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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: edema, fatigue major surgical or invasive procedure: none history of present illness: the pt is a 68 yo m with a h/o hemochromatosis and dm2 recently admitted to this hospital with a mssa bacteremia, pna, arf with creat 3.4, hyperk 6.0 and lactic acidosis with ag of 25. pt had fallen and was taking large amounts of motrin prior to that admission. on that admission, ekg showed right heart strain and possible lateral ischemic changes. pulmonary embolism was considered; v/q scan was read as low probability. he was admitted to the micu for hypotension and a pna and then sent to the floor, finished course oxacillin for bacteremia while in house. other issues during that hospitalization included: -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) -hiv, and rf were sent and found to be negative; scleroderma ab neg - tte was obtained and showed a dilated rv with severe global free wall hypokinesis and abnormal septal movement; moderate-severe pulmonary artery systolic hypertension consistent with a primary pulmonary process. lvef was >55%. -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. . pt returned to with c/o increased fatigue and marked increase in peripheral edema. on home o2 since discharge home. states compliant with meds. denies cp/worsened sob/abd pain/ha/f/c. admits cough with small amt white sputum occasionally. . ccu course: pt was started on viagra for primary pulmonary htn, and aggressively diuresed with lasix gtt and diuril for several days with net 7.4l with symptomatic improvement in sob on 5lnc, also started on anticoagulation with lovenox for several days however switched to hep gtt and will transition to coumadin. thoracentesis on removed ~800 cc serosanguinous fluid which was negative for malignant cells. he was also started on steroids for copd. his o2 sats were stable on 5lnc. on pt's sats stable while working with physical therapy. pt also noted to go in and out of af/flutter, was started on digoxin, dosed by levels. his cri was followed closely and cr stable at 1.9 in setting of aggressive diuresis. pt was also started on dilt for better hr control in setting of af/flutter. pt was called out of micu to floor in stable condition. 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, usually very active, plays golf, no tob use, can do all adls family history: parents died in their 50s, unknown cause, no fam hx of cad, dm, hemochromotosis, malignancy, hypercoaguable state physical exam: gen: elderly male, nad, full sentences vs: 97.6 98 152/80 16 89 ra 95% 5l nc heent: perrl, eomi, nl sclera, mmm neck: supple, no jvd cor: s1s2 rrr lungs: decreased bs bilat, scattered exp wheeze, ? crackles at l base abd: soft, nt/nd; eccymoses (fading) from previous heparin subq injections ext: 3+ pitting edema to knees bilat, +sacral edema neuro: a&ox3, cn intact, strength 5/5 prox & distal, no pronator drift, no asterixis skin: bronze color . . pertinent results: 05:41pm glucose-327* urea n-23* creat-1.3* sodium-131* potassium-4.5 chloride-96 total co2-27 anion gap-13 05:41pm wbc-7.5 rbc-3.79* hgb-11.0* hct-33.9* mcv-89 mch-29.1 mchc-32.5 rdw-18.7* 05:41pm neuts-79* bands-1 lymphs-7* monos-9 eos-3 basos-1 atyps-0 metas-0 myelos-0 05:41pm hypochrom-occasional anisocyt-2+ poikilocy-2+ macrocyt-2+ microcyt-1+ polychrom-1+ target-1+ burr-2+ 05:41pm pt-13.6* ptt-30.6 inr(pt)-1.2* 05:41pm plt smr-low plt count-80* . cxr : chest, pa and lateral: comparison is made to . the lung volumes are low. the picc line has been removed. allowing for low lung volumes, the cardiac and mediastinal contours are unchanged. there is a persistent right lower lobe opacity, probably some atelectasis in addition to effusion. there is also a left-sided effusion with parenchymal opacity obscuring the medial hemidiaphragm, which may represent atelectasis. right apical thickening is unchanged since a prior study from . impression: moderate bibasilar effusions and opacities, which are likely to represent atelectasis. underlying pneumonia cannot be excluded however. . cxr : preliminary read pa and lateral chest. there are bilateral moderate-sized pleural effusions with possible partial posterior loculation. the cardiac silhouette is enlarged. i doubt the presence of vascular congestion although appearances suggest possible underlying chronic lung disease with stranding in the right lung. since exam one day previous the equivocal interstitial edema appears improved or resolved. the effusions are associated with bibasilar subsegmental atelectasis. impression: short interval probable improvement/resolution of chf. no change in effusions. . r-sided cardiac cath: hemodynamics results body surface area: 1.95 m2 hemoglobin: 11 gms % fick **pressures right atrium {a/v/m} 13/13/11 right ventricle {s/ed} 82/21 pulmonary artery {s/d/m} 82/43/63 pulmonary wedge {a/v/m} 13/13/11 **cardiac output o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 56 card. op/ind fick {l/mn/m2} 4.4/2.2 **resistances pulmonary vasc. resistance 946 **% saturation data (nl) svc low 57 pa main 54 **arterial blood gas inspired o2 concentr'n 21 . comments: 1. vasodilator challenge in this patient with pulmonary hypertension revealed baseline severe pulmonary hypertension with pressures of 82/43. the ra pressure was slightly elevated at mean of 14mmhg with a relatively normal left sided filling pressure with pcwp of 11mmhg. the cardiac index was preserved at 2.2. 2. with 100% oxygen and then nitric oxide there was no decrease in pulmonary pressures. with oxygen pa was measured at 83/38 mean 57 and pcwp of 13mmhg. with nitric oxygen pressure was 91/39 wit mean of 60. the cardiac index did improve on oxygen to 2.7 and on nitric oxide to 3.2 final diagnosis: 1. severe pulmonary hypertension with normal left sided filling pressures, not responsive to vasodilators. . echo bubble study: conclusions: no definite right-to-left passage of microbubbles identified at rest or with maneuvers (cough, post-valsalva). the right ventricle is dilated with prominent free wall hypokinesis. . cxr: indication: chf versus developing pneumonia. a right subclavian vascular catheter remains in place, terminating at the junction of the superior vena cava and right atrium. the cardiac silhouette is enlarged but stable. there is upper zone vascular redistribution and perihilar haziness, not significantly changed. there is partial atelectasis of the right lower lobe with inferomedial displacement of the right major fissure. an area of increased opacity is noted within the left retrocardiac region, with interval improvement since the recent study. this is probably due to a combination of effusion and atelectasis. . chest ct: bilateral pleural effusion, moderate and low density on the left, and small with high density contents and perimeter enhancement is unchanged in both hemithoraces. bibasilar consolidation is more pronounced in comparison to the previous studies and may represent pneumonia or secondary atelectasis. prominence of the interlobular septa as well as some engorgement of the pulmonary vasculature represent congestive heart failure. imaged part of the upper abdomen demonstrate several gallstones in othewise normal gallbladder, calcified liver granuloma and nodularity of the liver margin (the patient has a known history of cirrhosis ). the spleen, adrenals, kidneys and pancreas are unremarkable except for left renal cortical atrophy. no suspicious lytic or blastic lesions within the bones were shown. prominent gynecomastia is due to cirrhosis. impression: 1) increased, moderate left pleural effusion. smaller high density right pleural fluid collection is unchanged. 2) increased bibasilar pulmonary consolidations, which may represent secondary atelectasis or pneumonia. 3) mild congestive heart failure. prominent coronary artery calcifications and cardiomegaly are unchanged. 4) gallstones without evidence of acute cholecystitis. . thoracentesis fluid: negative for malignant cells. -mesothelial cells and lymphocytes. . echo tte: conclusions: there is moderate symmetric left ventricular hypertrophy. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is markedly dilated. right ventricular systolic function appears depressed. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. the mitral valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. no vegetations seen (but cannot definitively exclude). . portable kub: impression: nonspecific bowel gas pattern. if clinically indicated, ct scan may be useful to further characterize this finding. this was discussed with dr. at approximately 3:30 a.m., . . abd u/s w/doppler: impression: . 1. no evidence of perihepatic ascites. 2. stable appearance of hepatofugal portal venous flow. 3. limited examination secondary to cirrhotic heterogeneously echogenic liver. although no focal liver lesions are identified, given the technical difficulties of this ultrasound surveillance, ct or mri surveillance for lesions could be performed for future examinations. . cxr: findings: there has been interval removal of the left ij line. ng tube is in the stomach. there is hazy bilateral increased vasculature and increased bilateral pleural effusion suggesting chf. impression: worsening chf. . ecg: sinus rhythm with first degree a-v block. since the previous tracing of the rhythm has reverted from atrial fibrillation to no significant change and the rate has slowed. diffuse non-specific st-t wave abnormalities persist. . labs: -last set wbc rbc hgb hct mcv mch mchc rdw plt ct 10:11am 13.1* 2.64* 7.6* 22.6* 86 28.7 33.5 19.1* 147 . pt ptt plt smr plt ct inr(pt) 10:11am 147* 10:00am 18.7*1 33.6 1.8* glucose urean creat na k cl hco3 angap 04:16am 68* 87* 2.4* 141 3.4 97 34* 13 --- coags: fibrino d-dimer 08:19am 159 01:58am 176# 03:49am * 05:45am 293 09:50am 332 . hemolytic w/u: ret aut 03:19am 6.5* 06:17am 6.7* 04:35pm 3.5 . hit ab test=neg: heparin dependent antibodies test result ---- ------ heparin dependent antibodies negative comment: negative for heparin pf4 antibody by complete report on file in the laboratory. . . caltibc vitb12 folate hapto ferritn trf 08:19am <20* 03:19am <20* 03:49am 169* 1695* greater th1 69 130* added chem 11:50am 1 greater than 20 ng/ml 05:45am 39 09:50am <20 . -- lfts: alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 04:16am 27 37 402* 103 125* 1.1 added osmo 8:24am 08:19am 26 39 441* 103 1.3 0.9* 0.4 03:19am 401* 1.2 05:27am 17 28 80 0.7 source: line-mlc 03:49am 21 38 346* 92 0.9 05:45am 353* 09:50am 466* 0.7 0.3 0.4 05:44am 21 36 429* 122* 0.8 . hbsag hbsab hbcab 06:55pm negative negative negative immunology dsdna 06:55pm negative protein and immunoelectrophoresis pep igg iga igm ife 06:55pm no specifi1 1054 557* 166 no monoclo2 . hcv ab 06:55pm negative . . c3 c4 06:55pm 83* 17 . --- micro: brief hospital course: the patient was admitted to the medical icu in critical condition in setting of severe pulmonary htn. his course was complicated by hemolytic anemia, gib, in setting of anticoagulation for his pulmonary htn. also c/b hepatic encephalopathy. per family and hcp-daughter , pt was made on and expired on . provided support to family towards the end of his complicated course of illness. . . medications on admission: 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 medications: none discharge disposition: expired discharge diagnosis: -hemochromatosis, esld -pulmonary hypertension -expired discharge condition: deceased discharge instructions: none followup instructions: none md, Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Diagnostic ultrasound of heart Thoracentesis Transfusion of packed cells Right heart cardiac catheterization Transfusion of other serum Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Acute and subacute necrosis of liver Acute kidney failure, unspecified Acquired coagulation factor deficiency Iron deficiency anemia secondary to blood loss (chronic) Portal hypertension Unspecified acquired hypothyroidism Atrial fibrillation Other chronic pulmonary heart diseases Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Long-term (current) use of insulin Infection and inflammatory reaction due to other vascular device, implant, and graft Other disorders of plasma protein metabolism Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Acute gastritis, with hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 70m acute cholecystitis x4days major surgical or invasive procedure: s/p open cholecystectomy and liver biopsy s/p ercp with biliary stent placement s/p placement of central venous catheter history of present illness: 70 y/o m with several day history of abdominal pain ??fevers, nausea, etc past medical history: - diabetes type 2 - neuropathy - retinopathy - gilberts syndrome social history: married and lives with wife pertinent results: 06:20am blood wbc-11.5* rbc-3.05* hgb-9.8* hct-29.3* mcv-96 mch-32.3* mchc-33.6 rdw-15.8* plt ct-257 12:20pm blood neuts-79.9* bands-0 lymphs-12.4* monos-5.7 eos-1.4 baso-0.6 06:20am blood plt ct-257 06:20am blood pt-13.6* ptt-64.8* inr(pt)-1.2* 06:20am blood glucose-98 urean-30* creat-1.4* na-140 k-4.3 cl-105 hco3-29 angap-10 06:20am blood alt-111* ast-225* ld(ldh)-341* alkphos-682* amylase-145* totbili-13.4* dirbili-11.0* indbili-2.4 07:09am blood alt-106* ast-204* ld(ldh)-309* alkphos-646* amylase-112* totbili-13.3* dirbili-9.9* indbili-3.4 12:30am blood alt-112* ast-224* alkphos-582* amylase-102* totbili-12.0* 04:07am blood alt-116* ast-246* alkphos-536* amylase-96 totbili-11.4* 02:01am blood alt-101* ast-180* ck(cpk)-527* alkphos-449* amylase-84 totbili-12.7* 06:20am blood lipase-215* 07:09am blood lipase-158* 12:30am blood lipase-125* 04:07am blood lipase-103* 02:01am blood lipase-118* 06:20am blood albumin-2.6* calcium-8.0* phos-2.4* mg-2.4 03:44pm blood hbsab-negative hbcab-negative igm hbc-negative 02:25pm blood -negative 03:44pm blood hcv ab-negative cardiology report echo study date of conclusions: 1.the left atrium is mildly dilated. the left atrium is elongated. 2.there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. resting regional wall motion abnormalities include basal and mid inferolateral severe hypokinesis-akinesis. 3. right ventricular chamber size is normal. 4.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. 5.the mitral valve leaflets are mildly thickened. the mitral valve leaflets are elongated. no mitral regurgitation is seen. 6.there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. specimen submitted: gallbladder, liver biopsy. procedure date tissue received report date diagnosed by dr. /cma?????? diagnosis: i. gallbladder (a-b): acute necrotizing cholecystitis superimposed on a background of chronic cholecystitis. ii. wedge biopsy of liver (c): 1. cirrhosis (confirmed by trichrome stain). 2. parenchyma: a. steatosis, large and small droplet forms, involving 5-10% of hepatocytes. b. multiple single apoptotic hepatocytes. c. foci of hepatocytes with cytoplasmic hyalin. 3. portal areas/fibrous tracts: variable active and chronic inflammation with focal bile duct proliferation. 4. iron stain: focally increased iron (2+/4+) in hepatocytes and kupffer cells. note: the findings are consistent with some type of toxic-metabolic liver injury with progression to cirrhosis. the specimen contains numerous lobular neutrophils, but it is difficult to determine whether these simply represent so-called "surgical hepatitis" or an aspect of toxic-metabolic hepatitis. in addition, subcapsular specimens such as this biopsy may be more fibrotic than deeper areas of the liver. clinical correlation is necessary to determine the etiology of the liver findings. clinical: cholecystitis, acute. fibrotic liver noted at surgery. brief hospital course: mr. is a diabetic with a history of an unknown liver disease thought to be - syndrome with an elevated bilirubin up to 5.9. he was admitted with 4 days of abdominal pain in the right upper quadrant, nausea and vomiting. the ultrasound was quite difficult but did show a normal size common duct at 5 mm sludge and a very difficult to visualize gallbladder. it was felt that percutaneous cholecystostomy tube was not possible. ercp was not warranted after consultation with dr. of gi. it was thought that his elevated bilirubin was due to his - syndrome. he was brought to the operating room the procedures performed on were 1. total cholecystectomy with oversew of cystic duct. 2. liver biopsy. 3. drainage of right upper quadrant. 4. laparoscopy. post op the patient was extubated in the pacu and then transferred directly to the icu for increasing bilirubin and creatinine. the patient was kept on unasyn. hepatology was consulted for input into the patient's underlying liver disease. in the icu the patient had worsening renal function and a decreased hct. he was given albumin and a unit of prbc. he also had pvc's and v-tach runs. cardiology was consulted and an echo was performend. the echo revealed and akinetic area of left ventricle. the patient improved and was transferred to the floor on pod3. on pod5 the patient had elevated lft's and bilirubin. he was taken for an ercp. a stent was placed and sludge was drained. during the procedure the patient became hypoxic and bradycardic. he was transferred to the icu intubated. the patient improved and was extubated and transferred to the floor. the patient continued to improve and tolerated a diet. he was seen by pt and cleared for home. he was discharged on pod8 to home with vna services. medications on admission: amaryl neurontin zestril discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. ursodiol 250 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 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:*2* discharge disposition: home with service facility: , discharge diagnosis: acute cholecystitis s/p open cholecystectomy and liver biopsy s/p ercp with biliary stent placement history of diabetes history of gilberts syndrome w/baseline bili of 1.7 discharge condition: stable discharge instructions: - you will be discharged to home with vna services to help with dressing changes - you may shower - you should continue the diet you began in the hospital - you should take all medications as instructed - do not lift anything heavier than a gallon of milk for the next six weeks - no soaking in baths, hot tubs, or swimming pools until cleared at a follow-up appointment - you will have several follow-up appointments you will need to make - these are very important - md or return to ed if t>101.5, chills, nausea, vomiting, chest pain, shortness of breath, severe abdominal pain, redness or smelly drainage from around your incision, or any other concern -please restart your home medications followup instructions: **you will need to call to confirm the following appointments. they are very important** - dr. : ( -> you need to see her monday . - cardiology clinic: ( -> you will need to schedule a follow-up appointment as well as an outpatient echo and stress test. - ercp with dr. (- please call for appointment next week - hepatology with dr. ( - please call diabetes center for blood sugar management ( md Procedure: Cholecystectomy Endoscopic insertion of stent (tube) into bile duct Open biopsy of liver Diagnoses: Cirrhosis of liver without mention of alcohol Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Other specified cardiac dysrhythmias Long-term (current) use of insulin Unspecified sleep apnea Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Laparoscopic surgical procedure converted to open procedure Acute and chronic cholecystitis Disorders of bilirubin excretion

history of present illness: the patient is a -year-old african-american female with a history of hypertension, hypercholesterolemia, coronary artery disease, cerebrovascular accident, abdominal aortic aneurysm, and severe dementia who presents with a upper respiratory infection initially to the clinic on and given azithromycin times five days. the patient was otherwise, she was in her usual state of health. on saturday () in the evening, the patient was noted to have a large hard stool with dark blood. on sunday morning, she had no blood in her diaper when changed but by the evening (at 6 p.m.) she had a large blood clot and dark blood saturating her diaper. the patient had no nausea, vomiting, abdominal pain, or hematemesis. in the emergency department, the patient's vital signs revealed a heart rate of 77, her blood pressure was 132/44, and her oxygen saturation was 97% on room air. her hematocrit was 27.8 (with a baseline of 35.3 in ) with normal platelets and coagulations. the patient was transfused 2 units of packed red blood cells. a tagged red blood cell scan showed an active hepatic flexure bleed. the patient went to angiogram for a possible embolization and was found to have a total superior mesenteric artery and internal mammary artery occlusion with no possible embolization intervention. her hematocrit was stabilized after a total of 3 units of packed red blood cells were transfused. she was watched in the medical intensive care unit, and her hematocrit on at 4 a.m. was 29% and remained in that range on . she continued to ooze some blood from her rectal tube. the patient's two daughters have expressed the desire for no surgery or heroic measures. the patient's code status was to remain do not resuscitate/do not intubate. the patient was transferred to the floor initially for observation. physical examination on presentation: physical examination revealed the patient's temperature was 96.7 degrees fahrenheit, temperature maximum was 96.7, her heart rate was 53 to 72, and her blood pressure was 135 to 167/48 to 58. generally, the patient was in no acute distress. she opened her eyes and was moaning. she was not communicative but was alert and at her baseline. head, eyes, ears, nose, and throat examination revealed the mucous membranes were moist. there was no jugular venous distention. cardiovascular examination revealed a regular rate and rhythm. there was holosystolic murmur at the apex. pulmonary examination revealed the lungs were clear to auscultation bilaterally. the abdomen was soft, nontender, and nondistended. there were normal active bowel sounds. there was no hepatosplenomegaly. the extremities were without edema. she had contracture of all four extremities. neurologically, she had increased tone in her left upper extremity and left lower extremity. she was moving all extremities well. her reflexes were equal bilaterally. pertinent laboratory values on presentation: laboratories revealed her white blood cell count was 10, her hematocrit was 30, and her platelets were 132. the patient's sodium was 142, potassium was 4.4, chloride was 112, bicarbonate was 22, blood urea nitrogen was 17, creatinine was 0.5, and her blood glucose was 103. her calcium was 8.2, her phosphate was 2.6, and her magnesium was 2.1. pertinent radiology/imaging: a tagged red cell scan on showed an active hepatic flexure bleed. angiography revealed total occlusion of the superior mesenteric artery and internal mammary artery with celiac collateral feeding superior mesenteric artery territory. no possible embolization. an esophagogastroduodenoscopy on showed normal esophagus, gastric, and duodenum. a colonoscopy on showed multiple diverticula in the entire colon, three polyps in the ascending colon (status post polypectomy), and no active bleeding. a chest x-ray showed cardiomegaly and increased interstitial markings. concise summary of hospital course by issue/system: 1. gastrointestinal bleed issues: gastrointestinal bleed localized to the hepatic flexure with a tagged red blood cell scan. the patient's was stabilized in the intensive care unit initially with a transfusion and was then transferred out to the floor. she had total superior mesenteric artery and internal mammary artery occlusion, and no embolization was possible by angiography. the family declined any surgery or other heroic measures, and she continued to have bleeding after transfer out of the intensive care unit, requiring four to six transfusions per day. the bleeding had slowed by . after having a family discussion with both of her daughters and the attending, her daughters understood that she would likely continue to bleed at home but there may be no other noninvasive interventions possible in the hospital. her daughters understood this and elected to take her home. 2. coronary artery disease issues: the patient with a troponin leak. there were no electrocardiogram changes. initially, her hematocrit was kept around 30%, but the patient remained transfusion dependent. 3. congestive heart failure issues: congestive heart failure was well compensated with an ejection fraction of about 45%. the patient was gently hydrated during her hospital stay and treated with packed red blood cells without any evidence of fluid overload. 4. joint contracture issues: the patient had contractures of all four extremities and was treated with physical therapy as an inpatient. 5. hypertension issues: the patient's blood pressure medications were held in the setting of an active bleed. 6. code status issues: the patient remained do not resuscitate/do not intubate during her hospital stay. condition at discharge: condition on discharge was guarded. code status on discharge: the patient to remain do not resuscitate/do not intubate, and her family understood her risk at home of continued bleeding. discharge status: the patient was discharged to home in the care of her two daughters. discharge instructions/followup: the patient was instructed to follow up with dr. and was to call for an appointment (telephone number ). medications on discharge: pantoprazole 40 mg by mouth once per day. , m.d. dictated by: medquist36 Procedure: Arteriography of other intra-abdominal arteries Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Acute vascular insufficiency of intestine Diverticulosis of colon with hemorrhage Psychogenic paranoid psychosis

history of present illness: the patient is a 64-year-old woman with a history of bipolar disease who was admitted with increasing lethargy, speech changes progressive over a two week period. she was also noted to have several days of nausea, vomiting and diarrhea. on the day of admission, her social worker called and noted that she sounded ill. ems was activated and upon arrival, she was found to be bradycardic with a heart rate in the 40s. she was brought to the for further management. past medical history: 1. type 2 diabetes 2. hypertension 3. osteoarthritis 4. status post hysterectomy 5. bipolar disorder 6. hypothyroidism 7. urinary incontinence 8. chronic diarrheal symptoms outpatient medications: 1. cogentin 1 mg p.o. q.d. 2. accupril 40 mg p.o. q.d. 3. lasix 20 mg p.o. q.d. 4. norvasc 2.5 mg p.o. q.d. 5. zocor 40 mg p.o. q.d. 6. risperdal 2 mg p.o. t.i.d. 7. synthroid 150 mcg p.o. q.d. 8. micronase 5 mg p.o. b.i.d. 9. klonopin 0.5 mg p.o. b.i.d. 10. lithium 300 mg p.o. t.i.d. allergies: no known drug allergies. social history: the patient smokes. she does not drink. she lives alone. her health care proxy is her separated husband, . physical examination: general: the patient was lethargic, but arousable and able to answer questions. vital signs: at the time of admission to the ccu, her vitals were as follows: temperature 97.6??????, blood pressure 130/70, pulse of 50, oxygen saturation of 88% on 100% nonrebreather. head, ears, eyes, nose and throat: dry oral mucosa. respiratory: she had bilateral crackles approximately the way up. cardiac: her rhythm was irregular and she was noted to be bradycardic. no murmurs. abdomen: benign. she is obese, but soft, nontender. extremities: trace edema bilaterally. neurologic: cranial nerves iii through xii were grossly intact. pertinent laboratory studies: white cell count 12.3, hematocrit 29.8, platelets 265. pt 12.9, inr 1.1, ptt 24.5. sodium 134, potassium 3.3, chloride 104, bicarbonate 19, bun 42, creatinine 1.5, glucose 204, calcium 8.4, phosphate 5.7, magnesium 2.4. arterial blood gases 7.28, 37, 190 on 100% nonrebreather. she also had a transaminitis with alt 126, ast 51, alkaline phosphatase 225, total bilirubin 0.6. lithium level was noted to be 2.4, therapeutic range 0.5 to 1.5. imaging: electrocardiogram showed sinus bradycardia at a rate of 36, pr intervals 186. qtc was prolonged at 560. chest x-ray showed pulmonary edema with increased vascularity in the upper lung fields. summary of hospital course: in the emergency department, the patient was noted to be in sinus bradycardia with a heart rate in the 30s and 40s and hemodynamically unstable with diastolic blood pressure falling from 100 to the 60s with decreased responsiveness. she was given 2.5 mg of atropine without effect and that was followed by 1 mg of epinephrine. she responded to the epinephrine by going into sinus tachycardia with a heart rate greater than 120. she developed chest pain and inferior lateral st depression. she subsequently went into a junctional rhythm at a rate of 50 with a systolic blood pressure in the 70s. dopamine was started a temporary ventricular pacer was placed. she was then admitted to the ccu team for further management. summary of her hospital course is as follows: 1. lithium intoxication: lithium was held and the patient was hydrated with hypotonic saline. during the hospitalization, gentle diuresis with lasix was required to maintain volume balance and the lithium level fell from 2.4 to less than 0.2. after consultation with the outpatient psychiatrist, dr. , the decision was made not to restart the patient on lithium at this time. 2. cardiac: the patient was evaluated by the electrophysiology service during this hospitalization. dopamine was weaned immediately after placement of the ventricular pacer. the temporary ventricular pacer was changed to an atrial pacer on for increased stability. this was then removed . since the patient was not to be restarted on lithium and she was hemodynamically stable, the decision was made not to put in a permanent pacer at this time. given her electrocardiogram changes and chest pain after admission after the administration of epinephrine. her enzymes were cycled and she was ruled out by enzymes. echocardiogram indicated normal ejection fraction of 60% to 65% with a moderately dilated la, mild to moderate mitral regurgitation and mild tricuspid regurgitation. 3. gastrointestinal: the patient related a four year history of diarrhea worsening just prior to admission. this was discussed with the primary physician, . . stool studies were sent and she will have an outpatient work up to be coordinated by dr. . the transaminitis at the time of admission with the exception of alkaline phosphatase spontaneously resolved with hydration and was most likely secondary to her hemodynamic instability at the time of admission. the alkaline phosphatase will be rechecked as an outpatient by her primary care physician. 4. renal: with hydration, her bun and creatinine returned to baseline status. 5. psychiatry: the patient was seen by dr. of the consult service and discussed with her outpatient psychiatrist, dr. . the decision was made to avoid lithium at this time. instead, she will be discharged on risperdal 2 mg p.o. t.i.d. and klonopin 2.5 mg p.o. b.i.d. with an atypical antipsychotic most likely to be started in the future as an outpatient. outpatient care will be coordinated by dr. . discharge medications: 1. accupril 40 mg p.o. q.d. 2. norvasc 2.5 mg p.o. q.d. 3. zocor 40 mg p.o. q.d. 4. synthroid 150 mcg p.o. q.d. 5. micronase 5 mg p.o. b.i.d. 6. risperdal 2 mg p.o. t.i.d. 7. klonopin 0.25 mg p.o. b.i.d. discharge diagnosis: 1. lithium intoxication discharge condition: the patient was discharged to health and rehabilitation at in stable condition. , m.d. dictated by: medquist36 d: 13:19 t: 13:24 job#: Procedure: Non-invasive mechanical ventilation Insertion of temporary transvenous pacemaker system Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypopotassemia Other specified cardiac dysrhythmias Obesity, unspecified Bipolar I disorder, most recent episode (or current) unspecified Other psychotropic agents causing adverse effects in therapeutic use

allergies: shellfish attending: chief complaint: doe major surgical or invasive procedure: mvr ( 27/29 ox-x valve)/ cryo maze history of present illness: 54 yo male with rheumatic heart disease. serial echos have shown progressive mitral stenosis. past medical history: rheumatic heart disease chronic af cva hepatitis b depression hyperlipidemia social history: works as real estate lives with wife and kids family history: non-contributory physical exam: nad hr 70 rr 16 bp 108/70 admission exam unremarkable with the exception of systolic murmur, diastolic murmur brief hospital course: mr. was admitted for cardiac cath and iv heparin after stopping his coumadin. cardiac cath on showed severe mitral stenosis, moderate pulmonary hypertension and normal coronary arteries. post cath he was started on iv heparin. he was taken to the operating room on where he underwent an mvr with a 27/29 on-x valve and cryo maze. he was transferred to the sicu in critical but stable condition. he was extubated and weaned from his vasoactive drips later that same day. he was transferred to the floor on pod #1. he was started on coumadin and heparin for his mechanical valve. mr. was seen in consultation by the physical therapy service. he was gently diuresed. by post-operative say nine he was ready for discharge to home. medications on admission: coumadin, atenolol, zocor, discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 6. 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:*0* 7. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 9. amiodarone 200 mg tablet sig: two (2) tablet po once a day: 400 daily x 1 week, than 200 daily until dc'd by cardiologist. disp:*60 tablet(s)* refills:*0* 10. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 5 days. disp:*5 tablet(s)* refills:*0* 11. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 5 days. disp:*10 capsule, sustained release(s)* refills:*0* 12. ibuprofen 400 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*30 tablet(s)* refills:*0* 13. warfarin 1 mg tablet sig: three (3) tablet po daily (daily): 3mg pm and have inr checked with results to clinic for further dosing. disp:*200 tablet(s)* refills:*0* 14. outpatient work pt/inr as needed first draw with results to phone:/fax: goal inr 3-3.5 15. lipitor 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: care group discharge diagnosis: rhd/mitral stenosis chronic af cva hepatitis b depression hyperlipidemia discharge condition: good. discharge instructions: call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. no lifting more than 10 pounds or driving until follow up with surgeon. shower, no baths, no lotions, creams or powders to incisions. followup instructions: provider: , m.d. date/time: 10:40 provider: , call to schedule appointment. appointment should be in 4 weeks dr. 2 weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Excision or destruction of other lesion or tissue of heart, open approach Open and other replacement of mitral valve Diagnoses: Atrial fibrillation Primary pulmonary hypertension Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Mitral stenosis

history of present illness: the patient is a 78-year-old female status post a fall down four stairs striking the right side of her head with positive loss of consciousness. the patient was taken to an outside hospital which showed bilateral frontal contusions, right frontal subarachnoid hemorrhage and a right ventricular bleed. the patient was alert, conversant, and she was moving all extremities at the outside hospital. she began to have nausea, vomiting, and decreased mental status with twitching. the patient was given 1 mg of ativan and continued to seize. the patient was med-flighted to for further management. past medical history: (the patient has a past medical history of) 1. dementia. 2. hypothyroidism. 3. skin cancer. past surgical history: past surgical history is unknown. allergies: the patient has an allergy to sulfa. medications on admission: medications included premarin, zoloft, levoxyl, zyprexa, folate, vitamin e, and vitamin c. physical examination on presentation: physical examination revealed the patient's temperature was 100.2, her blood pressure was 127/64, her heart rate was 61, and her oxygen saturation was 100%. the patient was intubated and sedated. the patient was not responsive to verbal stimulation. coma scale score was 6 on arrival. she withdrew in the upper and lower extremities to pain. she moved her left upper extremity spontaneously. the lungs were clear to auscultation. no thoracic deformities. head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. she was in a cervical collar with no neck swelling. the right eye was swollen with bruising over the left face. cardiovascular examination revealed a regular rate and rhythm. no murmurs, rubs, or gallops. the abdomen was soft and distended. no bowel sounds. extremity examination revealed a left knee contusion and abrasion. in the lower extremity, she had a left knee contusion with abrasion. no extremity deformities. the feet were cool. pulses were not found, but good positive capillary refill. she did have a right femoral arterial line in place. she was unresponsive to voice. the deep tendon reflexes were 2+ in the upper extremities and 1+ at the knees. brief summary of hospital course: the patient was admitted to the intensive care unit. a head computed tomography showed right small frontal contusions, ventricular hemorrhage, with no mass effect. cervical spine, chest, abdominal, and pelvic computed tomography were negative. the patient was admitted to the trauma intensive care unit for close observation. a repeat head computed tomography on showed no significant change. the patient continued to require close neurologic observation in the trauma intensive care unit. on the patient localized some left upper extremity localizing on the right and opened the left eye slightly. the pupils were equal, round, and reactive to light. her gaze was conjugant. the right pupil was slightly larger than the left. she blinked to confrontation and withdrew the left lower extremities. on , the patient attempted to localize in both upper extremities. she was moving the arms and legs spontaneously. pupils revealed right at 3 mm to 2 mm and the left at 3 mm to 2 mm and briskly reactive. a repeat computed tomography of the head showed left occipital increased in size with no mass effect or change. a computed tomography of the lumbar spine with thin cuts was obtained of the lumbar spine to rule out a l1 fracture. the computed tomography scan confirmed a l1 compression fracture. the patient was fitted for a tlso brace. on the patient did not follow commands, localized in the left upper extremity not in the right upper extremity. withdrew her lower extremity left greater than right. the pupils were 4 mm down to 3 mm. gaze was conjugant. neurologically, she was more lethargic. her head computed tomography from showed no interval change. the patient was scheduled for an electroencephalogram. electroencephalogram showed just generalized slowing. no generalized seizure activity was noted. the patient's cervical spine was cleared. the cervical collar was removed. the patient remained in the intensive care unit intubated and off all sedation. neurologically, the pupils were equal and reactive. she had localizing in the left upper extremity and was withdrawing both lower extremities. she was not following commands. she was continued on levaquin for seven days prophylactically against any potential source of infection; although, one had not been isolated by . the patient's condition remained intubated with no verbal response. the patient intermittently withdrew the right upper extremity to pain and localizing with the left upper extremity and withdrawing her lower extremities. on , the patient had positive blood cultures with gram-positive cocci in pairs and clusters. the patient was continued on levaquin for a 2-week course. the patient's condition continued to remain the same with an unchanged neurologic status. on , there was a family meeting and the patient's family wished to continue with aggressive care. the patient had a lumbar puncture on to rule out any cerebrospinal fluid infection. the neurology service was consulted. a fever workup was continued. on , the patient opened her eyes briefly. she was flexure posturing versus withdrawing in her upper extremities. the pupils were 3 mm down to 2 mm bilaterally. she was withdrawing both lower extremities to pain. intravenous vancomycin was started on as well as ceftazidime for gram-positive cocci in the blood with gram-positive cocci and gram-positive rods in her sputum. a lumbar puncture culture done revealed the lumbar puncture was negative for meningitis. the patient's temperature was up to 101.3 degrees fahrenheit. on , the patient was opening her eyes to stimulation. her pupils were brisk and symmetric. flexure posturing in the upper extremities and withdrawing in the lower extremities. the family requested a family meeting. the family decided to make the patient comfort measures only. the patient was extubated and passed away on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Unspecified acquired hypothyroidism Hemorrhage complicating a procedure Anoxic brain damage Accidental fall on or from other stairs or steps Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level Meningitis, unspecified

allergies: codeine attending: chief complaint: coronary artery disease major surgical or invasive procedure: cabg x 5 lima > lad, svg>plv>pda, svg>om1>om2 history of present illness: mr. is a 56 yo male with coronary artery disease, who presented to on for an elective cabg. past medical history: cad/mi () htn hyerlipidemia dm physical exam: alert, oriented, well-nourished, comfortable chest clear bilaterally rrr abdomen soft, nontender extremities warm, well-perfused brief hospital course: mr. cabg x5 on , which he tolerated well (see op note). he was transferred to the cardiac intensive care unit post-operatively, as per routine. he was extubated soon thereafter. it should be noted that this patient is a difficult intubation, but with the close assistance of anesthesia, there were no issues with extubation. he would remain in stable condition throughout his hospital stay. his chest tubes were removed on pod 1, and he was transferred from the icu to the floor in stable condtion. he was soon ambulating easily and often on his own. on pod 3, he did have a fever, however, he continued feeling well. his wound showed no signs of infection. a chest x-ray revealed no abnormal findings. his wbc on pod 4 was within normal limits. on pod 5, with mr. feeling well, ambulating easily, his sternum stable, and with his wound appearing to be healing well, he was discharged to home in good condition. he will follow-up within the next month for post-operative evaluation with dr. . discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 5 days. disp:*20 capsule, sustained release(s)* refills:*0* 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. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. 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* 5. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 25 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 5 days. disp:*10 tablet(s)* refills:*0* 9. glyburide 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. metformin 850 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: cad dm htn discharge condition: good discharge instructions: no lifting > 10# for 10 weeks may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions followup instructions: with dr. in weeks with dr. weeks with dr. in 4 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Old myocardial infarction

history of present illness: this is a 53-year-old white male with a history of diabetes mellitus type 2, hypertension, with neuropathy who presented with a four day history of chest pain and diaphoresis. of note, one month prior to admission, he had first ever episode of chest pain while walking his dog, characterized as pressure, which did not radiate, without associated symptoms except for diaphoresis. they resolved within ten minutes of lying down. this occurred three more times in the following weeks, until the friday prior to admission. the symptoms began in the morning and did not go away. review of systems: significant for fatigue for the same amount of time, temperature 102.6 on friday, occasional cough, no orthopnea, paroxysmal nocturnal dyspnea or claudication. in the emergency department, his electrocardiogram was noted to have st elevations in ii, iii and avf. he was taken to catheterization and had stenting of the right coronary artery using two overlapping stents. physical examination on admission: temperature 100.8. blood pressure 103/64. pulse 79. respiratory rate 12. he is % on room air. he was alert and oriented in no apparent distress. he had jugular venous pressure at 8 cm. pulmonary: clear to auscultation anteriorly. heart rate: regular rate and rhythm, no murmurs, rubs or gallops. extremities with 1+ pulses. groin without hematoma. laboratories at that time: white blood cell count 11.9, hematocrit 38.8, platelet count 177,000, 85% neutrophils, no bands. chest x-ray showed left ventricular enlargement, no congestive heart failure. cks were 623, 689, mb of 38, troponin of greater than 50. past medical history: 1. diabetes type 2. 2. hypertension. 3. neuropathy. home medications: zestril 10 mg po q.d., glyburide 10 mg q.d., nortriptyline, atenolol and neurontin. allergies: codeine which gives him a rash. social history: no tobacco ever. alcohol: five to six beers per day with occasional binge. no drugs. family history: no history of coronary artery disease. hospital course: post stent, the patient was put on telemetry, started on integrilin for 18 hours, restarted on a beta-blocker. the ace inhibitor was initially held until after the transthoracic echocardiogram. he was started on aspirin 325 mg q.d., plavix 75 mg for 30 days, fasting lipids were checked. his diabetes and other home medications were continued glyburide. he was also put on a regular insulin sliding scale. neuropathy: he was stable and continued on neurontin, as well as his nortriptyline. he was initially admitted to coronary care unit for monitoring due to his three vessel disease found on cardiac catheterization. he was then transferred on the to c med at which time his echocardiogram had been performed on , which showed an ejection fraction of 35-40%, left atrial mild dilatation, inferior, inferolateral, inferoseptal hypokinesis in those regions. the left ventricular systolic function was mildly to moderately decreased. the right ventricular systolic function was moderately to severely decreased. by the 7th, his fasting lipid results had returned showing triglycerides of 101, hdl 41, ldl of 92, total cholesterol of 153. he was on pravachol 20 q.d., with the hopes of increasing that dosage while in house, so his lfts were checked which revealed alt mildly elevated at 71, ast mildly elevated at 62, an ld of 466, alkaline phosphatase of 62, total bilirubin 0.8, thus, he was left on the pravachol 20 q.d. with hopes that the lfts would be followed by primary care physician and increased as tolerated. he continued to do well once transferred. the lopressor was increased from 25 b.i.d. to 37.5 mg b.i.d. captopril was restarted at 12.5 mg t.i.d. on the 7th. on the 7th, course was notable for a febrile episode to 101. chest x-ray, blood cultures and urine cultures were obtained. all were negative for infectious processes. on the 8th, he continued to improve, was working with physical therapy without difficulties, at which time he noticed that he was having left big toe pain, it was noted to be erythematous and extremely tender to touch, thus, an acute gout flare was diagnosed. he was started on colchicine 0.6 mg b.i.d. with improvement of symptoms. the patient was discharged home on with follow-up instructions to see his primary care doctor in seven to ten days, dr. , within one month, as well as an exercise stress mibi was scheduled for at 4:30 p.m. discharge medications: he was discharged home on his: 1. glyburide 10 q.d. 2. neurontin. 3. nortriptyline 50 mg hs. 4. toprol xl 50 mg q.d. 5. colchicine .6 b.i.d. until his acute gout flare had resolved. 6. lisinopril 10 mg po q.d. 7. pravastatin 20 mg q.d. 8. glyburide 10 mg q.d., 9. nitroglycerin sublingual 0.4 mg prn. 10. aspirin 325 mg q.d. 11. plavix 75 mg po q.d. times 30 days. of note, he also had a cough throughout his hospital stay. this improved significantly with incentive spirometer, thus, the patient was discharged home with the incentive spirometer with instructions to continue as needed. discharge status/follow-up: patient discharged home with follow-up with primary care physician, . , stress mibi, and outpatient cardiac rehabilitation. discharge condition: good. discharge diagnosis: acute myocardial infarction. , m.d. dictated by: medquist36 Procedure: 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 Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Gout, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Tachycardia, unspecified

history of present illness: the patient is a 54-year-old man status post living-unrelated transplant . transplant was difficult due to severe atherosclerotic disease of aorta to iliac vessels. postoperatively, ultrasound demonstrated reasonable arterial flow, but the renal vein was unable to be visualized. the patient was brought back to the or on for exploration of kidney, which demonstrated no evidence of renal vein thrombosis. on , the patient presented with increased weight gain, lower extremity edema, nausea, vomiting. patient after postop course was remarkable for dgf (atn) and the patient reports making approximately 1100 cc of urine per day. creatinine and bun have been relatively elevated, bun in the 90s, creatinine 4.0 postoperatively. patient also reports dysuria. patient complains of shortness of breath, dizziness, lightheadedness. the patient has approximately 3 loose bowel movements per day. decreased appetite but stable. three pound weight gain over the last few days. lasix was increased recently to 80 once daily without improvement. no hemodialysis postoperatively. past medical history: end-stage renal disease status post living-unrelated transplant complicated by poor arterial flow, status post exploration of kidney , history of type 1 diabetes with complications, complicated by retinopathy requiring bilateral laser surgery, as well as right vitrectomy, history of neuropathy in both hands and legs, history of cva with some left-sided weakness, history of cad, history of mi on several occasions in the past and 6 stents placed since , history of pvd with bilateral lower extremity bypass and toe amputation bilaterally, status post myocardial infarctions, also has a history of ejection fraction of 20%, gerd. past surgical history: cholecystectomy, status post living- unrelated renal transplant , with exploration of kidney on , status post bilateral lower extremity bypass, status post toe amputation bilaterally, status post placement of 6 cardiac stents in . medication on admission: tacrolimus 2 and 2, mmf 500 q.i.d., valcyte 450 every other day, bactrim ss 1 tab once daily, nystatin s and s 5 cc p.o. q.i.d., protonix 40 mg once daily, colace 100 mg b.i.d., toprol xl 25 mg once daily, lasix 40 mg once daily, phoslo tabs, plavix 75 once daily, rapamycin 2 mg once daily. allergies: ativan and nonsteroidal anti-inflammatory drugs. physical exam: temperature 96.8, heart rate 80, 114/68, 96 room air. no acute distress, awake, alert, oriented x3. cranial nerves grossly intact. cv regular rate and rhythm. lungs: decreased breath sounds at bilateral base, right greater than left. abdomen: well-healed incision, soft, nontender, nondistended. extremities: + pitting edema. labs on admission: the patient had a wbc of 1.9, hematocrit of 33.2, pt of 13.9, ptt 27.8, platelets 240, sodium 129, k 4.2, chloride 91, bicarbonate 24, bun and creatinine 81 and 4.1, glucose 230. hospital course: so, the patient was admitted. renal was consulted. patient was given iv lasix. plan was discussed with dr. . chest x-ray obtained on demonstrating failure with bilateral effusions consistent with fluid overload. on , an ultrasound was obtained of the kidney, duplex ultrasound, demonstrating normal appearance of the renal transplant with normal resistive indices ranging from 0.60 to 0.69, and also comment about bilateral pleural effusions. patient went to ultrafiltration on . patient does have a left av fistula which ultrafiltration was performed through that. a 2-d echo was performed on demonstrating ejection fraction less than 20%, compared with prior study that was reviewed on . right ventricle is now dilated with freewall hypokinesis, and the estimated pulmonary artery systolic pressure has increased. severity of mitral regurg and pulmonary artery hypotension are also increased. the patient continued with tacrolimus, rapamycin, mmf, valcyte. cardiology was consulted. cardiology met with patient and felt that patient should be on aspirin, plavix. suggested adjustment changes to medications. agreed with 80 mg of iv lasix for goal weight to be -1 to 2 liters. wound care nurse met with patient on because of sacral pressure ulcers, in which the patient had a right gluteal, left gluteal pressure ulcer, and made recommendations in regards to dressing changes. a right foot x-ray was obtained because of a right heel ulcer, demonstrating that there was no radiologic evidence of osteomyelitis. on , a right-sided ultrasound-guided thoracentesis performed by dr. and dr. , in which they removed 1300 cc of clear serosanguineous fluid. there were no complications. during hospitalization, patient had cmv viral load sent off which demonstrated that cmv-dna was not detected. on , the patient had a cardiac cath performed demonstrating baseline moderate-severe elevation in right heart pressures with low cardiac index. with dopamine infusion, no change in pcx and pa pressures, or systolic blood pressure, with progressive increase in cardiac index. a right ht left in place for continued hemodynamic monitoring in the ccu with drug therapy. so, the patient was on the cardiac service for monitoring, and transplant saw the patient daily and also managed his immune suppressant medications. wound care frequently saw patient for his decubitus pressure ulcers on his gluteus and right heel. infectious disease was consulted because of fevers, and blood cultures were sent on , in which a blood culture, sputum culture and urine culture were sent off, as well as a catheter-tip from pa line. all were unremarkable except for blood culture on demonstrating pseudomonas aeruginosa. the patient was placed on flagyl, zosyn, vancomycin on , after he had a temperature and id made recommendations. the patient started having diarrhea, so c. diff was sent off demonstrating no c. diff, no ova and parasites on . repeat cmv viral load was obtained demonstrating not detected. podiatry came to see patient on for his right heel ulcer. physical therapy/ occupational therapy saw patient and were consulted. on , patient had ultrafiltration through his left upper extremity fistula. he tolerated the procedure well. the patient was changed from multiple antibiotics to meropenem, continued on lasix. patient had repeat blood cultures on which demonstrated no growth. on , urine culture obtained demonstrated no growth as well. patient continued on ultrafiltration on . also, patient had ultrafiltration on , in which 1.5 l of fluid removed. patient's lasix drip was discontinued on . patient was started on epogen for anemia. patient was transferred from cardiac service to transplant service on , since patient was stable from a cardiac standpoint, but cardiology was still continuing to see patient. on , the patient had a picc line placed for iv antibiotics, and also had his ultrafiltration as well. serial chest x-rays demonstrated improved chf. on , placement of picc line demonstrates that there was more slightly prominent right pleural effusion, satisfactory position to right-sided picc line, and this film was compared to a previous film. question whether or not it was due to position, but because patient had very good saturations of 96-97% on room air, that clinically patient had no new findings of shortness of breath, chest pain which he did not require any oxygen, dr. felt safely with confidence that the patient could go home. patient was transitioned from fk to rapamycin while patient was an inpatient, and since the patient has been here, he has been on a single dose of rapamycin 6 mg once daily. levels range from 7.3 to which was 10.9. so, even though patient was deconditioned and physical therapy thought he should go to rehab, his wife who is an icu nurse felt strongly that she could take care of him with services at home. so, the patient was discharged to home with services on the following medications: tamsulosin 0.4 mg at bedtime, calcium acetate 667--2 tabs t.i.d. with meals, bactrim ss 1 tab once daily, protonix 40 mg q. 24, aspirin 325 mg once daily, tylenol 325--1-2 tablets q. h. p.r.n., plavix 75 mg once daily, mmf 250 b.i.d., ambien 1 mg at bedtime, valcyte 450 every other day, epogen 4000 units q. monday, wednesday and friday, b-complex, vitamin c, folic acid, isosorbide 1 tablet t.i.d., nystatin 10 ml p.o. q.i.d., tacrolimus 6 mg once daily, metolazone 10 mg once daily, bumetanide 3 mg b.i.d., aldactone 25 mg once daily, also meropenem 500 mg q. 12 for 2 days, and ciprofloxacin 500 mg once daily x4 days. patient will also be on an insulin fixed dose of 5 units of nph for breakfast and 4 units for dinner, and also sliding scale. patient has a hospital bed at home. patient has picc line care, iv pole pump, saline flushes, heparin flushes. physical activity can be weightbearing. the patient is follow-up with dr. and dr. next week. call for an appointment. patient should follow- up with dr. which is his cardiologist in . patient should have wound care to his gluteal area and to his right heel with duoderm gel and aloe ointment to his heel with protective gauze. the patient should follow-up with his podiatrist in as soon as possible for an appointment. also, patient's wife should call dr. this friday for record of his weight since being home and report that dr. by calling . final diagnoses: a 54-year-old status post living-unrelated transplant with congestive heart failure/fluid overload. major surgical procedures: 1. cardiac catheterization to evaluate pulmonary pressures. 2. peripherally inserted central catheter line placement for bacteremia, specific organism pseudomonas aeruginosa. , Procedure: Venous catheterization, not elsewhere classified Hemodialysis Thoracentesis Transfusion of packed cells Right heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Bacteremia Long-term (current) use of insulin Pressure ulcer, buttock Secondary hyperparathyroidism (of renal origin) Diarrhea Acute systolic heart failure Pressure ulcer, heel Complications of transplanted kidney Other toe(s) amputation status Pseudomonas infection in conditions classified elsewhere and of unspecified site Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled

history of present illness: the patient is a 53-year-old male who was admitted to an outside hospital on with chf and chest pain. the patient ruled out by cardiac enzymes, but had a bnp greater than 1400. the patient was started on natrecor and sublingual nitroglycerin. on , he became hypotensive with systolic blood pressures in the 80s, also had chest pain. ck, at that time, was 278 with troponin 9.3. no catheterization secondary to it being the weekend. his hematocrit was 33 on . the patient then had chest tightness. he received sublingual nitroglycerin and iv lopressor. the patient was then sent here for management of chf with consideration of cabg and management of now acute renal failure. otherwise, the patient has a history of iddm since age 7, cad, mi x2, refused cabg in , and history of chf. recent echocardiogram revealed dilated lv with inferior akinesis, which was new. the patient also had moderate mr, severe pulmonary hypertension, and an ef of 30 percent. otherwise, the patient has had a cva in the past. he has a history of chronic renal insufficiency, peripheral vascular disease, bilateral fem-, status post amputation of his second toe in both feet, neuropathy, retinopathy, gerd, and the patient was admitted with chest pain and chf. on , the patient had systolic blood pressures in the 80s. he had chest pain. sublingual nitroglycerin, morphine, and fentanyl patch were given. he was admitted to the ccu, got iv nitroglycerin, heparin gtt, natrecor, lasix, and made pain free, ruled in; however, on the day of admission to the , had new st depressions in v4 through v6, received sublingual nitroglycerin, became chest pain free, and his chf regimen was then changed to natrecor and bumex. allergies: ativan and nsaid. past medical history: his past medical history is significant for type 1 diabetes, since the age of 7; mi x2, cad, refused cabg in , history of chf with an ef of 30 percent, history of cva, history of peripheral vascular disease, status post bilateral fem-, status post amputation of second toe in both feet, history of neuropathy, retinopathy, and gerd. medications: the patient's medications on admission included, 1. natrecor 0.1 mg/kg/min. 2. heparin 850 units/hour. 3. nitrate 250 mg. 4. bumex. 5. nph, 24 units in the morning and 6 units in the evening. 6. phoslo. 7. aspirin 81 mg 1 p.o. q.d. 8. zocor 80 mg 1 p.o. q.d. 9. plavix 75 mg 1 p.o. q.d. 10. protonix 40 mg 1 p.o. b.i.d. 11. multivitamin. 12. toprol xl 150 mg 1 p.o. q.d. 13. also the patient at home is on cozaar, lasix, glyburide, and zestril. social history: he is retired, wife is a ccu nurse, has children, no tobacco, no etoh. family history: his sister has a history of diabetes and has had an mi in the past. physical examination: physical exam on admission includes the following, heart rate 87, blood pressure 109/72, temperature is 98.2 degrees, weight is 92.2 kg, saturating at 99 percent on 2 liters, respiratory rate is 12. generally, the patient is a very pleasant male, in no acute distress. heent: normocephalic, atraumatic. extraocular movements are intact. oropharynx is clear with moist mucous membranes. neck is supple with no thyromegaly. jvd is to the jaw. cardiac exam revealed regular rate and rhythm with a holosytolic murmur at the apex radiating to the axilla. lungs are clear to auscultation with crackles one- half the way up bilaterally. no wheezes or rales. abdomen has good bowel sounds, soft, nontender, and nondistended with no hepatosplenomegaly. extremities are free of any clubbing, cyanosis, or edema. second middle toe is missing bilaterally. his extremities are cool, positive dopplerable dps bilaterally. positive dopplerable right pt, but no left pt. the patient's ekg on admission, normal sinus rhythm; left atrial enlargement; st elevations in v1, v2; st depressions in v4, v5; t-wave inversion in v5, v6; q wave in lead iii. echocardiogram from revealed a dilated left ventricle; inferior, inferolateral, distal, anterior, distal anterior septal and apical akinesis, ef of 30 to 35 percent, moderate mr, trace ai, mild tr, severe pulmonary hypertension, left atrial enlargement compared to , inferior wall motion abnormalities, new left ventricular function is worse and pa pressures are higher. on , the patient had a cardiac catheterization, which revealed a codominant system, lmca was normal, lad with 80 percent proximal stenosis, 90 percent d1 left circumflex, om1 with 80 percent lesion, rca 70 percent mid lesion. the patient's telemetry was normal sinus rhythm. his data on admission, white count 6.9, hematocrit 33.8, platelet count 191. calcium 10.0, sodium 139, potassium 3.8, chloride 101, bicarbonate 26, bun 85; creatinine is 5.8, baseline was 3.8. hospital course: cardiac. the patient had an echocardiogram performed on , which revealed the following: an ef of 20 percent, left atrium that is mildly dilated, mild symmetric left ventricular hypertrophy, left ventricular cavity size is normal, overall left ventricular systolic function is severely depressed; and left wall motion was as follows: the patient had resting regional left ventricular wall motion abnormalities as follows, mid anteroseptal akinetic, mid inferoseptal akinetic, mid inferior akinetic, mid inferolateral akinetic, anterior apex akinetic, septal apex akinetic, inferior apex akinetic, lateral apex akinetic. one plus tr was seen, one plus mr. underwent cardiac catheterization on , which revealed the following: right coronary diffusely diseased, proximal lad diffusely diseased, left main normal, distal lad diffusely diseased, d1 diffusely diseased, mid circumflex discrete 70 percent lesion, obtuse marginal discrete 80 percent lesion. selective coronary angiography demonstrated a right dominant circulation with three-vessel coronary artery disease. the lmca had no angiographically apparent flow-limiting stenosis. lad was diffusely diseased in the proximal portion with a more focal 80 percent stenosis and diffuse disease into the distal vessel, first diagonal branch was diffusely deceased, the left circumflex had a 60 to 70 percent mid vessel stenosis, om1 had focal 80 percent stenosis in proximal portion, rca was dominant diffusely diseased vessel, distal rca was subtotally occluded with timi 0-1 flow. selective angiography of the lima and rima demonstrated normal vessels without angiographic evidence of flow-limiting atherosclerotic disease, pull back of catheters from the left subclavian artery demonstrated no evidence of a hemodynamically significant stenosis in the major vessel. left ventriculography was deferred. the resting hemodynamics demonstrated moderate pulmonary hypertension with a mean pap pressure of 40. left and right sided filling pressures were moderately elevated with mean rap of 14, mean pulmonary- capillary wedge pressure 29. cardiac index is preserved at 2.6 liters per minute per sq. m. a 11.5 french and 19.15 cm long quinton dialysis catheter was placed in the right femoral vein at the end of the case. successful ptca and stent of the mid and proximal rca with a 2.0 x 13 mm pixel and then by 2.5 x 16 and then by 2.5 x 24 and 2.5 x 12 taxus stents back to the ostium. there was no residual stenosis, no dissection with timi 3 flow noted. coronary artery disease status post nstemi, status post cardiac catheterization. the patient was maintained on aspirin, plavix, lipitor, and lopressor. he was continued on heparin gtt initially. for afterload reduction, the patient was maintained on isordil and hydralazine. ace inhibitor was not entertained given his acute on chronic renal insufficiency. carotid ultrasound was obtained and revealed noncritical stenoses of his carotid arteries bilaterally. congestive heart failure. the patient was maintained on natrecor gtt. additionally, the patient had his femoral quinton pulled and a right ij quinton placed for hemodialysis. the patient was maintained on hemodialysis and had very good diuretic effect. renal failure. the patient was maintained on hemodialysis as stated above. he had evidence of hyponatremia during his hospitalization, which was felt secondary to congestive heart failure as well as acute renal failure. insulin-dependent diabetes mellitus. the patient was maintained on nph regular insulin sliding scale and the nph was titrated up during his hospitalization. prophylaxis. the patient was maintained on heparin, bowel regimen, and ppi. discharge diagnoses: type i diabetes. hypertension. end-stage renal disease. hypercholesterolemia. peripheral vascular disease. status post myocardial infarction with stents to the rca. fop: dr. , ct surgery, at . the patient is to call on to schedule an appointment within one week. the patient was to continue on outpatient dialysis at dialysis center beginning on . the patient is to set up an appointment with his primary care physician within one week of discharge. discharge medications: 1. calcium acetate 667 mg 1 p.o. t.i.d. with meals 2. multivitamin 1 p.o. q.d. 3. plavix 75 mg 1 p.o. q.d. 4. aspirin 325 mg 1 p.o. q.d. 5. nph, to be used as directed. 6. toprol xl 25 mg to be taken 5 tablets 1 p.o. q.d. 7. protonix 40 mg 1 p.o. q.d. 8. atorvastatin 40 mg 1 p.o. q.d. die status: he will be discharged to home. will follow up with dr. and have hemodialysis. discharge condition: stable. he is oxygenating well on room air. he is hemodynamically stable and had no further episodes of chest pain, shortness of breath, or other cardiac symptoms. , md Procedure: 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 Hemodialysis Venous catheterization for renal dialysis Angiocardiography of right heart structures Injection or infusion of nesiritide Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Other chronic pulmonary heart diseases Peripheral vascular disease, unspecified Ulcer of heel and midfoot

history of present illness: the patient is a 54 year old male with endstage renal disease secondary to type 1 diabetes who presents for kidney transplant from wife. was started on dialysis in after having 47 years of diabetes which was complicated by both retinopathy, requiring bilateral laser surgery as well as right vitrectomy. history of neuropathy in both hands and legs. he has had a cva with some left sided weakness. history of coronary artery disease. he has had an myocardial infarction on several occasions in the past and 6 stents were placed in . he also had significant peripheral vascular disease with bilateral lower extremity bypass and toe amputations bilaterally. past medical history: gastroesophageal reflux disease. past surgical history: cholecystectomy. allergies: ativan and non-steroidal anti-inflammatory drugs. medications: the patient was taking: 1. isordil - 60 mg once daily. 2. aspirin, that was stopped on the day of admission. 3. plavix, discontinued on . 4. toprol 100 mg once daily. 5. nephrocaps one once daily. 6. lipitor. 7. aciphex. 8. temazepam. 9. insulin - 12 units nph q.a.m. and 6 units q p.m. regular insulin 8 units q.a.m. and 4 units q p.m. physical examination: general: in no acute distress. alert and oriented. no thyromegaly. dentures upper and lower. neck - free range of motion. heart: regular rate and rhythm. no murmurs or bruits. lungs: clear to auscultation. abdomen: nontender. nondistended. extremities: no clubbing, cyanosis or edema. mildly atrophic. height 68 inches. weight 160 pounds. blood pressure 137/51, heart rate 66, oxygen saturations 99% in room air. laboratory data on admission: white blood cell count 5.2, hematocrit 36.2, platelet count 177, sodium 144, potassium 4.3, chloride 99, po2 32, bun 36, creatinine 2.8, glucose 89, ekg was within normal limits. chest x-ray showed no bone destruction, bilateral effusions, right greater than the left, and enlarged cardiac silhouette. the patient was taken to the or on , for living unrelated renal transplant. surgeons were dr. and dr. , and dr. . the patient received general anesthesia. estimated blood loss was 400 cc. the patient did well intraoperatively. please seen operative note. the patient intraoperatively required take down of the renal artery anastomosis secondary to poor arterial inflow. he required iliac arteriotomy and embolectomy. post procedure he was managed in the post anesthesia care unit doing well. urine output was marginal over several hours. vital signs were stable. duplex of the kidney revealed good arterial wave forms with resistive indices of 0.57 to 0.61. there was no perinephric fluid collection. the patient was given intraoperative immunosuppression with 500 of solu-medrol, 1 gram of cellcept, atg 100 mg ancef, valcyte and heparin assay preoperatively. postoperative urine output was 10 to 20 cc an hour with half normal saline cc per cc replacement with a background iv of d5.5 of normal saline at 50 cc an hour. the patient was treated with morphine pca for pain and was managed on insulin subcutaneous injections for glucose control. postoperative hematocrit was 32.3, white blood cell count 4.6, k of 4.3, and creatinine of 3.3. the patient was transferred when stable to the medical surgical unit. urine output remained on the low side. nephrology was consulted and followed closely throughout the hospital course. iv fluid was decreased. breath sounds were decreased half way up on bilaterally. oxygen saturations were 98% on 2 liters, blood pressure 100/58. low dose lopressor was started on postoperative day 1. chest x-ray was repeated after placement of an ng tube for abdominal distention, nausea. repeat duplex revealed poorly visualized venous outflow. the patient returned to the operating room for reexploration of the kidney under general anesthesia by dr. with assistant dr. , resident on . please see operative note. minimal estimated blood loss. urine output q 1 hour 10 to 40 cc an hour. the patient was given iv dopamine and maintained on an iv of normal saline at 10 cc an hour. repeat chest x-ray to assess endotracheal tube was done. et tube was pulled back 5 cm. the patient was treated with morphine for pain, restarted on heparin 5000 units t.i.d. the kidney was noted to be pink with good arterial and venous flow. the patient was started on clear liquids on postoperative day 1. he did complain of some nausea. was consulted for management of hyperglycemia. blood sugars ran in the 300s. iv insulin drip was started and then later discontinued with adjustment of subcutaneous insulin. the patient underwent a tee on with notation of severely depressed right ventricular systolic function with moderate dilatation. systolic function was noted to be severely depressed globally. the apex was noted to be akinetic with moderate to severe ..... comments were noted that mitral valve flow was normal. the patient was transferred to the surgical intensive care unit postoperative reexploration of the kidney transplant. postoperative hematocrit was 27.7 with a white blood cell count of 6.6, creatinine was noted to be 3.7 and bun of 58, potassium 4.1. the patient ws intubated and sedated. he was on propofol for sedation and dopamine to increase cardiac output with goal to keep greater than cardiac index of 2 with blood pressure greater than 120. the patient was started on a lasix strip. the patient was extubated on postoperative day 2, 1. the patient was transferred from the post anesthesia care unit to the medical surgical unit on , with renal attending reviewed this case. the patient produced 1270 cc of urine over the prior 17 hours on lasix drip. prograf was deferred. the patient continued on atg. he received a total of 4, 100 mg once daily doses on postoperative day 4 and postoperative day 5. he received half dose for white blood cell count of 2.3 and 2.1 respectively. ng tube continued to drain minimal greenish drainage. the abdomen was soft and nontender, nondistended with no bowel sounds heard. lasix was weaned off on postoperative day 4. urine output for the previous 24 hours had been 1102 with a creatinine of 3.5. vital signs remained stable. repeat chest x-ray revealed worsening chf with notation of right large pleural effusion with moderate left effusion with left lower lobe consolidation. prograf was started on postoperative day 4 at 2 mg b.i.d, solu-medrol was tapered down to 25 mg po twice a day and then stopped on postoperative day 7. he continued in cellcept 1 gram b.i.d until postoperative day 8 when this was decreased to 500 mg qid. prograf level returned on postoperative day 7 with a left of 20. prograf was adjusted to 3 mg b.i.d. iv lasix was continued orally at 80 mg b.i.d foley was removed. the patient was unable to urinate. foley was replaced. the patient was given a second attempt at foley beig removed and again unable to void. foley was replaced and the patient was started on flomax 0.4 mg po qhs. of note the patient underwent biopsy of the transplant kidney on , postoperative 1, during reexploration of the transplanted kidney. biopsy results demonstrated no rejection. one unit of packed red blood cells was administered on for a hematocrit of 27.6. post transfusion hematocrit was 32.7. urine output was 1 liter. improved graft function was noted with a creatinine of 3.5 and bun of 88. the patient was advanced to renal diet. physical therapy was consulted. it was felt that the patient would require 2 to 3 treatments to improve endurance, balance and gait and see if safe for stair climbing. right lower quadrant incision remained intact with clips with scant serosanguineous drainage. - output initially was 300 cc. this diminished postoperatively. - was discontinued on postoperative day 7 and 6. epogen was started at 10,000 units 3 times a week. the patient was not iron deficient. protonix was started b.i.d for persistent nausea. phoslo was stopped. the patient was started on colace for complaints of inability to move bowels. the patient was passing flatus. cellcept was decreased to 500 qid for complaints of frequent stools. colace was held. creatinine was noted to increase on postoperative day . creatinine increased to 4.5 with a bun of 111. previous day urine output had been 755 cc with a combined po and iv intake of 300 cc. the patient had complained of nausea. iv fluid was given. urine output increased slightly for the subsequent 24 hours at a liter. repeat creatinine was 4.2. the patient remained afebrile. blood pressure 110 to 120/68 to 81. oxygen saturations on room air 96%. urine output averaged approximately 20 cc an hour despite an extra dose of lasix. the patient received inpatient nutritional assessment for decreased intake. napro was recommended. calorie counts were started. hemodialysis was deferred. cardiology was consulted on . cardiology was asked to see the patient for persistent congestive heart failure that was noted on x-ray and weight remained increased at 98 kg. recommendations were to decrease iv fluids, to continue with iv lasix 80 mg and to restart aspirin and plavix if surgically acceptable. in addition it was recommended to restart low-dose toprol 25 mg po once daily for low ef. dialysis was considered. a decision was made to hold off on dialysis and to monitor urine output and creatinine. repeat duplex revealed no hydro, no perinephric fluid collection. arterial wave forms were normal. the renal vein appeared to have a biphasic flow pattern consistent with right heart failure. given the stabilization of creatinine to 4.1, bun of 106, and urine output of 700 cc, it was decided to discharge the patient to home on prograf 2.5 mg twice a day for prograf level of 8.9. cellcept mg qid, to monitor the patient for the next few days. the patient was to be seen 2 days post discharge in the transplant office after a.m. labs were to be drawn. he was cleared by physical therapy. he was tolerating po intake with a fair intake. vital signs were stable. visiting nurse was set up for home pt. given the patient appeared somewhat depressed, it was felt that he would benefit by being at home with a hope that nutritional intake would improve in home environment. vna was consulted to continue wound care. it was noted that the patient had a 2.5 x 1.5 cm right gluteal stage 2 pressure ulcer as well as a 2 x 1.5 cm inferior pressure ulcer on the right gluteal area. recommendations by wound skin care nurse were to cleanse with normal saline, apply duoderm gel to the open areas, with no-sting barrier wipe to peri-wound skin and then leave in foam adhesive 4 x 4 dressing to be changed every 3 days. these recommendations were conveyed to the vna for outpatient management. the patient was discharged with a rolling walker to home to have physical therapy at home per recommendations. discharge medications: 1. nystatin 5 ml po qid. 2. bactrim single strength 1 tab once daily. 3. phoslo 2 tabs po t.i.d. 4. valcyte 450 mg po every other day. 5. percocet 1 to 2 tabs po q 4 to 6 hours. 6. flomax 0.4 mg po qhs. 7. protonix 40 mg once daily 8. colace 100 mg po b.i.d. 9. cellcept one tab po qid. 10. lasix 40 mg po once daily. 11. toprol 25 sustained release tab once daily 12. prograf 3 mg po b.i.d. 13. atorvastatin 10 mg po once daily. 14. insulin regular sliding scale qid. nph insulin 8 units q a.m, nph insulin subcutaneous q p.m. 15. nephro one cap po t.i.d. follow up appointment was made with dr. , on . discharge diagnosis: 1. endstage renal disease status post living unrelated kidney transplant . 2. reexploration of transplanted kidney with biopsy on , . 3 coronary artery disease. 1. congestive heart failure. 2. hyperlipidemia. 3. type 1 diabetes. 4. peripheral vascular disease. 5. gastroesophageal reflux disease. 6. peptic ulcer disease. 7. gluteal fold decubitus. 8. failure to thrive. 9. delayed graft kidney function. the patient was ambulatory and stable upon discharge. , Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Reopening of recent laparotomy site Other kidney transplantation Transfusion of packed cells Open biopsy of kidney Incision of vessel, abdominal arteries Transplant from live non-related donor Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Peripheral vascular complications, not elsewhere classified Old myocardial infarction Pressure ulcer, buttock Complications of transplanted kidney Other toe(s) amputation status Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Embolism and thrombosis of iliac artery Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled

allergies: penicillins attending: chief complaint: redness and swelling around peripheral iv site from recent admission major surgical or invasive procedure: transesophageal echocardiogram history of present illness: 69yo male with pmh dm, htn, cri, recently dx carcoinoid tumor of the rectum, hypothyroid, recent admission for hypercalcemia presents with cellulitis at prior iv site. . pt was admitted from with hypercalcemia presumed taking too much calcium supplementation and treated with hydration. . pt states that over the past 2 days he has had fevers, chills, and myalgias. after d/c he noted redness, warmth, and itchiness around right antecub at recent piv site. denies cough/sob, n/v/abd pain/diarrhea, dysuria/urinary frequency. denies cp/palp. . in the ed, initial vitals were t 101.8, p104, 118/80, rr20, 97%ra. noted to have redness and previous right antecub iv site. blood cultures sent. pt was given ancef 1gm, vanco 1gm, tylenol 1gm, 1l ns past medical history: 1. carconid tumor of colon - schedule for transanal excision of this tumor in the near future by dr. 2. thyroid carcinoma, status post total thyroidectomy. he states he had two surgeries, one in and one in on his thyroid. he is functionally hypoparathyroid and hypothyroid as a result of these surgeries. 3. type 2 diabetes - retinopathy, very early diabetic nephropathy 4. in his chart, it is stated that he had laryngeal carcinoma. there is no pathology in our system and the note that refers to this documents that this occurred circa . 5. hypocalcemia - since hypopth diagnosed, followed by dr. , on calcium and calcitriol past surgical history: 1. thyroid surgeries as above. 2. two emergent laparotomies following stabbings and . social history: from . has nine children,. previously smoked approximately two packs per day but quit in . h/o of heavy drinking, but not recently. family history: he is one of eight children. three of his siblings are deceased and presumably died from cancer. one of his brothers died at age 74 from liver dysfunction possibly from cancer. another brother died at age 80 from complications of "bone cancer." one of his sisters died at age 80 from an unknown cancer. his father died at age 82 from complications of the cva. his mother died at age 70 from complications of lung cancer. he apparently has had four maternal aunts who died of complication of lung cancer. all of his children are well. physical exam: vs: t99.8, p83, 122/78, rr18, 100%ra gen: well-appearing, nad heent: perrl, clear op, mmm cvs: rrr, nl s1 s2, 2/6 systolic murmur best heart at rusb radiating throughout precordium without radiation to carotids lungs: ctab, no c/w/r abd: soft, nt, nd, +bs ext: no le edema right antecub: ~10 x 4cm area of erythema, warmth, swelling (marked) without signif pain on palpation around prior scabbed over piv site pertinent results: 06:05pm wbc-8.0# rbc-3.77* hgb-12.3* hct-33.1* mcv-88 mch-32.5* mchc-37.0* rdw-14.4 06:05pm plt count-267 06:05pm neuts-82.0* lymphs-9.5* monos-7.2 eos-1.0 basos-0.3 06:05pm pt-11.9 ptt-26.0 inr(pt)-1.0 . : tte: conclusions: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. there is a mild coarctation of the distal aortic arch. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . : cxr impression: no acute cardiopulmonary process. . : right upper extremity venous ultrasound: -scale, color, and spectral doppler analysis were performed. there is no evidence of thrombus in the right internal jugular vein, right subclavian vein, right axillary vein, and right brachial vein. there is thrombus in the mid right cephalic vein extending distally to the level of the antecubital fossa. more proximally, the cephalic vein is patent. the basilic vein appears patent. impression: cephalic vein thrombosis. no right upper extremity deep venous thrombosis. . : tee: conclusions: no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). there are complex (>4mm non mobile) atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. there is no pericardial effusion. no vegetation or abscess seen. . micro: (first and last set of positive blood cultures - 3 out of 4 bottles) aerobic bottle (final ): reported by phone to , velezka , 11:10am. staph aureus coag +. final sensitivities. sensitivity for. 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 + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin-------------<=0.25 s penicillin------------ 0.06 s anaerobic bottle (final ): staph aureus coag +. sensitivities performed from aerobic bottle. brief hospital course: 69 yo m with pmh dm, htn, carcinoid tumor, hypothyroidism, hypoparathyroidism on ca supplements, recent adm for hypercalcemia presents with fever and found to have cellulitis at prior iv site. . 1. fever/cellulitis: the patient initially presented with what seemed to be a local cellulitis in the right antecubital fossa, but given that the patient was also febrile on admission, blood cultures were obtained which ended up growing out mssa. the patient was initially covered with vancomycin and with the speciation of mssa, we wanted to desensitize the patient to nafcillin (being the better antibiotic for mssa bacteremia). this was done successfully overnight in the micu, and the patient returned to the floor and was maintained on nafcillin throughout the rest of the admission. additionally, to evaluate the patient for possible endocarditis, he received a tte first which suggested aortic valve vegetations, but a tee only showed evidence of aortic plaques, no vegetations and no evidence of abscess. an ultrasound of the antecubital fossa showed a superficial thrombophlebitis. infectious disease consult was involved and recommended a total of 4 weeks of nafcillin from the date of last positive blood culture (). a picc was placed on . the first and last set of positive blood cultures were on , and surveillence cultures have all been no growth to date. . 2. mild transaminitis: the patient had a mild bump in his liver function tests soon after starting nafcillin. likely, it was medication induced and resolved by the time of discharge. . 3. cri: the patient had a small bump in his creatinine on admission, likely secondary to relative volume depletion in setting of insensible losses with fever. with initiation of antibiotics and fluid repletion, it has been within his normal baseline range. . 4. dm: the patient's metformin was held in the setting of bacteremia out of concern for acidemia. glipizide was added instead and glucose has been under better control. he was also maintained on a diabetic diet and covered with a regular insulin sliding scale. . 5. htn: continued lisinopril . 6. hypoparathyroidism: calcium, despite po supplementation ran low on several days during admission requiring iv repletion. calcium levels should be monitored carefully during rehab stay. . 7. hypothyroidism: continued levoxyl . medications on admission: lisinopril 2.5 mg qd levothyroxine 175 mcg qd iron 325 (65) mg qd calcitriol 0.25 mcg qd titralac (calcium) 1 spoonful po bid metformin 500 mg qd discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day). 4. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 5. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 6. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 7. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 8. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 9. insulin lispro (human) 100 unit/ml solution sig: one (1) sliding scale subcutaneous asdir (as directed). 10. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 11. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed. 12. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) spray nasal (2 times a day). 13. glipizide 5 mg tablet sig: one (1) tablet po daily (daily). 14. nafcillin in d2.4w 2 g/100 ml piggyback sig: two (2) grams intravenous q4h (every 4 hours) for 3 weeks. 15. sodium chloride 0.9% flush 10 ml iv daily:prn for pasv picc flush before and after each use inspect site daily 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: - discharge diagnosis: primary: cellulitis bacteremia (mssa) status post nafcillin desensitization . secondary type 2 diabetes hypoparathyroidism hypothyroidism rectal carcinoid tumor discharge condition: stable, afebrile discharge instructions: you were admitted because of a skin infection around the site of a peripheral iv. the bacteria managed to enter your blood stream and therefore we needed to rule out bacterial invasion of the heart, which was ruled out by transesophageal echocardiography. you will need to remain on intravenous antibiotics for 4 weeks, however. . if you experience fevers, chills, shortness of breath or chest pain, please seek medical attention. followup instructions: please be sure to make all of your follow up appointments: . infectious diseases: provider: , md phone: date/time: 9:00am . provider: , md phone: date/time: 3:00am Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Chronic kidney disease, unspecified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Cellulitis and abscess of upper arm and forearm Acute and subacute bacterial endocarditis Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Hypoparathyroidism Malignant neoplasm of rectum Postsurgical hypothyroidism Personal history of malignant neoplasm of thyroid

history of present illness: patient is a 69-year-old male with a history of diabetes mellitus type 2, hypertension, and chronic renal failure. over the past year, the patient has had increasing lower extremity edema and recurrent leg cellulitis. the patient was recently hospitalized at hospital (from until ) with complaint of weakness, chest heaviness, and shortness of breath. during his hospitalization, the patient was ruled out for a myocardial infarction, and was diuresed extensively with loss of 25 pounds. the patient complained of nausea, vomiting, and poor po intake, and underwent an egd, gastric biopsy was concerning for amyloidosis. the patient was subsequently transferred to for further workup. while on the medical service, the patient had two episodes of chest pain without electrocardiogram changes. his troponin was elevated to 1.1. on the morning following his transfer, the patient complained of nausea. he began to have episodes of hematemesis. his systolic blood pressure decreased to the 80s. the patient was administered intravenous fluids and was transferred to the micu for further management. past medical history: 1. non-insulin dependent-diabetes mellitus x15 years complicated by diabetic nephropathy. 2. chronic renal failure. renal biopsy in disclosed ssgs. baseline creatinine 2.5. 3. hypertension. 4. paroxysmal atrial fibrillation. 5. congestive heart failure. echocardiogram in at medical center disclosed concentric left ventricular hypertrophy, mildly decreased left ventricular function with an ejection fraction of 50-55%, rvh. 6. erosive esophagitis and gastritis with evidence of fold thickening and nodularity of the stomach. 7. coronary artery disease. cardiac catheterization in disclosed a 30% lesion in the marginal branch of the left anterior descending artery, and 30% lesion in the right coronary artery. remainder of coronaries satisfactory. 8. cellulitis of both legs. 9. malnutrition. 10. b12 deficiency. 11. depression. 12. anemia treated with iron supplementation and epogen. 13. plasma cell dyscrasia. bone marrow biopsy in disclosed 10% plasma cells. 14. prior episode of ischemic colitis diagnosed by colonoscopy . 15. history of spep showing three lambda-light chains and upep disclosing the presence of - proteins. social history: the patient is married. works as an accountant. denies use of tobacco, alcohol, and drugs. has three children and eight grandchildren. family history: significant for diabetes mellitus, no history of hypertension or kidney disease. medications: 1. glyburide 1.25 q day. 2. niferex 150 q day. 3. aldactone 25 . 4. lasix 120 tid. 5. aspirin 81 q day. 6. monthly b12 injections. 7. folate 1 q day. 8. zaroxolyn 2.5 q day. 9. potassium chloride 20 meq tid. inpatient medications on transfer: 1. famotidine 20 mg iv q12. 2. protonix 40 mg po q12. 3. celexa 20 q day. 4. reglan 10 qid. 5. carafate 1 tid. 6. megace 400 . 7. aspirin 81 q day. 8. allopurinol 100 q day. 9. lasix 100 q day. 10. multivitamin one q day. 11. folate 1 mg q day. 12. epogen 30,000 units subq 3x a week. 13. heparin 5,000 units subq . allergies: no known drug allergies. physical examination: general: pale elderly male appears depressed. vital signs: temperature 97.5, blood pressure 100/45, heart rate 63, respiratory rate 16, o2 sat is 98% on room air. heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light. extraocular movements are intact. oropharynx clear. neck: no jugular venous distention appreciated, no thyromegaly, no cervical lymphadenopathy. heart regular, rate, and rhythm, 2/6 systolic murmur at right upper sternal border. no rubs or gallops. lungs: crackles bilaterally at bases. abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, and no masses. extremities: dry and scaly skin changes on the lower extremities. no lower extremity edema. neurologic: alert and oriented times three. cranial nerves ii through xii are grossly intact. examination is otherwise nonfocal. laboratory data: white count 11.6, hematocrit 22.8, platelets 344. patient's baseline hematocrit is 35. chemistries: sodium 130, potassium 4.1, chloride 89, bicarb 30, bun 80, creatinine 2.4, glucose 126. calcium 8.1, magnesium 2, phosphorus 6.1. ck 20, troponin 1.1. pt 13.2, ptt 29, inr of 1.2. electrocardiogram: normal sinus rhythm at 80 beats per minute, normal intervals, normal p-r interval, left bundle branch block. chest x-ray: evidence of congestive heart failure with bilateral pleural effusions and atelectasis, cardiomegaly. as noted above, the patient was transferred to the micu on for treatment of gastrointestinal bleed. patient underwent upper endoscopy on . large amounts of clotted blood was noted in the antrum of the stomach. the gi service decided that they would repeat the egd when they could obtain better visualization of the stomach. hospital course by systems: 1. pulmonary: patient required intubation on for respiratory arrest due to mucus plugging. the patient underwent bronchoscopy at that time which disclosed thick purulent secretions in the left main stem bronchus. the patient was started on a course of broad-spectrum antibiotics (ceftazidime and vancomycin) to cover nosocomial pathogens. as noted above, the patient's chest x-ray disclosed the presence of bilateral pleural effusions. the patient underwent thoracentesis on . laboratory data was consistent with a transudative effusion. cytology cultures and gram stain were negative. due to the recurrent nature of the patient's pleural effusion, the patient required placement of bilateral chest tubes. patient underwent pleurodesis of the left sided chest tube. during his hospitalization, the patient's chest tubes have continued to drain significant amounts of pleural fluid. in addition, the patient has required repeated bronchoscopies during his micu stay due to recurrent purulent secretions. on , the patient was noted to have purulent secretions in the main stem bronchi and right lower lobe, consistent with a ventilator-associated pneumonia. bal culture disclosed presence of gram-negative rods. furthermore, on , the patient underwent bronchoscopy which disclosed moderate secretions and partial obstruction of the bronchus intermedius and left main stem bronchus. patient eventually was changed to imipenem and then meropenem for treatment of ventilator associated pneumonia. during his hospital stay, the patient was maintained on assist-controlled ventilation over the past few days. the patient has undergone trials of pressure support ventilation with a goal to wean the patient from the ventilator. 2. gi: as noted above, the patient underwent upper endoscopy on . large amounts of clotted blood was noted in the antrum of the stomach. on , the patient underwent repeat upper endoscopy. blood was noted in his stomach. in addition, the whole stomach was noted to have nodularity and erosions compatible with an infiltrated disorder. biopsies were done and pathology disclosed no evidence of neoplasm. however, it was noted that there was deposition of acellular pale eosinophilic material with a moderate degree of staining with red. the pathologist had included that this is an amyloid like substance, possibly light chains. since , the patient has not had any further episodes of hematemesis. however, he has had episodes of dark stools and clots per rectum. the patient has required a total of 13 units of packed red blood cell transfusions to maintain his hematocrit greater than 30 during his hospital stay. 3. cardiology: as noted above, the patient complained of chest pain early in his hospital stay, and was noted to have a troponin elevation to 1.1. echocardiogram was consistent with a restrictive cardiomyopathy with a normal ejection fraction. in early , the patient began to be hypotensive. a repeat echocardiogram was done to rule out pericardial effusion causing tamponade as an etiology of the patient's hypotensive. there was no evidence of pericardial effusion on the echocardiogram. due to concern for adrenal insufficiency, random cortisol levels were checked and the patient's cortisol level was found to be 15. he was started on a course of stress dosed steroids. furthermore, patient was noted to be febrile and there was concern for a distributive shock. patient has continued to demonstrate septic physiology during his hospital stay. on , dopamine was started, and the patient has required pressors for much of his micu stay. since , we are in the process of weaning off pressors. the patient continues to require multiple fluid boluses to maintain his blood pressure. 4. renal: as noted above, the patient has a history of chronic renal insufficiency due to ffgs and diabetic nephropathy. the patient's renal function has deteriorated during his hospital stay. renal service has been followed the patient and his renal decompensation was initially attributed to atn in the setting of the patient's gastrointestinal bleed. red staining of the patient's kidney biopsy from was negative for amyloidosis. during his micu stay, the patient had declining urine output. in addition, he had episodes of hematuria requiring placement of a three-way foley. patient's bun and creatinine continued to rise. a renal ultrasound did not disclose evidence of hydronephrosis. on , the patient was noted to have a two component pericardial friction rub. he was started on hemodialysis. hemodialysis has been difficult due to the patient's hypotension. however, he requires dialysis due to his worsening metabolic acidosis. the patient will have a permcath placed by transplant surgery. 5. heme: as noted above, the patient has required a total of 13 units of packed red blood cells during his hospital stay for a maintenance of a hematocrit greater than 30. the patient's last episode of hematemesis was . the patient is administered epogen at hemodialysis. 6. oncology: the hematology/oncology service has been following the patient. the patient meets three minor criteria for multiple myeloma, namely bone marrow biopsy with 10% plasma cells, positive upep, and igm less than 50. it is believed that the patient's gastric biopsy is consistent with a light-chain gastropathy, presumably from the multiple myeloma. chemotherapy has not been pursued during the patient's micu stay, but it is an option for the future. 7. infectious disease: as noted above, patient was started on broad-spectrum antibiotics to cover nosocomial pathogens on . during his hospital stay, multiple blood, fungal, sputum, and urine cultures have been sent to the laboratory for workup of a source of the patient's sepsis. on , the patient was noted to be positive for clostridium difficile. he has also had gram-negative rods and gram-positive cocci in his sputum. blood cultures have remained negative to date. ct scan of the chest and abdomen did not disclose evidence of an abscess. currently, the patient has been followed by the infectious disease service. he was treated with a seven day course of fluconazole for yeast in his sputum and urine. patient currently remains on flagyl for treatment of his clostridium difficile infection and meropenem for treatment for ventilator-associated pneumonia. 8. endocrine: patient has a history of diabetes mellitus. he has been maintained on an insulin drip during his micu stay. in addition, patient has been started on stress dosed steroids for treatment of adrenal insufficiency in the setting of sepsis. 9. nutrition: the patient has very poor nutritional status with an albumin in the range of .3. he has been maintained on tpn during his hospital stay. 10. neurology: while on the ventilator, the patient was maintained on versed and morphine for sedation. by , these sedatives were weaned off. the patient has been observed opening his eyes, yet currently does not respond to painful stimuli or commands. 11. vascular: on , it was noted that the patient had modeling of his feet and ischemia of his toes. pulses are detectable by doppler. vascular surgery consult has been obtained. it appears that the patient has gangrene of his right first toe. 12. prophylaxis: the patient has been maintained on pepcid and venodyne boots during his micu stay. the remainder of the hospital course will be dictated by the medical team, who takes over his care. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Thoracentesis Biopsy of bone marrow Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Esophagogastroduodenoscopy [EGD] with closed biopsy Injection into thoracic cavity Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Congestive heart failure, unspecified Acute posthemorrhagic anemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other shock without mention of trauma Multiple myeloma, without mention of having achieved remission Hemorrhage of gastrointestinal tract, unspecified Streptococcal septicemia

history of present illness: the patient is a 69-year-old man with type 2 diabetes complicated by end-stage renal disease on hemodialysis, hypertension, and a number of chronic medical problems listed separately who is transferred on the date of admission from hospital after presenting with congestive heart failure. the patient reports that he was in declining state of health for approximately one year. he has had persistent problems with peripheral edema, recurrent leg cellulitis, chronic debility. on admission, he complained of shortness of breath. serial markers ruled out myocardial infarction, however, the patient's chest x-ray at hospital was consistent with congestive heart failure. he underwent successful diuresis with lasix and zaroxolyn losing approximately 25 pounds over his hospital course. echocardiography revealed a preserved ejection fraction, mild tricuspid and mitral regurgitation and an electrocardiogram showed a left bundle branch block and an old myocardial infarction. patient also completed a course of oxacillin for lower extremity cellulitis. the patient complained of nausea and vomiting for one month prior to admission. he underwent esophagogastroduodenoscopy with biopsy which revealed proteinaceous infiltration of the gastric submucosa suggestive, but not confirming amyloidosis. was transferred to the for further evaluation. past medical history: 1. type 2 diabetes complicated by end-stage renal disease. 2. hypertension. 3. paroxysmal atrial fibrillation. 4. anemia secondary to renal failure. 5. chronic lower extremity cellulitis. 6. coronary artery disease, last cardiac catheterization was in showing a 30% lesion in the right coronary artery and a 30% lesion in the marginal branch in the left anterior descending coronary artery. 7. vitamin b12 deficiency. allergies: no known drug allergies. medications on transfer: 1. peripheral parenteral nutrition. 2. lexapro 10 mg daily. 3. prevacid 30 mg twice daily. 4. metoclopramide 10 mg 4x daily. 5. carafate 1 mg 3x daily. 6. megace 400 mg twice daily. 7. furosemide 100 mg daily. 8. aspirin 81 mg daily. 9. allopurinol 100 mg daily. 10. multivitamin. 11. erythropoietin. 12. folate 1 mg daily. social history: patient is an accountant. he does not consume alcohol or smoke cigarettes. vital signs: temperature 97.0, heart rate 88, blood pressure 130/60, and oxygen saturation of 92% on room air. generally, the patient was a depressed appearing man sitting comfortably in no acute distress. examination of the head, eyes, ears, nose, and throat was unremarkable. the heart examination showed a regular, rate, and rhythm, normal s1, s2, and a systolic murmur. lungs had decreased breath sounds at the bases. abdomen protuberant, soft, nontender, nondistended, decreased bowel sounds. extremities showed no evidence of edema or warmth. vascular examination showed intact peripheral pulses. laboratory evaluation: on presentation, the patient's white blood cell count was 14.3, hematocrit 34.4, platelets of 396. chemistry panel is unremarkable. hospital course: the patient was admitted to the medicine service initially. repeat hematocrit showed an acute drop in his hematocrit to 25.1 attributed to bleeding after esophagogastroduodenoscopy at the outside hospital. he was transferred to the intensive care unit and received a blood transfusion to restore his hematocrit to above 30. the patient had a long and complicated stay in the medical intensive care unit. 1. hypotension: the patient was persistently hypotensive upon admission to the intensive care unit requiring intermittent use of up to three pressors. attempts to wean these medications were ultimately unsuccessful. 2. respiratory: the patient was electively intubated three days after being transferred to the medical intensive care unit for airway protection, but was never extubated. the patient was treated with a 14 day course of meropenem for ventilator-associated pneumonia. 3. renal: the patient was dialyzed as his chronic renal failure progressed to end-stage renal disease on this admission. the uremia ultimately cleared, and the patient was able to answer questions by nodding yes and no. after temporarily employing a femoral catheter as well as a port-a-cath, the patient was ultimately dialyzed only with a port-a-cath, however, the femoral line in addition to a right subclavian line were found to be infected with vancomycin resistant enterococcal species, ultimately identified as eccm. the patient was then started on linazolid, however, his platelet count started to drop. he was switched from this to synercid in addition to persistent thrombocytopenia. the patient also had a drop in his white blood cell count and his hematocrit. in addition, the patient had worsening hypotension ultimately requiring dopamine, neo-synephrine, and vasopressin. 4. vascular: while the patient initially presented with resolution of a cellulitis, his toes became gangrenous. in addition, the patient had septic emboli in his fingertips. on , the patient's hypertension worsened, 3 mg of atropine and 4 mg of epinephrine were administered, however, chest compressions were not performed as cpr was not indicated for this patient. the patient expired at 8:12 pm. his wife, and son, , were contact. they declined an autopsy. discharge diagnoses: 1. enterococcal sepsis. 2. anemia due to blood loss. 3. multiple myeloma. 4. type 2 diabetes complicated by end-stage renal disease. 5. hypertension. dr., 12-838 dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Thoracentesis Biopsy of bone marrow Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Esophagogastroduodenoscopy [EGD] with closed biopsy Injection into thoracic cavity Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Congestive heart failure, unspecified Acute posthemorrhagic anemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other shock without mention of trauma Multiple myeloma, without mention of having achieved remission Hemorrhage of gastrointestinal tract, unspecified Streptococcal septicemia

allergies: aspirin attending: addendum: prior to discharge the patient experienced an episode of chest heaviness. cardiac enzymes and ekg were negative for mi. the discomfort settled quickly and she continued well. there were no further problems and she was discharged to the rehab facility the following day. pertinent results: wc 7.5 hct 28.2 plt 419 pt 22.1 inr 2.2 gluc 105 bun 19 cr 0.6 na 136 k 3.8 cl 99 hco3 28 cardiac enzymes negative ekg no acute changes suggestive of mi discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain/fever. 2. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 5. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 6. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 7. warfarin 2 mg tablet sig: one (1) tablet po at bedtime. 8. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 9. actonel 30 mg tablet sig: one (1) tablet po once a week. 10. bactrim suspension sig: one (1) ds twice a day for 3 days. disp:*qs * refills:*0* discharge disposition: extended care facility: for the aged - macu md, Procedure: Diagnostic ultrasound of heart Open reduction of fracture with internal fixation, femur Transfusion of packed cells Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Unspecified fall Osteoporosis, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other diseases of lung, not elsewhere classified Cerebral embolism with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Closed fracture of intertrochanteric section of neck of femur

allergies: aspirin attending: chief complaint: right hip pain major surgical or invasive procedure: open reduction with internal fixation right hip history of present illness: 73yo rh f who is pod#1 from r hip repair after a mechanical fall caused a fracture. perioperatively, she has been treated with a beta blocker and now postoperatively she has been started on lovenox for dvt prophylaxis. she was completely normal per her daughter today around 4-5pm, apart from pain, which was controlled with oxycodone (last dose 3pm and no further narcotics). at 8:30pm, however, the ortho pa was paged by the patient's nurse after she was found to have a new left facial droop and was thought to be disoriented and "confused", with slurred speech. we are consulted for concern of an acute infarction. the patient has had no nausea/vomiting and denies headache (in fact, she denies any difficulty or impairment). she denies dysarthria, though her son-in-law attests that her speech is markedly different from baseline. past medical history: pmh: no prior history of mi/cad or stroke no h/o htn osteoporosis copd mv prolapse s/p tah seen by neurology in by for rls (neuro exam with mild peripheral neuropathy only) social history: non smoker, social alcohol family history: nc pertinent results: admission labs: chol 89 triglyc 491 hdl 47 chol/hdl 1.9 ld32 glucose-121* urea n-19 creat-1.0 sodium-141 potassium-3.8 chloride-103 total co2-28 anion gap-14 wbc-6.5 rbc-4.11* hgb-12.4 hct-36.4 mcv-88 mch-30.2 mchc-34.1 rdw-14.1 neuts-69.6 lymphs-24.0 monos-3.7 eos-1.3 basos-1.4 plt count-195 pt-12.0 ptt-26.9 inr(pt)-1.0 : wcc7.3 hgb 10.3 hct 29 plt360 inr 2.4 na 136 k 3.8 cl 100 co2 28 bun 16 cr0.6 ct/cta: 1. no obvious infarcts are noted on the non-contrast ct. however, mri with diffusion-weighted imaging is more sensitive for the detection of acute infarcts. 2. short segment focal stenosis in the pericallosal artery and right middle cerebral artery m2 segment which could be stenoocclusive or thromboembolic. 3. mild atherosclerotic calcification in bilateral cervical internal carotid arteries, close to their origins, with no flow-limiting stenosis. 4. multilevel degenerative disease of the cervical spine, not adequately evaluated on the present study. 5. biapical pleural scarring. mri/mra: limited study due to motion artifact. there are multiple acute infarcts in the distal right mca territory, possibly embolic in etiology. tte: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. a small secundum atrial septal defect is present withbidirectional shunting (small amount). left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the aortic valve leaflets are mildly thickened. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. ct chest and abdomen 1. no central or segmental pulmonary embolism. 2. small bilateral pleural effusions with associated atelectasis. some small opacities in the right lower lobe are nonspecific, and could be regions of focal atelectasis. 5-mm pulmonary nodule in the right upper lobe. in the absence of known malignancy, followup in one year is recommended. postoperative appearance to the right hip and surrounding soft tissues and muscles consistent with recent surgery. cxr small bilateral pleural effusions with left basilar atelectasis. brief hospital course: mrs. presented to the emergency department complaining of right hip pain after a fall. she was evaluated by the orthopaedics department and found to have a right intertrochanteric hip fracture. she was admitted, consented, and medically cleared for surgery. on , she was prepped and brought down to the operating room for surgery. intra-operatively, she was closely monitored and remained hemodynamically stable. she tolerated the procedure well without any difficulty or complication. post-operatively, she was extubated and transferred to the pacu for further stabilization and monitoring. she was then transferred to the floor for further recovery. on the floor, she remained hemodynamically stable with her pain controlled. on , she had acute onset dysarthria, left facial droop and left arm/leg weakness. on exam, she also had left-sided neglect and anosognosia and was inattentive, falling asleep frequently. ct and mri showed right mca infarction and the patient was transferred to the icu for further monitoring. metoprolol was discontinued and blood pressure allowed to autoregulate. she was started on aspirin 325mg daily, as her previously documented "allergy" consisted only of gi upset. she was also started on zocor for secondary stroke prevention. flp was normal and hba1c 5.7. she had an uneventful icu course and by the next morning, her dysarthria and neglect had improved, leaving her with umn pattern of weakness, affecting her face/arm/leg. transferred to the floor. tte from was unremarkable for source of cardioembolism. tee showed small secundum asd with bidirectional flow, no source of thrombi and no significant aortic arch atheroma. cardioembolic event thought most likely etiology of stroke in presence inr 2.0, so new goal inr 2.5-3.5. cta of the neck showed "short segment focal stenosis in the pericallosal artery and right middle cerebral artery m2 segment" thought to be stenoocclusive or thromboembolic. she was covered with lovenox 60mg and started on coumadin 5mg qhs on , with the plan on continuing for 3-6 months and then transition to aspirin. lenis were negative for dvt. lovenox ceased on as inr therapeutic. inr supraptherapeutic to maximum 6.1 on . coumadin held. today () inr 2.4 and restarting coumadin at 2mg daily. please continue to monitor inr. there was an episode of hypotension overnight responsive to fluid treatment.repeat head ct was unchanged. abdominal ct was negative for retroperitoneal bleed. stools negative for blood. hct dropped to 22.0 and transfused 2 units rbc. conincident with hypotensive episode, increased oxygen requirement occurred with concern for pe in context of perioperative stroke. cta chest negative for pe. ct did show r upper lobe lung nodule which requires follow up scan at 1 year. hematocrit now stable. urinary tract infection was diagnosed on and treatment commenced with ciprofloxacin. switched from tablets to suspension following episode of vomiting. to complete 3 days course (day 2 today). repeat ct chest in 1 year for right upper lobe lung nodule. neurology and orthopedic follow up arranged. medications on admission: actenol discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain/fever. 2. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 5. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 6. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 7. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 3 days. 8. warfarin 2 mg tablet sig: one (1) tablet po at bedtime. 9. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 10. please restart actonel weekly (?dose 30mg qw) discharge disposition: extended care facility: for the aged - macu discharge diagnosis: right hip fracture multiple infarcts in r mca territory likely cardioembolic (af) post operative anaemia-transfused rbc discharge condition: improved: no neurologic deficit. r hip wound healing. discharge instructions: keep the incision clean and dry. you may apply a dry sterile dressing as needed for drainage or comfort. if you have any redness, increased swelling, pain, drainage, shortness of breath, or a temperature greater than 100.5, please call your doctor or go to the emergency room for evaluation. you may bear weight on your right leg. resume all the medication you took prior to admission and take all medication as prescribed by your doctor. feel free to call the orhtopedic office with any questions or concerns regarding the fracture or the neurology service regarding the stroke. followup instructions: 1. neurology: neurology dr tuesday .30 am 8 please bring referral from pcp. 2. orthopedics: please call dr. office @ for a follow up appointment in 4weeks after hospital discharge. 3. pcp: follow up with dr. one week after discharge from rehab. md, Procedure: Diagnostic ultrasound of heart Open reduction of fracture with internal fixation, femur Transfusion of packed cells Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Unspecified fall Osteoporosis, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other diseases of lung, not elsewhere classified Cerebral embolism with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Closed fracture of intertrochanteric section of neck of femur

service: history of present illness: mr. is a 64-year-old male with a history of alcohol use, grade ii/iii varices, alcoholic cirrhosis, and an esophagogastroduodenoscopy which demonstrated no evidence of recent bleeding performed secondary to a hematocrit drop in , and a was admitted to the intensive care unit secondary to hematemesis. the patient notes that he began to feel nauseated 36 hour prior to admission which led decreased oral intake. he induced himself to vomit, and the vomitus was significant for bright red blood. he called his primary care physician in the emergency department, a nasogastric lavage was significant for blood which did not clear after 3 liters of normal saline. the patient was noted to have a hematocrit drop from 39 to 35 after four hours. two large-bore peripheral intravenous lines were placed, and the patient was administered 2.5 liters of normal saline. the patient was started on protonix intravenously and octreotide in the emergency department. the patient was transferred to the medical intensive care unit, and the gastrointestinal service was consulted. an esophagogastroduodenoscopy was performed, and grade iii varices were demonstrated in the lower third of the esophagus. four bands were placed near the gastroesophageal junction for nonbleeding varices. there was also noted clotted blood in the stomach. while in the medical intensive care unit the patient was continued on octreotide, transfused 4 units of packed red blood cells, and transfused 2 units of fresh frozen plasma. mr. was transferred out of the medical intensive care unit to the medical floor in good condition on . upon speaking with mr. , he denied lightheadedness, headache, chills, and night sweats. the patient also denied chest pain, substernal chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, constipation, and hematochezia. prior to transferring mr. to the floor, he had tolerated clear liquids without incident. past medical history: 1. coronary artery disease; status post myocardial infarction in ; status post 2-vessel coronary artery bypass graft. the patient's bypasses included a left internal mammary artery to the left anterior descending artery and saphenous vein graft to the obtuse marginal. this mi occurred in the setting of an ugib. 2. congestive heart failure; echocardiogram in demonstrated an ejection fraction of greater than 75% with a left ventricular outflow obstruction. 3. hypertension. 4. alcohol abuse with cirrhosis and grade iii varices. 5. hypothyroidism. 6. depression. 7. anxiety. 8. iron deficiency anemia. 9. herniated disk (l5-l6). 10. esophagus demonstrated in . 11. talc pleurodesis for pleural effusion on . medications on admission: (medications on admission included) 1. aspirin 81 mg p.o. q.d. 2. lasix 20 mg p.o. q.d. 3. synthroid 112 mcg p.o. q.d. 4. mavik 4 mg p.o. q.d. 5. propranolol 20 mg p.o. q.d. 6. wellbutrin 150 mg p.o. b.i.d. 7. protonix 40 mg p.o. q.d. 8. multivitamin. 9. iron supplement. 10. vitamin c. allergies: no known drug allergies. social history: mr. has a history of alcohol abuse (as above). he had a several-month history with abstinence from alcohol; however, he noted that he had several drinks a few days prior to this admission. he has a remote history of tobacco use. he quit 25 to 30 years ago. he is a retired bakery owner and also worked for the court system. family history: family history was significant for head and neck cancer. the patient also has a family history of alzheimer's present in the patient's father. his mother had diabetes mellitus and congestive heart failure. physical examination on presentation: physical examination on transfer to the medical floor revealed vital signs with a temperature of 98, blood pressure was 140/100, heart rate was 80, respiratory rate was 20, oxygen saturation was 94% on room air. in general, a well-developed, well-nourished, obese male in no acute distress, sitting upright, dressed in street clothes. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. sclerae were anicteric. mucous membranes were moist. the oropharynx was clear. neck revealed jugular venous pressure not appreciated secondary to body habitus. chest revealed no dullness to percussion, clear to auscultation bilaterally (anteriorly and posteriorly). cardiovascular examination revealed a regular rate and rhythm. a soft first heart sound and normal second heart sound. a grade 3/6 systolic ejection murmur at the upper sternal border. no gallops or rubs were appreciated. the abdomen was obese, soft, nontender, and nondistended, normal active bowel sounds. no shifting dullness. no hepatosplenomegaly. extremities revealed no clubbing, cyanosis, or edema. neurologically, alert and oriented times three. cranial nerves ii through xii were intact. sensory and motor were grossly intact. pertinent laboratory data on presentation: laboratories on admission revealed white blood cell count was 8.1, hematocrit was 39.2, platelets were 128. sodium was 138, potassium was 4.1, chloride was 104, bicarbonate was 26, blood urea nitrogen was 11, creatinine was 0.7, and blood glucose was 162. liver function tests were significant for an alt of 35, ast was 39, alkaline phosphatase was 150, total bilirubin was 2.2. cardiac enzymes demonstrated a creatine kinase of 41. significant laboratories during admission revealed hematocrit dropped from 39.2 on admission to 28.7 on the day after admission. on the day of discharge, the patient's hematocrit increased to 34.3. the patient's peak creatine kinase was 56. troponin i was less than 0.3 on two laboratory draws. the patient's inr was 2.1 on admission; it was 1.9 on the day of discharge. the patient's liver function tests were significant for an alkaline phosphatase of 100 and a total bilirubin of 2 on discharge. several laboratories were pending at the time of discharge; including a ferritin level, iron level, hemoglobin a1c, and a thyroid-stimulating hormone. procedures/radiology/imaging: the patient had an esophagogastroduodenoscopy performed on with findings as in the history of present illness. hospital course: 1. gastrointestinal system: mr. presented to the emergency department with a history of nausea, induced vomiting, and hematemesis. the patient subsequent received nasogastric lavage which was significant for blood that did not clear with several liters of normal saline. an esophagogastroduodenoscopy was performed in the intensive care unit which demonstrated grade iii varices; however, no active bleeding varices were visualized. four varices were successfully banded near the gastroesophageal junction. the patient was maintained on intravenous protonix twice per day and octreotide while admitted. serial hematocrits were followed; the lowest hematocrit was 28.3, dropping from 39 on presentation. mr. received a total 4 units of packed red blood cells, and his hematocrit on discharge was 34. upon discharge, mr. was restarted on a beta blocker and he was provided instructions to follow up with his gastroenterologist in two weeks in order to have a repeat esophagogastroduodenoscopy performed. 2. cardiovascular system: mr. has a history of myocardial infarction in the setting of anemia in the past. he ruled out for a myocardial infarction by cardiac enzymes while admitted. secondary to his coronary artery disease, his goal hematocrit was greater than 30. on presentation, his blood pressure medications were held secondary to his active bleeding. the patient's ace inhibitor, beta blocker, and furosemide was restarted on the day prior to discharge. mr. remained hemodynamically stable and tolerate oral medications well. 3. hematology: mr. has a history of iron deficiency anemia. his hematocrit significantly dropped in the setting of active bleeding on presentation. he was transfused as indicated above with packed red blood cells and fresh frozen plasma. on presentation, his inr was noted to be evaluated, and he was admitted vitamin k. mr. was to be discharged on iron supplementation. secondary to the patient's upper gastrointestinal bleed, it was decided to hold aspirin therapy for one week upon discharge. 4. psychiatry: the patient has a history of alcohol abuse as above. he was maintained on a ciwa scale with ativan as needed. he did not demonstrate any significant signs of withdrawal while admitted. on discussion with mr. , he seemed motivated to quit alcohol use at this time and notes several ways to change behavior which leads to his alcohol abuse including a trip to , removing alcohol from home, and going to a different alcohol anonymous group. mr. was to follow up with his primary care physician at and will be put in contact with the social work service during his next visit. discharge disposition: the patient was to be discharged to home upon successfully tolerating a full liquid diet. condition at discharge: condition on discharge was stable. discharge status: the patient was to be discharged to home with followup by his primary care physician and gastroenterology. discharge diagnoses: 1. upper gastrointestinal bleeding. 2. grade iii esophageal varices. 3. anemia. 4. hypertension. 5. type 2 diabetes mellitus. 6. hypothyroidism. 7. cirrhosis with coagulopathy. medications on discharge: 1. propranolol 40 mg p.o. b.i.d. 2. lasix 20 mg p.o. q.d. 3. mavik 4 mg p.o. q.d. 4. paxil 20 mg p.o. q.d. 5. synthroid 112 mcg p.o. q.d. 6. protonix 40 mg p.o. q.d. 7. xanax 0.5 mg p.o. t.i.d. as needed (for anxiety). 8. aspirin 81 mg p.o. q.d. (the patient was to hold off on taking this medication for one week after discharge). discharge followup: 1. mr. was to see his primary care physician at (dr. ) on . 2. mr. will also need to follow up with gastroenterology. he will be called by this service to schedule a follow-up appointment within two weeks after discharge. dr., 12-797 dictated by: medquist36 Procedure: Endoscopic excision or destruction of lesion or tissue of esophagus Diagnoses: Congestive heart failure, unspecified Alcoholic cirrhosis of liver Iron deficiency anemia secondary to blood loss (chronic) Unspecified acquired hypothyroidism Esophageal varices in diseases classified elsewhere, with bleeding Other specified disorders of stomach and duodenum Other and unspecified alcohol dependence, unspecified

allergies: ceftrione allergy, possible anaphylaxis. chief complaint: respiratory distress and sepsis. history of the present illness: this is a 20-year-old caucasian male with no past medical history, who was medflighted from hospital after intubation for acute respiratory failure. the patient had been in his usual state of health until three to four days prior to admission, when he began to have flu-like symptoms, including myalgias, fatigue, nausea, vomiting, and watery diarrhea. he was seen by his primary care physician, . one day prior to admission. at that time, assessment was possible gi viral illness and he was given two liters normal saline for hypotension. that night, he had a syncopal event while talking to his family on the phone. the following afternoon he presented to the emergency department at hospital for sore throat, cough, and increasing shortness of breath. chest x-ray at hospital showed bilateral infiltrates and he was given one gram iv ceftriaxone and 250 mg azithromycin for presumed pneumonia. at that time, temperature was 97.0, blood pressure 95/65, heart rate 137, room air saturation was 89%. mr. became increasingly dyspneic with increasing respiratory rate, decreasing oxygen saturation requiring 100% nonrebreather. he was intubated for acute respiratory failure. laboratory data: significant labs from the outside hospital included a white count of 14.2, with 95% neutrophils, platelet count 75,000, inr 1.4, pt 13.4, creatinine 4.8, bun 64, and ck 1175 with mb fraction of 8%. hospital course: the patient was then transferred to for further management. in the emergency department, the patient was febrile with blood pressure 130/67, heart rate 150s. he was given 2 liters normal saline, one gram of vancomycin and the femoral line was emergently placed into the right groin. at this time, he was transferred to the micu. physical examination: examination on administered revealed the following: the patient was comfortable, sedated, intubated, moving all extremities spontaneously. heent: pupils small, 2-mm, but reactive. posterior oropharynx could not be assessed secondary to the tube. neck was supple. no jvd. no lymphadenopathy. heart: tachycardic, regular rhythm, no rubs, murmurs, or gallops. lungs: lungs were clear to auscultation bilaterally. abdomen: soft, nontender, nondistended, no hepatosplenomegaly. extremities: warm, clean, dry, and intact. they were stiff and difficult to move. there was 1+ radial and dp pulses. skin: mildly erythematous, raised with blanching papillary rash over the extremities and trunk. there was no petechiae. he had a few purpuric lesions over his lower extremities. neurological: the patient was moving all four extremities spontaneously with mild decerebrate posturing of the upper extremities. he had stiff rigid extremities, 3+ reflexes at the biceps and patella bilaterally. toes were downgoing bilaterally. laboratory data: labs on admission revealed the following: cbc showed a white count of 15.1, hematocrit 36.4, with platelet count of 47. chem 7: sodium 134, potassium 4.1, chloride 101, bicarbonate 19, bun 63, creatinine 4.2, blood sugar 155, alt 23, ast 32, alkaline phosphatase 36, total bilirubin 0.3, ck 1077, amylase 29, albumin 2.6, phosphatase 6.3, magnesium 1.4, calcium 5.2, pt 14.7, ptt 46.6, inr 1.5, differential on the white count was 77% neutrophils, 10% bands, 10% monos, 2% eosinophils. urine was significant for 3 to 5 white blood cells, 0 to 2 granulated casts, 0 to 2 hyaline casts. serum and urine toxic-metabolic panel was negative. lactate was 4.1. the abg in the emergency department revealed ph 7.18, pco2 50, o2 200, ionized 0.84. chest x-ray in the emergency department showed a right lower lobe consolidation. head ct showed no acute bleed, no hydrocephalus, no significant opacifications of the left sphenoid or maxillary sinus. ct of the abdomen and chest showed patchy bilateral infiltrates, consolidation of the right lower lobe, but no hydronephrosis. hospital course: upon arrival to the micu, mr. lumbar puncture, which had 8 white blood cells, 77% lymphocytes, 2% neutrophils, 21% monocytes. a femoral arterial line was also placed. the micu course is significant for the following: pulmonary: mr. was admitted in fulminant respiratory failure with severe hypoxemic respiratory failure and poor compliance. extensive adjustment of the ventilator including multiple recruitment maneuvers, a peep of 20, paralytics and proning was required to achieve pao2s in the 60s on fio2 of 1.0. pressure control ventilation was utilized with volumes of 6cc/kg per the ardsnet trial. he was ventilated in the prone position from to at which time enough margin was present to place the patient back into the supine position. he continued to gradually improve and was finally extubated on . mr. also two bronchoscopies during the micu stay. the initial bronchoscopy was on , which was unremarkable with no significant sputum or clots. this was repeated approximately 2 to 3 days later after a desaturation which revealed thick brown clots, which were suctioned out successfully and sent for culture. sputum cultures eventually grew out staphylococcus aureus, which was pansensitive. he was treated since admission with vancomycin, as well as other antibiotics, which will be detailed later for staphylococcus aureus pneumonia. cardiovascular: mr. maintained his blood pressure until the morning of . at that time, blood pressure began to decrease and he was placed on levophed and vasopressin for blood pressure maintenance. he was gradually weaned off these pressors. mr. was also tachycardiac throughout his stay, secondary to fever, septic cardiomyopathy. echocardiogram was done on , which showed ef of 15% with bilateral ventricular dysfunction. there were no focal-wall abnormalities - therefore this was reflective of sepsis related myocardial suppression. the echocardiogram was repeated on , which showed mild right ventricular depression and dilatation, but left ventricular function was within normal limits. mr. right heart catheterization on . initial pulmonary artery pressure was 34/25 with the mean of 29, wedge of 22, cvp of 20, heart output of 4.69, cardiac index of 2.88, svr of 921, pvr of 119. over the next few days the svr decreased to 600 with increasing cardiac output likely secondary to sepsis. he was placed on dobutamine to increase cardiac output with success. the dobutamine was finally discontinued approximately two days after initiation. fluids, electrolytes, and nutrition: mr. was npo for several days. he placed for about five days on tpn and then switched to tube feeds on . tube feeds had been tried before unsuccessfully secondary to poor gastric motility. high residuals were noted. infectious disease: mr. was initially suspected to have meningococcemia secondary to diffuse skin lesions and fulminant presentation. however, lp showed no organisms and only eight wbcs. similarly, his blood cultures were negative. he received one dose of ceftriaxone at the outside hospital. he was noted to have new maculopapular rash over his upper extremities and torso. ceftriaxone was discontinued on admission to secondary to possible allergy. however, this was restarted one day later per infectious disease recommendation and continued for two days. mr. showed increasing angioedema over the face with ct of the neck showing significant laryngeal edema as well. there was eosinophilia within the blood and ceftriaxone was discontinued at this time. it should be noted that mr. has a ceftrione allergy, possible anaphylaxis. he was also started on clindamycin, levaquin, doxycycline, and vancomycin for unknown infectious etiology. the vancomycin and clindamycin were for gram positive and doxycycline for possibility rickettsial disease even though it was not the usual season. mr. also received igg times two for possible toxic-shock syndrome. aso was positive and all viral cultures, including influenza, rsv, parainfluenza were negative. all cultures returned negative, including urine, blood, stool, csfs. the only positive cultures were staphylococcus aureus and minimal yeast in the sputum. with the advent of the pansensitive staphylococcus aureus clindamycin and doxycycline were discontinued six to seven days after starting. levaquin was discontinued on . vancomycin will be likely continued for ten days past the positive culture for staphylococcus aureus. it is currently dosed for hemodialysis. it should also be noted that mr. received xigris or apc activated protein c for approximately 30 hours. this was discontinued initially secondary to low platelets and high ptc and then again secondary to new anisocoria. head ct was repeated on , which showed no bleeding. renal: mr. was admitted with high bun, high creatinine of unknown etiology. at the outside hospital sediment was noted to have red blood cell casts and hyaline casts. this was repeated on admission to and only hyaline casts were noted, signifying possible atn. his renal function initially improved significantly with hydration and support. however, his ck which was mildly elevated on admission progressed to florid rhabdomyolysis with cks peaking at over 250,000. this was felt secondary to massive sepsis response but perhaps related to paralytics. the surgery team was consulted to rule out compartment syndrome which was determined not to be present. this unfortunately, caused a secondary significant renal insult. despite alkalinizing the urine mr. renal function again delined prior to ultimately recovering again. within the first 24hours, he became increasingly acidotic with ph of 7.06 and decreasing urine output. the renal service was consulted and recommended and started cvvh via a left femoral catheter. about ten days later, a right sided cvh catheter was introduced but unfortunately clotted off approximately 24 to 48 hours later. the cvh was finally discontinued on . on , mr. hemodialysis and this will be continued on a three-times-weekly basis. acidosis has completely resolved. skin: mr. was noted to have ecchymotic regions over the anterior thighs, feet and ankles bilaterally shortly after admission. these lesions appeared to be an extension of the initial maculopapular rash noted on admission. in the intervening days, they were noted to become increasingly necrotic in appearance. dermatology and plastic surgery services were consulted for guidance of management. eventually, some of the skin sloughed off. plastic surgery continued to follow -- mr. may require skin grafting at a later time. the fifth digit on both feet were affected. the plastic surgery team felt they may require amputation eventually. in the meantime, he has been treated with silvadene, xeroform, and kerlix per plastic surgery recommendations with daily improvement. hematology: mr. was noted to have low platelets and elevated creatinine suggesting possible hus versus ttp. the department of hematology was following the patient and noted that the smear had only a few schistocytes, but no obvious signs for ttp or hus. instead, the remainder of the diagnosis was dic and the coagulations were carefully monitored over the next few days. he received several platelet transfusions in the interim to keep his platelets above 30, especially while the patient was on apc. the thrombocytopenia eventually resolved and his platelets have returned to 369,000. mr. hematocrit had been intermittently down to 21.5 from the upper limits of 34 to 40. he was given two units of packed red blood cells. since then, mr. has maintained his hematocrit successfully. he was on epogen for three days for indication of decreased need for transfusions during his critical illness. endocrine: mr. blood sugars were noted to be excessively high secondary to sepsis and he was started on insulin drip for three days. prophylaxis: mr. was initially on iv protonix and heparin via the cvvh. pneumoboots were not used secondary to the skin lesions on his legs. subcutaneous heparin was utilized once his coagulation issues were resolved. lines: mr. had right ij placed, which was changed over a wire. he currently has right ij in place, day #8. right femoral hemodialysis on day #4. he recently had left radial line, which has been discontinued. disposition: mr. family is very supportive and has been in contact daily. is full code. he was being transferred at this time from the micu to the floor for further management. , p. m.d. dictated by: medquist36 Procedure: 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 Other bronchoscopy Other bronchoscopy Diagnoses: Acidosis Thrombocytopenia, unspecified Acute kidney failure with lesion of tubular necrosis Methicillin susceptible Staphylococcus aureus septicemia Acute respiratory failure Other shock without mention of trauma Methicillin susceptible pneumonia due to Staphylococcus aureus Other disorders of muscle, ligament, and fascia Other specified bacterial diseases

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headaches x 1 month, anterior communicating artery aneurysm found on mri at osh major surgical or invasive procedure: aca clipping cerebral angiogram right leg fasciotomy history of present illness: 55 y/o female with a h/o polycystic kidney disease who was sent for mri by her nephrologist after she told him she had been having headaches. mri reportedly revealed an anterior communicating artery anuerysm of 6mm x 6mm x 3mm projecting superiorly. she complains of approximately 1 month of headaches which last 1 day and she has /week. she describes the pain as in the front of her head ans sometimes radiating down into her neck. she does report a history of similar headaches in the past, for many years, of which some were much worse than her present headaches. there has been no sudden onset of her symptoms. she has had no n/v, visual changes, and no other associated symptoms. no fevers, cp/sob or other complaints. presently she has a mild headache of and claims the last severe headache she had was last sunday. past medical history: pckd, htn, mi(unknown age), hyperlipidaemia, bipolar disorder cholecystectomy nkda social history: lives with husband, no etoh, 60 pack years tob family history: non-contributory physical exam: physical exam: t: 98.7 bp: 124/67 hr: 82 r 16 o2sats 95% ra gen: wd/wn, comfortable, nad. heent: pupils: errla 3-2mm eoms intact neck: supple. lungs: cta bilaterally. cardiac: rrr. 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. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to 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, propioception, bilaterally. reflexes: b t pa ac right 2 2 2 2 left 2 2 2 2 toes downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements pertinent results: discharge labs: chem: 155 114 60 113 agap=15 3.6 30 1.1 comments: na: notified at 0845 on ca: 10.3 mg: 3.1 p: 3.7 phenytoin: 11.1 cbc: 95 15.1 11.6 485 34.1 nchct : status post anterior communicating artery aneurysm clipping with no evidence of an intracranial hemorrhage. careful followup should be obtained as the subdural and epidural gas present overlying the left frontal lobe appear to indent the brain in several locations, raising the possibility of tension pneumocephalus. carotid/cerebral angiogram : 1. optimal clipping of the anterior communicating arterial aneurysm with no residual aneurysm. 2. both a2 branches are patent. 3. minimal vessel spasm is noted in the left a1 segment. 5 mg of verapamil was infused into the left common carotid artery. ct head without iv contrast : again seen are multiple areas of low attenuation within the left parietal and frontal regions, in the aca and mca distribution consistent with areas of infarction, which were seen on the prior study. these demonstrate low attenuation consistent with expected changes. no new areas of intracranial hemorrhage identified. the appearance of the ventricles are stable in comparison to the prior exam. there is slight asymmetry and narrowing of the left frontal , likely reflecting mass effect from areas of infarction in the left frontal lobe. artifact can be seen from clips within the suprasellar region. the basilar cisterns are stable in appearance. there are stable post-surgical changes in the left frontal region from a craniotomy defect, with a small amount of pneumocephalus, which has also not significantly changed. there is minimal mass effect in the frontal region, which is also relatively stable in comparison to prior exam. impression: stable appearance of multiple areas of infarction within the left mca and aca distribution, with minimal mass effect, no new areas of intracranial hemorrhage. no significant interval change from the prior exam. rpt nchct : there has been interval improvement in the appearance of the brain since the prior study. the pneumocephalus has resolved, the mass effect on the frontal of the left lateral ventricle has improved. there has been evolution of the hypodensities involving the left anterior and middle cerebral arteries. no new areas of hypodensity are noted. clips are again seen in the suprasellar region, unchanged. the metallic hardware from prior left frontal craniotomy is again seen. there is slightly more prominence of the extra-axial space along the right frontal region than that was on prior studies. there is no high-density material within this area to suggest acute hemorrhage. no new areas of intra- or extra-axial hemorrhage are noted. the mastoid air cells and visualized paranasal sinuses are clear. the subcutaneous emphysema as well as the skin staples on the left have been removed. impression: 1. no acute intracranial hemorrhage. 2. evolving hypodensities in the left aca and mca territories consistent with evolving infarctions. improved mass effect on the frontal of the left lateral ventricle. 3. slightly more prominent extra-axial space in the right frontal region than on prior studies. bilat le us5/24/07: no evidence of dvt in the bilateral lower extremities. video oropharyngeal swallow: oral and pharyngeal swallowing video fluoroscopy was performed in collaboration with the speech and swallowing team. thin liquid, nectar-thick liquid, pureed consistency barium were administered. the oral phase demonstrates severe oral apraxia during feeding tasks. patient was unable to feed herself. there was moderate-to-severe deficit regarding bolus control and formation. oral transit was moderately prolonged and there was mild-to-moderate diffuse residue on the tongue and in the anterior and lateral sulci. ap tongue movement was mild to moderate impaired. the pharyngeal phase demonstrates mild delay in swallow initiation with mild vallecular residue of purees. hyolaryngeal excursion, laryngeal valve closure, epiglottic deflection, pharyngeal transit time, bolus propulsion, and pharyngoesophageal sphincter opening was adequate. there was mild aspiration of thin liquids. there was delayed reflexive cough. impression: severe oral dysphagia with mild pharyngeal dysphagia. there was mild aspiration of thin liquids during the study. brief hospital course: 55 f admitted for elective acom aneurysm clipping. the procedure was performed under general anaesthetic on and included placement of 2 clips between l a1-a2. post operative angiogram demonstrated optimal positioning of clips and minimal vasospasm treated with verapamil. the patient was transferred to the icu for ongoing care. the patient was extubated on . transfer to step-down occurred on . . ct head post angiogram demonstrated left basal ganglia, left frontal infarct (possibly secondary to intraoperative parenchymal retraction), and posterior left frontal infarct thought likely secondary to embolic phenomena during angiogram. . seizure prophylaxis was provided with dilantin (goal level 15-20). please continue to monitor level (11.1 on and 300mg extra given). . neurological examination during admission showed gradual improvement in level of consciousness. the patient was speaking in occassional words at discharge. there was evidence of partial l cn iii palsy with dilated left pupil, decreased reaction to light and impaired left eye movements (abduction preserved). there was persistent right sided weakness (rue-0/5; rle at toes/ankle). full power in l limbs. . the patient was assessed and therapy provided by ot/pt. . neurosurgery follow up will be with dr to be arranged for 4 weeks from discharge. . ischaemic right foot: overnight following angiogram the right leg was noted to be acutely ischaemic. right femoral and external iliac dissection was diagnosed on repeat angiogram. emergent treatment was provided consisting of thrombectomy of right iliac, common femoral and superficial femoral arteries with endarterectomy of the right common femoral artery and dacron patch angioplasty. abdominal and pelvic angiogram was performed with placement of right external iliac artery stent, and four compartment right lower extremity fasciotomies. post stent deployment angiogram showed resolution of obstruction and good flow through the stent. staples removed on . steristrips placed. allow steristrips to come of in their own time. shower. . partial nephrogenic diabetes insipidus: the patient was hypernatraemic during icu admission with maximum na of 158. the endocrine team were consulted on . etiology was felt to be most consistent with nephrogenic di. was closely monitored and corrected slowly with free water boluses and desmopressin. desmospressin was ceased on . free water boluses were continued to maintain in normal range. while npo for peg free water boluses were discontinued and na increased to 157. free water was restarted at 250ml q4h on and endocrine advice further obtained. dr (accepting care at ) was happy to continue management of . hyperglycaemia: the patient was treated with insulin gtt during icu stay with goal of normoglycaemia. this was transitioned to nph and insulin sliding scale on the floor with patient requiring between 0-10u short acting insulin per day. final weaning dexamethasone dose was administered on . insulin requirements were decreasing. the patient has been on insulin nph 12u , decreased to 6u on and on that day had no need for additional short acting insulin. during npo for peg nph insulin was held and not restarted as we anticipate she will likely have decreasing glucose levels and will continue to have decreasing insulin requirements. please continue to monitor sugar levels and treat as needed with sliding scale insulin or low dose nph. . leukocytosis: elevated wcc to max 39 on was observed post operatively in association with slow steroid taper and uti. wcc decreased gradually following cessation of steroids (15 on d/c). . urinary tract infection: e.coli uti was treated with ciprofloxacin for 10 days with final dose on . repeat u/a should be checked to ensure clearance of infection. . nutrition: nutrition was provided via ngt feeding. video swallow evaluation on showed severe oral dysphagia with mild pharyngeal dysphagia. there was mild aspiration of thin liquids. peg was placed on and feeds commenced on with free water boluses. medications on admission: lithium, elevil, buspar, atenolol, asa discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. docusate 50 mg/5 ml liquid sig: po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection every eight (8) hours. 5. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po tid (3 times a day). 7. phenytoin 50 mg tablet, chewable sig: four (4) tablet, chewable po bid (2 times a day). 8. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed: to groin intertrigo. 9. miconazole nitrate 2 % cream sig: one (1) appl vaginal hs (at bedtime) for 7 days. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). discharge disposition: extended care facility: medical center - discharge diagnosis: aca aneurysm right femoral and external iliac dissection partial nephrogenic diabetes insipidus with hypernatraemia hyperglycaemia associated with steroid use uti discharge condition: stable neurological examination with l partial cn iii palsy, and rsided weakness. discharge instructions: you have been treated with craniotomy and clipping of aca aneurysm and operation on the blood vessels approached from the right groin. ?????? have a family member check your incision daily for signs of infection ?????? take your pain medicine as prescribed ?????? you may wash your hair after sutures and/or staples have been removed ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, ibuprofen etc. ?????? if you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered call your surgeon immediately if you experience any of the following: ?????? new onset of tremors or seizures ?????? any confusion or change in mental status ?????? any numbness, tingling, weakness in your extremities ?????? pain or headache that is continually increasing or not relieved by pain medication ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f followup instructions: please call for neurosurgery appointment in 4 weeks with dr . you will need to have some imaging of the brain before the appointment. you will be advised of arrangements for this when you call to book follow up next week. . please have your doctors watch your level, blood sugars (insulin as needed) and dilantin level. . Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Percutaneous [endoscopic] gastrostomy [PEG] Clipping of aneurysm Arteriography of cerebral arteries Arterial catheterization Arteriography of other intra-abdominal arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Suture of cranial and peripheral nerves Procedure on four or more vessels Endarterectomy, lower limb arteries Other incision of soft tissue Cranial or peripheral nerve graft Insertion of one vascular stent Diagnoses: Urinary tract infection, site not specified Long-term (current) use of steroids Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Accidental puncture or laceration during a procedure, not elsewhere classified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cerebral aneurysm, nonruptured Peripheral vascular complications, not elsewhere classified Bipolar disorder, unspecified Raynaud's syndrome Arterial embolism and thrombosis of lower extremity Nephrogenic diabetes insipidus Iatrogenic cerebrovascular infarction or hemorrhage Polycystic kidney, unspecified type Third or oculomotor nerve palsy, partial

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cc: major surgical or invasive procedure: intubation r leg femoral artery thrombectomy cvl placement history of present illness: the patient is a 56 year old female patient with a history of anterior communicating artery anuerysm of 6mm x 6mm x 3mm s/p clipping admitted to dr. service on neurosurgery from to complicated by uti, ? partial nephrogenic diabetic insipidus ( 158 on desmospressin which was stopped on , followed by endocrine) right femoral and external iliac dissection post angiogram with emergent thrombectomy of right iliac, common femoral and superficial femoral arteries with endarterectomy of the right common femoral artery and dacron patch angioplasty, right external iliac artery stent, and four compartment right lower extremity fasciotomies, as well as left basal ganglia, left frontal infarct (possibly secondary to intraoperative parenchymal retraction), and posterior left frontal infarct thought likely secondary to embolic phenomena during angiogram who presented from today after being found unresponsive. a ct of the head was performed which showed (per neurosurgery report, no copies/report in patient chart from ed): . " no evidence of hemorrhagic stroke of ct. l aca and mca areas of infarct still present." . neurosurgery was consulted in the ed and noted possible tremors in lue ?seizure and ?new lle weakness but felt there were no acute neurosurgical issues. . . in the ed, vanco 1 gm iv, cefepime 2 gm iv given for ?empiric sepsis for a fever of 100.8. also, noted to have k of 5.7->5.9, give 10 units iv insulin with 1 amp of d50. no other meds given for hyperkalemia normal appearing ekg with no acute changes. . also, newly elevated lfts noted in ed: . alt 519, ap 506, ldh 801. bili 0.5. during last admit, alt, ast in 70, 50s range. . a right upper quadrant ultrasound was performed which showed: . no intra or extra-hepatic biliary dilatation. cbd is 5 mm. portal vein is patent. no ascites. s/p chole. labs were otherwise significant for the following: past medical history: *polycystic kidney disease *htn *mi(unknown age) *hyperlipidemia *bipolar disorder *anterior communicating aneurysm s/p elective clipping left basal ganglia, left frontal infarct (possibly secondary to intraoperative parenchymal retraction), and posterior left frontal infarct emboli from ct-a of head with resulting cn iii palsy, right sided hemiplegia * right femoral and external iliac dissection post angiogram with emergent thrombectomy of right iliac, common femoral and superficial femoral arteries with endarterectomy of the right common femoral artery and dacron patch angioplasty, right external iliac artery stent, and four compartment right lower extremity fasciotomies * nephrogenic di, followed by endocrine *h/o recent uti during last admit to social history: lived with husband previously, no etoh, 60 pack years tob. transferred from acute care rehab facility. family history: non-contributory physical exam: initial pex: tc = 99.6 tm = 100.8 in ed p=108 bp = 106/75 rr = 27 99% on 4 liters o2 . gen - non-responsive to verbal stimuli heent - pupils responsive to light, left eye >dilated than right (documented as old), anicteric, no head trauma, pursed lip breathing heart - rrr, no m/r/g lungs - ctab (anteriorly) abdomen - soft, nt, nd, decreased breath sounds, no hepatosplenomegaly, g tube ext - rue erythematous, swollen, hemiplegic on right side, moves lue spontaneously, no spontaneous movement of lle, retracts lle to painful stimuli back - unable to assess skin - warm, erythematous blanching rash on chest, abdomen neuro - cn iii ? palsy in left eye, lle no spontaneous movement, r sided hemiplegia, brisk lle dtrs, positive bilaterally, left upper extremity tremor with pill-rolling pertinent results: ruq u/s : impression: status post cholecystectomy. no intra- or extra-hepatic biliary dilatation. . head ct : conclusion: no evidence of hemorrhage. evolving acute infarction in the left frontal lobe, new since the study of , this region was obscured on the earlier examination of . . ct abd/pelvis : 1. large acute hemmorage within the right biceps femoris and surrounding soft tissues. the largest pocket of acute hemorrhage measures 4.2 cm in greatest dimension with a fluid-fluid level within. 2. large wedge shaped hypoattenuating region within the right lobe of the liver consistent with an infarct suggesting an acute portal vein thrombosis. 3. trace pericardial effusion. . head ct : 1. no evidence of acute intracranial hemorrhage or new major vascular territorial infarct. 2. continued evolution of large left eca and mca infarcts with mild edema and minimal subfalcine herniation (approximately 2 mm). 3. stable appearance of left frontal craniotomy and aneurysm clips in the suprasellar region. . brief hospital course: hospital course: her mental status change was thought secondary to old and concern for new r stroke given new l hemiparesis. followed by neuro, neurosurg and vascular teams. head ct showed new left large frontal cva. pt with unresponsive pupils, blunted reflexes, tachypnea, labile bp. was intubated for airway protection given her mental status. neurology evaluated patient but was not able to examine her off propofol given her instability. on hd#1 she was found to have a cold ischemic rle and she was evaluated by vascular surgery who took her immediately to the angio suite for a thrombectomy. they were able to restore her flow. given her multiple arterial clots (cva and rle arterial clot) and her drop in platelets, hitt was suspected and all heparin products were stopped. she was started on lepirudin given her lft abnormalities. she developed bleeding into her rle thigh given her recent intervention and she was aggressively transfused. her bp remained labile and required pressors to maintain adequate cpp. on hd#2, she continued to deteriorate with continued bleeding into her thigh. vascular surgery did not feel she was an adequate candidate for a re-operation. she was aggressively hydrated, maintained on pressors, and hyperventilated to prevent further acidosis. given her deteriorating hemodynamic status, as well as her very poor long term neurologic prognosis given her large stroke and complications, her family decided to convert her to comfort measures only on at 6pm. her pressors, fluids, and transfusions were stopped adn family was present at her bedside. she was kept on propofol, and a morphine gtt was added for comfort. she expired at 11:30pm. her family was notified and declined an autopsy. medications on admission: . acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. docusate 50 mg/5 ml liquid sig: po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection every eight (8) hours. 5. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po tid (3 times a day). 7. phenytoin 50 mg tablet, chewable sig: four (4) tablet, chewable po bid (2 times a day). 8. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed: to groin intertrigo. 9. miconazole nitrate 2 % cream sig: one (1) appl vaginal hs (at bedtime) for 7 days. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). discharge medications: n/a discharge disposition: expired discharge diagnosis: cva suspected hitt rle arterial thrombus arf liver infarct respiratory failure discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Venous catheterization, not elsewhere classified Transfusion of packed cells Endarterectomy, lower limb arteries Destruction of cranial and peripheral nerves Procedure on three vessels Diagnoses: Acidosis Hyperpotassemia Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Anticoagulants causing adverse effects in therapeutic use Hyperosmolality and/or hypernatremia Cerebral artery occlusion, unspecified with cerebral infarction Bipolar I disorder, most recent episode (or current) unspecified Arterial embolism and thrombosis of lower extremity Nephrogenic diabetes insipidus Portal vein thrombosis Hepatic infarction Polycystic kidney, unspecified type

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mvc major surgical or invasive procedure: left foot split thickness skin graft left orif tibial shaft fx left orif tibial malleollar fx left foot i/d of soft tissue injury left acetabular fracture left leg fasciotomies closure of left leg fasciotomies placement left traction pin removal of left traction pin serial vac changes and i&d of left foot open reduction internal fixation of left anterior acetabular fracture history of present illness: 49 y/o male transferred from hospital after mvc. patient restrained driver, who swerved to miss hitting a deer, went off the road into the and truck rolled over. past medical history: hard of hearing (uses hearing aids) social history: non-contributory family history: non-contributory physical exam: head pupils 3mm equal neck non tender trachea midline chest left tender bs clear abd nontender sft nondistended ext left tibial open fracture /fhl intact sensation intact pulses intact pertinent results: head and c-spine ct impression: 1) no acute intracranial hemorrhage or mass effect. no fracture. 2) well-circumscribed lucencies within c1 without evidence of cortical destruction, a finding that is of uncertain significance. ct torso impression: 1. small left pneumothorax adjacent to nondisplaced fractures of the left anterior third and fourth ribs and small foci of opacity within the anterior lingula and left lower lobe suggesting small areas of pulmonary contusion. 2. complex comminuted fracture of the left acetabulum with associated left pelvic hematoma. 3. fatty liver. pelvis impression: complex comminuted fracture of the left pelvis extending through the acetabulum with avulsed lateral fragment. consider ct scanning which may be helpful in further characterization and of aid in treatment planning. foot films findings: much detail is obscured by overlying casting material. the frontal view shows oblique fracture at the distal metatarsal of the second digit and slightly more proximally of the metatarsal bone of the fourth digit. no other fractures were seen. impression: fractures of the second and fourth metatarsal bones as described above; study markedly limited by overlying casting material. left foot, ap, lateral and oblique: comparison is made to . as before, evaluation is somewhat limited by the presence of overlying casting material. again seen are distal metadiaphyseal complete oblique fractures of the second and fourth metatarsal bones with slight displacement at both sites. there is also a dislocation of the fifth metatarsophalangeal joint, which was probably unchanged. in addition, a third fracture site is suspected at the base of the second phalanx along the medial base with probable intra-articular extension. the joint spaces preserved, however. impression: 1) oblique fractures through the second and fourth metatarsals. 2) suspected fracture at the base of the second proximal phalanx. 3) dislocation of the fifth mtp joint. 3:00 pm swab l foot wound. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram negative rod(s). wound culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). pseudomonas aeruginosa. heavy growth. of two colonial morphologies. non-fermenter, not pseudomonas aeruginosa. moderate growth. staphylococcus, coagulase negative. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 4 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ 2 s imipenem-------------- 2 s meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. angiogram : impression: left lower extremity arteriography reveals patency of the common femoral, profunda, superficial femoral and popliteal arteries along with a three-vessel runoff to the level of the foot. no focal stenosis or occlusion was identified. at the foot, there is patency of the dp and pt, with a patent and complete plantar arch. discharge labs: wbc-6.5 rbc-3.96* hgb-11.3* hct-34.4* mcv-87 mch-28.4 mchc-32.7 rdw-14.5 plt ct-289 pt-12.9 ptt-29.0 inr(pt)-1.1 glucose-106* urean-7 creat-0.5 na-139 k-4.0 cl-102 hco3-28 angap-13 brief hospital course: he was seen in the ed by ortho on and emergently taken to the or for orif of left tibial shaft fx with im rodding, i/d debridement of left foot soft tissue injury , orif of left tibial malleolar fx, left leg fasciotomies and placement of lef leg traction pin for left acetabular fracture - see op note for details. he was transfered the pacu in stable conditon. post op. he was on the trauma service in the trauma sicu where he remained stable and was extubated. he was seen by dr who explained to the patient and his family what would be the plan he agreed to it and he was taken on to the or for removal of a traction pin and open reduction of the left posterior acetabular fracture and closure of left leg fasciotomies, i/d of left leg soft tissue injury and placement of a vac dsd. he was transfered to pacu stable. in the pacu he was hypotensive and required vassopressors. he was transfered to the tramua sicu for 24 hrs and then to the cc6 floor after being weaned off pressors. dr spoke with the family again about the need to do another vac change prior to plastic surgery doing a flap closure on he returned to the or for i&d and a pinning of his metatarsal fx on . he again returned to the or for i&d vac dressing change and orif of the left anterior acetabular fx dr felt that his foot looked better the swelling was going down he was now made non weight bearing but may be oob to chair on he returned to the or and underwent a vac change. the wound looked good and was starting to have some granulation tissue form he returnedto the or on had vac removed on he had dressing change and then on had vac dsd placed. plastic surgery was consulted and dr performed a multiple skin grafts to his open areas on his left foot. post-operatively, he was transferred to the plastic surgery sergice. patient was placed on stirct bed rest and had the vac in place until post op day 5 (). in the interim, the plastics team eventually weaned him off the iv pains medications to regular po pills. he appears to be well controlled on oxycontin 30bid and dialudid po for breakthrough. his foley was did on morning of the 11th and his donor skin graft site was kept open to air. his vac was removed on post-op day 5, which revealed that the foot had taken to the multiple skin graft sites. the thought was to place the patient in a afo splint with ortho's approval and prior to discharge to rehab. however, the patient failed to tolerate splint as the current pins in his left foot limited his flexion. after discussion with ortho, they recommended discharge with his foot as is with range of motion as tolerated. they intend to take the pins out of his left foot when he returns for a follow-up appointment a week after discharge. they are aware of the patients foot being in plantar flexion and will work on placing patient in splint after pins are removed. the patient was tolerating a regular diet, on po pain medication and iv antibiotics. he awaited for placement until at which time he was discharged to rehab with followup appointments at the . medications on admission: none discharge medications: 1. oxycodone 10 mg tablet sustained release 12hr sig: three (3) tablet sustained release 12hr po q12h (every 12 hours). disp:*180 tablet sustained release 12hr(s)* refills:*2* 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. disp:*qs qs* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) subcutaneous qday (). disp:*qs qs* refills:*2* 6. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h () as needed. disp:*qs tablet(s)* refills:*0* 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. disp:*qs tablet, delayed release (e.c.)(s)* refills:*0* 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed: do not exceed mg acetaminophen per day . disp:*45 tablet(s)* refills:*0* 9. cefazolin 10 g recon soln sig: one (1) gram injection q8h (every 8 hours). disp:*90 gram* refills:*2* 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 11. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. discharge disposition: extended care facility: & rehab center - discharge diagnosis: left third and fourth rib fractures left pneumothorax status post chest tube placement blood loss anemia requiring transfusion hypotension requiring pressor support post operative fever left foot split thickness skin graft left foot soft tissue injuries left acetabular fracture left tibial shaft fracture left tibial malleollar fracture left metatarsal fracture discharge condition: stable discharge instructions: ortho discharge instructions transfer to rehab sp open reduction internal fixation left tibial fracture with im rod open reduction internal fixation of left tibial malleolar fracture left leg fasicotomies placement of left traction pin i/d of left foot wood removal of traction pin i/d left foot wound with vac dressing closure of left leg fasciotomies open reduction internal fixation of left posterior /transveres acetabular fracture i&d vac change metatarsal pinning i&d vac change open reduction internal fixation of left anterior acetabular fracture i&d vac change call with spiking fevers, increased redness, swelling or discharge of the wounds or pin sites. please work on passive range of motion of left foot to increase range of motion (currently in plantar flexion, work on getting foot to neutral. daily dressing changes to wounds, including xeroform and dry sterile dressing. routine pin care non weight bearing lle followup instructions: follow up with ortho trauma clinic in 1 week, call for an appointment follow up with plastic surgery in 1 week, call for an appointment Procedure: Arteriography of femoral and other lower extremity arteries Fasciotomy Other skin graft to other sites Other skin graft to other sites Advancement of pedicle graft 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 Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, other specified bone Open reduction of fracture with internal fixation, other specified bone Open reduction of fracture with internal fixation, tarsals and metatarsals Open reduction of fracture with internal fixation, tarsals and metatarsals Internal fixation of bone without fracture reduction, tibia and fibula Internal fixation of bone without fracture reduction, other bones Debridement of open fracture site, tarsals and metatarsals Debridement of open fracture site, tarsals and metatarsals Diagnoses: Traumatic pneumothorax without mention of open wound into thorax Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Closed fracture of two ribs Contusion of lung without mention of open wound into thorax Other chronic nonalcoholic liver disease Pseudomonas infection in conditions classified elsewhere and of unspecified site Street and highway accidents 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 acetabulum Open fracture of shaft of tibia alone Trimalleolar fracture, open Open fracture of metatarsal bone(s) Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B

allergies: sulfonamides attending: chief complaint: transfer from for acute on chronic respiratory distress. major surgical or invasive procedure: lumbar puncture on history of present illness: mr. is a 73 yo male with a complicated past medical history, recently discharged from on following a prolonged admission for stemi, respiratory failure felt secondary to pulmonary edema requiring intubation and subsequent tracheostomy failure to wean, sepsis and c.difficile colitis treated with vancomycin and flagyl with a course of levophed. he was discharged to for continued weaning. per , patient remained ventilator dependent, intermittently on ps 20/5 and back on ac 15/5/500/0.35 on . at osh, sputum cultures grew pseudomonas and mrsa, and he was restarted on zosyn () and vancomycin (). he completed his course of vancomycin on . however, today around 17:45, while being moved by the nursing staff, mr. started coughing. suctioned x 1, mucus not cleared. he then became dusky and cyanotic, and stopped breathing on his own. a code was called, + pulse. patient placed on fio2 100%. vitals hr 88-98, bp 150/80. abg done on fio2 100% 7.36/66/417/98%. at , bp dropped to 90, and patient was started on ns ivf, with improvement in bp. ekg without acute changes. he was transferred to ed for further management on ac, rr 15, peep 5, vt 500, fi02 1.0. in ed, bp 80/60, hr 80. continued on ivf (received total 2300cc), with improved bp to sbp 105-118. stool sent for c.diff and given flagyl 500 mg po x 1 dose. past medical history: 1. non-small cell lung cancer s/p xrt and chemotherapy in , s/p right pneumonectomy in for recurrence. chronic left pleural effusion. 2. sss status post pm/icd placement 3. copd/bronchiectasis 4. hypertension 5. cad, with known to rca. 6. chf with ef 25% on last echo on 7. bph 8. depression 9. left femoral av fistula 10. recent mrsa pneumonia and sepsis , treated with vancomycin 11. c. difficile colitis treated with flagyl (completed ) 12. status post peg tube placement 13. status post tracheostomy failure to wean 14. status post partial colectomy social history: son is next of . see below for contact information. has been living at house since . per , at baseline, patient not interactive. opens eyes spontaneously, withdraws to painful stimulus. family history: non-contributory physical exam: physical exam on admission: vitals: bp 90s-118/47-59, hr 80-90s. vent: ac, rr 15, peep 5, vt 500cc, fio2 1.0. gen: intubated, opens eyes, responds to painful stimulus. heent: pupils minimally reactive. sclera anicteric. neck: unable to assess jvp. resp: bronchial breathing over right hemithorax. ronchorous breath sounds left chest. limited examination. cvs: rrr. normal s1, s2. + s4. no murmur appreciated. gi: peg in place, site without drainage. bs present, hypoactive. abdomen soft. no grimacing with palpation. gu: foley in place. ext: 2+ edema both upper extremities, sacral edema. cool extremities. good pedal pulses peripherally. neuro: limited examination. withdraws to painful stimulus. moves all 4 extremities. pertinent results: labs: wbc-4.9 rbc-2.92* hgb-8.8* hct-26.2* mcv-90 mch-30.1 mchc-33.5 rdw-18.5* neuts-86.5* lymphs-7.5* monos-4.7 eos-1.2 basos-0.1 plt count-145* glucose-91 urea n-21* creat-0.6 sodium-143 potassium-4.2 chloride-106 total co2-32 anion gap-9 lactate-1.4 k+-3.9 abg: 07:30pm type-art po2-468* pco2-44 ph-7.50* total co2-36* base xs-10 intubated-intubated ekg (at , 17:11): atrial fibrillation, occasional v-paced, rate 74. normal axis. old twi v4-6. ekg in ed: afib, occasional v-paced, rate 83 bpm. normal axis. long qt interval (qtc 462 ms). st depressions v4, 5. mild st elevation in v3. old twi v4-6. **************** imaging: cxr: ett in correct position. pm wires in good position. s/p right pneumonectomy. blunting of left cpa likely effusion. new lower left lateral cw opacity, likely loculated pleural fluid. echo: left-to-right shunt across the interatrial septum. lvef 25%. resting wma include mid to distal septal akinesis, apical akinesis, inferior akinesis/hypokinesis, and mid to distal anterolateral hypokinesis/akinesis. no definite apical thrombus seen (cannot exclude). + ar. trivial mr. 1+ tr. ct head: new rounded low-density area measuring 2.5 cm in left basal ganglia, which partially extends to the left thalamus, probably representing subacute infarction. on this head ct without contrast, the evaluation is limited. cta chest: no evidence for pulmonary embolism. findings consistent with failure or fluid overload. development of small loculated pleural fluid collection along the periphery of the left major fissure or so-called pseudotumor, consistent with the recent chest x-ray. unchanged appearance of right pneumonectomy. echo: the left atrium is normal in size. overall lvef is difficult to assess due to poor echo windows although the basal lv appeas hyperdynamic without regional contraction abnormality (suspect significant improvement compared to prior study dated ). no masses or thrombi are seen in the left ventricle (due to poor echo windows cannot fully exclude). the ascending aorta is mildly dilated. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. there is a small pericardial effusion. there are no echocardiographic signs of tamponade eeg: markedly abnormal portable eeg due to the voltage suppression over the left hemisphere and due to the bursts of generalized slowing and right hemisphere slowing. the first abnormality raises the possibility of material (such as subdural fluid) interposed between the brain and recording electrodes or widespread cortical dysfunction on that side. anatomic correlation would be of interest if clinically indicated. the generalized slowing indicates a non specific dysfunction in midline structures. there was also evidence of subcortical dysfunction on the right side. no epileptiform features were seen. micro data: stool clostridium difficile toxin assay-pending csf;spinal fluid gram stain-neg fluid culture-neg; fungal culture-pending; acid fast culture-pending; viral culture-pending sputum culture-preliminary {pseudomonas aeruginosa} blood culture ngtd urine culture-final blood culture ngtd brief hospital course: mr. was admitted with respiratory failure, thought to be related to mucus plugging as well as a pseudomonal pneumonia. both of these etiologies were treated, and he continued to oxygenate and ventilate well on his usual ventilator settings. however, the issue that dominated the admission was his recent acute decline in mental status. he was thoroughly evaluated by neurology and underwent head ct, mri, lp, and eeg. this work-up demonstrated a small left basal ganglia infarct, likely cardioembolic. however, they felt this event could not account for his new, severe global deficit; this was thought to be secondary to a more pervasive process, likely anoxic encephalopathy, for which the prognosis is extremely grim. this was discussed at length in several family meetings involving the patient's wife, son, primary care doctor, icu attending, and neurology consultant in the presence of a russian interpreter. the end result of these discussion was that the patient's wishes would not be consistent with this new level of functioning from which he had little hope of recovery; the family decided to make him comfort measures only. he was disconnected from the ventilator and all medications beyond a morphine drip were stopped, and he expired shortly thereafter. the family was present. medications on admission: jevity 1.2 65 ml/hour continuous with water 240 cc q 8 hours lasix 40 mg iv qam (given ) vancomycin 1gm iv q 36 hours (last dose at on ). started on ) asa 325 mg po qd lansoprazole 30 mg po qam heparin 5000 units sc tid zosyn 4.5 gm iv q 8 hours (last dose on at 1400), started . metoprolol 37.5mg q 12 hours (last dose 07/25 in am) protein/soy supplement 2 scoops q 12 hours ipratropium/albuterol inhaler 4 puffs qid completed course of flagyl -->. discharge disposition: expired discharge diagnosis: anoxic encephalopathy acute respiratory failure chronic respiratory failure pseudomonal pneumonia volume overload chronic obstructive pulmonary disease bronchiectasis hyponatremia anemia of chronic disease secondary: 1. non-small cell lung cancer s/p xrt and chemotherapy in , s/p right pneumonectomy in for recurrence. chronic left pleural effusion. 2. sick sinus syndrome status post pm/icd placement 3. copd/bronchiectasis 4. hypertension 5. cad, with known to rca. 6. chf with ef 25% on last echo on 7. bph 8. depression 9. left femoral av fistula 10. recent mrsa pneumonia and sepsis , treated with vancomycin 11. c. difficile colitis treated with flagyl (completed ) 12. status post peg tube placement 13. status post tracheostomy failure to wean 14. status post partial colectomy discharge condition: expired md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Acute and chronic respiratory failure Pneumonia due to Pseudomonas Anoxic brain damage Automatic implantable cardiac defibrillator in situ Cerebral embolism with cerebral infarction Bronchiectasis without acute exacerbation Gastrostomy status Tracheostomy status

allergies: sulfonamides attending: chief complaint: adenocarcinoma of the right main bronchus major surgical or invasive procedure: right pneumonectomy with serratus muscle flap bronchoscopy mediastinal lymph node dissection exploratory laparotomy with lysis of adhesions foley catheter placement chest tube placement peripherally inserted central catheter nasogastric tube placement endotracheal tube placement epidural catheter placement history of present illness: this is a 73 year old russian gentleman who presented to the clinic with a diagnosis biopsy proven of adenocarcinoma of the right main stem. per his report he had been diagnosed and treated in the soviet for a right lung cancer 25 years ago. he has received a significant amount of radiation therapy and chemotherapy. patient also has had a known partial collapse and consolidation of the right lung for the past several years and increasing shortness of breath for the past six months. he has scoliotic spine and a significantly reduced right lung capacity. he is a very active gentleman. he is able to walk for one to two hours every day. past medical history: past medical history: 1. symptomatic cholelithiasis. 2. right-sided lung cancer, status post chemotherapy and radiotherapy. 3. copd/bronchiectasis 4. hypertension. 5. benign prostatic hypertrophy. 6. status post pacemaker. 7. history of depression. 8. status post partial colectomy in . 9. history of positive ppd in -no prophylaxis/active disease adenosine deaminase in 9/99 ~9.7, suggestive of possible tb pleural disease 10. history of exertional angina, which is currently asymptomatic. social history: he is a former smoker who has quit 25 years ago. he is retired and lives in an apartment for the elderly. he has been quite active until recently. pt with remote (20 pack year; quit 25 years ago) tobacco history. pt denies use of alcohol or ivda. he lives with his wife. his son and daughter speak english and are able to translate. family history: non-contributory physical exam: patient's physical exam on admission is as follows: vitals: t=97.8, bp=159/59, p=97, r=16, spo2=98%ra gen: nad, aaox3 heent: perrl, eomi, no lad cvs: rrr, no mrg pulm: cta bilaterally, no crw abd: soft, nt/nd, +bs ext: no cce, warm/dry with good cap refill neuro: no focal deficits, cn 2-12 grossly intact pertinent results: 04:47pm wbc-22.4*# rbc-3.82* hgb-10.4* hct-31.2* mcv-82# mch-27.3# mchc-33.4 rdw-16.9* 04:47pm glucose-140* urea n-22* creat-1.3* sodium-141 potassium-5.0 chloride-109* total co2-25 anion gap-12 04:47pm pt-17.3* ptt-34.2 inr(pt)-1.9 04:47pm plt count-238 04:47pm blood glucose-140* urean-22* creat-1.3* na-141 k-5.0 cl-109* hco3-25 angap-12 pathology examination # diagnosis: 1. mediastinal pleura (aa): lung parenchyma with chronic inflammation and fibrosis. no malignancy identified. 2. "part of thymus and anterior mediastinum" (a-e): adipose tissue with focal collection of macrophages, many ladened with carbon pigment. 3. endobronchial tumor (f): non-small cell carcinoma (see synopsis). 4. 4r, node (g-h): one lymph node, no malignancy identified. 5. right lung, pneumonectomy (i-p): non-small cell carcinoma (see synoptic report). vascular and bronchial margins are free. uninvolved lung shows collapse with hemorrhage and chronic inflammation. 6. ribs (q-r): bone and marrow with trilineage hematopoiesis. ct abdomen w/o contrast; ct pelvis w/o contrast 7:15 pm 1. evidence of viscus perforation with free air seen in the right lower quadrant. fat stranding and a small amount of free fluid are also seen in the right lower quadrant. there is possible pneumatosis of the cecum. findings are consistent with a perforated cecum likely due to ischemia. 2. scattered diverticula seen throughout the remainder of the colon without frank diverticulitis. 3. marked distention of the cecum measuring up to 10 cm. there is also distention of the ascending and transverse colons. there is no evidence of obstruction. unilat up ext veins us right 5:06 pm right subclavian vein thrombosis. limited examination, as above. the findings were discussed with dr. at the time of the exam. cardiology report echo study date of 1. the left atrium is mildly 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 cannot be reliably assessed. 3. the right ventricular cavity is mildly dilated. 4. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. 5. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 6. there is mild pulmonary artery systolic hypertension. 7.there is a small pericardial effusion. 8. compared with the findings of the prior study (tape reviewed) of , there has been no significant change. chest (portable ap) 8:03 am 1. slight increase in the size of the left pleural effusion. 2. no evidence of pulmonary edema. brief hospital course: mr. was admitted to thoracic surgery on for an intrapleural, intrapericardial pneumonectomy with serratus muscle flap bronchoscopy and mediastinal lymph node dissection. for details of the procedure, please see the operative report. upon completion of the operation, the patient was sent to the micu as a border for hypotension. his course in the micu was significant for afib/flutter which was controlled with verapamil and quinidine. of note, the patient was extubated in the or but which subsequently failed requiring re-intubation. he was then extubated the following day without issue thereafter. in the micu, eps interrogated his aicd after noting rare pvcs. then on pod#3 he was found to be stable enough and was then transferred to the floor. on pod#4, patient was seen by eps for an occurrence of a-flutter; was refractory to metoprolol and was then treated with digoxin and diltiazem which converted patient's rhythm to sinus. the digoxin and diltiazem was then subsequently discontinued with no need to start any antiarrhythmics at that time. however, on pod#7, patient was noted to have a-fib and was started on quinidine 324mg (1.5 tabs po q8hrs), a heparin drip and coumadin for anticoagulation. furthermore, on pod#7, patient began having changes in mental status, complaining of abdominal pain and distention and had need of increased fluids. despite having a completely benign exam and a white blood cell count within normal, he did have an elevated creatinine and lowered systolic blood pressure. the patient was then moved to the icu, a cardiac echo was done, a general surgery consult was obtained and the patient was made npo and had a nasogastric tube and arterial line placed. an abdominal ct showed free air within the right upper quadrant with significant inflammation/stranding about the cecum/appendix and questionable distention of the right colon. his abdominal exam also worsened at that point and general surgery was concerned about possible a perforated appendix, colonic ischemia secondary to the a-fib, or a perforation secondary to syndrome; an exploratory laparotomy was suggested and discussed with the family who agreed and wished to proceed. on patient underwent the exploratory laparotomy but was found to have no gross evidence of perforation. it is believed that the patient suffered a microperforation resulting in free air but which had subsequently healed. he was then taken to the sicu. on was restarted on a heparin drip, amiodarone and also extubated. on , patient was assessed for nutritional requirements and found to need tpn which was started that day. on a post-pyloric dobhoff feeding tube was placed by int. radiology for concerns of aspiration while attending to the patient's nutritional requirements; tpn was discontinued on and patient was moved to the floor. his pulmonary exam improved and begin to clear secretions much better throughout the remainder of his hospital course. on , a bedside swallowing study was performed for concerns of regurgitation possibly leading to aspiration; the study was within normal. the feeding tube was then discontinued and patient's diet was advanced to ground solids with boost supplementation. on , patient had 3 occurrence's of his aicd firing during the qrs complex. this was discussed with eps who recommended that the patient be switched to amiodarone 400mg po qd and be seen at his rehab facility this week by cardiology for possible aicd interrogation and further management. patient was then discharged on the same day to in good condition, ambulating and tolerating a ground diet. his inr was therapeutic and he was placed on 4mg of coumadin po qhs; the inr is to be checked twice a week on thursdays and mondays and the coumadin dosage adjusted accordingly. furtermore, he is to be discharged with a 7 day course of levofloxacin 500mg po qd. he is asked to follow-up with dr. in 1 week, dr. in general surgery in weeks. it is also requested that he be seen by cardiology at as mentioned above. medications on admission: verapamil 240mg po q8hrs protonix 40mg po qd mdi-flovent minoxidil discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 2-4 puffs inhalation q6h (every 6 hours) as needed. disp:*qs 1* refills:*0* 2. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*qs 1* refills:*2* 3. salmeterol xinafoate 50 mcg/dose disk with device sig: disk with devices inhalation q12h (every 12 hours). disp:*qs disk with device(s)* refills:*2* 4. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). disp:*qs 1* refills:*2* 5. amiodarone hcl 200 mg tablet sig: two (2) tablet po once a day. disp:*60 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. warfarin sodium 4 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: right lung carcinoma hypertension chronic obstructive pulmonary disease depression benign prostatic hypertrophy diabetes atrial fibrillation constipation hypovolemia discharge condition: good discharge instructions: you may restart any medications taken prior to hospital admission. you may have a regular diet. you may shower. please refrain from any strenuous lifting or activity for at least 1-2 months. followup instructions: please follow-up with dr. (thoracic surgery) in clinic in weeks. please call for an appointment. also, please follow-up with dr. (general surgery) in weeks. please call for an appointment. also, you have been scheduled for the following appointments. please try to keep these appointments: provider: clinic where: cardiac services phone: date/time: 2:00 provider: , md where: cardiac services phone: date/time: 2:30 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Exploratory laparotomy Arterial catheterization Other intubation of respiratory tract Radical dissection of thoracic structures Transfusion of packed cells Diagnoses: Other iatrogenic hypotension Congestive heart failure, unspecified Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Other specified intestinal obstruction Pleurisy without mention of effusion or current tuberculosis Malignant neoplasm of main bronchus Fitting and adjustment of automatic implantable cardiac defibrillator

allergies: sulfonamides attending: chief complaint: shortness of breath major surgical or invasive procedure: picc line placement thoracentesis chest tube placement history of present illness: 73year old man with history of right non-small cell lung ca s/p pneumonetctomy, copd, hypertension, sick sinus syndrome s/p and icd placement, bph, and depression presenting with shortness of breath. the patient had been admitted with dyspnea. extensive work up at that time included cardiac catheterization which showed total occlusion of rca, although no intervention was done. at that time, it was felt his symptoms were multifactorial with contributions from his copd and left sided pleural effusion. he underwent thoracentesis on ; 1300cc bloody fluid was drained. cytology was negative, however, given patient's history, it was still presumed to be malignant. pt subsequently discharged to home. . he presented to the ed with dyspnea and hypoxia, initially on a 100% non-rebreather, with oxygen saturation in the 60%'s. he was subsequently intubated and started on empiric antibiotics for a suspected pneumonia. he also became hypotensive after receiving sedation for intubation and was transiently on pressor support. . he was admitted to teh micu. he remained intubated with difficulty to wean from ventilator. this was again thought to be multifactorial, secondary to multifocal pneumonia, persistent pleural effusion, copd and poor pulmonary reserve s/p lobectomy. . he was treated with a 7 day course of meropenem () for a multifocal pneumonia. he underwent repeat thoracentesis to r/o empyema/help improve respiratory status, which revealed a chylous effusion thought to be due to disruption of thoracic duct during his lobectomy in . a chest tube was placed with persistent output. on , chest tube was changed from suction to wet seal. the patient was started on tpn which theoretically will decrease chylothorax. he was continued on inhalers for treatment of his copd. . the chylous effusion was followed by the pulmonary team, who recommended the patient be kept npo and be treated with 2weeks of tpn. repeat ct showed persistant output. as a result, thoracic surgery was consulted and performed a mechanical pleurodesis. in the sicu, the patient developed a respiratory acidosis and was intubated and extubated on . . sicu course was also notable for complicated left subclavian central venous access attempt with cannulation of the subclavian artery resulting in signficant bleeding and requiring vascular consultation. follow-up ultrasound did not show aneurysm/fistula formation. . on admission the patient was also noted to have a left scapular wound infection, persistent since his lobectomy in , . he was seen by plastic surgery, who recommended treatment with oxacillin which was discontinued. there were no plans for further surgery by the plastics team. he continued to have wound care addressed by the wound care service. past medical history: 1. non-small cell lung ca s/p xrt/chemo in and right pneumonectomy ; c/b chronic left-sided effusion 2. sick sinus syndrome s/p /icd placement 3. copd/bronchiectasis 4. s/p partial colectomy in 5. h/o (+)ppd in , not treated 6. hypertension 7. benign prostatic hypertrophy 8. depression 9. left femoral a-v fistula social history: former tob (~20 pack-yr hx), quit 25 yrs ago. lives with wife. denies etoh use. son & daughter involved in his care family history: denies history of mi no family h/o lung ca physical exam: tc=98.9 p=75 bp=128/47 rr+25 99% on 3 liters i/o 731/420 (am) 2700/2200 gen - nad, aox3, russian-speaking male heart - rrr lungs - decreased breath sounds on left with chest tube in place, wound dressing over right scapula abdomen - soft, nt, nd + bs ext - +2 nonpitting pedal edema bilaterally with bilateral scd pertinent results: 11:43pm ck(cpk)-65 05:56pm urea n-17 creat-0.9 potassium-4.3 04:20pm pleural tot prot-3.1 glucose-128 ld(ldh)-138 triglycer-281 04:20pm pleural wbc-600* rbc-* polys-7* lymphs-76* monos-14* eos-1* mesotheli-2* 02:51pm albumin-2.5* 02:36pm cortisol-14.9 12:30pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 12:24pm ck-mb-notdone ctropnt-0.02* 12:24pm wbc-10.5 rbc-3.65* hgb-8.4* hct-28.6* mcv-78* mch-22.9* mchc-29.3* rdw-18.0* 12:24pm neuts-94.3* bands-0 lymphs-3.1* monos-2.1 eos-0.3 basos-0.2 12:24pm hypochrom-2+ anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-2+ polychrom-occasional stippled-occasional elliptocy-1+ 10:45am wbc-15.2* rbc-3.72* hgb-8.5* hct-29.5* mcv-79* mch-23.0* mchc-28.9* rdw-18.0* 08:35am pt-12.8 ptt-23.0 inr(pt)-1.0 08:35am plt count-364# 08:35am ck-mb-notdone 08:35am ctropnt-0.03* 08:35am ck(cpk)-37* 08:58am lactate-1.3 08:58am type- comments-green top 10:05am lactate-1.3 radiology final report chest (portable ap) 5:58 pm chest (portable ap) reason: eval for re-accumulating / expanding effusion s/p chest tube medical condition: 73 year old man s/p right pneumonectomy w/ left pleural effusion admitted with acute sob now intubated and s/p an ngt placement. reason for this examination: eval for re-accumulating / expanding effusion s/p chest tube to water seal. please take cxr at 6pm (i.e. 6 hours s/p to water seal, thank you). indication: 73-year-old man with history of right pneumonectomy. now with acute shortness of breath. comparison: . single upright portable ap view of the chest: the patient is status post right pneumonectomy, with associated thoracic wall changes and shift of midline structures to the right. additionally, there is fullness of the perihilar vasculature, with left lower lobe atelectasis. a left-sided , median sternotomy wires, and wires in the mid-right chest are unchanged. impression: mild cardiac failure. radiology final report cta chest w&w/o c &recons 10:42 am cta chest w&w/o c &recons; ct 100cc non ionic contrast reason: eval for pe contrast: optiray medical condition: 73m s/p r pneumectomy, with resp distress, intubated reason for this examination: eval for pe contraindications for iv contrast: none. history: 73-year-old man status post right pneumonectomy with respiratory distress. evaluate for pe. comparison: . technique: multidetector axial images of the chest were obtained with iv contrast. 100 cc optiray. coronal and sagittal reformatted images were obtained. ct chest without and with iv contrast: the patient is status post right pneumonectomy. the main and left pulmonary arteries are patent without evidence of filling defects to suggest a pulmonary embolism. there has been interval increase in the left-sided pleural effusion. there has also been development of a left lower lobe consolidation with air bronchograms. there are additional patchy ground-glass opacities in the left upper lobe. the heart, pericardium, and great vessels are stable in appearance. the right hemithorax is stable in appearance. again, noted are enlarged right paratracheal nodes. visualized portions of the upper abdomen are stable in appearance. bone windows: there are no suspicious lytic or sclerotic lesions. again, noted are significant deformities of the right ribs. again, noted are the ett and dual-lead . impression: 1) no pe. 2) left lower lobe consolidation and patchy left upper lobe opacities which are worrisome for pneumonia. 3) interval increase in moderate-sized left pleural effusion. cath () - clean lcx, lmca, lad. rca to with l->r collaterals. unable to intervene on the rca. no significant shunt. . echo () - ef 60%. l->r shunt at rest across the intra-atrial septum. 1+mr, 1+tr. moderate pulm artery systolic htn. . chest ct () - no pe. lll consolidation and lul patchy opacity. interval increase in moderate left pleural effusion. chest (portable ap) 5:39 am findings: ap single view of the chest obtained with patient in semi-upright position is analyzed in direct comparison with the next previous similar study obtained on , (15 hours interval). the left sided chest tubes remain in unchanged position and there is no evidence of pneumothorax. no new parenchymal infiltrates are present. s/p right sided pneumonectomy and left sided permanent pacer with dual electrode system unchanged. ng tube reaches far below diaphragm as before. impression: no significant interval change. brief hospital course: the patient is a 73 year old male with a history of nsclc s/p right pneumonectomy, chemo/xrt and copd, presenting with dyspnea, transferred from thoracic surgical service after vats/mechanical pleurodesis for chylous pleural effusion. for details of hospitalization until transfer, please see history of present illness section. during his hospitalization, the following problems were addressed: # pna: the patient was diagnosed with a pneumonia in the micu and treated with a seven day course of meropenem. on transfer to the floor, he was afebrile with no leukocytosis. in micu, he was thought to have multifocal pna based on imaging although sputum culture was negative. # chylous pleural effusion: the patient presented with significant right pleural effusion. thoracentesis demonstrated a chylous effusion. interventional pulmonology was consulted and stated that the effusion was likely from injury to the thoracic duct during his previous surgery. they placed a chest tube and recommended tpn with octretide to help decrease tryglyceride intake and chylous output. a picc line was placed in the left upper extremity on , and tpn was begun on . the plan was for pleurodesis when drainage was <100 to <125 cc/ day. however, as mentioned, the ct continued to put out a significant amount of fluid and as a result, the patient was transferred to the thoracics service where he underwent a vats and talc pleurodesis on . he was briefly intubated in sicu for respiratory acidosis and was extubated on . the chest tube was pulled with post xray showing possible small apical left pneumothorax. subsequent cxr showed resolution. thoracic surgery signed off prior to discharge and recommended continued dry dressings to the chest tube site. he will continue on tpn, po intake no more than 200cc/day, otherwise npo, with continued octreotide for another week. # copd: he was continued on atrovent and albuterol inharlers per his outpatient regimen. he has poor pulmonary reserve given his pneumonectomy. # chf: the patient has an ef 60%, but likely has a component of diastolic dysfunction. he was diuresed to euvolemia after receiving fluids in the micu and ed for resuscitation. given his elevated bicarb, he was started on diomax in addition to the lasix. once patient was euvelomic, diuretics were discontinued. # htn: the patient's ace and bblocker were discontinued in the sicu as he was hypotensive. he continued to be normotensive off medication. these may be restarted once stable. # cad: patient has a history of cad, no active issues during this hospitalization. he was continued on aspirin. beta-blocker and ace inhibitor held due to blood pressure. once stabilized, he will likely be restarted on these medicaitons and statin. # back wound from previous pneumenctomy: the wound was growing mssa and patient was started in oxacillin (started on ). duration of treatment was determined by wound response, and we monitored lfts q 3-4 days while on oxacillin. oxacillin was discontinued . the plastics stated that low likelihood that the patient would be taken to the or for further debridement and signed off. wound care service was consulted and made recommendations. for details of wound care recc's, please see page 1 summary. # right upper extremity dvt: given the the patient's tenuous status and history of coffee-ground emesis, and low risk of pe and stroke with upper extremity clot no anticoagulation was initiated. # anemia: anemia was originally thought to be due to chronic disease, but when transferred to the floor, patient had stool that was guiac positive. he will be referred to gi for colonoscopy and further work-up once his acute pulmonary issues resolve. his hematocrit was monitored daily and remained stable. # foot drop: patient has a left-sided foot drop, thought to be due nerve injury. he will continue with physical therapy at for further care. # fen: the patient was discharged to rehab on tpn. this should be continued for another week. after that, can be slowly advanced. he should continue on a low triglyceride diet. a video swallow study is being done to evaluate for aspiration risk. # dispo: the patient was discharged to . his son was the primary contact. is a full code. he will follow-up with dr. , his pcp for further care. medications on admission: meds (on admission): 1. lasix 80 mg po daily 2. asa 325 daily 3. atenolol 25 mg po daily 4. protonix 5. colace 6. combivent 7. advair . meds (on transfer from micu): 1. tylenol 325-650 mg po q4-6hr prn 2. albuterol 2 puff ih q4h 3. ecasa 325 mg po qd 4. bisacodyl 10 mg po/pr daily:prn 5. captopril 12.5 mg po tid 6. citalopram 10 mg po qd 7. colace 100 mg po bid 8. heparin 5000 units sc tid 9. ipratropium 2 puff ih q4h 10. lansoprazole 30 mg po qd 11. metoclopramide 10 mg iv q6h prn nausea 12. metoprolol 25 mg po tid 13. morphine 2-4 mg iv q6h: prn 14. oxacillin 2g iv q6h 15. zolpidem 5 mg po qhs: prn . meds on transfer from sicu: insulin sc (per insulin flowsheet) hydromorphone 1 mg sc q6h:prn pain octreotide acetate 100 mcg sc tid start: start with next dose sucralfate 1 gm po qid ipratropium bromide neb 1 neb ih q6h albuterol 0.083% neb soln 1 neb ih q6h:prn citalopram hydrobromide 10 mg po daily metoclopramide 10 mg iv q6h:prn nausea aspirin ec 325 mg po daily ipratropium bromide mdi 2 puff ih q4h albuterol 2 puff ih q4h bisacodyl 10 mg po/pr daily:prn constipation docusate sodium 100 mg po bid discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). disp:*1 inh* refills:*2* 2. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). disp:*1 inh* refills:*2* 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. heparin sodium (porcine) 5,000 unit/ml solution sig: five (5) thousand units injection q8h (every 8 hours): for dvt prophylaxis. 7. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 8. metoclopramide 10 mg iv q6h:prn nausea 9. octreotide acetate 0.1 mg/ml solution sig: one (1) hundred micrograms injection tid (3 times a day). 10. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po daily (daily). 11. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). 12. insulin regular human 100 unit/ml solution sig: one (1) unit injection asdir (as directed): units per sliding scale: 200-250 2units 251-300 4units 301-350 6units. 13. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: - discharge diagnosis: primary: chylous pleural effusion (likely from thoracic duct injury) secondary: non-small cell lung ca copd sick sinus syndrome hypertension benign prostatic hypertrophy s/p partial colectomy depression discharge condition: stable discharge instructions: please call your doctor or come to ed if you develop chest pain, shortness of breath, nausea/vomiting, or fevers >101.3 followup instructions: provider: , .d. where: phone: date/time: 10:20 provider: call where: none cardiac services phone: date/time: 9:15 provider: call where: none cardiac services phone: date/time: 9:15 provider: clinic where: cardiac services phone: date/time: 11:00 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Transpleural thoracoscopy Transfusion of packed cells Scarification of pleura Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Other postoperative infection Congestive heart failure, unspecified Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of bronchus and lung Acute respiratory failure Automatic implantable cardiac defibrillator in situ Cardiac pacemaker in situ Hemorrhage of gastrointestinal tract, unspecified Other noninfectious disorders of lymphatic channels

allergies: sulfonamides attending: addendum: below are addended recommendations for weaning from mechanical ventilation. major surgical or invasive procedure: tracheostomy brief hospital course: respiratory failure aspiration/weakness: recommendations: during his hospital course, mr. respiratory failure was predominantly one of poor ventilation rather than oxygenation. his ventilatory difficulties were to respiratory muscle weakness of unclear etiology as well as his aspiration pneumonia. as pt continues to recover strength during rehab, the pt's plan of care should aim for the discontinuation of mechanical ventilation. we would plan a continued pressure support wean with intermittent trach-collar trials discharge disposition: extended care facility: - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Other gastroscopy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Transfusion of packed cells Diagnoses: Other primary cardiomyopathies Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of bronchus and lung Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Septic shock Automatic implantable cardiac defibrillator in situ Cardiac pacemaker in situ Septicemia due to anaerobes Unspecified hereditary and idiopathic peripheral neuropathy

allergies: sulfonamides attending: chief complaint: cardiac ischemia major surgical or invasive procedure: intubation peg placement history of present illness: 73 yo man w/ recent admit for dyspnea attributed to chf and pna/copd exacerbation and recent c. diff admitted with dyspnea. in ed received asa, 40 iv lasix, nitro gtt, lopressor for chf; azithro/ctx solumedrol/neb for possible copd exacerbation. cta (-) pe. admitted to . on (+) troponin (peak 0.61), cks am, had cp and dyspnea and was intubated for ?pulmonary edema. 2 mm ste v1-v4 with twi anterolaterally -> ccu. cath with non-occlusive dz (known to rca) and apical ballooning. extubated ; re-intubated when became hypoxic (o2 40%) and apneic following s&s eval. neuro concerned for bulbar weakness/nmj defect (mg, lems). lp (-), emg c/w diffuse axonal polyneuropathy. self-extubated 7:30 a.m., after which had apneic episodes up to 1 min, for which he was intubated. course also c/b right sc arterial cannulation during attempted rsc cvl placement. head ct w/ and w/o contrast (-) for acute process. past medical history: 1. non-small cell lung ca s/p xrt/chemo in and right pneumonectomy ; c/b chronic left-sided effusion 2. sick sinus syndrome s/p /icd placement 3. copd/bronchiectasis 4. s/p partial colectomy in 5. h/o (+)ppd in , not treated 6. hypertension 7. benign prostatic hypertrophy 8. depression 9. left femoral a-v fistula social history: currently residing in rehabilitation facility since last admission. prior to last admission, lived at home. good support. daughter and wife at the bedside. he is russian speaking, but daughter and wife speak . prior to last admission, had been somewhat active ?????? he could climb one flight of stairs without sob. since the last admission, he has been mostly in bed, with minimal activity out of bed, with assistance. history of tobacco use. quite 25 years ago after 20yrs x 1 pack/year (20 pack year hx) denies etoh, past or present. denies drugs. family history: denies history of mi, diabetes father died of stomach cancer mother died of ??????old age?????? no family h/o lung cancer physical exam: t96.6 hr80s-120s 80s-120s/60s-70s gen: intubated, awake, not following commands heent: perrl, mmm, anicteric sclera, et in place, neck supple card: tachycardic, sm heard beast at lusb chest: absent breath sounds right, rhonchourous diffusely on left abd: soft, nt, nd +bs ext: w/wp, 2+ dp b/l neuro: not following hand signal commands, withdraws to painful stimuli in ue and rle but not lle 1+ dtr in b/l pertinent results: 09:15pm urine color-yellow appear-clear sp -1.010 09:15pm urine blood-mod nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 09:15pm urine rbc-0-2 wbc-0 bacteria-none yeast-none epi-0 09:15pm urine mucous-few 08:10pm alt(sgpt)-10 ast(sgot)-23 ld(ldh)-225 ck(cpk)-30* alk phos-67 amylase-29 tot bili-0.4 08:10pm neuts-81* bands-2 lymphs-11* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:10pm neuts-81* bands-2 lymphs-11* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:10pm neuts-81* bands-2 lymphs-11* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:10pm pt-13.7* ptt-23.9 inr(pt)-1.2 tte: mildly dil ra with l-> r shunt across asd. ef 25%. mid-distal septak ak, apical ak, inf ak/hypok, mid-to distal nterolateral hypok/ak. brief hospital course: a/p: 73m with h/o nsclc s/p pneumonectomy, chf (lvef 25-30%), copd, presents with stemi likely apical ballooning syndrome and respiratory failure. 1) respiratory failure: pt initially p/w likely aspiration/pna superimposed on underlying pulmonary disease (s/p right pneumectomy, copd). following pt's catheterization on , pt was intubated and transferred to ccu. pt was extubated on the same day. pt was re-intubated on when became hypoxic (o2 40%). pt self extubated after which he became he had apnic episodes lasting up to one minute, for which he was re-intubated. pt received several dose of diamox given concern for decreased respiratory drive metabolic alkalosis. pt continued to fail pressure support trials apnea so trach placed on . pt again failed ps trial on day prior to discharge as pt became tachy with high rr (40s) on ps of 18. pt's present vent settings now ac vt 350 rr 22 fi02 0.25 peep 5. 2) stemi: on pt had elevated tpn level and ekg with ste v1-v4 with twi. on pt had acute chest pain and received cardiac catheterization which revealed only mild disease except known disease to rca with good collaterals and apical ballooning. elevated troponin levels attributed to apical ballooning vs. coronary vasopspasm. pt transferred to the ccu to intubation. in micu pt has been continued on asa. ace and bb held for septic shock. pt now back on ace-i. to be placed on bb post-d/c. 3) septic shock: on pt spiked a fever c. diff (+) with mrsa in urine/sputum. pt's sbps dropped to 70s with leukocytosis. pt given large volumes of fluid and placed on a titrated dose of levophed. pt placed on vanco for mrsa and flagyl for positive c. diff toxin. pt's volume status by maps and cvps resolved. pt off levophed since , afebrile, with resolving leukocytosis on vanco/flagyl. 4) neuromuscular weakness: due to pt's apneic episodes, there was a concern for apneic episodes/bulbar weakness during prior extubation. no current apneic episodes given le weakness and ?lue weakness, neuro suggested l&t spine ct and repeat head ct which were done on and were negative. an emg performed on was c/w general axonal sensorimotorpolyneruopathy, ?superimposed proximal myopathy; not c/w nmj disorder (lems or mg), though the study was limited. (-)mg ab; le panel negative; anti- pending. . 5) chf, ef 30%: diuresis was held due to septic shock/ hypotension. pt is presently 24l positive. pt restarted on lasix 10-20 mg qd on once his pressors were d/c'd. pt restarted ace-i on and has been titrated up to present dose. 6) right scapular wound: pt has had chronic wound since pneumonectomy. pt was continued on dressing changes. 7) f/e/n: pt on tube feeds by og throughout majority of hospital course. peg placed without complications on by gi. 8) ppx: pt on ppi and subq heparin throughout hospital course. 9) comm: son (cell phone). wishes to be called w/ all changes. 10) code: full medications on admission: atenolol 25 mg qd asa 325 mg q feso4 325 qd lasix 40 qd nitrofurantoin 100 mg qd acetazolamide ? dose lisinopril 5 mg qd discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 3. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 5. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 6. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day): is day 8 of 21 day course. pt's course to be completed on . 7. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 8. toprol xl 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day: pt can be titrated up on bb as tolerated. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: 1. respiratory failure s/p trach and peg 2. mental status changes, unclear etiology 3. neuromuscular weakness, unclear etiology 4. c diff colitis 5. mrsa pneumonia 6. chf, systolic dysfunction, ef 25% 7. stemi in setting of hypotension, resp failure secondary diagnoses: 1. cad s/p unsuccessful stenting of prca in 2. nsclc s/p xrt/chemo and r pneumonectomy 3. sss s/p /icd placement 4. copd/bronchiectasis 5. s/p partial colectomy in 6. h/o (+)ppd in , not treated 7. hypertension 8. benign prostatic hypertrophy 9. depression 10. left femoral a-v fistula discharge condition: stable, 98% on pressure support 15/5 discharge instructions: please take all medications as prescribed and go to all follow-up appointments. followup instructions: provider: , .d. where: phone: date/time: 9:30 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Other gastroscopy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Transfusion of packed cells Diagnoses: Other primary cardiomyopathies Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of bronchus and lung Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Septic shock Automatic implantable cardiac defibrillator in situ Cardiac pacemaker in situ Septicemia due to anaerobes Unspecified hereditary and idiopathic peripheral neuropathy

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: diaphagmatic hernia with left lung collaspe and decompression major surgical or invasive procedure: flexible and rigid bronch for therpauetic aspiration and stent placement. diaphragmatic hernia repair and g-tube placement history of present illness: ms. is an unfortunate 55-year-old woman with mild mental delay and obesity who also has kyphoscoliosis and pulmonary hypertension. she presented with a dense left pneumonia and was found to have very large pulmonary arteries but also her entire stomach in a transverse fashion in the thorax with associated omentum and transverse colon, representing a type 4 hernia. this distended stomach compressed the left main bronchus against the pulmonary artery and resulted in total collapse of the left lung. she was palliated with a silicone stent and aggressive daily bronchoscopy to re-aerate the left lung and improve her hypoxemia. it was recommended that she undergo reduction and repair of this large paraesophageal hernia. past medical history: hiatal hernia, asd, pah, mr, osa, seizure disorder, low b12, scoliosis; s/p open ccy social history: developmentally delayed lives in group home - her brother is her guardian family history: unknown physical exam: general: realatively well appearing scoliotic woman in nad heent: no dentition, neck supple, scoliotic. chest: clear on right, decreased throught on left abd: obese, round, soft, nt, nd extrem: no le edema neuro: pleasant and , developmentally delayed, answers questions approp. pertinent results: ct scan: impression: 1. large amount of retained secretions causing near complete occlusion of left mainstem bronchi stent with complete left lung collapse and corresponding leftward mediastinal shift. small-to-moderate left pleural effusion is not significantly changed from examination. 2. unchanged appearance to dilatation of the pulmonary arteries consistent with underlying pulmonary arterial hypertension. 3. slightly decreased findings of anasarca and haziness of the upper abdomen mesentery. unchanged appearance to known hiatal hernia. resolution of small adjacent pneumothorax. cxr chest, one view: comparison with . slight improvement in the complete collapse of the left lobe, though the distal portion of the left main stem bronchus is still not well-visualized. right lung appears better aerated today; there is some residual fluid and/or atelectasis near the minor fissure. cardiac, mediastinal, and hilar contours are not well evaluated, but the visualized portion is probably unchanged. osseous structures are similar to previous study. brief hospital course: pt was admitted on a chest xray revealed severe tracheobronchomalacia. the left bronchial tree is totally obstructed, whether by severe bronchomalacia, or by a long stricture is not clear. the left lung is collapsed. large hiatal hernia containing the entire stomach as well as a loop of colon. markedly dilated pulmonary arteries. after some discussion w/ interventional pulmonogy it was decided to place a silicone stent in the left main stem bronchus to improve aeration prior to surgical hernia repair. after agressive pulmonary tiolet pt was taken to the or for esophagogastroscopy,laparotomy with reduction of type 4 hiatal hernia, repair of hiatus, toupet partial fundoplication,tube gastrostomy, toilet bronchoscopy. post op course was complicated by prolonged intubation for pulmonary toilet in the sicu. pt was then successfully extubated and remained hemodyamnically stable and was transferred from the icu. she continued to require aggressive pulmonary toilet w/ serial flexible bronchoscopies for therapeutic aspiration of left lung. despite aggressive bronchs for pul toilet the secretions in the left lung did not clear. all bal's were neg and wbc remained flat. the decision was made to remove the silicon stent as secretions were accumulating in the stent further complicating the problem. her cxr showed minimal aeration in the upper lobe post stent removal. attempts were made to open the left lung with non-invasive ventilation, chest pt, and obtaining a thera-vest (the latter could not be obtained in the hospital, but is recommended as an outpatient) she progressed well for an operative standpoint. she is currently reg diet avoiding caffiene, carbonation, and sweet juices. her g-tube is a surgical gastric anchor and will remain in place for 1-2 months andwill be managed by dr. in follow up. the g-tube should not be used for feedings but should be flushed at least daily. the surgical abd incision opened slightly at the midportion and is clean and granulating well w/o any signs of infection. she will be discharged to a rehab/ facility where she should reside for less than 30 days. medications on admission: augmentin 875", flagyl 500''', prednisone 40, bumex 1, prozac 20, folic acid, gabapentin 600", seroquel 200am/300hs, calcium, protonix 40, actonel 35 qmon, mvi, colace, albut/atrov neb . discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 3. bumetanide 2 mg tablet sig: 0.5 tablet po daily (daily). 4. gabapentin 300 mg capsule sig: two (2) capsule po bid (2 times a day). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. fluoxetine 10 mg capsule sig: two (2) capsule po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 10. quetiapine 100 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). 11. quetiapine 100 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 12. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 13. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 14. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q8h (every 8 hours) as needed. 15. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 16. guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid (2 times a day) as needed for stent management. 17. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 18. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation q6h (every 6 hours). 19. acetylcysteine 10 % (100 mg/ml) solution sig: 1-10 mls miscellaneous q4-6h (every 4 to 6 hours) as needed for stent management. 20. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: of discharge diagnosis: hiatal hernia, asd, pah, mr, osa, seizure disorder, low b12, scoliosis; s/p open ccy left main bronchial silicon stent- stent removed diaphragmatic hernia repair w/ g-tube placement discharge condition: deconditioned discharge instructions: please call dr. office if you develop chest pain, worsening cough and congestion, fever, chills, nausea, vomiting or diarrhea, redness or drainage from your surgical incision or g-tube site. the g-tube is not to be used for feeding. please flush g-tube every 8hrs w/ 50cc water. followup instructions: you have a follow up appointment with dr. on at 10:30am in the clinical center . please arrive 45 minutes prior to your appointment for a cxr on the . you have a bronchoscopy with dr. on 11am. please report to surgical day care on one at noon. do not eat or drink after midnight the night before your bronchoscopy. Procedure: Fiber-optic bronchoscopy Fiber-optic bronchoscopy Fiber-optic bronchoscopy Fiber-optic bronchoscopy Other bronchoscopy Other bronchoscopy Other lavage of bronchus and trachea Non-invasive mechanical ventilation Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other gastrostomy Other procedures for creation of esophagogastric sphincteric competence Diagnoses: Pneumonia, organism unspecified Other convulsions Pulmonary collapse Ostium secundum type atrial septal defect Unspecified sleep apnea Primary pulmonary hypertension Other specified disorders of stomach and duodenum Other diseases of trachea and bronchus Diaphragmatic hernia with obstruction Moderate intellectual disabilities Other anomalies of spine

sx: phone numbers on trauma sheet not working for next of . pt stating he does not want anyone to know he is here. he does not believe he has any pmh or allergies. r: off sedation, , neuro status intact however remains concerning. p: team to discuss plan mom. scale in place. continue with close monitoring and management, pt . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Arterial catheterization Diagnoses: Open wound of scalp, without mention of complication Other respiratory abnormalities Unspecified contusion of eye Cortex (cerebral) contusion without mention of open intracranial wound, with no loss of consciousness Acute alcoholic intoxication in alcoholism, unspecified Open wound of hand except finger(s) alone, without mention of complication Other accidents

allergies: penicillins attending: chief complaint: known aortic stenosis with worsening left sided chest pain, fatigue and doe major surgical or invasive procedure: s/p avr(23mm ce pericardial) and mv repair history of present illness: mrs. is an 83 yo with known severe aortic stenosis and a few month h/o worsening doe, fatigue and left sided chest pain. cardiac catheterization showed 0.5cm2, moderate mr and no coronary artery disease. she was refered to dr. for operative management past medical history: pernicious anemia oa gerd hiatal hernia s/p l lobectomy s/p cholecystectomy s/p l leg vein stripping pertinent results: 06:40am blood hct-33.7* 07:10am blood wbc-6.6 rbc-3.51* hgb-11.0* hct-31.9* mcv-91 mch-31.4 mchc-34.5 rdw-13.1 plt ct-169 07:10am blood plt ct-169 06:40am blood glucose-101 urean-24* creat-1.0 na-139 k-4.6 cl-101 hco3-30* angap-13 brief hospital course: mrs was admitted to on and taken to the operating room with dr. for an avr/mv repair. she tolerated the procedure well and was transferred to the icu in stable condition. she was weaned and extubated without difficulty. postoperatively she had a good cardiac output, but had persistent hypotension for which she required neo synephrine. during this time she also had some sinus/junctional bradycardia and required atrial pacing. the neo synephrine was weaned to off by pod#6 and her sinus rhythm had returned. she was transferred from the icu to the floor, was started on lopressor without difficulty, and her epicardial pacing wired were removed without incident. she was started on lasix for diuresis and responded appropriately, although she was very fluid overloaded. it was determined by physical therapy that she would benefit from a stay at short term rehab, and on pod#8 she was cleared for discharge to rehab. medications on admission: atenolol 50mg daily omeprazole 20mg daily hctz 12.5mg daily feso4 325mg daily lipitor 10mg daily b12 injections monthly discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 2 weeks. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 5. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 8. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 9. ferrous sulfate 325 (65) mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: at discharge diagnosis: aortic stenosis s/p avr pernicious anemia osteoarthritis gerd s/p l lobectomy s/p cholecysetectomy s/p l leg vein stripping discharge condition: good discharge instructions: you may take a shower and wash your incision with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month followup instructions: follow up with dr. in weeks follow up with dr. in weeks follow up with dr. in weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Annuloplasty Diagnoses: Other iatrogenic hypotension Esophageal reflux Unspecified essential hypertension Thoracic aneurysm without mention of rupture Cardiac complications, not elsewhere classified Other specified cardiac dysrhythmias Mitral valve insufficiency and aortic valve stenosis Pernicious anemia

history of present illness: this is a 75-year-old male with a history of diabetes, who originally presented to the c-med service on with epigastric pain/pressure/diaphoresis, in addition to nausea, vomiting, and shortness of breath. he was found to be initially hypotensive to 85/33 with a pulse of 60. the patient was treated at an outside hospital with one-half dose of tpa, in addition to receiving heparin, nitroglycerin, and dopamine. the patient's ekg, at the time, was 100% v paced. his ck peaked at 233 with an mb of 19, an mb index of 35.6, and a troponin of 44.8. the patient went to catheterization on . at catheterization, he had right atrial pressures of 14, rv pressure of 35/10, pa pressures of 35/17, and a wedge of 22. patient was noted to have a mid left circumflex 90% occlusion, status post insertion of drug eluding stent with resultant timi-3 flow. patient was also noted to have moderate diffuse disease in the lad, and a small mild diffuse disease in the rca. echocardiogram on showed an ef of 60%, asymmetric lvh, and hypokinesis of the inferior and posterior walls, in addition to mild pulmonary artery hypertension. on , the patient was asked to be evaluated by the ccu team. he had spiked a fever up to 102.8. at that time, he flipped into atrial fibrillation with rates up to 130. the patient was noted to have an episode of respiratory distress and chest tightness times 90 minutes. patient was never hypoxic. patient received iv lopressor times two. the patient continued in atrial fibrillation at a lower rate of 90-100, but was noted to have mean arterial pressures of 50-60. currently, the patient is symptom free. he denies any headache, neck stiffness, cough, chest pain, shortness of breath, pleuritic pain, abdominal pain, diarrhea, gu symptoms, rash, joint pain. chest x-ray from was clear, ua was negative, and blood cultures were drawn. the patient was started empirically on vancomycin and levofloxacin for fear of sepsis. he also received a total of 2.5 liters of normal saline. the patient's blood pressure did not initially respond to the fluids on the floor and, for this reason, he was transferred up to the ccu. past medical history: 1. diabetes. 2. sick sinus syndrome, status post pacemaker placement in , replaced in , patient is av paced. 3. chf with peripheral edema. 4. hard of hearing. 5. hiatal hernia. 6. glaucoma. 7. history of dvt/pe. medications: 1. dilantin, 200 mg po b.i.d.. 2. nitroglycerin, p.r.n.. 3. lasix, 40 mg po q d. 4. aldactone, 50 mg po q d. 5. metformin, 500 mg po q h.s.. 6. glyburide, 5 mg po q a.m.. 7. xalatan. allergies: no known drug allergies. social history: the patient has a 10 pack year history of smoking, quit in the 's. patient has rare alcohol use. family history: negative for cad, although the patient has one brother with diabetes. physical examination: vitals: temperature 97.7, pulse 83, blood pressure 91/51. oxygen saturation 97% on room air. in general, the patient is in no apparent distress, no respiratory distress or use of accessory muscles. heent: mucous membranes moist, perrla, eomi. lungs: clear to auscultation bilaterally, no wheezes, crackles or rhonchi. cardiovascular: irregularly irregular, no murmurs. abdomen: soft, nontender, nondistended, normoactive bowel sounds. extremities: no cyanosis, clubbing or edema. neuro: alert and oriented times three. laboratory/diagnostics: white count 6.2, hematocrit 33.8, platelets 149. sodium 132, potassium 4.0, chloride 98, bicarbonate 22, bun 12, creatinine 0.7, glucose 154, calcium 8.7, magnesium 1.7, phosphorus 2.8. urinalysis: moderate blood, 0-2 red blood cells, 0-2 white blood cells, 0-2 squamous epithelial cells. blood cultures from : no growth. urine culture from : no growth. hospital course: in short, this is a 75-year-old male with diabetes, sick sinus syndrome, status post inferior mi with drug eluded stenting of the left circumflex artery, who now presents with fever up to 102.8 with hypotension, change from av pacing to atrial fibrillation which is new. 1. cad: as already noted, patient is status post imi. ekg showed q waves in the inferior leads. the patient was continued on aspirin, plavix, and lipitor. with this acute fever and hypotensive episode, in addition to the new atrial fibrillation, the patient's ck rose up to 790, but with a negative mb. the patient was able to be started on beta blocker which was titrated up. 2. hypotension: it is still somewhat unclear why the patient became hypotensive. the most probable explanation is that he became transiently bacteremic with a drop in his svr. there was no bleeding at the right femoral catheterization site. the patient did not initially respond to fluids on the floor but, after getting about three liters, he was able to keep his mean arterial pressure greater than 60. the patient never required pressors for blood pressure support. 3. rhythm: the patient was noted to be in new onset atrial fibrillation. this was likely secondary to his transient bacteremia. the patient initially had a rapid ventricular response, but responded well to lopressor, in addition to fluids. the patient spontaneously converted out of atrial fibrillation and was, once again, av paced. he was initially started on heparin for the atrial fibrillation. while we cannot totally rule out that the patient does not have paf, we did not feel like he needed long-term anticoagulation at this point. this should be readdressed as an outpatient. 4. id: patient spiked a fever up to 102.8. there was no localizing source of infection, no elevated white blood cell count. given the hypotension, he was empirically started on levofloxacin and vancomycin. given the negative culture data times 72 hours, the vancomycin was stopped. the patient was continued on a seven day course of levofloxacin. other sources of fever were considered but, given the rigors and the high temperature, bacteremia is most likely. condition on discharge: good. discharge medications: 1. tylenol, 325 mg po q 4-6 hours p.r.n.. 2. aspirin, 325 mg po q d. 3. xalatan. 4. lipitor, 10 mg po q d. 5. dilantin, 200 mg po b.i.d.. 6. plavix, 75 mg po q d times 12 months. 7. lopressor, 12.5 mg po b.i.d.. 8. levofloxacin, 500 mg po q d through . 9. metformin, 500 mg po q a.m.. 10. glyburide, 5 mg po q a.m.. 11. aldactone, 50 mg po q d. discharge instructions: the patient should follow-up with his pcp, addition to his cardiologist, dr. , within one week. the patient was instructed to see a doctor if he experienced any chest pain, shortness of breath, fevers or chills, nausea or vomiting, excessive sweating or dizziness. patient's lopressor dose should be titrated up as tolerated. in addition, he should be started on an ace inhibitor, given that he is post mi. diagnoses: 1. status post inferior mi, status post cardiac catheterization with stenting of left circumflex artery. 2. hypotension secondary to presumed transient bacteremia. 3. transient atrial fibrillation. 4. diabetes. 5. sick sinus syndrome, status post pacer. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Arterial catheterization Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Atrial fibrillation Acute myocardial infarction of inferolateral wall, initial episode of care Cardiac pacemaker in situ

history of present illness: this 69-year-old gentleman had a known history of mitral valve prolapse and a history of severe mitral regurgitation and congestive heart failure, who was referred in by dr. for outpatient cardiac catheterization prior to having surgical repair of his mitral valve. he is admitted to on after an episode of pnd and orthopnea. he was treated for congestive heart failure with diuretics. echocardiogram was done at that time which showed 4+ mitral regurgitation with partial leaflet flail and 1+ ai. his ejection fraction at that time was 55%. he then went home and returned for cardiac catheterization. past medical history: 1. mitral regurgitation. 2. congestive heart failure. 3. hypertension. 4. hypercholesterolemia. 5. epistaxis. 6. prostatism. 7. a-v nodal reentry tachycardia status post a-v nodal modification in . 8. status post tonsillectomy. allergies: he had no known allergies. preoperative laboratory work: white count of 6.9, hematocrit of 35.2, platelet count of 196,000. sodium 145, potassium 3.5, chloride 106, co2 28, bun 24, creatinine 1.1. medications at catheterization: 1. aspirin 81 mg po q day. 2. captopril 12.5 mg po tid. 3. lasix 10 mg po q day. 4. multivitamin one a day. 5. lipitor 20 mg po q day. 6. proscar 5 mg po q day. 7. terazosin 2 mg po q day. 8. ferrous sulfate q day. 9. 60 mg po bid. 10. aciphex 20 mg po q day. 11. potassium meq replacement q day; he was unsure of his dose. preoperative electrocardiogram: normal sinus rhythm with occasional pvc and an intraventricular conduction delay. preoperative chest x-ray: mild congestive heart failure with some peribronchial cuffing. please refer to the report from . he was seen by dr. and was seen dr. of cardiothoracic surgery in preparation for his minimally invasive mitral valve repair. his cardiac catheterization on showed normal coronary arteries with an ejection fraction of 55% and + mitral regurgitation. physical examination: on examination, he was in sinus rhythm with ectopic beats at 60, his blood pressure is 130/80. his distal peripheral pulses were intact. his chest was clear. heart sounds were normal with a mitral systolic murmur. no peripheral edema. his abdominal examination was benign. his right femoral catheterization site was not completely sealed at the time. on , he underwent mitral valve repair through minimally invasive approach by dr. , dr. , and dr. . please refer to the operative note. the valve had a quadrangular resection of the posterior leaflet and a 28 mm annuloplasty ring was placed. on postoperative day one while he had some ectopy and was a-paced with a blood pressure of 101/45, he started his aspirin. he was extubated the evening prior with a respiratory rate of 15, sating 98% on 40% face mask, white count of 14.5, hematocrit of 28. postoperative laboratories 149 sodium, potassium 4.6, chloride 109, co2 22, bun 21, creatinine 0.8, blood sugar of 149. he began lasix diuresis. his diet was advanced, and his chest pt was begun. he was seen by physical therapy and transferred out to the floor on postoperative day one, and was switched over to oral pain medications. he was seen by physical therapy to begin his ambulation. he was fairly independent in all of his activities. he had a little bit of serosanguinous drainage from his right chest tube. on progress notes from the ct surgery team for , 25th, and 26th, appear to be missing from the chart. patient had a junctional rhythm over 3.5 days as well as a fever which was treated with tylenol. he had one episode of supraventricular tachycardia. dr. , cardiology, mentioned that a permanent pacer may be a possibility, but would off to make sure that there was no infection involved with the fever. his heart rate was in the 60s down to 50s in the junctional rhythm. he continued with his external pacing. he is ambulating around the halls and tolerating his postoperative physical therapy well. his lungs were clear with a faint systolic rub. his blood pressure was 130/80 on the morning of the 27th. on postoperative day five, he was doing well. his chest tube had been discontinued the day prior. he did not require any pacing overnight. his underlying rhythm was sinus bradycardia, and he has come out of his junctional rhythms for very brief periods. he was in sinus rhythm in the 60s with the time of examination of 142/66, respiratory rate of 18, was sating at 96% on room air. his heart was regular, rate, and rhythm at the time. his lungs were clear bilaterally. his lungs were benign. he is still being monitored for the potential need of a pacemaker due to his junctional rhythm and bradycardia. on postoperative day six, he had maintained long periods of sinus rhythm overnight alternating with junctional rhythm with no episodes of either tachycardia or bradycardia. he was hemodynamically stable with a white count of 8.2, hematocrit of 23.1. his lungs were clear. his abdominal examination was benign. his chem-7 was within normal limits. his magnesium was 1.9. he continued to spend more time in sinus rhythm rather than junctional and continued to be hospitalized for monitoring his need for pacemaker. he was started on low dose lopressor to help control his rate as per dr. . he had an episode of atrial fibrillation that morning with a rapid rate, and was seen by dr. at that time. on postoperative day seven, he persisted in atrial fibrillation at a rapid rate. he received iv amiodarone, his beta blockers were discontinued with a plan to have a dual chamber pacemaker placed the following day. his heparin was discontinued. on , postoperative day seven, the patient continued to be in atrial fibrillation which was rate controlled. most of the time he was given 150 mg iv amiodarone bolus with no conversion to normal sinus rhythm and no significant change. he was tolerating his lopressor well at decreased dose, iv heparin continued, and he remained in atrial fibrillation with blood pressure of 116/70. his lungs are clear. his abdominal examination was benign. his incision was healing nicely. his lopressor was continued. his heparin was to be shut off at 2 am that night for pacemaker placement in the morning. on the 31st, he had good hemodynamics with no symptoms. heparin was off, 1 unit of packed red blood cells was given for his hematocrit. he remained in atrial fibrillation as previously noted, to receive a pacemaker that day. his lopressor was continued at 12.5 mg po bid and to continue on oral amiodarone. planned for discussion with cardiology. he had a dual chamber pacemaker and planned it for the 31st with dr. of cardiology with additional recommendations by dr. for management of his amiodarone. he was seen by case management on the 31st with a plan to have him go home and have care by vna services. pacemaker check was done with interrogation on , day of discharge by cardiology, and the patient was discharged to home with vna services on . discharge medications: 1. aspirin 325 mg po q day. 2. colace 100 mg po bid. 3. tylenol 325 mg two tablets po prn q4-6h. 4. percocet 5/325 1-2 tablets po prn q4-6h for pain. 5. atorvastatin 20 mg po q day. 6. ferrous sulfate 325 mg po q day. 7. vitamin c 500 mg po bid. 8. metoprolol 50 mg po bid. 9. coumadin 5 mg po q day. 10. amiodarone 200 mg po bid. 11. ibuprofen 400 mg po prn q6h as needed. follow-up instructions: the patient was instructed to have followup with dr. cardiology of cardiology for his inr and anticoagulation status and coumadin dosing as well as followup for his arrhythmia and pacemaker placement. he was also instructed to followup with dr. in one month in the office. he was discharged with vna services and of hearts monitor. in addition, he was to followup with cardiac services for his of hearts monitor evaluation, the center on , and to followup with dr. of ophthalmology on . the patient was instructed that dr. would be following his coumadin dosing and inr blood draws. discharge diagnoses: 1. status post minimally invasive mitral valve repair. 2. status post pacemaker insertion. 3. hypertension. 4. hypercholesterolemia. 5. status post congestive heart failure. 6. epistaxis. 7. prostatism. 8. arteriovenous nodal modification in . 9. status post tonsillectomy. discharge status: again the patient was discharged to home on . , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Atrial cardioversion Annuloplasty Diagnoses: Anemia, unspecified Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension Atrial fibrillation Personal history of tobacco use Other specified conduction disorders Other specified complications of procedures not elsewhere classified

history of present illness: the patient is a 74-year-old woman status post a left internal carotid artery angioplasty and stent placement. the patient was admitted to the icu status post stenting of the carotid artery on the left side with no intraprocedure complications. she was on a heparin drip overnight. she was awake, alert, and oriented x3. pupils were equal, round, and reactive to light. she had no nystagmus. she was following commands. she had a mild left ptosis with pupils, right was 3 down to 2.5, and left 2.5 down to 2. her facial strength was intact. she had no droop. her tongue was midline. she had no drift. she had strong femoral and pedal pulses. she was neurologically intact. started on aspirin 325 mg q.d. and plavix 75 mg p.o. q.d. she was out of bed postprocedure day number one, advancing diet. she had a 12-lead ekg, which showed no changes. she was on some levophed, which was weaned off and she was transferred to the regular floor on postprocedure day number one. on , she again was awake, alert, and oriented x3 with no headache, dizziness, or visual changes. eoms were full. face symmetric. no drift. strength was in all muscle groups. she was out of bed, ambulating, using an incentive spirometer. she was discharged to home on in stable condition on plavix and aspirin and followup with dr. in two weeks. discharge condition: her condition was stable at the time of discharge. , Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Unspecified essential hypertension Occlusion and stenosis of carotid artery without mention of cerebral infarction Other specified cardiac dysrhythmias

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: code stroke major surgical or invasive procedure: tee tpa history of present illness: ms is a 79 year old woman with a hx of htn and osteoarthritis who presents with recent onset of slurred speech and left sided weakness. . she says that she was feeling well until this afternoon when her left arm "wasn't doing what she wanted it to do." she estimates the time of symptom onset as 3pm, at the earliest. she was apparently trying to start dinner preparation when she noted that her left arm and hand was weak/incoordinated. she was unable to grasp some spinach with her left hand. she tried to grab on to a nearby chair with her left hand, but was not able to reach the chair or pull it towards her. she gradually fell to the floor when she lost her balance (she denies any trauma). when she tried to get up, she was unable to do so. she laid on the floor for about 30 minutes, when her son in law arrived home. he found her awake, lying on her left side in the kitchen. her speech was very slurred and difficult to understand. he helped her to sit up and called the patient's daughter who is an physician in . she told them to call 911. ems found her with slurred speech, dysarthria, and left sided weakness. her vitals in the field were: 160/90 88 fsg 107. . on ros, she denies recent illness. denies headache, neck pain, fever/chills, shortness of breath, chest pain, palpitations, n/v, or dysuria. . ed course: code stroke was called at 4:35 and the patient arrived in the ed at 4:45. i was present at the bedside when she arrived. initial neurologic exam (see below) revealed nihss = 5. she was taken to the ct scan at 5:00 pm. i read the ct at 5:05 and it was negative. coags were sent and were available around 5:15 (normal). risks and benefits were discussed with the patient who consented to t-pa, but asked me to call her daughter in who is an physician. daughter agreed to if we felt that it was indicated. past medical history: htn osteoarthritis no recent surgeries, no known hx of gi bleed (though daughter suspected 3 ago due to overuse of asa). social history: she lives in and was in visiting her daughter and grandchildren (due to fly bac to mi on saturday). she has 7 children. independent at baseline. no hx of tob, etoh or drugs. family history: grandmother had stroke late in life. no other neurologic problems in the family. miscarriages (2mo age). physical exam: t-afeb bp-200/100 hr-78 rr-18 o2sat-98% gen: lying in bed, nad heent: nc/at, moist oral mucosa neck: no tenderness to palpation, normal rom, supple, no carotid or vertebral bruit back: no point tenderness or erythema cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: + crackles at left base abd: +bs soft, nontender ext: no edema neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. she is attentive, says backwards. speech is fluent with normal comprehension and repetition; naming intact. she has moderate dysarthria. intact. registers , recalls in 5 minutes. no right left confusion. no evidence of apraxia or neglect. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. visual fields are full to confrontation, seems to extinguish dss on the left (inconsistent) iii, iv, vi: extraocular movements intact bilaterally, no nystagmus. v: sensation intact v1-v3 vii: left nlf flattening, left umn facial paresis viii: hearing intact to finger rub bilaterally ix, x: palate elevation symmetrical : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline, movements intact motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor left pronator drift tri wf we fe ff ip h q df pf r 4 5 5 5 5 5 5 5 5 5 5 5 l 4+ 5- 5 5 4 4 5- 5- 5 5 5 5 sensation: intact to light touch and pinprick. vibration and proprioception decreased in toes bilaterally. + extinction to dss on left reflexes: +2 throughout, brisk in le bilaterally toes downgoing bilaterally coordination: finger-nose-finger normal (+action tremor right >left), heel to shin normal, rams very slow on left. gait/romberg: unable to assess pertinent results: 04:48pm plt count-419 04:48pm wbc-10.7 rbc-4.84 hgb-15.6 hct-44.3 mcv-92 mch-32.2* mchc-35.3* rdw-13.0 04:48pm ck-mb-notdone 04:48pm ctropnt-<0.01 04:48pm ck(cpk)-62 04:48pm glucose-116* urea n-21* creat-0.9 sodium-143 potassium-3.9 chloride-102 total co2-25 anion gap-20 04:57pm glucose-113* na+-145 k+-3.7 cl--101 tco2-21 08:36pm %hba1c-5.2 -done -done 09:41pm pt-11.3 ptt-22. . ct head : there is no evidence of intracranial hemorrhage. no vascular territorial infarction has become apparent. overall, the appearance of the brain is stable compared to exam of four hours earlier. . us carotids: mpression: minimal plaque with bilateral less than 40% carotid stenosis. . mri/mra: 1. right temporal lobe infarction. 2. there is evidence of chronic microvascular infarction. 3. normal mra of the circle . . echo cor: 1. the left atrium is moderately dilated. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). tissue velocity imaging demonstrates an e/e' <8 suggesting a normal left ventricular filling pressure. 3. right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. 5.the mitral valve appears structurally normal with trivial mitral regurgitation. 6.there is no pericardial effusion. impression: no cardiac source of embolism seen. . tee : -simple plaque in descending aorta (non-mobile); no pfo; mild ar and mr (prelim results) brief hospital course: the patient is a 79 year old woman with a history of hypertension and osteoarthritis who presents with sudden onset of slurred speech and left sided weakness. her exam was significant for dysarthria, left facial droop, left arm (distal>proximal) weakness, and extinction to dss on the left (nihss =5: 2 for facial droop, 1 for left arm drift, 1 for dysarthria and 1 for extinction to dss). the patient was admitted to the stroke service for further workup and management. . 1. neuro: a ct upon admission was negative for a hemorrhage or mass. an acute stroke was therefore likely and iv tpa was given. the patient recieved a higher dose of alteplase as the infusion was not stopped at 1 hour. an incident report was submitted. the patient's family has explicitly stated that they do not want to further persue this issue. her deficits improved while the tpa was infused and remained stable throughout the remaining part of the hospitalization. all her symptoms resolved. an mri/mra showed acute strokes on dwi/flair in r-temp/insular region as well as a smaller one in the right occipital region. chronic small vessel disease was present in addition, mainly involving the frontal regions. per mra, her intracranial vessels were patent. the most likely cause of her acute stroke is embolic given the pattern of the strokes. a repeat head ct after 24hrs did not show hemorrhage. she was initially admitted to the icu for further monitoring, with vitals and neurochecks being checked per protocol. for stroke risk statification the following labs were obtained: hba1c 5.2, lipid profile:cholesterol:216; triglyc: 128; hdl: 48; chol/hd: 4.5; ldlcalc: 142; lft's pending. a tte showed no thrombus, lvef>55%, 1+ar. a tee was performed to evaluate for a pfo and to look for atheromata in the aortic arch. this study only showed a simple plaque in the descending aorta (no pfo or trhombus). carotid duplex showed no significant stenosis of the r-ica or l-ica. altogether, no clear focus was found that might have generated the emboli leading to her strokes. for management, i.e. secondary stroke prevention, she was started on a low dose asa 81mg, on aggrenox, and on lipitor 10mg. a low dose ace-inhibitor was added as well. . 2. pulmonary cxr showed no cardiopulmonary disease. . 3. cv: the patient ruled out for mi per serial cardiac enzymes. her antihypertensives were initially held to allow her bloodpressure to autoregulate. a low dose of lisinopril was started (2.5mg). her bloodpressure medication may be titrated up if needed during the next few weeks. . 4. gi: cardiac diet; well tolerated. . 5. endo: hba1c: 5.2. no intervention needed. . 6. proph: pneumoboots; protonix; bowel regimen . 7. id: the patient remained afebrile. . code: dnr/dni medications on admission: trimox 500mg tid tenormin 100mg qd norvasc 10mg qd dicyclomine 20mg q asa (ec) multiple per day discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. dipyridamole-aspirin 200-25 mg cap, multiphasic release 12 hr sig: one (1) cap po twice a day. disp:*60 cap(s)* refills:*2* 4. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. stroke 2. hypertension 3. hypercholesterolemia discharge condition: good; no residual deficits discharge instructions: please take your medications as instructed. . if you develop new weakness, numbness/tingling, slurred speech, word finding difficulties, double vision or blurry vision, please seek medical help immediately. followup instructions: please follow up with your primary care physician within one week. have him/her check your blood pressure and follow your lipid panel, and adjust the medications if needed. md, Procedure: Diagnostic ultrasound of heart Injection or infusion of thrombolytic agent Diagnoses: Unspecified essential hypertension Cerebral embolism with cerebral infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain. major surgical or invasive procedure: 1. cardiac catheterization. 2. esophagogastroduodenoscopy; electrocautery of - tear. 3. endotracheal intubation. 4. r internal jugular central line placement. history of present illness: 70 y/o male with htn, hypercholesterolemia s/p inferior stemi with cath showing 50% lcx and 90% distal rca, s/p cypher stent to rca. pt. received asa, plavix, and integrillin in cath lab. . on floor in the evening post-cath, pt. had large volume melena/brbpr. integrillin gtt was immediately d/c'd and volume resuscitation initiated. gi was contact. pt. soon after became nauseated and had lg. volume hemetemesis with frank clot. an ng-tube was placed and lavage revealed many clots, and bloody fluid after 4l lavage. hct dropped from 36 to 23. pt. received 4u prbc via iv on floor and 2 doses of 40mg iv protonix. a right-ij cordis catheter was inserted at this time. the pt was evaluated by gi, with plan for emergent upper endoscopy. blood transfusions continued upon transfer to ccu with protonix gtt. during egd maps declined to 40-50s with sedation, levophed started at 1 mcg/kg/min with improvement to map 60-70s. a line placeed without incident. egd further complicated by continued bloody emesis with clots despite erythromycin. pt was intubated for airway protection. past medical history: ?cad, ef 55% 4/05, cri 1.5, htn, gerd, hypercholesterolemia, bph, diverticulitis, s/p arthroscopic cholecystectomy, s/p appy, herniated disk at l4/5, gout, chronic pmr with anemia, exposure to rat poison, asbestos exposure - with pleural plaques, zoster ', pilonidal cysts social history: married to wife . former trailer driver, no etoh/illicits, former tobacco 1.5ppd quit 8 years ago. family history: father died of mi at 59, brother w/emphysema, mother died at 74 of renal failure, ?pat uncle and brother physical exam: vitals: 99.8 75 125/44 20 100%2l ht 65" wt 172lbs gen: nad, resting comfortably in bed. heent: perrl/eom intact, op clear, mmm, no jvd, no carotid bruit. neck: no masses, no lad. cv: rrr, nl s1s2, no murmurs. chest: cta b/l, no crackles or wheezes. abd: soft, nt/nd, +bs, no organomegaly. extr: warm well perfused, 2+ dp pulses, no cyanosis, no le edema. neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination, and language grossly non-focal. pertinent results: admission labs: 12:30am wbc-6.0 rbc-5.01 hgb-14.3 hct-39.2* mcv-78* mch-28.6 mchc-36.6* rdw-13.1 12:30am neuts-57.0 lymphs-33.5 monos-6.3 eos-2.8 basos-0.4 12:30am microcyt-1+ 12:30am plt count-236 12:30am pt-12.7 ptt-24.9 inr(pt)-1.1 12:30am glucose-93 urea n-21* creat-1.1 sodium-140 potassium-4.0 chloride-100 total co2-26 anion gap-18 12:30am calcium-9.7 phosphate-4.0 magnesium-2.2 12:30am ck(cpk)-249* 12:30am ck-mb-5 ctropnt-<0.01 . labs: 06:49am ck-mb-64* mb indx-12.6* ctropnt-0.34* 07:20pm ck(cpk)-1428* 07:20pm ck-mb-191* mb indx-13.4* 11:24pm ck(cpk)-1116* 11:24pm ck-mb-124* mb indx-11.1* ctropnt-4.13* . tte : the left atrium is normal in size. the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction. overall left ventricular systolic function is low normal (lvef 50-55%). resting regional wall motion abnormalities include mild inferior hypokinesis. right ventricular chamber size is normal. right ventricular systolic function is normal. the aortic valve leaflets are mildly thickened. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior report (images unavailable for review) of , the lv function was normal. . egd : the entire esophageal mucosa was coated with fresh blood. a 3-4 cm - tear was seen spanning from the distal esophagus to the ge junction. there was an adherent clot at the distal end of the - tear near the ge junction. there was no active bleeding. 5 cc epinephrine 1/ was injected around the adherent clot. -cap electrocautery was also applied for hemostasis successfully. the stomach was filled with dark blood and blood clots. the fundus was poorly visualized due to a large pool of blood and clots that could not be repositioned. there were no bleeding lesions in the stomach. the duodenal mucosa was coated with fresh blood. a blood clot was seen in the proximal bulb that was washed away with irrigation. there were no bleeding lesions in the duodenum. . cardiac cath : right dominant, 2v cad. lmca: no flow limiting stenosis; lad: mild disease; lcx: mild disease proximally and a 50% stenosis in the mid vessel, om1: moderate diffuse disease in distal portion; rca: subtotal occlusion in distal vessel before the bifurcation of the pda/pl branch. there were left to right collaterals seen. lvedp 26mmhg and rvedp 11mmhg, c/w biventricular diastolic dysfunction. mild pa htn, with pa systolic bp 47mmhg. left ventriculography revealed ef=54% with mild postero-basal hk. cypher stent placed to rca. brief hospital course: 70yom with nstemi s/p cath (cypher stent to rca), with large volume bleed from - tear. . # gi bleed: likely due to pre-existing - tear exacerbated by integrillin which was given for cath procedure. emergent egd revealed - tear in lower esophagus, which was injected with epinephrine and electrocauterized. initially managed on protonix gtt, transitioned to iv, then to po. pt. received erythromycin to promote gastric motility. pt. received 10u prbc, ffp and platelets before hemorrhage was controlled, and did not require additional transfusions after electrocautery. pt. was on a levophed gtt briefly for hypotension. due to concern for aspiration of hemetemesis, the pt. was intubated for the egd, and started on empiric antibiotic coverage for aspiration pneumonia consisting of vancomycin / levofloxacin / metronidazole. the pt. received these antibiotics for 3-days; they were stopped because the pt. was afebrile, with no elevated wbc count, and had no clinical signs of infection. the pt. was weaned off ventilation without complication, and was extubated and on room air within 2 days of intubation. . # cardiac: he came in with chest pain, found to have st segment elevation mi, underwent cardiac catheterization with rca stent for 90% occluded rca. he was started on asa and plavix for stent protection. he was eventually placed on bet-blocker and ace-inhibitor once hemodynamically stable. tight glucose control was maintained with an insulin sliding scale. a left ventriculogram revealed preserved ef, and diastolic dysfunction (mild inferior hk). he was given iv lasix to promote diuresis of excess fluids from ivf resuscitation and blood products, and was euvolemic at the time of discharge. the pt. was monitored on telemetry and remained in normal sinus rhythm with no significant events. medications on admission: hctz, flomax, allopurinol, tylenol, enalapril 10, asa 81 on day of admission, lipitor 10 discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atenolol 25 mg tablet sig: 0.5 tablet po once 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* 5. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. 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* 7. amoxicillin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 9 days. disp:*27 capsule(s)* refills:*0* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. non-st elevation mi of rca. 2. - tear. 3. htn 4. high cholesterol 5. gerd 6. coronary artery disease discharge condition: ambulatory. discharge instructions: please return to the emergency department if you have chest pain, shortness of breath, dizziness, rectal bleeding or any other concerning symptoms. . please take all medications as prescribed. . please keep all follow up appointments. followup instructions: 1.provider: , md phone: date/time: 11:00 . 2. please follow up with your primary care doctor in one to two weeks. you should have them refer you to cardiac rehabilitation. you should ask them to follow up on the throat culture that was done during your admission. . 3. please call ( for a cardiology appointment within three weeks. you should ask for appointment with dr. who performed your procedure. his number is . Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Other endoscopy of small intestine Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Insertion of endotracheal tube Arterial catheterization Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells 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 Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Unspecified pleural effusion Congestive heart failure, unspecified Pneumonitis due to inhalation of food or vomitus Acute myocardial infarction of inferolateral wall, initial episode of care Gastroesophageal laceration-hemorrhage syndrome Acute pharyngitis Other abnormality of red blood cells

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 68 year old aa female with 45 minutes of acute chest pain. major surgical or invasive procedure: cabgx4(lima->lad< svg->rca, om, ramus) cardiac cath history of present illness: 68 african american f with htn, hyerlipidemia, dm2, p/w cp acute onset, "felt like indigestion" lasting 45mins, radiating to back and under l arm. reportedly began while walking in house, no unusual exertion. pt experienced mild diaphoresis but no n/v, palpitations, sob. previously experienced similar pain a month ago which resolved spontaneously. at baseline develops doe after climbing a flight of stairs, but no pnd or orthopnea. . in ed, sbp 180-200's, received metoprolol 5mg iv x 3, hydralazine 20mg, slntg x 3, with overall resolution of chest pain. 1st set of ce negative. ekg with st depression in v2-v6 (no old). denies f/c, melena, brbpr, ha, dizziness, weakness, numbness, diarrhea, or constipation. past medical history: pmhx: 1. htn 2. g6pd carrier, does not have the disease. 3. dm2- per pt, glucose well controlled with last hgb a1c of 6. something. 4. cri (baseline 2.0) 5. hyperlipidemia social history: lives with daughter. tobacco, etoh, or drug use. family history: sister with cad at age 60s. mother died of mi physical exam: vs 97.3 155/68 64-91 16 94%on ra 105 kg gen: well-developed, well nourished. in bed nad. obese pleasant lady. heent: perrl, eomi, anicteric, op nlm mmm. neck: supple. o jvd elevation, no carotid bruit. chest: cta bilat cv: rrr with 3/5 systolic murmur best heard at r second intercostal space. normal s1, s2. no rubs, gallop. abd: obese, soft, nt, nd, nl bs. ext: 2+ dps equal bilat, 2+ radial equal bilat. + pitting lle edema bilat. skin: wnl neuro: aox3, cn 2-12 grossly nl. strength 5/5, sensation intact. pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:00am 12.9* 3.53* 10.2* 31.2* 88 29.0 32.9 15.2 246 basic coagulation (pt, ptt, plt, inr) plt ct 05:00am 246 chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:00am 64* 52* 2.1* 131* 4.4 100 21*1 14 1 note updated reference range as of chemistry totprot albumin globuln calcium phos mg uricacd iron 04:53am 2.3 radiology preliminary report chest (pa & lat) 11:15 am chest (pa & lat) reason: r/o inf., effusion medical condition: 68 year old woman with cad reason for this examination: r/o inf., effusion examination: pa and lateral chest. history: coronary artery disease. possible pleural effusion. impression: pa and lateral chest compared to prior chest radiographs since , most recently . since , the swan-ganz catheter has been removed, and there is less mediastinal vascular engorgement. moderate enlargement of the cardiac silhouette is also decreased. small bilateral pleural effusions and mild left lower lobe atelectasis are new. the upper lungs are clear. there is no pneumothorax. a right pic catheter projects over the expected course to the svc. comments: 1. selective coronary coronary angiography revealed a right dominant system with three vessel coronary artery disease. the had a 50% distal bifurcation lesion. the lad had 50% ostial disease with a 70% ostial small d2 lesion. the lcx had had sequential 90%, 50%, and 70% mid vessel lesions. the rca had mild ostial disease and an 80% mid vessel lesion at the origin of a large acute marginal branch which had sequential 90% lesions, and 70% mid to distal disease. 2. limited resting hemodynamics demonstrated significantly elevated system pressures with moderately elevated left sided pressures (lvedp 28 mmhg) and no gradient upon movement of the catheter from the ventricle back to the aorta. 3. left ventriculography was deferred. final diagnosis: 1. three vessel and moderate left main coronary artery disease. 2. mild elevation of left ventricular diastolic pressure. attending physician: , . referring physician: , . cardiology fellow: , , s. attending staff: , j. () brief hospital course: she presented to the er on and was hypertensive in the 180s-200s. she ruled in for an mi and was started on heparin and plavix. she had a negative mri/mra of the chest. hematology saw her for the g6pd and found that she does not have it, she is a carrier, and she was started on asa. she had angina at rest and was hypertensive when this would occur. on she underwent cardiac cath which revealed: 50% ., 50% ostial lad, 70% ostial d2, 90% lcx, and 80% mid rca lesion. she had an echo which showed an ef of 60-70% and minimal as. following her cath, her creatinine rose and peaked at 2.9. eventually it came down to 2.4 and on she had a cabgx4 w/ lima->lad, svg->rca, om, and ramus. she tolerated the procedure well and was transferred to the csru on neo and propofol in stable condition. she was extubated on pod#1 and her urine output dwindled on that day. renal was consulted and she was given volume and lasix and this eventually resolved. she continued to progress and had her chest tubes out on pod#1 and epicardial pacing wires on pod#3. she was transferred to the floor on pod#3 and required aggressive antihypertensive therapy. her creatinine came down to 2.1, and she progressed slowly and was discharged to rehab on pod#7 in stable condition. medications on admission: 1. hctz 50mg qday 2. glyburide 5mg 3. labetolol 400mg 4. diovan 240mg qday 5. norvasc 10mg qday 6. lipitor 40mg qday 7. avandia 4mg qday 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). 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 6. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 8. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 9. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 10. valsartan 160 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease chronic renal insufficiency niddm htn hyperlipidemia discharge condition: good. discharge instructions: follow medications on discharge isntructions. you may not drive for 4 weeks. you may not lift more than 10 lbs. for 3 months. you should shower, let water flow over wounds, pat dry with a towel. do not use lotions, powders, or creams on wounds. call our office for sternal drainage, temp.>101.5 followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 4 weeks. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Transfusion of packed cells Continuous intra-arterial blood gas monitoring Diagnoses: Anemia in chronic kidney disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease

allergies: lisinopril attending: chief complaint: aphasia major surgical or invasive procedure: none history of present illness: hpi: the patient is a 72 year old woman with a history of cad s/p cabg x4, hypertension, dm2, hyperlipidemia, and ckd stage iv who presents feeling shaky and diaphoretic at home, and in the ed developed aphasia and then a 2 minute witnessed seizure described as right beating horizontal nystagmus then right gaze deviation, clenched mouth, and clicking sounds with her mouth. per the ems report, they found her seated at home at 11:28 am complaining of shakiness and diaphoresis since this morning. she reported she was not feeling well, but denied chest pain, sob, nausea/vomiting, and cough. she was found to have bp 240/120, hr 124, rr 24, sao2 100% on ra, fsbg 330. she was oriented x3, no facial droop, normal speech and grip strength. she appeared shaky. she was transferred to the ed. while in the ed, fsbg 328. at 12:20 pm, the ed technician came in to evaluate the patient, and she was speaking jibberish. he was asking her orientation questions, and she could appropriately answer yes/no to her name and location, but when asked to actually say her name or date "jibberish" came out. she was evaluated then by the ed resident, who said she was diffusely shaking in her bilateral arms which appeared like rigors. she was nonfocal but per the ed resident was speaking "word salad". a code stroke was called. one minute later she had a witnessed seizure characterized by right horizontal nystagmus then right gaze deviation, mouth was clenched back, and making a clicking sound with her mouth. she had a diffuse tremor or her arms, but no generalized tonic clonic movements or bowel/bladder incontinence. she was given ativan 2 mg iv during the seizure activity, and the seizure lasted a total of 2 minutes. afterwards she was sleepy. the code stroke was cancelled, but emergent neurology consult was then called. past medical history: 1. cad, cabgx4(lima->lad< svg->rca, om, ramus) 2. htn 3. g6pd carrier, does not have the disease. 4. dm2- per pt, glucose well controlled with last hgb a1c of 6. something. 5. cri (baseline 2.0) 6. hyperlipidemia social history: she does not smoke or drink alcohol. she is working in security (desk job) for reuters. family history: sister with cad at age 60s. mother died of mi son has g6pd deficiency physical exam: vs: temp 98.2, bp 222/119->152/120->187/108, hr 118, rr 20, sao2 100% on ra genl: sleepy, nad, arouses to sternal rub heent: sclerae anicteric, no conjunctival injection, oropharynx clear neck: no nuchal rigidity cv: tachycardic, nl s1, s2, iii/vi systolic murmur best at lusb, no rubs or gallops chest: cta bilaterally anteriorly and laterally, no wheezes, rhonchi, rales abd: +bs, soft, ntnd abdomen neurologic examination: mental status: sleepy but arouses to sternal rub, this limits her exam. initially does not follow commands to open eyes or squeeze hands bilaterally. initially does not answer orientation questions, but upon repeat examination says her first name and her date of birth. cranial nerves: pupils equally round and reactive to light, 3 to 2 mm bilaterally. decreased blink to threat on the right. no obvious facial asymmetry. motor/sensation: normal tone bilaterally. no observed myoclonus or tremor. withdraws bilateral upper and lower extremities to noxious stimulus. reflexes: 2+ and symmetric in biceps, brachioradialis, triceps. 1+ and symmetric in knees, 0 and symmetric in ankles. toes downgoing bilaterally. gait: deferred pertinent results: labs on admissions: 12:30pm blood wbc-17.1*# rbc-4.81# hgb-14.1# hct-44.1# mcv-92 mch-29.3 mchc-31.9 rdw-15.3 plt ct-169 12:30pm blood neuts-82.4* lymphs-12.8* monos-4.4 eos-0.1 baso-0.3 12:30pm blood pt-12.4 ptt-25.0 inr(pt)-1.0 12:30pm blood glucose-322* urean-54* creat-3.1* na-147* k-3.9 cl-108 hco3-22 angap-21* 12:30pm blood alt-29 ast-39 ld(ldh)-682* ck(cpk)-483* alkphos-83 totbili-1.0 12:30pm blood ck-mb-7 ctropnt-0.02* 10:25pm blood ck-mb-6 ctropnt-0.02* 12:30pm blood albumin-3.6 calcium-9.1 phos-3.0 mg-2.2 12:30pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:31pm blood lactate-2.5* 01:35pm urine color-yellow appear-clear sp -1.019 01:35pm urine blood-lg nitrite-neg protein-500 glucose-100 ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 01:35pm urine rbc-* wbc- bacteri-few yeast-none epi- 04:13pm cerebrospinal fluid (csf) wbc-2 rbc-375* polys-51 lymphs-27 monos-22 04:13pm cerebrospinal fluid (csf) wbc-0 rbc-47* polys-5 lymphs-70 monos-25 04:13pm cerebrospinal fluid (csf) totprot-77* glucose-175 labs prior to discharge 05:10am blood wbc-10.6 rbc-3.69* hgb-10.7* hct-33.0* mcv-89 mch-28.9 mchc-32.4 rdw-16.2* plt ct-210 05:10am blood neuts-70.0 lymphs-18.3 monos-5.1 eos-5.9* baso-0.6 05:10am blood glucose-172* urean-54* creat-3.1* na-138 k-3.9 cl-106 hco3-21* angap-15 05:10am blood alt-84* ast-47* ld(ldh)-415* alkphos-87 totbili-0.4 05:10am blood albumin-3.1* calcium-8.1* phos-3.7 mg-2.0 05:30am blood triglyc-156* hdl-40 chol/hd-5.5 ldlcalc-148* 05:30am blood %hba1c-7.5* imaging: findings: there are extensive confluent t2 hyperintensities throughout the bihemispheric white matter, as well as extending into the deep brain nuclei, predominantly involving the thalami and to a lesser extent lentiform nuclei. similar signal abnormality is present within the brainstem, particularly the dorsal pons and midbrain. subtle scattered flair hyperintense foci are also noted in the cerebellar hemispheres. there is a punctate region of restricted diffusion within the left centrum semiovale (series 702, im 22). the remainder of the elsions do not demonstrate restricted diffusion. there are no findings of intracranial hemorrhage. the ventricles and cerebral sulci are unremarkable. there is small amount of fluid/mucosal thickening in the left mastoid air cells. impression: 1. extensive confluent signal abnormality within bihemispheric white matter, as well as the deep brain nuclei and brainstem. while the changes could relate to severe microvascular disease, some of the lesions are atypical- in the right frontal and temporal lobes and bilateral thalami. addiitonal superimposed causes related to inflammatory, infective etiology, drug- induced/immunosuppression related conditions are also in the differential diagnosis with less likely possibility of neoplastic etiology for some lesions. assessment is limited due to lack of iv contrast, which could not be given due to renal failure. correlation with labs, lp and a close follow up study if possible with gado can be considered to assess interval change. 2. single punctate focus of restricted diffusion within the left centrum semiovale compatible with acute infarct which could be either embolic or watershed in etiology. radiology report carotid series complete study date of 8:24 am findings: duplex evaluation was performed of bilateral carotid arteries. on the right there is mild heterogeneous plaque in the ica. on the left there is mild heterogeneous plaque in the ica. tortuous left ica. on the right systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 67/16, 70/18, 80/22 cm/sec. cca peak systolic velocity is 64 cm/sec. eca peak systolic velocity is 119 cm/sec. the ica/cca ratio is 1.3. these findings are consistent with <40% stenosis. on the left systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 69/14, 92/18, 81/17 cm/sec. cca peak systolic velocity is 69 cm/sec. eca peak systolic velocity is 54 cm/sec. the ica/cca ratio is 1.2. these findings are consistent with <40% stenosis. there is antegrade right vertebral artery flow. there is antegrade left vertebral artery flow. impression: right ica stenosis <40%. left ica stenosis <40%. tte () conclusions the left atrium is mildly dilated. the interatrial septum is aneurysmal. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. there is mild symmetric left ventricular hypertrophy with normal cavity size. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: no cardiac source of embolism identified. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. diastolic dysfunction. minimal aortic stenosis. compared with the report of the prior study (images unavailable for review) of , the aortic valve is now minimally stenotic. the other findings are similar. radiology report mrv head w/o contrast study date of 10:01 pm findings: there is narrowing of the left transverse sinus and sigmoid sinus, reflecting hypoplasia rather than thrombosis. there is apparent attenuation of the superior sagital sinus on the vertical posterior portion reflecting artifact. the remainder of the dural venous sinuses are normal. the deep cerebral veins are also normal. impression: no evidence for cerebral venous thrombosis. brief hospital course: ms. is a 72 year old woman with a history of cad s/p cabg x4, hypertension, dm2, hyperlipidemia, and ckd stage iv who presented on with headache, visual disturbance and a witnessed seizure in the setting of hypertension. # neuro: the patient's initial exam was limited by sleepiness felt to be post-ictal in nature. head ct showed a hypodensity in her left temporal lobe, which was felt to be a chronic infarct. an mri/mra was obtained and showed diffuse white matter changes as well as bilateral thalamic hyperintensities on t2 flare. she was admitted to the stroke service. her blood pressures were intially in the 160's (systolic) but began to rise, with minimal response to oral anti-hypertensives. given the increasing blood blood pressure with mri findings, a decision was made to transfer ms. to the icu given the concern for possible hypertensive encephalopathy. at the icu, ms. was started on iv drip of nicardipine and blood pressures stabilized. mrv was done to rule out sinus venous thrombosis with results showing, no evidence of cerebral venous thrombosis. clinically, ms. started to improve with improvement of speech with no word finding difficulty. it was suspected that her episode was due to hypertensive encephalopathy, in the context of not being able to tolerate her blood pressure medication during her episode of gastroenteritis prior to admission. she was restarted on her home blood pressure regimen, and her mental status improved, with no deficits on discharge. she did have a very small stroke on mri, for which she was switched from asa to plavix. she should continue on her simvastatin, however lfts were very mildly elevated on discharge, and should be rechecked in weeks. she will need a repeat mri in 3 weeks to evaluate progression, and will follow-up with neurology in 4 weeks. # renal: while in the icu, ms. renal condition started to decrease. on admission her creatinine was 3.1. while in the icu, the creatinine increased to 3.6. renal was consulted made the recomendation that since fena 0.4% was uninterpretable in setting of active diuresis, and feurea 28% was consistent with perfusion-related kidney injury the likely cause of the decreased renal function was likely malignant nephrosclerosis, and acute worsening of renal function may be a byproduct of successful lowering of bp to desired range. the reccomendation was made to treat hypertension with the same goals and avoid ace inhibitors/arbs. on the day of discharge her creatinine had begun to improve to 3.1. she will follow-up with her outpatient nephrologist. #heme: the patient also missed her regular epo shot that she regularly receives in the outpatient setting. nephrology has recommended that she hold epo in the immediate time period given the potential to increase blood pressures. this will be readdressed at her outpatient nephrology appointment. #id: urine culture positive for gardnerella vaginalis, received single dose of metronidazole. patient was afebrile throughout hospital course. medications on admission: amlodopine 10mg daily atorvastatin 60mg daily calcitriol 0.25mcg daily aranesp every other week furosemide 80mg dialy ezetimibe 10mg daily hydralazine 50m qid isosorbide dinitrate 40mg latanoprost 1 gtt ou at bedtime metoprolol 75mg po bid valsartan 320 mg po daily asa 81mg po daily feso4 325mg po daily humulin 70/30 20u twice daily mvi procrit discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 3. hydralazine 25 mg tablet sig: two (2) tablet po qid (4 times a day). 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. isosorbide dinitrate 20 mg tablet sig: two (2) tablet po bid (2 times a day). 6. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 10. insulin nph & regular human 100 unit/ml (70-30) suspension sig: twenty (20) units subcutaneous twice a day. 11. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. aranesp (polysorbate) 100 mcg/0.5 ml syringe sig: one (1) syringe injection once a month. 13. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 14. atorvastatin 60mg daily discharge disposition: home discharge diagnosis: primary: 1. posterior reversible leukoencephalopathy (pres); hypertensive encephalopathy 2. acute stroke, ischemic, left centrum semiovale 3. acute renal failure (worsening of chronic) discharge condition: stable condition. neurologic exam shows intact attention, language (naming, comprehension, and repetition); mild right pronator drift, 4+/5 strength at bilateral triceps, ip, and hs; intact sensation; mild hyperreflexia at right patella; all else normal. discharge instructions: you were admitted with difficulty speaking and a seizure, which was found to be due to pres, an encephalopathy due to hypertension (high blood pressure). the treatment of this is control of your blood pressure, which was done in the icu. due to your high blood pressure, you also had worsening of your kidney function. as a result, we made some changes in your medications: your lasix dose was cut in half; your diovan was (temporarily) stopped, and your metoprolol was increased. you should discuss these changes with your pcp as your renal function improves. . in addition, you have been started on plavix. you may take this in place of aspirin to prevent future strokes. finally, you have been scheduled to have a repeat mri of the brain as an outpatient to ensure resolution of the changes we saw. please take all medications as directed and keep all follow-up appointments. . if you have any further difficulty speaking, difficulty with vision, loss of consciousness, weakness, numbness, or facial droop, please call 911. if you have any questions about your neurologic care, you may call dr. at . followup instructions: please call your pcp's office at on monday to schedule a follow-up appointment. you should ask to speak to dr. nurse, m., so that she can schedule you to be seen in the next week. . in addition, you have the following appointments scheduled: 1. radiology: outpatient head mri phone: date/time: 3:00 2. neurology: , md phone: date/time: 1:30 3. nephrology (kidney): , md phone: date/time: 10:00 4. cardiology: , md phone: date/time: 4:40 . if you cannot keep any of these appointments, please call the number listed to re-schedule. Procedure: Spinal tap Incision of lung Diagnoses: Anemia, unspecified 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 Chronic kidney disease, Stage IV (severe) Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Other convulsions Other and unspecified hyperlipidemia Hypertensive encephalopathy Headache Obesity, unspecified Cerebral artery occlusion, unspecified with cerebral infarction Aphasia Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Hypoparathyroidism Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion. major surgical or invasive procedure: aortic valve replacement(25mm ce pericardial) history of present illness: this is a 60 yo male patient reports progressive dyspnea on exertion. he reprts sob with climbing two flights of stairs. stress test in revealed severe as with of 0.9 cm2. he was then referred for avr. past medical history: hyperlipidimia. hypertension. obesity. psoriasis. aortic stenosis. social history: works as sales manager. smoked ciagrs until . drinks drinks of alcohol per week. family history: both parents deceased with cad/mis, age unknown. pertinent results: 06:10am blood wbc-13.4* rbc-3.61* hgb-11.0* hct-32.1* mcv-89 mch-30.5 mchc-34.3 rdw-13.7 plt ct-122* 06:10am blood plt ct-122* 03:18am blood pt-13.6 ptt-28.3 inr(pt)-1.2 05:40am blood glucose-124* urean-33* creat-1.5* na-137 k-4.5 cl-103 hco3-25 angap-14 brief hospital course: mr. was admitted on his operative day ()and proceeded to the or for an aortic valve erplacement with dr. . please see op note for full details. he was successfully weened and extubated on his operative evening. on pod one he was transferred to the inpatinet floor for ongoing managemnt and rehabilitation. on pod two his chest tubes were discontinued and his l;asix dose increased for fluid retention. pod three was significant for discontinuation of his cardiac pacing wires and physical therapy. on pod four mr. a few short runs of atrial fibrillation -- with spontaneous conversion to sinus rhythm and increase in po lopressor. on pod five, it was decided that with no firther runs of atrial fibrillation and clearance by physical therapy that mr. would be safe for d/c home. medications on admission: toprol xl 25 daily. lisinopril 20 daily. lipitor 20 daily. aspirin 325 daily. triamterene/hctz 75/50 daily. vessellite (folic acid, b6, b12, e). discharge medications: 1. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po twice a day for 7 days. disp:*14 tab sust.rel. particle/crystal(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 5. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: aortic stenosis discharge condition: good. discharge instructions: follow meidcations on discharge instructions. you may not drive for 4 weeks. you may not lift more than 10 lbs. for 3 months. you should shower, let water flow over wounds, pat dry with a towel. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 4 weeks. make an appointment with cardiologist in 2 weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Other psoriasis

discharge status: the patient is to be discharged to rehabilitation. she is to have of hearts with the results called to dr. . follow up: she is also to have follow-up with dr. in two to three weeks and follow-up with dr. in two to three weeks, follow-up with dr. in four weeks, and follow-up with dr. in four weeks. condition on discharge: good. discharge diagnoses: coronary artery disease, status post coronary artery bypass graft times three, left internal mammary artery to left anterior descending coronary artery, saphenous vein graft to obtuse marginal, saphenous vein graft to right coronary artery. hypertension. hypercholesterolemia. congestive heart failure. atrial fibrillation. diabetes mellitus type 2. past surgical history: appendectomy. removal of pilonidal cyst. breast biopsy. oophorectomy. , Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Insertion of endotracheal tube Arterial catheterization Implant of pulsation balloon Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Transfusion of packed cells Diagnoses: Acidosis Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Unspecified disorder of kidney and ureter Sinoatrial node dysfunction Acute myocardial infarction of anterolateral wall, subsequent episode of care Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled

history of present illness: this 70 year old white female has a history of type 2 diabetes mellitus, hypertension, hypercholesterolemia, and smoking and has had one week of upper abdominal epigastric pain. she woke on the a.m. of admission acutely dyspneic and called an ambulance and was transferred to . an electrocardiogram revealed new q waves across the precordium with st elevations. she was placed on bipap for respiratory distress and received lasix, nitroglycerin drip, integrilin, heparin, aspirin and a beta blocker. she was transferred to for cardiac catheterization and was transferred to the catheterization laboratory. medications on admission: 1. glucotrol xl 1000 mg p.o. once daily. 2. glucophage 500 mg p.o. twice a day. 3. lipitor 40 mg p.o. once daily. 4. avapro. 5. aspirin. past medical history: noninsulin dependent diabetes mellitus. hypercholesterolemia. hypertension. history of atrial fibrillation fifteen years ago and was cardioverted. allergies: no known drug allergies. social history: she smoked two packs a day for many years and quit three years ago. she does not drink alcohol. she lives alone. family history: unremarkable. review of symptoms: nonfocal. physical examination: on physical examination, she is an elderly white female in no apparent distress. heart rate is 92, respiratory rate 14, blood pressure 106/65. head, eyes, ears, nose and throat examination is normocephalic and atraumatic. extraocular movements are intact. the oropharynx is benign. the neck was supple with full range of motion. no lymphadenopathy or thyromegaly. carotids are two plus and equal bilaterally without bruits. the lungs are clear to auscultation and percussion. cardiovascular examination is regular rate and rhythm, normal s1 and s2 with no murmurs, rubs or gallops. the abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. extremities were without cyanosis, clubbing or edema. pulses were two plus and equal bilaterally throughout. neurologic examination was nonfocal. hospital course: she was taken immediately to the cardiac catheterization laboratory where cardiac catheterization revealed left ventricle one plus mitral regurgitation and an ejection fraction of 25 percent with a hyperdynamic base and an extensive area of anterior and inferoapical dyskinesis. the left main had an 80 percent stenosis, left anterior descending coronary artery had a 90 percent stenosis, 70 percent midstenosis, and 99 percent midstenosis. the left circumflex had a 40 percent midstenosis. right coronary artery had an 80 percent midstenosis, 70 percent midstenosis and she had an intraaortic balloon placed at the time. on , she underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal and right coronary artery, cross time was 58 minutes, total bypass time 72 minutes. she was transferred to the csru on epinephrine, neo-synephrine and propofol. she had a stable postoperative night and was extubated on postoperative day number one. she remained on her epinephrine and that was weaned off on postoperative day number one. she then went into atrial fibrillation on postoperative day number one and was started on amiodarone and was given lopressor. she blocked down and was seen by electrophysiology who recommended the amiodarone and wanted to evaluate her for an icd. she was changed to oral amiodarone on postoperative day number two. she had her chest tubes discontinued on postoperative day number three. she required aggressive respiratory therapy. she was improving and she was anticoagulated with heparin as she was going in and out of atrial fibrillation. on , she went to the electrophysiology laboratory where she was inducible but it could have been because the amiodarone was in the proarrhythmic phase or because they did aggressive induction, but at that point, they decided to wait on icd and she will return to the electrophysiology laboratory in four weeks for question of placement of an icd. she was started on coumadin and she was transferred to the floor on postoperative day number seven. she continued to progress and was discharged to rehabilitation on postoperative day number nine in stable condition. her laboratories on discharge were white blood cell count 9.5, hematocrit 33.1, platelet count 231,000. sodium 142, potassium 4.2, chloride 107, co2 25, blood urea nitrogen 20, creatinine 1.3, blood sugar 182 with an inr of 2.3 medications on discharge: 1. potassium 20 meq p.o. twice a day times ten days. 2. colace 100 mg p.o. twice a day. 3. aspirin 81 mg p.o. once daily. 4. tylenol p.r.n. 5. percocet one to two tablets p.o. q4-6hours p.r.n. pain. 6. lipitor 40 mg p.o. once daily. 7. norvasc 5 mg p.o. once daily. 8. glucophage 500 mg p.o. twice a day. 9. glipizide 10 mg p.o. once daily. 10. amiodarone 400 mg p.o. twice a day for one week and then 400 mg p.o. once daily for a week and then 200 mg p.o. once daily. 11. flovent two puffs twice a day. 12. lasix 20 mg p.o. twice a day for ten days. 13. coumadin as directed for an inr goal of 2.0 to 2.5. discharge diagnoses: coronary artery disease. noninsulin dependent diabetes mellitus. hypercholesterolemia. hypertension. atrial fibrillation. follow up: she will be followed by dr. in four weeks, dr. in one to two weeks, dr. in two to three weeks and dr. in four weeks. , Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 Injection or infusion of platelet inhibitor Diagnostic ultrasound of heart Insertion of endotracheal tube Arterial catheterization Implant of pulsation balloon Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Transfusion of packed cells Diagnoses: Acidosis Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Unspecified disorder of kidney and ureter Sinoatrial node dysfunction Acute myocardial infarction of anterolateral wall, subsequent episode of care Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled

history of present illness: this is a 73 year old male with a past medical history significant for hypertension. he presented to an outside hospital with a history of worsening shortness of breath times four days. the patient was transferred to for cardiac catheterization, after electrocardiogram showed anterolateral st segment elevation and q waves. the patient states that he was in his usual state of health until four days prior to admission, when he began to experience shortness of breath and dyspnea on exertion. the patient attributed the symptoms to asthma, which he has a remote history of. symptoms were ameliorated but not entirely eliminated with rest. over the following few days, he experienced worsening shortness of breath, orthopnea, paroxysmal nocturnal dyspnea. he was then brought to the hospital where an electrocardiogram showed st segment elevations in v1 through v4 and lead 2. he was treated with supplemental oxygen, lasix, aspirin, nitroglycerin, morphine, heparin. he was then transferred to for cardiac catheterization. the patient denies paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, shortness of breath, or chest pressure. he can walk more than a mile on flat ground and climb two flights of stairs. he has not seen a doctor for several years and has untreated hypertension. past medical history: 1. asthma. 2. hypertension. allergies: no known drug allergies. medications: none. social history: the patient denies tobacco or alcohol use. family history: father had a myocardial infarction in his mid 60's. two brothers with myocardial infarction in mid 60's. physical examination: vital signs revealed a heart rate of 95; blood pressure 128/77; respirations 20; 90% on room air. general: no acute distress. lying awake, responsive, alert and oriented times three. head, eyes, ears, nose and throat: extraocular movements intact. pupils are equal, round, and reactive to light and accommodation. mucous membranes slightly dry. chest: clear to auscultation bilaterally. cardiovascular: jvp at 7 cm, normal s1 and s2. regular rate and rhythm. abdomen soft, nontender, mildly distended. bowel sounds present. extremities: no cyanosis, clubbing or edema. neurologic: alert and oriented times three. laboratory data: electrocardiogram showed sinus rhythm at 135 beats per minute; normal interval; normal axis; st elevations with q waves in leads v2 through v4. sodium 141; potassium of 3.3; chloride 104; bicarbonate 21; bun 23; creatinine 1.2; glucose 183. white blood cell count of 13.9. hematocrit of 43.8. platelets 327. serial ck's were also followed and were 63 to 58 to 55. ck mb not performed. troponin was less than 0.01; second troponin was .04. cardiac catheterization: hemodynamics mildly elevated; filling pressures with severely depressed cardiac index, consistent with cardiogenic shock. pulmonary capillary wedge: mean of 16; a wave of 18; v wave of 18. right atrium mean 10; a wave 15; v wave 12. aortic systolic 99, diastolic 73. mean of 83. pa systolic was 35; diastolic 20; mean of 27. rv: systolic 41; diastolic 3 and 13. cardiac output: initial was 3.33; post intervention was 3.35. cardiac index baseline of 1.62. post intervention was 1.73. post intervention pulmonary capillary wedge mean 20; a wave 24; v wave 25. ra mean 12; a wave 12; v wave 13. pa systolic 37; diastolic 21; mean 28. rv systolic 36; diastolic 8 and end 14. left ventriculography was not performed. coronary angiography: right dominant, lmca normal; left anterior descending 100% total occlusion; proximal origin t1; also occluded apical left anterior descending, fills via faint right to left collaterals intermedius. moderate sized vessel, 20% ostial stenosis of the left circumflex; small vessel, normal. right coronary artery: large ectatic vessel, 40% proximal stenosis with common 90% large pl branch. interventional details: the patient had a 42 cc intra-aortic balloon pump placed prophylactically in the left femoral artery. left anterior descending had a 3.5 by 23 mm hepikote stent placed with post dilation, utilizing 3.5 by 15 mc ranger. final angiography demonstrated 0% residual stent type but pruned appearance distal to the left anterior descending, beyond d-2, consistent with extensive previous infarction. given ongoing cardiogenic shock, they elected to treat right coronary artery as well. the patient had a 13 mm zeta stent with post dilation utilizing a 3.0 by 9 nc ranger, with 10% residual versus flow dissection. echocardiogram: left atrium is normal in size. there is severe regional left ventricular systolic dysfunction with an ejection fraction of 25%. there is akinesis of the apex. there is severe hypokinesis of the anterior wall and the anterior septum. the mild and distal lateral wall is hypokinetic. intrinsic left ventricular systolic function would be more depressed given the severity of valvular regurgitation. no thrombus is seen in the left ventricle. the right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aorta properly flows left to right. arterial leaflet is mildly thickened. trace aortic regurgitation is seen. there is no aortic stenosis. the mitral valve leaflets were mildly thickened. there is at least moderate 2+ mitral regurgitation. there is moderate pulmonary artery systolic hypertension. there is a trivial physiologic pericardial effusion. catheter wire seen in the right atrium. limited right coronary ultrasound: there is a large hematoma in the right groin; normal flow was identified with no superficial femoral artery and vein. no pseudo aneurysm was identified. hospital course: 1. cardiovascular: the patient was transferred from the emergency department up to the cardiac catheterization laboratory. in the cardiac catheterization laboratory, the patient had an intra-aortic balloon placed. temporary pacer was placed with percutaneous transluminal coronary angioplasty and stent to the left anterior descending using hepikote stent and percutaneous transluminal coronary angioplasty stent to the right pl branch, using a zeta stent. the patient was then placed on plavix and integrilin for 18 hours and transferred to the ccu for continued management. that same night, the patient developed an enlarging right groin hematoma after pulling of the arterial sheaths. occlusive pressure was applied for about 20 minutes and integrilin and heparin were held. the patient subsequently developed bradycardia down to the 50's and hypotension with systolic blood pressure of 70. interventional fellow was notified and the patient was given .6 of atropine and dopamine. blood pressure and heart rate responded with blood pressure rising to 110 over 70 with heart rate of 90. vascular surgery and radiology were consulted. the patient was stabilized off pressors and inotropes and was continued to monitor serial hematocrits q. four hours. stat ultrasound was obtained which showed a large hematoma in the right groin and no pseudo aneurysm. normally identified superficial femoral artery and vein. the patient was restarted on integrilin once the patient was stabilized. the patient was continued on his aspirin, plavix, atorvastatin, titration of metoprolol and captopril was done and then subsequently changed over to once a day dosing prior to discharge. intra-aortic balloon pump was removed on the fourth day of admission to the ccu without any complications. the patient, by numbers in the catheterization laboratory, showed that he was in heart failure. we continued to diurese him every night with goal negative fluid balance. the patient's lower extremities were intact neurovascularly. hematocrit remained stable after the third night of admission. the patient was started on coumadin once the intra-aortic balloon pump was discontinued on the fourth night of admission. the goal inr was 2 to 3. the patient was taught how to self administer lovenox injections and was given appointments to see his primary care physician doctor, dr. , for follow-up and inr monitoring. we recommended to the patient that he follow-up with an electrophysiologist as an outpatient for follow-up of his heart function. prior to discharge, the patient had two episodes of non sustained ventricular tachycardia. given his low ejection fraction and cardiac function, it was recommended that he see the electrophysiologist, , m.d. or dr. for further work-up and possible icd pacer. right groin hematoma remained stable throughout the remainder of his stay. vascular surgery followed up until discharge, noting that it was stable and no surgical intervention was needed at this time. pulmonary: the patient was given nebulizers prn, supplemental oxygen as needed. otherwise, he was stable. prophylaxis: intravenous heparin and protonix, then bridged with coumadin and changed over to lovenox. prior to discharge, the patient could self administer at home. physical therapy: physical therapy recommended that he was okay to go home from the hospital. they were to follow-up with short term goals and he was to ambulate with nursing. condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. congestive heart failure. 2. anterior wall myocardial infarction. 3. coronary artery disease. 4. status post percutaneous coronary intervention. discharge medications: 1. aspirin 325 mg q. day. 2. plavix 75 mg q. day. 3. pantoprazole 20 mg q. day. 4. atorvastatin 10 mg q. day. 5. wolfram 5 mg p.o. q h.s. 6. metoprolol succinate 100 mg p.o. q. day. 7. lisinopril 40 mg tablet q. day. 8. anoxaparen sodium 100 mg subcutaneous q. 12 hours for seven days. 9. outpatient laboratory work slip; inr to be checked every wednesday and every saturday. please have results sent to the patient's primary care physician. follow-up plans: 1. the patient is to follow-up with his cardiologist, dr. . dr. will call about an appointment or patient is to call dr. for an appointment, by calling . 2. the patient is to follow-up with an electrophysiologist, dr. or dr. . the patient is to call . 3. the patient is to follow-up with primary care physician, . at , , nh. the patient is to follow-up next monday, , at 8:15 a.m. for coumadin blood test. the patient is to follow-up on at 10 a.m. for regular check-up with dr. . , m.d. dictated by: medquist36 Procedure: 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 temporary transvenous pacemaker system Implant of pulsation balloon Right heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Hematoma complicating a procedure Asthma, unspecified type, unspecified Paroxysmal ventricular tachycardia Cardiogenic shock

discharge condition: good. primary pediatric care will be provided by dr. of medical associates. address: , , . telephone number: . she has been updated during the hospital stay and prior to discharge. care and recommendations: continue feedings on an ad lib schedule, enfamil 20 and breast feeding. follow up with dr . follow up with lactation service at or with lc at medical. the infant is being discharged on no medications. a state newborn screen was sent on . he has received his hepatitis b vaccination and has passed hearing screening in both ears. he has also passed car seat testing. discharge diagnoses: 1. prematurity 36 weeks gestation 2. twin #2 3. status post transitional respiratory distress 4. sepsis ruled out 5. physiological jaundice , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Prophylactic administration of vaccine against other diseases Circumcision 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 Other preterm infants, 2,000-2,499 grams Routine or ritual circumcision Other specified conditions involving the integument of fetus and newborn

history of present illness: the patient is a 59-year-old female with longstanding insulin-dependent diabetes who had been noted to have slowly progressive chronic renal failure believed secondary to her diabetes. the patient had been evaluated for a living-related kidney transplant by the transplant center. the patient had not progressed to requiring dialysis; although, her glomerular filtration rate was 16 ml per minute as of . the patient has had no uremic symptoms and continued to make normal urine volumes. the decision was made to proceed with a living-unrelated kidney transplant with a donor to be the patient's husband. past medical history: 1. diabetes diagnosed in with associated retinopathy and nephropathy. 2. aseptic meningitis; possibility secondary to amoxicillin use. 3. migraine headaches with malignant hypertension. 4. status post breast lumpectomy approximately 10 years ago with a benign pathology. 5. tonsillectomy. 6. skin graft at the right ankle secondary to a skiing accident. 7. gastroparesis. 8. gastroesophageal reflux disease. 9. gout. 10. hypothyroidism. 11. hypercholesterolemia. medications on admission: 1. aspirin 81 mg by mouth once per day. 2. effexor 75 mg by mouth once per day. 3. renagel 400 mg by mouth three times per day. 4. levoxyl 50 mcg by mouth once per day. 5. lipitor 40 mg by mouth once per day. 6. protonix 40 mg by mouth once per day. 7. diovan 80 mg by mouth twice per day. 8. diltiazem 120 mg by mouth once per day. 9. erythropoietin 3000 units every week. 10. ativan 1 mg by mouth as needed (for migraines). 11. ambien 5 mg by mouth as needed (for sleep). 12. quinine 325 mg by mouth as needed. 13. humalog sliding-scale. 14. lantus insulin 8.5 units at hour of sleep. allergies: reglan (which causes trembling). also, a potential reaction to amoxicillin. social history: the patient is married and occasionally uses alcohol. the patient had a distant history of tobacco use and quit while in her 20s. family history: the patient has two brothers and one sister. father died at an early age due to alcoholism. her mother is healthy, but has donated a kidney to one of the patient's sisters. one of the patient's brothers has diabetes, and the patient's sister also has diabetes. summary of hospital course: the patient was admitted to the on and was taken to the operating room where she underwent a living-unrelated kidney transplant (with the donor being her husband). the procedure was performed without complaints, and the patient was thereafter transferred to the postanesthesia care unit for continued monitoring. in the postanesthesia care unit, the patient's urine output was initially good; ranging from 30 cc to 50 cc per hour. however, in the morning on postoperative day one her urine output was noted to decrease to about 10 cc per hour. the patient's. the patient's blood pressure was also noted to trend down to a systolic blood pressure of 100. the patient was started on a neo-synephrine drip to try and keep her systolic blood pressure greater than 110 and later changed to greater than 120. the patient's urine output was noted to increase with this as well as with intravenous boluses of fluid. later in the morning on postoperative day one, the patient was also started on lasix with improvement in her urine output. the patient was seen by the transplant renal team. the cause for the patient's decreased urine output was not absolutely clear. the patient had a transplant kidney ultrasound which revealed some slow flow through the lower pole of the kidney which was believed likely secondary to the patient's anatomy. the patient's central venous pressure was only 4 at the time. the transplant renal team said to give the patient some increased intravenous fluids with a goal central venous pressure of greater than 10. the patient's serum creatinine was also noted to increase to a high of 2.8 on postoperative day two; gradually trending down to a creatinine of 2.1 on the day of discharge. this was believed secondary to some acute tubular necrosis. the patient was also seen by the diabetes center team in consultation, and her insulin medications were adjusted per their recommendations. the patient's immunosuppressive medications were dosed per her usual protocol. by postoperative day four, the patient appeared adequately fluid resuscitated with some signs of fluid overload. the patient was started on lasix. by postoperative day five, the patient was less fluid overloaded and had responded well to her lasix with a urine output of 5 liters on the day before and almost 1 liter on the first shift that day. by postoperative day six, the patient was deemed stable and ready for discharge. condition at discharge: stable. discharge diagnoses: 1. end-stage renal disease. 2. status post living-unrelated kidney transplant. medications on discharge: 1. percocet one to two tablets by mouth q.4h. as needed. 2. dulcolax 10 mg by mouth twice per day as needed. 3. diabetic medications as recommended by the diabetes center. discharge instructions/followup: 1. the patient was instructed to follow up with dr. in the clinic within one to two weeks following discharge. 2. the patient was also instructed to follow up with her endocrinologist within one to two weeks following discharge. 3. the patient was also instructed to follow up with transplant nephrologist within one to two weeks following discharge. , m.d. dictated by: medquist36 Procedure: Other kidney transplantation Diagnoses: Pure hypercholesterolemia Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Complications of transplanted kidney Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Background diabetic retinopathy Gastroparesis Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled Family history of diabetes mellitus

discharge status: the patient will be discharged to her nursing home. discharge medications: 1. vancomycin 1 gm after hemodialysis until 2. nph 20 mg in the morning, 15 mg at night 3. sliding scale insulin 4. hydralazine 20 mg po qid 5. isordil 10 mg po tid 6. aspirin 325 mg po qd 7. amiodarone 300 mg po qd 8. tums 9. lopid 600 mg po bid 10. propine eyedrops 11. epogen 3000 units subcutaneous 12. colace 13. reglan 10 mg po tid 14. nephrocaps 15. dulcolax 16. coumadin 2.5 mg po q hs the patient will need post follow up of inr at the nursing home. discharge diagnoses: 1. acute renal failure likely secondary to atn 2. new onset seizures 3. diabetes mellitus poorly controlled 4. coronary artery disease 5. schizophrenia 6. dementia 7. tardive dyskinesia 8. hypertension 9. congestive heart failure 10. parkinson's 11. anxiety depression 12. proximal atrial fibrillation 13. hypercholesterolemia 14. chronic anemia , m.d. dictated by: medquist36 d: 12:12 t: 12:23 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Pulmonary artery wedge monitoring Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Other convulsions Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Unspecified schizophrenia, chronic

history of present illness: the patient is a 72-year-old female who presented to the emergency room with acute onset of shortness of breath. the patient had been at her nursing home prior to this and developed respiratory distress with an oxygen saturation of 73% on room air which improved to 82% on non-rebreather with an elevated blood pressure of 210/120. she was given 40 mg iv lasix and nitroglycerin on transfer with some improvement. the patient is a poor historian because of her chronic schizophrenia and alzheimer's disease, but she apparently denied chest pain and stated that her shortness of breath improved with lasix and diuresis. in the emergency department her chest x-ray was consistent with congestive heart failure. she had a white blood cell count of 19. she had acute renal failure with a creatinine of 3.0. hematocrit had fallen to 25. past medical history: 1. diabetes mellitus. 2. schizophrenia. 3. hypertension. 4. congestive heart failure. 5. coronary artery disease status post myocardial infarction. 6. parkinsonism. 7. anxiety and depression. 8. alzheimer's disease. 9. tardive diskinesia. allergies: allopurinol and macrodantin. social history: she is a nursing home resident. her healthcare proxy is her daughter , phone . she is full code. physical examination: vital signs: pulse 86, blood pressure 182/71, respirations 16, oxygen saturation 100% on 5 l. general: she was alert and oriented to name only. she was in mild respiratory distress. she has severe tardive diskinesia with frequent lip smacking. heent: oropharynx clear. neck: supple. jvp approximately 11 cm. chest: rales approximately half way up with more prominence on the right than on the left. cardiovascular: tachycardiac. regular, rate and rhythm. s1 and s2 normal. no murmurs, rubs or gallops. abdomen: mildly obese. soft, nontender, nondistended. normoactive bowel sounds. extremities: no pedal edema. she had 1+ dorsalis pedis pulses. rectal: heme negative. laboratory data: labs on admission showed a urinalysis with moderate blood, greater than 300 protein, leukocyte esterase positive, 11-20 wbcs. electrocardiogram showed normal sinus rhythm at 88 beats per minute. she had a normal axis with occasional pvcs. she had old significant q-wave in lead iii with poor r-wave progression and t-wave inversions in v6. chest x-ray showed diffuse interstitial infiltrate, right greater than left. hospital course: 1. congestive heart failure: the patient was aggressively diuresed with progressive improvement in her respiratory failure. there was some difficulty controlling her blood pressure initially, but once she had good blood pressure control, her response to treatment was greatly augmented. she was taken off of the ace inhibitor because of acute renal failure and placed on a nitrate hydralazine regimen instead. cardiac echocardiogram was performed and showed diffuse left ventricular hypokinesis and akinesis with an ejection fraction of approximately 25% without significant valvular disease. 2. coronary artery disease: the patient ruled out by enzymes initially. she had exercise mibi test performed which showed large anterior wall with non-reversible perfusion defect, a smaller apical irreversible defect, and a moderate sized inferior wall non-reversible defect again with an ejection fraction of approximately 25%. the extensive nature of her disease was discussed with the family, and given the high risk of coronary catheterization with the risk of ............... to her kidneys and the uncertain benefit the patient would derive from coronary artery bypass procedure, it was decided to treat the patient medically. 2. acute renal failure: the patient appeared to have some component of chronic renal insufficiency at baseline with a baseline creatinine of around 1.9. with diuresis and careful titration of her medications, her creatinine progressively improved during her hospitalization stay after peaking at about 3.4 down to a level of 2.4 on the day prior to discharge. her gfr should be calculated to be approximately 20 ml/min given her age, and all medicine should be dosed appropriately. the patient should be on a renal diet and continue on tums for phosphate binding. she should follow-up with a nephrologist as an outpatient for further management of her renal disease which is most likely secondary to her diabetes and hypertension. 3. diabetes mellitus: her blood sugars were well controlled in the hospital, and the patient should continue on her standing regimen of nph with regular insulin sliding scale supplementation. 4. urinary tract infection: the patient had a urinalysis that appeared to be positive for urinary tract infection; however, urine cultures showed mixed flora consistent with fecal contamination. we will treat the patient empirically with a 10-day course of levofloxacin. 5. anemia: the patient appeared to have chronic anemia with a baseline hematocrit of approximately 25. she was heme negative on numerous analyses. ................... labs were all negative, and iron studies showed adequate levels. she was transfused 2 u of packed red blood cells during her stay and started on erythropoietin, as her anemia is most likely due to her chronic renal insufficiency. discharge medications: k-dur 20 meq p.o. q.d., lasix 80 mg p.o. q.d., epogen 3000 u subcue 2 times per week, amlodipine 2.5 mg p.o. q.d., hydralazine 40 mg p.o. q.i.d., tums 1 g p.o. q.d., isordil 40 mg p.o. t.i.d., digoxin 0.125 mg p.o. every other day, levofloxacin 250 mg p.o. every other day until , dipivefrin 0.1% o.u. b.i.d., propine 0.1% o.u. gtt b.i.d., lopid 600 mg p.o. b.i.d., tylenol 650 mg p.o. q.6 hours p.r.n., colace 100 mg p.o. q.d., nph insulin 32 u subcue in the morning, 8 u subcue in the evening, amiodarone 250 mg p.o. q.d., lopressor 12.5 mg p.o. b.i.d., enteric coated aspirin 325 mg p.o. q.d. diet: renal. the patient had a positive video swallow study for aspiration during her stay, so her diet should be pureed with honey-thick liquids. she should be positioned ................. upright and closely monitored for signs and symptoms of aspiration. condition on discharge: stable. discharge status: to her chronic care facility. discharge follow-up: with her regular primary care physician . ................ who should feel free to set up an outpatient evaluation with a nephrologist of his choice. discharge diagnosis: 1. congestive heart failure with an ejection fraction of 25%. 2. coronary artery disease with fixed defects. 3. diabetes mellitus. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Pulmonary artery wedge monitoring Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Other convulsions Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Unspecified schizophrenia, chronic

history of present illness: this is a 72-year-old caucasian female with diabetes, coronary artery disease, hypertension, chronic renal insufficiency as well as schizophrenia and dementia who was discharged from on with a diagnosis of congestive heart failure, chronic renal insufficiency and new urinary tract infection who now returns from her nursing home after being found hypoxic. the patient had been on 4 liters nasal cannula and saturating 74%. she had increased dyspnea and was increasingly agitated. during her hospital stay from to , the patient was found to be volume overloaded and hypertensive with borderline cardiac enzymes with peak mb of 11.3 and c troponin of 1.2. she was also noted to have increased creatinine from 1.9 baseline to 3.2 likely secondary to intolerance of high dose angiotensin receptor blockers. mrs. was diuresed and then changed to hydralazine and nitrates with improvement in her hypoxia, blood pressure and creatinine. creatinine on discharge was 2.4. echocardiogram showed diffuse left ventricular hypokinesis and akinesis with an ejection fraction of 25% without valvular disease. a p-mibi was conducted showing a large anterior wall fixed defect, smaller apical fixed defect and mid inferior fixed defect as well. decision was made against cardiac catheterization given the uncertainty of benefit and also the significant risks involved. she received 3 units of packed red blood cells for anemia presumably secondary to chronic renal insufficiency and started on epogen. of note, reticulocyte count was elevated. at that time, she was discharged on levofloxacin for presumed urinary tract infection. aspiration study was done at that time which showed significant aspiration risk. the patient is a poor historian secondary to schizophrenia and dementia. at admission, she reported mild shortness of breath, no fevers, cough, chest pain, chills, palpitations, nausea, vomiting, abdominal pain, diarrhea, dysuria. in the emergency department, the patient was afebrile with axillary temperature of 95.4??????, pulse 86, blood pressure 208/63. chest x-ray was consistent with congestive heart failure with consolidation of the right upper lobe. electrocardiogram was nonspecific. she was given 2 sublingual nitroglycerin x4. 2 mg of morphine, 2 inches of nitropaste, lasix 80 mg intravenous and then 160 mg intravenous with greater than 250 cc of urine output. at that time, she was admitted to medicine for further management. physical exam on admission: general: she is chronically ill-appearing 72-year-old white female, alert, slightly tachypneic. vital signs on admission: afebrile, pulse 69, blood pressure 176/66 pulse 20, 79% on 3 liters nasal cannula. skin: warm, dry, hirsute. head, ears, eyes, nose and throat: oropharynx clear, lip swelling. neck: supple, increased jugular venous distention. lungs: rales bilaterally on the right side from the base, on the left side from the base. no wheezes or egophony. cardiovascular: s1, s2, normal regular rate and rhythm, no murmurs appreciated. abdomen: obese, soft, nontender, nondistended. extremities: trace lower extremity edema, no calf tenderness. admission labs and x-rays: white count 20.6, hematocrit 37.9, platelets 390 with 8% neutrophils, 1% bands, 11% lymphocytes, 6% monocytes, 1% eosinophils and 1% myelocytes. pt 12.8, ptt 23.2, inr 1.1. urinalysis showed specific gravity of 1.025, ph of 3, greater than 300 protein, 100 glucose, no ketones. nitrite and leukocyte esterase negative, 3 to 5 red blood cells, 6 to 10 white blood cells, 3 to 5 epis. chem-7 showed the following: sodium 136, potassium 4.7, chloride 99, bicarbonate 20, bun 52, creatinine 2.8 up from 2.4, blood sugar 364. ck was 30, troponin 0.3. blood cultures x2 were pending. chest x-ray showed increased perihilar haziness and more prominent interstitial markings. there was focal opacification on the right upper lobe which was noted on the film but not on the film. there is no effusion. electrocardiogram was sinus rhythm with 92 beats per minute. there was first degree av block apparent in inferior r-wave progression. there is new t-wave inversion in v6 consistent with electrocardiogram from . hospital course: mrs. is admitted to the medicine team initially on and then on . 1. cardiovascular: mrs. blood pressure was noted to be elevated and blood pressure control was optimized using initially an nitroglycerin drip which was then replaced with increasing afterload reduction with isordil and hydralazine. norvasc was also increased from 5 mg up. she was also started on clonidine after a few days with maintenance of blood pressure 130s to 140s systolic. mrs. received cardiology consult on for maximization of her hypertension medications. she is noted to be in bradycardia and thus her toprol was held secondary to her heart rate. clonidine per cardiology consult was added on . 2. infectious disease: her urine culture was noted for enterococcus which was ampicillin and nitrofurantoin sensitive but levaquin resistant. she had been started on levaquin for urinary tract infection during the previous admission. however, this was changed to augmentin when sensitivities were known. 3. renal: mrs. creatinine was noted to become increasingly elevated and renal consult was obtained on . they recommended renal ultrasound at that time to rule out renal artery stenosis or hydronephrosis. however, this was found to be negative and had only increased echogenicity of the bilateral kidneys indicating intrarenal disease. initially, her increasing creatinine was thought secondary to her congestive heart failure and poor forward flow. she was given fluid challenges which only resulted in worsening pulmonary edema. creatinine contained a rise with a max of 4.8 initially. renal artery stenosis is negative. she is transferred to the ccu for swan-ganz catheterization and inotropic support to improve urine output and renal function. swan was placed with initial numbers including the following: pulmonary artery pressure 76/28, wedge 30, cvp 18, cardiac output 6.1, cardiac index 3.32, svr 721. she was given 240 mg of lasix and zaroxolyn without improvement of urine output. at that time, she was started in milrinone drip which resulted in the following numbers: pulmonary artery pressure 64/23, wedge 30, cvp 17, cardiac output 7 with cardiac index of 3.8. svr at that time was 653. this was declared to be unsuccessful and swan-ganz catheter was removed with replacement of triple lumen central catheter with two dedicated ports for dialysis. at this time, she was transferred to the floor for further management. on , a few hours after being transferred to the floor, ms. began to have increasing dyspnea, was diaphoretic and desaturated into the 70s on 100% nonrebreather. her oxygenation gradually increased with initial arterial blood gases of the following: ph 7.34, pco2 41, po2 43 which has been repeated and found to be ph of 7.3, pco2 40 and po2 49. she was given 1 inch nitropaste and 1 mg morphine. she was deemed to be resistant to diuresis and this was not tried at this time. noninvasive pressure ventilation was considered, but she was instead emergently intubated and brought to the micu for further management. during the next few days, she underwent ultrafiltration dialysis every two days with improvement of her congestive heart failure. she is extubated on and successfully weaned to 2 liters nasal cannula. 4. gastrointestinal: mrs. was noted to aspirate frequently during her micu stay. many of her po medications were continued, but she was given intravenous levaquin, flagyl and vancomycin for presumed aspiration pneumonia. vancomycin had been added on for staphylococcus aureus in her sputum from sputum culture. the sensitivities are still pending. mrs. was also noted to have coffee ground emesis from her nasogastric tube on beta intubation on . her stools were also noted to be guaiac positive, but her hematocrit was stable throughout. gastrointestinal was consulted and recommended elective endoscopy and colonoscopy at a later time. mrs. is now deemed to be stable and is to be transferred out to the floor at this time. past medical history: 1. diabetes mellitus 2. schizophrenia 3. hypertension 4. congestive heart failure 5. coronary artery disease status post myocardial infarction, no known catheter data. 5. parkinsonism 6. anxiety and depression 8. alzheimer's disease 9. tardive dyskinesia 10. paroxysmal atrial fibrillation 11. hyperlipidemia 12. chronic renal insufficiency with baseline creatinine of 1.9 13. chronic anemia secondary to chronic renal insufficiency 14. glaucoma admission medications: 1. k-dur 20 mg po qd 2. lasix 80 mg po qd 3. epogen 3000 units weekly 4. amlodipine 2.5 mg po qd 5. hydralazine 40 mg po qid 6. isordil 40 mg po tid 7. tums 1000 mg po qd 8. lopressor 12.5 mg po qd 9. nph 32 units in the morning, 8 units at night 10. digoxin 0.125 mg po qd 11. levaquin 350 mg po qd 12. dipivefrin 0.1 drops each eye 13. propine 0.15 drops each eye 14. lopid 600 mg po bid 15. tylenol 650 mg po prn 16. colace 100 mg po qd 17. amiodarone 250 mg po qd 18. aspirin 325 mg po qd allergies: mrs. is allergic to allopurinol, macrodantin and angiotensin receptor blocker. social history: she does not use tobacco or alcohol. she lives in . her health care proxy is her daughter, , who can be reached at the following number: (. further evaluation and events will be noted on a later discharge summary. dr., 12-aad dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Pulmonary artery wedge monitoring Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Other convulsions Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Unspecified schizophrenia, chronic

history of present illness: this is a -year-old female with known coronary artery disease, status post acute myocardial infarction the week prior to admission. the patient was taken to the cath laboratory the week prior and found to have three vessel disease with a significant right coronary artery stenosis of 90%. she received a thrombectomy and percutaneous transluminal coronary angioplasty with a in the distal right coronary artery. the other significant disease was a 30% left main coronary artery and a 70% proximal left anterior descending, as well as left circumflex 99% lesion were not intervened upon at that time. on her last hospital admission, she was found by echocardiogram to have an ejection fraction of 50% with 2+ mitral regurgitation and inferolateral akinesis. on the day of admission, , the patient presented to an outside hospital emergency room complaining of "abdominal tightness" and pain between the shoulder blades, similar to the symptoms that brought her to the hospital the week prior. an electrocardiogram showed st elevations in the posterolateral leads. integrilin was started and the patient was transferred to for emergency percutaneous transluminal coronary angioplasty. catheterization findings: hemodynamics: initial normal-low pa pressure, intermittent marked elevation with reflected v wave. at conclusion of case, pa pressure was 22/12. coronary angiography: right dominant circulation: left main coronary artery normal. left anterior descending: 70%. left circumflex artery: 99% long occlusion from av groove, left circumflex into marginal, supplying lateral wall and papillary muscle. some collaterals from right to left. right coronary artery: patent stented right coronary artery. small diseased posterior descending artery. timi three flow. intervention: successful percutaneous transluminal coronary angioplasty and stenting of the proximal circumflex to distal om1 was performed using five overlapping 2.5 mm stents for a total length of approximately 80 mm. left femoral arteriotomy closure was performed using angioseal. the patient was taken to the coronary care unit for observation. past medical history: 1. hypertension. 2. coronary artery disease with right coronary artery as mentioned (see history of present illness). medications: 1. plavix 75 mg q.d. 2. aspirin 325 mg po q.d. 3. lescol 80 mg q.d. 4. toprol xl 25 mg q.d. 5. lisinopril 5 mg q.d. 6. lansoprazole 30 mg q.d. allergies: penicillin leads to rash. social history: the patient lives alone. family history: unremarkable. physical examination: vital signs: temperature 100.8. blood pressure 117/37. heart rate 87. respiratory rate 15. oxygen saturation 96% on four liters. general: patient lying in bed in no apparent distress, appears younger than stated age, breathing comfortably. head, eyes, ears, nose and throat: pupils equal, round and reactive to light and accommodation. mucous membranes moist. neck supple, no jugular venous distention. chest: coarse breath sounds with upper airway noises. cardiac: regular rate and rhythm, 2/6 systolic murmur at the apex. nondisplaced point of maximal impulse. abdomen: nontender, nondistended, soft, positive bowel sounds. extremities: warm, 2+ dorsalis pedis pulse bilaterally, 2+ pitting edema, halfway up the leg to the knee. neurological: awake, alert and nonfocal. laboratory findings/initial studies: white blood cell count 9.0, hematocrit 28.8, platelet count 273,000. chem-7: sodium 130, potassium 3.6, chloride 95, bicarbonate 26, bun 15, creatinine 1.0, glucose 119. ck 150, arterial blood gas 7.5/33/94. electrocardiogram showed a normal sinus rhythm at 98 beats per minute with normal axis and intervals. st depressions in leads v2 through v4. catheterization report: see history of present illness. brief hospital course: the patient was admitted to the coronary care unit and placed on aspirin, plavix, fluvastatin, integrilin. the patient was switched from toprol xl to lopressor b.i.d. her ace was held given the large dye load. patient was placed on telemetry. a chest x-ray was obtained and the patient was transfused one unit of packed red blood cells due to a hematocrit of 26%. , the patient's metoprolol was changed to 25 q.a.m., 12.5 q.p.m. lisinopril was started at 5 mg after creatinine came back at 1.1. the patient was asymptomatic, but did complain of occasional dyspepsia. the hematocrit after one unit of packed red blood cells was at 26.9. the patient was transfused an additional two units of packed red blood cells which brought her hematocrit to 34.3. a chest x-ray was obtained the previous day which showed a small bilateral pleural effusions. an echocardiogram was obtained which showed: 1. the left ventricular cavity size as normal. overall left ventricular systolic function is difficult to assess, but is probably normal (left ventricular ejection fraction greater than 55%). 2. there is a pericardial effusion. the valves were not well visualized. : , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of other inferior wall, subsequent episode of care Acute myocardial infarction of other lateral wall, initial episode of care

past medical history: 1. hypertension. 2. coronary artery disease. 3. one week status post acute mi with rca . 4. plavix 75 q.d. 5. aspirin 325 q.d. 6. lescol 80 mg q.d. 7. toprol xl 25 mg q.d. 8. lisinopril 5 q.d. 9. lansoprazole 30 mg q.d. allergies: penicillin leads to rash. social history: the patient lives alone. does not smoke. does not drink. physical examination on admission: vital signs: temperature 100.8, blood pressure 117/37, heart rate 87, respiratory rate 15, breathing 96% on 4 liters. general: the patient appears younger than stated age, lying in bed, in no apparent distress, breathing comfortably. heent: pupils were equal, round, and reactive to light and accommodation. moist mucous membranes. neck: supple. no jvd. chest: coarse breath sounds bilaterally with upper airway sounds. cardiac: regular rate and rhythm. there was a ii/vi systolic murmur at the apex. no clicks, rubs, or gallops. nondisplaced point of maximal impulse. no jvd appreciated. abdomen: nontender, nondistended, soft with positive bowel sounds, no hepatosplenomegaly. extremities: warm, 2+ dorsalis pedis pulse bilaterally, 2+ pitting edema to the calves bilaterally. neurologic: nonfocal. laboratory/radiologic data: white count 9.0, hematocrit 28.8, platelets 273,000. abgs upon admission to the ccu 7.5, 33, 94. chem-7 was 130, 3.6, 95, 26, 15, 1.0, 119. ekg showed a normal sinus rhythm at 98 beats per minute with st elevations in ii, iii, avl of mm, st depression in v1 through v5. chest x-ray showed mild chf with cardiomegaly, bilateral small pleural effusions, patchy atelectasis in the lower lobes. hospital course: the patient was admitted to the ccu for monitoring both hemodynamic and on telemetry, placed on aspirin, plavix, fluvastatin, lopressor (switched from toprol xl) b.i.d. was titrated. her ace inhibitor was held given the large dye load on . the patient was on aspirin, epifubitamide, plavix 75, aspirin, fluvastatin 80, lisinopril 5, metoprolol 25 q.a.m., 12.5 q.p.m. the patient's cks dropped nicely from 150-300. the patient was transfused 2 units of packed red blood cells which brought the hematocrit from 26.9 to 34.3. on , the venous sheaths had been pulled the previous evening. the patient was given 20 of lasix to which she diuresed nicely. at this time, the patient was transferred to the floor. on the floor, the patient continued to complain of some mild dyspepsia for which she was given simethicone and maalox which alleviated her symptoms. the patient's oxygen was gradually weaned and on this date she was breathing at 96% on 2 liters. physical therapy consult was obtained, during which time the physical therapy goals were met. on , the patient was now breathing at 95% on room air. she was asymptomatic with overall resolution of ekg changes and ck trending down to 296. creatinine was stable at 1.3 and hematocrit stable at 32.5. condition on discharge: good. discharge status: the patient was discharged breathing at 95% on room air, maintaining her blood pressure on a stable medication regimen. discharge diagnosis: inferoposterior myocardial infarction, status post stents to the left circumflex artery. discharge medications: 1. aspirin 325 p.o. q.d. 2. clopidogrel bisulfate 75 mg p.o. q.d. 3. lansoprazole 30 mg tablets one p.o. q.d. 4. simethicone 80 mg tablet, 0.5 tablet p.o. q.i.d. p.r.n. 5. isosorbide dinitrate 10 mg tablet t.i.d. p.o. 6. pravastatin sodium 20 mg tablets, four tablets p.o. q.d. 7. metoprolol 50 mg tablet, one-half of one tablet p.o. b.i.d. 8. nitroglycerin 0.3 mg tablet sublingual, one tablet sublingual every five minutes p.r.n. chest pain, take one every five minutes, no more than three doses. follow-up: 1. the patient was discharged to her daughter, house, with visiting nurse to see her on the day after discharge . 2. she was instructed to follow-up with dr. at the heart center , , , for a follow-up appointment within one week. 3. the patient was advised to take her medications as prescribed and to return to the nearest emergency room with any new symptoms such as chest pain or discomfort, gi discomfort, shortness of breath, or bleeding. 4. the patient was discharged on a 2 gram or less sodium diabetic heart healthy diet, low in fat and cholesterol. 5. the patient was advised to refrain from heavy activities (lifting greater than 20 pounds or running) for at least one week and to get out of bed to a chair at least four times per day. , m.d. dictated by: , m.d. medquist36 d: 09:28 t: 14:45 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of other inferior wall, subsequent episode of care Acute myocardial infarction of other lateral wall, initial episode of care

history of present illness: the patient is a -year-old female with a history of hypertension who presented from an outside hospital with a st-elevation myocardial infarction in the inferior and posterior segments. the patient had multiple episodes of nausea, chest pressure, chest discomfort, and epigastric pain over the past two weeks prior to admission. each episode lasted approximately one hour. the pain and episodes were stuttering in duration and progression. the pain radiated to her back and neck and was associated with shortness of breath. the patient also had shortness of breath at rest. she presented to an outside hospital where her electrocardiogram showed first-degree atrioventricular block with st elevations in leads ii, iii, and avf; st depressions in leads i, avl, v2 through v6. she was placed on aspirin, heparin, nitroglycerin, lopressor, and integrilin with near resolution of anginal symptoms. the patient was then transferred via helicopter to the for emergent catheterization. an interventional heart catheterization was performed by dr. which demonstrated a right-dominant coronary circulation with left main coronary artery with a 30% tubular ostial calcification, left anterior descending artery 70% proximal lesion, diseased first diagonal, left circumflex with 99% long stenosis involving the origin/proximal portion of first obtuse marginal which filled retrograde by left-to-left collaterals; likely very chronic but contributory to anterolateral st depressions noted on electrocardiograms prior to transfer. the right coronary artery with initial timi-ii flow, sequential 90% tubular then 90% ulcerated hazy lesions just before short posterior descending artery (with 90% ostial) and large posterior left ventricular branches. post angio-jet predilation 3 balloon, lopressor, and deployment of 3.5 x 33 hepakote , posterior descending artery jailed and lost, unable to engage with base, right coronary artery 0% residual stenosis, timi-iii flow. while transferring the patient to the stretcher status post catheterization, the patient was given a tablet of plavix and became extraordinarily anxious upon attempting to swallow the pill. she then raised her heart rate to the 140s. her blood pressure went to 240/130, and the patient went into flash pulmonary edema. she was given lasix 40 mg intravenously times two and a nitroglycerin 200-mcg bolus followed by a nitroglycerin drip at 250 mcg/kg per minute. she was also fentanyl 25 mcg for anxiety. she also reported wheezing after being given a beta blocker. at that time, the patient's blood pressure was at 189/101, and she was transferred to the coronary care unit. physical examination on presentation: physical examination at the time of admission revealed heart rate was 122, blood pressure was 189/101, respiratory rate was 20, and the patient was saturating at 89% on 100% nonrebreather mask. in general, an elderly female producing pink frothy sputum, mildly uncomfortable. head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. mucous membranes were moist. on neck examination, unable to assess jugular venous pulsation. the lungs revealed rales all the way bilaterally. cardiovascular examination revealed a regular rate and rhythm. no murmurs, rubs, clicks, or gallops. the abdomen was soft, nontender, and nondistended. positive bowel sounds. extremity examination revealed dorsalis pedis, posterior tibialis, and radial pulses were 2+ bilaterally. no presacral or lower extremity edema. the right groin catheterization site was without hematoma or bruits. it was clean, dry, and intact. neurologic examination revealed alert and oriented times three. moved all extremities. pertinent laboratory values on presentation: laboratories revealed sodium was 140, potassium was 4.1, chloride was 119, bicarbonate was 19, blood urea nitrogen was 15, creatinine was 1, and blood glucose was 122. initial inr was 1.3. blood gas revealed 7.37/34/71. creatine kinase was . pertinent radiology/imaging: electrocardiogram at the outside hospital showed 1-mm to 2-mm st elevations in leads ii, iii, and avf with 3-mm to 4-mm st depressions in v1 through v6 (these were dynamic changes). at , she had a normal sinus rhythm with a prolonged p-r interval with normal axis. status post catheterization with a left axis deviation, still with 0.5-mm st elevations inferiorly. hospital course: on , the patient was on aspirin, lipitor, morphine, heparin, integrilin, and nitroglycerin drip. she was asymptomatic with no nausea, chest pain, chest pressure, shortness of breath, palpitations, or edema. her lung examination was markedly improved on her second hospital day with crackles halfway up. an echocardiogram was performed on which showed an ejection fraction of 50%. no aortic stenosis. mitral regurgitation of 2+ and 1+ tricuspid regurgitation. no effusions. the left atrium was mildly dilated with inferior wall motion abnormalities. a chest x-ray from early on showed likely congestive heart failure with a tortuous aorta, small pleural effusions (left greater than right), with pulmonary edema. there was a discussion on regarding taking the patient back to the catheterization laboratory for treatment of her left-sided disease. however, it was decided that at this time the culprit lesion was indeed the right coronary artery, and the left-sided lesions would possibly be corrected at a later date. on , the patient was placed on metoprolol 12.5 mg p.o. twice per day and given some as needed medications for her gas/bloating. she did have two brief hypotensive episodes to a systolic blood pressure of 90 which quickly corrected with 250-cc boluses times two. her creatine kinases trended down nicely from 3092 to 2199 to 1456. her mb fractions also trended down from 401 to 221 to 110. on , the patient was changed from atorvastatin to fluvastatin because of a recent study indicating a mortality benefit from fluvastatin as opposed to atorvastatin when combined with plavix. on , the patient was also started on lisinopril 5 mg p.o. every day and changed to toprol-xl 25 mg p.o. once per day. a physical therapy consultation was obtained which showed the patient fully able to ambulate without becoming symptomatic. her foley catheter was discontinued. condition at discharge: the patient was discharged in good condition. discharge instructions/followup: 1. the patient was informed to follow up with dr. (a cardiologist in ) within the next week (telephone number ). 2. dr. answering service was contact regarding our plans for followup with him at within the week. discharge disposition: she was sent home with the support of her daughter ( ) and given handouts on her condition. discharge diagnoses: acute st elevation inferoposterior myocardial infarction. congestive heart failure, systolic and diastolic acute on chronic. coronary artery disease. hypertension. hyperlipidemia. medications on discharge: 1. aspirin 325-mg tablet one tablet p.o. once per day. 2. clopidogrel bisulfate 75-mg tablet one tablet p.o. once per day. 3. lansoprazole 30-mg tablet one tablet p.o. once per day. 4. lisinopril 5-mg tablet one tablet p.o. once per day. 5. simethicone 80-mg tablet half to one tablet p.o. four times per day as needed (for gas). 6. metoprolol-xl 25 mg p.o. every day (do not crush). 7. fluvastatin 80-mg tablet one tablet p.o. once per day (do not crush). , m.d. dictated by: medquist36 d: 18:29 t: 10:45 job#: Procedure: 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 temporary transvenous pacemaker system Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of inferoposterior wall, initial episode of care Diastolic heart failure, unspecified Diseases of tricuspid valve First degree atrioventricular block

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: nausea/vomiting major surgical or invasive procedure: open cholecystectomy history of present illness: the patient is a 76 year old male with a history of htn, hl who presented to the er on after developing nausea, vomiting, abdominal pain after eating dinner around 5:30 pm. the patient was watching the sopranos on tv after dinner and developed sharp, epigastric pain radiating to his right flank. he had two episodes of nonbilious vomiting. he denies any recent fevers/chills/sick contacts/diarrhea/constipation. he admits to occasional alcohol and had 3 beers that night with his meals. he also admits to drinking one glass of scotch. he denies a history of heavy alcohol use. . the patient says that he has had 1 similar episode to this in the past about 15 years ago that he believes was gastric reflux. . in the ed, the patient received dilaudid for pain control and ivf at 200 cc/hr for 3 liters. his amylase was noted to be 151, lipase 125, hct 40, and cr 1.3. an abdominal ultrasound showed: redemonstration of cholelithiasis. no evidence of cholecystitis. normal cbd. no other imaging was performed. he was admitted for pain control which is now well controlled with dilaudid. . ros: . no chest pain, shortness of breath, cough, fevers, chills, diarrhea or constipation. no weight loss or jaundice. no bloody stools, no blood in urine. past medical history: htn hyperlipidemia elevated psa/ ? prostate cancer - followed by dr. cataracts s/p surgical removal in both eyes cri cr 1.1-1.2, ct in showed severe chronic right uteropelvic junction obstruction (believed to be congenital) diverticulosis colonic polyps h/o cholelithiasis social history: the patient lives with his wife . he drinks on occasion but denies heavy alcohol use. he drinks 1 glass of scotch on occasion (not daily) + 1-3 beers. denies tobacco. family history: mother died at 60 of pancreatic cancer; father died at 74, unsure of the cause of death possibly black lung as he was a coal miner physical exam: tc=97 p=80 bp=122/70 rr=16 85-90% on ra . gen - nad, aox3 heent - anicteric, mmm, external jvd to jaw, internal jvd cm pulsations heart - rrr, no m/r/g, physiologic split s2 lungs - crackles at both bases extending 1/2 up on the right abdomen - soft, nt, nd, + bs, no hepatosplenomegaly, no palpable masses ext - no c/c/e, +1 d pedis bilaterally back - no back pain, cvat skin - no rashes noted neuro - cn ii-xii grossly intact pertinent results: 12:17am pt-11.9 ptt-26.4 inr(pt)-1.0 12:17am plt count-318 12:17am microcyt-1+ 12:17am neuts-72.8* lymphs-18.9 monos-4.8 eos-2.4 basos-1.1 12:17am wbc-7.0 rbc-4.80 hgb-13.9* hct-40.4 mcv-84 mch-29.0 mchc-34.5 rdw-15.5 12:17am albumin-4.2 calcium-9.1 phosphate-3.2 magnesium-2.4 12:17am lipase-125* 12:17am alt(sgpt)-15 ast(sgot)-25 alk phos-70 amylase-151* tot bili-0.6 12:17am estgfr-using this 12:17am glucose-148* urea n-23* creat-1.3* sodium-140 potassium-3.3 chloride-97 total co2-31 anion gap-15 06:50am plt count-308 06:50am microcyt-1+ 06:50am neuts-93.2* lymphs-3.7* monos-2.6 eos-0 basos-0.5 06:50am wbc-14.5*# rbc-5.00 hgb-13.6* hct-42.4 mcv-85 mch-27.2 mchc-32.1 rdw-15.6* 06:50am magnesium-2.1 06:50am lipase-52 06:50am alt(sgpt)-16 ast(sgot)-23 alk phos-69 amylase-171* 06:50am glucose-132* urea n-20 creat-1.1 sodium-142 potassium-3.4 chloride-99 total co2-31 anion gap-15 06:50am glucose-132* urea n-20 creat-1.1 sodium-142 potassium-3.4 chloride-99 total co2-31 anion gap-15 02:34pm urine hyaline-0-2 02:34pm urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0-2 02:34pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 02:34pm urine color-yellow appear-clear sp -1.017 . ekg sinus bradycardia at 50 bpm. nl axis. no st changes. nonspecific twi in avl. q waves in iii, avf. compared to , no change. chest (portable ap) 6:53 pm right lower lobe atelectasis without evidence for pneumonia. . chest (portable ap) 4:28 am portable ap chest radiograph compared to . the heart size is normal. mediastinal and hilar contours are unremarkable. there is mild perihilar haziness and bronchial wall thickening which may represent fluid overload as well as small left pleural effusion cannot be excluded. there is no pneumothorax or focal lung consolidation. . liver or gallbladder us (single organ) 2:45 am findings: a 1.3 cm stone is again noted in the gallbladder neck. additional nondependent foci along the gallbladder wall are consistent with small polyps or adherent stones. there is no wall thickening or pericholecystic fluid. the common duct is not dilated. again seen is massive right hydronephrosis. impression: cholelithiasis without evidence of cholecystitis. . - ct abdomen/pelvis- in discussion with radiologist, evidence of acute cholecystitis, with stone in cystic duct, fat stranding. . brief hospital course: the patient is a 76 year old male with a history of htn, hl, ?prostate cancer who presents with nausea/vomiting,epigastric pain->back believed to be consistent with pancreatitis. . #acute pancreatitis- the patient reports an equivocal history of alcohol use. his mother had pancreatic cancer. the patient has only one functional kidney with a cr of 1.3. ct scan not performed on admission as felt patient had greater risk than benefit at this point to further assess the pancreas. abdominal ultrasound shows cholelithiasis without obstruction, cholecystitis. continue to monitor progression of pain, trended enzymes. cholelithiasis and alcohol considered as likely etiology. zofran for nausea, morphine, then to oxycodone for pain. patient had minimal discomfort on admission. fever to 102.4 and leukocytosis worsening overnight day two of admission. ct abdomen/pelvis ordered. performed night. 7am, ct with evidence of acute cholecystitis. abx initiated, unasyn. pt with + sign, very tender ruq. surgery contact. to or for lap cholecystectomy. hydration as tolerated, given chf. . hypoxia- desaturation post 3 liters fluid given in ed. jvp elevated. only sparse crackled. to 85% ra transiently. stable on 2l nc. cxr with atelectasis at right base. held on further hydration. considered pe. compression given splinting. pt was moved out of the icu after 3 days and his respiratory efforts improved. on hd 7 the patient was able to maintain adequate saturations of 97% on ra . # chf, ef unknown. evidence of hypoxia with crackles bilaterally on exam after aggressive fluid hydration with ns at 200 cc/hr x 3 liters in ed. dc'd ivf for now 10 mg iv lasix given hypoxia by nightfloat admitting resident. the patient had been sat'ing 100% on ra prior to receiving 3 liters of ivf in ed. sats stable at 95% 2l, ct abdomen with lung cuts to assess bases. . # glutealregion hematoma- as per previous ct scan in 06. patient will likely need repeat mri as outpatient as per dr. to reassess as still present. . # htn - hctz re initiated. . # hyperlipidemia- continue lipitor 10 mg po qd. . #fen - npo, ivf - held given fluid overload and desaturation. repleted potassium. . ppx - hep sq tid, ppi . code - full pt was able to tolerate a full regular diet on hd 7. his foley, jp drain were removed and his ivs were heplocked on hd7. staple were romved on pod #6. pt was tolerating a regular diet and was discharched home. medications on admission: lipitor 10 mg po qd hctz 25 mg po qd discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 2. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 3. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 5. hydromorphone 2 mg tablet sig: one (1) tablet po q3-4h (every 3 to 4 hours) as needed. disp:*40 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: gangrenous cholecystitis discharge condition: good, tolerating pos, ambulating, voiding discharge instructions: you had your gallbladder removed. your drains were removed during your hospital course. you will be discharged on pain medication. do drive or operate heavy machinery while on this medication. you will not be discharged on antibiotics. you may go about your usual daily activities. please call the clinic or go to your local emergency department for the following 1) temperate >101.5 2) increased pain 3) increased redness around the incision sites 4) increased drainage out of incision sites 5) inability to pass flatus 6) inability to pass stool for several days followup instructions: provider: , .d. date/time: 9:30 provider: , m.d. phone: date/time: 11:40 provider: , rn,ms,: date/time: 10:00 you should follow up with dr. in her clinic in 2 weeks. you should call to schedule an appointment. when making the appointment be sure to tell the nurse that you are scheduling your 1st post-operative appointment Procedure: Cholecystectomy Intraoperative cholangiogram Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Other and unspecified hyperlipidemia Hydronephrosis Acute pancreatitis Calculus of gallbladder with acute cholecystitis, without mention of obstruction Personal history of colonic polyps Laparoscopic surgical procedure converted to open procedure

history of present illness: the patient is an 83-year-old spanish-speaking female, admitted from nursing home with abdominal pain, nausea and vomiting. the patient's daughter is the patient's primary historian, and she states that the patient has had a long history of fatty food intolerance and intermittent right upper quadrant pain. she also says that she believes the patient had a cholecystectomy about 11 years ago in city, but isn't 100% certain. for the past one to two years, the patient has occasional abdominal pain, especially after eating, but no acute prolonged episodes. for the past several days, however, the patient has vomited almost daily, has not improved with compazine, and has taken little oral intake. laboratories from this morning at the nursing home revealed a white count of 14.6, with 93% neutrophils. examination done in the nursing home by the nurse-practitioner revealed right upper quadrant tenderness. she was referred to for workup of possible cholecystitis. past medical history: 1. cerebrovascular accident with residual right hemiparesis. she has no aphasia. she is bed-to-chair only. she is not ambulatory. 2. atrial fibrillation 3. history of congestive heart failure, currently asymptomatic on treatment 4. hypertension, baseline blood pressure approximately 150/80 5. obesity 6. depression 7. vitamin b12 deficiency medications on admission: 1. zestril 5 mg by mouth once daily 2. aggrenox one by mouth twice a day 3. tylenol 650 mg by mouth every eight hours as needed 4. prozac 40 mg by mouth every morning and 20 mg by mouth every evening 5. vitamin b12 1000 mcg intramuscularly monthly 6. diltiazem cd 180 mg by mouth once daily 7. lasix 40 mg by mouth once daily 8. potassium chloride 40 meq by mouth once daily 9. multivitamin one by mouth once daily 10. dulcolax as needed 11. peri-colace one by mouth once daily 12. colace 100 mg by mouth twice a day allergies: the patient has no known drug allergies. social history: the patient is a nursing home resident at . she currently is not drinking. she does not smoke cigarettes. physical examination: temperature 98.7, heart rate 80 to 100 and irregular, blood pressure 193 to 197/89 to 102, respiratory rate 18, oxygen saturation 96% on room air. in general, the patient is an alert, obese woman, spanish-speaking only, who does not appear in acute distress but seems flushed. head, eyes, ears, nose and throat shows mucous membranes are moist. there is no obvious scleral icterus. the neck is supple. there is no lymphadenopathy. jugular venous pressure is less than 5. the lungs are clear to auscultation bilaterally. the heart has an irregularly irregular rhythm. there is a ii/vi systolic murmur, loudest at the right upper sternal border. the abdomen has two old surgical scars, both midline, one above and one below the umbilicus. there is definite right upper quadrant tenderness. there is no rebound. there are normal bowel sounds. there is a vague mass in the right upper quadrant, just below the right costal margin. the extremities show trace edema. they are well perfused. neurologic examination shows a right hemiparesis, but she can move both arms and legs. laboratory data: on admission, white count 16.7, 92% polys, hematocrit 39.7, platelets 296. sodium 138, potassium 3.6, chloride 98, bicarbonate 27, bun 10, creatinine 0.6, glucose 115. ast 317, alt 312, alkaline phosphatase 417, total bilirubin 3.8, amylase 24, digoxin less than 0.3. urinalysis shows large leukocyte esterase, greater than 300 protein, trace ketones, 0-2 red blood cells, 21-50 white blood cells, moderate bacteria, 0-2 epithelial cells. imaging studies: abdominal ct showed intrahepatic ductal dilatation. the gallbladder was present. the common bile duct was dilated at approximately 18 mm. the gallbladder wall was mildly prominent. a right upper quadrant ultrasound showed intrahepatic ductal dilatation. the common bile duct was noted to be 2 cm dilated. there were no stones evident on ultrasound. the gallbladder wall was noted to be thickened. there was no pericholecystic fluid. electrocardiogram showed the patient to be in atrial fibrillation at a rate of 120. the axis was normal. the intervals were normal. there were st depressions in leads ii and avf, v4 through v6. there was borderline left ventricular hypertrophy. there was no old electrocardiogram for comparison. hospital course: in summary, the patient is an 83-year-old female with multiple medical problems, admitted with nausea, vomiting, and right upper quadrant abdominal pain, consistent with possible cholecystitis vs. cholangitis. 1. gastrointestinal: as stated, the patient was felt to have possible cholecystitis vs. cholangitis at the time of admission. she was started on ampicillin, gentamicin and flagyl for broad antibiotic coverage, and her abdominal examination was monitored closely. a surgical consult was called at the time of admission, and the patient was not currently felt to require surgery, but they agreed with the likely diagnoses and agreed with urgent endoscopic retrograde cholangiopancreatography for decompression of the biliary tree. the patient had endoscopic retrograde cholangiopancreatography performed on . findings at endoscopic retrograde cholangiopancreatography showed the esophagus, stomach and duodenum to be normal. the major papilla showed bulging. pus was noted to be coming from the major papilla as well. a sphincterotomy was performed, and multiple stones, from 5 to 20 mm, were extracted successfully. in addition, pus was drained from the biliary tree. at the end of the procedure, there were felt to be no stones left within the biliary tree. the patient appeared stable following endoscopic retrograde cholangiopancreatography, however, the day following endoscopic retrograde cholangiopancreatography, the patient clinically deteriorated. she had developed rapid atrial fibrillation, worsening congestive heart failure, and her abdomen was tense with rebound tenderness. in addition, her blood pressure was relatively low, down at 110/60. she was febrile to 101.3 per rectum. it was felt she may be developing early septic shock. she had an urgent percutaneous drainage of the gallbladder under ir guidance, and was transferred to the medical intensive care unit for closer monitoring. after percutaneous drainage of the gallbladder, the patient improved significantly, with decreasing fever, white count and abdominal pain. she was started on clear liquids on , and was advanced to full liquids. her liver function tests have continued to trend down throughout this hospitalization, with her ast peaked at 317 on admission, down to 22 on the day of this discharge summary. her alt has gone from 312 down to 32 at the time of this discharge summary. in regards to her pancreas status post endoscopic retrograde cholangiopancreatography, the patient has appeared to be stable, with no increased epigastric tenderness, however, her lipase was noted to be 258 on , which was up from 11 on . at the time of this discharge summary, a repeat lipase level is pending, and it is presumed to be trending downward, as the patient has no symptoms. she has had no nausea, vomiting, and no increased abdominal pain. she is tolerating full liquids without difficulty. it should be noted that the patient's pigtail catheter inadvertently fell out on . her abdominal examination has remained stable since that time. surgery as well as interventional radiology felt there was no need to replace the pigtail catheter, as the patient has clinically remained stable. abdominal examination on the day of this discharge summary showed the patient to still have some voluntary guarding in the right upper quadrant, but there was no rebound. the belly was soft. she had normal active bowel sounds, and she was not distended. 2. cardiovascular: the patient has a history of atrial fibrillation, normally well rate controlled, and a history of congestive heart failure, and was not noted to be having symptoms at the time of admission. however, on the morning of the second hospital day, the patient was noted to have increased heart rate in the 120s, as well as increased rales at the bases. she was given diltiazem intravenous push with some effect at that time. however, as her abdominal examination continued to worsen, and her fever got worse, so did her atrial fibrillation. by , the patient was in rapid atrial fibrillation with worsening congestive heart failure. she eventually had good response to intravenous doses of diltiazem. she was diuresed, and her cardiac examination improved with improvement in her abdominal condition. she has had no chest pain throughout her hospital stay. she had one ck and troponin checked at the time of admission, which were negative. at the time of this discharge summary, the patient is on her previous outpatient cardiac regimen, consisting of zestril 10 mg by mouth once daily, diltiazem cd 180 mg by mouth once daily, and lasix 40 mg by mouth once daily. she is not on any anticoagulation. 3. infectious disease: as already noted, the patient has had temperature spikes and elevated white blood cell counts secondary to cholecystitis/cholangitis. she has been on ampicillin, gentamicin and flagyl since the time of admission. bile taken at the time of endoscopic retrograde cholangiopancreatography has grown pansensitive enterococcus as well as pansensitive pseudomonas. her blood cultures were negative. urine cultures also were negative. the patient will require a full course of intravenous antibiotics. at the time of this discharge summary, she is on day nine out of 14 to 21 days. the exact duration of antibiotic therapy will be confirmed with the attending physician and noted on the page one. at the time of this discharge summary, the patient has been afebrile for greater than 24 hours. 4. fluids, electrolytes and nutrition: the patient has required repletion of her potassium and magnesium. her potassium will be checked on the morning of discharge and, if it remains low, she will be restarted on her previous 40 meq of potassium per day. however, her ace inhibitor dose has been increased from 5 to 10 mg, and this may help to keep her potassium at a higher level. in regards to her diet, she is currently on full liquids and tolerating them well. she will slowly be advanced to a low fat cardiac diet if her lipase is trending down. 5. code status: the patient has confirmed her do not resuscitate/do not intubate status. condition at discharge: stable. discharge medications: 1. zestril 10 mg by mouth once daily 2. colace 100 mg by mouth twice a day 3. dulcolax 10 mg by mouth/per rectum as needed 4. tylenol 650 mg by mouth every six hours as needed 5. diltiazem cd 180 mg by mouth once daily 6. prozac 40 mg by mouth every morning, 20 mg by mouth every evening 7. lasix 40 mg by mouth once daily 8. protonix 40 mg by mouth once daily 9. heparin 5000 units subcutaneously twice a day 10. ampicillin 500 mg intravenously every six hours 11. gentamicin 100 mg intravenously every 12 hours 12. flagyl 500 mg intravenously every eight hours discharge follow up: the patient will require follow up with surgery when she has completely recovered from this episode and has finished her course of intravenous antibiotics, for possible elective cholecystectomy. discharge diagnosis: 1. cholangitis 2. cholecystitis 3. choledocholithiasis 4. rapid atrial fibrillation 5. hypertension 6. depression 7. status post endoscopic retrograde cholangiopancreatography with stone extraction and sphincterotomy on 8. congestive heart failure , m.d. dictated by: medquist36 Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Percutaneous aspiration of gallbladder Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Other shock without mention of trauma Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Cholangitis Calculus of bile duct with other cholecystitis, without mention of obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mental status changes major surgical or invasive procedure: intubation now status post extubation history of present illness: 78yo man with history of htn, parkinsons disease, dementia was sent in from his nursing home with altered mental status. he was found to be hypoxic at the nursing home and less responsive than usual. he is typically minimally verbal per report from a nurse at his nursing facility. he was intubated for airway protection as he was minimally responsive on arrival and sent to the micu. his oxygen saturation at that time was 90% on nrb. he received narcan without effect. ct of his head demonstrated evidence of subacute and chronic ischemic strokes. during his micu stay, he was seen by the neurology consult team. eeg was without seizure activity. mri did not demonstrate any acute abnormalities. he remained hemodynamically stable and afebrile. . regarding his hypoxemia, he did not have any clear infiltrates on chest film. he had a cta done to rule out pe. this showed a left lower lobe infiltrate, but no evidence of pe. his initial labs were notable for hct of 30 with no prior for comparison, ua with no evidence for infection, chemistry with normal anion gap and lactate of 1.9. urine and blood cx were sent. ck and mb were normal (no initial troponin sent). serum tox screen was sent. also got 2.5l ns. . according to staff at his nursing facility, he is severely demented and minimally functional at baseline. he was eating breakfast the day of admission per history elicited by neurology and was noted to be altered and less responsive by staff. he did not have any focal weakness or aphasia at that time. vital signs were checked, and he was found to be hypoxic. he had his usual level of home oxygen off (commonly done during meals), but he was more hypoxic than is typical for him in this setting. he was assisted back to bed and then checked on several times over the next hour. finally, ems was called as he was persistently minimally responsive. past medical history: 1. hypertension 2. parkinson's disease 3. uti 4. prostate ca 5. s/p turp, obstructive uropathy 6. h/o positive ppd w/ negative cxr 7. dementia with h/o psychosis 8. h/o gastritis; s/p gi bleed 9. h/o bowel and bladder incontinence 10. macular degeneration 11. h/o cholecystitis 12. h/o pancreatitis 13. h/o iron def anemia 14. h/o etoh abuse 15. h/o leukocytosis 16. depression social history: lives at nursing home. by report, is totally dependent for adls. he is blind. baseline tremors, gait issues secondary to parkinsons. he's commonly agitated, combative, resistant. totally dependent for feeding. self-abusive behavior. family history: unknown physical exam: on arrival: gen intubated, sedated, withdrawing to pain: on admission neck supple, no jvd heent dry mucous membranes cv regular bradycardia, no m/r/g resp cta bilaterally abd flat, non-distended, nabs, no peritoneal signs rectal guaiac neg brown stool neuro: pupils about 1-2mm, minimally reactive. intact corneal reflexes. intact dolls eye. gag not assessed. withdrawing all extremities to painful stimuli. toes down going. pertinent results: labs on admission: wbc 5.7, hct 30.1, plt 174,000 inr 1.2 albumin 3.3, alt 19, ast 49, ldh 452 iron 21, tibc 312, ferritin 12 b12 1133, folate 13.8 tsh 5.9, free t4 1.1 retics 1.4% glucose 166, bun 26, creatinine 1.1, potassium 6.8 ua on : 0-2 wbcs, > 50 rbcs, 0-2 epis, otherwise negative cardiac enzymes with troponin 0.02 x 2 sets cortisol 28.3 serum tox negative lactate 1.9 . imaging: chest xray (): 1. no definite parenchymal consolidations, however, faint opacities are identified within the right and left lower lobes which may represent early pneumonia (possibly aspiration) or simply be an overlap of vascular structures. followup radiographs are recommended. 2. appropriate positioning of endotracheal tube with side port of nasogastric tube likely at ge junction. advancement is recommended. . ct head (): findings: there is no intracranial hemorrhage. there is sulcal and ventricular prominence to generalized brain atrophy. there is an area of encephalomalacia within the periventricular white matter in the region of the left caudate head. this represents a small chronic infarct. there is a late subacute infarct in the left temporal lobe. there is no definite hydrocephalus. the lateral ventricles are likely delineated due to generalized brain atrophy. please correlate clinically as to the possibility of normal pressure hydrocephalus. there is opacification of the paranasal sinuses as the patient is intubated. impression: no intracranial hemorrhage. subacute left temporal lobe infarct and a chronic left deep white matter infarct. . cta (): 1. no evidence of pulmonary embolism is seen. 2. area of parenchymal consolidation within the left lower lobe that most likely represents pneumonia/aspiration. please correlate clinically. . eeg (): this was an abnormal routine eeg due to the slow and disorganized background, suggestive of a moderate encephalopathy. infection, toxic/metabolic disturbances, medication effects and anoxia are among the most common causes. multifocal slowing seen suggests subcortical dysfunction. superimposed beta activity seen is most likely due to medication such as benzodiazpines or barbituates. no epileptiform discharges or seizures were seen. . mri/mra head (): moderate ventriculomegaly including dilatation of the lateral and third ventricles and prominence of temporal horns which in proper clinical setting could be due to normal pressure hydrocephalus. alternatively, this could be due to brain and medial temporal atrophy. chronic lacune left basal ganglia with chronic blood products. no enhancing lesions or mass effect seen. no evidence of acute infarct. normal mra of head. . ct abdomen/pelvis (): 1. massively dilated sigmoid colon that contains inspissated fecal material. this appearance is concerning for fecal impaction. there is also proximal dilatation of large bowel loops. no obstructing lesions are seen. 2. mild enlargement of intra- and extra-hepatic bile ducts. 3. 22-mm cystic lesion within the pancreatic head that is most worrisome for intrapancreatic mucinous neoplasm. 4. multiple hypodense lesions within both kidneys that most likely represent cysts; however, at least two lesions in the mid pole of the right kidney do not have the appearance of simple cysts. this area can be further followed up if clinically indicated. 5. consolidated area within left lower lobe that is supplied by a branch from the aorta. the appearance is consistent with sequestration. . microbiology: rpr nonreactive sputum culture: gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): sparse growth oropharyngeal flora. blood cultures (): no growth urine culture (): no growth . labs at discharge: brief hospital course: 78 yo m with h/o parkinsons disease, dementia, and htn admitted after being found unresponsive and found to have pneumonia, initially intubated for airway protection now extubated and doing well on room air. . # encephalopathy/change in mental status: it is unclear if the patient is now far from his baseline though reportedly he does speak a few words. it is conceivable that he was less responsive during his hypoxic episode. he was treated for (aspiration) pneumonia with resolution. mri was normal and eeg did not show any seizure activity. lfts were wnl and tox screen was negative. tsh was elevated but free t4 normal so no thyroid replacement. b12/folate wnl. neurology consulted and recommended continuing with medical regimen. question of normal pressure hydrocephalus on ct (prior films were not available for comparison so chronicity unknown) but per neurology, patient not candidate for shunt placement and no furhter intervention recommended at this time. of note, he did have an episode of decreased responsiveness while in-house that was attributed to a missed dose of sinemet +/- seroquel effect. the latter was discontinued and the former was resumed at usual dose with resolution. . # hypoxia- was intubated in setting of pneumonia and subsequently extubated with sats > 95% on room air. he does carry a history of copd with baseline home o2 requirement. suspect that this was further worsened in setting of new pneumonia. there was no sign of pe on cta. completed treatment for pneumonia with improvement. follow up chest images showed radiographic resolution. . # leukocytosis - likely secondary to pneumonia, resolved after completing antibiotic course. c. difficile studies were negative. . # parkinsons disease/dementia: back on treatment with sinemet, aricept, zoloft. changes per neuro recommendations risperdone was changed to seroquel but patient became somnolent so he was switched back to risperidone. not on namenda as it is not on formulary. patient was able to walk with physical therapy on but not capable of following instructions. . # history of iron deficiency anemia: microcytic anemia with hematocrit of 30 on admission; no prior for comparison. b12 and folate are wnl. tsh elevated but free t4 normal. has guaiac positive stools but stable hematocrity. could consider colonoscopy as outpatient if appropriate to overall goals of care and life expectancy (guardianship pending). . # h/o prostate cancer, urinary outlet obstruction, no acute issues. . # fen : speech and swallow consult recommending honey thickened liquids and pureed solids. . # ppx: sc heparin, ppi, head of bed elevation with aspiration precautions. . # full code per nursing home . # communication: discussed situation with nursing home; has been resident there for 10yrs. no family. nursing home will establish guardian upon patient's return. medications on admission: mvi vit b1 niacin 100mg qd risperdal 1mg at 5pm and 9pm namenda 10mg trazadone 75mg hs aricept 5mg qpm zoloft 50mg am sinemet 25/100 tid cal/vit d 600 colace 100mg senna 1 hydrocort 2.5% to rectal area discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) u injection tid (3 times a day): while nonambulatory. 2. bisacodyl 10 mg suppository sig: one (1) suppository rectal 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. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 5. hydrocortisone 2.5 % cream sig: one (1) appl rectal (2 times a day). 6. trazodone 50 mg tablet sig: 1.5 tablets po hs (at bedtime). 7. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 8. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 9. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po tid (3 times a day). 10. hexavitamin tablet sig: one (1) cap po daily (daily). 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 12. memantine 10 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: facility - discharge diagnosis: pneumonia with hypoxia, resolved . secondary: parkinson's disease dementia history of untreated prostate cancer history of positive ppd with negative cxr history of gastritis and gi bleed history of bowel and bladder incontinence history of alcohol abuse depression discharge condition: afebrile, normotensive, comfortable on room air. discharge instructions: please take your medications as prescribed. please call your doctor or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, decreased level of consciousness, passing out, falls, trouble breathing, decreased urine output, diarrhea, vomiting with inability to keep down liquids or medications, or any other concerns. followup instructions: please follow up with your primary care physician weeks after discharge. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Paralysis agitans Pneumonitis due to inhalation of food or vomitus Hypoxemia

code: full allergies: nkda 78 year old male found unresponsive in nursing home with drop in sats and rr this morning. brought in by ems to ew, intubated for mental status changes and increasing o2 requirements. head ct showed old infarcts and "late subacute infarct." questionable seizure activity. transferred to micu for further care. cta done before brought to unit, eeg done in unit, both results pending. neuro: pt arousable to pain on 15mcg/kg/min propofol. mae (but rigid), unable to follow commands, pupils pinpoint and minimally reactive. propofol turned of per eeg tech request x 1 hr, appears comfortable now on previous dose. remains in bilateral wrist restraints for safety. ordered for urgent mri. cv: hr sb 41-52 (unsure of baseline hr), nbp 120-140/60's but up to 160-170 systolic during eeg (propofol off). temp upon arrival to unit .9 axilaary, unable to obtain po/pr, warming blanket applied and temp up to 98.0. pt appears cachetic. resp: arrived on vent support, ac 500x14/100%/+5 with abg of 7.54/29/399, settings adjusted to ac 500x10/50%/+5. rr teens with sats 100%. lung sounds clear to coarse bilaterally. suctioned for thin, yellow secretions. gi: bs x 4, no stool this shift. ng tube patent, placement checked. gu: foley patent and draining clear, yellow urine. uo 30-100cc/hr. skin: piv x 2, breakdown to perineum area noted. ordered for hydrocortisone cream . social: no guardianship, no family noted. plan: follow up labs/culture data/procedure results wean vent support as tolerated sedation as needed for comfort monitor hr routine icu care and monitoring Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Paralysis agitans Pneumonitis due to inhalation of food or vomitus Hypoxemia

code: full allergies: nkda neuro: pt alert, mostly non-verbal, inconsistently answering to yes/no questions, inconsistently following commands. able to mae, assists with turns. some parkinsonian posturing noted. mri done yesterday unremarkable, eeg negative for status epilepticus. restarted on po psych medications. cv: hr sr/sb 51-68 with no ectopy noted, nbp 98-141/48/74, afebrile. most recent crit 27.1. resp: rr 10-22 with sats at 100% on 2l nc. lung sounds clear in apices, diminished in bases. strong non-productive cough. pt doing well post-extubation. gi: bs x 4, no stool this shift. started on pureed diet with nectar thick liquids which pt is tolerating well. meds crushed and mixed in with applesauce or pudding. gu: foley patent and draining adequate amount of clear, light yellow urine. am potassium of 3.4 being repleted. pt autodiuresing. started on ivf for negative fluid balance. id: pt afebrile, possible lll pna, vanco/zosyn d/c'd, and pt started on levo/flagyl. access: piv x 2 social: no living family, no legal guardian. plan: pt c/o to floor pt called out to floor Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Paralysis agitans Pneumonitis due to inhalation of food or vomitus Hypoxemia

chief complaint/ history of present illness: the patient is a 55-year-old man with known bicuspid aortic valve followed by dr. for the past several years for aortic regurgitation. over the past six months he has been experiencing worsening exercise tolerance and increasing dyspnea on exertion. an echocardiogram done on revealed severe aortic regurgitation and severely dilated lv cavity with an ef of 50%. he is now referred to for cardiac catheterization in preparation for aortic valvular replacement. past medical history: significant for hypertension, hypothyroidism, gout, sleep apnea, benign prostatic hypertrophy, torn rotator cuff and hernia repair times two. the patient denies claudication, orthopnea, edema, pnd, lightheadedness, tia, cva, melena or gi bleed. allergies: he has no known allergies. medications: prior to admission include captopril 50 mg tid, flomax 0.4 mg q d, synthroid 0.15 mg q d, vioxx 25 mg q d, viagra prn and aspirin 325 mg q d. social history: married, works as a operator. physical examination: height 5 feet, 11 inches, weight 230 lbs. vital signs, temperature 98, heart rate 48, sinus rhythm, blood pressure 124/30, respiratory rate 18. in general, healthy appearing 54-year-old man in no acute distress. neuro, grossly intact, no apparent deficits. pulmonary, lungs clear to auscultation bilaterally. cardiac, regular rate and rhythm, 4/6 systolic murmur. abdomen benign. extremities are warm and well perfused with no edema and 2+ pulses bilaterally throughout. laboratory data: white count 5.6, hematocrit 38.4, platelet count 197,000, pt 13.7, inr 1.2, sodium 140, potassium 4.1, chloride 106, co2 25, bun 21, creatinine 1.0, glucose 146. ekg is sinus rhythm with question j point elevation in v2. hospital course: as stated previously, the patient was admitted to for cardiac catheterization. please see catheterization report for full details. in summary, the catheterization showed 4+ ai with an ef of 45% and normal coronaries. the patient also had carotid ultrasounds on the day of his catheterization which revealed normal carotids. on the following morning the patient was brought to the operating room, please see or report for full details. in summary, the patient had a minimally invasive aortic valve replacement with a #27 mm st. jude valve. his bypass time was 112 min, cross clamp time was 83 min, he tolerated the procedure well and was transferred from the operating room to the cardiothoracic intensive care unit. at time of transfer his mean arterial pressure was 80, he was a paced at 80 beats per minute, he had propofol at 30 mcg/kg/minute. the patient did well in the immediate postoperative period. his anesthesia was reversed, sedation was discontinued, he was weaned from the ventilator and successfully extubated. on the morning of postoperative day #1 the patient remained hemodynamically stable, central lines were discontinued and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor the patient's chest tubes and foley catheter were removed with the assistance of the nursing staff and physical therapy. his activity level was increased on a daily basis. on postoperative day #3 he was begun on coumadin for his mechanical valve. on postoperative day #5 it was decided that the patient would be stable and ready for discharge as soon as his inr became therapeutic. at this time, postoperative day #4, we anticipate that the patient's inr will be therapeutic in the next 1-2 days. his physical exam is as follows: vital signs, temperature 99, heart rate 66, sinus rhythm, blood pressure 140/80, respiratory rate 18, o2 saturation 96% on room air, weight preoperatively was 101.9 kg, at discharge was 101.1 kg. alert and oriented times three, moves all extremities, follows commands. respiratory clear to auscultation bilaterally. cardiac, regular rate and rhythm, s1 and s2 with mechanical click, sternum is stable, incision with steri-strips, open to air, clean and dry. abdomen is soft, nontender, non distended, normoactive bowel sounds. extremities are warm and well perfused with no edema. laboratory data: white count 7.6, hematocrit 26.5, platelet count 187,000, sodium 140, potassium 4.1, chloride 103, co2 28, bun 15, creatinine 1.1, glucose 91. addendum will include up to date pt, inr. discharge medications: flomax 0.4 mg q h.s., levothyroxine 150 mcg q d, lasix 20 mg q d times 7 days, potassium chloride 20 meq q d times 7 days, coumadin - patient has received 5 mg q d times the past three days, his inr has yet to bump. his goal inr is 2.5 to 3. in addition, he takes percocet 5/325 1-2 tabs q 4 hours prn. condition on discharge: stable. discharge diagnosis: 1. aortic insufficiency status post aortic valve replacement. 2. hypertension. 3. hypothyroidism. 4. gout. 5. sleep apnea. 6. benign prostatic hypertrophy. 7. torn rotator cuff. 8. hernia repair times two. th is to have follow-up in the wound clinic in two weeks. he is to have follow-up with his primary care physician 1-2 days following discharge. his primary care physician will follow his coumadin and monitor his inr and he is to have follow-up with dr. in four weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Open and other replacement of aortic valve Aortography Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Gout, unspecified Aortic valve disorders Unspecified sleep apnea

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cabg x 3 (lima->lad, saphenous vein -->om, saphenous vein-->distal rca) on history of present illness: this is a 79 year old female who was transfered from an outside hospital where she presented 1 day ago in the emergency room with chest pain and dyspnea on exertion. she has a history of coronary artery diseas status-post catheterization on -elevation mi with 3 vessel disease seen and stenting of her left circumflex coronary. she was found to have ekg changes at the outside hosptial and elevated cardiac enzymes and was transferred here. she has no chest pain since admission. she has a history of diabetes and hypertension. on review of systems she has no fevers, abdominal pain, or cough. past medical history: s/p tah/bso s/p cholecystectomy type 2 dm status-post r fem->ant tibial bypass complicated by wound infection anxiety retinopathy hypertension coronary artery disease gerd st-elevation mi in w/ catheterization and stenting of left circumflex constipation social history: the patient lives with her grandson. she is non-english speaking. she has a history of tobacco use and occasionally drinks alcoholic beverages. family history: non-contributory physical exam: on admission: 97.6, 60 sinus, 174/73, 20, 96 % room air gen: no acute distress, comfortable heent: moist mucous membranes neuro: non-focal cv: regular rate and rhythm, no murmur pulm: bilateral basilar rales abd: soft, non-tender extr: absent palpable peripheral pulses in lle, rle with splint pertinent results: 12:35pm blood wbc-7.7 rbc-3.88* hgb-11.7* hct-35.6* mcv-92 mch-30.1 mchc-32.8 rdw-16.3* plt ct-254 06:22pm blood wbc-7.0 rbc-3.86* hgb-11.7* hct-35.1* mcv-91 mch-30.3 mchc-33.4 rdw-16.3* plt ct-253 12:35pm blood neuts-57.7 lymphs-32.9 monos-7.0 eos-2.2 baso-0.3 12:35pm blood pt-15.6* ptt-41.0* inr(pt)-1.4* 05:32am blood pt-26.1* inr(pt)-2.7* 04:15am blood pt-39.7* inr(pt)-4.4* 10:05am blood pt-25.5* inr(pt)-2.6* 05:00am blood pt-21.5* inr(pt)-2.1* 05:00am blood wbc-11.5* rbc-3.60* hgb-10.6* hct-31.1* mcv-86 mch-29.4 mchc-34.1 rdw-15.2 plt ct-327 12:35pm blood glucose-177* urean-15 creat-1.0 na-145 k-3.2* cl-106 hco3-32 angap-10 10:05am blood glucose-146* urean-38* creat-1.5* na-142 k-3.8 cl-100 hco3-33* angap-13 05:00am blood glucose-49* urean-31* creat-1.2* na-141 k-3.3 cl-99 hco3-34* angap-11 06:22pm blood alt-80* ast-58* ck(cpk)-19* alkphos-186* totbili-0.4 02:58am blood alt-33 ast-161* ld(ldh)-481* alkphos-83 amylase-69 totbili-0.4 12:52pm blood alt-38 ast-98* ld(ldh)-477* alkphos-244* amylase-71 totbili-1.1 12:35pm blood ck-mb-2 ctropnt-0.02* 06:22pm blood ck-mb-notdone ctropnt-0.03* 05:57am blood ck-mb-notdone ctropnt-0.03* 09:08pm blood ck-mb-notdone ctropnt-0.09* 04:22am blood ck-mb-notdone ctropnt-0.10* 12:35pm blood calcium-8.4 phos-3.2 mg-1.7 02:58am blood albumin-1.9* phos-2.9 mg-3.0* 03:26pm blood albumin-2.7* 06:22pm blood %hba1c-5.5 -done -done 06:12pm blood vanco-16.1* 08:02pm blood vanco-16.2* 04:39am blood vanco-24.4* 08:52am blood vanco-12.6* microbiology: blood culture: negative, c. diff: negative, c. diff: negative radiology: cxr: there are small bilateral pleural effusions and associated bibasilar opacities consistent with atelectasis and/or consolidation, especially in the left lower lobe, essentially unchanged. no definite new lung lesions. no pneumothorax. cxr: patient is status post interval median sternotomy and coronary artery bypass surgery. an endotracheal tube is present, terminating in the right main bronchus. swan-ganz catheter terminates in the distal right pulmonary artery, right picc line terminates in the superior vena cava, nasogastric tube terminates below the diaphragm, and mediastinal drains and left-sided chest tube are present. cardiac and mediastinal contours are stable compared to the preoperative radiograph. there is mild interstitial pulmonary edema present, note is made of patchy atelectasis in left lower lobe and lingula as well as a probable small left pleural effusion. cxr: 1. left picc terminating in the distal svc without evidence of pneumothorax. 2. continued bilateral pleural effusions and left basilar atelectasis cardiology: tte: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed with global hypokinesis and akinesis of the basal to mid inferior wall . tissue velocity imaging e/e' is elevated (>15) suggesting increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal. right ventricular systolic function is borderline normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the prior study (images reviewed) of , the overall lvef is similar and the degree of mitral regurgitation appears slightly less. tee: pre-bypass: the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is moderately depressed. resting regional wall motion abnormalities include akinetic basal inferior which is also aneurysmal; mid and apical anteroseptal and anterior hypokinetic walls; basal inferoseptal hypokinetic wall. right ventricular chamber size and free wall motion are normal. . mitral valve: the mitral valve leaflets are mildly thickened with no prolapsing or flail segments. evaluation by color flow doppler (vena contracta 4-5mm), pulmonary venous inflow (no systolic reversal or blunting of pulmonary veins of both sides), mitral annulus (30mm), dilated left atrium (4.7cm) and normal sized left ventricle in diastole (5.6 cm), a central regurgitant jet is visualized which is consistent with moderate (2+) mitral regurgitation under anesthesia and with provocative measures like trendelenburg position. postbypass: mild improvement in the wall motion abnormalities of the previously hypokinetic areas. lvef 40% with epinephrine running at 0.05mcg/kg/min. mitral regurgitation is mild to moderate. ascending aorta looks okay without any evidence of dissection. brief hospital course: this is a 79 year old female who was admitted with unstable angina on . this was in the setting of cardiac catheterization with stenting. she was hemodynamically stable on admission and was admitted to the floor for close monitoring. cardiology was upon admission for pre-operative planning and a preoperative echo was obtained. she was continued on lasix and beta-blockade preoperatively but plavix (for her recent lower extremity bypass) was held. vascular surgery consultation was obtained given her recent bypass procedure and history of groin infection and she was started on pre-operative antibiotics. consultation was also obtained for assistance with blood sugar control. she was taken to the operating room for a cabg x3 on (please see the operative note of dr. for full details). she was extubated without complication early in her post-operative course but required re-intubation for respiratory compromise. she had acute oliguric renal failure post-operatively which improved with hydration and diuretics. she also had acute atrial fibrillation post-operatively which was treated with amiodarone; she did, however require cardioversion for unstable afib on post-operative day 6. she was started empirically on vancomycin and meropenum for leukocytosis post-operatively in the setting of her known groin infection, as per infectious disease department recommendations. wet to dry dressings were continued to these incisions. of note, she developed what appeared to be a sternal wound infection vs partial dehiscence around one week post-operatively and vancomycin was continued. betadine occlusive dressings were applied daily to her sternum with improvement. from a nutritional standpoint, given her prolonged intubation she required some tube feeding post-operatively; eventually she was able to tolerate a regular diet. after her first re-intubation she was again extubated on post-operative day 6 without complication. she was transferred out of the intensive care unit on post-operative day 10. rehab screening was obtained. she was gently diuresed towards her preoperative weight. physical therapy worked with her daily for assistance with her postoperative strength and mobility. the wound care nurse for some mild pressure ulcers. her coumadin was titrated for her target inr of 2.0-2.5. a picc line was placed for her intravenous antibiotics. vancomycin and levofloxacin were continued per the infectious disease and vascular surgery service. she will remain on one additional week of vancomycin and levofloxacin from her date of discharge. the diabetes service continued to adjust her diabetes medications to ontain tight control of her blood suagrs. ms. continued to make steady progress and was discharged to rehabilitation on . she will follow-up with dr. , her cardiologist, the vascular surgery service and her primary care physician as an outpatient. dr. will manage her coumadin dosing and blood work when she is discharged from rehabilitation. medications on admission: on admission: lopressor 200 po bid protonix 40 po qdaily percocet prn ambien 5 mg po qhs lipitor 80 mg po qdaily aspirin 325 mg po qdaily plavix 75 mg po qdaily colace 100 mg po bid lasix 40 mg po qdaily insulin glyburide 5 mg po qdaily lisinopril 20 mg po qdaily discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours). disp:*120 capsule, sustained release(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. warfarin 1 mg tablet sig: one (1) tablet po daily (daily): adjust dosage based on inr goal 2.0-2.5 . disp:*30 tablet(s)* refills:*2* 6. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*240 tablet(s)* refills:*0* 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. disp:*qs ml(s)* refills:*0* 8. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen daily and prn. inspect site every shift 9. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 10. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. disp:*30 suppository(s)* refills:*0* 12. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 13. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*120 tablet(s)* refills:*0* 14. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. disp:*qs qs* refills:*0* 15. metolazone 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 16. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 17. 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* 18. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 7 days. disp:*2 tablet(s)* refills:*0* 19. bumetanide 0.5 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 20. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. disp:*qs qs* refills:*0* 21. insulin glargine 100 unit/ml solution sig: three (3) units subcutaneous at bedtime. disp:*qs units* refills:*2* 22. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 23. insulin regular human 100 unit/ml solution sig: one (1) injection four times a day: see regular insulin sliding scale qachs. disp:*qs qs* refills:*2* 24. vancomycin in normal saline 1 g/250 ml solution sig: one (1) intravenous q48hrs for 7 days: please check vanc trough with 3rd dose. disp:*qs qs* refills:*0* discharge disposition: extended care facility: medical center - discharge diagnosis: cad pvd htn hypercholesteremia mi tah/bso ccy dm discharge condition: good discharge instructions: shower, wash incisions with mild soap and water and pat dry. no lotions, creams or powders to incisions. call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. no lifting more than 10 pounds for 10 weeks. no driving until follow up with surgeon. followup instructions: 2 wound clinic on between 11-1pm follow up with dr. in two weeks follow up with pcp or primary care center in weeks. follow up with dr. in two weeks Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Other electric countershock of heart Pulmonary artery wedge monitoring Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Cellulitis and abscess of trunk Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Percutaneous transluminal coronary angioplasty status Subendocardial infarction, subsequent episode of care Ulcer of heel and midfoot Disruption of external operation (surgical) wound Ulcer of other part of lower limb

history of present illness: this 73 year-old female presented with complaint of increasing shortness of breath and cough for approximately six months getting progressively worse. for the week prior to presentation the patient was having significant cough with expectoration associated with paroxysmal nocturnal dyspnea and orthopnea. the patient has previously echocardiogram in which demonstrates preserved left ventricular systolic function but the presence of significant valvular gradient across the prosthetic mitral valve which has a mean of approximately 17 mmhg and a calculated mitral valve area of 1 sq cm. the patient was transferred to the on pressors, was stable hemodynamically and remained afebrile with mass approximately 30 to 34 for presumed thrombotic mitral valve. patient was admitted and patient had progressive shortness of breath, was intubated for respiratory distress initially, treated for cardiac shock, then presumed septic shock. outside hospital echo showed a va of only 1 cm sq with gradient of 20 mmhg, pa line at the outside hospital showed increasing rv, increasing pa, increasing rvr and pcwp is 25 to 35. allergies: to penicillin, fiorinal. current medications: vasopressin 0.1, levo 0.6, versed on transfer. medication as outpatient: toprol, lisinopril. patient had a te in the cardiac care unit on that showed dilated severely hypercontractile right ventricle, small hyperdynamic left ventricular, peak pressure across the mv of 50 to 64 mmhg with mean of greater than 40, severe tr. the findings were consistent with acute thrombus. past medical history: rheumatic mitral disease, status post mvr mechanical valve, hypotension, prerenal azotemia, lower gi bleed, short liver, diabetes, hypercholesterolemia, qrs respiratory failure with pulmonary edema and right ventricular failure, status post carbomedics mitral valve replacement in . physical examination: temperature 96.7, heart rate 140 to 200, blood pressure 120/60s. patient continued to be intubated, coarse breath sounds on examination. patient has 1+ dorsalis pedis bilaterally that were felt. on admission white blood cell count 11.3, hematocrit 34.7, platelets 181, sodium 134, potassium chloride 106, bicarb 15, bun 32, creatinine 2.5, glucose 179. patient was admitted to the cardiology service. patient was significant for having cardiogenic shock. patient received tpa 10 mg bolus and 90 mg over 90 minutes. on hospital day two patient continued to be kept n.p.o., remained afebrile, making good urine. on hospital day three patient received one unit of packed red blood cells for hematocrit of 27, was started on vancomycin-levo-flagyl for fever. patient was apneic. on hospital day number four patient had a neurology consult to assess the prognosis from taking off propofol. patient had ct of the brain which was negative for bleed and patient was still on propofol. it was hard for neurology to obtain an adequate examination. on hospital day number five she remained afebrile with stable vital signs except for the blood pressure which was approximately 82/43. patient continued to be monitored on hospital day number five. patient had low grade fever, had received a dose of lasix which produced a great output and patient was preopped. on hospital day number six patient had temperature of 100.2, otherwise was doing well. on hospital day number six patient was put on neo and decreased the lasix drip. on hospital day number seven patient was continued on neo. patient continued on pulmonary ps. patient had systolic blood pressure in the 80s. patient was started on neo-synephrine on the same day. the infectious disease service was consulted. they recommended stopping the vancomycin and levofloxacin as the clinical picture is consistent with drug fever. on hospital day number 7 general surgery was consulted for drop in hematocrit from 31 to 22 and right rectus sheath hematoma was found. patient was taken to the operating room and underwent evacuation of rectal hematoma and control of eight ligations, interferon and epo. patient was transferred crystalloid one pack and ffp two. serial cbc was obtained. laboratory data showed no organisms. patient was started on metoprolol. current medications: fentanyl 100 q day, versed 2 q day, lasix 10 per hour, neo 1, digoxin 0.0625, amiodarone 200 q day. on hospital day number nine the patient's medications were changed to ac for agitation and patient had decrease in blood pressure requiring second pressors. hematocrit was down to 18.7 from 22.8. patient was pancultured. on hospital day number 10 the patient had derm consult for rash. the assessment was that it was associated with drug. on hospital day number nine the patient was started on nasalide and started on that and levophed for low blood pressure. the patient also had a te which on the echo showed the anterior disc of the mitral prosthesis was immobile, mild to moderate valvular mitral regurgitation and moderate to severe tricuspid regurgitation. the patient grew out two bouts of gram positive cocci, received one unit of packed red blood cells. patient's white count was down to 11 from 17 with bacteremia. patient was continued on antibiotics. on hospital day number 12 patient had right internal jugular placed and patient's pressors were stopped and patient was able to maintain good blood pressure. on hospital day number 12 patient remained afebrile with stable vital signs. on hospital day number 12 the patient underwent cardiac catheterization that showed selective coronary arteries were without angiographic apparent flow demanding stenosis, dysfunction of the mechanical prosthetic mitral valve and immobile right stenosis, severe pulmonary artery hypertension and moderate right ventricular diastolic dysfunction. on hospital day 13 patient had a low grade fever of 100.9, blood pressure was 79/44, satting well. white count was 9.2, hematocrit 30.3, creatinine 0.7. patient was off her pressors. on hospital day 14 patient had been extubated and patient had dental consult. on hospital day 15 patient remained afebrile with stable vital signs. patient's white count was down to 6.8, hematocrit 31.5 and creatinine was 0.7. on hospital day number 16 patient had negative head ct, normal liver function tests, ammonia. patient was oriented to person only and slightly confused and was very pleasant, remaining afebrile with stable vital signs. on hospital day number 17 patient received lasix times two for goal 180 negative. patient was complaining of some hallucinations. patient was preopped and consented for surgery. on hospital day number 17 patient underwent re-do mvr with 27 mm mosaic porcine valve for severe mitral regurgitation and status post mvr in . patient has been on o2 pressure, cvpr of 13, pad of 28, pa 41. normal sinus rhythm at 97, was on propofol and nitroglycerine 0.7 when patient was transferred to csru. on postoperative day number one the patient was weaned from drips and continuously intubated with a low grade fever. otherwise was doing well. white count of 11.2, hematocrit of 34.6, creatinine 0.7. patient was weaned to extubate and removal of the chest tube. on postoperative day number two the patient was stopped on drips, temperature of 99.8 with normal sinus, blood pressure 134/56, was satting well. patient's mediastinal chest tubes were removed and lopressor was increased and lasix was started. on postop day number three the patient remained afebrile with stable vital signs in sinus taking adequate p.o. and making urine and white count of 10.7, creatinine 0.7. patient had a chest x-ray and was started on physical therapy and continued on metoprolol. patient's chest tube since midnight has been 500. on postop day number four patient remained afebrile with stable vital signs in sinus rhythm with some pvcs, took in 696 p.o., took out 1685, white count 9.6 and creatinine 0.7. the patient's sitter was discontinued and chest x-ray was obtained. x-ray showed status removal of the left chest tube and mediastinal tube and improved aeration of the left lower lobe. on postoperative day five patient remained afebrile with normal vital signs taking in 1100 p.o. and draining 550 plus but patient continued to have high chest tube output. the white count was 7.7, hematocrit 31.6 and creatinine 1.0. the mediastinal tubes were left in place. on postoperative day number six patient remained afebrile with stable vital signs, taking good p.o. and making some urine of 150 cc. as this patient is doing well, patient continues to have high output, thus pressor was continued. patient output was 2.8. on postoperative day number seven patient remained afebrile with normal vital signs, taking good p.o., making good urine. patient continued to have right chest tube output, thus chest tube was continued. at this time cardiac and thoracic surgery was consulted and they recommended doing doxycycline pleurodesis. on postoperative number 8 patient received doxy and there was some decrease in drainage but it continued to be significant. on postoperative day 9 patient continued had another doxycycline pleurodesis. patient tolerated the procedure well. on postoperative day 10 he continued to remain afebrile with stable vital signs, taking good p.o., making good urine and white count of 10.2, creatinine 0.9 and otherwise doing well. patient's chest tube output decreased significantly. on postoperative day number 11 patient remained afebrile with stable vital signs. patient's chest tube output was low for a 24 hour period of 195, thus it was removed. chest x-ray shows small apical pneumonia on the left side. otherwise patient is doing well. condition on discharge: good. discharge status: extended care facility. medications on discharge: lasix 40 mg p.o. b.i.d. for seven days, potassium 20 meq p.o. b.i.d. for seven days, colace 100 mg p.o. b.i.d., aspirin 325 mg p.o. q day, tylenol p.r.n., sliding scale insulin, metoprolol 50 mg p.o. b.i.d. final diagnosis: acute respiratory failure with pulmonary edema and right ventricular failure. status post carbomedics mvr in for valve dysfunction. hypotension. prerenal azotemia. lower gastrointestinal bleed. short liver. diabetes. hypercholesterolemia. rheumatic fever. hypertension. atrial fibrillation. status post epi, right epigastric hematoma and ligation of right inferior hypogastric. status post re-do mvr. follow up plans: follow up with dr. in six weeks. please follow up with dr. in two weeks. please call for follow up appointment. please follow up with primary care physician and cardiology in one to two weeks. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Incision of abdominal wall Open and other replacement of mitral valve with tissue graft Other surgical occlusion of vessels, abdominal arteries Injection into thoracic cavity Transfusion of packed cells Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Other complications due to heart valve prosthesis Bacteremia Cardiogenic shock Dermatitis due to drugs and medicines taken internally Hemoperitoneum (nontraumatic)

*allergies: sulfas, codeine *access: picc neuro: pt a&ox3, but was not earlier in shift. had ms changes w/ morphine, and has in past also according to daughter. morphine dc'd and started po percocet. c/o pain earlier this shift, aching all over. had abd pain overnight, came to eval. refusing meds later in shift, stated uncomfortable to swallow so crushed pills and put in jello/pudding. mae, follows commands, perl 3mm/brisk. cardiac: pt tachy in a.flutter, hr 90-140, sbp 101-124. metroprolol increased overnight, diltiazem po started today. issue is trying to control rate, then possibly send to floor. hct 29.1. ptt 61.4, heparin gtt running @ 1500cc/hr. next ptt lab @ 2200. resp: ls clear, rr 17-25, o2sat 92-95 on ra. to have bi-pap tonight for sleeping. says he feels nausea and anxiety w/ the bi-pap, may require ativan for its use. gi/gu: clear liquid diet, started not swallowing meds in afternoon, using pudding to help swallow crushed pills. +bs, golden/ stool out ileostomy and fistula. c.diff positive. urine out foley yellow/cloudy, 100-205, on po lasix. k 3.2 being repleated w/ 60meq po. fs 174-195 covered w/ humalog, has standing 20u glargine order am and pm. id: temp 97.3-97.8, wbc 26.1, remains on zosyn and flagyl. skin: intact, picc site intact. psychosocial: daughter has called several times today, given updates and informed on current condition. call again this evening. numbers are on the white board in the pt's room, please call w/ any new information. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Atrial flutter Systolic heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Other specified cardiac dysrhythmias Unspecified sleep apnea Septic shock Intestinal infection due to Clostridium difficile Old myocardial infarction Morbid obesity Personal history of venous thrombosis and embolism Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Colostomy status Fistula of intestine, excluding rectum and anus

*allergies: sulfas, codeine neuro: pt remains sedated on fent 50mcg/kg/min and versed 4mg/hr. arousable to voice, follows commands, mae, perl 3mm/brisk. no signs of pain per vitals. cardiac: nsr/st to start shift, also increased hr to >140 at times, dilt x1 order written, but pt eventually settled out and dilt not needed. later in shift, rhythm changed to a.fib/a.flutter, w/ ventricular bigemany, pt going in and out of this rhythm. ekg was done, md's have seen. this shift hr 70-129, sbp 103-155, map 66-93. levo remains off. a-line now in place. hct 26.3. inr 1.7. plt 492. resp: vent currently a/c 60%/550/22/5peep after abg 7.41/45/72/30, next abg on 60% pending. rr 20-23, o2sat 94-100, ls remain course on rside, but sound clearer on l. sxn infrequently for sm amt thick white sputum. gi/gu: remains npo, ogt clamped. +bs, colostomy draining loose golden stool, bag emptied, c.diff cx sent. enterostamo fistula from hx gunshot wound, draining golden liquid, bag emptied. urine out foley yellow/clear 70-140cc/hr. insulin gtt remains running, currently @ 7.5u/hr, cont fs q1h, fs 210-144, trending down this shift. bun 79, creat 2.7. abd ct scan early in shift for abd abscess, unable to complete scan d/t pt weight/size and inability to achieve readable scans. id: temp 97.5-98.0, wbc 20.6. piperacillin started. urine, sputum, blood (from a-line), and c.diff cx's sent. skin remains intact, iv sites wnl, dsg's changed, bath done. psychosocial: daughter called beginning of shift for update on current condition and poc. she called again around 0400 and stated she woke w/ anxiety, stated she lost her mother a few weeks ago and now her father is in the hospital and she is the only child, "daddy's little girl" as she stated. informed her that we are still searching for an infection source and that overnight he did not require heart mediations for rate and bp. she felt better, but i told her to call back around noon after rounds. did not hear from personal care attendant. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Atrial flutter Systolic heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Other specified cardiac dysrhythmias Unspecified sleep apnea Septic shock Intestinal infection due to Clostridium difficile Old myocardial infarction Morbid obesity Personal history of venous thrombosis and embolism Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Colostomy status Fistula of intestine, excluding rectum and anus

allergies: codeine / sulfa (sulfonamides) attending: chief complaint: respiratory failure major surgical or invasive procedure: intubation placement of picc history of present illness: hpi: 59m chf, dm2, partial colectomy with enterocutaneous fistula (developed several yrs ago, thought to be gun shot wound with left colectomy in ), afib, dvt 8 yrs ago, who originally presented to hospital on for workup of anemia and inpatient tte. . patiently initially was evaluated with symptomatic shortness of breath and fatigue; hct on was 31.4 (this is his baseline according to osh). tte was performed which showed an ef=15-20%; he was also found to be in afib/aflutter (?new); diltiazem gtt was started for rate control. his hematocrit decreased through the hospitalization. his cardiomyopathy was felt to be new and perhaps secondary to uncontrolled atrial fibrilation. his creatinine was also found to be rising throughout hospitalization (cri with cr=2.0, peak of 5.4). he also developed delta ms, and was subsequently found to be hypercarbic with subsequent bipap initiation. on hd #6 @ osh, his wbc increased to 37, tmax was 100.3, and he was subsequently started on broad spectrum abx (vanco/zosyn - 1st day ?). on the night of , he was transiently hypotensive (sbp to 60s, duration unknown), and he was intubated at this time for hypercapneic respiratory failure. he was transferred to the icu at this time. he then became hypotensive in the icu, again with sbp in 60s, and was started on phenylephrine and dopamine at this time. an intraabdominal source of infection was suspected, but pt could not fit in ct-scanner. he was transferred here for further management, imaging, and evaluation. past medical history: chf (ef15-20%) cad mi x 2 (most recent about 2 years ago) - stress ' showed probable inf. infarct - echo showed ef 55% no wma 40-50% anterioseptal hk hyperlipidemia htn dmii dm neuropathy gi bleed (date unknown) dvt (on coumadin), 8 yrs ago, on long term coumadin b/c of dvts and pe ckd (baseline = 2.0) gerd copd mobid obesity enterocutaneous fistula gsw (developed about 1-2 years ago) l hemicolectomy (in setting of gunshot wound ) h/o gib - ? cause of chronic anemia mri on - @ hospital - microangiopathic changes, but no cva copd social history: sh: former smoker, lives alone, no etoh, no known history of ivdu family history: fh: nc physical exam: vitals: total - 2.8l 98.1 111/37 af 85 22 93% ra 92-95% ra . gen: morbidly obese, pleasant male, interactive, axox3, nad on ra heent: nc, at, perrl, clear op neck: supple, no carotid bruits, no jvd cv: irreg rr, distant hs, no m/r/g chest: posterior exam limited due to large body habbitus, but no focal crackles, wheezes or rales appreciated anteriorly and laterally abd: + bs, soft, marked central obesity, no masses, no hsm, iliostomy bag draining yellow-brown liquid stool, no blood evident, miminal erythem around stoma site, left mid-upper quadrant fistula draining yellow tinged liquid, with pannus without erythema/rash. ext: +1 nonpitting edema, with lots of excess skin and vericose veins. skin: no sacral ulcer appreciated, pink, warm. pertinent results: admission labs: . 02:52pm urine ca oxal-mod 02:52pm urine granular-0-2 hyaline-0-2 02:52pm urine rbc-* wbc- bacteria-few yeast-none epi-0-2 02:52pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-6.5 leuk-sm 02:52pm urine color-yellow appear-clear sp -1.013 02:52pm pt-17.2* ptt-28.5 inr(pt)-1.6* 02:52pm plt count-450* 02:52pm neuts-88.3* lymphs-8.4* monos-3.2 eos-0 basos-0.1 02:52pm wbc-20.8* rbc-4.03* hgb-8.8* hct-28.7* mcv-71* mch-21.9* mchc-30.7* rdw-18.4* 02:52pm vanco-16.0* 02:52pm tsh-0.29 02:52pm osmolal-321* 02:52pm caltibc-289 haptoglob-334* ferritin-47 trf-222 02:52pm albumin-2.7* calcium-8.7 phosphate-6.0* magnesium-2.2 iron-18* 02:52pm lipase-12 02:52pm alt(sgpt)-7 ast(sgot)-12 ld(ldh)-136 alk phos-107 amylase-32 tot bili-0.5 02:52pm glucose-134* urea n-77* creat-3.0* sodium-135 potassium-4.4 chloride-97 total co2-22 anion gap-20 04:47pm lactate-1.3 04:47pm type-art temp-36.9 rates-16/ tidal vol-650 peep-5 o2-100 po2-334* pco2-47* ph-7.33* total co2-26 base xs--1 aado2-339 req o2-61 -assist/con intubated-intubated 10:00pm urine eos-negative 10:00pm urine osmolal-337 10:00pm urine hours-random urea n-436 creat-85 sodium-34 pertinent labs/studies: . labs/studies: . : portable chest - impression: bilateral pleural effusions with associated atelectasis. an underlying pneumonic process cannot be excluded in the left lower lobe. . : echo - the left atrium is mildly dilated. the inferior vena cava is dilated (>2.5 cm). left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is moderately-to-severely depressed (ejection fraction 30 percent) secondary to severe hypokinesis of the entire interventricular septum; the inferior and posterior walls are hyperdynamic. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. 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. . : picc placement - impression: malpositioned picc terminating in the right subclavian vein. contra-abnormalities in the region of the azygos vein may represent mass, lymphadopathy, or prominence of the azygos vein due to vascular congestion. no change in interstitial edema or left lower lobe consolidation/collapse. . : the endotracheal tube is being removed. the heart is enlarged. bilateral effusions are present, larger on the left than the right. left hemidiaphragm is not obscured and a consolidation and/or atelectasis in left lower lobe is not excluded. there is some pulmonary plethora consistent with failure. impression: some evidence of failure with bilateral effusions. . : portable abdomen - two upright views of the abdomen: the study is incredibly limited by patient body habitus. the abdominal structures appear uniformally white. this study is nondiagnostic. . : p-mibi - interpretation: this 59 yo diabetic male with a h/o cad & chf was referred to the lab for evaluation of new wma. the patient was infused with 0.142 mg/kg/min of iv persantine over 4 minutes. the patient denied any arm, neck, back or chest discomfort throughout the study. there were no significant st segment changes noted beyond baseline. the rhythm was atrial flutter with rare vpb's. there was an appropriate blood pressure response; heart rate response was flat. persantine was reversed with 125 mg of iv aminophylline. impression: no ekg changes from baseline in the absence of anginal symptoms. nuclear report sent separately. . mibi - 1. markedly limited study due to body habitus, such that only gated planar study could be performed. limited interpretation suggests fixed inferior wall defect with regional abnormal wall motion. . : renal us - slightly malrotated right kidney. no hydronephrosis . . microbiology: blood: : ng : ng : ng : ng . urine: : ng : ng . sputum: : rare op flora, rare yeast . stool: : c. diff positive : c. diff negative . . 02:52pm blood caltibc-289 hapto-334* ferritn-47 trf-222 02:52pm blood tsh-0.29 discharge labs: . 08:48am blood wbc-16.4*# rbc-3.98* hgb-9.0* hct-29.0* mcv-73* mch-22.6* mchc-31.0 rdw-22.3* plt ct-334 06:20am blood glucose-68* urean-66* creat-2.4* na-143 k-4.0 cl-112* hco3-23 angap-12 brief hospital course: a/p: patient is a 59 year old male with medical history significant for cad, dm, htn, ckd, morbid obesity, enterocutaneous fistula s/p gunshout wound to abdomen, hx of dvt and gi bleed who is transferred to from osh after initally presenting with shortness of breath, found to be in afib/flutter with rvr and echocardiogram demonstrating new cardiomyopathy. hospital course at outside hostpial complicated by acute on chronic renal failure, drifting hct, hypercarbic respiratory failure and hypotension requiring intubation and pressor support as well as leukocytosis with suspicion at outside hospital for intraabdominal process. . #. shock: the patient's shock was thought likely to be multifactorial. patient on presentation was known to have new systolic heart failure with echo as recent as revealing an ef of 50%. additionally however the patient presented with significant leukocytosis concerning for septic etiology. the patient on presentation was noted to have an enterocutaneous fistual (present for 1 to 2 years) raising suspicion potentially for an intraabdominal source of infection. unfortunately a ct scan was not possible given the patient's body habitus. there was additional concern for a lll pna and patient's stool samples were positive for c. diff. the patient's blood cultures were negative at hospital and all blood cultures drawn this admission are similarly negative. upon transfer from outside hospital pressors were discontinued and the patient was extubated 3 days after admission to the icu. although there was suspicion for a lll pna, no definite source was identifiable. the patient received a 10 day course of empiric therapy with zosyn and vancomycin. given + c. diff in stool, the patient has also been treated with a 14 day course of po flagyl for c. diff infection with conversion to c. diff toxin negative stool since treatment. the patient has since significantly improved clinically with resolving leukocytosis, which is presumed to have been from his c. diff infection. on admission the patient had a white count of 20.8 with peak value of 29.4. with regards to his cardiac depression the patient had an echocardiogram performed on admission to evaluate for cardiogenic shock. echo revealed moderately to severely depressed lv function (ef 30 percent) secondary to severe hypokinesis of the entire interventricular septum with hyperdynamic inferior and posterior walls. although echo reports are not available for review, the patient's notes report that echocardiograms were performed in showing at that time an ef 55% without any wall motion abnormalities. repeat echo in was reported to demonstrate a decrease in ef from 40 to 50% with anteroseptal hypokinesis. given concern for an ischemic cardiomyopathy the patient underwent a p-mibi this admission. unfortunately interpretation of nuclear imaging was again extremely limited secondary to the patient's body size. no ecg changes from baseline were seen with infusion of persantine and the patient experienced no anginal symptoms. limited nuclear images revealed likely that the left ventricular cavity size was normal. resting and stress perfusion images additionally revealed decreased tracer activity in the inferior wall with no definite reversibilty with gated images revealing akinesis of the inferior wall. in sum the study was thought to demonstrate a fixed inferior wall defect with regional abnormal wall motion. . # respiratory failure: as above, the patient developed hypercarbic respiratory failure, likely in the setting of sepsis as well as possibly failure given afib with rvr, requiring intubation on . the patient developed fluid overload by radiographs while intubated in the setting of sepsis physiology as well as volume resuscitation . the patient was successfully extubated on . the patient was diuresed with what was reported to be his outpatient regimen of lasix and zaroxyln post-extbuation given evidence for mild failure. the patient's respiratory distress has since completely resolved, but the patient experienced a creatinine bump in the setting of diuresis. given rise in creatinine from 2.0 to 2.9 diuretics were held. the patient's creatinine remained elevated and urine lytes on few occasions demonstrated a prerenal etiology. given this, the patient was actually given fluids back and his outpatient diuretics have continued to be held. given this dramatic response to what is reported to be his outpatient regimen there is some question if the patient is compliant with this regimen as an outpatient. the patient has mild le edema on discharge but continues to breath comfortably with excellent o2 sats on room air. given this, the patient will be discharged without his outpatient diuretics but instructions to follow up closely with his pcp. patient's creatinine has since corrected and he is being discharged without iv fluids or diuretics. . # afib/flutter: upon transfer from outside hospital the patient was known to be in afib/flutter, initially requiring dilt gtt. the patient was subsequently transitioned to po diltizem and lopressor with improved rate control and heart rate ranging 75-100 upon transfer to the floor. echocardiogram demonstrated as well mild la enlargement. as above, the patient in transfer was initially volume overloaded. the patient was continued on maximum dose long acting metoprolol xl 200 and diltiazem 240 qd. his hr remained in 60-80 without any pauses. the patient was continued on digoxin with a normal therapeutic level. the patient continued to receive with coumadin. in the setting of medical therapy, the patient's inr was temporarily supratherapeutic to a level as high as 8.4. the patient was without evidence of acute bleeding and his coumadin was held. the patient received 2mg sq vitamin k for partial reversal and the patient's inr was otherwise allowed to drift to therapeutic range. once at 3.0, coumadin therapy was reinitiated at the patient's reported outpatient dose of 5mg po qhs. however, the patient again became rapidly supratherapeutic with inr to 5.8. the patient's most recent inr is 4.0 after having again received 2mg vitamin k. the patient's coumadin has since been held. on transfer it is recommended that the patient have daily inr checked until he is on a stable dose of coumadin. given supratherapuetic inr twice with 5mg po qhs, it would be recommend to start at a lower dose of 2.5mg po qhs once inr approaches 2.0 and titrate as needed. . # chf - as above, the patient was found this admission to have an ef of 30% by echocardiogram with severe hypokinesis of the entire interventricular septum and hyperdynamic inferior and posterior walls. a very limited p-mibi however demonstrated a fixed inferior wall defect with akinesis of the inferior wall. as an outpatient the patient is maintained on a heart failure regimen of digoxin 125mcg qd, lasix 40mg po bid, and metolazone. in the icu the patient's outpatient lasix and metolazone were reinstated given volume overload. given depressed ef the patient would benefit from an ace. however, the patient's creatinine was thought to be limiting for which therapy with isordil and hydralazine was started to effect pre-load and afterload reduction respectively for the patient's depressed ef. as above, the patient's creatinine was noted to begin to rise with fena suggestive of a pre-renal etiology. the patient's diuretics were held and the patient actually required iv fluids to attempt to normalize his creatinine. on admission it was also unknown for how long the patient had been in afib/flutter without rate control suggesting additional possible etiology of tachyarryhtmia associated cardiomyopathy. with adequate rate control currently the patient should have follow up echo in a few months to evaluate for interval improvement in lv function. the patient is being discharged without iv fluids or standing diuretics but should have his volume status assessed clinically and chem-7 drawn at least twice weekly. . # cad: throughout his hospital course the patient was asymptomatic without any anginal symptoms. there was no indication of active ischemia on ekg. as above, given depressed ef, decreased from previous, as well as wall motion abnromalities the patient underwent a persantine mibi. in this very limited study secondary to patient's body habitus, no reversible ischemia was visualized, only a fixed inferior defect. the patient was continued on asa, lipitor 40, metoprolol xl. . # acute on ckd: on admission the patient had a creatinine of 3.0, thought likely to be secondary to atn in the setting of hypotension and sepsis. the patient's baseline creatinine is reported to be near 2.0. on presentation the patient had a fena of 0.9% supporting a pre-renal etiology. with resolution of sepsis the patient's urine output began to improve and the patient's creatinine began to normalize. however, in the setting of reinstating diuretics the patient again demonstrated a rise in creatinine to near 3.0 again with fena/urea suggesting volume depletion. despite discontinuing therapy with diuretics the patient's creatinine continued to remain elevated with decreased urine output. the patient required a number of ns boluses and was given iv fluids back with monitoring of his edema and pulmonary status given his depressed ef. the patient's creatinine has since returned to near baseline, although is mildy increased at 2.4. the patient appears relatively euvolemic on exam. however, it is suspected that given his limited mobility currently, the patient has had limited access to fluids. the patient should receive encouragement and access to fluids and may benefit from iv fluids if his creatinine is > 1.4. . # h/o dvt: the patient has a history of dvt 8yrs ago but still on coumadin per pcp. is currently being continued given afib. no le us were performed during this admission. . # anemia: the patient had guaiac + stools while in house without any brbp ostomy or melena to suggest any large volume bleeding. per reports the patient has a baseline hct of 25-30, with a microcytic anemia. iron binding studies were within normal limits although the patient's ferritin levels were at the lower limits of normal. there was no evidence for hemolysis and the patient demonstrated a normal reticulocyte count. the patient's hct was stable throughout the hospital course with admission hct of 28.7 and most recent hct of 29.0. it is recommended on discharge that patient have ongoing evaluation as an outpatient with endoscopy. . # dm: the patient was started on glargine 36 (outpatient regimen reported to be 40bid) with poor glycemic control. the patient's glargine was up titrated throughout his admission to most recently 44 units qam and 36 units qpm with addition of a tight humalog sliding scale as provided. . # code: full code . # pcp: . medications on admission: no chronic steroids - confirmed per pcp 20 lantus (pt states 40 ) lasix 40 potassium 20 dig 125 mcg qd levaquin 500 last filled lipitor 10 prozac 20 metolazone 5 renagel 800 tid coumadin 5 qd humalog . meds on transfer: hydrocortisone 100 mg q8h (d3, started ?) mycostatin tp mvi advair zocor prevacid 15 mg insulin gtt sq heparin renagel 1600 mg tid versed gtt fentanyl gtt levophed gtt vanco (by level) d4 zosyn 2.25 mg iv q8h d4 albuterol atrovent discharge medications: 1. sevelamer 800 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. disp:*60 capsule(s)* refills:*2* 3. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*1 unit* 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* 5. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*20 tablet(s)* refills:*0* 7. 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* 8. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). disp:*30 capsule, sustained release(s)* refills:*2* 9. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 10. hydralazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 11. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. metoprolol succinate 100 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po hs (at bedtime). disp:*60 tablet sustained release 24hr(s)* refills:*2* 13. insulin glargine 100 unit/ml solution sig: forty four (44) units subcutaneous qam. disp:*qs * refills:*2* 14. insulin glargine 100 unit/ml solution sig: thirty six (36) units subcutaneous at bedtime. disp:*qs * refills:*2* 15. insulin lispro (human) 100 unit/ml solution sig: one (1) unit subcutaneous four times a day: please check blood sugar before meals and before bedtime. please administer humalog insulin as per sliding scale provided on discharge papers. disp:*qs * refills:*2* discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: primary: sepsis cardiomyopathy respiratory failure acute renal failure afib . secondary: chf (ef 30%) cad s/p mi x2 htn hyperlipidemia diabetes history of gi bleed history of dvt, on coumadin ckd (basline cr near 2.0) gerd copd morbid obesity enterocutanous fistula gunshot wound () s/p left hemicolectomy s/p gunshot wounf () discharge condition: stable discharge instructions: 1. please take all medications as prescribed . 2. please keep all outpatient appointments . 3. please return to the hospital for symptoms of chest pain, shortness of breath, fever/chills, bleeding, or any other concerning symptoms followup instructions: 1. please continue care as directed by the medical staff at the extended care facility . 2. upon discharge from the extended care facility it is extremely important that you follow up closely with your primary care physician, . to have your inr checked frequently. this is because your inr went high very easily during your hospitalization and could result in serious bleeding if not carefully monitored. when you are discharged from the extended care facility, please call her office at to make an appointment to be seen within one to two weeks. in addition, you should go to her office within two to three days of discharge to have your inr checked at the laboratory. please call her office to let them know which day you will be going so they can monitor your coumadin therapy appropriately. additionally, you are being discharged without lasix and metolazone. this is because your kidney's were impaired this admission with too much lasix. you should be seen by dr. as above where assessment can be performed when to reintroduce these medications. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Atrial flutter Systolic heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Other specified cardiac dysrhythmias Unspecified sleep apnea Septic shock Intestinal infection due to Clostridium difficile Old myocardial infarction Morbid obesity Personal history of venous thrombosis and embolism Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Colostomy status Fistula of intestine, excluding rectum and anus

past medical history: 1. interstitial lung disease. 2. question of idiopathic pulmonary fibrosis for 2 to 3 years, never worked up. 3. gerd. 4. benign prostatic hypertrophy, status post turp in . 5. bilateral total knee replacements. 6. status post appendectomy. 7. left shoulder surgery. admission medications: 1. aspirin p.r.n. 2. aciphex. allergies: the patient has no known drug allergies. social history: the patient lives with his 76-year-old wife and still works part-time in a sporting goods store. he was a retired physical education teacher. the patient had a ten year pack history of smoking, quit 50 years ago. he uses occasional alcohol. no recent travel. no asbestos exposure. family history: noncontributory. physical examination on admission to the icu: vital signs: temperature 98.9, blood pressure 132/73, heart rate 85-90, respiratory rate 20-24, pulse ox 83-93% on nonrebreather. general: he was in minimal distress with difficulty breathing but pleasant. heent: pupils were equal, round, and reactive to light and accommodation. extraocular motions intact. the patient had moist mucous membranes. chest: bilateral rhonchi and crackles at the bases. cardiac: questionably irregular rate with s1, s2, no murmur. abdomen: positive bowel sounds, soft, nontender, nondistended. extremities: no edema, bilateral knee scars. neurologic: alert and oriented times three, moving all extremities. laboratory/radiologic data on admission: chemistries were unremarkable. the patient had a white count of 15.4, hematocrit 33.5, platelets 261,000. coagulation studies were unremarkable. the patient had a blood gas which was 7.48/36/66. the patient's urine had some white cells but was essentially unremarkable. the ekg showed atrial fibrillation versus mat with right axis right bundle branch block and some nonspecific st changes. chest x-ray, as in hpi. hospital course: the patient was brought into the micu. he spiked a fever and became delirious. cultures were sent of blood and urine and chest x-ray was repeated. over his first several days in the unit, the patient was treated conservatively with continued ceftriaxone and levaquin antibiotics, pulmonary therapy, and supplemental oxygen. he continued to be in moderate distress and from time to time became disoriented and agitated, requiring haldol and sedation. his atrial fibrillation was treated with anticoagulation and he was started on lopressor for rate control. after several days of conservative treatment, the patient was semi-electively intubated and had bronchoscopy performed on with multiple specimens sent. the patient's oxygenation and blood gas improved markedly on the ventilator. however, the bronchoalveolar lavage cultures essentially yielded no data in terms of micro-organism, fungal etiology, or legionella as all were negative. on , the patient was extubated after appearing to do well on his respirations. however, he gradually became tachypneic into the 40s with decreasing 02 values. he failed mask ventilation and was reintubated. it should also be noted that throughout the course of the patient's intensive care stay, his cvp was monitored and initially diuresis was attempted to improve his breathing and oxygenation. however, this failed. additionally, doxycycline was added for additional atypical antimicrobial coverage. on , a family meeting was held by dr. and numerous members of the patient's family to try to ascertain what the care plan should be and what the patient would want done. at this point, the family elected to watch the patient for several more days but fairly unanimously decided that he would most likely want conservative care and extubation eventually. on the patient's final days of micu hospitalization, his sedation was greatly lightened and he was able to communicate through hand squeezes and gestures with family and staff. the patient stated that he was in no pain. viral and other cultures continued to remain negative throughout the hospital stay. he had an additional febrile episode on and had sputum, blood, and urine cultures sent, all of which remained negative. on , the patient's family felt that they were ready to withdraw. dr. had some final discussions with the family including some thoughts of empiric steroid treatment versus going further with possible vats and/or tracheostomy. however, the family ultimately decided to make the patient cmo and extubate him. the patient passed away shortly thereafter. the patient's primary care physician, . of the gastroenterology department, was frequently in to see the patient and aware of the plans during all of these time periods. , m.d. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Atrial fibrillation Acute respiratory failure Postinflammatory pulmonary fibrosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cabgx4 history of present illness: 58 m c h/o hyperchol, and who has had cp and left arm pain for few weeks. had +ett at osh and transfered to for cardiac cath on . cath showed severe 3vd and he was d/c home for cabg schedule for . on he developed intermittent l sided chest pain lasting minutes at a time while at rest. not associated with diaphoresis or dyspnea. no radiaton to neck or arms. he went to osh and started on heparin gtt. he was transferred to for cabg. past medical history: 1. hyperlipidemia 2. htn 3. anxiety 4. cad -cath : 3vd lmca: mild diffuse dz lad: 95% mid lesion; distal r-l collaterals via acute marginal lcx: 80% prox; om1 60% rca: 80% distal; acute marginal 80% lesion lvgram: ef 50% with anteriolateral hk 5. s/p appy 6. s/p hernia hydrocele repair 7. s/p anal fissure surgery social history: attorney, also works in real estate and writes tour books related to national . lives alone. non smoker. family history: mother had af, pm, silent mi in later years. father had several cva's. physical exam: 139/61 79 20 97%(2l) gen: nad, comfortable, lying in bed flat heent: o/p clear, mmm, eomi neck: jvd @ 7 cm; no carotid bruits cv: rrr, no m/r/g pulm: cta b/l abd: soft, nt, nd; no cva tenderness ext: +2 carotid, radial, femoral and d.pedis pulses b/l; mild eccymosis at right groin sight; no femoral bruits neuro: cn ii-xii intact, moves all 4 ext pertinent results: ekg: nsr @ 65, n axis, no hypertrophy, ivcd (right bundle pattern); twi in iii, avf 11:00am blood wbc-6.7 rbc-4.47* hgb-14.4 hct-38.0* mcv-85 mch-32.3* mchc-38.0* rdw-12.4 plt ct-234 11:00am blood neuts-76.3* lymphs-19.9 monos-2.8 eos-0.4 baso-0.6 11:00am blood pt-13.3 ptt-28.3 inr(pt)-1.2 11:00am blood plt ct-234 11:00am blood glucose-125* urean-12 creat-0.8 na-138 k-3.6 cl-104 hco3-24 angap-14 11:00am blood alt-17 ast-16 ck(cpk)-62 alkphos-75 amylase-22 totbili-2.1* 11:00am blood albumin-4.2 11:00am blood %hba1c-4.9 -done -done brief hospital course: the patient was admitted to the hospital and taken to the operating room on , where he underwent a cabgx4. please see operative note for full details. the patient tolerated this procedure well. he was taken to the csru immediately post-operatively and was extubated that night. the following day, the patient did well and was transferred to the floor. on the night of post-op day #2, the patient became acutely confused and agitated. he was sedated and seen the following day by the neurologic and psychiatric services. it was felt at the time that this acute confusion was most likely due to a combination of narcotics and anxiety stemming from hospitalization rather than oxygen desaturation. the patient was transferred back to the csru for monitoring and was found to be mentating well throughout the remainder of his hospital stay. the patient was transferred back to the floor on post-op day #4. he was ambulated and cleared by the physical therapy service. he was discharged home on post-op day #6 in stable condition. medications on admission: 1. asa 325 po qday 2. lopressor 25 mg po bid 3. lipitor 10 mg po qday 4. ativan 0.5 mg po tid prn * had indigestion with captopril discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 10 days. disp:*20 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. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* discharge disposition: home with service facility: all care vna discharge diagnosis: coronary artery disease hypertension hypercholesterolemia anxiety disorder discharge condition: stable discharge instructions: please return tot he hospital or call dr. office of you experience chills or fever greater than 101 degrees f. please call if you notice redness, swelling, or tenderness of your chest wound, or if it begins to drain pus. no heavy lifting or driving until follow up with dr. . you may shower. wash incision with mild soap and waten, then pat dry. followup instructions: provider: , . follow-up appointment should be in 1 month please follow up with your primary care physician /or cardiologist in 2 weeks time. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Anxiety state, unspecified Delirium due to conditions classified elsewhere

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cardiac arrest due to ventricular fibrillation major surgical or invasive procedure: cardiac catheterization stent to left circumflex history of present illness: 58 year old male with unknown pmh p/w witnessed cardiac arrest in the field. he was in , by report cpr was started by retired nurses within seconds. ems arrived in 3 minutes and als was initiated. initial rhythm vf, pt shocked x9, given 300 amio, then another 150. atropine 1 mg, epi 3 mg, had regular rhythm at 15 minutes by ems strips, return of spontaneous circulation at 20 minutes by report. arrived at ed at at 25 minutes with vitals p 90 bp 112/p rr 16 sats 100% after being intubated on arrival. ecg showed afib with qs v1,2 st depressions v2-v5 with question of small st elevations i, ii. emergency head ct, ct of c-spine were negative. he was taken for urgent cath, found to have 80% lad lesion, and total occlusion to lcx which was treated with cypher x2. he was admitted to ccu for further mgmt and for cooling therapy. past medical history: r hip arthroplasty x2 social history: works as teacher in . divorced. no tobacco. beers/day. no drugs family history: noncontributory physical exam: gen: intubated, sedated heent: pupils sluggish but reactive heart: rr, ns1, s2, no appreciable murmurs lungs: coarse, no crackles abd: soft, nt, nd +bs ext: 2+ dp, radial pulses bilaterally neuro: moving arms spontaneously but not reacting to anything, legs rigid, extended at knees, plantar flexed at ankles pertinent results: 03:07pm wbc-7.9 hct-42.7 plt ct-266 07:44pm wbc-18.9 hct-40.3 plt ct-148 06:08am wbc-14.7 hct-27.8 plt ct-235 03:07pm pt-12.4 ptt-34.8 inr(pt)-1.1 07:44pm glucose-211 urean-15 creat-1.0 na-139 k-4.1 cl-106 hco3-20 06:08am glucose-119 urean-17 creat-0.6 na-139 k-3.9 cl-108 hco3-21 07:44pm ck-2985 ck-mb-137 mb indx-4.6 ctropnt-1.66 12:11am ctropnt-2.21 06:14am ck-4320 ck-mb- >500 ctropnt-2.32 06:08am ck-3160 ck-mb-118 mb indx-3.7 ctropnt-2.06 03:13pm lactate-10.2-->1.7-->1.0 03:31am blood wbc-9.8 rbc-3.36* hgb-10.7* hct-29.2* mcv-87 mch-31.7 mchc-36.5* rdw-15.0 plt ct-236 03:31am blood neuts-80.1* lymphs-14.1* monos-5.2 eos-0.6 baso-0.1 03:31am blood plt ct-236 03:31am blood glucose-103 urean-10 creat-0.7 na-141 k-3.2* cl-108 hco3-26 angap-10 03:31am blood totbili-1.4 dirbili-0.5* indbili-0.9 11:00am blood alt-75* ast-121* alkphos-39 totbili-1.1 03:31am blood calcium-8.5 phos-2.2* mg-1.7 06:50am blood wbc-7.4 rbc-3.31* hgb-10.3* hct-29.1* mcv-88 mch-31.1 mchc-35.3* rdw-14.6 plt ct-295 06:50am blood plt ct-295 06:50am blood pt-12.2 ptt-30.3 inr(pt)-1.0 06:50am blood glucose-92 urean-12 creat-0.7 na-141 k-3.5 cl-107 hco3-26 angap-12 11:38am blood wbc-8.5 rbc-3.09* hgb-9.8* hct-27.1* mcv-88 mch-31.7 mchc-36.2* rdw-14.3 plt ct-342 11:38am blood plt ct-342 11:38am blood k-3.7 cardaic catheterization: selective coronary angiography revealed a right dominant system with patent lmca and proximal lad. mid lad had a long 80% lesion. d1 had a 70% stenosis. lcx was proximally totally occluded. rca was free of angiographically apparent disease. left ventriculography was deferred. hemodynamic assessment showed normal left and right sided filling pressures and low normal cardiac index. successful stenting of the lcx with 3.5x28mm cypher and a 3.0x8mm cypher (post dilated to 3.5mm). occluded right iliac vessel. echo ():mild regional left ventricular systolic dysfunction c/w cad. possible regional right ventricular free wall hypokinesis. mild mitral regurgitation. ef 55% cxr(): new mild to moderate heart failure. resolv opacity in the right upper lobe. brief hospital course: 58 year old male w/ unknown pmh s/p vfib arrest. cath revealed lcx complete occlusion, which was stented. #cardiac: had acute mi, with cypher stent placed in the left circumflex artery. he was continued on aspirin, plavix, atorvastatin, and metoprolol. echo showed ef of 55%. s/p vf arrest, had atrial fibrillation in the ed. got amio loaded in field. was in sinus later and amio discontinued. pt remained hemodynamically stable following revascularization, without chest pain or further arrhythmias. he will need to follow up with dr. within the month. . #neuro: suffered anoxic brain injury as it took 20 minutes before heart revived after the vfib arrest. upon arrival at , pt underwent head & neck ct, which were unremarkable. neuro was consulted. pt started on cooling protocol. following cooling protocol, pt was weaned off sedatives, and slowly began showing signs of increasing neurologic function. following cessation of paralytics, pt was able to move all extremities without deficits; he was seen by pt and ot who both felt that he would benefit from a rehab stay. he required soft, ground diet initially, though was transitioned to full po after further evaluation by speech & swallow. the degree of anoxic brain injury sustained is unclear, though mri was unrevealing for significant anoxic damage (see report). the pt is pleasant & is oriented to self. however, he is not oriented to place or time, indicating some cognitive deficits. ## respiratory failure: patient intubated in setting of code, but extubated within 48 hours, without further respiratory problems. ## pneumonia: had leukocytosis on admission thought to be secondary to stress response; however, his leukocytosis persisted and his cxr revealed a rul infiltrate, thought to be aspiration. he was initially started on levaquin and flagyl, but later changed to vancomycin and zosyn given that he had been on a ventilator (to cover nosocomial pathogens). his infiltrates resolved on chest x-ray and he completed a 7 day course of antibiotics in house. his oxygen saturation was consistently > 97% on ra. ## etoh: pt reportedly drinks 6-12 beers/day. he required about 20 mg of valium on the 4th-5th days of hospitalization, however subsequently has not required any more doses, without any signs of withdrawal. ## fen: he was seen by speech and swallow who cleared him for a po diet with ground solids and thin liquids (cardiac heart healthy). he should continue on this diet for now, but should have a repeat speech and swallow evaluation at rehab at some point, as he may be able to have his diet advanced in the near future. ## social: from social work--pt has reported hx of etoh abuse. sw met briefly with pt and 2 sisters, then alone with sisters with pt's permission while he had a pt eval. pt presented as anxious and expressed wish to return home in near future. sisters, and , talked about their ambivalence about taking control while pt was confused, as pt has compartmentalized his life in past, so they were not familiar with his friends, and had limited knowledge of his ex-wife and family. sisters expressed concern pt has hx of heavy etoh abuse since adolescence. they state pt's mother expressed concern about his drinking when she was alive and pt lived with her. sisters have found large quantities of beer in his house and car since his hospitalization. they note pt is a much loved high school teacher and coach, and they have been surprised by the magnitude of public support for him in his small town. sisters do not believe pt has ever had a dui or legal consequences for drinking, nor blackouts, missed work or any previous attempts at sobriety. sister's articulate being committed to supporting pt's needs in community though one lives in oh. sisters report pt was fully independent with all pta, exercised regularly (swimming), gave up running due to past hip replacements. family note significant improvement in pt's mental status, but are aware of st memory deficits. medications on admission: none discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily) as needed for cad. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) as needed for stent. 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 4. multivitamin capsule sig: one (1) cap po daily (daily). 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. atenolol 50 mg tablet sig: 1.5 tablets po daily (daily). 8. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: & rehab center - discharge diagnosis: coronery artery disease secondary: anoxic brain injury pneumonia alcoholism atrial fibrillation, now in sinus discharge condition: stable discharge instructions: please take all medications as prescribed. if you have chest pian, shortness of breath, dizziness, fever, chills, abdominal pain please call the physician on call. please continue to take aspirin and plavix daily without fail. do not discontinue them unless told otherwise by your cardiologist. we are starting you on new medications like lisinopril, atenolol, aspirin, plavix, multivitamins, atorvastatin. please see the attched sheet for instructions regarding these medications. followup instructions: please call dr office () to ask about your appointment with him. please make a follow up appointment with your pcp dr () within one to two weeks. you have an appointment scheduled with neurologist dr () on at 11 am. provider: , md, phd: date/time: 11:00 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Anoxic brain damage Ventricular fibrillation Delirium due to conditions classified elsewhere Other abnormal blood chemistry Other and unspecified alcohol dependence, continuous Hip joint replacement Acute myocardial infarction of other lateral wall, initial episode of care

allergies: morphine attending: chief complaint: hepatitis c cirrhosis, ascited, encephalopathy major surgical or invasive procedure: liver transplant for hepatitis c cirrhosis and hemochromatosis history of present illness: 37 y.o. male with h/o cirrhosis hcv. admitted from for abd pain ? cholecystitis, but had negative hida and was discharged. admitted -51 for atn renal failure. not on hd yet. presents for liver transplant. past medical history: 1) cirrhosis secondary to hepatitis c, diagnosed in . intolerance to ifn/ribaviran therapy. genotype 1. on transplant list. 2) h/o of ivda -, + cocaine use. last + tox in 3) iron overload syndrome. genotyping for hemochromatosis negative, per report liver biopsy at outside hospital with normal hic. 4) bcc removed in 5) hernia repair 6) recent scalp furuncle, + mrsa, treated with bactrim 8) sbp , on cipro prophylaxis 10) depression 11) anemia 12) chronic hyperkalemia social history: mr. was diagnosed w/ hcv cirrhosis in . he used iv heroin for yrs starting at 20, but quit in after multiple incarcerations. when he became acutely ill with jaundice and ascites in , he moved back to , ma, and currenly lives with his mother who has power of attorney. he quit drinking in , and drank heavily intermittently before that. ex-smoker, quit recently. 10 pack-year history. family history: cousin with hemochromatosis physical exam: cv: ii/vi sem ch: quiet throughout but clear abd: mildly tender on r side, soft. liver enlarged but difficult to clearly measure. neg sign heent: grossly icteric, skin and sclerae, op clear. small lesion on left cheek. ext: 2+ distal pulses, cap refill ~1 sec. brief hospital course: taken to or for orthotopic (piggyback)deceased donor liver transplant pv-pv, cbd-cbd, no t-tube. he received 3,300 of crystalloid, 3units ffp, 2units of rbc, 2 units of plts and 1 cryo. ebl was 300. see operative report. given induction immunosuppression (simulect, cellcept, and solumedrol). a duplex of the liver demonstrated "unremarkable post-transplant liver ultrasound and doppler." he was transferred to sicu postop intubated and stable. on pod 1 sedation was decreased with goal to extubate. lungs were clear. hct was 25.4. he was transfused with 4 units of prbc and 1 unit of plts. jp 1 drained 385 and jp # 2 110cc. solumedrol m and cellcept 1gram were given. on pod 2, temperature was 101.7. blood and urine cultures were done and subsequently negative. jp 1 drained 1245 and #2 55. he was extubated. prograf was initiated in addition to cellcept and a daily solumedrol tapering dose for immunosuppression. liver duplex was normal. pain was managed with dilaudid prn. alt 222, ast 191, alk phos 98 and t.bili 3.7. lfts trended down until pod 4 when alk phos started to increase to 368. on pod 4, he received simulect 20mg iv. the lateral jp and ng were removed and diet was advanced to sips of clears. he became dyspneic and dropped 02 sat to 88% on ra. a 70% face mask was applied with o2 sat that increased to 98%. wheezing and decreased breath sounds were noted on the right. abgs,cxr and ekg were done. he was given albuterol neb treatment with improvement of o2 sat. abg was 7.32/48/75/26/-1. cxr revealed small bilateral pleural effusions that were stable. ekg was stable. he was treated with iv lasix 40 for volume overload. o2 remained at 92% on 5l face tent.he continued to receive albuterol neb treatments every 2-4 hours. he diuresed, but pao2 continued at 68 and pc02 53. diamox was added. he diuresed 4290cc with repeat abg of 7.35/54/83/31/12 and decreased wheezing. he required hand restraints for some confusion and pulling off o2. on pod 5, alk phos increased to 572 and t.bili to 3.1. a duplex of the liver demonstrated " interval development of a new fluid collection just deep to the left lobe of the liver extending into the left porta. the collection contains fluid and solid components, with septations. it measures 5.9 x 5.7 x 3.2 cm. aside from this collection, the left lobe parenchyma is normal in appearance. there is no intrahepatic biliary ductal dilatation. in addition, there is a second collection found in the right subhepatic region. this collection contains fluid and some echogenic material that may represent clot. this collection measures 7.5 x 3.0 x 4.7 cm. the parenchyma of the right lobe is normal in appearance, without biliary ductal dilatation. a right pleural effusion with associated atelectasis is noted." arterial/venous flow and resistive indices were normal. prograf level was 19.4 and prograf was held x 4 doses. repeat prograf level was 7.8 and prograf was resumed at 1mg on pod7. he was given 2 bags of platelets for a plt count of 68. a hit antibody was sent. medial jp was removed. on pod 7, he was coughing and raising thick, green sputum. he remained in the sicu for close management of respiratory and mental status. he had episodes of somnolence and confusion. at times, he appeared to be hallucinating. pain medication was decreased. on pod 8, he was transferred to the transplant unit. diet was advanced and pt continued to work with him. he required a 1:1 sitter as he was agitated, and pulling at iv lines and removing o2 tubing. foley was removed. percocet was decreased for sedation. on pod 9, he received pamidronate x1. calcium and vitamin d were started. alk phos increased to 566. a repeat duplex revealed ". patent portal vein, with most probably slight narrowing in the anastomotic site, demonstrating velocity gradient of uncertain significance. 2. unchanged subhepatic and left intrahepatic small fluid collections." prograf was increased for a level of 10.4. on pod 11 (), a liver biopsy was performed. this demonstrated "features indeterminate for acute cellular rejection. focal minimal lobular inflammation, nonspecific. focal poorly formed histiocytic aggregate, suggestive of granuloma". prograf was decreased to 1.5mg for a level of 13.5. prednisone remained at 20mg and cellcept at 1gram . a consult was obtained for elevated glucoses. these were treated with sliding scale insulin. recommendations, prandin 1mg prior to meals was started. on pod 13, he was alert and ambulatory. o2 sats were in the high 90's on room air. lungs were clear. he was tolerating a regular diet and vital signs were stable. hct trended down to 25.1. ast was 24, alt 40, alk phos 340 and t.bili 1.5. vna ( home care) was set up to assist with medication and insulin/glucose management as well as pt for strengthening and safety training. a rolling walker was provided for unsteady gait. his mother arranged for time off from work in order to provide 24 hour supervision as he did display poor safety awareness and judgement. incision was clean and dry. there was extensive ecchymosis on right side of abdomen and flank. he was discharged home with scheduled f/u appointments at the transplant office. medications on admission: protonix, quinine, actigall, ultram, lactulose, bumex, and cipro discharge medications: 1. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 2. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 3. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 4. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 5. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for prn: give only tablet every 8 hours if needed for pain. disp:*10 tablet(s)* refills:*0* 7. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 8. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 9. repaglinide 1 mg tablet sig: one (1) tablet po before lunch and before dinner () as needed for hyperglycemia. disp:*60 tablet(s)* refills:*0* 10. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. tacrolimus 0.5 mg capsule sig: three (3) capsule po 2x (times 2): 1.5mg twice daily. discharge disposition: home with service facility: home services discharge diagnosis: liver transplant for hepatitis c cirrhosis and hemochromatosis discharge condition: stable discharge instructions: call if nausea, vomiting, inability to take medication, redness/bleeding from incision, jaundice, or confusion labs every monday and thursday for cbc, chem 10, ast,alt, alk phos, t.bili, albumin and trough prograf level. results to be fax'd to no driving while taking pain medication no heavy lifting shower followup instructions: provider: , md, phd: lm center phone: date/time: 10:00 provider: , md, phd: lm center phone: date/time: 9:50 provider: , md, phd: lm center phone: date/time: 11:20 md, Procedure: Closed (percutaneous) [needle] biopsy of liver Other transplant of liver Transfusion of packed cells Transfusion of platelets Other operations on lacrimal gland Transplant from cadaver Diagnoses: Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Infection with microorganisms resistant to penicillins Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Delirium due to conditions classified elsewhere Other abnormal glucose

allergies: morphine attending: addendum: medication adjustments: coumadin 4 mg po daily tacrolimus 2 mg po bid please check pt, inr and tacrolimus trough discharge disposition: extended care facility: & rehab center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Hyperpotassemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other pulmonary embolism and infarction Other diseases of spleen

allergies: morphine attending: addendum: medication: bactrim 1 tab ss po daily discharge disposition: extended care facility: & rehab center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Hyperpotassemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other pulmonary embolism and infarction Other diseases of spleen

allergies: morphine attending: chief complaint: lethargy,increased lfts, feeding tube pulled out major surgical or invasive procedure: none history of present illness: 37 y.o. male s/p liver transplant who presented for increasing lfts, lethargy,hyperkalemia, and dislodgement of post pyloric feeding tube. he has had several admissions to since discharge post transplant for failure to thrive and abdominal pain over past two months. currently denies fever, chills, nausea, or vomiting. not eating and has been more withdrawn over past 24-48 hours. past medical history: hcv cirrhosis hemachromatosis bcc ascites, encephalopathy depression dm psh: liver transplant hernia repair physical exam: alert, lethargic, oriented x3, appears ill & frail, pale perrla, eomi, anicteric rrr, 2/6 sem heard best at apex lungs: ctab, no w/r/r abd: soft, ttp in luq, no masses, +bs x4, no rebound or guarding, incision well healed ext without c/c/e, 2+ distal pulses labs at osh: sodium 136, k+ 6.7, chloride 103, bicarb 28, bun 56, creatinine 1.0, glucose 183, calcium 10.4, ast 968, alt 712, alk phos 1101, t.bili 2.5, t. protein 5.6, albumin 3.2 pertinent results: 09:30pm glucose-99 urea n-51* creat-0.9 sodium-142 potassium-5.0 chloride-102 total co2-29 anion gap-16 09:30pm calcium-12.5* phosphate-5.2* magnesium-1.3* 05:05pm glucose-124* urea n-57* creat-1.1 sodium-138 potassium-7.0* chloride-103 total co2-27 anion gap-15 05:05pm alt(sgpt)-1148* ast(sgot)-997* ld(ldh)-317* alk phos-1440* amylase-15 tot bili-1.4 05:05pm lipase-11 05:05pm albumin-3.9 calcium-11.7* phosphate-5.1* magnesium-1.4* 05:05pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 05:05pm wbc-2.5*# rbc-3.88* hgb-11.4* hct-32.5* mcv-84 mch-29.4 mchc-35.1* rdw-16.6* 05:05pm plt count-172 05:05pm pt-12.1 ptt-25.2 inr(pt)-1.0 brief hospital course: admitted . potassium was 7.0. this was treated with iv insulin, dextrose, bicarb and calcium gluconate. ekg revealed non-specific lateral and anterolateral st-t wave changes. repeat potassium was 5.0. ct of the head revealed no intracranial hemorrhage or mass effect.chest and abdominal ct demonstrated the following " 1. diffuse bilateral segmental and subsegmental pulmonary emboli. 2. new large splenic infarct. 3. 5 mm nodule in the right lower lobe, which appears more prominent than on , possibly related to slice selection. follow-up is recommended in 3 months." on exam, he was awake, oriented to person & hospital only. respiratory rate was even, and non-labored. breath sounds were decreased at the bases. he was transferred to the sicu for close monitoring. he was started on iv heparin and ptts were monitored for goal 0f 60-80. coumadin was initiated. inr was 1.0 on . a tte was done to evaluate for source of pes and to assess for pfo. this demonstrated " conclusions: 1. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. 2. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. 3. the mitral valve appears structurally normal with trivial mitral regurgitation. 4. no evidence of endocarditis seen.". bilateral lower extremity noninvasive ultrasounds was done. a deep vein thrombosis was identified within the right popliteal vein. a left subclavian central venous line was inserted and a cxr demonstrated the tip in the upper svc. "compared to the previous study, the lungs are better expanded and there is near complete resolution of multifocal parenchymal opacities. lung volumes still remain low with crowding of the pulmonary vessels. residual right basilar opacity is present." a liver duplex demonstrated: "1. limited study shows heterogeneously echoic subhepatic area which likely represents evolution of previously identified collection in this area. 2. normal liver doppler ultrasound. 3. ultrasound-guided mark over the right lobe of the liver placed for biopsy to be performed by clinical staff." he was transferred out of the sicu and back to the med- unit once stable on hospital day 3. he was started on solumedrol 250mg iv qd for three days for presumed transplant rejection based on elevated lfts (ast 997, alt 1148, alk phos 1440 and t.bili of 1.4). lfts decreased to ast 27, alt 147, alk phos 564, and t.bili of 0.3 on . was consulted to help manage hyperglycemia. glucoses ranged between 180 and 430 at which time he was started on an insulin drip with glucoses imroving to 150. the insulin drip was tapered off and sliding scale insulin with long acting insulin resumed. he was continued on prednisone 10mg qd, cellcept 500mg qid and prograf 1.5mg . prograf levels were 13.5, 9.3, 10.6 and 10.1. a post pyloric feeding tube was replaced and tube feedings of nepro were started with goal rate of 60cc. the rate was advanced without any gi discomfort. was consulted. cycled tube feedings at 60cc/hour x 14 hours were recommended. psychiatry was consulted for evaluation of his depression. initial recommendations included restarting ritalin to help increase energy level due to depression and to encourage improved po intake. remeron was recommended as well as taper of zoloft. ritalin was held, zoloft was tapered off and remeron was initiated. a follow up psychiatry consult generated recommendations to delay restarting ritalin,taper zoloft and holding off on starting remeron and marinol until less confused. an eeg was recommended as well as checking tsh and b12 level. on admission, a urine tox screen was negative. blood cultures and a cmv viral load was drawn on . all were negative. wbc dropped to 1.9 on hospital day 2, and subsequently increased to 9.6 after administration of neupogen. vital signs were stable and he was afebrile. medications on admission: marinol 5mg , nph 17 units sc qam, nph 13 units sc q6pm, colace 100mg , epogen 8,000units sc q mon-wed-fri, tums 1 , prevacid 30mg , lopressor 37.5mg , mvi 1qd, prednisone 10mg qd, prandin 2mg , senokot 2tabs po qhs, zoloft 50mg qd, bactrim ds tab qd, valcyte 900mg qd, prograf 1.5mg , magnacal at 70cc/hr from 5p to 7am. discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 2. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 3. multivitamin capsule sig: one (1) cap po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. dronabinol 2.5 mg capsule sig: two (2) capsule po bid (2 times a day). 6. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po qid (4 times a day). 7. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 8. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 9. tacrolimus 0.5 mg capsule sig: three (3) capsule po bid (2 times a day). 10. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: extended care facility: & rehab center - discharge diagnosis: liver transplant rejection, treated with steroid pulses h/o hepatitis c pulmonary embolus, bilateral splenic infarct right popliteal dvt dm type ii hyperkalemia depression malnutrition discharge condition: stable discharge instructions: call transplant office if fevers, chills, inability to take medications, shortness of breath, chest pain, jaundice, diarrhea, abdominal pain or any concerns. labs every monday & thursday for cbc, chem 10,ast, alt, alk phos, t.bili, albumin, pt/inr, and trough prograf level. fax labs immediately to transplant office at goal inr for pes/dvt followup instructions: provider: scan where: radiology phone: date/time: 10:00 provider: , md, phd: lm center phone: date/time: 2:40 Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Hyperpotassemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other pulmonary embolism and infarction Other diseases of spleen

allergies: morphine attending: chief complaint: abdominal pain, shortness of breath. major surgical or invasive procedure: diagnostic paracentesis history of present illness: 36 year old male with hx of hepatic cirrhosis from hcv and hemochromatosis admitted with sob, worsening ascites, leakage from past paracentesis, and hyponatremia. he recently saw dr. on and was reinstated on the transplant list and his problem is worsening ascites/edema and hyponatremia. pt is being admitted because he has been more sob since last paracentesis, with difficulty moving around. denies hematemesis or hematochezia/melena. +bm with lactulose. denies abdominal pain but notes increasing abdominal girth. past medical history: 1)cirrhosis - hepatitis c diagnosed in secondary to jaundice. intolerance to ifn/ribaviran therapy. genotype 1 2) history of ivda -. also cocaine usem last + tox in mid-) hemachromatosis - no phlebotomy, and diagnosis uncertain. 4) bcc removed in 5) hernia repair 6) add 7) recent scalp furuncle ?????? mrsa. treated with bactrim 8) sbp ; started cipro ppx 9)ascites 10)depresion 11)hyponatremia 12)anemia 13)thrombocytopenia 14)hypoalbuminemia 15)h/o recent hyperkalemia social history: mr. was diagnosed w/ hcv cirrhosis and hemochromatosis in . he used iv heroin for yrs starting at 20, but quit in after multiple incarcerations. when he became acutely ill with jaundice and ascites in , he moved back to , ma, and currenly lives with mother who is power of attorney. he quit drinking in , and drank heavily intermittently before that. he smoked 1ppd for 10 yrs, but started nicotine patch recently and says no cigarettes for 2 weeks. he uses cocaine and has most recent tox screen positive in mid-. not currently on transplant list as a result of this. family history: cousin with hemachromatosis physical exam: 98.3 121/74 68 20 95%ra gen: bronze colored, overweight caucasian male in mild distress heent: scleral icterus present. op clear. mmm, nose with ? past surgery. cvs: rr, normal rate, i-ii/vi systolic murmur at rusb without radiation to carotids. lungs: crackles at bases bilaterally- way up. abd: nabs, soft, markedly distended- + ascites, diffuse mild tenderness. back: nontender extr: 3+ edema in legs past his knees. neuro: aaox3. responds to questions appropriately. no asterixis but mild bilateral hand tremor. pertinent results: wbc-8.7 hct-30.8* mcv-98 mch-32.8* mchc-33.4 rdw-18.2* plt ct-61* wbc-5.5 hct-30.5* mcv-96 mch-32.0 mchc-33.4 rdw-19.1* plt ct-42* neuts-58 bands-0 lymphs-23 monos-14* eos-4 baso-1 atyps-0 metas-0 myelos-0 neuts-45* bands-0 lymphs-32 monos-8 eos-3 baso-0 atyps-11* metas-1* myelos-0 pt-15.7* ptt-39.3* inr(pt)-1.6 pt-18.0* ptt-37.7* inr(pt)-2.0 pt-18.9* ptt-42.7* inr(pt)-2.3 pt-16.6* ptt-43.6* inr(pt)-1.8 glucose-100 urean-37* creat-2.7*# na-131* k-5.1 cl-99 hco3-26 glucose-134* urean-44* creat-2.9* na-135 k-5.0 cl-102 hco3-26 glucose-138* urean-39* creat-2.0* na-145 k-4.5 cl-107 hco3-28 glucose-89 urean-15 creat-1.0 na-139 k-4.0 cl-101 hco3-34* alt-40 ast-99* ld(ldh)-457* alkphos-142* totbili-7.9* alt-19 ast-35 alkphos-66 amylase-19 totbili-11.2* totbili-5.2* albumin-2.6* calcium-8.7 phos-5.8*# mg-2.0 phos-3.4 mg-1.5* caltibc-192* ferritn-1203* trf-148* ammonia-40 c3-33* c4-12 urine: 05:44pm urine color-yellow appear-clear sp -1.013 blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg rbc-0 wbc-0 bacteri-none yeast-none epi-<1 urine eos-negative urine hours-random urean-619 creat-102 na-39 totprot-9 prot/cr-0.1 urine osmolal-401 ascites: ascites wbc-48* rbc-137* polys-3* lymphs-19* monos-62* mesothe-16* ascites wbc-250* rbc-3700* polys-3* lymphs-15* monos-0 mesothe-5* macroph-77* time taken not noted log-in date/time: 4:50 pm peritoneal fluid time not noted on requisition or specimen peritoneal fluid. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. 5:58 pm peritoneal fluid **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. other micro: 5:25 pm blood culture **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. 2:46 pm urine **final report ** urine culture (final ): <10,000 organisms/ml. 6:19 pm bronchoalveolar lavage gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): columnar epithelial cells. no microorganisms seen. respiratory culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): viral culture (preliminary): no virus isolated so far. 12:30 pm sputum source: expectorated. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): sparse growth oropharyngeal flora. yeast. sparse growth. predominating organism. imaging: abd us : impression: 1) paracentesis, marked. 2) cholelithiasis, wall edema and thickening commonly associated with cirrhosis. common bile duct is not dilated. 3) cirrhotiform liver with all vessels patent. cxr : the heart is normal in size. the diaphragms are somewhat elevated and there are small effusions and mild bibasilar subsegmental atelectasis. mediastinal contours are normal. there is no bone destruction. impression: there is no significant change in the chest since . cxr : pa and lateral views of the chest: there are developing bibasilar areas of consolidation. there are likely small bilateral pleural effusions. the heart size is not significantly changed. the mediastinal and hilar contours are stable. no evidence of pneumothorax. the osseous structures are unchanged. impression: bilateral areas of consolidation consistent with multifocal pneumonia. follow-up study after clinical treatment is recommended to demonstrate complete resolution. mr abdomen : impression: 1) patent portal and hepatic veins and ivc. no thrombosis identified. the main portal vein also demonstrates hepatopetal blood flow. 2) findings consistent with the primary form of hemochromatosis. clinical correlation is recommended. 3) liver cirrhosis with portal hypertension. no suspicious liver masses identified. 4) moderate amount of abdominal ascites. 5) patchy bibasilar lung opacities. clinical correlation is recommended, as these opacities may be secondary to dependent atelectasis versus a bibasilar infectious process. ct chest : impression: 1. bilateral pleural effusion with marked bilateral opacities in the lungs, probably representing pulmonary edema. superimposed multifocal pneumonia should be considered in this patient with fever. if the patient has hemoptysis, diffuse hemorrhage is also a consideration. 2. right paratracheal lymph node measuring 12 mm in short axis. 3. atrophic liver, splenomegaly, ascites and lateral collateral vessels in this patient with end-stage liver disease. cxr : impression: marked improvement in bilateral lower lobe consolidations with only faint residual reticular opacity seen in these regions. improved congestive failure compared to the most recent study of . brief hospital course: mr. is a 36 year old male with cirrhosis secondary to hcv, hemochromatosis, and renal disease, who presented with increasing abdominal girth and abdominal pain x 2 wks. 1) liver failure/ascites: the patient presented with a worsening meld score pushing him further up the transplant list. an abdominal u/s on admission showed good portal and hepatic vein flow without clot, but severe ascites. an mri revealed patent vessels. the plan initially was for large volume paracentesis, however he was found to be in acute renal failure as well (see below), therefore he was given albumin and a diagnostic paracentesis was performed instead. there was no evidence for spontaneous bacterial peritonitis. his diuretics (lasix and aldactone) were held given his acute renal failure, and he unfortunately subsequently experienced steady accumulation of peripheral edema and ascites. his renal failure persisted despite holding lasix, and he was eventually transferred to the sicu for initiation of cvvhd and removal of fluid with lasix drip under a more controlled setting. in the sicu he had a therapeutic paracentesis and received cvvhd with massive improvement in his edema and ascites. he was transferred back to the floors after 3 days in the sicu. his renal function had improved back to baseline by the time of transfer (after a peak of 2.9), and he was therefore able to be restarted on diuretics. it was decided to try bumex rather than lasix, and continue aldactone. his meld remained high because of having received cvvhd, necessitating inpatient monitoring, and his mental status was borderline encephalopathic at times. we continued his lactulose and urosdiol. his meld dropped precipitously once one week out from cvvhd, and he was able to be discharged from the hospital. he was discharged on 1 mg bumex daily, and 50 mg spironolatone , as well as cipro 250 mg for sbp prophylaxis, and lactulose. he will get labs drawn 3 days after discharge, and will call dr. for an appointment. 2) acute renal failure: on admission he was noted to have a marked increase in creatinine from a baseline of 1.2 to 2.7. initially it was thought to be pre-renal from his liver disease and aggressive outpatient diuresis, however his creatinine did not improve with holding diuretics and giving albumin. additionally, he was never oliguric as would be seen with pre-renal failure or hepatorenal syndrome. urine lytes were not reliable in the setting of polyuria. given that hepatorenal syndrome was in the differential, however, he was started on midodrine and octreotide. his creatinine had actually begun to improve prior to transfer to the sicu, down to 2.2, however it was slow and his edema was increasing, therefore he was transfered to the sicu for cvvhd and diuresis. over the three days in the sicu his creatinine dropped precipitously and on transfer back to the floors his creatinine was back to 1.0. his acute renal failure is thought to have been secondary to atn, which has resolved. he was restarted on diuretics, and will need to have his renal function monitored to avoid further episodes of atn (likely secondary to pre-renal state). 3) pna: mr. presented with dyspnea, thought initially to be secondary to his large ascites - he had dullness at the bases of his lungs, with decreased air entry. however, he became progressively hypoxic, to the point where he required up to 2 l to keep his oxygen saturation above 90%, and a repeat cxr suggested bibasilar infiltrates. he was started on levaquin and flagyl, which were changed to vancomycin and zosyn on transfer to the sicu. he had a bal in the sicu which unfortunately didn't have any growth, therefore broad spectrum abx were continued. he completed 10 days of vanco/zosyn, as well as azithromycin for atypical coverage, and his oxygenation improved to baseline (98% on ra). he was discharged on cefpodoxime for 3 days (to complete a total antibiotic course of 14 days). 4) hyponatremia: secondary to liver disease. his hyponatremia resolved with holding diuretics and giving albumin. 5) anemia: his hematocrit has fluctuated greatly over the last few months, generally anywhere between 24 and 33. during the hospitalization it also fluctuated. at one point his hematocrit dropped from 33 to 28, and he did report some hematochezia, so a decision was made to scope. an egd showed possibly a small esophageal varix, and portal hypertensive gastropathy. a colonoscopy showed internal hemorrhoids. his anemia is an anemia of chronic inflammation. 6) fen: given his hyponatremia, he was fluid restricted to 1l. he was maintained on a low na diet. medications on admission: 1. pantoprazole sodium 40 mg tablet 2. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid 3. quinine sulfate 325 mg capsule sig: one (1) capsule po hs 4. multivitamin capsule sig: one (1) cap po daily (daily). 5. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h 6. lasix 40mg daily 7. spironolactone 150mg daily 8. ursodiol 300 mg tid 9. tylenol 500 qid 10. tramadol 50 qid prn pain. discharge medications: 1. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. quinine sulfate 325 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*2* 3. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. tramadol hcl 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 5. lactulose 10 g/15 ml syrup sig: thirty (30) ml po bid (2 times a day): please take enough to have at least 3 bowel movements a day - take more frequently if you are not having enough bowel movements. disp:*1800 ml(s)* refills:*2* 6. bumetanide 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. spironolactone 25 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 8. cefpodoxime proxetil 200 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days: this is an antibiotic for your pneumonia which is almost gone. disp:*6 tablet(s)* refills:*0* 9. outpatient lab work please check cbc, chem7, ast/alt/alp, total bilirubin, pt, ptt, inr. 10. cipro 250 mg tablet sig: one (1) tablet po twice a day: for prevention of infection. disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: acute renal failure secondary to acute tubular necrosis ascites end stage liver disease hepatitis c viral infection bacterial pneumonia discharge condition: improved abdominal pain and renal failure resolved. patient ambulating, having bms, urinating. o2 requirement at baseline. discharge instructions: if you experience any increasing abdominal pain, weight gain of more than a few pounds, increased swelling in your legs, fevers, chills, diziness, feeling as if you are going to pass out you should call dr. office. we changed some of your medications while you were in the hospital and you should take all of your new medications as prescribed. you will finish your course of antibiotics in 3 days - the antibiotic that you are on is called cefpodoxime and you should pick it up at the pharmacy today - 1st dose tonight. make sure that you are having at least 3 bowel movements a day - if you are not having at least 3, please increase the frequency of your lactulose to three times a day or four times a day as necessary. followup instructions: please call dr. office on monday morning to set up an appointment in the next week or two. provider: , md where: lm phone: you will need to get your labs checked this week, on tuesday or wednesday - we have given you a lab slip which you should bring with you to the lab. Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Chronic hepatitis C without mention of hepatic coma Hyposmolality and/or hyponatremia Portal hypertension Other sequelae of chronic liver disease Cocaine dependence, continuous Bacterial pneumonia, unspecified

allergies: morphine attending: chief complaint: recurrent ascites major surgical or invasive procedure: transjugular intrahepatic portosysyemic shunt placement therapeutic paracentesis transesophageal echocardiogram history of present illness: briefly, 38 yo m with a h/o hep c cirrhosis, episode of sbp, s/p liver transplant in , recent admission at for arf in the setting of new diuretic regimen, now transfered from an osh for evaluation of worsening lfts, which developed during a hospitalization for mi. as above the pt was recently admitted to for arf that developed after starting a regimen of lasix. with d/c of lasix, the pt's renal failure had largely resolved at the time of discharge from on . the day following discharge the pt had an episode of severe b/l neck pain that radiated down into his chest, associated with dyspnea. ems was called and pt's pain continued until he was electively intubated for catheterization, given ekg with st elevations in v1-v3. cath revealed a proximally occluded lad that underwent successful pci with a vision stent placed with a good result. pt was extubated on . his lft's were elevated with ast of 345 and alt of 127. the pt was transferred to and was initially admitted to the ccu to ensure cardiac stability. he is now being transfered to the hepatorenal service for further evaluation of his elevated lfts. presently he is denying cp/sob/hps/abdominal pain. he denies n/v. had loose bms last night. past medical history: 1 chronic hepatitis c -> cirrhosis - h/o ascites, encephalopathy, sbp - orthotopic deceased donor liver transplant on - one nodule of hcc found at time of transplant - c/b recurrent hep c after transplant - tx with interferon and ribavirin -> no response - vl 12,600,000 on - ifn, ribavarin d/c on - also c/b biliary anastamotic stricture s/p dilation and stenting - stent removed - liver bx shows recurrent, progressive hep c but no hcc - recurrent ascites 2 h/o hemochromatosis 3 dm2 4 h/o dvt and bilateral pe 5 h/o splenic infarct 6 ho stemi () social history: currently living with his mom. h/o etoh - quit in ' h/o ivdu - quit in ' family history: non-contrib physical exam: temp 98 bp 100/50 pulse 76 resp 20 o2 sat 100% ra gen - alert, no acute distress - extraocular motions intact, anicteric, mucous membranes dry neck - no jvd, no cervical lymphadenopathy chest - diminished breath sounds r base cv - normal s1/s2, rrr, no murmurs appreciated abd - soft, mildly distended, ruq tenderness to deep palpation, normoactive bowel sounds extr - no clubbing, cyanosis, or edema. 2+ dp pulses bilaterally neuro - non-focal skin - no rash pertinent results: 08:19pm glucose-167* urea n-42* creat-1.7* sodium-140 potassium-4.8 chloride-112* total co2-22 anion gap-11 08:19pm alt(sgpt)-115* ast(sgot)-304* ld(ldh)-322* ck(cpk)-29* alk phos-342* amylase-15 tot bili-2.2* 08:19pm lipase-9 08:19pm albumin-2.1* calcium-7.5* phosphate-3.5 magnesium-1.9 08:19pm wbc-4.1# rbc-3.00* hgb-10.1* hct-31.2* mcv-104* mch-33.7* mchc-32.4 rdw-15.6* 08:19pm neuts-64 bands-0 lymphs-20 monos-15* eos-1 basos-0 atyps-0 metas-0 myelos-0 08:19pm plt count-84* 08:19pm pt-14.0* ptt-37.3* inr(pt)-1.2* 04:30am blood wbc-3.9* rbc-3.46* hgb-11.2* hct-33.8* mcv-98 mch-32.4* mchc-33.2 rdw-16.8* plt ct-79* 04:30am blood plt ct-79* 04:30am blood pt-14.4* ptt-40.1* inr(pt)-1.3* 04:30am blood glucose-182* urean-38* creat-1.1 na-139 k-4.7 cl-111* hco3-22 angap-11 04:30am blood alt-138* ast-361* alkphos-351* totbili-2.8* 04:30am blood calcium-7.2* phos-3.5 mg-2.0 09:11pm urine color-amber appear-clear sp -1.018 09:11pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-sm urobiln-0.2 ph-5.0 leuks-neg 12:00pm ascites wbc-248* rbc-3889* polys-1* lymphs-78* monos-18* macroph-3* 12:00pm ascites totpro-1.8 ld(ldh)-141 albumin-1.1 11:01 am peritoneal fluid gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. blood culture pending blood culture aerobic bottle-pending; anaerobic bottle-pending inpatient blood culture aerobic bottle-pending; anaerobic bottle-pending inpatient immunology (cmv) cmv viral load-final negative ___________________ doppler u/s impression: 1) patent hepatic vasculature with unremarkable doppler waveforms. 2) coarsened, heterogeneous appearance of the transplant liver, largely new from , significance uncertain. 3) large amount of ascites; a site was marked in the right lower quadrant for paracentesis. 4) splenomegaly. tte conclusions: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is preserved except for probable mild mid anteroseptal hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. compared with the prior study (images reviewed) of , there is now a mobile echodense structure on the ventricular side of the mitral valve that may represent vegetation. left ventricular systolic function is now minimally depressed. tee : conclusions: 1. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is mildly depressed. 2. mild (1+) mitral regurgitation is seen. 3. no vegetations duplex u/s, : conclusion: fully patent tips with main portal velocity of 39 cm per second and intra tips velocities ranging from 85-143 cm per second. brief hospital course: a/p: 38 yo m s/p liver transplant in , h/o recurrent hepatitis c transferred from osh for eval of elevated lfts s/p mi. . #elevated lfts: chronically elevated since . initially s/p tx pt's ast/alt were normal. however, in were ranging 40s to low 100s. acute bump occured in late . ast/alt have remained on the high 100s to 300s since that time. as this has been a chronic change post transplant, this may be to known recurrence of hep c and/or hemachromatosis. of note, the pt's interferon therapy was discontinued a few weeks ago, but the pt had not appeared to respond to the therapy. more concerning these changes may be associated with rejection. ruq showed patent vasculature, no e/o cirrhosis. pt. was continued on lactulose, and his lfts remained stable throughout his stay. given his recurrent ascites, he was given a paracentesis taking off 3l, which recurred over the next few days, so tips was placed by ir. post, tips, bili rose slightly, but stabilized by discharge with edema and ascites stable. post-tips u/s showed tips patency. . #stemi: pt symptomatically stable, vss on tele throughout his stay without chest pain or shortness of breath. a tte was performed which showed minimally depressed lv function and an echodense structure on the mitral valve worrisome for endocarditis. subsequent tee ruled this out. he was coninued on bb/asa/ticlopidine with no statin, given concurrent liver dz. . #hyperkalemia: pt. was hyperkalemic, peaking at 5.9 in the context of arf. he was placed on a low potassium diet and kayexylate tid with resultant decrease in his potassium. he will require close follow up as outpt. to ensure that he does not develop hyperkalemia. . #arf: early in year, cr 0.7, but had been trending up. baseline prior to previous admissions 1.0-1.1. initially presented a few weeks back with arf in setting of increased diuretics. cr. had been trending down to 1.3 at previous discharge. upon current discharge, cr returned to baseline 1.1, after peaking at 2.0. arf thought to be prerenal vs. hepatorenal vs. contrast during cath/ fk506 toxicity. his urine lytes were consistent with prerenal arf, and gentle fluids and transfusion of 2u helped to return his cr to baseline upon discharge. his fk506 dose was decreased, maintaining level of at trough, given his concurrent renal failure and his diuretics were held throughout his stay. his cr returned to his baseline by discharge. diuretics were not restarted upon discharge . #anemia: hct drop since last d/c to present admit (31 at admission). likely to bleeding at cath site. had hct drop to 28 prior to therapeutic paracentesis, 24 immediately afterwards and received 2u prbcs with correction back to 33. suspect that the hct of have been measurement issue. stools were guaiac negative, and hct was stable for the last few days of his stay. . #ascites/pleural effusions: diminished breath sounds with known r pleural effusions, cxr stable. pt. with increasing ascites as has not been receiving diuretics renal status. received 3.5l therapeutic tap on , with tips done by ir on . post-tips doppler u/s showed patent tips prior to discharge. . #dm2: sugars continued to be high during admission, initially with sugars into the 300s. given recent mi, pt.'s sugars were more aggressively controlled. at discharge he was taking 16u nph (up from 10u on admit) with an increased iss. medications on admission: asa 325mg qd lopressor 12.5mg ticlopidine colace 100mg qd protonix 40mg qd tacrolimus 1mg remeron 15 mg qhs bactrim ds one tab qd sliding scale insulin discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 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:*2* 4. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: take 1 tab sl for chest pain. repeat after 5 minutes x 2. disp:*30 tablet, sublingual(s)* refills:*0* 6. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 7. ticlopidine 250 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(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. hydromorphone 2 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for back pain. disp:*30 tablet(s)* refills:*0* 10. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 11. tacrolimus 0.5 mg capsule sig: one (1) capsule po qam (once a day (in the morning)). disp:*30 capsule(s)* refills:*2* 12. insulin nph human recomb 100 unit/ml suspension sig: sixteen (16) units subcutaneous twice a day: give 16u in am and 16u in pm. disp:*3 bottles* refills:*2* 13. insulin regular human 100 unit/ml solution sig: per sliding scale units injection four times a day: give number of units per sliding scale. disp:*2 qs* refills:*2* 14. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. disp:*27 tablet(s)* refills:*0* 15. lactulose (for encephalopathy) 10 g/15 ml solution sig: thirty (30) mg po three times a day: titrate lactulose to bowel movements per day. disp:*3 qs* refills:*2* discharge disposition: home discharge diagnosis: recurrent ascites s/p liver transplant diabetes mellitus ________________ s/p stemi recurrent hepatitis c discharge condition: good, amblating, afebrile tolerating pos, satting well on ra. discharge instructions: please seek medical attention should you develop any of the following symptoms: increased confusion, lethargy, chest or abdominal pain, shortness of breath, bleeding from your rectum, henatemesis, decreased urine output, or increased abdominal distension. please adhere to a strict low potassium diet (<1g/day) for now until further notified by your pcp. take all medications as prescribed, including your tacrolimus at 0.5mg qday. take your lactulose regularly and titrate it to >3 bowel movements per day. take your ciprofloxacin, the antibiotic for your urinary infection twice a day for two more weeks. it is important to complete this antibiotic course. follow up with dr. at the appt. outlined below next week. have your labs drawn on monday prior to that appointment. followup instructions: please follow up with dr. on wed. at 11:30am to follow up your prograf levels, bilirubin, potassium and creatinine. in conjunction with your cardiologist dr. , he may decide to start you on a statin medication for your cholesterol as you have recently had an mi. please also attend the following appointments: cardiology: dr. 3:00 pm. , , ma . provider: , md phone: date/time: 11:40 Procedure: Diagnostic ultrasound of heart Percutaneous abdominal drainage Other endovascular procedures on other vessels Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Diagnoses: Hyperpotassemia Coronary atherosclerosis of native coronary artery Chronic hepatitis C without mention of hepatic coma Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Acute myocardial infarction of other anterior wall, initial episode of care Percutaneous transluminal coronary angioplasty status Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

discharge medications: fer-in- 0.2 cc daily. follow up: the patient is to be followed up at medical center by dr. . discharge diagnosis: premature male twin 34-35 weeks gestation. , Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Twin birth, mate liveborn, born in hospital, delivered by cesarean section Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Undiagnosed cardiac murmurs

past medical history: 1. cardiomyopathy, nonischemic, diagnosed in with an ef 10-15%. 2. status post cva times two, last one occurring approximately three years ago without any residual symptoms. 3. hyperlipidemia. 4. history of alcohol abuse. 5. cardiac catheterization on at outside hospital showing clean coronary arteries, increased right-sided pressure with ra pressure of 18, pulmonary capillary wedge pressure 23-29, cardiac output 2.3 and index 1.37. 6. hypothyroidism. 7. anxiety. 8. gout. 9. transthoracic echocardiogram on at showed ef 10-15%, left ventricular hypokinesis, anterior septal akinesis, small pericardial effusion. allergies: the patient has an allergy to bactrim. medications on transfer: (same as her home medications.) 1. paxil 25 mg p.o. q.d. 2. synthroid 88 mg p.o. q.d. 3. allopurinol 300 mg p.o. q.d. 4. digoxin 125 p.o. q.d. 5. lasix 10 p.o. q.d. 6. toprol xl 25 mg p.o. q.d. 7. lisinopril p.o. q.d. 8. coumadin 2.5 mg p.o. q.d. 9. aspirin. 10. mevacor 10 mg p.o. q.d. social history: the patient is a retired secretary, lives with her husband who is very supportive and involved in her care. alcohol: she previously drank greater than five glasses of wine per day but has had no alcohol since . she denied any current or remote history of tobacco use. family history: mother died of a myocardial infarct at age 57. maternal uncles all died of myocardial infarct. her cousin had idiopathic cardiomyopathy. physical examination on presentation: vital signs: temperature 102.8, blood pressure 97/60 with inspiration 98/58, heart rate 118, respiratory rate 18, oxygen saturation 96% on 2 liters nasal cannula. general: the patient was in no apparent distress. she was anxious and mildly dishevelled. heent: poor dentition. the extraocular muscles were intact. the pupils were equal, round, and reactive. the oropharynx was clear. neck: supple. no lymphadenopathy. increased jugular venous pulsation to the angle of the mandible. chest: lungs were clear to auscultation bilaterally except for decreased breath sounds at the bilateral bases. cardiovascular: tachycardiac but regular with muffled heart sounds. abdomen: soft, diffuse mild tenderness to palpation. normoactive bowel sounds. extremities: no lower extremity edema. there were no lesions or osler's nodes appreciated. neurologic: she was alert and oriented times three. cranial nerves ii through xii were intact. motor was , symmetric upper and lower extremities. laboratory/radiologic data: white count 13.1 with normal differential and no bandemia, hemoglobin 12.3, hematocrit 36.1, mcv 98, platelets 336,000. pt 15.8, ptt 29.5, inr 1.6. esr 116. sodium 133, potassium 4.4, chloride 96, bicarbonate 24, bun 12, creatinine 1.1, ast 13, alt 6, ldh 198, alkaline phosphatase 112, amylase 70, total bilirubin 0.5, total protein 6.9, albumin 3.1, calcium 9.6, phosphorus 4.1, magnesium 1.9. tsh 6.5, negative, rheumatoid factor negative. crp 10.88, significantly elevated. spep and upep negative. c3 and c4 levels were both within normal limits. digoxin 1.6 and normal. blood cultures: no growth times five sets. ekg on admission showed sinus tachycardia at a rate of 104, normal axis, normal intervals with nonspecific st-t wave abnormalities in v4-v6. impression: this is a 59-year-old female with a history of nonischemic cardiomyopathy with an ef of %, hypertension, history of alcohol abuse who was transferred from an outside hospital after being admitted for a three day history of spiking temperatures, chills, and rigors, found to have a large pericardial effusion. the patient was transferred to for evaluation of pericardial effusion and possible pericardiocentesis. hospital course: 1. pericardial effusion: upon transfer from the outside hospital, the patient was taken directly to the cardiac catheterization holding area where she was found to be hemodynamically stable. a transthoracic echocardiogram was performed while in the cardiac catheterization holding area which was found to show no echocardiographic evidence of tamponade with anterior portions of pericardial fluid loculated an echodense. the remainder of the pericardial fluid is echolucent. the effusion was moderate in size. her blood pressure was checked and she was found to have no evidence of pulsus paradoxus. as she was stable at that point, the decision was made not to proceed with pericardiocentesis and monitor the patient with medical management. she remained hemodynamically stable for the first three days of her hospitalization with heart rate ranging from 90s to low 110s with occasional tachycardia in the 130s to 140s. her blood pressure was in the 90-110/40-60 range which was near her baseline. her oxygenation remained well at 95% on room air. on , hospital day number three, she was taken to the cardiac catheterization laboratory and had a right heart catheterization performed which showed cardiac output of 4.5, cardiac index 2.5, pa pressure of 44/27, and no evidence of equalization of pressures. the pulse was measured in the catheterization laboratory to be 7 mmhg. therefore, it was felt that conservative management of the effusion was appropriate at that time. the following day, the patient became hypotensive with systolic blood pressures in the 60s and was started on dopamine on the floor. after initiation of 5 micrograms per kilogram per minute of dopamine, her blood pressure increased to approximately 85-90 and she was transferred to the cardiac care unit. while in the ccu, a transthoracic echocardiogram was performed which showed early unchanged pericardial effusion which was moderate in size, measuring less than 1 cm inferior to the left ventricle, 1-1.5 cm lateral to the left ventricle, less than 0.5 cm around the lv apex and anterior to the right ventricle and greater than 2 cm anterior to the right atrium. the asymmetric nature of the effusion again suggested loculation. she was weaned off dopamine in the cardiac intensive care unit after a swan-ganz catheter was placed. the swan-ganz catheter measured her wedge pressure to be 20, ra pressure of 17, and svr 730 with an elevated cardiac output of 7.4. this was slightly different from numbers during right heart catheterization the day before. she was off dopamine approximately 12 hours of initiation with stable systolic blood pressures in the 100-120 range. she was transferred back to the cardiology floor in stable condition on after a two day stay in the intensive care unit. on , a ct-guided pericardiocentesis was performed by radiology, at which time 15 cc of fluid was removed. analysis of this fluid showed a total protein of 5.2 and an ldh of 648. there were 0 red blood cells and 3,100 white blood cells which showed 90% neutrophilic predominance. judging by the analysis of the pericardial fluid, it appeared to be exudative in nature and cytology was sent. cytology showed no evidence of malignant cells. afb stain was performed on fluid as well as gram's stain culture, fungal culture, all were found to be negative. the etiology of the pericardial effusion still remains unclear at the time of this dictation. however, it is suspected to be a viral pericarditis/myocarditis; however, the , adenovirus, histoplasmosis serologies were all pending at the time of this dictation. her lyme serology was negative. a mycoplasma igm and igg were both negative as well. on , twenty-four hours after pericardiocentesis, a repeat transthoracic echocardiogram was performed which showed resolution of the pericardial effusion with stable ef of less than 20%. she remained hemodynamically stable after transfer out of the cardiac intensive care unit. 2. nonischemic cardiomyopathy: as described in the history of the present illness, the patient was diagnosed with nonischemic cardiomyopathy in , approximately two months prior to current admission. she was evaluated for a cardiac transplant at that point and was found not to need one at the current time. she has been managed with diuresis at home and just prior to current admission had been doing excellent. cardiac enzymes were cycled during this hospitalization and were negative times three sets. she had some chest discomfort during this hospitalization which was thought secondary to her large effusion rather than ischemia given her normal coronary arteries per cardiac catheterization two months prior. once hemodynamically stable, she was diuresed with 10 mg p.o. lasix with 10 mg iv lasix p.r.n. for the three days prior to discharge, she was felt to be volume overloaded and was run negative with a decrease in her weight of approximately 2 kilograms. at the time of discharge, she was felt to be mildly volume overloaded but back to her baseline. her oxygen saturations were 95% on room air and decreased to 90-91% with ambulation. 3. nsvt: while on the cardiac floor, she was seen by electrophysiology initially for evaluation for pacemaker placement who felt that it was not necessary at this time. they were reconsulted after she had two episodes of nsvt of 15 and 16 beats. she was asymptomatic and denied any palpitations, lightheadedness or shortness of breath during these episodes. her digoxin level, tsh and chemistry panel were checked following these episodes and were found to be within normal limits except for mildly elevated tsh given her hypothyroidism. she was started on amiodarone 400 mg p.o. b.i.d. for which she will complete three weeks of therapy and then switched to 400 mg p.o. q.d. she is being sent out of the hospital on a holter monitor given her initiation of amiodarone. lfts were checked prior to initiation of therapy an were found to be within normal limits. she will follow-up with dr. and possibly electrophysiology once stable on a dose of 400 mg q.d. of amiodarone. 4. infectious disease: the patient had spiking temperatures through the first three to four days of hospitalization to as high as 102.8. she had blood cultures performed on five different occasions and were found to all be no growth. a urine culture was performed when a foley was placed in the intensive care unit and was shown to be contaminated. as she was asymptomatic from a genitourinary point of view, it was not felt that her urine culture was the source of her spiking fevers. the infectious disease team was consulted while she was in the intensive care unit given her swan numbers of increased cardiac output to 7.3 and a decreased svr to around 700 for evaluation of infectious etiology of her pericardial effusion and hemodynamic instability. she was not felt to be septic and the infectious disease team recommended viral serologies for evaluation of the pericardial effusion. she was found to have a negative igg and igm for mycoplasma and a negative lyme titer as well. urine histoplasma antigen was checked as well as a and b and adenovirus which is pending at the time of this dictation. as described above, once pericardiocentesis was performed, pericardial fluid was gram's stain negative, culture negative, and afb negative. therefore, the leading theory for the patient's pericardial effusion was from a viral infection that had not been identified at this time. with the exception of one fever to 100.0 on , five days prior to discharge. the patient remained afebrile for the remainder of the hospitalization. 5. pulmonary: during evaluation for fever of unknown origin, she had a ct scan of her torso which showed enlarged right tracheal lymph node measuring 1.8 by 2.1 cm and multiple other prominent right paratracheal lymph nodes as well as multiple subcentimeter prominent lymph nodes in the perivascular space and the aorticopulmonary window. the pulmonary team was consulted on possible mediastinoscopy and biopsy of the larger right tracheal lymph node to evaluate for lymphoma as an etiology of her pericardial effusion. it was the feeling of the pulmonary team as well as the congestive heart failure team that the lymph nodes were secondary to congestive heart failure and a biopsy was not indicated at this time. she will follow-up with a repeat chest ct approximately two to three weeks after discharge for regression of lymph nodes. if they are still present at that time, she will follow-up with the pulmonary team, dr. , who will perform mediastinoscopy plus biopsy of lymph nodes. she was also noted to have bilateral pleural effusions, right greater than left and given her spiking fevers and unclear etiology of pericardial effusion she was taken to the interventional pulmonary laboratory for possible ultrasound-guided thoracentesis. under ultrasound evaluation, she was found to have less than 1 cm of pleural fluid and, therefore, it was not felt that a thoracentesis was indicated. she did not have the procedure performed and it was felt that her effusions would regress with appropriate diuresis. 7. rheumatology: in evaluation of her pericardial effusions, an esr was checked and was found to be 116 and on repeat was 115. crp was also checked and found to be significantly elevated at 10.88. through workup of systemic rheumatologic disease as a cause of her effusion, she had and rf checked which were both found to be negative. compliment levels were checked and also found to be negative. a ch50 and an ace level are pending at this time to evaluate for sarcoidosis. the rheumatology team was consulted and did not feel given her clinical history and supportive laboratory tests that she had any evidence of systemic rheumatologic disease. her gout remained well controlled on allopurinol 300 mg q.d. 8. endocrinology: tsh was checked and found to be elevated on two separate occasions and, therefore, her synthroid dose was increased from 88 micrograms to 100 micrograms q.d. the increase in her synthroid dose also showed positive effects on blood pressure and heart rate. 9. right shoulder pain: after pericardiocentesis, the patient complained of right shoulder pain which was evaluated by upper extremity ultrasound as this was the location of her central venous catheter while in the intensive care unit. this was found to be negative for deep venous thrombosis. a chest x-ray was performed as well and she had no evidence of elevated hemidiaphragm, ruling out phrenic nerve injury as the etiology of the pain. the pain resolved spontaneously and it was felt that it was most likely positional given her extended period of lying in a decubitus position while in radiology to have the effusion drained. 10. hematology: she was found to have anemia of chronic disease by iron studies. her crit remained stable throughout the hospitalization and she was given 2 units of ffp for an elevated inr. the increased inr was likely secondary to her coumadin which she was taking as an outpatient but was not continued during the hospitalization. she was not sent out on coumadin as her only indication was for cardiomyopathy/decreased ef and cva times two. instead, she was placed on aggrenox for cva prevention and coumadin will not be continued. disposition: the patient was evaluated by physical therapy the day before discharge. it was found that she was safe for discharge to home. she had minor desaturation with ambulation, otherwise, did excellent. discharge diagnosis: 1. pericardial effusion, status post ct-guided drainage, etiology unclear, however, suspect viral source. 2. pleural effusions, likely secondary to congestive heart failure. 3. history of nonischemic cardiomyopathy with ejection fraction 10-14%. 4. mediastinal lymphadenopathy. 5. nonsustained ventricular tachycardia, recently started on amiodarone. 6. hypotension, status post transient dopamine infusion and cardiac intensive care unit admission. 7. transient febrile illness of unclear etiology. 8. hyperlipidemia. 9. hyperthyroidism. 10. history of alcohol abuse. 11. anxiety. 12. gout. discharge medications: 1. paxil 20 mg p.o. q.d. 2. digoxin 0.125 mg p.o. q.d. 3. synthroid 100 micrograms p.o. q.d. 4. allopurinol 300 mg p.o. q.d. 5. lasix 10 mg p.o. q.d. 6. toprol xl 25 mg p.o. q.a.m. 7. lisinopril 2.5 mg p.o. q.h.s. 8. aggrenox one tablet p.o. b.i.d. 9. amiodarone 400 mg p.o. b.i.d. until and then 400 mg p.o. q.d. until instructed to change dose by cardiologist. 10. mevacor 10 mg p.o. q.d. discharge instructions: 1. the patient will follow-up with primary care physician, . , in approximately one to two weeks after discharge. 2. she will follow-up with dr. on . 3. she will have a follow-up ct scan in two weeks for which she will call for a specific appointment time. 4. she is being sent out on the of hearts monitor with instructions provided prior to discharge. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Pericardiocentesis Pulmonary artery wedge monitoring Diagnoses: Other primary cardiomyopathies Unspecified pleural effusion Congestive heart failure, unspecified Unspecified acquired hypothyroidism Other chronic pulmonary heart diseases Systolic heart failure, unspecified Unspecified viral infection Tachycardia, unspecified Acute idiopathic pericarditis

history of present illness: this is a 38-year-old male who was initially admitted on to the intensive care unit after being transferred from where he had a seizure during an electromyogram. after being postictally confused for five minutes, the patient became acutely agitated, went into rapid atrial fibrillation, was given labetalol and lopressor and returned to a sinus rhythm. however, his agitation continued to increase with diaphoresis, confusion, and combativeness. the patient received increasing doses of haldol and ativan and required mechanical restraints. he was transferred to the intensive care unit for intubation to protect his airway during this increasing agitation and confusion. a toxicology screen at that time was positive for cocaine and thc but not alcohol. however, the patient did have a history of heavy binge drinking prior to this episode. in the intensive care unit, the patient was weaned off his ativan drip, changed to a valium taper and a ciwa scale. he was extubated on . also in the intensive care unit, he had a hepatitis screen that showed him positive for hepatitis c antibody and negative hepatitis a or hepatitis b antibodies. he grew out hemophilus influenza from his sputum and received three days of levofloxacin and flagyl, but he had no other respiratory complaints, and these were discontinued. the patient was then transferred to the floor to the team after his extubation and decreased agitation. at that time, he had no agitation. no fevers, chills, shortness of breath, tremulousness, abdominal pain, or diarrhea. past medical history: 1. alcohol abuse. 2. right calcaneal fracture. allergies: no known drug allergies. medications on admission: protonix and ativan drip on transfer from . medications on transfer: (medications on transfer on the floor) 1. subcutaneous heparin. 2. ativan as needed; ciwa scale. 3. multivitamin. 4. haldol 2.5 mg p.o. twice per day and 2.5 mg p.o. as needed. 5. valium 5 mg p.o. three times per day (standing dose). 6. thiamine. 7. folate. social history: the patient formerly drank two to three drinks per night but recently increased this to 10 drinks per day in the preceding week. he is a construction worker. he smokes half a pack of tobacco per day. family history: mother died of cancer of unknown type at the age of 37. physical examination on presentation: physical examination revealed temperature maximum was 99, temperature current was 98.6, heart rate was 57 to 79, blood pressure was 100 to 135/56 to 80, respiratory rate was 15 to 27, and oxygen saturation was 96% on room air. in general, he had slurred speech but was pleasant. head, eyes, ears, nose, and throat examination revealed extraocular movements were intact. pupils were equal, round, and reactive to light and accommodation. mucous membranes were moist. chest revealed equal rhonchi throughout. cardiovascular examination revealed bradycardic. normal first heart sounds and second heart sounds. no murmurs, gallops, or rubs. the abdomen revealed normal active bowel sounds. nontender and nondistended. no organomegaly. extremity examination revealed no clubbing, cyanosis, or edema. pertinent laboratory values on presentation: laboratories on transfer revealed white blood cell count was 4.5, hematocrit was 35.2, platelets were 159, and mean cell volume was 93. sodium was 139, potassium was 3.8, chloride was 103, bicarbonate was 27, blood urea nitrogen was 5, creatinine was 0.7, and blood glucose was 105. magnesium was 1.7, calcium was 9.2, and phosphorous was 3.7. human immunodeficiency virus test was negative. hepatitis qualitative rna was pending. hepatitis c antibody positive. alt was 31, ast was 36, and total bilirubin was 1.1. albumin was 3.7. pertinent radiology/imaging: electrocardiogram revealed sinus bradycardia at 57. qtc was 457, and this normalized upon discharge to 407. assessment: this is a 38-year-old male with alcohol withdrawal seizures and a new diagnosis of hepatitis c. hospital course by issue/system: 1. alcohol withdrawal issues: the patient was weaned off his valium. his alertness increased as he was weaned off the benzodiazepines. he was to follow up with his primary care doctor and said he would attend alcohol anonymous meetings. 2. hepatitis c issues: this is a new diagnosis. the patient had his hepatitis a and hepatitis b immunization. he will need two more hepatitis b immunizations. his liver function tests were not elevated, and his liver function of albumin and inr were within normal limits. he was to follow up with his primary care doctor for further treatment plans for his hepatitis c. 3. hematologic issues: the patient had a mild anemia and thrombocytopenia; most likely consistent with his alcohol abuse. he had a borderline macrocytic. discharge disposition: the patient was to be sent home to . discharge instructions/followup: the patient was to follow up with his primary care doctor. he stated he would attend alcohol anonymous. medications on discharge: he was to be sent home on thiamine, folate, multivitamin, and a nicotine patch. discharge diagnoses: 1. alcohol withdrawal seizures requiring intubation. 2. hepatitis c. condition at discharge: condition on discharge was good. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Chronic hepatitis C without mention of hepatic coma Other, mixed, or unspecified drug abuse, unspecified Atrial fibrillation Other convulsions Alcohol abuse, unspecified Cocaine abuse, unspecified Alcohol withdrawal

past medical history: 1. hypertension. 2. diabetes mellitus, noninsulin-dependent. 3. hypercholesterolemia. 4. gout. 5. peripheral vascular disease. 6. known right iliac artery aneurysm. 7. history of complete heart block, status post permanent pacer insertion. 8. elevated psa. 9. status post aaa repair in . 10. status post cholecystectomy. 11. status post right inguinal hernia repair. 12. history of left elbow bursitis. 13. status post right fem-. social history: the patient has a history of remote tobacco abuse. he lives with his sister in . he admits to a minimal amount of etoh use. allergies: streptokinase. admission medications: 1. lopressor 50 mg p.o. t.i.d. 2. vasotec 10 mg q.a.m., 5 mg q.p.m. 3. norvasc 2.5 mg p.o. q.d. 4. pravachol 40 mg p.o. q.d. 5. digoxin 0.25 mg p.o. q.d. 6. lasix 40 mg p.o. q.o.d. 7. enteric coated aspirin 325 mg p.o. q.d. 8. plavix 75 mg p.o. q.d. 9. vitamin e. 10. nitroglycerin p.r.n. 11. glucophage 500 mg p.o. q.p.m. 12. probenecid 125 mg p.o. b.i.d. hospital course: the patient was admitted to the and underwent preoperative evaluation for cardiac surgery. he had electrophysiology consult to evaluate his pacemaker which was functioning properly. he underwent a dental evaluation which showed that he had no problems that would put him at risk for cardiac surgery or aortic valve replacement. the patient had an ultrasound of his carotid arteries which showed no significant stenosis. on, the patient was taken to the operating room with dr. . the patient underwent an aortic valve replacement with a 23 mm - pericardial valve as well as a cabg times one with svg to om. in the operating room, a transesophageal echocardiogram showed that the patient's ejection fraction was 20-25%. the patient was transferred to the intensive care unit on low-dose epinephrine infusion and propofol. total cardiopulmonary bypass time was 132 minutes, cross-clamp time 100 minutes. the patient was weaned and extubated from mechanical ventilation on his first postoperative evening. the patient's hemodynamics as well as his cardiac index remained good. the epinephrine was weaned to off on postoperative day number one with continued good hemodynamics. the patient was started on captopril for afterload reduction. on postoperative day number one, the electrophysiology service interrogated the patient's internal pacemaker which showed that it continued to function appropriately after bypass surgery. on postoperative day number two, the patient was noted to have mild thrombocytopenia. heparin dependent antibodies were sent to the laboratory which were subsequently negative. on postoperative day number two, the patient was transferred from the intensive care unit to the regular part of the hospital. the patient began ambulating with physical therapy. the patient had complaints of right scapular and back pain which the patient had previously and this pain responded well to percocet. the patient was started on lasix for diuresis. on postoperative day number three, the patient was noted to have an elevated white blood cell count. all of his incisions looked fine without erythema or drainage. blood, urine, and sputum cultures were sent. the patient was also noted to have a rising creatinine. the patient's baseline creatinine was thought to be 1.1 to 1.5. the patient's creatinine on postoperative day number three rose to 1.6. the patient's captopril was discontinued as this was thought to be the likely source. repeat laboratory studies later on postoperative day number three showed that the patient had a rising potassium up to 5.6. the patient was given one dose of kayexalate and subsequently the patient's potassium returned to . also, the laboratory studies on postoperative day number three, the patient's white blood cell count which had been 16 had risen to 19 with a left shift. the patient's urinalysis showed positive blood, positive protein, small leukocyte esterase, red blood cells, and many bacteria. the patient was started on levofloxacin for a presumed urinary tract infection. on postoperative day number four, the patient's repeat liver function tests which on postoperative day number three had been only mildly elevated, had risen significantly with ast that had risen to 1,260 from 264, alt 2,002 from 279. a gi consult was obtained and the patient's medications that were thought to be the most likely culprits were discontinued. the patient had his probenecid, pravastatin, his levofloxacin discontinued and because of the patient's multiple ongoing issues it was elected to transfer the patient back into the intensive care unit for closer monitoring. as the day progressed on postoperative day number four, the patient began complaining of increasing nausea and right upper quadrant pain. a right upper quadrant ultrasound performed at the bedside showed normal flow within the portal and hepatic veins. the common bile duct was within normal limits without evidence of choledocholithiasis. the gallbladder was found to be absent. the hepatology service felt that the most likely cause of the transaminitis was medication. the patient had liver function tests followed daily after that and they continued to trend down thereafter. the patient's inr which had risen to 1.5 to 1.6 proceeded to decrease to 1.3. the patient also had a transthoracic echocardiogram performed which showed an ejection fraction of 15-20%, normal left ventricular wall thickness, mildly dilated left ventricular cavity, normal right ventricular wall thickness, normal right ventricular chamber size, 1+ mitral regurgitation, 2+ tricuspid regurgitation, a normally functioning aortic bioprosthetic. overall, it was felt to be not significantly changed from preoperatively. the patient's urinary tract infection which had initially been treated with levofloxacin was subsequently treated with iv ceftriaxone as levofloxacin was potentially one of the medications that was contributing to the elevated transaminases. the patient's creatinine began to decrease and the patient's white blood cell count began to decrease as well on the antibiotics. by postoperative day number eight, the patient had stabilized. the acute transaminitis was resolving and the patient was transferred back from the intensive care unit to the regular part of the hospital. on postoperative day number nine, the patient worked with physical therapy and was able to complete a level v which included walking 500 feet and climbing one flight of stairs without difficulty without requiring oxygen and remaining hemodynamically stable. the hepatology service on postoperative day number nine still did not have a clear etiology of the elevated liver function tests; however, they recommended that the patient follow-up with his primary care physician as an outpatient for monitoring of his liver function tests as well as checking , afp, a ferritin, a tibc, and ama. over this period of time, the patient continued to complain of symptoms of reflux. the patient has a history of reflux disease and with his elevated liver function tests, his h2 blocker and proton pump inhibitor were discontinued. the patient was medicated with maalox which had good effect. the patient was started on carafate for stress ulcer prophylaxis. on postoperative day number ten, the patient's pacer wires were removed without difficulty. on postoperative day number 11, the patient was noted to have edematous bilateral lower extremities with his right leg greater than his left. his right leg was the site of his saphenous vein harvest; however, the patient complained of significant calf tenderness and cramping when he was walking. it was decided to perform a right lower extremity ultrasound to rule out dvt. this was negative for any clot and the patient was noted to have small bilateral pleural effusions on chest x-ray. the patient was given a dose of iv lasix with prompt response for large amounts of urine output and decrease in the edema in his lower extremities. byperative day number 11, the patient was cleared for discharge to home; however, on his laboratory examination on postoperative day number 11, the patient was noted to have a slightly more elevated white blood cell count of 16.9. the patient's white blood cell count had been remaining in the mid teens range. this was elevated from the prior day at 13.8. this was discussed with dr. and dr. examined the patient. the patient had been afebrile, felt well, and had wanted to go home. it was decided that the patient would be pan cultured and would be discharged to home with strict instructions to return to the hospital if he had any evidence of fever or felt unwell and the cultures would be followed for any evidence of infection. the patient's urinalysis showed occasional bacteria, no white blood cells, no leukocyte esterase, essentially negative for a urinary tract infection. the patient's blood cultures are pending at this point. the patient's chest x-ray showed continued small bilateral pleural effusions. therefore, the patient is cleared for discharge to home. condition on discharge: t maximum 97.8, pulse 73, asensed v paced, blood pressure 134/80, respiratory rate 18, room air oxygen saturation 94%. white blood cell count 15.9, hematocrit 32.5, platelet count 253,000. potassium 4.5, bun 30, creatinine 1.1. ast 37, alt 243, alkaline phosphatase 72, ldh 30, amylase 122, lipase 17. the patient was awake, alert, and oriented times three, neurologically nonfocal, ambulating without difficulty. the heart revealed a regular rate and rhythm without rub or murmur. the lungs revealed that breath sounds were clear bilaterally, decreased at the posterior bases. no wheezes, rhonchi, or rales noted. the patient does not have a productive cough. the abdomen revealed normoactive bowel sounds, soft, nontender to light or deep palpation, nondistended. the patient was tolerating a regular diet and having regular bowel movements. sternal incision revealed that the steri-strips were intact. the incision was clean and dry. there was no erythema or drainage. the sternum was stable. the patient has bilateral trace to 1+ pitting edema of the right lower extremity vein harvest site. steri-strips were intact. the incision was clean and dry without erythema or drainage. disposition: the patient is to be discharged to home in stable condition. discharge diagnosis: 1. coronary artery disease and aortic stenosis. 2. status post aortic valve replacement and coronary artery bypass graft. 3. history of complete heart block with permanent pacer insertion. 4. postoperative transaminitis, now resolving. 5. postoperative urinary tract infection. 6. persistent postoperative leukocytosis. 7. chronic renal insufficiency. discharge medications: 1. enteric coated aspirin 325 mg p.o. q.d. 2. digoxin 0.125 mg p.o. q.d. 3. plavix 75 mg p.o. q.d. 4. norvasc 2.5 mg p.o. q.d. 5. oxycodone 5 mg p.o. q. four to six hours p.r.n. 6. lopressor 100 mg p.o. b.i.d. 7. lasix 20 mg p.o. b.i.d. times ten days. 8. potassium chloride 10 meq p.o. b.i.d. times ten days. 9. carafate 1 gram p.o. q.i.d. 10. colace 100 mg p.o. b.i.d. 11. calcium carbonate 500 mg p.o. q.d. 12. glucophage 500 mg p.o. q.d. the patient is to be discharged home in stable condition. fop: the patient is to follow-up with his primary care physician, . .................... in one week for repeat laboratory evaluation of his postoperative transaminitis. the patient is to follow-up with his cardiologist, dr. , in one to two weeks. the patient is to follow-up with dr. in two weeks. the patient is to return to the floor in one week for a wound check. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Diagnoses: Other primary cardiomyopathies Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome 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 Aortic valve disorders

allergies: compazine / promethazine / tylox / demerol attending: chief complaint: esrd major surgical or invasive procedure: status post livng related kidney transplant history of present illness: 46-year-old, caucasian lady with a long and complicated history. in brief, she has had two prior deceased donor kidney transplants. the first one was in for rapidly progressing glomerulonephritis which was lost due to acute rejection. she had a subsequent transplant in which recently failed and she has been back on hemodialysis for approximately two months via a perm cath past medical history: -type a aortic dissection -colon resection secondary to diverticulitis and colostomy which has been closed -multiple cvas with residual right-sided weakness and slurred speech. -she has had numerous skin cancers requiring resection -bilateral reductive mastectomy, -osteoporosis, hyperparathyroidism, and hypertension social history: she has a history of smoking for about 10 years. she smokes approximately one pack per month physical exam: general: no acute distress, awake, alert and orient to time person and place heent: eomi, peerla, neck supple, clear oropharynx cardio: rrr lungs: cta b/l abd: soft, non-tender, positive bowel sounds pertinent results: 09:24pm urine color-straw appear-clear sp -1.013 09:24pm urine blood-lg nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 09:24pm urine rbc-* wbc-0 bacteria-few yeast-none epi- 06:20pm glucose-102 urea n-52* creat-6.2*# sodium-141 potassium-4.6 chloride-104 total co2-21* anion gap-21* 06:20pm calcium-9.3 phosphate-5.6* magnesium-2.4 06:20pm plt count-261 06:20pm wbc-9.6 rbc-5.02 hgb-14.6 hct-44.6 mcv-89 mch-29.1 mchc-32.8 rdw-18.8* 06:20pm pt-19.0* ptt-30.0 inr(pt)-2.5 brief hospital course: pt was admitted for elective living donor kidney tranplant. procedure was performed by dr. . please see operative note for details. patient tolerated procedure well and had an uneventful recovery in pacu. patient was subsequently tranfered to the transplant floor on . her postoperative course went as expect acheiving goals of adequate urine output, good po intake, out of bed and ambulating with good pain control. on postoperative day 7 discharge plans were discussed with patient after appropiate education for wound care and medication administration was given by nursing staff. after stable postoperative course it was agreed by supervising attending and patient that discharge would take place on the pending appropiate fk level. patient was discharged with a fk level 4.9 up from <1.5 the previuos day. she is d/c with appropiate followup appointment and medication. discharge medications: 1. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). disp:*14 tablet(s)* refills:*2* 2. valganciclovir 450 mg tablet sig: one (1) tablet po daily (daily). disp:*7 tablet(s)* refills:*2* 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:*2* 4. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). disp:*600 ml(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 7. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*7 tablet(s)* refills:*2* 8. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. disp:*14 tablet(s)* refills:*0* 9. prednisone 5 mg tablet sig: five (5) tablet po once (once) for 1 doses. 10. prednisone 5 mg tablet sig: five (5) tablet po once (once) for 1 doses. 11. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 12. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed. disp:*25 capsule(s)* refills:*0* 13. labetalol 100 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 14. warfarin 1 mg tablet sig: one (1) tablet po hs (at bedtime). 15. tacrolimus 1 mg capsule sig: two (2) capsule po bid (2 times a day) for 2 doses. discharge disposition: home discharge diagnosis: esrd discharge condition: stable discharge instructions: call dr. office if fevers, chills, nausea, vomiting, inability to take medication, increased abdominal pain, increased redness, drainage, or bleeding from incision. shower no driving while taking pain medication no heavy lifting followup instructions: provider: , md phone: date/time: 10:10 provider: , md phone: date/time: 10:00 provider: , md phone: date/time: 10:50 Procedure: Other kidney transplantation Continuous intra-arterial blood gas monitoring Transplant from live related donor Diagnoses: End stage renal disease Tobacco use disorder Unspecified essential hypertension Paroxysmal ventricular tachycardia Personal history of other malignant neoplasm of skin Osteoporosis, unspecified Late effects of cerebrovascular disease, aphasia Family history of malignant neoplasm of breast Personal history of other diseases of digestive system

history of present illness: this is a 49-year-old hiv positive man with a history of mitral valve disease followed over the years, last echo showing an ef of 60 percent with an lv that was moderately dilated and trace ai (aortic insufficiency), moderate to severe mitral prolapse and 4+ mr (mitral regurgitation) and trivial tr (tricuspid regurgitation). a cardiac mr done in showed an ef of 61 percent with an effective forward ef of 40 percent, bileaflet mitral valve prolapse with moderately severe mr, moderately enlarged left and right atriums. the patient reports that he has been asymptomatic and is feeling well. he has a history of hypertension, hiv and mitral valve disease. no known drug allergies. medications: sustiva 600 q.day, neurontin 300 q.day, epival 300 q.day, diovan 80 q.day, pepcid p.r.n., albuterol p.r.n. and viread 300 mg q.day. social history: single, lives alone. works in fund raising. physical exam: height 6 feet, 3 inches, weight 195 pounds. general: in no acute distress. neurologic: alert and oriented x3. moves all extremities. nonfocal exam. respiratory: clear to auscultation bilaterally. cardiac: s1-s2. there is a diastolic murmur. abdomen: soft, nontender, nondistended with normal active bowel sounds. extremities: warm and well-perfused with no edema or varicosities. laboratory data: white count 7, hematocrit 38.6, platelets 148, sodium 141, potassium 5.1, chloride 104, co2 31, bun 14, creatinine 1.0, glucose 71. chest x-ray showed no evidence of acute pulmonary disease. urinalysis was negative. following catheterization, the patient was discharged to home and scheduled to return as an outpatient for minimally invasive repair of mitral valve, as stated. the patient is a direct admission to the operating room. please see the or report for full details and summary. he had a minimally invasive mitral valve repair with a no. 32 - annuloplasty band. he tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was in a sinus rhythm at 70 beats per minute with a mean arterial pressure of 62 and a cvp of 14. he had propofol at 40 mics/kilogram/minute and epinephrine at 0.03 mics/kilogram/minute. the patient did well in the immediate postoperative period. his anesthesia was reversed. he was weaned from the ventilator and successfully extubated. on postoperative day 1, the patient remained hemodynamically stable. he was weaned from all iv cardioactive medications, transitioned to oral medications, all central lines were removed, as was his foley catheter and he was transferred from the cardiothoracic intensive care unit to 52 for continuing postoperative care and cardiac rehabilitation. additionally on postoperative day 1, the patient's chest tubes were removed. over the next 2 days, the patient's activity level was increased with the assistance of the nursing staff as well as physical therapy staff. he otherwise had an uneventful postoperative course. on postoperative day 3, it was decided that the patient was stable and ready for discharge to home. at the time of this dictation, the patient's physical exam is as follows: vital signs temperature 98.9, heart rate 67 sinus rhythm, blood pressure 95/52, respiratory rate 18, o2 sat 94 percent on room. weight preoperatively 89 kg, at discharge is 96.9 kg. physical exam: general: no acute distress. neurologically alert and oriented x3. moves all extremities. follows commands. nonfocal exam. pulmonary: clear to auscultation bilaterally. cardiac: regular rate rhythm, s1-s2 with no murmur. incision is a right thoracic minimally evasive incision with steri-strips, is open to air, clean and dry without erythema or drainage. abdomen: soft, nontender, nondistended with normal active bowel sounds. extremities: warm and well-perfused with no edema. the patient is to be discharged to home with visiting nurses. condition at time of discharge: good. fop: in the clinic in 2 weeks and with dr. in 4 weeks. discharged diagnoses: 1. mitral regurgitation, status post minimally invasive mitral valve repair with a no. 32 - annuloplasty band. 2. hypertension. discharge medications: include aspirin 81 mg q.day, colace 100 mg b.i.d., neurontin 300 mg q.day, percocet 5/325 1-2 tablets q. h. p.r.n., ibuprofen 800 mg q.8 h., metoprolol 25 mg b.i.d, epival 300 mg q.day, sustiva 600 mg q.day, and viread 300 mg q.day. , m.d. Procedure: Open heart valvuloplasty of mitral valve without replacement Diagnoses: Mitral valve disorders Unspecified essential hypertension Human immunodeficiency virus [HIV] disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: st segment elevation myocardial infarction major surgical or invasive procedure: heart catheterization x2 mechanical ventilation intraaortic balloon pump thransvenous pacermaker wire history of present illness: 72 year old man dm2, htn, hyperlipidemia, a-fib (but not taking coumadin for the past week), asd, h/o pe s/p ivc filter placement, mild lv global dysfunction, mod mr, mild rv dysfunction, developed dizziness starting 8am (no chest pain). went to osh er at 10:45 am- by this time symptoms resolved. found to have st elevation in inferior leads with reciprocal changes in in av1 and avl, anterior leads. bp 90's hr 60's in a-fib. eta 30 minutes (from hospital). cath reealed multivessesl sx- midlad 80%, d1 80-90%, mlcx 95-99%, mrca 100%. c- decided not to take to or related to prior sternotomy and chronic venous disease. in ccu- bradycardic , hypotensive --> pea arrest--> fluids/dopamine--> hypertensive and tachy --> vtach--> lidocaine --> bp high, svt --> pt was coded for > 1hr --> taken back to cath lab--> rec'd three rca stents, iabp, transvenous pacer. past medical history: 1. chronic afib/aflutter 2. asd s/p repair 3. htn 4. hypercholesterolemia 5. dmii 6. previous dvt w/ recurrent pe; s/p filter placement in c/b migration and urgent sternotomy w/ repair of atrial perforations x2 7. recurrent le venous stasis ulcers s/p failed skin grafts to site social history: he lives with his sister and brother-in-law. formerly worked for . denies alcohol, drug, or tobacco use. family history: n/c physical exam: gen: critically ill, unresponsive heent: vomiting cards: irregular distant sounds pulm: diffusely rhoncorous, on vent abd: soft, no hsm extrem: hemosideran deposition anterior tibia b. pertinent results: 03:00pm pt-16.9* ptt-62.2* inr(pt)-1.6* 03:00pm glucose-126* urea n-19 creat-1.3* sodium-138 potassium-4.6 chloride-104 total co2-26 anion gap-13 05:30pm hypochrom-1+ anisocyt-normal poikilocy-1+ macrocyt-1+ microcyt-normal polychrom-normal ovalocyt-1+ 05:30pm wbc-20.3*# rbc-3.55* hgb-11.1* hct-33.9* mcv-96 mch-31.4 mchc-32.9 rdw-16.0* 09:42pm wbc-21.1* rbc-3.31* hgb-10.5* hct-29.6* mcv-89# mch-31.8 mchc-35.6* rdw-16.3* 09:42pm ck-mb-196* mb indx-12.0* ctropnt-10.02* 09:54pm lactate-2.7* 09:54pm type-art po2-169* pco2-38 ph-7.43 total co2-26 base xs-1 echocardiogram conclusions: the left atrium is moderately dilated. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed. resting regional wall motion abnormalities include inferior akinesis and inferolateral hypokinesis (estimated ejection fraction ?40%). the right ventricular cavity is dilated. right ventricular systolic function appears depressed. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic root is mildly dilated. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared to the prior study of , findings are similar. aortic regurgitation now may be slightly more prominent. cardiac catheterization comments: 1) initial angiography was unchanged from previous catherization. the rca had a 100% mid vessel occlusion with collaterals to the distal vessel from the left system. the lad and cx had high grade lesions. 2) successful ptca, thrombectomy, and stenting of the distal, mid, and ostial rca with multiple cypher stents. a 2.75x16 mm taxus was deployed in the distal rca and was postdilated with a 2.75 mm nc balloon. overlapping 3.0x16 mm and 3.5x28 mm taxus stents were placed in the mid rca and the 3.5 mm stent was postdilated with a 3.5 mm nc balloon. a 3.5x16 mm taxus stent was placed in the ostial rca and postdilated with a 4.0 mm nc balloon. final angiography revealed <10 % residual stenosis, no dissection, and timi 3 flow. (see ptca comments) 3) successful placement of an iabp and transvenous pacemaker given the bradycardic arrest and cardiogenic shock. 4) resting hemodynamics revealed severely elevated right and left sided filling pressures, moderate pulmonary hypertension, and normal cardiac outputs. final diagnosis: 1. three vessel coronary artery disease. 2. cardiogenic shock with severely elevated left and right sided filling pressures with normal cardiac outputs on iabp support. 3. acute inferior myocardial infarction, managed by acute ptca, temporary pacemaker, and iabp. 4. ptca of rca vessel with multiple drug eluting stents. brief hospital course: 72yo m with multiple cardiac risk factors presented with stemi, found to have 3vd awaiting cabg, became hd unstable, coded > 1hr, brought back to cath lab and received four taxus stents to rca. patient was stabilized in the ccu on two pressors, intraortic balloon pump and transvenous pacer wire. these were all weened over the course of 4 days. through discussions of risks and benefits with ct surgery, the patient's family, and primary cardiologist dr. it was decided to not undergo cabg for multivessel disease. the family decided on dnr/dni code status at that time. with the patient stable off iabp and pressors he was extubated on however developed pulmonary edema and increased oxygen requirement. was placed on bipap as temporizing measure. further discussion with family confirmed dnr/dni status, and they later decided to make the patient comfort measures only. morphine drip was titrated for comfort and air hunger. the patient was pronounced dead at 11:25am on . medications on admission: sotalol 80 po tid amlodipine 5mg daily coumadin glyburide 2.5 po twice daily fosamax zestril 5 lipitor 10 hctz 25 tamsulosin 0.4 discharge medications: n/a discharge disposition: expired discharge diagnosis: st elevation mi discharge condition: pt expired Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Left heart cardiac catheterization Insertion of endotracheal tube Non-invasive mechanical ventilation Insertion of temporary transvenous pacemaker system Implant of pulsation balloon Other conversion of cardiac rhythm Transfusion of packed cells Transfusion of other serum Insertion of drug-eluting coronary artery stent(s) Infusion of vasopressor agent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Insertion of four or more vascular stents Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Peripheral vascular disease, unspecified Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Cardiac arrest Cardiogenic shock Acute myocardial infarction of inferolateral wall, initial episode of care Personal history of venous thrombosis and embolism Acute systolic heart failure Hematemesis

allergies: lidocaine (anesthetic) / procanbid / quinidine / relafen attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 84 yo m with h/o cad s/p cabg 22yrs ago, s/p multiple pci's, chf w/ ef 20%, s/p icd, dm, htn, hypercholesterolemia, prostate ca, diverticulitis. presented to osh with non-radiating cp at rest/n/diaphoresis/sob. ecg w/ 1mm ste in inferior leads in setting of lbbb. transfered from to for pci and further medical management. past medical history: 1.cad s/p cabg 22yrs ago, 2.s/p multiple pci's, 3.chf w/ ef 20%, 4.s/p icd, 5.dm, 6.htn, 7.hypercholesterolemia, 8.prostate ca, 9.diverticulitis. social history: no tob, no etoh, no ivdu physical exam: t98 bp101-107/63-78 p77 98%ra gen-looks weel heent-unremarkable cvs-nl s1/s2, no s3/s4/murmur, no pedal edema, jvp flat, dp 1+ bilaterally resp-ctab gi-nl bs, benign pertinent results: 07:30am blood wbc-13.3* rbc-3.56* hgb-11.3* hct-34.8* mcv-98 mch-31.7 mchc-32.4 rdw-14.3 plt ct-290 07:59am blood hypochr-1+ anisocy-occasional poiklo-2+ macrocy-2+ microcy-normal polychr-normal burr-2+ acantho-1+ 07:30am blood plt ct-290 07:30am blood pt-14.0* ptt-25.5 inr(pt)-1.2 07:30am blood glucose-90 urean-47* creat-1.5* na-140 k-5.0 cl-105 hco3-25 angap-15 03:27am blood ck(cpk)-324* 03:27am blood ck-mb-19* mb indx-5.9 03:30am blood ck-mb-82* mb indx-7.8* 06:45pm blood ck-mb-184* mb indx-11.3* 10:00am blood ck-mb-279* mb indx-17.3* ctropnt-8.12* 07:30am blood mg-2.4 08:45am blood vitb12-1230* folate-19.9 10:00am blood triglyc-59 hdl-45 chol/hd-3.4 ldlcalc-98 02:36pm blood type-mix po2-31* pco2-43 ph-7.41 calhco3-28 base xs-0 02:36pm blood lactate-1.8 brief hospital course: 1. cad on admission, mr. was taken to cardiac cath on showed three vessel cad. the left main stent was widely patent. the lad was chronically occluded proximally. the left circumflex stent was widely patent. the large lower pole of the om1 was totally occluded by thrombus. the rca had 60% proximal isr which appeared unchanged from one year ago. the rca was chronically totally occluded distally and appeared unchanged. the svg-lad was known to be occluded and was not injected. successful ptca/stenting of the large om1 (lower pole). resting hemodynamics demonstrated markedly elevated filling pressures and low cardiac output, conistent with cardiogenic shock. mean ra pressure was 16 mm hg and mean pcw pressure was 37 mm hg. moderate pulmonary hypertension was present. an intra-aortic balloon pump was placed and patinet observed in ccu. he was weaned off balloon pump within 24 hours.he initially required dobutamine but was weaned on . he was subsequently transferred to the floor with stable vitals.he was continued on asa, plavix, statin, acei and lipitor 2. chf echocardiogram done on showed ef 15-20%, dilated and elongated, ra mod dilated, akinesis of most of the wall with relative sparing of the lateral wall, rv mildly dilated, trace ar, mod tr, mod pah patient was on ace and decreased digoxin to 0.0625. his digoxin level was 1.1 3. rhythm patient has runs of vt with icd in place. these episodes were not associated with symptoms. 4.gi he initially had some diarrhea. c diff toxin was sent and was negative 5. pscyh according to patient, he has suicidal ideation eg. taking whole bottle of digoxin and has very sad affect. in house psychiatry evaluation did not show the need for sitter. however, they recommended psychiatry evaluation at the rehabilitation center. patient also refuses to take plavix although the importance had been repeatedly stressed medications on admission: lopressor, digoxin, lasix, aspirin, lisinopril, oral hypoglycemic . discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 2. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day) for 30 days. 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. atorvastatin calcium 40 mg tablet sig: two (2) tablet po qd (once a day). 5. digoxin 125 mcg tablet sig: 0.5 tablet po qd (once a day). 6. betaxolol hcl 0.25 % drops, suspension sig: one (1) drop ophthalmic (2 times a day). 7. captopril 25 mg tablet sig: one (1) tablet po tid (3 times a day). 8. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 11. glipizide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 12. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). discharge disposition: extended care facility: of discharge diagnosis: unstable angina chf discharge condition: chest pain free discharge instructions: please return to the hospital or call your doctor if you have chest pain or if there are any cnoncerns at all please take all the medication prescribed to you especially the medication called "plavix". it is absolutely critical that you do not stop plavix in order to prevent the stent in your heart from forming clots. followup instructions: provider: clinic where: cardiac services phone: date/time: 2:30 please call dr. at to make an appointment upon your discharge from rehab Procedure: 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 Implant of pulsation balloon Diagnoses: 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 Coronary atherosclerosis of autologous vein bypass graft Cardiogenic shock Acute myocardial infarction of other inferior wall, initial episode of care Other complications due to other cardiac device, implant, and graft Diarrhea

allergies: lidocaine (anesthetic) / procanbid / quinidine / relafen attending: chief complaint: weakness major surgical or invasive procedure: none history of present illness: mr. is an 84 yo gentleman with a significant cardiac history including a recent admission of which he was taken to cardiac cath on with ptca/stenting and admitted to the ccu for cardiogenic shock. echocardiogram done on showed ef 15-20%, dilated and elongated, ra mod dilated, akinesis of most of the wall with relative sparing of the lateral wall, rv mildly dilated, trace ar, mod tr, mod pah. patient had runs of vt with an icd in place. the episodes were not associated with symptoms. furthermore on that admission, according to patient, he had suicidal ideation eg. taking whole bottle of digoxin and had very sad affect. in house psychiatry evaluation did not show the need for sitter. however, they recommended psychiatry evaluation at the rehabilitation center. he was discharged to a nursing home on . he has had a decreased appetite and nausea since discharge and has not had anything to eat in 4 days, but complains of increased thirst. he was been feeling very weak and tired. he has had frequent loose stools througout the week which stopped yesterday. he also had three episodes of syncope while sitting in a chair at the rehab facility; denies any pre-syncopal sequelea including lightheadedness, palpitations, vision changes, nausea, chest pain, or shortness of breath. he has baseline shortness of breath that has been unchanged. he says he never experiences chest pain, but did feel 'like someone was sitting on me' before his last admission. he has not had that feeling in the past week. feeling very down but not suicidal in the ed. ed course: came from , with trop 0.6 in the ed. heparin started and cxr shows worsening failure. no ischemic changes on ekg. admit to medicine on telemetry for medical management of symptoms and serial enzymes and ekgs to rule out mi. aware of patient admission. past medical history: 1.cad s/p cabg 22yrs ago 2.s/p multiple pci's 3.chf w/ ef 15-20% 4.s/p icd 5.dm 6.htn 7.hypercholesterolemia 8.prostate ca 9.diverticulitis social history: distant tobacco history (4 packs a day) no etoh, no ivdu wife, , involved in care. family history: nc physical exam: vitals: 96.6 128/72 75 24 95% 2l gen: pleasant, quiet, eldery man, laying in bed under covers, in nad heent: peerl, eomi, anicteric, mmdry neck: supple, no jvd, no carotid bruits lungs: decreased breath sounds on right, no crackles or wheezes. cv: distant heart sounds, rr +s1s2 no m/r/g abd: soft, nt/nd +bs no hsm ext: no c/c/e. warm, 2+dp ble neuro: a+ox3. cn ii-xii intact grossly. flat affect, occational smiling/laughs pertinent results: 08:05am blood wbc-16.0* rbc-4.08* hgb-13.0* hct-39.7* mcv-97 mch-31.8 mchc-32.7 rdw-14.6 plt ct-322 05:24am blood wbc-8.6 rbc-3.30* hgb-9.7* hct-31.3* mcv-95 mch-29.3 mchc-30.9* rdw-15.1 plt ct-257 02:32am blood wbc-9.2 rbc-3.39* hgb-10.0* hct-31.8* mcv-94 mch-29.5 mchc-31.4 rdw-15.0 plt ct-259 08:05am blood neuts-84.4* lymphs-9.7* monos-5.0 eos-0.6 baso-0.4 05:36am blood neuts-89.9* bands-0 lymphs-3.9* monos-5.4 eos-0.6 baso-0.2 08:05am blood pt-14.7* ptt-26.7 inr(pt)-1.4 08:05am blood plt ct-322 03:15pm blood pt-15.0* ptt-28.1 inr(pt)-1.4 02:32am blood plt ct-259 08:05am blood glucose-102 urean-70* creat-2.0* na-139 k-4.9 cl-102 hco3-21* angap-21* 09:34pm blood glucose-130* urean-72* creat-2.0* na-137 k-5.4* cl-103 hco3-17* angap-22* 05:24am blood glucose-109* urean-29* creat-1.9* na-135 k-4.3 cl-95* hco3-27 angap-17 02:32am blood glucose-86 urean-36* creat-1.9* na-134 k-3.8 cl-95* hco3-26 angap-17 08:05am blood alt-85* ast-83* ck(cpk)-59 alkphos-167* amylase-71 totbili-1.4 06:03am blood alt-55* ast-22 ld(ldh)-301* alkphos-117 totbili-0.9 08:05am blood lipase-60 08:05am blood ctropnt-0.66* 03:15pm blood ck-mb-notdone ctropnt-0.57* 12:35am blood ck-mb-notdone ctropnt-0.57* 08:05am blood calcium-9.6 phos-5.5*# mg-2.6 02:32am blood mg-2.1 08:05am blood osmolal-307 06:00am blood tsh-3.8 11:31pm blood tsh-4.6* 11:50am blood tsh-4.4* 05:24am blood tsh-5.9* 11:50am blood free t4-1.5 05:24am blood t4-7.0 11:50am blood hbsag-negative 08:05am blood digoxin-0.5* 04:13pm blood digoxin-0.6* 04:16am blood digoxin-0.7* 09:20pm blood theophy-3.7* 04:46am blood theophy-11.4 06:20am blood theophy-20.7* 08:22am blood theophy-25.7* 05:24am blood theophy-14.8 11:50am blood hcv ab-negative 08:21am blood lactate-2.2* 12:41am blood freeca-1.14 05:00am blood freeca-1.04* 02:32am blood amiodarone and desethylamiodarone-pnd brief hospital course: 84 yo m with multivessel cad, s/p cabg, severe chf (ef 15%), discharged one week pta after presenting with inferior mi (peak ck 1600, trop t 8.2) for which he received a stent to his om-1, that hosp course c/b cardiogenic shock, now p/w progressive fatigue, minimal po intake, and 3 episodes of syncope. 1. cardiovascular a. cad: s/p cabg, recent imi s/p om-1 stent placement: pt was continued on plavix and atorvastatin. can't take asa due to gib. b. heart failure: ef 10-15%, recent infarct pt presenting in florid chf, initially responded to natrecor and lasix but then stoped making any progress, was transferred to ccu for swan placement and tailored therapy. in ccu, lasix was initially d/c'd and pt was cont on natrecor alone. then milrinone was added to increase inotropy, with improved hemodynamics based on the swan. uo also increased. subsequently started on vasopressin and lasix drip. natrecor was then d/c'd. spironolactone was added. plan was to send the patient home on milrinone, but pt unable to afford iv milrinone plus has shown increased mortality. vasopressin was tapered off, milrinone was briefly d/c'd until pt starting having resp distress followed by vtach to vfib stopped by the firing of his aicd. milrinone was restarted, became difficult to wean, theophylline was tried as substitute but pt couldn't tolerate, then aminophylline was used with success and milrinone was finally d/c'd. aminophylline still has abilities to dilate renal arteries, stimulate the cns, and +inotropic effects but has less diarrhea and is available in pill form. c. rhythm: patient had multiple runs of sustained v-tach during this hospital admission. all were asymptomatic except for 2 episodes, one where pt syncopized and recovered almost immediately, and the other a vtach to vfib episode on when his aicd fired. was started on amiodarone and digoxin. ecg meets criteria for ivcd but not lbbb so ep says no biv pacer needed. 2. pulmonary hypoxia and resp alkalosis in setting of chf likely due to pulmonary edema, chronic effusions; responded well to treatment of chf, diuresis. pt also had complication of pneumothorax, right apical, while placing r ij central line. resolved spontaneously with no chest tube required. 3. renal: acute (prerenal) on chronic (iga nephropathy) pt was overdiuresed initially and given his low co ended up underperfusing his kidneys to the point of going into met acidosis from azotemia. creatinine decreased gradually with slowing of diuresis regimen. no dialysis required, pt asymptomatic. 4. neuro/psych: depression. psych recommends no antidepressant therapy at this time. no haldol/ativan/ambien/benzos given h/o hallucinations/confusion. aminophylline has improved pt's mood slightly but he remains labile. continue for now. zyprexa qhs for confusion. h/o suicidal ideation on prior admission, but no si this admission. 5. heme: leukocytosis, thrombocytopenia, anemia - all stable. wbc elevated since admission. patient remains afebrile off all antibiotics and w/u, including blood cx, urine cx, and cxr negative. 6. fen: poor po intake. considered megace and marinol but not good options given side effect profiles. encourage po's. repleted lytes as needed. medications on admission: remeron 15mg po qhs asa 325mg qd plavix 75mg qd zantac 150mg lipitor 80 mg qd colace 100mg glipizide 5mg captopril 12.5 mg tid betaxolol hcl 0.25% 1 drop ou digoxin 0.0625mg qd discharge medications: 1. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). 2. betaxolol hcl 0.25 % drops, suspension sig: one (1) drop ophthalmic (2 times a day). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. digoxin 125 mcg tablet sig: 0.5 tablet po 2x/week (mo,we). 6. spironolactone 25 mg tablet sig: 0.5 tablet po qd (once a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po qd (once a day) as needed. 10. captopril 12.5 mg tablet sig: 0.25 tablet po tid (3 times a day). 11. olanzapine 2.5 mg tablet sig: two (2) tablet po qd (once a day). 12. furosemide 40 mg tablet sig: three (3) tablet po bid (2 times a day). 13. aminophylline 100 mg tablet sig: 0.5 tablet po q8h (every 8 hours). 14. amiodarone hcl 200 mg tablet sig: two (2) tablet po qd (once a day) for 10 days: please give from through . 15. amiodarone hcl 200 mg tablet sig: one (1) tablet po once a day: please start on after the 400mg qd dosing is complete. tablet(s) discharge disposition: extended care facility: hospital - discharge diagnosis: chf s/p recent imi acute renal failure depression v tach discharge condition: stable discharge instructions: please continue to take all your medications as prescribed. after rehabilitation, you will need to set up an appointment to see dr. and/or dr. to be evaluated further. please return to hospital or call your doctor , chills, very poor urine output, lightheadedness, confusion, shortness of breath, chest pain, or any concerns. followup instructions: please participate fully in your rehabilitation plan while at the rehab facility. also, please set up an appointment with dr. and/or dr. upon leaving the rehab facility. you have the following appointment also on file: provider: clinic where: cardiac services phone: date/time: 2:30 Procedure: Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Injection or infusion of nesiritide Diagnoses: Thrombocytopenia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Iatrogenic pneumothorax Mechanical complication of automatic implantable cardiac defibrillator Certain sequelae of myocardial infarction, not elsewhere classified, other

history of present illness: this was an 82-year-old unrestrained driver in a mvc, car versus barrier, transferred from an outside hospital with cervical spine fractures by report, high-speed mvc with significant front end damage, positive airbag deployment, positive loss of consciousness, gcs was 14 at the scene and 15 in the emergency department. the patient had remained hemodynamically stable on admission with no complaints. past medical history: 1. coronary artery disease status post ptc and stent placement. 2. hypertension. 3. gastroesophageal reflux disease. 4. spinal stenosis status post back surgery. 5. hypothyroidism. 6. arthritis. 7. high cholesterol. 8. status post spine fusion. 9. benign prostatic hypertrophy. medications on admission: 1. naprosyn. 2. lipitor. 3. synthroid. 4. ............ 5. proscar. 6. captopril. 7. isordil. 8. nadolol. allergies: the patient has no known drug allergies. social history: he denied tobacco and drank alcohol socially. physical examination: on examination the patient's vital signs were temperature 98.1, pulse 64, blood pressure 164/73, respiratory rate 18, o2 saturation 93% on two liters. gcs 15. generally he was comfortable. heent: there was an 8 cm laceration over the right forehead which was sutured, left periorbital ecchymosis. pupils were equal, round, and reactive bilaterally, 2 mm, positive small 0.5 cm superficial distal tongue laceration. neck: there was no cervical spine tenderness. the face was stable. heart: regular rate and rhythm. lungs: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended. pelvis: nontender and stable. back: no stepoffs and nontender, with a lower midline scar. rectal: normal tone, guaiac negative, no masses. extremities: there was 2+ pedal edema, full range of motion x 4. abrasions of the knees and hands bilaterally. there was motor strength bilaterally in the upper and lower extremities. laboratory data: cbc was 8.1, hematocrit 36, platelet count 210. chemistries showed a sodium of 138, potassium 5.3, chloride 107, bicarbonate 23, bun 40, creatinine 1.8, glucose 149, amylase 83. urinalysis showed 25-50 red blood cells and 4+ bacteria. ekg showed no ischemic changes and normal sinus rhythm at 65 at the outside hospital. laboratory studies here showed a white count of 18.7 with an hematocrit of 33, platelet count 229, pt 14.5, ptt 25.8, inr 1.4, fibrinogen 208. chemistries were all within normal limits. lactate was 1.8. urinalysis showed greater than 50 red blood cells, 0-2 white blood cells and a few bacteria. urine and serum toxicology screens were negative. x-ray of the cervical spine showed hardware of c4 and c5. chest x-ray showed cardiomegaly, left-sided lingular pulmonary contusion, no pneumothorax, and a questionable widened mediastinum. pelvis x-ray was negative. ct of the chest showed a left lingular contusion. ct of the abdomen was negative. ct of the head was negative. ct of the cervical spine showed a fracture at the base of c2 extending into the left body; anterior arch of c1 there was a fracture with slight displacement and distraction, c4, c5, c6, anterolisthesis at fusion block, c1 right lamina fracture nondisplaced. examination in the emergency department showed a question of fluid in morison's pouch. hospital course: the patient was admitted to the trauma surgical intensive care unit and neurosurgery was consulted. mri of the cervical spine and tls films were also ordered. the neurosurgical plan was to remain in the hard collar at all times with log-roll precautions and they were going to follow the tls films and mri of the spine. there was no need for steroids at that time secondary to patient being asymptomatic from the injury. they were to decide on further management of halo versus fusion and they would further discuss and consider the need for angiogram. mri was performed. it was a limited study secondary to patient motion artifact and lack of comparison study demonstrating the acute fractures. the report showed no definite edema within the bony structures, however the high t2 ir signal both anterior to the spine and posterior to the spinous processes may represent edema. there was spinal stenosis, ligamentous injury could not be evaluated in this study. after mri reports and discussion with the attending, and discussion with the family, it was decided that treatment options were hard collar versus surgical fusion. given that the patient had multiple comorbidities, the discussion resulted in the decision to treat with cervical spine hard collar for 12 weeks and reevaluation based on flexion-extension films. if the fracture was still deemed to be unstable at that time then the plan was to consider surgical fusion. this plan was discussed with the family who agreed with the planned decision. at 22:00 the anesthesia attending was called to the surgical intensive care unit for cardiac arrest of the patient. the resident on call was called at 21: an a-line in the patient. at that time the patient was saturating in the 90s on a face mask. the patient became tachypneic and bilateral wheezes were noted. an a-line was placed and arterial blood gases were sent. a chest x-ray was taken. albuterol treatment was also given. at that point the patient was noted to be in cardiac arrest and a code was called. the anesthesia attending, dr. , was called to the code and was able to intubate the patient with a 7.5 et tube with the neck held in in-line traction and the cervical collar in place. the placement of the et tube was verified using co2 detection and bilateral breath sounds. simultaneously, cardiopulmonary resuscitation was initiated and acls algorithm was followed. a left thoracotomy was performed and bilateral chest tubes were placed. the left thoracotomy revealed a full heart without signs of hypovolemia. the patient was asystolic throughout the code without response to aggressive pharmacologic measures per acls protocol and cardiac compression both externally and internally. the patient also received aggressive fluid resuscitation and the patient was pronounced at 22:21. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Arterial catheterization Incision of chest wall Diagnoses: Coronary atherosclerosis of native coronary artery Open wound of forehead, without mention of complication Closed fracture of second cervical vertebra Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle Closed fracture of one rib Contusion of lung without mention of open wound into thorax Concussion with loss of consciousness of unspecified duration Street and highway accidents Closed fracture of first cervical vertebra

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall major surgical or invasive procedure: none on this admission history of present illness: yo woman with h/o niddm, htn, hyperchol, on asa transferred s/p fall with an osh hct showing sah. she reportedly had a mechanical fall witnessed by her sister. did hit her head. she does not remember if she lost consciousness. her sister brought her to hospital, where she had a hct and was transferred here. past medical history: niddm htn hypercholesterolemia social history: lives with sister family history: not elicited physical exam: pe: vs: t96.5, hr 84, rr 16, sao2 96%/ra genl: in a cervical collar, lying still heent: ncat, mmm, op clear cv: rrr, nl s1, s2 chest: cta bilaterally abd: soft, ntnd, bs+ . neurologic examination: mental status: alert, awake, oriented to place and name, not date (, ?year). inattention, unable to perform bw. difficulty w/ naming (called thumbnail "peanut"). cranial nerves: pupils post-surgical but equally responsive (minimal), eom full w/o nystagmus, v1-3 intact, face symmetric, decreased hearing, palate elevates symmetrically, tongue midline with nl movements. motor: moves all extremities, lifts legs bilaterally, grip strong bilaterally. sensory: intact to lt throughout gait: deferred . pertinent results: 04:02am blood wbc-9.2 rbc-3.24* hgb-10.2* hct-30.1* mcv-93 mch-31.5 mchc-33.9 rdw-16.9* plt ct-118* 02:00pm blood wbc-7.5 rbc-3.69* hgb-11.5* hct-33.6* mcv-91 mch-31.1 mchc-34.2 rdw-16.7* plt ct-119* 02:00pm blood neuts-83.6* lymphs-13.3* monos-2.6 eos-0.5 baso-0 04:02am blood plt ct-118* 04:02am blood glucose-153* urean-21* creat-1.1 na-141 k-4.3 cl-110* hco3-23 angap-12 02:00pm blood glucose-159* urean-19 creat-1.1 na-139 k-4.3 cl-105 hco3-27 angap-11 04:02am blood albumin-3.4 calcium-8.2* phos-2.5* mg-2.1 05:06pm blood type-art po2-179* pco2-36 ph-7.34* caltco2-20* base xs--5 05:06pm blood glucose-174* 02:21pm blood freeca-1.22 06:15pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-7.0 leuks-mod 06:15pm urine rbc-* wbc-21-50* bacteri-few yeast-none epi- . . 1:31 am sputum site: endotracheal gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): multiple organisms consistent with oropharyngeal flora. . . ct head w/o contrast 5:31 pm impression: no significant change in appearance of hypodense material within the basal cisterns, consistent with subarachnoid hemorrhage. cta could be helpful for further evaluation, this was discussed with dr. . there is a plan to obtain cta when the patient is more stable. note added at attending review: the value of cta is questionable, unless this is truly a spontaneous hemorrhage. however, there are small amounts of dural thickening and possible subdural hemorrhage along the falx anteriorly and overlying the right frontal lobe. these suggest trauma, as does the distribution of the blood into the inferior frontal subarachnoid space. thus, there may be a combination of subarachnoid hemorrhage and inferior frontal hemorrhagiv contusion- all compatible with trauma. correlation with the clinical history is recommended. . . ct c-spine w/o contrast 3:29 pm impression: 1. no evidence of fracture or abnormal prevertebral soft tissue swelling. 2. cervical spondylosis. 3. subarachnoid hemorrhage seen on ct of the head not well evaluated on this study. 4. small nodular density at the right apex possibly represents convergence of vessels. correlation with prior studies if available is recommended. . . ct head w/o contrast 3:29 pm impression: hyperdense material within the basal cisterns consistent with subarachnoid hemorrhage. no evidence of shift of normally midline structures or hydrocephalus. note added at attending review: there is a left parasagittal linear skull fracture without depression. . . ct head w/o contrast 6:29 pm impression: no change in the subarachnoid and likely small subdural hemorrhages. . . chest (portable ap) 2:38 pm a single ap view of the chest is obtained at 1445 hours and compared with the prior day's radiograph. the patient has been extubated. since the prior examination, the patient has developed opacity in the right lower lobe. there is also increased interstitial markings in the right upper lobe and to a lesser extent in the left lung compared with the prior examination. the findings may represent asymmetric pulmonary edema. however, particularly in the right lower lobe, aspiration or pneumonitis must be considered.. . . brief hospital course: this patient was admitted to under the neurosurgery service on after being transfered from an outside hospital. the patient was evaluated in the ed and had a ct scan (findings as above). the patient was intubated for airway protection after an episode of vomiting. she was then brought to the surgical icu for furthur monitoring. her initial ct scan of her head was stable compared to that of the outside hospital. . on , the patient was extubated. she had some respiratory difficulties, with tachypnea and a raised pc02. she was evaluated via a chest xray. her neurological status had greatly improved overnight and through the course of the day. . the following day on , . a/p: yo female with history of htn, hypercholesterolemia who presented from osh with subdural bleed and ams who had a stemi and arf while in house. . # stemi: apppears to be anterior wall - cardiology consulted - not a cath candidate because of arf and intracranial hemorrhage - started on aspirin, statin, bb - unable to start hydralazine for afterload reduction, given low bps - echo to assess cardiac function - see results above - consistent with r and l sided heart failure. . # arf: most likely secondary to poor forward flow in setting of significantly depressed ef. - creatinine rising from 1.1 on admission to 2.9 - pt noted to have signif decreased uo, not significantly responsive to fluids - given lasix with increased uo, then creat bumpted to 2.9 . # aspiration pna: patient with ms changes and 3-4l o2 requirement after aspiration. would also account for her elevated wbc count. - oxygenating and ventilating well after event. abg: 7.36/39/145 with normal lactate. . # altered mental status: several reasons for ams including: - mi, arf, uti, aspiration pna and intracranial bleed . # subdural bleed: - neuro/neurosurg recs - dilantin for seizure prophylaxis - level 16.5 on day of admission - serial head cts have been stable - patient with aneurysm - per neuro, would consider an mri to properly assess this if pt stable . # anemia: - iron studies c/w acd . # uti: - treat with levofloxacin for 7 days since she has a foley - renally dosing levofloxacin . # fen: tf . # hypernatremia: d51/2ns to replete some free water. . # diabetes mellitus: titrate up ssi. . # ppx: - ppi - no heparin intracranial bleeds - pneumoboots - sliding scale insulin . # code status: patient can be intubated if it is felt it would be for a short period of time. no chest compressions or defibrillation medications on admission: asa glyburide detrol fe vit c simvastatin allopurinol discharge medications: na discharge disposition: expired discharge diagnosis: deceased discharge condition: deceased discharge instructions: na followup instructions: na Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Pure hypercholesterolemia Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Unspecified fall Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness

allergies: no drug allergy information on file attending: chief complaint: altered level of consciousness and ich seen on ct at osh major surgical or invasive procedure: nil history of present illness: 78 yo man with parkinsonism for 5 years, possible msa, type 2 dm, who was in his usoh until 5 days ago when he had "convulsions" of his entire body without loss of consciousness. he was taken to hospital, admitted, and his selegeline and "bladder medication" were stopped and he improved over two days. he was treated with levaquin for a uti. as of two days ago, he was awake, and able to feed himself - he has trouble talking because of his parkinsonism. the next day, he was sent to a nursing home - his wife and daughters reports that he was "much worse", and complained of a headache for which he was given tylenol. he was "comatose" and this morning was taken back to where a nchct showed a new, large right fronto-parietal ich. he was transferred to emergently. in the ed, he was seen by neurosurgery and the decision was made not to seek surgical intervention. he was then intubated, placed on propofol, and received 1000mg iv phenytoin for seizure prophylaxis. ros: no recent falls or trauma. past medical history: # parkinsonism - possible msa - family denies precipitous cognitive decline. he has been in a nursing home for several months because of fall risk. # dm type ii no known drug allergies social history: currently lives at nursing home. quit smoking 40 years ago. physical exam: bp 164/68 map 103 hr 50 rr 17 general appearance: critically ill, intubated heart: regular rate and rhythm without murmurs, rubs or gallops lungs: clear to auscultation bilaterally. abdomen: soft, nontender extremities: no clubbing, cyanosis or edema neurological: intubated - examined with propofol shut off for 2 minutes. no response to voice. grimaces to sternal rub. pupils are pinpoint and minimally reactive. corneals and nasal tickle are intact bialterally. ocrs and gag intact. right arm purposeful in response to noxious stimuli. left arm with extensor posturing to noxious, withdraws both legs to noxious. the plantar reflexes are extensor. pertinent results: 136 100 13 184 4.4 26 0.9 ca: 9.0 mg: 2.1 p: 4.3 9.4>13.7/37<177 pt: 12.1 ptt: 26.7 inr: 1.0 imaging: nchct: ~85cc acute hemorrhage in right fronto-parietal lobe with surrounding edema and intraventricular extension. there is near-total effacement of the right posterior of the lateral ventricle with a few mm of midline shift. the perimesencephalic cisterns are patent however ther is a hypodensity at the left anterior mesencephalon, suggesting possible infarcation. brief hospital course: 78 yo man with large right ich of unclear etiology; cortical location suggests amyloid angiopathy, hemorrhagic tansformation of ischemic stroke, or underlying mass. there is intraventricular extension, and given his age, and size of the hemorrhage, suggested his prognosis was poor. the family elected not to pursue neurosurgical intervention. he was admitted to nicu with close observation, blood pressure control, goals normothermia, and normoglycemia and treated with dilantin. there was no clinical improvement and the family elected to optimise his comfort care. he died on . medications on admission: sinemet 25/100 tid aricept zocor namenda asa 81 daily discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Computerized axial tomography of head Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Subarachnoid hemorrhage Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Paralysis agitans Senile dementia, uncomplicated History of fall

discharge condition: the infant is discharged in good condition. he is transferred to the newborn nursery. primary pediatric care: will be provided by comprehensive health center. care recommendations: 1. feedings: on an ad lib schedule. 2. medications: the infant is discharged on no medications. 3. a car seat position screening test needs to be done prior to discharge. 4. a state newborn screen was sent on day of life number three. 5. the infant has received no immunizations to date, however, consent has been obtained for the hepatitis b vaccine. 6. immunizations recommended: synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks, with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for pre-term infants with chronic lung disease once they reach six months of age. before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. discharge diagnosis: 1. prematurity, 34 6/7 weeks gestation 2. sepsis ruled out 3. status post respiratory distress due to retained fetal lung fluid , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Enteral infusion of concentrated nutritional substances 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 Other preterm infants, 2,000-2,499 grams Other respiratory problems after birth 33-34 completed weeks of gestation

history of present illness: mrs. is a 39 year-old female patient who suffered bilateral lower extremity injuries. hospital course: her right lower extremity underwent emergent management for an open fracture with debridement and ankle splinting fixation. she subsequently presented for staged reconstruction of her distal tibia. she was taken to the operating room by dr. on when she underwent open reduction internal fixation of the fibula and tibia for the pilon type fracture as well as syndesmotic repair. she tolerated the procedure well and was taken to the recovery room without incident. she had previously undergone open reduction internal fixation of the left tibia by dr. on . she was eventually discharged to rehab with clean wounds, to follow-up with dr. . discharge medications: anticoagulation in the form of lovenox and pain control medication in the form of oral narcotics. , md Procedure: Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Internal fixation of bone without fracture reduction, tibia and fibula Diagnoses: Dysthymic disorder Unspecified fracture of ankle, open Other and unspecified alcohol dependence, unspecified Home accidents Suicide and self-inflicted injuries by jumping from other man-made structures Closed fracture of shaft of tibia alone Fracture of medial malleolus, open

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bloody diarrhea this morning major surgical or invasive procedure: colonoscopy icu monitoring history of present illness: 80 year old female with hx of hx of htn, hypothyroid, oa, spinal stenosis presents with brbpr and watery diarrhea x 5 hrs this morning. pt states that on friday she began to feel "sick" with cough, decreased, appetite, sob, difficulty swollowing due to dryness, and muscle aches. she states that she took robitussin and aspirin at the suggestion of her pcp and experienced some relief. syptomes persisted through weekend. monday night was "a disaster" as symptoms became progressively worse. tuesday morning, at 5 am, pt experienced crampy abd. pain with watery diarrhea mixed with bright blood. pt called pcp who told pt to report to the ed. . in pt received 2lns, anzemet and compazine. ct abd. showed large heterogeneous filling defect of ascending colon, suspicious for malignancy. constrast seen distal to lesion with no small bowel dilitation. hypodense liver lesions in right lobe of liver. multiple sigmoid diverticuli. no evidence of diverticulitis. scoliosis with degenerative changes through out spine and pelvis. abnormal focal mixed heterogeneous lesions of fat, soft tissue, and bone density within mid abdomen--both intra and extraluminal. in addition chest x-ray showed 7 mm nodule projecting over the lower left hemithorax, which may represent a granuloma. . pt denies chest pain, nausea, vomiting, hematemesis, dysuria, change in bowel or bladder function, no weight loss, or headaches. . pmh: 1. gerd 2. htn 3. oa 4. spinal stenosis 5. cholonic polyps s/p removal 00'reveiled polyps in the cecum and sigmoid colon, diverticulosis of the sigmoid colon, internal hemorrhoids, otherwise normal colonoscopy to cecum. 6. hypothyroid . allergies: knda . medications: levothyroxine sodium 50 mcg tabs (levothyroxine sodium) 1 po qd, hold one day per week calcium carb chw 500mg (calcium carbonate antacid) 3 po qd aspirin tab 81mg ec (aspirin) 1 qd fosamax tab 70 mg one po qam, on an empty stomach, once per week ocuvite tab (multiple vitamins-minerals) 1 po qd lisinopril 20 mg tabs (lisinopril) 1 po qd prilosec cap 20mg cr (omeprazole) one po qd prn norvasc tab 5mg (amlodipine besylate) 1 tab po qd hydrochlorothiazide caps 12.5 mg (hydrochlorothiazide) 1 po q am amoxicillin cap 500mg (amoxicillin) 4 tab 1 hr prior to dental work darvocet-n 100 100-650 mg tabs (propoxyphene n-apap) 1 po q4 - 6 hours percocet tab 5-325mg (oxycodone-acetaminophen) 1-2 tabs po q 4-6 hours prn pain cosamin ds caps (nutritional supplements) 1 po qd relafen 500 mg tabs (nabumetone) 1 po qd . fhx: son died of colon ca at 36. father died of mi at age . mother died of stomach ca at age 78. . social: retired personel rep for govt. 3 children. lives alone in apt. retired head of scholarship fund. no tabacco since age 30, occasional etoh. . physical exam: vitals: t:98.6 hr:91 bp:155/68 rr:19 o2:97%ra gen: elderly woman layingon left side nad heent: ncat, perrl, eomi without nystagmus, o/p clear no exudates neck: no lymphadenopathy, no thyromegally chest: coarse exp. ronchi at llb, otherwise cta cv: distant s1 and s2, ii/vi crescendo/decrescendo systolic ejection murmur at rusb w/o radiation, ii/vi blowing holosytolic ejection murmur at apex w/o radiation, +s3, no rubs or heaves. abd: soft, nt/nd, 4x4cm movable nonfluctuant mass at rlq, +bs. ext: w/w/p no c/c/e weak pt bilaterally. neuro: a&o x3, no focal deficits moving all fours. . labs: see below. . imaging: ct abd. and pelvis: impression: 1. large heterogeneous mass within the cecum and ascending colon along with low-density lesions within the right lobe of the liver, likely representing malignancy. 2. no evidence of small bowel obstruction. 3. sigmoid diverticulosis without evidence of diverticulitis. marked hypertrophy of the sigmoid probably secondary to diverticulosis, however, cannot rule out colitis. 4. mixed attenuation lesions within the lower abdomen with questionable attachment to the uterus, likely representing bilateral dermoids. 5. small low attenuation filling defect within the small intestine of unclear etiology. . chest x-ray:impression: 7 mm nodule projecting over the lower left hemithorax, which may represent a granuloma. . assesment:80 year old female with hx of hx of htn, hypothyroid, oa, spinal stenosis presents with brbpr and watery diarrhea x 5 hrs this morning. . brbpr: likely primary colon malignancy. pt with 4x4cm movable nonfluctuant mass at rlq in addition to ct findings with large heterogeneous mass within the cecum and ascending colon along with low-density lesions within the right lobe of the liver, likely representing malignancy. in addition, pt has an hx of colonic polyps and a positive family fhx of colon son having died at 36 of colon ca. - npo and ng-tube - golytely - colonoscopy tomorrow - gi consult tomorrow appreciate recs. - surgery consult appreciate recs. - consider onc. consult . uti: pt with an active ua. - ciprofloxacin iv x 3 days . htn: pt with htn bp in the 150s/60s. pt on lisinopril, amlodipine, and hctz as out pt. doses not available, will follow with family or pcp . - hctz 25 ivqd- will follow up with family tomorrow . hypothyroid: pt with hypothyroid on thyroxyl - continue thyroxyl ng . oa: pt with oa of right hip. pt on darvocet as an out pt. - will manage pain with morphine sulfate 1-2mg for now . spinal stenosis/lbp: pt on darvocet as an out pt. - will manage pain with morphine sulfate 1-2mg for now . gerd: pt with hx of gerd. - pantoprazole 40 mg iv . ppi: pantoprazole, pneumo boots. . code: presumed full . dispo: admit to medicine . . levothyroxine sodium 50 mcg tabs (levothyroxine sodium) 1 po qd, hold one day per week calcium carb chw 500mg (calcium carbonate antacid) 3 po qd aspirin tab 81mg ec (aspirin) 1 qd fosamax tab 70 mg one po qam, on an empty stomach, once per week ocuvite tab (multiple vitamins-minerals) 1 po qd lisinopril 20 mg tabs (lisinopril) 1 po qd prilosec cap 20mg cr (omeprazole) one po qd prn norvasc tab 5mg (amlodipine besylate) 1 tab po qd hydrochlorothiazide caps 12.5 mg (hydrochlorothiazide) 1 po q am amoxicillin cap 500mg (amoxicillin) 4 tab 1 hr prior to dental work darvocet-n 100 100-650 mg tabs (propoxyphene n-apap) 1 po q4 - 6 hours percocet tab 5-325mg (oxycodone-acetaminophen) 1-2 tabs po q 4-6 hours prn pain cosamin ds caps (nutritional supplements) 1 po qd relafen 500 mg tabs (nabumetone) 1 po qd 80 year old female with hx of hx of htn, hypothyroid, oa, spinal stenosis presents with brbpr and watery diarrhea x 5 hrs this morning. pt states that on friday she began to feel "sick" with cough, decreased, appetite, sob, difficulty swollowing due to dryness, and muscle aches. she states that she took robitussin and aspirin at the suggestion of her pcp and experienced some relief. syptomes persisted through weekend. monday night was "a disaster" as symptoms became progressively worse. tuesday morning, at 5 am, pt experienced crampy abd. pain with watery diarrhea mixed with bright blood. pt called pcp who told pt to report to the ed. . in pt received 2lns, anzemet and compazine. ct abd. showed large heterogeneous filling defect of ascending colon, suspicious for malignancy. constrast seen distal to lesion with no small bowel dilitation. hypodense liver lesions in right lobe of liver. multiple sigmoid diverticuli. no evidence of diverticulitis. scoliosis with degenerative changes through out spine and pelvis. abnormal focal mixed heterogeneous lesions of fat, soft tissue, and bone density within mid abdomen--both intra and extraluminal. in addition chest x-ray showed 7 mm nodule projecting over the lower left hemithorax, which may represent a granuloma. . pt denies chest pain, nausea, vomiting, hematemesis, dysuria, change in bowel or bladder function, no weight loss, or headaches. . past medical history: 1. gerd 2. htn 3. oa 4. spinal stenosis 5. cholonic polyps s/p removal 00'reveiled polyps in the cecum and sigmoid colon, diverticulosis of the sigmoid colon, internal hemorrhoids, otherwise normal colonoscopy to cecum. 6. hypothyroid social history: retired personel rep for govt. 3 children. lives alone in apt. retired head of scholarship fund. no tabacco since age 30, occasional etoh. family history: son died of colon ca at 36. father died of mi at age . mother died of stomach ca at age 78. physical exam: vitals: t:98.6 hr:91 bp:155/68 rr:19 o2:97%ra gen: elderly woman layingon left side nad heent: ncat, perrl, eomi without nystagmus, o/p clear no exudates neck: no lymphadenopathy, no thyromegally chest: coarse exp. ronchi at llb, otherwise cta cv: distant s1 and s2, ii/vi crescendo/decrescendo systolic ejection murmur at rusb w/o radiation, ii/vi blowing holosytolic ejection murmur at apex w/o radiation, +s3, no rubs or heaves. abd: soft, nt/nd, 4x4cm movable nonfluctuant mass at rlq, +bs. ext: w/w/p no c/c/e weak pt bilaterally. neuro: a&o x3, no focal deficits moving all fours. pertinent results: colonoscopy (): consistent with severe ischemic colitis wbc increased from 13 at admission to 50 on day patient was made cmo brief hospital course: 80f with hx of hx of htn, hypothyroid, oa, spinal stenosis who presented with brbpr. colonoscopy was consistent with ischemic colitis. . # ischemic cholitis (ascending, hepatic and splenic flexure): ct findings with large heterogeneous mass within the cecum and ascending colon along with low-density lesions within the right lobe of the liver (concerning for colon cancer) but colonoscopy showed no mass and was consistent with severe ischemic colitis. unclear whether this ischemic colitis is from emboli or worsening atheromatous disease. surgery was consulted and followed the patient throughout hospitalization. option of surgical intervention was discussed but patient and family did not want to pursue surgery, despite grim prognosis of medical management with such severe ischemic colitis. patient was therefore treated conservatively with iv hydration and was initially kept on antibiotics (zosyn, flagyl). the patient's wbc continued to rise, likely from uncontrolled bacterial translocation across her ischemic bowel wall. lactate was wnl. culture data did not grow anything (to date). given the patients grim prognosis and refusal of surgical intervention (which would also hold high risks of morbidity and mortality), patient and family requested comfort measures only on . all medications were discontinued except those for comfort, including morphine prn. the pt expired on at 7 am. family was notified. # acute renal failure (baseline around 1.3): the patient's renal function was worse than her baseline at admission and continued to deteriorate throughout her hospitalization, possible from emboli vs sepsis. # uti: positive urinalysis at admission, initially treated wtih flagyl/zosyn. all antibiotics were discontinued on . # htn: bp medication # hypothyroid: levoxyl was held as pt was npo # code: dnr/dni; patient was made comfort measures only at patient and family request on . # communication: son medications on admission: levothyroxine sodium 50 mcg qd, hold one day per week calcium carb chw 500mg 3 po qd aspirin tab 81mg ec qd fosamax tab 70 mg one po qam, on an empty stomach, once per week ocuvite tab (multiple vitamins-minerals) 1 po qd lisinopril 20 mg tabs po qd prilosec cap 20mg cr po qd prn norvasc tab 5mg po qd hydrochlorothiazide caps 12.5 mg qam amoxicillin cap 500mg 4 tab 1 hr prior to dental work darvocet-n 100 100-650 mg tabs (propoxyphene n-apap) 1 po q4 - 6 hours percocet tab 5-325mg (oxycodone-acetaminophen) 1-2 tabs po q 4-6 hours prn cosamin ds caps (nutritional supplements) 1 po qd relafen 500 mg tabs (nabumetone) 1 po qd discharge medications: pt expired discharge disposition: expired discharge diagnosis: death due to ischemic colitis discharge condition: n/a discharge instructions: n/a followup instructions: n/a md Procedure: Closed [endoscopic] biopsy of large intestine Diagnoses: Acidosis Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Unspecified acquired hypothyroidism Acute vascular insufficiency of intestine Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction

allergies: tetanus toxoid attending: chief complaint: found down major surgical or invasive procedure: intubation for airway protection tsicu monitoring ng tube placement scalp laceration repair history of present illness: 88 y.o. male found down at the side of the street. when initially seen by ems, pt was tachycardic and unresponsive with hr ranging from 180-190. lasix, nitro, and cardizem were given en route and the pt was brought to . on arrival the pt had a gcs of 8. the pt was intubated in the ed for airway protection and decreased mental status. past medical history: htn psoriasis cirrhosis diabetes mellitus social history: lives alone family history: non-contributory physical exam: on arrival to the ed prior to intubated: vitals temp 101 bp 135/77 103 16 97% on 4l gcs 8 gen: unable to follow-commands, pt withdraws to pain, moving all 4 ext heent: laceration posterior r occiput, 2 cm in length, perrl 3 to 2 mm bilaterally, tm clear, oral pharynx w/out trauma, midface stable, trachea midline pulm: equal bs bilaterally cv: sinus tach abd: soft, nd, fast neg ext: 2+ edema up to thighs bilaterally back: no step-offs on palpation of spine rectal: nl tone, guiac neg skin: extensive psioratic changes pertinent results: ct head w/o contrast 8:05 pm impression: right temporal and frontal hemorrhagic contusions along with small right sided subdural hemorrhage without significant mass effect ecg study date of 7:47:06 pm rate 113 probable atrial fibrillation with ventricular premature complexes left axis deviation rbbb with left anterior fascicular block nonspecific st-t wave changes since previous tracing, the heart rate is slower ct head w/o contrast 10:30 am impression 1.) slight increase in size in the right subdural hematoma. 2.) stable right intraparenchymal hemorrhage, with new areas of left intraparenchymal hemorrhage and left subdural hemorrhage. 3.) increase in the left soft tissue swelling. no mass effect, however. mr cervical spine 11:00 am impression: 1. no evidence of a ligamentous injury. 2. mild degenerative changes, including bilateral neural foraminal narrowing at c5-c6 without spinal stenosis. ct head w/o contrast 10:27 am impression: stable appearance of right frontal/temporal contusion, right sided subdural and subarachnoid hemorrhage compared to the previous study. ct head w/o contrast 9:00 am impression: 1) right frontal-temporal infarction with hemorrhagic conversion. no significant interval change in the left subfalcine herniation. bifrontal convexity subdural hematomas, right greater than left. 2) bilateral subdural hematomas. 3) chronic small vessel infarction. no significant interval change since . brief hospital course: after stabilization in the trauma bay, pt was taken emergently to ct. non-contrast head ct revealed right temporal and frontal hemorrhagic contusions along with small right sided subdural hemorrhage without significant mass effect. other studies including chest, abdomen, and pelvis ct showed no injuries. the pt was transferred to the tsicu for monitoring of his . to : pt remained intubated in the tsicu for monitoring. neurosurg was consulted and his head injury was not applicable for operative management. serial head ct studies revealed worsening hemorrhage with subsequent herniation. the pt was made dnr/dni on and extubated. : pt transferred to the floor late in the evening and expired on the afternoon of secondary to respiratory arrest. the family was present at the bedside. medications on admission: unknown discharge medications: not applicable discharge disposition: home facility: pt expired discharge diagnosis: bilateral subdural hematomas right frontal-temporal infarction with hemorrhagic conversion left subfalcine herniation hypertension diabetes mellitus psiorasis cirrhosis respiratory failure discharge condition: pt expired discharge instructions: pt expired followup instructions: pt expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Closure of skin and subcutaneous tissue of other sites Diagnoses: Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Unspecified fall Mitral valve insufficiency and aortic valve insufficiency Hyperosmolality and/or hypernatremia Other psoriasis Diseases of tricuspid valve Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: found unresponsive by family major surgical or invasive procedure: intubation and mechanical ventilation external ventricular drain placed cerebral angiography history of present illness: 75 year old man with a history of hypertension was transferred to after being found unresponsive by wife. per family, patient had been shopping throughout the morning with his wife. they currently live in an apartment and are selling their house. they stopped by the house ~11am to check on it, and pt went around to back deck to make sure back door was locked. wife waited in the car. she reports that he got out of the car slowly and with difficulty and then seemed to walk fine. 3-4 minutes later when he had not returned, she drove car around and saw him laying face up on the back deck. she reports that his eyes were open and at midline gaze, but he was unresponsive. ems was immediately activated and found the patient with "agonal breathing and no gag reflex." he was subsequently sedated with versed and intubated in the field and brought to . there a head ct uncovered a subarachnoid hemorrhage and he was noted to be in atrial fibrillation on ekg (no previous history of afib). he was then transferred emergently to er for neurosurgical evaluation. he arrived here at 2:20 pm. he was treated with flagyl, levaquin, dilantin, and tylenol (febrile to 101.8). the neurosurgery service did not feel an intervention was warranted and requested evaluation by neurology at 5 pm. according to family, he has history of gait difficulties and moving "slowly." about 3 months ago, pt was evaluated for ?nph by dr. in neurology at with lumbar puncture. family reports some improvement in gait after tap. repeat lp was planned for early to re-evaluate and determine if diagnosis of nph was correct. family reports that for the last ~3 weeks his gait had again started to worsen, with him moving more slowly, especially getting in and out of car. review of systems largely unobtainable since pt intubated and unresponsive. family does reports that pt complained of "dizziness" last week. he had not told them of any other problems. he had been moving about "slow" all morning, and in fact for the last few weeks per his son. past medical history: 1. hypertension 2. anxiety 3. h/o gait disorder, ?nph (see hpi) social history: lives with wife. recent alcohol or tobacco use family history: son with afib s/p ablation. physical exam: vitals: 101.8 80 150/96 16 100% intubated general: older man lying still on bed neck: supple lungs: decreased breath sounds at the bases cv: regular rate and rhythm abdomen: non-tender, non-distended, bowel sounds present ext: warm, no edema neurologic examination: no response to loud voice; left fist clenching to sternal rub; pupil 1mm b/l and minimally reactive; unable to test dolls as pt. still in hard collar; weak corneal reflex b/l, weak gag reflex b/l; face symmetric; some spontaneous mvt. in left arm and leg; withdraws slightly to pain on left extremities, minimal flexor posturing to pain on right, dtr's brisk 2+ throughout, toes upgoing b/l pertinent results: wbc-11.4* (89n, 7l, 3m) hct-42.6 plt-113* pt-12.0 ptt-29.3 inr(pt)-1.0 na-141 k-4.1 cl-105 hco3-25 bun-23* creat-1.5* gluc-89 albumin-3.8 calcium-9.2 phosphate-2.4* magnesium-1.8 alt-20 ast-32 alk phos-92 tot bili-0.8 lipase-27 amylase-109* ck(cpk)-67 ck-mb-notdone ctropnt-<0.01 ua: blood-lge nitrite-neg leuk-neg rbc->50 wbc-0 bact-none head ct/cta (): extensive subarachnoid hemorrhage in the quadrigeminal cistern, right sylvian fissure, right occipital , right frontal horns, bilateral posterior parietal regions, around the posterior interhemispheric fissure and along the falx. these findings are suspicious for traumatic subarachnoid hemorrhage. hemorrhagic dural metastasis is a possibility but considered very less likely. bifrontal subdural hygroma is noted of uncertain clinical significance. punctate hemorrhage in the pons, which may represent a tiny shear injury. hemorrhage is also noted adjacent to the interhemispheric fissure in the right lateral ventricle. ct angiogram demonstrates good flow in the anterior and posterior circulation. no definite aneurysms or vascular malformation. brief hospital course: 75m h/o htn found unresponsive by wife and neurological exam with comatose mental status, and few lateralizing focal deficits. head ct with multiple intraparenchymal and subarachnoid hemorrhages. pt was admitted to the neurology icu for further management. 1. neuro: etiology of subarachnoid bleeds is unclear, though most likely related to trauma as pt was found down, lying on his back. alternative possibilities included aneurysm or vascular malformation in the brainstem that bled, resulting in fall which then caused traumatic sah. the somewhat nodular appearance on ct of the bleeds also suggested possible dural metastases as etiology. mri with contrast showed no evidence of dural metastases or other enhancing lesions. csf cytology was negative for malignant cells. neither mra nor cta showed aneurysm, but mri with contrast did have some enhancement in the brainstem near the intraparenchymal bleed, so vascular malformation was still possible. on (day #5 since sah) a cerebral angiogram was performed by dr. in interventional neuroradiology. angiogram showed no evidence of aneurysm, vascular malformation or vasospasm. thus, most likely etiology of bleed is traumatic as result of fall backwards onto deck. etiology of fall is somewhat unclear. two most likely possibilities are secondary to patient's gait disorder, or could be due to sinus pauses on conversion from afib back to sinus rhythm (see below for more details). patient remained minimally responsive for the first 14 days in the hospital. he was started on dilantin for seizure prophylaxis given the likely closed-head injury and the subarachnoid blood. an eeg was performed to ensure that he was not having subclinical, nonconvulsive seizures as the cause of his decreased alertness. it showed rare blunt and sharp waves over the right posterior quandrant, no epileptiform activity, and generalized delta frequency slowing suggesting a moderate to severe encephalopathy. --still with minimal resposiveness --nimodipine 60 q4h and dilantin for sah --eeg prelim read with no epileptiform and mod-severe encephalopathy --repeat ct with more blood around midbrain/pons and worsening hydrocephalus, so neurosurg put vent drain in --mri and ct of c-spine with no injury-->d/c'd hard collar --neurosurg following --angio --no aneurysm, no avm seen, no vasospasm either. all looked good. will keep sbp 110-140s where its been -nimodipine and dilantin/keppra eventually discontinued as patient showed no evidence of seizure activity or vasospasm 2. pulm: intubated, vented. had been doing well on fio2 0.30 with po2 ~100 but on had po2 ~60 and had to increase fio2 to 0.40. has pna--see id below 3. id: has been persistently febrile (101-102), unclear --sah vs infection. wbc still normal, but on had incr'd o2 requirement and thick yellow sputum. sputum from with serratia. started ctx on . cxr with rll opacity and right effusion. changed abx to levoflox on as serratia tends to become resistant to cephalosporins per lab, on found to be cipro resistant, so then switched to meropenum . 4. cv: a) afib with rvr: on night of starting having afib/rvr (no history of such, though ?found by ems in afib per son) and started on amio iv load am . then while amio going in, had multiple sinus pauses, up to ~8 sec!, mostly when flipping out of afib back to sinus. ep consulted, and since they can't be sure that he wasn't doing this without the amio (he has had dizziness in past few weeks) and since can't be sure that fall wasn't symptomatic sinus pause, they will put in temporary pacer (has to be temporary given pna currently) on . --so new attndg on ep and plan changed--will just watch on tele in icu until afeb/pna over and then put in permament pacer --currently on dilt gtt for rate control. avoid amio if can per ep --no heparin/coumadin for paf for now given ich b) bp: nimodipine for sah, goal bp<130 fen: tfs ppx: ppi, iss, boots. start hep sc (24hrs after angio) full code comm: with wife and dtr medications on admission: aricept, metoprolol, zoloft, trazodone, ativan discharge medications: 1. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 3. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 4. heparin sodium (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 6. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 7. metoclopramide 5 mg/ml solution sig: ten (10) mg injection q6h (every 6 hours) as needed. 8. metoprolol tartrate 5 mg/5 ml solution sig: five (5) mg intravenous q6h (every 6 hours). 9. meropenem 1 g recon soln sig: 1000 (1000) mg intravenous q8h (every 8 hours) for 6 days. discharge disposition: extended care facility: - discharge diagnosis: 1. stroke 2. afib 3. subarachnoid hemorrhage discharge condition: stable neurologic exam discharge instructions: please return to nearest er if symptoms worsen. please take all medications as prescribed. keep all follow-up appointments. followup instructions: please follow-up with dr. / in 4 months, call to schedule a convenient time. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Arterial catheterization Temporary tracheostomy Ventricular shunt to extracranial site NEC Diagnoses: Pneumonia due to other gram-negative bacteria Unspecified essential hypertension Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Atrial fibrillation Unspecified fall Acute respiratory failure Cerebral artery occlusion, unspecified with cerebral infarction Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress. major surgical or invasive procedure: placement of mini-tracheostomy tube, . history of present illness: 76 y.o. gentleman with history of recurrent pneumonia, paf, cognitive deficits readmitted from rehabilitation hospital where he had been transferred after recent 25 d admission to for subarachnoid hemorrhage with ventricular drain placement, course c/b prolonged intubation necessitating trach and peg. pt tracheostomy had undergone recent decannulation. he presents with two days of increased secretions, tachypnea and slightly altered mental status with desaturation to the 80s. pmh also notable for recurrent pneumonia he has a h/o serratia pna requiring meropenem and per the ed notes the patient was to be started on ceftriaxone for serratia isolated from his sputum. he had also been recently started on bactrim for a uti, and flagyl to prevent cdiff with the initiation of these abx. in the ed he was found to be febrile to 102, tachypneic with rr =40 and tachycardic to 112. wbc at 13.5 (pmn predominance) initial lactate was 3.1, subsequently declined to 1.2. initial abg 7.42/33/74. ecg revealed sinus tach with pacs. he was given ivf, vanc, ceftazadime 1 g and ivf and tylenol. past medical history: 1) htn 2) gait abnormality presumed to be nph since per family it improved after lp at . gait abnormality reported to have worsened recently. 3) sah in diagnosed after pt found down. sah suspected secondary to trauma. external ventricular drain placed head ct demonstrated multiple sahs and intraparenchymal hemorrhages but angio negative for anneurysm, s/p ventricular drain, trach and peg 4) atrial fibrillation discovered when he presented with ich with 8 sec pauses 5) h/o recurrent pnas - serratia initially pan sensitive but required switch from levo to ?? 6) h/o sinusitis/seasonal allergies per family. social history: lives with wife. 80 pk-year smoking history, quit 20 years ago. no recent alcohol or tobacco use. family history: son with afib s/p ablation. physical exam: tm/tc = 102.6 rectally, hr = 113, 105/28, rr = 40, 97% 100% nrb gen: cachectic elderly male, tachypneic with coarse breath sounds, + temporal wasting. alert with eyes open. heent: ncat, pupils min reactive, anicteric. op clear with dry mm neck: no jvd cv: tachy, nml s1, s2, no m/r/g lungs: crackles and decreased bs @ right base. abd: peg tube site c/d/i, soft, nt, nd, nabs, guaic -ve per ed, stage iv sacral decub which probes to the bone. no prurulent exudate, red granulation tissue observed. extremities: fem pulses 2+ b/l with left bruit, no edema, no open wounds. warm and dry but dpp not appreciated bilaterally. neuro: alert, directs gaze to the sound of my voice but does not obey commands. withdraws to pain. pertinent results: laboratories on admission: 12:06pm blood wbc-13.5*# rbc-4.13*# hgb-12.0*# hct-37.1*# mcv-90 mch-29.1 mchc-32.4 rdw-15.0 plt ct-290 12:06pm blood neuts-91.7* lymphs-5.7* monos-2.2 eos-0.4 baso-0 12:06pm blood pt-13.2 ptt-31.7 inr(pt)-1.1 12:06pm blood glucose-122* urean-24* creat-1.0 na-133 k-4.9 cl-96 hco3-26 angap-16 12:06pm blood calcium-8.9 phos-4.1 mg-1.9 01:21pm blood type-art po2-74* pco2-33* ph-7.42 calhco3-22 base xs--1 12:12pm blood lactate-3.1* 01:21pm blood lactate-1.2 ****** cxr: ? rul consolidation but may have been present in . no ptx. l base not seen in x ray. ******* ecg: sinus tach, nml axis, no acute st-t changes ****** ct head : conclusion: perhaps very slight increase in size of the subdural hemorrhages, which still appear chronic in age. ******** saccrum/coccyx the lateral view has some of the osseous detail obscured in the region of the sacrum and the distal coccyx is cut off from view. frontal view has poor angulation and overlying soft tissue structures preclude definitive evaluation. degenerative features are seen in the lower lumbar spine. impression: quality of the films is not sufficient for ruling out osteomyelitis. if this is a real clinical concern, ct scan may be more valuable. ********* b/l le veins findings: grayscale and doppler son of the left and right common femoral, superficial femoral, and popliteal veins were performed. normal flow, augmentation, compressibility, waveforms are demonstrated. there is no intraluminal thrombus. ******* cxr impression: ap chest compared to 8:40 a.m. on . disparity in lung volume, right substantially greater than left has been present without appreciable change since . left lung though small is otherwise unremarkable. the right lung is presumably hyperinflated. there is no pneumothorax or pleural effusion, although the lateral aspect of the right hemithorax is excluded from the examination and the patient is rotated. i would recommend a repeat view carefully position with the patient erect. heart size is normal and mediastinum is midline. *************** echo conclusions: 1. the left atrium is normal in size. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild global left ventricular hypokinesis. overall left ventricular systolic function is low normal (lvef 50-55%). 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4. the aortic root is moderately dilated. the ascending aorta is mildly dilated. 5. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation seen. 6.the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. 7. the estimated pulmonary artery systolic pressure is normal. 8.there is no pericardial effusion. brief hospital course: this is a 76 year-old gentleman with history of recurrent pnuemonia, paroxysmal atrial fibrillation, sacral decubitus wound, and recent admission for subdural and subarachnoid hemorrhage. he was readmitted from rehabilitation hospital admitted for day history of respiratory distress, fever, increased secretion, presumed secondary to nosocomial and/or aspiration pneumonia. febrile, tachypneic in ed with elevated wbc. also slightly worsened mental status. started on vancomycin, ceftriaxone, flagyl empirically for presumed nosocomial and/or aspiration pneumonia microbiological studies revealed gram positve rods in sputum, also gram positve rods with gram negative rods in sacral decub wound. the blood cultures from also grew out g+ cocci. 1) respiratory failure / hypoxemia: on day one of micu admission pt noted to be afebrile, but with yellow, thick secretions. one mucus plug was suctioned. secretions diminished through night. following morning pt afebrile oxygenating and ventilating well on 50% mask as shown by arterial blood gas. given fever, leukocytosis, increased secretions, pt's increased resp distress was thought to be due to pneumonia though no infiltrate was seen on xray. given h/o resistant serratia, and long-term care facility residency he was started on broad spectrum antibiotics to cover a nosocomial pneumonia-- vancomycin and ceftriaxone. he was also started on flagyl due to his aspiration risk. he also received aggressive pulmonary toiiet to aid with secretion clearance. initially, he was placed on a 100% nonrebreather, but with suctioning and clearance of mucous, he was quickly weaned to nasal canulla. his lung exam and resp distress all improved quickly within 2 days of initiation of antibiotics. he was called out to the floor on . sputum culture did not reveal definite pulmonary pathogen. bactrim was stopped. on , pt was noted to be more tachypneic, tachycardic into 120s, and with increasing o2 requirement. he was readmitted to the micu for stablization. the somewhat acute onset was concerning for pe in the setting of tachycardia. however, cta was not done as patient not a candidate for anticoagulation with heparin; instead, b/l le u/s was done with no evidence of dvt and no need for ivc filter. not thought to be heart failure, as cxr and exam did not suggest this, and he appeared dry rather than wet. the most liklely etiology was mucous plugging, and when it was apparent that he had continued increased secretions without a good cough, it was decided to place a minitrach (). this method worked to help with suctioning secretions and the patient was noted to have a stronger cough. an echo was performed to rule out cardiac source of hypoxia and was normal. by discharge he was on a face mask, sating 96-100%, not tachypnic, in no respiratory distress. antibiotics were stopped after a full 7 day course (d/c ). . 2) fever/infection: likely due to pneumonia and treated as above. no evidence of ongoing uti though pt has history of this. althought the sacral debub ulcer did not appear clinically infected it did grow out mrsa and gram negative rods. the patient completed a 7 day course of vancomycin and cefriaxone. an film of the saccrum/coccyx was obtained and did not show osteomyletis, but this was of poor qualitiy. no ct was obtained to further evaluate this. his blood cultures grew out coagulase negative staph. . 3) mental status: on admission, pt was more lethargic and less interactive than at baseline, though even at baseline, his mental status is limited. a head ct did not reveal any acute process such as intracranial hemorrhage. with treatment of his infection and resp distress, his mental status returned to baseline. . 4) sacral decubitus ulcer: wound care team contact and wet-to-dry dressing applied. he was continued on vitamin c. on he was changed to qd aquacel dressing changes per would care team consult. due to stage iv decubitus ulcer, plastics was contact to evaluate surgical options for closure of wound. however, they stated that creating a flap was not an option as these fail in 95% of patients and expose the patient to an additional site that could become ulcerated and infected. their recommendations were to continue aggressive wound care to keep the area clean. swab of the would grew sparse mrsa, sparse enterococcus, and sparse corynebacterium. there was a discussion regarding whether the patient is colonized with mrsa at this site and whether or not the presence of mrsa necessitated treatment. id was consulted and it was felt that because the patient did not have a white count, was afebrile, and because the wound did not look actively infected, there was no indication for long-term iv antibiotics. the best care to give this patient was felt to be optimal wound care. . 5) history of a-fib: in sinus rhythm. continued on lopressor. heparin was relatively contraindicated and not used. . 6) fen: pt continued on tube feeds. persistent hyponatremia which is chronic--free water flushes were held on his tube feeds. when he went to the micu, he was bolused with fluids and his na returned into a normal range. would recommend limiting free water at rehabilitation facility. . 7) anemia - hct decreased since admission. likely pt was hemoconcentrated on admission and now returning to baseline of low 30s. no obvious source for bleed. will cont to follow hcts. . . 8) communication - wife medications on admission: lopressor 25 vit c bactrim t flagyl 500 tid tylenol erythromycin gtt opth nystatin donepezil 5mg qhs reglan methylphenydate lansoprazole sq heparin albuterol discharge medications: 1. memantine 5 mg tablet sig: one (1) tablet po bid (). 2. heparin sodium (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 3. donepezil 10 mg tablet sig: 0.5 tablet po hs (at bedtime). 4. erythromycin 5 mg/g ointment sig: 0.5 ointment ophthalmic (2 times a day). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. albuterol sulfate 0.083 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for wheezing. 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 8. methylphenidate 10 mg tablet sig: one (1) tablet po bid (2 times a day). 9. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 10. metoclopramide 5 mg/5 ml solution sig: ten (10) ml po qidachs (4 times a day (before meals and at bedtime)). 11. lansoprazole 30 mg susp,delayed release for recon sig: one (1) solution po daily (daily). 12. ascorbic acid 90 mg/ml drops sig: five hundred four (504) mg po tid (3 times a day). 13. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 14. sodium chloride 1 g tablet sig: three (3) tablet po three times a day. 15. ascorbic acid 500 mg tablet sig: one (1) tablet po three times a day. 16. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. discharge disposition: extended care facility: - discharge diagnosis: aspiration pneumonia. nosocomial pneumonia. sacral decubitus wound infection. subarachnoid and subdural hematoma. discharge condition: good. afebrile, no respiratory distress with reduced secretions. discharge instructions: patient to return to rehabilitation facility. followup instructions: rehabilitation facility. Procedure: Enteral infusion of concentrated nutritional substances Revision of tracheostomy Diagnoses: Anemia, unspecified Pneumonia due to other gram-negative bacteria Urinary tract infection, site not specified Hyposmolality and/or hyponatremia Atrial fibrillation Pulmonary collapse Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Bacteremia Pressure ulcer, lower back Late effects of cerebrovascular disease, aphasia Communicating hydrocephalus Foreign body in larynx Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation

discharge medications: same as prior discharge summary addendum except discontinue vancomycin. discharge to hospital for acute rehabilitation. follow up with primary care physician, . in and ear, nose and throat follow up in two months for tracheostomy tube examination. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other permanent tracheostomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Bronchoscopy through artificial stoma Insertion of totally implantable vascular access device [VAD] Other gastrostomy Aspiration of other soft tissue Aspiration of other soft tissue Diagnoses: Urinary tract infection, site not specified Other pulmonary insufficiency, not elsewhere classified Candidiasis of mouth Other constipation Acute bronchitis Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of other specified part of esophagus Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Tracheoesophageal fistula

discharge medications: 1. vancomycin 1 gram q12 hours. 2. bowel regimen with senna and lactulose. 3. protonix. 4. ativan p.r.n. 5. percocet elixir. follow up: the patient will follow up in one to two weeks time from acute rehab with her primary care physician. family is intermittently involved in her care and will receive training along with the patient for proper tracheostomy tube care at acute rehabilitation. the patient's code status was determined on this admission to be dnr/dni. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other permanent tracheostomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Bronchoscopy through artificial stoma Insertion of totally implantable vascular access device [VAD] Other gastrostomy Aspiration of other soft tissue Aspiration of other soft tissue Diagnoses: Urinary tract infection, site not specified Other pulmonary insufficiency, not elsewhere classified Candidiasis of mouth Other constipation Acute bronchitis Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of other specified part of esophagus Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Tracheoesophageal fistula

history of present illness: the patient is a 69 year old female with no significant past medical history who presented to hospital with acute onset of respiratory distress. the patient had been noticing an enlarging neck mass for the past three to four years. as hospital notes, the patient noticed increasing phlegm production two days prior to admission and increasing shortness of breath. she was being evaluated by otorhinolaryngology as an outpatient and sent to hospital for head/neck/chest computerized tomography scan. while in the waiting room the patient had an acute onset of respiratory distress requiring intubation and was admitted to the hospital intensive care unit. because the outside hospital was unable to provide radiation, the patient was transferred to the . 100 cc of necrotic material was aspirated from the left neck mass which by report is consistent with squamous cell carcinoma. computerized tomography scan of the neck/chest revealed a 7 by 7 cm left-sided neck mass with deviation of the trachea to the right and compression of the trachea around the endotracheal tube. no obvious tumor was seen in the chest computerized tomography scan. past medical history: none. allergies: no known drug allergies. medications: medications as an outpatient, none. medications on transfer were heparin subcutaneously, morphine and ativan prn. family history: non-contributory social history: the patient lives with one son and her grandson. she quit tobacco 30 years ago and smoked less than half a pack per day for a few years. she denies alcohol use. she works at and was working prior to her otorhinolaryngology visit. before that she worked for 14 years at a stride-rite factory gluing soles to bottom of shoes. laboratory data: laboratory studies at an outside hospital revealed sodium 138, potassium 3.9, chloride 101, bicarbonate 31, bun 7, creatinine .8, glucose 128, white blood cell count 8.2, hematocrit 32.9, platelets 300, ldh 228. arterial blood gases, pressor support ventilation of 10 and 5 is 7.54, 27, and greater than 250. physical examination: on physical examination vital signs were 100.2, heartrate 98, blood pressure 141/93, respiratory rate 14 and oxygen saturations 100%. in general the patient is an elderly female in no apparent distress, awake, and answering questions. head, eyes, ears, nose and throat, extraocular muscles intact. pupils, equal and reactive to light and accommodation. large left-sided neck mass, nontender, approximately 8 by 8 cm. small 1 cm area of ecchymosis around the biopsy site. heart, normal s1 and s2, no murmurs, rubs or gallops. lungs clear to auscultation bilaterally. abdomen obese, soft, nontender, positive bowel sounds. extremities, no cyanosis, clubbing or edema. radiographs: chest x-ray from outside hospital, large left neck mass with questionable mediastinal lymphadenopathy, endotracheal tube at carina. chest computerized tomography scan without contrast, large neck mass, 7 by 7 in diameter, left trachea shifted to right, trachea compressed around endotracheal tube. computerized tomography scan of chest revealed multiple anterior mediastinal lymph nodes and para-aortic tracheal compression with deviation to the right, no parenchymal lung lesions are seen, small left pleural effusion. hospital course: this is a 69 year old female with left-sided neck mass consistent with squamous cell carcinoma, most likely of esophageal origin, causing airway compromise, intubated for airway protection. 1. left-sided neck mass - on arrival to , the patient was evaluated by radiation medical oncology and otorhinolaryngology. it was felt given the size of the mass that extubation could not be done safely without further securing the airway. the patient had a computerized tomography scan of the neck and chest with contrast and an magnetic resonance imaging scan of the chest which revealed the following. computerized tomography scan of the head revealed no evidence of intracranial metastatic disease. computerized tomography scan of the chest showed a large neck mass which tracks along the posterior wall of the trachea into the thoracic inlet, measuring 7 by 11 cm, multiple enlarged mediastinal lymph nodes and a small lower thoracic vertebral body hemangioma. the magnetic resonance imaging scan of the neck with gadolinium showed redemonstration of an enormous neck mass with probable infiltration in the region of the left carotid sheath and other signs of spread. in light of these findings, the patient was scheduled for operating room placement of a tracheostomy. the patient was sent to the operating room on , hospital day #9. in the operating room the procedure was noted to be very difficult and a tracheoesophageal fistula was found. the patient's trachea was dissected to the fifth tracheal ring and an endotracheal tube was placed instead of a stable tracheostomy tube, given the difficulty of the procedure. on hospital day #10, the patient had an open gastrostomy tube placed and a port-a-cath placed by general surgery. a panendoscopy was done at the time of her tracheostomy placement on hospital day #10 which showed diffuse tumor in both the trachea and the esophagus. multiple biopsies were done of the esophagus and it was felt at this time that the tumor was originating from the cervical esophagus, although this could not be definitely confirmed. on the day after gastrostomy tube and port-a-cath placement, extensive discussions were taken with the family. interventional pulmonology was consulted for possible stenting of the esophageal tracheal fistula, however, given the location it was felt that no stent could be placed in either the esophagus or the trachea at this time. given the poor prognosis with the extent of disease, complicated by the tracheoesophageal fistula, the decision on whether to pursue radiation and chemotherapy was in question. the patient met with both radiation oncology and medical oncology and was told about the risks and benefits of treatment. given the fistula, it was thought that radiation and chemotherapy, while possibly able to provide some local control of tumor extension, would only worsen the fistula and cause neutropenia increasing infection risk. the patient decided that she wanted to not pursue chemotherapy and radiation therapy and would want to go home with home hospice care. the patient was also made do-not-resuscitate at this time. given the unusual nature of the patient's tracheostomy tube, a customized tracheostomy was ordered and is currently enroute to the hospital. the patient is to have a more permanent airway placed on wednesday, . if the patient is able to tolerate the patient and her airway remains stable, she should be able to be discharged home with maximal home services. during this hospitalization palliative care was consulted to aid in placement and home services. they are currently following the patient and have already provided some possible resources for the patient. 2. tracheobronchitis - on hospital day #2 the patient had a bronchoscopy to evaluate for any intrinsic compression of airways by the neck mass. airways appeared patent below the endotracheal tube, however, numerous secretions were seen. bal later grew out staphylococcus aureus which was pansensitive. the patient completed a ten-day course of levaquin and clindamycin which was later added after the tracheal esophageal fistula was found. currently, the patient has occasional secretions and lowgrade temperatures, however, secretions overall have decreased this admission and the patient's cough has not increased. we will try to observe the patient off of antibiotics but anticipate that she may continue to have lowgrade fevers due to her tracheoesophageal fistula and extent of tumor burden. 3. urinary tract infection - the patient had an urinary tract infection during this admission which was escherichia coli pansensitive. the patient was treated with levaquin, and subsequent cultures have remained negative. the foley catheter was discontinued on hospital day #19. 4. thrush - it was noted that the patient has several plaques on her tongue and was started on nystatin swish and swallow which will have to continue while at home. 5. constipation - it was noted that the patient had multiple episodes of constipation in the setting of roxicet narcotic use for incisional pain. this has resolved with an adequate bowel regimen. 6. physical therapy - the patient was evaluated by physical therapy who felt that the patient may be able to be discharged home with maximal services. the patient has been ambulating without complications. 7. respiratory status - the patient was initially on vent support, however, this was slowly weaned during her hospital course and she is currently on a t-piece 24 hours a day without any necessary vent support. she should be able to go home with a similar apparatus. she no longer needs any vent support. 8. tubes, lines and drains - the patient has had her foley catheter discontinued. she has a port-a-cath which has been deaccessed and has a percutaneous endoscopic gastrostomy tube. she is currently receiving tube feeds 24 hours a day at 60 cc/hr. 9. code status - the patient is currently do-not-resuscitate. discharge diagnosis: 1. stage 4 cervical esophageal cancer 2. airway compromise, status post tracheostomy 3. tracheobronchitis 4. urinary tract infection 5. thrush 6. constipation an addendum will be added to this dictation summary with the rest of the hospital course. this dictation cover the timeframe from to . disposition will be determined at a later date. the patient will follow up with her primary care physician, . who is . dr., 12-981 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other permanent tracheostomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Bronchoscopy through artificial stoma Insertion of totally implantable vascular access device [VAD] Other gastrostomy Aspiration of other soft tissue Aspiration of other soft tissue Diagnoses: Urinary tract infection, site not specified Other pulmonary insufficiency, not elsewhere classified Candidiasis of mouth Other constipation Acute bronchitis Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of other specified part of esophagus Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Tracheoesophageal fistula

past medical history: 1. coronary artery disease, status post catheterization in with diffuse lad disease. the patient had a normal p mibi in . 2. history of left bundle branch block. 3. history of noninsulin-dependent diabetes mellitus. 4. hypertension. 5. anemia secondary to mgus. 6. status post left carotid endarterectomy. 7. history of zoster. allergies: the patient has no known drug allergies. medications on admission: 1. aspirin 325 mg p.o. q.d. 2. atenolol 50 mg p.o. q.d. 3. lasix 80 mg p.o. q.d. 4. mavik 16 mg p.o. q.d. 5. metformin 500 mg p.o. b.i.d. 6. norvasc 10 mg p.o. q.d. 7. iron 325 mg p.o. q.d. social history: the patient quit smoking approximately 25 years ago. she denied alcohol use. she lives alone. she served as a waitress for 52 years. physical examination on admission: in general, the patient was comfortable in no acute distress. heent examination revealed that the oropharynx was clear with moist mucous membranes. neck: jvp went to the level of approximately 10 cm. the neck was supple. chest: rales at both bases were noted. heart: regular rate and rhythm with normal s1, s2 with no appreciable murmurs. abdomen: soft, nontender, nondistended, guaiac negative in the emergency department. extremities: trace pedal edema with 1+ dp pulses. laboratories on admission: white count 6.5, hematocrit 28.8, platelets 253,000. chem-7 on admission revealed a sodium of 135, potassium 5.0, bun 37, creatinine 1.4, glucose 145, magnesium 2.2. pt 12.5, inr 1.1, ptt 30.2. the ekg was normal sinus rhythm with left bundle branch block. chest x-ray was notable for mild chf. hospital course: the patient is a 73-year-old with known coronary artery disease, left bundle branch block, presenting with chest pain. the patient's presentation was concerning for acute coronary syndrome and her admission ekg had an old left bundle branch block with no significant change from a prior ekg. the patient was treated for acute coronary syndrome with aspirin, nitro drip, heparin drip, as well as aggrastat. she had cardiac enzymes cycled which had negative ck and troponin. the patient was ruled out for myocardial infarction with enzymes. she went to cardiac cath where right heart catheterization revealed hemodynamics with a right atrium pressure of 15, pulmonary artery pressure of 62/28 with a mean of 43, and pulmonary capillary wedge pressure of 19. a wave 29 with v of 22. the patient's cardiac output by fick was 5.09 liters per minute. given the patient's renal labs at that point revealing a creatinine of approximately 1.6 and the patient's hematocrit was 28.7, it was decided to admit the patient to the ccu briefly for blood transfusion, hydration, and acetylcysteine treatment. the patient received a total of 2 units of packed red blood cells during this admission. her hematocrit on admission was 28.8 and had increased to 32.2 after 2 units of the packed red blood cells. after the patient's prehydration and blood transfusion, she underwent cardiac catheterization. the cardiac catheterization showed three vessel coronary artery disease. the lmca had a distal 40% stenosis which involved the origins of the lad and lcx, lad had moderate disease throughout which was more severe in the middle with a maximal stenosis of 50-60%. the circumflex had a 50% stenosis. the catheterization was also notable for moderate diastolic biventricular dysfunction as well as severe pulmonary hypertension. after the catheterization, the patient was transferred back to the cardiac medicine floor where she had an echocardiogram which showed the left atrium to be mildly dilated with mild metric lv hypertrophy. there was mild lv systolic dysfunction with mild hypokinesis of the anterior septum. the rv was normal size with normal free wall motion. regarding the patient's catheterization, it was felt that the patient should continue her current medical management and in addition imdur 30 mg p.o. q.d. was added to her regimen. discharge condition: good. discharge status: the patient is to be discharged to home. discharge diagnosis: 1. status post cardiac catheterization and history of coronary artery disease. 2. history of noninsulin-dependent diabetes mellitus. 3. history of anemia. discharge medications: 1. mavik 16 mg p.o. q.d. 2. imdur 30 mg p.o. q.d. 3. lasix 80 mg p.o. q.d. 4. protonix 40 mg p.o. q.d. 5. iron 325 mg p.o. t.i.d. 6. metoprolol 50 mg p.o. q.d. 7. aspirin 325 mg p.o. q.d. 8. sublingual nitroglycerin p.r.n. 9. norvasc 10 mg p.o. q.d. 10. metformin 500 mg p.o. b.i.d. follow-up: the patient is to follow-up with her cardiologist, dr. , in two weeks. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other chronic pulmonary heart diseases Unspecified disorder of kidney and ureter Heart disease, unspecified

discharge status: the patient was to be discharged to the tippete house. medications on discharge: 1. morphine 5 ml t0 10 ml of a 10-mg/5 ml solution by mouth q.4h. as needed (for discomfort). 2. ativan 0.5 mg by mouth q.4-6h. as needed (for anxiety). discharge instructions/followup: none. , m.d. dictated by: medquist36 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 Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Acute respiratory failure Septic shock Malignant neoplasm of other parts of bronchus or lung Encounter for palliative care Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]

history of present illness: ms. is a pleasant 77-year-old female who was recently diagnosed with nonsmall cell lung cancer in , and is status post four treatments consisting of taxol, carboplatin and xrt to the right pretracheal mediastinal area, who presents to the emergency department with fever and decreased blood pressure along with some confusion. the patient was recently discharged on with the new diagnosis of her nonsmall cell lung cancer and was sent to for conditioning while receiving her chemotherapy. the patient had been tolerating the treatments well until the night before admission when she started complaining of fatigue, and her o2 sat dropped to 93% on room air. later on, the patient became very hypoxic with an oxygen saturation of 87% on room air, and started experiencing lethargy along with increased confusion. the patient received percocet for her pain, and her temperature spiked to 101.8, and o2 sats continued to drop to 86% on 4 liters of nasal cannula. the patient also had decreased urine output, and her blood pressure on arrival to the ed was 100/60, with a pulse of 110, and a respiratory rate of 30. the patient also started to experience some diaphoresis along with accessory muscle use, and was sent to the ed of . on admission, the patient denied any headache, neck stiffness, rash, cough, shortness of breath, chest pain, abdominal pain, dysuria, frequency, urgency of her urine. the patient was started on zosyn and transferred to the kenard-icu on the mus ....... protocol for a working diagnosis of septic shock secondary to pneumonia. past medical history: 1. nonsmall cell lung cancer. 2. copd. allergies: no known drug allergies. social history: she was a retired psychologist at . she lives alone in , . she used to smoke but quit 15 years ago, but occasionally has 1 or 2 cigarettes a week. denies any iv drug use, but is an occasional alcohol drinker. medications on admission: 1. colace 100 mg . 2. protonix 40 mg qd. 3. trazodone 25 mg q hs prn. 4. tylenol prn. 5. percocet prn. 6. calcitonin 200 u intranasal qd. 7. albuterol-atrovent inhalers. 8. lasix 20 mg . 9. lactulose. 10.fluoxetine 20 mg qd. 11.dexamethasone 4 mg po qid. physical exam on admission - vital signs: temperature 95, pulse 107, blood pressure 132/68, respiratory rate 20, o2 sat 95% on 4 liters. general: pleasant, elderly female who appeared to be in no acute distress on admission. heent: perrla. neck: supple, dry mucosal membranes. heart: s1, s2, tachycardic. lungs: diffuse expiratory wheezing with no accessory muscle use at the time of admission. no paradoxical breathing. abdomen: soft, nondistended, nontender, positive bowel sounds. extremities: warm, no edema, 2+ pulses. neuro: alert, awake, oriented x 3, motor strength in upper and lower extremities. labs at admission: white count 0.2, anc 170, crit 33.2, platelets 85, pt 12.4, ptt 29.1, inr 1.0, sodium 124, potassium 4.7, chloride 93, bicarb 23, bun 19, creatinine 0.2, glucose 84, mag 1.6, phosphorus 2.7, alt 30, ast 26, amylase 37, lipase 9, alk phos 109, total bili 0.8, albumin 2.8, lactate 1.8. urinalysis was negative with no signs of infection. abgs 7.43, pco2 35, po2 77 on 100% nonrebreather. radiographic images: chest x-ray showed a large spiculated density in the right hilum, 7.0 x 5.2 cm, along with adenopathy. pulmonary vasculature was slightly prominent with kerley b lines consistent with chf. improved bilateral pleural effusions as compared to prior x-rays. ekg: showed 100 beats per minute, rate sinus rhythm, normal axis, normal intervals, delayed r wave progression, and there was some t wave inversions in v2-v4. hospital course - 1) sepsis/id: the patient presented to the hospital with hypotension, fever, lethargy, and had a white count of 0.2 most likely secondary to her most recent chemotherapy. although initially there were no clear presenting symptoms, or signs of patient infection, the patient was started on broad coverage of zosyn, zithromax and vancomycin. blood cultures, urine cultures, sputum cultures were sent, and throughout the hospital course the patient's blood culture grew back positive for strep pneumoniae, and so the patient was tailored accordingly to the sensitivities, and was started on ceftriaxone 1 gm qd. in addition, the zithromax and the zosyn were stopped, since the urine legionella was negative. the patient was also started on stress dose steroids of hydrocortisone 100 mg iv tid which the patient continued for 7 days. throughout the hospital course, the patient's white blood count slowly began to rise without requiring any neupogen. a surveillance set of blood cultures was sent on , and another one on which showed no further growth in the blood. the patient completed a 7-day course of iv ceftriaxone. 2) respiratory: when the patient initially presented, the patient did not appear to be in respiratory distress. however, throughout the hospital course a cat scan was obtained that showed significant right middle lobe and right lower lobe pneumonia, although the patient not producing much sputum. the patient was continued on the ceftriaxone, and on the patient was intubated secondary to respiratory failure. the patient began to retain carbon dioxide and became confused and less responsive. the patient was extubated on in anticipation for comfort measures only since the patient's condition continued to deteriorate with a very poor prognosis. 3) cardiology: the patient has no known coronary artery disease, and throughout the hospital course the patient was in sinus rhythm with occasional pacs and ectopy. the patient was tachycardic which was thought to be a combination from her being in sepsis, volume overload due to resuscitation, respiratory distress. in addition, after intubating, the patient became very hypotensive and had decreased urine output, and so required a significant amount of fluid resuscitation along with levophed to help maintain her blood pressure. her levophed was slowly weaned off a day or two prior to her extubation, since she was able to maintain an adequate amount of blood pressure. 4) heme/onc: the patient completed chemotherapy consisting of taxol, carboplatin and xrt for nonsmall cell lung cancer. dr. who is her primary oncologist was involved during the care of this patient in the icu who recommended that there was no need for neupogen, as her white count would slowly increase. dr. also had an extensive discussion with the family that despite her aggressive treatment, her prognosis is very poor, and so at that time it was decided that she would be extubated for goals of comfort measures only. 5) lines/access: the patient will have a right subclavian line to help get her medications to make her comfortable consisting of morphine and ativan. 6) code: the patient is dnr/dni. 7) communication: the healthcare proxy is her brother, , and their family consisting of mr. , , and ms. were very involved in her care. discharge status: the patient is being discharged to either inpatient hospice versus home hospice with comfort measure goals. discharge condition: the patient is comfortable at this time. discharge medications: morphine prn. discharge diagnoses: 1. nonsmall cell lung cancer. 2. pneumococcal pneumonia. 3. chronic obstructive pulmonary disease. 4. depression. , m.d. dictated by: medquist36 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 Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Acute respiratory failure Septic shock Malignant neoplasm of other parts of bronchus or lung Encounter for palliative care Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]

allergies: patient recorded as having no known allergies to drugs attending: addendum: podiatry performed an osteotomy on left second toe. there were no complications. patient still ready for rehab. swab from still reporting: gram + cocci to id or sensitivities discharge disposition: extended care facility: health of - md Procedure: Venous catheterization, not elsewhere classified Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Aortography Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Other amputation below knee Endarterectomy, lower limb arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Atrial flutter Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Chronic obstructive asthma, unspecified Arterial embolism and thrombosis of lower extremity Atherosclerosis of native arteries of the extremities with ulceration Other bone involvement in diseases classified elsewhere Personal history of peptic ulcer disease Atherosclerosis of autologous vein bypass graft of the extremities Chronic osteomyelitis, ankle and foot

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral foot ulcers major surgical or invasive procedure: right below knee amputation left5 sfa to pt bypassgraft with issvg, left sfa endartectomy, angioscopy angio with bilateral lower extremity runoff picc line rt. history of present illness: 86y/o male with histroy of pvd s/p rt. fem-dp bypass graft with composite svg for rt. foot ulcer returned for right calf wound infection s/p primary closure d/c returns now with persistant right foot wound and new left #2 toe tip wound which probes to bone.denies any constutional symptoms.now admitted for evaluatiion and treatment. past medical history: seizure disorder, last seizure hypertension asthma sleep apnea, uses cpap avascular necrosis of left hip history of peptic ulcer disease macular degeneration colonic polyps internal hemmroids anxiety disorder s/p left hip arthroplasty s/ppartial gastrectomy s/p left hip revision s//p umbilical hernia repair bph social history: retired single. lives in a trailer home. has not been home since habits former d/c x 19 yrs etoh; d/c'd x 19 years family history: unknown physical exam: vital signs: 97.5-56-20 138/68 heent:rt. carotid bruit. carotid pulses palpable 1+ no jvd lungs: l > chest a/p diameter with expiratory wheezes lt.>rt.ronchros rt. air way sounds heart: distant ? irregular. no mumur or gallop abd: protrubrent, soft, nontender active bowel sounds. no abdominal bruits. pv: right foot: lateral foot wouond 2x3cm with clean base with tendon exposed . no excudates. left #2 toe tip wound probes tobone. no erythema,excudate, excudaates pulses: right femoral 2+ palpable,absent popliteal pulses bilaterally,rt. dp absent. rt. pt dopperable. left pedal pulses dopperable. graft pulse palpable. neuro: orient x3. grossly intact pertinent results: 11:51pm wbc-5.1 rbc-2.69* hgb-7.8* hct-24.6* mcv-92 mch-29.2 mchc-31.9 rdw-15.8* 11:51pm plt count-231 11:51pm pt-13.3 ptt-28.6 inr(pt)-1.1 11:51pm glucose-212* urea n-34* creat-1.5* sodium-138 potassium-4.6 chloride-102 total co2-26 anion gap-15 11:51pm calcium-8.6 phosphate-3.2 magnesium-2.2 brief hospital course: admitted to vascular service. wound cultures obtained. started on vanco,levo, and flagyl. placed on bedrest. wound care began. u/s of carotids rt. ica 40-50%, left ica 60-69%. graft duplex : occluded graft. rt. sfa and tibial disease with severe forefoot decreased flow.angiogram: severe bilateral femoral -tibial disease. rt. bka pod# 5/dos left sfa-pt bpg with issvg and lefeet sfa endarectomy, angioscopy. patient tolerated the procedure and tranasfered to pacu extubated.urinary output borderline. fluid bolus prn.transfused for hct. 28.2 pod# no overnight events.afebrile. dieta advanced. iv fluids heplocked. pod# afebril wounds clean dry and intact. graft pulse palpabale with palpable pedal pulses. pt evaluated patient. recommend rehabilitation. piccline placed for continued antibiotics for two weeks.social service consult for emotional support. pod# patient is doing well and ready for rehab. he is full weight bearing. medications on admission: detrol 2mgm amidarone 200mgm qd cozaar 50mgm qd lasix 40mgm qd glipazide 10mgm qd lipitor 10mgm qd protonix 40mgm qd kcl 50meq qd avandia 8mgm qd colace 100mgm lopressor 75mgm atrovent mdi puff 2 qid emycin 500mgm x 10 days () percocet tab q4h prn discharge medications: 1. amiodarone hcl 200 mg tablet sig: one (1) tablet po daily (daily). 2. losartan potassium 50 mg tablet sig: one (1) tablet po daily (daily). 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 4. glipizide 10 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. rosiglitazone maleate 8 mg tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 9. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 11. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 weeks. 12. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 weeks. 13. tolterodine tartrate 2 mg tablet sig: one (1) tablet po bid (2 times a day). 14. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 16. vancomycin hcl 1,000 mg recon soln sig: one (1) gm intravenous twice a day for 2 weeks. 17. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 18. insulin reg (human) buffered 100 unit/ml solution sig: as directed injection four times a day: ac: glucoses <150/no insulin glucoses 151-200/2u glucoses 201-250/4u glucoses 251-300/6u glucoses 301-350/8u glucoses 351-400/10u glucoses > 400 / 12u. discharge disposition: extended care facility: health of - discharge diagnosis: bilateral foot infection history of seizure disorder hypertension asthma/copd left hip avascular necrosis s/p hip arthroplasty ,revision history peptic ulcer disease, asymptomatic diabetes type 2 with nocturnal hypoglycemia coronary artery diseased gout history of pvd s/p rt, fem-dp with composite vein discharge condition: stable discharge instructions: moniter cbc, bun, cr weekly while on vancomycin followup instructions: 2 weeks dr. . call for appoointment Procedure: Venous catheterization, not elsewhere classified Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Aortography Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Other amputation below knee Endarterectomy, lower limb arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Atrial flutter Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Chronic obstructive asthma, unspecified Arterial embolism and thrombosis of lower extremity Atherosclerosis of native arteries of the extremities with ulceration Other bone involvement in diseases classified elsewhere Personal history of peptic ulcer disease Atherosclerosis of autologous vein bypass graft of the extremities Chronic osteomyelitis, ankle and foot

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: disabling cludication major surgical or invasive procedure: right femoral to peroneal bypass graft with insitu vein, angioscopy and valvelysis rt. 5th ray amputation with vac dressing history of present illness: 70y/o nondiabetic with seizure disorder, hypertension,sleep apnea with history of bilateral calf claudication at less than block.underwent outpatient angiogram. returns for elective vascular surgery. past medical history: seizure disorder, last seizure hypertension asthma sleep apnea, uses cpap avascular necrosis of left hip history of peptic ulcer disease macular degeneration colonic polyps internal hemmroids anxiety disorder s/p left hip arthroplasty s/ppartial gastrectomy s/p left hip revision s//p umbilical hernia repair bph social history: retired print shop worker. married lives with his wife. former d/c 19 years ago 3 beer / night family history: unknown physical exam: vital signs: 96.6-65-20 199/79 oxygen saturation 97% room air general: alert ,cooperative white male . no acute distress heent: carotids palpable no bruits lungs: clear to auscultation herat: regular rate rythmn without mumur abdomen: begnin pulses:palpable carotid, radial pulses bilaterally. femorals not palpable secondary to abdominal obesity.popliteal pulses nonpalpable pedial pulses dopperable bilaterally neuro: intact pertinent results: 08:45pm glucose-249* urea n-113* creat-3.0*# sodium-130* potassium-5.2* chloride-94* total co2-24 anion gap-17 08:45pm ck(cpk)-156 08:45pm ck-mb-2 ctropnt-0.05* 08:45pm calcium-8.6 phosphate-4.5 magnesium-2.8* 08:45pm wbc-12.9*# rbc-3.57* hgb-10.3* hct-29.9* mcv-84# mch-28.9 mchc-34.5 rdw-15.7* 08:45pm plt count-289# 08:45pm pt-31.5* ptt-62.6* inr(pt)-6.2 06:27pm urine color-ltamb appear-cloudy sp -1.020 06:27pm urine blood-lge nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 06:27pm urine rbc-791* wbc-52* bacteria-many yeast-many epi-<1 brief hospital course: trnasfered to for evaluation of right foot wound. wound was sustaianed secondary to fall four weeks ago. patient suffered nondisplaced fracture of right hmerous and right shoulder injury. patient was placed in sling for immoblization. he was noted to have a right foot necrotic wound.his anemia was corrected with transfusion of 2 units packed red blood cells.blood and urine cultures were no growth. picc line placed for poor iv access and iv antibiotics.cardology ;consluted for abnormal admitting ekg.a flutter note as rythmn on ekg. recommendations were pmibi,echo, eps consult for consideration of electrical conversion to sinus rythmn. echo: left artrial dilitation. lefet ventricular wall thickness and cavity size normal. no thrombs,valves without structural disease. akensis of anterior and apical wall of left ventricle. fe 55%. stress negative for symptoms or ekg changes. study fixed defect of inferior and apical wall (severe) and fixed defect of basal inferior wall. ef 45%. ct head done for mental status changes. ct consisted with old left occiptual infract and left frontal lobe old encephlomalicia no acute changes. right excisionl foot wound debridment.electrophysology consulted. recommendations: af/flutter chronic. obtain pft, along with thyroid,and liver function test for base ine. start amidarone 400mgm tid x 4 days the 400mgm . no tee required. patient can proceede with any surgical intervention.mra obtained .bilateral femoral -tibial disease. recommend llimited angio study to better define disease in affected foot. patient converted to nsr on amidarone.betablocker and losartan adjusted for better for rate control and systolic hypertension. angiogram toletated. thyroid and liver function studies stable.transfused 2 units for hct. 26. vanco d/c oxycilin started.s/p right fem-pedal bypass graft with composite svg.transfered to pacu stable with palpable pedal graft. pod#1no overnight events. nitro weaned. chest pt continued . diet advanced as tolerated . qntbiotics continued and patient remained in vicu.thrombocytopenia noted.hit sent.result negative. platlet count improved with d/c heparin. pod# 4 transfered to regular nursing floor. pod# 7 rigth 5th ray amputation.transfused one unit packed red blood cell for hct of 25.8 secondary to wound drainage. pod# vac dressing to ray amputation last changes .transfered to vicu for mental status changes and hct. of 24. transfused.gi consulted for positive stool guiac and positive ng drainage. transfered to icu for respiratory failure secondary to hypercapnea ,reintubated. recommendations from gi, follow serial hct's, hold anticoagulation. consider gi scoping upper and lower when medically stqable. required vasopressor support for his hypotension. head ct negative for acute bleed or infract. vac dressing changed with excisional debridment at bed side. duplex of right upper extremity negative for dvt. consulted for glucose managment secondary to recurrent hypoglycemic episodes on oral agents.recommendations: hold oral , adjust regular insulin scale once taking by mouth. pod#14/8 extubated and transfered to vicu. no overnight events. aline discontinued. god large bm!!.glycemic control improved with holding oral agents and using regular insulin scale.physical thearphy recommends rehabiltation prior to discharge to home for continued strenghting and mobility.foley discontinued. central line taken out and d/c to rehab. will need to stay on coumadin 1mg for awhile before advancing. will need to follow up with dr. in two weeks and need out patient gi work up for the melena. medications on admission: see d/c rx discharge medications: 1. losartan potassium 50 mg tablet sig: one (1) tablet po qd (once a day). 2. glipizide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 3. rosiglitazone maleate 8 mg tablet sig: one (1) tablet po qd (once a day). 4. pravastatin sodium 10 mg tablet sig: one (1) tablet po qd (once a day). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for headache. 7. tolterodine tartrate 2 mg tablet sig: one (1) tablet po bid (2 times a day). 8. levofloxacin 500 mg tablet sig: one (1) tablet po q48h (every 48 hours). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po qd (once a day). 10. atorvastatin calcium 10 mg tablet sig: one (1) tablet po hs (at bedtime). 11. amiodarone hcl 200 mg tablet sig: two (2) tablet po tid (3 times a day). discharge disposition: extended care facility: health of - discharge diagnosis: disabling claudication respiratory failure secondary to hypercapnea blood loss anemia, corrected gi bleed, stable discharge condition: stable discharge instructions: vac dressing change q3days.last change followup instructions: dr. 2 weeks . call for appointment. followup with gi for evaluation of gi bleed? Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arteriography of femoral and other lower extremity arteries Amputation of toe Other (peripheral) vascular shunt or bypass Excisional debridement of wound, infection, or burn Arteriography of other specified sites Transfusion of packed cells Transfusion of other serum Application of pressure dressing Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Iron deficiency anemia secondary to blood loss (chronic) Other convulsions Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Atrial flutter Percutaneous transluminal coronary angioplasty status Other persistent mental disorders due to conditions classified elsewhere Ulcer of other part of foot Acute respiratory failure Hypotension, unspecified Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Blood in stool Old myocardial infarction Chronic obstructive asthma, unspecified Atherosclerosis of native arteries of the extremities with gangrene Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Cellulitis and abscess of other specified sites Myasthenia gravis without (acute) exacerbation

history of present illness: mr. is a 72-year-old male with a prior medical history significant for a myocardial infarction in . he was originally treated at an outside hospital in with a successful percutaneous transluminal coronary angioplasty of an occluded obtuse marginal i. he was also found to have a 50% mid-left anterior descending lesion at the time. the patient reports that he also underwent coronary stenting for this lesion, but no report was available. the patient did well until recently, when he began to complain of progressive exertional chest discomfort and shortness of breath. he now gets short of breath after walking approximately one-half block. on , the patient underwent a stress test which was stopped due to severe shortness of breath and fatigue after 3 minutes 30 seconds. he also complained of chest discomfort at the time, with minimal electrocardiogram changes. a mibi at the time revealed a moderate lateral wall and apical reversible defect in addition to a fixed inferior defect. left systolic ejection fraction was approximately 54%. the patient denied any symptoms of claudication, orthopnea, edema, paroxysmal nocturnal dyspnea, or lightheadedness. on , the patient underwent cardiac catheterization given the symptoms of exertional chest pain and a positive mibi. cardiac catheterization showed three vessel coronary artery disease with mild systolic ventricular dysfunction and moderate diastolic ventricular dysfunction. the patient presented to cardiac surgery for a possible surgical solution. past medical history: 1. coronary artery disease status post stenting 2. history of myocardial infarction in 3. diabetes type 2 4. hyperlipidemia past surgical history: 1. carpal tunnel surgery 2. remote history of hernia repair as a child 3. melanoma resection from head and back allergies: no known drug allergies. medications: 1. aspirin 325 mg by mouth once daily 2. atenolol 25 mg by mouth once daily 3. klor-con 10 meq once daily 4. lasix 40 mg by mouth once daily 5. lipitor 20 mg by mouth once daily 6. nitro patch as needed 7. insulin 70/30 58 units every morning, 44 units at dinnertime laboratory data: hematocrit 48.2, white blood cell count 8.2, platelet count 202. pt 14.4, ptt 29.6, inr 1.4. urinalysis negative. glucose 173, bun 20, creatinine 1.0, sodium 144, potassium 3.9. total bilirubin 1.1, calcium 8.5, magnesium 2.4. social history: the patient is married and lives in . hospital course: the patient was referred to cardiac surgery given the results of cardiac catheterization. specifically, cardiac catheterization showed a normal left main. the left anterior descending artery had an 80% stenosis in the proximal vessel, a 90% stenosis in the mid-vessel. the first diagonal branch had a 70% stenosis proximally. the left circumflex artery had a mild luminal irregularity. the first obtuse marginal branch was occluded at its origin. the left posterior descending artery had a discrete 90% stenosis at its origin. left ventriculography revealed hypokinesis of the inferior wall and a calculated ejection fraction of approximately 52%. the patient was admitted to cardiac surgery. on , the patient underwent coronary artery bypass grafting x 3 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to left posterior descending artery). the patient tolerated the procedure well. there were no complications. please see the full operative report for details. the patient remained intubated, and was transferred to the intensive care unit in stable condition. on postoperative day one, he was in sinus tachycardia. he remained hemodynamically stable. he was diuresed appropriately. perioperative antibiotics were administered. the chest tube was removed on postoperative day one. he was placed on insulin drip. he was slowly being weaned off of supplemental oxygen. the patient was transferred to the floor on postoperative day one. physical therapy was consulted, which followed the patient throughout his hospitalization, and eventually recommended rehabilitation center after discharge. the patient continued to make adequate urine. he remained in sinus rhythm. he was noted to be tachycardic most of the time, into the 90s and 100s, even though his lopressor dose was gradually increased. he remained afebrile. the diabetes service was consulted to optimize his insulin regimen, and obtain better control of his blood sugars. the pacing wires were removed on postoperative day three. the patient was continued on amiodarone and lopressor. on postoperative day two, the patient had a very short run of what appeared to be atrial fibrillation, which lasted several seconds, and then he spontaneously reverted to sinus rhythm. he had another episode on postoperative day four, which again lasted just a few seconds. in addition, the patient complained of decreased appetite. nutritional services was consulted to evaluate his caloric intake. the patient's appetite improved. he was ambulating with assistance. he remained in sinus rhythm. his incision was clean, dry and intact on the day of discharge. condition on discharge: good. discharge disposition: rehabilitation facility. discharge diagnosis: 1. three vessel coronary artery disease status post coronary artery bypass grafting x 3 2. diabetes mellitus type 2 3. hyperlipidemia discharge medications: 1. lantus (glargine) 40 units at bedtime 2. aspirin 325 mg by mouth once daily , 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 Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Cardiac complications, not elsewhere classified Atrial fibrillation Other specified cardiac dysrhythmias Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Old myocardial infarction

history of present illness: this 24 year old male, who was an unrestrained back seat passenger in a motor vehicle accident, presented to the on . the patient denied any loss of consciousness and was ambulating at the scene, reportedly complaining of neck pain. the patient remained hemodynamically stable, was placed on a backboard and had a cervical collar placed around his neck. past medical history: none. past surgical history: none. medications on admission: ephedrine supplement. allergies: the patient has no known drug allergies. physical examination: upon presentation to the emergency room, the patient had a temperature of 99.4, blood pressure 109/59, pulse 85, respiratory rate 18 and oxygen saturation 98% in room air. coma score was 15. the patient was alert, oriented and conversing appropriately. on physical examination, the cervical collar was in place. head, eyes, ears, nose and throat: pupils equal, round, and reactive to light and accommodation, extraocular movements intact, abrasion noted over right side of face, nares, throat, oropharynx and tympanic membranes clear bilaterally. chest: nontender to palpation, symmetrical rise, clear to auscultation bilaterally. cardiovascular: regular rate and rhythm. abdomen: soft, nontender, nondistended, pelvis stable to rocking and palpation, anterior, posterior and lateral. rectal: guaiac negative. extremities: moderate tenderness to palpation over the right distal femur and knee area with 2+ pulses distally in both upper and lower extremities. neurologic: sensation intact sharp touch as well as dull touch bilaterally in upper and lower extremities, motor exam intact with 5/5 strength in all four extremities, both flexors and extensors. back: the patient was rolled for examination, which was negative for any obvious injuries, negative for any step-offs; palpation of the midline vertebral. laboratory data: admission white blood cell count was 12.9, hematocrit 42.3, prothrombin time 12.5, partial thromboplastin time 23.1 and inr 1. venous blood gases showed a ph of 7.41, pco2 45, po2 51, bicarbonate 30 and base excess of +2. radiologic data: chest x-ray was negative for any acute injuries. pelvic x-ray was negative for any fracture or acute injury. x-rays and ct scans of the cervical spine corroborated the previous diagnosis of a c2 fracture or a "hangman's" fracture with c2 to c3 disk space disruption. an x-ray was done of the right femur, with four views, which showed no evidence of a fracture. on , an mri of the cervical spine was performed as well as an mra of the cervical vasculature; significant findings were the c2 fracture dislocation with disk herniations at c5-6, c6-7 level. mra demonstrated the absence of flow in the distal portion of the right vertebral artery. hospital course: the on-call spine consultation service was asked to see the patient. they subsequently put the patient on strict cervical spine precautions and requested a magnetic resonance imaging scan of the cervical spine to evaluate the c2-3 disk space disruption. the patient was admitted to the trauma surgery service until attending physician, . . the patient was then preopped to undergo a planned procedure of an anterior c2 to c3 discectomy and fusion. preoperatively, the patient underwent a cerebral angiogram to study the carotid and vertebral arteries as well as the circle of . upon completion of the carotid and cerebral angiogram, it was found that the patient had a transsection of the nondominant and small caliber right vertebral artery at the level of c2, which was the level of the known fracture. the left vertebral artery had excellent flow and supplied the right sided vasculature, with reflux noted into the distal right vertebral artery. at this point, the patient was taken to the operating room after consent was obtained, where he underwent a c2-3 fusion and discectomy. the patient remained in a cervical collar postoperatively at all times. the patient remained hemodynamically stable throughout his entire hospital course and was neurologically intact, without any focal deficits during his entire hospital stay. the patient was transferred to the surgical floor for observation and neurologic checks postoperatively. his diet was advanced as tolerated. the cervical collar remained in place at all times. once again, while on the surgical floor, the patient remained hemodynamically stable, was afebrile, as well as neurologically intact without any focal deficits. he remained in this collar at all times except when bathing. he was advanced to a full diet. his bowel function returned to . the patient was discharged on . condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. fracture of c2. 2. disruption of the c2-3 disk space. discharge medications: percocet 5/325 mg one to two tablets p.o.q.4-6h.p.r.n. discharge instructions: the patient was instructed to ambulate in cervical collar at all times; collar should be worn at all times except when showering and bathing. the patient was instructed to return to the emergency room immediately if he experienced any change in sensation in the extremities or trunk, weakness in any extremity, difficulty breathing, fevers, chills, nausea, vomiting or increasing neck pain. follow-up plans: the patient has made arrangements to follow up with dr. in for follow-up on his postoperative care. the patient should follow up with dr. or orthopedics, telephone number ; he should call to schedule an appointment. , m.d. dictated by: medquist36 Procedure: Other cervical fusion of the anterior column, anterior technique Excision of intervertebral disc Other partial ostectomy, other bones Diagnoses: Closed fracture of second cervical vertebra Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle Closed dislocation, second cervical vertebra

history of present illness: the patient was admitted to on , for chronic obstructive pulmonary disease exacerbation treatment. she was found on the ground on . initial ct scan was noted for bleed but she subsequently developed decreased mental status. repeat ct scan on , revealed left subdural hematoma with midline shift. she was transferred to where, on presentation, she was somewhat awake and was able to squeeze the left hand on command, but was not able to move the right side of her body at all. she developed increasing somnolence and was taken to the operating room for a craniotomy and evacuation. she was initially transferred to the surgical intensive care unit. there, she continued to have very poor mental status. she occasionally appeared able to follow commands, but was not displaying purposeful movements of the upper or lower extremities. she was transferred to the medical intensive care unit on , for management of recurrent fevers to a temperature of 101.0 f, to 102.0 f., as well as for a failure to wean off the ventilator. she had a tracheostomy in place and while in the medical intensive care unit received trials where she was allowed to breathe on her own off the ventilator. she usually was only able to breathe for several hours before she would fatigue and would have to be put back on the ventilator. she continued to spike temperatures to 101.0 f., to 102.0 f. the source of these fevers were unclear. sputum, blood and urine were cultured multiple times and were always negative. a ct scan of the chest did not reveal any obvious source of infection. her mental status continued to be poor; she was unable to speak. she did not appear able to make purposeful movements and in general did not display any improvement in her neurologic status. given her overall poor prognosis and her very low probability for a meaningful recovery, the family decided on , that they wished to withdraw care for her on the evening of . addendum to discharge summary to follow. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Thoracentesis Other lavage of bronchus and trachea Arterial catheterization Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Unspecified fall Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Polycythemia vera

past medical history: copd; chronic a fib; cad; chf; polycythemia; renal insuffiency, ? acute vs chronic; drainage of subdural hematomy ; trach . pt was admitted to nebh for 3 weeks for pneumonia. she was doing well until she was re-admitted for copd exacerbation. on she fell oob and hit her head which produced a large subdural hematoma. she was transfered to for evacuation of the hematoma. she has been in the nsicu since but now has a fuo and failure to wean so he was transfered to the micu. review of systems: resp/gu- she was yesterday and she is being suctioned for tan blood tinged sputum. her vent is on psv 14. she was on 16 cm and dropped to 12 but she didn't tolerate it so she was increased to 14 which she is tolerating. she has a lll consolidation and has a cvp of 14-16. she received lasix 40 mg at 1500 which she responded to with 700cc over 2 hours but she is now down to 20 cc/hr. her tidal volumes have been varied from 500-700 with rr 16-32. cardiac: b/p 120-132/40's, hr 110-120 afib with rare pvc's. neuro: she has been minimally responsive in the micu. she will open her eyes to stimuli but she has not moved her arms or legs. the nsicu has described a waxing and mental status. today the family reported that she was tracking with her eyes to different family members and that she can move her arms (not her legs). the incision site from the surgery is healing well, the staples were removed. id: pt arrived on the floor with a temp of 101.6 which she maintained for 2hours before dropping. she was cultured by sputum, urine and one set of blood cultures from the triple lumen. no antibotics have been ordered yet. ? site of lll consolidation, sinusitis, or menigitis. plan is for a lp to be done tonight or tomorrow. gi: pt had sump ngt in place but it was removed and changed to a pedi feeding tube due to the chance of sinustis. she is receiving promote with fiber at goal rate of 55cc/hr. she has a rectal bag in place draining brown liquid stool. skin: pt has the intact incision on the left side of her head from the hematoma evactation. she also has a decubi on her coccyx that is covered by intact duoderm. she was seen by the skin care rn who applied with duoderm wound gel to the base and duoderm to the top. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Thoracentesis Other lavage of bronchus and trachea Arterial catheterization Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Unspecified fall Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Polycythemia vera

allergies: procardia attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp with plastic stent placement history of present illness: year old male with history of coronary artery disease and atrial fibrillation was admitted on for acute abdominal pain which occured shortly after eating. pain was sharp and non-radiating, localized in the right upper quadrant. his lfts, alk phos, and bilirubin were elevated. he had never experienced pain similar to this in the past. mr. nausea, vomiting and chest pain. he was admitted to the surgical team for further care and monitoring. past medical history: 1. coronary artery disease status post cabg in . 2. atrial fibrillation on coumadin. 3. vestibular schwannoma treated with chemotherapy at . 4. history of a hiatal hernia. 5. total radical resection of the prostate. 6. bilateral inguinal hernia repairs social history: the patient denies any tobacco use, but admits to occasional alcohol use. he lives alone and is retired. family history: none physical exam: vit: temp 99.6 hr 84 sinus bp 137/62 rr 30 o2 sat 95% on 3l face mask eomi,nc/at, perrl, anicteric ctab rrr iii/vi systolic murmur +bs, distended, tympanic, ruq ttp no edema, 2+ pedal pulses foley in place pertinent results: : wbc-6.1 rbc-4.90 hgb-15.7 hct-41.7 mcv-85 mch-31.9 mchc-37.5* rdw-13.8 plt ct-149* pt-21.9* ptt-32.9 inr(pt)-3.4 plt ct-149* glucose-136* urean-21* creat-1.1 na-138 k-4.4 cl-99 hco3-26 angap-17 alt-281* ast-464* ld(ldh)-694* alkphos-179* totbili-3.2* lipase-239* calcium-9.9 phos-3.2 mg-2.1 lactate-2.7* : wbc-3.9* rbc-3.96* hgb-12.7* hct-34.3* mcv-87 mch-32.1* mchc-37.1* rdw-13.6 plt ct-168 : pt-15.0* ptt-29.9 inr(pt)-1.5 k-4.0 : totbili-1.4 : lipase-105* : calcium-8.4 phos-2.4* mg-1.8 brief hospital course: mr. developed tachypnea in the ed and his o2 sats were in the high 80's to low 90's. he was afebrile and cxr showed no evidence of consolidation. he was given lasix and placed on oxygen. his sats improved and an abdominal ct was ordered which showed evidence of cholecystitis. gi was consulted and ercp was performed the same day. he required 4 units ffp to correct his inr prior to procedure. there were no stones in his bile duct and a biliary stent was placed. he was trasferred to the icu for further monitoring due to his troubles maintaining his o2 saturation. by hospital day 3, his sats improved and he was transferred to the floor. his lfts trended down and his symptoms improved. he was started on a light diet and will be discharged to rehab when a bed is available. inr will be monitored by pcp. has been instructed to follow up with dr. in weeks. he will also f/u with gi for a repeat ercp and sphincterotomy in 2 weeks. medications on admission: plavix, trazadone, protonix, lopressor, asa, coumadin, isosorbide, colace, senna discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 6. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. warfarin 2 mg tablet sig: one (1) tablet po hs (at bedtime): please adjust dose based on daily inr results. goal inr . 11. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 10 days. 12. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 10 days. discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: cholecystitis discharge condition: good discharge instructions: please call your doctor or go to the er if you experience any of the following: high fevers >101.5, severe pain uncontrolled by your medication, worsening nausea/emesis. will need daily inr checks until therapeutic on a coumadin regimen. will also need to hold asa, plavix, and coumadin prior to ercp. please follow gi recommendations when appointment is made in regards to holding those medications. followup instructions: provider: , md phone: date/time: 1:50 dr. (for repeat ercp) - please call or for an appointment. will need repeat ercp in 2 weeks. Procedure: Endoscopic insertion of stent (tube) into bile duct Transfusion of other serum Diagnoses: Atrial fibrillation Aortocoronary bypass status Long-term (current) use of anticoagulants Cholangitis Calculus of bile duct with acute cholecystitis, without mention of obstruction