was involved and the medical intensive care unit attending to conduct brain death examinations and a cerebral perfusion study was conducted on the afternoon of to confirm brain death which demonstrated no cerebral flow. in light of this fact with the clinical examination demonstrating significant neurological injury indicative of brain team, an adequate mechanism to lead to brain death, and irreversibility demonstrated by the nuclear study showing no cerebral flow, the patient was declared dead at 4:45 p.m. on . the attending, the intensive care team, the organ bank, and all consulting services were informed and agreed upon this decision and the family was with great regret informed of this unfortunate outcome despite our best efforts. the family declined a postmortem and declined organ transplantation. the case was referred to the medical examiner's office and an autopsy was declined at that time. the attending staff had constant involvement with the case as well as all consult teams. , m.d. 2923 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other diagnostic procedures on brain and cerebral meninges Diagnoses: Traumatic pneumothorax without mention of open wound into thorax Closed fracture of malar and maxillary bones Closed fracture of orbital floor (blow-out) Closed fracture of other facial bones Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle Closed fracture of shaft of humerus Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with prolonged [more than 24 hours] loss of consciousness, without return to pre-existing conscious level Closed fracture of mandible, ramus, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: r pleuritic chest pain and shortness of breath x1 day major surgical or invasive procedure: s/p liver transplant ivc filter cholangiogram liver biopsy3/31 cardiac cath history of present illness: p/w right chest pain and shortness of breath since previous evening. had liver biopsy and complained about chest pain and sob. past medical history: olt , rejection rx'd with solumedrol hep c varices h/o encephalitis myoclonus/seizures s/p tx social history: lives with roommate on . has supportive family although they live near physical exam: vs 100.3-116-116/64-22, o2 88% on 100% nrb mod distress, alert neck: soft, supple, no jvd no bruits chest; rr, st, no murmurs lungs: decreased bs at bases bilat abd: soft nt, nd ext no edema pertinent results: 09:43pm glucose-115* urea n-8 creat-0.6 sodium-136 potassium-3.3 chloride-95* total co2-32* anion gap-12 09:43pm alt(sgpt)-235* ast(sgot)-298* ld(ldh)-487* alk phos-309* amylase-33 tot bili-0.7 09:43pm lipase-15 09:43pm albumin-3.1* calcium-8.5 phosphate-3.3 magnesium-1.6 uric acid-2.7* 09:43pm tsh-1.8 07:39pm pt-15.4* ptt-84.5* inr(pt)-1.5 03:34pm hct-33.4* 03:34pm pt-15.2* ptt-68.4* inr(pt)-1.5 02:10pm glucose-177* urea n-8 creat-0.5 sodium-136 potassium-3.6 chloride-99 total co2-27 anion gap-14 02:10pm ck(cpk)-29* 02:10pm ck-mb-notdone ctropnt-0.01 02:10pm calcium-8.0* phosphate-2.8 magnesium-1.6 02:10pm wbc-6.5 rbc-3.60* hgb-10.9* hct-31.5* mcv-88 mch-30.2 mchc-34.5 rdw-18.0* 02:10pm plt count-331 02:10pm pt-15.5* ptt-105.5* inr(pt)-1.5 11:55am type-art po2-70* pco2-35 ph-7.53* total co2-30 base xs-6 11:45am wbc-7.3# rbc-3.93* hgb-11.8* hct-34.9* mcv-89 mch-29.9 mchc-33.7 rdw-17.7* 11:45am plt count-368 08:25am glucose-165* urea n-10 creat-0.6 sodium-139 potassium-3.5 chloride-97 total co2-29 anion gap-17 08:25am alt(sgpt)-216* ast(sgot)-281* ck(cpk)-26* alk phos-338* tot bili-0.6 08:25am ck-mb-notdone ctropnt-0.02* 08:25am albumin-3.6 brief hospital course: admitted on s/p liver biopsy for follow up of rejection that was treated with solumedrol. complained of right pleuritic chest pain since the day before. he had some shortness of breath as well. he was admitted to the micu and had a chest ct that revealed a right pulmonary artery saddle embolus. results revealed the following: ct chest with iv contrast: there are tubular shaped filling defects extending across the bifurcation of the main pulmonary arteries. in addition, filling defects are seen at the branch points of the right main pulmonary artery and left main pulmonary artery with extension into the segmental pulmonary arteries. there is flow in the subsegmental pulmonary arteries but a paucity of opacification of the right lower lobe vessels. lung windows demonstrate a patchy area of consolidation in the posterior right lower lobe. there are no pleural or pericardial effusions. no axillary, mediastinal, or hilar lymphadenopathy. the heart and pericardium are within normal limits. visualized portions of the upper abdomen are remarkable for two rounded low attenuation areas in the right hepatic lobe of fluid density. bone windows: there are no suspicious lytic or sclerotic osseous lesions. ct reconstructions: coronal and sagittal reformatted images confirm the above axial findings. value grade i. impression: 1) extensive bilateral pulmonary embolism involving major, lobar and segmental divisions. 2) patchy right lower lobe consolidation. 3) two rounded low attenuation hepatic foci of fluid density. given this report, he was initiated on iv heparin. o2 sat was in 80s. he was placed on a non-rebreather 50%. he was hemodynamically stable. ct surgery was consulted to evaluate for embolectomy. evaluation revealed that he was not a candidate for surgical intervention at this stage. dr. (vascular medicine/cardiology attending) was consulted to evaluate for thrombolysis. after consultation with drs. and , a ivc filter was placed on via left brachial site without complication. please see procedure note for further details. on hd 1 he was transferred to the sicu where he spiked a temperature of 103.5. he was pancultured for fever. he was hydrated with iv d5w with bicarbonate and heparin was adjusted by q2 hour coags. his abg was improved. bilateral leg duplex ultrasound was done revealing old small clot in l sfv. on hd 3 he was experiencing increaed chest pain on the left side. this was concerning for reinfarction of lung. a cardiac echo revealed the following: the left atrium was normal in size. overall left ventricular systolic function appeared normal. due to suboptimal technical quality, a focal wall motion abnormality could not be fully excluded. right ventricular systolic function appeared normal. the aortic valve leaflets (3) appearred structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appeared structurally normal with trivial mitral regurgitation. moderate tricuspid regurgitation was seen. there was moderate pulmonary artery systolic hypertension. there was no pericardial effusion.compared with the findings of the prior study (tape reviewed) of , there was no diagnostic change. an ekg was done that suggested signs of strain with rate of 110 in nsr. twave was down in va5-v6, inferior and lateral leads. cardiology was asked to evaluate. findings were reviewed with dr. and a repeat cta was suggested to assess stability of the thrombus. a cxr revealed no acute changes. zosyn and vancomycin were started for fever and iv fluid changed to d51/2ns at 75. urine output was good, pain was controlled with prn iv dilaudid and nebs were given. o2 sat was 99% on 50% face mask. he received a unit of prbc on for a hematocrit of 26. neurology was consulted on hd 4 for medication review for history of seizures and myoclonus. he was noted to be quite ataxic on exam. continuation of clonazepam and keppra were recommended as well as corrected dilantin level of 15-20. recommended eventual taper of dilantin with keppra as monotherapy, but not in the acute care setting due to high risk of seizure. dilantin was increased to 100mg tid with an extra dose given for corrected level of 10.9. on he was noted to be breathing better. cultures were normal. a ct of the abdomen without and with iv contrast was done for persistent elevated lfts. this revealed: the lung base images reveal the known pe demonstrated as big filling defects within the lower lobe arteries blaterally. there is a large consolidation within the right lower lobe, demonstrating either pneumonia or unusual infarct. the transplanted liver demonstrates numerous low-attenuation lesions throughout both lobes of the liver, all of them small, up to 3 cm except for one in segment v of the liver, which measures 6 x 4 cm. there is no enhancement within or around any of these lesions and there is no free air within them. they all demonstrate fluid attenuation, around 10 hounsfield units. periportal edema is demonstrated. there is no intra- or extrahepatic biliary dilatation. no arterial supply is demonstrated within the liver and a hepatic artery is demonstrated only proximally outside the liver. the portal vein, hepatic veins and ivc are patent. there are no enhancing lesions within the liver. there is a trace amount of fluid around the liver. the spleen is homogeneous and enlarged. the kidneys, adrenal glands, pancreas, and unopacified loops of small and large bowel are unremarkable. there is a filter in the ivc. there are multiple small lymph nodes, but no significant lymphadenopathy. given the liver findings, drainage was planned after hct of 24.7 was treated with 2 units of prbc. ast was108, alt 97, alk phos 436, t.bili 0.8 and hep c viral load was 13.1m. on he had drainage of a right lobe bilioma and a drain was placed. bilioma felt to be secondary to bile duct ischemia do to known hepatic artery thrombosis. he was relisted for liver transplant. neuorology reassessed h/o nonconvulsive seizures and myoclonus. dilantin taper was initiated. no seizures were noted during this hospital stay. a cardiac cath was performed on for evaluation of arterial hypertension and pe.pa mean was 22. he remained in icu on iv vancomycin, zosyn, bactrim, gancyclovir and fluconazole. cultures were negative. he was transfered to the transplant unit on hd 8. vital signs were stable. blood glucose increased to 400 which required iv insulin therapy. glucoses trended down and was consulted. insulin sliding scale with glargine was initiated.iv hydration was continued for decreased po intake and hyperglycemia. a foley was left in place do to difficulty with incontinence. urine cx negative. lung sounds remained diminished with o2 sat of 95%. coumadin 5mg was initiated on hd 15. inr increased to 3.5 after a second dose of 5mg of coumadin. heparin iv was stopped. inr decreased to 3.0 on hd 16. coumadin was resumed at 2mg. an cholangiogram was done on revealing small amount of contrast passing into a small normal size bile duct. extravasation was noted under capsule. study was stopped and normal size bile ducts were noted. a triphasic liver ct was performed.impression: 1) no hepatic arterial flow visible within the liver, as documented on prior imaging studies. patent portal vein. 2) multiple low-density areas within the liver consistent with infarct/biloma. a drain is located within one of these collections and contains some residual contrast material, which does not appear to connect to the biliary tree. 3) bilateral pulmonary emboli. right internal iliac vein thrombus visible, but ivc filter is also noted to be in place. 4) increased consolidation at the right lung base with increase in size of right partially loculated pleural effusion. pneumonia should be considered. on hd 16 () patient was insistent upon discharge to home against medical advise. he had been advised to stay another day to repeat coags. he refused and signed ama form. he will follow up in am for labs at hospital. the transplant coordinator will obtain results and adjust. he was given medication schedule with script for percocet# 20 and coumadin 2mg po qd. labs will be drawn twice weekly with results fax'd to transplant center. follow up appointments were reviewed. pt evaluated him and felt he was stable for discharge with home pt and a cane. vna will follow him at home. he was afebrile and vital signs were stable. he was tolerating his diet and was ambulating independently. labs on : wbc 3.4, hct 28.6, potassium 3.5, creatinine 1.0, bun 10, ast 23, alt 16, alk phos 310, t.bili 0.4, pt 21.8, inr 3.0. level 15.3. medications on admission: klonopin 0.25mg tid, fluconazole 400qd, lasix 20mg qd, mmf 1gram , protonix 40mg qd, dilantin 260mg qd, rapamune 6mg qd, lipiotr 10mg qd, methadone 100mg qd, valcyte qd, bactrim ss 1 qd, keppra discharge medications: 1. valganciclovir hcl 450 mg tablet sig: two (2) tablet po daily (daily). 2. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). 5. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 6. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. methadone hcl 10 mg tablet sig: two (2) tablet po daily (daily). 8. methadone hcl 40 mg tablet, soluble sig: two (2) tablet, soluble po daily (daily). 9. sirolimus 1 mg tablet sig: three (3) tablet po daily (daily). 10. prednisone 5 mg tablet sig: two (2) tablet po daily (daily). 11. percocet 5-325 mg tablet sig: 1-2 tablets po prn q 4-6: for pain. disp:*20 tablet(s)* refills:*0* 12. coumadin 1 mg tablet sig: two (2) tablet po once a day: pcp to monitor labs. have inr/pt/ptt drawn with mon & thurs labs. disp:*60 tablet(s)* refills:*1* 13. insulin regular human 100 unit/ml solution sig: one (1) injection four times a day. discharge disposition: home with service facility: vna of discharge diagnosis: s/p r saddle pulmonary embolus, l pulmonary embolus s/p liver transplant hepatic artery thrombosis hep c seizures myoclonus type 2 dm, steroid induced discharge condition: stable. discharge instructions: call if any fevers, chills, shortness of breath, chest pain, nausea, vomiting, inability to take medications, bleeding, increased jaundice or lack of bile drainage from bile drain. labs every monday & thursday for cbc, chem 10,ast, alk phos, alt, t.bili, albumin, pt, ptt, inr and trough rapamune level. fax results immediately to transplant office and dr. (pcp) coumadin (blood thinner)dose will be managed by dr. followup instructions: provider: , md where: lm center phone: date/time: 3:00 provider: , md where: lm center phone: date/time: 3:00 provider: , md where: lm center phone: date/time: 11:40 provider: , call to schedule appointment md, Procedure: Interruption of the vena cava Closed (percutaneous) [needle] biopsy of liver Right heart cardiac catheterization Other cholangiogram Percutaneous aspiration of liver Diagnoses: Anemia, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other, mixed, or unspecified drug abuse, unspecified Other convulsions Primary pulmonary hypertension Complications of transplanted liver Other pulmonary embolism and infarction Myoclonus Posttraumatic stress disorder

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever, seizures, respiratory distress major surgical or invasive procedure: none history of present illness: patient is a 49 year-old male status post orthotopic liver transplant on , with biliary sepsis, seizures, resp distress, unresponsiveness and worsening liver failure. the patient also has hepatic artery thrombosis and a right saddle pulmonary embolus. past medical history: olt , rejection rx'd with solumedrol hep c varices h/o encephalitis myoclonus/seizures s/p tx social history: lives with roommate on . has supportive family although they live near family history: noncontributory brief hospital course: : sp ir drainage of biloma of r inf lobe of the liver. tx'd -had bronchospasm with meripenim. : bc (+) klebsiella, u cx-p, bld cx-klebsiella (only s-imipenem), bl-gnr, -cath tip-neg, -bile: gnr x 2, -() klebsiella (s-meropenum, s-imipen, s-ceftriaxone, s-cefipime) -urine-neg, bld-neg, mrsa-ngtd, - bl-ngtd, -bile-klebsiella (s-imip, r-), -mrsa-neg, rectal swab: + vre, u: neg, bl: klebsiella, (r to , to imipen), cath tip: neg, sp: gnr sparse, bld: coag neg staph (r ox, vanc), bld: coag neg staph (r ox, senx vanc) bile:lactobacillus, staph coag neg, yeast, gnr, bile: staph coag neg, yeast, gnr, sp: yeast, bl: klebsiella 10 fr to r flank, right subhepatic biloma with serosang fluid aspirated and sent for culture. cx: klebsiella pneumoniae-panresistant. sensitive to imipenem. wbc-10.1 remains in icu. patient awaiting another transplant. a+ox3, responsive to questions. right flank pigtail remains in place, secured with statlock, draining bilious drainage. remains in icu and has been consistently febrile. is presently refusing all further invasive procedures/interventions. spoke briefly to patient who said "i have a lot of searching to do. i've been here since ." right pig cath. in place draining moderate amounts of bilious drainage. statlock secure. biliary tube is presently capped. patient has been made cmo, placed on hydromorphone drip with lorazepam prn for agitation. /05 - pt. with cmo, deceased on . plan: cmo, dilaudid drip to comfort medications on admission: sirolimus 6mg po daily mycophenolate mofetil 1000mg po bid prednisone 10mg po daily valgancyclovir 900mg po daily bactrim ss po daily methadone 100mg po daily clonazepam .25mg po tid dilantin 260mg po daily keppra 1500mg po bid atorvastatin 10mg po daily furosemide 20mg po daily fluconazole 400mg po daily percocet prn discharge disposition: expired discharge diagnosis: end-stage liver failure discharge condition: deceased md, Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed (percutaneous) [needle] biopsy of liver Other intubation of respiratory tract Transfusion of packed cells Transfusion of other serum Other cholangiogram Other percutaneous procedures on biliary tract Transfusion of platelets Injection or infusion of oxazolidinone class of antibiotics Infusion of vasopressor agent Diagnoses: Thrombocytopenia, unspecified Unspecified pleural effusion Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Severe sepsis Atrial fibrillation Other convulsions Acute and chronic respiratory failure Iatrogenic pneumothorax Long-term (current) use of insulin Other specified disorders of biliary tract Other septicemia due to gram-negative organisms Infection and inflammatory reaction due to other vascular device, implant, and graft Embolism and thrombosis of other specified artery Complications of transplanted liver Cholangitis Obstruction of bile duct Acute pancreatitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall from ladder 20 feet after sustaining a seizure major surgical or invasive procedure: open reduction internal fixation distal radial fracture, multiple facial fracture, and mandibular fracture with fiberoptic nasotracheal intubation. history of present illness: 31 m fell from 20 foot ladder after a questionable seizure, gcs15, combative at scene, hemodynamically stable, neurologically intact. past medical history: seizure disorder social history: +tobacco, +etoh, -drugs family history: n/a physical exam: t= 100.4 hr=120 bp=125/89 sao2=100% 2l gen: gcs15, combative, following commands heent: blood around face, abrasion r. cheek, blood from nose, tm clear, tenderness of midface, l. mandible neck: c-collar, trachea midline chest: cta b/l heart: rrr abd: soft, nt, nd, fast - rectal: good tone, guaic - back: logroll with tenderness over t/l spine, no bruises ext: b/l knees with bruises, - swelling, l. wrist tender/swelling neuro: moex4 sensation intact x4, all peripheral pulses palpable pertinent results: 07:15pm fibrinoge-178 07:15pm plt count-333 07:15pm pt-12.0 ptt-19.7* inr(pt)-1.0 07:15pm wbc-10.9 rbc-4.51* hgb-14.0 hct-37.0* mcv-82 mch-31.0 mchc-37.8* rdw-13.5 07:15pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 07:15pm valproate-93 07:15pm amylase-49 07:15pm urea n-11 creat-1.1 07:17pm glucose-127* lactate-5.7* na+-144 k+-3.5 cl--107 tco2-21 10:25pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-6.5 leuk-neg forearm (ap & lat) left 7:59 pm impression: intra-articular impacted radial head fracture with 5 to 6 mm of positive ulnar variance. minimally displaced fracture of the base of the third metacarpal. knee (2 views) bilat 7:58 pm impression: no fracture. ct torso impression: 1. no evidence of acute intrathoracic or intra-abdominal solid organ injury. 2. focal hypodensity within the posterior aspect of the spleen likely representing asymmetric perfusion. 3. there are several loops of proximal small bowel within the left upper quadrant, which demonstrate prominant walls. given the lack of oral contrast, and the mechanism of injury, this likely reflects a combination of underdistention and ingested contents. 4. bilateral l5 spondylolysis. ct maxillofacial ct facial bones: there are fractures involving the lateral walls of the orbits bilaterally, with two fracture lines noted on the right. additionally, there are comminuted fractures involving the medial and lateral walls of the maxillary sinuses, the ethmoid bone, and the medial and lateral pterygoid plates on the right. there is a fracture line extending through the left side of the hard palate. the comminuted fracture in the posterolateral wall of the right maxillary sinus also extends to involve the posterior inferior orbital floor at that location. there is prolapse of muscle and fat into the right maxillary sinus. there is a fracture through the anterior aspect of the lesser of the sphenoid. the ethmoid and frontal air cells are well aerated. there are fractures through the angle of the mandible bilaterally (comminuted on the left), with leftward displacement of the body mandible. blood and fluid can be seen within both maxillary sinuses. additionally, there is soft tissue air adjacent to the left lateral maxillary wall. impression: there are multiple facial fractures, as described above. note added at attending review: there are bilateral zygomatic arch fractures. ct c-spine: impression: 1. no fracture or spondylolisthesis of the cervical vertebral bodies is identified. 2. bilateral mandibular rami fracture. ct head without iv contrast: impression: 1. no intracranial hemorrhage is identified. 2. multiple facial fractures are seen, as described above. these are better evaluated on the dedicated ct scan of the facial bones, performed on the same day. ap chest and ap pelvis: impression: no fracture or pneumothorax identified. brief hospital course: patient admitted to the trauma service from the ed with multiple facial fractures, b/l mandibular fractured, and l. distal radius fracture. patient admitted to trauma step-down with telemetry. a daubhoff tube was placed on for tubefeeds. patient was followed by orthopedics, plastics, omfs, and neurology. on , patient had 3 episodes of asymptomatic skipped heartbeats. on , patient was brought to or for orif of l. distal radial fracture and orif of facial and mandibular fractures. patient was intubated via fiberoptic nasotracheal approach. there were no complications. patient was transferred to the tsicu post-op. given extensive facial swelling, he was intubated until when chest xray indicated improved aeration. he was extubated uneventfully. patient was transferred to the floor on . on tube feeds were stopped as he was able to take sufficient po intake via a straw. he did not have witnessed seizure activity during this hospitalization. medications on admission: depakote discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane qid (4 times a day). disp:*1800 ml(s)* refills:*2* 2. colace 150 mg/15 ml liquid sig: ten (10) ml po twice a day as needed for constipation: take colace while taking codeine to prevent constipation. disp:*200 ml* refills:*0* 3. acetaminophen-codeine 120-12 mg/5 ml elixir sig: ten (10) ml po every 4-6 hours as needed for pain. disp:*200 ml* refills:*0* 4. ibuprofen 100 mg/5 ml suspension sig: twenty (20) ml po three times a day as needed for pain. disp:*200 ml* refills:*0* 5. erythromycin 5 mg/g ointment sig: 0.5 cm ophthalmic four times a day: qid in ou; to incision sites. disp:*1 tube* refills:*0* 6. valproic acid 250 mg/5 ml syrup sig: ten (10) ml po three times a day. disp:*500 ml* refills:*2* 7. keppra 100 mg/ml solution sig: five (5) ml po twice a day. disp:*350 ml* refills:*1* discharge disposition: home discharge diagnosis: 1. multiple facial fractures including b/l mandibular fracture with displacement, b/l orbital wall fracture, fracture of hard palate. 2. left distal radial fracture. discharge condition: good discharge instructions: you were hospitalized at after a fall. from the fall, you had multiple facial and jaw fractures, and a fracture of your left wrist. to treat your jaw fracture, your jaw has been wired. you will only be able to drink liquids until the wires are removed. you should try to drink 5 cans or boost or ensure (liquid nutritional supplement) each day to make sure that you get enough nutrition. you have been given a pair of wire cutters. if you develop any difficulty breathing, start vomiting or choke, you should use the wirecutters to cut the wires keeping your jaw shut. you should then go immediately to an emergency department. you should continue to wear the splint on your wrist until otherwise notified by orthopedics. please call doctor or go to the emergency department for: *fever greater than 101 *nausea/vomiting *inability to eat *wound redness/warmth/swelling/foul smelling drainage *difficulty breathing *pain not controlled by pain medications *numbness or weakness in your left hand/fingers *increased swelling or increased pain in your left hand/fingers *if your left hand/fingers turn blue or cold *seizures *if you have to clip the wires on your jaw *if you develop confusion, are excessively drowsy/difficult to awaken *any other symptoms that concern you. please resume taking all medications as taken prior to this surgery and pain medications and stool softener as prescribed. for your seizures, you have been prescribed dilantin (valproic acid) and keppra. please follow-up as directed. followup instructions: you will follow-up weekly at the clinic (friday afternoons) with dr. until further notice. please call to make an appointment. you should follow-up with plastic surgery on friday (call to make an appointment). you should follow-up with orthopedics with dr. 10 days after your surgery (i.e. around ). call to make an appointment. we have schedule a follow-up appointment with dr. (neurology) on at 12:00. call for directions or if you need to change this appointment. provider: . & phone: date/time: 12:00 you should follow-up with your primary care physician weeks. you should contact at to make a follow-up appointment. md, Procedure: Enteral infusion of concentrated nutritional substances Open reduction of maxillary fracture Open reduction of fracture with internal fixation, radius and ulna Open reduction of mandibular fracture Closed reduction of fracture without internal fixation, radius and ulna Elevation of skull fracture fragments Other open reduction of facial fracture Open reduction of nasal fracture Closed reduction of fracture without internal fixation, carpals and metacarpals Diagnoses: Epilepsy, unspecified, without mention of intractable epilepsy Personal history of noncompliance with medical treatment, presenting hazards to health Accidental fall from ladder Closed fracture of malar and maxillary bones Closed fracture of other facial bones Closed fracture of nasal bones Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness Other closed fractures of distal end of radius (alone) Closed fracture of mandible, unspecified site Closed fracture of base of other metacarpal bone(s)

history of present illness: baby girl is former 30 weeks gestational age premature infant who is currently day of life 46, corrected 36 and gestational age. the infant was born to a 26 year old gravida ii, para i, now ii mother. prenatal screens has blood group o positive, antibody positive with positive anti-d antibodies thought to be secondary to rhogam. hbs antigen negative, rpr nonreactive, rubella immune, gbs unknown. pregnancy was complicated by maternal pregnancy induced hypertension over the 2 weeks prior to delivery. mother was treated with labetalol. mother was transferred from hospital on the day prior to delivery due to fetal distress. mother presented with decreased fetal movement and revealed nonreassuring fetal heart rate tracing and biophysical profile 4 out of 8. mother was started on magnesium sulfate and treated with betamethasone. the infant was delivered on , by cesarean section. rupture of membranes at delivery with clear fluid. the infant emerged with good tone and spontaneous cry. routine drying, suctioning and stimulated. apgar 7 at 1 minute and 8 at 5 minutes. the infant was transported to neonatal intensive care unit in room air without complications. physical examination: on admission to neonatal intensive care unit, weight 1050 grams, length 3515 centimeters, head circumference 25 centimeters. vital signs stable. pink nondysmorphic premature infant with iugr. otherwise, exam was remarkable for mild to moderate respiratory distress. hospital course by system: respiratory. on admission due to increased oxygen requirement and mild respiratory distress, the infant was placed on cpap. chest x-ray was consistent with mild to moderate hyaline membrane disease. she remained on cpap for the first 3 days of life and was weaned to room air on day of life 4. she remained in room air since then requiring no additional respiratory support. she was started on caffeine on day of life 4 due to increased amount of spells. she remained on caffeine through day of life 21 and it was discontinued on . she remained spell free since then. cardiovascular. baby girl remained stable with normal cardiac exam through her hospital stay. intermittent soft murmur was heard at left lower sternal border and thought to be consistent with a flow murmur. fen/gi. on admission, baby girl was made npo. iv fluids were started at 80 cc/kg with d10w. it was changed to pn with intralipid on day of life 1. enteral feeds were introduced on day of life 3. they were slowly advanced due to increased amount of aspirate. she was at full feeds and off pn on day of life 16. her calories were increased to 26 calories per ounce breast milk with promod. she demonstrated good weight gain with this calorie intake. her calories were decreased to enfamil 24 calories per ounce with enfamil powder on . at discharge, her feeds at 150 cc/kg minimum p.o. with enfamil 24 calories per ounce. she was treated with phototherapy for hyperbilirubinemia. her bilirubin peaked on day of life 1 at 4.9. phototherapy was discontinued on day of life 4. discharge weight is 2175 gms. hematology. initial cbc with white blood cell count 5.9, 40 polys, 0 bands, hematocrit 59, platelets 136,000. her last hematocrit was done on , and was 45. she was on iron supplementation through her hospital course. infectious disease. she was treated with ampicillin and gentamicin on admission for maternal factors. her blood cultures remained negative at 48 hours and antibiotics were discontinued on day of life 2. she remained without any signs of infection through her hospital course. neurology. a head ultrasound on day of life 7, on , showed small right subependymal hemorrhage. follow-up head ultrasound was done on , and demonstrating evolving small right subependymal hemorrhage. follow-up head ultrasound was done on , at discharge and was normal. hearing screen was done on , and infant passed in both ears. ophthalmology. eyes examined most recently on , revealing immaturity of the retinal vessels, zone 3, with no rop as of yet. a follow-up examination should be scheduled in 3 weeks after the last eye exam on the week of . condition on discharge: stable. discharge disposition: discharged home with parents. name of primary pediatrician dr. , pediatrics. telephone number (. the infant passed car seat test on . last state newborn screen was done on . vaccination. hepatitis b vaccine was given on . synagis was given on . immunization recommended. synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria: born at less than 32 weeks, born between 32 and 35 weeks with 2 of the following: daycare during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, school age siblings, or 3 with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. follow-up appointment. follow-up appointment with primary care pediatrician is scheduled for the day after discharge. follow-up appointment with pediatric ophthalmologist for follow-up of retinopathy of prematurity should be scheduled in the week of . discharge diagnosis: prematurity, apnea of prematurity, rule out sepsis, , dictated by: medquist36 d: 16:51:22 t: 21:49:38 job#: Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery 29-30 completed weeks of gestation Undiagnosed cardiac murmurs Other apnea of newborn Intraventricular hemorrhage unspecified grade Fetal growth retardation, unspecified, 1,000-1,249 grams

discharge condition: stable. discharge disposition: newborn nursery for routine care. name of primary pediatrician ( pediatrics) . care and recommendations: feeds at transfer breast feeding q three hours with bottle feeds of pumped breast milk on top of that. medications on discharge: none. car seat screening: not needed. state newborn screens: sent. immunizations received: hepatitis b vaccination given. immunizations recommended: routine newborn vaccinations. discharge diagnoses: 1. transient tachypnea of the newborn, resolved. 2. mild indirect hyperbilirubinemia, concurrent. 3. sepsis ruled out. , m.d. dictated by: medquist36 Procedure: Non-invasive mechanical ventilation Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Unspecified fetal and neonatal jaundice Transitory tachypnea of newborn

history of present illness: this is a 72-year-old female patient without a history of coronary artery disease. she reports a 10-year history of anginal-like symptoms with a negative stress test in . over the past four month she reports progressive angina with pain and pressure radiating to her left arm, shoulder, neck, left jaw, and cheek. only with exertion and resolving with rest and/or sublingual nitroglycerin. a stress test in showed posterolateral ischemia and an ejection fraction of 72 percent. at this time, she was referred for cardiac catheterization. cardiac catheterization on revealed an ejection fraction of 66 percent, lad stenosis of 70 percent, left circumflex stenosis of 70 percent, and om1 stenosis of 80 percent. at this time, she was referred for coronary artery bypass grafting by dr. . past medical history: hypertension, elevated lipids, cerebrovascular accident in , osteoarthritis, bursitis of the hips, renal calculi, and status post lithotripsy in . past surgical history: right carpal tunnel release and left thumb joint replacement in . allergies: no known drug allergies. medications on admission: lipitor 80 mg once daily, aspirin 325 mg once daily, tramadol 50 mg at bedtime as needed, lisinopril/hydrochlorothiazide combination 10/12.5 mg once daily, ibuprofen once daily, and zyrtec as needed. social history: she lives in with her husband. retired but volunteers often. she drives. she uses a cane when she is tired. she has a history of tobacco use; having quit one week prior to initial visit on with less than a 50-pack-year history. she denies any alcohol use. physical examination on presentation: height was 5 feet 2 inches tall and weight was 148 pounds. the heart rate was 83 in sinus rhythm, the blood pressure was 108/69, the respiratory rate was 21, and oxygen saturation was 100 percent on room air. in general, the patient was lying flat in bed in no acute distress. neurologically, alert and oriented times three, appropriate, and moved all extremities. positive carotid bruits bilaterally. respiratory examination revealed clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm. s1 and s2. a positive blowing systolic murmur. gastrointestinal examination revealed soft, round, nontender, and nondistended with positive bowel sounds. the extremities were warm and well perfused. no edema or varicosities with good dorsalis pedis and posterior tibial pulses bilaterally. laboratory data on presentation: white blood cell count was 6.7, hematocrit was 29.9, and platelets were 233. pt was 13.5, ptt was 29.3, and inr was 1.9. sodium was 139, potassium was 3.2, chloride was 104, bicarbonate was 29, blood urea nitrogen was 28, creatinine was 0.7, and glucose was 215. alt was 16, ast was 14, alkaline phosphatase was 58, amylase was 82, total bilirubin was 0.3, and albumin was 3.9. discharge status: to rehabilitation. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting times three. 3. hypertension. 4. elevated lipids. medications on discharge: 1. lipitor 40 mg p.o. once daily. 2. colace 100 mg p.o. twice daily. 3. lasix 20 mg p.o. twice daily. 4. potassium chloride 20 meq p.o. twice daily. 5. dilaudid 2 mg to 4 mg p.o. q.4-6h. as needed (for pain). 6. lopressor 25 mg p.o. twice daily. 7. aspirin 81 mg once daily. discharge follow-up plans: 1. the patient is to make an appointment to see dr. in approximately four weeks. 2. the patient is also to make an appointment to see dr. . in two to four weeks' time. 3. she should make an appointment with her primary cardiologist in one to two weeks' time. , m.d. Procedure: Single internal mammary-coronary artery bypass (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Other and unspecified hyperlipidemia Calculus of kidney Polyp of vocal cord or larynx

medications on admission: lipitor 60 mg q.d., singulair 10 mg q.d., vista 15 mg q.d., vioxx 25 mg q.d., glucophage 1000 mg p.o. b.i.d., flovent, albuterol p.r.n., .................. q.d., atenolol 50 mg q.d., lisinopril 40 mg q.d., avandia 6 mg, vista 60 mg, ecasa 325 p.o. q.d. laboratory data: normal. creatinine 0.8; white count 11.5, hematocrit 35.7. physical examination: vital signs: she was afebrile. vitals signs stable. general: she was in no apparent distress. heent: pupils equal, round and reactive to light. no jugular venous distention. no bruits. neck: supple. lungs: clear to auscultation bilaterally. heart: regular, rate and rhythm. normal s1 and s2. no murmurs, rubs or gallops. abdomen: soft, nontender, nondistended. bowel sounds present. extremities: warm and well perfused. no varicosities. no clubbing, cyanosis,or edema. pulses 2+ bilaterally, 1+ dorsalis pedis, no posterior tibial palpable. hospital course: she was prepped preoperatively for surgery. she was taken to the operating room on , where coronary artery bypass grafting times four was performed, and was transferred to the csru postoperatively. she was weaned from her ventilator and extubated. she did well. she was started on beta-blockers after her neo-synephrine was weaned off, and her chest tubes were removed. physical therapy was consulted while in the intensive care unit to assess mobility and ambulation. it was felt that she would be safe to go home at that time with continued therapy while in the hospital. she continued to improve and was started on lopressor. she was hemodynamically stable and was tolerating a clear diet. she was started on lasix and transferred to the floor. postoperatively her foley was removed. on , the patient improved on the floor, and her wires were removed on postoperative day #4. she had some slight drainage on , and the steri-strips were removed, and betadine was placed on the site, and the incision was watched. tentatively the patient is scheduled to be discharged home in stable condition on . discharge medications: avandia 6 mg p.o. q.d., glucophage 100 mg p.o. b.i.d., percocet tab p.o. q.4 hours p.r.n., motrin 400 mg p.o. q.4 hours p.r.n., ecasa 325 p.o. q.d., colace 100 mg p.o. b.i.d., zantac 150 mg p.o. b.i.d., kcl 20 meq p.o. b.i.d., lasix 20 mg p.o. b.i.d., lopressor 25 mg p.o. b.i.d. con on discharge: the patient was discharged home in stable condition and was instructed to follow-up with her primary care physician weeks and with dr. in approximately four weeks. discharge instructions: the patient was instructed to watch out signs of infection at the incision site. discharge diagnosis: 1. coronary artery disease status post coronary artery bypass grafting times four. 2. hypertension. 3. high cholesterol. 4. diabetes. 5. asthma. 6. diverticulosis. discharge status: the patient was discharged home in stable condition. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified

allergies: nkda past medical history: crf,? etiology -dialysis has been discussed; niddm; bell's palsy in past; club feet -wears braces, had bilat corrective surgeries. pt was in usual state of health until he reported felt dizzy. his mental status continued to decrease so that the emt's were called. the emt's reported left sided weakness, b/p 200's, and more lethargic. in the ew he vomited and so he was intubated for airway protection. he had a ct scan and an mri prior to transport to the micu for management. review of systems: pt received 8 mg ativan ivp from 10:50 to 11:50, 12:40 he received 6mg ativan prior to the mri, and he received 2mg ativan in the ew. upon arrival in the micu at 3:00 he is very sedated responding to only to stimuli. he is moving all extremities but not to commands. his pupils are pinpoint. the mri showed a basal cerebellar and right midbrain cerebebral peduncle stroke. he was not a canidate for tpa. he was started on heparin at 900 u/h (without bolus) at 3:30 and will need a ptt at 9:30. he is to have the head of his bed flat. resp: pt arrived intubated on a/c 700x12, peep 5 fio2 100%. o2 sats were 100#. breath sounds were clear but diminished in the bases. the vent was changed to imv 700 x12 peep 5, fio2 50%. he is not breathing over the vent. abg pending. there is a possiblity of aspiration following his vomiting in the ew. cardiac: b/p has been 170-180/70-80, hr 100-106, sr no vea. the plan is to maintain his b/p 140-180. he is receiving ns at 100cc/hr. gi: he has an ogt in place draining bile secretions. abd soft and non-tender, (+) bowel sounds. gu: foley in place draining light yellow urine. u/o ~200cc/hr. bun 104, creat 3.6. lines: he has a #18a in his right hand, following multiple attempts a second iv failed. a left radial a-line was inserted with difficulty. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Insertion of endotracheal tube Diagnoses: Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Bell's palsy Hyperosmolality and/or hypernatremia Talipes, unspecified Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Occlusion and stenosis of vertebral artery with cerebral infarction

history of present illness: the patient is a 77-year-old man, transferred to the neurology service after a four day admission to the intensive care unit. mr. is not able to provide a coherent story at this time, but he states that he came to the hospital on because he had a seizure. medical records documented that he became dizzy at about 9:30 p.m. on , which was not , and could not keep his eyes open. he would fall asleep quickly, and his wife noted a left facial droop. he was brought to the emergency room and noted to have a systolic blood pressure in the 200s. his initial examination documented him as alert, with limited verbal output, comprehending commands, having a left facial droop and upper motor neuron pattern, weakness in the left arm, intact sensation, and a left visual field cut. signal abnormalities were noted in both cerebellar hemispheres. this symptoms were not amenable to tpa, so mr. received intravenous heparin. in the intensive care unit, mr. was extubated, and his strength improved somewhat. he was transferred to the regular neurology floor on , for further management. past medical history: chronic renal insufficiency, type 2 diabetes, bell's palsy, clubbed feet. medications on admission: enalapril 10 mg by mouth once daily, lipitor 10 mg by mouth once daily, lopressor 25 mg by mouth twice a day, aggrenox one capsule by mouth once daily, multivitamin one capsule by mouth once daily, protonix 40 mg by mouth once daily. family history: unable to obtain. social history: no smoking, occasional alcohol use, married, lives at home with wife. physical examination: vital signs: temperature 98.9, blood pressure 160/86, pulse 94, breathing at 28, oxygen saturation 96% on 2 liters. in general, he is a well-developed, well-nourished, elderly man, lying in bed, eating dinner. head, eyes, ears, nose and throat: no evidence of trauma. neck: no carotid bruits or thyromegaly. pulmonary: clear to auscultation bilaterally. cardiovascular: regularly, no murmurs. abdomen: soft, nontender, positive bowel sounds x 4. extremities: clubbed feet, no edema. there is distal wasting in the shins and calves. mental status: he is awake, alert and oriented times three. language is fluent, with good comprehension and repetition. he has a mild anomia, and cannot do months of the year backwards accurately. can perform simple calculations in his head. visual acuity is 20/70 in both eyes. he has a left homonymous hemianopsia that is greater in his inferior visual fields. extraocular movements intact, pupils 3 to 2 bilaterally. he has a left facial droop, upper motor neuron type. facial sensation is intact. hearing is intact to finger rub. palatal elevation is symmetric. shoulder shrug and head turning are symmetric. the tongue is midline. on motor examination, he has normal tone and bulk throughout. there were no fasciculations. his strength in the deltoids was decreased bilaterally to 4+ on the left side, 4- on the right. he has 5- strength in his left triceps, and he has a barely detectable pronator drift on the left. his reflexes are 1+ throughout. his toes are upgoing bilaterally. his sensation is intact to pain and touch throughout. decreased proprioception in his toes. coordination: finger-to-nose is clumsy with both hands. rapid alternating movements is slow bilaterally. laboratory data: on transfer to the neurology service, white count 11.9, hematocrit 28, platelets 240. sodium 147, potassium 4.4, chloride 113, bicarbonate 24, bun 56, creatinine 2.1, glucose 59. calcium 8.7, magnesium 1.4, phosphate 3.3. triglycerides 140, hdl 48, ldl 96. radiology: mri shows no diffusion abnormalities in the cerebrum, however, there are slight changes in bilateral cerebellar hemispheres, and there is mild to moderate stenosis of bilateral vertebral arteries. hospital course: after being admitted to the intensive care unit and extubated, he was transferred to the neurology floor. his lipitor, aggrenox, enalapril and lopressor were continued. he had a transthoracic echocardiogram, which showed no evidence of thrombus in the left atrium or left atrial appendage, no atrioseptal defect or patent foramen ovale. he had an mr of his chest to look for potential sources of posterior circulation emboli. there was mild to moderate focal stenosis at the origin of the right vertebral artery and mild focal stenosis at the origin of the left vertebral artery. there was good anterograde flow in both arteries. mild focal stenosis was also noted at the origin of the left common carotid artery. the patient remained stable while on the neurology . he will be discharged to rehabilitation. discharge diagnosis: 1. bilateral cerebellar infarctions with minimal resulting deficits 2. chronic renal insufficiency 3. type 2 diabetes 4. bell's palsy on left side 5. clubbed feet discharge medications: 1. lipitor 10 mg by mouth once daily 2. lopressor 25 mg by mouth twice a day 3. aggrenox one capsule by mouth once daily 4. multivitamin one capsule by mouth once daily 5. protonix 40 mg by mouth once daily 6. avapro 300 mg by mouth once daily he will follow with me, dr. , as an outpatient for neurology purposes. he is being discharged in stable condition. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Insertion of endotracheal tube Diagnoses: Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Bell's palsy Hyperosmolality and/or hypernatremia Talipes, unspecified Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Occlusion and stenosis of vertebral artery with cerebral infarction

history of present illness: this is a 58 year old, left handed, white female, retired bank clerk who had a cold with frequent coughing for a few days, then developed episodic severe headache times one to two days. she also noted mild left leg weakness when attempting to climb stairs on the day of admission, which led to going to an outside hospital emergency room at hospital. ct scan done at hospital was positive for acute subarachnoid hemorrhage with blood throughout the basal cisterns, slightly greater on the right side. therefore, she was transferred to neurosurgical evaluation and treatment. she was reportedly neurologically intact and stable at the outside hospital with the only finding of mild right sided eyelid ptosis. past medical history: history of hypertension. medications on admission: premarin, verapamil, avapro, diovan, aspirin, caltrate, atenolol. allergies: no known allergies. review of systems: recent history of an upper respiratory infection, but otherwise unremarkable. family history: mother is deceased secondary to subarachnoid hemorrhage. she lived for approximately four years in a coma following the acute onset of the subarachnoid hemorrhage. social history: the patient is a retired bank clerk. she is married with a supportive family. denies use of alcohol. quit tobacco in after a two pack per day history for 20 years. physical examination: in general, she was a well-developed, well-nourished, white female in no acute distress. she was afebrile at 96.9, blood pressure 148 to 155 systolic over 69 to 72 diastolic. heart rate 89 normal sinus rhythm. respiratory rate 20. oxygen saturation on 2 liters nasal prong was 96%. head was normocephalic, atraumatic. right pupil was 5 mm and essentially nonreactive and dilated. left pupil was 2.5 mm and reactive to 2 mm with light. extraocular movements intact, but she was not able to converge the right eye medially toward the tip of the nose. smile was equal. facial sensation was intact in all three branches. tongue was midline. palate raised bilaterally in the midline. there was no upper extremity arm drift. strength was in all muscle groups in bilateral upper and lower extremities. sensation was intact to bilateral light touch. deep tendon reflexes were 2+ and equal bilaterally throughout. plantar responses were downgoing. chest was clear. heart was regular rate and rhythm with a 2/6 systolic ejection murmur radiating to the axilla. abdominal exam was unremarkable. extremities were without cyanosis, clubbing or edema. laboratory data: on admission hematocrit was 39.4, white blood cell count 6.8, platelet count 252. chem-7 was within normal limits. coags were also found to be within normal limits. ct scan from the outside hospital was reviewed which showed acute subarachnoid hemorrhage with blood in bilateral, right greater than left, basal cisterns and extending around the brain stem bilaterally, consistent with the high likelihood of aneurysm rupture. a nonenhanced ct on the evening of admission to confirmed the above findings with no additional bleeding. hospital course: the patient was subsequently admitted to the hospital to the neuro intensive care unit and seen by dr. and was stabilized with nipride to keep blood pressure below 140 and begun on nimodipine 60 mg p.o. q.four for relieve of any potential spasm of the intracerebral arteries. patient was subsequently taken to the angiogram suite for diagnostic angiogram and also had coiling of the aneurysm at that time. she also had placement of a ventricular drain immediately subsequent to the aneurysm coiling. patient tolerated the entire procedure well and spent the next several days in the neuro intensive care unit for close neurologic monitoring as well as for careful blood pressure control. the patient's postoperative course was essentially unremarkable. she was noted to have persistence of right third nerve palsy throughout the hospitalization with a dilated, nonreactive pupil on the right and ptosis of the right eyelid. the remainder of patient's postoperative course was essentially unremarkable. followup studies showed no evidence of further bleeding and no evidence of spasm of the cerebral arteries. due to the clinical findings, patient was subsequently transferred from the neuro intensive care unit to the medical surgical floor. she was maintained in the hospital until the morning of , at which time she was discharged to home in the care of her family. she had been seen for postoperative physical therapy evaluation for evaluation of level of safety and ambulation and home safety eval and was considered safe for discharge to home. therefore, she was discharged home in the care of her family in the midday of , with followup to see dr. in clinic in approximately two to three weeks' time. condition on discharge: stable and improved with persistence of right third nerve palsy, but otherwise neurologically intact. discharge medications: the patient was instructed to resume all of her preadmission antihypertensives as well as her preadmission premarin. she was also given a prescription for tylenol with codeine for relief of any severe headache and instructed to use plain tylenol for relief of any mild headache. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Ventricular shunt to extracranial site NEC Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Unspecified essential hypertension Subarachnoid hemorrhage Cerebral aneurysm, nonruptured Third or oculomotor nerve palsy, partial

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: excertional chest pain major surgical or invasive procedure: cabgx2(lima->lad, svg->om) lymph node biopsy of lul history of present illness: mr. is a 48 y/o spanish speaking male with a h/o of htn, dm2, hyperlipidemia, tobacco abuse, cad, recently diagnosed lung cancer who presented with chest pain over the last several weeks, described as pressure with radiation to both arms and associated with sob, associated wqith excertion but also occuring at rest. it is not associated with diaphoresis, nausea, or vomiting. last chest pain was this morning. currently he is chest pain free. he underwent ett on day of admission during which he developed sscp and dyspnea after 2.5 min which was and progressed to and then resolved with oxygen after 6 minutes. rhythm remained sinus without ectopy. 0.5mm downsloping st depressions were noted on lead ii, avf at 5.5 minutes exercise that resaolved 2 min into recovery stage. hemodyanmic response to limited exercise was appropriate. nuclear report showed moderate to severe reversible perfusion defects in the septum and anterior wall extending to the apex with associated hypokinesis consistent with a proximal lad lesion, lvef 45%. he had a cardiac cath at in which showed 1 vessel cad with a distal lm stenosis of 30%, lad 50% proximal disease, lcx 40% proximal disease. rca was small, non-dominant, and without lesions. lvedp measured at 25 mmhg, ef 54%. after stress results patient underwent cath which showed 2 vessel disease with 60-70% lm disease, 70% plad, and 70% plcx. he had no intervention. past medical history: hypertension diabetes hyperlipidemia cad non-small-cell lung ca, diagnosed in past 1-2 weeks; t3 n2 disease making him stage iiia lung cancer. low back pain, multiple herniated disks social history: from prior note. lives in with his wife. three children. prior tobacco abuse of ppd x 34 years; currently smoking one to pack cigarettes/day. originally from , moved to us in . previously worked at a paper recycling factory but stopped approximately 10 years ago after a work related injury. denies etoh and recreational drug use. family history: not elicited physical exam: lying in bed, comfortable but tearfull t 98.5 bp 146/93 hr 96 rr 20 sat 98% on ra heent: sclera anicteric, mm moist neck: good carotid pulses, no bruits chest: lungs clear heart: rrr. no m/g/r. abd: +bs, soft, nt, nd ext: warm, well perfused, equal femoral pulses without bruits, 2+ popliteal pulses, 1+ dp pulses pertinent results: 05:26pm glucose-133* urea n-9 creat-0.7 sodium-138 potassium-3.1* chloride-101 total co2-27 anion gap-13 05:26pm alt(sgpt)-19 ast(sgot)-17 amylase-34 tot bili-0.3 05:26pm albumin-4.1 05:26pm %hba1c-6.9* -done -done 05:26pm wbc-11.4* rbc-4.57* hgb-13.9* hct-38.6* mcv-85 mch-30.3 mchc-35.9* rdw-14.8 05:26pm pt-12.4 ptt-23.5 inr(pt)-1.0 05:26pm plt count-333 04:45am blood wbc-7.7 rbc-3.41* hgb-10.1* hct-29.1* mcv-85 mch-29.5 mchc-34.6 rdw-14.9 plt ct-367# 04:45am blood plt ct-367# 04:45am blood glucose-117* urean-10 creat-0.7 na-141 k-4.1 cl-102 hco3-25 angap-18 cardiac catheterization 1. two vessel coronary artery disease. 2. significant left main stenosis. exercising mibi moderate to severe reversible perfusion defects in the septum and anterior wall extending to the apex with associated hypokinesis consistent with a proximal lad lesion. left ventricular cavity size is slightly larger on exercise images consistent with transient ischemic dilatation. head mri nearly uninterpretable study due to gross patient motion. possible left frontal developmental venous anomaly. perhaps the patient would be better able to tolerate a ct scan of the brain with resultant less image degradation due to motion artifacts. echo he left atrium is normal in size. no mass/thrombus is seen in the left atrium or left atrial appendage and the right atrium or the right atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction. overall left ventricular systolic function is mildly depressed. resting regional wall motion abnormalities include mild hypokinesis in the apical anteroseptal and anterior walls. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. head ct no evidence of intracranial hemorrhage or acute territorial infarction. cxr left apical lung mass and pneumothorax are relatively unchanged when compared to . patient is again noted to be status post cabg. bibasilar atelectasis is slightly worse on the left when compared to the previous study. shift of the trachea from the midline to the right is unchanged from the previous exam. mediastinal lymph node biopsy i. lymph node, mediastinal level five (a): mediational poorly differentiated carcinoma with squamous features, present within one lymph node (+). ii. lymph node, mediastinal level six (b): one lymph node, no malignancy identified (0/1). brief hospital course: mr. was admitted to the on following an exercise tolerance test for a cardiac catheterization. this revealed a 70% stenosed left main, a 70% stenosed left anterior descending artery and a 70% stenosed left circumflex artery. heparin was started for anticoagulation. given the severity of his disease, the cardiac surgical service was consulted. mr. was worked-up in the usual preoperative manner. given his history of lung cancer, the thoracic surgery service was consulted for a mediastinal lymph node biopsy at the time of his surgery. a head mri was performed to rule out metastatic disease which was not interpretable due to motion artifact. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to two vessels as well as a mediastinal lymph node dissection. postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. on postoperative day one, mr. and was extubated. beta blockade and aspirin were resumed. as he was experiencing significant pain, the pain service was consulted who started a dilaudid pca pump. he was then transferred to the cardiac surgical intensive care unit for further recovery. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. on , mr. became somewhat agitated and anxious. clonopin was given with good effect and a psychiatry consult was obtained. haldol was recommended as needed and a head ct was obtained. this revealed no evidence of intracranial hemorrhage or acute territorial infarction. his narcotics were discontinued with subsequent stabilization of his delirium. vancomycin was started for mild sternal serous drainage. the pathology results of mr. mediastinal lymph node biopsy revealed mediational poorly differentiated carcinoma with squamous features, present within one lymph node (+). mr. continued to make steady progress and was discharged home on postoperative day seven. he will follow-up with dr. , hiss cardiologist, dr. of the thoracic surgery service and his primary care physician as an outpatient. medications on admission: allergies: nkda meds: motrin 800 mg po tid atenolol 50 mg po daily hctz 25 mg po daily asa 81 mg po daily gemfibrozil 600 mg po bid elavil 50 mg po daily actos 15 mg po daily zantac 150 mg po bid albuterol 2 puffs fioricet prn flexeril 10 mg po prn percocet 1-2 tabs q8h prn discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. disp:*14 tablet(s)* refills:*0* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. pioglitazone 15 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. hydromorphone 2 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*50 tablet(s)* refills:*0* 7. lopressor 50 mg tablet sig: 1.5 tablets po three times a day. disp:*135 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: coronary artery disease discharge condition: good discharge instructions: follow medications on discharge instructions. you may not lift more than 10 lbs. for 3 months. you may not drive for 4 weeks. you should shower daily, let water flow over wounds, pat dry with a towel. do not use powders, lotions, or creams on wounds. call our office for sternal drainage, temp>101 followup instructions: follow up with dr. in four weeks follow up with dr. for tues. , follow up with dr. for 1-2 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Incision of mediastinum Transfusion of packed cells Simple excision of other lymphatic structure Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Other and unspecified angina pectoris Malignant neoplasm of upper lobe, bronchus or lung Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Delirium due to conditions classified elsewhere Displacement of lumbar intervertebral disc without myelopathy

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 48m left upper lobe lung nodule stage iiia non small cell lung cancer, s/p chemo/radiation therapy major surgical or invasive procedure: bronchoscopy, video assisted thoracoscopy left upper lobectomy c/b left pulmonary artery laceration converted to anterior thoracotomy, 1l ebl, ekg changes. history of present illness: 49-year-old gentleman who was found to have a left upper lobe non-small cell lung cancer and a positive level 5 lymph node. for this, he underwent induction chemoradiotherapy and his re-staging ct scans showed an improvement in the size of the primary mass and the nodal metastases. past medical history: hypertension, diabetes mellitus 2, hyperlipidemia, coronary artery disease s/p cabg , stage iiia non small-cell lung ca left upper lobe, low back pain, mult. herniated disks s/p chemotherapy and radiation therapy social history: from prior note. lives in with his wife. three children. prior tobacco abuse of ppd x 34 years; currently smoking one to pack cigarettes/day. originally from , moved to us in . previously worked at a paper recycling factory but stopped approximately 10 years ago after a work related injury. denies etoh and recreational drug use. family history: not elicited pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 12:46am 5.3 3.03* 9.8* 27.6* 91 32.5* 35.7* 20.2* 153 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 12:46am 153 12:46am 12.6 24.6 1.1 chemistry renal & glucose glucose urean creat na k cl hco3 angap 12:46am 115* 11 0.7 137 4.1 98 33* 10 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 12:46am 47* 78* 1066* 56 1.9* 0.9* 1.0 cpk isoenzymes ck-mb mb indx ctropnt 12:46am 14* 1.3 0.73*1 1 ctropnt > 0.10 ng/ml suggests acute mi chemistry totprot albumin globuln calcium phos mg uricacd iron 12:46am 9.4 2.9 1.8 brief hospital course: 48m lul stage iiia nsclc, s/p chemo/xrt admitted same day on for bronchoscopy, mediastinoscopy, lul lobectomy by vats converted to anterior thoracotomy due to tear in superior branch of pulmonary artery. patient transfused w/ 2uprbc intra-op, stabilized, tolerated procedure, transferred to pacu extubated, ct to suction, on neo gtt. post-op ekg> changes>nstemi. cpk/mb--1066/14, t=.73. started on b- blocker post-op. pod#1<>- bronchoscopy for moderate secretions pod#3 <>- rhonchi, minimal ct output (50/10/5), ct placed to waterseal, and left ct(#2) d/c in afternoon. cxry w/ small hydropneumothorax. pt transferred to floor. loperssor increased 75mg , diuresed w/ lasix 20 mg iv. clear liqs started. pod# decreased drainage from blakes -blakes d/c'd. cxr stable. po pain med. pod#6- patient stable, tolerating po pain rx, moved bowels prior to d/c. pt discharged in stable condition late in afternoon in company of son to home. discharge instructions given and reviewed w/ patient and by rn. medications on admission: nexium 40', atenolol 100", ecasa 81', actos 30', gemfibrozil 600', cxycontin 20'';perc 2q4h discharge medications: 1. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. gemfibrozil 600 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day): do not take your atenolol while taking this medication. disp:*180 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 7. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 8. oxycodone 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q8h (every 8 hours) as needed for pain. disp:*60 tablet sustained release 12hr(s)* refills:*0* 9. oxycodone 5 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for breakthrough pain. disp:*60 tablet(s)* refills:*0* 10. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for increaased/thickened sputum. 11. actos 30 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: pmh: hypertension, diabetes mellitus 2, hyperlipidemia, coronary artery disease s/p cabg , stage iiia non small-cell lung ca left upper lobe, low back pain, mult. herniated disks s/p chemotherapy and radiation therapy discharge condition: good discharge instructions: call dr./thoracic surgery office for: fever, shortness of breath, chest pain, excessive foul smelling drainage from incision sites. take previous medications as stated on discharge instructions. take new medications as directed and as needed. you may shower on friday. remove ct dressing after showering and change daily as needed w/ bandaid or guaze. no tub baths or swimming for 3-4 weeks. followup instructions: call dr./thoracic surgery office for a follow-up appointment. Procedure: Fiber-optic bronchoscopy Fiber-optic bronchoscopy Other intubation of respiratory tract Biopsy of lymphatic structure Suture of artery Mediastinoscopy Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Accidental puncture or laceration during a procedure, not elsewhere classified Pulmonary collapse Other and unspecified hyperlipidemia Malignant neoplasm of upper lobe, bronchus or lung

discharge medications: atenolol ............. 0.25% 1 drop o.s. b.i.d., lorazepam 2 mg q.4 hours p.r.n., percocet 1 tab p.o. p.r.n. q.4 hours pain, colace 100 mg p.o. b.i.d., reglan 5 mg iv q.6 hours p.r.n., plavix 75 mg p.o. q.d., aspirin 325 mg p.o. q.d., zantac 150 mg p.o. q.d., albuterol nebs 1 q.4 hours p.r.n., zolpidem 5 mg q.h.s. p.o. p.r.n., vancomycin 750 mg iv on , day of discharge, then discontinue, lopressor 25 mg p.o. b.i.d., heparin 5000 u subcue b.i.d., captopril 6.25 mg p.o. t.i.d., nph 15 u q.a.m. and q.p.m., regular insulin sliding scale as noted on the discharge form protocol, robitussin 5 cc q.6 hours p.r.n. discharge instructions: intensive chest physical therapy and suctioning, vent wean, and tracheostomy trials as specified. follow-up blood sugars q.4 hours with insulin sliding scale adjustments. specific instructions were given also not to pull the tracheostomy without either ent or surgery evaluation prior to doing so. follow-up: the patient was instructed to follow-up with the attending surgeon in the office, dr. in approximately one month after discharge. disposition: the patient was discharged to rehabilitation on . , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Hemodialysis Temporary tracheostomy Implant of pulsation balloon Percutaneous aspiration of gallbladder Other cholangiogram Injection or infusion of nesiritide Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Acute kidney failure, unspecified Acute myocardial infarction of other anterior wall, initial episode of care Cardiogenic shock Infection and inflammatory reaction due to other vascular device, implant, and graft Acute diastolic heart failure Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled

history of present illness: this a 59 year old female with diabetes mellitus and known coronary artery disease who was cathed in at . cath at that time showed severe three vessel coronary artery disease, but patient was elected to be treated medically due to poor targets. since her cardiac catheterization she had two episodes of heart failure and presented to emergency department on , with an acute mi. cardiac catheterization was performed on , the day of admission, which revealed left main coronary artery disease with 30% stenosis, diffuse disease of the left anterior descending with 80% midocclusion. left circumflex was occluded. mid-right coronary artery with 40% stenosis and diffuse disease in the posterior descending artery. an intra-aortic balloon pump was placed at that time. patient was referred to the cardiac surgery service for coronary artery bypass grafting. patient underwent coronary artery bypass grafting times three on . saphenous vein graft to distal left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to right posterolateral. total cardiopulmonary bypass time was 113 minutes. total clamp time was 59 minutes. patient was transferred in normal sinus rhythm at 82 beats per minute, hemodynamically stable, to the cardiac surgery recovery unit on 0.3 mcg per kg per minute of milrinone, 1.2 mcg per kg per minute of neo-synephrine, 10 mcg per kg per minute of propofol and an insulin drip at 2 units per hour. past medical history: significant for coronary artery disease; type 1 diabetes mellitus complicated by diabetic retinopathy, diabetic nephropathy and diabetic neuropathy; chronic renal insufficiency with baseline creatinine of 2.0; peripheral vascular disease status post right fem- surgery. medications on admission: humulin 25/10, lasix 40 mg q.d., atenolol 100 mg q.d., aspirin, imdur 30 mg p.o. q.d., ambien 10 mg p.o. q.d., lipitor 10 mg p.o. q.d., accupril 10 mg p.o. q.d. allergies: no known drug allergies. social history: the patient does not have a history of tobacco use nor does patient have a history of alcohol use or abuse. laboratory data: white count 11.6, hematocrit 27.8, platelet count 106. sodium 139, potassium 5.2, bun 46, creatinine 1.2, glucose 201. magnesium 2.7. hospital course: the patient was extubated on , which was postoperative day one. on postoperative day one patient had a low grade temperature of 100.8 with t-max of 101.7, with an intra-aortic balloon pump still at 1:1, on neo-synephrine at 3.5, off milrinone. physical exam benign. plan was to wean neo-synephrine and wean the balloon pump. on postoperative day two patient still with low grade temperature of 100.2 and t-max of 101.7. still on neo-synephrine at 0.9. intra-aortic balloon pump at 1:2. white count 9.8, hematocrit 24.5, platelet count 80. sodium 139, potassium 4.7, bun 47, creatinine 1.4, glucose 130. physical exam still remained benign. patient was awake and alert with good cardiac index with the intra-aortic balloon pump at 1:2. plan was to change the balloon pump to 1:3 in the morning and to possibly discontinue the intra-aortic balloon pump and subsequently wean neo-synephrine. plan was also to transfuse one unit for hematocrit of 24.5. on postoperative day three patient was afebrile, however, t-max of 101.3 which was at 6:00 o'clock p.m. patient was still on milrinone and neo-synephrine with an index of 2.05, making good urine. chest tube was putting out minimal amount. white count 14.1, hematocrit 28, platelet count 79. sodium 137, potassium 4.5, bun 53, creatinine 1.7. physical exam remained benign. over the last 24 hours patient was in and out of a-fib and a-flutter throughout the night for which she was placed on amiodarone. currently in atrial fibrillation at 77 beats per minute. cardiology came by to see patient for atrial fibrillation. they recommended to possibly taper off milrinone which may be exacerbating the situation. they also recommended oral amiodarone versus iv amiodarone and to transfuse patient for low hematocrit. on postoperative day four patient now in normal sinus rhythm, however, with decreased urine output, on dobutamine at 4.5, neo-synephrine at 1.4, amiodarone and insulin. afebrile. normal sinus rhythm at 88 beats per minute. otherwise vital signs stable. white count 14.2, hematocrit 32, platelet count 117. creatinine up from 1.7 to 1.9 with bun of 55. on physical exam patient had decreased breath sounds at both bases with 1+ edema of the lower extremities. patient was alert with no deficits. on postoperative day five patient still on dobutamine at 2.5, insulin, milrinone at 0.5, neo-synephrine at 0.25. twenty four events included an episode of pulmonary edema. patient afebrile in normal sinus rhythm at 99 beats per minute. vital signs otherwise stable. white count 14.4, hematocrit 28.1, platelet count 125. creatinine increasing from 1.9 to 2.1. on physical exam lungs had coarse breath sounds bilaterally with bibasilar crackles. patient with adequate urine output after administering lasix three times. patient was also noted to be confused, requiring frequent reorientation. heart failure team came by to see patient at which time they recommended that if blood pressure decreases or mean arterial pressure decreases to less than 60, they would add vasopressin. they also recommended zaroxolyn 2.5 mg p.o. times one, to start a lasix drip and can increase up to 20 mg drip per hour. if lasix does not work, to change to bumex 2 mg iv b.i.d., increasing up to 4 mg iv b.i.d. to also increase milrinone to 0.6 if mao2 is in the 50s. renal came by and saw patient on at which time they recommended sending urine sodium, creatinine, urea and protein to assess pre-renal and atn parameters. they also recommended a renal ultrasound to determine the etiology of the underlying renal disease. they also planned to initiate cvvhd given the significant chf necessitating 100% nonrebreather with poor response to diuretics. they also said that we could discontinue the lasix drip. on postoperative day six patient afebrile in normal sinus rhythm, alert and awake with increasing white count from 14.4 to 19.4, hematocrit stable at 31. creatinine was 2.3. physical exam unchanged aside from 2+ pitting edema in all extremities. patient now on cvvh for fluid overload and renal insufficiency. on milrinone, amiodarone with cardiac index of 2.74, now making urine so lasix was discontinued. patient was reintubated on at the request of the sscu staff for respiratory failure. on postoperative day seven patient still afebrile in normal sinus rhythm at 94, intubated on simv and pressure support 500 and 12 breathing 5 above the vent 80% fio2 with adequate urine output. white count coming down from 19.4 to 14.5 with stable hematocrit. creatinine was 2.2. extremities will less edema. otherwise exam unchanged. plan is to continue with cvvh and to continue amiodarone and milrinone. renal came by and saw patient on at which time they recommended to continue patient on milrinone to optimize cardiac function. to continue cvvh. they also recommended to recheck sodium in the afternoon for patient's hyponatremia. if still low, to consider changing replacement fluids to normal saline. to continue anticoagulation with heparin 500 units per hour with a goal ptt of 50 to 80. on postoperative day eight patient with low grade temperature of 99.9, still intubated with rising white count to 17.5, stable hematocrit. creatinine was 1.8. on physical exam patient was intubated and sedated with coarse upper airway noise and decreased edema in the lower extremities. plan was to begin weaning milrinone. to continue cvvh. on postoperative day nine 24 hour events included cvvh being clotted. patient afebrile with cardiac index of 2.2, in sinus rhythm at 78, good urine output, still intubated and sedated with minimal lower extremity edema. plan was to try to attempt to wake up patient and to attempt extubation. to continue milrinone, neo-synephrine and pitressin. the heart failure team came by again at which time they recommended to continue present pressor support and to check lactate and to continue cvvhd. renal came by and saw patient and restarted cvvh which was clotted overnight. restarted it at 9:00 a.m. on patient underwent placement of a right subclavian cordis and swan-ganz. on postoperative day 10 patient on vancomycin and levo as well as vasopressin, neo-synephrine, milrinone and insulin. afebrile, in sinus rhythm at 65. still intubated and sedated. on physical exam the left foot appeared more mottled than normal and cool with a faintly dopplerable dp pulse and palpable pulse on the right dp. plan was to attempt to wean pitressin and try to extubate. continue cvvh. to continue levo for patient's upper respiratory tract infection, as patient grew out neisseria in sputum, and vancomycin for an infected right ij site. extubation was attempted on the 15th, however, anesthesia was called to reintubate patient for respiratory failure after extubation trial. on postoperative day 11 patient still on vanco and levo as well as vasopressin, milrinone, insulin, neo-synephrine. afebrile, in normal sinus rhythm at 82, intubated, on cvvhd with creatinine of 1.5 and white count of 14.6 and stable hematocrit of 27.5. on physical exam the neck was very erythematous with purulent right ij site. on postoperative day 12 still on the same drips. twenty four events included increasing cvvh to 100 per hour. patient was afebrile with stable output and index. still intubated with decreased white blood cell count of 11.7, stable hematocrit and creatinine of 1.5. on physical exam left toe was mottled and cold, otherwise unchanged. on postoperative day 13, 24 hour events included cvvh being clotted overnight. patient still on the same drips with an index of 2.0 and cvp of 14. still intubated. physical exam remained unchanged. white count down to 10.7, hematocrit stable with creatinine of 1.5. plan was to continue to watch hematocrit. patient was transfused one unit of packed red blood cells bringing hematocrit up to 27. plan was also to put patient on nepro tube feeds. renal evaluated patient on at which time they recommended sending a urinalysis for patient's hematuria and for patient's metabolic acidosis which was improved after antibiotics. they wanted us to follow patient's abgs and to continue to transfuse red blood cells, increase intravascular volume with a goal of 1 to 2 liters negative a day. that same day a left femoral central venous quinton catheter was placed with cvvh flow now being excellent through this new catheter since there was a clot in the ij catheter. renal recommended keeping ptt at 60 to 80, however, closer to 80 to avoid clotting again. on postoperative day 14 patient on day six of vanco and levo. still on milrinone, neo-synephrine, pitressin, propofol, still intubated and sedated with a rising white count of 13.3, stable hematocrit of 29.9, creatinine of 1.4. physical exam remained unchanged. plan was to continue tube feeds. patient was v-paced overnight due to slow junctional rhythm. possible discontinuation of patient's amiodarone. continue vanco and levo for enterobacter and e.coli which grew out of the cultures. to continue to watch patient's hematocrit. on postoperative day 15 patient in normal sinus rhythm, afebrile, still intubated and sedated with stable white count and hematocrit. slightly hyponatremic at 131 with bun of 27, creatinine of 1.3. physical exam unchanged. plan was to continue levofloxacin for the uri and the enterobacter in blood and sputum. renal came by and saw patient at which time they noted that patient responded to 40 mg iv of lasix with a decreased neo-synephrine drip today. they recommended adding lasix iv q.d. and b.i.d. and to decrease the amount removed by cvvh to transition her off cvvh. they recommended increasing intravascular volume and keeping hematocrit greater than 30. on postoperative day 16 patient with low grade temperature of 99.5, still in sinus rhythm at 78. stable white count of 12.1 with hematocrit of 27. bun and creatinine stable. physical exam unchanged. on milrinone and pitressin with good cardiac index. plan was to have a trial off cvvh today and to increase lasix to increase patient's urine output. plan was also to transfuse one unit of packed red blood cells and to continue levofloxacin. renal again saw patient on at which time they recommended to discontinue heparin and to discontinue cvvh machine. to administer patient 40 to 60 mg iv of lasix b.i.d. to keep patient even and to continue with blood transfusion. on postoperative day 17 patient with low grade temperature of 100.6, in sinus rhythm at 79. still intubated, opening eyes. physical exam remained unchanged. white count of 13.8, hematocrit stable at 30.5. bun 32, creatinine 1.4. still on milrinone, pitressin and propofol. plan was to continue tube feeds and erythromycin. to continue with lasix. patient with good urine output without cvvh. to continue levo for enterobacter and e.coli. on postoperative day 18 patient still with low grade temperature of 100.4, in sinus rhythm at 95, index of 3.29. white count increasing to 15.2 with stable hematocrit of 31.8. bun 43, creatinine 1.6. on milrinone and propofol now. physical exam remained unchanged. patient still intubated and following commands. plan was to possibly wean milrinone and check the mixed venous. continue lasix. patient still with good urine output. plan was to also pull the quinton catheter because of patient's rising white count and low grade temperature. on postoperative day 19, day 11 of levofloxacin, with a low grade temperature of 100.8 and t-max of 102, in sinus rhythm at 89, now just on insulin and propofol with an index of 2.81. still intubated, following commands, in no apparent distress with a rising white count of 19.7 and stable hematocrit of 32.4. physical exam remained unchanged. plan was to check blood cultures, urine cultures, stool cultures, chest x-ray and to pull the swan and the left subclavian line due to patient's spike in temperature. on postoperative day 20, day 12 of levofloxacin, with low grade temperature of 99.7, t-max of 101.3, in sinus rhythm at 99 with rising white count now at 24.4, stable hematocrit 32.4 with stable platelet count of 376. bun 51, rising creatinine of 1.8. patient still intubated, in no apparent distress. physical exam unchanged. gram negative rods were found in patient's sputum. chest x-ray was going to be checked. patient still with good urine output on lasix drip. sputum with gram negative rods on levofloxacin. plan is to add vancomycin. other cultures were pending. on postoperative day 21, day 13 of levofloxacin and day two of restarted vancomycin, with t-max of 102, t-current of 99.3, in sinus rhythm at 84. still intubated, however, awake and alert. physical exam remained unchanged. white count down to 17.7, hematocrit stable. bun 68, creatinine rising at 2.2. plan was to try to extubate patient and to continue promote tube feeds. patient had adequate urine output. plan was to continue to check creatinine. id recommended adding fluconazole. thoracic surgery came by to consult patient to evaluate the airway. they stated that patient had no symptomatic edema and they stated that we would perform a t-piece trial to rest patient overnight with the possibility of extubating patient in the morning. the following morning there was an excellent cuff fit. patient went 1 1/2 hours on t-piece trial yesterday and extubated without problems on . on postoperative day 22, day 14 of levofloxacin, day three of vancomycin, day two of fluconazole, patient with low grade temperature of 99.5, currently afebrile, in sinus rhythm at 75. awake and alert, answering questions. white count 15.1, stable hematocrit. bun was 79, creatinine 2.1. physical exam remained unchanged. on postoperative day 23 patient afebrile, in sinus rhythm at 87. white count down to 13.4, hematocrit stable. bun 72, creatinine 1.7. plan was to start patient on p.o. diet and to possibly discontinue lasix and to continue current antibiotic regimen. on postoperative day 24, day 16 of levofloxacin, day five of vancomycin, day four of fluconazole, in normal sinus rhythm at 82, afebrile. white count 12.8, hematocrit 27.7. bun 76, creatinine 1.7. physical exam remained unchanged. plan was to have a jocelin consult for patient's diabetes management. jocelin came by to see patient at which time they recommended patient to follow up at jocelin for diabetic care. jocelin had an extensive discussion with patient's husband and patient. they arrived at the decision to change to glargine and humalog. on postoperative day 25 patient now on day six of vancomycin, in sinus rhythm at 93, afebrile with white count of 12.6, stable hematocrit. bun 69, creatinine 1.8. resting comfortably. physical exam benign. plan was to continue vancomycin for two weeks. jocelin came by to see patient again at which time they recommended continuing iv insulin and adjust the rate from now until pre-supper and then before supper to check blood glucose and to give the sliding scale of humalog. to increase lantus to 20 units q.h.s. to use the new humalog scale. on postoperative day 26 patient on vancomycin. hemodynamically stable. physical exam unchanged. patient now on fluconazole three out of five days. on postoperative day 27 patient on day seven of 14 of vancomycin and day four of five of fluconazole. patient afebrile. sinus tach at 101. physical exam remained benign with stable hematocrit and stable white count. jocelin came by and saw patient again on at which time they recommended to continue lantus at 25 units q.h.s. to check 3:00 o'clock finger stick blood glucose. to be on guard for lows. to increase pre-meal humalog sliding scale and to watch bun and creatinine closely with start of ace inhibitor post mi. hem/onc came by and saw patient on at which time they felt that patient's condition was most consistent with reactive thrombocytosis which may also be due to iron deficiency, although the rather abrupt onset of the rise in the platelet count was not consistent with that. they thought that since these are normal platelets, the risk of thrombosis is very low and is not a concern until the platelet count exceeds 1,000,000. they also felt that one issue is that in those patients with platelet counts this high, which is over 400,000, serum potassium level may be falsely elevated. therefore if serum potassium came back elevated, they would recommend that this be followed up with plasma potassium before treating. they said they would continue to follow patient during her hospitalization. on postoperative day 28, on day eight of 14 of vancomycin and day five of five of fluconazole, 24 events included atrial fibrillation versus atrial tachycardia overnight. started on lopressor. with a low grade temperature of 100. physical exam remained unchanged. white count 12.7, stable hematocrit. bun 40, creatinine 1.3. plan was to continue lopressor and to consider restarting amiodarone. to continue antibiotics. on postoperative day 29, , anesthesia was called to see patient to reintubate patient for respiratory distress and confusion. patient was reintubated without complications. pulmonary came by to see patient for the reintubation at which time they recommended to continue pip, tazo and vanco, to obtain sputum for gram stain and culture, to obtain chest ct angio as planned. to cycle cardiac enzymes and repeat ekg. to repeat a surface echo and when extubated to obtain a speech and swallow evaluation for aspiration risk. ct angio of the chest was reviewed. there was no clear consolidation. there was a large pleural effusion, right greater than left and a tiny pe noted. the assessment leaned more toward decompensation and chf. additional recommendations by pulmonary included treating for chf and checking daily weights. a therapeutic thoracentesis and to send the fluid for ph, ldh, protein, cell count with diff and culture. on postoperative day 30, 24 hour events included transfusion of two units of packed red blood cells. ct of the chest and abdomen. intubation for chf. panculturing. pulmonary and general surgery consults. patient afebrile, in normal sinus rhythm at 70. still intubated, sedated, but arousable. physical exam remained unchanged. white count 17.7, stable hematocrit 34.1. plan was to drain the pleural effusion today and to try to work toward extubating patient. gi to do percutaneous cholecystostomy today and to start tube feeds once stable. to follow up bun and creatinine after dye load. to continue vanco and zosyn. general surgery came by to see patient on at which time they stated that they could not rule out calculus cholecystitis. they recommended to drain the gallbladder with a catheter through the liver. a cholecystostomy tube 8 french was inserted under ultrasound guidance on and approximately 60 cc of thin bile was aspirated. it was sent for culture and sensitivity. the plan was to leave this in for six weeks even if it stopped draining. pulmonary came by to see patient again on at which time they recommended to decrease fio2 to 40%. to perform thoracentesis of the right sided effusion. to send pleural fluid for ldh, protein, cell count and culture. to check troponin and ck. on postoperative day 31, day 11 of 14 of vancomycin and day three of zosyn, 24 hour events included percutaneous cholecystostomy, picc being removed, bilateral pleural effusion drainage, right draining 600, left draining 350. propofol drip. white count down to 15.7, stable hematocrit. bun 30, creatinine 1.5. physical exam remained unchanged. on postoperative day 32 physical exam remained unchanged. white count down to 11.5, hematocrit stable. creatinine up to 1.8. plan was to restart the standing lasix, continue lopressor and to possibly extubate patient today with the possibility of trach placement. on postoperative day 33, day 13 of 14 on vancomycin, day four of zosyn, patient with low grade temperature of 99.6, still intubated, however, comfortable. physical exam unchanged. white count and platelet count and hematocrit unchanged. bun 42, creatinine 1.9. plan was to possibly perform a trach tomorrow and to possibly discontinue the chest tubes. due to the rising white blood cell count and low grade temperature, to possibly panculture patient again. on postoperative day 34, day 14 of 19 of vancomycin and day six of zosyn with a low grade temperature of 100.4. plan was to trach patient today. on patient underwent percutaneous tracheostomy without complications. on postoperative day 36 patient's condition remained unchanged. nph of 10 b.i.d. was started. stable hematocrit and white count. bun 43, creatinine 1.5. speech and swallow came by and saw patient on the 11th at which time they stated that patient is not a good candidate for a video swallow study to rule out aspiration because patient presents without overt signs and symptoms of aspiration at the bedside. recommendations were to limit the wear schedule of the passy-muir valve to every four hours for no more than 15 minutes trial. monitor o2 sats and patient's respirations. maintain tube feeds. remain npo. obtain a video swallow study tomorrow to rule out aspiration. the remainder of the chart will be dictated upon discharge of the patient. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Hemodialysis Temporary tracheostomy Implant of pulsation balloon Percutaneous aspiration of gallbladder Other cholangiogram Injection or infusion of nesiritide Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Acute kidney failure, unspecified Acute myocardial infarction of other anterior wall, initial episode of care Cardiogenic shock Infection and inflammatory reaction due to other vascular device, implant, and graft Acute diastolic heart failure Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled

discharge status: the patient was to be discharged back to the community hospital. the attending, dr. , has already talked to her primary care physician who has accepted her back to the community hospital. discharge instructions/followup: the patient was to be seen by her primary care physician in the outside community hospital. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other electric countershock of heart Arteriography of femoral and other lower extremity arteries Thoracentesis Replacement of tracheostomy tube Injection or infusion of nesiritide Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Methicillin susceptible pneumonia due to Staphylococcus aureus Atherosclerosis of native arteries of the extremities with gangrene Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Ulcer of other part of lower limb Infection of tracheostomy

history of present illness: the patient was initially seen in the emergency room. she had recently been discharged from rehab after a long postoperative course after undergoing coronary artery bypass graft requiring a tracheostomy. she now presents with a left foot that is cold and painful over the last 24 hours. she is now admitted for further evaluation and treatment. past medical history: coronary artery disease, type 1 diabetes with triopathy, chronic renal insufficiency baseline creatinine 2.0, peripheral vascular disease. past surgical history: coronary artery bypass graft surgery with saphenous vein graft to the right posterolateral coronary, the obtuse marginal one in the left anterior descending . percutaneous tracheostomy with tube placement and flexible sigmoidoscopy with aspiration of tracheal broncho tree on . cardiac catheterization on demonstrated right coronary artery dominant system with severe three vessel disease, left main trunk had 30% stenosis at the ostium. the left anterior descending coronary artery had diffuse disease with a mid 80% stenosis. the diagonal one was occluded. the left circumflex main was occluded. the right coronary artery had a mid 40% lesion with diffuse disease into the posterior descending coronary artery with an 89% stenosis of right coronary artery and distal posterior descending coronary artery. resting measurements revealed pulmonary wedge pressure of 20, cardiac index of 1.7. an attempt was made to try to stent the left circumflex origin, but this was aborted. echocardiogram done on demonstrated left ventricular ejection fraction of 30% with severe inferior posterior hypokinesis and akinesis. he is status post right femoral popliteal bypass graft. allergies: no known drug allergies. medications: percocet tablets, colace 100 mg b.i.d., plavix 75 mg q day, reglan 5 mg a.c. and h.s., aspirin 325 mg q day, vasotec dose not indicated, lopressor 25 mg b.i.d., nph insulin 38 units q.a.m. and 28 units at h.s., lasix 40 mg b.i.d., procrit 20,000 units q friday. physical examination: vital signs were stable. temperature max was 98.7, 123/50, 93, 24, and 90% with a face mask. chest examination lungs showed coarse breath sounds bilaterally. the heart was a regular rate and rhythm. the abdominal examination was soft, nondistended, nontender. cholecystostomy tube was in place. rectal examination was guaiac negative. no masses. peripheral vascular disease pulses femorals palpable bilaterally. the left popliteal was biphasic signal. the right popliteal was absent. the dorsalis pedis pulse on the right was biphasic. the posterior tibial pulse on the right was biphasic signals only. the dorsalis pedis pulse on the right was palpable and absent posterior tibial pulse. the right graft was palpable. the forefoot was ischemic and cool to touch with diminished sensation. laboratories in the emergency room: white blood cell count of 4.3, hematocrit of 30.6, bun 66, creatinine 1.6, k 5.0, pt/inr were normal. electrocardiogram was without ischemic changes. hospital course: the patient was seen by the vascular service. dr. followed the patient for cardiac care. was involved regarding diabetic management. initial arteriogram planed for was deferred secondary to the patient's elevated bun of 2.7. her lasix was held and serial creatinines were obtained. renal was consulted regarding her acute renal failure. recommendations they felt this was secondary to hypovolemia both to poor oral intake and diuretic use. intravenous fluids were instituted. her and ace inhibitors were held and diuretics were held and her beta blockers were held for a systolic blood pressure less then 100. because of the patient's renal status she underwent a bilateral mra run off. the abdominal mra showed a mild and distal abdominal aorta appears to be within normal limits. there is no significant stenosis. the proximal celiac trunk or the proximal superior mesenteric artery with a single right renal arteries bilaterally. on the right the run off showed good in flow without significant stenosis of the common iliac, external iliac, femorals, superficial femoral artery and popliteals. a three vessel run off was identified with poor quality proximal at and posterior tibial peroneal arteries. there were multiple foci of moderate stenosis identified in the proximal half of each of the three vessels. anterior tibial and posterior tibial occluded at the level of the mid calf and the peroneal occludes in the distal one third of the calf. bypass graft was identified extending to below the popliteal artery with a good anastomosis. there is good flow identified within the dorsalis pedis artery. the bypass graft was patent. on the left side there was no in flow disease. there is three vessel run off. the anterior tibial provides flow to the dorsalis pedis pulse. there are multiple areas of mild to moderate stenosis along the at length. the dorsalis pedis pulse is diseased, but of good caliber. posterior tibial occludes at the distal one third of the calf, collateral vessels are identified in the medial calf extending to the level of the ankle, which reconstitutes at the plantar arch. the peroneal occludes in the distal one third. with intravenous hydration and holding her diuretics and ace an abrs the creatinine showed a significant improvement and over the next 48 hours she returned to baseline. the patient developed a total white blood cell count of 32.3. the patient had blood urine sputum cultures obtained all which were negative. the chest x-ray showed bilateral lower lobe consolidation/collapse with worsening left sided pleural effusion. white blood cell count over the next several days improved after aggressive pulmonary care. her white blood cell count on was 17.9, hematocrit 30.9, platelets 392k, bun 90, creatinine 1.7, k 4.6. the patient underwent a left leg arteriogram on , which demonstrated patent bk popliteal, diseased at at the origin, tibial peroneal trunk was diseased. there was a patent at through the calf with diffuse disease distally. the posterior tibial and peroneal were occluded with reconstruction of the dorsalis pedis at the foot that is patent and two tarsal branches in the forefoot with incomplete arch. post angiogram the patient's renal function remained stable without an increase in her creatinine. it was determined that surgery would be deferred until the patient's nutritional renal status were more stabilized. she will be transferred to rehab for continued care and with follow up with dr. in two weeks. on discharge her white blood cell count was 21.3, hematocrit 30.9, platelets 430k, sodium 144, potassium 5.2, chloride 109, co2 23, bun 88, creatinine 1.8. discharge medications: insulin fixed doses, nph 34 units q.a.m. and 18 units at bedtime with a humalog sliding scale . for breakfast, lunch, dinner and at bedtime please see enclosed flow sheet. flagyl 500 mg t.i.d., heparin 5000 units subq b.i.d., dulcolax suppositories 10 mg prn, dulcolax tablets prn, trazodone 100 mg at h.s. prn, colace 100 mg b.i.d., guaifenesin 5 to 10 cc q 6 hours prn, tylenol 325 to 650 mg q 4 to 6 hours prn, timolol ophthalmic drop 0.25% one os b.i.d., alpidem 5 mg at h.s. prn, epogen 20,000 units q friday subq, metoprolol 25 mg b.i.d. hold for systolic blood pressure less then 100, heart rate less then 55, albuterol nebulizers q 4 to 6 hours prn, protonix 40 mg q day, and percocet tablets one to two q 4 hours prn for pain. dressings to the left foot is dry sterile dressing with a multipodus splint placed at all times. discharge diagnoses: 1. ischemic left foot secondary to tibial disease. 2. type 1 diabetes with triopathy. 3. status post tracheostomy, stable. 4. bilateral lower lobe opacities, stable. 5. hyperglycemia corrected. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other electric countershock of heart Arteriography of femoral and other lower extremity arteries Thoracentesis Replacement of tracheostomy tube Injection or infusion of nesiritide Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Methicillin susceptible pneumonia due to Staphylococcus aureus Atherosclerosis of native arteries of the extremities with gangrene Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Ulcer of other part of lower limb Infection of tracheostomy

history of present illness: the patient is a 60 y/o female with a history of coronary artery disease and peripheral vascular disease. she is s/p myocardial infarction and coronary artery bypass grafting in recent past which has been complicated by severe left forefoot ischemia and gangrene. procedure & detail: the patient has brought to the interventional suite placed in supine position after adequate sedation ____ anesthesia, per nursing she was prepped and draped in the normal sterile manner. retrograde right femoral access was obtained using a 19 gauge single wall puncture needle, 0.035 starter wire, and a 4 french sheath. the starter wire was easily advanced into the infrarenal aorta and this was followed with a 4 french omniflush catheter. using the omniflush catheter in conjunction with an angle glidewire, access to the left common iliac artery was obtained. the wire was then advanced down into the left common iliac artery, left external iliac artery, left common femoral artery and finally into the left superficial femoral artery and popliteal artery. this catheter was then changed over for a 4 french angled glide catheter which was placed at the level of the above knee popliteal artery. the wire was removed and limited arteriogram of the left lower extremity was obtained from the level of the knee down to the level of the foot. at this time, all catheters, wires and sheaths were removed and access site was sealed with direct pressure. the patient was taken to the postoperative anesthesia care unit in stable condition. dr. was (over) 3:36 pm uni-lat femoral clip # reason: please do a limited arteriogram of the left leg looking from contrast: optiray amt: 36 ______________________________________________________________________________ final report (cont) present for the entire procedure and fluoroscopy was utilized. angiographic findings. this is a limited arteriogram of the popliteal artery beginning just above the knee. this demonstrates that there is a patent popliteal artery from its mid portion to below the knee portion. there is mild disease at the origin of the anterior tibial and tibioperoneal trunk. however, the anterior tibial artery is patent as well as the entire tibioperoneal trunk and the origins of the peroneal and posterior tibial arteries. the peroneal and the posterior tibial arteries both occlude approximately 1/3rd of the way down the calf. the posterior tibial artery unreconstitutes in short segments. subsequently reoccludes. the anterior tibial artery is of adequate caliber and remains patent throughout the calf. there is, however, approximately a 3 cm segment of anterior tibial artery in the distal calf which is diffusely diseased but with multiple stenoses approximately 60-80% along that 3 cm length. there is also a focal stenosis at the level of the ankle which is approximately 60-80% as well. arteriogram of the foot demonstrates there is a patent dorsalis pedis artery that is patent with 2 tarsal branches which serves at the forefoot. there is ____ plate arch. there is a small segment of posterior tibial artery that reconstitutes but then there does not lead to a plantar artery, however, just leads to multiple collaterals. Procedure: Venous catheterization, not elsewhere classified Other electric countershock of heart Arteriography of femoral and other lower extremity arteries Thoracentesis Replacement of tracheostomy tube Injection or infusion of nesiritide Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Methicillin susceptible pneumonia due to Staphylococcus aureus Atherosclerosis of native arteries of the extremities with gangrene Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Ulcer of other part of lower limb Infection of tracheostomy

past medical history: 1. hypertension. 2. esophageal spasm. 3. elevated blood sugar. 4. hypothyroidism. medications on admission: 1. tricor 160 mg p.o. q.d. 2. omeprazole 20 mg p.o. q.d. 3. levoxyl 150 mcg p.o. q.d. 4. isosorbide 30 mg p.o. q.d. 5. nitroglycerin prn. 6. metamucil 6 q.d. 7. multivitamin. 8. ecotrin 325 mg p.o. q.d. 9. atenolol 25 mg p.o. q.d. allergies: he is allergic to clindamycin, he gets a rash. family history: his family history is unremarkable. social history: he lives with his wife. does not smoke cigarettes and has a drink about once a month. review of systems: review of systems is significant for left knee arthritis, esophageal spasm, and cardiac symptoms as above. physical exam: on physical exam, he is a well-developed elderly white male in no apparent distress. vital signs stable and afebrile. heent exam: normocephalic, atraumatic. extraocular movements are intact. oropharynx is benign. neck was supple, full range of motion, no lymphadenopathy or thyromegaly. carotids were 2+ and equal bilaterally without bruits. lungs are clear to auscultation and percussion. cardiovascular exam: regular rate and rhythm, normal s1, s2 with no murmurs, rubs, or gallops. abdomen was soft, nontender, was obese with positive bowel sounds, no masses or hepatosplenomegaly. extremities are without clubbing, cyanosis, or edema. neurologic examination was nonfocal. pulses were 2+ and equal bilaterally throughout with the exception of the dp, which was 1+ and equal bilaterally. on , he underwent a cabg x3 with a lima to the lad, reverse saphenous vein graft to the om and pda. cross-clamp time was 64 minutes. total bypass time 92 minutes. he is transferred to the csru on propofol and neo-synephrine. he was extubated the morning of postoperative day #1, and he had his neo-synephrine weaned. he received a unit of blood on postoperative day #2 and remained on the neo-synephrine. on postoperative day #3, his chest tubes were d/c'd. he was transferred to the floor in stable condition. he was also seen by for consult. he continued to slowly progress, but required aggressive physical therapy. he had his pacing wires d/c'd on postoperative day #4. liberalized his sliding scale, and then he did not require insulin, so they felt he needed to be diet controlled and follow up with them for teaching. on postoperative day #7, he was discharged to rehab in stable condition. his laboratories on discharge: hematocrit 24.2, white count 8,000, platelets 308,000. sodium 135, potassium 4, chloride 100, co2 27, bun 36, creatinine 1.4, blood sugar 128. medications on discharge: 1. colace 100 mg p.o. b.i.d. 2. percocet 1-2 tablets p.o. q.4-6h. prn pain. 3. ecotrin 325 mg p.o. q.d. 4. lasix 20 mg p.o. b.i.d. for seven days. 5. potassium 20 meq p.o. q.d. for seven days. 6. lopressor 25 mg p.o. b.i.d. 7. tricor 160 mg p.o. q.d. 8. prilosec 20 mg p.o. q.d. fo: he will be followed by dr. in weeks, dr. in weeks, dr. in four weeks, and he needs to followup with clinic and to sign up for classes for diabetic teaching. discharge diagnoses: 1. coronary artery disease. 2. hypercholesterolemia. 3. noninsulin-dependent diabetes. 4. hypertension. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism

history of present illness: this is a 76 year old male with a known history of coronary artery disease, who reports some episodes of chest pain with radiation to his jaw, right ear, and right arm. he also reported progressive shortness of breath, all occurring a few times over the past couple of months. he said he also had one episode on while at rest. he had a stress test on which showed inferior, posterior and lateral infarct, inferoapical lateral hypokinesis and ejection fraction of 47 percent. he denied any nausea, vomiting or diaphoresis. his cardiac catheterization showed ejection fraction of 51 percent, lad 90 percent lesion, circumflex 90 percent lesion, om1 80 percent lesion and the rca 70 percent lesion. his past medical history includes being hard of hearing, hypothyroidism, no tendons in his right foot and hepatitis in . past surgical history includes appendectomy, tonsillectomy and left ear surgery at age 6 months. he had no known drug allergies. medications preop were levothyroxine, 100 mcg po daily and ibuprofen, 800 mg po prn. he is married and lived in . he is retired. he had no tobacco history and no use of alcohol. preop chest x-ray showed no active lung disease, but tortuosity of thoracic aorta with calcification. please refer to the official report dated . preop ekg on showed sinus rhythm at 93 with some low amplitude t waves and lvh. please refer to the official report dated . on exam he is 5 feet 8 inches tall, 152 pounds, in sinus rhythm at 86 with a blood pressure of 162/97, respiratory rate 16, sating 98 percent on room air. he was lying flat in bed in no apparent distress. he was alert and oriented times three and appropriate. moving all extremities. his lungs were clear bilaterally. his heart was regular rate and rhythm with s1 and s2 tones and a grade 2/6 systolic ejection murmur. his abdomen was soft, flat, nontender, nondistended with positive bowel sounds. extremities warm, dry and well perfused with no edema or varicosities noted. he had 2 plus bilateral radial and dp pulses and 1 plus bilateral pt pulses. preop labs are as follows. white count 4.9, hematocrit 30.1, platelet count 161,000. sodium 139, potassium 3.3, chloride 108, bicarb 28, bun 38, creatinine 0.8 with a blood sugar of 158. pt 13.0, ptt 31.2, inr 1.1. ast 13, alt 15, alkaline phosphatase 68, total bilirubin 0.5, albumin 3.5. urinalysis preop was negative for uti, but had trace hematuria. additional labs as follows: albumin 3.5, cholesterol 142, anion gap 10, triglycerides 70, hdl 36, cholesterol to hd ratio 3.9, calculated ldl 92. the patient went home over the weekend and came back for surgery on , the day of admission, and underwent coronary artery bypass grafting times four with lima to the lad, vein graft to the om, vein graft to pl and vein graft to the rca by dr. . he was transferred to the cardiothoracic icu in stable condition on a neo-synephrine drip at 0.3 mcg per kg per minute and a propofol drip at 30 mcg per kg per minute. on postoperative day one, the patient was stable hemodynamically with a blood pressure 106/50 in sinus rhythm at 97. he remained ventilated with cpap early that morning with a white count of 8.1, hematocrit 32.8. potassium 4.4, bun 20, creatinine 0.9. pa pressures of 38/16 with an index of 3.35 and a mixed venous of 80 percent. he was also evaluated by case management. later that evening he was extubated, overnight had some wheezes and got some racemic epinephrine therapy, kept in the unit on postoperative day one just to keep an eye on his respiratory status. he was evaluated by case management on postoperative day two. his creatinine remained stable at 0.9. he was hemodynamically stable with a blood pressure of 136/66 in sinus rhythm in the 90s. beta blockade was begun. he was transferred out to the floor. a swallow study was ordered as there was some question of some aspiration risk and was to be re-evaluated during the day. if a swallow study was needed, it would be ordered for him at that time. his beta blockade was increased on postoperative day two on the floor. he was evaluated by physical therapy and was encouraged to increase his activity level and ambulate with the physical therapist and the nurses. on his chest tubes were discontinued and his wires were discontinued. on postoperative day three he was alert and oriented. he had nonfocal exam. his lungs were clear. his heart was regular rate and rhythm. he remained on lasix, 20 mg twice a day. lopressor was increased to 75. pacing wires were discontinued. he was sating 93 percent on 4 liters nasal cannula. his foley was removed and he voided successfully. he had evaluation by orthopedics given the fact that he had no tendons in his right foot and had a long-standing old remote injury. he complained of some pain on ambulation. they recommended possible strength training exercises, elevating his foot and ankle, only weightbearing as tolerated and giving him ibuprofen for prn pain control. he was alert and oriented and steady on his feet. his diet was advanced. on postoperative day three his creatinine remained stable at 1.0 with hematocrit of 32.8 and white count of 11.5. he was independently ambulating. was denying any pain. he appeared to be sleeping well. he had a t-max of 100.3 on postoperative day three, but then rapidly became afebrile. he was ambulating a level 5 and moving all extremities and doing extremely well. on the day of discharge his blood pressure was 156/76, sating 97 percent on room air. heart rate 80. his lungs were clear bilaterally. his heart was regular rate and rhythm. he was alert and oriented. his abdomen was soft, nontender, nondistended. he had some trace bilateral lower extremity edema. he was doing very well and was discharged to home with vna services on with the following discharge instructions. he was instructed to see dr. in the office approximately four weeks postop and to see his primary care physician in approximately two weeks post discharge. discharge diagnoses: 1. status post coronary artery bypass grafting times four. 2. hard of hearing. 3. hypothyroidism. 4. status post right foot injury with absence of tendons. 5. remote hepatitis in . discharge medications: 1. colace, 100 mg po twice a day. 2. enteric coated aspirin, 81 mg po once a day. 3. percocet 5/325, 1 to 2 tablets po prn q4 hours for pain. 4. levothyroxine sodium, 100 mcg po once daily. 5. metoprolol, 75 mg po twice a day. 6. lasix, 20 mg po once a day for 7 days. the patient was discharged to home on . , Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified acquired hypothyroidism Other and unspecified angina pectoris Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Stridor

allergies: morphine / lopid attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 71 m with hx cad and hyperlipidemia was admitted to hospital for turp (day of admission to ccu). asa was held for sx which proceeded uneventfully. postop, he developed cp and neck pain. ecg was obtained demonstrating sr in the 70s and 5mm inferior st elevation; pt was given asa, nitrates, iv heparin and xferred to . . in the cardiac cath lab, the svg graft to rca was down w/biliary stent visualized. the lesion was felt to be high risk for intervention and was thus not intervened upon. lcx was occluded. fic co was 7.48. past medical history: cad- several right coronary angioplasties in mid . single vessel bypass to rca. biliary stent to rca bypass in c/b mi. report of lv dysfunction following cath; specific ef not known. prostate hypertrophy s/p turp multiple urinary infections ulcerative colitis kidney stones arthritis colonic polyps social history: former smoker; quit mid . no excess etoh. wife passed away in recent months. family history: nc physical exam: 81 89/54 20 lying in bed s/p cath in nad perrla, mmm, no carotid bruits ctab nl s1/s soft, nt, nd, +bs ext warm x 4 w/+dp bil a&o x 3; moving all 4 ext pertinent results: 138 103 12 101 4.5 28 1.2 ............... 15 300 35.5 . cath: graft to rca w/large biliary stent not patent. co by fick 7.48. brief hospital course: a/p: 71 m with hx cad and hyperlipidemia admitted with inferior mi s/p turp. . imi: rca lesion felt to not be ammenable to cath. medical management of ami to consist of asa 325 daily, lipitor 80mg daily, metoprolol 25mg . patient was restarted on toprol xl at outpatient dose of 50mg qd prior to discharge. he was also started on cozaar25mg daily. he is to continue the regimen on discharge. his cardiac enzymes trended down by time of discharge - 132 on d/c with peak of 1688 on . he was walking the floor without chest pain/sob. tte on revealed 20%ef and: 1. the left atrium is mildly dilated. 2. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis. overall left ventricular systolic function is severely depressed. 3. the aortic root is mildly dilated. the ascending aorta is mildly dilated. 4. the aortic valve leaflets are mildly thickened. 5. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. ef severely depressed - out of proportion to damage likely to occur from his acute event. the etiology of this is likely ischemia vs htn. recommend nuclear stress test or other study (ie cardiac mr) in future to assess viability of cardiac tissue. repeat tte 1 month to consider icd placement. f/u with outpatient cardiologist within 2 weeks. plan for outpatient cardiac rehab. . s/p turp- patient was seen by urology during admission. cbi was continued until early am of . foley then d/c'ed and patient had no difficulty with urination thereafter. denied dysuria. on day of d/c, he was day of cipro with plans to be placed back on bactrim ppx after cipro course complete. . fen- cardiac/hh diet. . medications on admission: cardizem cd 180mg qd, toprol xl 50mg, lipitor 10mg qd, prilosec 20 qd discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. atorvastatin calcium 80 mg tablet sig: one (1) tablet po daily (daily). 3. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 4 days. disp:*8 tablet(s)* refills:*0* 4. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 5. losartan potassium 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 7. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual as needed as needed for chest pain: please take one tablet if you develop chest pain. repeat up to 2 more times every 5 minutes if pain not resolved. call you pcp if you require this medication. disp:*15 tablets* refills:*0* 8. bactrim oral 9. bactrim please continue your outpatient bactrim doses once you have completed the course of ciprofloxacin. discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary diagnosis: 1. inferior mi s/p turp 2. hematuria s/p turp secondary diagnosis: 1. cad s/p cabg (svg-rca) 2. prostate hypertrophy s/p turp 3. ulcerative colitis 4. kidney stones 5. arthritis discharge condition: stable discharge instructions: please call your pcp or return to the ed if you develop chest pain, shortness of breath, difficulty with urination, or other worrisome symtpoms. please complete your course of ciprofloxacin and once complete, please restart your outpatient bactrim prophylaxis medication please take all medications as precribed. followup instructions: follow up with your urologist, dr. please call your cardiologist, dr. , to schedule a follow up appointment within 2 weeks of discharge. please discuss with him being set up with cardiac rehabilitation. please call your pcp to schedule follow up appointment within 6 weeks. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of right heart structures Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Acute myocardial infarction of other inferior wall, initial episode of care Other complications due to other cardiac device, implant, and graft Diseases of tricuspid valve

history of present illness: the patient is a 54-year-old male with morbid obesity with a current body weight of 314 pounds, and a height of 5 feet 10 inches, and a body mass index of 45. he has been on numerous weight loss programs in the past without significant long-term success, and he has multiple obesity-related comorbidities including type 2 diabetes, hypertension, dyslipidemia, sleep apnea, and irritable bowel syndrome, venous stasis syndrome, and osteoarthritis, and a history of depression. past surgical history: past surgical history is significant for excision of lipoma. medications on admission: (current medications include) 1. avapro 300 mg p.o. once per day. 2. hydrochlorothiazide 50 mg p.o. once per day. 3. covera 250 mg p.o. once per day. 4. glyburide 5 mg p.o. three times per day. 5. glucophage 500 mg p.o. three times per day. 6. vioxx 25 mg p.o. once per day as needed. 7. various vitamin supplements. hospital course: the patient was taken by dr. to the operating room on and underwent an open gastric bypass and cholecystectomy. postoperatively, the surgery went well. on postoperative day one, the patient became septic, febrile, and hypotensive, and developed acute abdominal pain. the - drain that was left in the operating room began to drain out bilious material, and the patient was transferred to the intensive care unit and resuscitated, and the patient was emergently taken back to the operating room and underwent an exploratory laparotomy. during this procedure, the patient appeared to have a diffuse bile peritonitis with the gastric remnants appeared to be a leak coming from the gastric remnant, and the leak was oversewn and repaired, and the abdomen was irrigated. a gastrojejunostomy tube was left in the gastric remnant. it was felt that the patient probably had an anastomotic leak with a clot passing distally obstructing the common limb and led to the over distention of the gastric remnant. postoperatively, the patient was transferred to the intensive care unit, and the patient was extubated on postoperative day one. the patient was placed on broad spectrum antibiotics including flagyl for his peritonitis, and the patient began to progress well since then. on postoperative day two, the patient underwent a swallow study which was normal and did not show any leak at the anastomotic site. the patient's white blood cell count began to gradually come down, and the patient was placed on a stage i diet and transferred to the floor. the foley was subsequently discontinued, and the left - drain was discontinued on postoperative day four. the patient was out of bed ambulating. on the patient was deemed ready for discharge to home. prior to discharge, the patient was afebrile with stable vital signs. his chest was clear. the heart was regular in rate and rhythm. the abdomen was soft, nontender, and nondistended. the incision was clean, dry, and intact. the left - drain was also discontinued. the right - drain remained in because of high output. the patient was taught to take care of the - drain at home. the patient had a gastrojejunostomy tube which will be capped when he goes home. the patient was up walking around ambulating and tolerating a stage iii diet prior to discharge and had been passing flatus. discharge status: the patient was discharged to home. discharge instructions/followup: 1. the patient was to follow up with his primary care doctor in one week. 2. the patient was instructed to not take his antihypertensive medication and not to take his oral anti-hyperglycemic agents. 3. the patient was instructed to do fingersticks at home and use an insulin sliding-scale. the patient was to follow up with his primary care physician in one week for adjustment of anti-hyperglycemic agents and his insulin dose. 4. the patient was to follow up with the gastric clinic in two weeks. 5. the patient was also instructed to crush all pills. medications on discharge: 1. zantac 150 mg p.o. twice per day. 2. roxicet 5 mg to 10 mg p.o. q.4-6h. as needed. 3. levaquin 500 mg p.o. once per day (for seven days). 4. flagyl 500 mg p.o. three times per day (for seven days). 5. hydrochlorothiazide 25 mg p.o. once per day. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Cholecystectomy Reopening of recent laparotomy site High gastric bypass Other gastrostomy Suture of laceration of stomach Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified sleep apnea Morbid obesity Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Venous (peripheral) insufficiency, unspecified Irritable bowel syndrome

history of present illness: this is an 83 year-old woman who presented initially to the on with right sided costovertebral and chest pain status post fall. chest x-ray revealed multiple rib fractures, but without evidence of a pneumothorax. she was discharged to home. while at home she experienced an episode of acute shortness of breath. she returned to on the day of admission and found to be hypotensive with a blood pressure in the 80s and tachypneic. in the emergency department she was intubated and a chest tube was placed for pneumothorax. after placement of the chest tube her pressure returned to the 120s, but remained labile. she gives a history of increased frequency of falls. past medical history: chronic obstructive pulmonary disease, hypertension, bronchitis. medications on admission: norvasc, atrovent, albuterol, serevent and flovent. allergies: penicillin. family history: breast cancer. social history: denies use or abuse of tobacco or alcohol. physical examination on admission: temperature 97.6. blood pressure 151/66. pulse 60. respiratory rate 12. 100% on a ventilator. gcs of 10. she is awake, alert, intubated and comfortable. she is normocephalic, atraumatic. extraocular movements intact. pupils are equal, round and reactive to light. her chest is clear to auscultation bilaterally with decreased breath sounds at the right base. there is a right chest tube without any evidence of air leak. her heart is regular. her abdomen is soft, nontender, nondistended. she has a lower midline scar from a previous surgical incision. her extremities are warm and without evidence of edema. radiology: dedicated films of the ribs revealed right rib fractures of 8, 9, 10 and 11 and a potential fracture of ribs 7 and 8. chest x-ray revealed no pneumothorax after chest tube placement. hospital course: 1. pulmonary: as previously described mrs. initially sustained a pneumothorax, which was treated with a chest tube. the chest tube was removed on hospital day number two. follow up x-rays revealed no persistent pneumothorax. during her hospitalization she was given an extubation trial on hospital day number one, which she failed becoming tachypneic and unable to breath several minutes after the extubation. subsequent extubation trial was given several days later. again she failed this trial promptly as well. her hospital course was marked by much difficulty managing her pulmonary status. she had frequent bronchospastic episodes where she was unable to pass air. these episodes were treated with multiple bronchodilators including the use of epinephrine. generally these episodes resulted in the need for increased sedation and increased reliance on mechanical ventilation. during this hospitalization after two failed extubation trials she was found self extubated moments after she had done this. anesthesia was called and after prolonged period of time an airway was unable to be placed. efforts included direct laryngoscopy using a bougie and fiberoptic intubation. an emergent cricothyroidotomy was performed. this procedure was performed by dr. and assisted by dr. and dr. . two days later on an elective tracheostomy was performed. 2. neurological: mrs. pain was initially treated with rib blocks and ultimately treated with an epidural catheter. she was kept comfortable using intermittently propofol drips, dilaudid drips and even benzodiazepines for comfort. 3. cardiovascular: as was noted in the history of present illness, mrs. blood pressure was labile during the entire hospitalization. it was felt the use of pain medication tended to decreases her blood pressure also requiring the need for vasopressors. intermittently the neo-synephrine and levophed were used. the epidural catheter was eventually discontinued when she became hypotensive. during this hospitalization she was ruled out for myocardial infarction. management of her volume status and cardiac status necessitated the need for a pulmonary artery catheter. placement of the pulmonary catheter revealed pulmonary hypertension. this pulmonary hypertension was felt to be complicating her pulmonary status. consultation with the pulmonary service was done and it was ultimately recommended beginning diltiazem drip. in order to maintain mrs. on a diltiazem drip levophed and dopamine were needed to maintain her blood pressure. 4. gastrointestinal: during this hospitalization a dobbhoff feeding tube was placed. tube feeds respalor were given at a rate sufficient to maintain her caloric needs. she was also placed on carafate for gastrointestinal prophylaxis. 5. infectious disease: sputum cultures during this hospitalization grew out enterobacter and coag positive staph. for this mrs. was treated with vancomycin and ciprofloxacin. this was an appropriate regimen based on the sensitivities of these organisms. all other blood and urine cultures remained negative. 6. renal: the initial chest x-ray appeared wet. also during several of her initial desaturation episodes physical examination revealed crackles. it was felt as though decreasing her intravascular volume would help her pulmonary status. mrs. was started on a lasix drip early in her hospitalization. despite being on a lasix drip her daily weights continued to increase and she became more total body water overloaded. her intravascular status was managed both by chest x-ray, clinical examination and pulmonary artery catheter. on admission her creatinine was 1.4 and exhibiting some degree of baseline renal dysfunction. creatinine remained stable until cicu day number thirteen where upon her creatinine began to slowly rise. by cicu day number nineteen her creatinine was 4.7. she was exhibiting signs of uremia. the renal service had been consulted and indicated that in order for mrs. to recover she would need hemodialysis. this offer was presented to the family, which declined hemodialysis. additionally, complicating mrs. picture was an initial ct scan of her abdomen obtained in the emergency department revealed bilateral renal masses. it was felt that these were most consistent with renal cell carcinoma. a long discussion with the family concerning her pulmonary status, her acute renal failure and the presence of metastatic disease to decide her further course. a final family meeting occurred on . at this point her pulmonary status, renal status and the possible evidence of metastatic disease were brought to the family. the decision was made to make mrs. comfort measures only. at this point she was weaned off her pressors and a morphine drip was started. her ventilatory support was discontinued. on mrs. was pronounced dead by house officer. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Temporary tracheostomy Other partial laryngectomy Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Unspecified fall Malignant neoplasm of kidney, except pelvis Acute respiratory failure Traumatic pneumothorax without mention of open wound into thorax Closed fracture of five ribs

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization x 2 intra-aortic balloon pump insertion history of present illness: pt is a 87 yo greek speaking male with pmhx significant for cad s/p mi w/ pacemaker in , pvd, and cva admitted fot cardiac catheterization after presenting to hospital w/ chest pain. history provided largely by patient's son who acted as translator. son noticed that his father had used nine nitroglycerin tablets since the . pt apparently had used nitroglycerin tablets for a 24 hour period between . he states father was complaining of pressure in his chest typical of past heart attack symptoms. he also experienced some tingling in his lips. pt reports experiencing the pressure while at rest but did not report any heart palpitations, shortness of breath, or sweating. per son, his father has had some increased swelling in his legs since . son states that the father has complied with medications but ate liberally during the holiday. after hearing that his father was having chest symptoms, son brought patient to hospital. past medical history: cad mi ' s/p pacemaker & ' pvd b/l carotid endarterectomy b/l fem- bypass graft cva iliac stent x 4 on right, x 2 on left social history: patient lives with wife. has 40 pack year history of smoking and quit 15 years ago. he does not drink alcohol. family history: father - mi mother - cancer, possibly gastric brother - cad physical exam: gen: lying in bed, comfortable, nad heent: dry mucous membranes, perrl, eomi neck: supple, jvp 8 cm cv: rrr s1 s2, 3/6 sem @ llsb lungs: cta b/l abdomen: soft nt nt +bs ext: leg brace on right, 1 + edema, groin c/d/i neuro: l eyelid droop, moving all four extremities pertinent results: ecg - sinus rhythm, ventricular paced rhythm . cardiac catheterizaton - 1. selective coronary angiography revealed a left-dominant system with severe left main and 3-vessel coronary disease. the lmca had a 90% ulcerated ostial lesion and a 60% distal lesion. the lad had moderate diffuse disease throughout and an occluded large first diagonal branch which fills via left-left collaterals. the lcx is a dominant vessel with an 80% stenosis in the proximal om1 branch. the rca is nondominant small vessel and subtotally occluded in the proximal portion. 2. limited venography of the ivc revealed a small saccular dilation of the superior ivc just proximal to right atrium. 3. resting hemodynamics revealed elevated right-sided filling pressures and markedly elevated left-sided filling pressures (mean ra 12 mmhg and mean pcw 34 mmhg with somewhat prominent v-waves to 47 mmhg). the pa pressure is moderately elevated (mean pa 44 mmhg). the cardiac index is low-normal at 2.1 l/min/m2. 3. supravalvular aortography revealed 1+ aortic regurgitation. limited peripheral angiography of the left iliac system revealed a widely patent proximal iliac stent and mild-moderate diffuse disease distal to the stent. 4. due to severe left main disease and ongoing chest discomfort, a 7 french 30 cc intra-aortic balloon pump was inserted. balloon inflation timing was optimized for diastolic augmentation and systolic unloading. tte - the left atrium is elongated. a left-to-right shunt across the interatrial septum is seen at rest consistent with the presence of an atrial septal defect. there is left ventricular hypertrophy with thinned inferolateral wall. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. resting regional wall motion abnormalities include inferolateral akinesis and anterolateral hypokinesis. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is mild to moderate aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. cardiac catheterization - 1. resting hemodynamics revealed mildly elevated filling pressures with low c.i. 2. iabp was adjusted and mean bp was 80, unloaded systolic bp was 105, augmented diastolic bp was 122. 3. selective coronary angiography revealed of this left dominant system revealed a 90% thrombotic, ulcerated lm stenosis, a 70% distal lm stenosis, a 90% ostial lad stenosis, a 100% d1 steonosis, a diffuse up to 50% lcx stenosis and a 80% ostial om1 stenosis. the rca was not filmed. 4. successful stenting of the ostial lm with a 3.5x8mm cypher to 4.5 (see ptca comments). 5. successful stenting of the distal lm/ostial lad with a 3.5x23mm cypher des (overlapping with the ostial lm stent) postdilated to 4.5 (see ptca comments). 6. successful rescue /baloon ptca of the ostial lcx with a 2.5x9mm nc ranger at 14 atms (see ptca comments). 7. abdominal aortography revealed patent celiac and mesenteric arteries with no evidence of thronbotic/embolic occlusion of the major branches. the ostium of the celiac artery had a 60% stenosis. tte - 1. there is severe symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is a generalized dyssynchronous motion and mild global left ventricular hypokinesis. overall left ventricular systolic function is mildly depressed. 2. the aortic valve leaflets (3) are mildly thickened. mild to moderate (+) aortic regurgitation is seen. 3. the mitral valve leaflets are mildly thickened. there is moderate thickening of the mitral valve chordae. mild (1+) mitral regurgitation is seen. 4. there is a small, echo dense, pericardial effusion. 5. compared with the findings of the prior study of , there has been no significant change. 09:30pm type-mix 09:30pm o2 sat-68 09:26pm type-art po2-99 pco2-38 ph-7.48* total co2-29 base xs-4 09:26pm o2 sat-98 05:50pm glucose-165* urea n-51* creat-1.1 sodium-141 potassium-3.7 chloride-101 total co2-27 anion gap-17 05:50pm albumin-3.6 cholest-113 05:50pm triglycer-149 hdl chol-24 chol/hdl-4.7 ldl(calc)-59 05:50pm wbc-8.7 rbc-4.06* hgb-12.8* hct-37.1* mcv-92 mch-31.6 mchc-34.6 rdw-13.7 05:50pm neuts-72.2* lymphs-19.3 monos-7.3 eos-0.9 basos-0.3 05:50pm plt count-165 05:50pm pt-14.6* ptt-41.4* inr(pt)-1.3 05:23pm type-art o2 flow-4 po2-55* pco2-39 ph-7.44 total co2-27 base xs-1 comments-nasal brief hospital course: the patient was initially taken to the cath lab where he was found to have a 90% lmca occlusion and an 80% lcx occlusion. he was transferred to the ccu with an iabp given a pcwp pf 34 in the cath lab. an lmca stent was planned for later in the hospitalization. in the interim he was maintained on aspirin, lipitor, heparin, and plavix. pm the patient complained of vague abdominal. he was also noted to have a drop in cardiac index from 1.9 -> 1.5. dobutamine was then started. ~ 6 am on the patient was noted to have a drop in bp. as a result, dopamine and levophed were initiated. he was noted to be barely arousable with an abg 7.26/49/99/26. pt also found to be diaphoretic with a pa02 of 80-84% and was intubated. the patient developed arf with a cr rise from 1.1 - > 1.9 as well as a lactate of 5.4 this was all deemed to be from hyperperfusion from cardiogenic shock with a possible component of septic shock due to an abdominal source. a conversation was then held with the patient's son regarding possible heroic pci of the lcma lesion in order to improve the patient's hemodynamics. though this procedure was high risk it was explained to the son that this was his father's options were limited. the son wished to pursue with the intervention. the patient was brought to the cath lab where he had stents placed in his lm & lad with dilation of his lcx. upon return from the cath lab the patient had a persistentent lactic acidosis with a lactate of 7.4. his abdomen was also tense and distended with minimal bowel sounds. he was started on broad spectrum abx. during pm, pt's hct dropped from 33 to 22 and he was noted to have developed a right thigh hematoma at the cath site. heparin drip was stopped, pt was transfused prbcs and pressure was applied to groin with eventual hemostasis. repeat hct was 32 post-transfusion. the patient remained pressor dependent and required liberal infusion of ivf to maintain his bp. he also began third spacing fluid and dropping o2 sats on increased vent settings. his lactate reached as high as 12.8 and repeat abg's showed pa02's consistently in the 50's. at this point the patient's son was called to discuss the patient's grim prognosis. the son elected to have his father made care only with ceasing of all heroic measures. at this point, pressors, fluids, abx were all stopped. the patients ventilator settings were decreased and he was given fentanyl boluses for pain. within two hours the patient went into asystole and expired. medications on admission: asa 81 mg daily plavix 75 mg daily hydrocodone 500 mg one tab q 6/prn diclofenac 50 mg daily norvasc 5 mg daily lopressor 75 mg lipitor 40 mg daily zestril 10 mg daily oxybutynin 2.5 mg tid omeprazole 20 mg daily imdur 60 mg daily lasix 40 mg q am kcl 20 mg q am discharge medications: na discharge disposition: expired discharge diagnosis: cardipulmonary failure discharge condition: expired discharge instructions: na followup instructions: na Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Coronary arteriography using a single catheter Insertion of endotracheal tube Injection or infusion of thrombolytic agent Aortography Implant of pulsation balloon Insertion of drug-eluting coronary artery stent(s) Infusion of vasopressor agent Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Hematoma complicating a procedure Aortic valve disorders Cardiac arrest Cardiogenic shock

past medical history: 1. noninsulin dependent diabetes mellitus. 2. history of prostate cancer status post prostatectomy 10 years ago. 3. asbestosis. 4. hypertension. 5. a 30 to 40 pack year smoking history, quit in the 70s. 6. status post biopsy of a right anterior tibial lesion with a follow up bone scan and ct scan of the abdomen and pelvis to rule out metastasis from prostate cancer. results are unknown. allergies: no known drug allergies. preoperative medications: 1. imdur 30 milligrams po q day. 2. lipitor 20 milligrams po q day. 3. glucotrol 5 milligrams po q day. 4. tiazac 360 milligrams po q day. 5. diovan 80 milligrams po q day. 6. aspirin 325 milligrams po q day. laboratory data: white blood cell count 7.5, hematocrit 46.2, platelet count 184,000, sodium 140, potassium 4.5, chloride 106, bicarb 26, bun 19, creatinine 1.2. blood sugar 150. ho course: the patient was taken to the operating room on with dr. for cabg times three. in the operating room it was difficult to place a foley catheter preoperatively. urology was consulted. flexible cystoscopy showed a bladder neck stricture. a wire was placed and the stricture was dilated. a foley catheter was inserted. the patient underwent cabg times three, lima to diagonal, saphenous vein graft to rca, saphenous vein graft to om. the patient was transferred to the intensive care unit in stable condition. the patient was weaned and extubated from mechanical ventilation on postoperative day one. the patient remained in the intensive care unit requiring neo-synephrine infusion to maintain adequate blood pressure. the patient was transferred out of the intensive care unit on postoperative day two. the patient's chest tubes were removed on postoperative day two. post chest tube removal chest x-ray demonstrated a small left apical pneumothorax from which the patient was asymptomatic. the patient was transferred to the floor and began ambulating with physical therapy. the patient's temporary pacing wires were removed on postoperative day three. the patient's foley catheter was removed on postoperative day five. the patient is to void prior to discharge otherwise foley catheter will be re-inserted. repeat chest x-ray on demonstrated a continued small left apical pneumothorax unchanged from previous chest x-ray of . it is felt that the size and stability of the pneumothorax did not require any intervention. the patient was cleared for discharge on to rehabilitation facility as it was felt that the patient would need continued physical therapy and short term rehabilitation. condition at discharge: tmax 100.4 f, t current 99.1 f. pulse 94, sinus rhythm. blood pressure 122/52. oxygen saturation 94% on two liters nasal cannula. the patient's weight on is 105 kilograms. the patient was 99 kilograms preoperative. white blood cell count 9.9, hematocrit 26.9, platelet count 233,000, sodium 140, potassium 4.3, chloride 100, bicarbonate 31, bun 19, creatinine 0.9, blood sugar 169. the patient is alert and oriented times 3, neurologically grossly intact. cardiovascular - regular rate and rhythm. no audible rub or murmur. extremities are warm and well perfused. respiratory - breath sounds are decreased bilaterally with crackles at the left base. gi - abdomen is obese, soft, positive bowel sounds, nontender, nondistended, positive bowel movement. extremities - right lower extremity incision is clean, dry and intact. the patient has dermabond over the incision. sternal incision - steri strips are intact, no erythema or drainage is noted. there is scant amount of serosanguinous drainage from the medial chest tube site with no erythema noted. discharge medications: 1. lopressor 50 milligrams po bid. 2. lasix 20 milligrams po bid times 10 days. 3. kcl 20 milliequivalents po bid times 10 days. 4. colace 100 milligrams po bid. 5. ranitidine 150 milligrams po bid. 6. enteric coated aspirin 325 milligrams po q day. 7. lipitor 20 milligrams po q hs. 8. glucotrol 5 milligrams po q day. 9. ibuprofen 400 milligrams po q four to six hours prn. 10. oxycodone 5/325 one to two tablets q four to six hours prn. 11. dulcolax suppository one po q day prn. 12. regular sliding scale insulin for blood sugar of 150 to 200 give three units subcutaneous; for blood sugar 201 to 250 give five units subcutaneous; blood sugar 251 to 300 give seven units subcutaneous; blood sugar 301 to 350 give 9 units subcutaneous. discharge diagnosis: 1. coronary artery disease status post cabg. 2. noninsulin dependent diabetes mellitus. 3. history of prostate cancer status post prostatectomy ten years. 4. bladder neck stricture, status post dilation. 5. history of asbestosis. die instructions: the patient is to be discharged to a rehabilitation facility in stable condition. the patient is to follow up with dr. in three to four weeks. the patient is to follow up with dr. in three to four weeks. the patient is to follow up with dr. upon discharge from rehabilitation. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Dilation of bladder neck Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of malignant neoplasm of prostate Bladder neck obstruction Asbestosis

history of present illness: the patient is a 72-year-old gentleman status post fall off a horse which was unwitnessed. he was found on the trail with his riding helmet beside him. he was able to give his name but was otherwise disoriented. he was transferred to hospital. by report his gcs was 14, but he had no purposeful movement. head ct showed traumatic subarachnoid hemorrhage with bifrontal contusions, multiple convexity skull fractures with no significant displacement, no more than thickness of the bone, one small area of pneumocephalus on the base of the thalamus. the patient was seen by the ophthalmology service for the left frontal skull fracture which extended into the left orbital roof. no surgical intervention was needed. his globes were intact, and there was no need for surgical repair of the orbital roof. the patient was also seen by ct surgery for question of an esophageal . the patient was intubated and sedated in the or on propofol. when lightened, he was restless, unable to focus, moving all extremities, left greater than right. he did not open his eyes or follow commands. he localized with his left upper extremity. he had withdraw in the bilateral lower extremities. in the right upper extremity, he lifted against gravity but weaker than the left. right pupil was 4 mm and reactive, left is irregular and nonreactive, surgical. he did have cornuals, gag, and cough. the patient had repeat head ct on , which was unchanged from the previous day ct. on , the patient was awakened and attentive. left pupil was surgical, right was 4.5 down to 4.0 and reactive. he had purposeful movements of the left greater than right. smile was symmetric. the patient had mra/mrv to rule out stroke as the cause for right upper extremity weakness which was negative. it was unclear as to the cause of the decreased movement in the right upper extremity. we recommended weaning from the ventilator and weaning sedation. the patient had repeat chest ct. thoracic surgery felt there was a low probability of an esophageal , prophylaxis antibiotics were discontinued on . on , the patient opened his eyes and followed voice. he occasionally followed commands. he continued with right-sided weakness. ophthalmology was consulted again who said that he showed evidence of healing corneal abrasions. the patient will need follow-up with outpatient ophthalmologist after discharge. the patient was extubated on and transferred to the regular floor on . he was seen by physical therapy and occupational therapy and found to require acute rehabilitation prior to discharge to home. discharge medications: lopressor 50 mg p.o. b.i.d. hold for systolic blood pressure less than 110, heart rate less than 55, hydralazine 20 mg p.o. q.6 hours, hold for systolic blood pressure less than 110, heart rate less than 55, nystatin ointment 1 application topically q.i.d. p.r.n. to affected areas, insulin sliding scale, captopril 25 mg p.o. t.i.d., hold for systolic blood pressure less than 100, erythromycin ophthalmic ointment 0.5% o.u. at h.s., nystatin oral suspension 5 cc p.o. q.i.d., heparin 5000 u subcue q.12 hours. condition on discharge: the patient's neurologic status improved greatly. he was awake and alert and oriented times , moving all extremities, but continued with some right-sided weakness. he was following commands and was out of bed ambulating with assistance. follow-up: he will need to follow-up with dr. on one month with repeat head ct. he was stable at the time of discharge. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Superficial injury of cornea Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Closed fracture of orbital floor (blow-out) Other accidental fall from one level to another

allergies: nka pmh: htn, high cholesterol brief ros: neuro: pt unresponsive, does not follow commands. upper extremities are flaccid. slight movement of legs to noxious stimuli. -cough -gag on admission. pupils are small 2mm on right 2.5mm on left react sluggishly to light. cv: bp 130/77. hr 56 sinus brady. ivf ns w/40meq kcl at 100cc/hr infusing. resp: pt intubated on ac 12, tv 500, fio2 40% with 5cm peep. lungs clear upper lobes and coarse at bases. suctioned for small amt clear secretions via ett. gi: ogt in place, clamped. pt is npo and on famotidine as gi prophylaxis. gu: uo is brisk via foley and urine is clear. id: pt cool on admission with temp 97 rectally. blankets applied. iv access: three peripherals intact. social: family have been in to see pt while she was in ew and are aware of all decsions. pt has orders for ativan/morphine as needed but dose not seem to require this at this time. they wanted to keep pt on the vent tonight and will discuss possible withdrawal of the vent tomorrow. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Obstructive hydrocephalus Pure hypercholesterolemia Unspecified essential hypertension Intracerebral hemorrhage Acute respiratory failure

history of present illness: patient is an 83-year-old female with a history of hypertension and hypercholesterolemia, who on was found unresponsive in her chair by a neighbor. at that point, the patient was transferred to hospital. she was determined to be unconscious on arrival with a flaccid right side staring to the left and incontinent of urine. her vitals at that time were 97.7, 64, 16, blood pressure 154/80, and 100% on nonrebreather. fingerstick blood sugar was 85, ck 11, troponin negative, ekg normal sinus rhythm. the patient was intubated for questionable airway protection. a head ct revealed a large intraparenchymal bleed 3.7 x 3 cm to the left thalamus extending to ventricular region resulting in obstructive hydrocephalus and effacement of sulci. patient was given 1 gram of dilantin and ativan in on route to . in the emergency department at , the patient was found to have a blood pressure of 108/58, heart rate of 56, an abg of 7.5/30/20.7 with a peep of 5 and a fio2 of 0.6. the patient was initially seen by neurosurgery and they reviewed a repeat head ct, which showed expansion of the intraparenchymal bleed in the left thalamus, then measuring 5.2 x 3 cm. there is blood in the left ventricle in the basilar cisterns. the health care proxy, nephew , was at that point was spoken to, who refused invasive procedures and life prolonging measures. the patient received intravenous fluid boluses for systolic blood pressures in the 80s as well as 10 mg iv of decadron x1. she was transferred to the medical intensive care unit at that point at . past medical history: 1. hypertension. 2. hypercholesterolemia. allergies: no known drug allergies. medications: 1. detrol. 2. lipitor. 3. cardizem. 4. potassium chloride. social history: patient lives in . her health care proxy is nephew, . family history: patient has a sister with a brain hemorrhage status post evacuation. patient had another sister with multiple sclerosis. physical exam on admission: vitals are as follows: temperature 97.0, blood pressure 133/77, pulse 51, respiratory rate 14. general: patient is a thin caucasian female, intubated, sedated with no spontaneous movements. heent: pupil on the left measured 3.0 down to 2.5 with light exposure, pupil on the right measured 2.5 down to 2.0 in light exposure. she had a left corneal reflex, and no right corneal reflex. neck: supple, no masses, no lymphadenopathy. lungs: clear to auscultation bilaterally. cardiovascular: regular, rate, and rhythm, positive s1, s2, no murmurs, rubs, or gallops. abdomen: soft, nontender, nondistended, normoactive bowel sounds. extremities: trace edema bilaterally. neurologic: no gag reflex, right corneal reflex absent, withdraws to painful stimuli in the left extremities. no posturing, no other abnormalities noted. laboratories on admission: cbc is as follows: white blood cell count 11.1, hematocrit 42.7, platelets 183. electrolytes and renals as follows: sodium 142, potassium 3.0, chloride 106, bicarb 21, bun 15, creatinine 0.6, glucose 145. abg: 7.5/30/237 with a fio2 of 0.6 and settings on the ventilator as follows: peep of 5, tidal volume of 500, fio2 0.4, pip of 26. chest x-ray on admission as follows: the intubation tube is in the correct position. no evidence of pleural effusion or abnormal pulmonary vasculature. ekg: bradycardia with sinus rhythm at 56 beats per minute, left axis deviation, poor r-wave progression, no ischemic changes evident. head ct: left thalamus hemorrhage measuring 5.2 cm x 3 cm with mass effect, ventricular extension, and concern for impending herniation. obstructive hydrocephalus with blood in the lateral ventricles in the third and fourth ventricle also evident. impression: the patient is an 83-year-old female with a history of hypertension, hypercholesterolemia, who presented with a large intraparenchymal cerebral hemorrhage complicated by obstructive hydrocephalus, not a candidate for neurosurgical intervention per the family, intubated, dnr. hospitalization course: the patient was initially intubated on admission , but after extensive discussions with health care proxy, it was decided that the patient could be extubated on as they did not want any further intervention. patient initially had intravenous access and was repleted for her electrolyte abnormalities. she was also maintained on famotidine and pneumoboots. however, social work and neurosurgery as well as the medical intensive care unit team had a discussion with the family, who expressed their wishes not to continue with intervention. the family only desired to have comfort measures only maintained. therefore, the patient was only maintained on her lorazepam and morphine as well as tylenol for comfort. these medications were administered sublingually. foley catheter remained in place. scopolamine patch was also administered on . on , the patient became progressively tachypneic and finally expired at 9:34 a.m. the family was contact and it was decided that an autopsy would not be pursued. there is no reason for medical examiner intervention as the cause of death was known. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Obstructive hydrocephalus Pure hypercholesterolemia Unspecified essential hypertension Intracerebral hemorrhage Acute respiratory failure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from ich with intra-parenchymal bleed major surgical or invasive procedure: none history of present illness: the patient is a 75 year old man with a history of hypertension and high cholesterol, now presenting on transfer from an osh with a large right intraparenchymal cerebral bleed. as per his chart, he originally presented to the osh with the complaint of inability to feel his right leg. an angiogram of the leg uncovered a right femoral artery occlusion and he was given t- pa (iv). the next morning, the patient developed a left hemiparesis with left facial droop and a right gaze preference. an emergent ct scan of his brain showed multiple hemorrhages primarily in the right frontal lobe, but also including the left parietal lobe and right cerebellum. review of systems: -not obtainable past medical history: -umbilical hernia repair -gall bladder removal in -hypertension -high cholesterol -aortofemoral + fem- bypass -turp in social history: -no known history of tobacco or alcohol family history: -father died at age -mother died of heart attack physical exam: vitals: 98.6 140/70 54 18 100% intubated general: elderly man, moving right arm in bed, some distress neck: supple lungs: coarse breath sounds cv: regular rate and rhythm, bradycardic abdomen: non-tender, non-distended, bowel sounds present ext: warm, no edema neurologic examination: no eye opening to loud voice or sternal rub; not following simple commands to squeeze hands or open eyes; pupils minimally reactive to light but equal; no dolls eye movements; left facial droop; spontaneous movement of rue, rll, and lll, no movement of lue; withdraws to pain on all extremities except left arm-here he extensor postures; reflexes brisk throughout with no large asymmetries; toe upgoing on left, down on right pertinent results: cbc: 13.6/20.0/182 chem: 135/4.1 102/24 17/0.7 122 c/m/p: 8.7/2.2/2.2 coags: 14.7/26.9/1.4 head ct: multiple discreet areas of hemorrhage, prominent in the right frontal lobe; intraventricular extension; some edema with mass effect brief hospital course: the patient was admitted from an osh for management of a large intra-parenchymal hemmorrhage. patient patient had a poor neurologic examination on admission. the patient continued to deteriorate and on hospital day #5 was pronounced brain dead. as per the families wishes, he became an organ donor. medications on admission: -nadolol -hctz -lisinopril -zocor -baby asa -mvi -trental discharge medications: n/a discharge disposition: expired discharge diagnosis: 1. intraparenchymal hemmorrhage discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Transfusion of packed cells Transfusion of other serum Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Intracerebral hemorrhage Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Arterial embolism and thrombosis of lower extremity Iatrogenic cerebrovascular infarction or hemorrhage Fibrinolysis-affecting drugs causing adverse effects in therapeutic use

history of present illness: this is a 53-year-old woman without significant past medical history, who was in her usual state of health until about two months ago. on , she suffered an l1 burst fracture and left rib fracture secondary to a fall from a ten foot ladder (per patient) or from a second-floor window (per patient's daughter) at home. she was initially seen at an outside hospital two days later, after the incident. she was transferred to immediately for surgical intervention. she had a relatively uneventful perioperative course except for one unit of packed red blood cell transfusion postoperatively. she had a total l1 vertebrectomy, fusion and segmental instrumentation of t12 to l3, cage placement at l1, and autograft during the first surgery. she was evaluated by psychiatry at that time for possible paranoia and questionable suicidal ideation postoperatively. medical workup at that time included a negative rpr, normal thyroid function tests, and a head mri showing possible chronic microvascular ischemia. she was sent to a rehabilitation facility on , in stable condition. about one month later, on , she was readmitted for elective second operation to correct kyphoscoliosis. again she had an uneventful operative course. the second operation included a posterior fusion of t9 to l3, multiple thoracolumbar laminectomies, segmental instrumentation of t9 to l3, and right iliac crest graft. postoperatively, however, she suddenly decompensated in the post-anesthesia care unit while she was receiving a transfusion of one unit of packed red blood cells. she complained of sudden onset of chest pain and shortness of breath with oxygen saturations dropping to 70%, blood pressure dropping to 70/40. she was intubated immediately, and transferred to the surgical intensive care unit for further management. progressive loss of bilateral translucency on chest x-ray and positive anti-hla and anti-granulocyte antibodies on hematological workup were all consistent with trali (transfusion-associated lung injury). while in the surgical intensive care unit, her postoperative course was further complicated with methicillin-sensitive staphylococcus aureus bacteremia, pneumonia, and wound infection (which were documented with positive cultures on ). these events eventually led to a prolonged intubation. after she was started on intravenous oxacillin on , she had very good response, with decreased fever and decreased white blood cell count, as well as clearing of bacteremia which was documented by several blood cultures drawn on later days. she also underwent incision and drainage of posterior wounds on . wound cultures showed decreased colonization of methicillin-sensitive staphylococcus aureus and rare colonies of e. coli. she also had a diagnostic pleural tap on for persistent left pleural effusion. the final culture was negative. she had repeated tte on which showed no vegetation and left ventricular ejection fraction greater than 55%. she also had a ct of the chest, abdomen and pelvis on , which showed improving effusion and normal bowels with old splenic infarct. ct angio was also performed, which showed improving atelectasis and effusion without evidence of pulmonary emboli. she was extubated on , and transferred to medicine on in stable condition. medications: oxacillin, lopressor, subcutaneous heparin, zantac, ativan, haldol, colace, epogen, vitamin d, nasogastric tube feeds allergies: no known drug allergies. social history: works full-time as an insurance underwriter. lives alone. questionable alcohol. family history: schizophrenia past medical history: uterine fibroids review of systems: unavailable physical examination: temperature 100.9, blood pressure 132/80, pulse 122, respirations 16, oxygen saturation 94% on room air. general: thin, middle-aged woman, lying in bed, with thoracolumbar brace in place. a little confused, able to follow simple commands, answering simple questions. alert and oriented x 1 (person). no apparent distress. head and neck: normocephalic, atraumatic, anicteric, pupils equal, round and reactive to light. neck supple. chest: well-healed left lateral posterior surgical scar, nontender, no erythema. cardiovascular: normal s1 and s2, no murmurs, rubs or gallops. lungs: clear to auscultation bilaterally (anterior and lateral). abdomen: soft, nontender, nondistended. extremities: warm to touch, no edema or cyanosis. distal pulses 2+ bilaterally. no calf tenderness. on venodynes. neurological: cranial nerves ii through xii intact, strength equal bilaterally, sensory intact. psychiatric: appeared disoriented and paranoid. skin intact, no rashes. laboratory data: white cell count 17.9, hematocrit 34.1, platelets 509. differential: 71% neutrophils, 19% lymphocytes, 8% monocytes, 2% eosinophils. sodium 138, potassium 3.8, chloride 104, bicarbonate 24, bun 7, creatinine .3, glucose 76. calcium 8.2, phosphorus 3.6, magnesium 1.6. pt 13.0, ptt 30.4, inr 1.2. liver function tests: ast 82, alt 52, ld 319, alkaline phosphatase 201, amylase 29, lipase 22. two recent blood cultures on and were negative. urine culture on and were negative. wound culture on showed decreased methicillin-sensitive staphylococcus aureus. stool cultures were negative for c. difficile. catheter tip culture on was negative. chest x-ray on showed decreased left pleural effusion without pneumothorax, decreased congestive heart failure, persistent left basilar atelectasis. ct on showed an old splenic infarct, no abnormal bowel or liver or fluid collection. ct angio showed no evidence of pulmonary emboli, increased left pleural effusion, ground-glass attenuation consistent with volume overload. tte: left ventricular ejection fraction greater than 55%, small pericardial effusion. pleural tap showed no malignant cells. hospital course: while on the medical service, she was continued on oxacillin and showed improvement with decreased white blood cell count and decreased temperature. six weeks of intravenous oxacillin was recommended by infectious disease consult, given the patient's high risk of relapse due to the hardware placed inside the originally-infected wound. a picc line has been placed for the long course of intravenous antibiotic treatment. so far, all blood cultures drawn after starting oxacillin were negative to date. her initial symptoms of tachycardia have also resolved, likely due to a combination of measures including intravenous hydration, improved pulmonary function with incentive spirometer. repeated chest x-ray showed improving atelectasis. repeated cta revealed no evidence of pulmonary emboli. after she was medically stabilized and weaned off all sedatives including haldol, ativan, zantac, her mental status improved dramatically. signs of underlying psychiatric disorder became more obvious. she appeared paranoid and delusional at times, and seemed lacking of insight into her disease. given her questionable history of alcohol abuse and poor nutritional status currently, vitamin b12 and folate and thiamine and a multivitamin were given as supplements. a head ct revealed age-inappropriate atrophy such as seen in increased risk for dementia. psychiatry recommended restarting on haldol to control psychotic symptoms and continue one-to-one sitter until the patient was no longer at high risk of eloping from the hospital. the patient's psychotic symptoms improved with gradually increased doses of haldol. now the patient has been doing well without a one-to-one sitter for more than 24 hours. discharge condition: stable discharge status: rehabilitation facility discharge diagnosis: 1. l1 burst fracture and left rib fracture status post l9 to t3 fusion 2. methicillin-sensitive staphylococcus aureus wound infection 3. methicillin-sensitive staphylococcus aureus pneumonia 4. methicillin-sensitive staphylococcus aureus bacteremia 5. psychotic disorder, unspecified discharge instructions: wear thoracolumbar brace for three months when out of bed. activities as tolerated. discharge medications: oxacillin 2 grams every four hours intravenously for a total of six weeks (until ), haldol 2 mg every morning and 2 mg daily at bedtime, trazodone 50 mg daily at bedtime, lopressor 100 mg twice a day and hold for systolic pressure less than 100 or heart rate less than 60, multivitamin one tablet once daily. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Lumbar and lumbosacral fusion of the anterior column, posterior technique Local excision of lesion or tissue of bone, other bones Excision of bone for graft, other bones Diagnoses: Other postoperative infection Bacteremia Methicillin susceptible pneumonia due to Staphylococcus aureus Scoliosis [and kyphoscoliosis], idiopathic Unspecified psychosis

allergies: cyclophosphamide attending: chief complaint: transient cp found to be hypotensive with evidence of uti --> code sepsis major surgical or invasive procedure: none history of present illness: 63f with cholangiocarcinoma and metastatic rcc with known liver involvement who presented to ed with c/o cp found to be hypotensive and jaundice. pt reports 4 days of worsening jaundice and abdominal pain. pain is poorly described without clear localization. pt with worsening n/v and ability to tolerate po. most recent bm several days ago was normal in color without evidence of bleeding. no hematemesis. no dysuria/frequency/urgency. pt describes a 30 minute episode of cp in the setting of nausea that resolved on its own. no associated sob. no doe. no le edema. mild dry/unproductive cough. no fever/chills/sweats. upon arrival in the icu, pt feels a better after getting ivf. . ed course: triaged as urosepsis for which a central line was placed and aggressive hydration initiated. initial lactate 4.4 improved to 2.0 after 4 liters of ns. abx -> levo/flagyl. given bb and asa for cp protocol and became transiently hypotensive. pt admitted to from ed with concerns of sepsis. past medical history: -? cholangiocarcinoma -metastatic rcc: dx . pt not tx candidate, being seen by hospice. -htn -dm2 -cad: small fixed and reversible defects in -chf: echo with impaired relaxation, lvh, normal lvef -copd -pul fibrosis -hcv -gout -ra social history: lives at home with husband. . former nursing aid. smoked for 40 yrs, quit 12 yrs ago. has home health aide and vna; refused hospice. family history: mother with dm, father with cad physical exam: gen- fatigued, jaundiced but comfortable heent- perrl, eomi, icteric, op wnl, dry mm neck- no jvd/lad; l-ij in place cv- rrr, s1s2, no m/r/g pul- fair air movement abd- soft, nd, diffuse tenderness worse ruq. with + hm, no rebound, no present, hypoactive bs extrm- r>l 1+ nonpitting le edema (chronic), wwp, ra changes in hands/feet neuro- a&ox3, no focal cn deficits, appropriate, strength/sensation grossly intact pertinent results: admission labs: 03:45pm blood wbc-1.3* rbc-4.52 hgb-12.2 hct-36.7 mcv-81* mch-27.0 mchc-33.3 rdw-22.4* plt ct-399 03:45pm blood plt smr-normal plt ct-399 05:10pm blood pt-13.7* ptt-20.8* inr(pt)-1.2* 05:10pm blood glucose-151* urean-61* creat-2.2*# na-138 k-3.9 cl-93* hco3-28 angap-21* 05:10pm blood alt-9 ast-64* ck(cpk)-31 alkphos-288* amylase-18 totbili-16.3* 05:10pm blood lipase-11 05:10pm blood ck-mb-notdone ctropnt-0.06* 04:00am blood albumin-2.3* calcium-8.6 phos-3.9 mg-1.8 05:10pm blood calcium-9.1 phos-4.4 mg-1.5* 05:10pm blood cortsol-41.9* 04:15am blood cortsol-20.1* 05:10pm blood crp-51.3* 03:49pm blood lactate-4.4* 07:45pm blood lactate-2.2* 08:58pm blood lactate-2.0 04:58am blood lactate-1.4 4:30 pm urine site: clean catch **final report ** urine culture (final ): klebsiella pneumoniae. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin----------<=0.25 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . imaging: : liver us: 1. multiple heterogeneous masses in the liver, representing known cholangiocarcinoma. bilateral mild intrahepatic ductal dilation. 2. sludge in gallbladder, and possibly in cbd. . mrcp: 1. widespread liver metastases, with findings more suggestive of cholangiocarcinoma than metastatic renal cell cancer. 2. findings consistent with extrinsic compression of the extrahepatic common hepatic duct by a large metastasis in the caudate lobe, including associated intrahepatic biliary ductal dilatation. 3. smooth appearance of the intra- and extra-hepatic ducts without strictures or areas of focal abnormality. 4. layering sludge within the gallbladder, but no evidence of sludge or stones in the bile ducts. 5. low signal lesion in the left kidney, previously characterized as most likely representing a renal cell carcinoma. . renal us: no hydronephrosis. this cystic structure projected within the renal sinus on some of the sagittal images is consistent with the previously known large renal cyst. no definite hydronephrosis. the urinary bladder was empty on account of foley catheter. . cxr on admission: consolidation in bilateral lower lobes, which may represent pneumonia or aspiration superimposed upon underlying chronic lung disease. a component of pulmonary edema is also possible. (final read changed from the previously written prelim read: the cardiac and mediastinal contours are unchanged compared to the prior study. note is made of increased faint opacities in left lower lobe, with interstitial opacities, which may represent pulmonary edema, however, superimposed pneumonia especially in left lower lobe is also a possibility if the patient has infectious symptoms. note is made of opacity in right lower lobe as well, which may represent atelectasis versus pneumonia. possible small pleural effusion is seen. lung volumes are small due to low inspiratory level. note is made of somewhat prominent colon gas with elevated left diaphragm.) . discharge labs: brief hospital course: # ? sepsis: on admission the pt was noted to have a lactate of >4, tachycardia, hypotension and a ua that was suggestive of infection. later, the urine culture grew gnr. the preliminary read of the patient's cxr was atelectasis, however, subsequent read suggested bibasilar infiltrates that could be consistent with pneumonia. initially the biliary tree was suspected to be another possible source of infection. following mrcp, it was felt that this was less likely. on arrival to the icu, the pt was afebrile without tachycardia or tachypnea. the lactate improved with ivf. the pt was treated with zosyn and was initially on the sepsis protocol with a central line. the sepsis protocol was discontinued on hd#2 as the pt was afebrile with stable vital signs. zosyn was continued to cover uti, possible cholangitis (though unlikely), and possible aspiration pneumonia. . # jaundice: the pt had a bilirubin that was elevated markedly from baseline, though alkaline phosphatase remained only somewhat elevated from baseline. this raised concer for extrinsic compression of the biliary tree from tumor. mrcp was obtained and showed extrinsic compression from a mass in the caudate lobe of the liver. it was felt that it would be possible to stent this open via ercp if the patient so desired. . # arf: fena was low, renal us was negative for hydronephrosis. creat decreased in the icu from 2.2 to 1.7 with hydration. (baseline 1.0) . # onc: peripheral cholangio-ca and met rcc. not a therapeutic candidate. there were . # cad: cp was not felt to be cardiac in nature. the pt had a fixed defect on mibi but initial enzymes were negative by ck. asa and bb were held in the icu. atorvastatin was continued. . # chf: reported ef 50-65% (). diuretic and aldactone were held given volume status and arf. . # htn: as above held anti-htn . # pain control: one of the patient's main complaints was pain. she described diffuse pain that was bothersome constantly. she was continued on her home dose of fentanyl patch. she became nauseated and did not tolerate her oxycontin. morphine worsened her nausea. dilaudid was used in conjunction with anzemet with good result. . # copd/pulm fibrosis: felt to be stable. nebs were used as needed and azathioprine was held until creatinine decreased to normal range. . pt was transferred to the on , required pressors and ivfs to maintain pressure. pt became progressively more dyspneic and after extensive discussion with the family, the patient was made comfort care only. pt expired on at 1700. family was present and requested an autopsy medications on admission: bumetanide 3mg asa 325 aldactone 25 qd lipitor 20 protonix 40 toprol xl 25 kcl 180 meq colace ambien 10mg qhs azathioprine 10mg qd oxycodone 5mg q4hr prn discharge medications: n/a discharge disposition: extended care discharge diagnosis: urosepsis pneumonia cholangiocarcinoma discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Endoscopic sphincterotomy and papillotomy Endoscopic retrograde cholangiography [ERC] Diagnoses: Coronary atherosclerosis of native coronary artery Malignant neoplasm of liver, secondary Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Gout, unspecified Malignant neoplasm of kidney, except pelvis Pneumonitis due to inhalation of food or vomitus Postinflammatory pulmonary fibrosis Hydronephrosis Cholangitis Malignant neoplasm of intrahepatic bile ducts

allergies to sulfa and dilantin please see flowsheet for more details this is a 61 y/o lady who recently finished a 6 wks course of xrt/chemo for glioblastoma, found secondary tumor during chemotherapy and had a cyber knife radiological procedure on . no other sign. past med. hx. presented to after a couple days of feeling weak and c/o left elbow reddness, pain and swelling. found to be tachycardiac, febrile to 102.8, hypotensive to 85-90 systolic. given a total of 5l of ns, vancomycin and rocephin iv. questionable reaction to vancomycin as pt developed marked reddness to face/neck and arm infusion site. given benadryl and tylenol. also, rec'd demoral 12.5 mg iv for rigors. responded well to fluid boluses and being admitted to m/sicu for closer monitor and further management of her left arm cellulitis and ? sepsis. arrived to m/sicu at 1645. review of system: neutropenic precautions neuro: alert and oriented x 3 at present. some difficulty w/ appro. words at times. perla. healing scare to left side of head just behind ear to top of head. c/o left elbow pain (cool compress applied). pulm: ra sats 89-90%. placed on 4l nc w/ sats to 94-97%. lung sounds clear in upper lobes/diminished in bases. rr regular and unlabored. no cough noted. cv: st with rare pvc's. bp stable at present. finished additional 2l ns (total 7l) on arrival to . temp at present 100.2. edema to left arm noted. piv x 2 (#18/#20). gi/gu: + bs noted. abd is soft, nt, nd. no bm. npo except for ice chips/meds. foley in place w/ good uo. skin: reddened elbow noted and marked. scheduled for x-ray. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Urinary tract infection, site not specified Unspecified septicemia Sepsis Pulmonary collapse Anxiety state, unspecified Malignant neoplasm of parietal lobe Cellulitis and abscess of upper arm and forearm Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Dehydration Home accidents Effusion of joint, upper arm

allergies: sulfa (sulfonamides) / percocet attending: chief complaint: fever, neutropenia, and swollen, painful left elbow major surgical or invasive procedure: picc line placement history of present illness: 61-year-old right-handed woman with glioblastoma multiforme, s/p subtotal resection on , involved-field cranial xrt, and chemotherapy (last taken on ). she developed a fever to 102 f, hypotension to sbp 90s today, and came to our emergency room. husband first noted left elbow 3-4 weeks ago which resolved in 2 days after application of neosporin (there was a question of spider bite). then 3 days ago she noted erythema which increased and associated with increasing edema and tenderness. today, the patient was practically unable to move elbow due to pain. she experienced fever and chills that began yesterday, but she did not take her temperature. her review of system is notable for a new dry cough x 6 days. she also developed diarrhea but stopped 3 days ago when she stopped taking colace. she has fatigue but no sob, congestion, abdominal pain, dysuria, bright red blood per rectum, or melena. there was no trauma to elbow. there was no recent sick contacts or travel. regarding her oncologic history, her symptoms began in late with headache, word-finding difficulties, memory loss, and confusion. she was found to have a left parietal brain lesion. after subtotal resection on , underwent involved-field xrt with concurrent temozolomid. she also received 1 treatment with cyberknife radiosurgery to an enhancing lesion in the right occipital lobe, together with temozolomide. in the emergency room, her temperature was 102.6 f, hr 130s (sinus tachycardia), and systolic bp 90s-100s (baseline sbp 120s-130s). her wbc was 0.3 with no neutrophils or bands. her u/a showed no wbc but there was nitrates and bacteria. her serum lactate was 3.9. blood and urine cultures were sent. her chest cta was negative for pulmonary embolism, but there was mild left lung apical patchy ground-glass opacity; there was a question of atelectasis versus pneumonia. she received oxygen at 7 liters via nasal cannula in the emergency room but her systolic bp persisted in 90s-100s. emergency department did not start on sepsis protocol because her serum lactate was not > 4 and she was responsive to fluid, despite the elevated temperature, heart rate, and wbc. past medical history: glioblastoma multiforme of left temporoparietal lobe anxiety social history: never smoked, drinks alcohol on rare occasions. lives with husband. worked as secretary. family history: father had lung cancer. mother had disease. her siblings are all healthy. she has 1 son and 1 daughter, and both of them are healthy. physical exam: physical examination: vital signs: temperature 102.6 f in emergency department; current temperature 100.2 f; heart rate 108; blood pressure 106/56; respiratory rate 16; oxygen saturation 99% on 2 liters. gen: cushingnoid faced woman, fatigued appearing, otherwise in no acute distress lying in bed heent: perrla, eomi, anicteric, pale conjunctival membranes, dry mucous membranes, +scars on scalp from prior neurosurgery neck: no lad cv: rrr tachycardic, nl s1, s2 no m/r/g pulmonary: cta bilaterally abdomen: nabs, soft, nt/nd, well-healed vertical incision extremities: lue elbow has 5-cm area of erythema, warmth, mild fluctuance, and tenderness to palpation. she is unable to abduct at elbow more than 5 degrees secondary to pain. her lower extremities are cool, without c/c/e. she has 2+ dorsalis pedis pulses bilaterally neurologic examination: her mental status is intact. she is awake, alert, and oriented x 3. her language is fluent with good comprehension. cn ii-xii are intact. her motor strength is motor in rue; lue examination limited due to pain at elbow. in the lower extremities, she has 4-/5 strength bilaterally at thigh flexors, 5/5 strength at quadriceps, hamstrings, foot dorsiflexion, and plantar flexion. her reflexes are 2- but her ankle jerks are absent. she has downgoing toes. sensory examination reveals normal sensory examination. coordination examination does not reveal dysmetria. her gait is steady. she does not have a romberg. pertinent results: 12:10pm wbc-0.3* rbc-4.61 hgb-14.8 hct-41.3 mcv-90 mch-32.1* mchc-35.8* rdw-13.9 12:10pm neuts-0* bands-0 lymphs-65* monos-35* eos-0 basos-0 atyps-0 metas-0 myelos-0 12:10pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-1+ polychrom-occasional 12:10pm plt smr-low plt count-140* 12:10pm pt-13.5* ptt-24.5 inr(pt)-1.2 12:10pm sed rate-70* 12:10pm glucose-114* urea n-14 creat-0.6 sodium-138 potassium-3.4 chloride-101 total co2-24 anion gap-16 12:10pm alt(sgpt)-35 ast(sgot)-22 alk phos-88 tot bili-0.6 01:05pm lactate-3.9* 01:07pm ck-mb-notdone ctropnt-<0.01 01:07pm crp-67.5* 01:07pm ck(cpk)-11* 02:08pm urine rbc-0 wbc-0 bacteria-mod yeast-none epi-0-2 02:08pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 02:08pm urine color-straw appear-clear sp -1.023 l elbow xray : four radiographs of the left elbow demonstrate no joint effusion. no fracture. no cortical fragmentation to suggest osteomyelitis. regional soft tissues are unremarkable. impression: unremarkable radiographs, left elbow. mri of l elbow: mr left elbow without contrast: there is a moderate elbow joint effusion. the bone marrow appears normal in signal intensity characteristics. there is circumferential edema within the subcutaneous tissues about the elbow. there is fluid signal intensity in the region of the olecranon bursa, suggestive of bursitis. there is more confluent high signal intensity surrounding the musculature at the elbow joint. it is not clear if this represents dense edema or frank fluid, as this study is limited without intravenous contrast. also noted is diffuse increased signal intensity within the musculature about the elbow, suggestive of myositis. impression: 1. moderate elbow joint effusion. 2. diffuse increased signal intensity within the musculature about the elbow, consistent with nonmyositis. 3. olecranon bursitis. 4. edema within the subcutaneous tissues about the elbow, suggestive of cellulitis. ct of the chest: there are no significant axillary, mediastinal, or hilar lymph nodes. there is a small hypodense area in the left lobe of the thyroid measuring 1.2 x 0.8 cm. ultrasound could be performed for further evaluation. there is no pericardial effusion. the heart is of normal size. the great vessels are unremarkable. there is no evidence of aortic dissection. there is fluid in the pericardial recess anterior to the aorta, which is unchanged when compared to prior study. the pulmonary artery is normal size. there are no filling defects in the pulmonary artery branches. there is no evidence of pulmonary embolism. the airway is patent to level of subsegmental bronchi. there are subsegmental atelectasis in the right middle lobe and lower lobes. there are emphysematous changes in the lungs. there is a patchy ground-glass opacity in the left upper lobe near the apex that is new when compared to the prior study and of unclear significance. it most likely represents an area of pneumonia. there are no pleural effusions. limited images of the upper abdomen do not reveal significant abnormality. impression: 1. no evidence of pulmonary embolism. 2. emphysema. 3. subsegmental atelectasis. 4. small patchy ground-glass opacity in the left apex of unknown clinical significance. it could representa small focus of pneumonia. it is new when compared to the prior study from , . attention on follow to confirm resolution is recommended. ekg : sinus tachycardia modest diffuse nonspecific st-t wave abnormalities since previous tracing of , sinus tachycardia rate slower and st-t wave abnormalities are less prominent 1:20 pm swab source: left elbow bursa pus. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final ): staph aureus coag +. rare growth. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin-------------<=0.25 s penicillin------------ =>0.5 r anaerobic culture (final ): no anaerobes isolated. bcx : no growth (final) bcx : no growth (final) brief hospital course: this is a 61-year-old woman with glioblastoma multiforme, s/p involved-field xrt, surgery, involved-field cranial irradiation, and chemotherapy presented with neutropenic fever, left elbow bursitis/cellulitis, uti, and possible pneumonia on chest ct. 1. neutropenic fever/hypotension: in the , the patient was aggressively fluid resuscitated, and her blood pressure responded without any pressor. sources of infection included left elbow bursitis/cellulitis, pneumonia, and uti. in the setting of neutropenic fever, the patient was started on broad spectrum antibiotics with vancomycin, ceftazidime, and azithromycin (for atypical pneumonia), as well as gentamicin x 1 dose in context of continued destabilization and need for double gram negative coverage. central venous pressure improved to over the course of 48 hours, and blood pressures stabilized. patient had no more fever. patient received stress dose steroids as well as neupogen. orthopedics was consulted for her left elbow bursitis/cellulitis. x-ray and mri did not reveal osteomyelitis. orthopedics felt that possible bursitis; however, symptoms improved with antibiotics. on transfer to the omed service, the patient was afebrile and hemodynamically stable. she was continued on neupogen, vancomycin, ceftazidime, and azythromycin. on , given her enterococcal uti is pansensitive and the patient no longer neutropenic, vancomycin and ceftazidime were discontinued and cefazolin iv was started to cover both enteroccocus and left elbow cellulitis. neupogen was discontinued on . azythromycin was discontinued after completion of 7 day course on . also, on , the left elbow had increased warmth and erythema as well as enlargement of fluid sac. also, patient's wbc increased despite the discontinuation of neupogen was disproportionately high with a presence of dohl bodies and toxic granulations on smears suggestive of undertreated or persistant infection. thus, cefazolin was discontinued, and vancomycin was restarted on . the left elbow responded well to vancomycin and the fluid sac broke open spontaneously, draining pus. the patient had a picc line placed in her right arm and was discharged with 10 more days of vancomycin to finish a 2 week course. 2. hypoxia: the paitnet required o2 supplement temporarily. cxr showed small bilateral pleural effusions and atelectasis. with incentive spirometry use, the patient's sat improved to 95% on ra. 3. glioblastoma multiforme: chemotherapy was held. continued on keppra and decadron. given on steroids, fs blood glucose was checked 4 times daily and they were mostly in the 100's, not requiring a long acting insulin. 4. transaminitis: she had elevated ast and alt from . rechecked and was normal. 5. anxiety: lorazepam prn helped. 6. prophylaxis: sliding scale insulin and finger stick blood glucose given on steroids; ppi, subcutaneous heparin, and bowel regimen were administered as well. 7. fen: regular diet 8. full code: patient does not want prolonged intubation if m.d.s think poor recovery. medications on admission: decadron 4 mg p.o. tid keppra 1000 mg p.o. protonix 40 mg p.o. colace 100 mg p.o. lorazepam 1 mg p.o. p.r.n. percocet 1-2 tablets p.o. p.r.n. g-csf 300 mcg x 10d, started 2d ago pentamidine, aerosolized temodar chemotherapy discharge medications: 1. saline flush 0.9 % syringe sig: five (5) ml injection sash as needed for flushing for 10 days. disp:*qs for 10 days * refills:*0* 2. heparin flush 100 unit/ml kit sig: three (3) ml intravenous sash as needed for iv abx therapy for 10 days. disp:*qs for 10 days * refills:*0* 3. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. dexamethasone 4 mg tablet sig: one (1) tablet po q8h (every 8 hours). 7. vancomycin 1,000 mg recon soln sig: one (1) gm intravenous q 12h (every 12 hours) as needed for for cellulitis/bursitis for 10 days. disp:*qs for 10 days gm* refills:*0* discharge disposition: home with service facility: healthcare discharge diagnosis: left elbow bursititis/cellulitis urinary tract infection dehydration glioblastoma multiforme discharge condition: afebrile, no longer neutropenic, improved left elbow and feeling good. discharge instructions: return to the emergency department or call dr. if you develop fever, chills, nausea, vomiting, worsening pain or redness in your left elbow, chest pain, shortness of breath, or any other concerning symtpoms. take your medications as instructed. keep your follow up appointments. followup instructions: provider: mri phone: date/time: 12:15 provider: , md phone: date/time: 2:00 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Urinary tract infection, site not specified Unspecified septicemia Sepsis Pulmonary collapse Anxiety state, unspecified Malignant neoplasm of parietal lobe Cellulitis and abscess of upper arm and forearm Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Dehydration Home accidents Effusion of joint, upper arm

allergies: sulfa (sulfonamides) / percocet / dilantin attending: chief complaint: new right occipital lesion on mri major surgical or invasive procedure: right occipital steriotactic biopsy. history of present illness: is a 61 year-old right-handed woman with a multifocal left temporal glioblastoma multiforme. she is here with her husband, brother and son after a head mri. her walking is now normal without any imbalance and she no longer is using the cane. her decadron had been lowered one month ago but she developed severe headaches so this was increased back up to the 2 mg daily. the headaches are less intense but occur most often on awakening in the left fronto-parietal region but are not daily. she still gets floaters in the left eye and feels that her vision is "off" at times. there is tingling of the right 4th and 5th digits. her neurologic history began on with word finding difficulty, memory loss, confusion and holocranial dull headache. she came to our emergency room and a head mri revealed a left temporal mass. only 80% of the tumor could safely be resected. pathology revealed glioblastoma. this was followed by involved-field radiation with temodar 75 mg/m2. cyberknife radiation was given to the right occipital nodule on . mri on the showed right occipital enhancing lesion, therefore dr decided to do steriotactic brain bx to differenciate tumor growth versus radiation necrosis. past medical history: 1. subtotal resection on by , md 2. involved-field cranial irradiation + temodar () to 6000 cgy 3. cyberknife radiation to right occipital lesion on 4. hospitalized /05 for fever, neutropenia and left elbow abscess 5. monthly temodar started 6.glioblastoma multiforme of left temporoparietal lobe 7.anxiety social history: never smoked, drinks alcohol on rare occasions. lives with husband. worked as secretary. family history: father had lung cancer. mother had disease. her siblings are all healthy. she has 1 son and 1 daughter, and both of them are healthy. physical exam: vs: 97.5 hr:95 rr:16 bp:141/83 o2sat:97 ra gen: alert, awake, nad cvs: rrr, normal s1 s2. abd: soft, nt, nd, bowel sounds presernt. extr: no c/c/e. skin:intact. neuro: she is alert and oriented to time, person, and place. language is clear and fluent with good comprehension. pupils are 4 mm and equally reactive. visual fields and eom's are full without nystagmus. hearing is intact to finger rub. face is symmetric and sensation is intact. tongue is midline. palate rises symmetrically. shoulder shrug is strong. there is no drift. strength is . sensation is intact to light touch. reflexes are 2- in the upper extremities and 2+ in the lower. romberg is negative. unable to tandem. gait is normal based and steady. pertinent results: mr head w & w/o contrast 6:51 am mr head w & w/o contrast; mr contrast gadolin reason: asl/wand protocol for stereotactic brain biopsy . contrast: magnevist medical condition: 61 year old woman with glioblastoma. reason for this examination: asl/wand protocol for stereotactic brain biopsy . indication: glioblastoma. wand protocol for stereotactic brain biopsy. technique: multiplanar t1- and t2-weighted images of the brain were obtained, with diffusion-weighted images. post-contrast t1-weighted images were also obtained. findings: again demonstrated are multiple areas of abnormal enhancement within the brain, unchanged. the right medial inferior parietal lobe rounded enhancing lesion and the lesion of the left posterior corpus callosum are unchanged in size and appearance. associated increased t2 signal associated with these lesions is unchanged as well. the left temporal lobe tumor resection site is unaltered, with blood products and mild irregular enhancement. no new sites of abnormal enhancement are detected. impression: no significant change compared to the exam. brief hospital course: , is a 61 year old woman who brought in electively in who underwent right occipital stereotactic biopsy under mac. she had preoperative a mri wand protocol study. patient tolerated procedure well, no intraoperative complications occurred, with minimal blood loss. patient transferred to pacu for close monitoring after 6 hours of stay in transferred to floor. her neurologic exam is same as preoperative state, she still has word finding difficulty, full strength. she has been ambulating, tolerating her diet without difficulty, voiding freely. her headache has been under good control. she has been afebrile and vital signs has been stable throughout her hospital stay. she discharged home with follow up discharge instructions. discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. decadron 4 mg tablet sig: 1/2 tablets(2mg) tablet po once a day: discuss further continuation at the follow up with dr . disp:*14 tablet(s)* refills:*0* 4. tylenol 325 mg tablet sig: 1-2 tablets po every 4-6 hours. discharge disposition: home discharge diagnosis: right occipital lesion discharge condition: neurologically stable. discharge instructions: keep your inscion site dry and clean. do not wet until sture removed.monitor for redness, swelling, or drainage. report fever greater than 101.5, chills or any other neurologic symptoms that may be concerning. followup instructions: follow up in brain clinic() on at 1pm. sture will be removed at the time of follow up. Procedure: Closed [percutaneous] [needle] biopsy of brain Diagnoses: Anxiety state, unspecified Accidents occurring in other specified places Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Malignant neoplasm of temporal lobe Other specified disorders of nervous system

allergies: iodine; iodine containing attending: chief complaint: need for feeding tube major surgical or invasive procedure: peg history of present illness: patient with prolonged history with repiratory failure transferred here for peg placement. past medical history: -s/p appendectomy -h/o polio as a child; wife tells me he was diagnosed in the 's during the polio epidemic; had a headache at the time; no weakness or diarrhea -recent new atrial fibrillation -h/o recent pneumonia -dvt lower extremity physical exam: neuro-alert, disoriented cor-irregularly irregular lungs-cta b/l abd-doft nt/nd ext-no edema pertinent results: 07:48pm glucose-98 urea n-27* creat-0.7 sodium-138 potassium-4.9 chloride-101 total co2-30 anion gap-12 07:48pm alt(sgpt)-23 ast(sgot)-17 alk phos-125* amylase-44 tot bili-0.6 07:48pm lipase-27 07:48pm albumin-3.1* calcium-8.8 phosphate-4.6* magnesium-2.1 07:48pm wbc-9.6 rbc-3.63* hgb-10.2* hct-30.5* mcv-84 mch-28.2 mchc-33.6 rdw-17.0* 07:48pm plt count-222 07:48pm pt-13.7* ptt-26.4 inr(pt)-1.2* brief hospital course: patient had a peg placed on with no complications. tube feeds were restarted. lovenox (therapeutic dose) was started as a bridge to coumadin. patient briefly went into rapid afib which was controlled with b-blockade and calcium channel blockers. a chest ct to follow up his pulmonary disease was also done. this showed improvement of ground glass opacities and pleual effusions with slightly worsening fibrosis. discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 2. insulin regular human 100 unit/ml solution sig: sliding scale injection asdir (as directed). 3. enoxaparin 80 mg/0.8 ml syringe sig: 70 mg subcutaneous q12h (every 12 hours). 4. alprazolam 0.25 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for agitation. 5. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for agitation. 6. warfarin 1 mg tablet sig: one (1) tablet po once (once) for 1 doses. 7. metoprolol tartrate 5 mg/5 ml solution sig: one (1) intravenous q6h (every 6 hours). 8. lansoprazole 15 mg susp,delayed release for recon sig: one (1) po once a day. discharge disposition: extended care facility: discharge diagnosis: s/p peg afib dvt ards pneumonia s/p jejunal resection tear discharge condition: stable discharge instructions: daily inr until . continue lovenox until then. secure g-tube at all times. chem 10 to assess electrolytes in 2 days. free water boluses through tube may need to be adjusted. thank you. followup instructions: as needed Procedure: Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Congestive heart failure, unspecified Atrial fibrillation Gastroesophageal laceration-hemorrhage syndrome Attention to gastrostomy Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity

*allergies: iv contrast neuro: pt awake and most shift, sleeping at times. fam visited most of the day. able to nod answers and trying to speak but remains trached on vent. follows commands and mae. perl 3mm/brisk. no complaints of pain. oob to chair w/ , tolerated well for 4h then returned to bed. no haldol required today. cardiac: a.fib w/o ectopy, hr 79-93, sbp 115-148. a-line is positional, adjust wrist to check bp. hct 31.4, stable. resp: psup 18/ peep 5/ 40%. no vent changes. rr 25-35, but >40 at times, remind to slow breathing and he settles out. o2 sat 98-100%. am abg 7.47/46/122/34. ls coarse upper bilat and coarse lower rl, crakles lower ll. in am, resp sxn'd thick tan plug that occluded in-line sxn cath. cath changed and sputum sent for cx. cxr done this afternoon, awaiting results. gi/gu: tf currently @ goal 55cc/hr (novasource pulmonary). diet need is increased fat, decreased carb. k not repleated as team felt unnecessary at this time. +bs. urine out foley yellow/clear 20-80cc/hr. liquid brown stool this am. fs 129 and 95, riss. id: temp 97.5-98.0, wbc 12.3. blood and sputum cx pending. psychosocial: fam visited most of day, worked w/ case manager regarding rehab placement. fam would like private room @ hosp in . informed that private room may not be possilbe. fam worried about another pt and/or many visitors coming in w/illness and making her husband more ill. no word on available room, but case management is working on it. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Replacement of tracheostomy tube Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Intestinal bypass or anastomosis status Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Other chronic pulmonary heart diseases Acute and chronic respiratory failure Postinflammatory pulmonary fibrosis Pressure ulcer, lower back Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Personal history of poliomyelitis

allergies: iodine; iodine containing attending: addendum: additional procedures: lumbar puncture bronchoscopy , flexible bronchoscopy performed and tracheostomy tube switched to 8 biovona. please follow cuff pressure and keep < 25mmhg. the 8 portex requred pressures of 35mmhg to maintain a seal and the bronchoscopy showed focal malacia at the cuff site prompting the change to the 8 . vent 7.48/29/126 ps 18/5 fio2 0.4 tv 480 mv 17.3 discharge disposition: extended care facility: northeast - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Replacement of tracheostomy tube Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Intestinal bypass or anastomosis status Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Other chronic pulmonary heart diseases Acute and chronic respiratory failure Postinflammatory pulmonary fibrosis Pressure ulcer, lower back Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Personal history of poliomyelitis

allergies: iodine; iodine containing attending: chief complaint: the patient is an 80 year old man with a history of poliomyelitis as a child, new onset atrial fibrillation, and recent gi bleed now presenting with respiratory failure. the patient problems began in late when he presented to his cardiologist with increased shortness of breath and was found to be in rapid afib and congestive heart failure. he went for a cardiac catheterization at the time which showed severe lad disease. the cath procedure was complicated by a presumed reaction to the contrast dye. he was noted to have a bilateral pneumonia and was started on doxycycline. the patient was discharged home later afebrile and on warfarin and lasix. he epresented about a week later to the hospital, febrile and with hematemesis and brbpr--his bp was 80/38 with a hr of 125; inr was 6.2. he was found to have bleeding jejunal diverticulas and - tear--both of which were surgically corrected. he underwent a head ct for "sundowning" which was normal by report. he remained intubated, febrile, was started on vanco, cefepime and flagyl and transferred to for further care. major surgical or invasive procedure: percutaneous tracheostomy history of present illness: this is a 80 year old male with recent admit to hospital due to acute dyspnea. he has a new onset a- fib, chf, s/p jejunal resection on , for bleeding diverticulae. transferred from hospital for failure to wean from vent. since being at , he has remained intermittantly febrile (fever curve has improved). he is noted by the nursing staff to intermittanly follow simple commands, moving all extremities, and has become agitated at times requiring ativan, fentanyl, haldol and more recently seroquel. he gets ativan 1 mg tid standing, fentanyl patch in addition to prn's of those. his respiratory status has remained tenuous and has been diagnosed with atypical pneumonia vs. early ards. he was transferred to the surgical service of on for failure to wean from vent. he was febrile and hypotensive after transfer, and pressors were started. the pressors were weanted and he was felt to be in ards. he was trached on and has had generally not been able to be weaned since that time. he has completed courses of empiric antibiotics. he has been slowly getting better since that time, and is being transferred to the micu service for failure to wean from the ventilator. past medical history: past medical history: -s/p appendectomy -h/o polio as a child; wife tells me he was diagnosed in the 's during the polio epidemic; had a headache at the time; no weakness or diarrhea -recent new atrial fibrillation -h/o recent pneumonia social history: social history: -married and lives with wife -no tobacco or alchol use -worked as a machinist family history: family history: -father had a stroke at 90 -mother died of old age -no h/o neuromuscular problems physical exam: v: tm 99.2 115/52 (98/45-146/75) 82 (66-83) simv/ps 450x23 40% 7.38/50/183 breathing at 36 pip 25 plat 29 (yesterday) i/o 990/970 (urine) gen: no apparent distress. heent: op clear, mm dry neck: no jvd resp: clear bilaterally cv: irreg, tachy normal s1s2 no murmurs abd: soft ntnd midline incision well healed. ext: scd's in place. no cyanosis, clubbing, edema neuro: responsive to voice. denies pain. pertinent results: 12:58am blood wbc-9.2 rbc-3.91* hgb-11.6* hct-33.4* mcv-86 mch-29.5 mchc-34.6 rdw-15.2 plt ct-123* 12:58am blood neuts-80.3* lymphs-13.4* monos-3.3 eos-1.8 baso-1.1 12:58am blood pt-16.0* ptt-29.3 inr(pt)-1.5* 01:45am blood ret aut-2.8 12:58am blood glucose-98 urean-26* creat-1.1 na-137 k-4.0 cl-100 hco3-28 angap-13 12:58am blood alt-20 ast-28 ld(ldh)-500* alkphos-98 totbili-1.3 01:30am blood lipase-21 09:03pm blood probnp-* 01:30am blood calcium-7.0* phos-2.9 mg-1.8 01:32am blood caltibc-124* trf-95* 02:17pm blood hapto-316* 05:57pm blood tsh-2.5 05:57pm blood cortsol-13.9 . histoplasma ag neg adenovirus pcr neg legionella pneumophila antibody neg mycoplasma pneumoniae antibody igm neg chlamydia pneumoniae antibody panel neg mycoplasma pneumoniae antibody, igg pos . bal no growth and neg cytology lp negative for infection and cytology bronchoalveolar lavage no growth and neg cytology 9:46 am rapid respiratory viral screen & culture rapid respiratory viral antigen test: negative viral culture cytomegalovirus-like cytopathic effect . pcxr mild interstitial pulmonary edema has improved over the past five days. moderate cardiomegaly persists. there is no focal pulmonary abnormality to suggest pneumonia. feeding tube ends in the proximal jejunum. tracheostomy tube is canted in the trachea and should be evaluated clinically to determine the position is acceptable. there is no pleural effusion or pneumothorax. . cxr: global interstitial abnormality, low lung volumes . ekg atrial fibrillation with a controlled ventricular response. delayed r wave transition. downsloping st segment depressions in leads v4-v6 suggest the possibility of lateral ischemia. compared to the previous tracing of the rate is diminished and the downsloping st segment depressions in the lateral precordial leads are slightly more prominent. clinical correlation is suggested. intervals axes rate pr qrs qt/qtc p qrs t 80 0 72 320/355.71 0 -4 -118 . echo: ef60%/2+mr/1+tr . ct chest: 1. bilateral ground-glass opacities, fibrotic changes, pleural effusions and possible lower lobe consolidations. these findings may be consistent with ards. 2. no evidence of pulmonary embolism within the limitations of the study. . us l le: left lower extremity dvt extending from the common femoral vein to the popliteal vein. . tte=ef60%, mild tr/mr; (cath=30%stenosis lad, mod-severe mr, ef 41%) . eeg: no actual sharp or epileptiform discharges were seen. no electrographic seizures were recorded. this eeg is most consistent with an encephalopathy. . ct head: no intracranial hemorrhage. no evidence of a major vascular territory acute infarct . upper ext u/s negative for dvt brief hospital course: the patient is an 80 year old man with a h/o recent onset atrial fibrillation, gi bleed, and ards now presents with continued respiratory failure. his neurologic exam demonstrates obtundation--perhaps related to multiple sedating meds. his head ct shows 2 hypodensities in the right cerebellum that may be new. the neurologic differential for respiratory insufficency would include: muscle- critical illness myopathy; nmj: myasthenia , nerve: aidp (had reflexes), critical illness polyneuropathy; cord: high cervical cord injury (does not seem paraparetic); anterior cell- als, west , enteroviruses (does have h/o questionable h/o polio). impression is for a non-neurologic cause of his respiratory failure (pna, ards). pt secondary to his respiratory failure underwent tracheostomy on /5. . #) respiratory failure - patient was trached . now oxygenating and ventilating adequately. increased secretions but afebrile, cxr with improved edema and no pna. large amount of measured dead space contributing to difficulty weaning. ******continue high fat and low-carb diet to avoid worsening tachypnea, pco2******* goal is to gradually decrease pressure support 18/5->15/5 as tolerated on . continue nebs prn. increased cuff pressures to 35 so tracheostomy tube was changed . . #) hyprenatremia - patient developed hypernatremia of unclear etiology. possibly secondary to na retention. continuing tf with free h20 boluses with good results. . #) encephalopathy and agitation - d/ced standing haldol, use sparingly prn. minimize sedation for now and avoid benzos or narcotics. patient mental status clearing, able to follow voice commands (squeeze hand and wiggle toes). . #) left leg dvt - holding coumadin on due to supratherapeutic inr. no pe on cta. restart coumadin once inr<3 for goal of 2.0-3.0 for at least 6 months. . #) h/o chf - echo ef60%/2+mr/1+tr with pa diastolic hypertension. . #) atrial fibrillation - supratherapeutic inr initially upon transfer to micu. resumed coumadin with goal inr 2.0-3.0 for afib. coumadin was held on due to upratherapeutic inr. resume coumadin when inr<3.0. continued metoprolol for rate control. . #) fen - continued insulin sliding scale. low-carboohydrate tube feeds. . #) prophylaxis - continued prevacid, bowel regimen, supratherapeutic inr. . #) access - d/ced a line , dobhoff . #) precautions - for vre colonization . #) code - full, discussed with wife . #) communication - with wife . #) pt/ot - seen by pt, encourage oob to chair and strength-building . #) dispo - to rehab. medications on admission: -seroquel 25 mg (started today) -metoprolol -ativan 0.5-1 mg q4hr prn -levofloxacin -fentanyl patch -haloperidol 0.5-1 qhs prn -nebs -insulin sc -fentanyl 12.5-25 mcg iv q2hr prn -protonix . . meds on transfer from sicu: lansoprazole oral suspension 30 mg ng daily acetaminophen (liquid) 325 mg po q4-6h:prn magnesium sulfate 2 gm / 100 ml d5w iv prn albuterol-ipratropium puff ih q6h metoprolol 50 mg po tid albuterol 6 puff ih q4h:prn midazolam hcl 0.5 mg iv q1h: prn artificial tear ointment 1 appl ou prn miconazole powder 2% 1 appl tp tid:prn calcium gluconate 2 gm / 100 ml d5w iv prn nystatin oral suspension 5 ml po qid:prn digoxin 0.25 mg iv daily start: oxycodone-acetaminophen elixir ml po q4-6h:prn haloperidol 10 mg po bid potassium chloride 40 meq / 100 ml sw iv prn heparin flush cvl (100 units/ml) 1 ml iv daily:prn warfarin 5 mg po daily insulin sc (per insulin flowsheet) sliding scale . previous antibiotics: vanco (stopped ) flagyl (stop ) discharge medications: 1. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 2. acetaminophen 160 mg/5 ml solution sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 3. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed. 4. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 5. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 6. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 7. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 9. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed: 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen daily and prn. inspect site every shift . 13. coumadin 1 mg tablet sig: holding tablet po at bedtime: please resume coumadin when inr<3.0 with goal inr of 2.0-3.0. will need to be anticoagulated for 6 months until . discharge disposition: extended care facility: northeast - discharge diagnosis: primary diagnosis: ards secondary diagnosis: atrial fibrillation (since ) chf ef 60% 2+mr (last echo ) phtn dvt right leg this hospitalization h/o polio in childhood discharge condition: good discharge instructions: please take medications as prescribed. please keep follow-up appointments. if you have any worsening respiratory distress, change in mental status, fevers/chills or any other worrying symptoms, please your md. current vent settings: cpap w/ & w/o ps pressure support level: 15 cm/h2o peep: 5 cm/h2o fio2: 40 % continue with high-fat, low carbohydrate tube feeds given vd/vt of .68 followup instructions: please schedule an appointment to see your primary care physician 1 week of discharge. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Replacement of tracheostomy tube Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Intestinal bypass or anastomosis status Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Other chronic pulmonary heart diseases Acute and chronic respiratory failure Postinflammatory pulmonary fibrosis Pressure ulcer, lower back Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Personal history of poliomyelitis

allergies: crestor attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 64f hx cad s/p mi in with 2 des placed to the plad, icmy ef 45-50%, htn, hlp who presented to the ed with chest burning. at 4am she awoke with substernal chest burning radiating to the back associated with nausea, no vomiting or dyspnea. . in the ed, she was found to have ekg changes with st elevations in v1-v2. she was given heparin, plavix loaded, full strength aspirin and morphine/slntg for pain. catheterization demonstrated total occlusion of the lad in the proximal portion of her previous stent. thrombectomy was performed and another des was placed. she was transferred to the ccu for further management. . upon arrival to the ccu, she was chest pain free and felt comfortable. she was on a nitroglycerin drip and was hemodynamically stable. past medical history: past medical history: 1. cardiac risk factors: -diabetes, +dyslipidemia, +hypertension 2. cardiac history: anterior stemi in with 2 des in lad 3. other past medical history: - pad - ischemic cm with ef 45% - htn - hlp social history: social history - tobacco history: never smoked - etoh: does not drink - illicit drugs: no drugs family history: family history: - strong family history of cardiac disease in her first and second degree relatives physical exam: general: nad. oriented x3. mood, affect appropriate. neck: supple, unable to appreciate jvd due to position. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. mild bibasilar rales. abdomen: soft, ntnd, obese. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: 06:30am blood wbc-5.1 rbc-3.96* hgb-10.5* hct-32.6* mcv-82 mch-26.4* mchc-32.1 rdw-13.4 plt ct-208 05:30am blood wbc-5.3 rbc-3.96* hgb-10.5* hct-32.6* mcv-82 mch-26.6* mchc-32.2 rdw-13.3 plt ct-198 01:27am blood wbc-5.0 rbc-4.04* hgb-10.8* hct-33.3* mcv-83 mch-26.6* mchc-32.3 rdw-13.4 plt ct-208 05:12am blood wbc-5.4 rbc-4.08* hgb-10.9* hct-33.7* mcv-83 mch-26.7* mchc-32.3 rdw-13.3 plt ct-210 06:55am blood wbc-8.7 rbc-4.57 hgb-12.3# hct-38.4# mcv-84 mch-26.9* mchc-32.0 rdw-13.4 plt ct-281 05:30am blood neuts-60.5 lymphs-31.7 monos-5.5 eos-1.8 baso-0.4 06:30am blood plt ct-208 06:30am blood pt-12.1 ptt-29.1 inr(pt)-1.1 06:30am blood glucose-121* urean-12 creat-0.7 na-141 k-4.6 cl-107 hco3-28 angap-11 06:55am blood glucose-179* urean-18 creat-0.8 na-137 k-7.9* cl-102 hco3-25 angap-18 06:30am blood alt-27 ast-37 ld(ldh)-486* alkphos-41 totbili-0.5 05:30am blood alt-30 ast-46* ld(ldh)-605* alkphos-46 totbili-0.5 08:58pm blood ck(cpk)-4058* 01:01pm blood alt-56* ast-346* ld(ldh)-657* ck(cpk)-3786* alkphos-50 totbili-0.3 01:01pm blood lipase-19 05:12am blood ck-mb-133* mb indx-5.1 ctropnt-3.84* 08:58pm blood ck-mb-423* mb indx-10.4* ctropnt-6.69* 06:55am blood ctropnt-<0.01 06:30am blood albumin-3.8 calcium-9.1 phos-3.5 mg-2.0 01:01pm blood mg-2.0 cholest-204* 06:30am blood %hba1c-6.6* eag-143* 05:30am blood %hba1c-6.5* eag-140* 01:01pm blood triglyc-47 hdl-64 chol/hd-3.2 ldlcalc-131* , f 64 cardiovascular report cardiac cath study date of *** not signed out *** brief history: this is a 65 year-old woman with hypertension, dyslipidemia, and coronary artery disease who presented with refractory chest pain despite aggressive early medical management. her coronary history is notable for an anterior st-elevation myocardial infarction on , at which time culotte stenting of the proximal lad and d1/s1 branches. a 2.75x16mm taxus stent was used in the septal-lad and a 3.0x12mm taxus stent was used in the diagonal-lad. rca stenosis (80-90%) was not intervened upon at that time. indications for catheterization: coronary artery disease, canadian heart class iv, unstable. prior q wave anterior mi, . prior ptca . procedure: coronary angiography via percutaneous entry of the right common femoral artery with a 6f sheath. 4fr jl4 catheter was used to engage the left coronary artery. 4fr al2 catheter was used to sub-selectively engage the right coronary artery. percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. hemodynamics results body surface area: 1.69 m2 hemoglobin: 12.3 gms % fick **pressures left ventricle {s/ed} -/28 aorta {s/d/m} 157/86/115 **cardiac output heart rate {beats/min} 83 rhythm sinus o2 cons. ind {ml/min/m2} 125 other hemodynamic data: the oxygen consumption was assumed. **arteriography results morphology % stenosis collat. from **right coronary 1) proximal rca discrete 80 2) mid rca discrete 80 2a) acute marginal normal 3) distal rca normal 4) r-pda normal 4a) r-post-lat normal **arteriography results morphology % stenosis collat. from **left coronary 5) left main normal 6) proximal lad discrete 100 12) proximal cx normal 13) mid cx normal 13a) distal cx normal 14) obtuse marginal-1 normal 15) obtuse marginal-2 normal 16) obtuse marginal-3 normal **ptca results lad ptca comments: a 6fr xblad 3.5 guiding catheter was engaged into the lmca and a choice pt es guidewire was used to cross the lesion. an otw balloon was used to ensure intralumenal postion and following that an export catheter was used for manual thrombectomy for 8 passes. following thombectomy, angiography revealed a significant proximal lad stenosis. a 2.5x20mm apex balloon was used to predilate the lesion and a 2.75x28mm promus des was placed at the lesion in the proximal lad to 12atm. a 3.25x15mm nc quantum apex balloon was used to post-dilate the stent to 22 atm. timi 0 flow was present prior to the intervention and timi iii flow at the end. no complications. a 6fr angioseal device was deployed successfully in the right cfa with excellent hemostasis. technical factors: total time (lidocaine to test complete) = 1 hour 12 minutes. arterial time = 1 hour 10 minutes. fluoro time = 31.7 minutes. irp dose = 2719 mgy. contrast injected: non-ionic low osmolar (isovue, optiray...), vol 280 ml premedications: midazolam 0.5 mg iv fentanyl 75 mcg iv asa 325 mg p.o. clopidogrel 600mg nitroglycerine gtt anesthesia: 1% lidocaine subq. anticoagulation: heparin 3000 units iv other medication: eptifibatide 13.6ml (2mg/ml) ivb f/b 11.5ml/hr (75mg/100ml) cardiac cath supplies used: - , choice pt extra support 300cm 2.0mm , apex rx 20 2.5mm , apex rx 20 2.0mm , quantum maverick 12mm 3.25mm , quantum maverick 15mm 6fr cordis, .75 6fr cordis, xblad 3.5 6fr , angioseal vip 2.75mm , promus rx 28mm 6fr , export aspiration catheter - allegiance, custom sterile pack - merit, left heart kit - , priority pack 20/30 comments: 1. selective coronary angiography of this right-dominant system demonstrated severe 2 vessel cad. the lmca was normal. the lad was totally occluded at the proximal segment of the prior stent. the lcx was normal with a large om branch. the dominant rca, which had an anomolous origin in the left coronary cusp, was only sub-selectively engaged, and had 80% stenoses in the proximal and mid-vessel segments, which were not significantly different from images during her catheterization. 2. limited resting hemodynamics revealed elevated left-sided filling pressures with a measured lvedp of approximately 28mmhg. systemic arterial pressure was elevated with a measured central aortic pressure of 157/86/115. 3. left ventriculography was deferred. 4. successful thrombectomy and pci to the plad with a 2.75x28mm promus des. 5. angioseal to the right cfa site. 6. no complications. final diagnosis: 1. severe 2 vessel cad. 2. elevated left-sided filling pressures. 3. continue asa and clopidogrel indefinitely. 4. continue integrillin for 18hr post-pci. 5. repeat echocardiography and consider elective revascularization of rca disease. 6. successful pci to the plad with promus des. 7. angioseal to the right cfa. 8. no complications tte the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is severe regional left ventricular systolic dysfunction with akinesis of the anterior wall, septum and apex. the remaining segments contract normally (lvef = 25%). no masses or thrombi are seen in the left ventricle. there is a distal septal post infarction ventricular septal rupture (vsr). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: severe regional left ventricular systolic dysfunction, c/w extensive anterior infarction. post-infarction distal ventricular septal rupture. compared with the prior study (images reviewed) of , regional wall motion abnormalities are significantly more extensive and the ventricular septal rupture is new. findings discussed with the ccu team including dr. . tte the left atrium is normal in size. a patent foramen ovale is present with premature appearance of saline contrast in the left atrium after intravenous injection. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction visualized on the limited views with septal and apical near akinesis. no definite ventricular septal defect is identified, though a small systolic color flow doppler jet is seen near the apex of the right ventricle (clip #) . right ventricular chamber size and free wall motion are normal. the mitral valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: patent foramen ovale. no definite ventricular septal defect identified normal left ventricular cavity size with regional systolic dysfunction. compared with the prior study (images reviewed of ), no definite color flow signal of a vsd is seen and a pfo is now identified. cxr no acute cardiopulmonary pathology brief hospital course: 64 year old female with hypertension, hyperlipidemia, coronary artery disease, infarct-related cardiomyopathy with an ef 45%, cad s/p plad stent after stemi, hlp, htn who presents with chest pain found to have st elevations on ekg with total occlusion of the lad on cath. . # stemi/cad: on cardiac catheterization, ms. was found to have total occlusion of the lad in the proximal area of her previous stent, thrombectomy and drug eluting stent placement were performed. she remained hemodynamically stable after the procedure for the remainder of her hospital course and was free of chest pain, dyspnea or palpitations. cardiac enzymes peaked and declined appropriately. she received integrillin post-cath per protocol. she was initially on a nitroglycerin drip, which was weaned shortly after arrival to the ccu. once heart rate improved to 70s-80s, her metoprolol was restarted. aspirin 325mg, plavix 75mg were started. she was started on crestor 40 for acute mi in spite of having a past history of myalgias with statin use; throughout her hospitalization she refused her statin intermittently. ct surgery was consulted and they wil see her as an outpatient to discuss the possibility of cabg in the future. . # concern for vsd, now resolved: she had a post-catheterization echocardiogram, which was significant for color-flow imaging suspicious for vsd. however, the patient had no murmur, was entirely hemodynamically stable, and repeat echo with bubble study performed on clarified that there was no vsd. the patient was found to have a patent foramen ovale with valsalva. echo also demonstrated a small right ventricle which likely contributed to the colour flow imaging appearance of abnormal flow. . # schf: hx of icmy with ef 45-50% with 2+ tr. lvedp at end of case 28 suggesting fluid overload, with likely worsening ef. echocardiogram on shwoed a worse ef of 25%, but repeat echo on showed improvement of ef with improvement in septal wall motion. her oxygen saturations remained good throughout her hosptalisation, and she did not have any other evidence of fluid overload. her beta and ace inhibitor were restarted once blood pressures improved, and will require continued titration as an outpatient as we were unable to uptitrate her ace due to blood pressure concerns. . # hyperlipidemia: she as difficulty with crestor and lipitor with myalgias, appears to have been on/off statins recently. last ldl was 299. she was restarted on her home dose of crestor 20mg three times per week and will follow up with lipid clinic for further management of her hypercholesterolemia. . # hypertension: low-normal bp during this admission. as blood pressure improved, we restarted her on metoprolol and lisinopril, which will need further uptitration as an outpatient. . transitional issues: - she will followup with dr. in clinic and will need uptitration of her antihypertensive medication as tolerated. - given her history of myalgias with statin therapy, her home dose statin (crestor 20mg 3 days per week) and will need to followup in lipids clinic for optimisation of her medical management. - she will followup with cardiothoracic surgery regarding the possibility of future cabg. medications on admission: ibuprofen - 600 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day for blood pressure metoprolol succinate - 100 mg tablet extended release 24 hr - one tablet once a day nifedipine - 30 mg tablet extended release - 1 tablet(s) by mouth once a day rosuvastatin - 20 mg tablet - 1 tablet(s) by mouth daily acetaminophen - 500 mg tablet - 2 tablet(s) by mouth three times a day as needed for pain also called tylenol aspirin - 81 mg tablet, delayed release (e.c.) - 2 tablet(s) by mouth once a day discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 4. toprol xl 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 5. crestor 20 mg tablet sig: one (1) tablet po 3 days/ week. 6. ibuprofen 600 mg tablet sig: one (1) tablet po three times a day as needed for pain. discharge disposition: home discharge diagnosis: coronary artery disease ischemic cardiomyopathy (weak heart muscle, ef 45%) hypertension dyslipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you were admitted for a heart attack, which was treated with a drug-eluting stent. ultrasound imaging of the heart showed some reduction in function due to the heart attack. medication changes: increase aspirin 325mg daily indefinitely start plavix 75mg daily for minimum of one year decrease lisinopril to 10mg daily stop nifedipine *otherwise, continue your medications as usual* your cholesterol has been an issue, the numbers are very high but you are unable to tolerate many of the cholesterol medications. we scheduled you an appointment in the lipid clinc, this is to help find a medication(s) you can tolerate which will help to lower your cholesterol. *follow a low cholesterol, low fat diet if you have chest pain at home you can take nitroglycerin under your tongue as directed. if the pain does not go away, call 911. if you have pain in your right groin, fevers, chills or shortness of breath, call dr. . for your heart failure diagnosis: weigh yourself daily, md if weight goes up more than 2 lbs in 2 days or 5 lbs in 3 days, follow a low salt diet, restrict your fluid intake to 1500 ml/ day. followup instructions: department: internal medicine when: thursday at 3:15 pm with: , md building: (, ma) campus: off campus best parking: free parking on site department: cardiac surgery when: tuesday at 1:30 pm with: , md building: lm campus: west best parking: garage department: cardiac services when: wednesday at 3:40 pm with: , md building: sc clinical ctr campus: east best parking: garage dr. () fri 8:30 am lipid clinic Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Transluminal coronary atherectomy Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Percutaneous transluminal coronary angioplasty status Acute myocardial infarction of anterolateral wall, initial episode of care Other and unspecified hyperlipidemia Ostium secundum type atrial septal defect Long-term (current) use of insulin Old myocardial infarction Family history of ischemic heart disease Acute on chronic systolic heart failure Atherosclerosis of native arteries of the extremities, unspecified

past medical history: 1. hypertension. 2. hypercholesterolemia. 3. chondrocalcinosis. 4. carpal tunnel syndrome. 5. gerd. admission medications: 1. atenolol 25. 2. crestor 10 q.d. 3. uniretic 15/25. allergies: the patient has no known drug allergies. social history: the patient denied tobacco. the patient denied alcohol or other drug use. physical examination: vital signs: on admission, the patient was afebrile, blood pressure 146/88, pulse 71, respirations 18. general: the patient was a well appearing female in no acute distress. cardiac: regular rate and rhythm, normal s1, s2. no murmurs were appreciated. lungs: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended, good bowel sounds. extremities: there was no edema in the extremities. the dorsalis pedis pulses were 2+ bilaterally. laboratory and radiologic data: on admission, white count 10.8, hematocrit 38.2, platelets 324,000. hospital course: 1. coronary artery disease: the patient was taken to cardiac catheterization where she was found to have two vessel disease. the proximal lad was found to have a 90% lesion with a septal branch with a 95% stenosis and a diagonal branch with 99% stenosis. the patient had twin lad stents to the lad diagonal and lad septal branches with taxus stents. this restored flow appropriately. the patient also had proximal rca lesion of 80% and a mid rca lesion of 80-90% which were not intervened upon. the patient was given an aspirin and plavix and in addition started on a beta , ace inhibitor, and these were titrated up as her blood pressure tolerated. given the fact that the patient had issues with muscle cramping with atorvastatin in the past, she was started on pravastatin which should give less of these side effects. the patient will follow-up with cardiology in one months time for further management of her coronary artery disease and further evaluation of her remaining rca lesions. 2. pump: the patient had an echocardiogram to assess her lv function. she was found to have an ejection fraction of 30-35% as well as an akinetic apex and apical mid and septal akinesis. given the fact that the patient had significant apical akinesis, she was started on heparin with a transition to coumadin for anticoagulation for stroke prevention in the setting of apical akinesis. on discharge, the patient was given lovenox injections which should be continued until the patient reaches a therapeutic dose of coumadin. 3. rhythm: the patient was monitored on telemetry throughout her hospitalization with no significant events. the patient had an ep evaluation and will be followed-up by dr. . in-house, the patient had a signal-averaged ekg. she will follow-up with dr. with an echocardiogram on in a meeting to discuss risk stratification for sudden cardiac death and possible icd placement. 4. neurology: the patient complained of left lower extremity weakness with ambulation two days after her cardiac catheterization. the patient had no evidence for weakness on examination with good proximal and distal strength in the lower extremities as well as intact sensation. the patient worked with physical therapy and was able to ambulate without difficulty. she was also able to ascend stairs without difficulty. the patient was already on an aspirin and plavix should this represent a small stroke. however, there was no evidence for neurologic deficit on examination and this will be followed-up by her primary care physician. 5. hematology: the patient was discharged on coumadin for apical akinesis and stroke risk. this will be further monitored by her primary care physician, . , who will adjust her coumadin dose. condition on discharge: stable. discharge status: to home. discharge diagnosis: st elevation myocardial infarction, status post left anterior descending artery stent. discharge medications: 1. aspirin 325 q.d. 2. lisinopril 5 q.d. 3. toprol xl 100 q.d. 4. coumadin 5 q.d. 5. plavix 75 q.d. 6. lovenox 60 mg b.i.d. until therapeutic on coumadin. 7. pravastatin 80 q.d. follow-up plans: the patient will follow-up with her primary care physician in the week following discharge for further monitoring of her inr and adjustment of her coumadin dose. the patient will also follow-up with electrophysiology with dr. on . in addition to this, the patient will follow-up with cardiology, dr. , and dr. , on for further monitoring. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care

service: nephrology history of present illness: the patient is a 29-year-old female with a history of renal transplant in , who had worsening renal failure for the past several months. her chief complaints were hypotension and seizure. months prior to admission and had been more hypertensive recently, requiring blood pressure medications. she was noted to have worsening renal function secondary to recent preeclampsia and her blood pressure control was thought to be secondary to renal failure. a renal biopsy showed severe nephron loss and scarring, although no rejection. the patient had since been followed by dr. in the renal at approximately 1 am on the morning of admission, the patient experienced a severe headache accompanied by nausea and vomiting. her temperature was normal and her blood pressure at home was 220/130 at that time. the patient deferred coming to the emergency room, but at 5 am her husband awoke to find her with her teeth and fists clenched close to her sides for approximately five minutes in duration. there was no incontinence of stool or urine. the ems was called and the patient was noted to have a systolic blood pressure of 220. the patient was sent to an outside hospital and at 6 am was started on a nipride drip. at 6:15 am, she had her second seizure that was a generalized tonic-clonic seizure. she was given 3 mg of ativan intravenous and lasix intravenous. at 7 am, she was given another 1 mg intravenous. after her first event, she was postictal for 15 minutes and then was responsive. she was transferred to at 7:30 am and continued on the nipride drip. she was also given hydrocortisone and thiosulfate. past medical history: 1. renal transplant from her sister with 6/6 hla match in for congenital abnormality and focal segmental glomerular sclerosis. 2. history of preeclampsia. 3. hypertension. medications on admission: 1. atenolol 50 mg p.o. q.d. 2. lasix 80 mg p.o. b.i.d. 3. hytrin 1 mg p.o. h.s. 4. nifedipine 90 mg p.o. q.d. 5. lipitor 10 mg p.o. h.s. 6. medrol 12 mg p.o. q.d. 7. rapamycin 4 mg p.o. q.d. social history: the patient was married with a one year old child family history: the patient's mother had celiac sprue. allergies: there were no known drug allergies. laboratory data on admission: the patient had a white blood cell count of 10,500, hematocrit of 28.6 and platelet count of 133,000. there was a sodium of 143, potassium of 4.6, chloride of 104, bicarbonate of 17, bun of 85, creatinine of 6.7 and glucose of 96. the urinalysis showed one white blood cell and greater than 300 protein. electrocardiogram: the electrocardiogram showed normal sinus rhythm with no acute changes. radiology: a head ct scan was performed and was negative. hospital course: 1. renal: the patient had a tunnel catheter placed on and was begun on hemodialysis on . she was continued on nephrocaps and tums. electrolytes were followed and remained normal. the patient is to continue on hemodialysis from this point on. her family is being re-screened for possible repeat renal transplant. the patient's immunosuppression regimen was tailored down, given her failed transplant. she was continued on rapamycin 2 mg p.o. q.d. and her rapamycin level was within normal limits at the time of her admission. her seizure was not felt to be due to overdose. the patient was continued on medrol 12 mg p.o. q.d. cellcept was discontinued. 2. neurology: the patient had a negative lumbar puncture performed as well as a negative head ct scan. all viral and bacterial cultures were negative. she had an electroencephalogram that showed a question of a temporal lobe abnormality with a possible focus for seizure. she was continued on dilantin at discharge. she had no further episodes of seizure. 3. cardiovascular: the patient had very poorly controlled hypertension. she had increasing doses of antihypertensives added on. her blood pressure was well controlled on the discharge regimen including hytrin, labetalol, procardia and lasix. her blood pressure at the time of discharge was under 150 systolic. 4. infectious disease: the patient was noted to have a urinary tract infection. she was started on amoxicillin, to be continued after discharge. 5. heme: the patient had a hematocrit that was stable, but she was started on epogen during dialysis. this was restarted after her hypertension was more controlled. disposition: the patient was discharged to home in stable condition. discharge medications: 1. labetalol 300 mg p.o. t.i.d. 2. procardia xl 90 mg p.o. b.i.d. 3. captopril 50 mg p.o. t.i.d. 4. dilantin 300 mg p.o. h.s. 5. ativan 1 to 2 mg p.o. every six hours p.r.n. for anxiety. 6. amoxicillin 500 mg p.o. q.d. on hemodialysis days. 7. rapamycin 2 mg p.o. q.d. 8. medrol 12 mg p.o. q.d. 9. tums 500 mg p.o. t.i.d. 10. nephrocaps one tablet p.o. q.d. 11. lipitor 10 mg p.o. h.s. 12. tylenol 650 mg p.o. every four to six hours p.r.n. follow up: the patient is to follow up at the dialysis unit on monday, , at noon for her next hemodialysis treatment. she is also to follow up in the neurology center with dr. on at 2:30 pm, or the next available cancellation appointment. she was also instructed to call dr. with any questions and to report to the emergency room or call 911 if she had further seizures. she is going to need her dilantin level followed up as an outpatient. discharge diagnoses: 1. end stage renal disease with failed renal transplant, on hemodialysis. 2. hypertensive emergency under control. 3. seizure disorder. , m.d. dictated by: medquist36 Procedure: Spinal tap Incision of lung Hemodialysis Venous catheterization for renal dialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Anemia in chronic kidney disease Pure hypercholesterolemia Urinary tract infection, site not specified Acute kidney failure, unspecified Other convulsions Complications of transplanted kidney

allergies: patient recorded as having no known allergies to drugs attending: addendum: on examination the day of discharge, mr. was noted to have some erythema and warmth surrounding the endoscopic vein graft harvest site at his left knee and calf. he was started on keflex with plans to return the following week for a wound check. discharge medications: 1. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. celecoxib 200 mg capsule sig: one (1) capsule po qd (). 6. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily): 400 mg daily x 1 week (), then 200 mg ongoing . 7. colace 100 mg capsule sig: one (1) capsule po twice a day. 8. furosemide 40 mg tablet sig: one (1) tablet po once a day. 9. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day. 10. warfarin 1 mg tablet sig: two (2) tablet po daily (daily). 11. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 7 days. discharge disposition: extended care facility: healthcare, md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Injection or infusion of platelet inhibitor Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, open approach Reopening of recent thoracotomy site Open and other replacement of aortic valve with tissue graft Other operations on heart and pericardium Transfusion of packed cells Transfusion of other serum Transfusion of platelets Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Atrial fibrillation Hemorrhage complicating a procedure Personal history of other malignant neoplasm of skin Mitral valve stenosis and aortic valve stenosis Arthropathy, unspecified, site unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass graft x 2 (svg to ramus, svg to om), aortic valve repalcement w/ 21mm cr magna tissue valve, maze procedure cardiac catheterization history of present illness: 77 y/o male with known aortic stenosis and coronary artery disease who has been medically managed since . referred for cardiac cath to re-evaluate as and cad given increase in dyspnea on exertion and fatigue. past medical history: coronary artery disease, aortic stenosis, paroxysmal atrial fibrillation, hypercholesterolemia, rheumatic fever (as child), arthritis, duodenal ulcer, benign prostatic hypertrophy s/p prostate surgery , skin cancer s/p excision from nose . s/p elbow surgery d/t bursa, s/p tonsillectomy, s/p appendectomy, s/p left knee surgery social history: retired. denies tobacco or etoh use. family history: non-contributory physical exam: vs: 90 20 132/75 124/77 5'" 200# general: wd/wn male in nad, lying flat after cath skin: unremarkable, -lesions heent: eomi, perrl, nc/at neck: supple, from, -jvd, carotid bruit vs. radiation of murmur chest: ctab -w/r/r heart: rrr w/ 4/6 sem with radiation to carotids abd: soft, nt/nd +bs ext: warm, well-perfused, -edema, 2+ pulses throughout, spider veins neruo: mae, a&o x 3, non-focal pertinent results: ct: 1. no evidence of retroperitoneal hematoma. 2. below the left inguinal ligament, tiny hyperdense foci adjacent to the adductor compartment may represent small residual hematoma, and are likely related to catheterization in this region. 3. moderately large bilateral pleural effusions with compressive atelectasis. 4. minimal pneumomediastinum and anterior chest wall subcutaneous emphysema consistent with recent surgery. cath: 1. selective coronary angiography revealed a right dominant system with patent lmca. the lad, lca and the rca had mild plaquing. the ramus had a 90% ostial lesion. there was a torally occluded small diagonal branch that filled via collaterals from the rca. 2. left ventriculography was deferred. 3. hemodynamic assessment showed normal right and mildy elevated left sided filling pressures and preserved cardiac output. there was a 50 mm hg transortic gradient consistent with severe aortic stenosis. pci of the ramus intermedius. cnis: there is less than 40% right ica stenosis and less than 40%left ica stenosis with antegrade flow in both vertebral arteries echo: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef 70-80%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. there is mild mitral stenosis secondary to the annular calcification. trivial mitral regurgitation is seen. there is no pericardial effusion. cxr: the cardiac silhouette, mediastinal and hilar contours are normal. the pulmonary vasculature is normal and there is no pneumothorax. the lungs are clear without consolidations or effusions. the surrounding soft tissue and osseous structures demonstrate mild degenerative changes in thoracic spine. 06:55am blood wbc-12.6* rbc-4.10* hgb-12.3* hct-35.9* mcv-88 mch-29.9 mchc-34.2 rdw-17.2* plt ct-158 06:55am blood plt ct-158 06:35am blood pt-13.3* inr(pt)-1.2* 06:55am blood urean-25* creat-1.2 k-4.1 06:35am blood glucose-97 urean-27* creat-1.1 na-140 k-4.1 cl-99 hco3-33* angap-12 brief hospital course: mr. a cardiac cath on which revealed severe aortic stenosis with one vessel disease. cardiac surgery was consulted and he pre-operative testing. on he was brought to the operating room where he an aortic valve replacement, coronary artery bypass graft x 2 and maze procedure. please see operative report for surgical details. patient tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition. later on op day he continued to have significant amount of post-operative bleeding and was brought back to the operating room for re-exploration. please see separate dictated operative report. he was then taken back to the csru. he remained intubated until post-op day three secondary to poor oxygenation. he was started on a lasix gtt and his chest tubes were removed on post-op day one/two. his platelet count started to trend down (lowest was 47) and he was tested for hit. on post-op day three he appeared to have an expanding abdomen with hypotension and a ct was performed. ct revealed no retroperitoneal bleed. on post-op day three he was weaned from sedation, awoke neurologically intact and was extubated. hit panel came back negative. by discharge his platelets increased to 158. on post-op day five his epicardial pacing wires were removed, coumadin was restarted and he was transferred to the telemetry floor. since extubation he did have some confusion and disorientation w/ hallucinations and haldol was started. mr. was very decompensated and physical therapy worked with him for strength and mobility throughout hospital course. he was ready for discharge to rehab on pod #7. medications on admission: lasix 60mg qd, digoxin 0.125mg t/th/s/s, digoxin 0.25mg m/w/f, aspirin 81mg qd, celebrex, ntg gtt, vit c, vit e, mvi, coumadin (last dose 1/21) discharge medications: 1. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. celecoxib 200 mg capsule sig: one (1) capsule po qd (). 6. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily): 400 mg daily x 1 week (), then 200 mg ongoing . 7. colace 100 mg capsule sig: one (1) capsule po twice a day. 8. furosemide 40 mg tablet sig: one (1) tablet po once a day. 9. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day. 10. warfarin 1 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: extended care facility: healthcare, discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 2 aortic stenosis s/p aortic valve repalcement paroxysmal atrial fibrillation s/p maze procedure pmh: hypercholesterolemia, rheumatic fever (as child), arthritis, duodenal ulcer, benign prostatic hypertrophy s/p prostate surgery , skin cancer s/p excision from nose . s/p elbow surgery d/t bursa, s/p tonsillectomy, s/p appendectomy, s/p left knee surgery 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. in 4 weeks dr. in weeks dr. in weeks Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Injection or infusion of platelet inhibitor Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, open approach Reopening of recent thoracotomy site Open and other replacement of aortic valve with tissue graft Other operations on heart and pericardium Transfusion of packed cells Transfusion of other serum Transfusion of platelets Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Atrial fibrillation Hemorrhage complicating a procedure Personal history of other malignant neoplasm of skin Mitral valve stenosis and aortic valve stenosis Arthropathy, unspecified, site unspecified

allergies: patient recorded as having no known allergies to drugs attending: addendum: the patient is supposed to be on vancomycin for 2 weeks. discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 9. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 2 weeks. 10. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily) for 7 days: for 7 days, then 200 mg daily ongoing starting . 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 12. lasix 40 mg tablet sig: one (1) tablet po once a day for 7 days: then dosing rehab md. 13. warfarin 1 mg tablet sig: five (5) tablet po today only: 5 mg today , then daily dosing rehab md; target inr 2.0-2.5. 14. potassium chloride 20 meq packet sig: one (1) pscket po once a day for 7 days: then dosing rehab md. 15. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed: each port daily and prn. discharge disposition: extended care facility: - md Procedure: Venous catheterization, not elsewhere classified Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Transfusion of other serum Diagnoses: Pure hypercholesterolemia Other postoperative infection Atrial fibrillation Disruption of internal operation (surgical) wound Aortocoronary bypass status Heart valve replaced by other means Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of anticoagulants

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sternal dehiscence major surgical or invasive procedure: - sternal debridement and rewiring history of present illness: 78 y/o gentleman s/p cabg/avr who experienced a coughing spell resulting in the dehissence of his sternum. he returns for further management. past medical history: coronary artery disease s/p cabg/avr/maze, aortic stenosis, paroxysmal atrial fibrillation, hypercholesterolemia, rheumatic fever (as child), arthritis, duodenal ulcer, benign prostatic hypertrophy s/p prostate surgery , skin cancer s/p excision from nose . s/p elbow surgery d/t bursa, s/p tonsillectomy, s/p appendectomy, s/p left knee surgery social history: retired. denies tobacco or etoh use. family history: non-contributory physical exam: vs: 90 20 132/75 124/77 5'" 200# general: wd/wn male in nad, lying flat after cath skin: unremarkable, -lesions heent: eomi, perrl, nc/at neck: supple, from, -jvd, carotid bruit vs. radiation of murmur chest: ctab -w/r/r. no erythema or drainage. sternum unstable heart: rrr w/ 4/6 sem with radiation to carotids abd: soft, nt/nd +bs ext: warm, well-perfused, -edema, 2+ pulses throughout, spider veins neruo: mae, a&o x 3, non-focal pertinent results: 05:16pm pt-33.3* ptt-34.7 inr(pt)-3.6* 05:16pm plt count-311# 05:16pm wbc-13.0* rbc-3.86* hgb-11.4* hct-34.9* mcv-90 mch-29.6 mchc-32.8 rdw-17.0* 05:16pm glucose-109* urea n-22* creat-1.1 sodium-135 potassium-4.6 chloride-101 total co2-27 anion gap-12 cxr since small bilateral pleural effusion has decreased on the right. aside from linear atelectasis at the left base, the lungs are clear. cardiomegaly, following avr and cabg, is stable. echo overall left ventricular systolic function is normal (lvef>55%). there are simple atheroma in the ascending aorta. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. a bioprosthetic aortic valve prosthesis is present. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. the motion of the mitral valve prosthetic leaflets appears normal. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. mild mitral stenosis - note mva 1.5 cm. there is a moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. note rt sided pleural effusion present. pericardial effusion much improved s/p surgical intrevention, especially in the rt atrial distribution. 05:19am blood wbc-9.3 rbc-3.06* hgb-9.2* hct-27.5* mcv-90 mch-30.2 mchc-33.6 rdw-16.5* plt ct-265 05:02am blood hct-28.8* 06:52am blood pt-13.9* inr(pt)-1.2* 05:02am blood k-3.8 brief hospital course: mr. was admitted to the on for further management of his sternal dehiscence. intravenous antibiotics were started. he was taken to the operating room on where he a sternal debridement and rewiring. postoperatively he was taken to the intensive care unit for monitoring. shortly thereafter, he awoke neurologically intact and was extubated. a gentamycin irrigation drip was continued. he was transferred to the step down unit on postoperative day one. intraoperative cultures were notable for rare coagulase negative staphlococcus. vancomycin 2 week course started and beta blockade titrated. picc line placed to complete abx therapy at rehab. coumadin started for pafib as well as continuation of amiodarone. chsest tubes removed/ gentamicin irrigation stopped on .he made good progress and was cleared for discharge to rehab on . pt. is to make all follow-up appts. as per discharge instructions.discharge inr is 1.2 today ( up from 1.1 yesterday). target inr for a fib is 2.0-2.5. medications on admission: 1. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. celecoxib 200 mg capsule sig: one (1) capsule po qd (). 6. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily): 400 mg daily x 1 week (), then 200 mg ongoing . 7. colace 100 mg capsule sig: one (1) capsule po twice a day. 8. furosemide 40 mg tablet sig: one (1) tablet po once a day. 9. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day. 10. warfarin 1 mg tablet sig: two (2) tablet po daily (daily). 11. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 7 days. discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 9. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 7 days. 10. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily) for 7 days: for 7 days, then 200 mg daily ongoing starting . 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 12. lasix 40 mg tablet sig: one (1) tablet po once a day for 7 days: then dosing rehab md. 13. warfarin 1 mg tablet sig: five (5) tablet po today only: 5 mg today , then daily dosing rehab md; target inr 2.0-2.5. 14. potassium chloride 20 meq packet sig: one (1) pscket po once a day for 7 days: then dosing rehab md. 15. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed: each port daily and prn. discharge disposition: extended care facility: - discharge diagnosis: sternal dehiscence s/p rewiring s/p coronary artery bypass graft x 2 (svg to ramus, svg to om), aortic valve replacement w/ 21mm ce magna tissue valve, maze procedure discharge condition: stable discharge instructions: 1) please report any fever greater then 100.5. 2) monitor wounds for signs of infection. these include redness, drainage or increased pain. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. report any increased or worsening swelling of your lower extremities. 4) no driving for 1 month. 5) no lifting greater then 10 pounds for 10 weeks. 6) do not apply lotions, creams or powders to incision until it has healed. 7) call with any questions or concerns. 8) target inr 2.0-2.5 followup instructions: provider: . cardiac surgery lmob 2a date/time: 2:15 please follow-up with your cardiologist dr. in weeks. follow-up with primary care physician . in 2 weeks. call all providers for appointments. Procedure: Venous catheterization, not elsewhere classified Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Transfusion of other serum Diagnoses: Pure hypercholesterolemia Other postoperative infection Atrial fibrillation Disruption of internal operation (surgical) wound Aortocoronary bypass status Heart valve replaced by other means Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of anticoagulants

history of present illness: the patient is a year old gentleman who is a former surgeon who was admitted at midnight with right foot numbness and decrease in movements and decrease in temperature of the right foot. however, the patient denies pain on initial presentation and the patient has experienced recent fall with no trauma to the right lower extremity. he denies claudication or resting pain. the patient is ambulatory upon arrival to the emergency room. past medical history: significant for hypertension, coronary artery disease, status post myocardial infarction times two and transient ischemic attacks. past surgical history: status post left carotid endarterectomy and status post appendectomy, status post open cholecystectomy, status post transurethral resection of prostate and status post hip replacement. medications on admission: detrol 4 mg p.o. q.d.; nifedipine 30 mg p.o. q.d., aspirin 325 mg p.o. q.d., zantac 150 mg p.o. b.i.d. allergies: no known drug allergies. physical examination: on presentation the has palpable femoral pulse bilaterally, palpable popliteal triphasic bilaterally. no dopplerable dorsalis pedis or posterior tibial on the right side. he has monophasic dorsalis pedis and monophasic posterior tibial on the left side. hospital course: at this time the patient was diagnosed with having peripheral vascular disease despite his long history of claudication. the patient was put on heparin for anticoagulation and the patient was admitted to the vascular surgery service. emergent arteriogram showed acute thrombosis of the right atrial artery. the patient was begun on total parenteral alimentation treatment and cardiology was called to assess the patient's risk for bypass surgery. cardiology cleared the patient for bypass surgery. the patient had preoperative laboratory work done which showed an ejection fraction of 30%. the patient was taken to the operating room on and underwent a right femoral tibial bypass graft with greater saphenous vein in situ graft with valve lysis by dr. . on postoperative day #1 the patient was noted to have loss of pulse signal and graft pulse was no longer palpable. the patient was also noted to have oozing from the incision site. the patient's pulse was noted to be decreased on postoperative day #1 and the patient's condition was guarded at that time. on postoperative day #1 the patient had a brief episode of bradycardia and a pacing swan was placed and from electrocardiogram the patient appeared to have a right bundle branch block that was newly developed. cardiology was on board and lopressor beta blockade was discontinued. at the time due to the critical nature of the patient's condition the patient was transferred to the intensive care unit and the patient's renal function appeared to be worsening and nephrology was consulted. with their recommendation the ace inhibitor was discontinued and non-steroidal anti-inflammatory drugs were discontinued. the patient was begun to be given transfusion. the patient appeared to have an acute myocardial infarction postoperatively and renal failure secondary to lack of volume resuscitation. the patient was transferred onto the intensive care unit in guarded condition. on postoperative day #2, on repeat enzymes, the patient's peak ck appeared to be around 700 and it was clear that the patient had perioperative myocardial infarction and the patient was kept in the intensive care unit to stabilize his cardiac and renal status. on postoperative day #3 the patient's graft appeared to be viable. the patient has a warm foot and palpable dorsalis pedis on the right foot. the incision appeared to be still slightly oozy and the patient had ace bandage wrap around the right leg. on postoperative day #6 the patient was noted to have a lower gastrointestinal bleed and bled in stool and gastroenterology was consulted. it was on their recommendation heparin was discontinued and the patient's bleeding appeared to stop and gastroenterology recommended outpatient colonoscopy in the future. on postoperative day #8 the patient's condition appeared to be improving and the patient's renal function appeared to be improving and the patient appeared to be recovering from the acute tubular necrosis and renal failure. from the cardiology point of view, the patient's condition is stabilizing and the patient was transferred onto the vascular intensive care unit on , which was postoperative day #9. under cardiology's recommendation the ace inhibitor was increased. chest x-ray was taken to assess his cardiac status. the patient was put on sips for p.o. intakes and the patient appeared to be improving. on postoperative day #10 after discussion with the family the patient was made do-not-resuscitate following the family and patient's wishes. on postoperative day #10 at approximately 6 pm the patient went into respiratory distress with audible wheezes bilaterally and a copious amount of secretion and respiratory treatment with albuterol inhaler given and suctioning was carried out. at that time it was clear that the patient does not want to be nasotracheal suctioned and appears to be better coherent. the patient at that time was sating at 96% on 5 liters and it appeared that the patient went into bronchospasm and retained secretions with impaired secretion clearance, although after numerous albuterol treatment the patient was not able to clear his secretion and the patient was made do-not-intubate. the patient expired at 9:30 on . the patient is deceased on with final cause, the patient is a year old gentleman status post right femoral-tibial bypass graft. his course was complicated by myocardial infarction and renal failure. his condition appeared to be improving, however, on , the patient had absolute bradycardia and became acutely apneic and the patient developed bronchospasm and retained secretion which was not able to be cleared by suctioning and the patient was made do-not-intubate and no intubation was carried out. the patient deceased from respiratory distress. the patient underwent autopsy, results pending. , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Incision of vessel, lower limb arteries Pulmonary artery wedge monitoring Diagnoses: Atherosclerosis of native arteries of the extremities with intermittent claudication Cardiac complications, not elsewhere classified Hemorrhage complicating a procedure Acute respiratory failure Other specified cardiac dysrhythmias Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of unspecified site, initial episode of care Arterial embolism and thrombosis of lower extremity

history of present illness: the patient is a 62-year-old african-american male with a history of severe chronic obstructive pulmonary disease and asthma (on home oxygen and steroids) and a history of coronary artery disease who presented to the emergency room on after being found by a neighbor in respiratory distress. the patient remembers being sick with a cold for the week prior to admission; a cold which was productive of cough, headache, fatigue, and worsening shortness of breath and wheezing. the patient noted he was using his inhalers and nebulizers more frequently over that time and not gaining relief of his symptoms. he denied any palpitations, but he did not some lightheadedness. he also recalled some episodes of chest tightness associated with his shortness of breath and not associated with exertion. he noted he tried some sublingual nitroglycerin tablets which relieved some of the pain. on the night prior to admission, the patient again noted an episode of pain in his chest which was relieved with nitroglycerin. he also remembers having significant respiratory distress, and that is the last thing he remembers. he was apparently found by a neighbor calling for help and was brought into the emergency room. in the emergency room, he was noted to be in significant respiratory distress with an arterial blood gas which showed a ph of 6.96, a pco2 of 180, and a po2 of 112. the patient was sedated and intubated. he was transferred to the intensive care unit. he was then transferred to the medical team on after being extubated for two days. past medical history: 1. asthma. 2. chronic obstructive pulmonary disease (requiring home oxygen of 2 liters and chronic steroids at 20 mg p.o. per day). 3. history of a seizure disorder. 4. history of non-q-wave myocardial infarction. 5. history of hypertension. 6. question history of cerebrovascular accident. medications on admission: (medications on admission included) 1. lipitor 10 mg p.o. q.d. 2. verapamil 120 mg p.o. b.i.d. 3. prednisone 20 mg p.o. q.d. 4. mysoline 50 mg p.o. q.h.s. 5. imdur 30 mg p.o. q.d. 6. albuterol 2 puffs inhaled b.i.d. as needed. 7. serevent 2 puffs inhaled q.d. 8. singulair 10 mg p.o. q.d. 9. pulmicort 2 puffs inhaled q.d. 10. albuterol nebulizers. 11. 60 mg p.o. q.d. 12. advair 2 puffs inhaled b.i.d. 13. aspirin 325 mg p.o. q.d. 14. home oxygen (2 liters). 15. calcium 500 mg p.o. q.d. 16. vitamin d 400 units p.o. q.d. allergies: no known drug allergies. social history: the patient lives alone at the house in which is an independent living facility for the homeless people with illnesses. he has a daughter in . he has a 40-year smoking history of two to three packs per day. he quit seven years ago. no current alcohol use; although, extensive alcohol in the past which he discontinued in . he denies any intravenous drug use and has used marijuana in the past. physical examination on presentation: physical examination on admission to the medical intensive care unit revealed vital signs with a blood pressure of 125/66, heart rate was 108, temperature was 97, oxygen saturation was 95% on a ventilator set at 500/14 positive end-expiratory pressure of 5 and 100% of fio2. the patient was intubated and sedated. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. pupils were equally round and reactive to light. they went from 4 mm to 3 mm. the oropharynx was moist and pink. no tongue lacerations. neck revealed no jugular venous distention. no lymphadenopathy. lung examination revealed prolonged expiratory phase with significant expiratory wheezes (right greater than left), and coarse breath sounds bilaterally. cardiovascular examination revealed a regular rate and rhythm. normal first heart sounds and second heart sounds. no murmurs, rubs, or gallops. the abdomen was firm, nontender, and nondistended. positive bowel sounds. extremity examination revealed no edema, but clubbing was present. neurologically, the patient was sedated, grimacing to sternal rub, not responding to verbal stimuli, and was moving upper extremities spontaneously. no reflexes were able to be elicited. pertinent laboratory values on presentation: laboratory studies on admission revealed white blood cell count was 9 (with 38% neutrophils, 45% lymphocytes, and 11% monocytes), hematocrit was 44, and platelets were 113. sodium was 141, potassium was 4.5, chloride was 100, bicarbonate was 33, blood urea nitrogen was 9, creatinine was 0.8, and blood glucose was 150. creatine kinase was 364, mb was 1.8, troponin was less than 0.3. free calcium was 1.36. arterial blood gas revealed 6.96, with a pco2 of 180, and a po2 of 112. pertinent radiology/imaging: electrocardiogram on admission was sinus with normal intervals, axis was -90, with p-pulmonale, and low voltage in precordium. no st-t wave changes. a chest x-ray showed hyperinflation and ett about 10 cm above the carina. hospital course by issue/system: the patient is a 62-year-old male with severe chronic obstructive pulmonary disease who comes in with a chronic obstructive pulmonary disease exacerbation requiring intubation and intensive care unit stay. 1. pulmonary issues: the patient was intubated for hypercarbic respiratory failure. he was treated with a ventilator, with nebulizers, and with intravenous steroids. he received medication for sedation so that he did not fight the ventilator. a chest x-ray after several days of admission revealed an infiltrate, and sputum grew out moraxella. the patient was started on levofloxacin 500 mg q.d. on and was to continue for a 10-day course. the patient had significant amounts of thick sputum. the patient was extubated on . his respiratory status continued to improve with around the clock nebulizers and continued inhaler use. he was put on prednisone 40 mg and kept there. upon discharge, the patient was q.4h. around the clock albuterol and atrovent nebulizers with his inhalers in between. the patient was also receiving guaifenesin and mucomyst for his sputum. his pneumonia was being treated with levofloxacin and was to continue for a total of 10 days. he has been seen by respiratory therapy who recommended a flutter valve for the patient to help with his secretion mobilization. 2. cardiovascular system: the patient has a history of coronary artery disease with a non-q-wave myocardial infarction in the past. he was continued on aspirin and lipitor. his antihypertensive medications were held due to some hypotension while he was ventilated, and initially status post extubation. the patient ended up having a positive creatine kinase with a troponin leak of 2. he also had electrocardiogram changes with his electrocardiogram revealing t wave inversions in the inferior leads as well as v3 through v6. these were new changes. he was seen by cardiology, who recommended a dobutamine stress test when the patient's respiratory status has improved. they also recommended continuing full-strength aspirin of 325 mg, low-dose lopressor at 6.25 mg p.o. b.i.d., and continuing imdur 30 mg p.o. q.d. they recommended an echocardiogram, which the patient received. this echocardiogram revealed an ejection fraction of greater than 55%. the left atrium was normal in size. normal right ventricular wall thickness. left ventricular cavity size was normal. left ventricular wall motion was normal. the right ventricular free wall was hypertrophied. the right ventricular cavity was markedly dilated. there was severe global right ventricular free wall hypokinesis. the aortic root was mildly dilated. trivial mitral regurgitation was seen. there was moderate pulmonary artery systolic hypertension. there was no pericardial effusion. the patient should follow up in the cardiology clinic for a stress test as an outpatient for evaluation of his coronary artery disease. 3. renal system: the patient with a stable blood urea nitrogen and creatinine and good urine output. 4. endocrine system: the patient was initially started on intravenous steroids and changed to prednisone 40 mg p.o. q.d. a slow taper should be planned, and the patient is on chronic doses of 20 mg p.o. q.d. he was getting sliding-scale insulin while on the steroids. he was continued on his calcium and vitamin d. 5. fluids/electrolytes/nutrition issues: the patient with a metabolic alkalosis; most likely due to volume depletion. he received intravenous fluids while nothing by mouth, and his oral intake improved over his hospital stay. 6. hematologic issues: on admission, the patient had a hematocrit of 44, which fell to 32 on ., and dropped to 29 on . his hematocrit then improved 37.6 spontaneously on the day prior to discharge. he had a mean cell volume of 74. 7. infectious disease issues: the patient was found to have a moraxella pneumonia. he was treated with levofloxacin for a total of a 10-day course. blood cultures and urine cultures have been negative. discharge disposition: the patient was to be discharged to . dr. been in contact with the patient's primary care physician, she is aware of the events of his hospital stay. discharge diagnoses: 1. chronic obstructive pulmonary disease flare. 2. moraxella pneumonia. 3. non-q-wave myocardial infarction. 4. coronary artery disease. 5. history of a seizure disorder. medications on discharge: (medications on discharge included) 1. tylenol p.o. as needed 2. lipitor 10 mg p.o. q.h.s. 3. primidone 50 mg p.o. q.h.s. 4. vitamin d 400 units p.o. q.d. 5. salmeterol inhaler 2 puffs inhaled b.i.d. 6. levaquin 500 mg p.o. q.d. (times five more days). 7. senna two tablets p.o. q.d. 8. bisacodyl 10 mg p.o. q.d. 9. colace 100 mg p.o. b.i.d. 10. prednisone 40 mg p.o. q.d. 11. albuterol inhaler 2 puffs inhaled q.4h. 12. atrovent inhaler 2 puffs inhaled q.4h. 13. aspirin 325 mg p.o. q.d. 14. metoprolol 6.25 mg p.o. b.i.d. 15. imdur 30 mg p.o. q.d. 16. nitroglycerin 0.3 mg sublingually q.5min. as needed (for chest pain). 17. albuterol nebulizers q.4h. around the clock. 18. atrovent nebulizers q.4h. around the clock. 19. guaifenesin 5 cc to 10 cc q.4-6h. as needed. 20. calcium carbonate 500 mg p.o. q.d. 21. mucomyst nebulizers q.4-6h. as needed. 22. ambien 5 mg p.o. q.h.s. as needed (for sleep). , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Anemia of other chronic disease Subendocardial infarction, initial episode of care Pneumonia due to other gram-negative bacteria Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Other convulsions Acute respiratory failure Hypotension, unspecified

allergies: bactrim attending: chief complaint: copd exacerbation major surgical or invasive procedure: none history of present illness: the patient is a 63 year old male transferred from after having increased wheezing, shortness of breath, and continued smoking. he has severe copd, is on home o2, and has had numerous admissions for copd flare with 2 previous intubations, and was recently tapered down to prednisone 20mg daily. on admission, he noted several days of runny nose, sore throat, decreased po intake, and feeling like he "had a cold." no n/v/d, no abd pain, no cp. he stated that his symptoms became worse on the day of admission, and was noted to be hypoxic to 85-90% on 2l. he was brought to the ed and started on bipap. he was also given solumedrol 125mg and levofloxacin 500mg. past medical history: * copd/emphysema - on home o2; numerous flares + 2 intubations; on slow steroid taper. no documented pft's. * asthma * hyperlipidemia * depression * atopic dermatitis * hx of tobacco, etoh use * hx of cad - mi , ef 55% * htn * anemia of chronic disease * hx of seizures, tx with primidone * ? hx of cva * hx of lung nodule on cxr, not seen on ct social history: patient lives at . 40-pack-yr smoking hx, continues to smoke. no etoh. family history: notable for dm and cad. physical exam: on admission to icu: t 95.4, hr 116, bp 151/99, rr 25-35, o2 sat 100% on bipap gen: pt in mild resp distress, using accessory muscles. heent: perrl bilaterally, op clear, nonicteric sclera, mmm, no jvd chest: poor air movement bilat; mild crackles at rlb, prolonged exp phase, end exp wheezes bilaterally cor: distant heart sounds, regular, tachy, no m/r/g abd: s/nt/nd ext: no le edema neuro: ii-xii intact pertinent results: 04:35pm blood wbc-7.4 rbc-6.11 hgb-14.6 hct-44.6 mcv-73* mch-23.9* mchc-32.8 rdw-13.1 plt ct-222 04:35pm blood neuts-77.6* lymphs-12.5* monos-6.3 eos-3.0 baso-0.6 04:35pm blood hypochr-1+ microcy-2+ 04:35pm blood pt-12.8 ptt-23.6 inr(pt)-1.0 04:35pm blood glucose-107* urean-16 creat-0.9 na-137 k-5.7* cl-97 hco3-31* angap-15 04:58pm blood type-art peep-5 o2-40 po2-61* pco2-65* ph-7.31* calhco3-34* base xs-3 intubat-not intuba 05:54am blood wbc-9.6 rbc-4.67 hgb-11.4* hct-33.6* mcv-72* mch-24.5* mchc-34.0 rdw-13.8 plt ct-164 05:54am blood glucose-140* urean-15 creat-0.8 na-139 k-4.5 cl-96 hco3-38* angap-10 05:54am blood calcium-9.0 phos-3.1 mg-2.0 04:35pm blood ck(cpk)-399* 04:47am blood ck-mb-12* mb indx-3.6 ctropnt-<0.01 02:01pm blood ck-mb-10 mb indx-3.7 ctropnt-<0.01 chest xray : cardiomediastinal silhouette is within normal limits. the left upper lobe is particularly lucent, more so than the right upper lung zone, consistent with history of copd. no evidence of pneumonia or pneumothorax. blunting of the left costophrenic angle is stable. brief hospital course: 1) copd exacerbation: the patient responded well to a copd regimen of frequent every 3 hour nebulizer treatment with flovent, serevent, albuterol, and singular as well as solumedrol plus levofloxacin. by the evening of hospital day two, the patient's respiratory improved to where he did not require persistent bipap. there were, however, 1-2 episodes where the patient required a few hours of bipap both of which occurred during minimal exertion from bed to chair after eating. this was attributed to the patient's poor respiratory reserve. by the day of discharge, however, the patient had improved beyond baseline with oxygen saturations 99-100% on his outpatient oxygen requirement of 2 liters nasal cannula. he was tapered from 80 mg methylprednisolone every 8 hours to 60 mg every 8 hours to 50 mg prednisone every day with the thought that the patient will need a very slow steroid taper given his prolonged outpatient dependence. the patient was urged to quit smoking daily and given a nicotine patch to help with cravings. 2) cad: the patient was ruled out times 3. he was continued on aspirin for coronary syndrome prophylaxis in light of the patient's previous myocardial infarction. 3) remote seizure history: the patient was continued on his outpatient dose of primidone. no seizures were noted during his hospital admission. 4) depression: the patient was continued on his outpatient dose of prozac. he did not admit to typical symptoms of depression during his hospital course and reported a stable and good mood. 5) physical therapy: the patient was evaluated by physical therapy who recommended short term rehabilitation during his stay at the . medications on admission: * prednisone 20mg qd * primidone 50mg qd * protonix 40mg qd * singulair 10mg qd * 60mg * asa 81mg qd * lipitor 10mg qd * mvi 1 tab qd * vit d 400u qd * prozac 20mg qd * klonopin 0.25mg * duoneb qd discharge medications: 1. clonazepam 0.5 mg tablet sig: one (1) tablet po qd (once a day). 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 3. clonazepam 0.5 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. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 6. multivitamin capsule sig: one (1) cap po qd (once a day). 7. fexofenadine hcl 60 mg capsule sig: one (1) capsule po bid (2 times a day). 8. fluoxetine hcl 20 mg capsule sig: one (1) capsule po qd (once a day). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. atorvastatin calcium 20 mg tablet sig: one (1) tablet po qd (once a day). 11. montelukast sodium 10 mg tablet sig: one (1) tablet po qd (once a day). 12. salmeterol xinafoate 50 mcg/dose disk with device sig: one (1) disk with device inhalation q12h (every 12 hours). 13. fluticasone propionate 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 14. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 3 days: end date: . disp:*3 tablet(s)* refills:*0* 15. primidone 50 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 16. ipratropium bromide 0.02 % solution sig: inhalation q3hrs (). 17. albuterol sulfate 0.083 % solution sig: inhalation q3h (every 3 hours). 18. ipratropium bromide 0.02 % solution sig: one (1) inhalation q2prn (). 19. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 20. prednisone 20 mg tablet sig: see below for instructions tablet po as below: please give 50mg (2.5 tabs) qd x 1 week. then 40mg (2 tabs) qd x 1 week. then 30mg (1.5 tabs) qd x 1 week. then 20mg (1 tab) qd x 1 week. then 10mg (0.5 tabs) ongoing. disp:*50 tablet(s)* refills:*1* 21. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal qd (once a day). disp:*30 patch 24hr(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: * copd exacerbation * severe reactive airway disease * severe emphysema * depression. discharge condition: stable. discharge instructions: 1. please take all your medications, including regular nebulizer treatments, as instructed. 2. please use nicotine patches and stop smoking cigarettes. 3. please seek medical attention if you experience any of the following symptoms: lightheadedness, chest pain, persistent and worsening shortness of breath, severe abdominal pain, upper respiratory congestion, or any other new symptoms. followup instructions: please follow up with your primary care doctor within 1-2 weeks regarding this hospital admission. md, Procedure: Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Other chronic pulmonary heart diseases Other convulsions Other and unspecified hyperlipidemia Acute respiratory failure Old myocardial infarction

history of present illness: this is a 62-year-old male with longstanding severe emphysema/copd requiring home oxygen with a history of multiple hospitalizations for exacerbation requiring intubation and antibiotics (last one in ), presents with worsening shortness of breath for one week. the patient was last seen in the emergency room on for "copd exacerbation" after he ran out of nebulizers and being exposed to smoke in a kitchen. he was treated at the time with iv solu-medrol one dose and nebulizers twice, and discharged home and o2 saturation was approximately 95% on 4 liters of oxygen (baseline). in the past week, he had finished a steroid taper back to 20 mg p.o. q.d. which is his baseline. at this time, he started noticing increased worsening of his dyspnea and a productive cough of white yellow sputum. at this time he was using nebulizers every hour. at 6:30 a.m., on the day of admission, he ran out of nebulizers and called emts. in the emergency room, he was found to be in acute distress, and tripod position and breathless. vitals showed a pulse of 96, blood pressure of 156/96, respiratory rate of 28-32, and an o2 saturation of 100% after nebulizer treatment. he again was treated with solu-medrol 125 mg iv and albuterol nebulizers. he desaturated from 90% to 60%, but refused intubation, so he was placed on heliox without any improvement. he was started on 100% nonrebreather mask with sats increasing to 97%. at this time, he was transferred to the micu. abgs drawn at that time showed a ph of 7.23 and a pco2 of 85. while in the micu, he was started on bipap with o2 saturations ranging from 88 to 92%, however, he had another episode of desaturation and he was put back on 100% nonrebreather mask restoring his saturations. he was continued on solu-medrol drip 125 mg q.6h., nebulizer treatments q15 minutes and started on empiric antibiotic therapy with levofloxacin. he had improved air movement on icu day #2. his steroids were changed from iv to prednisone p.o. 60 mg. his nebulizers were weaned down to q2-3h and he was weaned down to nasal cannula on 2 liters and maintaining his sats around 90-93%. upon transfer to the floor, he felt much improved, but tired. he had decreased appetite. he denied any fevers, chills, chest pain, abdominal pain, nausea, vomiting, or diarrhea. past medical history: 1. copd/emphysema: diagnosed in . on home oxygen 2 liters of nasal cannula x24 hours. he is on chronic prednisone dose of 20 mg q.d. he sleeps on three pillows and has no orthopnea. no pulmonary function tests on record here. 2. reactive airway disease/asthma. 3. coronary artery disease: non-q-wave myocardial infarction on . echocardiogram showed an ejection fraction of 55% at that time with right ventricular hypertrophy and dilatation of the right ventricle with global hypokinesis of the right ventricle and moderate pulmonary artery systolic hypertension. he was scheduled to undergo a stress test at the time, but has not gone. 4. hypertension. 5. dyslipidemia. 6. cerebrovascular accident. 7. seizure disorder: on primidone stable. 8. atopic dermatitis. 9. chronic anemia. social history: lives by himself at the house in with vnas and home makers helping with food and house keeping. his daughter is in the area and sees her "on and off." he last smoked in . up to that time he was smoking about 1-2 packs per day for 20 years. he denies any recent alcohol. although to prior to ', he had a history of alcohol abuse drinking a pint of daily. he denies any iv drug use. family history: noticeable for diabetes mellitus and hypertension. denies history of cancer or heart disease. allergies: he is allergic to sulfa, causes facial edema. medications: 1. albuterol/ipratropium 1-2 puffs q.d. 2. ipratropium one nebulizer treatment q.4-6h. prn. 3. albuterol one nebulizer treatment q.4-6h. prn. 4. prednisone 60 mg q.d. 5. zolpidem 5 mg q.h.s. prn. 6. tums 500 mg b.i.d. 7. atorvastatin 10 mg p.o. q.d. 8. verapamil 120 mg q.d. 9. primidone 50 mg q.h.s. 10. aspirin 325 mg q.d. 11. vitamin d 800 mg q.d. 12. isosorbide mononitrate 30 mg q.d. 13. pantoprazole 40 mg q.d. physical examination on admission: vital signs: blood pressure 170/113, pulse is 103 beats per minute, respiratory rate of 22, and 100% oxygen on 100% nonrebreather mask. in general, he was in mild distress using sternocleidomastoid, pursed breathing in between words and sentences. his sclerae were anicteric. his pupils are equal, round, and reactive to light and accommodation. his neck showed no jugular venous distention. his chest showed moderate air movement with expiratory wheezes and hyperresonant to percussion. his heart was tachycardic, but regular, normal s1 and s2 with a positive s4, no murmurs or gallops. his abdomen had paradoxical movement on inspiration, was soft, nontender, nondistended with normal bowel sounds. he had no costovertebral angle tenderness. he had no clubbing, cyanosis, or edema on his extremities, but they were cool. neurologically, he was alert and oriented to person, place, and time. sensory and motor were grossly intact. laboratories on admission: white count of 6, hematocrit of 44.6, platelets of 256. he had a sodium of 135, potassium of 4.8, chloride of 94, bicarbonate of 40, bun of 9, creatinine of 0.7, and a sugar of 141. calcium was 9.0, magnesium was 1.9 and phosphate was 2.4. his urinalysis was negative. urine cultures were sent. chest x-ray done showed no chf or focal consolidation, but evidence of hyperinflation consistent with emphysema. ekg shows sinus rhythm at 97 beats per minute with atrial premature beats, which were new since the last tracing of , normal axis, normal intervals, and no st segment changes. hospital course by problems: 1. copd exacerbation with acute respiratory failure: upon transfer to the floor, the patient was started on 2 liters nasal cannula of oxygen and prednisone of 60 mg p.o. q.d. and nebulizer treatments spaced out every two hours prn. during the next couple days, series attempts were made at weaning off the nebulizer treatments and spacing them out, however, the o2 saturations dropped and the patient continued to complain of shortness of breath. on hospital day #6, the patient was able to tolerate q.4h. nebulizer treatments and was noticeably feeling much better with o2 saturations ranging between 95 and 98% on 2 liter nasal cannula. he was continued on levofloxacin throughout the hospitalization. 2. lung nodule ?: on chest x-ray, the patient was found to have a lung nodule on the right middle lobe measuring 3 mm. it was consistent with one observed back in . per pcp's recommendations, a chest ct was ordered which showed severe bullous emphysema with large bullae at the left apex and no pulmonary nodule or mass corresponding to the abnormality described by the chest x-ray. however, several small opacities in both lungs were noticed and recommended that it should be re-evaluated in three months. 2. hypertension: blood pressure well controlled on verapamil and isosorbide mononitrate. stable. 3. coronary artery disease: ekg showed new onset of atrial premature beats. unclear clinical significance. patient is asymptomatic. no events during hospitalization. 4. seizure disorder: patient continued on primidone. no seizure activity noted. 5. fen: patient was on a cardiac diabetic diet. the electrolytes were replenished prn. 6. prophylaxis: patient was placed on pantoprazole and subq heparin given his lack of ambulation. discharge medications: 1. levofloxacin 500 mg p.o. q.d. for a total of 14 days, seven days left on treatment. 2. tylenol 325 mg p.o. q.4-6h. as needed. 3. docusate. 4. senna. 5. pantoprazole 40 mg q.d. 6. isosorbide mononitrate 30 mg p.o. q.d. 7. vitamin d 400 units two tablets p.o. q.d. 8. aspirin 325 mg p.o. q.d. 9. primidone 50 mg p.o. q.h.s. 10. verapamil 120 mg p.o. q.d. 11. atorvastatin 10 mg p.o. q.d. 12. guaifenesin 600 mg two tablets p.o. q.12h. 13. fexofenadine 60 mg p.o. b.i.d. 14. tums 500 mg p.o. b.i.d. 15. albuterol/ipratropium aerosol 1-2 puffs q.4h. 16. albuterol 0.083% solution one nebulizer treatment every four hours as needed. 17. ipratropium bromide 0.02% solution one nebulizer treatment q.4-6h. as needed. 18. zolpidem 5 mg p.o. q.h.s. 19. prednisone taper from 60 mg to 20 mg in 5 mg decrement every four days. disposition: he was discharged to home with vna services in stable condition. discharge diagnoses: 1. acute respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease. 2. acute bronchitis. 3. critical care. 4. emphysema. 5. hypertension. code status: full. discharge followup: 1. patient is to followup with dr. within one week of discharge. 2. patient has a scheduled appointment with the pulmonary clinic at the . phone number is on at 10:45 a.m. with dr. . he is required to report to the pulmonary breathing test center at the building at 10:45. , m.d. dictated by: medquist36 Procedure: Non-invasive mechanical ventilation Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Other convulsions Acute respiratory failure Old myocardial infarction Other diseases of lung, not elsewhere classified

history of present illness: the patient is a 62 year old male with longstanding, severe chronic obstructive pulmonary disease, requiring home oxygen and with a recent exacerbation in requiring -medicine intensive care unit admission, intubation and antibiotics who presents two days after discharge to rehabilitation, with shortness of breath. the patient was admitted to on with shortness of breath requiring intubation and a medicine intensive care unit stay, with a course complicated by a non-q wave myocardial infarction. the patient was treated for ................. pneumonia and discharged to rehabilitation on . the patient was then discharged to house on . the patient was discharged from rehabilitation on a medicine regimen that differed from his previously which had included chronic prednisone 20 mg q.d. the patient at this time of discharge from rehabilitation was not on any chronic prednisone dosage. over the next two days, the patient noted that he had increased shortness of breath, a productive cough with sputum change to a yellow color, increased watery eyes, and increased nasal discharge. on the morning of , the patient noted that he was in extreme shortness of breath and "couldn't do this anymore." the patient called 9-1-1 and was taken to the emergency department. the patient denies recent fevers, chest pain, nausea, vomiting, abdominal pain, change in stools, diarrhea, constipation, dysuria, or joint pain. allergies: the patient has a questionable allergy to bactrim which causes edema. past medical history: 1. chronic obstructive pulmonary disease - per the patient diagnosed since . on home oxygen, 2 liters nasal cannula for 24 hours a day. has been on chronic prednisone 20 mg a day for multiple months. the patient sleeps on three pillows. he can not lay flat secondary to shortness of breath. no pulmonary function tests were on record for our examination. 2. asthma. 3. coronary artery disease - non-q wave myocardial infarction in - cardiac echocardiogram on showed ejection fraction of 55%, right ventricular wall hypertrophy and cavity dilatation with marked wall motion hypokinesis, normal left and right atria, left ventricular wall thickness but no wall motion abnormalities. mild tricuspid regurgitation and mitral regurgitation. moderate pulmonary artery systolic hypertension. upon discharge in , the patient had been recommended to have an outpatient stress test; the patient is awaiting outpatient workup. 4. hypertension. 5. hypercholesterolemia. 6. history of stroke. 7. seizure disorder. 8. atopic dermatitis. 9. iron deficiency anemia/anemia of chronic disease. family history: notable for the patient might have one brother with diabetes mellitus although the patient is unsure of this. the patient denies health problems in any of his three other siblings who are between the ages of 70 and 80 years old. the patient notes five children to be in good health with no known health problems. the patient denies any family history of cancer or heart disease. social history: the patient's social history is notable for the patient smoking one to two packs per day for 20+ years. per the patient he quit in . per the social worker and resident nurse house there is evidence that either the patient is smoking in his apartment or someone else is smoking in the patient's apartment where the patient has his home oxygen. the patient also has a history of alcohol (one-half pint of per day), per the patient he quit in . the patient has a history of marijuana use. the patient denies intravenous drug use or further street drug use. the patient lives at house, a home for the homeless elderly. he has a section viii housing apartment there. the patient has multiple children, but all but one live in . the patient has one daughter who lives in , her name is , the patient also has a nephew who lives in and checks in on the patient, nephew's name is . physical examination: the patient's physical examination upon presentation included vital signs of 95.8, heartrate 104, blood pressure 164/136, respiratory rate 40, oxygen saturation 98% on nonrebreather. constitutional-severe respiratory distress, alert, cooperative. head, eyes, ears, nose and throat-pupils equal, round and reactive to light, extraocular movements intact. neck-positive use of accessory respiratory muscles. chest-poor air entry bilaterally, no wheezes noted. cardiovascular-tachycardiac, regular rhythm, s1 and s2 present. genitourinary-no costovertebral angle tenderness bilaterally. gastrointestinal-bowel sounds present, soft, nontender, nondistended belly. skin-no rashes, capillary refill less than 2 seconds. neurologic-cranial nerves ii through xii intact, strength and sensory within normal limits. laboratory data: pertinent laboratory data included a white blood cell count of 8.7, hematocrit 37.4, platelets 297, mcv 73, differential for white blood cell count 47.7 polys, 33.1 lymphocytes, 12.1 monocytes, 6.5 eosinophils, 0.6 basophils. the patient's arterial blood gases included ph 7.18, pco2 109, po2 92. the patient's bicarbonate at the time was 34. chest x-ray was notable for emphysema, no evidence of pneumonia or heart failure. hospital course: in the emergency department, the patient was noted to be in extreme shortness of breath with accessory respiratory muscle use, inability to speak a full sentence, occasional hypertension to the 190s/120s and arterial blood gas of 7.18, 109, 92. the patient refused intubation. the patient was given multiple albuterol and atrovent nebulizers and started on intravenous steroids. the patient's shortness of breath improved with the nebulizers and his blood pressure normalized. the patient was admitted to the medicine intensive care unit. upon arrival in the medicine intensive care unit, the patient was started on bipap and an empiric course of levofloxacin for presumed respiratory infection. the patient ruled out for an myocardial infarction. the patient was able to be weaned off of bipap and onto oxygen nasal cannula on the morning of hospital day #2. as the patient had minimal shortness of breath and required nebulizers only every 4 hours he was deemed in condition for floor transfer. the patient was transferred to the medical service. over the next four days, the patient was given a two day course of high dose methylprednisolone and then restarted on prednisone 40 mg q.d. the patient was also weaned off of 4 liters nasal cannula oxygen to oxygen 2 liters nasal cannula which is the patient's home dose. the patient's respiratory status returned to baseline within the next few days of hospitalization. occupational therapy was consulted to visit the patient. occupational therapy noted the patient had decreased mobility, decreased cognition of safety and general deconditioning. they recommended either longterm placement or increased services in his current home. physical therapy saw the patient and noted he had impaired gait and locomotion when ambulating. they worked with him for two days at the hospitalization at the end of which he was at his baseline. physical therapy recommended either longterm placement or increased services at his current location. due to concerns over the patient's ability to take his home medicine regimen, neuropsychiatry was consulted. upon their testing, they determined he had moderate to severe global dysfunctioning, decreased attention span, decreased memory and decreased breathing. they did not see him likely to be able to work from a pill dispenser. they did not see him likely to be able to handle his medicine regimen. they could not make any assessment about his competency without further assessment. the house staff, attending, care , and social worker were concerned that the patient would be unable to handle his medicine regimen at home. multiple meetings were held between those individuals as well as including the , the social worker from house, and the resident nurse house. after much discussion together, and with the patient and his daughter, and nephew, , it was decided that the patient could return home to the house with services and with the understanding that his nephew and daughter were to stop in and visit him twice a day to help him manage his medications. the patient's nephew and daughter understood and agreed to this. the patient also understood that he can not smoke or allow smoking in his apartment or anywhere near his home oxygen. the patient understands that this is a not only to himself but to his neighbors at the house. the landlord and the social worker drew up an agreement that the patient signed, agreeing that he would no longer smoke or allow smoking in his apartment. upon this condition, the patient is being allowed to return home to the house. hence, the patient was discharged to the house with services and the understanding that his nephew and daughter would further aid him in his medications. the patient also agreed to visit his nurse practitioner, , more often to better optimize for chronic obstructive pulmonary disease management. discharge medications: 1. verapamil 120 mg p.o. b.i.d. 2. aspirin 325 mg p.o. q.d. 3. atorvastatin 10 mg p.o. q.d. 4. primidone 50 mg p.o. q.d. 5. imdur extended release 30 mg p.o. q.d. 6. calcium carbonate 500 mg p.o. q.d. 7. cholecalciferol 400 units p.o. q.d. 8. salmeterol 21 mcg one to two puffs inhaler b.i.d. 9. montelukast sodium 10 mg p.o. q.d. 10. fexofenadine 60 mg p.o. b.i.d. 11. levofloxacin 500 mg p.o. q.d. for four days 12. pantoprazole 40 mg p.o. q.d. 13. ferrous sulfate 325 mg p.o. q.d. 14. prednisone 40 mg p.o. q.d. from to mg p.o. q.d. for through mg p.o. q.d. thereafter 15. combivent 103/18 mcg two puffs inhaled q. 6 hours 16. atrovent 0.2 mg/ml solution, one ml nebulizer every 6 hours 17. albuterol sulfate 0.83 mg/ml solution one nebulizer every two hours prn wheezing 18. albuterol sulfate 0.83 mg/ml one nebulizer every 6 hours 19. albuterol sulfate 0.83 mg/ml one to two puffs inhaled q. 2 hours prn shortness of breath or wheezing condition on discharge: the patient is being discharged in fair condition. final diagnosis: chronic obstructive pulmonary disease exacerbation , m.d. dictated by: medquist36 Procedure: Non-invasive mechanical ventilation Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Other convulsions Personal history of tobacco use Abnormality of gait Acute respiratory failure Old myocardial infarction Iron deficiency anemia, unspecified

allergies: patient recorded as having no known allergies to drugs attending: addendum: please note as a secondary diagnosis that the patient has congestive heart failure. discharge disposition: home with service facility: multicultural vna md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atherosclerosis of native arteries of the extremities with intermittent claudication Other specified forms of chronic ischemic heart disease Hypovolemia Acute myocardial infarction of other inferior wall, subsequent episode of care

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: positive stress-mibi major surgical or invasive procedure: cardiac catheterization history of present illness: 71yo m with htn, hypercholesterolemia, pvd, +tob and recent imi 2 weeks ago presents for cardiac evaluation after positive stress test today. the pt is and speaks little english. history was obtained through translation via the patient's daughter. over the past year the pt has developed increasing doe and claudication. he currently developes these symptoms after walking approximately one block. the claudication is felt bilaterally and improves with resting. approximately 2 weeks prior to admission the patient experienced malaise one evening. he denies having experienced cp, sob, jaw pain, l arm pain, diaphoresis or nausea at the time of his malaise. two to three days afterward he was found to have new ekg changes consistent with an imi. approximately one week prior to admission the patient had an echocardiogram which the patient's daughter said was abnormal. on the day of admission the patient had an outpatient stress-mibi which was abnormal and he was sent to the ed. the patient remained asymptomatic during his stress-mibi and denies having ever experienced cp, jaw pain, or l arm pain with exertion. in addition, he denies f/c/s, n/v/d, abdominal pain, melena, hematochezia, recent weight changes, orthopnea, pnd and dysuria. . in the ed, the pt had the following vs: t99.5 p60 bp: 159/82 rr22 o2sat: 100% on 2l. pt was given 325mg asa x1 and iv metoprolol 5mg x1 with good response of his bp. past medical history: 1. cad 2. hypercholesterolemia 3. htn 4. pvd 5. glaucoma social history: lives w/wife. 50 pack-yr hx, now at 4 cigs/day. etoh approx 4 drinks/wk family history: no cad, cva, dm in family physical exam: vs: t 99.5 p 69 bp: 150/74 rr 16 o2sat: 98% on ra gen: awake, alert, laying in gurney in nad. heent: eomi. perrl. op clear w/mmm. no oral lesions. neck: supple. no . unable to appreciate jvp cv: rrr s1 s2. no m/r/g pulm: ctab abd: soft. nabs. ntnd. no masses or hepatomegaly. ext: cool. unable to palpate dp/pt pulses bilaterally. femoral pulses 2+ bilaterally. pertinent results: studies: ed ekg: sinus, irregular, approx. 60bpm, nl axis, nl pr, narrow qrs, nl qt, lae seen in ii, twi in inferior leads, lateral st depressions (i, avl, v4-v6) . cxr : no acute cardiopulmonary process . stress-mibi : stress: ischemic ekg changes (3-4mm st depressions) in the setting of baseline abnormalities without anginal symptoms . mibi: 1. severe, predominately reversible perfusion defects in the anterior, septal and apical walls consistent with multivessel ischemic disease. fixed perfusion defect at the base of the inferior wall. 2. severe global hypokinesis with a calculated ejection fraction of 27%. likely post stress ischemic dilation of the left ventricular cavity. brief hospital course: /p: 71yo m with recent silent imi (cardiac risk factors include known cad, pvd, htn, hypercholesterolemia, +tob) presents for evaluation after positive stress test. . 1. cv: a. coronaries: the pt has known cad with imi in recent past. stress test was positive with reversible perfusion defects in ant, septal and apical walls consistent with multivessel ischemia as well as severe global hk. ---telemetry and ecg in am ---cycle ce x3 - if pt rules in, will start hep gtt and consider gp iib/iiia inhibitor as well. ---cath in am - will d/w cards fellow re: white board. ---asa 325mg once daily ---supplemental oxygen to obtain sao2 of 100% ---metoprolol 25mg titrate up as tolerated ---start captopril 6.25mg tid titrate up as tolerated ---lipitor 80mg qhs - will also obtain lipid panel and lft in am. ---hold plavix given suggestion of multivessel ischemic disease on mibi and possibility of cabg in near future. ---pt is currently pain free, however if he were to develop sx will start hep gtt and consider gpiib/iiia inhibitor as well. . b. pump: the pt has global hk with calculated ef of 27% on mibi. this may reflect some element of myocardial stunning after recent imi and therefore may recover function with time. will aim for afterload reduction for now and follow signs and sx of chf. ---transition metoprolol short acting to toprol xl when at a stable dose ---titrate up acei as tolerated. ---daily weights and ins/outs. . c. rhythm: the ecg has some evidence of sinus node dysfunction and is concerning for wandering pace maker. ---telemetry ---cont. bb as above. ---discuss with cards re: significance of rhythm. 2. glaucoma: not an active issue, cont. eye drops. ---lumigan gtt ---cosopt gtt the above hospital course pertains to the patient's stay while on the medical service. on the patient was taken to the or for a 3 vessel cabg (lima to lad, svg to om, svg to pda). the patient tolerated surgery well, was extubated the night of surgery and was transferred from the csru on postop day one to the regular cardiac hospital floor. on post op day two the patient's foley was removed and with his chest tubes. on post op day three the patient's pacing wires were removed. the patient tolerated a cardiac heart healthy diet, diuresed well after surgery while his pain was controlled throughout his hospital stay. the patient was discharged on post op day five. he will follow up with his pcp 10 days for medication adjustment if needed and routine blood work. additionally, the patient was cleared by physical therapy and he will be going home with visiting nursing services to monitor his wounds, assure medication compliance and check vital signs. medications on admission: 1. lipitor 10mg qhs 2. asa 325mg once daily 3. atenolol 25mg once daily 4. lumegon gtt for eyes 5. cosopt gtt for eyes . 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. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours). disp:*20 capsule, sustained release(s)* refills:*0* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 10 days. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: multicultural vna discharge diagnosis: pvd cad htn hypercholesterolemia discharge condition: stable 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. you must follow up with a primary care physician 10 days for medication adjustment and rountine laboratories. followup instructions: provider: , . call to schedule appointment within 1 month provider: , appointment should be in days provider: appointment should be in days Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atherosclerosis of native arteries of the extremities with intermittent claudication Other specified forms of chronic ischemic heart disease Hypovolemia Acute myocardial infarction of other inferior wall, subsequent episode of care

allergies: aleve attending: chief complaint: hip fracture major surgical or invasive procedure: r hip orif cental line (r ij, r subclavian dialyisis line) r picc line placed history of present illness: 70yo man with esrd not yet on hd, dm, pvd who initially presented s/p fall while getting out of bed in setting of hypoglycemia and poor appetite. he landed on his r hip and sustained a displaced femoral neck fracture. he was found by his son on the floor next to his bed, who called ems. on arrival to an osh he was found to have fs 36 and the above fracture and he was sent to for further management. he was recently treated at an outside hospital from for a r great toe cellulitis and was discharged to home on iv antibiotics (imipenem and zyvox). he was found to have a necrotic r great toe on arrival. he was medically cleared for the or and had a hemiarthroplasty of the r hip, immediate post op period was complicated by dka and the patient was sent to the micu, where he was kept on an insulin drip for one day. since then he has had very volatile fs, running between very elevated and quite low. has been following and with their recs the pt's fs have been stable off d5 for the last 24 hours. . hospital course has also been complicated by hospital acquired lll pneumonia for which he is being treated with vanco/zosyn, ms changes believed to be due to narcotics/psychotropic meds, development of a coccygeal decubitus pressure ulcer, and elevated inr in setting of coumadin use s/p femoral fracture (avoiding lovenox given cri). he has been followed by renal, id, , surgery and orthopedic surgery throughout his stay. . ros: pt reports mild pain in his r hip and r toe. no cp, no sob, no other complaints. eating well. past medical history: cri dm pvd with r great toe cellulitis/necrosis htn social history: lives with son and daughter-in-law, usually i in adls; 100+ py tobacco hx, quit ( ppd x 40y); no etoh or other drugs family history: nc physical exam: 99.1, 155/52, 63, 13, 98% ra, fs 74-123 gen: confused man, nad, oriented x 3 with much effort, answers questions but very circuitously heent: perrl, op not injected, mmm, cm ii-xii intact neck: no jvd, no lad pulm: decreased bs and inspiratory rhonchi at bilateral bases anteriorly cor: rrr, s1s2, no r/g/m abd: soft, nt, nd, +bs, no hsm ext: r great toe black and necrotic, r hip wound c/d/i, staples in place, nontender, nonerythematous, trace edema bilaterally, small 2x2cm coccygeal decub stage ii, bilateral pt and dp not palpable gu: yellow urine in foley, scrotum erythematous with fungal skin infection around scrotal skin and inguinal folds pertinent results: labs: 141 110 56 83 agap=13 4.6 18 4.7 . ca: 7.4 mg: 2.1 p: 4.8 other blood chemistry: vanco: 21.2 (last dose on ) . ....7.6 87 15.3>---<191 ...**23.5** . pt: 26.6 *ptt: 112.3* inr: 2.7 . coloryellow appearclear specgr1.012 ph 5.0 urobilneg bilineg leukneg bldlg nitrneg prot100 glu100 ketneg . mg: 2.1 acetone:negative comments: detects acetone + acetoacetate not beta-hydroxy butyrate _ _ _ _ _ _ _ _ _ ________________________________________________________________ femur (ap & lat) right 1:17 am pelvis (ap only); hip unilat min 2 views right ap pelvis and ap and lateral views of the right femur. there is a right subcapital/transcervical femoral fracture with superior displacement of the distal fracture with limb shortening. there is varus angulation of the fragments. the femoral head articulates with the acetabulum appropriately. the left femoral neck appears intact. no fractures are detected involving the right femur or knee. the soft tissues are unremarkable. impression: 1. right femoral subcapital/transcervical fracture with impaction and varus angulation of the distal fragment. 2. extensive calcifications. _ _ _ _ _ _ _ _ _ ________________________________________________________________ chest (pre-op ap only) 1:23 am impression: ap chest reviewed in the absence of prior chest radiographs: lungs clear. heart size top normal, exaggerated by low lung volumes and supine positioning. no pleural effusion or evidence of central adenopathy. no pneumothorax. tip of a right-sided central venous catheter projects over the junction of the brachiocephalic veins. _ _ _ _ _ _ _ _ _ ________________________________________________________________ ct head w/o contrast 11:35 am non-contrast head ct: no priors for comparison. no hydrocephalus, shift of normally midline structures, hemorrhage, or infarct is identified. calcified internal carotid arteries are noted. no fracture. retention cyst vs polyp in left maxillary sinus; other imaged sinuses are clear. there is cavernous carotid artery calcification. _ _ _ _ _ _ _ _ ________________________________________________________________ chest (pa & lat) ap and lateral chest radiographs: dating back to , there has been interval development of left lower lobe consolidation obscuring the left hemidiaphragm consistent with pneumonia. cardiac, mediastinal, and hilar contours are stable. right internal jugular catheter tip is seen within the mid svc. no evidence of pneumothorax or pleural effusions. osseous and soft tissue structures are unremarkable. _ _ _ _ _ _ _ _ _ ________________________________________________________________ radiology final report aorta and branches aorta and branches u/s 1:15 pm the abdominal aorta is normal in caliber measuring 2.3 cm in maximal diameter and showing no focal aneurysmal dilatation. there is some elevated atherosclerotic plaque in the distal abdominal aorta and at the iliac bifurcation. these plaques do not compromise flow, however. the possibility of the plaques being a source for peripheral emboli cannot be assessed by this technique. iliac arteries are normal in caliber bilaterally. _ _ _ _ _ _ _ _ _ ________________________________________________________________ cardiology report echo study date of measurements: left ventricle - ejection fraction: 60% (nl >=55%) interpretation: findings: left atrium: no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. right atrium/interatrial septum: normal interatrial septum. no asd or pfo by 2d, color doppler or saline contrast with maneuvers. left ventricle: overall normal lvef (>55%). right ventricle: normal rv systolic function. aorta: no atheroma in aortic arch. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no masses or vegetations on aortic valve. no ar. mitral valve: normal mitral valve leaflets. no mass or vegetation on mitral valve. physiologic mr (within normal limits). tricuspid valve: normal tricuspid valve leaflets. no mass or vegetation on tricuspid valve. physiologic tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no vegetation/mass on pulmonic valve. conclusions: 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. 2.overall left ventricular systolic function is probably normal (lvef>55%), however, the probe was not passed beyond the ge junction and transgastric views were not obtained. 3.right ventricular systolic function is normal. 4.there are simple atheroma in the descending thoracic aorta. 5.the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. 6.the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. physiologic mitral regurgitation is seen (within normal limits). 7. no vegetation/mass is seen on the pulmonic valve. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ video oropharyngeal swallow 2:49 pm oropharyngeal video fluoroscopic study: oropharyngeal video fluoroscopic swallowing evaluation was performed with speech and swallow therapist, and demonstrates mild oral and pharyngeal dysphasia, mild swallowing delay. mild silent aspiration was noted. no significant improvement in mild aspiration. for further details please refer to speech and swallow report. _ _ _ _ _ _ _ _ _ ________________________________________________________________ foot ap,lat & obl bilat 3:26 pm bilateral feet, six views: no cortical destruction or irregularity is identified to indicate osteomyelitis. the mineralization is normal. there are diffuse calcifications. the joint spaces are preserved. there is a posterior and plantar calcaneal spur on the left. impression: no radiographic evidence of osteomyelitis. brief hospital course: # r great toe and left toe necrosis: likely embolic. tee, aorta mra and lower extremity angiogram did not show any source of emboli. pt was on anticoagulation for right hip orif..completed several weeks of heparin gtt..and currently on aspirin for prophylaxis. also started on statin for possiblity of cholesterol emboli. xray do not show sign of osteomylelitis. no signs of active infection. followed by vasuclar surgery while in house who plan for amputation after discharge at outpt follow up. . # r femoral neck fracture s/p hemiarthroplasty- repaired on - pt to f/u with dr. in ortho clinic 1-2w after discharge . - wbat for pt. - staples removed . # dm/dka: initially developed dka in setting of orthopedic surgery around . treated with insulin drip in the icu. sent to floor with closed gap. developed dka again on in setting of fever and hospital aquired pna/ again treated in teh icu with insulin drip. transferred back to floor on . glucose has been stable and lantus dose titrated up as diet increased. has been difficult to follow gap with renal acidosis. have been following urine ketones which are negative at the time of discharge. . # cri: pt with esrd but not yet on hd. renal following during hospitalization and pt requiring frequent adjustments to phosphate binders, lytes, etc. never required hd despite dye load from angiogram. renal care will needs to be continued, unclear when pt will need hemodialysis. . # lll pneumonia: likely hospital acquired, treated with 14d course of zosyn and vanco for broad coverage. afebrile. cultures negative. . # ms change: confused in the settin gof high inr (up to 13). head ct negative. likely delerium secondray to illness and medication (narcotics and benzodiazepines). mental status is now back to baseline. . #hypotension/hypoxia/bradycardia - on, pt was found unresponsive at 9am. the previous night he had been getting hydration for renal ppx prior to dye load. initial assement - rr 5, bp 50/pal, sinus brady at 34. given 200 mg iv lasix push, 1 amp atropine, and narcan. pt responed with increased hr and rr. ct scan done showed no bleed. likely volume overload, leading to hypoxia and and bradycardia. resolved quickly and never recurred. # htn: fairly well controlled at present. continue bb, norvasc, hydralazine. titrate as tolerated. . # diarrhea; c diff negative x 3. continue to follow for frequency. . # coccygeal decubitus ulcer and penile ulcer- continue wound care as previously. turn q2 hours as tolerated. coccygeal swab + for pseudomonas which was more likely a colonization rather than infection. coccygeal ulcer had an overlying fungal infection that improved with local care. . # penile necrosis - secondary to foley trauma from pt pulling on it in setting of altered mental status. seen by urology who recommend leaving foley in place, securing it tightly to leg, and local wound care with bacitracin and silvadeine. # access: picc placed . . #aspiration risk - pt failed speech and swallow eval. recommend thin liquids and observation. medications on admission: asa lantus 35, hiss iron sulfate qday mag oxide 400mg po qday sodium bicarb 650po norvasc 10 qday toprol 25 po qday allopurinol 100 po qday was on 6wk course of imipenem 250mg , zyvox 600mg discharge medications: 1. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 2. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day). 3. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical qid (4 times a day): apply to penis. 4. lidocaine hcl 2 % gel sig: one (1) appl mucous membrane prn (as needed). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). 9. silver sulfadiazine 1 % cream sig: one (1) appl topical qid (4 times a day): apply to penis. 10. sodium bicarbonate 650 mg tablet sig: two (2) tablet po qid (4 times a day). 11. epoetin alfa 10,000 unit/ml solution sig: one (1) ml injection qmowefr (monday -wednesday-friday). 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 14. calcium carbonate 500 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 15. hydralazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). 16. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 17. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 18. insulin glargine 100 unit/ml cartridge sig: seven (7) units subcutaneous once a day. 19. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 20. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 21. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 22. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 23. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 24. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. 25. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 26. calcitriol 0.5 mcg capsule sig: one (1) capsule po daily (daily). discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: hip fracture renal failure peripheral disease diabetic ketoacidosis pneumonia discharge condition: stable discharge instructions: please follow up as directed. followup instructions: provider: , surgery (nhb) date/time: 11:15 . please see the urology department at the first available appointment on 3pm with dr. ( . provider: , md phone: date/time: 3:00 . provider: xray (scc 2) phone: date/time: 2:40 . please make a follow up appointment with your renal (kidney) doctor. md Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Arteriography of femoral and other lower extremity arteries Venous catheterization for renal dialysis Partial hip replacement Aortography Transfusion of packed cells Transfusion of other serum Injection or infusion of oxazolidinone class of antibiotics Hip bearing surface, metal-on-metal Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Acute kidney failure, unspecified Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cellulitis and abscess of leg, except foot Peripheral vascular complications, not elsewhere classified Long-term (current) use of insulin Pressure ulcer, lower back Diarrhea Hypovolemia Accidental fall from bed Atherosclerosis of native arteries of the extremities with gangrene Drug-induced delirium Other and unspecified coagulation defects Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Arterial embolism and thrombosis of lower extremity Other closed transcervical fracture of neck of femur Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Other complications due to genitourinary device, implant, and graft Cellulitis and abscess of toe, unspecified Other specified analgesics and antipyretics causing adverse effects in therapeutic use Dermatophytosis of groin and perianal area Redundant prepuce and phimosis Vascular disorders of penis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dizziness major surgical or invasive procedure: cardiac cath history of present illness: 74 yo male with hx of hypecholesterolemia and aortic stenosis who presented to hospital for an outpatient workup after having a syncopal episode 2 weeks ago. pt is very active and typically goes for a 4 mile powerwalk everyday without ever having chest pain. he also drinks 5 glasses of morning everyday before his powerwalk. 2 weeks ago, he was powerwalking and felt lightheaded and found himself on the ground. he states that his mental status was clear right after the event. he is unaware how long he was done. he reports no chest pain, no visual changes, no seizure like activity, no post-ictal like state, no weakness, no urinary or bowel incontinence. pt got up from the ground and was able to resume his exercise without symptoms. since the, he noticed he was getting more "dizzy" near end of his daily "power walks" of 4.5 miles. also he occasionally feels "dizzy" or lightheaded while seated (i.e. at church). with all of these events, there are no associated symptoms. no chest pain, no palpitation, no diahoresis, no nausea/voming, no fever/chills. pt then went to hospital to get an outpatient workup of his symptoms. per pt report, workup included "normal" carotid studies, "normal" stress test, ct showed calcified coronaries suspicious for l main aneurysm. pt then underwent elective cath which revealed 60% proximal lad lesion (per report but the cardiologist there thought was more risky lesion), and normal lcx and rca. echo showed moderate as with calculated area of 1.2 cm2, peak gradient of 48 mm hg. per pt, as is old and has been stable for 20 years by serial echos. pt was transferred to for interventional cath. past medical history: hypercholesterolemia htn- diagnosed 2 weeks ago. hx of pericarditis 12 yrs ago aortic stenosis -stable over 20 yrs with serial echo gerd social history: pt lives alone, power walks 4.5 miles daily, never smoked in life, and hardly drinks alcohol. family history: father died from mi at age 68 physical exam: vs: afebrile hr 72 bp 142/88 rr 16 o2sat 95% ra gen; well appearing, well nourished male in nad heent: nc/at, perrl, eomi, oropharynx clear, mmm, no jvd cor: rrr s1 s2 iii/vi systolic murmur loudest at rusb, lusb. lungs: cta bilaterally abd: soft, ntnd ext: no edema, groin site c/d/i neuro: alert and oriented x3, cnii-xii pertinent results: cath : ptca comments: initial angiography demonstrated 70% proximal lad stenosis.... at this point a decision was made to obtain arterial access via the right arm. the right radial access was unsuccessful due to inability to advance the wire despite good pulsatile flow. the brachial artery was then accessed successfully. significant subclavian tortuosity was encountered and a catheter was advanced into the aorta in a retrograde fashion from the right brachial artery but we still unable to engage the artery with a al1.5 guide catheter. supravalvular aortography with the al1 catheter in the ascending aorta demonstrated extreme tortuosity of the right subclavian and a normal aortic root. attempts to remove the al1 guide resulted in kinking of the catheter and eventual removal with difficulty. angiography of the brachial artery performed through the 6f sheath demonstrated serial stenosis and dye hangup in the artery at the mid arm level. the sheath was withdrawn and a 4f glide catheter was advanced over a angled stiff wire to the aorta and was used to exchange a choice floppy wire. angiography via the sheath in the right brachial artery revealed improvement in the suspected pleating artifact. the wire was removed and angigraphy was performed via a 4f dilator which demonstrated significant tortuosity of the brachial artery and almost complete resolution of the pleating artifact, normal flow and no dissection. exercise mibi: impression: 1) moderate to severe apical and distal anterior wall reversible defect. 2) moderate, partially reversible inferior wall defect. 3) calculated ejection fraction of 49%. head ct: findings: there is residual iv contrast from patient's recent cardiac catheteriztion, that limits evaluation for acute intracranial hemorrhage. there is no mass effect or shift of normal mid- line structures. the ventricles and sulci are prominent consistent with some age related involutional change. the - white matter differentiation is preserved. the partially visualized paranasal sinuses and mastoid air cells are well aerated. abd/pelvis ct: impression: large left groin hematoma. no retroperitoneal hemorrhage. large mass in the muscle of the upper right thigh as described above. brief hospital course: 1)cad: pt was transferred from an outside hospital for a possible interventional cath for a proximal lad lesion seen on a diagnositic cath. although pt never had chest pain, his symptom of dizziness and syncope was thought to be possibly related to ischemia given the finding of the cath done at osh. although it was reported as 60% stenosis, after reviewing the cath images, it was thought that his lesion was more significant than that. he underwent cardiac cath with plan to stent the lesion. however, pt has multiple tortuous arteries making entrance to the coronaries very difficult. the catheter could not be placed to the coronaries because of anatomical difficulties. after the cath, pt developed left groin hematoma requiring pressure to be applied. during that time, he got vasovagal and became hypotensive in the sbp of 60's-70's requiring atropine. the blood pressure came back up the first episode, but he again vasovagaled the second time requiring dopamine drip as well as atropine briefly. during these events, pt had conscious but suddenly became amnesic not remembering the events in the past 2 days. pt was alert and able to answer questions about the remote memory. his neurlogical exam was completely benign except for the lack of short term memory. he as sent for head ct to rule out stroke/bleed, as well as abdominal ct to rule out retroperitoneal bleed which were both negative. pt was transiently transferred to ccu for observation. pt's memory came back within several hours with complete resolution. neurology thought that it was transient global amnesia in a setting of syncope. pt's hct droppped from 40->31 but remained stable at that level. since pt could not get any intervention during the cath, he was sent for an exercise mibi which showed moderate to severe apical and distal anterior wall reversible defect, moderate, partially reversible inferior wall defect, and calculated ejection fraction of 49%. after long discussion, it was decided to medically treat the patient since the likelihood of another unsuccessful cath was high given his arterial anatomy. since he was not having symptoms at rest, this approach was thought the safest way at this time. 2)syncope: pt's hx unlikely to be seizure or tia. the syncopal episode he had may be arrhythmia or aortic stenosis related or vasovagal/hypersensitive carotid. during the exercise mibi, he did develop svt of 150's where he felt fatigued. it was thought that as would not be the cause since his as is mild on echo. pt was seen by neurology who felt that it was not neurologic but recommended outpatient mra to see if there is any abnormalities in the vertebrobasilar system. pt was discharged home with of hearts. 3)hyperlipidemia: pt was continued on lipitor medications on admission: lipitor 20 mg po qd ranitidine 150 mg po qd asa 81 mg po qd discharge medications: 1. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 2. lipitor 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 4. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: syncope cad-60% stenosis of lad discharge condition: hemodynamically stable, no symptoms of dizziness while ambulating. discharge instructions: pt was instructed to take all of the medications as instructed. pt needs to wear the of hearts monitor and press the button as instructed when he develops symptoms. he should also avoid strenuous exercise for the next 2 weeks while he is on the monitor. he shoud seek medical attention if he develops dizziness, black out spells, chest pain, diaphoresis, palpitation, nausea/vomiting, arm pain. notice that lipitor was increased to 40 mg, and new medication metoprolol was added. pt was given a list of phone numbers for the cardiac rehab which he should discuss with dr. on his next visit. followup instructions: follow up with dr. in 1 month. follow up with dr. from neurology in weeks. follow up with dr. in 2 weeks Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Hematoma complicating a procedure Aortic valve disorders Transient global amnesia

allergies: vasotec attending: chief complaint: 62m w/ increasing doe major surgical or invasive procedure: mv repair(28mm physio ring) history of present illness: this 62m has a history of cad w/ prior mis and has had increasing doe and a murmur for the past 10 years. he has been followed by serial echos and a recent echo revealed severe mr. had a cardiac cath which showed: 4+mr, an lvef of 25%, a 30% rca stenosis. he is now admitted for elective mvr with dr. . past medical history: cad, s/p ptca copd bph bladder ca gout htn niddm psoriasis cardiomyopathy s/p mix2 chf gerd pvd w/lle claudication s/p multiple cystoscopies s/p vasectomy and reversal of vasectomy s/p r eye tumor removal s/p l hand surgery s/p choley social history: pt. is a nurse who lives with his son and grandson. cigs: smoked 3ppd for many years, currently smokes 4 cigs/day. etoh: none x 5 years family history: sister w/ cad physical exam: in nad avss heent: nc/at, perla, eomi, oropharynx benign neck: supple, from, no thyromegaly or lymphadenopathy, carotids 2+=bilat. without bruits. lungs: clear to a+p cv: rrr without r/g/m abd: +bs, soft, nontender, without masses or hepatosplenomegaly ext: no c/c/e, pulses: r fem and pt=1+ r dp and rad=2+ l fem, dp, rad.=2+ l pt=1+ neuro: nonfocal pertinent results: 02:24am blood wbc-8.9 rbc-3.60* hgb-9.3* hct-28.4* mcv-79* mch-26.0* mchc-32.9 rdw-16.6* plt ct-306 09:00am blood pt-19.3* ptt-63.5* inr(pt)-1.8* 02:24am blood glucose-133* urean-18 creat-1.0 na-133 k-4.4 cl-96 hco3-27 angap-14 brief hospital course: this pt. was admitted on and underwent mv repair with a 28mm ce physio ring. he tolerated the procedure well and was transferred to the csru in stable condition on dobutamine, neo, and propofol. he was extubated on pod#1 and had his chest tubes d/c'd as well. he remained on dobutamine and this was weaned slowly over the next few days. he went into af and was started on amiodorone. he required respiratory therapy and was transferred to the floor on pod#4. he continued having intermittent af and was anticoagulated with heparin and coumadin. his epicardial pacing wires were d/c'd on pod#5. he continued to progress and was discharged to home in stable condition on pod#7. medications on admission: spiriva ih qd advair 100/50 asa 81 mg po daily vit c 1000 po daily folic acid 400 po daily crestor 20 po daily toprol xl 50 po daily omeprazole 20 po daily lasix 20 po bid kcl 10 meq po daily allopurinol 300 po daily 60 po daily quinapril 80 po daily flomax 0.4 po daily albuterol ih prn lidex cream 0.5% prn 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:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. 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* 4. rosuvastatin 5 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. quinapril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 5 days: then decrease dose to 400 mg po daily for 7 days, then decrease dose to 200 mg po daily. disp:*50 tablet(s)* refills:*0* 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*60 disk with device(s)* refills:*2* 8. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 9. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). disp:*30 patch 24hr(s)* refills:*0* 10. furosemide 20 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 11. prilosec 40 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* 12. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po daily (daily). disp:*60 capsule, sustained release(s)* refills:*2* 13. allopurinol 300 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 14. flomax 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po once a day. disp:*30 capsule, sust. release 24hr(s)* refills:*2* 15. coumadin 3 mg tablet sig: one (1) tablet po once a day for 2 days: then take as directed by dr. inr of .5. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: coronary artery disease mitral regurgitation 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. do not drive for 4 weeks. do not lift more than 10 lbs. for 2 months. followup instructions: clinic in 2 weeks dr in 4 weeks dr. in weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Annuloplasty Transfusion of packed cells Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Gout, unspecified Atrial fibrillation Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Alkalosis Personal history of malignant neoplasm of bladder

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain and dyspnea on exertion major surgical or invasive procedure: - mitral valve replacement(31mm ce permount pericardial bioprosthetic valve), cabgx1(vein graft to first obtuse marginal), and maze procedure history of present illness: mr. is a 72 y/o man with a three year history of mr followed by serial echocardiograms at the . a recent echocardiogram in revealed severe mr with a flail posterior leaflet. he was admitted to the va and underwent a tee which was stopped due to nsvt vs. svt. cardiac catheterization in confirmed 4+ mr. angiography revealed a 70% lesion in the circumflex and a 50% lesion in the lad. mr. was seen in clinic and now presents for surgical management of his coronary artery disease and mitral regurgitation. past medical history: mr, cad, bph, hyperlipidemia, htn, svt vs. nsvt preoperatively, history of severe nose bleeds, lipoma, s/p appendectomy, s/p tonsillectomy, s/p umbilical hernia repair social history: retired. lives with wife in . quit smoking in after ppd starting in middle school. family history: brother with ppm/ptca/stent. father with . physical exam: vitals: bp 160-180/ 80, hr 45-50 gen: wdwn gentleman in nad skin: warm, dry, multiple nevi and small lipomas heent: ncat, perrl, anicteric sclera, mild cataracts, op benign neck: supple, no jvd lungs: clear, mild kyphosis abd: benign, obese. neuro: nonfocal pertinent results: wbc-10.8 hct-28.0* inr 1.9 wbc-12.3* rbc-3.37* hgb-10.6* hct-30.4* mcv-90 mch-31.5 mchc-34.9 rdw-13.3 plt ct-460* urean-18 creat-1.2 k-5.3* blood calcium-8.7 mg-2.6 brief hospital course: mr. was admitted to the on for surgical management of his mitral valve and coronary artery disease. on the day of admission, he was taken to the operating room where a mitral valve replacement, coronary artery bypass grafting and a maze procedure were performed. the operation was uneventful but his operative course was complicated by traumatic foley placement secondary to his bph. for surgical details, please see seperate operative note. he required flexibile cystoscopy for placement of foley and was started on a drip for hematuria. after the operation, he was brought to the csru for invasive monitoring. given his history of svt and maze procedure, amiodarone was resumed. within 24 hours, he awoke neurologically intact and was extubated. initially hypoxic, his oxygenation improved with diuresis. on postoperative day two, he transferred to the sdu. low dose beta blockade was resumed and diuresis was continued. on postoperative day five, he experienced new onset slurred speech and left facial droop. his systolic bp at the time of neurologic event was in the 90's to low 100's. a stat head ct scan and mri/mra were obtained and the neurology service was consulted. head mr found no evidence of acute infarction or abnormalities except slightly diminished flow signal within the right sylvian middle cerebral artery branches compared to the left side, while ct scan showed no intracranial hemorrhage or mass effect. carotid noninvasive studies found no evidence of significant carotid stenoses and showed appropriate antegrade flow in the vertebral arteries. all afterload agents were temporarily discontinued including amiodarone in order to maintain cerebral perfusion and avoid further hypotension. warfarin anticoagulation was also initiated. based on the above studies, the neurology service suspected a tia secondary to decreased cerebral perfusion. his neurological status improved and returned to baseline within 24 hours. amiodarone and low dose betablockade were eventually resumed. warfarin was dosed daily for a goal inr between 2.0 - 2.5. he remained mostly in a normal sinus rhythm but intermittent paroxysmal atrial fibrillation versus svt were noted on telemetry. the rest of his hospital course was uneventful and he was medically cleared for discharge to home on postoperative day eight. at discharge, his bp was 117/55 with a hr of 84. his oxygen sat was 98% on room air and his chest x-ray showed small bilateral pleural effusions. all surgical wounds were clean, dry and intact. he was voiding without difficulty and his hematuria had completely resolved. he will eventually need to follow up with dr. as an outpatient for diagnostic ep study in the near future. medications on admission: amiodarone 400mg qd lopressor 25mg aspirin 325mg qd hctz 25mg qd fosinopril 40mg qd serax 15mg qhs fish oil calcium vitamins discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. disp:*20 tablet(s)* refills:*0* 3. tamsulosin 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* 4. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. warfarin 2.5 mg tablet sig: one (1) tablet po qpm: take as directed by md. daily dose may vary according to inr. disp:*30 tablet(s)* refills:*2* 6. senna laxative 25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 9. toprol xl 25 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 with service facility: vna discharge diagnosis: mr, cad, postop atrial fibrillation/svt, postop tia, hematuria, bph, hyperlipidemia, htn, svt vs. nsvt preoperatively, history of severe nose bleeds, lipoma discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) you may wash you incisoin and pat dry. no swimming or bathing until it has healed. 5) no lotions, creams or powders to wound until it has healed. 6) no lifting greater then 10 pounds for 10 weeks. 7) no driving for 1 month. 8) take warfarin as directed. followup with dr. for dosing. p instructions: follow-up with dr. in weeks, call for appt. follow-up with dr. for coumadin dosing. follow-up with dr. , call for appt. follow up with dr. , call for appt Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, open approach (Aorto)coronary bypass of one coronary artery Open and other replacement of mitral valve with tissue graft Insertion of indwelling urinary catheter Control of (postoperative) hemorrhage of prostate Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Paroxysmal ventricular tachycardia Multiple involvement of mitral and aortic valves Hypoxemia Iatrogenic cerebrovascular infarction or hemorrhage Other complications due to genitourinary device, implant, and graft Urethral false passage Other specified transient cerebral ischemias Lipoma, unspecified site

history of present illness: this patient is a 56 year old female who is diagnosed with a gastric mass by computerized tomography scan that was performed on . this mass was highly suspicious for an infiltrative neoplasm of the fundus and body of the stomach/linitis plastica. endoscopy was then performed, which revealed a gastric mass involving the gastric cardia, fundus and body and entering into the distal esophagus just above the esophagogastric junction. biopsies were performed and this demonstrated poorly differentiated adenocarcinoma with a component of signet ring cells. she presents to the for resection of her stomach and placement of a feeding jejunostomy by dr. . past medical history: 1. hypertension. 2. polycystic kidney disease. 3. chronic renal insufficiency. 4. lower mandible resection for malocclusion at age 18. medications on admission: 1. atenolol 25 mg p.o. q. day. 2. nexium 20 mg q. day. 3. norvasc 5 mg q. day. allergies: penicillin. hospital course: the patient was admitted on and underwent a total gastrectomy with feeding jejunostomy performed by dr. . the patient tolerated the procedure well. there were no immediate postoperative complications. please the operative note for further details. her pain was well controlled with an epidural, and the patient had an nasogastric tube that was placed to continuous level of suction. on postoperative day #2, the patient's tube feeds were started at 1/2 strength at 20 cc/hr. on postoperative day #4, the patient was doing well in the usual postoperative course. an upper gastrointestinal series was performed, which demonstrated a patent gastrointestinal tract with no leakage. the patient had some episodes of vomiting that evening. because of the upper gastrointestinal results from earlier that day, it was believed that her nausea and vomiting was due to postoperative ileus. her tube feeds were held but her epidural was discontinued. dr. would also stop by to see the patient and wrote that he would follow up with the final pathology results and have the patient follow up as an outpatient following her discharge for further evaluation or adjuvant chemoradiation. the patient continues to have nausea and vomiting and progressively is having increasing abdominal pain and on , the patient began to appear ill. a small bowel perforation was suspected, and a foley catheter was placed, intravenous fluids were initiated, broad spectrum antibiotics were started and the patient was planned to go to the operating room for exploration. in the operating room, it was found that there was a kink distal to the gastrojejunostomy which resulted in perforation of the gastrojejunostomy. the jejunostomy was repaired during this operation. following the operation, the patient appeared to develop a septic picture. the patient was continued with volume resuscitation, serial arterial blood gases were obtained, and a chest x-ray was performed. later that evening, the patient developed respiratory distress with tachypnea and shallow breathing and shortness of breath. the patient was reinstated successfully. her arterial blood gases following sedation was 7.35, 31, 90, 18, and -7. she was transferred to the surgery intensive care unit for further care. she was given 1 unit of blood for a hematocrit of 22.8. she was continued on levofloxacin and flagyl. aggressive fluid resuscitation was required for a hypotensive episode. she was started on levophed and given albumin to help with her low blood pressure. she also developed a reaction to heparin, with decrease in platelet count down to 49 from 93. she became positive for heparin-induced thrombocytopenia. fluconazole was also added for further broad-spectrum coverage. her tube feeds were also restarted, and nutrition made recommendations for appropriate tube feeds. because of her heparin-induced thrombocytopenia, the patient was started on coumadin. as her blood pressures improved or remained stable, the patient was begun with lasix diuresis. meanwhile, her white count started to climb from 14 to 23.8 on . a repeat abdominal computerized tomography scan showed persistent dilated loops of small bowel that was performed on . on , the patient went down for a second exploratory laparotomy. a takedown of the jejunostomy and replacement of the jejunostomy tube was performed as well as lysis of adhesions. there was no apparent perforation. she was then again transferred to the surgery intensive care unit for further management. at this time, blood cultures that were taken on , returned with gram positive cocci and pairs in chains. she was then started on vancomycin for coverage. this culture eventually turned out to be vancomycin-resistant enterococcus. her vancomycin was then switched over to linezolid for coverage. these cultures were sensitive to linezolid. on , she was finally extubated in the intensive care unit. during the following days, she appeared to go through a psychotic episode and delirium. a neurologic consultation was obtained. there was a small lacunar infarct that was visualized on head computerized tomography scan. the patient had some slight left-sided weakness, but it was felt that this left-sided weakness was her baseline. it was felt that her mental status was mostly secondary to metabolic encephalopathy. narcotics were held for agitation, and the patient was given haldol instead. the patient was transferred to the floor on . a follow up computerized tomography scan was performed, which found an abdominal abscess that was anterior to the rectum. she was sent to interventional radiology for drainage of the rectal abscess in a prone position. during this procedure she had desaturations with a slow recovery. the patient was on bipap with oxygen saturations of 86 to 88%. because she started to have increasing oxygen requirements it was best that she be transferred to the intensive care unit for intubation and further management. she was given 2 units of packed red blood cells for her hematocrit of 23.6 which she responded to with a post transfusion hematocrit of 33. there were no further events in the intensive care unit and she was finally extubated on . during this time, her levofloxacin and flagyl were discontinued. her pelvic abscess also revealed vancomycin-resistant enterococcus, and her linezolid and fluconazole were continued. on , the patient was felt to be ready for transfer to the floor again. neurologically the patient began to improve in terms of her mental status. her tube feeds were advanced appropriately. a bedside swallowing evaluation was performed, and the patient did not demonstrate any aspiration potential. she was then started on clears and her tube feeds were continued to be advanced to full strength. during the rest of her hospital course, the patient's foley catheter, central line, - drain, and pigtail catheter were eventually removed. the neurology service felt positive about her neurologic prognosis. she did demonstrate a dramatic improvement in her mental status before discharge. physical therapy also thought that she would do well at acute rehabilitation placement. before discharge to the rehabilitation, the patient was tolerating tube feeds at full strength at 60 cc/hr. she was also tolerating some full clears and some soft solids. she appeared almost to be at her baseline neurologically. her case manager ultimately found a spot for her at , for which she was screen for appropriately. she is planned for discharge on to this facility. discharge status: acute rehabilitation. discharge condition: good. discharge diagnosis: 1. gastric adenocarcinoma. 2. respiratory failure. 3. status post jejunostomy redo. 4. status post small bowel perforation/repair. 5. hypertension. 6. sepsis. medications on discharge: 1. albuterol inhalers. 2. artificial tears. 3. aspirin 325 mg q. day. 4. hydralazine 20 mg p.o. t.i.d. 5. insulin sliding scale. 6. .................... 0.125 mg q. 4 hours prn for bladder spasms. 7. linezolid 300 mg p.o. b.i.d. 8. lopressor 100 mg p.o. b.i.d. 9. coumadin, daily dosing to be determined by inr. her inr on was 2.6 which was therapeutic. her inr should be between 2 and 3. follow up instructions: the patient is to follow up with dr. within two weeks. the patient is also to follow up with dr. who is the radiation oncologist, phone . the patient is to follow up within two weeks. discharge disposition: discharge facility will be , . , m.d. dictated by: medquist36 d: 09:37 t: 09:43 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other total gastrectomy Other enterostomy Other enterostomy Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Transfusion of packed cells Revision of gastric anastomosis Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Other postoperative infection Unspecified septicemia Paralytic ileus Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Iatrogenic cerebrovascular infarction or hemorrhage Malignant neoplasm of cardia

allergies: heparin (hit), latex, pcn, pmed hx: gastric ca, htn, pckd, cri systems review neuro: she does not open her eyes, does not follow commands, she responds to nail bed stimulation by flexing, perl, she does have a gag, she has coughed for me once. she was seen by neurology here, she cont to be in status. she was started on phenobarb iv, dilantin conts (her level was 20 this morning). cv: sbp 130-160/80s, hr 60s-70s, she conts on her cv meds resp: ls clear, 02 sat on ra 98-99% gi: she has a pej, to be npo except meds gu: a foley was placed, good u/o id: she has been afebrile, her wbc was 36 today - her neupogen was d/ced, sh was seen by id. Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Unspecified essential hypertension Candidiasis of mouth Grand mal status Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Personal history of malignant neoplasm of stomach

history of present illness: the patient is a 56 year old woman with a history of locally advanced stage 3b gastric cancer status post subtotal gastrectomy who presents with febrile neutropenia and diarrhea. the patient was initially diagnosed in when her workup of weight loss and abdominal distention led to a gi evaluation. she had a subtotal gastrectomy in with postoperative course including sepsis, intubation and small bowel obstruction requiring several re-explorations. vre infection and heparin induced thrombocytopenia, without clear evidence of thrombosis. subsequently, she improved and started adjuvant 5- fu/lv chemotherapy from to 14 as a prelude to chemo/radiation in approximately one month. since starting chemotherapy, the patient has noted worsening fatigue, nausea and diarrhea. the diarrhea had gotten worse over the days prior to admission and is dark and "smells like blood." the night prior to admission, she spiked a fever to 101 with chills and came in on the day of admission for further evaluation. review of systems: review of systems was positive for shortness of breath, nausea, uri symptoms since the 5-fu started. it was negative for headache, lightheadedness, chest pain, abdominal pain, lower extremity edema. past medical history: stage 3b gastric cancer. it was a grade 3, t3, n2 tumor with peri-neural lymphatic invasion. she is status post subtotal gastrectomy in that was complicated by sepsis and respiratory failure, small bowel obstruction, encephalopathy and abdominal abscess. status post 5-fu/leucovorin chemotherapy. heparin induced thrombocytopenia without thrombosis. hypertension. polycystic kidney disease. chronic renal insufficiency. status post lower mandible resection with prosthesis several years ago. allergies: penicillin which causes anaphylaxis, latex which causes a rash, heparin and nickel. medications on admission: atenolol 100 mg , protonix 40 mg qd, hydralazine 25 mg tid, compazine 10 mg q6h, prn, ativan 0.5 to 1 q6h, prn, k/b/l and oxycodone 5-10 mg q4-6h, prn for pain. social history: the patient is a former nurse who worked at a rehab facility. she lives in with several of her children. she denies alcohol use and has a 30 pack year smoking history but quit this year. her daughter is her hcp. family history: family history if negative for malignancy. father has polycystic kidney disease. physical examination: on examination, the patient's temperature was 98.8, pulse 58, blood pressure 142/76, respiratory rate 20, sating at 99 percent on room air. in general, she was tired but in no acute distress. head and neck exam showed mild thrush but moist oropharynx. neck showed no jugular venous distention. lungs had decreased breath sounds at the bases but no crackles or wheezes. heart was regular with no murmurs, rubs or gallops. abdomen was soft and nontender with normoactive bowel sounds. extremities had no cyanosis, clubbing or edema. laboratory: white count was 0.6 with 40 percent polys, 50 percent lymphs, 4 percent eos and 6 percent atypicals. hematocrit was 33.3, platelets 43, sodium 140, potassium 2.8, chloride 110, bicarb 19, bun 17, creatinine 2.0, glucose 138, calcium 2.6, alt 10, ast 15, total bilirubin 0.8 and lactate was 1.7. her urinalysis was negative. radiology: a chest film showed patchy atelectasis of the left base. hospital course: febrile neutropenia: there was no clear identifiable source. given the patient's copious mucus secretion and mucositis and neutropenia, she was covered empirically with cefepime. she tolerated the antibiotics without any complications. the patient was started on neupogen to increase her counts. after several days, her absolute neutrophil count rose and she became afebrile and there were no further infectious disease complications over the course of her admission. diarrhea: the patient has a history of black stools that were concerning but her stools were guaiac negative. after several days, her diarrhea stopped and this was not a further concern. the diarrhea was likely related to chemotherapy. altered mental status/neuro: towards the end of the first week of her admission, when her counts had recovered, the patient became delirious. at first, she was inattentive and this progressed rapidly to becoming very altered and nonresponsive. initially, the concern was for infection and so she had a torso ct with contrast which did not show any evidence for abscess or infection in her chest or abdomen. she then had a head mri which did not disclose any acute abnormality or explain her altered mental status. there was no evidence for metastases. the following day, the patient became rigid and was very lethargic. a spinal tap was performed that showed 0 white cells and 0 red cells with a protein of 71. at this point, a neuro consult was obtained who thought the differential diagnosis included paraneoplastic disease leading to altered sensorium. the following day, the patient became progressively more unresponsive and so an eeg was performed. this showed nonconvulsive status epilepticus. the patient was started on dilantin, while improving her eeg, did not improve her mental status. at this point, it was decided that for the patient to be better treated, she would require phenobarbital as well as dilantin. given the concern for airway protection, she was transferred to the icu for close monitoring. at this point, she had loading with dilantin and phenobarbital which achieved adequate levels after several days. there was no evidence for further status epilepticus on the eeg and her mental status slowly improved. she was able to become more interactive and able to speak in short sentences. she is significantly below her baseline but improved from when she initially developed these symptoms. she is profoundly weak with some cogwheeling suggestive of upper motor neuron damage. she is at risk for aspiration. as for the underlying etiology, it is completely unclear. one possibility is that she had 5-fu toxicity, perhaps secondary to dihydropyrimidine dehydrogenase deficiency, although one would not have expected her counts to recover as they did. she was started on thiamine empirically which may or may not have made a difference, although its use has been reported (micromedex) in similar situations. the remainder of the workup for the source of the seizures was negative and she will need close outpatient neurology follow-up. hypertension: the patient has a history of hypertension. she was initially continued on her outpatient medications of atenolol and hydralazine. however, her blood pressure dropped when she started on the dilantin and so she was just maintained on atenolol therapy. code status: the patient was admitted to hospital as a full code. after further discussion with her oncologist, the patient was made dnr/dni. once the decision was made to put her on phenobarbital, however, the code status was temporarily reversed. once it became evident she would not require intubation, it was changed back to dnr/dni which is where she is at this point. condition on discharge: stable. discharge status: to rehab. discharge diagnoses: gastric cancer. febrile neutropenia. nonconvulsive status epilepticus. hypertension. discharge medications: 1. dilantin 120 mg po q8h. 2. colace 100 mg po bid. 3. lactulose 30 cc po tid prn, constipation. 4. phenobarbital 100 mg ng qd. 5. lansoprazole 30 mg ng qd. 6. atenolol 50 mg po qd. 7. regular insulin sliding scale. with respect to her nutrition, the patient was continued on her tube feeds. these were increased once her po intake declined significantly. follow up: follow up plans will be detailed in the addendum to this dictation. , Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Unspecified essential hypertension Candidiasis of mouth Grand mal status Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Personal history of malignant neoplasm of stomach

history of present illness: this is a 56-year-old woman with stage 3b gastric carcinoma originally admitted to the o-med medicine service. the patient is status post subtotal gastrectomy, as well as 5-fluoro uracil two weeks prior to admission. she presented with subjective fever, diarrhea and found to be neutropenic. the patient had been diagnosed with gastric carcinoma in when a work-up for weight loss and abdominal pain led to a gastrointestinal evaluation. the patient had a subtotal gastrectomy in , which was complicated by a difficult postoperative course including sepsis with vre incubation and small bowel obstruction. the patient subsequently improved and then had a course of 5- fluoro uracel from to as a preclude for a possible chemoradiation one month later, but since during the chemotherapy, the patient noted mouth sores with fatigue, nausea and diarrhea with diarrhea increasing to the point in the past few days prior to admission that was almost melanic in color and "smells like blood". on the night prior to admission, she had a fever of 101 with chills and electively came to the hospital for further evaluation. review of symptoms: positive for shortness of breath, as well as nausea and upper respiratory problems since the 5- fluoro uracil started, but denied any headache, chest pain, lightheadedness, abdominal pain or lower extremity edema. past medical history: notable for gastric carcinoma, grade timi grade iii-ii with a subtotal gastrectomy in and a course of 5-fluoro uracil. she also had heparin-induced thrombocytopenia. positive history of hypertension. she has a history of polycystic kidney disease and a history of chronic renal insufficiency. allergies: penicillin which causes anaphylaxis and heparin- induced thrombocytopenia, as well as nickel sensitivity. medications prior to admission: 1. atenolol 100 mg b.i.d. 2. protonix 40 mg q day. 3. hydralazine 25 mg t.i.d. 4. compazine p.r.n. 5. ativan 0.5-1.0 mg p.o. q six hours p.r.n. 6. oxycodone 5-10 mg p.o. q 4-6 hours p.r.n. social history: the patient is a registered nurse who worked at a rehabilitation facility and lives in . she has five children. she denies any etoh, but has a positive thirty pack year smoking history. she only quit smoking this year. family history: negative for any history of malignancy, but her father had polycystic kidney disease. physical examination: upon admission, her temperature was 98, pulse 58, blood pressure 142/75, respirations 20, 99 percent saturation on room air. general: she looked tired but was in no apparent distress. heent: notable for some mild thrush, but moist mucous membranes. neck had no jugular venous distension. lungs were notable for decreased breath sounds at the bases. cardiovascular examination was regular with no murmurs, rubs or gallops. abdomen was notable for decreased bowel sounds, but was very soft and nontender. she had a well healed midline scar. extremities showed no evidence of cyanosis, clubbing or edema. laboratory data: initial labs showed the patient's whites were 6, hematocrit 33.3, platelets 43. hospital course: throughout the course of the next few days of the patient's hospitalization, her mental status began to decline. a neurology consult was called on after a head magnetic resonance imaging scan done on showed no evidence of any metastatic disease or infarcts; only evidence of some minimal small vessel ischemic disease. the patient had two lumbar punctures neither of which revealed any obvious sources of infection. however, an electroencephalogram performed was notable for the presence of nonconvulsive status epilepticus. the patient was transferred to the fenard intensive care unit on . the patient was loaded with both dilantin, as well as phenobarbital and infectious disease was consulted. ultimately, no organism grew out of any of her cultures, including her cerebrospinal fluid, which was also sent off for hsv pcr ultimately came back negative. the patient then received a few days of empiric acyclovir treatment for possible hsv, though that was discontinued once the results came back negative. blood, urine and cerebrospinal fluid cultures, again, remained negative. during the hospitalization, the patient was started on empiric intravenous thiamine at 100 mg q day with possible suspicion of a possible deficiency in dihydropyrimidine dehydrogenase, which is an enzyme necessary for metabolism with 5-fluoro uracil and in some published studies, the patients became encephalopathic with this deficiency and became encephalopathic after being treated with 5-fluoro uracil. this was done empirically without any western blots or protein evidence or enzymatic activity evidence of this patient to reveal this deficiency. over the course of the patient's hospitalization, she did gradually improve on this treatment of thiamine, dilantin and 5-fluoro uracil. the patient's code status was, after much discussion with the family, made "do not resuscitate" and "do not intubate". the plan as of this dictation now is for the patient to be called to the regular hospital floor and to be sent home with services. the family and patient indicate that they do not want rehabilitation placement and would prefer outpatient physical and occupational therapy via her home situation. discharge medications will be dictated as an addendum to this discharge summary. , Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Unspecified essential hypertension Candidiasis of mouth Grand mal status Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Personal history of malignant neoplasm of stomach

history of present illness: this is an addendum to the patient's discharge summary, dictated on . hospital course: problem 1: nutrition and swallow. the patient was noted to be aspirating on her food and so a swallow study was obtained. this confirmed that the patient had moderate to severe oral mylopharyngeal dysphagia with impaired orophage. she aspirated nectar, thin and thick liquids. the patient was started on pureed solids and honey- thick liquids. she tolerated that without any complications. in the future, when her mental status clears, the patient should have a repeat swallow study, so her diet can be advanced. in the meantime, she was continued with increased j tube feeds including free water boluses. problem 2: thrush. towards the end of her admission, the patient developed oral thrush. she was initially treated with diflucan. this does interact with dilantin and phenobarbital. these levels were checked and were normal. by discharge, the patient no longer needed the diflucan. at rehabilitation, she should continue either with nystatin swabs that are soaked in nystatin and brushed throughout her mucosa or, if possible, clotrimazole troches. this depends on her degree of mental status. condition on discharge: stable. discharge status: to rehabilitation. discharge diagnoses: non convulsive status epilepticus. febrile neutropenia. gastric cancer. 5-fu toxicity. discharge medications: 1. phenobarbital 100 mg q. h.s. per j tube. 2. pantoprazole 30 mg nasogastric q. day. 3. atenolol 50 mg twice a day per j tube. 4. regular insulin sliding scale. 5. phenytoin suspension, 120 mg q 8 hours nasogastric. 6. nystatin 5 cc four times a day with a swab that is soaked in nystatin, brushing her oral mucosa. follow up: the patient will follow-up with dr. on for neurology follow-up. she should contact dr. office to schedule a follow-up appointment within 2-3 weeks. , Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Unspecified essential hypertension Candidiasis of mouth Grand mal status Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Personal history of malignant neoplasm of stomach

history of present illness: the patient is an 80-year-old male with significant coronary/vascular past medical history (ejection fraction of 15-20%, coronary artery disease status post coronary artery bypass grafting, peripheral vascular disease, congestive heart failure, atrial fibrillation, chronic renal insufficiency), admitted on , for an elective cardiac catheterization secondary to increased dyspnea on exertion. during the procedure, the patient was noted to have a ramus intermedius lesion, and intervention was planned. the patient developed a dense right-sided hemiparesis and became unresponsive. he was intubated for airway protection and transferred to the ccu. head ct showed no evidence of hemorrhage at that time, and therefore it was thought likely to be a left posterior cerebral embolus causing ischemic damage during the procedure, and the patient was started on a heparin drip. mri on revealed hemorrhagic infarct/conversion (left thalamic/occipital lobe, posterior portion, left temporal lobe, cerebellar, and pons). the heparin was stopped at this time, and a repeat ct on confirmed the bleeding. another repeat ct on showed no interval changes. the patient was started on a course of levofloxacin and flagyl on for an increasing white count felt to be possibly left lower lobe atelectasis versus aspiration pneumonia. he was transferred from the ccu to the neurology team on after being extubated on . on , the patient was noted to be hypernatremic and started on free water boluses but subsequently had desaturations to the low 90s which improved with lasix. past medical history: 1. cardiomyopathy with an ejection fraction of 15-20%, 3+ mitral regurgitation, 2+ tricuspid regurgitation. 2. status post coronary artery bypass grafting in with lima to left anterior descending, saphenous vein graft to obtuse marginal to ramus, and saphenous vein graft to posterior descending artery. 3. peripheral vascular disease. 4. chronic renal insufficiency. 5. congestive heart failure. 6. atrial fibrillation. medications on admission: coreg 3.125 b.i.d., lanoxin 0.25 mg q.d., zocor 10 mg q.d., captopril 6.25 mg t.i.d., lasix 40 p.o. q.d., aspirin 325 q.d. allergies: no known drug allergies. social history: the patient is a former pipe smoker. he lives with wife. family history: father deceased of myocardial infarction at age 48. physical examination: vital signs: on transfer to the medical service, temperature was 96.8??????, t-max 97.5??????, blood pressure 90/50, ranging 90-110/50s, heart rate 51, range 60-80s, respirations 24, oxygen saturation 92% on room air. general: the patient was nonverbal, mildly tachypneic. heent: slight dry mucous membranes. neck: no jugular venous distention at 45??????. cardiovascular: normal rate on exam. regular rhythm. there was a holosystolic murmur at apex. positive s3. lungs: crackles at lower lung fields bilaterally. abdomen: positive bowel sounds. soft and nontender. extremities: no edema. pneumoboots in place. neurological: there was right hemiparesis. he moved left arm, leg, and toes spontaneously. he had left eye lid ptosis with left pupil dilated and minimally reactive to light. laboratory data: on transfer white count was 24.6; sodium 159, bun and creatinine 68/2.0. cardiac catheterization on : 1. significant lesion in the proximal native ramus. all other native vessels were occluded. 2. patent saphenous vein graft to obtuse marginal with occluded jump segment to ri. patent saphenous vein graft to posterior descending artery and lima to left anterior descending. 3. ramus intervention deferred secondary to development of right-sided hemiparesis. tte on , showed an ejection fraction of 15%, with resting regional wall motion abnormalities including interseptal akinesis, atypical akinesis, inferolateral akinesis, and hypokinesis elsewhere, severe global right ventricular free wall hypokinesis, moderate to severe 3+ mitral regurgitation, moderate 2+ tricuspid regurgitation. head ct without contrast on showed no acute intracranial pathology including no signs of intracranial hemorrhage or infarct. mr of head without contrast on showed hemorrhagic infarct including the left thalamus, occipital lobe, posterior portion of the left temporal lobe, cerebellum, upper pons, and superior aspect of the superior cerebral peduncle. findings are indicative of occlusion of a portion of the posterior cerebral artery and left superior cerebellar artery. mra of the ................ showed a poorly seen left-sided posterior cerebellar artery. this was suggestive atherosclerotic or embolic disease. ct of the head without contrast on showed evolving posterior circulation infarct affecting the left occipital lobe, temporal lobe, cerebellum, midbrain, and thalamus. ct of the head without contrast on showed stable appearance of brain since previous study on . ct of the head without contrast on showed interval resolution of the previously noted hemorrhage in the left thalamus and midbrain. again noted was a posterior circulation infarct affecting the left occipital, temporal lobes, cerebellum, midbrain, and thalamus. there was no evidence of hydrocephalus or mass affect. scrotal ultrasound on showed bilateral hydroceles. chest x-ray on showed signs suggestive of asymmetric congestive heart failure. culture data: the patient had a urine culture on and positive for 10,000-100,000 enterococcus species which were resistant to levofloxacin, ampicillin, and vancomycin. urine culture sent on , remained negative to date. the patient was c-diff negative times three. the patient was with negative blood cultures throughout his stay. this was last sent on . hospital course: the patient was an 80-year-old male with a significant history of dilated cardiomyopathy with depressed ejection fraction (15%), coronary artery disease, chronic renal insufficiency, admitted for elective cardiac catheterization secondary to increased dyspnea on exertion, who subsequently experienced a left pca embolic stroke with subsequent hemorrhagic transformation. 1. neurologic: the patient was with events of cardiac catheterization and initial intensive care unit stay as detailed in history of present illness. the patient's neurologic deficits improved gradually throughout his stay as he regained some strength and movement of his right upper and lower extremities; however, his left eye remained closed with a dilated pupil. repeat ct on revealed interval resolution of hemorrhagic infarct. therefore, the stroke team recommended anticoagulation for a goal inr of , given the patient's stroke risk in the setting of his cardiomyopathy and depressed ejection fraction. 2. cardiomyopathy/congestive heart failure: the patient had resolved oxygen requirement throughout his stay and had an oxygen saturation greater than 92% on room air at the time of discharge. he remains on aspirin, statin, and his digoxin was decreased from 0.25 to 0.125 secondary to elevated levels. the patient's ace inhibitor and beta-blocker were held through portions of his stay secondary to low blood pressures, but these were added back prior to discharge and recommend titration of dose as tolerated. 3. ventricular ectopy: the patient was noted to have frequent premature ventricular contractions and occasional runs of nonsustained ventricular tachycardia during his stay. the patient was found to have no significant metabolic derangement or electrocardiogram changes suggestive of ischemia. therefore, the etiology of his ectopy was felt to be related to his structural heart disease associated with his profound cardiomyopathy. the patient had not been on his carvedilol at the time of these events, and once these were restarted, the patient was still having occasional premature ventricular contractions but no runs of nonsustained ventricular tachycardia. 4. hypernatremia: the patient's hypernatremia resolved gradually with increased and free water boluses, as the etiology was felt to be secondary to dehydration/decreased access to free water. urine electrolytes were consistent with this diagnosis and did not show any evidence for diabetes insipidus as a potential etiology. sodium at the time of discharge was 141. 5. leukocytosis: the patient remained afebrile and hemodynamically stable throughout his stay, however at times had rising white count. urine culture sent on revealed 10,000-100,000 enterococcus, and urinalysis revealed white blood cells but no bacteria. given the rising white count in his urine results, the patient was initiated on ampicillin with a planned treatment for a 14-day course (enterococcus species in urine was noted to be resistant to levofloxacin). the patient remained with negative c-diff cultures and blood cultures. at the time of discharge, the patient's white count had trended down and was 13.3. 6. acute on chronic renal failure: at the time of transfer to the medicine service, the patient's creatinine was 2.0, and the patient was felt to be intravascularly dry, and therefore diuresis was held. his creatinine gradually trended downward. at the time of discharge, creatinine was noted to be 0.9 with a prior baseline noted to be 1.2. 7. scrotal edema: the patient was noted to have scrotal edema which was stable throughout his stay. scrotal ultrasound revealed the etiology as bilateral hydroceles. 8. fen: the patient was evaluated by speech and swallow and was noted to have a nonfunctional oral and pharyngeal swallow; therefore, they recommended strict npo with peg tube placement for long-term nutrition. this was placed by interventional radiology on . they recommend repleting potassium for less than 4 and magnesium for less than 2, given history of coronary artery disease. the patient's free water boluses currently at 250 cc q.6 hours. 9. physical therapy/occupational therapy: the patient was evaluated by both physical therapy and occupational therapy and felt to be a fair candidate for a significant degree of recovery and would therefore likely benefit from an acute rehabilitation facility. condition on discharge: the patient is in stable condition, moving all extremities, with an oxygen saturation greater than 92% on room air. discharge status: the patient is to be discharged to an acute rehabilitation facility. discharge diagnosis: 1. cerebrovascular accident (left pca). 2. cardiomyopathy (ejection fraction of 15%). 3. coronary artery disease. 4. urinary tract infection. 5. hypernatremia. 6. congestive heart failure. 7. peripheral vascular disease. 8. anemia. 9. chronic renal insufficiency. discharge medications: aspirin 325 p.o. q.d., heparin 5000 u subcue b.i.d., pravastatin 20 mg p.o. q.d., lansoprazole 30 mg p.o. q.d., digoxin 125 mcg p.o. q.d., carvedilol 3.125 mg p.o. b.i.d., captopril 12.5 mg p.o. t.i.d., coumadin 5 mg p.o. q.h.s., goal inr of , ampicillin 1000 mg p.o. q.6 hours for 10 days to be completed on . follow-up: the patient should arrange follow-up with his primary care physician . as appropriate. dr., 12-929 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Left heart cardiac catheterization Coronary arteriography using a single catheter Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Insertion of other (naso-)gastric tube Angiocardiography of right heart structures Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified protein-calorie malnutrition Atrial fibrillation Hyperosmolality and/or hypernatremia Iatrogenic cerebrovascular infarction or hemorrhage

allergies: levofloxacin/dextrose 5%-water attending: addendum: pt has no pcp. , md, is now designated at pcp and follow up phone number given for patient to call after discharge. also, pt continued on sc heparin at the facility until he can walk 100 feet twice a day. discharge disposition: extended care facility: medical center - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Temporary tracheostomy Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Cocaine abuse, unspecified Acute respiratory failure Dermatitis due to drugs and medicines taken internally Obesity, unspecified Other specified antibiotics causing adverse effects in therapeutic use Diastolic heart failure, unspecified Acute sinusitis, unspecified Other specified diseases of hair and hair follicles

allergies: levofloxacin/dextrose 5%-water attending: chief complaint: transfer from osh for hypercapnic, hypoxic respiratory failure major surgical or invasive procedure: intubation, tracheostomy, g tube placement history of present illness: 47 year old man with pmh significant for heart failure 4-5 years previous without good medical follow up presented at in on with complaint of leg swelling and shortness of breath over previous 4-5 days, although according to his family these symptoms had been going on much longer, greater than a month or two. he had no complaints of fevers, chills, chest pain, or other symptoms at that time. . in their ed, he was found to be hypertensive and hypoxic with le edema, decreased breath sounds, and o2 sat of 71%. he was given lasix with improvement in sat to 94%. he was admitted to the floor, but was found to be in increasing respiratory distress and was intubated for a pco2 of 112 (7.18/112/72) and transferred to the micu. he was found to have an elevated d-dimer, but was unable to have a ct scan due to his excessive weight, so was empirically started on heparin. a tte showed pericardial effusions from 1-2.3 cm, and dilated pulmonary artery. lv function appeared within normal limits. leg ultrasound showed no clots. he persistently had a large aa gradient and was ventilated on simv with 100% oxygen but abg at transfer was 7.42/41/64, so he was transferred to the micu for further workup and treatment. past medical history: chf, unknown ef but "lv function ok" cocaine use asthma as child likely osa per family, obseved to occasionally be apneic at night social history: single but lives with partner of 24 years. has 4 children with previous partners, locations unknown. occasional crack cocaine use, last a few weeks ago. no tobacco or etoh. no official health care proxy at time of admission (default for medical decision making is his group of siblings, primarily in contact with , his sister, since pt's parents are deceased and children are estranged) family history: father had emphysema and type ii diabetes. mother had pneumonia and mi at age 70. sister osa. physical exam: t98.2 130/70 82 18 95% ventilator: ac 700x18 100% peep 12 (abg 7.45/44/85 lactate 2.7) gen: obese man in nad heent: ngt, ett in place neck: obese, no appreciable jvd resp: diminished bs but generally clear cv: rrr nl s1s2 no apprecible murmurs abd: obese soft ntnd +bs ext: 1+ edema on legs. onchomycosis. neuro: intubated, sedated. pupils equal and reactive. skin: numerous tattoos, erythematous areas on chest. pertinent results: osh labs (current labs below) . 11.1\15.2/287 /47.5\ 85p 2b 6l 5m 2 meta . 138 93 8 -------------< 160 3.8 38 1.0 ca 8.5 . t bil 1.0 d bil 0.2 ast 19 alt 15 alb 2.3 tp 5.3 b12 370 folate 11.4 . tox negative bnp 75 (0-100) . ekg (osh) nsr at 80, left axis deviation, poor r wve progression in precords. twi in iii, v1-v3. no st changes, no q waves . cxr: bibalisar atelectasis vs infiltrate. cardiomegaly. wide mediastinum/ dilated pulmonary arteries. . sputum cx: staph aureus clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s . urine cx negative . blood cultures: multiple taken since admission, negative or no growth to date at . (1/2 bottles grew coag - staph from osh cultures) . 04:11am blood wbc-10.2 rbc-4.62 hgb-13.2* hct-41.2 mcv-89 mch-28.6 mchc-32.1 rdw-15.1 plt ct-373 01:00am blood wbc-16.3* rbc-5.09 hgb-15.0 hct-46.5 mcv-91 mch-29.6 mchc-32.3 rdw-15.1 plt ct-274 04:56am blood neuts-79.0* lymphs-12.6* monos-4.8 eos-3.1 baso-0.6 04:11am blood plt ct-373 03:22am blood pt-13.0 ptt-23.8 inr(pt)-1.1 12:30am blood pt-17.0* ptt-78.7* inr(pt)-2.0 01:00am blood pt-13.6* ptt-41.3* inr(pt)-1.3 04:11am blood glucose-119* urean-12 creat-0.6 na-142 k-3.7 cl-103 hco3-27 angap-16 04:56am blood glucose-97 urean-11 creat-0.7 na-142 k-3.8 cl-104 hco3-28 angap-14 04:10am blood glucose-94 urean-11 creat-0.7 na-144 k-3.8 cl-105 hco3-31 angap-12 01:00am blood glucose-170* urean-16 creat-1.0 na-136 k-3.5 cl-97 hco3-29 angap-14 04:17am blood ck(cpk)-267* 01:00am blood alt-12 ast-31 ld(ldh)-353* alkphos-64 amylase-53 totbili-0.5 04:11am blood calcium-8.7 phos-3.5 mg-1.7 04:56am blood calcium-8.5 phos-3.4 mg-1.8 iron-34* 01:00am blood albumin-3.0* calcium-8.6 phos-3.1 mg-1.6 04:56am blood caltibc-233* trf-179* 12:03pm blood type-art temp-37.3 rates-/42 tidal v-580 peep-10 fio2-40 po2-153* pco2-32* ph-7.46* calhco3-23 base xs-0 intubat-intubated vent-spontaneou 08:34am blood type-art temp-37.3 rates-/42 tidal v-580 peep-10 fio2-40 po2-63* pco2-40 ph-7.44 calhco3-28 base xs-2 intubat-intubated vent-spontaneou 03:52am blood type-art temp-36.7 rates-18/ tidal v-700 peep-15 fio2-100 po2-58* pco2-45 ph-7.44 calhco3-32* base xs-5 aado2-625 req o2-100 intubat-intubated 06:31pm blood o2 sat-97 10:11am blood freeca-1.16 . cxr: an element of fluid overload; smaller heart size vs. prior. . cta chest: 1. limited examination for pulmonary embolism. there is no large embolus within the main, right or left pulmonary arteries. no definite filling defects are identified in other segmental and subsegmental branches. 2. moderate cardiomegaly, and a moderate pericardial effusion. 3. bibasilar consolidation versus atelectasis. 4. large main pulmonary artery, suggesting pulmonary arterial hypertension. . echo conclusions: 1.the left atrium is normal in size. an echo contrast study was peformed at rest only. while the study was limited and the images difficult to interpret confidently, no intracardiac shunt is seen. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). 3.the right ventricular free wall is hypertrophied. the right ventricular cavity is moderately dilated. right ventricular systolic function appears depressed. 4.the aortic valve leaflets appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. 5.the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. 6. the pulmonary artery systolic pressure could not be determined. 7.there is an anterior space . this is most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. . cxr small bilateral pleural effusions are unchanged. heart size is normal. bilateral hilar enlargement has progressed since reflecting interval increase in pulmonary artery pressure. tracheostomy tube is in standard placement. feeding tube can be traced to the lower esophagus, the tip is indistinct and the upper abdomen is not included on the study. repeat examination will be performed at no charge to the patient. . ekg sinus rhythm precordial/anterior t wave abnormalities - are nonspecific but cannot exclude in part ischemia - clinical correlation is suggested since previous tracing of , no significant change brief hospital course: 47 year old man with hypoxic, hypercapnic respiratory failure likely secondary to obesity hypoventilation syndrome transferred to for intensive care. . # hypoxic/hypercapnic respiratory failure pt initially had wide a-a gradient c/w shunt physiology such as intracardiac shunt, or pe. those diagnoses were ruled out with echo and cta chest (ruled out significant pe). the pt's course coupled with those labs was consistent with obesity hypoventilation syndrome. p:f ratio now improved. lenis negative. ps and peep weaned to the point that the pt could talk while on trach collar without his passy muir valve in place as the cuff leak was significant. since this meant he was preserving little to no peep, his progress was deemed to be significant from last week requiring peep in 20s. . #. fever differential included bleeding vs. infection. the pt's hct was stable and rectal was negative and his clinical stability collectively offered evidence against a source of bleeding. infectious sources were pursued and he was empirically treated with a 7 day course of vancomycin and ceftazidime for nosocomial sinusitis well into his hospital course. on day 3 of those antibiotics his fever resolved and his nasal discharge was significantly reduced. prior to that, there was concern for pneumonia on admission, for which he was treated with levofloxcacin initially. he developed a rash which was characterized as a drug rash by dermatology on day 1 of levofloxacin. he was transitioned to ceftriaxone, which was ultimately stopped after a 7 day course w/ a relatively unremarkable cxr. he had a mild folliculitis that resolved w/ topical clindamycin. his urine was free of bacteria and his line cultures were unremarkable. when nearing discharge he was afebrile and showed no clinical indication of having a significant infection. . # neurologic status pt was noted to have disconjugate gaze a few days in a row when he was deeply sedated with midazolam and fentanyl. the gaze was variable in its presentation and would resolve sporadically. as the pt's sedation was weaned, he was not found to have this on subsequent exam. this was thought to be toxic/metabolic rather than neurologic given the variable presentation and the resolution w/ resolution of the mental status. doll's eyes negative. . # congestive heart failure the pt's echo showed ef >55% and pt did well with diuresis without more help than his home diuresis regimen. . #. hct change, approximately 10 initially, now stable he has no evidence of bleeding and his hematocrit has been stable for over one week in the low 40s. no evidence of gib, hematoma, or any other source. . # fen the pt is getting screened for further po intake as he failed his initial swallow evaluation. pt has a g tube and has been tolerating tube feeds well. . # the pt received heparing subcutaneous, a bowel regimen, and a ppi . # code the patient was full code throughout the hospitalization. . # communication/social issues the pt's official medical decision maker is his sister, (lives in , ) in conjunction with the other siblings. the pt's parents are deceased and the children are estranged. the pt's partner of 24 years was upset with her lack up input, but did show up to the family meeting and there was apparently little disagreement between her and the pt's siblings. the topic of health care proxy was broached but not resolved. patient received flu vaccine and pnemovax before discharge. sputum culture before discharge came back positive for mrsa and the pt was continued on vancomycin for a seven day course, which was originally started for nosocomial sinusitis. medications on admission: meds at home: h/o lasix 4-5 years ago . meds on transfer: asa 81 qd unasyn 3g iv q8h levoquin 750 iv q24 pepcid 20 iv bid solumedrol 60 mg iv q6h lasix 40 mg iv qd ntg paste 1" to chest q6h ativan 1mg q1h prn morphine 3-5 mg iv prn pavulon 3-5 mg iv prn versed 1-2 mg iv prn propafol 59 mcg/kg/min heparin @ 1500/hour traumacal tubefeeds 10 cc / hour discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4-6h (every 4 to 6 hours) as needed. 4. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed: do not take more than 12 pills in 24 hours. 6. clindamycin phosphate 1 % solution sig: one (1) appl topical (2 times a day) for 10 days: end date: . 7. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day) for 10 days: end date: . 8. senna 8.6 mg tablet sig: 0-4 tablets po bid (2 times a day): titrate to bm/day (give 4 tabs if 0 bm; reduce to 0 if >4 bm/day). 9. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation: hold if 1 or more bm per day. 10. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for oral thrush for 7 days. 11. amoxicillin-pot clavulanate 250-62.5 mg/5 ml suspension for reconstitution sig: two (2) po q8h (every 8 hours) for 2 days: end date: . 12. sodium chloride 0.9 % parenteral solution sig: three (3) ml intravenous daily (daily) as needed: to keep line open. 13. vancomycin 1,000 mg recon soln sig: one (1) gram intravenous every twelve (12) hours for 2 days: end date: . discharge disposition: extended care facility: medical center - discharge diagnosis: obesity hypoventilation syndrome congestive heart failure (diastolic heart failure) nosocomial sinusitis mrsa (source: sputum) discharge condition: stable. vaccinated with flu vaccine and pneumovax. discharge instructions: most of the tracheostomy care will be taken care of by the vent weaning facility. make sure to call or come back with any questions or concerns that you might have. see the instructions below for care and emergency procedures in relation to you tracheostomy care. also, come back for chest pain, shortness of breath, trouble breathing, unexplained sweating. do not drink alcohol, do not smoke, and do not use any drugs, including cocaine. cocaine can damage your lungs and heart very seriously, which will make it more difficult to heal and breath well. tracheostomy care what you should know: a tracheostomy (tra--ah-stuh-) or "trach" is a tube to help you breathe. it is put into a small opening in your neck called a stoma, then into your trachea. the trachea is also called the windpipe. the outer cannula of your trach tube fits into your stoma. the inner cannula fits inside the outer cannula. the inner cannula may be locked so that when you cough it does not out. you do trach care so you can breathe easily. there are two parts to trach care: suctioning. suctioning is done using a long, thin, tube (catheter) with a hole to control when and how long you suction. the tube is attached to a machine that makes the suction. suctioning removes that build up in the throat. if the get too thick to be coughed out, they must be suctioned. cleaning. cleaning keeps the cannula path open. after you leave: how do i instill sterile salt water into my trach? caregivers may show you how to instill sterile salt water into your trach. if your caregivers have told you to instill sterile salt water into your trach, follow the steps listed below. gather the items you will need: a 5 or 10 ml syringe or a spray. sterile salt water. 4 x 4 gauze pads to catch the fluid you cough up. wash your hands carefully and dry them completely before and after instilling sterile salt water. if you are using a syringe, draw up the sterile saline into the syringe. if you are using a spray, unscrew the top. while breathing in, slowly squirt (or spray) ml's of the sterile salt water solution into the trach tube. you need enough sterile salt water to loosen , but not so much that it makes you cough as it goes in. when you cough up , it should not be tiring. the fluid should be loose or thin enough to cough out easily. how do i suction my trach? when you suction your trach, the catheter ( long, thin tube) should not go into the trach further than the end of the trach tube. your caregivers will the safe place on the catheter to not insert the catheter beyond while suctioning. make sure you the correct place on each new catheter you use. gather the things you will need before you start: suction machine with suction tubing. small bowl. sterile salt water. suction catheter with safety . gloves. turn on the suction machine. set the dial between -80 and -120 mmhg. attach suction tubing to the suction machine. fill the small bowl with some of the sterile salt water. put the sterile lid back on the jar of sterile salt water. do not touch the inside of either the jar or lid. set the small bowl to the side of your work table. wash your hands with soap and water. dry your hands and put on gloves. take the suction catheter out of its package. hook it to the suction tubing on the suction machine. dip the catheter tip into the sterile salt water. this will make the catheter easier to put into your trach. take a few deep breaths. gently put the wet catheter into your trach tube or stoma. put the catheter in to the marked place. do not cover the catheters control valve while you are putting the catheter into your trachea. covering the valve will start the suction. the control valve is the small hole near the end that is in your hand. slowly pull the catheter out of your trach tube. as you pull it out, use your thumb to cover and uncover the catheters control valve. this will start and stop the suction. do this several times. do not keep the control valve covered all the time. also, roll the catheter between your thumb and fingers as you pull it out of your trachea. suction no longer than 10 seconds. if you suction longer than that, the amount of oxygen in your lungs may fall too low. put the tip of the catheter into the sterile salt water in the bowl. put your thumb over the control valve to clear the suction catheter and tubing. turn off the suction machine and remove the catheter from the suction tubing. throw the catheter into a trash can. rinse the small bowl and the collection bottle from your suction machine with soap and water. how do i clean my inner cannula? the inner cannula of your trach is very important. from your throat can thicken in your inner cannula. thickening will make the hole in the cannula get smaller. as the hole gets smaller, it will be harder for you to breathe. the inner cannula can easily be removed for cleaning. do not use just the outer cannula to breathe through. if you do not use the inner cannula, you may have an emergency if the outer cannula builds up . some caregivers will want you to remove and replace the inner cannula with another disposable inner cannula. other caregivers will want you to clean your reusable inner cannula. clean or replace your inner cannula often, at at least twice a day. if you have a new trach, you will need to clean or replace the inner cannula about every 4 hours. you should have two inner cannulas available. this way, as you use one, you may clean the other. gather the things you will need to clean your inner cannula: a clean inner cannula. a small bowl. water that was boiled for 20 minutes then cooled to room temperature. 3 percent hydrogen peroxide. pipe cleaners for cleaning the inside and a small brush for cleaning the outside of the cannula. a cotton cloth. put about 2 ounces of the boiled water and 2 ounces of hydrogen peroxide into the small bowl. place a mirror in front of you so that you can see your face and throat. wash your hands with soap and water carefully, and dry them completely. unlock the inner cannula. use the hand you do not write with to keep the outer cannula from moving. using the hand that you do write with, remove the inner cannula. the inner cannula comes out easily if you pull out and down at the same time. put a clean, moistened, inner cannula inside the outer cannula. lock the inner cannula in place. clean the dirty cannula by soaking it in peroxide and water. as the hydrogen peroxide works, it will bubble. when the bubbling stops, clean the outside of the cannula with the brush, and the inside with pipe cleaners. rinse the inner cannula under running water. make sure all the hydrogen peroxide has been rinsed off. dry the inner cannula with the cotton cloth. store the clean cannula where it will stay clean and easy to reach. a small, plastic, snack-type storage bag works well. how do i change my trach tube? you may have been shown how to change your trach tube by your caregiver. if you have, follow the steps below to change your trach tube at home: gather the things you need before you start: a clean trach tube. twill or velcro trach tube ties. scissors. two small bowls. sterile saline solution. 3 percent hydrogen peroxide. tap water. trach bib (optional). cotton-tipped applicators. a trash container. trach tube one size smaller than the one you are using. mirror. good lighting. adjust your mirror and light so you can see your trach area clearly. mix about 2 ounces of peroxide with 2 ounces of tap water in one of the small bowls. pour some sterile saline into the second bowl. remove your trach bib if you have one and throw it away where children and pets cannot get to it. wash your hands carefully and dry them completely. remove the inner cannula and put the obturator into the outer cannula. put new ties on the trach tube you will put in. remove or cut the trach ties on the trach tube in your throat. remove your trach tube by pulling out and down. using the cotton-tipped applicators clean the area around the stoma by working from the stoma to the skin. be careful not to allow any of the into the stoma. cotton-tipped applicators dipped in the peroxide solution can be rolled over areas where there are . the area will foam. it will loosen the so they can be gently rolled away from the stoma and removed. look at the area around the stoma for redness, hardness, or pus. if you see any of these things, call your caregivers when you are finished changing your trach and let them know. put the end of the trach tube into the sterile saline. it is easier to insert the clean trach if it is wet. insert the new trach tube in and down with the obturator in place. do not force the trach tube. when the trach tube is in, quickly remove the obturator. if you are having trouble getting the trach tube in, try to ease it by gently turning it from side to side. if you cannot get the trach tube in, use the smaller one. if you still cannot get the trach tube in, call 911 for help. your stoma will not close suddenly. stay calm and wait for help to arrive. secure your trach ties. put the inner cannula into the outer cannula and lock it in place. if you use a trach bib, place it under the trach faceplate. how do i care for my trach faceplate and stoma? it is important to look at and clean your stoma at least once a day. if you have a new trach you will have to clean the stoma several times a day. look for redness, hardness, pus, and any that may be stuck on or around the stoma. if you notice any redness, hardness or pus, call your caregiver. need to be removed carefully and as completely as possible. gather the items you will need to clean your stoma: cotton-tipped applicators. tap water. 3 percent hydrogen peroxide. a small clean bowl. a trash container. wash your hands carefully and dry them completely. when cleaning the stoma, work from the stoma toward skin. be careful as you work under the faceplate of the trach tube. or any other matter should not go into the stoma opening. pour some hydrogen peroxide into the bowl. pour an equal amount of water into the bowl. dip a cotton-tipped applicator into the hydrogen peroxide and water mixture. lightly roll the applicator along the fluid areas. the peroxide solution ill foam. using a new applicator each time, continue to put the peroxide solution on areas where there are . the will loosen. remove them with applicators, throwing away applicators after each contact. peroxide will not foam when the area is clean. how do i change my trach bib? your caregivers may want you to use a trach bib. a trach bib is used to catch any that come from your stoma. this will help keep the skin around the stoma from getting sore. you may use a pre-cut non-raveling (does not make loose threads) bib, or make one. if you make or use a bib, follow the steps in this section. wash your hands carefully and dry them completely. to make a trach bib, use a 4-inch by 4-inch non-raveling pad. cut a slit from the edge to the center of the pad. slide the two sides under the faceplate and up and around the stoma. how do i make sterile (germ-free) salt water? you will need sterile salt water if you instill it into your trach tube before suctioning. you will also need sterile salt water for your suctioning catheter. to make sterile salt water: you will add 1 teaspoon of salt to a quart of water. gather the things you will need: saucepan. metal tongs. clean 1 quart glass jar with lid. 1 teaspoon of regular cooking salt. tap water. place the jar, lid, and metal tongs in the saucepan. allow the handle of the tongs to stick out from the saucepan. fill the pan with tap water to cover the jar. boil the water for 30 minutes. after boiling for 30 minutes, allow the water to cool until you can touch the tongs. pick up the jar with the tongs and place it right side up on a table. fill the jar with the boiled water from the saucepan. measure one teaspoon of salt and place it in the jar. put the lid on the jar using the tongs. tighten the lid and shake the solution to mix thoroughly. store the solution in the refrigerator and use for up to 3 days. discard unused sterile salt water after three days. how do i change the ties on my trach? you will need another person to help you when you change the ties on your trach. when the ties are not on, one person needs to hold the trach in place until the new ties are on. without the ties, you may cough out the trach tube by accident. a trach tie is usually made of some kind of twill. a tie may also have a velcro close. some people with permanent trachs have their jeweler make them a trach tie. follow these steps to change twill ties: while one person is holding the trach faceplate in place, cut your old tie. remove the tie carefully from each of the holes in your faceplate. thread the new tie through the hole on one side of the faceplate, and around the back of your neck. thread the end of the tie through the hole in the other side of the faceplate. bring the two ends of the tie together. tie the ends using a square knot. make sure that the knot is secure, but not too tight. you should be able to put one finger under the tie easily. the knot should not loosen if pulled. how can i add humidity to keep thin? thin are easier to cough out and to suction. there are two ways to help keep your thin: add humidity where you live, and drink plenty of liquids. humidifier. a gallon humidifier in the area where you spend your day will help keep your thin. also, keep a humidifier going in your bedroom at night. you may use warm or cold humidifiers. clean the humidifiers daily to stop germs from growing. drink plenty of liquids. drink at least six to eight (8-ounce) cups of liquid during the day, unless your caregiver tells you not to. drinking enough liquid will help keep the in your throat thin and easy to cough up. what should i do when i go outside? cover your trach. it is important to protect your throat and lungs from germs, foreign bodies like hair and dust, and dry air. your mouth and nose usually do this for you. tie a scarf below your chin and let it cover your trach. do not use silk or any material that may cling to the trach as you breathe in. water is a . golfing, gardening, walking are encouraged. avoid boating, swimming, and fishing. if you are under water there is no way to hold your breath. water will be able to enter your lungs and you may drown. call if: you still have trouble breathing after coughing or suctioning. your stoma is swollen, red, or has pus coming out of it or from around it. this may mean it is infected. you get a temperature over 100.5 degrees. you have questions or concerns about your tracheostomy or medicine. seek care immediately if: you are very short of breath and coughing or suctioning does not help. your trach falls out. call 911 or 0 (operator) to get to the nearest hospital or clinic. do not drive yourself! followup instructions: call your primary care doctor from the ventilator weaning facility and make an appointment. if you do not have a primary care doctor, call the () at and explain that you need a new primary care doctor. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Temporary tracheostomy Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Cocaine abuse, unspecified Acute respiratory failure Dermatitis due to drugs and medicines taken internally Obesity, unspecified Other specified antibiotics causing adverse effects in therapeutic use Diastolic heart failure, unspecified Acute sinusitis, unspecified Other specified diseases of hair and hair follicles

history of present illness: the patient is a 34-3/7 weeks female infant, #2, admitted for issues of prematurity. she was born to a 34-year-old, g3, p2, mother with an of . prenatal screens, negative mom, antibody negative, rpr nonreactive, unknown gbs, rubella immune, hepatitis b surface antigen negative. pregnancy was complicated by mono-di spontaneous twin gestation with growth discordance in twin b since weeks' gestation, however, normal amniotic fluid throughout pregnancy. mother received rhogam at 28 weeks. due to worsening growth restriction in twin b (this twin), the babies were delivered on , at 33-3/7 weeks. they were betamethasone complete at that time. delivery was unremarkable. apgar scores were 8 and 9 respectively. rupture of membranes was at the time of delivery. the infant emerged active with good respiratory effort and was brought to the nicu for further care. physical examination: weight 1855 g, head circumferential 30.5 cm, length 43 cm, rash consistent neonatal pustule melanosis. otherwise normal exam. normal female genitalia. baby was left on room air and feeds were started via gavage tube. hospital course: the following is the hospital course by systems dictated on , at day of life 37: respiratory: baby on room air from time of birth. she was started on caffeine for some apnea of prematurity which was discontinued on day of life 14, . last spell was on day of life 13. cardiovascular: hemodynamically stable throughout hospitalization. no murmur at time of discharge. fen/gi: on full pg feeds by day of life 5. on full p.o. feeds with breast milk 24 kcal/oz by similac concentration on day of life 36, . baby also on iron 2 mg/kg/day and multivitamin 1 ml p.o. daily. infectious disease: had an initial 48-hour sepsis rule out with ampicillin and gentamicin. cultures were negative and antibiotics were discontinued. neurology: no head ultrasound at this time. the infant was greater than 32 weeks gestational age at birth. ophthalmology: no exam at this time. infant greater than 32 weeks gestation at birth. audiology: hearing screen was performed with auditory brainstem responses and was passed bilaterally. condition on discharge: stable. disposition: discharged to home. primary pediatrician: dr. , phone #, fax #. care recommendations: feeds at discharge: continue breast milk 24 with similac 4 kcal/oz or just breast feeding. continue iron and multivitamins as well. medications: iron 2 mg/kg/day, multivitamin daily. car seat position test screening: state newborn screening: sent and without abnormality. immunizations received: hepatitis b vaccination #1 on . immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for all household contacts and out-of-home caregivers. follow up: with primary pediatrician, dr. at pediatrics on , at 10 a.m. discharge diagnosis: 1. prematurity. 2. twin gestation. 3. apnea of prematurity, resolved. 4. hyperbilirubinemia, resolved. Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,750-1,999 grams 33-34 completed weeks of gestation Other specified conditions involving the integument of fetus and newborn

allergies:codiene. shellfish. iv contrast. iodine. darvon. cipro. * pcn. social:separated lives w daughter. neg etoh/tobacco. crf:cad. dm. htn. elevated cholesterol. present hx: presented to md's office w sob 7 cough-ekg w ?ischemic chgs-to -admitted for ro. ro w neg ck's x3. echo- hk inferior/posterior walls & transfered to for further evaluation. cardiac cath-wo flow limiting cad. sheaths dced wo comp. episode of coughing-r groin bleed-rxed w manual pressure w cessation of bl. resumed again requiring c-clamp & then fem-stop. co r thigh & lower back pain cb hypotension-rxed w ivf (2l) w bp back to normal. hct decreased from am 38.9 to 30.7 & r-groin hematoma noted & outlined. transfered to ccu for further care. o:neuro=very pleasant & cooperative. wo neurological deficit. pulm=o2 4l nc w sats upper 9o's. breath sounds=clear. wo co sob/ dyspnea. cv=hemody stable. ivf-ns @ 100ml/hr x2l. pos pedal pulses. gi=npo except for meds. gu=foley. adeq uo. id=afebrile. misc=presented co r-groin & lower back discomfort. rxed w ms04 iv w success. hematoma outlined-wo increase. hct stable low 30's-awaiting am hct. evaluated by surgery. code status=full. a:wo further increase in hematoma. hct stable low 30's. discomfort decreased from initial assessment. p:contin to follow hcts-?tx hct <30. ct scan in am to document bl. contin present med management. Procedure: Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Esophageal reflux Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hematoma complicating a procedure Percutaneous transluminal coronary angioplasty status Old myocardial infarction Chest pain, unspecified

history of present illness: the patient is a 61 year old female with a history of coronary artery disease status post myocardial infarction in , status post left anterior descending stent placement, type 2 diabetes mellitus, hypercholesterolemia, and hypertension, who presents to via , where the patient was hospitalized for rule out myocardial infarction after presenting with substernal chest pain, as if an elephant was sitting on her chest. ekg at that time showed t wave flattening in the lateral leads. the patient was ruled out by enzymes times three and underwent stress echocardiogram at on the day of admission which revealed ischemic st changes and new reversible defects with failure of the inferior and posterior walls to augment. the patient was admitted to service for catheterization and possible intervention. on admission, she denied chest pain, shortness of breath, nausea or vomiting. past medical history: 1. coronary artery disease status post myocardial infarction in with a stent to the left anterior descending. 2. diabetes mellitus. 3. hypercholesterolemia. 4. hypertension. 5. gastroesophageal reflux disease. 6. osteoporosis. 7. fibromyalgia. 8. right sided cerebrovascular accident in . medications on admission: 1. glucophage. 2. glucotrol. 3. lopressor. 4. aspirin. 5. diltiazem. 6. accupril. 7. plavix. physical examination: on admission, vital signs were afebrile; blood pressure 117/76; breathing at 14; pulse 82; o2 saturation 98% on room air. in general, she is in no apparent distress, alert and cooperative. cardiovascular: regular rate and rhythm, normal s1, s2. no murmurs, rubs or gallops. lungs are clear to auscultation bilaterally. extremities with no cyanosis, clubbing or edema noted. abdomen is soft. there are positive bowel sounds throughout. she has no tenderness or distention. laboratory: on admission, white count 7.1, hematocrit 36.3, platelets 236. sodium 140, potassium 3.9, chloride 102, bicarbonate 26, bun 12, creatinine 0.8. glucose 153. stress echocardiogram on , showed ischemic changes in the inferior posterior wall, failure to augment, st depressions inferolaterally. allergies: the patient's allergies include codeine, shellfish, intravenous contrast dye, iodine, extract, darvon, ciprofloxacin and penicillin. social history: no alcohol and no tobacco use. hospital course: the patient was admitted to the service on . she underwent cardiac catheterization on . the patient's cardiac catheterization demonstrated normal coronary arteries, mild diastolic dysfunction with normal systolic ventricular function. the patient, post-procedure, developed a large hematoma in her right groin. her hematocrit dropped from 39 to 31, and remained stable between 30 to 33. a ct scan on , showed a right anterior abdominal wall hematoma extending superiorly from the right groin. the patient's serial hematocrits were stable as previously noted, other than the abdominal groin pain, and the patient was asymptomatic. she did not describe any chest pain, shortness of breath, lightheadedness, palpitations, coldness, numbness or tingling in her right lower extremity. she had good pulses. the hematoma subsequently resorbed, and the patient was transferred back to the floor for further management from the cardiac care unit. while on the floor, the patient's cough progressively worsened. this coughing was reduced after the patient's prinivil was discontinued. cozaar was started at that time and the patient's cough essentially resolved. on the last hospital day, the patient developed symptoms of a urinary tract infection. urinalysis and urine culture are pending at this time. the patient is being discharged home on . discharge medications: 1. protonix 40 mg p.o. q. day. 2. losartan 50 mg p.o. q. day. 3. colace 100 mg p.o. twice a day. 4. glucophage 500 mg p.o. twice a day. 5. glipizide 10 mg p.o. q. day. 6. lopressor 25 mg p.o. twice a day. 7. plavix 75 mg p.o. q. day. 8. aspirin 325 mg p.o. q. day. 9. diltiazem 180 mg p.o. q. day. 10. macrodantin 100 mg p.o. twice a day times three days. discharge diagnoses: 1. coronary artery disease status post myocardial infarction in with a stent to the left anterior descending. 2. diabetes mellitus. 3. hypercholesterolemia. 4. hypertension. 5. gastroesophageal reflux disease. 6. osteoporosis. 7. fibromyalgia. 8. right sided cerebrovascular accident in . 9. right groin hematoma which is resolving. 10. urinary tract infection, which is under treatment with macrodantin. discharge instructions: 1. the patient will follow-up with her cardiologist, dr. in two weeks' time. , m.d. dictated by: medquist36 Procedure: Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Esophageal reflux Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hematoma complicating a procedure Percutaneous transluminal coronary angioplasty status Old myocardial infarction Chest pain, unspecified

allergies: penicillins / sulfamethoxazole-trimethoprim / ciprofloxacin / iodine / lipitor / codeine / darvon-n / demerol / morphine / sulfa (sulfonamide antibiotics) / lopressor / lisinopril / shellfish / sesame oil / fish derived / milk / sunflower oil / melon / artificial attending: chief complaint: extertional chest pain and dyspnea on exertion major surgical or invasive procedure: coronary artery bypass graft x2 history of present illness: this 70 year old female reports shortness of breath, belching and chest pressure with minimal exertion relieved with rest. she feels like she is "gasping for breath" after climbing about one flight of stairs. the episodes are sometimes associated with lightheadedness and diaphoresis. she reports having had several episodes of waking up from sleep with the symptoms. she completed a stress echo on , which revealed no evidence of inducible ischemia at achieved workload, however, there is a significant decrease in exercise capacity in comparison to the last stress test from . she was referred for cardiac catheterization for further evaluation. she was found to have three vessel disease and is now being referred to cardiac surgery for revascularization. past medical history: coronary artery disease hypertension hyperlipidemia insuline dependent diabetes mellitus s/p bms to lad diabetic retinopathy s/p stroke mild left leg "dragging" when fatigued gastroesophageal reflux asthma s/p hysterectomy s/p ovarian surgery s/p cholecystectomy bilateral cataract surgery social history: lives with:alone contact: (daughter) phone # occupation:retired cigarettes: smoked no yes other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use:denies family history: premature coronary artery disease- paternal family with multiple members with cad physical exam: pulse:62 resp:12 o2 sat:97/ra b/p right:142/64 left:136/59 height:5'5" weight:173 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: all are palpable carotid bruit right: none left: none pertinent results: 03:41am blood wbc-11.5* rbc-3.29* hgb-9.7* hct-28.7* mcv-87 mch-29.5 mchc-33.8 rdw-12.9 plt ct-373 02:04am blood wbc-16.7* rbc-3.50* hgb-9.9* hct-30.0* mcv-86 mch-28.4 mchc-33.1 rdw-12.9 plt ct-389 03:41am blood glucose-104* urean-24* creat-0.7 na-138 k-4.4 cl-103 hco3-27 angap-12 02:04am blood glucose-55* urean-28* creat-0.7 na-138 k-4.0 cl-99 hco3-29 angap-14 intra-op tee conclusions pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened, with moderate mac. no mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is av-paced, on no inotropes. preserved biventricular systolic fxn. no mr, no ai. aorta intact. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 18:25 ?????? caregroup is. all rights reserved. brief hospital course: she was originally scheduled for surgery in mid noven=mber but presented to the ed on with unstable angina. on she was taken to the operating room where double bypass grafts were performed. she weaned from bypass on neo synephrine and propofol in stable condition. she awoke intact, was extubated and weaned from pressor support. she developed atrial fibrillation and because of her beta blocker allergy, diltiazem was given for rate control. amiodarone was subsequently begun and she converted to sinus rhythm. she was diuresed to her preoperative weight and cts and temporary pacing wires were removed per protocol. physical therapy worked with her for mobility.she was transferred to in on for rehabilitation and further recovery prior to returning to her home situation. arrangements were made for follow up. she had recurrent atrial fibrillation on and was given extra intravenous amiodarone and converted to sinus. coumadin was begun at this point due to the recurrent nature of the dysrhythmia. by the time of discharge on pod 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to rehab in good condition with appropriate follow up instructions. medications on admission: diovan, lantus, pravastatin,aspirin, diltiazem hcl, stool softener, glipizide, claritin, metformin, multivitamin discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 4. valsartan 320 mg tablet sig: one (1) tablet po once a day. 5. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 4 weeks. disp:*50 tablet(s)* refills:*0* 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. insulin glargine 100 unit/ml (3 ml) insulin pen sig: as directed subcutaneous once a day: 10units at hs daily. 8. pravastatin 10 mg tablet sig: one (1) tablet po once a day. 9. amiodarone 200 mg tablet sig: as directed tablet po as directed: 200mg twice daily for 4 weeks, then 200mg daily until instructed to stop. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 12. glipizide 10 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): taper 400 mg x 7 days, then 400 mg po qd, then 200 mg po qd untill f/u with pcp. 14. diltiazem hcl 30 mg tablet sig: three (3) tablet po qid (4 times a day). 15. warfarin 5 mg tablet sig: one (1) tablet po once (once): inr goal is . 16. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: at village - discharge diagnosis: s/p coronary artery bypass grafts hypertension hyperlipidemia noninsulin dependent diabetes mellitus coroanry artery disease s/p bms to lad diabetic retinopathy s/p stroke mild left leg "dragging" when fatigued gastroesophageal reflux asthma s/p hysterectomy & ovarian surgery s/p cholecystectomy s/p bilateral cataract surgery paroxysmal atrial fibrillation discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. edema none discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. () on at 1:15pm in the medical office building, ., . cardiologist: dr. on at 1pm please call to schedule appointments with your primary care: dr. () in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Long-term (current) use of insulin Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to other cardiac device, implant, and graft Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy

history of present illness: the patient was an 1875 gm product of a 34 week gestation born to a 30 year old gravida 3, para 0-2 woman. mother's history of was notable for bilateral ectopic pregnancies resulting in bilateral fertilization in . the patient immigrated to the united states at approximately 23rd week and underwent obstetric care at health center. at she was noted to have diastolic hypertension which was followed but did not require treatment. in addition she underwent serial ultrasounds because of slow growth of twin a. decreasing growth velocity over the past week prompted delivery today. antigen negative status, rpr nonreactive, a positive blood type, antibody negative, rubella not immune. mother's group b streptococcus was unknown. there were no sepsis risk factors. rupture of membranes occurred at the time of delivery, no intrapartum antibiotics administered. at delivery the patient did well, apgars were 9 and 9. required blow-by oxygen and stimulation in the delivery room. the patient was brought to the newborn intensive care unit after visiting with the parents. physical examination: physical examination on admission revealed a pink, active, nondysmorphic who is well perfused and saturated in room air. skin was without lesions. cardiac examination showed a normal s1 and s2 without murmurs. pulses were 2+ and equal bilaterally without delay. abdomen was benign. there was no hepatosplenomegaly or masses. genitalia was a normal premature female. neurological examination was nonfocal and age appropriate. spine was intact. hips were normal. hospital course: cardiovascular/respiratory status - the patient is well saturated and perfused in room air. she had no murmur. blood pressure was within normal limits. the patient did not require any supplemental oxygen or other support after returning from the delivery room. fluids, electrolytes and nutrition - the patient was maintained npo and placed on intravenous fluids. with this her blood sugar was normal. hematological status - the complete blood count and differential was obtained at the time of delivery. results are pending at the time of this dictation. infectious disease - the patient was not begun on antibiotics because of her asymptomatic state and low sepsis risk. antibiotics will be started at the discretion of the team. neurological status - the patient was manifesting normal neurological examination during her hospital stay here. discharge disposition: the patient is to be transferred to newborn intensive care unit for ongoing care because of lack of nicu bed space in the . discharge diagnosis: 1. 34 week premature infant 2. rule out sepsis , m.d. dictated by: medquist36 d: 16:42 t: 17:38 job#: Procedure: Interview and evaluation, described as comprehensive Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Other preterm infants, 1,750-1,999 grams

history of present illness: baby is an 1855 gm baby born at 31 gestational age to a 34 year old gravida 5, para 2 now 3 diabetic mother with the following prenatal screens - a positive; antibody negative; hepatitis b surface antigen negative; rubella immune; rpr nonreactive; group b streptococcus unknown. past medical history of the mother was notable for insulin dependent diabetes mellitus since three years ago, currently on insulin pump. pregnancy was reportedly uncomplicated with spontaneous onset of preterm labor progressing to repeat cesarean section under spinal anesthesia for breech presentation. rupture of membranes at the time of delivery yielding clear amniotic fluid, no maternal fever or evidence for chorioamnionitis or fetal tachycardia. the infant was initially hypotonic, apneic and bradycardiac to 90 heartbeats per minute. he was suctioned, dried and stimulated and given some positive pressure bagged mask ventilation times one minute with good response. subsequently he had spontaneous breathing and cry at one to two minutes of life. apgars were 5 at one minute and 8 at five minutes. he was transferred to neonatal intensive care unit for respiratory distress. physical examination: birthweight was 1855 gm (75th percentile), head circumference 30.25 cm (50th to 70th percentile), length 41.5 cm (25th to 50th percentile), . the anterior fontanelle was soft and flat, nondysmorphic, palate intact, normal neck and mouth. moderate nasal flaring prior to intubation. chest had moderate intercostal and subcostal retractions, decreased breathsounds bilaterally and a few scattered crackles, well perfused, regular rate and rhythm, femoral pulses normal, normal s1 and s2, no murmurs. abdomen was soft, nondistended, three vessel umbilical cord, no organomegaly and no masses. active bowel sounds. patent anus. normal male preterm genitalia with testes descended bilaterally. the baby was active and alert, responds to stimulation. tone initially was decreased, generalized but improved over the first 30 minutes of life, moving all extremities symmetrically. normal gag and grasp, normal hips and clavicles. impression: this is a 31 6/7 weeks gestation male infant with respiratory distress, likely secondary to surfactant deficiency and sepsis risk. hospital course: 1. respiratory - the baby was intubated, given his respiratory distress and surfactant times one dose was administered with good response. he was subsequently extubated on the same day to room air, however, subsequently on day of life #2 he was restarted on nasal cannula for apnea of prematurity with frequent apnea and bradycardia associated with desaturations. he was also started on caffeine loaded with 20 mg/kg times one dose followed by the maintenance dose of 5 mg/kg/day. prior to transfer, he remained on nasal cannula 113 250 cc of flow. the blood gas obtained on day of life #4 while on nasal cannula was 7.45/39/61. 2. cardiovascular - has been hemodynamically stable throughout his neonatal intensive care unit course. no murmur on examination. 3. fluids, electrolytes and nutrition - was started on enteral feeds on day of life 0 and has been gradually advanced on volume. he is currently taking total fluid 140 cc/kg/day, breastmilk or pe 20 at nearly full volume. he has been maintaining his blood glucose. 4. gastrointestinal - had transient hyperbilirubinemia, with peak bilirubin of 9.1 on day of life #2. he was started on single phototherapy which was discontinued on day of life #4 with a bilirubin level of 7.0. a bilirubin will be obtained on day of life #5. 5. infectious disease - was started on ampicillin and gentamicin for rule out sepsis. his blood cultures remained negative at 48 hours at which time the antibiotics were stopped. 6. neurology - had a head ultrasound on day of life #4 which was negative. 7. hematology - initial hematocrit was 52.4, no transfusion was given during this admission. condition on discharge: has been stable on nasal cannula with occasional apnea of prematurity, mostly self-resolved. he remains on caffeine. he has been tolerating his advancing enteral feeds without difficulties. discharge disposition: is to be transferred to . care/recommendations: feeds at discharge - breastmilk and pe 20 at nearly full volume, total fluids of 140 cc/kg/day. medications - caffeine at 5 mg/kg/day. state newborn screen - sent. follow up appointments - recommended two to three days after neonatal intensive care unit discharge. discharge diagnosis: 1. prematurity at 31 weeks 2. respiratory distress 3. rule out sepsis , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Other phototherapy Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,750-1,999 grams 31-32 completed weeks of gestation

maternal hx - 28 year old g1p0->1 woman with non-contriobutory past medical history and the following prenatal screens: b positive, dat negative, hbsag negative, rpr non-reactive, rubella immune, gbs positive. antenatal hx - for ega 39-5/7 weeks. pregnancy was uncomplicated. she underwent cesarean section for non-reassuring fetal heart rate. maternal intrapartum fever to 101.3 degrees. intrapartum antibacterial prophylaxis was administered beginning 11 hours prior to delivery. rom occurred 18 hours prior to delivery, yielding clear amniotic fluid. mother received epidural anesthesia. neonatal course - infant emerged with good tone and cry. she was bulb suctioned and dried. she had apgars 8 at one minute and 9 at five minutes. pe very well-appearing infant in no distress bw 3370g hr 170 rr 70 t 99.4 bp 75/36 (51) sao2 100% in room air heent afsf; non-dysmorphic facies; palate intact; neck/mouth normal; normocephalic; no nasal flaring chest no retractions; good bs bilat; no crackles cvs well-perfused; rrr; femoral pulses normal; s1s2 normal; 1/6 sem ulsb without radiation abd soft, non-distended; no organomegaly; no masses; bs active; anus patent; umbilical cord intact gu normal female genitalia cns active, alert, resp to stim; tone normal and symm; mae symm; suck/root/gag intact; grasp symm integ normal msk normal spine/limbs/hips/clavicles inv d-stick 90 impression term infant with 1. sepsis risk, based on maternal gbs colonization and intrapartum fever to > 101 degrees. infant remains otherwise asymptomatic. 2. cardiac murmur, consistent with closing pda. infant shows no other cardiorespiratory signs or symptoms plan -a cbc and blood culture have been drawn. given the height of the fever, we will start empirical broad spectrum antibiotic coverage for an anticipated course of 48 hours, with longer treatment contingent on wbc, blood culture or appearance of sigsn/symptoms consistent with infection -follow murmur clinically, with plan for further investigation if it persists at the time of discharge -parents updated by Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition

history of present illness: baby girl is the 2385-gram product of a 35 and 4/7 weeks gestation (edc of ), born on to a 30-year-old g2/p1 mother with prenatal screens of blood type a+, antibody negative, rpr nonreactive, rubella immune, hbsag negative, gbs unknown. mom had delivered a previous infant at 30 weeks gestation due to hellp syndrome. that infant was cared for in the nicu at that time. this pregnancy was complicated by hypertension, treated with labetalol. due to worsening hypertension, mother was taken for c-section delivery. no sepsis risk factors were noted. infant emerged vigorous with apgar scores of 8 and 8. she needed blow-by 02 to maintain color in the delivery room, and was then taken to the nicu for further management of prematurity. examination on admission: weight of 2385 grams (which is 50th percentile), head circumference of 31 cm (which is 25th percentile), length of 45.5 cm (which is 50th percentile). vital signs were stable. d-stick was 61. the infant appeared appropriate for gestational age. skin had some petechiae in the bilateral groin region and some in the left axilla. heent was normocephalic. anterior fontanel was open, flat. intact palate. red reflex was present bilaterally, and the neck was supple. the lungs showed shallow respirations with minimal air entry and intermittent grunting. cv showed a regular rate and rhythm with no murmur. femoral pulses were 2+ bilaterally. the abdomen was soft with active bowel sounds. no masses or distention. the extremities were warm and well perfused with brisk capillary refill. gu showed normal preterm female external genitalia. the anus was patent. hips were stable. clavicles were intact. neuro showed good tone, normal gag. review of hospital course by systems: 1. respiratory: the infant required cpap for respiratory distress. the infant was on a maximum cpap support of cpap of 6 with an fio2 at 21%. within 12 hours of life, the infant weaned to room air and has remained stable on room air since that time. intermittent grunting was noted, that steadily improved. at present, the infant's oxygen saturations have been in the high 90s with no increased respiratory effort, and respiratory rates in the 20s to 40s range, and comfortable breathing with clear and equal lungs. 2. cardiovascular: the infant has maintained a normal cardiovascular status with no need for hemodynamic support. 3. fluids, electrolytes and nutrition: iv fluid was started on admission to the nicu. p.o. feeds were initiated on day of life #2 after the infant weaned off of cpap and developed a comfortable respiratory status. the infant is presently ad lib p.o. feeding of breast milk/breast feedings or enfamil 20 with iron as supplement. is voiding and stooling well. infant weaned off ivf by day of life #2. last electrolytes were measured on and were normal with sodium 137, potassium 4.9, chloride 106, and bicarbonate 21. weight on was 2210 gm. 4. gastrointestinal: phototherapy was initiated on day of life #4 for a bilirubin level of 11.5/0.3. phototherapy was given for a 12-hour interval and subsequently discontinued; and a rebound bilirubin level drawn on was 10.0. a follow-up bilirubin is planned for am of . 5. hematology: hematocrit at birth was 54.8 with a platelet count of 391. the infant has had no hematologic issues. 6. infectious disease: a cbc a blood culture were screened on admission to the nicu. the blood culture remains negative. the cbc was not left shifted. the white count was 9400 with 22 polys and 0 bands. the infant did not require any antibiotic therapy. 7. neurologic: the infant has maintained a grossly normal neurologic exam for gestational age. 8. sensory/audiology: initial hearing screen was referred in one ear; repeat screen is pending. 9. psychosocial: a social worker has been in contact with the family. there are no active ongoing social service issues at this time. if there are any concerns a social worker can be reached at (. condition on discharge: good. discharge disposition: mother remains hospitalized due to difficulties with blood pressure control; infant will therefore be transferred to regular nursery, cns service. name of primary pediatrician: dr. ; telephone # (. care and recommendations: 1. feeds: ad lib p.o. feedings by breast milk or supplemented with enfamil 20 with iron. 2. medications: none. 3. a car seat safety screening was passed on . immunizations received: hepatitis b vaccine was given on . immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with 2 of the following: daycare during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. discharge followup: 1. a follow-up appointment is recommended with the pediatrician in days. discharge diagnoses: 1. prematurity. 2. transient tachypnea of the newborn, resolved. 3. sepsis; ruled out. 4. hyperbilirubinemia. , md Procedure: Parenteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Transitory tachypnea of newborn

allergies: penicillins / sulfa (sulfonamide antibiotics) / cleocin / lipitor / pravachol / dabigatran / avelox / captopril attending: chief complaint: weakness/fatigue major surgical or invasive procedure: picc line placement for milrinone infusion picc line removal history of present illness: patient is an 82yo m with pmhx of stage 4 systolic heart failure, ef 15%; s/p biv icd downgrade to biv pacemaker; s/p cabg times 2 who presents after biv pacemaker downgrade for management of heart failure. patient was last hospitalized for a heart failure exacerbation at in . he was diuresed; his wife reports that since this admission, the patient has steadily gained weight, particularly in his legs and abdomen. wife describes a basketball appearing belly with measured increases in his abdominal girth- 35inches (at baseline) to 40inches recently. the patient's wife denies poor appetite in the patient, but reports small portion sizes for meals. the patient has been taking 80mg po lasix twice daily; however, given the increased abdominal girth, the patient's outpatient cardiologist, dr. , tried xiroxalin once weekly. however, the addition of xiroxalin resulted in decreased sbp, as low as 85/55. this augmentation to diuresis was then discontinued. the patient has orthopnea requiring an elevated head of bed in addition to 2 pillows. he will have sob with exertion and with limited activity (ie walking to the bathroom). on arrival to the floor, patient denies chest pain and shortness of breath. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. on review of systems, patient has no history of any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. wife denies recent fevers, chills or rigors. all of the other review of systems were negative. past medical history: 1. heart failure history - presumed etiology: ischemic - systolic chf - last known ef in year: by report ef 15% - when was the last known hf admission: none on file at ; per family last hf admission in . - known ??????dry?????? or ??????baseline?????? bnp: unknown . 2. cardiac history: - cardiac equivalents or risk factors: (-)diabetes, (+)dyslipidemia, (-)hypertension, (-)current smoking, (+)family history of cad, (-)peripheral arterial disease, (-)stroke - anatomy: cabgx2 cabg (svg to lad, svg to d1, svg to cx with jump to om1); : redo cabg: lima to lad, svg to om1, svg to pda] - percutaneous coronary interventions: : cypher stenting of svg to om - pacing/icd: s/p biv icd implant in ; s/p generator replacement in - arrhythmias: ?????? afib s/p cardioversion; chads score of 2 on coumadin ?????? h/o vtach, vfib, cardiac arrests: nsvt - history of cardiotoxic chemotherapy: none - thoracic radiation for cancer of: none . other past medical history: --s/p aaa repair at in --h/o ulcerative colitis --anxiety --mohs surgery for basal cell skin cancer (s/p several surgeries on different sites of his face) --tonsillectomy --episodes of epistaxis, requiring an emergency room visit, s/p cauterization --decubitus on buttocks- wife describes this to be the size of a pencil eraser . social history: patient is married with five children. ambulates with walker. no history of falls. sleeps in a hospital bed with head elevated. incontinent of both urine and stool, wears depends. occupation: previously was employed as a tax accountant --etoh: none --tobacco: none home care services: physical therapy twice a week, home health aide daily for several hours. family history: there is no documented family history of dilated cardiomyopathy, premature atherosclerotic cardiovascular disease, sudden death, hypertrophic cardiomyopathy, or inborn errors of metabolism affecting the cardiovascular system physical exam: admission physical exam: dry wt: unknown, present weight 150 pounds (68.1kg) t= 98.3 bp = 99/57 (97-104/57-84) pulse = 62 rr and o2 sat: 97% ra general: alert, oriented, no acute distress, cachectic appearing male heent: perrl, sclera anicteric, mmm, oropharynx clear neck: engorged ijv; jvp is 6-cm water, with positive hepatojugular reflux lungs: crackles up to one-third of the lung field posteriorly without wheezes cv: regular rate and rhythm, normal s1 + s2; 2/6 systolic murmur best appreciated at the rusb, but heard throughout the precordium. no rubs, gallops abdomen: distended. soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: 4+ bilateral lower extremity edema up to 15-cm above the medial malleolus; chronic venous stasis changes with hyperpigmentation and stasis dermatitis; warm, well perfused, 1+ pulses in le bilaterally, no clubbing, cyanosis skin: slight yellowing of the skin, though no scleral icterus. neuro: cn??????s intact, motor function grossly normal, no notable focal neuro deficits, mood and affect are appropriate discharge physical exam: unchanged from above, except as below: discharge weight: 63.2kg abdomen: minimal distention, soft/nt, normoactive bs ext: 3+ pitting edema in the pertinent results: admission labs: 10:45am blood wbc-4.9 rbc-3.38* hgb-10.4* hct-33.1* mcv-98 mch-30.8 mchc-31.5 rdw-13.5 plt ct-256 10:45am blood pt-20.3* ptt-31.9 inr(pt)-1.9* 10:45am blood glucose-83 urean-61* creat-2.1* na-138 k-3.7 cl-96 hco3-34* angap-12 10:45am blood albumin-3.4* 10:18pm blood calcium-8.6 phos-3.1 mg-2.2 10:45am blood digoxin-2.3* . discharge labs: 07:35am blood wbc-6.4 rbc-3.29* hgb-10.0* hct-32.0* mcv-97 mch-30.4 mchc-31.2 rdw-13.7 plt ct-197 07:35am blood pt-21.5* ptt-33.7 inr(pt)-2.0* 07:35am blood glucose-82 urean-64* creat-2.2* na-138 k-4.2 cl-96 hco3-32 angap-14 07:35am blood calcium-8.9 phos-3.5 mg-2.3 . microbiology: 7:04 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. 10:05 am stool consistency: not applicable source: stool. clostridium difficile toxin a & b test (pending): . imaging: chest x-ray : findings: as compared to the previous radiograph, the patient now shows massive cardiomegaly and perihilar vascular congestion, pulmonary edema and mild-to-moderate right pleural effusion. there is unchanged evidence of a left pectoral pacemaker, the generator has been replaced in the interval. . tte the left atrium is dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef= 20 %) secondary to akinesis of the inferior and posterior walls and severe hypokinesis of the rest of the left ventricle. the right ventricle was poorly visualized but appears dilated and profoundly hypokinetic on very limited imaging (primarily of the infundibulum/outflow tract). the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. at least moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . cardiac catheterization comments: 1) resting hemodynamics prior to initiation of milrinone therapy revealed moderate pulmonary arterial hypertension, with a pa pressure of 62/18 mmhg. the catheter was difficult to wedge at this point. 2) after milrinone therapy was administered (50 mcg/kg bolus over 10 minutes, followed by 0.375 mcg/kg/min for 10 minutes), the degree of pulmonary arterial hypertension was similar, with a pa pressure of 63/20 mmhg. the wedge pressure was mild-to-moderately elevated at 19 mmhg. 3) notably, the pa saturation increased from 52% at baseline to 64.5% after milrinone administration; this corresponded to an increase in cardiac index from 1.9 l/min/m2 at baseline to 2.6 l/min/m2 after milrinone administration. final diagnosis: 1. moderate pulmonary arterial hypertension. 2. low cardiac index, improved with milrinone without change in other parameters. 3. will transfer to ccu with pa catheter in place and milrinone continued. . tte the left ventricular cavity is dilated. overall left ventricular systolic function is severely depressed (lvef= 25 %). the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. an eccentric, posterolaterally directed jet of moderate (2+) mitral regurgitation is seen. due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (coanda effect). the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study off milrinone (images reviewed) of , the current study on milrinone shows an increased left ventricular ejection fraction. . wrist(3 + views) right: right wrist, three views: there is diffuse osteopenia which limits detection of subtle non-displaced fractures. within this limitation, no fracture or dislocation is seen. degenerative changes at the first cmc and triscaphe joints consist of subchondral sclerosis and osteophytosis with associated joint space narrowing. the soft tissues are unremarkable. incidentally noted are atherosclerotic vascular calcifications. impression: no fracture or dislocation. degenerative changes at the first cmc and triscaphe joints. brief hospital course: 82m history of stage iv systolic heart failure (ef 15%) s/p biv icd downgrade to biv pacemaker, s/p cabg times 2 who presents after biv pacemaker downgrade for management of acute on chronic systolic heart failure, with initiation of milrinone this admission. # chronic systolic heart failure: cardiomyopathy is likely secondary to ischemia. patient is nyha class 4. given his volume overload upon presentation and low systolic blood pressure, the patient was started on a lasix drip. digoxin was discontinued given the elevated serum level of 2.3 at admission. patient was then taken to catheterization lab for right heart catheterization with milrinone trial that showed that his low cardiac index improved with milrinone without change in other parameters. the patient was transferred to the ccu for monitoring after milrinone trial. right heart cath showed: fick co/ci 3.4/1.91. with milrinone: 4.6/2.59. baseline - ra: 19, wedge: 27, pa 62/18 (37). with milrinone in lab - pcw: 19, pa 63/20 (34), pvr=270. o2 sat: 52 to 65%. in the ccu, the patient was monitored carefully, cardiac output and diuresis was improved on milrinone. on : ra 14, pa 55/21 (34), co/ci: 5.5/3, svr=550. pa catheter was discontinued. his primary cardiologist recommended keeping him on 0.375 mcg/kg/min iv. patient was transitioned from lasix drip to po torsemide. picc line was initially placed so patient can receive home infusion of milrinone, however he self d/c'd the picc line while he was confused. the patient was continued on 60mg oral torsemide and lisinopril 2.5mg daily (changed from on admission with no adverse effects). coreg was switched to toprol by the ccu team as well. digoxin was held given supratherapeutic level on admission and fluctuating renal failure. after family meeting with the patient, family, and palliative care, the decision was made that he would not continue home milrinone. this decision was made in part because it would be difficult for him to keep the picc line in place and being on milrinone limited his options for rehab placement. the patient and his family further expressed that the priority is for him to be home eventually, and they in the end, felt too overwhelmed with the prospect of milrinone at home given his intermittent confusion and lack of 24 hour care. he did diurese well and benefited from the milrinone infusion while in the hospital. torsemide should be titrated after leaving the hospital to allow stable weight and net even to 500cc negative/day after leaving the hospital. # renal insufficiency: patient with unknown baseline; presented with a serum creatinine of 2.1 on admission. serum creatinine ranged from 1.9-2.2 during this admission. the patient's renal insufficiency was thought to be from poor forward flow secondary to the patient's underlying heart failure. # status post biv pacemaker downgrade: patient previously had a biv pacemaker with icd which was replaced to biv pacemaker without icd by ep (given goals of care, dnr status). the site remained clean, dry, and intact through the admission. the patient was placed on clindamycin three times daily for infectious prophylaxis; the clindamycin was discontinued after 6 days. he will follow-up in device clinic after discharge. # atrial fibrillation: chads-2 score of 2. patient on warfarin with goal inr . warfarin was continued through the admission per home dosing; inr was monitored daily. inr on day of discharge was therapeutic. # diarrhea: patient with liquid stools after being treated with clindamycin for infection prophylaxis after pacer replacement. a stool c. diff was sent which was negative and his diarrhea improved. of note, he has ulcerative colitis. --chronic issues-- # coronary artery disease: patient status post cabg x2 and pci to grafts. patient denied chest pain through the admission. patient not on a statin secondary to leg aches in the past. aspirin 81mg daily was continued through the admission. # anxiety: patient's home trazodone 25mg daily was continued through the admission. he was intermittently anxious through the hospitalization asking for family members often. when family members were present, the patient would become less anxious. # decubitus ulcer: patient with decubitus ulcer on buttocks. patient was seen by wound care who suggested aloe to the healing area daily. # poor appetite/wasting: continued megace at home dosing. # transitional issues: -will not continue on milrinone infusion which was during this admission because of difficulty keeping a picc line in after discharge -inr will be checked on on -check chemistry 10 on to assess renal function and electrolytes, replete k and mg as needed. -daily weights and i/o's monitoring for goal of stable weights or even to 500cc/day negative. titrate torsemide dose up as needed to achieve this in conjunction with outpatient cardiologist, dr. . #code status: patient was dnr/dni during this hospitalization and palliative care was involved. the family understands mr. has an end-stage illness and are receptive to eventually having hospice involved in his care, possibly when he leaves rehab and is back home. they were given hospice resources on discharge. medications on admission: medications - prescription carvedilol - (prescribed by other provider; dose adjustment - no new rx) - 6.25 mg tablet - 1 tablet(s) by mouth three times a day 1 in a.m and midday. 2 in pm 4 tabs/day digoxin - (prescribed by other provider) - 125 mcg tablet - 1 tablet(s) by mouth 4x/ week only tuesday/thursday/friday/sunday furosemide - (prescribed by other provider) - 80 mg tablet - 1 tablet(s) by mouth every morning, one at noon time crushed in applesauce- difficulty swalling megestrol - (prescribed by other provider; dose adjustment - no new rx) - 40 mg tablet - 1 tablet(s) by mouth three times a day crushed in applesauce-difficulty swallowing potassium chloride - (prescribed by other provider) - 20 meq packet - 1 packet(s) by mouth daily telmisartan - (prescribed by other provider) - 40 mg tablet - tablet(s) by mouth daily every morning trazodone - (prescribed by other provider) - 50 mg tablet - 0.5 (one half) tablet(s) by mouth every evening warfarin - (prescribed by other provider) - 1 mg tablet - 1 tablet(s) by mouth daily . medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - one tablet by mouth once a day folic acid - (prescribed by other provider) - 0.4 mg tablet - one tablet by mouth once a day multivitamin - (otc) - tablet, chewable - one tablet by mouth once a day discharge medications: 1. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime). :*30 tablet(s)* refills:*0* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. folic acid 400 mcg tablet sig: one (1) tablet po once a day. 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 6. torsemide 20 mg tablet sig: three (3) tablet po daily (daily). 7. megestrol 40 mg tablet sig: one (1) tablet po three times a day. 8. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 9. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: apple rehab discharge diagnosis: primary diagnosis: chronic systolic heart failure dyslipidemia discharge condition: mental status: confused, sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization at . after replacement of your pacemaker, you were admitted for management of your heart failure. the decision was made to start a medication called milrinone through iv infusion to help your heart failure symptoms. this medication was stopped before discharge after a discussion with you and your family. take all medications as instructed. note the following medication changes: start lisinopril 2.5mg daily start torsemide 60mg daily. your rehab facility may increase the dose as needed. start metoprolol succinate 50mg daily stop digoxin stop telmisartan stop lasix (furosemide) stop coreg (carvedilol) stop potassium (your potassium levels have been good in the hospital) keep all hospital follow-up apppointments. your up-coming appointments are listed below. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: name: , r. specialty: internal medicine/cardiology address: 27 dr, , phone: appointment: monday at 3pm department: cardiac services when: thursday at 11:00 am with: device clinic building: sc clinical ctr campus: east best parking: garage Procedure: Revision of lead [electrode] Right heart cardiac catheterization Implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P] Central venous catheter placement with guidance Diagnoses: Congestive heart failure, unspecified Atrial fibrillation Aortocoronary bypass status Other chronic pulmonary heart diseases Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other specified forms of chronic ischemic heart disease Anxiety state, unspecified Personal history of other malignant neoplasm of skin Cachexia Old myocardial infarction Long-term (current) use of anticoagulants Pressure ulcer, buttock Diarrhea Encounter for palliative care Do not resuscitate status Acute on chronic systolic heart failure Tricuspid valve disorders, specified as nonrheumatic Fitting and adjustment of automatic implantable cardiac defibrillator Orthopnea Pressure ulcer, unspecified stage Personal history of sudden cardiac arrest Other dependence on machines, supplemental oxygen

history of present illness: the patient is a seventy-one-year-old male with a previous history of an intravascular abdominal aortic aneurysm stent placement and a coronary artery bypass graft back in who presented to his primary care physician with progressive rest angina, who was then subsequently referred to the for cardiac catheterization. the patient thus presented to the cardiac catheterization laboratory on , and after undergoing catheterization, was found to have three vessel disease and his previous grafts were no longer functioning. the patient denies any claudication, paroxysmal nocturnal dyspnea, orthopnea, lightheadedness, pedal edema. the patient's coronary artery disease risk factors include, hypertension, hypercholesterolemia and a cigar smoker for thirty years. the patient has no history of diabetes. past medical history: past medical history is significant for coronary artery disease, myocardial infarction times two, abdominal aortic aneurysm repair, hypertension, hypercholesterolemia. allergies: allergies include penicillin and sulfa. medications: the patient's medications at home include, aspirin, captopril, digoxin 0.25 mg by mouth every day, coreg 6.25 mg by mouth twice a day, asacol, zantac and a multivitamin. physical examination: on examination, he was afebrile with stable vital signs. the patient's heart was regular rate and rhythm. lungs were clear to auscultation. abdomen was soft and nontender. extremities, there was no clubbing, cyanosis or edema. laboratory data: the patient's hematocrit on admission was 39. the patient's international normalized ratio was 1.3. the patient's blood, urea and nitrogen and creatinine was 20 and 1.0. hospital course: thus the patient underwent cardiac catheterization which showed occluded saphenous vein grafts to his left anterior descending artery and diags and this was referred to dr. .................... for cardiac surgery. the patient subsequently underwent a redo coronary artery bypass graft times three on . the patient received a left internal mammary artery graft to the left anterior descending artery, a saphenous vein graft to the om and a saphenous vein graft to the patent ductus arteriosus. the patient tolerated the procedure well without any complications. the patient's postoperative course has been rather unremarkable. the patient progressed extremely well and was transferred out of the intensive care unit on postoperative day number one. the patient was also noted to be doing extremely well with physical therapy and had reached a level of 5 by postoperative day number three. this patient currently is postoperative day number three, tolerating a regular diet. all of his incisions look clean, dry and intact and at a level of 5, the patient is ready to be discharged to home. of note, preoperatively, the patient had an episode of nonsustained ventricular tachycardia. for this, cardiology had seen the patient and recommended a electrophysiologic study, however, the patient at this time refused to undergo any further testing and wishes to be discharged to home without any study in the hospital and also without any further cardiac monitoring at home. the patient will likely follow-up with cardiology in one month to re-address the issue of a possible electrophysiologic study. condition: the patient's condition at discharge is stable. discharge diagnosis: the patient's discharge diagnoses is status post redo coronary artery bypass graft times three. discharge medications: the patient's discharge medications will include, coreg 6.25 mg by mouth twice a day. lasix 20 mg by mouth twice a day times seven days. potassium chloride 20 milliequivalents by mouth twice a day times seven days. percocet one to two by mouth every four hours to six hours as needed. colace 100 mg by mouth twice a day. digoxin 0.25 mg by mouth every day. aspirin 81 mg by mouth every day. discharge instructions: the patient will follow-up with his primary care physician and with dr. .................... in approximately three to four weeks. the patient is being discharged in stable condition. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Other and unspecified hyperlipidemia

history of present illness: this is a 75 year-old male with a history of multiple myeloma on thalidomide who was found in the field having generalized tonic clonic seizures for 20 minutes. there was no family to provide history at this time. he was given 4 mg of ativan at the scene which broke his generalized activity. he was still observed to have bilateral abdominal convulsions and was then given 2 more mg of ativan. at this time, around 7:35 a.m. he arrived at the emergency department and neurology was called. on initial observation he was unresponsive to verbal and noxious stimuli and was noticed to rhythmic abdominal contractions. he also had a mild right eye deviation. he was immediately started on phenytoin and 500 mg was infused over ten minutes. to expedite the infusion the remaining 500 mg was infused as cerebryx. after the dilantin load his gaze was in primary position and there were no longer any abdominal contractions. stat laboratories and blood cultures were drawn. the patient was started on ceftriaxone after an initial rectal temperature of 102.5 was confirmed. pertinent history from the prior notes: "his treatment initially included radiation to an l2 plasmacytoma, as well as a full course of melphalan and prednisone completed on . since that time he was treated with pulse dexamethasone for approximately 11 months through the end of . his treatments also included aranesp every two weeks and zometa every three weeks. at his last clinic visit we did change mr. therapy from pulse dexamethasone to thalidomide at 100 mg daily. this was due to the fact that mr. had been on dexamethasone for almost one year. prior to switching therapy a repeat bone marrow biopsy was done on which revealed a hypercellular marrow with involvement of known plasma cell myeloma as well as decreased iron stores. there was no evidence of dyspoiesis. mr. took approximately 19 days of thalidomide at 100 mg daily. since the thalidomide was started e was then started on ritalin for the side effects of slowness due to the thalidomide. past medical history: b12 deficiency with a peripheral neuropathy, prostate cancer, psa was 6.5 in , conservative treatment was undertaken, peptic ulcer disease, esophagogastroduodenoscopy consistent with gastritis, multiple myeloma as above, hypertension and status post appendectomy. medications: iron 325 mg daily, zoloft 50 mg daily, vitamin b12 2,000 mcg daily roxicet p.r.n., folic acid 1 mg daily, ranitidine 250 mg b.i.d., thalidomide 100 mg q.d. allergies: no known drug allergies. social history: the patient is widowed but is quite independent in has activities of daily living and lives with his family. physical examination: initially the patient was unarousable and unresponsive to verbal and tactile stimulus. by the time of discharge the patient was sitting up, alert, awake and answering questions appropriately following simple commands. had no motor deficit, was without pronator drift and otherwise has intact coordination. laboratory studies: the white count on was 6.6, hematocrit 33.3, the hematocrit has ranged from 25.6 to 33 throughout the hospital course. platelet count 425, inr 1.0. urinalysis has been negative on . however, it was positive on . the patient received days of bactrim. cerebrospinal fluid: white count 0, red count 0. liver function tests: alt 9, ast 27, alk phos 66, amylase 78, total bilirubin 0.6, troponin less than .01. vitamin b12 919. the phenytoin level on was 16.6. initial tox screen was negative. total protein in the cerebrospinal fluid 20, glucose 80. urine cultures were no growth. mrsa screens were negative. blood cultures were no growth. cerebrospinal fluid gram stain and culture. the gram stain was negative. the culture was contaminated with coagulase negative staphylococcus, cryptococcal antigen negative, fungal culture negative, viral cultures negative. head ct showed no hemorrhage, only some atrophy and old infract. mri of the head showed evidence of small vessel disease, no acute infarct or abnormal enhancement. the video swallow on showed no evidence of aspiration or penetration. cytology of the cerebrospinal fluid was negative for malignant cells. eeg consistent with severe encephalopathy or extensive bilateral subcortical disease. beta activity likely represents intercurrent medication effects. this can be seen with benzodiazepines or barbiturates. no evidence of ongoing seizure at this time. hospital course: the patient was admitted to the intensive care unit for seizures. he was initially intubated and his dilantin level was titrated up to about 15. he remained intubated for a couple of days until he self extubated. he did well after this point and went to the floor. once on the floor he did remain somewhat lethargic with phenytoin level of 20 to 21 as well as urinary tract infection. the urinary tract infection was treated. he completed a course of three days of bactrim. the dilantin dose was decreased to 250 b.i.d. and 100 t.i.d. to 100 t.i.d. the patient began to be more alert and on discharge was nearly at his baseline. however, his family noted that he did seem to be still somewhat more lethargic than usual. he was discharged to in good condition on . his medication are metoprolol 75 mg p.o. b.i.d., thiamin 100 mg p.o. q.d., vitamin b12 2,000 mcg p.o. q.d., ferrous sulfate 325 mg p.o. q.d., multivitamin 1 capsule p.o. q.d., folic acid 1 mg p.o. q.d., phenytoin 100 mg p.o. t.i.d., flumotidine 20 mg p.o. b.i.d. the patient will follow up in neurology clinic with dr. . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Personal history of malignant neoplasm of prostate Other convulsions Multiple myeloma, without mention of having achieved remission Psychostimulants causing adverse effects in therapeutic use Other sedatives and hypnotics causing adverse effects in therapeutic use

allergies: roxicet attending: chief complaint: fevers, fatigue major surgical or invasive procedure: implantation ddd electrophysiology study history of present illness: mr. is a 64 yo man with history of bicuspid av s/p and mssa endocarditis and repeat , afib on coumadin and amiodaron, bronchiectasis and gib who presented to complaining of fatigue and fevers. he was recently admitted to with a gib in which resolved. he was in his usual state of health until about two days ago when he began feeling subjective fevers and weakness. today he decided to call ems because he could not walk more than 10 steps. in the ed, he was found to be febrile, to have a leukocytosis and hypotensive with a pulse in the 30's. ekg showed a sinus rate of 140 and 1:3 block. levaquin, gentamycin and were given. a rij was placed despite an inr of >4. . on arrival to the ccu he was febrile, hypotensive, and bradycardic. tele showed complete heart block. ep was consulted and a transvenous pacing wire was placed at the bedside with fluoroscopic guidance. past medical history: 1. bicuspid av-s/p in 92, mssa endocarditis and abscess- s/p redo in 5/00 2. afib on amiodarone 3. bronchomalecia and bronchiectesis 4. gastritis 5. cabg times 3- (, lvef>55%) 6. hypercholesterolemia 7. htn 8. diverticulosis and lymphoid aggregates on colonoscopy in 9. impotence 10. hernisted disc 11. stroke () ax 12. thoracic aneurysm social history: divorced, 2 sons, etoh (per pt) but + h/o drinking 1 gallon of wine daily in that pt always denied, no current tobacco, 4ppd times 30 years and quit in 92, no ivdu, divorced, can do all adls. at baseline he walks a quarter of a mile every day. he will get short of breath on walking quickly blocks. family history: nc per patient pertinent results: 08:07pm pt-52.3* ptt-66.0* inr(pt)-6.2* 01:48pm glucose-102 urea n-15 creat-1.0 sodium-139 potassium-4.3 chloride-109* total co2-23 anion gap-11 06:30pm wbc-23.0*# rbc-3.83* hgb-11.3* hct-33.2* mcv-87 mch-29.5 mchc-34.0 rdw-15.2 06:27am glucose-92 urea n-19 creat-1.4* sodium-141 potassium-4.0 chloride-111* total co2-21* anion gap-13 renal u.s. 1:08 pm impression: no masses, stones, or hydronephrosis present within the kidneys. chest (portable ap) 5:16 pm impression: no significant interval change. ecg study date of 10:41:52 am regular ventricular pacing rhythm - no further analysis since previous tracing, ventricular paced rhythm present unilat up ext veins us right port 12:59 pm impression: 1) no evidence of deep venous thrombosis in the right upper extremity. 2) large hetergenous round area within the right axilla, likely a hematoma. right axillary vein was not visualized. echo study date of conclusions: there are complex (>4mm) atheroma in the descending thoracic aorta. a well-seated bileaflet aortic valve prosthesis is present. the aortic prosthesis discs appear to move normally. there is a small 3mm fluttering echodensity is seen on the lvot side of the valve consistent with vegetation/thrombus. no aortic valve abscess is seen. mild (1+) aortic regurgitation is seen. mild to moderate (+) mitral regurgitation is seen. impression: small echodensity on the aortic valve disc consistent with a vegetation (or thrombus) as described above. mild aortic regurgitation. moderately dilated aortic arch and proximal descending aorta. ct abdomen w/contrast 2:06 pm impression: 1. no evidence of abscess, as clinically questioned. 2. gallstone. 3. bilateral renal cysts. 4. mild dependent atelectasis. ct head w/o contrast 10:06 am impression: no evidence of acute intracranial hemorrhage. no ct evidence of brain ischemia. brief hospital course: a/p: 64m w/ cad s/p cabg, , mssa endocarditis, repeat and bentall procedure, who presented with bradycardia, hypotension and fever/leukocytosis. found to have a likely vegetation on his av by tee with chb s/p pm on . . #)av node dysfuction, complete heart block evolved back to type 2, then type 1 heart block. pt required a temporary wire early in hospital course. pt had eps which showed h-v interval in the 80's (prolonged) and on faster rhythm he went in 2:1 block. had permanent on , heparin restarted. also on coumadin. - in nsr on , intermittently v paced - interrogated by ep on . - outpatient follow up. - beta-blocker restarted without difficulty. in nsr on discharge. #) hematoma right arm - the patient developed a spontaneous hematoma on heparin on . he was evaluated by vascular who recommended arm elevation and ace wrap. his hct dropped from 31 to 26 but has remained stable at 26. - an ultrasound was obtained on which showed no clot. - given his high risk of stroke with an , the heparin was restarted around pm on . - improved on and resolved by the time of discharge. . #) af: the patient had been on amiodarone- this was dc'd on as he developed 2nd degree av block on tele but restarted on without event post . he was discharged on coumadin. #) htn: . his hctz and beta-blocker were restarted. ace was held with acute renal failure. . #) arf - cr rose to 1.4 from 1.1 which was felt to be most likely from gentamycin toxicity. - his fena was <1 with rare eos on ua. he was given ivf with no improvement of his kidney function. - we continue to hold his ace. - renal ultrasound on showed no acute abnormalities. - a cr of 1.4 was deemed to be his new baseline. . #) culture negative endocarditis: id evaluated him inhouse and subsequently signed off. vegetation seen on tee. -the plan is for 6 weeks of cefepime, vanco, and initially 2 wks gentamycin. - no rifampin per id given multiple drug interactions. - had acute rise in cr on , therefore dc'd gentamycin and he did not receive this for the remainder of his stay. - his vanco was dosed by level, trough <15 with results as an outpatient to be faxed to his id specialist per their request. - prior to dc, his level had been greater than 15 and was held two days prior to dc with permission to be restarted at 750 mg iv qd as an outpatient. -picc placed on tuesday in rue. . #) cad - restarted asa 81 mg on . resarted bb. held ace with arf. zetia, statin. . #) h/o gi bleed: the patient has known angioectasia and had gi bleed without multiple diverticula as well. was to have outpt appointment with in surgery but missed it because of hospitalization. this was rescheduled prior to dc. - gi had seen the patient on and felt no need for scope this admission. - - on , the patient noted black appearing stool (started iron day before). guaiac negative, hemo stable. hct stable and required no transfusions for this reason. - this was not an active issue for the remainder of his stay. . #) mechanical av valve: required prolong hospitalization for heparin/coumadin bridge pre and post procedure. he required up to 10 mg of coumadin in-house to get a therapeutic inr, goal 2.5-3.5. - he formerly took 5 and 7.5 mg of coumadin at home. - he will have his inr checked in 2 days and have the results faxed to the coumadin clinic to adjust his coumadin dose accordingly. - although coumadin 10 mg was required to achieve a therapeutic inr, he will be discharged on coumadin 7.5 mg. . #) anemia - concerning drop from 30->26 on to 22 on . guaiac negative. the hct drop was felt to be secondary to his right arm hematoma. - he was transfused 2 units from to . his hct remained stable thereafter and he required no further transfusions. . #) code status: full code. . #) dispo: home with vna. medications on admission: amiodarone 200mg daily, dicloxacillin 25omg q8, hctz 25mg daily, lipitor 80mg, lisinopril 5mg daily, metoprolol xl 12.5mg daily, mvi, protonix, coumadin 2.5mg daily, zetia 10mg daily discharge medications: 1. cefepime 2 g recon soln sig: one (1) intravenous twice a day for 3 weeks. disp:*56 * refills:*0* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 6. 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* 7. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). 8. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. disp:*30 ml(s)* refills:*3* 11. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 12. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for 5 days. disp:*50 ml(s)* refills:*0* 13. metoprolol tartrate 25 mg tablet sig: 0.25 tablet po bid (2 times a day). disp:*15 tablet(s)* refills:*2* 14. acetaminophen 500 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 15. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. disp:*2 * refills:*1* 16. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 17. outpatient lab work inr check 2 days after discharge with results faxed to pcp. vanco trough checked 2 days after discharge with results faxed to pcp. should continue for trough <15. 18. sodium chloride 0.9 % parenteral solution sig: one (1) 3 cc intravenous once a day. disp:*30 * refills:*3* 19. 500 mg recon soln sig: 1.5 intravenous once a day for 3 weeks: 750 mg iv qd. hold for trough >15. disp:*30 * refills:*3* 20. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 21. warfarin 5 mg tablet sig: 1.5 tablets po hs (at bedtime). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: culture negative endocarditis complete heart block with implantation paroxysmal atrial fibrillation gentamicin-induced renal insufficiency discharge condition: stable discharge instructions: please continue your antibiotics and cefepime for a total of 6 weeks (last dose ). please fax troughs to dr. , your infectious disease specialist, weekly. her fax is . the rn will call you at home to check pm (see below). followup instructions: please follow up with the infection specialist - provider: , md phone: date/time: 9:00 provider: call phone: date/time: 11:30 you have an appointment with your cardiologist, dr. , on at 2:00pm. his office is located on the of the building. please call ( should you have any questions. you have an appointment with your electrophysiologist, dr. , on ***. his office is located on the of the building. please call ( should you have any questions. provider: md phone: date/time: 10:00 provider: , m.d. phone: date/time: 8:30 provider: , md phone: date/time: 2:30 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Catheter based invasive electrophysiologic testing Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Aortocoronary bypass status Hematoma complicating a procedure Hypotension, unspecified Atrioventricular block, complete Long-term (current) use of anticoagulants Infection and inflammatory reaction due to cardiac device, implant, and graft

allergies: roxicet attending: chief complaint: black stools and hematocrit drop major surgical or invasive procedure: gastroscopy history of present illness: 64 yo male w/ hx of afib, cad s/p cabg (), on warfarin, htn, diverticulosis, and gastritis, s/p recent admission in for hct drop w/ gastritis and recent nl egd in who presented to the ed on with black/tarry stools x 2 and lightheadedness with standing. his hct was found to be decreased by 9 points from the beginning of . he was also found to be bradycardic to the high 30s with bps in the 70s systolic. he received a 1 time dose of atropine that brought his hr up to the 70s. he received 40 mg iv protonix and 2l ivfs with improvement in sbps to 90s. he was admitted to the icu. he received a total of 4 u prbc with stabilization of his hct. he remained hd stable but continued to be relatively bradycardic (asymptomatic) with hrs in 40s. he had a small bowel enteroscopy which showed mild gastritis. he was undergoing a capsule endoscopy on transfer to the floor. past medical history: 1. bicuspid av-s/p in 92, mssa endocarditis and abscess- s/p redo in 5/00 2. afib on amiodarone 3. bronchomalecia and bronchiectesis 4. gastritis 5. cabg times 3- (, lvef>55%) 6. hypercholesterolemia 7. htn 8. diverticulosis and lymphoid aggregates on colonoscopy in 9. impotence 10. hernisted disc 11. stroke () ax 12. thoracic aneurysm social history: divorced, 2 sons, etoh (per pt) but + h/o drinking 1 gallon of wine daily in that pt always denied, no current tobacco, 4ppd times 30 years and quit in 92, no ivdu, divorced, can do all adls. at baseline he walks a quarter of a mile every day. he will get short of breath on walking quickly blocks. family history: nc per patient physical exam: general: nad. heent: perrl, eomi, sclera anicteric. mmm, op without lesions neck: supple, no jvd. pulm: decreased breath sounds bibasilar, crackles in the left base, no wheezes, or rhonchi. cardiac: nl s1/s2 w/ mechanical click, + 2/6 sem loudest at lusb. abdomen: soft, nt, nd, + bs, + small ventral hernia, reducible. no masses. (+) hm ~3 cm below costal margin. no rebound/guarding ext: no edema b/l, 2+ dp pulses b/l. skin: no rashes or lesions noted. ecchymosis over epigastrium. neuro: alert & oriented x 3. cranial nerves: ii-xii intact. normal strength, and tone throughout. pertinent results: 09:04pm hgb-8.7* calchct-26 08:45pm glucose-113* urea n-43* creat-1.7* sodium-140 potassium-3.2* chloride-99 total co2-28 anion gap-16 08:45pm estgfr-using this 08:45pm alt(sgpt)-23 ast(sgot)-20 ck(cpk)-74 alk phos-63 amylase-190* tot bili-0.3 08:45pm lipase-53 08:45pm ck-mb-notdone ctropnt-<0.01 08:45pm albumin-4.5 08:45pm wbc-9.6 rbc-2.62*# hgb-8.3*# hct-23.2*# mcv-89 mch-31.6 mchc-35.6* rdw-16.6* 08:45pm neuts-71.4* lymphs-22.6 monos-3.3 eos-2.4 basos-0.2 08:45pm anisocyt-1+ 08:45pm plt count-331 08:45pm pt-30.0* ptt-28.3 inr(pt)-3.2* : capsule endoscopy: 1. multiple non bleeding angioectasias in the small bowel 2. puntacte erythematous patches throughout the proximal small bowel 3. lymphangiectasias 4. fresh bleeding in the mid and distal small bowel without an identifiable site. brief hospital course: in brief, the patient is a 64 year old male with history of cad s/p cabg, mechavr on coumadin, gib in past, admitted to icu w/black, tarry stools x 2 days and a hct drop of 9 points, s/p 4 u prbc now hd stable with stable hct. . 1.) gib: the patient presented with 2 days of melanotic stools and a significant hematocrit drop. he remained hemodynamically stable. small bowel enteroscopy relatively unrevealing. pill enteroscopy revealed possible avms vs mass. his hct stabilized. he will follow-up with general surgery for intra-enteroscopy as outpatient. . 2.) mechanical : pts hct stablizied as above. he was bridged to coumadin with heparin. . 3.) cad: known cad with cabg in . there were no active issues. he continued on his beta-blocker and statin. he can resume his aspirin after following up with general surgery to plan the next steps in his gi bleed evaluation. 4.) prophylaxis: iv heparin, po ppi . 5.) code: full medications on admission: lopressor 12.5 mg twice a day protonix 40 mg twice a day aspirin 1 tablet a day dicloxacillin 250 mg three times a day lipitor 80 once a day hydrochlorothiazide 25 mg daily amiodarone 200 mg once a day coumadin 7.5 mg once a week and 5 mg on the other days multivitamin daily zetia 10 mg once a day lisinopril 5 mg once a day iron daily discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. dicloxacillin 250 mg capsule sig: one (1) capsule po tid (3 times a day). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 5. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. lisinopril 5 mg tablet sig: one (1) tablet po once a day. 8. warfarin 2.5 mg tablet sig: asdir tablet po at bedtime: take 7.5 mg on then take 5 mg therafter until f/u with clinic. 9. zetia 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: primary: gi bleed, bradycardia . secondary: aortic valve replacement cad discharge condition: good. stable hematocrit and vital signs. tolerating oral medication and nutrition. discharge instructions: you have been evaluated and treated for a gastro-intestinal bleed. the likely source of the bleed was a small area in the intestine. the bleeding stopped and your blood counts stabilized. you will need to follow-up with the gi surgeon to plan the next steps of your treatment for the bleeding. please continue all of the medications as prescribed. you should discuss with dr. when you should restart taking the aspirin which normally take for your heart. please attend the recommended follow-up appointments. if you develop any new or concerning symptom particularly bright red stools, chest pain, shortness of breath; please seek medical attention immediately. followup instructions: provider: , m.d. phone: date/time: 11:30 provider: , md phone: date/time: 1:30 provider: md phone: date/time: 10:00 please call the clinic at to get your blood checked in days. Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Aortocoronary bypass status Heart valve replaced by other means Long-term (current) use of anticoagulants Chronic obstructive asthma, unspecified Hemorrhage of gastrointestinal tract, unspecified

code: full allergies: nkda events: endoscopy done this afternoon, no active signs of bleeding noted. echo done this afternoon. afternoon crit 25.0 down from 27.0. neuro: pt a&o x 3, mae in bed, able to reposition himself as needed, follows commands consistently, interacts appropriately with staff. pt denies pain. cv: hr sinus brady/1st degree av block 57-64, nbp 94-118/56-69. one episode of bradycardia hr to 39 during endoscopy, no atropine needed (asymptomatic with stable bp), resolved on own. no blood transfused this shift. most recent crit 25.0 down from 27.0 this am. team aware, will transfuse if pt acutely rebleeds. next crit due at 2200. echo done this afternoon, results pending. amio dose given at 1400 to control rhythm with h/o afib. coags sent; inr 2.5. team expresses concern if inr <2.0 d/t risk of thrombosis with avr. ?starting heparin at that point...follow coags closely. resp: pt on nc @ 2l. rr 9-18 with sats >98%. lung sounds clear in apices and diminished in bases with one episode of wheezing in left apex. pt has productive cough. gi: endoscopy done this afternoon no active signs of bleeding seen. received total of 3mg versed and 100mcg fentanyl. given one time dose of ampicillin for procedure. pt ordered for clear liquid diet, tolerating well. pt stating he is very hungry. bowel sounds x 4, abdomen soft and distended, no stool this shift. gu: pt voiding clear, yellow urine using urinal. approximately 200cc/void. pt currently +2.5l for today. access: piv x 2, both patent and can draw blood. skin: intact. echhymotic area to upper abdomen, pt does not recall any injury. social: sister called in today, updated on pt's condition and plan of care. Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Aortocoronary bypass status Heart valve replaced by other means Long-term (current) use of anticoagulants Chronic obstructive asthma, unspecified Hemorrhage of gastrointestinal tract, unspecified

code: full allergies: roxicet events: repeat crit 30.2 up from 25.5. pt npo for capsule study, finished 2l golytely prep. neuro: pt a&o x 3, very pleasant. pt able to reposition himself as needed and transfer from bed to commode on own. follows commands. pt denies any pain. cv: hr 53-81 1st degree avb with no ectopy noted, nbp 103-155/50-92. no episodes of pt dropping hr this shift. no blood products given this shift. repeat crit 30.2 up from 25.5 (last transfused last evening with 1unit prbc's). goal crit >25. inr and crit to be checked . if inr <2.0 please notify team. ekg done. cardiac enzymes negative for mi. asa and beta-blocker continue to be held. resp: lung sounds clear throughout. rr 12-23 with sats >98% on ra. pt has productive cough with white, thick sputum. gi: pt currently npo for capsule study. finished 2l of golytely and awaiting procedure. bowel sounds x 4, abdomen soft and distended. pt passing large amounts of clear, brown, liquid stool. gu: pt voiding clear, yellow urine using urinal. access: piv x 2, both patent and draw back. social: sister in to visit today, updated on pt's condition and plan of care. plan: monitor crit and inr npo for capsule study continue to monitor hr Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Aortocoronary bypass status Heart valve replaced by other means Long-term (current) use of anticoagulants Chronic obstructive asthma, unspecified Hemorrhage of gastrointestinal tract, unspecified

allergies: roxicet / cefepime attending: chief complaint: back pain major surgical or invasive procedure: cvl and left ij line placed. abdominal compartment syndrome due to left retroperitoneal and sigmoid mesenteric hematoma status post decompressive laparotomy with evacuation of retroperitoneal hematoma and packing for hemostasis, placement of silo closure with reinforced silastic. reopening of prior laparotomy for removal of packing, abdominal washout and partial closure. hemostasis of spleen. abdominal washout and partial closure; gastrostomy; drain retroperitoneal hematoma. reopening of postop abdomen. adhesiolysis (x3 hours). drainage of left retroperitoneal hematomas times 2. silastic silo closure with " patch". washout of the abdomen, partial closure. irrigation and debridement of open abdomen with split-thickness skin graft 800 sq cm us guided per-chole tube ct-guided drainage of a large retroperitoneal collection history of present illness: mr. is a 67 year old male with a st. mechanical aortic valve admitted for subtherapeutic who presents with 2 days of low back pain. there was no associated trauma or injury. the pain is in his central lower back, is present almost all the time, and varies in severity up to . it is throbbing in nature and worse when sitting up or flexing his legs. it is worse with palpation. he has also noticed increased abdominal distention in the last few days. he has tried tylenol for pain without much relief. he was discharged on on lovenox bridge and coumadin. other than his lovenox and coumadin, he has no new medications or changes in his medication. he was discharged 7.5 mg daily (up from 5mg 6 days per week, 7.5mg on sundays), but his was 1.9 on and his dose was increased to 10 mg qd. his last dose of coumadin was . he was taking lovenox 100mg sc bid, last dose 4/20 in the morning. he took his antihypertensives and asa this morning. he denies any lightheadedness, cp, sob, nausea, vomiting, diarrhea, constipation (though no bm today), red/maroon/bloody stools, hematuria. . in the ed, initial vitals were 97.2 66 102/68 18 98. he was then noted to have systolic pressures in the 70s and he was complaining of lightheadedness; he was transferred to the core. ekg showed paced rhythm and hematocrit was noted to be 31.4 from 39.2 one week prior. cta was done for concern of dissection and showed a left rp bleed with active extravasation at the left iliacus muscle. he received d5w with bicarb for renal protection. was 4.2 and creatinine was newly elevated to 1.7. his pressures were noted to increase to the 100s systolic, and he was given 2 units of ffp, 1 unit prbcs, 3.2l ivf. he was noted to void only 100 cc in the ed. vascular surgery and ir were both consulted for possible intervention. ir recommended reversal of coagulopathy for < 2, and consider embolization if hct continues to fall. the patient received 4mg iv morphine x 2 for abdominal pain when pressures were improved, with improvement in pain. repeat vitals: hr 80, bp 111/70 18 100% ra. fast exam showed a small pericardial effusion. cardiology recommended slow reversal with ffp; no indication for vitamin k. in ed, unable to place foley due to resistance. . on the floor, patient was given second unit of prbc. repeat 2.4, and pt was ordered for 2 more units of ffp. repeat hct stable at 26.6. lactate 3.9. attempted to place foley but unable to due to resistance; urology consulted. creatinine stable at 1.6. bladder scan showed 50 cc urine in bladder. ivf were started at 150 cc/hr. past medical history: 1. mechanical av: pt had bicuspid av requiring replacement. aortic valve replacement with the bentall procedure done in with a redo procedure done in secondary to methicillin-sensitive staphylococcus aureus abscess. 2. afib: ( sigma dual chamber) placed in setting of chb in , continues amiodarone. 3. bronchomalecia and bronchiectesis 4. h/o gi bleed () 5. cad requiring cabg: svg to lad, sbg to om, and svg to pda 6. hypercholesterolemia 7. htn 8. copd 9. endocarditis: pt has had multiple episodes of endocarditis, most recently in with concern for culture negative endocarditis (veg seen on valve), per recommendation of infectious disease team at (consulted in prior hospitalization) he will require chronic levofloxacin 10. herniated disc 12. thoracic aneurysm 13. pulmonary hematoma in requiring pulmonary decortication and surgical evacuation of hematoma from left upper lobe of lung. 14. septic cerebral emboli () without residual defecits. . percutaneous coronary intervention, in anatomy as follows: no report on omr . /icd, in , sigma dual chamber placed for complete heart block. social history: retired electrician. on disability since sustaining spinal injury during fall at work. divorced. quit smoking in prior to valve replacement, prior to this he smoked 2 packs per day. he drinks wine occasionally. no illicit drugs. lives alone. two children who live out of state. family history: mother died at 78 of intracranial aneurysm rupture father lived to 96 - "died of old age" two sisters who are well. physical exam: vitals: t: 97.1 bp: 109/66 p: 89 r: 16 o2: 100% on ra general: alert, oriented, mild distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: rhoncorous breath sounds bilaterally, no crackles cv: regular rate and rhythm, normal s1 + s2, ii/vi sem at base abdomen: firm, tender to palpation in left flank > diffusely, distended, bowel sounds present, no rebound tenderness or guarding, multiple ecchymoses present at sites of lovenox injections; firm mass in left flank at site of increased tenderness gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: bcx no growth egd severe sb ischemia that would explain gi bleeding bcx no growth cdiff neg bcx no growth cdiff neg tee lvef > 55%, no veggies on valves or wires bile albicans picc tip prelim - no significant growth cvc tip staphylococcus, coagulase negative. >15 colonies cxr ett 7cm above carina otherwise no sig interval change cxr unchanged echo nl lvef, nl fxn mech av, no mass/veg on valves, tr ar ct torso sm b pl eff, rph unchanged, lg l abd wall fl collection ct head no ich, no mass effect, no midline shift, patent art, possible old stoke x2 pleural fluid gram stain negative, culture no growth cxr pre-existing retrocardiac and left basal opacity stable bcx no growth ucx no growth sputum no legionella, no growth. kub tubular structure slightly diagonal to the spine is projecting over the abdomen. no safe evidence for other foreign bodies cath tip culture: no growth cxr lll atelectasis. small bilateral pleural effusions mrsa neg cxr new rij catheter with tip at brachiocephalic-svc junction, no ptx cxr ng tube appears to have been pulled back, now in mid-esophagus ecg new t wave inversions noted in the limb leads,frequent pvc's ,nsr bcx ngtd sputum moraxella species ucx neg 05:54pm fibrinoge-322 12:15pm blood wbc-10.3# rbc-3.43* hgb-10.7* hct-31.4* mcv-92 mch-31.1 mchc-33.9 rdw-14.2 plt ct-218 04:15am blood wbc-11.5* rbc-2.77* hgb-8.7* hct-24.6* mcv-89 mch-31.3 mchc-35.3* rdw-14.9 plt ct-132* 02:30pm blood wbc-13.2* rbc-2.74* hgb-8.6* hct-23.7* mcv-87 mch-31.4 mchc-36.2* rdw-14.7 plt ct-119* 01:58am blood wbc-18.5* rbc-3.00* hgb-9.3* hct-25.9* mcv-86 mch-30.9 mchc-35.8* rdw-15.1 plt ct-131* 10:47am blood wbc-21.6* rbc-3.10* hgb-9.5* hct-27.2* mcv-88 mch-30.7 mchc-34.9 rdw-15.2 plt ct-131* 12:45pm blood wbc-15.0* rbc-3.27* hgb-10.3* hct-27.8* mcv-85 mch-31.5 mchc-37.1* rdw-16.2* plt ct-131* 02:42am blood wbc-8.7 rbc-3.16* hgb-9.6* hct-29.4* mcv-93 mch-30.4 mchc-32.8 rdw-15.7* plt ct-409 10:23pm blood hct-24.3* 06:13am blood hct-25.3* 06:22pm blood hct-28.9* 05:52pm blood wbc-10.8 rbc-3.13* hgb-9.1* hct-28.3* mcv-90 mch-29.2 mchc-32.4 rdw-16.3* plt ct-311 01:09am blood wbc-10.2 rbc-2.93* hgb-8.5* hct-26.1* mcv-89 mch-28.9 mchc-32.5 rdw-16.1* plt ct-295 01:02am blood wbc-21.6* rbc-2.95* hgb-8.4* hct-26.0* mcv-88 mch-28.6 mchc-32.4 rdw-15.8* plt ct-423 02:40am blood wbc-19.3* rbc-3.58*# hgb-10.5*# hct-32.1*# mcv-90 mch-29.3 mchc-32.7 rdw-16.7* plt ct-220 04:31am blood wbc-19.2* rbc-3.54* hgb-10.1* hct-31.0* mcv-88 mch-28.4 mchc-32.4 rdw-16.3* plt ct-211 12:15pm blood pt-40.3* ptt-47.8* (pt)-4.2* 05:54pm blood pt-25.1* ptt-39.2* (pt)-2.4* 04:15am blood pt-21.4* ptt-33.6 (pt)-2.0* 02:12am blood pt-13.2 ptt-28.2 (pt)-1.1 03:52am blood pt-12.7 ptt-38.0* (pt)-1.1 02:42am blood pt-12.5 ptt-48.4* (pt)-1.1 02:39am blood pt-13.4 ptt-63.5* (pt)-1.1 02:11am blood pt-13.3 ptt-60.9* (pt)-1.1 05:21am blood pt-12.6 ptt-52.3* (pt)-1.1 05:00am blood pt-12.9 ptt-36.6* (pt)-1.1 12:27am blood pt-13.0 ptt-32.2 (pt)-1.1 07:00am blood pt-15.8* ptt-77.9* (pt)-1.4* 05:02am blood pt-13.6* ptt-40.1* (pt)-1.2* 06:03am blood pt-13.2 ptt-51.2* (pt)-1.1 12:28am blood pt-13.9* ptt-150* (pt)-1.2* 12:20am blood pt-14.8* ptt-35.2* (pt)-1.3* 10:10am blood pt-13.6* ptt-33.6 (pt)-1.2* 12:15pm blood glucose-134* urean-24* creat-1.7* na-139 k-5.0 cl-102 hco3-27 angap-15 10:32am blood glucose-151* urean-37* creat-2.9* na-140 k-4.2 cl-103 hco3-26 angap-15 12:45pm blood glucose-123* urean-38* creat-2.2* na-136 k-4.1 cl-104 hco3-23 angap-13 02:49pm blood glucose-93 urean-22* creat-1.0 na-138 k-3.9 cl-104 hco3-26 angap-12 01:45pm blood glucose-103* urean-16 creat-0.9 na-138 k-4.3 cl-99 hco3-31 angap-12 09:15pm blood glucose-115* urean-18 creat-1.1 na-137 k-4.9 cl-103 hco3-24 angap-15 01:51am blood glucose-106* urean-17 creat-0.9 na-137 k-3.8 cl-105 hco3-24 angap-12 05:21am blood glucose-87 urean-14 creat-0.9 na-142 k-3.9 cl-108 hco3-25 angap-13 01:07am blood glucose-97 urean-10 creat-0.6 na-140 k-4.1 cl-106 hco3-29 angap-9 02:54pm blood glucose-104* urean-46* creat-1.6* na-133 k-4.0 cl-94* hco3-26 angap-17 06:03am blood glucose-110* urean-15 creat-0.6 na-142 k-3.1* cl-107 hco3-26 angap-12 08:29am blood glucose-111* urean-29* creat-2.2* na-150* k-3.9 cl-118* hco3-23 angap-13 10:47am blood alt-38 ast-65* ld(ldh)-263* ck(cpk)-2467* alkphos-46 totbili-1.2 01:15am blood ck(cpk)-2890* 12:28am blood alt-28 ast-30 ld(ldh)-419* ck(cpk)-98 alkphos-127 totbili-0.5 02:45pm blood alt-102* ast-282* alkphos-113 totbili-0.8 brief hospital course: 67m with st. mechanical aortic valve admitted for sub therapeutic now on lovenox bridge and coumadin who presents with 2 days of low back pain and found to have retroperitoneal hematoma . # retroperitoneal bleed. he was found to have a large retroperitoneal hematoma with evidence of active arterial extravasation on imaging in the setting of a supra therapeutic and lovenox bridge. he was admitted to the medical icu for further management. initially he remained hemodynamically stable but with declining hematocrits despite prbc transfusion suspicious for active bleeding his home aspirin, coumadin, lovenox, and antihypertensives were held. his supra therapeutic was reversed with fresh frozen plasma. the general surgery, vascular surgery, and interventional radiology services were consulted for possible operative/procedural management. he underwent mesenteric angiogram although an active source of bleeding was not able to be identified. he developed hypotension requiring vasopressor support. he developed worsening renal failure with limited urine output, elevated bladder pressures, and elevated ck levels concerning for abdominal compartment syndrome. he was evaluated by general surgery... . # acute renal failure. the patient developed oliguric acute renal failure initially due to hypovolemia in the setting of acute bleed, later exacerbated by abdominal compartment syndrome. medications were renally dosed... . # mechanical aortic valve: the patient was found to have a supra therapeutic in the setting of anticoagulation with coumadin with a lovenox bridge. given the active bleed, his anticoagulation was held and his coagulopathy reversed with fresh frozen plasma, which was discussed with cardiology. . # fever: he developed a fever to greater than 101 on hospital day 3. there was concern for pneumonia given evidence of a new infiltrate on imaging so he was empirically started on broad spectrum antibiotics... . # atrial fibrillation. he was continued on his home dose of amiodarone. metoprolol was initially held in the setting of active bleeding. . # cad s/p cabg. his home aspirin was initially held in the setting of an active bleed. . # hyperlipidemia. his simvastatin was held in the setting of increasing ck levels. . # hypertension. his home lisinopril, metoprolol, hctz were initially held in the setting of active bleeding. . # copd. he was continued on home atrovent. . general surgery was consulted for retroperitoneal bleed secondary to anticoagulation. recommendations: reverse , admit to micu, serial hcts, place foley catheter, secure iv access, angio for possible embolization of vessel, type/cross, transfuse if necessary. ir consulted, recommended ultrasound-guided left common femoral artery access, abdominal aortogram, it reveled extensive atherosclerotic disease as seen on prior ct, no active contrast extravasation identified. patient was transfused 2 units of blood. serial hematocrits slowly treading down. received 4 units of ffp and vitamine k. continue fluid resuscitation. patient increase respiratory distress, diaphoresis, cold and clammy extremities. attempted bipap which help respiratory status but patient was unable to tolerate it. iv lasix given with minimal response. patient was intubated for anesthesia. labs showed ck of 740, bladder presser of 29. concerning for abdominal compartment syndrome. cvl and left ij line placed patient was taken to the or for abdominal compartment syndrome due to left retroperitoneal and sigmoid mesenteric hematoma status post decompressive laparotomy with evacuation of retroperitoneal hematoma and packing for hemostasis, placement of silo closure with reinforced silastic. taking back to the sicu, intubated on ps, ivf resuscitation, transfused 2u rbc. reopening of prior laparotomy for removal of packing, abdominal washout and partial closure. hemostasis of spleen. abdominal washout and partial closure; gastrostomy; drain retroperitoneal hematoma. transfused 1 unit prbc patient underwent thoracentesis for bilateral pleural effusions. noted to have decreased movement in his right, ct scan head showed chronic infarct within the right pca territory (present on ct from ). hypo density noted within the margin between the left pca and mca, suggestive of possible subacute watershed infarct, neurology recommended to maintain anticoagulation with goal ptt 50-70 to avoid new embolic events, though current infarct was likely watershed in the context of hypotension to the 70s systolic. reopening of postop abdomen. adhesiolysis (x3 hours). drainage of left retroperitoneal hematomas times 2. silastic silo closure with " patch". continue management in the icu. physical therapy was consulted. patient in levaquin and zosyn for pneumonia. intubated and sedated on mechanical ventilation, fentanyl and versed for sedation. neurology checks q 4 hours. arf for hypovolemia improving. serial hematocrit checks. patient transfused 2 rbc for hct of 23. patient continue to do well. washout of the abdomen, partial closure. patient was transferred to the floor after procedure. pt extubated irrigation and debridement of open abdomen with split-thickness skin graft 800 sq cm. patient returned to the floor after procedure. tube feeds re started. received 3u of prbc for hct drop from 26 to 17 --> responded to 31 picc dc'd, tip sent for culture, 2 pivs placed. vac removed; adaptic and gauze with wound vac dressing ng overlying. ct scan torso: newly distended gallbladder with wall edema, internal sludge, and a gallstone, concerning for cholecystitis. stable retroperitoneal hematoma and anterior fluid collection, not significantly changed in size since the prior examination. interval decrease in size of a previously seen left lateral conal fascial fluid collection. no new fluid collection seen. improved bibasilar atelectasis. near complete resolution of a previously seen right pleural effusion. large amount of mesenteric stranding and edema about a large abdominal wall defect, compatible with post-surgical changes. us guided per-chole tube. ir draining of gallbladder. micafungin started-yeast in bile, + id approval, speciation ordered,foley out. tee without vegetations, remained intubated overnight transferred to unit for hypotension, transfused 1 rbc, intubated, disimpact ed. perch drain placement x2 by ir id summary: over the past 10 days he has been intermittently hypotensive, febrile with a leukocytosis which raises concern for an infected source. he is at risk for a number of sources of infection, most obviously is his rp hematoma and open abdominal wound which now has a drain placed in the hematoma. this collection of blood is an excellent medium for varied organisms to grow. we will await culture data from this source. his gallbladder was distended on imaging and now has albicans growing from the bile. this yeast should be sensitive to fluconazole and we do not need the micafungin. he has pleural effusions, his nurse reports increased secretions and now has gnr and gpc's from his sputum which may indicate a pulmonary source of infection and a hospital acquired source of infection is of additional concern. he has been a on a chronic quinolone prophylaxis for years and now has increased diarrhea in the setting of a rising wcc, which raises the possibility of c difficile. therefore we recommend broad coverage for this chronically hospitalized critically ill patient with , levofloxacin, flagyl, and fluconazole. this should provide broad gram positive, fungal and anaerobic coverage as well as some gram negative coverage. should he decompensate overnight we recommend switching his levofloxacin for meropenem which would provide broader gram negative coverage. successful ct-guided drainage of a large retroperitoneal collection likely hematoma. drain was placed in the left psoas collection, however no fluid was drained. a drain was left in situ as requested by the referring physician. extubated, wbc treading down, vac changed, on and off neo. confused but otherwise stable in tsicu ceftriaxone started for e coli in sputum d/c vac speech and swallow evaluation suggest initiating a po diet of thin liquids and moist, ground solids when fully awake and alert. 1:1 supervision- hold meals if too lethargic. continue tube feeds as needed to meet nutritional needs. pt will benefit from continued nutrition input to adjust tube feeds as needed cholecystostomy tube fell out; desat w/ lll collapse on cxr . patient had massive gi bleeding, coded in the floor was intubated on mechanical ventilation, transfused and fluid resuscitated, on pressors egd today revealed severe erythema and ulceration in the entire visualized area from the duodenum and up to proximal jejunum consistent with diffuse bowel ischemia. - agree with efforts to maintain the hemodynamic status of the patient via transfusions and fluids. recommend ppi gtt or pantoprazole 40 mg iv bid to prevent further acid induced damage to the duodenum - poor prognosis. eeg this is an abnormal portable eeg due to a burst suppression pattern which can be seen in anoxic ischemic encephalopathy secondary to cardiac arrest or in the setting of high dose sedating medications like midazolam. in the absence of high dose sedating medications, the presence of a burst suppression pattern is a poor prognostic sign. no epileptiform discharges or electrographic seizures were seen during this recording. family meeting, patient expired on medications on admission: amiodarone 200mg daily aspirin 81mg daily atrovent iron 325mg daily hctz 25mg daily lipitor 80mg daily lisinopril 20mg daily metoprolol 100mg mvi omeprazole 20mg senna prn coumadin 10mg daily (increased from 5mg 5 days prior) lvenox bridge discharge medications: none. discharge disposition: expired discharge diagnosis: new diagnosis retroperitoneal hematoma secondary to anticoagulation. compartment syndrome secondary to retroperitoneal hematoma. subacute watershed cerebral infarct. acute renal failure dur to hypovolemia pneumomia gastrointestinal bleeding diffuse bowel ischemia old diagnosis 1. mechanical av: pt had bicuspid av requiring replacement. aortic valve replacement with the bentall procedure done in with a redo procedure done in secondary to methicillin-sensitive staphylococcus aureus abscess. 2. afib: ( sigma dual chamber) placed in setting of chb in , continues amiodarone. 3. bronchomalecia and bronchiectesis 4. h/o gi bleed () 5. cad requiring cabg: svg to lad, sbg to om, and svg to pda 6. hypercholesterolemia 7. htn 8. copd 9. endocarditis: pt has had multiple episodes of endocarditis, most recently in with concern for culture negative endocarditis (veg seen on valve), per recommendation of infectious disease team at (consulted in prior hospitalization) he will require chronic levofloxacin 10. herniated disc 12. thoracic aneurysm 13. pulmonary hematoma in requiring pulmonary decortication and surgical evacuation of hematoma from left upper lobe of lung. 14. septic cerebral emboli () without residual defecits. percutaneous coronary intervention, in anatomy as follows: no report on omr /icd, in , sigma dual chamber placed for complete heart block discharge condition: expired discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Diagnostic ultrasound of heart Diagnostic ultrasound of heart Percutaneous abdominal drainage Other skin graft to other sites Excision or destruction of peritoneal tissue Other lysis of peritoneal adhesions Arteriography of other intra-abdominal arteries Reopening of recent laparotomy site Reopening of recent laparotomy site Reopening of recent laparotomy site Other repair of abdominal wall Other repair of abdominal wall Other cholecystostomy Other laparotomy Other gastrostomy Delayed closure of granulating abdominal wound Other immobilization, pressure, and attention to wound Other immobilization, pressure, and attention to wound Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Acquired coagulation factor deficiency Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Chronic airway obstruction, not elsewhere classified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Other and unspecified hyperlipidemia Heart valve replaced by other means Acute respiratory failure Anoxic brain damage Peritoneal adhesions (postoperative) (postinfection) Septic shock Cardiac pacemaker in situ Anticoagulants causing adverse effects in therapeutic use Acute vascular insufficiency of intestine Hemoperitoneum (nontraumatic) Displacement of lumbar intervertebral disc without myelopathy Nontraumatic compartment syndrome of abdomen

allergies: iodine attending: chief complaint: 77m with history of cad, af, esophageal adenocarcinoma s/p xrt, resection and chemotherapy who initially presented with tachypnea pericardial and pleural effusions and transferred to micu after thoracentesis, pericardiocentesis and pericardial window with chest tube for pneumothorax. stable respiratory status since transfer to floor. major surgical or invasive procedure: pericardiocentesis right anterior mini thoracotomy and pericardial window bronchoscopy right heart catheterization picc placement history of present illness: admitted to from rehab with tachypnea and hypoxia. per osh records, patient had been experiencing shortness of breath, with o2 sats in the high 60's, rr in 40's. o2 sats improved with lasix up to 90% on 2l, bp 98-109/40-60s, hr 70-80s. pt was given cefepime and levaquin for r-sided infiltrate seen on cxr and underwent a us guided thoracentesis for r-sided effusion. 1 liter of serous fluid removed, post-procedure cxr showed 10% r apical pneumothorax. in addition, patient went into a-fib w/ hr into 160's. patient given dig, amiodarone (loaded and drip x 6 hours) and diltiazem drip. patient underwent echo which showed large pericardial effusion, sent to for evaluation/pericardiocentesis. . of note, patient recently discharged from after 2 week hospitalization for bilateral pleural effusions and pneumonia. . on admission, patient states that he been feeling progressively sob for the past week, and has noticed increased swelling of his lower extremities, making it difficult to walk. denies any current chest pain, reports currently breathing comfortably. no f/c/n/v. h/o productive cough. + orthopnea. past medical history: htn, lung disease, pleural tap 1l on right , copd exacerbation, esophageal cancer- barrett's, stage ii, t1, n1, mo adenocarcinoma, s/p resection, chemo and radiation (completed approx. 2 months ago), j-tube in place for supplemental nutrition, paf on coumadin (saw mirbach for tachy thought to be a-fib/flutter after adenosine x1), h/o cardioversion, anemia, h/o kidney stones, "trigger finger", cataract surgery social history: married w/ two sons, lives w/ wife . former manager of phone company. + 60 pack year tob history, quit 6 months ago. +h/o etoh, quit 6 months ago. family history: mom deceased at 78 from mi, dad deceased from ms at 44. brother w/ quad bypass 78. physical exam: 97.0/ 72/ 28/ 111/72 85kg/ 93% on 5l nc gen:pale, awake, alert, sitting up in bed, breathing comfortably heent:atraumatic, anicteric sclerae, clear op neck:no carotid bruits, jvp about 10cm cv:muffled and distant hs, no murmurs appreciated, +pleural rub, +femoral pulses, faint but +dp and pt pulses. pulsus of 9. lungs:diminished on r, crackles at bases, deeply productive cough abdomen: soft, j-tube in place, site cdi, nabs, nt ext:+ pitting edema bilaterally on le, ue edema bilaterally, + clubbing of nails, resting tremor of r leg neuro:a/o x3, spontaneous movement x4. no focal deficits pertinent results: ekg: a-fib, low voltage in precordial and limb leads, no st changes or twi . cath (): right heart catheterization demonstrated elevated right atrial and right ventricular end diastolic pressures which were approximately equal to pericardial pressures (12 mmhg0 suggestive of early tamponade. after pericardiocentesis, pericardial pressures returned to 0 mmhg. cardiac output calculated using the fick method demonstrated moderate to severely diminished cardiac index of 2.0l/min/m2 prior to pericardiocentesis, with improvement to 2.6l/min/m2 after pericardiocentesis. pa sat improved 48 to 58. . echo (): approximately 1 cm wide partially echo dense region around the heart (most prominent anteriorly) consistent with probable somewhat organized pericardial effusion and pericardial thickening. no definite echocardiographic signs of tamponade are identified but views are technically suboptimal. echo (): moderate sized pericardial effusion. no right ventricular diastolic collapse is seen. there is sustained right atrial collapse, consistent with low filling pressures or early tamponade echo (): moderate pericardial effusion, anterior to ra and rv, consistent with loculation echo (): anterior space fat pad, but possible loculated anterior pericardial effusion echo (): large pericardial effusion with increased intrapericardial pressure, ef 50-60% . cxr (, 14:26): probable small right apical pneumothorax. status post placement of small bore chest tube. moderate right and small left pleural effusions. cxr (, 10:30): worsening atelectasis in the right lung. lucency at right lung apex, without definitive visceral pleural line identification. status post esophagectomy and pullup procedure. improving left pleural effusion and enlarging right pleural effusion cxr (): bilateral pleural effusions and associated atelectases in both lower zones. no pneumothorax. cxr (): mild pulmonary edema, moderate bilateral pleural effusions (r>l) cxr (): bilateral pleural effusions (l>r), pulmonary edema on right side, rll collapse . cytology - bronchial brushings - reactive bronchial epithelial cells. . chest u/s - bilateral pleural effusions . ct-chest/abd/pelvis - - interval decrease in pericardial effusion and right-sided pleural effusion with left-sided pleural effusion, not significantly changed. interval increase in size of right-sided pneumothorax compared to prior chest ct. compressive atelectasis in both lungs with no specific evidence for aspiration. no evidence of gi or bowel obstruction. cholelithiasis. small nonobstructing stones in the right kidney. low attenuation lesion in the left kidney that likely represents a cyst, that is not fully characterized on this noncontrast study. . 07:26pm glucose-128* urea n-25* creat-0.6 sodium-140 potassium-4.2 chloride-103 total co2-29 anion gap-12 07:26pm ck(cpk)-13* 07:26pm ck-mb-notdone ctropnt-<0.01 07:26pm albumin-2.3* calcium-7.4* phosphate-3.2 magnesium-1.5* iron-28* 07:26pm caltibc-212* vit b12-933* folate-14.0 ferritin-347 trf-163* 07:26pm wbc-12.6* rbc-2.83* hgb-9.2* hct-27.3* mcv-96 mch-32.5* mchc-33.7 rdw-15.8* 07:26pm ret aut-2.8 07:26pm pt-17.8* ptt-33.5 inr(pt)-2.2 07:26pm blood caltibc-212* vitb12-933* folate-14.0 ferritn-347 trf-163* 01:35am blood type-art temp-37.1 po2-66* pco2-54* ph-7.40 calhco3-35* base xs-6 10:45am other body fluid wbc-444* hct,fl-2* polys-22* lymphs-10* monos-7* eos-1* mesothe-1* macro-59* 10:45am other body fluid totprot-3.6 glucose-99 ld(ldh)-343 amylase-16 albumin-2.0 02:26pm pleural totprot-2.1 ld(ldh)-88 albumin-1.1 02:26pm pleural wbc-17* rbc-510* polys-39* lymphs-26* monos-25* meso-8* macro-2* 06:06am blood wbc-8.8 rbc-3.16* hgb-10.3* hct-29.5* mcv-93 mch-32.5* mchc-34.8 rdw-16.5* plt ct-245 05:11am blood wbc-12.1* rbc-3.27* hgb-10.7* hct-30.5* mcv-93 mch-32.6* mchc-35.0 rdw-16.4* plt ct-235 05:00am blood wbc-13.8* rbc-3.12* hgb-10.1* hct-30.2* mcv-97 mch-32.4* mchc-33.4 rdw-16.1* plt ct-266 05:15am blood wbc-8.6 rbc-2.71* hgb-8.8* hct-27.0* mcv-100* mch-32.4* mchc-32.5 rdw-15.9* plt ct-245 04:15am blood wbc-10.3 rbc-2.80* hgb-9.0* hct-26.0* mcv-93 mch-32.3* mchc-34.7 rdw-16.2* plt ct-318 03:52am blood wbc-9.6 rbc-3.40*# hgb-10.9*# hct-30.3*# mcv-89 mch-32.1* mchc-36.0* rdw-16.0* plt ct-225 05:00am blood pt-15.0* ptt-32.3 inr(pt)-1.5 06:51am blood pt-14.4* ptt-50.4* inr(pt)-1.4 07:45am blood pt-14.3* ptt-32.8 inr(pt)-1.4 04:15am blood pt-16.2* ptt-108.1* inr(pt)-1.8 04:12am blood pt-15.1* ptt-74.0* inr(pt)-1.6 03:52am blood pt-14.3* ptt-28.9 inr(pt)-1.4 06:06am blood glucose-83 urean-21* creat-0.5 na-140 k-4.8 cl-100 hco3-35* angap-10 05:00am blood glucose-128* urean-16 creat-0.5 na-139 k-4.3 cl-99 hco3-34* angap-10 04:15am blood glucose-100 urean-22* creat-0.4* na-140 k-4.0 cl-98 hco3-37* angap-9 03:52am blood glucose-71 urean-18 creat-0.5 na-143 k-4.2 cl-98 hco3-33* angap-16 02:16pm blood alt-10 ast-8 ld(ldh)-126 alkphos-66 totbili-0.3 04:12am blood totprot-4.7* calcium-8.2* phos-3.3 mg-1.5* 02:51pm blood type-art rates-/28 fio2-100 po2-194* pco2-91* ph-7.26* calhco3-43* base xs-10 aado2-450 req o2-75 intubat-not intuba 09:48pm blood type-art temp-37.7 po2-76* pco2-54* ph-7.47* calhco3-40* base xs-13 intubat-intubated 12:18am blood type-art temp-37.4 rates-20/26 tidal v-450 peep-5 fio2-50 po2-102 pco2-54* ph-7.46* calhco3-40* base xs-12 -assist/con intubat-intubated 04:12am blood type-art temp-36.9 rates-/24 peep-5 fio2-50 po2-73* pco2-58* ph-7.43 calhco3-40* base xs-11 intubat-intubated vent-spontaneou 01:43pm blood type-art temp-37.8 rates-/72 fio2-40 po2-103 pco2-75* ph-7.37 calhco3-45* base xs-13 intubat-not intuba comment-nebulizer 05:56am blood type-art temp-36.7 fio2-50 po2-81* pco2-61* ph-7.39 calhco3-38* base xs-8 03:45pm blood type-art temp-36.7 po2-118* pco2-62* ph-7.37 calhco3-37* base xs-8 . discharge labs: 07:05a na 137 cl 98 bun 18 glc 114 k 4.6 bicarb 33 cr 0.5 ca: 7.9 mg: 1.6 p: 3.6 pt: 13.9 ptt: 62.7 inr: 1.3 ----------- 12am heparin dose: 1180 ptt: 60.8 ---------- 5:05p heparin dose: 1180 ptt: 65.2 ----------- 09:05a heparin dose: 1120 pt: 13.9 ptt: 53.8 inr: 1.3 brief hospital course: 77 y/o male w/ long history of smoking, a-fib, htn, copd, and esophageal cancer rx w/ chemo, surgery, and radiation; s/p thoracentesis, who presents with hypoxia, tachypnea, concern for tamponade on echo done at osh. 1. cardiac in terms of his vessels, he was stable, with no acute concerns to suggest ischemia. the patient had negative cardiac enzymes on admission. he was restarted on his beta blocker once his blood pressure was able to tolerate it, and was titrated up to a dose of metoprolol 25mg tid. in terms of his pump, the patient underwent a repeat echo immediately upon admission which showed a large circumferential effusion, with an estimated ef >55%. he underwent a pericardiocentesis on with removal of over 300 cc of bloody exudative fluid. cultures from the fluid were negative, and the preliminary report on the cytology of the fluid is negative for malignancy. the patient underwent subsequent repeat echoes which showed a stable, persistent anterior effusion. thoracic surgery was consulted to evaluate patient for a pericardial window, felt that procedure would carry a higher risk given past surgery for esophageal cancer. patient would need risk stratification prior to surgery. the patient had an echo on the day of discharge, which showed an increase in the pericardial effusion (loculated) w/ ra collapse and evidence of constrictive pericarditis as well. the decision was made for patient to undergo a pericardial window, and was taken to the or on . will need to follow up on fluid cytology, pathology, and culture results. report was negative for malignant cells. in addition, the patient had a history of atrial fibrillation, and underwent both electro cardioversion and chemical conversion with ibutilide at the osh. although in nsr on admission, the patient subsequently developed an atrial tachycardia/a-flutter rhythm with a heart rate up to 140's. rate control was attempted with iv calcium channel blocker, iv metoprolol, and iv amiodarone; but ultimately required conversion again with ibutilide. the patient remained in nsr with effective rate control on amiodarone and metoprolol. patient currently on tid amiodarone but can be switched to once daily amiodarone on . the patient was restarted on heparin after an occluding thrombus was seen in his left cephalic vein. he is being transferred to rehab on heparin drip for bridge to coumadin. his goal ptt is 60-80 and his goal inr is . patient will need to have his inr followed closely as an outpatient once discharged from extended care facility. . 2. pulmonary- the patient was admitted with hypoxia/tachypnea, likely secondary to bilateral effusions and ? infiltrate/infection seen on chest x-ray. the patient was placed on oxygen with a goal saturation in low-mid 90's given his history of copd, with continuation of his advair/atrovent/spiriva/xopenex. the oshs were contact for results from his thoracentesis-->which were c/w a transudative fluid, all cultures negative, however it was unclear as to whether any sample was sent for cytology. the patient underwent a chest ct, which showed significant consolidation on the right, a right hydropneumothorax from the prior tap at the osh, bilateral pleural effusions, and changes consistent with pneumonitis form xrt. given that the patient had recently been treated with levaquin at the osh, the patient was started on ceftriaxone to complete a ten day course, and azithromycin. pulmonary was consulted, and they recommended completing the course of antibiotics and felt that further thoracentesis would be low yield, but that the patient should have a repeat ct in a few weeks to evaluate for resolution of his effusions. the patient underwent a repeat ct prior to pericardial window procedure, which showed an increase in his effusions bilaterally, thus pleural fluid was also removed during the procedure with samples sent for cytology/path/culture. the patient's breathing and oxygen saturation remained stable throughout his hospitalization, and his cough lessened in severity. the patient became acutely hypoxic and tachypneic on am of , requiring transfer back to ccu for intubation. cxr showed r apical pneumothorax, dart chest tube placed by thoracic service w/out much improvement on repeat cxr. pulmonary reconsulted, decided patient will need bronch and that primary issues were no longer cardiac but rather pulmonary. decision made to transfer patient to micu team. while on the micu service the pt's minichest tube was pulled on . f/u cxr revealed a stable ptx. the pt was extubated on and continued to do well from a respiratory standpoint with chest pt and pulmonary toilet. however post extubation pt continued to have recurrent atrial tach. patient cardioverted on w/ ibutilide (1.6 mg) and is now on amiodarone, rhythm mostly sinus with freq pacs. beta blocker was re-added once his hypotension resolved. he was back in afib/flutter , unresponsive to iv metop and dilt drip, converted by ep with ibutilide. the pt is now stable in nsr on amiodarone. his respiratory status has been stable since transfer to the floor. his o2 sats are 94-96 on 2l nc. patient can be weaned off supplemental o2 as tolerated. patient started on standing lasix for prevention of volume overload. . 3. id- the patient was started on ceftriaxone and azithromycin for pneumonia, showed some improvement in his productive cough while on antibiotics and completed course. cultures from his pericardial fluid were negative, cultures from pleural fluid negative from following "very low numbers" of coagulase negative staphylococcus on . patient remained afebrile without a leukocytosis during remainder of his admission. . 4. anemia- likely iron deficiency anemia in addition to element of anemia of chronic disease secondary to malignancy. the patient was transfused 2 units of prbcs with appropriate increases in his hct during admission. iron studies were sent, which were c/w iron deficiency anemia, vitamin b12 and folate were normal. the patient had several episodes of guaiac positive brown stool, and although he states that he has had a colonoscopy within the past five years, he will likely need a gi workup as an outpatient. although kidney function appeared normal with a creatinine of .5, the patient would likely benefit from iron/epogen supplementation as an outpatient. would recommend starting weekly epoen injections. . 5. fen- the patient was restarted on tf through his j-tube per nutrition recommendations. evaluated with bedside speech and swallow evaluation as well as video swallow. he can have thin liquids and pureed consistency solids as per their recs. he must take small, single sips of thin liquids by cup or straw. he was noted to have a metabolic alkalosis, with an initial bicarb of 34 that rose to 37. this was thought to be secondary to contraction alkalosis as patient received some lasix, in addition to a compensatory alkalosis for a respiratory acidosis from his copd, and resolved without specific intervention. bicarb 33 at time of discharge. would monitor closely as patient started to standing lasix to prevent volume overload. patient required aggressive magnesium supplementation and should have his electrolytes monitored closely. . 6. oncology- the patient was recently treated for stage ii esophageal cancer, s/p resection, chemo and xrt with intended cure. heme/onc was consulted and recommended that patient undergo restaging with a pet scan as an outpatient. the patient did not show signs of metastasis on ct done here, and the preliminary cytology report from his pericardial fluid was negative for malignancy, however it was noted that this does not rule out a malignant effusion given the low sensitivity of cytology. the patient stated that he wants to continue his oncology care through , and has a follow-up appointment scheduled with his oncologist for . . 7. dispo: the patient was seen by pt/ot prior to discharge, and the patient should see his pcp after leaving extended care facility so that a follow-up echo can be arranged, in addition to coumadin management and monitoring of his qt interval, as many of his medications cause a prolonged qt. medications on admission: admit meds from osh: amiodarone gtt at 0.5mg/min diltiazem gtt furosemide 40mg daily advair kcl metoprolol 100mg tid dulcolax mom albuterol mvi reglan coumadin levofloxacin cefepime discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. terbinafine 1 % cream sig: one (1) appl topical (2 times a day) for 3 weeks. 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours). 4. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. 8.6 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. captopril 12.5 mg tablet sig: one (1) tablet po tid (3 times a day). 10. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 12. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 13. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 14. heparin (porcine) in d5w 100 unit/ml parenteral solution sig: one (1) sliding scale intravenous asdir (as directed): please continue heparin sliding scale w/ ptt goal 60-80 until inr therapeutic at 2-3. 15. amiodarone 200 mg tablet sig: one (1) tablet po three times a day: please continue this dose for 10 days through and then switch to 200mg once daily. 16. epogen 20,000 unit/ml solution sig: one (1) injection injection once a week. 17. magnesium oxide 400 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: of discharge diagnosis: pericardial effusion pleural effusion copd a-flutter/a-fib s/p chemical conversion hypertension esophageal adenocarcinoma discharge condition: stable discharge instructions: please take all of your other medications as instructed. please maintain your follow-up appointments as listed below. please call your doctor or return to the hospital if you develop shortness of breath, chest pain, fever or chills. please have a follow-up echo in about 4 weeks. followup instructions: 1. you have an appointment scheduled with your oncologist for at 9am at the with dr. at . 2. please follow up with your primary care doctor within weeks of discharge from rehab facility. 3. please contact dr. with any questions by paging him at , pager #. Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Pericardiocentesis Thoracentesis Injection or infusion of other therapeutic or prophylactic substance Arterial catheterization Closed [endoscopic] biopsy of bronchus Other conversion of cardiac rhythm Pericardiotomy Transfusion of packed cells Right heart cardiac catheterization Transfusion of other serum Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Pulmonary collapse Acute respiratory failure Iatrogenic pneumothorax Other complications due to other vascular device, implant, and graft Iron deficiency anemia, unspecified Personal history of irradiation, presenting hazards to health Mixed acid-base balance disorder Acute pericarditis, unspecified Personal history of malignant neoplasm of esophagus

contrast: 100 cc of optiray was given due to history of allergies. chest ct with iv contrast: no significantly enlarged lymph nodes are seen within the mediastinum, hila, or axillae. the heart size is normal, although there is evidence of a moderate amount of mediastinal lipomatosis. note is also made of coronary artery calcifications. there are no pleural or pericardial effusions. no large nodules are seen within the right upper lobe. perhaps the apparent nodular opacity seen on preop chest x-ray is related to prominent costochondral junction. within the right lower lobe, there are three subcentimeter ground glass nodules. there is a tiny nodule in the right upper lobe.there is a 3 mm tiny nodule within the right middle lobe (series 3, image 23). there is a 5 mm round, ground glass nodule in the right lower lobe posteriorly (series 3, image 34). in addition, there is a 2-3 mm tiny nodule in the right middle lobe peripherally (series 3, image 35). their appearance is nonspecific, and in the absence of known malignancy, or risk factors for pulmonary neoplasm such as smoking, they may represent benign nodules such as noncalcified granulomas. no other lung nodules are identified. in the imaged portions of the upper abdomen, the liver, gallbladder, pancreatic body and tail, adrenal glands, spleen, and upper poles of the kidneys are unremarkable. no suspicious osseous lesions are seen. there are degenerative changes noted in the spine. impression: three, tiny subcentimeter nodules at the right lung base which are noncalcified. in the absence of known malignancy and in a patient without significant risk factors such as smoking, these may represent benign nodules such as noncalcified granulomas. the apparent nodule in the right upper lobe seen on preoperative chest radiograph was due to prominent costochondral junction. (over) 4:04 pm ct chest w/contrast; ct 100cc non ionic contrast clip # reason: preop for cabg tomorrow, has 2 opacities on cxr, r/o maligna contrast: optiray amt: 100cc ______________________________________________________________________________ final report (cont) Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Other and unspecified coronary arteriography Open and other replacement of aortic valve (Aorto)coronary bypass of one coronary artery Open and other replacement of mitral valve Other repair of vessel Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Hemorrhage complicating a procedure Mitral valve insufficiency and aortic valve stenosis

history of present illness: this is an 81 year-old man with a past medical history significant for coronary artery disease status post coronary artery bypass graft in with left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to obtuse marginal, saphenous vein graft to distal right coronary artery, also with a past medical history significant for high cholesterol, status post bilateral tkr, with actinic keratosis, and aortic stenosis with a valve area of 1 by catheterization and echocardiogram 9/. also with hypertension and chronic vertigo. allergies: penicillin, lobster, lamb and pork. medications on transfer: axid 150 mg, aspirin 81 mg, pravachol 10, flomax, lasix 40, lopresor 25, zocor 5 and ditropan at 5. hospital course: this is an 81 year-old mildly demented male with a history of coronary artery disease status post coronary artery bypass graft times three with aortic stenosis who presented after a syncopal episode with associated congestive heart failure. prior to this episode he gave a history of progressive dyspnea on exertion. he denies cerebrovascular accident, transient ischemic attack, claudication or diabetes. the patient underwent a re-do coronary artery bypass graft times, one supraventricular tachycardia to old posterior descending coronary artery graft and acute marginal and an avr with 21 mm pericardial valve on . the patient left the operating room in sinus rhythm at 109 on vasopressin, epi, milrinone, dobutamine and amiodarone. the patient was transferred to the cardiac surgery intensive care unit. on physical examination postoperatively that day the patient remained sedated. dobutamine was decreased to 3 mics per kilogram. epi, vasopressin, milrinone and amiodarone were all maintained. respiratory wise there was an unsuccessful attempt to wean. there was bloody fluid leaking from the chest dressing as well as left femoral dressing with bloody drainage. postoperative day one the patient was febrile with a temperature max of 101.3, temperature current of 100.9 and sinus tachycardia at 110 on an simv of 800 and 16. the patient on balloon pump one to one on amiodarone, epi, insulin, milrinone, morphine drip, nimbex, dressings. on physical examination the patient was as stated paralyzed with an open chest. laboratories, white blood cell count 5.6, hematocrit 26.1, platelet count 111, sodium 142, potassium 4.1, bun 16, creatinine 1.3. the plan was to continue vent support. when he arrived to the intensive care unit he arrived with his chest open. postoperative day one the plan was to continue dressing cardiovascular wise, keep the patient npo, continue insulin drip, continue antibiotics and correct the patient's coagulopathy aggressively and to continue following the patient's bun and creatinine. postoperative day two the patient on vanco with an intra-aortic balloon pump at one to one, amiodarone, dobutamine, epi, insulin, lasix, milrinone, morphine, nimbex, aspirin, protamine. the patient is still febrile at 102 in sinus at 91, still intubated and sedated. on physical examination the patient still with an open chest and the rest of examination unchanged. white count up to 10.3 with a hematocrit of 28.9, platelet count down from 88 to 77, sodium 140, potassium 4.2, bun 17, creatinine 1.4. glucose of 117 with a mixed venous of 57%. the plan was to continue the patient on support, continue lasix drip. with the patient npo start levo intravenous. the patient remained sedated that day on vasopressin, neo, milrinone, dobutamine unchanged, intra-aortic balloon pump later that day at 1.1 to 2 with improved blood pressure, but increased pa pressures. output and index were stable. echocardiogram was requested by dr. , which showed mild aortic insufficiency with preserved left ventricular function. the patient was underfilled, 4+ mr and a clot was noted around the heart. there were no signs or symptom of tamponade. lasix was increased at 10 mics per hour with mild increased diuresis. the patient was then decided to be taken to the operating room. the daughter was med flighted and consent was obtained via the phone from dr. and anesthesia. the patient received a dose of levaquin and last dose of vanco prior to transfer to the operating room. the plan was to have a mitral valve repair verus replacement. postoperative day three from the avr re-do coronary artery bypass graft and postoperative day zero from the mitral valve regurgitation, the patient returned from the operating room late . a mitral valve replacement was done with a #25 bioprosthetic. the patient still remained on the same preop drip. the levophed drip, however, was added in the operating room with the transthoracic intra-aortic balloon pump at one to one, the patient had no distal pulses, feet were cool and the doctor was made aware. the chest was still open with the new left pleural chest tube added in the operating room. the patient respiratory wise was on 100% fio2, 12.5 peep rate of 18, poor sats 57 to 71%, multiple amps of bicarb were given for metabolic acidosis, sats were in the 90 to 96. there was still a large amount of chest tube drainage with multiple blood products, protamine and amicar were also given. the abdomen was distended and firm. og tube draining a small amount of green bilious material. the patient was still sedated on intravenous propofol and morphine and paralyzed with nimbex drip. they were unable to assess the pupils and open the patient's eyes due to the patient's swelling. on at 11:47 a.m. postoperative day one status post mitral valve regurgitation, postoperative day four status post avr re-do coronary artery bypass graft, the patient's daughter was spoken to regarding her father's grave status. the patient's daughter and mother have chosen to not come in. neurologically, the patient's propofol was turned off and valium was given in small increments. cardiovascular wise the patient was still on levo, epi, vasopressin, dobutamine, milrinone, amiodarone with a amicar bolus and drip ending at 11:00 a.m. the patient with a heart rate in sinus rhythm with first degree av block with runs of ventricular bigeminy unable to pace with epicardial wires or ground skin leads. the ioban was removed from the chest and dr. with the assistance of dr. expelled a large amount of clot and blood from the chest cavity with minimal improvement in hemodynamics. the area was then flushed with warm saline. 2 units of packed red blood cells were given. the patient with massive total body fluid overload. they were able to obtain weak signals posterior tibial pulses via doppler early in the morning. the feet were cool and modeled left greater then right. the patient's acidosis was treated with multiple amps of bicarb. abdomen was still large, distended and firm with no bowel sounds. the patient remained anuretic. lasix drip was stopped. the skin with multiple fluid blisters all over the , right groin draining serous, left groin clips draining serosanguinous fluid. the plan was still currently full code. at 4:26 p.m. the patient's condition continued to deteriorate with dropping sats, blood pressure and cardiac output and severe acidosis despite maximum inotropic counter pulsation and vasopressor support. blood pressure was unresponsive to doubled pitressin with continued downward spiral. the rhythm appeared occasionally water with loss of p waves. at 5:59 the patient was on maximal drips and vent support overnight and throughout the day. dr. had several discussions with the family over the past 24 hours describing the patient's grave condition. it was mutually decided to make the patient comfort measures only. the drips were discontinued and the patient died within five minutes, asystolic with no blood pressure at 5:55 p.m. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Other and unspecified coronary arteriography Open and other replacement of aortic valve (Aorto)coronary bypass of one coronary artery Open and other replacement of mitral valve Other repair of vessel Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Hemorrhage complicating a procedure Mitral valve insufficiency and aortic valve stenosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral arm pain major surgical or invasive procedure: orif of bilateral humerus fracture history of present illness: 71 year old female patient who was involved in a motor vehicle accident. she sustained bilateral upper extremity injuries requiring surgical management, given that they are bilateral. she presents today for operative fixation, primarily of the right distal humerus fracture, sequentially followed by the left humerus fracture. she understands the indications and risks, which were clearly discussed with her and her family. she understands that her right elbow will have significant difficulties in terms of range of motion and stiffness, and that she will require significant therapy to regain functional range of motion of her right elbow. past medical history: pmh: cad s/p mi, copd, htn, ^chol, t2dm, pvd, anemia, pud, osteoporosis, depression, lbp/oa psh: l cea , bilat iliac angioplasties (neg angio ), r thr, btl, hemorrhoidectomy social history: lives with husband occasional etoh family history: nc physical exam: gen-alert/oriented vs-98.9, 120/82, 96, 20, 95%ra cv-rrr lungs-cta bilat abd-soft nt/nd ext: rue-hindge elbow brace in place, incision with small amt of sero/sang d/c, without evidence of infection. +m/r/u nerve intact. +radial pulse. lue-incision clean/dry/intact. +m/r/u n. intact, +radial pulse. pertinent results: 08:20pm glucose-131* urea n-40* creat-1.3* sodium-146* potassium-3.9 chloride-111* total co2-26 anion gap-13 08:20pm wbc-10.2 rbc-3.50*# hgb-11.3*# hct-32.7*# mcv-93 mch-32.4* mchc-34.6 rdw-14.7 brief hospital course: 71 yo woman s/p transferred to from osh. patient was evaluated in emergency department. patient was found to have bilateral humerus fractures. patient was admitted to trauma service and taken to trauma icu for serial hct, patient remained stable in unit. plan was for surgical fixation of bilateral humerus. patient was taken to surgery on for orif of bilateral humerus fracture. surgery went without complications, please see op-note . patient was taken to post-operative holding area after surgery. patient remained afebrile/vital signs stable. patient was then transferred to orthopedic floor. while on floor patient remained stable. pain was well controlled, hct on did drop to 23, patient was transfused 2 units and hct bumped appropriately. occupational therapy was initiated for prom of upper extremity bilaterally. patient continued to progress throughout hospital course. on day of discharge pain was well controlled, incision was clean/dry/intact, hct was stable at 33, pain was well controlled. patient was discharged in stable condition. medications on admission: , , lisinopril/hctz 20/12.5', toprol xl 50', lipitor 20', lasix 20', tramadol 50", ativan 0.5 prn, atrovent, calcium 600", mylanta prn, actonel, mvi, nasacort, prilosec 20', feso4, vit discharge medications: 1. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 2. hydrochlorothiazide 25 mg tablet sig: 0.5 tablet po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 4. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 5. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. 8. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 10. beclomethasone diprop monohyd 0.042 % aerosol, spray sig: one (1) nasal daily (daily) as needed. 11. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 12. oxycodone 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. discharge disposition: extended care facility: house nursing home - discharge diagnosis: bilateral humerus fracture post-op anemia discharge condition: stable discharge instructions: please cont with non-weight bearing upper extremity bilaterally. hindged elbow brace to right arm. please keep incision clean. please do not scrub or wash incision with soap. if incision gets wet please pat dry. oral pain medication as needed. please call/return if any fevers, or increased discharge from incision. followup instructions: follow-up with dr. 2weeks after discharge, please call this week for appt. . md, Procedure: Venous catheterization, not elsewhere classified Transfusion of packed cells Open reduction of fracture with internal fixation, humerus Open reduction of fracture with internal fixation, humerus Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Peripheral vascular disease, unspecified Osteoporosis, unspecified Old myocardial infarction Closed fracture of unspecified condyle(s) of humerus Closed fracture of shaft of humerus Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle

allergies: clopidogrel attending: chief complaint: s/p fall major surgical or invasive procedure: splenectomy history of present illness: 84 y/o male w/ h/o siezures who fell 1 week ago. initially the patient complained about some abdominal pain. the patient was evaluated at an osh and noted to have a right clavicular fracture and splenic laceration / hemoperitoneum. the patient was transfered to and underwent splenectomy. past medical history: a-fib chf cva w/ r hemiparesis broken r clavicle seizures oa dementia back problems physical exam: 98.4 hr 75 120/82 rr 12 gen: nad heent: nc/at neck: no midline tenderness, pain on motion chest: rrr, no mgr pulm: ctab abd: diffusely tender ext: tenderness to palp right shoulder, bruise right shoulder; no edema neuro: non-focal pertinent results: 09:25pm wbc-9.1 rbc-2.56* hgb-6.7* hct-21.7* mcv-85 mch-26.2* mchc-30.8* rdw-17.9* brief hospital course: 84 y/o male w/ h/o seizure disorder who fell and subsequently had a splenic laceration w/ hemoperitoneum and was transfered to for further management. on initial evaluation here the patient was noted to have a hct of 26.6. he was taken emergently to the or for splenectomy. in the or the patient recieved 2 l of ivf, 3 u of prbc. the patient tolerated the procedure well w/o complications and was transfered to the t/sicu. the patient was started on levaquin for uti on hd 2 and extubated/transfered to the floor on hd 3. the patient was discharged to a rehab facility on hd 5. he was tolerating po and doing well. he will follow up in trauma clinic in weeks. at discharge the patients dilantin level was 3.3. he is currently on an increased dose of dilantin 200 mg po tid, increased from 100 mg po tid. he will have another dilantin level checked in 1 week. medications on admission: dilantin atenolol aricept discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 2. percocet 5-325 mg tablet sig: one (1) tablet po every hours as needed for pain for 7 days. 3. atenolol 50 mg tablet sig: one (1) tablet po twice a day. 4. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po tid (3 times a day). 5. aricept 5 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: extended care facility: of discharge diagnosis: 1. splenic laceration s/p fall secondary to seizure discharge condition: good discharge instructions: please call your primary care doctor or go to the emergency department if you experience fevers, chills, nausea, vomiting, abdominal pain, seizures, or for other concerns. take caution when walking in wooded areas to avoid ticks now that you are more suseptible to infections without a spleen. followup instructions: please follow up in the trauma clinic in weeks. Procedure: Total splenectomy Transfusion of packed cells Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Other convulsions Unspecified fall Other persistent mental disorders due to conditions classified elsewhere Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum Injury to spleen without mention of open wound into cavity, massive parenchymal disruption

allergies: aspirin attending: chief complaint: unwitnessed fall major surgical or invasive procedure: egd history of present illness: ms. is a yo blind female with a dementia and h/o colon cancer in , rectal prolapse, gait disturbance and osteoporosis who was found down in nursing home. it is unknown how long she was down, or if there was loc (though patient denies), unknown if she hit her head/neck. patient has had rectal prolapse for many years per her assistant and uses stool softeners and has refused treatment in past. patient says she has had brbpr for many years. she also has longstanding rle weakness and uses a walker to get around. she says she has frequent falls. . in the ed, her c-spine films were negative as was a head ct. a surgery consult was called and they reduced the rectal prolapse at bedside. she did have n/v x1 which resolved with anzemet. her vs were stable. she was given 2l ivf and a tetnus shot. her ekg showed slight st depression in v4 and v5 (likely from poor baseline). u/a and bcx were sent in addition to labs. . patient is demented but ros on the floor is as follows: she denies pain except for a burning in her eyes which is long standing. she denies sob, cp, dysuria (she has a foley in), abdominal pain or rectal pain. she denies n/v, f/c. past medical history: 1. osteoporosis. 2. colon cancer in . 3. memory loss. 4. hypothyroidism 5. history of frequent falls 6. rectal prolapse 7. infiltrating lobular carcinoma of the breast 8. mild renal insufficiency baseline creatinine 1.3-1.5 . past surgical history: 1. left hemicolectomy in . 2. open reduction/internal fixation of the left hip in . 3. cataract surgery. 4. left modified radical mastectomy dr social history: the patient lives in the . she has been a widow for eight years. family history: family history is significant only for a maternal niece with breast cancer at the age of 78. physical exam: vitals - 97, 112/60, 16, 96% ra, fs 173. weight 56.2 kg general: ill appearing elderly female smelling of melena heent: pt would not open mouth for exam. left eye opaque. lungs: diminished breath sounds bilaterally without w/r/r cv: rrr with 3/6 systolic murmur heard best at usb abdomen: +bs, midline scar, soft, ntnd extremities: r elbow skin tear. no e/c/c. r lateral malleolous is edematous but non-tender. echymoses surrounding iv sites. rectal: rectal prolapse with small amount of brbpr pertinent results: studies: ct c spine impression: marked degenerative changes. no acute fracture. dilated upper esophagus with fluid level. please correlate clinically. . xray pelvis: impression: 1. limited study due to overlying bowel gas. 2. no evidence of displaced fracture involving the right hip. 3. faint lucency along the right iliac could represent an artifact, however, cannot rule out a fracture . ct pelvis: impression: no evidence of acute femoral or acetabular fracture. . cxr: impression: no evidence of acute cardiopulmonary process. large hiatal hernia. . egd: impression: large hiatal hernia ulcers in the gastroesophageal junction above the hiatal hernia normal mucosa in the stomach normal mucosa in the duodenum . pertinent labs: ce x3 negative u/a on admission was negative u/a on discharge is pending and culture pending. will need to be followed up. . hct on admission was 44.6 and dropped to 29.7 the next morning and then repeat was 24.1. after transfusions and egd, hct on discharge was stable at 30.2. . chemistries on discharge: glucose-106* urean-23* creat-1.2* na-144 k-3.9 cl-111* hco3-21* . cbc on discharge: wbc-9.7 rbc-3.40* hgb-10.5* hct-30.2* mcv-89 mch-31.0 mchc-34.9 rdw-16.9* plt ct-213 brief hospital course: ms. is a year old female with a history of dementia, chronic falls with gait disturbance, chronic rectal prolapse, colon cancer in who presented s/p unwitnessed fall and rectal prolapse. while on the medical floor, pt was noted to have melanotic stools x2, as well as brbpr (chronic), and 1 episode of coffee ground emesis. her hct decreased from 44.6 on admission to 29.7 the next morning with repeat at 24.1 (recent baseline in was 30). her bp was 80/50 transiently, but this improved after ivf. she received 2 u prbc's. micu admission was requested for frequent vital monitoring and hct checks prior to endoscopy. she went to micu on . her hct was stable in the icu and she remained hemodynamically stable. she went for egd the afternoon of and was transferred back to the floor. her hospital course is described by problem below. . # gi bleed - extensive discussion with the patient and her daughter revealed that they did not want a colonoscopy done nor did they want extensive procedures or surgeries. the patient's dnr/dni status was confirmed and treatments would be symptomatic. a egd was acceptable in case there was an on going bleed which could be easily intervened on. egd showed large sliding hiatal hernia and a few non-bleeding ulcers in teh ge junction above the hernia. these ulcers were believed to be the source of bleeding. she was monitored with serial hct which were stable (30.2 on discharge). she was being treated with twice daily pantoprazole for the ulcers and stool softeners for her chronic rectal prolapse. she continues to have guiac positive stools. hct should be checked on to ensure no active blood loss needing transfusion. she will be discharged on omeprazole . . # hypernatremia: after the episode of gi bleeding, she became hypernatremic to 152. her free water deficit was calculated to be 2.3l and she was repleted with d5w and her hypernatremia resolved. . # rectal prolapse/brbpr: chronic issue. surgery was consulted in the ed and reduced the rectal prolapse. again per family and patient, patient has not wanted further aggressive treatment for this condition. she does have h/o colon cancer. last cea in was 4.1 from 2.6 in . of course a colonoscopy would be recommended, but the patient and family have declined. she should be continued on stool softeners to help prevent rectal straining. . # fall: the patient originally presented with an unwitnessed fall. imaging studies revealed no fractures. she was ruled out for an mi with ce x3 being negative and no events on telemety. her fall was likely related to her gi bleed and dehydration. in addition, this could likely be mechanical given history of recurrent falls, blindness, and dysequillibrium. physical therapy worked with the patient while in house and found her to be quite weak and needing extensive assisstence. they recommended rehab for physical therapy as the patient currently lives in with help only during the week days. the patient's daughter agreed. . # low grade fevers: she had a low grade fever of 100.1 one time, and a u/a and culture was pending at discharge. this will need to be followed up in case she had a uti. . # hypothyroidism: continued levothyroxine. . # cri: cr is around baseline 1.2 (1.3-1.5). her cr was stable through admission. . # dementia: continued home medications. . # eye burning: chronic issue. patient legally blind. her eye drops were continued. . #fen: regular diet with ensure supplements tid; replace lytes prn. hypernatremia as above. hypophosphatemia and hyokalemia were issues while in house. please check electrolytes as in discharge instructions on and replete as needed. . #ppx: pneumoboots for dvt ppx given bleeding, ppi for gi ppx, bowel regimen . #codes status: dnr/dni. confirmed with daughter who is the hcp, as of patient is main concern. no invasive procedures or surgery. . # contacts: daughter: (c) (h) x 404 work (caretaker): (c) (h) . # dispo: rehab in . patient has follow up with dr. (pcp) on at 11:10am. . medications on admission: prilosec. multivitamin. synthroid 25 mcg p.o. q. d. namenda *nf* 10 mg oral arimidex *nf* 1 mg oral qam ascorbic acid 500 mg po qam donepezil 10 mg po qam levobunolol *nf* 1 drop ou prednisolone acetate 1% ophth. susp. 1 drop left eye vitamin e 400 unit po bid discharge medications: 1. donepezil 5 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 2. anastrozole 1 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 3. ascorbic acid 500 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 4. memantine 5 mg tablet sig: two (2) tablet po bid (2 times a day). 5. levothyroxine 25 mcg tablet sig: one (1) tablet po qam (once a day (in the morning)). 6. hexavitamin tablet sig: one (1) cap po qam (once a day (in the morning)). 7. vitamin e 400 unit capsule sig: one (1) capsule po bid (2 times a day). 8. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic (2 times a day). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 11. levobunolol 0.25 % drops sig: one (1) drop ophthalmic (2 times a day). 12. prilosec 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po every twelve (12) hours. 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 14. outpatient lab work please check cbc and electrolytes including sodium, potassium, bun, cr, cl, bicarb, magnesium, phosphate, calcium glucose on . 15. dvt ppx please place pneumoboots to lower extremities. 16. neutra-phos mg packet sig: one (1) po three times a day for 1 days: please start in am on . discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: ugi bleed- ulcers s/p fall rectal prolapse with chronic brbpr hypernatremia . secondary diagnosis: hypothyroidism cri with basline cr 1.3-1.5 h/o colon cancer discharge condition: stable hct and vital signs. tolerating oral intake. discharge instructions: you were admitted after a fall. you likely fell because you were dehydrated from bleeding in your stomach. you were found to have ulcers in your stomach and should now take prilosec twice a day instead of once a day. . you have a urinalysis and culture pending at the time of discharge. you will need to have this followed up as an outpatient. you will receive a call if your culture is positive for infection and you will then need antibiotics. . please check cbc and electrolytes including sodium, potassium, bun, cr, cl, bicarb, magnesium, phosphate, calcium glucose on . please replete as needed. please fax the results to dr. at . . given your hospitalization, you will need physical therapy to help rebuild your strength. this is why you are going to a rehab facility. . please continue your medications as prescribed. . please return to your physician or to the emergency room if you have fevers >101, chills, black or tarry stools, large amounts of blood from the rectum or bloody emesis, lightheadedness or any other symptoms which are concerning to you. followup instructions: please make an appointment with dr. , your pcp, 11:10am. please call if you need to change this appointment. Procedure: Other endoscopy of small intestine Transfusion of packed cells Manual reduction of rectal prolapse Diagnoses: Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Diaphragmatic hernia without mention of obstruction or gangrene Osteoporosis, unspecified Personal history of malignant neoplasm of large intestine Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Dehydration Hyperosmolality and/or hypernatremia Rectal prolapse

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob major surgical or invasive procedure: v/q scan ct scans tte tee picc placement bedside thoracentesis ct-guided thoracentesis persantine cardiac stress test history of present illness: pt. is a 68 yo active retired man with hemochromatosis, cirrhosis and dm, who had a mechanical fall 2 weeks prior to admission while at his winter home in . after falling, he developed left sided rib pain (later found to be due to rib fracture), and sought care at the local ed, where he was told to take tylenol. after continuing to have pain for several more days he returned to the ed and was prescribed motrin for the rib pain. he reports taking 600mg every 4-5 hrs for 3-4 days. he also reports having very diminished appetite and eating and drinking very little during this time. three days pta, he developed sob. at the urging of his children, he flew back from fl to be seen here in . in addition to decreased po intake, he reported insomnia and nausea/dry heaves. he denied abdominal pain, fevers, chills, sick contacts, or travel out of the country. . on admission, ekg showed right heart strain and possible lateral ischemic changes. pulmonary embolism was considered; v/q scan was read as low probability. acute coronary syndrome was also considered, and cardiac enzymes were elevated with troponin 0.12 and mb index 14.8. heparin gtt was started, along with asa and beta blocker. also on admission, he was found to have lactic acidosis in setting of arf (creatinine 3.4 with baseline 1.1) with serum lactate 3.9 --> 6.7 and anion gap of 25. serum potassium was 6.0 and bicarb 12. he was given bicarb gtt for acidosis and kayexelate, insulin and glucose for elevated k. . initial temp was 94.4 and cxr showed vague opacity in rml. blood cultures were drawn and levo/vanc started. in the ed, patient has 2 transient episodes of hypotension which resolved spontaneously. he was admitted to the micu. past medical history: pmh: * hemochromatosis with monthly phlebotomy; dx 15 yrs ago * cardiac involvement from hemochromatosis * dm * hx of colon polyps * gallstones (asx) * hypothyroidism * arf in setting of nsaid use 13 years ago, requiring 5 months of hd. social history: widowed, occ alcohol, no cigarettes family history: parents died in their 50s, unknown cause physical exam: vs: t 95.2 bp 132/43 hr 74 rr 15 o2sat 100% nrb gen: nad, pleasant heent: perrl, eomi, no scleral icterus, mm dry neck: jvp flat, no lad chest: gynecomastia, decreased breath sounds at the bases, no wheezes, no crackles cv: distant heart sounds, rrr, no m/r/g abd: normal bowel sounds, soft, nontender, no hepatomegaly ext: bilateral 2+ pitting edema, flat maculopapular rash on left foot, 2+dp bilaterally nro: cn 2-12 intact, 5/5 strength throughout pertinent results: labs on admission : . wbc-16.3*# rbc-4.63 hgb-13.8* hct-39.5* plt count-131* mcv-85 mch-29.7 mchc-34.8 rdw-16.6* neuts-92.6* lymphs-4.4* monos-2.9 eos-0 basos-0.1 . sodium-130* chloride-92* total co2-13* glucose-291* urea n-52* creat-3.2*# sodium-129* potassium-5.4* chloride-93* total co2-14* anion gap-27* lactate-6.7* . alt(sgpt)-21 ast(sgot)-37 ck(cpk)-122 alk phos-156* amylase-265* tot bili-1.1 lipase-12 albumin-2.6* . ck-mb-18* mb indx-14.8* ctropnt-0.12* . urine blood-lg nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-mod urine rbc-0-2 wbc-* bacteria-none yeast-none epi-0 urine hours-random urea n-247 creat-178 sodium-49 potassium-38 urine osmolal-358 . type-art po2-74* pco2-29* ph-7.35 total co2-17* base xs--7 . . studies: . #. v/q scan interpretation: ventilation images obtained with tc-m aerosol in 8 views demonstrate very heterogenous ventilation with numerous subsegmental defects bilaterally. perfusion images in the same 8 views show numerous small bilateral non-segmental defects. these defects are in the same areas as the ventilation defects, but are less prominent. the ap dimension is enlarged, and the diaphgrams are flattened. the chest x-ray is clear. the above findings are consistent with a low probability for pulmonary embolism, but are consistent with copd. . #. tte conclusions: the left atrium is elongated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is moderate to severe pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with preserved global systolic function. right ventricular cavity enlargement with free wall hypokinesis and moderate-severe pulmonary artery systolic hypertension c/w a primary pulmonary process. . #. ecg sinus rhythm, right ventricular hypertrophy, diffuse st-t wave changes with borderline prolonged/upper limits of normal q-tc interval - could be due in part to right ventricular hypertrophy but clinical correlation is suggested since previous tracing of , further st-t wave changes present and q-tc interval appears short. . #. ct chest with contrast impression: 1. right loculated collection which has high ct attenuation value and may represent either empyema or hemorrhage within pleural effusion. 2. right lower lobe opacity with bronchial wall thickening which may represent pneumonia/aspiration. 3. right basilar atelectasis. 4. small left pleural effusion. 5. ground-glass opacity in the right apex. this should be followed up with a ct in three months. 6. focal ground-glass opacity in the right middle lobe and right lower lobe may represent infectious/inflammatory etiology. this could also be followed up on the ct which will be obtained in three months. 7. atherosclerotic coronary calcifications. 8. gallstones without evidence of cholecystitis. 9. liver granulomas. . #. renal us : findings: the right kidney measures 9 cm in length, previously measuring 9.5 cm. the left kidney measures 10.2 cm in length, previously measuring 10.7 cm in length. in the interpolar region of the right kidney, there is an area with lobulated appearance consistent with cortical scarring, unchanged from the prior study. in the interpolar region of the left kidney, there is a tiny cortical crystal. there is no hydronephrosis, stones, or renal masses. there is no perirenal fluid. the bladder is unremarkable. impression: 1. slight interval decrease in size in both kidneys. 2. there is no hydronephrosis. 3. stable area of cortical scarring in the right kidney. . #. tee conclusions: 1. the left atrium is dilated. 2. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is difficult to assess but is probably normal. 3. there are complex (>4mm) sessile atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 4. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. 5. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 6. there is a small pericardial effusion. 7. no evidence of endocarditis seen. . #. cta chest : 1. no evidence of pulmonary embolism. 2. unchanged right loculated collection within the pleural space of hyperattenuation. given the appearance with increased subpleural fat, this has the appearance of chronic right effusion. it is difficult to comment on possible thickening of the pleura. 3. small left simple effusion, slightly increased from the prior study. 4. 3-mm nodule in the right middle lobe. in the absence of known malignancy, one-year ct followup could be considered. 5. atherosclerotic coronary artery calcifications. 6. cirrhosis of the liver, with low-attenuation oval lesion near the dome. it is incompletely characterized on the study. 7. gallstones without evidence of cholecystitis. 8. left lateral fifth and seventh rib fractures. 9. cystic structure above the manubrial notch without enhancement, incompletely characterized on this study. . #. core biopsy of r solid pleural effusion . #. stress test exercising stress test: no anginal symptoms or ecg changes from baseline. n persantine mibi: left ventricular cavity size is normal. resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. gated images reveal normal wall motion. the calculated left ventricular ejection fraction is 71%. no prior studies are available for comparison. impression: normal myocardial perfusion. ef 71%. brief hospital course: #. anion gap acidosis: was likely due to lactic acidosis given his high lactate on admission. high lactate production likely occurred sepsis and poor perfusion, and arf prevented clearance of lactate. was treated with bicarb in the ed and gap resolved. . #. hyperkalemia: resolved after receiving kayexelate, insulin and glucose in ed. . #. rv strain/pulmonary hypertension: on tte was obtained and showed a dilated rv with severe global free wall hypokinesis and abnormal septal movement. he was also noted to have moderate-severe pulmonary artery systolic hypertension consistent with a primary pulmonary process. lvef was >55%. elevated tropinins measured in the ed were thought to be due to rv strain combined with decreased renal clearance. by , troponin had trended down and heparin gtt was discontinued. for his pulmonary hypertension observed on echo, a pulmonary consult was obtained. acute pe was thought to be an unlikely cause of his echo findings given the negative v/q scan on admission, but chronic pe was thought to be a possibility. cta was obtained on , which was negative. other etiologies were considered, including porto-pulmonary hypertension from cirrhosis. hiv, and rf were sent and found to be negative. scleroderma antibody test is pending. he will undergo an outpatient work-up for pulmonary hypertension with pfts, sleep study, and outpatient appointment with dr. . . #. hypoxia: the patient was dyspneic on admission, and was maintained on supplemental oxygen for oxygen saturations that dropped into the high 80's at rest on room air. this was thought to be related to a presumed rml pneumonia (seen as opacity on admission cxr) and underlying pulmonary hypertension seen on echo. however, the opacity observed on cxr was not seen on ct from , so it is unlikely that the original opacity represented a pneumonia as originally thought. his dyspnea slowly improved, and he was weaned from supplemental oxygen by . however, on he again developed an oxygen requirement after iv fluids were initiated in preparation for receiving iv contrast, and on , resting oxygen saturation was measured at 89% on room air at rest, 85% while ambulating. cta showed an enlarged left-sided pleural effusion (fluid density) and a r-sided pleural effusion that was determined to be solid on thorocentesis (path result is pending). these findings, in combination with his pulmonary hypertension and deconditioning were thought to account for the patient's continued hypoxia. diuresis was initiated the following day, and satrurations improved, but he continued to have an oxygen requirement. he had also been noted to have worsened dyspnea while ambulating, and a stress test was performed to rule-out an anginal component. stress test was normal, showing no ecg changes or anginal component and normal myocardial perfusion with ejection fraction of 71%. by discharge, oxygen saturations were 98% on 3l, and he was discharged home on 2l oxygen via nasal cannula. . #. acute renal failure: on admission, the patient had a creatinine level of 3.4. this appeared to be related to a prerenal state, as supported by his history of very poor po intake x 10 days and fena<1%. the possibility of atn from nsaids was also considered given his recent history of taking motrin for pain, and renal followed the patient until cr had improved. renal ultrasound showed no hydronephrosis. creatinine slowly improved with ivf and time, and had decreased to 1.2 by (most recent baseline measurement was 1.1 in ). when the patient's home diuretics were subsequently restarted for hyponatremia and fluid overload, cr rose again to 1.6. by discharge, the patient's creatinine was 1.4. . #. staph bacteremia: blood cultures on admission grew mssa (4/4 bottles from ). renally-dosed vancomycin was started on , then switched to oxacillin on when sensitivities returned. 2/2 blood cultures from also grew staph aureus. surveillance cultures since then have been negative. tee done not show any valvular abnormalities. a picc line was placed on and the patient completed a 14-day course of iv antibiotics on and the picc was removed prior to discharge. . #. hyponatremia: while in the icu, the patient had one set of serum chemistries with serum sodium of 122. remainder of values were in 130s until fluids were started on in preparation for cta with dye load. next measured na was 127 on . he was fluid restricted to 1500cc/day and encouraged to improve his food intake, which had been poor throughout his admission. given that he also had evidence of total body fluid overload (peripheral and abdominal edema), he was restarted on his home diuretic regimen of lasix 20mg and spironolactone 25mg. by , na had risen to 131. . #. uti: urine labs from showed uti, for which the patient was treated with a 7 day course of levofloxacin that finished on . urine cx was negative, but was sent after the patient had started levofloxacin and vancomycin. fever curve remained flat. . #. anxiety: the patient consistently reported having a "nervous stomach" that felt like it had "knots in it." he has had these sensations for many years, and reported that it made eating difficult because it caused him to feel nauseus. this was thought to be a manifestation of anxiety, and the patient was tried on 0.5mg of ativan. this was subsequently discontinued when he was found to be excessively somnolent. the patient agreed to start remeron for help with anxiety and appetite stimulation. he tolerated it well and was discharged on 15mg remeron qhs. . #. dm: the patient recived qid finger sticks and was treated with bedtime glargine and iss. blood glucose measurments fluxuated with his po intake and adjustments were made as appropriate. . #. hypertension/ cad: the patient was treated with asa 325mg and metoprolol 12.5mg tid. as the patient had no apparent indication for digoxin, this was held during his hospitalization. he was discharged on atenolol 12.5mg daily and asa 325mg daily. stress test revealed no hypoperfusion at rest or with persantine stimulation. . #. nutrition: albumin was 2.6 on admission, 2.4 on . the patient reported a 10 day history of anorexia on admission and continued to have poor po intake throughout most of his hospitalization. he cited lack of appetite and nausea caused by his "nervous stomach" as reasons for his poor intake. the patient was maintained on a renal diet with liquid supplements (boost) tid. he had poor compliance until 2 days prior to discharge, when he reported an increase in appetite and improved po intake was recorded. . #. hemochromatosis/cirrhosis: remained stable during this hospitalization. . #. hypothyroidism: remained stable. he was treated with his home dose of levothyroxine 100 mcg daily during this admission. . # physical therapy: the patient was evaluated and followed by pt, who felt he was safe to return to his daugter's home. . # prophylaxis: the patient was treated with incentive spirometry, h2 blocker, and sc heparin (which was discontinued when he began ambulating) . #. abnormal tests requiring outpatient follow-up: seen on cta : 1. 3mm pulmonary nodule in the right middle lobe. 2. hypodense oval lesion approx 8mm at the liver dome. recommend follow-up ct in 1 year. medications on admission: meds on admission: * spironolactone 25mg daily * lasix 20mg daily * digoxin 0.125mg daily * synthroid 0.1mg daily * folic acid 1mg daily * diltiazem 30mg daily * insulin discharge medications: * spironolactone 25mg daily * furosemide 20mg daily * synthroid 0.1mg daily * folic acid 1mg daily * diltiazem 30mg daily * mirtazapine 15mg at bedtime * aspirin 81mg daily * combivent 103-18 mcg/actuation aerosol 1 puff qid * oxygen 2-3l via nasal cannula to keep o2 sat>94% * insulin discharge disposition: home with service facility: discharge diagnosis: 1. staph aureus bacteremia 2. pulmonary hypertension 3. acute renal failure 4. lactic acidosis 5. dibetes mellitus 6. hemochromatosis/cirrhosis discharge condition: stable. requiring supplemental oxygen at 2l via nasal cannula. discharge instructions: 1. call your doctor or go to the er for: - fever > 101 - chest pain, shortness of breath, weakness - other concerns 2. please use wear your oxygen at all times. avoid smoking or open flames as oxygen is flammable. 3. please take all of your medications as prescribed 5. take the ensure supplement drinks three times a day; these can be purchased at most pharmacies. followup instructions: 1. dr. at 9:15 am (please call before appointment to update your registration information) 2. sleep study-office will call you to schedule appointment. you can contact them at 3. pulmonary function tests: 11:30am (please go to the building & check-in at rehab services) 4. dr. (pulmonary) 1:10pm md Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Other pleural biopsy Diagnoses: Acidosis Hyperpotassemia Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Infection with microorganisms resistant to penicillins Other chronic pulmonary heart diseases Methicillin susceptible Staphylococcus aureus septicemia Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Dehydration Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Unspecified analgesic and antipyretic causing adverse effects in therapeutic use