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allergies: procardia attending: addendum: pt is also fo follow-up ercp in weeks from now. discharge disposition: extended care facility: for the aged - md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Transfusion of other serum Trocar cholecystostomy Diagnoses: Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Long-term (current) use of anticoagulants Paralytic ileus Acute cholecystitis

allergies: procardia attending: chief complaint: abdominal pain major surgical or invasive procedure: percutaneous cholecystostomy tube history of present illness: patient is a year old man who was discharged recently from () after recovering from cholangitis who presented again on with a 24-hour history of vague abdominal discomfort with a fever to 101.0. 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. he has a supportive family (niece, nephew). family history: none physical exam: temp 102.0 hr 91 bp 134/45 rr 24 sao2 97% room air alert, oriented irregularly irregular rhythm cta b/l soft, nontender, nondistended. slightly tender diffusely, +bs hyperactive. rectal guiac negative. pertinent results: 08:50pm wbc-7.9# rbc-4.08* hgb-13.0* hct-35.4* mcv-87 mch-31.8 mchc-36.7* rdw-13.7 08:50pm neuts-89* bands-2 lymphs-3* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:50pm plt count-141* 08:50pm pt-21.7* ptt-34.0 inr(pt)-3.4 09:06pm lactate-4.0* 08:50pm glucose-173* urea n-16 creat-1.0 sodium-134 potassium-3.6 chloride-99 total co2-21* anion gap-18 08:50pm alt(sgpt)-26 ast(sgot)-25 alk phos-64 tot bili-0.9 08:50pm lipase-45 brief hospital course: the patient was admitted and had a right upper quadrant ultrasound which showed sludge (s/p previously placed biliary stent) and a small amount of wall edema. no ductal dilatation, no u/s sign. he was admitted to the crimson surgery service for antibiotics, iv fluids and serial exams. ercp was contact and saw the patient. the patient had a hida scan which showed non-filling of the gallbladder. the patient underwent placement of a percutaneous cholecystostomy tube by interventional radiology. immediately following the procedure he had shaking chills and was transferred overnight to the icu for close monitoring. cultures from the bile sample grew e. coli. blood cultures were negative. he was transferred to the floor and recovered well with chest physical therapy, getting out of bed to chair. bowel function slowly returned to after a few days of ileus. the patient did complain of intermittent pain at the chole tube site, sometimes radiating up toward his right chest. ekgs were without any changes, 3 sets of cardiac enzymes were negative, and the patient was otherwise asymptomatic. a picc line was placed for a 2 week course of iv zosyn. his aspirin and plavix (for cardiac stents) were restarted on hospital day 7. his creatinine level increased from baseline 1.1 to 1.8. the previously administered vancomycin was discontinued and he was adequately hydrated. he tolerated a regular diet, supplemented with boost. physical therapy worked with the patient. he was deemed fit for discharge to rehab on hospital day 9. medications on admission: amlodipine 5 trazodone 50 metoprolol 25 asa 81 plavix 75 warfarin protonix 40 colace 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 for shortness of breath or wheezing. 3. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 6. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day): continue until ambulating regularly. 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. warfarin 1 mg tablet sig: one (1) tablet po once (once): titrate to inr 2.0-3.0. 10. piperacillin-tazobactam 4.5 g recon soln sig: one (1) recon soln intravenous q8h (every 8 hours) for 6 days. 11. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 12. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stools. discharge disposition: extended care facility: for the aged - discharge diagnosis: acute cholecystitis discharge condition: stable discharge instructions: please call or return if you have a fever >101.4, persistent nausea/vomiting, persistent diarrhea/constipation, redness swelling or purulent drainage at the percutaneous cholecystostomy tube, any problems with the drainage tube, or any other concerns. followup instructions: please see dr. in 1 week. call to arrange an appointment. please follow up with your primary care doctor and cardiologist as directed. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Transfusion of other serum Trocar cholecystostomy Diagnoses: Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Long-term (current) use of anticoagulants Paralytic ileus Acute cholecystitis

allergies:procardia pt had failed attempt at stent placement during ercp. today he underwent a drain into gallbladder, through liver and upon return to floor became febrile,tachycardic, tachypnic, wheezing and rigors. received 5mg iv lopressor x2,albuterol neb, and 20 mg iv lasix. foley cath placed. good diuresis from lasix. dispo--full code. ros: cardiac--sbp 100/50,hr 87 afib. resp--wearing o2 via 100% non rebrether with sao2 99%. to wean down o2. lungs with crackles in bilateral bases. gi--npo at present. +bs. gu--foley cath patent draining lgr amts of clear urine. endo--unremarkable at present. skin--grossly intact except for dry oral membranes. id--afebrile at present. pain--denies pain. neuro--alert and oriented. mae spont and to command. coping--pt is requesting his hearing aid and water. this rn placed 1 hearing aid in denture cup with his dentures. a-- yo male in nad with crackles in bases bilaterally. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Transfusion of other serum Trocar cholecystostomy Diagnoses: Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Long-term (current) use of anticoagulants Paralytic ileus Acute cholecystitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bladder cancer major surgical or invasive procedure: vesiculectomy with ileal neobladder construction history of present illness: this is a 61-year-old man who presented with gross hematuria and had a diagnosis of moderate grade tcc in . he underwent 3 courses of bcg and in , developed t2 muscle invasive tcc. he was aware of all options for treatment, and wished for radical cystectomy with creation of neobladder. past medical history: arthritis, gerd, bladder cancer s/p bcg x2 and cystoscopy. social history: no alcohol abuse, no nicotine abuse. was in printing business, used dyes. family history: 3 uncles, 2 with bladder ca physical exam: heent: no significant abnormalities noted cv: rrr no mrg appreciated resp: cta b/l, no rrw abd: soft, tender appropriately to palpation, bs +, mildly distended, wounds cdi ext: no cce, peripheral pulses palpable b/l pertinent results: 06:30am blood wbc-7.1 rbc-3.55* hgb-11.2* hct-32.1* mcv-90 mch-31.5 mchc-34.8 rdw-15.0 plt ct-264 06:22pm blood wbc-8.6 rbc-4.00*# hgb-12.5*# hct-36.5*# mcv-91 mch-31.2 mchc-34.1 rdw-14.6 plt ct-167 06:30am blood plt ct-264 06:22pm blood pt-15.1* ptt-31.7 inr(pt)-1.4* 06:30am blood glucose-123* urean-30* creat-1.3* na-137 k-4.1 cl-105 hco3-25 angap-11 02:45pm blood urean-15 creat-1.4* 04:28am blood ck-mb-15* mb indx-1.1 ctropnt-<0.01 08:12pm blood type-art temp-37.6 po2-108* pco2-45 ph-7.36 caltco2-26 base xs-0 intubat-not intuba brief hospital course: pt was admitted for vesiculectomy and ileal neobladder construction. pt did well post operatively, but had episodes of pvc's for which he was taken to micu for observation. cardiology evaluated pt in micu and began lopressor 25 mg for ventricular bigeminy. on pod 2 pt was transferred to floor where he passed flatus and was advanced slowly on his diet, which he tolerated in continuity. pt conitued to have flatus for entire post operative course, and normal bowel function returned on pod 8. pt's pain was intiially controlled with a pca, whcih was changed over to oral pain medication on pod 3. hospital course was significant for leakage of serous fluid for the first 5 post operative days. jp creatinine was elevated and ctu was c/w with extravasation of urine form neo bladder. there was no ureteral leak on ctu. pt was taught on how to flush foley catheter, and was confortable with home care. jp output dropped to less tha 10cc for 24hrs, and was d/c'd prior to discharge. on pod 9 pt was cleared for discharge and sent home with scheduled for follow up in 7 - 10 days for removal of catheter. pt was given bactrim for 7 days and instructed to begin ciprofloxacin on day prior to appointment with dr. for catheter removal. medications on admission: advair 250/50, flonase 1 , singulair 10 qd, zyrtec 15 qd, zocor 40 hs, albuterol neb prn discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for 10 days. disp:*50 tablet(s)* refills:*0* 5. bactrim 400-80 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 6. cipro 250 mg tablet sig: one (1) tablet po twice a day for 7 days: do not start this medication until the day before you return to office for foley catheter removal. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: bladder cancer discharge condition: stable discharge instructions: return to er if: - persistent temp > 101.4 - severe abdominal or pelvic pain - persistent nausea, vomiting or diarrrhea - pus or bloody discharge from wound or urine followup instructions: f/u with dr. in 1 -2 weeks, call office for appointment Procedure: Radical cystectomy Formation of cutaneous uretero-ileostomy Division or crushing of other cranial and peripheral nerves Regional lymph node excision Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Acute posthemorrhagic anemia Cardiac complications, not elsewhere classified Chronic kidney disease, unspecified Other specified cardiac dysrhythmias Other emphysema Polycythemia vera Malignant neoplasm of lateral wall of urinary bladder

history of present illness: this is a 48-year-old african american female with a past medical history significant for mental retardation and unspecified seizure disorder and an atrial septal defect who initially presented to on with a one week history of progressing increasing lethargy and weakness. the patient lives in a group home at community health center and has been noted to be more confused with decreased activity per her caregivers. in the emergency room, patient was found to have a temperature of 90.0 fahrenheit. she received intravenous fluids, bair hugger and a dose of vancomycin, levofloxacin and flagyl with a significant improvement in her clinical condition. chest x-ray at the time revealed patchy multifocal pneumonia with right pleural effusion and a chest ct confirmed these results and ruled out any loculated effusion. she was then deemed stable to go to a general medical floor when she suddenly had a seizure and became hypotensive with a systolic pressure of 90. she responded to aggressive fluid resuscitation but four hours later, had a second seizure and remained in respiratory distress with a respiratory rate of 40 and an oxygen saturation of 97% on 100% nonrebreather and an arterial blood gas with a ph of 7.15, co2 67 and 02 of 60. she was thus transferred to the medical intensive care unit for appropriate airway management, seizure and pneumonia treatment. physical examination: initial admission revealed remarkable for a temperature of 90.0, blood pressure 115/53, pulse 87 and respiratory rate 22, oxygen saturation 92% on room air. in general, this was a mildly obese african american female who appeared her stated age and in no acute distress. she was alert, awake and oriented to person and time. her neck was supple without any adenopathy or jugular venous distention. lungs were remarkable for coarse crackles bilaterally with decreased breath sounds at the bases. cardiovascular exam revealed a regular rate and rhythm with no rubs, murmurs or gallops appreciated. abdomen was obese, but otherwise benign. extremities revealed 1+ pitting edema bilaterally with good pedal pulses and neurological exam was nonfocal and symmetric. laboratories on admission: notable for a white blood cell count of 2.9, with 69% polys, hematocrit of 33.7, platelet count 76,000. dilantin level 23, bun 21, and creatinine 0.7, bicarbonate of 24, sodium 143, and potassium 5.1. inr of 1. a lactate level of 0.5. negative urinalysis. negative head ct. electrocardiogram showing normal sinus with normal axis and normal intervals, small q wave in leads i and avl and t wave inversions in leads avl, and v2 to v3. medications on admission: keppra 500 b.i.d., prempro, dilantin 100 b.i.d., neurontin 1200 t.i.d., colace, topamax 250 q.p.m., 150 q.a.m. allergies: no known drug allergies. social history: lives in a group home in , otherwise, negative times three. mother is in the area and involved in care. the patient is full code. intensive care unit course: unfortunately, miss remained in the intensive care unit for the duration of her hospital stay and her condition progressively deteriorated. she developed severe acute respiratory distress syndrome making it quite difficult to ventilate and oxygenate her. various recruitment maneuvers and procedures were attempted to no avail. she developed septic shock, but unfortunately, no clear source was identified. cultures returned positive only for methicillin resistant staphylococcus aureus on a catheter tip and c. difficile toxin in the stool for which she was treated with an adequate course of both vancomycin and flagyl. unfortunately, towards the end of her hospital stay, miss continued to remain febrile and hypotensive despite an infectious disease consultation, as well as broad spectrum antibiotics and antifungals. towards the end of her hospitalization, the patient was maximized on three different pressors with persistent hypotension. she went on to develop multiorgan failure including worsening renal function thought to be secondary to acute tubular necrosis from high doses of intravenous ativan. in addition, her hospital course was also complicated by worsening pancreatitis, anemia, thrombocytopenia, a severe ileus, paroxysmal atrial fibrillation and worsening acidemia. the patient's code status was eventually changed to comfort measures only and she passed away on . an autopsy was granted at the time of death. , 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 Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Pulmonary artery wedge monitoring Diagnoses: Acidosis Acute kidney failure, unspecified Unspecified septicemia Other convulsions Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Paralytic ileus

technique: axial images of the abdomen and pelvis were obtained after the administration of 150 cc of optiray per history of allergies. comparison with prior ct from . ct of the abdomen with iv contrast: there has been interval resolution of the bilateral pleural effusions. there are bibasilar atelectases. there is minimal pericardial fluid. the liver is normal in size without evidence of focal lesions. again seen are multiple gallstones. the pancreas and spleen are unremarkable. the low-attenuation lesions in both kidneys are not significantly changed, allowing for differences in the timing of the bolus. again seen is the retropancreatic mass which is slightly decreased in size compared to the prior exam. there are a few sub-cm retroperitoneal and mesenteric lymph nodes, stable compared to the prior exam. the adrenals are normal. loops of small bowel and large bowel are not dilated. there is a small amount of ascites, decreased compared to the prior exam. ct of the pelvis with iv contrast: the bladder and both ureters are normal. the uterus is present; again seen is a low-attenuation mass in the lower uterine segment probably related to a fibroid. there is a small amount of pelvic fluid. the pelvic lymphadenopathies remain stable. there is no free air in the abdomen. there are degenerative changes throughout the spine. impression: 1) no evidence of perforation or bowel obstruction. 2) interval resolution of bilateral pleural effusions and decrease in the amount of intraabdominal ascites. Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Biopsy of bone marrow Injection or infusion of cancer chemotherapeutic substance Diagnoses: Acidosis Thrombocytopenia, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Human immunodeficiency virus [HIV] disease Other malignant lymphomas, unspecified site, extranodal and solid organ sites Anemia in neoplastic disease

history of present illness: this is a 37-year-old male who presents to the ccu in arrhythmia, question svt, question v tach. the patient had no significant past medical history until two months ago when he began experiencing palpitations and was found to be in arrhythmia, probable svt, question v tach. the patient was converted with a calcium channel block. he was discharged home. the patient had ep study at on with no ablation. the patient had 6-7 episodes over the past two months, each time converted on calcium channel blocker or beta blocker or with vagal maneuvers. this a.m. on the patient awoke tired at noon, felt fatigued, mildly dyspneic, went to outside hospital, found to be in cardiac arrhythmia. the patient received adenosine 6 mg iv times one, 12 mg iv times one, lopressor 5 mg iv times one, verapamil 5 mg iv times one, with no change. the patient was then cardioverted 100 joules to normal sinus rhythm. he then reverted back to his arrhythmia and was loaded with procainamide and converted to normal sinus rhythm after 1 gm iv over one hour and then started on a drip at 2 mg per minute. the patient was transferred from outside hospital and ?????? hour before he arrived he went back into his arrhythmia. at arrival the patient had no complaints, no chest pain, shortness of breath, no nausea, vomiting, no palpitations, no lightheadedness. past medical history: 1) cardiac arrhythmia times two months, status post ep study . 2) increased cholesterol. 3) status post vasectomy. allergies: penicillin. the patient gets edematous. medications: as an outpatient, lopressor 100 mg , propafenone, asafex 20 mg po q d, niacin 500 mg po q d. on presentation, procainamide drip at 2. social history: the patient works at . no alcohol, no tobacco, no drug abuse. the patient lives at home in with his parents. family history: father with cad, with mi in his 60's. physical examination: on admission, general, pleasant, no apparent distress. vitals, blood pressure 107/59, pulse 172, pulse ox 97 on two liters, respiratory rate 22. heent: anicteric, mucus membranes moist. neck, no jvp appreciated, 2+ carotids, no lad. heart, regular rhythm, tachycardic, s1 and s2, no murmurs, rubs or gallops. lungs are clear bilaterally. abdomen obese, soft, nontender, non distended, positive bowel sounds. extremities, no edema bilaterally. neuro, alert and oriented times three, mentating well. laboratory data: from , white count 8,000, hemoglobin 16.9, hematocrit 48, platelet count 196,000, sodium 136, potassium 5.0, chloride 96, co2 28, bun 15, creatinine 1.2, glucose 157, total protein 7, albumin 4.4, calcium 9.3, ast 22, alt 35, alkaline phosphatase 103, ck 46, ldh 273, troponin i less than .3, pt 12, inr .98, ptt 36.1. chest x-ray, question enlarged cardiac silhouette, no acute cardiopulmonary process. ekg, svt at 174, right bundle branch block, left axis. the right bundle branch block is old. hospital course: 1. cardiology: patient had procainamide drip stopped as he was in his cardiac arrhythmia. he was started on lidocaine with 70 mg iv bolus and started at a drip of 1 mg per minute. he converted to normal sinus rhythm at 90 at 11 p.m. on . at midnight, however, he went back into his arrhythmia. he was given lido 35 mg iv push. he did not convert. he was converted, however, after removal of his defibrillator pad. the patient had episodes of cardiac arrhythmia throughout the night of into the morning of and he was converted these times with vagal maneuvers. the patient, on the morning of had his lido drip stopped and promptly went back into his cardiac arrhythmia. he was subsequently taken to the ep lab where he had two ablations. first ablation was right bundle branch re-entry vs nodofascicular bpt. other ablation was an av nrt. the patient did not require pacer after his av nrt ablation. the patient was transferred to the floor in stable condition after his ep study. the patient had episodes of sinus tachycardia on the evening of and into the morning of which was thought related to his infectious disease issues. the patient was stopped from lopressor and propafenone and patient was discharged on niacin 500 mg extended release q a.m. as his only cardiac meds. the patient was to follow-up with dr. , his cardiologist at at 2:30 p.m. 2. infectious disease: the patient had a temperature spike to 102.3 at 7:50 p.m. on . the patient had urine cultures, blood cultures, urinalysis and a chest x-ray done. chest x-ray showed no acute cardiopulmonary process. blood cultures showed no growth over 24 hours. urine culture showed no growth over 24 hours. antibiotics were not started. the patient had no focal signs or symptoms suggestive of bacterial infection. the patient denied any chest pain, shortness of breath or urinary symptoms, nausea, vomiting, diarrhea, headache or stiff neck. the patient states he had been around somebody with a viral bronchitis. etiology to his fever was thought to be secondary to a viral process. the patient was instructed to follow-up with his primary care physician if any focal symptoms occurred. 3. gi: the patient is on a proton pump inhibitor as an outpatient. this is followed by his primary care physician for question gerd. the patient denies any symptoms of gerd. the patient was instructed to follow-up with primary care physician as to whether he would need his proton pump inhibitor. the patient was discharged on his outpatient dose of asafex 20 mg po q d. 4. prophylaxis: the patient was maintained on protonix throughout his stay and discharged home on asafex 20 mg po q d. the patient was also started on subcu heparin 5000 subcu while he was at bedrest post ep study. this was stopped upon discharge home. 5. fluids, electrolytes & nutrition: the patient was npo for his ep study. the patient had q d lyte checks which revealed no abnormalities. the patient was placed on a regular diet. discharge status: stable. discharge diagnosis: 1. cardiac arrhythmia with successful ablation of nodofascicular bpt vs rbb reentrant. the patient also had av nrt ablated. 2. hypercholesterolemia. 3. viral syndrome. 4. question gerd. discharge medications: asafex 20 mg po q d, niacin extended release 500 mg po q a.m. discharge status: no change in code status. the patient is full code. discharge appointments: the patient is to follow-up with outpatient cardiologist, dr. , at 2:30 p.m. , md dictated by: medquist36 Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Diagnoses: Other specified cardiac dysrhythmias Other specified complications of procedures not elsewhere classified

history of present illness: the patient is status post percutaneous nephrostomy for nephrolithiasis obstructing the left kidney with pyelonephritis and becoming septic. other medical conditions: radical prostatectomy for which he received x-ray therapy. hypercholesterolemia. chronic low back pain. osteoarthritis. physical examination: on admission, the patient had temperature of 101.1 degrees, blood pressure was 113/52, pulse of 97, respiratory rate of 14, 97 percent on room air. the patient was alert and oriented to person, place, and time. cardiovascular: regular rate and rhythm. normal s1 and s2. no murmurs, rubs, or gallops. lungs were clear to auscultation. abdomen was soft, obese, positive bowel sounds, nontender, and nondistended. no peripheral edema. hospital course: the patient was scheduled for a cystoscopy. on the day of cystoscopy, the patient became febrile to 102 degrees and then to 104 degrees very quickly over the course of an hour or two. it was suspected that he would get septic, and he was deemed to high a risk for general anesthesia and was taken to fluoroscopy suite where he had a percutaneous nephrostomy on the left side. the fluid drained from there was stained and cultured. it grew out gram- positive cocci, coagulase-negative staphylococcus. the growth was sparse. the thought was that he was already on iv antibiotics, ampicillin, and gentamicin that would have covered other gram-positives, possibly streptococci and gram- negative bugs, so that they did not show up on culture, so he was continued on iv antibiotics. after the nephrostomy, he was taken to the unit where he spent two nights until he became more stable. while in the unit, his blood pressures dipped to the 90s systolic. when he was afebrile with pulse back up to systolic in the 120s, he was brought out of the unit to the floor where he recovered nicely. also while in the unit, he had a low potassium of 3.4 and required supplemental potassium; and to bring up his blood pressure, he was bolused multiple liters of normal saline. other important studies include a ct that showed a 1 cm stone at the upj junction that was the cause of the obstruction. during the fluoroscopic percutaneous nephrostomy, they were able to pull that stone back, but did not extract it. discharge status: good. he was afebrile, tolerating a regular diet, and ambulating without difficulty with pain well controlled on oral medications. discharge medications: 1. levaquin 500 mg p.o. q.d. 2. amoxicillin 500 mg t.i.d. for 14 days. the patient was asked if he had all home medications, and he replied yes. after discharge, he asked for some fioricet and was given 10 fioricet. follow up: the patient is to follow up in dr. office in 7 to 10 days. , dictated by: medquist36 d: 08:20:28 t: 09:07:27 job#: Procedure: Percutaneous nephrostomy without fragmentation Diagnoses: Pure hypercholesterolemia Unspecified septicemia Hypopotassemia Unspecified sleep apnea Hydronephrosis Calculus of kidney Pyelonephritis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: leaking urine from thigh wound, non-functional suprapubic catheter. major surgical or invasive procedure: radical cystectomy with ileal loop diversion history of present illness: 59 y/o man with ureterocutaneous fistula leaking to inner thigh secondary to prostate cancer treated with rrp, later treated with xrt and hormonal therapy. complicated by bladder neck stricture. trial of antibiotics and suprapubic drainage failed. now to have ileal loop divrsion and cystectomy. past medical history: 1. h/o prostate ca s/p prostatectomy/xrt/hormone tx 8 yrs ago c/b bladder neck stricture, psa has been undetectable x 7 yrs 2. enthesitis of adductor tendons - on prednisone for inflammation, mri: adductor tendon tears 3. recurrent nephrolithiasis 4. htn 5. hypercholesterolemia 6. chronic back pain (followed in pain clinic) since ' 7. chronic left lower extremity pain, s/p selective nerve root block and sacroiliac joint injections (this is attributed to his lbp) 8. grave's disease 9. h/o migraines 10. h/o cellulitis in foot associated w/ a blister years ago 11. h/o utis (pseudomonas s pip/tazo and cipro but not levo and enterococcus s nitrofurantoin in ) pshx: 1. transurethral lithotripsy and repeat urethral dilatation in at hospital 2.s/p urethral dilatation at social history: lives with wife of 30 years. three children no h/o tobacco. occasional, social alcohol. no illicit drug use. retired. used to work in computers family history: noncontributory physical exam: vitals: tm/c: 98.6/98.2 hr 62 bp 129/78 rr 18 o2: 97% ra chest: ctab cv: rrr abd: with urostomy bag in right lower quadrant, clean and intact. dressing removed. wound with staples, healing well,no erythema or exudates. abdomen is nd, soft, with mild apporpriate incisional tenderness. ext: wwp. pertinent results: 07:04pm glucose-200* urea n-8 creat-0.7 sodium-141 potassium-4.2 chloride-107 total co2-21* anion gap-17 07:04pm calcium-8.3* magnesium-1.2* 07:04pm wbc-12.2*# rbc-4.64 hgb-12.2* hct-34.8* mcv-75* mch-26.2* mchc-34.9 rdw-16.5* 07:04pm plt count-449* 04:29pm type-art tidal vol-649 o2-50 po2-169* pco2-36 ph-7.44 total co2-25 base xs-1 intubated-intubated vent-controlled 04:29pm glucose-184* lactate-1.8 na+-137 k+-3.8 cl--108 04:29pm hgb-8.6* calchct-26 04:29pm freeca-1.12 12:17pm type-art po2-156* pco2-32* ph-7.48* total co2-25 base xs-1 12:17pm lactate-2.4* 12:17pm hgb-10.0* calchct-30 12:17pm freeca-1.19 11:10am type-art po2-151* pco2-37 ph-7.46* total co2-27 base xs-3 11:10am lactate-1.8 11:10am hgb-8.4* calchct-25 08:38am type-art rates-/12 tidal vol-600 o2-60 po2-229* pco2-36 ph-7.51* total co2-30 base xs-6 intubated-intubated vent-controlled 08:38am glucose-122* lactate-1.5 na+-137 k+-3.7 cl--102 08:38am hgb-9.2* calchct-28 08:38am freeca-1.15 brief hospital course: the patient tolerated his procedure without intraoperative complications. his hospital course was uneventful. he was observed for 1 day in the icu prior to being transferred to the floor. his ngt was self-d/c'd pod1. his pain was initially controlled with toradol and iv narcotics, then a fentanyl patch, and eventually only with a low dose of oral dilaudid. he ambulated without assistance. he passed flatus pod4, and his diet was advanced. he tolerated a regular diet prior to discharge. he continued on iv vancomycin and fluconazole during his hospital stay and is discharged on iv vancomycin. his jp drain was removed prior to discharge. his vac sponge was changed during this hospital admission. he is discharged home with vna services pod5 in stable condition, tolerating po intake, on po medications and iv vancomycin through his picc line, ambulating without assistance, and with his vac sponge in place. medications on admission: iv vancomycin/fluconazole fentanyl patch colace senna gabapentin protonix asa lipitor venlafaxine fe dulcolax ibuprofen morphine po ambien flagyl discharge medications: iv vancomycin 1g q12h dilaudid 2mg po q4-6h prn pain home meds discharge disposition: home with service facility: home health services discharge diagnosis: urethrocutaneous fistula s/p cystectomy w/ ileal conduit urinary diversion discharge condition: good Procedure: Radical cystectomy Formation of cutaneous uretero-ileostomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Pure hypercholesterolemia Unspecified essential hypertension Personal history of malignant neoplasm of prostate Bladder neck obstruction Toxic diffuse goiter without mention of thyrotoxic crisis or storm Late effect of radiation Unspecified osteomyelitis, pelvic region and thigh Urethral fistula

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: intubation extubation history of present illness: pt is a 61 y.o male with h.o prostate ca, pe, nephrolithiasis, pelvic osteo, hl, chronic back and lle pain, , utis, urethral dilatation, multiple leg and pelvic debridements who was biba to the ed reportedly after construction workers found him "acting funny". per report, pt found to be altered by construction workers and naked at his home. ems came, pt walked to ambulance, "slightly confused" maybe pupils dilated rather than constricted. he was given 2mg iv narcan. upon arrival to the , pt thought to be in acute opiate w/d agitated, writhing. no history able to be attained. aaox1 . initial vitals: 97 171/74, 67, 16 sat 100% on ra. he was given ativan and 4mg morphine initially. however, he then had to be intubated due to behavior, in 4 pt restraints. ngt placed. . pt underwent head ct that was negative for acute process, lp, cxr. however, u/a was noted to be positive. . patient was given 6mg ativan, 5mg of haldol, 4mg morphine, benedryl, famotidine, propofol, thiamine, folate, mvi, and zosyn, vanco as wekk as 2l ns. ekg-sinus @66, qtc 430, did not appear anti-cholinergic. . last vitals-98.8 113/52, 92 16 100%, . upon arrival to the floor, pt is sedated/intubated. past medical history: # h/o prostate ca s/p prostatectomy/xrt/hormone tx, c/b bladder neck stricture, psa has been undetectable, s/p cystectomy for fistula complicated by abscesses. # enthesitis of adductor tendons # h/o pe # recurrent nephrolithiasis # hypercholesterolemia # chronic back pain (followed in pain clinic) since ' # chronic left lower extremity pain, s/p selective nerve root block and sacroiliac joint injections (this is attributed to his lbp) # grave's disease # h/o migraines # h/o cellulitis in foot associated w/ a blister years ago # h/o utis (pseudomonas s pip/tazo and cipro but not levo and enterococcus s nitrofurantoin in ) # transurethral lithotripsy and repeat urethral dilatation in at hospital # s/p urethral dilatation at # multiple leg/pelvis debriedments due to fistula from urinary tract into leg social history: he lives with wife of 30 years. he has three children. he denies h/o tobacco use. he reports occasional, social alcohol use. he has a remote history of drug use, no ivda. he used to work in computers and is currently retired. family history: father with mi in 40s, dm. mother with alzheimer's dementia. physical exam: physical exam: vitals: t 95.2, bp 109/59, hr 44, sat 100% on ac, 40%/600/14/5 general: nad, intubated/sedated heent: sclera anicteric, nc/at, perrla, eomi neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally/anteriorly, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no guarding. +urostomy in place with clear yellow urine. gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro:intubated/sedated, but moves all 4 extremities. pertinent results: 03:00pm blood wbc-5.7 rbc-4.81 hgb-13.6* hct-41.3 mcv-86 mch-28.2 mchc-32.8 rdw-14.2 plt ct-306 04:12am blood wbc-6.6 rbc-4.54* hgb-12.9* hct-38.8* mcv-86 mch-28.4 mchc-33.2 rdw-14.3 plt ct-257 04:12am blood pt-12.6 ptt-24.4 inr(pt)-1.1 03:00pm blood glucose-128* urean-17 creat-0.8 na-141 k-4.0 cl-106 hco3-23 angap-16 04:12am blood glucose-106* urean-13 creat-0.7 na-141 k-3.6 cl-110* hco3-22 angap-13 04:12am blood albumin-3.7 calcium-8.9 phos-2.9 mg-1.9 03:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:22pm blood lactate-3.4* 05:05pm blood glucose-115* lactate-1.0 04:38am blood lactate-1.3 . csf fluids negative for meningitis. . ct head: findings: there is no hemorrhage, edema, mass effect, or acute vascular territorial infarction. ventricles and sulci appear normal in size and configuration. there is no midline shift. the -white matter differentiation remains well preserved. the basilar cisterns and quadrigeminal plate are patent. osseous structures appear intact. there is slight congestion of the nasal passages, likely secondary to patient's intubated status. impression: no acute intracranial abnormality. . cxr: impression: intubated patient with et tube 6.7 cm from the carina. otherwise, no acute cardiopulmonary process in a slightly technically limited study. brief hospital course: pt is a 61 y.o male with h.o prostate ca with fistulous and infectious complications, pelvis osteo, pe, nephrolithiasis, hl, chronic back and lle pain, , utis, multiple leg debridements with presents with ams. # ams- secondary to medication error and exacerbated by opiate withdrawal. the patient was found altered at home, given narcan and woke up to become very combative and difficult to control. he was treated with several medications in the ed, but needed to be intubated to have a ct scan and lp. his ct and lp were both negative. he was monitored overnight and treated with zosyn for a supicious ua. in the am of his second day of hospitalization, he woke up and self-extubated himself despite being on a propofol gtt. his mental status began to clear over the course of the day, and he remember that instead of taking his 2.5 tabs of methadone, he took 2.5 tabs of ambien. that was likely the cause of his altered mental status. he was appropriate, although somewhat somnulent, at the time of transfer from the micu. through the rest of his hospitalization, the patient's mental status returned to baseline and he was able to be started on his home medications without incident. # opiate withdrawal - patient has opiate dependence as he has been on chronic methadone and percocet for pain control. pt was given narcan by ems which escalated his ams. while pain medications were initially held while the patient was intubated, his home regimen of opiates were restarted following extubation. # urostomy -pt with h.o prostate ca s/p surgical intervention with h.o fistulas. now urostomy. although the initial ua was positive, this was thought to represent colonization rather than true infection. the patient was initially treated for a uti as a possible source for his altered mental state. however, after the patient was extubated and it became clear that ams was due to medication/ opiate withdrawal rather than infection, all antibiotics were stopped. # - tsh normal medications on admission: methadone 25 mg tid percocet 5-325 mg q6hrs prn effexor 75 mg effexor er 37.5 mg daily simvastatin 10 mg daily ambien 10 mg qhs ? hypertensive medicine discharge medications: 1. methadone 5 mg tablet sig: five (5) tablet po tid (3 times a day). 2. atorvastatin 10 mg tablet sig: one (1) tablet po once a day. 3. oxycodone 5 mg tablet sig: one (1) tablet po four times a day. 4. cyclobenzaprine 10 mg tablet sig: one (1) tablet po three times a day as needed for muscle spasm. 5. venlafaxine 37.5 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po bid (2 times a day). 6. zolpidem 10 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: home discharge diagnosis: acute delerium due to medication opiate dependence with acute withdrawal benign hypertension grave's disease discharge condition: good discharge instructions: please return to the hospital with fever, chills, nausea, vomitting, diarhea or other concerning symptoms. it is important to not mix up your medications. you may consider a pill box to assist you in this. followup instructions: follow up with your pcp as previously scheduled Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Opioid type dependence, unspecified Other and unspecified hyperlipidemia Poisoning by other sedatives and hypnotics Toxic diffuse goiter without mention of thyrotoxic crisis or storm Lumbago Drug-induced delirium Drug withdrawal Accidental poisoning by other specified sedatives and hypnotics Benign essential hypertension

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transferred from for streptococcus pneumoniae sepsis and mental status changes major surgical or invasive procedure: intubation lumbar puncture thoracentesis tte history of present illness: is a 33-year-old woman with a history of hodgkin??????s disease and splenectomy 20 years ago who presented to with pneumococcal sepsis on and was transferred to the micu on . she was in her usoh until , when she developed chills, diarrhea, dry heaves, and had several near-syncopal episodes. she was taken to the ed, where she was febrile, tachycardic, and hypotensive. blood cultures were drawn, which eventually grew strep pneumoniae in bottles. she was fluid resuscitated, given xigris, and treated with vancomycin and ceftriaxone. follow-up blood cultures were negative. she developed hypoxemic respiratory failure due to fluid overload and required intubation. two days after admission she was noted to be minimally responsive. a head ct was negative, and the family requested transfer to for further neurologic workup. also of note, during her admission the patient developed hyperbilirubinemia (tbili 3.8, direct 3.3), elevated alk (274), and thrombocytopenia (nadir 32). in addition, a cxr on showed a consolidation at the right base. the patient was transferred to the micu on . her micu course was notable for: 1) id: the patient was continued on vancomycin/ceftriaxone with a planned 14-day course. an lp was negative. she had a thoracentesis on of her right basilar consolidation; analysis was consistent with a transudate and fluid sent for culture showed no growth. she had a persistently elevated wbc in the 20s to 30s with intermittent low-grade fevers. repeat blood cultures and a urine culture showed no growth. stool was negative for c. diff. 2) pulmonary: the patient responded well to diuresis and was extubated on . thoracentesis as above. 3) gi: the patient continued to have hyperbilirubinemia, elevated alk, and slightly elevated ast/alt. a ruq ultrasound was negative. 4) heme: the patient had a persistently low hct (27 to 28), but her thrombocytopenia resolved. she had a negative hemolysis and dic/ttp/hus workup. hit antibody was negative at . stool was guaiac negative. 5) neuro: neurology consult felt that the patient??????s mental status changes were likely due to toxic metabolic abnormalities and sedating medication. however, given the finding of upgoing toes on physical exam, they recommended a brain and c-spine mri. by the day of transfer to the floor, the patient??????s mental status had returned to . 6) nutrition: the patient was maintained on tpn and tube feeds while intubated. she failed a swallow study after extubation and was on maintenance ivf on transfer to the floor. past medical history: 1) hodgkin??????s disease , s/p xrt, abvd, and splenectomy 2) premature ovarian failure 3) splenectomy as above; had pneumovax in 4) hypothyroidism social history: lives with her husband, adopted 8-week-old baby boy, and dog. works at in . no smoking, etoh, or drugs. family history: nc physical exam: pe on admission to floor from micu: vitals: tc 98.6, bp 120/70, p 98, r 20, o2 sat 98% on ra gen: nad, tired-appearing heent: bilateral subconjunctival hemorrhages. no cervical lad. cards: rrr, no m/g/r pulm: coughs with deep inspiration. ctab. abd: soft, nt, nd. positive bowel sounds in all 4 quadrants ext: no le edema. excoriated papules on l inner thigh (biopsied) neuro: eomi, perrl. oriented x 3. upgoing toes bilaterally. pertinent results: labs on transfer to floor from micu: wbc 23.3, hgb 8.9, hct 27.4, mcv 91, rdw 15.5, plt 313 diff: n85, b1, l8, m4, e0, b0, atyp 1, metas 1 pt 12.7, ptt 24.4 fibrinogen 575 na 142, k 4.3, cl 111, hc03 22, glucose 80 alt 73, ast 75, alk 402, tbili 2.0, lipase 235 ca 7.7, phos 2.4, mg 1.8 micro: -- csf: gram stain and culture negative -- blood cultures from x2: no growth to date -- urine culture negative -- skin blister sent for herpes culture ?????? pending -- pleural fluid: gram stain 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): no growth. -- c. diff negative cxr : a right-sided central venous catheter is seen with the tip positioned in the distal svc. again seen are bilateral pleural effusions. there has been interval removal of an et and ng tube. scattered left retrocardiac atelectasis is noted. the pulmonary vasculature is unchanged. impression: interval removal of an et and ng tube. bilateral pleural effusions are again seen, without any interval change. ruq us : normal decompressed gallbladder. no evidence of intrahepatic bile duct dilatation. brief hospital course: 1) pneumococcal sepsis: the patient was maintained on ceftriaxone while in house. vancomycin was discontinued after as cultures from showed sensitivity to ceftriaxone. the patient will complete the last two days of a 14-day course of antibiotics with po levofloxacin at home, as cultures were sensitive to levofloxacin. the source of her sepsis was felt to be pulmonary based on an infiltrate seen on cxr at . while on the floor, the patient's leukocytosis resolved and she remained afebrile. the patient will follow up with dr. at infectious disease clinic on for discussion of repeating the pneumovax vs. prevnar. 2) mental status changes: the patient's mental status changes had resolved by the time she was transferred to the floor. brain and c-spine mris were negative. 3) anemia: while in house the patient had a stable anemia with hct about 27. mcv and rdw were normal. she was guaiac negative and had a negative hemolytic workup. iron studies were negative for iron deficiency. her anemia was felt to be secondary to bone marrow suppression due to infection. a reticulocyte count was low, consistent with bone marrow suppression. 4) thromocytopenia/thrombocytosis: the patient was initially thrombocytopenic, with platelets 91 on transfer from . hit antibody sent at was negative. dic and hemolysis labs were negative; there were no schistocytes on peripheral smear. after several days the patient's thrombocytopenia resolved and she developed thrombocytosis, with platelets reaching a peak of 1306 on discharge. a peripheral smear was negative for platelet clumping. this thrombocytosis was felt to be reactive in the setting of infection and asplenia. heme/onc was curbsided and recommended against aspirin treatment. the patient will get a follow-up platelet count checked with her pcp. 5) hyperbilirubinemia/transaminitis: after reaching a peak tbili of 4.6, the patient's hyperbilirubinemia had resolved by the time of discharge. her ldh had normalized (peak 307). her alt, ast, and alk elevations had improved, though all were still elevated at discharge (alt 91 from peak 103, ast 59 from peak 82, alk 227 from peak 407). a ruq ultrasound was negative for liver lesions or intrahepatic bile duct dilatation. these lab abnormalities were felt to have been caused by tpn. 6) chemical pancreatitis: the patient had an elevated amylase (peak 170) but never had abdominal pain. her amylase had decreased to 131 by discharge. 7) heart murmur: a i-ii/vi systolic murmur was heard on exam on the day of discharge. a tte was done to rule out endocarditis; it showed no vegetation. 8) dysphagia: the patient received tpn and tube feeds while intubated. after extubation she failed a swallowing study. she refused ng tube placement and received only maintenance ivf until passing a repeat swallowing study three days later. this study did, however, show trace aspiration, and the patient will have a repeat swallowing study as an outpatient. 9) skin lesions: in the micu the patient was noted to have several small erythematous papules on her left inner thigh. cultures were sent for herpes, which were still pending at discharge. 10) subconjunctival hemorrhages: the patient had bilateral subconjunctival hemorrhages secondary to traumatic intubation. an ophthalmology consult at ruled out endophthalmitis and intraocular hemorrhage. 11) hypothyroidism: the patient was maintained on iv levothyroxine until she was taking po's, when she was transitioned to po levothyroxine. she will have her tsh checked as an outpatient. 12) ovarian failure: the patient's estrogen/progesterone replacement therapy was reinstituted as per her home regimen after she began taking po's. 13) disposition: the patient will continue to work with physical therapy as an outpatient. 14) code status: full code medications on admission: home meds prior to admission: 1. levothyroxine 75mcg po q24h 2. medroxyprogesterone acetate 10mg po on days of cycle 3. estradiol 2mg po q24h discharge medications: 1. levothyroxine 75mcg po q24h 2. medroxyprogesterone acetate 10mg po on days of cycle 3. estradiol 2mg po q24h 4. levofloxacin 500mg po qd x 2 days, first dose 6/9 discharge disposition: home with service facility: discharge diagnosis: pneumococcal sepsis hypoxic respiratory failure hyperbilirubinemia transaminitis thrombocytopenia reactive thrombocytosis anemia chemical pancreatitis pleural effusion discharge condition: ambulating with pt, urinating/bming on own, tolerating po diet discharge instructions: if you have fevers/chills, shortness of breath, or abdominal pain, please call your doctor or come to the er. please complete all your antibiotics. please have your platelet count checked on friday . followup instructions: 1) you have an appointment at the infectious disease clinic () with dr. . date/time: 9:30 a.m. the specific question to address with dr. is whether the standard pneumovax or prevnar is more appropriate for you. 2) please call your pcp to make an appointment within the next two weeks. you will need to get your tsh (thyroid test) rechecked and to follow up on the biopsy of your l thigh lesions. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Unspecified pleural effusion Severe sepsis Acute respiratory failure Septic shock Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Acute pancreatitis Personal history of hodgkin's disease

history of present illness: this is a 73 year old woman who was transferred on , from hospital with abdominal pain. she had been admitted at the outside hospital on , and had at that time complaints of right sided shoulder pain and was found to have asthmatic bronchitis, and then subsequently found to have methicillin resistant staphylococcus aureus pneumonia. also, she was treated for methicillin resistant staphylococcus aureus pneumonia with vancomycin. she had this worsening abdominal pain and it was decided to be transferred to the for further work-up of this. hospital course: during her admission to the medical service, the patient had a general surgical consultation which was done on . the initial impression was two weeks of abdominal pain with a differential including ischemic colitis, infectious colitis such as with c. difficile, diverticulitis. the patient unfortunately was unable to take intravenous contrast so her ct scans that were obtained were all without intravenous contrast making bowel wall and ischemia more difficulty to diagnose in her case. the gi service was following her very carefully as well. the patient underwent aggressive intravenous hydration. dr. was the initial surgical attending of record. most of her pain was in her left lower quadrant and suprapubic. she also had some bloody diarrhea and progressive abdominal distention, which was concerning prior to her transfer to us, at the outside hospital. the ct scan of the abdomen that had been obtained showed a thickened sigmoid. barium enema showed some mucosal ulcerations. she, during her hospitalization up to the , had been treated with antibiotics including vancomycin, ceptaz and flagyl. the patient had been passing flatus and had liquid stools. on abdominal examination she was soft and moderately distended. there were no palpable masses appreciated. her rectal examination was guaiac positive with loose stool present. there were no palpable masses. the patient had a variety of stool studies sent. she continued on levaquin and flagyl. levaquin was added because she was noted to have a positive urinalysis and for gram negative enteric coverage as well. hospital course: the hospital course was basically passing flatus and stool with low grade temperatures and waxing and left lower quadrant pain. the patient essentially had a picc placed on , #5 french dual-lumen large catheter in the right arm. she did require a blood transfusion for decreasing hematocrit and was started on tpn. she had a pleural fluid tap for an effusion. she had a flexible sigmoidoscopy on the 26th. the flexible sigmoidoscopy showed some pseudomembranes and the patient was given flagyl p.o. three times a day. c. difficile toxins were sent and the final on the gi study was an active colitis. differential was continued ischemic versus infectious colitis. on , she had a right upper extremity ultrasound which did not show evidence of a venous thrombosis. all stool cultures were negative. of note, incidentally, the patient suffered from audio toxicity upon her presentation to this hospitalization and it was unclear exactly the etiology of this audio toxicity as her hearing was markedly decreased. after multiple discussions with the family and dr. in dr. absence, and the gi attending, dr. and their service, the patient consented to an operation. of note, on , a c. difficile toxin positive but all other things were negative for c. difficile. she was taken to the operating room after a short trial of p.o. vancomycin after the c. difficile toxin became positive. however, clinically her examination did not improve, so she was taken to the operating room with a preoperative diagnosis of ischemic colitis and postoperative diagnosis was gangrenous contained perforated colitis. she underwent an exploratory laparotomy on , and had a subtotal abdominal colectomy with end-ileostomy, a hartmann's sigmoid procedure and a splenectomy, wash-out of her abdominal cavity, repair of some serosal injuries to the small intestine. the patient's operative findings were that of a gangrenous contained perforated colon, soilage frankly to the abdomen, dead splenic flexure adherent to the spleen requiring splenectomy. the patient was taken to the intensive care unit postoperatively. her postoperative course was most remarkable for self-extubation followed by re-intubation followed by an additional round of elective extubation and re-intubation, and the patient had been intermittently treated with vancomycin for a methicillin resistant staphylococcus aureus pneumonia and methicillin resistant staphylococcus aureus in the sputum which she had had at the outside hospital and was continuing on. she finally had a tracheostomy placed for failure to wean off the ventilator. her early ostomy functional, patent and productive. the patient had been on tpn and was changed to tube feeds at goal which she tolerated well. perioperatively, the patient was maintained on intravenous lopressor and gradually she was switched over to p.o. lopressor and p.o. diltiazem, and of which she had been on a calcium-channel blocker preoperatively prior to admission. she has been followed by physical therapy and nutrition as well as speech and swallowing, which helped place a passe-muir valve with some vocalization but inability to tolerate p.o. and to coordinate swallowing. for her infectious disease course, she was maintained on triple antibiotics postoperatively, of vancomycin, levofloxacin and flagyl, a ten-day course of vancomycin and when that was stopped, her white count increased and she developed fevers ago. that was restarted after sputum, blood and urine were sent. her blood cultures had been negative. her urine grew out enterococcus which was not thought to be pathogenic at the time and her sputum continued to grow out methicillin resistant staphylococcus aureus. the patient was maintained on deep venous thrombosis prophylaxis of subcutaneous heparin. she was on carafate while intubated, and then she has been on tube feeds at goal. she is not on any further ulcer prophylaxis. she received aggressive resuscitation and her postoperative course involved significant diuresis with maximum of 40 twice a day of lasix down to 20 twice a day of ng tube lasix and currently she will stop lasix as she appears to be euvolemic and has lost all the anasarca that she had accumulated. past medical history: 1. significant for degenerative joint disease. 2. ischemic colitis. 3. chronic obstructive pulmonary disease. 4. diverticulitis. 5. clostridium difficile toxin positive. 6. hypertension. 7. ejection fraction of greater than 55%. 8. two plus mitral regurgitation and two plus aortic stenosis, secondary av block with pacemaker placed prior to this hospitalization and currently repaced. 9. methicillin resistant staphylococcus aureus bronchitis. allergies: ivp dye and epinephrine. medications at home: 1. verapamil 120 mg p.o. q. day. 2. tiazac 120 q. day. 3. levaquin which was started from an outside hospital. 4. albuterol. 5. phenergan with codeine for some cough and bronchitis that she had been prescribed prior to hospitalization. medications on discharge from this hospitalization: 1. lopressor 50 mg per ng tube twice a day to be held for heart rate less than 60 and blood pressure less than 100. 2. diltiazem 30 mg per ng tube four times a day; hold for systolic blood pressure less than 100. 3. paxil 20 mg q. day. 4. sliding scale regular insulin. 5. heparin 5000 units subcutaneously twice a day. 6. flovent 120 micrograms dosing, three puffs inhaled twice a day. 7. serevent one to two puffs inhaled twice a day. 8. vancomycin 1 gram intravenous q. 12 with peak and trough checks q. 72 hours and should be checked on , next. 9. levothyroxine 75 micrograms per ng q. day. 10. promod with fiber, goal of 60 cc an hour. 11. epoetin alfa 40,000 subcutaneously one time per week. 12. iron sulfate 325 mg per ng tube three times a day, elixir. 13. multivitamin, ultram, one per ng tube q. day. 14. ativan 0.5 mg intravenously q. six p.r.n. 15. tylenol elixir 650 mgs per ng q. six p.r.n. special treatments and frequency: 1. ostomy care. 2. wound care; the patient has a small opening at the inferior aspect of her wound which is not grossly infected and is granulating well. this had been draining a small amount of yellowish fluid and is packed very very loosely, minimal maybe a 2 by 2, normal saline wet-to-dry three times a day. 3. vancomycin level checks. 4. aspiration precautions. 5. speech evaluation for passe-muir valve and swallowing coordination. 6. physical therapy aggressively to regain strength, stamina and mobility. 7. nutrition for her tube feeds and monitoring her nutritional status. the patient should be continued on vancomycin for 12 additional days after discharge. laboratory: on discharge, white count is 13.3, hematocrit 27.9, platelets 367. sodium 136, potassium 4.5, bun 31, creatinine 0.7, glucose 112, calcium 8.1, magnesium 2.1, phosphorus 3.4. there is no new culture data awaiting her. on physical examination, she was alert, awake and appears oriented. she has a tracheostomy which is patent and secure. she is not sedated. her chest sounds clear. her cardiovascular system is regular, paced. head and neck is unremarkable except for the tracheostomy. abdomen is soft, nontender, nondistended, with a stoma that is pink and patent in the right lower quadrant with the inferior pole of her wound slightly opened and packed. no surrounding erythema. no current drainage. her extremities are warm without edema. she has a right sided picc line. she has venodyne boots placed on both lower extremities and tube feed in place, ng tube plus pyloric feeding tube. condition at discharge: stable. discharge diagnoses: 1. status post subtotal colectomy with a poor ischemic colitis. 2. status post splenectomy. 3. tracheostomy. 4. respiratory failure on ventilator. 5. methicillin resistant staphylococcus aureus pneumonia. disposition: to a rehabilitation facility. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Open and other left hemicolectomy Other bronchoscopy Temporary ileostomy Temporary tracheostomy Flexible sigmoidoscopy Total splenectomy Suture of laceration of small intestine, except duodenum Diagnoses: Chronic airway obstruction, not elsewhere classified Perforation of intestine Accidental puncture or laceration during a procedure, not elsewhere classified Intestinal infection due to Clostridium difficile Mitral valve insufficiency and aortic valve stenosis Methicillin susceptible pneumonia due to Staphylococcus aureus Accidental cut, puncture, perforation or hemorrhage during surgical operation Unspecified vascular insufficiency of intestine

history of present illness: this is a 53-year-old male right-hand dominant construction worker, who amputated his finger while working with a wood cutter approximately 45 minutes prior to presenting to the emergency department. in the emergency department, patient received tetanus, ancef, and morphine. physical exam: patient was afebrile with stable vital signs. alert and oriented. clear to auscultation. abdomen is soft and nontender. good peripheral pulses. the left fourth digit was amputated at approximately the pip region. it appeared to be a clean amputation. brief hospital course: the patient was taken to the operating room, where fourth digit replantation was performed. patient tolerated the procedure well and was admitted to the intensive care unit postoperatively. patient was maintained with q.1h. finger checks while in the intensive care unit. he is on a dilaudid pca. he remained afebrile with stable vital signs during that time. postoperative laboratories were within normal limits. patient remained with a good dopplerable pulse in the left fourth finger. the patient's laboratories remained within normal limits. patient was transferred to the floor on postoperative day two. he was on dextran at 30 cc an hour. continued on kefzol. regular diet was started. patient was maintained with elevated room temperature with the arm elevated as well, and doppler checks of the finger were continued while on the floor. patient was also maintained on aspirin. foley was discontinued without event. patient is placed in an ulnar gutter splint without problems. continued to remain afebrile with stable vital signs while on the floor. occupational therapy saw the patient while in-house and dextran was d/c'd prior to discharge. patient went home on postoperative day six without event. discharge status: patient was discharged to home. discharge medications: 1. aspirin. 2. vicodin. 3. keflex for seven days. follow-up instructions: patient will follow up with dr. one week from discharge. discharge diagnosis: left finger amputation status post left finger reattachment. , m.d. dictated by: medquist36 Procedure: Finger reattachment Diagnoses: Traumatic amputation of other finger(s) (complete) (partial), without mention of complication Accidents caused by other specified machinery

allergies: penicillins attending: chief complaint: sob, hypercapnea major surgical or invasive procedure: endotracheal intubation history of present illness: 68m with history of copd (on 2-3l o2 at home) with history of multiple intubations, cad with ischemic cardiomyopathy (ef 20-25%) who was transferred to from an outside hospital on with sob. pt initially noted fever to 102, 4 days prior to admission. however patient was without respiratory complaints or cough. pt was started on course of azithromycin as an outpatient for suspected bronchitis and reports some improvement in pulm sx. the evening prior to admisssion, the patient became progressively dyspnic with a minimally-productive cough. pt presented to an outside hospital where he was found to have hr 150 that was believed to be possible aflutter but, per report, was found to be sinus tachcardia. cxr, per report, was consistent with mild chf and possible rml pna. abg on 100% nrb was 7.25/61/77. further treamtent at outside hospital included asa 325, ntg sl times 2, alb/atr nebs, lasix 60 mg iv, sloumedrol 125mg iv, ceftriaxone and moxifloxacin. pt was subsequently transferred to for further management. on arrival to micu pt felt "much better" and was without chest pain, palpitations, n/v, abd pain, dysuria/frequency. he was transferred to the floor, however he subequently developed sob and diaphoresis. he developed increased respiratory distress, abg's revealed (ph 7.33/44/70 lactate 4.9->7.22/66/130 @ 11am->7.3/59/145. pt was again brought to the micu and intubated for this resp distress. past medical history: copd (2-3l home o2, intubated 3 times for exacerbations) cad s/p mi and stent (unclear anatomy/location of stent) cardiomyopathy, ischemic (ef 20-25%) hypercholesterolemia htn chronic kidney disease baseline cr 1.8 periph vascular disease cva, multiple with residual r>l weakness, aphasia parox atrial fibrillation peripheral neuropathy social history: h/o heavy tob use quit as well as prior etoh abuse, no illicit drug use. pt lives with his wife and is able to ambulate with walker at baseline. family history: nc physical exam: 1) on presentation (): vs- 98.4, hr 111, bp 110/59, rr 24, 96% 50% face mask 7.41/42/103 gen- elderly man, mild exp aphasia, mod resp distress while speaking in short sentences heent-perrl, eomi, op wnl, dry mm neck-supple, jvp at ~10cm, no lad cvs-tachy with rr, no m/r/g pulm-tachypneic, decreased bs thru/o, bibasilar rales at bases incompletely cleared with cough, no audible wheezes abd-soft, nt, nd, nabs ext-no c/e, left shin abrasion, 1+ dp b/l neuro-a&o3, 4/5 weakness thr/o, 3+ dtr , 2+ dtr 2) on transfer to micu: vs- 98.9, hr 102 (90-110), bp 124/62 (90-120/50-60), rr 24, 95% 4lnc gen- elderly man, comfortable, no resp distress heent-perrl, eomi, op wnl, dry mm neck-supple, jvp at ~8-10cm cvs-distant hs, tachy but rr, s1/s2, no m/r/g pulm-tachypneic, decreased bs, bibasilar rales at bases, mild exp. wheeze at upperlung fields b/l, no rhonchi. speaks in short sentences abd-soft, ruq tenderness, +/- , nd, nabs ext-no c/c/e, left shin abrasion, 1+ dp b/l neuro-a&o3, answers questions, follows commands pertinent results: 1. cxr at admission: emphysema. right lower lobe patchy opacity concerning for pneumonia. left basilar patchy opacity may represent atelectasis or infection as well. 2. cxr (): worsening pneumonia w/underlying emphysema 3. cxr (): bilat pleural effusions, improved rll opacity, probable mild chf. 4. echo (): overall left ventricular systolic function is severely depressed. resting regional wall motion abnormalities include inferior, inferoseptal and inferolateral and apical akinesis with a small apical aneurysm present. right ventricular chamber size is normal. right ventricular systolic function appears depressed. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. moderate (2+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. 5. lab data: - microbiology: blood and urine cx with no growth. sputum with no microorg seen. influenza dfa negative. - probnp (): 12,009 (range 0-229, levels >1000 have 78% ppd) - peak ck 390 on - tropt 2.86 () - creatinine 1.3 (at admission) -> 1.6 () -> 0.9-1.0 brief hospital course: 68 yo man with h/o copd, cad, cardiomyopathy with depressed ef who presented with sob and hypercapnia in setting of copd exacerbation s/p intubation and micu for resp failure c/b nsvt. icu course significant for: 1) pulm: resp failure copd exacerbation. self-extubated icu d#2, reintubated icu d#3 for resp failure. copd treated with slow steroid taper, nebs. extubated again icu d#5 complicated by resp. distress requiring nrb -> bipap and received lasix 40mg iv. 2) cvs: during initial icu presentation, was hypotensive requiring pressor support (weaned off over first 2 days). during micu course, suffering from runs of nsvt. with tachycardia, evidence of demand ischemia by ce's and ecg. tachycardia with ectopy, likely secondary to respiratory distress; responded to b-b. cardiology felt likely has new coronary lesion and recommended cath given h/o 3vd. pt was initially to be transferred to for cath (accepting physician, . () or dr. , interventionalist), however, he decided he did not want an intervention and was d/c'ed home. heparin not initiated. medical management was maximized. 3) id: rll pna treated with 10 day course of ctx (finished ). 4) hypotension: bp dropped after intubation. best guess of sequence of events is mucous plug leading to hypoxemia that caused inadequate oxygen supply to the myocardium causing transient myocardial ischemic; ck, ck-mb, and troponin rising on transfer to micu. this may have led to transient cardiac failure (quasi-cardiogenic shock). bp initially maintained on levophed hospital course by problems: 1) copd exacerbation in setting of pna. pt with acute respiratory decompensation requiring intubation on thought to be secondary to mucous plug. respiratory status returned to baseline prior to discharge. - he was treated with a slow steroid taper, tiotropium, advair, singulair, and alb prn 2) chf: pt with h/o cardiomyopathy and ef 30%. he was euvolemic without evidence of decompensated chf at time of discharge. i/o goal of even to slightly negative was maintained on lasix 40 mg (home regimen 80 ). he was continued on an acei for afterload reduction. his heart rate was well controlled on metop 25 . 3) cad: 3vd s/p mi and stent. elevated trop-t likely demand ischemia in setting of tachycardia (sinus tach with ectopy thought to be to resp distress). ecg with st depression lat. cardiac enzymes trending down at time of discharge. cardiology feels there may be a new lesion and given h/o 3vd and would prefer cath, however pt declines. he understands risks and benefits he was continued on asa, lipitor (80mg), b-b, acei (lisinopril 5 mg). he had no subsequent events on tele. 4) nsvt: pt with intermittent runs of nsvt during micu stay likely secondary to demand ischemia and lung disease. benefit from icd placement. will defer to pt's outpt cardiologist. rate well controlled on metop 25 . 5) rll pna. received 10 day course of ctx (ended on ). 6) crf. baseline cr thought to be 1.8, however creat improved to 0.9 at time of discharge. 7) fen: he was tolerating a low sodium/cardiac diet at time of discharge. checking qid finger sticks with riss while on steroids. 8) ppx: pp1, hepsc/pneumoboots. started on ca/vit d supplements given prolonged course of steroids. 9) access: l subclavian line placed . arterial line placed on while in icu. 10) full code 11) dispo: d/c'ed home with services. medications on admission: asa, lipitor, lasix 80 , singulair, flomax, advair, albuterol prn, spiriva, neurontin, potassium discharge medications: 1. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day): discontinue once ambulating regularly. 2. lipitor 80 mg tablet sig: one (1) tablet po once a day. 3. montelukast sodium 10 mg tablet sig: one (1) tablet po daily (daily). 4. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q4-6h (every 4 to 6 hours) as needed. 5. tamsulosin hcl 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 6. prednisone 20 mg tablet sig: 1.5 tablets po daily (daily): plan slow taper. 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 8. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 9. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 10. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 12. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 13. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 14. insulin regular human 100 unit/ml solution sig: as directed units injection four times a day: sliding scale for fs glucose >121 while on prednisone. 15. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) inhalation inhalation once a day: (use ipratropium mdi qid if this is not available). 16. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 17. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 18. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). discharge disposition: home with service facility: discharge diagnosis: chronic obstructive pulmonary disease exacerbation bacterial pneumonia, right lower lobe congestive heart failure non-st-elevation myocardial infarction discharge condition: stable, tolerating pos discharge instructions: please call your primary care physician or return to the hospital if you experience chest pain, shortness of breath, fever >100.4, or have any other concerns. please weigh yourself daily. if your weight increases by 3 lbs call dr. . please do not drink more than 1.5 liters per day. please adhere to a low na diet. followup instructions: follow-up with primary care physician/cardiologist within weeks Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Other specified disorders of pancreatic internal secretion Adrenal cortical steroids causing adverse effects in therapeutic use Obstructive chronic bronchitis with (acute) exacerbation Other specified forms of chronic ischemic heart disease Acute respiratory failure Other specified cardiac dysrhythmias Late effects of cerebrovascular disease, aphasia Foreign body in larynx Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Bacterial pneumonia, unspecified

history of present illness: this is a 41-year-old white male banker, who presented with severe headache on . patient presented with severe headache which began 36 hours prior to admission on . the patient reported headaches started gradually, but became severe quickly, which prevented him from doing normal activities. the headaches did improve with advil. the patient slept well that night, awoke headache free on . patient noted that his headache returned at a fairly rapid progress. patient also took advil at that time, and it did seem to respond. he went to lift weights and exercise, and immediately after exercising on , he felt his headache acutely become worse with neck stiffness and gradual onset of nausea. patient was taken by ems to an outside hospital hospital, where ct scan showed question of subdural subarachnoid hemorrhage around brain stem level. patient was emergently transferred to . past medical history: viral meningitis in . medications: none. social history: rare cigar, otherwise nonsmoker. rare etoh. allergies: no known allergies. review of systems: unremarkable. physical examination: patient was afebrile, blood pressure 127/78, tachycardic in the 120's, normal sinus rhythm, 16, 98-100% on room air. slightly sleepy, however, the patient had recently received morphine and ativan. was easily awakened alert and oriented times three, conversant and fluent. repeat phrases well. pupils were equal and reactive bilaterally. extraocular muscles were full, no nystagmus. smile is equal. neck was mildly stiff or rigid. decreased range of motion. no drift. strength were in all major muscle groups. sensation intact throughout to light touch. deep tendon reflexes were 2+ throughout. no clonus. lungs were clear. heart was regular at 120. abdomen is soft and nondistended. extremities without any edema. patient did not have a lumbar puncture. patient's ct scan from the outside hospital showed faint increased density in the area of foramen magnum, not in basal cistern. there is no evidence of more typical star sign or blood distribution on the level of cisterns or circle of . the patient was admitted to the neuro intensive care unit, where he received frequent neurological checks. his blood pressure was kept under 140. a mra was ordered. patient had lumbar puncture done and opening pressure of 195. this was done in the intensive care unit, and fluids were sent for cell count. lumbar puncture showed 182,500 red blood cells in tube one and 127,500 red blood cells in tube four. patient was brought to the neuro interventional angiography suite and had a cerebral angiogram done, which showed a c5 spinal avm with one or more feeding artery aneurysms and mass effect from an anterior subdural hematoma. patient completed procedure without problems. was further monitored in the intensive care unit overnight. patient was moved to the regular floor on the , where his headache and neck ache continued to resolve. discharge instructions: the patient was discharged on the with followup instructions to see dr. at for further treatment of this malformation. the patient was told to return if he has any further neurological problems or redevelops a headache or neck stiffness. discharge medications: the patient was given pain medications: percocet 1-2 tablets po q4-6h for pain and was also told to take colace with that. no other medications were given. the patient was discharged neurologically intact. , m.d. dictated by: medquist36 Procedure: Spinal tap Incision of lung Arteriography of cerebral arteries Diagnoses: Subarachnoid hemorrhage Spinal vessel anomaly

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: confusion, slurred speech, facial droop. major surgical or invasive procedure: endotracheal intubation egd history of present illness: 80 year old male with history of cri, htn and prostate ca presents to ed with acute onset of confusion, slurred speech and increased left facial droop. in ed, neuro noted left weakness and facial droop, mri with new corona radiata stroke without evidence of bleed. patient intubated for airway protection. pt found to have mi - ekg with depression in v1 and v2, positive troponin and ck-mb. tte with intra-atrial masses (tumor w/ thrombosis vs. myxoma vs. atypical veg). in ed, patient also incidentally found to have uti. patient heparinized for nstemi but developed gib afterwards, heparin subsequently discontinued. past medical history: seizure prostate ca glaucoma cri dementia htn brief hospital course: patient admitted on intubated s/p cva, mi, with uti and atrial mass of unkown etiology. pt had gi bleed after heparinization, which was stopped. neurology following for multiple small embolic strokes, thought to be secondary to emboli from the cardiac mass & recommending anticoagulation - eeg negative for seizure activity. cardiology following for mi & cardiac mass - thought to be calcified annular mass with overlying thrombus, needs anticoagulation for stabilization of clot to prevent further embolization. ct surgery consulted - patient not a candidate for surgery. gi consulted & egd performed demonstrating diffuse esophagitis with contact bleeding & linear ulcerations in duodenal bulb. after discussing risks/benefits with family, decision was made to attempt anticoagulation again - stopped after 2nd gi bleed requiring blood transfusion. patient treated with antibiotics for uti (ampicillin), and subsequent pneumonia (vanc & ceftaz). over the hospital course, the patient was showing no signs of making a neurologic recovery, remaining unresponsive. after numerous discussions with family, it was decided to place the patient on comfort measures only. the patient was then extubated, and all medications except for morphine were stopped. the patient breathed spontaneously at approximately 16 breaths per minute with o2 sats in the 70's, and sbp's in the 90's. he remained stable overnight, and had no change in appearance the next am, seemed comfortable, with agonal respirations. at 11:05 am, was called by nurse -- pupils were fixed and dilated, no pulse or heart rhythm, no respirations, and patient was pronounced dead at 11:05 am. the family was notified and declined a post-mortem exam. discharge disposition: home discharge diagnosis: primary: cardiopulmonary arrest cerebrovascular accident myocardial infarction secondary: prostate cancer chronic renal insufficiency seizure disorder hypertension discharge condition: expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Subendocardial infarction, initial episode of care Mitral valve disorders Urinary tract infection, site not specified Acute kidney failure, unspecified Other pulmonary insufficiency, not elsewhere classified Cerebral embolism with cerebral infarction Hemorrhage of gastrointestinal tract, unspecified

service: medicine history of present illness: the patient is a 51 year old male with a smoking history and copd who was recently diagnosed with squamous cell cancer in the right main stem bronchus, status post mediastinoscopy and bronchoscopy performed on . he initially was doing quite developed a productive cough without hemoptysis, increasing shortness of breath, no fever or chills. patient denied nausea, vomiting or diarrhea. on , patient had markedly increased shortness of breath with midsternal chest pain. patient went to hospital and in the emergency room an abg was below the 50s. patient was intubated and started on gatifloxacin for questionable post obstructive pneumonia. patient also received lasix for diuresis. patient was then transferred to on , for rigid bronchoscopy and right main stem stenting. patient was accepted to the micu. of note, bronchoscopy on , showed a large endobronchial lesion at the right main stem takeoff with almost complete occlusion of the bronchus. biopsies were sent which showed squamous cell carcinoma. mediastinoscopy showed dense fibrous reaction in the anterior aspect of the trachea. there was question of lymph node versus mass distension. past medical history: 1. chronic obstructive pulmonary disease. 2. squamous cell lung cancer. 3. chronic lower back pain. allergies: no known drug allergies. medications on transfer: gatifloxacin and flagyl. social history: patient lives with wife. smokes approximately pack per day of cigarettes. patient drinks approximately six beers every other day. he is unemployed. physical examination: in general, patient was intubated and sedated. temperature 98.8, heart rate 65, blood pressure 105/57, oxygen saturation 97% with vent setting at ac tidal volume 500, respirations 16, peep 7.5, fio2 0.6. heent pupils equal and reactive. neck supple, no lymphadenopathy. lungs had diffuse rhonchi and wheezes. cardiovascular distant heart sounds, normal s1, s2 without murmurs. abdomen soft, absent bowel sounds, no masses. extremities no cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. laboratory data: white count 27.1, hematocrit 29.8, platelets 603. pt 14.1, inr 1.3, ptt 32.1. lactate 1.4. sodium 136, potassium 4.7, chloride 98, bicarbonate 24, bun 31, creatinine 0.9, glucose 121. lfts were remarkable for ldh of 494. phosphorus was 5.2. chest x-ray right upper lobe collapse with hyperlucency of the right middle lobe and right lower lobe. small right pleural effusion. left lung with diffuse haziness. hospital course: 1. pulmonary. the patient was admitted to the micu and intubated and sedated. patient underwent bronchoscopy and stenting of the right main stem bronchus on . bronchoscopy showed near complete obstruction of the right main stem bronchus with lobulated tumor tissue. right upper lobe bronchus was completely obstructed with tumor mass. right middle lobe and right lower lobe bronchi were patent with no tumor tissue. tumor in the right main stem bronchus was destructed with electrocautery. further tissue was removed with the rigid flexible bronchoscope. patient was extubated on , status post stenting. patient was placed on a brief prednisone taper for questionable copd inflammation secondary to the tumor. patient was also continued on levofloxacin and flagyl for post obstructive pneumonia. patient's oxygenation remained stable during his hospital stay. patient was transferred out of the micu on . patient was continued on albuterol and atrovent mdi and nebulizer for diffuse wheezing. patient was able to ambulate with oxygen saturation of 92%. patient was weaned from oxygen completely on . 2. cardiovascular. the patient was noted to have a bradycardic episode into the 40s post bronchoscopy and stent placement. ekg showed sinus rhythm at 45 beats per minute with qtc of elevations. troponin was found to be elevated at 3.2 with normal cks. it was thought that this elevated troponin was secondary to stress from the procedure. patient was placed on aspirin and beta blocker. an echo was obtained on , which showed an ejection fraction of 55% to 60% with trivial mitral regurgitation and mild pulmonary artery systolic hypertension. lipid panel was obtained which showed ldl of 86, triglycerides 98, hdl 26. patient will likely need an outpatient stress test performed once his pulmonary issues and oncologic issues remain stable. 3. oncology. the patient underwent a bone scan, chest ct scan, head ct scan, abdominal and pelvic ct performed to assess for metastases. there was no evidence of metastases, however, on bone scan there was evidence of a focus of radiotracer activity in the cervical spine which may be secondary to degenerative disease. patient will follow up in thoracic oncology clinic with dr. and this appointment will be arranged for him. 4. alcohol abuse. the patient was placed on a ciwa scale and there was no evidence of withdrawal. 5. pain. the patient was placed on oxycontin and oxycodone for his lower back pain. condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. squamous cell lung cancer with large obstructing right upper lobe mass. 2. status post stent in right main stem bronchus. 3. copd. 4. non-q wave mi. 5. lower back pain. discharge medications: 1. nicotine patch 21 mg transdermal q.d. 2. albuterol inhaler one to two puffs inhaled q.six hours p.r.n. wheeze. 3. ipratropium bromide two puffs inhaled q.six hours p.r.n. wheeze. 4. levofloxacin 500 mg p.o. q.d. times eight days. 5. flagyl 500 mg p.o. t.i.d. times eight days. 6. thiamine 100 mg p.o. q.d. 7. folic acid 1 mg p.o. q.d. 8. multivitamin one cap p.o. q.d. 9. aspirin 325 mg p.o. q.d. 10. oxycodone/acetaminophen one to two tabs p.o. q.four to six hours p.r.n. pain. 11. oxycontin 10 mg p.o. q.12 hours p.r.n. pain. 12. docusate sodium 100 mg p.o. b.i.d. 13. bisacodyl 10 mg p.o. q.d. p.r.n. constipation. 14. atenolol 25 mg p.o. q.d. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other intubation of respiratory tract Endoscopic excision or destruction of lesion or tissue of bronchus Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Other pulmonary insufficiency, not elsewhere classified Obstructive chronic bronchitis with (acute) exacerbation Other specified cardiac dysrhythmias Malignant neoplasm of upper lobe, bronchus or lung Other and unspecified alcohol dependence, unspecified Alcohol withdrawal Malignant neoplasm of main bronchus

technique: ct chest with iv contrast. ct of the airway was performed during dynamic aspiration. 100 cc of optiray was administered iv for patient's history of allergies. ct chest with iv contrast: soft tissue windows reveal supraclavicular lymph nodes on the right side, measuring approximately 16 mm in short axis. there is bulky right paratracheal lymph nodes, measuring approximately 2 cm in short axis. a large mass is present in the right hilar measuring approximately 4.4 x 3.4 cm in size. there is associated right hilar and subcarinal lymphadenopathy. the right upper lobe bronchus is obstructed. the patient is status post stent placement in the bronchus intermedius. soft tissue density is noted in the stent. considering the proximety of the stent to the adjacent tumor this most likely represents tumor invasion rather than granulation tissue. the cross sectional area of the stent is stenosed by approximately 45%. the right pulmonary arteries are encased by the hilar mass, stretched and narrowed, but appear patent. right middle lobe and right lower lobe bronchi appear patent. trace bilateral pleural effusions are noted. lung windows reveal a calcified granuloma in the right lung base. diffuse air space ground glass opacifications are present bilaterally, left greater than right. post obstructive atelectasis of the right upper lobe is seen. expiration images demonstrate no evidence of tracheobronchomalacia. the patient also has an abdominal ct on the same day. please see the abdominal ct for the full report for abdominal findings. bone windows reveal no significant abnormalities. expiration images reveal no excessive airway collapse that is suggestive of tracheobronchomalacia. impression: (over) 1:27 pm ct trachea w/c & w/recons; ct 100cc non ionic contrast clip # reason: squamous cell ca,s/p stent,assess airway involvement of tumor field of view: 40 contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont) 1. large right hilar mass obstructing the right upper lobe bronchus with post obstructive atelectasis of the right upper lobe. mediastinal lymphadenopathy is also noted. 2. the patient is status post stent placement in right mainstem bronchus and bronchus intermedius. soft tissue density is present within the stent, with associated luminal narrowing. this may represent tumoral involvement, and less likely represents granulation tissue or secretions. note is also made of thickening of the wall of the right mainstem bronchus extending to its origin from the carina. the right middle lobe and lower lobe bronchi are patent. 3. diffuse ground glass opacities in the lungs, left greater than right, which may represent infectious pneumonitis, drug reaction or hypersensitivity pneumonitis. less likely this could represent lymphangetic carcinomatosis. addendum: multiplanar and 3-d images were reconstructed and reviewed in conjunction with the axial images. they confirm the presence of right upper lobe bronchial obstruction. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other intubation of respiratory tract Endoscopic excision or destruction of lesion or tissue of bronchus Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Other pulmonary insufficiency, not elsewhere classified Obstructive chronic bronchitis with (acute) exacerbation Other specified cardiac dysrhythmias Malignant neoplasm of upper lobe, bronchus or lung Other and unspecified alcohol dependence, unspecified Alcohol withdrawal Malignant neoplasm of main bronchus

history of present illness: the patient is a 51 year old male who in late , early developed an upper respiratory infection. after his symptoms failed to improve, he underwent evaluation with radiography which eventually demonstrated a collapsed right upper lung with a right upper lobe hilar mass. bronchoscopy with transbronchial biopsy demonstrated a nonsmall cell lung carcinoma. mediastinoscopy was negative for mediastinal involvement. the patient's postoperative course was complicated by respiratory insufficiency requiring intubation. he was transferred to where a rigid bronchoscopy and debridement of the right main stem endobronchial tumor opening up the right lower and right middle lobe. a stent was also placed in the right main stem bronchus to maintain patency. the patient was discharged and now returns to the thoracic oncology multidisciplinary center for evaluation. it was decided to treat the patient with neoadjuvant chemotherapy/radiation to be followed by possible sleeve lobectomy. since that time, the patient has completed chemotherapy and radiotherapy. a repeat chest ct scan showed significant regression of the tumor within the right upper lobe bronchus to the point the right upper lobe was back spanned. there was no significant reduction of the tumor mass at the tracheobronchial angle. past medical history: 1. herniated discs. 2. possible myocardial infarction. medications on admission: 1. oxycontin. 2. percocet. allergies: the patient has no known drug allergies. social history: the patient smoked one and one half packs a day for forty years. he continued to smoke up to eight days ago. family history: the patient's father died of lung cancer. mother died of diabetes mellitus. sister currently has coronary artery disease. physical examination: the patient is a well developed male in no apparent distress. temperature is 97.3, pulse 72, oxygen saturation 97% in room air, blood pressure 100/64. head, eyes, ears, nose and throat - sclera is anicteric. neck - no supraclavicular or cervical lymphadenopathy. lungs are clear to auscultation bilaterally. heart is regular rate and rhythm without murmur. the abdomen is soft without masses. extremities - inguinal and groin regions have no lymphadenopathy. extremities show no cyanosis, clubbing or edema. hospital course: the patient was admitted on , and taken directly to the operating room where a bronchoscopy and right pneumonectomy was performed. the patient initially tolerated the procedure quite well. he had a chest tube in place. he was on perioperative kefzol and managed by acute pain service. chest tube was removed on postoperative day one, perioperative ancef was continued for one week. the patient was advanced on his diet. unfortunately on postoperative day number two, the patient started to experience some respiratory distress that over the course of the day was progressive to the point the patient required transfer to the intensive care unit for closer monitoring. the patient received in the intensive care unit two units of packed red blood cells for anemia. the patient received lasix in an attempt to decrease what initially appeared to be fluid on the lung. the patient was put on broad spectrum antibiotics, initially levofloxacin and flagyl and then zosyn. it was finally decided the patient had a post pneumonectomy contralateral lung respiratory distress syndrome associated with inflammation. the patient was started on epogen. over the course of the next several days, the patient required aggressive pulmonary treatment including cpap and steroids. when the patient was adequately stable, he was transferred back to the regular cardiothoracic floor where he slowly improved. the patient did essentially require aggressive respiratory therapy including oxygen and periodic nebulizer treatments. it was felt by the team that the patient will benefit from a period of rehabilitation in an acute pulmonary rehabilitation setting. for that matter, he is being discharged tomorrow in stable condition to acute pulmonary rehabilitation facility. he will need to follow-up with dr. in one to two weeks. the patient may shower but not take any baths. he should avoid driving while on pain medications. he should avoid strenuous activity. medications on discharge: 1. nicotine patch 21 mg td once daily. 2. prednisone 10 mg p.o. times five days. 3. levofloxacin 500 mg p.o. q24hours times five days. 4. ranitidine 150 mg p.o. twice a day. 5. colace 100 mg p.o. three times a day p.r.n. 6. nystatin swish and swallow 5 ml p.o. four times a day p.r.n. 7. oxycodone 10 mg p.o. q3-4hours p.r.n. pain. 8. oxycodone sustained release 30 mg p.o. q8hours. 9. midazolam 1 to 2 mg intravenously q4hours p.r.n. 10. diazepam 5 mg p.o. q6hours p.r.n. 11. albuterol one nebulizer treatment q3-4hours p.r.n. 12. heparin 5000 units subcutaneous q12hours. , m.d. dictated by: medquist36 Procedure: Fiber-optic bronchoscopy Diagnoses: Acute posthemorrhagic anemia Malignant neoplasm of upper lobe, bronchus or lung Chronic and other pulmonary manifestations due to radiation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: "worse headache of my life", diplopia, nausea. major surgical or invasive procedure: suboccipital craniotomy for tumor resection. ventriculostomy placement. lumbar drain placement. history of present illness: 22 year-old white male with history of migrane, presented to ed c/o incresed headache for 3 days, nausea, diplopia, diziness, photophobia, and blurred vision. patient trie dhis imitrex and excedrin for headache but didn't helped the headache.patient headache intensity was day before to emergency visit, while in ed.head ct revieled 4th ventricle mass and hydrocephalus, no midline shift.patient admitted to tsicu where ventriculostomy drain placed openin pressure 14-16 with clear csf for closer management of icp and posiible surgery. past medical history: migrane headache 4 rt ventricule mass since age 5, no f/u until now. left knee surgeryx2. social history: will be graduating this summer from universiy in accounting major.somekes on weekends. occ etoh with friends.denies recreational drug use. family history: father has dm physical exam: general: temp;97.9 pulse;94 bp; 109/68 rr;18 sao2; 99 ra. patient lying in bed, nad. cvs: rrr, s1, s2, no m/g/r. lungs: cta a/p bilat. abd: soft, nontender,bowel sounds are present. ext: no edema. neuro:alert, orientedx3, language fluent. perrl, positive fine nystagmus on horizantal line.cn ii-v,vii , viii-xii intact. cn vi paralysis. strenght in all muscle group.sensation intact t/o to light touch.positive for vibration t/o. coordination mild bilateral dysmetria.dtr:2+ t/o, toes downward. pertinent results: 10:25am glucose-82 urea n-11 creat-1.0 sodium-134 potassium-4.3 chloride-94* total co2-30* anion gap-14 10:25am glucose-82 urea n-11 creat-1.0 sodium-134 potassium-4.3 chloride-94* total co2-30* anion gap-14 10:25am wbc-4.4 rbc-4.98 hgb-15.4 hct-43.3 mcv-87 mch-30.9 mchc-35.6* rdw-12.5 10:25am plt count-144* 10:25am pt-12.8 ptt-29.2 inr(pt)-1.0 10:25am d-dimer-185 brief hospital course: 22 year-old white male with history of migrane, presented to ed c/o increased headache for 3 days, nausea, diplopia, dizziness, photophobia, and blurred vision. head ct revealed th ventricle mass and hydrocephalus, no midline shift .patient admitted to ts icu where ventriculostomy drain placed opening pressure 14-16 with clear csf for closer management of icp.mri showed large fourth ventricular mass consistent with ependymoma. patient became intermittently agitated, confuse, and disoriented, attempted to pull his ventriculostomy on his way to head ct on . patient and family pursued with surgery for the fourth ventricle mass, which preformed on resection of the tumor with suboccipital craniotomy.patient transferred from tsicu to neurosurgery stepdown unit on in the aftenoon of .patient neurologically remained stable.all preop symptoms resolved after surgery.ventricular drain discontinued on .lumbar drain placed on for csf leakage from his occipital incision site.lumbar drain gradually weaned to d/c on . pateint denies any headache, no leakage from the site. discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 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. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*0* 4. dexamethasone 2 mg tablet sig: one (1) tablet po bid (2 times a day): start decadron 1mg(1/2tablet) twicwe a day for 3 days.then decadron 1mg( tablet) once day for 3 days, then stop . disp:*10 tablet(s)* refills:*0* 5. chlorpromazine 25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. disp:*20 tablet(s)* refills:*0* 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. discharge disposition: home discharge diagnosis: fourt ventricule mass discharge condition: neurologically stable. discharge instructions: report increaed heaache, visual changes, double vision nausea, vomiting.report any drainage, redeness, swelling from insicion site. followup instructions: follow up for staples to be removed @ 11am in dr. office (lumbar to be removed at the same day of cranial staples removal) follow up in brain tumor clinic: provider: , md where: neurology phone: date/time: 15:00 Procedure: Spinal tap Incision of lung Spinal tap Incision of lung Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Intravascular imaging of intrathoracic vessels Diagnoses: Esophageal reflux Sixth or abducens nerve palsy Other specified complications of procedures not elsewhere classified Communicating hydrocephalus Benign neoplasm of brain

history of present illness: the patient is a 48-year-old woman who was transferred from . the patient originally presented to her pcp approximately one week prior to admission here with increasing cough, dyspnea and fatigue. she was given a z-pak for treatment along with albuterol. despite this, she continued to worsen and became febrile. so, she was admitted to on . at the hospital, she was started on rocephin and levaquin for a right lower lobe pneumonia seen on chest x-ray. she continued to have increasing respiratory distress with hypoxia. she was also significantly tachypneic. at this time, repeat chest x-ray showed bilateral diffuse infiltrates consistent with ards. the patient was intubated and then transferred to micu. past medical history: hypothyroidism. depression. anxiety disorder. medications: 1. levoxyl 112 mcg q.d. 2. prozac. 3. codeine for cough. allergies: no known drug allergies. social history: the patient is unemployed. she smokes approximately one pack per day. she drinks alcohol socially. physical examination: on admission, vital signs: temperature 101.4, blood pressure 101/62, pulse 80, respiratory rate 19 on a ventilator with settings of assist control at 500/12 and a peep of 5. general: the patient is intubated and sedated, but easily arousable. heent: pupils equally round and reactive to light. sclerae are anicteric. et tube is in place. neck: soft and supple. cardiovascular: normal. chest: faint scattered wheezes bilaterally. abdomen: benign. extremities: warm with good distal pulses. there is no edema. neurologic: able to follow simple commands. laboratory data: labs on admission from outside hospital, cbc notable for a white count of 21.9 with hematocrit of 36.3 and normal platelets. chem-7 notable for potassium of 3.2 and bicarbonate of 30. lfts show an elevated alt of 52 and ast of 101 with normal alkaline phosphatase and total bilirubin. latest arterial blood gas with ph of 7.45, pco2 43 and po2 155 on 100 percent oxygen via ventilator. radiographic studies: chest x-ray shows right middle lobe, right lower lobe, and left lower lobe infiltrates. ekg shows normal sinus rhythm at 70 beats per minute with normal axis and intervals, borderline lvh. summary of hospital course: respiratory: on admission, the patient had what appeared to be acute respiratory distress syndrome secondary to community-acquired pneumonia. she was maintained on a ventilator and ventilated according to ardsnet protocol. for antibiotic coverage of her pneumonia, she was started on levaquin, ceftriaxone, and vancomycin. over the next two days after admission, the patient's vent settings were gradually weaned, and she was extubated two days after being transferred to this hospital. after extubation, the patient was oxygenating well on face mask. she did continue to have a persistent fairly severe cough; however, her cough was weak due to abdominal muscle pain from repeated coughing. the cough was mostly nonproductive. the patient was breathing comfortably. as there was no identified bacterial pathogen on any cultures, the patient was continued on the triple antibiotics for first several days of the hospitalization. she was also on round-the-clock atrovent and albuterol nebulizers. once the patient was transferred out of the icu and after extubation, the antibiotics were gradually narrowed. the vancomycin and levaquin were discontinued after approximately four days in the hospital. the ceftriaxone was discontinued after four days in the hospital, and the patient was to continue on levaquin. the patient had gradual improvement in her oxygenation. pain control: the patient had fairly significant abdominal pain secondary to persistent cough. she was started on a regimen of ms contin with oxycodone for breakthrough pain. this helped her somewhat though she has continued to have difficulty coughing due to the pain. tylenol and ibuprofen were also added for better control. transaminitis: the patient was noted to have mild transaminitis on admission. however, this was felt to be due to her significant infection. this should continue to be followed as an outpatient to assure that it returns back to normal. anemia: the patient's reticulocyte count showed inadequate production. iron studies showed a mixed picture with decreased iron and decreased iron to tibc ratio suggestive of iron-deficiency anemia, but also normal to high mcv. b12 was noted to be low and the patient was given an injection of im b12 while in the hospital. she was also started on iron supplementation. hypothyroidism: the patient was continued on synthroid for her chronic hypothyroidism. discharge status: the patient was discharged home with services. discharge condition: good. discharge diagnoses: community-acquired pneumonia. acute respiratory distress syndrome. iron-deficiency anemia. hypothyroidism. discharge medications: 1. levothyroxine 75 mcg q.d. 2. prozac 40 mg q.d. 3. levaquin 500 mg q.d. for 7 days after discharge. 4. guaifenesin syrup p.r.n. cough. 5. oxycodone 10 mg q.4 h. p.r.n. for pain. 6. colace 100 mg b.i.d. 7. ms contin 30 mg b.i.d. 8. ibuprofen 800 mg q.8 h. 9. albuterol 1 to 2 puffs q.6 h. p.r.n. 10. atrovent 1 puff q.6 h. p.r.n. discharge instructions: follow-up plans: the patient was instructed to call her pcp, . , to follow up the week of discharge. she is also to call her pcp if she has increasing shortness of breath or fevers. , dictated by: medquist36 d: 17:19:48 t: 00:27:21 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Pneumonia, organism unspecified Other pulmonary insufficiency, not elsewhere classified Unspecified acquired hypothyroidism Personal history of tobacco use Hepatitis, unspecified Generalized anxiety disorder

allergies: tetanus toxoid attending: chief complaint: elective right carotid stent major surgical or invasive procedure: carotid stent per crest trial history of present illness: 62 yo f w/ h/o cva (slurred speech ), cea at osh (), htn, iddm w/ recent carotid duplex study done on revealing a tight stenosis of r ica 80-99% and minimal stenosis on the left <20%. pt had episode of slurred speech and upper extremetiy incoordination with b/l cva's on mri. pt now reports some neurological improvement with some mild speech difficulty and questionable short-term memory problems. tee w/o clot. pt underwent cath with successful stenting of her r ica. cath: 0% residual w/ normal flow. past medical history: pvd, htn, cva, s/p cea, s/p r fem- social history: she lives alone. children provide emotional support for her. she does drink alcohol approximately "a few drinks a week" but no more than one drink a day. she does smoke tobacco. family history: negative for stroke. mother deceased of unclear etiology. father deceased of complications of diabetes and coronary disease. physical exam: vital signs: blood pressure is 130/72, pulse 76, respirations 18. heent: sclerae anicteric, oropharynx without erythema. neck: supple, midline trachea, right carotid bruit is auscultated. cardiac: regular rate and rhythm; no murmurs, rubs, or gallops. lungs: clear to auscultation bilaterally. extremities: no clubbing, cyanosis, or edema. pulses are palpable. neurologic: mental status: she is alert and oriented x3. with nih stroke scale card, her naming and repetition are intact, however, with spontaneous speech, she does make occasional paraphasic errors, and she does make paraphasic errors with words aloud from the card. she is able to read and write and to distinguish left from right on herself and on the examiner. her attention testing as before, she is able to spell "world" forwards appropriately but not backwards. recall is at 3 minutes. she was able to perform calculations and follow 3-step commands. she is oriented times the month, year, her own name, the current president, and the previous president as well as today's date and place and floor. cranial nerves perrla, eomi, visual fields full. v1, v2, v3 intact to light touch. face symmetric. hearing intact. oropharynx elevates symmetrically. tongue protrudes midline. motor: no pronator drift. strength is throughout all 4 extremities including deltoid, biceps, triceps, wrist flexion, wrist extension, finger flexion, grip, finger extension, hip flexion, knee flexion, knee extension, plantar flexion, dorsiflexion. normal muscle tone and bulk. no tremor, fasciculation, or atrophy observed. sensory intact to light touch times all 4 extremities, no sensory neglect, proprioception intact. deep tendon reflexes are trace throughout downgoing toes bilaterally. coordination intact finger-to-nose and heel-to-shin. gait was unable to be tested, as she is currently hooked up to cardiac monitoring in the cardiology holding area, and an iv is currently being placed. (exam performed by dr. pertinent results: 05:44pm pt-15.4* inr(pt)-1.5 08:15am pt-18.2* inr(pt)-2.1 12:50pm blood wbc-12.5* rbc-4.38 hgb-12.5 hct-36.4 mcv-83 mch-28.5 mchc-34.2 rdw-13.9 plt ct-344 12:50pm blood glucose-218* urean-12 creat-0.5 na-139 k-4.0 cl-104 hco3-24 angap-15 mri scan of the brain, bilateral infarcts on diffusion-weighted imaging including the right centrum semiovale, left posterior parietal temporal region. previous infarct left frontal consistent with left frontal encephalomalacia and deep white matter disease were also observed. on , mr angiography of the cerebral vessels was reportedly within normal limits. brief hospital course: 62 yo female w/ dm2, htn, hypercholesterolemia, diffuse vasculopathy, and h/o recent cva admitted for elective r carotid stent. 1. pt underwent cath with successful stenting of her r ica with 0% residual stenosis and normal blood flow. her sbp was kept above 110 during her hospital stay. phenylephrine was initially needed to keep her bp at goal, however was able to be d/c'ed several hours after her procedure. she had no evidence of vagotonia. , plavix, and lipitor were started after the procedure. no heparin was administered. neuro checks were done q 4 hrs, w/o evidence of deficits. pt denied visual changes, lightheadedness, numbness, weakness, or confusion. she will follow up with drs. and in the next week for bp check, she will hold her outpt bp meds until that time. she will be rechecked by dr. in 1 month. 2. htn. anti-hypertensives held post procedure until follow up with dr. within one week. phenylephrine given initially as needed to keep bp > 110. 3. dm. blood sugars well controlled on iss. her oral hypoglycemics were held initially but restarted prior to discharge. medications on admission: actos 45 qd, metformin 1000 mg , lisinopril 20 qd, lovastatin 80 , 325, mvi, ca, coumadin, lantus 60 u q pm discharge medications: 1. atorvastatin calcium 40 mg tablet sig: two (2) tablet po qd (once a day). 2. multivitamin capsule sig: one (1) cap po qd (once a day). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po q day (). 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). 6. insulin glargine 100 unit/ml solution sig: 0.6 ml subcutaneous at bedtime. 7. med change please stop taking your zestril/linisopril stop taking your coumadin 8. actos 45 mg tablet sig: one (1) tablet po once a day. 9. metformin hcl 1,000 mg tablet sig: one (1) tablet po twice a day. 10. physician # md ( discharge disposition: home discharge diagnosis: htn hypercholesteremia dm pvd cva, bilateral s/p cea rt discharge condition: good discharge instructions: please call drs. if you have any lightheadedness, change in vision or any otherr neurological symptoms his # is ( call your primary care doctor dr. at if you have fever>101, chills or feel unwell followup instructions: please see drs. and this week for a blood pressure check. his assistant will contact you. if you do not hear from him by wed then please call him at ( md, Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Peripheral vascular disease, unspecified Personal history of tobacco use Occlusion and stenosis of carotid artery without mention of cerebral infarction Late effects of cerebrovascular disease, other speech and language deficits Other specified complications of procedures not elsewhere classified

allergies: demerol / iodine attending: chief complaint: labile blood pressure major surgical or invasive procedure: arterial line placement history of present illness: 56f with h/o stage iv ovarian ca , recurrent dvts, morbid obesity and htn who was sent to the ed from oncologist's office with creatinine of 3.2 after five days out from an abd ct with iv contrast on to evaluate for peritoneal mets. she was also taking increasing doses of mscontin for pain as her kidney fxn was declining. she has been mildly somnelent for few days pta with occasional nausea and headache. no fevers, chills, diarrhea, hematuria, sob. she does report decreased urine output over the past several days. . in ed, she did not have accurate blood pressure measurements secondary to her obesity and an inability to find an extra large bp cuff. systolic bps were recorded from the 50s to the 160s, though she had no clinical evidence of hypotension. cardiology was called for echo which revealed no evidence of tamponade, with nml ef. pt received a total of 4l ns. a left radial a line was placed, she had persistent hypotension, with her blood pressure supported with pressors and ivf in the micu. of note, she had a prompt response to narcan, so it was thought her change in mental status was both contrast nephropathy and a decreased ability to metabolize opioids while she was increasing her dose at home. renal was consulted, and incr her renal perfusion with pressors, ivf, lasix challenges. as obstruction was considered, a renal ultrasound on demonstrated no evid of hydronephrosis. her creatinine continued to improve, and at the time of her transfer to the floor, her cr was 1.2, down from 6.6 on . . she was started on a heparin drip given her h/o ue dvt in the right axillary and subclavian veins, previously managed with lovenox. a le doppler on demonstrated no dvts. it is unclear why the pt was not on coumadin at home. at transfer to floor, she was changed from heparin drip to sq lovenox. . heme-onc also followed the pt, she is s/p 5 cycles of /taxol with resistant disease and will be switched to doxil per dr. . she has persistently low hct/plt, which heme/onc feels is a likely side effect of chemo. she is dnr/dni. past medical history: 1. diabetes mellitus type 2 2. stage iv ovarian/peritoneal ca dx'd after presentation wtih new ascites and doe, exudative pleural effusion returned as adenocarcinoma. elevated ca-125. status post 3 cycles of taxol and carboplatin (last ). oncologist = 3. morbid obesity 4. h/o recurrent rle dvts following trauma to rle, s/p ivc filter >6 yrs ago. had been off anticoagulation x 6 years prior to current dvt. started on lovenox on . 5. hypertension 6. hypercholesterolemia 7. osteoporosis 8. s/p c past surgical history: s/p cholecystectomy s/p tah (ovaries left in place) has right port-o-cath social history: she used to work as a computer programmer. history of ivdu (heroin), none in a number of years. history of heavy alcohol consumption. ex-smoker, she quit about 10 years ago. she used to smoke about ppd x years. disabled from leg injury in past. family history: mother with history of stomach cancer. brother with hepatitis. father in good health. physical exam: pe: bp: af 90's/70's p:67 rr: 14 oxygen sat: 94%ra gen: chronically ill. a&o x 3. heent: left eye down and out. left ptosis. perrl. neck: swelling or right arm swelling. the right port-a-cath is okay. lungs: show diminished breath sounds at the bases, left greater than right. cardiac: regular rate and rhythm, no murmur, rub or gallop. abdomen: obese with normal bowel sounds. exam limited by body habitus. extremities: warm without rash. neuro: non-focal other than left eye esotropia and ptosis. no papilledema. normal gait. strength 5/5 upper and lower extremities. sensation intact throughout. pertinent results: ct of the chest with iv contrast: there is interval decrease in the left-sided pleural effusion with interval improved aeration of the left lung. there is residual left-sided atelectasis. multiple calcified granuloma at the left lung base are again demonstrated and unchanged. the airways appear patent to the level of the segmental bronchi bilaterally. the heart, pericardium, and great vessels are unremarkable. ct of the abdomen with iv contrast: multiple intra-abdominal fluid collections are again demonstrated and not significantly changed in size or distribution compared to the prior study. the appearance of a high density, thin, rim surrounding many of these collections is again seen and unchanged. the liver, spleen, adrenal glands, kidneys, stomach, small bowel, and large bowel are unremarkable. the pancreas is poorly visualized and appears atrophic. an ivc filter is in place. multiple gastrohepatic ligament nodes measuring 11 and 12 mm in short axis diameter are stable. no free air is seen. ct of the pelvis with iv contrast: the bladder, distal ureters, rectum, and sigmoid colon are unremarkable. there is no pelvic or inguinal lymphadenopathy. ct head: no obvious mass or midline shift or other evidence increased icp. (unofficial read). cxr : impression: resolving left lower lobe opacity which may relate to resolving atelectasis or improving pneumonia. persistent small left pleural effusion. echo : conclusions: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. there are no echocardiographic signs of tamponade. brief hospital course: a/p: 56f with h/o stage iv ovarian ca, recurrent dvts, morbid obesity and htn with acute renal failure contrast nephropathy, and altered mental status increasing opioid doses in setting of failing kidneys (kidneys not able to clear mscontin). . 1. acute renal failure, contrast nephropathy: given temporal relationship to contrast study, we felt this was most likely contrast nephropathy. her fena was calculated to be 0.4% which can be consistent with renovascular constriction from contrast in the setting of dm. her renal ultrasound was without evidence of obstruction. we held her acei given arf, and increased her renal perfusion in the icu with ivf, pressors and lasix challenges. her creatinine responded appropriately, and her renal function demonstrated a downward trend in creatinine. she urinated well, with discharge cr at 1.2 (her baseline). renal was consulted and followed pt throughout her hospital course. . 2. cardiovascuar/hypotension: the etiology of her presenting hypotension was unclear, given she had no active infection and this was not a septic picture. she had +mrsa sputum with ?pna. her echo on admission demonstrated ef=60%, but suboptimal anterior fat pad, so tamponade could not initially be ruled out. she did not have a pulsus parodoxicus or elevated jvp. . 3. change in mental status secondary to uremia vs oversedation, with decreased clearance of mscontin. following admission to the icu, she developed worsening mental status, that responded well to 0.4 mg narcan. of note, her mscontin dose recently increased to 100 mg po bid, so we felt that she had decreased clearance in setting of arf. her head ct was wnl; and the pt was refusing mri (to look for carcinomatous meningitis). she can follow up as an outpatient with dr. regarding mri for staging workup of the brain. at discharge, her mental status is clear. . 4. pulmonary: during her stay, she had a left pleural effusion with left lower lobe opacification, suggesting atelectasis versus consolidation on cxr. furthermore, her sputum cx came back positive for mrsa. this could be due to colonization vs. mrsa pna. she has remained afebrile, however, satting 100% on ra. this was resolving on subsequent cxrs. . 5. chronic anemia. her hematologist/oncologist felt this is likely secondary to treatment with the /taxol regimen. pt is s/p 5 cycles. we followed serial hcts, without need for transfusion. this will be monitored as outpatient. . 6. right dilated pupil: question with regards to the chronicity as pt reports having this in the past, but it is not documented in prior notes. initial head ct negative. pt does not want further imaging studies despite our explaining our concern for increased intracranial pressure or carcinomatous meningitis. - f/u with mri with dr. , if pt agrees. . 6. rue dvt: dx with thrombus in right axillary and subclavian veins, previously managed with lovenox. unclear why pt was not on coumadin. the pt is now on sq lovenox 120mg sq qam, 150mg sq qhs. she was on a heparin gtt while in the micu. . 7. dm: continue present outpatient management. on ssi in the hospital. . 8. code status: pt is dnr/dni. partner's sister is patient's hcp. discharge medications: 1. ferrous sulfate 325 (65) 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 bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. disp:*qs mdi* refills:*0* 4. 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* 5. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*2* 7. enoxaparin sodium 120 mg/0.8 ml syringe sig: one (1) subcutaneous qam (once a day (in the morning)). disp:*qs 120mg/0.8ml syringes* refills:*2* 8. enoxaparin sodium 150 mg/ml syringe sig: one (1) 150mg/ml syringes subcutaneous qpm (once a day (in the evening)). disp:*qs 150mg/ml syringes* refills:*2* 9. flovent 110 mcg/actuation aerosol sig: 2 puffs inhalation q4-6h prn wheezing. disp:*1 mdi* refills:*2* 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po 4 times per day prn as needed for pain: can take an additional 4 pills total throughout the day for breakthrough pain. max per day: 8 pills. disp:*40 tablet(s)* refills:*0* 11. levaquin 500 mg tablet sig: one (1) tablet po once a day for 6 days. disp:*6 tablet(s)* refills:*0* discharge disposition: home with service facility: greater vna discharge diagnosis: 1. acute renal failure secondary to intravenous contrast/contrast-induced nephropathy 2. opioid ingestion in setting of acute renal failure leading to altered mental status 3. pneumonia 4. stage iv ovarian cancer 5. type ii diabetes mellitus 6. morbid obesity 7. h/o recurrent deep venous thrombosis 8. hypertension 9. hypercholesterolemia 10. osteoporosis discharge condition: stable discharge instructions: if you experience any chest pain, shortness of breath, decreased urine output, nausea or vomiting, please report to the er immediately. please take all of your medications. please follow up with your physicians (appts listed below). followup instructions: 1. provider: , md where: hematology/oncology phone: date/time: 12:00 2. provider: date/time: 12:30 3. provider: , rn where: hematology/oncology phone: date/time: 12:30 4. please follow up with dr. . her office number is . please call this number as soon as possible to schedule a follow-up appointment. Procedure: Arterial catheterization Diagnoses: Pneumonia, organism unspecified Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Secondary malignant neoplasm of pleura Accidental poisoning by other opiates and related narcotics Osteoporosis, unspecified Morbid obesity Poisoning by other opiates and related narcotics Anemia in neoplastic disease Secondary malignant neoplasm of retroperitoneum and peritoneum Malignant neoplasm of ovary

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left sided weakness, acute onset major surgical or invasive procedure: mri/ t-pa tee history of present illness: this is a 41 year-old rh man with a history of dm, htn, high cholesterol, current heavy smoker, obesity who presents with sudden onset left- sided weakness. pt lives in and was in on business. he went to sleep at 11pm wed night and awoke at ~11:50 with a feeling that his left arm was not his and belonged to someone else. he called his wife who noted his speech sounded slurred. he attempted to walk over to the door but was unable to and eventually crawled to his door. his wife called the hotel who then called ems, and ems busted down the door. patient arrived in the ed at 1am and was found to have left hemiplegia and sensory loss, slurred speech, and a left field cut, nihss score of 16. he was given t-pa within 25 min of arriving to the ed. prior to t-pa a head ct was obtained that showed hypodensity and sulcal effacement in right temporal lobe, no bleed. blood glucose was 209, bp 158/78, hr 85, inr 1.2. transferred to the icu for monitoring. his exam improved remarkably. this afternoon he has no complaints - no chest pain, palpitations, sob, abdominal pain, ha, tinnitus, numbness or weakness, no visual distrubances. he only asks to go outside for a smoke. past medical history: htn dm, adult onset high cholesterol cri gout hep c s/p interferon therapy low platelets secondary to liver disease (per patient) prio etoh withdrawl seizure 6 yrs ago for which he was on dilantin for 6 months. social history: lives in county, ny with his wife. in on business. heavy smoker 4ppd since age 12, polysubstance abuser in the past, "you name it, i've done it." not currently using in drugs. etoh in the past, none x 6 yrs. family history: cousin with stroke at age 55, aunt with a stroke in her 80's. physical exam: before t-pa: nihss 15 he is awake, alert, and follows commands. he is fluent. repetition and naming are normal. he neglects the left side but complicated by left field cut. he has a moderate facial weakness of the left side. ductions are full. he has moderate dysarthria but speech is comprehensible. he cannot suspend left arm or left leg against gravity. there is no movement of the left arm to pain. left leg flinches to pain. he holds right arm and leg off bed without drift for 10 and 5 seconds, respectively. sensation to light touch is reduced on the left arm and leg. he extinguishes on the left to dss. toe is briskly up on the left. ftn is normal on the right. after tpa upon transfer to the floor: vitals: 98.9 138/80 86 18 98% on ra gen: no acute distress, obese man, irritable affect skin: no rash heent: nc/at, anicteric sclera, mmm neck: supple, no carotid bruits chest: normal respiratory pattern, cta bilat cv: regular rate and rhythm without murmurs abd: soft, nontender, nondistended, +bs, no hsm extrem: trace pedal edema neuro: mental status: patient is alert, awake, irritable affect. oriented to person, place, time and president back to . good attention. language is fluent with good comprehension, repitition, able to no dysarthria. no apraxia, agnosias, no neglect. able to calculate, no left/right mismatch. cranial nerves: i: deferred ii: visual acuity: 20/50 ou without glasses. visual fields: full to left/right/upper/lower fields. fundoscopic exam: discs flat, fundi clear, no hemorrhages or exudates. pupils: 4->2 mm, consenual constriction to light. no scotomas. iii, iv, vi: eoms full, gaze conjugate. no nystagmus. mild left ptosis. v: facial sensation intact over v1/2/3 to light touch and pin prick. vii: mild lower face droop, mild upper left eye weakness with squinting eyes viii; hearing intact to finger rubs ix, x: normal labial/lingual/gutteral sounds. symmetric elevation of palate. : scm and trapezius bilaterally xii: tongue midline without atrophy or fasciulations. sensory: normal sensation to touch, pinprick, proprioception. motor: normal bulk, tone. no fasciculations. mild left arm drift. no adventitious movements. no asterixis. strength: full in all muscle groups (delt, , tri, we, wf, fe, ff, interosseus, ip, q, ham, df, pf, te, tf). reflexes: br tri pat ach toes rt: 2 2 2 2 2 mute left: 2 2 2 2 2 up coordination: normal finger-to-nose, heel-to-shin. slightly slowing of the on the left gait: normal narrow based gait, slightly unsteady with tandem walking, slightly wobbly with rhomberg but did not fall or lean. pertinent results: 01:40am wbc-8.7 rbc-4.35* hgb-13.4* hct-37.2* mcv-86 mch-30.8 mchc-36.0* rdw-12.9 01:40am neuts-54.6 lymphs-30.3 monos-5.8 eos-8.4* basos-1.1 01:40am plt count-164 01:40am pt-13.5 ptt-26.7 inr(pt)-1.2 01:40am glucose-246* urea n-54* creat-2.1* sodium-142 potassium-4.5 chloride-106 total co2-26 anion gap-15 04:00am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 10:00am triglycer-176* hdl chol-40 chol/hdl-4.0 ldl(calc)-85 10:00am cholest-160 10:00am alt(sgpt)-29 ast(sgot)-16 alk phos-205* tot bili-0.3 carotid us: minimal plaque with a left less than 40% carotid stenosis. on the right, there is no evidence of carotid stenosis. mri/a: abrupt obstruction of the inferior division of the right middle cerebral artery- embolus suspected. there is a large territory of patchy areas of restricted diffusion in the right temporal lobe in the distribution of the inferior division of the right middle cerebral artery. there are also several subtle patchy areas of increased flair signal intensity in the right temporal lobe which may reflect early evolution of infarct. a small rounded focus of abnormal flair signal intensity is also noted along the periventricular white matter of the right lateral ventricle which appears to correspond to a hypodensity on the recent ct scan which could indicate a chronic lacunar infarct. there is no shift of normally midline structures, mass effect or hydrocephalus. there are no abnormal areas of susceptibility. the visualized paranasal sinuses and osseous structures are unremarkable. tee: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve is bicuspid. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. brief hospital course: mr. came to the ed within the 3 hour window period for t-pa, no bleed on head ct, was given t-pa with complete resolution of his left hemiplegia. repeat head ct showed no post-t-. his stroke appeared to be embolic given its location to the right mca. however, tee was negative for endocarditis/pfo/asd/aortic atheroma. it was only positive for a bicuspid aortic valve for which he should take antibiotcis prior to dental procedures and the like. carotid ultrasound - no plaque in the right ica, <40% stenosis in the left ica. he was placed on a baby aspirin and for secondary stroke prophylaxis. in addition, his tricor was continued and a statin was added to his cholesterol medical management. his bp meds were initially held given the acute stroke, then several days later his bp rose to 180's. ramipril was started. there is some discreptancy as to what bp he was taking at home as his pharmacist gave us a list with a ccb, ard and an acei. his pcp was re: the need for the patient to followup with him re: his blood pressure management. the patient has an appointment with his pcp, . () tomorrow (day after discharge). his hospitalization course was complicated by hematuria after a foley was placed prior to t-pa. urology was consulted and recommended following his hct and the hematuria. the hematuria resolved and his hct remained stable. he was encouraged to stop smoking, given the nicotine patch while in house. medications on admission: (per his pharmacy as patient can't remember doses, ) diovan 240 mg a day cardizem cd 360 mg a day wellbutrin sr 150 mg a day (for smoking cessation) amaryl 4mg tricor 160mg a day ramipril 2.5 mg a day allopurinol 100 mg a day colchicine 0.6 mg a day humalog 75/25 25units discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po qd (once a day). disp:*30 tablet, chewable(s)* refills:*2* 4. dipyridamole-aspirin 200-25 mg capsule, multiphasic release sig: one (1) cap po bid (2 times a day). disp:*60 cap(s)* refills:*2* 5. atorvastatin calcium 10 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 6. fenofibrate micronized 160 mg tablet sig: one (1) tablet po qd (once a day). 7. glimepiride 4 mg tablet sig: one (1) tablet po bid (2 times a day). 8. allopurinol 100 mg tablet sig: one (1) tablet po qd (once a day). 9. colchicine 0.6 mg tablet sig: one (1) tablet po qd (once a day). 10. insulin continue your home insulin regimen of humalog 75/25 25 units . check your finger sticks before each meal and at bedtime. 11. ramipril 5 mg capsule sig: one (1) capsule po qd (once a day). disp:*30 capsule(s)* refills:*2* 12. work excuse please excuse mr. from missed work. he suffered a stroke and was admitted to from to . please feel free to page me with questions/concerns. , md pager discharge disposition: home discharge diagnosis: new dx: right mca cerebral infarction existing dxs: diabetes mellitus hypertension hypercholesterolemia chronic renal insufficiency gout hepatitis c s/p interferon therapy discharge condition: improved, minimal residual weakness, ambulating, swallowing, back to baseline. discharge instructions: 1. please take all medications including the new medications, aspirin, plavix, statin. please check your finger sticks 4 times a day and keep a log and call your pcp with results. we have not restarted several blood pressure medications that you were on. please review with your pcp the blood pressure medications you should and should not be taking. 2. please attend all followup appointments. 3. please return to the ed if you experience new weakness, numbness, or other concerning symptoms. followup instructions: please f/u with your pcp, . , in ny please f/u with a neurologist in , or, if you prefer you can follow up with dr. of the stroke clinic. md, Procedure: Diagnostic ultrasound of heart Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Unspecified disorder of kidney and ureter Cerebral embolism with cerebral infarction Other malaise and fatigue

history of present illness: was born at 25 4/7 weeks gestation to a 35 year old gravida 3, para 2, now 3 woman. the prenatal screens were blood type 0 positive, antibody negative, rubella immune, rpr nonreactive, hepatitis surface antigen negative and group streptococcus unknown. this pregnancy was uncomplicated until the day of delivery with the onset of preterm labor. the infant was delivered by cesarean section for breech positioning and question of abruption. the infant emerged without respiratory effort, required intubation in the delivery room. apgars were 1 at one minute, 6 at five minutes and 7 at ten minutes. the birth weight was 980 gm, birth length was 36 cm and the birth head circumference was 24.5 cm. admission physical examination: the admission physical revealed an extremely premature, nondysmorphic infant. her anterior fontanelle was open and flat. her palate was intact. her eyelids were still fused. she had bruising of her arms and legs. she had fair air entry bilaterally after intubation. her heartsounds were normal with no audible murmurs. the abdomen was soft, no organomegaly. she had rigid tone throughout. she was pink and well perfused. hospital course: (by systems) respiratory status - she was intubated in the delivery room. she received two doses of surfactant. she successfully weaned to nasopharyngeal continuous positive airway pressure on day of life #27 and weaned to nasal cannula oxygen on day of life #36 and then weaned to room air on day of life 79 where she has remained. she was treated with caffeine for apnea of prematurity from day of life #20 to day of life #57. her last episode of bradycardia was on . on examination her respirations are comfortable and her lung fields are clear in each lung. cardiovascular status - she initially received a fluid bolus for hypotension and has been normotensive since that time. she was treated with one course of indocin for a patent ductus arteriosus which was confirmed by echocardiogram on day of life #2. her heart was otherwise structurally normal on that echocardiogram. a follow up echocardiogram on day of life #4 showed a tiny insignificant patent ductus arteriosus and no further treatment was given. on she had a cardiac echocardiogram again due to clinical decompensation. there was no patent ductus arteriosus at that time, and she had a normal arteriotomy. she continues to have an intermittent grade i to ii/vi systolic ejection murmur at the left upper sternal border consistent with peripheral pulmonic stenosis. she is pink and well perfused. fluids, electrolytes and nutrition status - her discharge weight is 3,090 gm. her length is 50 cm, and her head circumference is 35.5 cm. enteral feeds were begun on day of life #7. she had reached 100 cc/kg/day of enteral feeds on day of life #12 and she had a clinical presentation of necrotizing enterocolitis and feedings were stopped for 14 days. she was treated with hyperalimentation and interlipids during that time. feeds were restarted on day of life #27. she reached full volume feed on day of life #34, and then increased to a maximum calories of 30 cal/oz with added promod. at the time of discharge she is eating formula, enfamil 26 cal/oz on an adlib schedule. gastrointestinal status - was treated with phototherapy for hyperbilirubinemia of prematurity from day of life #1 until day of life #8. her peak bilirubin occurred on day of life #6 and was 4.7, direct 0.4. on day of life #32 her bilirubin was checked again due to her jaundice color and her total was 9.4 and her direct was 2.5. at that time she was six days into her refeeding after being treated with hyperalimentation for approximately three weeks. on day of life #67, a repeat bilirubin was total 5.3, direct 3.6. her liver function studies showed alt of 66 and ast of 128, urine cytomegalovirus at that time was negative. hepatitis b surface antibody was negative. hepatitis b surface antigen was negative. hepatitic c antibody was negative. an abdominal ultrasound done on was within normal limits although no gall bladder was visualized. her last bilirubin on the day of discharge was total of 4.2 and direct 2.9. she was evaluated by gastrointestinal service on . they requested an alpha 1- antitrypsin and pi-typing stat, that was done on and was pending at the time of discharge. she is scheduled to have a hida scan to rule out biliary atresia at on . she was started on phenobarbital at 3 mg/kg/day on to be continued until the hida scan. she was also treated for medical necrotizing enterocolitis. she received 14 days of ampicillin, gentamicin and clindamycin and bowel rest from day of life 12 until day of life #26. blood cultures from that time remained negative. hematology - received multiple transfusions of packed red blood cells during her neonatal intensive care unit stay. her last hematocrit on was 26.1, reticulocyte count 6%. she was receiving supplemental iron approximately 2 mg/kg/day. infectious disease status - was started on ampicillin and gentamicin at the time for sepsis suspected. she completed seven days for presumed sepsis. blood cultures and cerebrospinal fluid cultures from that time remained negative. ampicillin, gentamicin and clindamycin were begun on day of life #12, for medical and necrotizing enterocolitis. she completed 14 days of those antibiotics. blood cultures remained negative. she has remained off systemic antibiotics since that time. on she completed five days of erythromycin ophthalmic ointment for conjunctivitis. orthopedics - she had a hip ultrasound on the day of discharge due to her breech presentation, in accordance with the aap recommendations, and this was normal. neurologic - head ultrasound on , , and , were within normal limits. audiology - hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. ophthalmology - the infant's eyes were examined most recently on and revealed retinopathy of prematurity, stage 2, zone 2 in both eyes, 5 o'clock hours in the eye and 6 o'clock hours in the left eye with mild plus disease in the left eye. she will have a follow up ophthalmology appointment at with dr. on . psychosocial - the parents have been very involved in the infant's care throughout her neonatal intensive care unit stay. condition on discharge: the infant is discharged in good condition. disposition: the infant is discharged home with her parents. primary pediatric care: provided by dr. , , , phone . care/recommendations: feedings - 26 cal/oz formula made with 4 cal/oz by concentration and 2 cal/oz of corn oil on an ad lib schedule. medications - 1. phenobarbital 9 mg p.o. q. day to be continued until the hida scan; 2. iron sulfate (25 mg/ml), 0.3 cc p.o. q. day carseat test - the infant has passed carseat position screening test. state newborn screen - her last state newborn screen was sent and . immunizations - the infant has received the following immunizations: hepatitis b vaccine #1 on ; hepatitis b vaccine #2 on . dtap #1 on , he had hib #1 on , ipv #1 on . prevnar (pneumococcal 7-valent conjugate vaccine) and synagis #1 on . recommended immunizations: i. 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; 2. born between 32 and 35 weeks with two of the three of the following - daycare during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings; or 3. with chronic lung disease. ii. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. follow up: follow up for this infant includes- 1. outpatient hida scan at , at 10am. needs to be npo for four hours prior to the study. 2. follow up in the clinic with dr. after the hida scan, the clinic is held on monday morning, phone #. dr. , beeper #. 3. ophthalmology, appointment with dr. of , ophthalmology on , telephone #. 4. infant follow up program, phone #, they will call the parents for an appointment. 5. early intervention of the regional child developmental center, phone #. 6. network, phone #1-. discharge diagnosis: 1. status post prematurity at 24 4/7 weeks gestation 2. status post respiratory distress syndrome 3. status post apnea of prematurity 4. status post patent ductus arteriosus 5. status post medical necrotizing enterocolitis 6. status post hyperkalemia 7. neonatal cholestasis 8. status post unconjugated hyperbilirubinemia of prematurity 9. anemia of prematurity 10. status post presumed sepsis 11. status post conjunctivitis 12. retinopathy of prematurity 13. status post chronic lung disease , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Other phototherapy Diagnoses: Hyperpotassemia Single liveborn, born in hospital, delivered by cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Patent ductus arteriosus 25-26 completed weeks of gestation

history of present illness: the patient is 59 year old male with known coronary artery disease. he reported new onset angina with radiation to arms and upper back times two months which was brought on by activity and usually relieved with rest. he had a positive stress test on , with chest pain and st segment depression. on , he underwent cardiac catheterization which revealed three vessel disease. he was now referred to the cardiac surgery service for surgical intervention or bypass surgery. as well as the chest pain, he also reported dyspnea on exertion, fatigue and diaphoresis. past medical history: hypercholesterolemia. past surgical history: tonsillectomy. minor back surgery for removal of tumor. allergies: no known drug allergies. medications on admission: 1. lipitor 10 mg p.o. daily. 2. aspirin 325 mg p.o. daily. social history: he lives in with his wife. is a current tobacco smoker with a forty pack year history. he works full time as a project manager, and he drinks a couple beers a day. family history: he has no family history of coronary artery disease. review of symptoms: all review of systems are negative except the ones that were mentioned in the history of presenting illness. physical examination: the patient is five foot ten inches, 180 pounds, pulse 64, sinus rhythm, blood pressure 150/90, respiratory rate 21. the patient was generally lying flat in bed in no acute distress. he is awake, alert and oriented times three, responding appropriately to all questions and commands. he had fine rales at the right lung base. his heart rate was regular rate and rhythm, positive s1 and s2, no clicks, rubs or murmurs or gallops. his abdomen was soft, flat, nontender, nondistended with positive bowel sounds. his extremities were warm and well perfused, nonedematous without any varicosities. his pulses were bilateral radial pulse two plus, bilateral dorsalis pedis pulses one plus and bilateral posterior tibial pulses were two plus. laboratory data: his preoperative chest x-ray showed no acute cardiopulmonary process. preoperative electrocardiogram was 62 beats per minute, sinus rhythm. his urinalysis was negative. his preoperative laboratories were as follows: white blood cell count 6.7, hematocrit 37.6, platelet count 202,000. sodium 139, potassium 3.8, chloride 106, bicarbonate 24, blood urea nitrogen 10, creatinine 0.8, glucose 92. prothrombin time 12.9, partial thromboplastin time 26.5, inr 1.0. alt 16, ast 20, alkaline phosphatase 79, total bilirubin 0.4, albumin 4.2. urinalysis was negative. hemoglobin a1c was 5.8. his cardiac catheterization results were as follows: he had a totally occluded left anterior descending coronary artery after a proximal mild lesion of 30 percent and his left circumflex was 60 percent occluded. obtuse marginal one was 90 percent and his right coronary artery was totally occluded and ejection fraction was 60 percent. ho course: on , the patient was brought into the operating room and after being intubated and foley induced by anesthesia, he underwent coronary artery bypass graft times three. grafts were as follows: left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal, saphenous vein graft to diagonal. this procedure was performed by dr. . the patient tolerated the procedure well. his total cardiopulmonary bypass time was 97 minutes. his cross clamp time was 65 minutes. following the procedure, the patient was transferred to the csru. he was receiving nitroglycerin drip 1 mcg/kg/minute and he was being titrated on propofol. his vital signs on transfer, he had a mean arterial pressure of 63, cvp of 78 and heart rate of 81 beats per minute and was being a paced. later this day on , once the patient was in csru, he was successfully extubated. on postoperative day number one, the patient was hemodynamically stable with a blood pressure of 94/47, heart rate 70, and he had an oxygen saturation of 99 percent on three liters of nasal cannula. the plan today was to wean and discontinue his neo-synephrine and nitroglycerin which was currently at 1.2 of neo-synephrine and 0.25 of nitroglycerin and to start lasix. due to poor target, to start oral nitrates. also, since apparently the patient was a difficult intubation, it was thought that the patient would need to have a swallowing evaluation which was performed on postoperative day number two. on postoperative day number two, the patient was hemodynamically stable and physical examination was unremarkable. swallowing evaluation recommended soft liquids and then thin liquids, swallow with head turned over right shoulder and with chin tucked to his chest, alternate liquids and one sip to clear throat and if the dysphagia was not resolved by monday, the patient would need a vv consult. on postoperative day number three, the patient was transferred to a telemetry floor. the chest tubes were discontinued. on postoperative day number four, the patient was hemodynamically stable, no events overnight. his physical examination was unremarkable. his pacing wires were still intact. the plan was just to continue advanced activity. the patient is out of bed with physical therapy, occupational therapy and incentive spirometry. on postoperative day number six, the patient appeared to be doing well. there were no events overnight and he was hemodynamically stable with pulse of 80, sinus rhythm, blood pressure 136/74, respiratory rate 20. his epicardial pacing wires were removed today and today is also the day that he will be discharged. physical examination on discharge date of , was as follows: he was neurologically alert and oriented with no focal deficits. his lungs were clear bilaterally. his heart rate was regular rate and rhythm. his sternal incision was dry, no drainage, no erythema, and it was stable. his abdomen was soft, nontender, nondistended with positive bowel sounds. his extremities were warm and nonedematous. his leg incision was clean and dry. there were no chest tubes and no pacing wires were intact. he was discharged to home with services in good condition. discharge diagnoses: coronary artery disease, status post coronary artery bypass graft times three. hypercholesterolemia. medications on discharge: 1. colace 100 mg one p.o. twice a day. 2. ranitidine 150 mg one p.o. twice a day. 3. aspirin 81 mg one p.o. daily. 4. percocet 5/325 one to two tablets p.o. q4hours as needed for pain. 5. lipitor 10 mg p.o. daily. 6. thiamine 100 mg p.o. daily. 7. folic acid 1 mg p.o. daily. 8. lasix 20 mg p.o. daily for seven days. 9. potassium chloride 10 meq two capsules p.o. q12hours. 10. atenolol 25 mg p.o. daily. 11. isosorbide mononitrate 30 mg sustained release one p.o. q24hours. 12. nicotine patch 14 mg per 24 hour patch, one patch per 24 hours times seven days and then nicotine 7 mg 24 hour patch, one patch 24 hours times two weeks. fop: the patient was recommended to follow-up with dr. in four weeks and follow-up with dr. in one to two weeks. , m.d. 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 Pure hypercholesterolemia

past medical history: none. admission medications: none. allergies: the patient has no known drug allergies. physical examination on admission: vital signs: heart rate 80, blood pressure 130/palpable, mechanically ventilated, with 02 saturations of 100%, gcs of 3. heent: the pupils were 3 mm, equal and reactive bilaterally to light. the tms were clear and the midface was stable. there was a hard c collar in place on the neck and the trachea was midline. he has a regular rate and rhythm without any murmurs. there was a large avulsion injury to the chest with an open right pneumothorax. the abdomen was soft and there were bowel sounds. the pelvis was stable to in the ap and lateral direction. rectal was heme-negative with decreased tone noted. the extremities were warm without any deformities or obvious dislocations with 2+ pulses in all distal extremities. laboratory/radiologic data: hematocrit 42, white count 17, inr 1.2. negative serum tox for alcohol and other drugs. the urine was positive for opiates which he had been stated prior to intubation. hospital course: the patient became hypotensive in the emergency department. fast scan was positive for blood in the abdomen. a cordis was placed in the right femoral vein. the patient received 2 liters of crystalloid and 4 units of blood. a right chest tube was inserted. the patient was taken to the operating room for emergent surgery. exploratory laparotomy revealed a large liver laceration which was patched and packed. several short mesenteric bleeders were also ligated. a large avulsion to the right and left chest wall were repaired by thoracic surgery. after irrigation and debridement, a left chest tube was also inserted. the right-sided chest was explored without any evidence of foreign body or obvious vascular injury. an intraoperative tee was performed that showed normal cardiovascular function and no injury to the aorta. the abdominal wound was left open and the patient was transferred to the surgical intensive care unit. the following day, he returned to the operating room for the removal of the packs and an abdominal washout and the abdominal wound was closed. at this point, he had several radiological studies revealing a t11 compression fracture on his t11 films that was confirmed by ct. a ct of the head, c-spine, and ls were normal with the exception of an arachnoid cyst noted on the head ct. plastic surgery was consulted regarding the patient's extensive thoracic wounds. the patient was started on oral prednisone for an extensive outbreak of poison . he also received wet-to-dry dressings for a 2 cm deep avulsion injury to the left buttock not initially noticed upon his presentation. his condition continued to improve and he was extubated uneventfully and transferred to the floor where upon his chest tubes and - drains slowed in output. when these were removed, he was fitted with a tlso brace and subsequently evaluated by physical therapy for the need of rehabilitation versus discharge to home. it was felt that the patient would be able to be transferred home without difficulty and would be able to care for his wounds. final diagnosis: 1. status post motorcycle accident. 2. right chest wall avulsion/degloving. 3. right open pneumothorax. 4. liver laceration. 5. left buttock avulsion. 6. t-11 compression fracture. 7. contact dermatitis. recommended follow-up: the patient should follow-up with thoracic surgery either dr. or dr. in one week after discharge. he also needs to see dr. regarding the t-11 fracture within two weeks. the patient should follow-up in the trauma clinic in two weeks and also with his primary care doctor as needed. discharge medications: 1. ibuprofen 600 mg p.o. t.i.d. 2. oxycodone sr 20 mg q. 12 hours with a two week supply dispensed. 3. oxycodone/acetaminophen 5/325 mg p.o. q. six hours p.r.n. with 30 dispensed and one refill. 4. docusate 100 mg p.o. b.i.d. 5. benadryl 25 mg p.o. p.r.n. 6. lactulose 10 mg p.o. b.i.d. p.r.n. constipation. 7. keflex 500 mg p.o. q.i.d. for three days. 8. prednisone taper for four days. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Exploratory laparotomy Exploratory laparotomy Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Excision of lesion of muscle Diagnoses: Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Injury to multiple and unspecified intrathoracic organs, with open wound into cavity Injury to liver with open wound into cavity, laceration, unspecified Injury to other intra-abdominal organs with open wound into cavity, peritoneum Open wound of chest (wall), without mention of complication Other motor vehicle traffic accident involving collision on the highway injuring motorcyclist Traumatic pneumothorax with open wound into thorax Open wound of buttock, without mention of complication Open wound of hip and thigh, without mention of complication

past medical history: osteoporosis of the hip and spine. right breast cancer, status post radiation therapy approximately six years prior. mitral valve prolapse, which was diagnosed as a teenager. past surgical history: right ovarian oophorectomy, right partial mastectomy with two subsequent tissue removal surgeries, and a left leg benign tumor removal. meons: medications when she first saw dr. were as follows: 1. actonel every week. 2. caltrate every week 3. fish oil every day. allergies: she has no known drug allergies. social history: she is a former graphic designer, lives with her husband and two children in . she quit smoking approximately 18 years prior after having smoked one pack per day for seven years. she admitted to a glass of wine approximately every two weeks. she used marijuana remotely in college. no use of other recreational drugs. radiographic studies: ct scan of the chest on showed a 5 cm ascending aorta, small pulmonary av malformation in the right lobe, in the medial basal segment, and descending aorta within normal limits. please refer to the final report. preoperative laboratory data: sodium 137, potassium 3.8, chloride 106, co2 24, bun 14, creatinine 0.7 with a blood sugar of 120. her lfts were normal. pt 12.5, ptt 33, and inr of 1.0. white count 4.8, hematocrit 35.2 with a platelet count of 196,000. preoperatively, her ekg showed sinus bradycardia at 57 with left anterior hemiblock. physical examination: her height is 5 feet 6 inches with a weight of 138 pounds. on exam, she appeared to be well- hydrated, appearing younger than her stated age with no rashes or lesions. her pupils were equally round and reactive to light and accommodation. her eoms were intact with normal buccal mucosa and dentition. her neck was supple with no jvd, lymphadenopathy, or thyromegaly. her chest was clear bilaterally without wheezing, rhonchi, or rales. her heart was bradycardiac in a regular rhythm with positive s1 and s2 sounds and a grade 2 to 3 over 6 systolic murmur heard best at the lower sternal border and third intercostal space. her abdomen was soft, nontender, and nondistended with normal bowel sounds. no hepatosplenomegaly. her extremities were warm and well perfused with no edema or cyanosis. she had no obvious varicosities. her neurologic exam was grossly intact without any motor or sensory deficits. she had 2 plus bilateral femoral pulses, 2 plus bilateral dp pulses, 1 plus bilateral pt pulses, and 2 plus bilateral radial pulses without any carotid bruit. hospital course: on the day of admission, , she underwent ascending aortic aneurysm repair with a 26 mm gelweave tube graft and an aortic valve replacement with a 21 mm regent mechanical valve. she was transferred to the cardiothoracic icu in stable condition on a propofol drip at 20 mcg per kg per minute and a nitroglycerin drip at 0.5 mcg per kg per minute. on postoperative day one, she had been extubated overnight. she had increased chest tube output, was receiving platelets and ddavp. she had an echocardiogram to rule out any cardiac tamponade from bleeding. she was in sinus rhythm at 78 with a cardiac index of 2.79. she received three units also of packed red blood cells and two units of platelets for repletion. her hematocrit was 30 with a white count of 12.1 and an inr of 1.0. postoperative labs also included a white count of 12.1, a platelet count of 356,000, sodium 140, potassium 4.8, chloride 110, co2 24, bun 11, and creatinine 0.5 with a blood sugar of 101. she was on an insulin drip at 4 for mildly elevated blood sugars. she was responsive. her heart was in regular rate and rhythm. her lungs were clear bilaterally. her abdominal exam and incisional exams were benign. her extremities were warm and well perfused without any edema. she continued on perioperative kefzol antibiotic coverage and was encouraged to use her incentive spirometer and to get out of bed by the nurses. she was stable. her diet was advanced. her swan was discontinued. on postoperative day two, her hematocrit drifted back down to about 26.1. she had increased mediastinal contour on chest x- ray, but remained clinically stable. she was in sinus rhythm in the 90s with a blood pressure of 97/53, saturating 99 percent. she received one additional packed red blood cell transfusion. her white count dropped slightly to 10.2. her creatinine remained stable at 0.5. she began her aspirin regimen as well as beta-blockade and lasix diuresis. her diet was advanced and her electrolytes repleted as needed. on postoperative day three, her chest tubes had been discontinued as was her foley catheter. her inr was 1.3, as she now had begun her coumadin aiming for a therapeutic dose for her mechanical aortic valve. she had decreased breath sounds at the bases. her heart was regular in rate and rhythm. her sternum was stable. her pacing wires were discontinued, and she continued on lopressor beta-blockade as well as lasix diuresis, and she was transferred out to the floor. she was seen by case management for clearance for vna home services. she was also evaluated by the physical therapy team. on postoperative day four, she was doing well without any complaints of shortness of breath, chest pain, or palpitations. she had a t-max of 100.7 degrees, heart rate rose slightly to 102 with a blood pressure of 97/66. she was saturating at 93 percent on room air. she remained in a sinus rhythm with good pulses and minimal peripheral edema. she was doing well and ambulating. her anticoagulation continued to be underway with her inr rising that morning slightly to 1.4. she continued with a 3 mg coumadin dose and started iron for some mild anemia. her hematocrit dropped slightly to 24.6 with the plan to let her be discharged home once her inr crossed 1.5 and she was able to do the stairs. she continued to ambulate with physical therapy and was doing very well and feeling better with each passing day. onperative day five, she had no new complaints and was doing very well. she reported having been woken up once during the night with a thumping sensation in her chest, but telemetry showed nothing other than some pvcs. she had no dyspnea, chest pain, or other palpitations. she had good pulses throughout. she remained in sinus rhythm without any jvd or peripheral edema. her sternotomy wound was healing well. she had positive bowel sounds. her inr rose to 1.5 and hematocrit of 25.0. her potassium remained stable at 4.3 and also her creatinine at 0.5. discussion was had as to whether or not to increase her coumadin dosing as she was not rising fast enough on a 3 mg dose, to let the decision be made by dr. . the patient was also seen again by case management to plan for her discharge to home. the patient did have some diarrhea on the during the evening and was given some trazodone also to help her feel a little bit more comfortable. she had a small nosebleed and complained a little bit of some cramping without a bowel movement. at 03:30 in the morning on the she was in sinus rhythm with the exception of quick bursts of sinus tachycardia. please refer to the follow-up note listed on telemetry. the patient had no complaints and was sleeping at the time. her blood pressure at that time was 112/45 and was saturating 98 percent on room air with a heart rate of 71 and a respiratory rate of 18 and was afebrile. on, postoperative day seven, the patient was discharged to home in stable condition with instructions to follow up with her primary care physician, . , in approximately one to two weeks; her cardiologist, dr. , in approximately one to two weeks; and to follow up with dr. in the office at approximately three to four weeks for her postoperative surgical visit. discharge diagnoses: status post aortic valve replacement and replacement of ascending aorta with gelweave graft. osteoporosis of the hip and spine. right breast cancer with radiation therapy and right partial mastectomy. mitral valve prolapse. status post right oophorectomy. status post removal of benign left leg tumor. discharge medications: 1. lasix 40 mg q.a.m and 20 mg q.p.m. through with instructions for the patient to call dr. , her primary care physician, to discuss whether it needed to be continued. 2. potassium chloride 20 meq p.o. b.i.d., also to be discussed with dr. for dosing past . 3. zantac 150 mg p.o. b.i.d. 4. niferex 150 mg p.o. q.d. 5. folic acid 1 mg p.o. q.d. 6. multivitamin 1 tablet p.o. q.d. 7. vitamin c 500 mg p.o. b.i.d. 8. tylenol with codeine no. 3, 1 to 2 tablets p.o. p.r.n. q.4 h. for pain. 9. lopressor 12.5 mg p.o. b.i.d. 10. coumadin 3 mg p.o. q.d. for 3 days, then inr check on with inr and coumadin dosing management by dr. . discharge disposition: the patient was discharged to home in stable condition on . , m.d. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Resection of vessel with replacement, thoracic vessels Transfusion of packed cells Diagnoses: Anemia, unspecified Unspecified essential hypertension Thoracic aneurysm without mention of rupture Congenital insufficiency of aortic valve

allergies: bleomycin / bactrim / iv dye, iodine containing attending: chief complaint: respiratory distress major surgical or invasive procedure: mechanical ventilation (/08) history of present illness: 45 yo m with pmh of recurrent hodgkin's lymphoma (since ) s/p auto and allogeneic transplant with recurrence, last chemotherapy (gemcitabine, navelbine, decadron ), ? of bleomycin toxicity recently discharged after prolonged hospitalization with micu stay, pneumonia, complicated by renal failure requiring temporary hemodialysis, who presented with sob. he states this feels like an asthma exacerbation. . was febrile when seen in clinic to 102, 88% on ra, was noted to be wheezing and tachycardic. received 2 gm cefepime, posiconazole, and solumedrol 20mg iv (takes 10mg prednisone at baseline). pt was admitted to bmt. he was continued on cefepime and vancomycin was added to abx coverage. pt became progressively tachypneic and was called to evaluate patient. . on eval, patient was in respiratory distress, using accessory muscles, tachypneic to the 40s, o2 sat of 90% on 6l with hr in the 140s. abg was 7.23/36/59/16. lactate 1.7. he was transferred to the for further management. he was intubated on arrival without complication ros: denies any recent sick contacts. notes mild pleuritic chest pain and nausea. no emesis, abdominal pain, diarrhea, brbpr, urinary complaints. past medical history: - hodgkin's lymphoma. dx . s/p multiple courses of chemo complicated by bleomycin lung toxicity and relapse of disease. s/p autogeneic stem cell transplant in and allo bmt in . undergoing monthly chemo with gemzar, navelbine and decadron. complete onc history available in onc admit note. - prior severe pneumonias, including likely prior infection. - hypothyroidism - asthma - hbv core ab positive - s/p biliary stent social history: on disability. previously employed as a child psychologist for public school system. divorced with a son. denies etoh, tobacco or drug use. family history: father had "lymphoma of bone," dm, htn. physical exam: vs: t 102 bp 79/55 (normotensive prior to intubation) hr 129 97% on ac 24x450 peep 5 fio2 50% gen: nad, intubated, sedated heent: perrl, op clear, mmm, conjunctiva pink, sclera anicteric neck: unable to assess jvp chest: ctab anteriorly and laterally cv: rrr, normal s1 and s2, no m/r/g abd: soft, nt, nt, no masses, or organomegaly ext: wwp, lue significant 3+ edema, other ext no c/c/e skin: neuro: perrl, responds to verbal stimuli but does not follow commnands pertinent results: cxr : 1. right middle and lower lobe consolidation, concerning for infection. 2. slight decrease in small left pleural effusion and unchanged small right pleural effusion. 3. otherwise no significant change when compared to the previous radiograph. cxr : in comparison with the study of , the endotracheal and nasogastric tubes have been removed. no change in the appearance of the central venous catheter. patchy opacification in the right mid lung may be slightly less. otherwise, little change. ct w/o contrast : 1. no pulmonary edema. multifocal pneumonia progressed since chest ct, but improved when chest radiographs are reviewed between and . 2. right infrahilar mass decreased in size since , retroperitoneal adenopathy and left adrenal mass decreased since . these areas may represent treatment response of lymphoma. 3. conventional chest radiography should be sufficient to chart the course of intrathoracic findings over the near future. brief hospital course: 45 yo m with a long history of recurrent hodgkin's lymphoma s/p allogeneic transplant with recurrence admitted with fever, hypoxia and new pulmonary infiltrates, intubated given respiratory distress. respiratory distress & icu course: transferred to micu the morning after admission on and intubated for respiratory distress. intubated on presentation to icu for respiratory distress. thought initially to have pneumonia - infiltrates in rul and rml. for empiric coverage, posaconazole, vancomycin, meropenem, and levofloxacin were started per id recommendations. bal was performed. bronchoscopy demonstrated mild erythema of airways but no visible obstruction. pcp, , and viral cultures were negative. afb, legionella, galactomann negative. cryptococcus antigen, cmv viral load negative. urine legionella negative. sputum, blood, and urine cultures negative. beta-glucan was positive, although patient did not improve on anti- alone. with lack of success with antibiotics, thought then switched to possibility of fluid overload. diureses with lasix with rapid resolution of symptoms. vigileo showed co=9.6, ci=5.8, indicating hypervolemia with good cardiac function. pulmonary -occlusive disease was considered to be etiology - diagnostic work up would include right heart catheterization. patient does not want any invasive procedures at this time. on , he was given ivig. a tte demonstrated preserved ef with new tr gradient. on , vancomycin was stopped per id and bmt recs. he was started on furosemide 20mg iv x2 with good urine output and then on a lasix drip on . on , he was extubated. a sputum gram stain showed 1+ gpc in pairs, chains, and clusters, and vancomycin was restarted. on , he was extubated and satting well on only on 2l nc. he was called out. hypoxia/pneumonia - hypoxia was thought to be either from a infection that returned following the discontinuation of posaconazol, or from a new bacterial pneumonia. levoquin (started ) and vancomycin were stopped when called out (). all diagnostic studies were negative except for some pleural gram stains showing gpc and a positive b-glucan (drawn before ivig). standing po lasix was stopped and he continued to breath well with even i/os. he was continued on solmeterol, ipatroprium, prednisone 10 mg daily. a repeat beta-glucan was elevated (> 500), but as this was drawn after ivig, this was of unclear significance. he had a low-grade temp to 100 and mild hypotension on concerning for infection. vancomycin was added back. id was reconsulted. repeat chest ct showed interval improvement. fevers resolved. on , vancomycin was discontinued and meropenem was stopped on . he remained afebrile with normal pressures off antibiotics. mild fevers and hypotension were thought not to be related to infection ** posaconazole needs to be continued, start date . # hodgkin's lymphoma. recurrent, last chemotherapy with gemcitabine, navelbine, and decadron on . given acute respiratory failure and possible infection, further treatment was delayed. he was continued on acyclovir prophylaxis. # deconditioning - his multiple hospitalizations and chronic disease have left him severly deconditioned. he was seen by physical therapy. following several days of active physical therapy he was able to walk with a walker again, but still unable to stand from sitting. he was discharged to a facility where he can continue active physical therapy. # acute renal failure. this was felt to be due to contrast. falling since last admission when patient was suspected of having renal failure secondary to contrast. last admission which required hd; had renal biopsy at that time with findings consistent with atn. good urine production > 100/hour while on lasix with stable creatinine. medications renally dosed. his creatinine continued to improve following discharge from the micu, when his lasix was discontinued. his creatinine on discharge was 1.6 # history of bleomycin toxicity. goal to limit oxygen supplementation to less than 2l to prevent further lung toxicity. # hypothyroidism. he was continued on home levothyroxine. # hbv core ab positive. he was continued on lamivudine therapy. # fen: regular diet. magnesium and potassium sliding scales # prophylaxis: ppi, ambulation, bowel regimen. inhaled pentamadine was last given on # access: r portacath # contact: hcp, , father of patient, . # code: full. discussed with patient . medications on admission: -levothyroxine 75 mcg po daily -salmeterol 50 mcg/dose inhalation q12h -lorazepam 0.5- 1mg po q6h prn anxiety, insomnia, nausea -oxycodone 5-10 mg po q6h prn -olanzapine 2.5 mg po hs prn -ipratropium bromide 1 inhalation -pantoprazole 40 mg po q24h -albuterol inh 1-2 puffs q4h -lamivudine 100 mg po daily -acyclovir 400 mg po q12h -methyl salicylate-menthol 15-15 % ointment topical prn -prednisone 10mg po daily discharge medications: 1. posaconazole 200 mg/5 ml suspension sig: five (5) ml po qid (4 times a day). 2. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) ml inhalation q6hrs () as needed for prn wheeze. 3. lamivudine 100 mg tablet sig: one (1) tablet po daily (daily). 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 5. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. lorazepam 0.5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for anxiety, nausea. 8. oxycodone 5 mg capsule sig: one (1) capsule po every six (6) hours as needed for pain. 9. acyclovir 200 mg capsule sig: two (2) capsule po q12h (every 12 hours). 10. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) puff inhalation qid (4 times a day). 11. polyethylene glycol 3350 100 % powder sig: seventeen (17) g po daily (daily). 12. heparin lock flush (porcine) 100 unit/ml syringe sig: five (5) ml intravenous prn (as needed) as needed for de-accessing port. 13. levothyroxine 75 mcg tablet sig: one (1) tablet po once a day. tablet(s) 14. salmeterol 50 mcg/dose disk with device sig: one (1) inh inhalation every twelve (12) hours. 15. olanzapine 2.5 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. discharge disposition: extended care facility: discharge diagnosis: hypoxic respiratory failure pneumonia hodgkin's lymphoma deconditioning acute renal failure hypothyroidism discharge condition: t 97.5 hr 102 bp 130/85 rr 18 sat 95/ra well appearing. severly deconditioned but able to walk with a walker. discharge instructions: you were admitted for respiratory distress, which was thought to be caused by a pneumonia as well as fluid in your lungs. you were restarted on posaconazole for this and should continue this medication. followup instructions: provider: , phone: date/time: 3:00 provider: , md phone: date/time: 9:00 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Injection or infusion of immunoglobulin Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Constipation, unspecified Peripheral stem cells replaced by transplant Acute respiratory failure Hypotension, unspecified Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites Other postprocedural status Hyperosmolality and/or hypernatremia Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Other and unspecified mycoses Pneumonia in other systemic mycoses Mixed acid-base balance disorder Other drugs and medicinal substances causing adverse effects in therapeutic use Hypogammaglobulinemia, unspecified

allergies: bleomycin / bactrim attending: chief complaint: fever major surgical or invasive procedure: none history of present illness: 45 yo m with a long history of recurrent hodgkin's lymphoma s/p auto and allogeneic transplant with recurrence on monthly chemotherapy admitted after he presented for scheduled chemotherapy with fevers to 101 in clinic and transferred to the icu for persistent hypotension after bronchoscopy. . the patient initially presented to clinic on for scheduled gemzar, navelbine and decadron therapy. he was found to have a fever to 101. on review of systems at that time the patient did admit to feeling fatigued and generally unwell possibly with a component of pleuritic chest pain and dry cough. cxr at that time revealed an evolving rll and lingular/lul infiltrate. he was admitted for further evaluation with cxr and ct chest concerning for evolving pneumonia. the patient was started on vancomycin, cefepime and voriconazole. during his hospital stay, the patient did have relative hypotension as at baseline to the range of sbp 90's with tachycardia to the low 100's. the patient did have individual sbp measurements overnight prior to transfer as low as 80's, reportedly fluid responsive. . the patient was brought to the icu for elective bronchoscopy. during the procedure, the patient received 1mg midazolam and a bolus of 25mcg of fentanyl. post-procedure the patient was persistently hypotensive to the range of sbp 78-82 with intact mentation though some complaints of feeling tired and mildly lightheaded. his hypotension was refractory to 1l of ns. the patient was kept in the for further monitoring. . of note, the patient has a history of multiple episodes of pneumonia in the past most recently with fungal pnuemonia based upon positive galactomannan in . . ros: denies any recent sick contacts. notes mild pleuritic chest pain and nausea. no emesis, abdominal pain, diarrhea, brbpr, urinary complaints. past medical history: past medical/surgical history: hodgkin's disease (see below) hypothyroidism asthma s/p biliary stent (see below) hepatitis b core+ . oncologic history: 1. diagnosed with stage iib hodgkin's lymphoma in 12/99, completed abvd for four cycles with the last 1 cycles without bleomycin due to pulmonary toxicity, followed by consolidative mantle radiation therapy. 2. relapsed in treated with ice x2 cycles, high-dose cytoxan for stem cell mobilization followed by cbv with autologous stem cell transplant on . 3. relapsed in treated with eshap x 1 cycle in preparation for allo stem cell transplant, which he underwent on from a sibling related donor with fludarabine and cytoxan conditioning. transplant complicated by liver gvhd confirmed by a biopsy on treated with prednisone. also noted to be hepatitis b core antibody positive at that time and began on lamivudine to prevent reactivation. 4. evidence for recurrent disease and status post a donor lymphocyte infusion on with a second one on . 5. further progression of his disease in and treated with eshap x 2 cycles on and . 6. enrolled on the dc/dli protocol and received these infusions in mid with progressive disease particularly in his lung base. 7. outpatient regimen of rituxan and gemcitabine with unfortunately progressive symptoms and then followed with two more cycles of eshap in and with an excellent response to therapy. 8. enrolled on an experimental protocol at the involving anti-ctla-4 antibody with donor lymphocyte infusions support with relatively stable disease. 9. further progression of his disease over several months with particularly increasing abdominal involvement and treated with another cycle of eshap in . 10. treated with cep chemotherapy on with a donor lymphocyte infusion on at 1 x 108 t cells per kilogram with marked gvhd of the liver with increased transaminases and bilirubin requiring cellcept and prednisone with eventual resolution. 11. following discontinuation of his immune suppression and no further gvhd, noted for further progression of his disease, he was treated with cep chemotherapy on , , and with a response to treatment. also requiring periodic thoracenteses of now recurrent pleural effusions. 12. status post dli on at a dose of 1 x 10(8) t cells per kilogram. 13. presented in with increased liver function tests and bilirubin with infiltration of the pancreatic head with intrahepatic biliary ductal dilatation. he had a biliary stent placed. this was changed in . 14. treated with day 1,2,3 only of cep starting on with evidence for disease response on ct scan from . 15. rescanned in with progression of disease and then received two more cycles of cep on and with ct scan on with response to therapy. 16. consideration of another dli, but developed progression of disease with recurrent hydronephrosis. treated with another cycle of cep on . d8 held due to low counts. during this admission, also had thoracentesis for pleural effusions. 17. planned evaluation for h-dac inhibitors at . social history: had been working full time as a child psychologist for the public school system, now on disability. he lives in . he has an son, cared for by his ex-wife. is in a relationship with a woman, who often helps him with logistics of treatment and of activities of daily living. he denies alcohol, smoking, or drug use. family history: father had "lymphoma of bone," dm, htn physical exam: vitals: t: 101 bp: 100/49 p: 120 r: 22 sao2: 95% general: awake, alert, nad, pleasant, appropriate, cooperative. heent: ncat, perrl, eomi, no scleral icterus, mmm, no lesions noted in op neck: supple, no significant jvd or carotid bruits appreciated pulmonary: l sided rales up to inferior edge of scapula, cta on right cardiac: rr, nl s1 s2, no murmurs, rubs or gallops appreciated abdomen: soft, nt, nd, normoactive bowel sounds, no masses or organomegaly noted extremities: no edema, 2+ radial, dp pulses b/l lymphatics: no cervical or supraclavicular lymphadenopathy noted skin: no rashes or lesions noted. . pertinent results: labs: 146 116 51 101 agap=15 3.1 18 3.4 ca: 7.5 mg: 1.6 p: 3.0 alt: 20 ap: tbili: 0.2 alb: ast: 16 ldh: 368 dbili: tprot: : lip: source: line-picc 93 6.2 7.8 42 d 22.6 n:91 band:2 l:2 m:4 e:1 bas:0 neuts: toxic granulation poiklo: 1+ ovalocy: 1+ tear-dr: occasional plt-est: very low pt: 10.2 ptt: 22.5 inr: 0.8 source: line-picc labs: 137 101 20 agap=13 -------------< 94 3.3 26 1.2 ca: 9.7 mg: 1.7 p: 3.1 estgfr: 65 / >75 (click for details) alt: 11 ap: 40 tbili: 0.3 alb: 3.7 ast: 16 ldh: 216 dbili: 0.1 9.9 6.2 >----< 9.9 165 28.9 n:70 band:0 l:18 m:12 e:0 bas:0 anisocy: 1+ macrocy: 1+ plt-est: normal gran-ct: 4660 ct chest: 1. overall improving patchy ground-glass opacities within the lungs bilaterally. slight increased opacities involving anterior right upper and right middle lobes. findings again suggestive of infection. 2. unchanged mediastinal mass. 3. slight decrease in size of right lower lobe mass. 4. slight decrease in size of incompletely evaluated retroperitoneal lymphadenopathy. 5. tiny perihepatic ascites. ct abd: 1. overall, stable retroperitoneal disease burden. 2. slight improvement in some regions of consolidation within the lungs, although there is increased ground-glass opacity seen in the upper lobe of both the right and left lungs. this may be secondary in part to regions of improving aeration when compared to prior consolidation, although some regions which appear to have worsening ground-glass opacity may be secondary to atypical infection including processes such as pcp, other infectious/inflammatory processes. 3. unchanged appearance of mediastinal masses. 4. multiple hypodense foci seen within the spleen and liver. these presumably may be secondary to hodgkin involvement, and while somewhat more prominent than on prior examination, they do not appear to be new. 5. moderately severe narrowing of the splenic vein, without total occlusion at this time. in addition, there is moderate-to-severe narrowing of the mid portal vein as well. pathology sigmoid colon biopsy: 1. diffuse regeneration of the crypts, consistent with a healing process (see note). 2. no viral inclusions, granulomas or tumor seen. 3. immunostain is negative for cmv with satisfactory control. renal biopsy, needle: consistent with "acute tubular necrosis", see note. bone marrow and core biopsy: 1. markedly hypocellular marrow with left-shifted myelopoiesis, dysmegakaryopoesis, and mild eosinophilia, see note. 2. no hodgkin lymphoma seen. note: overall the findings are suggestive of acute marrow injury from secondary causes such as medications, toxic/metabolic, immune insult etc. please correlate with clinical and other laboratory, including cytogenetic findings. brief hospital course: assessment: 45-year-old man with a history of hodgkin's disease status post multiple disease relapses after auto and allo sct, most recently treated with gemzar, navelbine and decadron on 30 day cycle, who presented with fever to 101 prior to chemotherapy administration. . ## fever/pneumonia: ct findings suggested pneumonia as source of fevers. he was initally treated with levoquin, but this was changed to vancomycin cefepime/voriconizole for broader coverage. beacause of concern for sepsis, the patient was transferred to for bronchoscopy which revealed thick white secretions c/w pna. small blood in one of bal samples was likely due to trauma. following bronchoscopy, the patient's sbp dropped to 60s with versed so got 500 cc bolus with improvement to 80s-90s. post bronchoscopy cxr showed slight worsening of rll infiltrate. sputum cultures were negative. pt was started in extended course of abx. the patient had a repeat bronchoscopy on , with bal cultures showing just oropharyngial flora and no pcp. remained afebrile off antibiotics prior to discharge. pt continued home salmeterol and albuterol for asthma . ## hypotension: pt was noted to be hypotensive during his admission. he had a history of chronic steroid use which had been discontinued. it was felt that his hypotension was possibly due to adrenal insufficiency and he was restarted on stress dose steroids with marked improvement in hemodynamic response. pt became nauseated and did not take prednisone or other oral meds and was noted to have additional episodes of hypotension . he was switched to po prednisone on and was discharged on prednisone 10 mg daily. - consider tapering off prednisone as an outpatient. . ## diarrhea: , pt reported having several loose stools. he was started on flagyl with concern for c. difficile. gi was consulted and the patient was subsequently started on po vancomycin, however c. dif testing was negative x 3. flex sig was recommended done on showing normal mucosa in the sigmoid colon (biopsied). . ## acute renal failure: on , pt was noted to have a non-gap metabolic acidosis with a creatinine of 1.5. he was started on iv fluids with bicarb, however renal function progressively worsened despite hydration. renal service was consulted. a vanco level was 57. potentially nephrotoxic medications were held, (including acyclovir). dialysis was initiated on . renal biopsy done on c/w atn. he continued on dialysis until and his hd line was removed on . creatinine was stable around 3.4 off dialysis. - follow electrolytes - outpatient renal f/u scheduled. . ## hodgkin's lymphoma: the patient had a history of multiple relapses. he was scheduled to receive gemzar, navelbine and decadron. treatment was initially on hold given possible infectious issues. however, there was concern that renal failure, diarrhea and rising ldh may be related, however renal and gi biopsies were not consistent with lymphoma. . # hypotension. hemodynamically stable; thought to be due to adrenal insufficiency. pt was on hydrocortisone but switched to prednisone. was stable but had additional hypotension on so was restated on high dose steroids- now on 10 mg methylprednisolone daily. . # hbv core ab positive. continue lamivudine therapy. dosing was adjusted for crcl. - readjust dose per renal function. . # fen: regular diet. tpn initiated due to poor po intake. stopped . . # access: l portocath . # contact: hcp, , father of patient, . medications on admission: acyclovir 200 mg q8hrs albuterol prn levothyroxine 75 mcg daily salmeterol 50 mcg lamivudine 100 mg daily lorazepam 1 mg q8hrs prn oxycodone 10 mg q6hrs prn prednisone 10 mg daily olanzapine 2.5 mg qhs prn multivitamin discharge medications: 1. 3 in 1 commode 2. rolling walker 3. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. salmeterol 50 mcg/dose disk with device sig: disk with devices inhalation q12h (every 12 hours). 5. lorazepam 0.5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for anxiety, insomnia, nausea. disp:*20 tablet(s)* refills:*0* 6. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. disp:*20 tablet(s)* refills:*0* 7. olanzapine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. disp:*30 tablet(s)* refills:*0* 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation (2 times a day). 9. 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* 10. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every four (4) hours. 11. lamivudine 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 12. acyclovir 200 mg capsule sig: two (2) capsule po q12h (every 12 hours). disp:*120 capsule(s)* refills:*0* 13. methyl salicylate-menthol 15-15 % ointment sig: one (1) appl topical prn (as needed). 14. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: pneumonia, hodgkin's disease discharge condition: stable discharge instructions: you were admitted with fevers, pneumonia, low blood pressure, low platelets, and acute kidney failure. please follow up in oncology clinic to check your blood cell and platelet counts tomorrow. followup instructions: provider: phone: , extansion # 1 date: 2:00 pm provider: , md phone: date/time: 9:00 am provider: phone: date/time: 2:30 pm Procedure: Parenteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Biopsy of bone marrow Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Closed [endoscopic] biopsy of large intestine Diagnoses: Pneumonia, organism unspecified Acidosis Other iatrogenic hypotension Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Constipation, unspecified Bone marrow replaced by transplant Peripheral stem cells replaced by transplant Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites Diarrhea Hypovolemia Glucocorticoid deficiency Mixed acid-base balance disorder Hepatitis B carrier

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mvc major surgical or invasive procedure: : right knee laceration wash out and repair. : hard cast application to left lower extremity. history of present illness: 36male in mvc w/ +etoh. prolonged extrication. aao at scene. taken to osh and intubated and transferred from osh for outside hospital for intraperitoneal bladder rupture. past medical history: htn social history: hctz 12.5 daily atenolol 50 daily motrin 600 tid ambien xanax lunesta seroquel family history: noncontributory physical exam: alert 118 147/81 100% on vent intubated and sedated; c spine immobilization +seat belt sign cta r knee w/ sutures intact pertinent results: 11:05pm hct-34.0* 07:48pm hct-37.3* 04:07pm hct-36.6* 04:30am hct-37.2* 06:33am blood wbc-9.1 rbc-3.50* hgb-11.5* hct-33.0* mcv-94 mch-32.7* mchc-34.7 rdw-13.0 plt ct-248 06:05am blood wbc-9.8 rbc-3.32* hgb-10.9* hct-31.8* mcv-96 mch-33.0* mchc-34.4 rdw-13.2 plt ct-215 06:25am blood hct-34.3* 01:59am blood wbc-9.9# rbc-3.52* hgb-11.7*# hct-33.3* mcv-95 mch-33.2* mchc-35.1* rdw-13.2 plt ct-197 01:20am blood wbc-20.6* rbc-4.66 hgb-15.3 hct-43.8 mcv-94 mch-32.8* mchc-34.8 rdw-13.1 plt ct-294 06:33am blood plt ct-248 06:05am blood plt ct-215 06:05am blood pt-12.0 ptt-25.8 inr(pt)-1.0 01:20am blood fibrino-234 06:33am blood glucose-103 urean-7 creat-0.9 na-138 k-4.1 cl-100 hco3-27 angap-15 06:05am blood glucose-116* urean-9 creat-0.9 na-138 k-4.0 cl-102 hco3-27 angap-13 01:59am blood glucose-112* urean-9 creat-1.0 na-140 k-4.4 cl-106 hco3-26 angap-12 06:33am blood alt-22 ast-51* ld(ldh)-345* alkphos-44 amylase-50 totbili-0.6 08:00pm blood alt-22 ast-57* ld(ldh)-349* alkphos-42 amylase-39 totbili-0.6 01:59am blood alt-25 ast-55* ld(ldh)-445* alkphos-43 amylase-34 totbili-0.4 04:30am blood alt-29 ast-56* ld(ldh)-360* alkphos-46 amylase-40 totbili-0.2 06:33am blood lipase-27 08:00pm blood lipase-20 01:59am blood lipase-17 04:30am blood lipase-21 06:33am blood albumin-3.7 calcium-8.9 phos-3.7 mg-1.7 08:00pm blood albumin-3.6 06:05am blood calcium-8.3* phos-2.8 mg-1.6 04:30am blood albumin-3.6 calcium-7.7* phos-3.9 mg-1.6 01:20am blood asa-neg ethanol-143* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:12am blood type-art po2-67* pco2-45 ph-7.41 calhco3-30 base xs-2 intubat-not intuba 01:24am blood glucose-111* lactate-2.6* na-146 k-4.5 cl-109 . tib/fib (ap & lat) left port 10:04 am foot ap,lat & obl left port; tib/fib (ap & lat) left port reason: ttp / fx medical condition: 36 year old man with mva reason for this examination: ttp / fx history: fracture. seven radiographs of the left ankle and foot demonstrate a minimally displaced, oblique, intraarticular fracture of the medial malleolus. the mortise is congruent. the talar dome maintains a normal contour. no fibula fracture. in particular frontal and lateral radiographs of the proximal leg demonstrate no proximal fibular fracture. soft tissues are unremarkable. no periarticular erosions. assessment is slightly limited by technique, but there is likely normal mineralization. impression: medial malleolus fracture as described. . foot ap,lat & obl right port 9:17 am foot ap,lat & obl right port reason: mva / fx medical condition: 36 year old man with mva reason for this examination: mva / fx history: fracture. three radiographs of the right foot demonstrate normal mineralization. the joint spaces are maintained without periarticular erosion. no fracture. soft tissues are unremarkable. there is no evidence of tibiotalar joint effusion. no localizing history provided. impression: unremarkable radiographs of the right foot. . chest (portable ap) 5:08 am chest (portable ap) reason: eval location of ng tube medical condition: 36 year old man with new ng tube, please eval location reason for this examination: eval location of ng tube history: assess nasogastric tube. single portable radiograph of the chest demonstrates an endotracheal tube with its tip just above the level of the clavicular heads measuring 5.5 cm above the level of the carina. there is a nasogastric tube present with its tip in the stomach. the left costophrenic angle is excluded from the imaged field of view. left perihilar airspace opacity with faint air bronchograms may represent the sequela of aspiration. there is mild bibasilar atelectasis. no pneumothorax. impression: support lines as described. left perihilar airspace opacity. the finding could represent the sequela of aspiration, in the proper clinical setting. bibasilar atelectasis. . ankle (ap, mortise & lat) right 1:58 am knee (ap, lat & oblique) right; ankle (ap, mortise & lat) righ reason: fracture medical condition: 36 year old man s/p mvc, lac on knee reason for this examination: fracture indication: 36-year-old male with motor vehicle accident, laceration of the knee. technique: eight views of the right knee. no comparison. findings: there is no fracture or dislocation identified. note is made of multiple lucencies in the soft tissue anterior to the knee, probably representing subcutaneous and intra-articular air secondary to the laceration noted on the physical exam. impression: no definite fracture on the radiograph. multiple lucencies in the soft tissue anterior to the knee. the finding represents subcutaneous and intra-articular air. . ct abdomen w/contrast 1:27 am ct chest w/contrast; ct abdomen w/contrast reason: trauma field of view: 36 contrast: optiray medical condition: 36 year old man s/p mvc reason for this examination: trauma contraindications for iv contrast: none. indication: 36-year-old male with motor vehicle accident. technique: contiguous axial ct images of the chest, abdomen, and pelvis are obtained with the administration of iv contrast , 130 cc of optiray. multiplanar reformation images are reconstructed. no comparison. findings: chest: there is no evidence of mediastinal hematoma. no pericardial effusion. thoracic aorta is unremarkable. note is made of bilateral pleural effusion with opacities in dependent portion of lower lobes, which may represent atelectasis. note is made of consolidation in the superior segment of left lower lobe, which can be due to atelectatic changes, however, contusion is another possibility in the presence of recent trauma. abdomen: note is made of somewhat hyperdense ascites anterior to the liver. there is hemorrhagic fluid in the right retroperitoneum abutting the second and third portion of duodenum, suggestive of retroperitoneal hematoma and duodenal injury. no evidence of free air is noted. note is made of fat stranding surrounding the hematoma. fat stranding and hemorrhagic fluid extend inferiorly along the right psoas muscle. bilateral ureters are opacified. note is made of extravasation of the contrast posterior to the bladder, suggestive of bladder injury. the extravasation is most likely involving both extra and intra peritoneal components, however, the evaluation is somewhat limited without enough contrast filling of the bladder. the liver is unremarkable without evidence of focal liver lesion. gallbladder contains residual contrast. spleen, adrenal glands, renal parenchyma and distal small bowel and large bowel are unremarkable. no significant lymphadenopathy. non-displaced fracture of left transverse process of l1 is noted. impression: 1. extravasation of the contrast from the bladder into the lower pelvis, representing bladder injury and rupture, probably with both intra- and extra- peritoneal components. urological consultation is recommended. (if the situation permits, the ct cystogram with contrast filling of the bladder will provide further information.) 2. hemorrhagic fluid with soft tissue stranding in right retroperitoneum, surrounding second and third portion of the duodenum extending inferiorly along the right psoas muscle, representing retroperitoneal hematoma. the distribution of the hematoma is worrisome for retroperitoneal organ injury, especially duodenum. 3. dependent opacities in bilateral lower lobes with effusion. consolidation in superior segment of left lower lobe, which may represent contusion in the presence of recent trauma. 4. small amount of hemorrhagic ascites anterior to the liver. the information was discussed with trauma team in person at the time of examination, and was discussed with dr. . 5. non-displaced fracture of the left transverse process of l1 is noted. . ct c-spine w/o contrast 1:25 am ct c-spine w/o contrast reason: fracture medical condition: 36 year old man s/p mvc reason for this examination: fracture contraindications for iv contrast: none. indication: 36-year-old male with motor vehicle accident. c-spine ct: there is no evidence of subluxation or fracture. prevertebral soft tissue is unremarkable. the patient is status post intubation. note is made of fluid in nasopharynx. impression: no evidence of gross fracture or subluxation. . ct head w/o contrast 1:24 am ct head w/o contrast reason: trauma medical condition: 36 year old man s/p mvc reason for this examination: trauma contraindications for iv contrast: none. indication: 36-year-old man with motor vehicle accident. non-contrast head ct: there is no evidence of acute intracranial hemorrhage. no mass effect. no shift of normally midline structures. note is made of fluid in nasopharynx. mucosal thickening in ethmoid sinus is seen. no evidence of fracture. impression: no acute intracranial hemorrhage. fluid in nasopharynx. soft tissue swelling in the right side anterior to the orbit. . trauma #2 (ap cxr & pelvis por reason: trauma medical condition: 36 year old man s/p mvc reason for this examination: trauma indication: 36-year-old male with motor vehicle accident. chest and pelvic radiograph. no comparison. findings: endotracheal tube is terminating just below the thoracic inlet. nasogastric tube terminating in left upper quadrant. note is made of somewhat widened mediastinal contour, however, the evaluation is limited due to overlying trauma artifact. lung volumes are small. pelvis: the evaluation of the pelvis is somewhat limited due to overlying trauma board artifact. no definite diastasis or fracture. please also refer to the official report of ct torso study. . ct abd w&w/o c 4:09 pm ct abd w&w/o c; ct pelvis w&w/o c reason: hematoma characterization? field of view: 38 contrast: optiray medical condition: 36 year old man with bladder rupture and hematoma on prior ct, still ttp multiple areas. po and iv contrast please. reason for this examination: hematoma characterization? contraindications for iv contrast: none. indication: bladder rupture and retroperitoneal hematoma on prior ct, with persistent tenderness to palpation in multiple areas. comparison: , torso ct. technique: axial multidetector ct images of the abdomen and pelvis were obtained without contrast and then with 150 cc of intravenous optiray in early and delayed phases. abdomen ct with and without contrast: previously noted small bilateral pleural effusions have resolved. bibasilar dependent pulmonary opacities have decreased in size, likely representing atelectasis. there is a new small peripheral ground-glass opacity in the posterolateral right upper lobe and lateral right middle lobe with a nonspecific appearance, atypical for atelectasis or aspiration. the nasogastric tube terminates in the proximal stomach. incidental note is made of contrast excretion into the gallbladder. the liver, spleen, pancreas, adrenal glands, kidneys, and abdominal bowel loops appear unremarkable. there is a decreased amount of ascites. there is increased swelling in the muscles of the left abdominal wall/flank (internal and external obliques and transversus abdominis) with lost of fat planes, consistent with increasing hematoma. pelvis ct with and without contrast: previously noted right retroperitoneal blood collection is no longer identified in its previous location. there is a new presacral blood collection, which may represent redistribution of blood products in the setting of bed rest. residual stranding is between the aorta and cava. there is a foley catheter in the bladder. there is fat stranding in the prevesical space, likely reactive given known bladder rupture. the prostate, seminal vesicles, pelvic bowel loops, and rectum appear unremarkable. bone windows: fracture of the left transverse processes of l1 is again noted. impression: 1. increasing hematoma of the internal and external obliques and transversus abdominis, muscles of the left abdominal wall and flank. 2. shift of right retroperitoneal blood products into the presacral space. 3. small amount of ascites, decreased since the previous study. 4. fat stranding in the prevesical space, likely reactive in the setting of known bladder rupture. 4. interval improvement in bilateral lower lobe pulmonary opacities, which likely represent atelectasis. new small subpleural opacity in the right lung, which appears nonspecific. 5. fracture of the left transverse process of l1 vertebra. . c-spine trauma w/flex & ext 5 views 11:46 am c-spine trauma w/flex & ext 5 reason: fx or dislocation? ortho spine has requested these films. th medical condition: 36 year old man with mvc 3 d ago. reason for this examination: fx or dislocation? ortho spine has requested these films. thank you. history: mvc three days ago, question fracture or dislocation. cervical spine, five views. on the neutral lateral view, c1 through lower portion of c7 is demonstrated. the c7-t1 disc space and t1 are not included. there is straightening of usual lordosis, with a collar in place. no listhesis is identified. vertebral body and disc heights are preserved. there is mild diffuse prevertebral soft tissue swelling, of indeterminate significance given the presence of an et tube. no gross degenerative changes are identified. lateral masses are symmetric about the dens. on the flexion view, there is good of motion. c1 through the c6-7 disc space is demonstrated. no listhesis or instability is suggested. on the extension view, there is good range of motion and no listhesis or instability is detected through the level of upper c7. impression: good range of motion. no evidence of instability through the level of the c6-7 disc space. assessment of the more caudal levels is limited on this exam. . mr cervical spine 12:31 am mr cervical spine; mr thoracic spine reason: please evaluate cervical spine for ligamentous injury medical condition: 36 year old man with reason for this examination: please evaluate cervical spine for ligamentous injury indication: 36-year-old man in motor vehicle accident. evaluate for cervical spine ligamentous injury. note is made of the ct c-spine of . technique: sagittal t1- and t2-weighted images of the cervical spine were obtained with axial gradient echo scans of the c2/3 through c7/t1 disc interspaces. sagittal t1- and t2-weighted images of the thoracic spine were obtained. findings: examination is limited secondary to poor image quality from motion and pulsation artifacts. on sagittal images of the cervical spine, the skull base through t3 vertebrae are well evaluated. there is no prevertebral or paraspinal pathology. there is no abnormal alignment or loss of disc height. there is no evidence of spinal stenosis. the visualized spinal cord and its contents are unremarkable. sagittal t1- and t2-weighted images of the thoracic spine demonstrate no evidence of abnormal alignment or fracture. the visualized portions of the cord are unremarkable. impression: poor image quality limits examination. no gross evidence of vertebral or spinal cord pathology. . chest (portable ap) 10:21 am chest (portable ap) reason: infiltrate? consolidation? effusion? medical condition: 36 year old man with tachycardia after mvc w/ multiple wounds, now w/ confusion. reason for this examination: infiltrate? consolidation? effusion? chest history: tachycardia after mvc. comparison: . since the prior study, the patient has been extubated and the ng tube has been removed. the patient is taking a somewhat decreased inspiratory effort. there are bands of linear density at the base of the left lung consistent with atelectasis. no focal infiltrates are seen. there is no pneumothorax. the cardiomediastinal silhouette is unchanged. impression: no pneumothorax. low lung volumes with associated atelectasis. brief hospital course: mr did well during his hospitalization. he was intubated at the outside hospital. he was noted to have a bladder rupture, which was seen by urology. there was discussion regarding whether it was intra- or extraperitoneal. ultimately, the ct was read as likely both intra and extraperitoneal components. urology elected to put him on cipro prophylactically. the pt did well w/ good urine output and stable renal indeces. . the pt had a left medial malleolus fx, which was casted by orthopedics. . the pt had a right knee intraarticular wound that was cleaned out and treated w/ kefzol for 4 days. it looked well w/o erythema, drainage, edema, or tenderness during his stay. . the patient was seen by physical therapy and social work during his stay. medications on admission: hctz 12.5 daily atenolol 50 daily motrin 600 tid ambien xanax lunesta seroquel discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q2-8h:prn as needed for asthma symptoms: if you use this more than every 4 hours, see a doctor. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 3. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 4. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours): please address this medicine with the urologist. 6. fluocinonide 0.05 % ointment sig: one (1) appl topical (2 times a day): to right arm itchy area. 7. colace 100 mg capsule sig: one (1) capsule po twice a day: do not take if > 1 bm/day. 8. senna 8.6 mg capsule sig: one (1) capsule po bid:prn: hold if > 1 bm/day. discharge disposition: extended care discharge diagnosis: left medial malleolus fracture. motor vehicle collision. bladder rupture. retroperitoneal hematoma. left l1 transverse process fracture. discharge condition: stable. discharge instructions: discharge to the custody of the police and the police for outstanding warrants. . you have a bruise in your abdominal wall and inside your abdomen. the pain will lessen over time. we have given you pain medicine to control this. do not put any weight on your left leg. . you had a bladder rupture which has been healing. stay on the antibiotics as directed until you follow up with a urologist. followup instructions: you need to see doctors in the following specialties for your injuries: 1. urology, 10 days from date of discharge. you will need a voiding cystourethrogram to further evaluate your bladder rupture. 2. orthopedics, 2 weeks from date of discharge. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closed reduction of fracture without internal fixation, tibia and fibula Other arthrotomy, knee Myotomy Diagnoses: Unspecified essential hypertension Closed fracture of lumbar vertebra without mention of spinal cord injury Bipolar I disorder, most recent episode (or current) unspecified Open wound of knee, leg [except thigh], and ankle, without mention of complication Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle Injury to bladder and urethra, with open wound into cavity Fracture of medial malleolus, closed

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: asymptomatic major surgical or invasive procedure: cabg x 4 (lima->lad, svg->rca sqeuential om1, om2) history of present illness: 53 yo caucasian male with family history of premature cad and positive ett. referred for cath which showed ef 45%, 60-70% lad, cx 100%, om 2 100%, 90% rca. referred for surgical revascularization. past medical history: elev. chol. tonsillectomy exc. pilonidal cyst social history: car salesman 35 cigarettes per week no alcohol lives with wife family history: father with mi at 53 physical exam: hr 66 rr 19 6'1" 88.5 kg nad skin/ heent unremarkable neck supple, full rom lungs ctab rrr soft, nt, nd, + bs warm, well-perfused, no edema, no varicosities neuro grossly intact left fem 2+ dp/pt/radials 2+ bilat. r hand perfused with occluded right radial on exam no carotid bruits pertinent results: 06:02am blood wbc-19.9* rbc-3.67* hgb-11.7* hct-33.5* mcv-91 mch-32.0 mchc-35.0 rdw-12.3 plt ct-262 06:08am blood wbc-12.0* hct-29.6* 06:38am blood hct-30.3* 06:02am blood plt ct-262 06:02am blood glucose-135* urean-16 creat-0.9 na-136 k-4.2 cl-99 hco3-27 angap-14 06:38am blood k-4.2 06:02am blood mg-1.8 brief hospital course: admitted on and underwent cabg x4 with dr. . transferred to the csru in stable condition on nitroglycerin and propofol titrated drips. extubated later that afternoon neurologically intact. chest tubes removed on pod #1, off all drips and transferred to the floor to begin increasing his activity level. on pod #2, beta blockade was titrated and gentle diuresis was continued. pacing wires were removed without incident on pod #3. he continued to make excellent progress and was cleared for discharge to home with services on pod #4. he is to follow up with pcp, and surgeon as outlined in the discharge instructions. medications on admission: asa 325 mg daily lipitor 10 mg daily toprol 25 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(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:*0* 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 weeks. disp:*14 tablet(s)* refills:*0* 7. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 1 weeks. disp:*28 capsule, sustained release(s)* refills:*0* 8. toprol xl 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: cad s/p cabg x4 hyperlipidemia s/p t&a s/p pylonidal cyst removal discharge condition: good. discharge instructions: calll with fever, redness or drainge from incision or weight gain more than 2 pounds in one day or five in one week. shower, no baths, no lotions, creams or powders to incisions. no lifting more than 10 pounds or driving until follow up with surgeon. followup instructions: dr. 4 weeks dr. 2 weeks dr. 2 weeks Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: inability of extended care facility to administer meds major surgical or invasive procedure: gastrografin swallow evaluation video esophageal evalaution ct guided aspiration of prevertebral fluid collection history of present illness: this is a 74 year-old man with history of hepatits b and c, syphylis, hypertension who suffered a fall from wheelchair at home on , mri at osh revealed c3-c4 area suspicious for osteomyletis, sent to . c-spine and x-ray at that time showed no pathology. he was recently discharged from () to rehab after findings here including c3-c5 / ?staph osteomyletitis, discitis, para-verterbral abcess s/p discectomy/vertebrectomy on . he was discharged on amphotericin and vancomycin. rehab was unable to administer amphotericin and so he returned on . since that time, he has been followed by ortho as primary as well as id, medicine consult. he is now found to have arf during this admission in addition to his previous medical issues. on last admit, hiv, tte, optho eval for endoopthalmitis/retinitis were all negative. when seen on transfer the patient reports dysphagia and sore throat. denies odynophagia. has trouble swallowing pills and solids particularly, but fluids as well. no nausea, vomiting, diarrhea or constipation. has decreased po intake. no bowel or bladder incontinence and no sensory changes. he reports some continued neck pain, as well as pain in his shin. has not been feeling feverish and denies chills. denies chest pain, shortness of breath, abdominal pain. past medical history: hep b/c syphylis htn left lower extremity ulcer w/ psuedomonas peripheral neuropathy s/p total knee replacement s/p triple a repair family history: na physical exam: vs: 130-138/70's hr 74-77 rr: 20 98tmax 98%rm air gen: nad, pleasant man appearing his stated age, with collar in place, became tearful during exam heent: collar in place, ncat, mmm, neck has some edema under chin, non-tender, no lymphadenopathy, masses, thyromegaly or thyroid nodules appreciated. perlla. no jvd, no canon a waves, no radiation of pulse to carotids. lung: decreased breath sounds on the left, especially at base, right-cta. heart: irregular, s1 and s2 wnl, no murmurs, rubs or gallops abd: +b/s, soft, nt, nd extr: lle-bandage in place, no discharge. no edema, clubbing or tenderness neuro: a and oriented x3. pertinent results: admit labs: 05:14am wbc-5.2 rbc-3.89* hgb-10.5* hct-32.3* mcv-83 mch-27.1 mchc-32.7 rdw-14.3 05:14am plt count-251 05:14am glucose-120* urea n-9 creat-1.1 sodium-142 potassium-3.6 chloride-103 total co2-26 anion gap-17 05:14am calcium-9.8 phosphate-3.6 magnesium-1.9 12:50am vanco-20.5* rule out mi labs: 08:47pm ck(cpk)-32* 08:47pm ck-mb-notdone ctropnt-0.01 04:26am blood ck(cpk)-35* 04:26am blood ck-mb-notdone 01:06pm blood ck(cpk)-36* 01:06pm blood ck-mb-notdone 04:15am blood ck(cpk)-30* 04:15am blood ck-mb-notdone ctropnt-<0.01 cervical spine series w/ flexion/extension : there is bony destruction involving the anterior portions of the bodies of _cv3 and cv4 as previously demonstrated. no evidence of instability on lateral flexion and extension films. there is narrowing of the c5-6 and c6-7 discs as previously demonstrated. there is slight widening of the prevertebral soft tissues at the c3-4 level. video oropharyngeal swallow: the study was performed in conjunction with the speech therapist. various consistencies of barium were administered. there is no evidence of aspiration. penetration was noted with thin liquids and nectar. the barium tablet passed freely into the stomach. impression: no evidence of aspiration. brief hospital course: the patient was transferred to the micu for management of his airway secondary to his dysphagia and for his acute renal failure. hospital course, by problem: 1. prevertebral fluid collection - seroma vs hematoma vs abcess. has been imaged by ct w/o contrast, mri, and x-ray. ent scope showed posterior pharyngeal edema between the glottis and epiglotis w/ mild degree of airway narrowing. on broad spectrum antibiotics. ent rescoped and found no perforation, after which he was transferred to the floor for further management. he underwent a ct guided aspiration of the prevertebral collection. this was limited to only 0.5 cc of aspirate which was negative for growth on culture. subsequent to these results, his meropenem and vancomycin were discontinued. he then underwent a cspine series with flexion and extension radiographs and was determined to have no cervical instability. his cervical collar was removed without any complications. 2. fungemia - blood growing para. from line (). surveilance blood cx negative. was on ampho but secondary to acute renal failure was switched to fluconazole. subsequent to these results, his meropenem and vancomycin were discontinued. tte was negative. he refused ophthalmologic examination. 3. acute renal failure - cr up to 2.2 from baseline of 1.0. likely secondary to pre-renal hypovolemia and vanc/ampho. he was hydrated and switched to fluconazole from amphotericin and his creatinine stabilized around 1.5 4. anemia - hct 27.5 down from 31-34 (baseline). mcv microcytic. he had no evidence of acute bleeding and his iron studies were consistent with anemia of chronic disease. he did receive 2 units of prbcs while on the floor as the hct drifted to below 25. he will need an outpatient colonoscopy. 5. ekg consistent w/ wandering atrial pacemaker. echo consistent w/ lvh. couple runs of nsvt, asymptomatic. ruled out for myocardial infarction. he heart rate was maintained on lopressor. 6. hypertension-he was given iv lopressor while he was npo and this was switched to po after he was able to swallow. once he tolerated po, his nifedipine was switched to amlodipine as his heart rate did go into the 40s with lopressor. 7. dysphagia - secondary to prevertebral mass. he initially failed speech and swallow study while in the micu and was made npo, but after being ruled out for esophageal perforation and transfer to the floor, subsequently had no difficulties passing a reevaluation. he was advanced to soft solids and thin liquids and then to regular diet without difficulty. medications on admission: vancomycin, amphotericin, metoprolol, nifedipine, protonix, haldol discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po qd (once a day) as needed. 2. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 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. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 8 weeks. disp:*112 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 7. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. 8. haloperidol 1 mg tablet sig: two (2) tablet po bid (2 times a day) as needed. 9. amlodipine besylate 5 mg tablet sig: two (2) tablet po qd (once a day). disp:*60 tablet(s)* refills:*2* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. gabapentin 100 mg capsule sig: two (2) capsule po tid (3 times a day). disp:*180 capsule(s)* refills:*2* 12. morphine sulfate 2 mg iv q4h:prn 13. ondansetron 2 mg iv q6h:prn discharge disposition: extended care facility: healthcare - discharge diagnosis: primary diagnoses: 1) c3-c5 , osteomyelitis and disciitis 2) prevertebral abscess 3) acute renal failure secondary diagnoses: status post discectomy/vertebrectomy hypertension wandering atrial pacemaker anemia hepatitis b hepatitis c syphillis peripheral neuropathy left lower extremity ulcer discharge condition: stable and improved. his airway was patent and he had no dysphagia. he passed speech and swallow study and was tolerating a regular diet with continued strict aspiration precautions while eating. his creatinine trended now and settled at what is likely his new baseline of 1.5-1.6. discharge instructions: call your doctor or return to the emergency room immediately if you experience fever greater than 100.4, shaking chills, shortness of breath, difficulty swallowing, chest pain, worsening neck pain or sudden numbness/tingling, or weakness in your arms or legs, or loss of bowel or bladder control. followup instructions: 1. provider: , md where: lm disease phone: date/time: 10:30 2. provider: , od where: phone: date/time: 9:00 3. follow up with your orthopedist, dr. in one to two weeks. call to make an appointment. 4. follow up with your primary care doctor, dr. in 2 weeks. Procedure: Transfusion of packed cells Aspiration of skin and subcutaneous tissue Diagnoses: Anemia of other chronic disease Unspecified essential hypertension Acute kidney failure, unspecified Unspecified viral hepatitis C without hepatic coma Atrial fibrillation Unspecified osteomyelitis, other specified sites Paroxysmal ventricular tachycardia Disseminated candidiasis Infection and inflammatory reaction due to other vascular device, implant, and graft Hyperosmolality and/or hypernatremia Unspecified hereditary and idiopathic peripheral neuropathy Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Ulcer of lower limb, unspecified Other and unspecified disc disorder, cervical region

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: neck pain s/p fall from wheelchair major surgical or invasive procedure: c3-4 abcess removal history of present illness: 74 yo male presents in ed on s/p fall from wheelchair at home. complained of mile neck pain. pt taken to osh where mri of c-spine revealed suspicious area at c3-c4. question of epidural abcess. no weakness or parasthesias were demonstrated. pt transfered to for further eval. ed started pt on vancomycin and unasyn for antibiotic coverage. past medical history: hep b/c syphylis htn foot ulcer peripheral neuropathy family history: na physical exam: 100.0 149/61 60 20 a&o answering questions appropriately hard collar rrr cta b bue brief hospital course: seen by neurology and orthopedics/spine in ed. mri showed c3-5 osteomyelitis, discitis, w/ concern for epidural abscess. initially placed on vancomycin, but by , blood cultures grew . id was consulted and ambisome was added. taken to or for c3/4 discectomy/vertebrectomy w/ dr. . infectious disease was consulted and recommended multiple tests including to pull picc line, obtain ophthalmology evaluation to r/o fungal retinitis, hiv, tte, and ekg. while in the hospital, the patient exhibited waxing/ mental status and paranoid ideation. he claimed the medical staff were "performing experiments" on him and didn't believe that the fungemia was real. pt's delerium was evaluated w/ repeat head ct, ua/cx, lfts/ammonia, cxr. no obvious source of delirium besides infection itself. seen by psych and recommended haldol . ekg showed wandering atrial pacemaker. cardiology and medicine recommended low dose beta blockers, but patient refused. pt did appear to improve, but continued to refuse multiple tests, including optho evaluation, hiv, and tte. picc line replaced. per id, ambisome was changed to amphotericin qd preceeded by 500 cc ivf bolus. they recommended 8 weeks of ampho and vanc. discharge disposition: extended care facility: healthcare - discharge diagnosis: c-spine abcess discharge condition: good discharge instructions: activity as toloerated. c-collar x 4 weeks. amphoteracin/vanco iv x 8 weeks. please bolus 500cc ns prior to each amphoteracin dosage. please check weekly cbc, lfts, lytes and creatinine while on abx and fax to dr. . followup instructions: please follow up with dr. in days. please follow up with dr. in clinic and check weekly cbc, lfts, lytes and creatinine while on abx and fax to dr. md, Procedure: Transfusion of packed cells Aspiration of skin and subcutaneous tissue Diagnoses: Anemia of other chronic disease Unspecified essential hypertension Acute kidney failure, unspecified Unspecified viral hepatitis C without hepatic coma Atrial fibrillation Unspecified osteomyelitis, other specified sites Paroxysmal ventricular tachycardia Disseminated candidiasis Infection and inflammatory reaction due to other vascular device, implant, and graft Hyperosmolality and/or hypernatremia Unspecified hereditary and idiopathic peripheral neuropathy Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Ulcer of lower limb, unspecified Other and unspecified disc disorder, cervical region

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath and fatigue major surgical or invasive procedure: cardiac catheterization with bare metal stent to lad endotracheal intubation central venous line placement picc line placement peg tube placement intubation axillary lymph node biopsy history of present illness: mr. is a 46 year-old man with a pmhx significant for hiv (dx'd , cd4 260 in , last vl was , self d/c'd harrt in mid financial difficulty, no history of opportunistic infections) in usoh until one month prior to presentation when he began to develop myalgias, fevers, chills, progressive doe, pnd, and eventually orthopnea. over this month he also had multiple episodes of vomiting and weight loss. he saw his pcp two weeks prior to presentation regarding these symptoms. a cxr showed an upper lobe infiltrate, and he was treated with a z-pac, without symptomatic improvement. he was referred to the ed for further evaluation on . in the ed, ekg revealed st elevation in the anterior leads. a cxr showed diffuse bilateral infiltrates. past medical history: 1. hiv, diagnosed in . discontinued haart in mid- financial struggle. no history of opportunistic infections. last cd4 260, vl in . 2. hyperlipidemia social history: mr. works at a zoo. multiple animal exposures. ex-smoker. family history: n/a physical exam: physical examination in ed (per records): vitals: t 97.7, hr 117, bp 101/77, rr 16, sat 100% on room air. heent: perrla neck: supple, no lad, no jvd. resp: cta bilaterally. no wheezing. cvs: normal s1, s2. no s3, s4. no murmur or rub. gi: no flank or pelvic pain. integument: no suspicious lesions. neuro: alert and oriented x 3. pertinent results: relevant studies in hospital: labs on admission: wbc-7.7 rbc-4.28* hgb-11.8* hct-36.6* mcv-85 mch-27.6 mchc-32.3 rdw-14.3 neuts-67.8 lymphs-28.1 monos-3.6 eos-0.2 basos-0.3 plt count-235 ck(cpk)-117 ck-mb-2 ctropnt-0.08* glucose-106* urea n-19 creat-1.1 sodium-132* potassium-5.8* chloride-99 total co2-23 anion gap-16 albumin-3.1* calcium-7.9* phosphate-4.6* magnesium-1.9 lipase-24 alt(sgpt)-24 ast(sgot)-33 ld(ldh)-347* alk phos-142* amylase-33 tot bili-0.4 cardiac catheterization: 1. selective coronary angiography demonstrated a right dominant system with a ramus branch and one vessel cad. the left main was a long vessel with mild plaquing. the lad had an ostial subtotal occlusion and a proximal total occlusion. the distal lad filled faintly by left to left collaterals. the lcx was modest av groove vessel with small om branches. the ramus intermedius was large with a 30% mid vessel lesion. the rca had diffuse plaquing to 30% proximally. there were some septals providing collateral flow to the lad. 2. resting hemodynamics demonstrated cardiogenic shock. right sided filling pressures were markedly elevated with a mean ra pressure 18 mm hg. left sided filling pressures were also elevated with a mean pcw pressure of 24 mm hg and lvedp of 23 mm hg. cardiac index was markedly depressed at 1.0 l/min/m2, based on an assumed oxygen consumption index. there was no evidenc of a gradient across the aortic valve on pullback of the pigtail catheter from the left ventricle. moderate pulmonary hypertension was present. 3. an 8 french 40 cc intra-aortic balloon pump was placed via the right common femoral artery. there was appropriate augmentation of the diastolic pressure and unloading of the ventricle. after balloon augmentation, the cardiac index rose to 1.8 l/min/m2. 4. successful pci of the proximal lad with a 2.0 x 18 mm pixel stent, post-dilated with a 2.5 mm balloon at 18 atm (see ptca comments). 5. abdominal aortography was performed with a 4 french tennis racquet catheter using 30 cc of contrast at 15 cc/second. there was adequate runoff with mild diffuse plaquing in the bilateral iliac and right common femoral arteries despite the presence of the iabp sheath. final diagnosis: 1. one vessel cad. 2. cardiogenic shock. 3. successfl pci of the lad for acute anterior myocardial infarction. echo: the left atrium is moderately dilated. the right atrium is moderately dilated. a patent foramen ovale is present. the inferior vena cava is dilated (>2.5 cm). the left ventricular cavity is moderately dilated. there is severe global lv hypokinesis with distal septal and apical dyskinesis. the basal to middle septum is thinned and akinetic. a large, non-mobile thrombus is seen in the left ventriclar apex (2.0 x 3.0 cm) extending down the distal septum. the right ventricular cavity is dilated. right ventricular systolic function appears depressed. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. ct of the chest with iv contrast: bilateral axillary, left internal mammary, precarinal, and subcarinal lymphadenopathy is again noted, unchanged since the prior study. left subclavian approach swan-ganz catheter terminates within the left main pulmonary artery. a focal area of soft tissue within the left ventricular cavity presumably represents the patient's known thrombus. the heart is enlarged but there is no pericardial effusion. the appearance of the lungs is unchanged since the prior study. again, seen are multifocal areas of parenchymal opacification in a peribronchovascular distribution as well as smaller nodular opacities. peripheral left basilar opacities are again identified associated with a small amount of pleural fluid. the airways remain patent to the level of the subsegmental bronchi bilaterally. ct of the abdomen with iv contrast: oblong hypodensity extending from the splenic hilum to the posterior aspect of the spleen likely represents a splenic infarct. a smaller area of decreased attenuation is identified as well. the splenic vein and artery appear patent. the liver, gallbladder, pancreas, adrenal glands, and right kidney appear grossly normal. there is a peripheral area of hypodensity involving the left kidney in a single image, possib ly representing a renal infarct. left kidney otherwise enhances and excretes contrast. stomach and visualized loops of small and large bowel are unremarkable. the aorta and its major intra- abdominal branches appear patent. there is no free fluid within the abdomen. ct of the pelvis with iv contrast: a small focus of gas within the urinary bladder, presumably related to prior instrumentation. the distal ureters, seminal vesicles, and pelvic loops of bowel appear grossly normal. there is no free fluid within the pelvis. bone windows: no suspicious lytic or blastic lesions are identified. impression: 1) unchanged appearance of bilateral peribronchovascular airspace opacities as well as multiple peripheral poorly defined nodular opacities. differential diagnosis remains unchanged and includes infection, septic emboli, cryptogenic organizing pneumonia, and vasculitis. 2) stable appearance of mediastinal and axillary lymphadenopathy. 3) findings consistent with splenic infarcts involving the posterior aspect of the spleen. 4) focal area of hyperperfusion within the lateral mid pole of the left kidney possibly an infarct. 5) ill-defined soft tissue within the left ventricle presumably represents the patient's known left ventricular thrombus. ct head w/o contrast: there is no evidence of intracranial hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct. -white matter differentiation is preserved. note is made of a mucosal retention cyst in the left maxillary sinus. osseous and soft-tissue structures are otherwise unremarkable. impression: no evidence of intracranial hemorrhage or other acute intracranial pathology. eeg: this is a discontinuous bedside eeg telemetry from -29 that was abnormal due to the presence of a low voltage background rhythm with occasional low voltage periods of delta and alpha frequency activity. these findings suggest deep, midline subcortical dysfunction and are likely a medication effect due to propafol. as the record progressed, higher voltage, hz delta frequency activity was seen. this also suggests deep, midline subcortical dysfunction and is consistent with an encephalopathy that, again, may be due to a medication effect. during the recording, intermittent arm twitching and upper body fasciculations were noted and there was no evidence of seizure activity. no lateralizing abnormalities were seen. sinus tachycardia was noted. : right upper quadrant ultrasound: comparison is made to a ct scan dated . liver demonstrates no focal or textural abnormalities. there is no intrahepatic or extrahepatic ductal dilatation. the common bile duct measures 2.2 mm in diameter. the portal vein is patent with flow in the appropriate direction. there is mild distention of a sludge containing gallbladder. the pancreas is normal in appearance. there is a small amount of pericholecystic fluid as well as focal wall edema. small amount of ascites is present adjacent to the right lobe of the liver. there is a small right pleural effusion. impression: mildly distended sludge containing gallbladder, small amount of pericholecystic fluid and focal wall edema as above. these findings are concerning for, but not diagnostic of, cholecystitis. if there is continued clinical concern for cholecystitis, a hida scan is recommended. hida: negative right axillary lymph node biopsy: hiv-associated adenopathy with follicular involution, lymphocyte depletion, follicular dendritic cell hyperplasia and histiocytic hyperplasia see note. ct of the chest without intravenous contrast: in comparison with the previous examination, there has been marked interval progression of bilateral patchy and nodular pulmonary parenchymal opacity consistent with multifocal pneumonia. there is a new large right-sided pleural effusion and interval increase in size of a moderate left pleural effusion. the visualized portions of the heart and pericardium appear unchanged. visualization of the mediastinal structures is limited due to lack of iv contrast. the airways are patent to the level of the segmental bronchi bilaterally. limited images of the upper abdomen, including limited images of the liver, spleen, and stomach, appear unremarkable. bone windows: bone windows demonstrate no evidence of suspicious lytic or sclerotic osseous lesions. there is significant motion during image acquisition, which limits visualization of fine osseous detail within the ribs, particularly on the right. impression: significant interval progression of bilateral pulmonary parenchymal consolidation consistent with multifocal pneumonia. interval increase in bilateral pleural effusions. microbiology/serology work-up: urine legionella negative dfa negative for influenza on admission induced sputum negative for pcp, cryptococcal antigen negative ebv serology negative cmv viral load negative galactomannan antigen positive on first assay (false positive on zosyn), then negative on repeat testing. bartonella serology negative monospot ngative toxoplasma serology negative stool positive for c. difficile. -> c. diff negative x3 s/p treatment (last test on neg). wound swab from peg site: pseudomonas but thought to be colonization by id. no signs of abscess or deeper infection on abd ct. urine culture: pseudomonas thought to be colonization by id. ua neg x2. id recommends against treatment. sputum gram stain: gram neg rods and gram positive cocci in pairs and clusters. ngtd ua: clear; uctx: ngtd all blood cultures ngtd brief hospital course: a/p: 46 year-old male with hiv previously on haart, admitted with 1 month of doe, chf symptoms, found to have anterior st elevations on ekg in ed and total occlusion of lad in cath lab, status post stent placement (bare metal stent) on , also with bilateral pulmonary infiltrate on cxr. his hospital course will be reviewed by problems as it was complicated by multiple issues. . 1) cv: a). cad: as mentionned above, mr. was taken to the cath lab on where he was found to have total occlusion of the lad and received a bare metal stent. right heart catheterization showed elevated pcwp of 26 and mvo2 sat of 24%, with ci of 1.0. an iabp was placed with improvement in ci to 1.8, and dopamine was initiated. he was subsequently transferred to the ccu for further care. it was felt that the mi was not acute given the low enzyme levels (troponin 0.08, flat mb on ) but most likely represented an event a couple weeks old. of note, plavix was held in anticipation for invasive diagnostic procedures for his pulmonary process. he had a heparin coated bare metal stent placed on , and plavix was stopped despite such a short course. it was not restarted due to persistent bleeding from epistaxis. . b). pump: an echo on revealed an ef 10-15% and an apical lv thrombus, and mr. was started on heparin iv. during his course in the ccu, he was switched to milrinone for inotropic support, and diuresis was initiated given elevated filling pressures and poor ef. lasix and milrinone therapy were tailored to increase his cardiac index by following pap values. during this part of the hospital course he had several episodes of svt responsive to lopressor, and later had nsvt for which milrinone wean was accelerated. as tolerated by good cardiac index, he was weaned off the iabp and started on ace-inhibitor, and weaned off milrinone. digoxin was also started and coreg was added. . he was transferred to the floor on , stable on ace inhibitor and bb. on the second day on the floor, he became hypotensive and developed a fever to 102.5. he was given fluids and placed on dopamine out of concern for sepsis and possible cardiogenic shock, and transferred back to the ccu. over that night he was switched to levophed as he was too tachycardic on dopamine. a swan was again placed and the numbers were consistent with cardiogenic shock and superimposed sepsis. pressors were changed to milrinone. . he has remained on milrinone since his transfer back to the ccu, and has been on intermittent ace inhibitor therapy (held in the setting of hypotension and rising creatinine). we were eventually able to titrate lisinopril to 5 mg po qd. therapy was tailored to the patient's bp and urine output once the pa line was out. few attempts to wean milrinone have been unsuccessful because of hypotension. the chf service was consulted, with recommendations to start digoxin for inotropic support, and transfuse to keep hematocrit > 30, both of which were done. of note, while in the ccu, mr. had recurrent episodes of complete heart block, and digoxin was discontinued. he was also diuresed with lasix boluses prn for goal daily even to negative fluid balance. at some point he was so fluid overloaded, he required lasix gtt with additional boluses to attain euvolemia. . however, the patient's congestive heart failure continue to worsen throughout his course. at first, the patient wished to be dnr/dni with continued measures to save his life including milrinone. the swan was discontinued with persistently low cardiac indexes in the 1.4 range on milrinone. however, the patient then reversed his code status as he was given the hope that he might recover. despite this hope, the patient's congestive heart failure worsened to the point that recovery is slim and he will remain dependent on milrinone for the rest of his life. meanwhile, he would occasionally drop his pressures and require levophed. on dobutamine, he developed ectopy and this was stopped. at the patient's family's request, dr. from , a heart failure expert, came to evaluate the patient and agreed that the patient would not be a candidate for a left ventricular assist device or heart transplant as the patient has no intrinsicly preserved heart function to support such a thing. furthermore, his pulmonary status is so poor that he would not tolerate a heart transplant. in addition, dr. from the brighham also offered a second opinion in which he at first suggested repeating a ct scan of his chest, improving his nutritional status and repeating an echocardiogram to assess the patient's improvement and consider lvad. however, a repeat ct scan showed minimal improvement of the patient's boop on prednisone, a repeat echo showed decreased systolic function and although he is at goal tpn, his nutritional status will not further improve. therefore, the patient has been denied by the for further intervention as well. . the patient continued to be dependent on milrinone and levophed for inotropy and pressure support. multiple attempts were made to wean down the levophed dose in an attempt to discharge/transfer pt to home/floor, however this proved very difficult due to repeated episodes of hypotension. on the last days of his hospitalization, his hypotensive episodes became worse most likely secondary to sepsis and he required higher and higher doses of leveophed to maintain pressures. at some point, the levophed was not able to support his blood pressure and max dose milrinone was unable to generate sufficient forward flow to maintain tissue perfusion. . c). rhythm: the patient had been tachycardic to 140-160s since admission but was started on amiodarone on and had shown signs of better nodal control. the patient only had occasional episodes of tachycardia after wards. he was therefore continued on amiodarone at 100mg once daily dose (lower than normal dose due to history of significant bradycardia with full dose amiodarone). the patient was continued to be observed on telemetry as well during his hospitalization. . . 2) pulmonary: a). pulmonary infiltrates/boop: given his initial cxr with bilateral patchy infiltrates, mr. was started on levoquin for coverage of atypicals and cap organisms. id was consulted. he was placed on isolation out of concern for possible tb, and bactrim was added pending rule out pcp. cd4>200 and negative induced sputum x2, bactrim was discontinued. vancomycin was added for gram positive coverage. a ct chest was eventually performed to further characterize his pulmonary lesions, and revealed bilateral conglomerated central peri-bronchovascular opacity with air bronchograms as well as multiple peripheral scattered poorly defined nodular opacities and foci of ground-glass opacity and lymphadenopathy. the differential diagnosis included atypical infection, cryptogenic organizing pneumonia, atypical vasculitis, sarcoidosis, and neoplastic processes such as kaposi sarcoma and lymphoma. an extensive non-invasive work-up including induced sputum for pcp, , legionella, as well as blood cultures, sputum cultures, cryptococcal antigen, chlamydia psitacci, histoplasmosis, coccidioidomycosis, chlamydia pneumonia, bartonella titers, was non-revealing. he also did not respond to broad-spectrum antibiotics. . pulmonary was consulted, along with id and a tissue diagnosis was recommended. a vats was felt to be the best diagnostic procedure. however, thoracic surgery declined vats given the patient's tenuous respiratory and cardiac status. attempt was made to perform a bronchoscopy with biopsy on but was aborted given the patient's tenuous hemodynamics. the yield of such a procedure was also anticipated to be low, and the risk/benefit ratio of elective intubation was not favorable. given his generalized lymphadenopahy, he underwent a right axillary lymph node biopsy on . initial pathology reports were suggestive of an atypical tumor. however, further evaluation was felt consistent with hiv adenopathy with non-specific histiocytic proliferation, and the biopsy turned out to be non-diagnostic. special stains and immunophenotyping were also unrevealing. . given the above, mr. was started on empiric steroid and antifungal therapy on . heme was also consulted, who felt that his pulmonary process was unlikely to be lymphoma. in the differential were ks, cop (boop), lymphoma (unlikely), infection (unlikely). on , a galactomannan antigen came back positive at 0.79 (drawn on ). given this positive result, caspofungin was changed to voriconazole, and steroids were d/c'd. a repeat galactomannan was sent on . the patient was on zosyn at the time of the first sample, which can cause false positive results. the repeat galactomannan eventually came back negative. given this negative result as well as lack of clinical and radiographic improvement, antifungal therapy was discontinued after completion of a 7-day course. . a repeat chest ct was performed on , which revealed stable pulmonary infiltrates. after discussion with pulmonary and id services, empiric steroid therapy was reinitiated on . a repeat ct chest performed on showed slight radiographic improvement, and methylprednisolone was changed to prednisone 60 mg po qd. he will need at least 6 months of therapy for presumed boop (cop). of note, bactrim prophylaxis was also initiated given repeat cd4 186 and steroid therapy. . the patient was treated empirically for boop on prednisone which has been tapered to 50 mg from 60 mg, with a slow taper over 6 months. a repeat ct scan after at least a month of steroids showed minimal improvement. he continued to have a rapid respiratory rate but expressed his wish to be intubated if needed. pulmonary no longer followed the patient and we continued steroids and bactrim prophylaxis. furthermore, we discussed the patient with id who recommended no additional hiv prophylaxis. . b). respiratory failure: this is most likely secondary to volume overload from end stage heart failure. the patient was intubated for severe respiratory distress with tachypnea to 60s, sao2 of 80% on nrb and abg of 7.4/34/43 on nrb. the patient remained tachypneic and was overbreathing the vent, possibly due to the sepsis or other metabolic derangement. the sedation was increased sequentially in attempts to better control his respiratory status. he was unable to be extubated prior to expiration. . . 3) id: please see above for work-up of pulmonary infiltrates. as mentioned above, mr. was started on levaquin on admission for coverage of cap and atypicals. vancomycin was eventually added for improved gram positive coverage, and he completed a 7-day course of both antibiotics. . on , he became hypotensive and developed a recurrent fever to 102.5. vancomycin and levofloxacin were restarted, and zosyn was added to broaden gn coverage. he continued to spike fever despite broad spectrum antibiotic coverage. an extensive infectious work-up, including induced sputum for pcp, , legionella, as well as blood cultures, sputum cultures, cryptococcal antigen, chlamydia psitacci, histoplasmosis, coccidioidomycosis, chlamydia pneumonia, bartonella titers, was non-revealing. he had a positive femoral catheter tip culture on positive for enteroccus, felt a likely contaminant. all antibiotics were d/c'd on . stool cultures were positive for c. diff on , and flagyl was started. oral vancomycin was eventually added on given ongoing diarrhea. vancomycin was d/c'd on and flagyl was d/c'd on . he has been afebrile since . . a peg tube was placed on , complicated by significant pneumoperitoneum. hence, broad spectrum antibiotherapy was reinitiated with vancomycin, levofloxacin and flagyl. the patient completed this course of antibiotics without difficulty and remained symptom free until when his white count began to rise. this was felt to be no surprise as the nursing staff reported seeing the patient self-contaminate himself on many occasions by touching his stool and then touching his nose and mouth with the same hand. on , the patient's white count rose to 17 and although he had not yet spiked, he was pancultured and placed on vanco/levo/flagyl empirically for a day course without ever manifesting any sx, the vanc/levo/falgyl course was completed. . the patient complained of significant hoarseness and dysphaga in his throat. he was initially treated symptomatically with viscous lidocaine and improved oral hygiene. in addition, he was started on fluconazole for treatment of oral thrush which was thought to be the causative organism. cmv viral load in was negative, however repeat viral load on was 6200. id was consulted regarding treatment for cmv esophagitis, however they did not recommend treatment without a tissue diagnosis given the multiple toxicities of gancyclovir. a tissue diagnosis could not be obtained due to the fragile nature of the patient's cardiopulmonary status which may have led to earlier respiratory failure and intubation. . the pt spiked a temperature to 101 again on (3days post intubation) at which point he was started on vancomycine for presumed mrsa vap. gram positive cocci were found in the sputum gram stain. on day 4 of intubation, the patient spiked a temperture to 104 and ultimately reuquired a cooling blanket and around the clock tylenol to defervese. the patient was started on levofloxacin and flagyl in addition to the vancomycin. he subsequently dropped his pressures requiring inc. doses of levophed suggesting he was in severe sepsis. a repeat sputum gram stain showed gram postivie cocci as well as gram negative rods suggesting the causative organism were most likely mrsa and pseudomonas. antibiotics were continued, however he expired from overwhelming sepsis and multi organ failure refractory to two max dose pressors. . during the course of his admission, the patient was found to have a low cd4 count and the decision regarding re-starting hiv med was deferred from id to pcp . who has been following his hiv care. ultimately his hiv meds were not re-started due to the signfiicant side effects of the medication given the patient's many complications and acutely ill state. . . 3) neuro: on , in the setting of recent hypotension and high fever, mr. had a seizure and required intubation for airway protection. neurology was consulted. ct with and without contrast showed no bleed/mass, electrolytes were essentially unchanged, and lp was without infection (although it was remarkable for an elevated total protein). eeg was consistent with diffuse encephalopathy, possibly medication-related. given negative work-up, his seizure was felt most likely in the setting of fever. per neurology, he was started on dilantin for seizure prophylaxis. the latter was eventually changed to keppra in the setting of elevated lft's. he has had no recurrence of his seizure, but has been intermittently confused with poor short-term memory. the possibility of a thalamic stroke was raised by neurology, but he subsequently improved and further work-up was not pursued. . given his ongoing tachypnea and - breathing despite radiographic improvement and fair chf control, the possibility of a central process was again raised. attempt was made to obtain a head mri on which was aborted given patient agitation and inability to lay still. . he remained on keppra 1gm po bid which was discontinued early in as it was felt that this medication was not necessary to prevent further seizures. this was discussed and agreed with by neuro. . . 4) renal: pt developed atn (muddy brown casts in urine) most likely secondary to transient ischemic insult from hypotension. duration of oliguria was very short < 24hours followed by extensiv diuresis (post atn diuresis) despite cessation of diuretics. this was complicated by frequent episodes of metabolic alkalosis: given his significant diuresis as well as the inc. bicarb, the patient was thought to be in contraction alkalosis. as well as fluid over load. these fluid balances were managed with differing levels of diuretics including lasix bolus to gtt as well as acetazolamide, natrecor and renal dosed dopamine gtt. his fluid balances remaiend difficult to manage throughout his stay. in addition, the patient had frequent electrolyte imbalances which were also difficult to manage due to their wide fluctuations. this ranged from signficnt hyponatremia to hyperkalemia as well as hyperkalemia which were all managed clinically. . . 5) gi: a). elevated lft's: on , mr. was noted to have elevated lft's. interestingly, he had elevated alp + ggt>>>> ast and alt. peak alp 1457, ast 271 and alt 128 on with normal bilirubin. a ruq ultrasound was performed on which revealed a mildly distended sludge containing gallbladder with a small amount of pericholecystic fluid and focal wall edema. given theses results, a hida scan was performed, which was normal. hepatology was consulted on with an impression of drug-induced liver disease versus infiltrative process (infection or lymphoma), although the latter was felt unlikely. dilantin was felt to be the possible culprit, and was weaned to off. he was transitioned to keppra for seizure prophylaxis, with parallel improvement in his lft's. however, as kepra affects lfts, this was discontinued without further issues. his lfts continued to trend down and were felt to be elevated secondary to hepatic congestion. . b). pancreatitis: the patient developed acute ruq pain with elevated amylase and lipase. the ruq us showed sludge in cbd suggesting possible pancreatitis due to sludge from chronic tpn. pt was placed on bowel rest and tg were taken out of tpn. although ercp or mrcp would have been ideal to ascertain and possibly treat the ongoing gi process, gi believed he would most likely not tolerate either procedure. therefore a decision was made in conjunction with the gi team to persue a conservative management as above. the amylase and lipase did decrease slowly almost normalized prior to expiration. . . 6) apical thrombus: the patient has a large left ventricular apical thrombus secondary to poor lv function. as a result, he was bridged to coumadin. however, during the week of , the patient's inr rose suddenly to as high as 9.5 and he developed spontaneous epistaxis that required 4 blood transfusions and 4 units of ffp. ent was asked to evaluate the patient and placed nasal packings to prevent further epistaxis. they placed the patient empirically on cefazolin while the packing remains in place. his coumadin was held in the setting of these nosebleeds. once the packing were removed and the patient was able to maintain appropriate hct, he was started on loevenox 30mg for two weeks followed by heparin gtt for treatment o his apical thrombus. . . 7) fen: poor po intake in the setting of tachypnea and critical illness. he refused ng tube and dob hoff placement, and was started on tpn on . he finally underwent peg tube placement on at the bedside with gi and anesthesia present. post-procedure, incidental note was made of significant abdominal free air on ct chest. he also complained of ongoing abdominal pain. an erect cxr revealed significant free air, and surgery was consulted. a gastrograffin ct abdomen was performed on which showed no extravasation of contrast indicating a leak. . the peg tube was used initially with high residuals and increased abdominal pain. repeat films showed persistent air in the peritoneum a month after the peg placement which was felt not to be unusual. it was felt that by using the peg, the patient's abdominal pain was significantly worse than if he received tpn through a picc. therefore, we have continued to provide him tpn nutrition and disontinued the peg tube. the patient was encouraged to continue on a fluid-restricted, brat-like diet. however the patient was known to eat sardines and chinese food which exacerbated his congestive heart failure and precipitated a sharp decline in his function and caused increased abdominal pain. multiple discussions regarding moving the peg tube to pej tubes were undertaken during his hospital course, however neither gi, ir, or ip was willing to perform the procedure given the patient's significant comorbidities and high risk of intubation. the patient was continued on tpn until his expiration. . . 8) code status: the patient has significant heart disease with severe lv dysfunction (ef of 10%). as such, he was unable to create any forward flow without max dose milrinone and additional pressure support with levophed. as per our transplant service (and two other independent cardiologists from outside institutions), he was not a candidate for heart transplant or lvad secondary to pulmonary hypertension and significant rhf. in addition, he has had significant complications including boop, lv thrombus formation with significant epistaxis secondary to supratherapeutic inr, worsening immunosuppression from hiv, with cmv infection and atn. throughout his hospital course, we had multiple discussions with the family regarding goals of care. over the last several days of his hospitalization, he developed severe sepsis from what appears to be gpc and gnr of unclear origin. given his underlying heart condition and all of these complications, his prognosis was poor. during the last days of his hospitalizations we had multiple discussions with the hcp, the family, ethics service as well as palliative care service daily to address goals of care. the hcp communicated to the team her desires to stop any additional treatments. she was interested in taking treatment regimens away with the understanding that we will not re-start them. on the last day of his hospitalization, he was unable to maintain pressures despite max dose milrinone and levophed and he was having high fevers despite multiple antibiotics. given the rapid and what appeared to be fatal progression of his many illness, the hcp made the patient dnr and dni. the patient expired later that afternoon. medications on admission: none. discharge medications: none. discharge disposition: extended care discharge diagnosis: pneumonia sepsis. cardiomyopathy with congestive heart failure. coronary artery disease. boop. acute renal failure. discharge condition: pt. expired. discharge instructions: pt. expired. followup instructions: pt expired. Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Aortography Implant of pulsation balloon Pulmonary artery wedge monitoring Biopsy of lymphatic structure Nonoperative removal of heart assist system Injection or infusion of nesiritide Infusion of vasopressor agent Control of epistaxis by posterior (and anterior) packing Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Severe sepsis Acute myocardial infarction of other anterior wall, initial episode of care Other convulsions Candidiasis of mouth Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute and chronic respiratory failure Iatrogenic pneumothorax Cardiogenic shock Other specified septicemias Intestinal infection due to Clostridium difficile Pressure ulcer, lower back Embolism and thrombosis of other specified artery Cytomegaloviral disease Acute pancreatitis Epistaxis Other gastrostomy complications Other specified alveolar and parietoalveolar pneumonopathies Enteritis due to other viral enteritis Myocarditis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: severe chest and back pain with fever and leukocytosis major surgical or invasive procedure: - cardiac catheterization. placement of iabp - cabgx3 (left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal branch and the posterior descending branch. - placement of an iabp - exploratory laparotomy history of present illness: this is a 59 yo male with a past medical history significant for diabetes, hypertension, question of sarcoidosis who presented to the emergency department with fever, chills, and back pain. patient states that he has had the back pain for months but now the pain is more localized to his midline. the patient states that he has had diarrhea for the last couple of weeks but in combination with constipation. pt denies any dyspnea, diaphoresis, melena, hematuria, dysuria. in emergency department, mr. was febrile to 102.9. he was initially worked up for aortic dissection and had a ct of the chest and abdomen. an ekg was done after he returned from ct and he was found to have st elevations, .5-1mm in i, avl and 2 mm in v2. he was urgently taken to the cath lab where he was found to have a 90% ostial lesion of the left anterior descending artery, 50% stenosed circumflex artery and an 80% stenosed right coronary artery. hemodynamics showed a cardiac output of 5.76, an index of 2.44 and a sytemic vascular resistance (svr) of 444. no intervention was made as patient's left anterior descending artery lesion was near the circumflex and there was concern for blocking left coronary ciculation as patient was left side dominant. an intra-aortic balloon pump was placed and mr. was transferred to the floor for stabilization with antibiotics for infection, and potential evaluation for surgical revascualrization when stable. upon leaving the cath lab, he became hypotensive. he was started on low dose dopamine but then he became tachycardic so pt was switched to neo-synephrine with good relief. upon arriving to the floor the patient had a white cell count of 25. he was started on empiric coverage of vanomycin, levofloxacim and flagyl. the white cell began trending up from 23.4 on admission -> 26.5 -> 36.8 -> 46.1. later linezolid was added when it was found that he had a history of methicillin resistent staph aurea (mrsa) and vancomycin resistent enterococcus (vre) from past wound infections. pt on the floor trended upwards from 259 -> -> 3352. cardiology fellow called about possibility of taking patient to cath lab in light of continued ischemia. it was deemed that due to pt anatomy, he was not a candidate for peructaneous intervention. when mr. initially came to the floor his blood gas (abg) was 7.34/28/94 with a lactate of 1.4. he was found to have a non-anion gap metabolic acidosis. he was on a nonrebreather and then transitioned to cpap. a 3am gas showed 7.25/47/131 w/ lactate of 2.1. he seemed to be tiring and anesthesia was called to intubate mr. . chest x-ray showed bilateral patchy infiltrate. he was transitioned to low volume to mimize barotrauma for suspected acute respiratory distress syndrome. other issues included a rising creatinine of 2.3 (baseline 1.5-1.8)on and a question of vertebral osteomyelitis. id consult was obtained and the abx recommendations were followed. he also developed hyperkalemia and was seen by renal service for arf. pt. also had a small gi bleed with ngt coffee grounds emesis on heparin. iabp was removed and treatment continued for lle cellulitis. he also continued lasix duresis with periodic neosynephrine support. he was extubated on . referred to dr. of ct surgery. he recommended infectious issues be competely resolved before cabg and a myocardial viability study. patient contnued to have episodes of diarrhea. he continued his courses of vanco and zosyn.cabg was scheduled but then postponed for a rising creatinine again (2.2). dr. reviewed the high risk status of his surgery with the patient (10-15% mortality). cabg performed on by dr. with a lima to lad, svg to om and svg to pda. he was transferred to the csru on epinephrine, levophed, milrinone and insulin drips.he was extubated on . pressor wean was begun and epinephrine and levophed were off later in the day. pt. remained on lidocaine, milrinone, and neosynephrine drips. chest tubes were removed. creatinine was 2.9 on . he had an episode of vt and had cardioversion on . he was also transfused and started on a natrecor drip. swan was exchanged to a triple lumen catheter on . ep was consulted for recurrent vt. amiodarone drip was started. he also had episodes of rapid afib. on , he had a vfib arrest and was shocked x 4. cath was considered but his creatinine was at 3.0 at the time and cardiology felt it best to monitor him closely. ischemia was not suspected given the large area of his anterolateral infarction.the following day it was 3.2. he continued to receive sq heparin for his mobility status. he remained on amio, natrecor, and lidocaine drips and continued with zosyn. he was diuresed with lasix drip for volume overload. on the afternoon of , the pt. was reintubated for respiratory distress. he went to the cath lab for iabp and swan placement. heparin was switched to iv dosing. milrinone and neo drips were restarted. on , a quinton cath was placed in the left femoral vein to allow for the institution of cvvhd. he remained sedated with propofol. tee was performed on which revealed severely depressed lv function with ef 20-25%.a small pericardial effusion was noted and there were multiple wall motion abnormalities including anterolateral akinesis. on , he had a run of afib, torsades and a 23 beat run of vt with poor perfusion and severe hypotension. he was cardioverted and then paced. he had 4+ ble edema. right dp pulse was not dopplerable at this time, and toes were cyanotic, but warm. iabp was pulled at 4:30am by cardiology for the compromised circulation in that leg. he remained somewhat hypotensive at this time (sbp 70-80's). vascular surgery was called when the pulse did not return in this foot. he continued to be severely acidotic with base excess of minus 4 to minus 16. there was slight improvement in his doppler signal, but ischemia with ?thrombus was considered. platelet count was 69k at that time with an inr of 2.3. at this time, there was concern for his bowel circulation given his acidosis that was not responding to therapy. the patient remained critically ill and ischemic mesentery was suspected by the transplant service. mr. was seen and evaluated by dr. of general surgery. he had requested correction of the coagulopathy and additional lfts in preparation for emergency exploratory laparotomy. the patient was taken to the or on the morning of and had an emergency lap by dr. . during the attempted bowel resection for mesenteric ischemia, the patient suffered vtach and a vfib arrest that did not respond to multiple shocks, cpr, and acls protocol meds. he was pronounced expired at 10:24 am by dr. of transplant surgery. past medical history: charcot foot - vre/mrsa past infecftions hypertension hyperlipidemia diabetes mellitus questionable sarcoidosis morbid obesity social history: smokes cigars 1-2 per day. denies alcohol use. works for local sports radio show. family history: non-contributory physical exam: ed vitals - temp 102.9 bp 60/palp hr 110 rr 24 o2 sat 97% on nrb gen: ill appearing heent: pupils eaqual and reactive, oropharynx clear resp: clear cv: distant heart sounds, no murmur, gallop or rub abd: obese, nontender, guaiac (-) back: no costovertebral tenderness ext: no cyanosis, clubbing or edema, left charcot foot deformity w/ bulging at left ankle, no drainage, warmth, or erythema neuro: alert, appropriate, moving all four extremities pertinent results: initial cxr - no acute cardiopulmonary disease ecg - st elevations .5-1 mm in i, avl, 2 mm in v2 cath - 90% ostial lesion of the left anterior descending artery, 50% circumflex artery, and an 80% right coronary artery. echo - ef 40-45%, nl lv cavity size, possible hypokinesis at apex, rv free wall motion preserved echo - lvef 35-40%, mild lvh, moderate systolic dysfunction, sever hypokinesis of basal system. ct chest/abdomen - 1) severe coronary artery calcification 2) mediastinal lymphadenopathy unchanged from prior 3)left sided exophytic renal cysts, probable hyperdense cysts within mid pole of right kidney. labs; (admission/discharge) 03:00pm wbc-23.4*# rbc-4.43* hgb-13.0*# hct-36.8* mcv-83 mch-29.4# mchc-35.3* rdw-15.5 03:00pm ctropnt-0.03* 03:00pm ck(cpk)-81 03:00pm glucose-217* urea n-82* creat-1.5* sodium-138 potassium-5.7* chloride-104 total co2-23 anion gap-17 03:44pm lactate-2.5* 05:43pm wbc-26.5* rbc-3.99* hgb-11.8* hct-33.7* mcv-85 mch-29.6 mchc-35.0 rdw-15.7* 05:43pm alt(sgpt)-22 ast(sgot)-34 ck(cpk)-259* alk phos-65 amylase-59 tot bili-0.3 08:25pm ck-mb-169* mb indx-9.5* ctropnt-2.87* 08:25pm glucose-262* urea n-79* creat-1.6* sodium-138 potassium-5.2* chloride-108 total co2-17* anion gap-18 08:25pm wbc-36.8* rbc-4.12* hgb-11.9* hct-34.8* mcv-85 mch-28.9 mchc-34.1 rdw-15.7* 02:44am blood wbc-33.7* rbc-3.71* hgb-11.1* hct-34.0* mcv-92 mch-29.8 mchc-32.5 rdw-16.8* plt ct-69* 06:30am blood plt smr-very low plt ct-50* 06:30am blood pt-23.4* ptt-150* inr(pt)-3.4 02:44am blood urean-43* creat-2.7* na-132* cl-89* hco3-12* 07:46am blood alt-3820* ast-8175* ld(ldh)-9610* alkphos-168* totbili-4.0* 10:00am blood glucose-79 lactate-23.0* na-132* k-5.1 cl-90* x-ray marked arthropathy consistent with the given history of charcot foot, worse since the prior studies. infection can have a similar appearance and clinical correlation is requested. echo conclusions: 1 the left atrium is dilated. 2. the left ventricular cavity is mildly dilated. there is moderate global left ventricular hypokinesis, apical akinesis and some preservation of basal wall motion. overall left ventricular systolic function is moderately depressed. no masses or thrombi are seen in the left ventricle with and without contrast. 3. the aortic valve leaflets (3) are mildly thickened. 4. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. echo 1. technically difficult study. 2.left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed. resting regional wall motion abnormalities include apical and lateral wall akinesis. 3. the number of aortic valve leaflets cannot be determined. the aortic valve is not well seen. no ai seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen 4.there is no pericardial effusion echo left ventricular systolic function appears depressed, probably severely, in technically suboptimal views. the anterior septum appears akinetic, there may be septal hypokinesis and there is hypokinesis elsewhere. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. compared to the prior study of , the pericardial effusion is now larger (a trivial effusion was previously present) echo the left atrium is mildly 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. the left ventricular cavity is mildly dilated. the lv systolic function is severely depressed (ef 25%). the best preserved segments are the basal inferior and basal inferolateral segments. the anterior wall and the septum are severely hypokinetic/akinetic, the anterolateral wall is hypokinetic and the apex is akinetic/hypokinetic. no lv aneurysm is seen. right ventricular chamber size and free wall motion are normal. intraaortic balloon pump is noted in the descending thoracic aorta. simple aortic plaque is noted in the aortic arch. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is a small pericardial effusion. mri foot small crescentic area of nonspecific enhancement immediately abutting the distal edge of the fibula with associated signal abnormality on the t1- weighted images. the differential includes both reactive tissue (eg granulation tissue, fibrosis, synovium) and infectious phlegmon. no focal fluid collection is identified. there is no marrow edema to suggest osteomyelitis. a small area immediately around the hardware is obscured by metal artifact but much of the remainder of the heel and foot is well-seen. cardiac catheterization 1. severe systolic and diastolic ventricular dysfunction. 2. severe primary pulmonary hypertension. 3. placement of iabp brief hospital course: mr. was admitted to the medical center on for further management of his chest pain. he was taken to the cardiac catheterization lab where he was found to have severe three vessels coronary disease. as his left anterior descending artery was markedly calcified with a short left main, intervention was declined given the risk of jailing the circumflex artery which was his dominant vessel. an intra-aortic balloon pump was placed. heparin, integrillin and aspirin were started for anticoagulation. mr. became hypotensive after his catheterization and pressors were started. he subsequently became acidotic and required intubation in the cardiac care unit. given his leukocytosis, sepsis was suspected and vancomycin, flagyl and linezolid were started. given his charcot foot, the podiatry service was consulted. medications on admission: kcl furosemide 80 po bid allopurinol 100 mg po daily diovan hct 160/25 po daily atenolol 50 mg po bid folic acid 1 mg po qd norvasc 10 mg po qd lipitor 40 po qd sl nitroglycerin discharge medications: none discharge disposition: expired facility: discharge diagnosis: s/p coronary artery bypass grafting x3 acute myocardial infarction severe acidosis with mesenteric ischemia acute renal failure s/p intraaortic ballon pump removal with ischemia of leg lle cellulitis leukocytosis discharge condition: expired in or Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Insertion of endotracheal tube Hemodialysis Other electric countershock of heart Exploratory laparotomy Implant of pulsation balloon Implant of pulsation balloon Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Injection or infusion of nesiritide Injection or infusion of oxazolidinone class of antibiotics Infusion of vasopressor agent Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Unspecified septicemia Severe sepsis Cardiac complications, not elsewhere classified Atrial fibrillation Infection with microorganisms resistant to penicillins Other chronic pulmonary heart diseases Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Acute myocardial infarction of anterolateral wall, initial episode of care Cardiac arrest Cellulitis and abscess of leg, except foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Cardiogenic shock Septic shock Morbid obesity Other complications due to other cardiac device, implant, and graft Acute vascular insufficiency of intestine Below knee amputation status Arterial embolism and thrombosis of lower extremity Atherosclerosis of native arteries of the extremities with ulceration Acute on chronic combined systolic and diastolic heart failure Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Acute gastritis, with hemorrhage Chronic osteomyelitis, ankle and foot Arthropathy associated with neurological disorders

discharge medications: 1. lopressor 12.5 mg b.i.d. 2. lasix 20 mg b.i.d. times ten days. 3. potassium chloride 20 meq b.i.d. for ten more days. 4. colace 100 mg by mouth twice per day. 5. aspirin 325 mg p.o. q.d. 6. percocet one to two tablets every four to six hours as needed for pain. 7. zantac 150 mg b.i.d. condition on discharge: stable. disposition: to an extended care facility. diet: cardiac heart healthy diet. activity: should be as tolerated, but the patient will require assistance for ambulation, and further physical therapy to help build increased strength and mobility. follow-up: mr. should follow-up with his cardiologist in the next one to two weeks. he should also follow-up with dr. in four weeks time. he should also follow-up with his primary care physician in approximately three to four weeks. an appointment will be made for him to be seen in the clinic here at in the next one to two weeks. discharge diagnosis: 1. coronary artery disease, status post coronary artery bypass graft times three on with an ejection fraction of 55%. 2. prostate cancer, status post radical prostatectomy. 3. hypercholesterolemia. 4. brief episode of atrial fibrillation postoperatively which resolved with medication and has not recurred. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Atrial fibrillation Personal history of malignant neoplasm of prostate Unspecified disorder of kidney and ureter

history of present illness: mr. is a 73-year-old male with a past medical history significant for prostate cancer (status post radical prostatectomy in ), who was in in the middle of when during a daily walk he began having chest pain associated with dry heaves. this pain was relieved by rest. he reported never having experienced this type of pain before and denied any associated shortness of breath. he returned to where he saw his primary care physician who sent him for a stress test, which was done at the . this revealed septal ischemia with st segment changes on electrocardiogram. the patient underwent cardiac catheterization on which showed severe 3-vessel coronary artery disease. he denies dysuria, fevers, chills, nausea, vomiting, renal problems, or claudication. the patient was found not to have had a myocardial infarction by enzymes at . he was found to have mild chronic renal insufficiency with a baseline creatinine of 1.5. past medical history: 1. prostate cancer. 2. hypercholesterolemia. 3. mild chronic renal insufficiency. past surgical history: 1. radical prostatectomy in . 2. open reduction/internal fixation of the right ankle. medications on admission: medications on admission included . allergies: no known drug allergies. social history: mr. had a prior history of tobacco use; approximately 10 pack years, which he had quit approximately 10 years ago. he states that he has one alcoholic drink per night. family history: family history was noncontributory. physical examination on presentation: the initial physical examination revealed mr. was found to have a temperature of 98.3 degrees fahrenheit, heart rate was 62 (in sinus rhythm), and blood pressure was 107/50, with an oxygen saturation of 90% on room air. in general, he was in no acute distress. on cardiovascular examination he was found to have a regular rate and rhythm. normal first heart sound and second heart sound. no murmurs, rubs, or gallops. his lungs were clear to auscultation bilaterally. his abdomen was soft, nontender, and nondistended, with a well-healed prostatectomy scar. his extremities showed a small amount of edema around the right ankle. otherwise, they were warm, dry, and well perfused. his pulse examination showed 2+ palpable femoral, popliteal, dorsalis pedis, and posterior tibialis pulses bilaterally. pertinent laboratory values on presentation: laboratories on admission revealed his complete blood count was significant for a white blood cell count of 6.1 and hematocrit was 35.9. chemistry-7 showed sodium was 137, potassium was 3.8, chloride was 106, bicarbonate was 23, blood urea nitrogen was 20, creatinine was 1.3, and blood glucose was 152. radiology/imaging: the patient had an electrocardiogram from the which showed flipped t waves in leads iii, avr, and v1. there were no signs of acute ischemia by electrocardiogram. the patient also had a carotid ultrasound which showed no evidence of carotid artery plaques. a chest x-ray was done which was clear and showed no abnormalities. hospital course: mr. was admitted to the cardiothoracic surgical intensive care unit on where he was started on lopressor, aspirin, and a heparin drip. the patient did well during the subsequent two days with no issues. on , the patient was taken to the operating room where he underwent a coronary artery bypass graft times four under general endotracheal intubation. please refer to the dictated operative note for full details of this procedure. in summary, the patient had a left internal mammary artery to the left anterior descending artery graft as well as saphenous vein grafts to the posterior descending artery and obtuse marginal arteries. the patient tolerated the procedure well, and following surgery was transferred from the operating room to the cardiothoracic intensive care unit. at this time, he was being a-paced at a rate of 74 beats per minute and came to the intensive care unit on a neo-synephrine drip as well as a propofol drip. he did well overnight with neo-synephrine being titrated to maintain a systolic blood pressure of greater than 140. he required continued use of propofol for sedation, but did appropriately follow commands. on postoperative day one, he did require 4 liters of lactated ringer's, 500 cc of hespan as well as 2 units of packed red blood cells for labile blood pressures. he was continued on a neo-synephrine drip at that time. he was extubated later on postoperative day one which he tolerated without incident. at this time, he continued to have moderate amounts of serosanguineous drainage from his chest tubes as well as an air leak. he was able to maintain his blood pressure and heart rate without being paced, and a slow wean of his neo-synephrine drip was begun. later on postoperative day two, mr. went into a rate atrial fibrillation with a heart rate up into the 130s. he was given intravenous lopressor as well as intravenous magnesium and amiodarone. his neo-synephrine drip, which had been weaned off, was subsequently restarted. at this time, he was rate controlled with a heart rate in the low 100s and in atrial fibrillation. however, shortly thereafter, he converted back into a normal sinus rhythm with a heart rate in the 70s, and he remained there throughout the rest of the shift. he did require a small amount of neo-synephrine to maintain his systolic blood pressure above 100. it was noted early on postoperative day three that he no longer had an air leak from his chest tubes. later on postoperative day three, the patient's arterial line and chest tubes were removed. he was out of bed to the chair for the first time, and he subsequently ambulated with assistance. he remained in a normal sinus rhythm throughout that day. on postoperative day four, the patient was deemed ready and stable for transfer to the regular floor. the patient continued to do quite well after arrival to the floor. he remained in almost sinus rhythm with no further episodes of ectopy. he did quite well working with physical therapy, ambulating multiple times a day with assistance. on postoperative day number ten, it was felt that the patient was stable and ready for discharge from the hospital. he was doing extremely well from a cardiopulmonary standpoint. it was, however, felt in conjunction with physical therapy, that the patient would benefit from and require a short stay at a rehabilitation facility to help further build increased strength and mobility. at the time of discharge, he was afebrile with a heart rate of 80, in sinus rhythm, and a blood pressure of 90/60, with a room air oxygen saturation of 92%. he was alert and oriented to person, place, and time. he moved all extremities and followed commands. his heart showed a regular rate and rhythm with normal s1, s2, and no murmurs. his sternum was stable, and his sternal incision was healing nicely with no erythema or drainage. his lungs were clear to auscultation bilaterally. his abdomen was soft, nontender, nondistended, with no hepatosplenomegaly or other palpable masses. he continued to have approximately 1+ lower extremity and pedal edema, for which he was continuing to be diuresed. discharge medications: 1. lopressor 12.5 mg b.i.d. 2. lasix 20 mg b.i.d. times ten days. 3. potassium chloride 20 meq b.i.d. for ten more days. 4. colace 100 mg by mouth twice per day. 5. aspirin 325 mg p.o. q.d. 6. percocet one to two tablets every four to six hours as needed for pain. 7. zantac 150 mg b.i.d. condition on discharge: stable. disposition: to an extended care facility. diet: cardiac heart healthy diet. activity: should be as tolerated, but the patient will require assistance for ambulation, and further physical therapy to help build increased strength and mobility. follow-up: mr. should follow-up with his cardiologist in the next one to two weeks. he should also follow-up with dr. in four weeks time. he should also follow-up with his primary care physician in approximately three to four weeks. an appointment will be made for him to be seen in the clinic here at in the next one to two weeks. discharge diagnosis: 1. coronary artery disease, status post coronary artery bypass graft times three on with an ejection fraction of 55%. 2. prostate cancer, status post radical prostatectomy. 3. hypercholesterolemia. 4. brief episode of atrial fibrillation postoperatively which resolved with medication and has not recurred. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Atrial fibrillation Personal history of malignant neoplasm of prostate Unspecified disorder of kidney and ureter

history of present illness: the patient is a 73-year-old male who underwent cardiac consultation secondary to a positive exercise tolerance test. the patient denied any exertional chest discomfort or dyspnea and also any palpitations. the patient had an exercise treadmill test and a near syncopal episode after finishing his exercise treadmill test but recovered quickly. a recent abnormal echocardiogram was consistent with a dilated left ventricle with moderate aortic insufficiency and a suggestion of inferior hypokinesis. a thallium test demonstrated a fixed inferolateral defect. the patient had a cardiac catheterization performed at hospital on . this revealed a short left main coronary with mild-to-moderate plaque in the mid left anterior descending artery, an ejection fraction of 71%, with inferobasal hypokinesis. the patient now presents for revascularization as well as valve repair. past medical history: 1. kidney stones. 2. benign prostatic hypertrophy. medications on admission: doxazosin and methylate. allergies: allergy to penicillin. physical examination on presentation: in general, the patient was an elderly male in no acute distress. vital signs were stable and afebrile. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. extraocular movements were intact. pupils were equal, round, and reactive to light. sclerae were anicteric. the throat was clear. the neck was supple, midline. no bruits. no jugular venous distention. no masses or lymphadenopathy. the chest was clear to auscultation bilaterally. heart was regular in rate and rhythm with a to 3/6 systolic ejection murmur. the abdomen was soft, nontender, and nondistended. no masses or organomegaly. extremities were warm and well perfused. neurologically, alert and oriented times three. no gross motor or sensory deficits were noted. pertinent laboratory values on presentation: preoperative laboratory studies performed on revealed complete blood count with white blood cell count of 8.4, hemoglobin was 13.4, hematocrit was 40, and platelets were 201. prothrombin time was 13, inr was 1.1, partial thromboplastin time was 35.7. chemistries revealed sodium was 142, potassium was 4.1, chloride was 103, bicarbonate was 26, blood urea nitrogen was 98, creatinine was 1, and blood glucose was 78. liver function tests revealed alt was 13, ast was 14, alkaline phosphatase was 118, total bilirubin was 0.9. type and screen was performed on . radiology/imaging: a preoperative chest x-ray on showed borderline cardiomegaly but no evidence of acute cardiopulmonary process. hospital course: the patient was admitted for coronary artery bypass grafting times three with a left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. the atrial valve was replaced with a 27-mm pericardial valve. the patient tolerated the procedure without complications. in the postoperative period, the patient was transferred to the intensive care unit for closer monitoring. the patient was extubated without incident on postoperative day zero. on postoperative day one, the patient was on a neo-synephrine drip at 0.75, and this was weaned as tolerated. the patient did well without any remarkable events and was transferred to the floor on postoperative day two. the patient was maintained on telemetry and shown to have a few premature ventricular contraction, but no significant arrhythmia. on postoperative day three, the patient's chest tubes were discontinued. again, the patient had some isolated premature ventricular contractions, but no other significant arrhythmia. the patient did seem to have a change in mental status on postoperative day four with the patient somewhat delirious and confused. he was occasionally violent and threatened the nursing staff. the patient was placed in restraints to prevent interference with therapy as well as accidental injury to the staff. the patient's wife came in the early hours of the morning, and this seemed to have a calming effect and helped to reorient the patient. subsequently to this, the patient had no episodes of confusion. however, he did have an acute rise in his creatinine on postoperative day six from a range of 0.9 to 1.2 to a level of 4. a foley was replaced in order to assess urine output, and renal consultation was done. the patient also had loose stools during this time, and clostridium difficile cultures were sent. the patient was transfused one unit of packed red blood cells on postoperative day six. the renal service saw the patient on postoperative day seven and felt the patient's acute renal failure was most likely of postrenal etiology; especially given his history of severe benign prostatic hypertrophy. replacement of the foley catheter seemed to aid the patient's renal function. an ultrasound did show moderate-to-severe right hydronephrosis, as well as a minor left-sided hydronephrosis, and an enlarged prostate. the nephrology service recommended keeping the foley in place in order to allow voiding and accurate urine output measurements. the patient's creatinine decreased immediately subsequent to this. the patient was placed on flagyl for empiric clostridium difficile infection. the patient did have some sinus tachycardia on postoperative day eight. he later had an episode of rapid atrial fibrillation in the morning of postoperative day nine. the patient responded to 10 mg of intravenous lopressor and 150-mg bolus of amiodarone. concern for an embolus at this point prompted the decision to begin the patient on anticoagulation. a heparin drip was begun, and coumadin therapy was started as well. for the remainder of his postoperative stay, the patient had an unremarkable course and was awaiting a therapeutic anticoagulation. the patient was discharged on postoperative day twelve, tolerating a regular diet, and adequate pain control on oral pain medications, with a inr of 1.8. although the patient's inr was not therapeutic, it was felt that since his inr had been on the rise with a daily dosage of 5 mg of coumadin that he could be released. this was done at the patient's urging, as he was anxious to get home as well as his family; particularly in the light of his mother-in-law's passing on the day of discharge. it was reinforced to the patient that his inr was not yet therapeutic and that close followup would be necessary. physical examination on discharge: physical examination on discharge revealed vital signs were stable, afebrile. the patient was making good urine output. the chest was clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm without murmurs, rubs, or gallops. the surgical incision was clean, dry, and intact without drainage. the abdomen was soft, nontender, and nondistended. the extremities were warm and not cyanotic. there was 1+ pitting edema in the lower extremities bilaterally. neurologic examination was intact. pertinent laboratory values on discharge: laboratories on discharge revealed complete blood count with a white blood cell count of 13.3, hematocrit was 25.2, and platelets were 340. prothrombin time was 16.3, inr was 1.8, and partial thromboplastin time was 37.9. chemistry panel revealed sodium was 142, potassium was 4, chloride was 109, bicarbonate was 23, blood urea nitrogen was 31, creatinine was 2, and blood glucose was 87. magnesium was 1.9. the patient had two negative clostridium difficile cultures, and flagyl was discontinued. medications on discharge: 1. colace 100 mg p.o. b.i.d. 2. aspirin 325 mg p.o. q.d. 3. lopressor 50 mg p.o. t.i.d. 4. coumadin 5 mg p.o. q.d. 5. amiodarone 400 mg p.o. b.i.d. 6. iron sulfate 325 mg p.o. q.d. 7. terazosin 4 mg p.o. q.h.s. 8. percocet 5/325 one to two tablets p.o. q.4h. as needed. 9. vitamin c 500 mg p.o. b.i.d. 10. ibuprofen 400 mg p.o. q.4-6h. as needed. 11. tylenol p.o. as needed. 12. milk of magnesia p.o. as needed. condition at discharge: condition on discharge was good. discharge status: discharge status was to home with . discharge diet: diet is cardiac. die instructions/followup: 1. the patient must have close anticoagulation followup, and this was to be done through services. 2. the patient was to follow up with his urologist on wednesday and go home with a leg bag to his foley catheter. 3. the patient should follow up in cardiology within one to two weeks for adjustment of cardiac medications as well as possible diuresis. 4. the patient should follow up with dr. in four weeks' time. 5. of note, the patient was not sent home on lasix; although he still had some peripheral edema. he was diuresing well and with his history of acute renal failure, it was felt best not to send the patient home on a nephrotoxic . , 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 Open and other replacement of aortic valve Diagnoses: Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Aortic valve disorders Retention of urine, unspecified Hydronephrosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motor vehicle accident major surgical or invasive procedure: s/ bolt now removed open tracheostomy. open gastrostomy history of present illness: 25 yo female unrestrained rear passenger in high speed mvc. she was intubated on scene and transported to an area hospital. because of her injuries she was then transfered via to for further care. in ed, she was hemodynamically stable, gcs=8 with pupils 8mm and fixed. head ct revealed multiple areas of subarachonoid hemorrhage. past medical history: none social history: she lives at home with her parents and younger brother and sister. pt is unemployed but trying to get work through . she is described as having some deficits in her communication at baseline. family history: noncontributory physical exam: t:101 bp:130/60 hr:83 rr:16 o2sats:100% intubated gen: wd/wn, comfortable, nad. heent: pupils: pupils equal, unreactive. eoms-not tested small sutured laceration to left chin neck: in cervical collar. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: recently had sedation. not opening eyes, not following commands. gcs 7. pertinent results: 08:40pm urine rbc-* wbc-0-2 bacteria-mod yeast-none epi-0-2 08:40pm wbc-28.0* rbc-4.29 hgb-12.9 hct-36.9 mcv-86 mch-30.0 mchc-34.8 rdw-13.5 08:40pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 08:40pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg ct abd/pelvis : impression: 1. left chest tube terminating in the lung apex with small anterior residual pneumothorax, and a probable burgeoning contusion in the left lateral lung. 2. grade ii splenic laceration measuring 1.3 cm with a small (10%) subcapsular hematoma. 3. the nasogastric tube should be advanced at least 5 cm to be in the proper location (sidehole is in the distal esophagus head ct: impression: extensive, diffuse subarachnoid hemorrhage within the temporal and frontal lobes, bilaterally. the ventricles and cisterns are patent, without hemorrhage. there is no other extra- and no intra-axial hemorrhage, and no evidence of cerebral edema or skull fracture. c spine: impression: no evidence of cervical spine fracture or malalignment head ct: impression: since the previous study, no change in pattern of distribution of subarachnoid hemorrhage. no new hemorrhage is seen. no evidence of hydrocephalus or any signs of herniation. right frontal icp monitoring device is identified, new since the previous study mri head: impression: extensive areas of abnormal t2 signal including within the brainstem consistent with diffuse axonal shear injury. no acute infarct. scattered areas of magnetic susceptibility are also consistent with the above- mentioned findings. bilateral subarachnoid hemorrhages noted on the prior head ct. brief hospital course: upon arrival to the ed, a stat chest x ray showed complete white out on the left, a chest tube was immediately placed. on subsequent review, the white out was believed to be caused by a right mainstem intubation by ems; the ett was repositioned. she had ct scan of her head, neck, and torso which demonstrated l small residual pneumothorax, l lung contusion, multiple l rib fractures and a grade ii spleen laceration in addition to her sah. once stabilized in the ed she was transferred to the trauma icu where neurosurgery immediately placed a bolt for icp monitoring. her blood pressure was tightly controlled to maintain a sbp less than 140, tight glucose control, dilantin, mannitol were initiated, and close icp monitoring with goal cpp>60. she had no further intracranial bleeding but mri on hd 6 showed diffuse axonal injury. she was seen daily by pt and ot and made slow improvement. prior to discharge, she is able to sit in a chair, interact with family, and write a few words on paper to communicate with her family. regarding her other injuries, her pain was controlled, her hct remained stable with serial hct initially for her splenic lacerations. her chest tube was put to water seal and removed without residual pneumothorax. due to an inability to protect her airway on hd 10, a open tracheostomy was performed by dr. . she was subsequently successfully weaned from the vent and trach mask without problems. at the same time, an open gastrostomy was performed for feeding. ms. tube feeds and bowel function returned. hd 14 she was transferred to a step down unit and had no complications. she did have periods of mild agitation which seemed to be related to mucous plugging via her trach as her behavior improved after suctioning. she did require a small dose of ativan as a result. overall there have been no behavioral issues with her; she did however require a 1:1 sitter after falling out of bed. no further injuries were noted as a result of this fall. medications on admission: none discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. albuterol 90 mcg/actuation aerosol sig: 4-6 puffs inhalation q6h (every 6 hours) as needed. 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. 5. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 6. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. discharge disposition: extended care facility: - discharge diagnosis: s/p motor vehicle crash primary: diffuse sah, diffuse axonal injury, left rib fractures, left small pneumothorax, grade 2 splenic laceration with subcapsular hematoma discharge condition: stable followup instructions: please follow up with the trauma clinic in 4 weeks; call for an appointment. please follow up with dr. , neurosurgery in 4 weeks, please ask them to arrange a repeat head ct scan when you make the appointment ( Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closure of skin and subcutaneous tissue of other sites Other gastrostomy Other diagnostic procedures on brain and cerebral meninges Diagnoses: Traumatic pneumohemothorax without mention of open wound into thorax Open wound of jaw, without mention of complication Contusion of lung without mention of open wound into thorax Closed fracture of multiple ribs, unspecified Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Injury to spleen with open wound into cavity, hematoma without rupture of capsule Motor vehicle traffic accident of unspecified nature injuring passenger in motor vehicle other than motorcycle

allergies: lovastatin attending: chief complaint: brbrp major surgical or invasive procedure: colonoscopy egd history of present illness: yo f with history of dementia, depression, htn and dyslipidemia transferred from nursing home with brbpr. the patient was noted to have an unknown amount of bright red blood and clots from her rectum the morning of admission and was transferred for evaluation. per ems notes, the patient was also somewhat altered and had questionable left-sided facial droop on transfer. the patient cannot provide an adequate history, and does not remember if she has had fevers, chills, night sweats, weight loss, diarrhea or melena. she denies abdominal pain, rectal pain/pruritis. she does not remember if she has had nsaids recently. she did report feeling tired. in , pt was given 1l ns. gi performed ng lavage which was negative for blood. pt initially transfered to floor, hemodynamically stable. however, began to have large amounts of brbpr with volumes ranging from 500-750cc of bright red blood. pt transfered to icu for dropping hct and bp. bp dropped from 160's-->130's. pt had colonoscopy on which showed diverticulosos with likely source of bleed right-sided diverticular disease. however, no active bleeding noted. pt received 2 additional units of prbc in the micu for a total of 3 units. pt trnasfered to floor after hct stable for 24 hours. however, once on floor pt again began to have alrge volumes of brbpr. initially bp stable, however began to drop to 100's systolic. pt transfered back to micu for closer monitoring and had tagged rbc scan after another unit prbc and ivf. tagged rbc negative. pt now stable with hct stable at 33 (baseline 40) for >24 hours. will transfer back to the floor for furhter management of gib. past medical history: 1. moderately advanced multi-infarct dementia. 2. left occipital stroke in . 3. hypertension. 4. dyslipidemia. 5. aortic arch aneurysm. 6. coronary artery disease. 7. wrist fracture. 8. osteoporosis. 9. depression. 10.seasonal allergies. social history: the patient resides at . denies tobacco, alcohol, drug use. family history: non-contributory. physical exam: vitals: tm: 98.9, tc: 97.9, bp: 142/74, hr: 81, rr: 20, o2: 96% 2l gen: elderly woman in nad, talkative and pleasant. heent: perrl, eomi, mmm, op clear neck: supple, no evidence of lad or jvd lung: cta bilaterally card: rrr, nml s1s2, hsm at apex abd: nabs, soft ntnd, midline pulsation palpable. no bruits appreciated. ext: no edema neuro: alert and oriented to person and "", and year. muscle strength 5/5 throughout, sensation intact to lt. pertinent results: 12:00pm wbc-7.3 rbc-3.37* hgb-10.2* hct-30.2* mcv-89 mch-30.3 mchc-33.9 rdw-13.6 12:00pm neuts-76.9* lymphs-17.0* monos-3.9 eos-1.9 basos-0.3 12:00pm plt count-250 09:00am glucose-113* urea n-28* creat-1.0 sodium-140 potassium-4.4 chloride-105 total co2-30* anion gap-9 head ct: 1. no intracranial hemorrhage or ct evidence of acute infarction. 2. stable exam compared with . 03:01am blood wbc-10.2# rbc-3.86* hgb-11.6* hct-33.9* mcv-88 mch-30.0 mchc-34.2 rdw-14.8 plt ct-178 12:00pm blood neuts-76.9* lymphs-17.0* monos-3.9 eos-1.9 baso-0.3 03:01am blood plt ct-178 03:01am blood pt-14.0* ptt-32.7 inr(pt)-1.2 03:01am blood glucose-74 urean-16 creat-0.7 na-138 k-3.7 cl-103 hco3-22 angap-17 03:01am blood calcium-8.7 phos-2.7 mg-1.5* colonoscopy: showed mult non-bleeding diverticuli. no diverticulitis, no avm, no polyps. brief hospital course: by problem: 1. brbpr: pt had colonoscopy on admission as she was ahving large amounts of bright red blood per rectum. bp was quite stable durint this initial episode, therefore the more likely source was lower gi. however, on ng lavage in pt had what was described as flecks in lavage but no clear coffee ground material or clots. based on colonoscopy likely source right sided diverticulum. given the patient's advanced dementia, age and code status, conservative management favored in this case. in addition, while the patient was in the medical team and surgical team met with family to discuss surgical options and family is against surgical intervention. if patient does rebleed, would recommend bleeding scan with interventional radiology cauterization. pt was followed by dr. while in the hospital and can be contact if pt rebleeds. pt remained hemodynamically stable for >72 hours. she required a total of 4 units of prbc during admission to keep hct >30. - pt should have hct checked for next three days and then one week later as well to make sure there is no slow bleed. - aspirin was held while in the hospital, but can be restarted as an outpt. - pt should continue on protonix 40mg po bid x 6months then qd. 2. dementia: pt with long-standing hx of multi-infarct dementia with evidence of memory and language difficulties on exam. also has evidence of left-sided facial droop, likely from previous strokes. no other focal findings on exam. head ct revealed no new findings. - pt was continued on memantine, aracept and zoloft during admission. - pt seen by psych for competency. pt deemed unable to make decisions. psych also recommended seroquel 12.5 qhs for agitation with haldol prn. however, seroquel seemed to be too sedating. pt did very well with reorienting excersizes and did not require haldol after transfered from the icu. 3. htn: pt does not have clear history of htn, and was not on bp meds on admission. while pt in icu had pressures >180 systolic and required iv hydralizine to control. however, once pt stable on floor, no longer required bp meds. - would recommend follow-up as an outpt for possibily of starting bp meds if bp does become elevated. bp while in hospital 120-140 systolic. 4. depression: pt with history of depression and states "i want to die" on admission. will continue present management. pt seen by psych and social work and recommended no change in current medications. - continued zoloft 5. uti: has positive ua with 11-20 wbc. - urine cx positive for alpha-strep. pt received 5 days of cipor at 250mg po qd. no further abx treatment as outpt necessary. 6. osteoporosis: pt was continued on tums. 7. fen: pt was kept npo while actively bleeding. once stable, pt received clears and was advanced to a full diet which she tolerated well. pt received iv hydration while npo. electrolytes were checked daily and repleted as needed. 8. ppx: pneumoboots. ppi. 10. code: after family discussion with health care proxy () pt was made dnr/dni. medications on admission: mvi zoloft 50mg daily asa 81mg daily aricept 5mg daily colace 100mg albuterol 2p memantine 10mg daily caco3 500mg tid mom 30ml daily bisacodyl 10mg daily prn prochlorperazine 10mg q6h prn nausea fleet enema prn acetaminophen prn discharge medications: 1. sertraline hcl 50 mg tablet sig: one (1) tablet po daily (daily). 2. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 3. donepezil hydrochloride 5 mg tablet sig: one (1) tablet po hs (at bedtime). 4. memantine hcl 5 mg tablet sig: two (2) tablet po qday (). 5. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 7. aspirin 81 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - / of discharge diagnosis: gi bleed dementia discharge condition: stable discharge instructions: please return to the hospital if you develop bleeding per rectum, shortness of breath, chest pain, or any other severe symptoms. please contact your doctor if you have any questions about your symptoms. followup instructions: please check hct x3 days and then one week later. please follow-up with your pcp weeks for bp check and hct check. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Colonoscopy Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Unspecified essential hypertension Depressive disorder, not elsewhere classified Personal history of other diseases of circulatory system Osteoporosis, unspecified Diverticulitis of colon with hemorrhage Senile dementia, uncomplicated

history of present illness: this is a 72-year-old male with a history of alcohol dependence, hepatitis c, depression, and cocaine use, who presents with chest pain, nonradiating, substernal in location with associated shortness of breath, nausea, vomiting, and diarrhea for the past 90 minutes in the setting of recent cocaine use. patient also noted complaints of generalized headache worsening over the day increasing to severity on presentation. patient also noted tarry stools for the past several days, inability to stand, difficulty walking, and dizziness. denied fevers, chills. patient became obtundent in the emergency department after benzodiazepine administration. he was restrained due to becoming combative with ed staff. in the emergency department, he had a head ct, lumbar puncture, tox screen, and heart rate controlled with labetalol. he required restraint and was given ativan for agitation control. past medical history: 1. alcohol dependence with multiple admissions at detox centers greater than 10 times. 2. alcoholic hepatitis. 3. hepatitis c. 4. depression. 5. back pain. 6. cocaine abuse. 7. status post appendectomy. 8. right inguinal hernia repair. 9. left hip fracture. 10. left rotator cuff tear. 11. lumbar laminectomy in . allergies: no known drug allergies. medications: none currently. social history: long history of substance abuse including alcohol and cocaine. patient has a girlfriend. physical exam: temperature 98.4, blood pressure 118/68, heart rate 94, respiratory rate 16, and 100% on room air. general: asleep, nonresponsive to voice in 4-point restraints, thin, elderly male appearing stated age. heent: extraocular muscles are intact. pupils are equal, round, and reactive to light. neck is supple, no lymphadenopathy. heart: regular rate and rhythm, normal s1, s2. lungs: clear anteriorly. abdomen: positive bowel sounds, nontender, and nondistended. positive hepatomegaly. extremities: no cyanosis, clubbing, or edema. neurologic: restrained, nonresponsive secondary to sedation. laboratory data on admission: white count 13.8, hematocrit 36.2, platelet count of 138. electrolytes: sodium 142, potassium 5.3, chloride 108, bicarbonate 24, bun 68, creatinine 1.1, glucose of 152. urinalysis negative. tox screen positive for cocaine. ct of the head: no intracranial hemorrhage. cerebrospinal fluid: 0 white blood cells, 0 red blood cells, protein 31, glucose 87. gram stain: 1+ polys. ekg: right bundle branch block, heart rate 93. hospital course: 1. cardiovascular: patient has now known cad, but did have a troponin leak and elevated ck-mb on admission in the setting of recent cocaine use. his cardiac enzymes did trend downward during initial hospital stay. was not given heparin given evidence of an upper gi bleed. he had no significant ekg changes. he was initially treated with labetalol for heart rate and blood pressure control, but was changed to lopressor on and then back again to labetalol on out of concerns for recurrent cocaine use. no aspirin was given, given the patient's recent history of gi bleed. aside from the initial presentation of chest pain, the patient had no further recurrence of chest pain or other symptoms to suggest ischemia. 2. respiratory: patient developed respiratory distress on hospital day two. he was discovered to have tachypnea and abgs done at that time showed hypercarbic respiratory failure. patient was assessed by the intensive care unit and intubated shortly after. patient had been sedated with standing ativan and aspiration was suspected. patient was started on a course of clindamycin and levaquin for two days, but had no evidence of pneumonia on serial chest x-rays. patient remained intubated until . he initially required face tent for adequate oxygenation, but did trend down to room air by the time of discharge requiring intermittent albuterol/atrovent nebulizers prn. the reason for the respiratory failure was suspected to be aspiration pneumonitis given the clinical scenario and lack of infiltrates on his chest x-ray. 3. substance abuse: the patient had cocaine intoxication on presentation and has a long history of alcohol dependence. social work consultation was obtained late in his hospital course when the patient's mental status had improved. he will require outpatient management of this chronic issue. patient was initially managed for withdrawal symptoms using the ciwa protocol, however, due to mental status issues, and then respiratory decompensation due to aspiration, he was weaned off of benzodiazepines, which were discontinued on . 4. mental status changes: patient was unresponsive on admission secondary to substance use and benzodiazepine administration in the emergency department. patient was ruled out for cva by head ct and was ruled out for meningitis by lumbar puncture in the emergency department. his mental status improved each day during his hospital stay as benzodiazepines were weaned. he was started on zyprexa for management of delirium. by the time of discharge, the patient's mental status had markedly improved and he was alert and oriented x3. 5. infectious disease: patient did have elevated white blood cell count and fever in the setting of aspiration, both did trend down to normal during his hospital stay. chest x-ray done on showed no evidence of pneumonia. urinalysis was negative as well as lumbar puncture. patient was ruled out for endocarditis as a new murmur was appreciated on examination during his micu stay. a transthoracic echocardiogram was negative for endocarditis and blood cultures were unrevealing. patient was noted to have h. pylori infection and was started on course of amoxicillin, clarithromycin, and proton-pump inhibitor, and will need to complete a two-week course for treatment. this was initiated on . patient was afebrile and stable at the time of discharge without white blood cell count elevation. 6. gastrointestinal: patient had guaiac-positive stool with a history of melena. on presentation, he did have a 10-point hematocrit drop in the first 24 hours of his hospital stay. he did receive 2 units of packed red blood cells with good response. he was evaluated by the gi service, who did an egd that showed two gastric ulcers that were not actively bleeding and no evidence of varices. his hematocrit did remain stable for the remainder of the hospital stay. he was continued on his proton-pump inhibitor. 7. in regard to his cirrhosis that was documented from abdominal ultrasound , the patient does have evidence of chronic lft elevation, but no coagulopathy. he did have ongoing transaminitis and therefore a right upper quadrant ultrasound was obtained on . patient was treated initially with lactulose during his hospital course, which was discontinued due to persistent diarrhea. 8. fluids, electrolytes, and nutrition: patient was given thiamine, folate, and multivitamin due to his history of alcohol abuse and poor nutrition. his electrolytes were monitored closely. he did have transient hypernatremia, which did resolve with iv fluid administration. he was evaluated by the speech and swallow service on , who cleared him for soft solids and thin liquids. his poor swallow was likely secondary to intubation. discharge condition: afebrile, hemodynamically stable, alert and oriented times three, and improved respiratory status. discharge status: to rehabilitation. discharge diagnoses: 1. chest pain with evidence of myocardial damage. 2. cocaine intoxication. 3. alcohol withdrawal. 4. delirium. 5. gastrointestinal bleed. 6. helicobacter pylori infection. 7. aspiration pneumonitis. 8. respiratory failure. discharge medications: 1. pantoprazole 40 mg p.o. q.12h. x14 days. 2. clarithromycin 500 mg p.o. b.i.d. x12 days. 3. amoxicillin 500 mg p.o. q.8h. x12 days. 4. labetalol 100 mg p.o. b.i.d. 5. olanzapine 2.5 mg p.o. t.i.d. prn agitation. 6. olanzapine dasintigrating tablet aka zydis 5 mg p.o. q.h.s. 7. folic acid 1 mg p.o. q.d. 8. thiamine 100 mg p.o. q.d. 9. multivitamin one tablet p.o. q.d. 10. ipratropium bromide nebulizer one nebulizer inhaled q.6h. 11. albuterol nebulizer solution one nebulizer inhaled q.4h. 12. acetaminophen 325 mg p.o. q.4-6h. prn fever, do not exceed 2 grams per day. 13. albuterol mdi 4-8 puffs inhaled q.4h. prn. recommended followup: patient will need followup with his primary care physician, . as well as with psychiatrist, social worker to address his ongoing issues with substance abuse, details of his followup will be documented in his discharge summary paperwork. , m.d. dictated by: medquist36 d: 11:38 t: 11:49 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Acute posthemorrhagic anemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Acute myocardial infarction of unspecified site, initial episode of care Hyperosmolality and/or hypernatremia Other, mixed, or unspecified drug abuse, continuous Other and unspecified alcohol dependence, continuous

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pea arrest major surgical or invasive procedure: rij line history of present illness: 51 yo male with pmh iddm, cad (s/p mi), chf with ef 17%, found down by family. in pea arrest upon ems arrival. given epi x2 and atrophine x1. went into vfib arrest and shocked 1-2x. given amio 300mg x 1. given ivb. intubated in the field. evaluated at , where he was started on bicarb and dopa gtt. he is transferred from osh for further evaluation. . here, pt was given insulin 10u for glucose 400. found to have hyperkalemia of 6 and given calcium gluconate, insulin, kayexalate, continued on bicarb drip. started on levo/vanco/flagyl. pt seized and given dilantin 1gm and ativan 4mg iv. given iv lasix 80 x1. bedside echo showed very poor ef and lots of "bubbles" in heart. head ct with subtentorial subdural hematoma, ?clot in sagittal sinus, ? early infarct in l temporal. neurosurgery evaluated pt, and did not feel that sdh was large enough to evacuate. past medical history: 1. brittle iddm (25 yrs) - complicated by neuropathy 2. cad, s/p mi () 3. pvd 4. chf with ef 17% (as of ) 5. htn 6. status post right hallux and first ray amputation ( osteo) 7. hx of elevated lfts 8. hx etoh abuse 9. hx multitrauma in motorcycle accident 10. seizures related to hypoglycemia 11. coagulopathy social history: smokes one ppd, hx of etoh abuse; sober "many years". used to work as head mechanic for p&b bus line family history: father with chf physical exam: vs: bp 108/71, p90, 96% on cmv ventilation: tv 600 (actual 688), rr14, peep 5, fio2 1 gen: intubated, sedated heent: pupils fixed and dilated at 4mm; positive doll's eyes cvs: rrr, nl s1 s2, no m/g/r lungs: ctab anteriorly abd: soft, nd, hypoactive bs ext: no edema, multiple round ulcerations on bilateral legs, amputation of right big toe, cold feet, cyanotic toes, dp difficult to palpate neuro: posturing to noxious stimulus pertinent results: admission labs: 02:00am blood wbc-7.8 rbc-4.28* hgb-14.4 hct-44.4# mcv-104*# mch-33.7* mchc-32.5 rdw-16.4* plt ct-177 02:00am blood pt-19.5* ptt-42.2* inr(pt)-2.7 05:23am blood fdp-80-160* 05:23am blood fibrino-205 d-dimer-5467* 02:00am blood glucose-615* urean-71* creat-2.4*# na-130* k-6.0* cl-85* hco3-19* angap-32* 02:00am blood alt-157* ast-290* ck(cpk)-357* alkphos-208* amylase-121* totbili-2.8* 02:00am blood albumin-2.5* calcium-9.6 phos-7.4*# mg-1.9 02:00am blood type-art po2-84* pco2-35 ph-7.26* calhco3-16* base xs--10 02:04am blood lactate-11.3* ekg: difficult to interpret. lots of artifac. no obvious ste. . cxr: diffuse patchy opacities, bilateral effusion (l>r) . head ct: subtentorial subdural hematoma; no midline shift; no tonsillar herniation; possible hyperdense clot in sagittal sinus; ? loss of grey white matter differentiation in left temporal lobe raising question of early infarct. . abd ct: dilated, fluid filled loops of bowel with mucosal thickening and enhancement c/w hyperperfusion in setting of cardiac arrest; large bilateral pleural effusion and patchy opacities; diffuse ascites and fluid in mesentery . - echo mild hk of distal septum, normal ef - echo with global lv hk and dilation, ef 25%, mild la enlargement brief hospital course: 51 yo male with pmh iddm, cad, severe chf, htn, hx of etoh abuse found down in pea arrest and admitted with hypotension, sdh, ?saggital sinus clot, and multi-system organ failure including liver failure, acute renal faulire, acute respiratory failure, and cardiovascular collspe. he was persistantly hypotensive and requiring pressor support. neurology and neurosurgery consults were obtained. given his seizures and decreased activity on eeg, he was felt to have anoxic brain injury. the family wished to withdraw care. medications on admission: 1. vasotec 10mg qam, 5mg qpm 2. isordil 20mg tid 3. lasix 80mg 4. carvedilol 6.25mg 5. aspirin 6. nph and regular insulin ss 7. neurontin 600mg 8. digoxin 0.25mg qd discharge disposition: expired discharge diagnosis: pea arrest acute renal failure upper gi bleed anoxic brain injury discharge condition: deceased Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Other convulsions Acute respiratory failure Anoxic brain damage Acute myocardial infarction of unspecified site, initial episode of care Subdural hemorrhage Cerebral artery occlusion, unspecified with cerebral infarction Acute alcoholic hepatitis Phlebitis and thrombophlebitis of intracranial venous sinuses

allergies: cats and beef attending: chief complaint: doe, orthopnea major surgical or invasive procedure: redo sternotomy, avr (19mm st. tissue) flexible cystoscopy, foley catheter placement history of present illness: m w h/o tissue mvr w dr. in . he has done well since this time. over the last several months he has noted some dyspnea with exertion and did have one episode of orthopnea. he is able to walk 1 mile daily and row at the gym w/o difficulty. climbing stairs and bending over to tie his shoes will occasionally elicit dyspnea. he denies chest pain or syncope. he was initially referred for percutaneous avr, but does not qualify given his prosthetic mitral valve. he has come to discuss his surgical option. past medical history: aortic stenosis pmh: aortic stenosis conduction system disease- 1st deg. av block/rbbb/lafsb raynaud's diverticulosis bph lyme disease (remotely) dyslipidemia mild carotid art dz-by us in past surgical history mitral valve replacement (27 tissue) resection of necrotic small bowel and repair of strangulated right inguinal hernia left herniorrhaphy right thyroidectomy bilateral cataract extraction social history: lives with: alone, widower- lives in near daughter spends in a cabin in ny without electricity- he uses a wood stove- for which he cuts all his own wood and is quite independent in adls occupation: retired physics professor tobacco: none etoh: none activity: walks 1 mile per day without rest, rows 15min. at gym family history: mother died of pancreatic cancer at 81yo father died at 84yo physical exam: pulse:90 resp: 16 o2 sat: 98%-ra b/p right: 126/80 left: 130/82 height: 62" weight: 123.4lb general: nad, skin: dry intact right fourth fingernail- onychomycotic heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur 3/6 systolic murmur abdomen: soft non-distended non-tender +bs extremities: warm , well-perfused edema none varicosities: spider veins and minor varicosities neuro: grossly intact pulses: femoral right: 2+ left:2+ dp right: 2+ left:2+ pt : 2+ left:2+ radial right: 2+ left:2+ carotid bruit right: no left: no pertinent results: intraop tee conclusions pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is mildly depressed. (lvef 45 - 50%). with borderline normal free wall contractility. there are simple atheroma in the descending thoracic . the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). trace aortic regurgitation is seen. a bioprosthetic mitral valve prosthesis is present. residual mean gradient = 3. trivial mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is av paced, on no inotropes. there is a well-seated prosthetic aortic valve with no leak and no ai. residual mean gradient = 11 mmhg. there is preserved biventricular systolic fxn. trace mr. t. the sgc is at the pa bifurcation. 06:25am blood wbc-7.9 rbc-3.64* hgb-10.7* hct-32.6* mcv-90 mch-29.5 mchc-32.9 rdw-14.6 plt ct-130*# 06:25am blood glucose-95 urean-34* creat-0.9 na-142 k-3.6 cl-100 hco3-34* angap-12 04:35am blood glucose-102* urean-22* creat-1.1 na-135 k-4.0 cl-97 hco3-32 angap-10 06:00am blood wbc-8.6 rbc-3.75* hgb-11.3* hct-34.3* mcv-91 mch-30.2 mchc-33.0 rdw-14.7 plt ct-86* brief hospital course: the patient was brought to the operating room on where the patient underwent redo sternotomy and aortic valve replacement with a 19mm st. tissue valve. urology was consulted for difficult foley placement pre-operatively. cystoscopy was performed and foley placed. he was maintained on antibiotic prophylaxis for this. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. he developed atrial fibrillation and was started on amiodarone and coumadin. he had two episodes of 3 second conversion pauses, and pacing wires were left in for this. chest tubes and pacing wires were discontinued without complication. his foley was removed on post operative day 5 and he voided after removal without difficulty. 5 day course of prophylatic antibiotics was completed. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 6 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to nursing and rehab in in good condition with appropriate follow up instructions. medications on admission: vitamin c 500 vitamin d 400 qd iron supplement 325 qd multivitamin qd florastor- scheduled to stop amoxicillin prophylaxis prn discharge medications: 1. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 7. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. warfarin 2 mg tablet sig: one (1) tablet po once (once): check inr in am - dose as directed for inr goal 2-2.5 for afib. 10. lasix 20 mg tablet sig: one (1) tablet po once a day for 5 days. 11. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 5 days. discharge disposition: extended care facility: rehab & nursing center - discharge diagnosis: aortic stenosis pmh: aortic stenosis conduction system disease- 1st deg. av block/rbbb/lafsb raynaud's diverticulosis bph lyme disease (remotely) dyslipidemia mild carotid art dz-by us in past surgical history mitral valve replacement (27 tissue) resection of necrotic small bowel and repair of strangulated right inguinal hernia left herniorrhaphy right thyroidectomy bilateral cataract extraction discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage edema: trace discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon dr. at on at 9am, cardiologist dr. on at 10am please call to schedule the following: primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr coumadin for atrial fibrillation goal inr 2-2.5 first draw day after discharge then please do inr checks monday, wednesday, and friday for 2 weeks then decrease as directed by rehab Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Ureteral catheterization Insertion of indwelling urinary catheter Other urethroscopy Diagnoses: Other iatrogenic hypotension Acute posthemorrhagic anemia Atrial fibrillation Aortic valve disorders Heart valve replaced by transplant First degree atrioventricular block Urethral false passage Right bundle branch block and left anterior fascicular block

history of present illness: the patient is an 84 year-old male with acute 4+ mitral regurgitation transferred in from an outside hospital. the patient had congestive heart failure and cardiogenic shock. he came to medical center for emergent mitral valve replacement. catheterization showed a normal coronary artery and 4+ mitral regurg. past medical history: congestive heart failure, cardiogenic shock and acute mr. ho course: the patient was taken by dr. to the operating room on . the patient underwent mvr with a #27 porcine valve. postoperatively, the patient did well. he was extubated and weaned off drips without incident. chest tube was discontinued, however, the patient did develop a slow heart rate and a blood pressure requiring pacing with pericardial leads. on pacer, the patient's heart rate was set at 70 and blood pressures ran 98/60. the patient required pacer for a few days and was stable and was transferred to the floor. prior to discharge the patient's pacer was set to aai at 52 and the patient's intrinsic heart rate was at around 74 and is normal sinus. the patient's blood pressure was around 98 to 100/60 to 70. vital signs were stable. asymptomatic. the patient did not experience any palpitations, dizziness and was ambulating at a level three prior to discharge. discharge medications: lasix 20 mg po b.i.d. times five days, k-ciel 20 milliequivalents po b.i.d. times five days and aspirin 81 mg po q.d. th will be discharged to a rehab center and told to follow up with dr. in three to four weeks. upon discharge the patient is normal rate and rhythm. incision is healed. no drainage. no pus. sternum stable and the patient was ambulating at a level three. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker Open and other replacement of mitral valve with tissue graft Monitoring of cardiac output by other technique Diagnoses: Anemia, unspecified Unspecified essential hypertension Mitral valve insufficiency and aortic valve insufficiency Rheumatic heart failure (congestive) Cardiogenic shock Diseases of tricuspid valve

history of present illness: the patient is a 26 and week infant admitted for issues of prematurity. the infant was born to a 16 year-old g1 p0 mother with type b positive, antibody negative, hepatitis b surface antigen negative, rubella immune and rpr nonreactive. estimated date of confinement based on last menstrual period and consistent with 14 week ultrasound. prenatal course: 1. dynamic cervix with periods of premature dilatation. 2. maternal pyelonephritis evident by urine and culture, positive for enterococcus and abnormal renal ultrasound, mother received cefotaxime and gentamycin for 3 to with temperature max of 104, repeat urine and cultures negative. 3. readmitted for bed rest on due to cervical dilatation, received betamethasone at that time and . today mother with contractions noted as well as increased cervical dilatation. she is brought to the obstetrical floor for close observation, placed in reverse trendelenburg position and started on magnesium sulfate. fetus was in footling breech position. when the mother was observed to have vaginal bleeding, infant was delivered by stat c section due to concern for possible abruption and concern of prolapsed cord. no maternal fever. rupture of membranes at delivery. unknown gbs. no maternal antibiotics at the time of delivery. infant delivered on at 9:54 p.m. by stat c section. mother received anesthesia by spinal method. infant emerged vigorous. brought to warmer, dried and bulb suctioned. given blow by oxygen for central cyanosis with good response. heart rate was greater then 100, intubated by 3.5 minutes of age due to increased work of breathing. apgars of 8 at one minute and 8 at five minutes. brought to the neonatal intensive care unit for further evaluation. physical examination: heart rate 180s. pressure within normal limits. temperature 96.3. o2 saturation 94% on simv, weight 815 grams 25th percentile, length 33.5 cm 25th percentile, head circumference 23.25 cm 10 to 25th percentile. active infant anterior fontanel soft, open and flat. normal s1 and s2. no murmur. moderate aeration bilaterally. mild intercostal and subcostal retractions. abdomen soft, nontender, nondistended. extremities warm slightly decreased perfusion. patent anus. intact spine. bruising noted on right upper chest, right knee and upper back. hospital course: 1. cardiovascular: baby boy did require dopamine for the first 24 to 48 hours of life. max dopamine requirement was 20 micrograms per kilo per minute. on day of life two a murmur and clinical signs and symptoms consistent with a pda were noted. indocin was empirically stared with prompt resolution of those signs and symptoms. for persistent metabolic acidosis a repeat echocardiogram was performed on day of life five and showed that the pda was closed structure and function of the heart was within normal limits. 2. respiratory: the patient was treated with two doses of survanta. he weaned promptly on his ventilator settings. on day of life four he was extubated to a cpap of 5. he did cpap have quite a few and dramatic apnea and bradycardic episodes. his caffeine was bumped and bolused to give him 8 mg per kilogram per day of caffeine intravenously. he currently has been switched from bubble nasal cannula cpap to nasopharyngeal cpap. if his apnea and bradycardic episodes remain constant and severe we plan to reintubate him and place him back on simv. 3. fen: the patient was started on 100 cc per kilo per day of total fluids. most recently increased it to 150 cc per kilogram per day for a weight loss of 124 grams giving him a current weight of 691 grams. he was initially npo after completing his course of indocin. he was started on feeds at 10 cc per kilogram per day where he currently remains. 4. access: he initially had a uac and uvc in place. the uac was discontinued on day of life four. on day of life five our plan is to replace the uvc with a peripherally inserted central catheter. 5. electrolytes were closely monitored. he did develop an impressive metabolic acidosis with a bicarb of 13 and a metabolic acidosis on arterial and capillary gases. in addition to adding maximum acetate in his pn we have given him a single sodium bicarb bolus on day of life four. this persistent metabolic acidosis did raise the concern of a persistent pda with absent murmur, however, an echocardiogram has ruled this out as a cause of the metabolic acidosis. we have also recent a cbc and culture to investigate this metabolic acidosis. 6. infectious disease: the patient was initially placed on ampicillin and gentamycin. this was discontinued after 48 hours of sterile cultures. as mentioned above a repeat cbc and cultures for metabolic acidosis was sent on day of life five. 7. hematology: hematocrit on admission was 39.8 with initial platelet count of 65 that was rechecked and was actually 266. most recent hematocrit was 31. we plan to transfuse him within the next 24 hours. the patient developed physiologic hyperbilirubinemia with a max bilirubin of 4.4. he remains on single phototherapy. 8. neurological: the patient did have a cranial ultrasound on day of life five that was within normal limits. 9. social: mom is a 16 year-old single mother, but is engaged to the baby's father. she has met with social workers and we continue to keep her updated. , m.d. dictated by: medquist36 Procedure: 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 Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Other phototherapy Prophylactic administration of vaccine against other diseases Umbilical vein catheterization Destruction of chorioretinal lesion by laser photocoagulation Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period 25-26 completed weeks of gestation Stenosis of pulmonary valve, congenital Other transitory neonatal electrolyte disturbances

past medical history: 1. hypertension. 2. history of cva. 3. arthritis. 4. high cholesterol. 5. hemorrhoidal surgery. medications at home: 1. aspirin 81 mg. 2. captopril 50 mg b.i.d. 3. atenolol 50 mg q.d. 4. vioxx 25 mg q.d. 5. tylenol. 6. colace. 7. serax. 8. lipitor 20 mg q.d. 9. hydrochlorothiazide 25 mg q.d. 10. protonix. allergies: the patient has no known drug allergies. social history: the patient has a distant smoking history and only occasional alcohol usage. physical examination on admission: vital signs: the patient was afebrile with vital signs stable. general: the patient was in no acute distress. heart: regular rate and rhythm. lungs: clear to auscultation bilaterally. abdomen: soft, mildly obese, nondistended with mild epigastric tenderness to palpation. laboratory data/studies: on admission, the laboratories were notable for a white count increasing from 8 to 16.5 and hematocrit drop from 34.6 down to 28 with a 2 unit transfusion bringing it up to 30.5. the electrolytes were within normal limits as were the coagulations. the lfts were elevated; alt to 79, ast 193, alkaline phosphatase 394, total bilirubin 1.2. the patient's ercp on showed large periampullary diverticulum, small stone in the distal common bile duct, biliary sphincterotomy stretching with common bile stone. no cannulation of pancreatic duct. ercp on showed active oozing of visible vessel at the apex of sphincterotomy site consistent with bleed with epi injected and hemoclipped. hospital course: surgery was consulted after the gi fellow had informed the medical team that ercp or egd would not be helpful at the time as the patient continued to require transfusions. interventional radiology felt that angiogram would not be helpful. the patient was continued to be transfused and the hematocrit continued to decrease. on hospital day number three, the patient was taken to the operating room for an exploratory laparotomy, cholecystectomy, common bile duct exploration, and repair os sphincter of oddi bleeder, placement of duodenostomy, gastrostomy, and jejunostomy tubes. the patient tolerated the procedure without complications, but did require 7 units of packed red blood cells and 4 units of ffp with 4 liters of crystalloid perioperatively. the patient's hematocrit eventually stabilized on postoperative day number three. the patient was placed on tube feeds and eventually was transferred to the floor on postoperative day number three and started on sips. the patient's tube feeds continued to be advanced and the patient was advanced to clears on postoperative day number six to full liquids to soft solids on postoperative day number seven. the patient continued to do well. he was felt to be ready for discharge on postoperative day number ten as he was tolerating a regular diet, ambulating relatively well with good p.o. pain control and passing flatus and having bowel movements. the patient was felt to be ready for home with home pt and vna just for j tube flushing. the patient is to follow-up with dr. . discharge medications: 1. iron supplements. 2. tylenol. 3. atenolol 50 mg q.d. 4. aspirin 81 mg q.d. 5. captopril 50 mg b.i.d. 6. lipitor 20 mg q.d. 7. hydrochlorothiazide 25 mg q.d. 8. percocet one to two tablets q. four to six hours p.r.n. 9. protonix 40 mg q.d. condition on discharge: good. discharge status: to home. discharge diagnosis: 1. status post exploratory laparotomy, cholecystectomy, and common bile duct exploration with repair of sphincter of oddi bleeder with placement of duodenostomy, gastrostomy, and jejunostomy tubes. , m.d. dictated by: medquist36 d: 06:04 t: 19:08 job#: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Other enterostomy Enteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Arterial catheterization Cholecystectomy Endoscopic control of gastric or duodenal bleeding Other gastrostomy Exploration of common duct Suture of unspecified blood vessel Other surgical occlusion of vessels, unspecified site Pancreatic sphincteroplasty Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Hemorrhage complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Osteoarthrosis, unspecified whether generalized or localized, site unspecified Tachycardia, unspecified Acute pancreatitis Calculus of gallbladder with acute cholecystitis, without mention of obstruction

his discharge medications have been amended to: 1. captopril 25 milligrams po three times a day. 2. cipro 500 milligrams po bid for a total of five days. 3. amiodarone 400 milligrams po once a day. 4. lasix 40 milligrams po twice a day. 5. k-dur 20 milliequivalents po once a day. 6. dilaudid 2 milligrams tablets one to two tablets every four hours as needed for pain. 7. colace 100 milligrams po twice a day. 8. aspirin 325 milligrams po once a day. 9. zantac 150 milligrams po twice a day. discharge condition: fair. discharge status: he is being discharged home. die follow up: follow up with dr. and dr. . dr. for all cardiology related issues. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Monitoring of cardiac output by other technique Diagnoses: Unspecified essential hypertension Other specified cardiac dysrhythmias Mechanical complication due to heart valve prosthesis Mitral valve insufficiency and aortic valve stenosis

history of present illness: the patient is a 66-year-old male who presented for an avr on . he was a repeat repair. he is status post mvr, avr tissue repair in with a bioprosthetic valve. review of systems: showed orthopnea, dyspnea which had been increasing. catheterization earlier this month showed 4+ aortic regurgitation, ejection fraction preserved. allergies: tetracycline. no allergy to shellfish, no allergy to dye. medications at home: lasix 80 mg by mouth once daily, k-dur 20 meq once daily, xanax .5 mg by mouth three times a day as needed, cardia xt 180 once daily which was held by dr. . past medical and surgical history: significant for the avr repair, mvr repair in , hypertension, no diabetes, no hypercholesterolemia, no stroke, no cerebrovascular accident, no myocardial infarction. social history: he denied smoking. he denied ethanol abuse. physical examination: vitals on admission were a temperature of 98.4, pulse 73, blood pressure 124/62, respiratory rate 16, oxygen saturation 98% on room air. physical examination was significant for bilateral lower extremity 2+ edema. there was a loud diastolic murmur. ho course: the patient was made nothing by mouth, consented, and taken to the operating room on . he had a cbc of 8.3/41.0/163. chemistry 13.7/28.3/100.3 for the coags. chemistry 143/4.7/106/27/30/1.4. the patient was taken for an avr re-do with a ce-21 with dr. . he tolerated the procedure well. postoperatively, he was transferred to the unit, where he was on amiodarone and nipride drips, which were slowly discontinued. he was on cipro postoperatively, as well as captopril and amiodarone since he had ventricular bigeminy. on , the patient was transferred back to the floor. his chest tubes and wires had been discontinued as of postoperative day three. the patient was doing well, tolerating a diet, was level iv, and was discharged on to home after completing a level v. discharge medications: captopril 12.5 mg by mouth three times a day, ciprofloxacin 500 mg by mouth twice a day, amiodarone 400 mg by mouth once daily, lasix 80 mg by mouth twice a day, potassium chloride 20 meq by mouth twice a day, percocet for pain one to two tablets every four to six hours as needed, aspirin 325 mg by mouth once daily, zantac 150 mg twice a day, colace 100 mg by mouth twice a day. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Monitoring of cardiac output by other technique Diagnoses: Unspecified essential hypertension Other specified cardiac dysrhythmias Mechanical complication due to heart valve prosthesis Mitral valve insufficiency and aortic valve stenosis

allergies: tetracycline attending: addendum: pt was also discharged on keflex 500 mg po q6h. he should continue this until the drainage from his wound ceases and the wound is dry. discharge disposition: extended care facility: center - md Procedure: Total hip replacement Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Heart valve replaced by other means Heart valve replaced by transplant Urinary complications, not elsewhere classified Spinal stenosis, unspecified region Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh Other congenital deformity of hip (joint)

allergies: tetracycline attending: chief complaint: left hip pain/ osteoarthritis major surgical or invasive procedure: : left thr history of present illness: the pt is a 69 year old male with a severely arthritic left hip. this hip has been bothering him for upwards of 2 years and radiographic studies have demonstrated complete bone on bone involvement with lateral osteophyte formation, and a relatively acetabulum consistent with ddh. he does relate a single incidence of trauma to the hip back approximately 11 years ago during a hurricaine, but that probably is not a major component. he at this point states that his pain, which he feels primarily in the left groin, is with activity, with rest. he is able to walk only about 2 blocks. he occasionally has used a crutch in the past but not presently. he has a lot of discomfort when he transitions from a seated to a standing position. he can still ambulate sequentially on stairs, more problem ascending than descending but oftentimes has to revert back to one step at a time. it is painful for him to be in a plane or a car for persistent periods of time. the hip pain wakes him up every 2 or 3 hours at night. past medical history: past medical history: 1. hx congestive heart failure, most recent echo with 1+ mr, ef > 55% 2. hypertension. 3. atrial fibrillation (status post direct current cardioversion in ; on coumadin and amiodarone). 4. hypothyroidism. 5. spinal stenosis with chronic pain. 6. aortic valve replacement nine years ago with recent revision in to a bovine valve. 7. erectile dysfunction. social history: retired jewelry designer. does not smoke. he drinks occasional wine, occasional hard drinks. he is unable to exercise because of hip pain. family history: non-contirbutory physical exam: aao x 3 rrr w/ sys murmur cta bilaterally s/nt/nd incision clean and intact, no erythema, staples in place, mild serosanguinous discharge bilateral lower extremities neurovascularly intact pertinent results: 06:20am blood wbc-10.8 rbc-3.77* hgb-11.3* hct-33.5* mcv-89 mch-30.1 mchc-33.8 rdw-14.4 plt ct-102* 09:00am blood urean-18 creat-1.3* brief hospital course: the patient was admitted after his procedure which he tolerated well. please see the dictated operative note for further details. in the pacu, the pt was noted to be excessively sleepy with occassional desaturations when he would fall asleep. he was therefore admitted to the icu for observation overnight. as the anesthetic cleared the pt's system, the episodes ceased and he was trnasferred out to the floor early in the morning of pod#1. on arrival to the floor, he was noted to be relatively hypotensive with low urine output. he was mentating fine and only complained of pain at the procedure site. more aggressive fluid resuscitation was begun. likely secondary to dehydration, the pt went into acute renal failure with a doubling of his creatinine to a high of 2.6. fluid resusucitation was continued and all potentially nephrotoxic medications were held. also on pod#1 the physical therapy service began working with the pt and continued to work with him throughout his hospitalization. lovenox therapy was also initiated. in prior discussions with the pt's cardiologist and pcp, was determined that the pt no longer needed to be on coumadin for his past episodes of atrial fibrillation, and so this medication was not restarted post-op, and instead the pt will have the usual 2 week course of dvt prophylaxis with lovenox. by pod#2, the pt's renal function had corrected and he began auto-diuresing. his creatinine returned to his baseline of 1.3 by the time of discharge. he was gradually restarted on his usual home medications including his usual diuretics. xrays obtained demonstrated the hip components in good position. the pt's foley catheter was removed on pod#3. the pt's wound continued to mildly ooze serosanguinous drainage and he was prophylactically placed on keflex while the draining continued. the pt's other main issue during his admission was pain control. after initial control with a pca, he was transitioned to oral pain medication. adequate pain control was eventually achieved with oral dilaudid. by the day of discharge, the pt was tolerating a regular diet with his pain adequately controlled on oral pain medication. he was discharged to rehab in stable condition with instructions to follow up with dr. in the office. medications on admission: percocet aldactone coumadin klonopin amiodarone protonix levothyroxine lisinopril lasix discharge medications: 1. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) subcutaneous daily (daily) for 2 weeks. disp:*qs syringes* refills:*0* 2. hydromorphone hcl 2 mg tablet sig: 1-3 tablets po every four (4) hours as needed for pain. disp:*60 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. amiodarone hcl 200 mg tablet sig: one (1) tablet po daily (daily). 6. levothyroxine sodium 175 mcg tablet sig: one (1) tablet po daily (daily). 7. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 8. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. lisinopril 20 mg tablet sig: one (1) tablet po bid (2 times a day). 10. spironolactone 25 mg tablet sig: 0.5 tablet po daily (daily). 11. diazepam 5 mg tablet sig: 0.5-1 tablet po q6h (every 6 hours) as needed for anxiety, pain spasm. disp:*30 tablet(s)* refills:*0* 12. lasix 20 mg tablet sig: 0.5 tablet po once a day. discharge disposition: extended care facility: center - discharge diagnosis: left hip pain/ oa discharge condition: stable discharge instructions: dry sterile dressing to wound daily until wound is dry. then leave wound open to air. once wound is dry you may allow it to get wet, but avoid soaking the wound or scrubbing with soap. continue to do your physical therapy and exercises. do not drink alcohol while taking pain medication and do not drive until cleared to do so by your doctor. call dr. office or come to the er if you develop any fevers > 101.5, or increasing pain, redness, swelling, or discharge from the wound. followup instructions: provider: , md where: orthopedics phone: date/time: 1:20 Procedure: Total hip replacement Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Heart valve replaced by other means Heart valve replaced by transplant Urinary complications, not elsewhere classified Spinal stenosis, unspecified region Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh Other congenital deformity of hip (joint)

allergies: procanbid / norpace / zestril / celebrex / betapace / lipitor attending: chief complaint: chest pain on exertion major surgical or invasive procedure: cabg x 2 (lima->lad, svg->om) cardiac catheterization history of present illness: mr. is a delightful 75 year old gentleman with a history of a past myocardial infarction who reports new chest pain and dyspnea over the past couple of months. he has a past history of atrial fibrillation with tachy brady syndrome for which a permenant pacemaker was placed. he underwent a stress test in which was stopped secondary to fatigue and chest pain. his ejection fraction was noted to be 39% on scan. mr. was admitted today for a follow-up cardiac catheterization which revealed an 80% stenosed left main coronary artery, a 50% stenosed proximal right coronary artery and an ejection fraction of 35%. due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. past medical history: hypercholesterolemia tachy-brady syndrome atrial fibrillation myocardial infarction depression carotid artery stenosis s/p paer implantation gerd osteoarthritis social history: lives with daughter in . retired chef. quit smoking 40 years ago after a 30 pack year history. drinks a couple of glasses of wine per week. family history: no known coronary artery disease physical exam: ht 69" wt 210 lbs vs: 105 af bp 155/70 96% room air oxygen saturation gen: laying flat in bed s/p catheterization in no apparent distress. neuro: moves all extremities, nonfocal. lungs: clear cardiac: irregular rhythm, no murmur. abd: soft, nontender, nondistended, normoactive boel sounds. ext: warm, well perfused. no edema, no varisocities. pulses: 2+ radial, femoral, dorsalis pedis and posterior tibial bilaterally. pertinent results: 10:30am inr(pt)-1.3 08:44pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 01:30pm glucose-127* urea n-18 creat-0.8 sodium-142 potassium-3.7 chloride-106 total co2-28 anion gap-12 01:30pm alt(sgpt)-10 ast(sgot)-17 alk phos-73 amylase-21 tot bili-0.8 dir bili-0.2 indir bil-0.6 01:30pm wbc-6.7 rbc-3.89* hgb-11.6* hct-35.1* mcv-90 mch-29.8 mchc-33.1 rdw-13.8 07:15am blood wbc-10.2 rbc-3.41* hgb-10.4* hct-31.5* mcv-92 mch-30.5 mchc-33.1 rdw-13.8 plt ct-290 07:15am blood pt-20.8* ptt-114.7* inr(pt)-2.7 07:15am blood glucose-167* urean-25* creat-1.0 na-139 k-3.7 cl-98 hco3-33* angap-12 cxr no previous films are available on pacs for direct comparison at this time. there is a mild thoracic scoliosis convex to the right. there is slight cardiomegaly with lv predominance but no evidence for chf. a dual chamber right sided pacemaker is present with atrial and ventricular leads in situ, in good location. the lungs are clear. there is minimal blunting of posterior costophrenic angle. degenerative changes are present in the thoracic spine and there are surgical clips in the right upper abdomen presumed s/p cholecystectomy. cxr ap & lateral chest views have been obtained in this patient now demonstrating status post sternotomy, and the presence of multiple surgical clips in the left-sided anterior mediastinum are consistent with bypass surgery. a right-sided permanent pacer in anterior axillary position is connected to two intervavitary electrodes terminating in positions compatible with right atrial appendage and apical portion of right ventricle correspondingly. there is no evidence of pneumothorax. the right-sided diaphragm is well delineated, but the left-sided diaphragm is obliterated and blunted. lateral pleural sinus is consistent with postoperative pleural effsion of moderate degree. review of the patient's radiologic records demonstrates that the preoperative chest examination in pa & lateral technique was performed on , then demonstrating mild cardiac enlargement, moderately widened and elongated thoraic aorta with calcium deposits in the wall. the pulmonary vasculature did not demonstrate any congestive pattern. the right-sided permanent pacer with dual-electrode system existed already at that time. comparison of today's fourth postoperative examination, now in pa/lateral technique, demonstrates considerable postoperative mediastinal widening to persist, and the left lower lobe atelectasis-pleural density is new and has not normalized as yet. further postoperative follow-up exam is advised. there is no evidence of remaining pneumothorax. cardiac catheterization 1. selective coronary angiography revealed a right-dominant system. the lmca was calcified with an 80% lesion. the lad and lcx both had mild disease. the rca had a 50% ostial lesion with no flow limiting stenoses. 2. left ventriculography revealed a moderately decreased ejection fraction (ef 35%) with global hypokinesis. there was 1+ mitral regurgitation. 3. resting hemodynamics revealed mild/moderately elevated left and right-sided filling pressures (ra mean 9mmhg, pa mean 28mmhg, pwcp mean 13mmhg). the estimted cardiac index was 2.0 l/min/m2. there was no gradient on pull back across the aortic valve. ekg atrial fibrillation, average ventricular rate 100-115, and rate-related left bundle-branch block. non-specific repolarization abnormalities. compared to the previous tracing of the overall ventricular rate is slightly faster and rate-related left bundle-branch block is new. ekg atrial fibrillation with a ventricular response of 93. left bundle-branch block. compared to the previous tracing of the ventricular response has slowed. otherwise, no diagnostic interim change. carotid duplex ultrasound minimal plaque with bilateral less than 40% carotid stenosis. pathology cardiac tissue consistent with atrial appendage, with myocyte hypertrophy. brief hospital course: mr. was admitted to the medical center on for a cardiac catheterization. this was significant for an 80% stenosed left main coronary artery, a 50% stenosed right coronary artery and an ejection fractionof 35%. due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization and mr. was worked-up in the usual preoperative manner. his coumadin was stopped and his inr was allowed to drift towards normal. a carotid duplex ultrasound was obtained which showed less then a 40% stenosis in the bilateral internal carotid arteries. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to two vessels. postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. his pacemaker was interrogated following surgery and was found to be functioning within normal limits. he remained in atrial fibrillation which was treated with diltiazem and digoxin for rate control. mr. had some postoperative delerium which resolved over several days without further workup. on postoperative day two, mr. e neurologically intact and was extubated. coumadin was started for anticoagulation for atrial fibrillation. gentle diuresis was initiated. the physical therapy service was consulted for assistance with his postoperative strength and mobility. heparin was started while his inr was subtherapeutic on coumadin. on postoperative day four, mr. was transferred to the cardiac surgical step down unit for further recovery. he continued to work with physical therapy for postoperative mobility. as his inr became therapeutic on coumadin, his heparin was discontinued. his chest tubes were removed per protocol. mr. continued to make steady progress and was discharged home on postoperative day seven. he will follow-up with dr. , his cardiologist and his primary care physician as an outpatient. medications on admission: cardizem 120mg once daily multivitamin lopressor 100mg once in the morning and 75mg once in the evening coumadin 3mg once daily adjusted for inr btween 2.0-3.0 aspirin 81mg once daily zantac 150mg once daily discharge medications: 1. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. diltiazem hcl 90 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 7. 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* 8. warfarin sodium 1 mg tablet sig: one (1) tablet po once a day for 1 doses: no coumadin on , and , then give 1mg on . inr to be drawn on , and called to dr. office for continued dosing. disp:*90 tablet(s)* refills:*0* 9. furosemide 20 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: cad afib discharge condition: good discharge instructions: no lifting > 10 # or driving for 1 month no creams or lotions to any incisions may shower, no bathing or swimming for 1 month followup instructions: with dr. in 4 weeks with dr. in 2 weeks with dr. in weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures (Aorto)coronary bypass of one coronary artery Other operations on heart and pericardium Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Atrial fibrillation Other specified congenital anomalies of heart Paroxysmal ventricular tachycardia Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Cardiomegaly

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cc: major surgical or invasive procedure: surgical repair of wrist laceration history of present illness: hpi: 20 year old woman with pmh significant for major depression with no previous suicide attempts, hospitalizations, or past treatment was brought to emergency department on for suicide attempt. she had attempted to slash her wrists, as well as overdose on aspirin. she reports that she has been overall feeling depressed over the past several years, but has been having worsening depressed mood and hopelessness over the past week. she also cites subacute stressors with concerns over long-distance relationship with her boyfriend and strained relationships with friends. she endorsed depressed mood, anhedonia, increased sleep, and decreased energy as well. she reports that she has never sought any treatment or counseling historically for her depression. she denies any manic symptoms. she denies any psychotic symptoms. . she was reported to have taken 50 tabs of 325mg asa. tox screen on admission significant for asa level of 57; otherwise, toxicology screen was negative for etoh, acetmnphn, , , tricyc (serum), and benzos, barbs, opiates, cocaine, amphet, mthdne (urine). . in ed, received activated charcoal 50g, bicarbonate 150meq x three and started on d5 c bicarb infusion. her intial acid/base status was notable for combined respiratory alkalosis and increased anion gap acidosis. ros: otherwise unremarkable except as described in hpi. no fever/chills/nausea/vomiting/chest pain/dyspnea/or other systemic complaints. past medical history: pmh: 1. h/o major depression - no previous treatment or counseling. no prior suicide attempts. 2. h/o bilalateral knee surgery for acl tears with soccer. 3. h/o hand tendon repair. 4. remote h/o aseptic meningitis social history: sh: originally from upstate . family is still living there. she is a student ( year) at . she denies any etoh abuse. she does report regular marijuana use. also decreasing amount of tobacco abuse, currently at two cigs per day. she denied any intranasal or intravenous drug abuse. family history: fh: father with major depression. mother with hypertension. physical exam: pe: vitals: 98.7, 115 sinus tachy, 109/52, 24, 98% on ra . gen: alert, oriented; no acute distress. heent: anicteric sclera; no injection resp: cta bilaterally with no focal findings; no resp distress cv: rrr, no m/r/g; no jvd abd: soft, non-tender, non-distended; nabs ext: no peripheral le edema. notable for multiple superficial lacerations at bilateral wrists. pertinent results: 06:00am blood wbc-4.6# rbc-4.15* hgb-12.2 hct-35.0* mcv-84 mch-29.4 mchc-34.8 rdw-13.7 plt ct-180 05:45am blood wbc-9.9 rbc-4.70 hgb-14.3 hct-38.6 mcv-82 mch-30.5 mchc-37.1* rdw-13.5 plt ct-245 06:00am blood glucose-121* urean-7 creat-1.0 na-135 k-4.3 cl-107 hco3-24 angap-8 12:10am blood glucose-108* urean-8 creat-1.1 na-137 k-3.8 cl-104 hco3-27 angap-10 06:33pm blood glucose-116* urean-8 creat-1.1 na-141 k-2.8* cl-102 hco3-29 angap-13 04:04pm blood glucose-119* urean-9 creat-1.1 na-142 k-2.4* cl-100 hco3-31 angap-13 02:16pm blood glucose-113* urean-9 creat-1.1 na-144 k-2.5* cl-102 hco3-31 angap-14 09:46am blood glucose-111* urean-9 creat-0.9 na-146* k-2.3* cl-103 hco3-30 angap-15 05:45am blood glucose-102 urean-11 creat-1.1 na-142 k-3.9 cl-104 hco3-21* angap-21* 06:00am blood calcium-8.2* phos-3.1 mg-2.3 12:10am blood calcium-8.2* phos-4.0 mg-2.4 04:04pm blood calcium-7.8* phos-4.0 mg-1.7 05:45am blood calcium-9.8 phos-3.8 mg-1.8 06:00am blood asa-5 06:33pm blood asa-14 04:04pm blood asa-19 02:16pm blood asa-22 12:04pm blood asa-28* 09:46am blood asa-36* 07:45am blood asa-47* 05:45am blood asa-57* ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:25am blood type-art temp-36.1 po2-67* pco2-43 ph-7.35 calhco3-25 base xs--1 intubat-not intuba 07:39pm blood type- po2-41* pco2-44 ph-7.45 calhco3-32* base xs-5 intubat-not intuba 04:38pm blood type- po2-70* pco2-45 ph-7.45 calhco3-32* base xs-6 02:38pm blood type- temp-37.1 po2-67* pco2-42 ph-7.51* calhco3-35* base xs-8 12:19pm blood type- temp-37.1 po2-73* pco2-37 ph-7.54* calhco3-33* base xs-8 10:08am blood type- temp-37.1 po2-80* pco2-35 ph-7.57* calhco3-33* base xs-9 intubat-not intuba comment-rm air 07:54am blood type-art po2-142* pco2-35 ph-7.60* calhco3-36* base xs-12 06:01am blood type-art po2-177* pco2-28* ph-7.46* calhco3-21 base xs--1 brief hospital course: this is a 20 yo woman with history of untreated major depression who was admitted with suicide attempt with bilateral wrist lacerations and asa overdose. . 1) aspirin overdose: the patient took approximately 50 pills of 325 mg aspirin. the initial aspirin level was 57 at 5:45am; ingestion of aspirin was thought to be around 1am. - acid/base status significant for mixed respiratory alkalosis and increased anion gap metabolic acidosis on admission - in ed received activated charcoal 50g, bicarbonate 150meq x three and started on d5 c bicarb infusion - was started on a d5 c bicarb continuous infusion for alkalinizing urine with goal urine ph of 7.5 to 8.0 - lytes, asa levels, vbgs, and urine ph were checked every two hours over the course of -> asa level at noon was 28 and bicarb gtt was shut off; recheck of asa level 2 hours later was 14 so bicarb gtt continued to stay off; activated charcoal was also d/c'd - renal and toxicology followed closely - last asa level this morning was 5, with a normal vbg and urine ph of 8 -> these labs no longer need to be checked as the asa has been excreted from the system . 2) hypokalemia - k was 2.2 at nadir secondary to intracellular shifts from alkalinization - k was aggressively repleted at approx 10 meq/hr until k was 4.3 this morning and stable . 3) wrist laceration - sutured by plastic surgery - will need f/u in hand clinic (, call to make appt) either in or with any hand surgeon in days - needs to be on cefazolin for 7 days -> ? switch to po keflex . 3) depression/suicide attempt - history of major depression. - psych consulted and following, recommend 1:1 sitter and no meds at this point - likely will need inpt psych admission . 4) fen -tolerating po's , maintenance ivf d/c'd -lytes stable, will check in pm today . 5) proph - oob, eating . 6) access - peripheral iv . 7) dispo - inpatient psych vs. medical floor -> medically stable, can go to inpt psych if psych agrees medications on admission: meds: no chronic or over the counter medications. no antidepressants. discharge medications: 1. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 2. keflex 500 mg capsule sig: one (1) capsule po every six (6) hours for 5 days. discharge disposition: extended care discharge diagnosis: aspirin overdose depression multiple wrist laceration bilateral discharge condition: stable - patient medically improved from aspirin overdose and will need to follow up outpatient with plastic surgery regarding wrist laceration. patient will be followed by psychiatry regarding depression discharge instructions: please continue to take medications as directed. you will need to follow up in hand clinic (, call to make appt) either in or with any hand surgeon in days please continue to take keflex as directed followup instructions: you will need follow up in hand clinic (, call to make appt) either in or with any hand surgeon in days. md Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Acidosis Open wound of wrist, with tendon involvement Suicide and self-inflicted injury by cutting and piercing instrument Alcohol abuse, unspecified Hypopotassemia Alkalosis Family history of psychiatric condition Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics Cannabis abuse, unspecified Poisoning by salicylates Major depressive affective disorder, single episode, severe, without mention of psychotic behavior Objective tinnitus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cocaine overdose major surgical or invasive procedure: intubation history of present illness: 43 y/o m with pmh significant for bipolar disorder admitted to on following a cocaine overdose. pt was in his normal state of health until . at that time, he was being persued in his car by the police and swallowed maybe twenty nine one gram packets of cocaine wrapped in cellophane at approximately 3:30 pm on . apparently he had punctured some of these bags in order to get high. ems was called to transport the pt to the ed. in route, he was given 20 mg of valium. the pt's vs in the osh ed were 101.6 142/94 130 22 94%. glascow coma scale was 15. urine tox screen was positive for etoh and cocaine. the pt was given activated charcoal and a gallon of golytely. at 6:00 pm, the pt sufferred a witnessed seizure and was given multiple doses of ativan to break the seizure. he was intubated for airway protection and transferred to for further care. . on arrival to the ed, the pt's vs were 100.8 112 166/112 --> 128/76 22 100% on 550/15/50% with a peep of 5. pt was given ativan 4 mg x1, 2l of golytely, charcoal, and started on a propofol drip. pt was noted to have qt prolongation on his ecg which was initially felt to be due to his cocaine ingestion. however, toxicology felt that this was unlikely and a qrs prolongation would be more expected with cocaine overdose. the pt has continued to have ecgs followed on a regular basis and agressive electrolyte replacement. pt was extubated on the morning of without difficulty. by that time, his stool had cleared with the golytely. on , the pt was continuing to pass bags of cocaine in his stool. he will be transferred to the floor for further care. in speaking with the pt, he has no complaints at this time. he denies any pain and reports that he feels well. specifically, pt denies cp and abdominal pain. no sob. past medical history: 1. bipolar disorder 2. attention deficit disorder 3. s/p fracture of left foot social history: pt reports that his only family is his mother but he has not yet told her of his current situation as he does not want to upset her. he reports that he does hav a pcp he saw last week but declines to reveal her name. he reports "she is my friend and i don't want her to get into trouble." he declines to explain this further. pt has smoked ppd for the past two years. he reports occasional etoh use. family history: noncontributory. physical exam: 98.7 136/95 109 14 99% ra gen- well appearing, slightly disheveled man resting in bed. alert and oriented. nad. cardiac- rrr. s1 s2. no m,r,g. pulm- ctab. no wheezes, rales, or rhonchi. abdomen- soft. nt. nd. positive bowel sounds. extremities- no c/c/e. pertinent results: reports: . supine abdomen (): there is a normal bowel gas pattern without evidence of obstruction. no definite foreign bodies are identified. densities within the upper right colon and left colon likely represent fecal material. no intraperitoneal free air is identified; however, the upper portions of the abdomen are not included on exam. the nasogastric tube tip is at the gastroesophageal junction and should be advanced. osseous and soft tissue structures are unremarkable. impression: no definite foreign body is identified. nasogastric tube tip at the ge junction and should be advanced. . portable chest (): cardiac, mediastinal, and hilar contours are within normal limits. there is crowding of the pulmonary vasculature which may be secondary to low lung volumes on the exam. there is no overt pulmonary edema. mild blunting of both costophrenic angles represent a small amount of pleural effusion. no focal consolidations are identified. the endotracheal tube is in appropriate position within the thoracic inlet. the nasogastric tube side ports are within the esophagus and should be advanced. osseous and soft tissue structures are unremarkable. impression: mild blunting of the costophrenic angles which may represent small pleural effusions. no overt pulmonary edema or focal consolidations. nasogastric tube side ports are within the esophagus and should be advanced. . labs: . 08:25pm blood wbc-13.8* rbc-4.31* hgb-13.1* hct-35.7* mcv-83 mch-30.4 mchc-36.6* rdw-13.1 plt ct-235 08:25pm blood neuts-83.4* bands-0 lymphs-12.5* monos-3.7 eos-0 baso-0.3 08:25pm blood hypochr-normal anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 08:25pm blood plt smr-normal plt ct-235 08:25pm blood pt-13.8* ptt-21.8* inr(pt)-1.3 05:35am blood ret aut-1.5 08:25pm blood glucose-92 urean-14 creat-0.9 na-143 k-3.6 cl-109* hco3-22 angap-16 08:25pm blood alt-26 ast-35 ck(cpk)-790* alkphos-74 amylase-34 totbili-0.6 08:25pm blood ck-mb-6 ctropnt-<0.01 08:25pm blood albumin-3.7 calcium-7.5* phos-3.0 mg-1.5* 08:25pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg 09:00am blood wbc-8.5 rbc-4.25* hgb-12.9* hct-35.9* mcv-85 mch-30.3 mchc-35.8* rdw-12.7 plt ct-236 05:35am blood wbc-9.0 rbc-4.13* hgb-13.0* hct-35.9* mcv-87 mch-31.5 mchc-36.3* rdw-13.7 plt ct-228 02:13pm blood wbc-9.5 rbc-4.00* hgb-12.6* hct-34.7* mcv-87 mch-31.4 mchc-36.2* rdw-13.6 plt ct-224 04:57am blood wbc-9.0 rbc-4.03* hgb-12.3* hct-35.2* mcv-87 mch-30.4 mchc-34.8 rdw-13.8 plt ct-203 09:00am blood plt ct-236 05:35am blood plt ct-228 02:13pm blood plt ct-224 02:13pm blood pt-12.8 ptt-22.9 inr(pt)-1.1 04:03am blood pt-13.2 ptt-24.4 inr(pt)-1.2 04:57am blood plt ct-203 08:25pm blood plt smr-normal plt ct-235 09:00am blood glucose-94 urean-6 creat-0.8 na-139 k-3.8 cl-100 hco3-28 angap-15 12:00am blood glucose-98 urean-6 creat-0.8 na-144 k-3.8 cl-106 hco3-30 angap-12 05:35am blood glucose-84 urean-2* creat-0.8 na-141 k-3.5 cl-107 hco3-25 angap-13 02:13pm blood glucose-119* urean-2* creat-0.7 na-143 k-3.7 cl-110* hco3-25 angap-12 04:03am blood glucose-78 urean-3* creat-0.7 na-142 k-3.5 cl-110* hco3-19* angap-17 04:35pm blood glucose-69* urean-6 creat-0.6 na-139 k-3.8 cl-111* hco3-18* angap-14 04:57am blood glucose-73 urean-10 creat-0.7 na-141 k-3.5 cl-110* hco3-23 angap-12 04:35pm blood ck(cpk)-441* 04:57am blood ck(cpk)-629* 08:25pm blood alt-26 ast-35 ck(cpk)-790* alkphos-74 amylase-34 totbili-0.6 04:35pm blood ck-mb-9 ctropnt-<0.01 04:57am blood ck-mb-12* mb indx-1.9 ctropnt-<0.01 08:25pm blood ck-mb-6 ctropnt-<0.01 09:00am blood calcium-9.1 phos-4.1 mg-1.5* 12:00am blood calcium-9.4 phos-3.9 mg-1.6 05:35am blood calcium-8.7 phos-3.1 mg-1.4* iron-61 02:13pm blood calcium-8.7 phos-2.7 mg-1.4* 04:03am blood calcium-8.2* phos-2.5* mg-1.6 04:35pm blood calcium-7.7* phos-2.3* mg-1.9 04:57am blood calcium-7.0* phos-1.1*# mg-2.4 05:35am blood caltibc-225* vitb12-373 folate-10.7 ferritn-179 trf-173* 08:25pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg 01:24am blood type-art tidal v-600 fio2-40 po2-177* pco2-35 ph-7.41 calhco3-23 base xs--1 09:28pm blood type-art po2-244* pco2-45 ph-7.32* calhco3-24 base xs--3 08:41pm blood lactate-1.2 k-3.6 01:24am blood freeca-1.01* . micro: . 8:20 pm urine site: catheter **final report ** urine culture (final ): no growth. brief hospital course: 43 y/o m with pmh significant for bipolar disorder admitted to on following a cocaine overdose. he was intubated prior to arriving in the icu, was subsequently extubated and transferred to the floor for further care. . 1. cocaine overdose with body stuffing- pt did not display signs of cocaine packet rupture during the admission. he had episodes of anxiety , but did not shows signs of acute cocaine toxicity. responded well to 1mg po ativan. toxicology was following during his stay in the icu. an agressive bowel regimen was used to try to collect cocaine packets from the pt's stool. he recieved several days of golytely and passed between 9 and 11 bags of cocaine. on the floor, he used the toilet several times despite instructions to use only the commode and we were not able to recover further bags. . 2. pt had qt prolongation on ecgs. this was not felt to be due to the cocaine overdose but possibly due to hypocalcemia. - repeat ecg showed improved qt interval. - agressive magnesium replacement was used - avoided medications that prolong the qt. - monitored on telemetry during the entire admission, without significant events. . 3. pt had question of charcoal aspiration. left lung opacification seen on cxr on , which could have represented early asipraton or atelectasis. pt had stable oxygen saturation and was clear on pulmonary exam. - was not treated with abx - repeat cxr was normal. . 4. pt was under custody and was monitored by officer(s) at all times, up until the day prior to discharge when he was arraigned and released from custody. . 5. fen- regular diet plus golytely. agressive electrolyte replacement. . 6. proph- sc heparin; ppi; bowel regimen; aspiration percautions. . 7. access- pivs. . 8. code status- full code. . 9. dispo: home medications on admission: 1. effexor 150 mg daily discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. venlafaxine 75 mg capsule, sust. release 24hr sig: two (2) capsule, sust. release 24hr po daily (daily). 3. magnesium oxide 400 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 4. outpatient lab work please have a chemistry panel checked on monday . your primary care physician should follow up the results. discharge disposition: home discharge diagnosis: primary diagnosis: cocaine overdose with body stuffing secondary diagnosis: bipolar disorder discharge condition: stable discharge instructions: 1. please take all medications as prescribed. 2. please keep all follow up appointments. 3. seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. followup instructions: please follow up in prison with a physician as needed. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Hypocalcemia Cocaine abuse, unspecified Accidental poisoning by central nervous system stimulants Bipolar I disorder, most recent episode (or current) unspecified

other medical hx not contributory to infant's medical status. social hx: mother and mgm and sibs involved /visiting with baby, appear , supportive, attentive. no social history or other family hx contributory to baby's medical status. upon admission to nicu: gen: aga (2320 g) hispanic female, breathing ra, in nad, pink, well perfused, vigorously crying. active, normal tone, movements, posture, strength. growth parameters: wt 2320 gm, hc 32 cm, l 46 cm. t=98.6 p 140s, rr 50s, spo2 97% in ra, bp 58/31, mean 40, heent: nc, af soft/flat. eyes nl by external appearance. exam of fundi deferred due to ointment in eyes. nose, mouth, ears appear wnl. neck and clavicles appear wnl. chest: clear=bs, (subsequently mild, intermittent grunting that resolved). cv: nl heart sounds, no murmur, pulses and perfusion wnl. abd: not distended, soft, no masses, no h/s megaly. bs+. gu: nl female. anus patent. back appears wnl. skin appears wnl. extremities: appear wnl. neuro: appears appropriate for 35.5 wk ga. (see under gen assessment above.) assessment: prematurity: 35.5 wk ga female no evidence of respr distress at this time. plan: monitor infant for cvr stability, including apnea/bradycardia/desaturations; feeding ability, temp stability. infant will remain in nicu for monitoring and managment at this time. if infant appears to be clinically stable and mature for care in nbn over the course of the first 24 hr, then infant will be transferred to nbn. Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: exertional chest discomfort, positive stress test major surgical or invasive procedure: three vessel coronary artery bypass grafting utilizing the left internal mammary artery to the left anterior descending artery, vein graft to obtuse marginal and vein graft to the right coronary artery. history of present illness: mr. is a 57 year old male with a history of hypertension and elevated cholesterol. over the last two years, he has noted some dyspnea and chest tightness when involved in strenuous activities - ie. climbing flight of stairs. he denies any symptoms at rest. he also denies claudication, orthopnea, pnd, edema, palpitations, syncope and presyncope. in , he underwent an ett at . at five minutes, he developed marked dyspnea and chest tightness. imaging revealed an lvef of 60% with a fixed inferior lateral wall defect with minimal reperfusion. follow up echocardiogram showed focal inferior hypokinesis with 1+ mitral regurgitation. subsequent cardiac catheterization on showed multivessel disease with normal left ventricular function. coronary angiography showed a 50% distal left main lesion; the lad had a long 60% stenosis; the circumflex had a 90% proximal lesion; while the rca had a total occlusion with right to left collaterals. past medical history: hypertension, hypercholesterolemia social history: married, with three children. he works for the air force. he denies tobacco and excessive etoh. family history: no premature coronary disease. physical exam: bp: 124/79, pulse: 50-60, resp: 14 with 100% room air. general: well developed male in no acute distress heent: oropharynx benign neck: supple, no jvd lungs: clear heart: regular rate and rhythm, normal s1s2, no murmur abdomen: soft, nontender, nondistended, normoactive bowel sounds ext: warm, no edema pulses: 2+ distally, no femoral or carotid bruits pertinent results: 04:55am blood hct-25.5* 04:45am blood glucose-111* urean-19 creat-0.8 na-134 k-4.2 cl-97 hco3-31 angap-10 04:45am blood wbc-8.9 rbc-2.65* hgb-8.1* hct-23.7* mcv-90 mch-30.5 mchc-34.1 rdw-13.7 plt ct-138* 06:55pm hct-31.8*# 06:55pm plt count-169# brief hospital course: on , dr. performed three vessel coronary artery bypass grafting utilizing the left internal mammary artery to the left anterior descending artery, vein graft to obtuse marginal and vein graft to the right coronary artery. following the operation, he was brought to the csru. within 24 hours, he awoke neurologically intact and was extubated. he initally required atrial pacing for sinus bradycardia but otherwise maintained stable hemodynamics. he weaned from inotropic suppport without difficulty. on postoperative day one, he transferred to the sdu. his native heart rate gradually improved and atrial pacing was no longer required. low dose beta blockade was eventually resumed and advanced as tolerated. pacing wires were eventually removed without complication. he remained in a normal sinus rhythm. he responded well to lasix and by discharge, was approaching his preoperative weight with room air oxygen saturations of 96%. over several days, he made clinical improvements and progressed well with physical therapy. he was cleared for discharge to home on postoperative day five. at discharge, he was slightly fluid overloaded and will required several more days of gentle diuresis. medications on admission: lipitor 10 mg qd, atenolol 25 mg qd, aspirin 325 mg qd discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. 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. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 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. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. polysaccharide iron complex 150 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 9. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: care discharge diagnosis: coronary artery disease discharge condition: good. stable. discharge instructions: follow medications 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. do not use lotions, creams, or powders in wounds. call our office for sternal drainage, temp>101.5. followup instructions: make an appointment with dr. for 4 weeks. make an appointment with dr. for 1-2 weeks. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Other and unspecified angina pectoris

history of present illness: this is a 62-year-old gentleman who was transferred to on after a positive dobutamine stress echocardiogram and a subsequent cardiac catheterization which showed 89 percent left main lesion, a totally occluded right coronary artery, and a left anterior descending with multiple irregularities, and an ejection fraction of 35 percent the patient 40 percent. the patient had been experiencing back pain and was beginning evaluated preoperatively for a spinal fusion. past medical history: hypertension. hypercholesterolemia. asthma. status post tonsillectomy. allergies: no known drug allergies. preoperative medications: 1. lisinopril 20 mg by mouth once per day. 2. 260 mg by mouth once per day. 3. celebrex 200 mg by mouth three times per day as needed. 4. hydrochlorothiazide 25 mg by mouth once per day. 5. lipitor 20 mg by mouth once per day. 6. soma 350 mg by mouth twice per day as needed. 7. patanol eyedrops 0.1 percent both eyes twice per day. summary of hospital course: the patient was admitted and started on a heparin infusion. the patient was taken to the operating room on with dr. for a coronary artery bypass grafting times four with left internal mammary artery to left anterior descending, saphenous vein graft to rpl, saphenous vein graft to obtuse marginal, and saphenous vein graft to first diagonal. please see the operative note for full details. the patient was transferred to the intensive care unit in stable condition. the patient was weaned and extubated from mechanical ventilation on the first postoperative evening. the patient was noted to have a dropping hematocrit. the patient was transfused 2 unit of packed red blood cells. the patient was started on lasix. his chest tubes were removed without incident. the patient had been started on amiodarone in the operating room for atrial and ventricular ectopy. the patient was continued was amiodarone with no further ectopy. the patient was started on lopressor on postoperative day three. he was transferred to the floor on postoperative day three. the patient's pacing wires were removed without incident. the patient began ambulating with physical therapy. by postoperative day six, the patient had completed a level v physical therapy. he was able to ambulate 500 feet and climb one flight of stairs, and he was cleared for discharge to home. condition on discharge: temperature maximum was 98.2 degrees fahrenheit, his pulse was 70 (in sinus rhythm), his blood pressure was 120/61, his respiratory rate was 15, and his oxygen saturation was 99 percent on room air. neurologically, the patient was awake, alert and oriented times three. heart was regular in rate and rhythm. no murmurs or rubs. respiratory examination revealed breath sounds were clear bilaterally. gastrointestinal examination revealed the abdomen was obese, soft, nontender, and nondistended. there were positive bowel sounds. the lower extremities with 2 plus pitting edema. the right lower extremities revealed vein harvest site was clean, dry, and intact. right thigh was ecchymotic but not tender. the sternal incision was clean, dry, and intact. the staples were intact. there was no erythema. the sternum was stable. the patient's back had a maculopapular rash on the lower back which was pruritic; which appeared to be a contact dermatitis. his white blood cell count was 8.5, his hematocrit was 24.4, and his platelet count was 260. sodium was 134, potassium was 4.5, chloride was 97, bicarbonate was 26, blood urea nitrogen was 21, and his creatinine was 0.9. the patient's weight on was 145 kilograms. the patient weighed 140 kilograms preoperatively. discharge diagnoses: coronary artery disease. atrial fibrillation. medications on discharge: 1. atenolol 25 mg by mouth once per day. 2. lasix 40 mg by mouth twice per day (times 10 days). 3. potassium chloride 20 meq by mouth twice per day (times 10 days). 4. colace 100 mg by mouth twice per day. 5. enteric coated aspirin 325 mg by mouth once per day. 6. percocet 5/325-mg tablets one to two tablets by mouth q.4- 6h. as needed. 7. plavix 75 mg by mouth once per day. 8. celebrex 200 mg by mouth twice per day. 9. lipitor 20 mg by mouth once per day. 10. iron sulfate 325 mg by mouth twice per day. 11. vitamin c 500 mg by mouth twice per day. 12. amiodarone 400 mg by mouth once per day (times one week) then 200 mg by mouth once per day. 13. lisinopril 5 mg by mouth once per day. discharge disposition: the patient was to be discharged to home in stable condition. discharge follow up: the patient was instructed to follow up with his cardiologist - dr. - in one to two weeks. the patient was instructed to follow up with his primary care physician in one to two weeks. the patient was instructed to follow up with dr. in three to four weeks. , Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Insertion of temporary transvenous pacemaker system Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Obesity, unspecified

allergies: caffeine attending: chief complaint: status post fall, dizziness major surgical or invasive procedure: tee mr cervical spine w/o c ct chest w/contrast cta head & neck w&w/o c & reco c-spine, trauma mr head w & w/o contras tte ct head w/o contrast history of present illness: 83 yo female with h/o breast ca s/p mastectomy and chemo and h/o syncope vs seizure event in who is transferred with a left cerebellar ich. she was feeling fine the morning of presentation and got into a shower. she then felt lh and increased the hot water. she still felt lh, leaned forward to grab something and her "head swam" and she felt strange. she then went down to her knees and realized she was going to faint. she reports hitting her shoulder, but she does not think she hit her head(she is not sure though). she was apparently in the tub for some time unable to get up(possibly hours) before her son found her and called ems. she went to and had a head ct which showed a left cerebellar hemisphere hemorrhage with some edema, but no obstruction of the 4th ventricle. she was given mannitol 25g and transferred here. she has been mildly confused; per her son, this started about 3 weeks prior to presentation, fairly acutely. for example, she has been calling the cat the wrong name, went out on the balcony not fully dressed, and thought it was the fourth of last week. she is usually fully functional at home, living just with her cat, so this was a significant change from her baseline. she also has a positive troponin, but had no cp or ecg changes and no asa was given due to the hemorrhage. ros: patient denies any fever, chills, nausea, vomiting, headache, dysarthria, dysphagia, neck pain, weakness, numbness, tingling, visual changes, diplopia, hearing changes, chest pain, shortness of breath, or bowel/bladder problems. past medical history: -breast ca s/p mastectomy and chemo. right mastectomy 6 yrs ago, followed by chemo and tamoxifen. she had recurrence in lns and was treated with 16 months chemo ~1 yr ago. she was off for several months, then got new lns, so started xrt and got 37 treatments which finished 6 weeks ago. she also gets frequent prbcs. onc is dr at n-w (part of farber) -h/o possible seizure in (mri at that time with age related change only by report) -gerd -anemia social history: lives alone with cat. son involved in care. no smoking. etoh socially. family history: no strokes. sister and mother with htn. physical exam: on admission: vitals:98.1, 96, 160/124->142/94, 16, 98% on ra gen:nad. heent:mmm. sclera clear. op clear neck: no carotid bruits cv: rrr, no murmurs/gallops/rubs lung: clear to auscultation bilaterally ext:no cyanosis/edema neurologic examination: mental status: awake and alert, cooperative with exam orientation: oriented to person, , and attention: able to do dowf not b language: fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors no apraxia, no neglect. ? ext to dss on right intact calculation poor. $1.50=8 cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2mm bilaterally. visual fields are full to finger movement. 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, intact movements motor: normal bulk and tone bilaterally postural tremor in l>r ue. no resting tremor d t b we fif ip q h df pf te() right * 5 5 5 5 5 5 5 5 5 5 5 left 5 5 5 5 5 5 5 5 5 5 5 5 no pronator drift sensation: intact to light touch, pinprick, temperature (cold), vibration throughout all extremities. reflexes: b t br pa ankle right 2 t t 1 0 left 2 t t 1 0 toes were downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements normal, ffm normal. gait: not tested pertinent results: labs at osh: chem:138/3.2/100/25/27/1/88 ca=9.7, alb=4.2, alt=37, ast=54 ck=552, mb=12, trop=0.128 cbc:12.6/34.7\106 92% polys inr=1, ptt=33.3 on admission: cbc: wbc-11.6* rbc-3.31* hgb-11.5* hct-31.8* mcv-96 mch-34.9* mchc-36.3* rdw-17.5* plt ct-100* coags: pt-13.8* ptt-32.3 inr(pt)-1.2* chem10: glucose-109* urean-26* creat-1.0 na-139 k-3.3 cl-105 hco3-22 calcium-9.5 phos-4.0 mg-2.2 flp: cholest-163 triglyc-90 hdl-46 chol/hd-3.5 ldlcalc-99 ces: ck(cpk)-690* ck-mb-16* mb indx-2.3 ctropnt-0.16* ck(cpk)-624* ck-mb-13* mb indx-2.1 ctropnt-0.18* ck-mb-9 ctropnt-0.20* %hba1c-pnd imaging: hct : 1. small hyperdense focus in the left cerebellum likely represents subarachnoid hemorrhage. mild surrounding edema, but no significant mass effect on the fourth ventricle. 2. chronic small vessel ischemic disease, with additional area of hypodensity in the right parietal lobe that may represent an area of subacute infarction. if there is clinical concern, mri would be more sensitive for evaluation of acute brain ischemia. mri : multiple infarcts involving several vascular territories, the largest area involving the right temporal and parietal regions, which appear acute and subacute. the areas of enhancement could certainly represent some of the more acute foci of infarction. blood products in both the right parietal region as well as the left cerebellum. these multiple findings can be unified with the diagnosis of emboli. please consider a cardiac echo to evaluate for thrombus and defects such as a pfo or asd. follow up examination in a few days may help to differentiate multiple emboli from the possibility of metastatic disease given the patient's history of breast cancer. c-spine x-ray: 1. limited study as described above. the cervical spine cannot be fully evaluated on these views; however, there are no signs for acute injury. if there is high clinical concern, cross-sectional imaging with ct scan can be performed. 2. extensive degenerative change of the cervical spine. there is also retrolisthesis of c3 over c4 and anterolisthesis of c4 over c5. cta head & neck w/contrast: 1. 3mm left supraclinoid internal carotid artery aneurysm. 2. fusiform aneurysm or pseudoaneurysm in the v3 segment of the right vertebral artery. 3. right upper lobe peripheral consolidation could represent areas of infection/neoplasm or pulmonary infarct from emboli. chest ct w/contrast: 1. air bronchogram containing right upper lobe opacity is likely infectious with malignant etiologies including a slow growing bronchoalveolar carcinoma felt less likely. slightly prominent peripheral interstitial markings more inferiorly is also likely infectious however underlying lymphangitic spread of tumor cannot be excluded. recommend appropriate treatment and repeat ct examination in three months to assess for change. 2. small pericardial effusion. small right renal hypoattenuating lesion, likley benign but too small to characterize. 3. moderate hiatal hernia. 4. moderate atherosclerotic vascular disease. tee : the left atrium is mildly 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. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast at rest x 2 (unable to cooperate with maneuvers). there are simple atheroma in the aortic arch and descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. impression: simple atheroma in the aortic arch and descending thoracic aorta. mild-moderate mitral regurgitation. brief hospital course: patient is an 83 yo female with h/o breast ca s/p mastectomy and chemo and history of syncope vs seizure event in , confusion x 3 weeks, who is transferred with a left cerebellar ich. on mri, found to have multiple infarcts, likely embolic as there is a large right temporoparietal infarct and multiple other small infarcts in anterior and posterior circulations bilaterally. . 1. neurology: initial and repeat head ct stable. mri showed right temporoparietal infarct, several other small right and left infarcts, c/w embolic source or prothrombotic state. it was felt that she was prothrombotic and hypercoaguable due to her malignancy. we did not start anticoagulation because of the presence of a large hemorrhagic transformation in the cerebellum. started asa 325. lipid panel was total 163/hdl 46/triglycerides 99/ldl 90, increased pravastatin to 40. hemoglobin a1c was 4.7. plan to repeat mri with contrast in one month and follow-up in clinic at that time to readdress starting anti-coagulation such as lovenox. plan discussed with patient and son who understand the risks of bleeding on anti-coagulation soon after the stroke and of subsequent strokes from prothrombotic state due to her underlying metastatic breast cancer. 2. she had a right upper lobe peripheral consolidation seen on cxr, which could represent areas of infection/neoplasm or pulmonary infarct from emboli. she will need follow up cxr or ct scan, as an outpatient to further assess the nature of this finding. her pcp was notified. 3. status post fall: ct c-spine done at hospital, report no fracture but positive for retrolisthesis. mri c-spine without ligamentous injury. . 4. cards: monitored on telemetry without events. patient had elevated tropt (peak 0.20) with normal mb index. tte with normal ef, agitated saline contrast study revealed late bubbles which may reflect pulmonary a-v shunting but cannot exclude intracardiac shunt. tee negative for valvular vegetations, clot, large atheromas or asd/pfo. tsh and lfts normal . 5. id: ct chest performed showed air bronchogram containing right upper lobe opacity, likely infectious with malignant etiologies including a slow growing bronchoalveolar carcinoma felt less likely. slightly prominent peripheral interstitial markings more inferiorly is also likely infectious however underlying lymphangitic spread of tumor cannot be excluded. recommend appropriate treatment and repeat ct examination in three months to assess for change. started on cipro for treatment of community acquired pneumonia for 7 day course. . 6. gu: continued her home detrol. . 7. heme: iron studies consistent with anemia of chronic disease. per her son, she has been intermittently anemia since start chemotherapy and has required blood transfusions in the past. she drifted down to a nadir of 22.5 and was transfused two units of packed red cells on with an appropriate bump in her hct to 30.9. she will need intermittent checks of her hct and should be tranfused for hct<25. her stools were guaiac'd and were negative. . 8. ppx: ppi, riss, tylenol . 9. other: pt/ot evaluated patient and recommended discharge to rehab. medications on admission: medications: 1. ketoprofen 50 daily 2. detrol la 4 mg 3. pravachol 20 4. tramadol 50 prn 5. omeprazole discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 3. insulin regular human 100 unit/ml solution sig: per sliding scale units injection asdir (as directed). 4. tolterodine 2 mg tablet sig: one (1) tablet po bid (2 times a day). 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 10. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 11. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours): until . 12. heparin lock flush (porcine) 10 unit/ml solution sig: five (5) ml intravenous daily (daily) as needed: 10 ml ns followed by 5 ml of 10 units/ml heparin (50 units heparin) each lumen daily and prn. inspect site every shift. . 13. metaxalone 800 mg tablet sig: one (1) tablet po at bedtime as needed for muscle spasm. discharge disposition: extended care facility: healthcare - discharge diagnosis: primary diagnosis: - left cerebellar abd right parietal infarcts with hemorrhagic conversion secondary diagnosis: - metastatic breast ca - gastroesophageal reflux - anemia discharge condition: good. alert and oriented x2, not to date. cranial nerves intact. right postural tremor. left finger curl. left upper motor neuron pattern arm weakness (dist>prox). discharge instructions: you have embolic strokes to your brain. you will need to follow-up with the stroke neurologist and get a repeat mri brain with contrast (see below). you will need your red blood cell count checked by your primary care physician one week after discharge. please take medications as prescribed and keep your follow-up appointments. if you have any weakness, numbness/tingling, difficulty speaking, sudden vision or hearing changes or any other worrying symptoms, please call your primary care physician or return to the emergency department. followup instructions: pcp: , md phone: date/time: 11:30 stroke neurologist: , md, phd: date/time: 3:00 repeat mri brain with contrast in one month. please call (#1) repeat chest ct with contrast in 3 months. please call (#1) md, Procedure: Diagnostic ultrasound of heart Transfusion of packed cells Diagnoses: Esophageal reflux Personal history of malignant neoplasm of breast Secondary hypercoagulable state Anemia in neoplastic disease Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified Cerebral thrombosis with cerebral infarction

allergies: caffeine / heparin agents attending: chief complaint: brbpr major surgical or invasive procedure: picc line placed and removed ?egd history of present illness: patient is a 83yo woman who was transferred from with 3 days of brbpr found in her diaper. she has a medical history of breast cancer s/p mastectomy, radiation, tamoxifen who had ln recurrance 2 years ago treated initially with chemo and then with radiation. more recently (6 weeks ago) she had a cerebellar ich/cva, coag negative bacteremia and presumed endocarditis (on vanco via picc line) and c. diff colitis (with wbc max of 42,000 on requiring flagyl + po vanco and associated with lgib) and a left superficial thrombosis associate with her picc. . she was first noted to have blood clots mixed with her stool on and which worsened over the next 3 days. she was transfused 2u prbc on and . . in the ed her vs were stable; 99.2, hr in 80-90's, systolics in 120's, o2sat 90's on ra. her physical exam showed her to be alert and would open eyes to command (unclear baseline), benign abdomin, bright red blood in diaper, rectal not done. ng tube was already in place from (but above the diaphragm). reportedly an aspiration showed gastric contents without blood. hct was 27.2 and plts 54. she was transfused plts. cxr showed ng tube mal-placement. . surgery was made aware. gi was consulted and plans to see patient on floor. . unable to obtain ros. son/hcp reports that since her strokes 6 weeks ago that she is slow to respond, difficult to wake up, but will respond with opening her eyes/shaking her head and speaking, although her speach is difficult to understand. he reports that her memory of people's identity is good, but she is not oriented to place or time past medical history: left proximal brachial thrombosis secondary to picc line () -coagulase neg staph bacteremia/port removal in with presumed endocarditis and planned 6wk abx treatment -c.diff colitis tested positive and started on flagyl with addition of vanco. ct abd showed colitis of descending/sigmoid colon -? lgib in past -breast ca s/p mastectomy and chemo. right mastectomy 6 yrs ago, followed by chemo and tamoxifen. she had recurrence in lns and was treated with 16 months chemo ~1 yr ago. she was off for several months, then got new lns, so started xrt and got 37 treatments which finished in . she also gets frequent prbcs. onc is dr at n-w (part of farber) -h/o possible seizure in (mri at that time with age related change only by report) -gerd -anemia -? gall stones (h/o elevated lfts) - hit ab positivity social history: recent rehab resident, prior to cva lived at home with cat. son involved in care. no smoking. etoh socially. family history: no history of strokes. sister and mother with htn. physical exam: pe: vs: 99.2f hr 89 bp 154/81 100% ra general: elderly woman in nad, alert, minimally responsive heent: perrl 2 to 2.5, op with dry mucous membranes, dried mucous, poor dentition. neck: attempted ej site, chest: ctab, right mastectomy scar, left porta cath removal site with bleeding and yellow not foul smelling discharge with no erythema/swelling. cardiac: distant, rrr no m/r/g abd: +bs, soft, no guarding, no rebound, diffusely tender ext: 2+ pulses, cool extremities skin: stage i on coccyx, no petchiae neuro: alert, arousable, not oriented to place, date, age is "too old", moving all 4 and responds to commands in right arm, feet bilaterally, toes mute bilaterally. pertinent results: 09:01pm glucose-84 urea n-53* creat-0.8 sodium-141 potassium-4.1 chloride-109* total co2-26 anion gap-10 09:01pm calcium-8.7 phosphate-3.6 magnesium-2.3 09:01pm pt-14.2* ptt-32.2 inr(pt)-1.3* 07:05pm wbc-14.9* rbc-2.63* hgb-8.9* hct-25.0* mcv-95 mch-34.0* mchc-35.7* rdw-22.7* 07:05pm plt count-122*# 02:20pm urine hours-random 02:20pm urine gr hold-hold 02:20pm urine color-yellow appear-clear sp -1.016 02:20pm urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 02:20pm urine rbc-* wbc-* bacteria-mod yeast-many epi-0 02:20pm urine granular-0-2 01:50pm glucose-96 urea n-59* creat-0.8 sodium-142 potassium-4.3 chloride-108 total co2-27 anion gap-11 01:50pm estgfr-using this 01:50pm ck(cpk)-51 01:50pm ctropnt-0.19* 01:50pm ck-mb-notdone 01:50pm wbc-12.4*# rbc-2.77* hgb-9.2* hct-27.2* mcv-98 mch-33.2* mchc-33.8 rdw-22.5* 01:50pm neuts-88* bands-0 lymphs-1* monos-7 eos-0 basos-0 atyps-1* metas-3* myelos-0 01:50pm plt count-54*# 01:50pm pt-13.4* ptt-33.6 inr(pt)-1.2* brief hospital course: in the micu, pt was found to be hit positive and was taken off all heparin products. she required numerous transfusions of prbcs but her vs never showed changes indicating hd compromise. rather, her transfusion requirements were similar to those she experienced as an outpatient. abd ct showed an enlarging splenic infarct. her mental status slowly improved over the course of her micu course such that she was responsive and more alert upon call out to the floor but still only a and o x1.1 _______________________________ #lower gi bleed - patient was initially admitted for the hospital for passing blood clots mixed with stool. she initially required multiple units of prbcs. egd done while in the unit was unrevealing for a source of bleeding. initially colonoscopy was deferred because it was thought to be of limited utility and benefit. while on the floor, the patient's hct was initially stable. she was continued on iv flagyl for her cdiff colitis, which was thought to be a possible source of her bleeding. her hct started trending down and there was noted to be a few clots and some blood mixed with the stool. she was again transfused 2 units prbcs. gi was again consulted and they decided to perform a colonoscopy to attempt to identify a source of continued bleeding. colonoscopy only showed multiple diverticuli and internal hemorrhoids, both of which were thought to be possible sources of her gi bleeding. . #recent cva and intracranial hemorrhage - before this admission, the patient had a history of multiple embolic strokes as well as an acute intracranial hemorrhage. after initial discharge from the micu, there was a question of possible anticoagulation in this patient because of concern for hit. a repeat mri was performed which showed an interval increase in embolic phenomenom as well as a subacute on chronic hemorrhage. repeat echo was performed to evaluate embolic strokes. again, no vegitations were seen on the cardiac valves and no pfo was seen. . #thrombocytopenia - there was an initial concern for hit in this patient. hematology was consulted to help with assessment for the diagnosis and determination if anticoagulation is needed. with regard to the diagnosis of hit, it is unlikely that she has this. her thrombocytopenia has been going throughout her inpatient stay at both the and hospitals. in addition, there are many confounding factors for this finding, including consecutive infections and polypharmacy (vancomycin, ciprofloxacin). furthermore, her optical density value is 0.45 and the cut-off for a positive test result is 0.40. publications support an optical density of 1.0 better for the diagnosis of hit. for these reasons, the heme service did not believe that she had hit and thus argatroban was not indicated. . #coag neg staff endocarditis - on past admission, the patient had 4/4 bottles positive for coag neg staff. tte at the time was negative for vegitations. she is being treated with a 6 week course of vancomycin. repeat echo done on current admission still did not show any vegitations. . #breast cancer - she is followed by dr. at nw. on this admission, a new area of destruction of cortex of the medial portion of the left ilium was seen on ct abd. there was a concern for possible metastatic lesions from her breast cancer verses metastatic lesions from another unknown primary source. options for further work up were discussed with dr. . these were presented to the patient's son. son relayed that his mother would not want any further treatment including both chemo or radiation. based on this desire, it was decided that no further work up of this lesion was warrented as the patient would not want treatment. . #fen - the patient has been maintained on a ng feeding tube for most of her hospital stay. a swallow study completed showed that she would be able to safely tolerate ground food and thin liquids. tube feeds were stopped and the patient was encouraged to eat. it was very difficult for the patient to sucessfully take in po, either because of neurological dysfunction or a lack of desire. the option of peg placement was discussed with the family. _____________ after discussion with the patients son who is her health care proxy, it was decided to make the patient comfort care only. all of her antibiotics and other medications not related to comfort were discountinued. she will be discharged with oral morphine for comfort. she is being discharged to a hospice facility for further care. medications on admission: 1. fluconazole 2. furosemide 3. iron supplement 4. methylphenidate 5. vanco 1g qd discharge medications: 1. methylphenidate 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. morphine concentrate 20 mg/ml solution sig: 2.5-5 mg po q2h (every 2 hours) as needed for discomfort. disp:*qs 1mth * refills:*0* 3. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual q4hr prn () as needed for secretions. disp:*qs 1mth tablet, sublingual(s)* refills:*0* discharge disposition: extended care facility: house (hospice home) - discharge diagnosis: lower gi bleed intracranial hemorrhage endocarditis cdiff colitis pneumonia deep vein thrombosis discharge condition: patient is comfort care only and will be discharged to hospice for further care. discharge instructions: patient was treated in house for multiple medical problems. after discussion with son who is patients health care proxy, it was decided to make her comfort care only. she will be discharged to hospice. followup instructions: patient will be discharged to hospice care facility. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Colonoscopy Transfusion of packed cells Transfusion of platelets Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Acute posthemorrhagic anemia Personal history of malignant neoplasm of breast Intracerebral hemorrhage Hypopotassemia Bacteremia Intestinal infection due to Clostridium difficile Acute and subacute bacterial endocarditis Anticoagulants causing adverse effects in therapeutic use Hemorrhage of gastrointestinal tract, unspecified Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Secondary malignant neoplasm of bone and bone marrow Personal history of irradiation, presenting hazards to health

allergies: heparin agents attending: addendum: please check vitals every 2-4 hours. discharge disposition: extended care facility: - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Thoracentesis Thoracentesis Infusion of drotrecogin alfa (activated) Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Anticoagulants causing adverse effects in therapeutic use Acute myocardial infarction of unspecified site, initial episode of care Other and unspecified complications of medical care, not elsewhere classified Attention to tracheostomy

allergies: heparin agents attending: chief complaint: transferred from hospital w/ ami s/p cabg, resp failure s/p trach, cva major surgical or invasive procedure: bilateral thoracenteses history of present illness: 62 y/o m with pmhx significant for hyperchol, htn developed sudden onset nausea, diaphoresis, presyncope on while in land. he was then taken to a local hospital in where he was found to have acute stemi. he was then transferred to hospital in where he had a cath which showed totally occluded left main, dz in r post descending and stenoisis of proximal lad. he immediately underwent an emergent cabg and had 6 grafts placed. on , he was extubated. soon after his extubation, he went into pea. he then had a ? embolic stroke with right sided hemiplegia with ct brain showing hypodensity in left parietal region, l external capsule region. during his postoperative period, he developed hit (started on bivalirudin) and afib (started on amiodarone drip). he was then trached on and started on dialysis on for renal failure. during his osh course, he developed low grade fevers between 100-101 with all workup being negative including blood cx, urine cx, sputum cx, ct chest/abd/pelvis although his chest xray did show lll consolidation. he was emperically started on meropenem, linezolid, diflucan and his white count started coming down and was afebrile for 24 hrs before transfer to . he was transferred to as was wished by his family with the plan to eventually transition him to a rehab. past medical history: hypercholesterolemia hypertension social history: no smoking/drinking history family history: noncontributory physical exam: 100.4, 134/69, 89, 12, 98% cpap/ps ps/peep of 15/5 tv of 575 w/ rr 15 fio2 0.4 heent: trach, ng tube, dobhoff heart: s1/s2, no mumur lungs: coarse crackles abd: distended, bs +, non-tender, no rigidity/guarding ext: no edema, ulcer on left foot, cellulitis on incision on left foot neuro: perla 5 mm, eomi, right hemiparesis, downgoing plantars bilaterally pertinent results: 10:10pm blood wbc-17.7* rbc-3.17* hgb-9.8* hct-29.5* mcv-93 mch-31.0 mchc-33.3 rdw-19.3* plt ct-414 04:35am blood wbc-8.5 rbc-2.95* hgb-9.2* hct-27.2* mcv-92 mch-31.3 mchc-33.9 rdw-17.4* plt ct-295 10:10pm blood pt-17.2* ptt-53.1* inr(pt)-1.6* 04:35am blood pt-40.9* ptt-77.3* inr(pt)-4.6* 10:10pm blood glucose-124* urean-69* creat-3.0* na-145 k-5.4* cl-108 hco3-23 angap-19 04:35am blood glucose-128* urean-63* creat-1.7* na-138 k-3.3 cl-103 hco3-25 angap-13 10:10pm blood alt-50* ast-44* ck(cpk)-930* alkphos-150* amylase-62 totbili-1.0 03:00am blood alt-36 ast-19 alkphos-128* totbili-0.5 10:10pm blood lipase-28 10:10pm blood ck-mb-3 ctropnt-6.26* 03:00am blood ck-mb-3 03:00am blood ck-mb-3 ctropnt-4.90* 05:26am blood ck-mb-4 ctropnt-2.30* 05:15am blood ck-mb-4 10:10pm blood albumin-4.1 calcium-8.8 phos-7.5* mg-3.4* cholest-109 04:35am blood calcium-8.4 phos-3.5 mg-2.5 04:15am blood %hba1c-5.5 -done -done 10:10pm blood triglyc-162* hdl-21 chol/hd-5.2 ldlcalc-56 08:03am blood type-art temp-37.4 rates-/21 tidal v-500 fio2-40 po2-111* pco2-34* ph-7.47* caltco2-25 base xs-1 intubat-intubated vent-spontaneous investigations at osh . leni: neg ueusg: chr rij dvt, superficial left cephalic vein thrombosis . r/l carotid: no evidence of stenosis . echo : -ef of 25% -trace pericardial effusion -sev lv ef -mild mr tr . ct chest : large bil pleura effusion w/ compression atelectasis in lung bases w/ diffuse pulmonic infiltrates . ct abd/pelvis (for fuo) on - l inguinal hernia w/o obstruction - diverticulosis - fluid collection in the anterior abdomial chest wall . chest - diff pulm infiltrates - bil effusions - dense lll consolidation . ct brain - no ich/mass effect - hypodensity in left parietal region, l external capsule . ekg afib @ 110/, dep in lateral leads brief hospital course: 62 m w/ htn, hyperchol p/w stemi s/p cabg, cva, resp failure s/p trach, afib, hit, arf on hd . 1) cardiac: a) coronaries: patient is s/p stemi with emergent cabg performed at hospital, 6-vessel bypass. - bb (will try maximal blockade), asa - started low-dose acei once cr =1.5 (in the setting of resolving atn) - lipitor initially started for modification of hyperlipidemia. patient had elevated cpk status-post lipitor. ck trending down with discontinuation. statin held for now; will need to be re-addressed as outpatient. . b) rhythm: h/o afib during recent hospitalization. - chads2 score undetermined (1 point definitely for htn only; unable to determine if patient has long-term chf as cardiac remodeling still in progress, no prior h/o dm, and cannot determine definitively if embolic cva related to cva) - argatroban for anti-coagulation; have now bridged to coumadin for goal inr - initially on amio gtt for rate/rhythm control -> tapered with amiodarone hcl 300 mg po bid duration x 7 days (end date ); then amiodarone 300 mg daily . c) pump: - echo: ef of 25% initially s/p mi on at osh - repeat tte on shows depressed lvef, but unable to quantify because of limited echo windows - acei, bb - diuretics prn . 2) resp failure: was intially on imv, switched to cpap/ps, now s/p trach and s/p extubation. respiratory status was further compromised by bilateral pleural effusions. pt currently able to breath with trach mask for 20-24 hours at a time but becomes subjectively dyspneic and requests cpap/ps for 2-4 hours after that; this should continue to improve. -pe unlikely, leni's were negative, although upper ext usg showed chronic rij dvt, superficial left cephalic vein thromosis - diuresed prn for pulm edema; however, patient auto-diuresed with resolving atn - thoracenteses performed under ultrasound guidance on & for large pleural effusions . 3) fevers: of unknown source, white count trending down (compared to osh). consider nosocomial pneumonia vs. drug fever. - patient managed initially on meropenem and linezolid but changed to cefepime and linezolid for vap and good response to fever; sputum cultures grew , plan for nafcillin through . . 4) stroke: presumed embolic event, consider in the differential dvt vs. hypokinetic cardiac thrombus s/p mi vs. pfo. afib seems unlikely to be the cause as the temporal relationship does not correspond, although again this cannot be determined. patient with residual right side hemiplegia which correlates with infarction of left parietal region and left external capsule region. - asa; argatroban transitioning to coumadin - per neurology consult: recommended tte to evaluate for pfo. bedside tte inadequate secondary to poor patient windows. no bubble study performed. patient sent for nuclear right vetriculogram to eval for ef but again, study inadequate. per cardiology - although unable to see pfo - treatment would be lifelong asa therapy. because patient had massive mi, he will already be on chronic asa therapy and finding of pfo would not change treatment. - bilateral ue ultrasounds: no signs of clot. . 5) acute renal failure: likely due to atn in the setting of hypovolemic shock - initially managed at osh with hd but this measure was discontinued after arrival to with resolution of arf. hd catheter pulled , tip sent for culture. - on arrival to , patient initially managed with diuril and iv lasix with good response. afterward, patient autodiuresing well. - renally dose meds; now corrected for improving renal function - acei restarted once cr =1.5. . 6) anemia: baseline hct unknown, hct stable compared to osh - transfuse for hct <28 in the setting of recent mi and chf - epo - hemodynamically stable . 7) thrombocytopenia: unclear baseline plt count; however, downward trending from 400+ on admission to to 221. consider linezolid-induced thrombocytopenia. - h/o hit per osh - confirmed that patient received no heparin flushes; documented in allergy list . 8) hyperglycemia: patient does not carry a diagnosis of dm, now with persistent hyperglycemia and requirement of ~60 units/day of insulin. initially was managed with insulin gtt; now transitioned to nph 25 units qam, 10 units qhs, plus ssi for coverage. . 9) ppx: protonix, hob elevation, pneumoboots. regarding need for anti-coagulation, patient has multiple indications, including afib (chads2 score undeterminable), embolic cva, deep vein thrombus, hit. duration of anticoagulation therapy for each of these comorbidities varies; will bridge to coumadin therapy now with argatroban, with plan to determine duration of therapy in discussion with cardiology as outpatient. . 10) fen: started on tube feeds for nutritional support. s&s study on revealed patient able to tolerate pureed solids and thin liquids. po intake very slow at first and patient unable to meet caloric requirements; tube feeds continued while advancing diet. replete electrolytes to maintain k>4, mg>2. - aspiration precautions - if pt able to continue advancing diet over next week or two, would favor tapering tube feedings and resuming normal diet. if not able to maintain caloric intake, will need peg, but pt appears able to tolerate increasing po diet for now, so hopefully will avoid peg with dobhoff for now. . 11) access: picc (repositioned ), dialysis catheter (discontinued ), aline (discontinued ) . 12) code status: full . contact: wife - (h: , c: ) medications on admission: medicatons at home asa mva meds on transfer from osh carvedilol 6.25 mg amiodarone gtt angiomax novolin r iss asa 325 protonix 40 mg iv diflucan 200 mg q4 alumin linezolid 600 mg q12 senna docusate ferric gluconate niacin lipitor 10 meropenem 1g q12 . prn meds albuterol lorazepam lopressor zofran dilaudid discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 3. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 4. warfarin 2 mg tablet sig: two (2) tablet po hs (at bedtime). 5. amiodarone 200 mg tablet sig: 1.5 tablets po daily (daily) for 7 days. 6. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). 7. albuterol sulfate 0.083 % solution sig: one (1) inhalation inhalation q6h (every 6 hours) as needed. 8. insulin nph human recomb 100 unit/ml suspension sig: as dir subcutaneous twice a day: 25units qam and 10units qpm. 9. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). 10. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 11. nafcillin in d2.4w 2 g/100 ml piggyback sig: two (2) grams intravenous q6h (every 6 hours) for 5 days. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p coronary artery bypass grafting perioperative embolic stroke heparin induced thrombocytopenia ventilator associated pneumonia discharge condition: fair discharge instructions: take all medications as directed. followup instructions: call your pcp for an appointment within one week of leaving rehab. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Thoracentesis Thoracentesis Infusion of drotrecogin alfa (activated) Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Anticoagulants causing adverse effects in therapeutic use Acute myocardial infarction of unspecified site, initial episode of care Other and unspecified complications of medical care, not elsewhere classified Attention to tracheostomy

allergies: lisinopril / nsaids / nesiritide attending: chief complaint: shortness of breath major surgical or invasive procedure: hd history of present illness: ms. is a 86f with h/o colon cancer, esrd on hemodialysis, diastolic chf, pulmonary hypertension, and prior cephalic vein thrombosis who presented to the ed on with dyspnea. the patient's dialysis catheter became dislodged . consequently she missed her normal dialysis session . on she had a new tunneled catheter placed, but was not dialyzed. the afternoon of her daughter noticed that the patient seemed increasingly dyspneic and was hypertensive to 200's. she was given hydralazine and clonidine and the bp improved to 160's. she called her daughter ~3am on due to worsening dyspnea. the patient denies any accompanying headache, vision changes, chest discomfort, palpitations, nausea, vomiting, cough, weakness or loss of sensation. ems was called, and she was given cpap with some relief of her dyspnea. per her daughter, similar symptoms have occurred 3 times in the past. in the ed her vitals were bp 258/61 rr 28 o2 100% on cpap, 89% on room air (temperature was not recorded). she was started on a nitroglycerin drip, and given calcium and bicarbonate for a potassium of 7.1. she was weaned off nippv, with o2 saturation of 97% on 3l nc. she was subsequently transferred to the icu for further monitoring and dialysis. past medical history: 1) hypertension 2) stage v chronic kidney disease, followed by dr. . 3) diastolic chf (ef 60% on tte in ), likely volume related in the setting of her renal disease. 4) rheumatic fever, with the following valvular abnormalities: mild aortic stenosis, moderate aortic regurgitation, mild mitral stenosis, mild to moderate mr, mild tr. 5) severe pa systolic hypertension 6) renal artery stenosis: mri atrophic r kidney, moderate stenosis of r renal artery, l renal artery normal. 7) peripheral vascular disease: has claudication. 8) right cephalic vein dvt in 9) colon cancer in , status post resection. 10) hyperlipidemia 11) right bundle branch block 12) anemia of renal failure 13) osteoarthritis 14) osteopenia 15) glaucoma social history: lives at home, usually alone, but recently the daughter has moved in with her. she does not smoke, drink alcohol, or use iv drugs. family history: mother- htn physical exam: t 98.2 p 50 bp 196/76 o2 97% on 2l rr 24 general: pleasant elderly woman in no acute distress cv: regular rate s1 s2 ii/vi sem at rusb with i/vi diastolic decrescendo murmur as well at rusb pulm: lungs with crackles at bases bilaterally, no wheezes or rhonchi. r chest with tunneled catheter. abd: soft, nontender, +bs extrem: warm and well perfused, no edema neuro: alert and answering questions appropriately, moving all extremities pertinent results: 07:45am blood wbc-8.1 rbc-3.86* hgb-11.7* hct-34.8* mcv-90 mch-30.3 mchc-33.6 rdw-18.6* plt ct-180 05:00am blood neuts-91.0* bands-0 lymphs-5.1* monos-2.7 eos-1.0 baso-0.2 07:45am blood pt-11.5 inr(pt)-1.0 07:45am blood glucose-106* urean-82* creat-6.2*# na-141 k-5.8* cl-106 hco3-23 angap-18 05:00am blood ctropnt-0.09* 05:13am blood type-art po2-440* pco2-35 ph-7.38 caltco2-22 base xs--3 05:00am urine color-yellow appear-clear sp -1.009 05:00am urine blood-neg nitrite-neg protein-100 glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 05:00am urine rbc-0-2 wbc-0-2 bacteria-occ yeast-none epi-0-2 cxr findings: ap view of the chest on upright position. the cardiac silhouette cannot be evaluated on this ap view. the right-sided central venous catheter is unchanged. the left costophrenic angle is blunted consistent with pleural effusions. left lung base atelectasis are noted. there is no evidence of pneumothorax. there is a right lung base opacity obscuring the right-side cardiac border which may represent right middle lobe atelectasis vs. pneumonia. pprominence of the pulmonary vasculature is noted, consistent with mild chf. the osseous structures are unchanged. impression: 1. right middle lobe atelectasis vs. pneumonia. 2. mild chf with small left- sided pleural effusion. ekg sinus bradycardia at 56bpm, left axis, old rbbb, peaked t's that are new compared to ekg. inverted t in v3 on ekg has flipped to positive. no signs of acute ischemia. brief hospital course: 1. dyspnea - the patient's dyspnea was thought to be secondary from volume overload, occuring in the context of esrd and a missed hemodialysis session, as well as hypertension leading to flash pulmonary edema. her dyspnea following hemodialysis. 2. hypertension - the patient's hypertension is also likely related to volume overload. her blood pressures improved following dialysis and resumption of her home course of toprol, clonidine, amlodipine, and hydralazine. 3. hyperkalemia - the patient's potassium normalized following dialysis. 4. esrd - renal following, on dialysis mwf. 5. fen - continue sevelemer, nephrocaps. medications on admission: 1. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. sevelamer 800 mg tablet sig: two (2) tablet po tid (3 times a day). 4. calcium acetate 667 mg capsule sig: three (3) capsule po tid w/meals (3 times a day with meals). 5. clonidine 0.1 mg tablet sig: three (3) tablet po tid (3 times a day). 6. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 7. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 10. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). discharge medications: 1. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. sevelamer 800 mg tablet sig: two (2) tablet po tid (3 times a day). 4. calcium acetate 667 mg capsule sig: three (3) capsule po tid w/meals (3 times a day with meals). 5. clonidine 0.1 mg tablet sig: three (3) tablet po tid (3 times a day). 6. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 7. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 10. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: home with service facility: caretenders discharge diagnosis: primary: hyptertensive emergency secondary: diastolic chf esrd discharge condition: stable, shortness of breath relieved discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: followup instructions: provider: , m.d. date/time: 8:30 -cont hd on mwf md, Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease End stage renal disease Congestive heart failure, unspecified Primary pulmonary hypertension Personal history of malignant neoplasm of large intestine Diastolic heart failure, unspecified

allergies: lisinopril attending: chief complaint: diarrhea major surgical or invasive procedure: none history of present illness: mrs. is an 84 yo f h/o cri, htn, gerd, colon ca, neprhotic syndrome, dc'd after low anterior resection of colon. now p/w 1wk h/o diarrhea worsened one day prior to admission, found to have wbcc 30 in ed, admitted and started on both p.o. vanco and iv flagyl. began to have brbpr on , on had flex sigmoidoscopy showing pseudomembranes with recurrent c.diff vs. bowel ischemia as etiology. then developed some sob/fluid overload and was started on lasix and neseritide gtt's. had had some intermittent afib which was thought to be contributing to presumed diastolic dysfunction. tx to ccu for worsening tachypnea and oliguria on nesiritide and lasix gtt. was cardioverted chemically with good result. also developed acute on chronic renal failure for which nephrology has been following, zenith of 6.0, now back at baseline creatinine of 2.0's. past medical history: recent admission to from to for treatment of likely viral gastroenteritis, pna, transaminitis, discharged to rehab in - ras: mri () atrophic r kidney, mod stenosis of r renal artery, l renal artery normal - cri/nephrotic range proteinuria: baseline cr 2.5; followed by dr. (nephrology) - pvd/claudication - nephrotic range proteinuria - gerd - htn: poorly controlled (sbp in 200s), echo ef >55%, mod ar, mild mr, ascending aorta mildly dilated, abdm aorta mildly dilated, ao valve leaflets mildly thickened - hyperlipidemia - total chol 255 (), ldl 138 (), hdl 31, (), tg 312 () - glaucoma - rheumatic fever - anemia - - mid 30s - hyperkalemia - osteoarthritis - osteopenia social history: living alone independently prior to last hospitalization. several children and grandchildren in the area who are involved in her care. denies alcohol or tobacco use. family history: noncontributory. physical exam: tm 95.7, bp 108/50, p 93, r 25, 98% ra perrl. op clr jvp not appreciable. regular s1,s2. no m/r/g lca b/l +bs. soft. nt. nd. 2+ lower and upper ext edema pertinent results: admission labs: . cbc: wbc-41.4*# rbc-4.35 hgb-13.0 hct-37.5# mcv-86 mch-29.8 plt 167 diff: neuts-93.1* bands-0 lymphs-5.6* monos-1.1* eos-0.1 basos-0.2 . chem 7:glucose-81 urea n-64* creat-4.1*# sodium-135 potassium-5.1 chloride-103 total co2-20* anion gap-17 albumin-1.8* calcium-7.3* phosphate-4.0 magnesium-2.0 . lfts: alt(sgpt)-10 ast(sgot)-24 alk phos-150* tot bili-0.4 . ct: 1. extensive pan colitis consistent with the clinical diagnosis of c-dif colitis. there is no evidence of toxic megacolon or perforation or abscess. 2. new small bilateral pleural effusions. 3. small amount of ascites. . right ij central line with the tip in the right atrium. no evidence of pneumothorax. . micro: cdiff : negative cdiff : negative cdiff : negative cdiff : negative cdiff : negative * blood cx : negative urine cx : <10,000 organisms brief hospital course: 84 yo f w/ h/o cri, htn, h/o nephrotic syndrome, w/ diarrhea, c.diff pos at rehab, failure to respond to flagyl, w/ elev wbc, and negative ct. a brief-problem based hospital course is outlined below. 1) presumed c.diff infxn- admitted and started on p.o. vancomyin and iv metronidazole, w/ addition of levofloxacin for broad spectrum coverage given recent abd surgery. cholestyramine was initially given for toxin binding. wbc was 30 on admission and trended down with abx; however, c.diff toxin neg x5, so diagnosis remains presumptive. c. diff b toxin was sent and was negative as well. she completed a 3 week course of po vanco and iv flagyl antibiotics, which was completed on . she subsequently remained afebrile without further diarrhea, and was able to tolerate po's. 2) pt began having episodes of brbpr on with resultant slow hct drop. gi and surgery were consulted. pt had no abdominal pain, but given recent surgery and low albumin, we were concerned that the bleed may be evidence of ischemic bowel or dehiscence. pt was also having intermittent episodes of tachycardia, raising the possibility that she was having embolic phenomena with acute ischemia. however, she had no abdominal pain to suggest this. colonoscopy was done on , showing severe c dif vs. ischemic bowel. surgery found that pt was not surgical candidate and believed her bleeding and mucosal damage was c dif and would continue to improve. biopsy results showed no evidence of c.dif, but given pt's tenuous status, po vanco and iv flagyl were continued while awaiting toxin b. it is quite possible that the mucosal changes seen on colonoscopy were the result of c dif infxn, which had been treated w/abx and resolved, leaving the mucosae to heal. as well, gi felt there may be a superimposed ischemic insult. no further work-up was performed since she had good clinical resolution of her colitis, following completion of cdiff treatment. 2) acute renal failure w/ cri- renal team was consulted on admisison. baseline cr is approx 2.0. on admission this was significantly elevated to 4.1. fena was c/w prerenal etiology and patient had r ij placed in ed, started on ns for volume resusciation. this was undertaken slowly given that pt had an albumin of 1.4 and pleural effusions were noted on ct. fluids were changed to 1/2ns w/ bicarb on hd2. cr trended down each day and the patient has maintained oxygenation. alb/cr ratio not c/w nephrotic range proteinuria- thus it was felt that the low alb was likely multifactorial. pt initially required boluses of 500cc ns to maintain uop ~20-30cc/hr. with hydration and improvement in her diarrhea, her cr steadily decreased and returned to baseline of 1.6. she was seen by renal who felt that her increase in creatinine may have been secondary to atn/hypotension and recommended avoiding aggressive overdiuresis. she did subsequently require aggressive diuresis given her rapid afib/chf with lasix and niseritide drips. however her creatinine remained at baseline of 1.7-2.0 with diuresis. she did develop a transient metabolic alkalosis, which was felt likely from volume contraction alkalosis. therefore her lasix was weaned to 40mg daily and her bicarb trended back down to 30. her creatinine was stable at 1.6 at the time of discharge. 3) pt was noted to be mildly thrombocytopenic on admisison. unclear why it was low when patient presented. most likely extreme inflammatory/sirs response (given elev lactate on admission). her plt count dropped to 95 and dic workup and hit ab were sent, both negative. her plt count rose as her clinical condition improved and remained in normal range for the duration of her hosital course. 4) htn - pt's baseline sbp is in the 180s-200s range. on admission, bp was low 3rd spacing and early sepsis. her bp responded to fluids and she remained relatively normotensive. she was continued on metoprolol for hr/bp control and isordil/hydral was added for afterload reduction. 5) chf - evidence of chf on initial cxr. her ef was found to be 40% (previously normal), bringing up concern for ischemic event precipitating her failure. in support of this she was noted to have wall motion abnormalities on echo with inferoseptal/basal hypokinesis. diagnostic catheritization was not performed due to her renal insufficiency and decompensated chf. she was managed medically, and on the chf service was consulted for management. she was initiated on aggressive diuresis with iv lasix for goal -1.5l per day. she was transferred to the ccu briefly on for more tailored therapy and diuresis for her chf (lasix boluses and nesiritide) with good effect (negative approximately 500 cc overnight). she was transferred back to the floor on lasix boluses. due to continued evidence of volume overload she was given 160mg iv + started on lasix drip at 10mg/hr. then started nesiritide (1mcg/kg) followed by gtt at 0.01mcg/kg/min. diuresed well to this and maintained bp well, however after increasing natrecor to 0.015, went back into rapid afib. stopped natrecor on . stopped lasix gtt on given persistent good diuresis. now tapered down to 40mg daily lasix/day + afterload reduction w/ isordil/hydral on . at the time of discharge, she was felt to be euvolemic with goal of matching ins and outs daily. we will continue her on this regimen upon discharge. 7. atrial fibrillation: initially converted from raf by medical cardioversion performed with procainamide gtt in the ccu at 13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. became hypotensive to 60's systolic, but subsequently recovered. then again went into raf on early am. initially hr controlled w/ iv lopressor/iv dilt. then medical cardioversion w/ procainamide. became hypotensive to 70's systolic after about 10 minutes on procainamide , this was stopped and her blood pressures normalized. she then converted 10 min later to nsr. she has been in nsr the remainder of her hospital course. she is not on coumadin due to risk for bleed. in addition, amiodorone was discussed as a medical option for continued rythm control. however, given the side effect profile, the family and patient were more comfortable with holding off on adding amiodorone at this time. they understand that there is a higher risk of conversion back to atrial fibrillation and increased risk for stroke without amiodorone. we will continue rate control with metoprolol as mentioned at 25mg tid, and may titrate up as needed to maintain hr <80. 8. cad- wall motion abnormalities on echo w/ inferoseptal/basal hk. currently chest pain free. continuing with medical management. on statin/b-blocker. no plan for cath at this time given her renal insuff/co-morbiditites. also holding off on aspirin currently given her bleed risk. this will be re-addressed as an outpatient through her pcp . . 9. anemia- initially had episode of gi bleed with blood loss anemia requiring 3 units of packed red blood cells. hematocrit subsequently normalized. however, she subsequently was noted to have a low, but stable, hematocrit at 28-29. repeat stool guaiacs were all negative and she had no further evidence of bleed or hemolysis. iron stores were also found to be within normal limits, with low tibc and high ferritin suggesting anemia of chronic disease. this was felt likely secondary to chronic renal insufficiency. she was started on epo 2,000 units q m,w,fr on . the goal transfusion criteria would be 30 given her history of cad, however, we have held off on further transfusion at this time given her known chf with recent severe volume overload. we have set transfusion goal at hct>28, and transfused with 1 unit packed red blood cells and 20mg iv lasix for hct <28. 10. tachypnea- resolved. her transient tachypnea was felt likely secondary to volume overload. there was no evidence of infiltrate by cxr. her abg at the time on showed 7.29/43/99. her respiratory status subsequently improved that same day on following iv lasix and atrovent nebulizers. avoided albuterol nebulizers over concern for tachycardia. 11. f/e/n- started on tpn for nutritional supplementation. she also had a swallow study which showed ability to tolerated regular solids and thin liquids. she has been taking in po's as tolerated, but has continued to require tpn to reach nutritional goals. this will be continued upon discharge at rehab. medications on admission: aspirin 81mg--one by mouth every day calcium --one tablet three times a day clonidine hcl 0.1 mg--4 tablet(s) by mouth twice a day colace 100mg--take one pill twice a day as needed for constipation lasix 20 mg--1 tablet(s) by mouth once a day lopressor 50mg--one half tablet by mouth twice a day nizoral 2%--use as directed norvasc 10mg--one by mouth every day phoslo 667mg--two tabs three times a day with meals per renal pletal 50mg--as per dr tylenol/codeine no.3 30-300mg--one tablet by mouth q 6 hours as needed for pain ultram 50mg--one half tablet by mouth twice a day as needed for leg pain vitamin d unit--one tablet q week discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever, pain. 2. brimonidine tartrate 0.15 % drops sig: one (1) drop ophthalmic q8h (every 8 hours). 3. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 4. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for dry nasal mucosa. 5. albuterol sulfate 0.083 % solution sig: one (1) inhalation q3-4h () as needed. 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 7. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). 8. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 9. loteprednol etabonate 0.5 % drops, suspension sig: one (1) ophthalmic daily (). 10. brinzolamide 1 % drops, suspension sig: one (1) ophthalmic (2 times a day). 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 12. famotidine 20 mg tablet sig: one (1) tablet po daily (daily). 13. hydralazine hcl 25 mg tablet sig: one (1) tablet po tid (3 times a day). 14. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). 15. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 16. epoetin alfa 2,000 unit/ml solution sig: one (1) ml injection qmowefr (monday -wednesday-friday). discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1. rapid atrial fibrillation 2. congestive heart failure (ef 40%) 3. hypotension 4. gastrointestinal bleed 5. coronary artery disease 6. refractory c.diff 7. non-healing surgical wound 8. deconditioning 9. malnutrition 10. contraction alkalosis 11. chronic renal insufficiency discharge condition: stable. discharge instructions: you are being discharged to rehab. please follow-up with dr. 1-2 weeks after discharge from rehab. followup instructions: please follow-up with dr. 1 week after discharge from rehab. you may call to make an appointment at Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of large intestine Transfusion of packed cells Injection or infusion of nesiritide Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Unspecified protein-calorie malnutrition Atrial fibrillation Candidiasis of mouth Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Atherosclerosis of renal artery Intestinal infection due to Clostridium difficile Personal history of malignant neoplasm of large intestine Hemorrhage of gastrointestinal tract, unspecified Diastolic heart failure, unspecified

allergies: penicillins / naproxen / dilantin attending: chief complaint: feces on walls major surgical or invasive procedure: hemodialysis hd line placement re-suturing of permacath site history of present illness: 47 yo female with hiv, hep c, hepatic encephalopathy, presented to er for smearing feces on the wall. notes from nursing home state rash started , blood shot eyes and low grade temps. pt states rash is itchy but not painful. per family members, rash started at least for 1 wk. rocephin started recently ?date, d/c . pt denied any new meds, but is not a reliable historian. pt recent admit at hosp for grand mal seizure, also admit at hosp on for abd pain. in , pt passed a large amount of foul smelling green diarrhea, guaiac + stool and ms has improved. stool was sent for c-diff and various stool cx. bcx sent. ct head ordered. past medical history: 1. hepatitis c cirrhosis-genotype 1, vl 6,500,000 . incomplete treatment trial with ifn/ -, stopped due to neutropenia 2. esophageal varices- egd-varices at the gastroesophageal junction, grade i 3. h/o hepatic encephalopathy with multiple admissions for this 4. hiv-(- vl>100,000 copies, cd4 233)- was off of avr therapy since late but restarted a few months ago 5. renal failure secondary to diabetes 6. diabettes mellitus 7. gerd 8. chronic pancreatitis 9. htn 10. cholecystectomy social history: no current smoking, alcohol, no drug use. the patient has a prior history of heavy alcohol use and has not drank in over a year. 25-pack-year smoking history. prior history of cocaine use/ivdu but quit many years ago. pt was homeless but now lives at a nursing home. family history: mother with type 2 diabetes. physical exam: 98.4 78 107/70 18 99%ra gen: aa female lying in bed in dark, refused to have lights on due to 'lights bothers me', my eyes hurts. heent: conjunctiva injected bilat, lips with erosions and crust, palate with erythematous lesions. neck: slightly stiff, no lad, no jvd cv: reg rate, s1 s2, +harsh systolic murmur loudest at rusb abd:+distension, +occasional spider angioma, +dullness to percussion laterally over abd, +tenderness ruq&over epigastrum,nr/no mass, no pulsation ext: +2 le pitting edema with diminished dp pulses. neuro: lethargic, eye exam difficult due to covered with lots of pus. oriented to person and place. not cooperative. skin: diffused erythematous lesions including palms and soles with red macules and papules, some lesions excoriated; some lesions on leg non-blanching. pertinent results: cxr: no radiographic evidence of acute cardiopulmonary process. 03:54pm glucose-83 urea n-61* creat-3.7* sodium-134 potassium-3.4 chloride-106 total co2-17* anion gap-14 03:54pm alt(sgpt)-19 ast(sgot)-47* alk phos-135* amylase-395* tot bili-0.6 03:54pm lipase-123* 03:54pm albumin-1.9* calcium-6.9* phosphate-3.9 magnesium-1.3* 03:54pm acetone-neg 03:54pm phenytoin-9.8* 03:54pm wbc-8.5 rbc-2.77* hgb-8.9* hct-26.5* mcv-96 mch-32.1* mchc-33.5 rdw-18.4* 03:54pm neuts-41* bands-2 lymphs-20 monos-32* eos-1 basos-1 atyps-3* metas-0 myelos-0 03:54pm hypochrom-normal anisocyt-1+ poikilocy-1+ macrocyt-occasional microcyt-occasional polychrom-normal target-occasional burr-occasional teardrop-occasional 03:54pm plt smr-low plt count-113* 03:54pm pt-14.2* ptt-36.8* inr(pt)-1.4 05:21pm ammonia-50* 04:00pm lactate-1.8 . micro studies: urine pend blood cx , pend eye swab: gram stain 2+pmns, no microorg, virus neg. bacterial cx appears to be cancelled. respiratory culture viral cx negative hsv viral swab oropharynx negative for hsv csf: negative cryptococcus, neg fluid cx, viral cx, fungal cx, with gram stain showing no pmns and no microorganisms. . punch biopsy, skin left anterior thigh: vacuolar interface dermatitis with pigment laden scale, scattered epidermal civatte bodies, edema, and superficial dermal pigment incontinence. no epidermal necrosis is seen in this sample, however there is a focal early subepidermal split. the findings are consistent with an interface-type reaction including an interface-type drug reaction and/or a lesion along the spectrum of erythema multiforme/ syndrome. . mri head : 1. right parietal lobe lesion with susceptibility and questionable adjacent tiny area of enhancement, corresponding to the lesion seen on the patient's prior ct study of . this likely represents a small focus of hemorrhage versus a vascular malformation. . cxr impression: 1. right ij line is in good position. there is no pneumothorax. 2. focal opacity at the left costophrenic angle consistent with atelectasis or infiltrate. 3. eighteen millimeter nodule seen in the left mid lung field, which was in a different position on a prior study from . if clinically indicated, further evaluation with a chest ct is recommended. . ct torso : heart size mildly enlarged, tunnel dialysis cath in proximal ra; no hilar lad, bibasilar lad, no pulm nodules; small left pleural effusion; liver/gb/spleen/bowel unremarkable; suggstion of renal disease; no osseous lesions; large amount of ascites . ct head : tiny high attenuation focus representing hemorrhage unchanged from with small amt of edema; also area of high attenuation below r parietal bone but image limited by motion and is likely motion artifact but new subdural bleed cannot be excluded . xray l/t/s spine: no fracture . ct head repeat : intraventricular hemorrhage in the r occipital . . ct head : interval increase in degree of hemorrhage present within the septum pellucidum and layering within the lateral ventricles bilaterally with stable appearance of right centrum semiovale foci of hemorrhage. . ct head : findings: hemorrhage within the septum pellucidum is unchanged when compared to prior study. the blood within the occipital horns of the lateral ventricles is also unchanged. the ventricles are stable in size since the prior study. there is no evidence of hydrocephalus. again noted is a small focus of hemorrhage in the right centrum semiovale which is unchanged when compared to the prior study. impression: stable appearance of the head. stable hemorrhage within the septum pellucidum and within the lateral ventricles. no new hemorrhage identified. . ct head findings: there is a new area of high density in the anterior interhemispheric fissure extending on both sides of the anterior falx cerebri. some of this may be subdural in nature, but it appears to largely represent subarachnoid blood. it is layering along the right a1 portion of the anterior cerebral artery. ventricular dimension is unchanged. impression: new anterior interhemispheric hemorrhage with features as discussed above. this hemorrhage may be in continuity with the septal hematoma superiorly, but this is indefinite. . brief hospital course: a/p 47 yo female with hiv, hep c, hepatic encephalopathy, presented to er for change mental status and rash, found to be syndrome based on clinical impression with supporting skin 4mm punch biopsy. pt then seemed to develop a fibrinogen defect causing ivh and resulting in 2 micu transfers for iv amicar. . #ivh: pt fell off ir table on , resulting in r eye hematoma and laceration. pt was taken immediately for ct head and neck. c spine was negative for fracture. she had no c spine ttp, so c collar was removed. pt did have lumbar and thoracic spinous process tenderness so xray of spine was ordered. on read of head ct, there was the old subcortical small bleed and ?new r parietal bleed vs motion artifact. xray of spine was negative for fracture. repeat head ct showed the ?subdural bleed was an artifact, but there was a new area of intraventricular hemorrhage in the r occipital . heme onc was contact and recommended iv amicar (given it was felt the pt had a fibrin related defect), neuro agreed. the pt was transferred to the micu for iv amicar for 24 hrs at 0.2 gm/hr after an initial 1 gm loading dose. she was also given cryoprecipitate. repeat ct head on revealed interval increase in degree of hemorrhage present within the septum pellucidum and layering within the lateral ventricles bilaterally with stable appearance of right centrum semiovale foci of hemorrhage. neurosurgery at this time felt the pt had no evidence of hydrocephalus and no obstruction of her 3rd and 4th ventricles (thus there was no further intervention). the pt was started on metoprolol 25 mg and hydralazine 25 mg po qid to maintain sbp less than 140 (pts sbp was up to 160 on ). repeat ct head on revealed stable appearance of the hemorrhage in the lateral ventricle. the pt was again transferred to the floor on with repeat head ct on . the pt found to have a new area of high density in the anterior interhemispheric fissure extending on both sides of the anterior falx cerebri. the pt was given plt to maintain above 100, vit k for inr of 68, and cryoprecipitate to maintain fibrinogen levels greater than 200. she was again transferred to the micu for iv amicar infusion while patient was intubated as she was somnolent and unable to protect her airways. patient's neurological status continued to deteriorate and she remained unresponsive. patient's family decided to make the patient dnr/dni and she was extubated. patient remained apnic after extubated and comfortable on morphine drip. she expired on . . #. ams: her mental status intially appeared to have returned to her baseline after a large bowel movement in the ed. lp was clear essentially ruling out meningitis, especially hsv meningitis. she was initially mostly clear mentally, but at times seems to have short-term memory difficulty. however, neuro was concerned that pt was becoming more encephalopathic so her lactulose was titrated up to 45 q 8 hr prn for 2 bm per day. following her ivh on , the pts mental status declined, at times only responsive to painful stimuli and not following commands. patient remained in sub-optimal mental status with acute worsening after re-bleeding discovered on . . # bleeding diathesis: neuro felt that the small rounded density seen in subcortical white matter on head ct from was not a hemorrhage, but needed to be evaluated by mri head w/ contrast and susceptibility series given her hiv history. mri was c/w small hemorrhage vs vascular malformation. this finding was not alarming until the pt developed a subsequent bleed in the pineal region on , further evolution of bleed on , and new vs extension of bleed into the anterior interhemispheric region. in addition the pt underwent permacath placement for hd , complicated by persistent oozing at site. initially it was felt her catheter was oozing secondary to a mechanical complication. however, the pt subsequently developed oozing from her l thigh bx site and bleeding from her nose (). the ddx of the continued bleeding included mechanical,low plt count, plt dysfunction, and coagulopathy esld and crf. vwf screen was neg, but in setting of multiple blood products. factor viii was wnl. dic labs (fibrinogen nl) and coags wnl. pt received 30 mcg ddavp x3 on , cryo x1 on , ffp on bag plt , 2 bag plt/10 ug ddavp/30 ug ddavp , 30 ug ddavp on , and plt plus cryo on . she was taken to ir x 1 with suture placement and dressing, taken back at 3am for persistent ooze, given silver nitrate cautery, with hemostasis. general surgerywas called, and sutured permacath site on , resutured it for persistent bleed. pt was taken to ir on with thrombin injected around permacath site and new sutures placed. on pt was taken to ir to examine the permacath for leak, but the pt fell off ir table and further workup was haulted. heme/onc was consulted for the pts bleeding, and it was felt pts bleeding may be secondary to functional fibrinogenemia in the setting of esld (fibrinogen prior ot receiving ffp/cryo this admission was in the 100s). per heme/onc recs, topical amicar was applied to the pts permacath and thigh bx site, achieving temporary hemostasis. the pts depakote was also discontinued on given that depakote has been noted to cause bleeding in the setting of surgery. once the pt was noted to have a new intraventricular hemorrhage in her r occipital on , the pt was started on iv amicar per heme/onc recs for emergent bleeding, and the pt was transferred to the unit. please see above for further course of her ivh. . #. conjunctivitis: the pt was noted to have bilateral conjuncitivitis with mucopurulent discharge bilaterally. ophthalmology was consulted for further management in this hiv positive patient. her conjunctivitis was originally concerning for neisseria gonorrhea per ophthalmology, cx swab sent, gram stain sent (not done, cancelled test) and viral cx found to be negative. given possible severe allergy to pcn and ceftriaxone and possibly levoflox, we curbsided id, and the pt received 6 days of po azithromycin, with erythromycin eye drops. however, on physicial exam pt still with mucopurulent discharge, and bilateral conjuncitivits. since she was not improving, ophtho recommeded starting polysporin ointment. her mucopurulent discharge resolved on polysporin. on , the decision was made to stop po azithromycin. artifical tears was ordered for the pt as well. the pt received polysporin ointment qid in house and after d/c she was ordered artificial tears q 6 hr prn. the pt is to follow up in clinic after discharge. . #. rash: dermatology was consulted in the ed and felt that this rash was consistent with a syndrome due to levofloxacin, ceftriaxone, or dilantin. less likely to be caused by oral hsv, and pt was initially tx with iv acyclovir, which was subsequently discontinued. her skin punch biopsy in the anterior left thigh revealed vacuolar interface dermatitis with pigment laden scale, scattered epidermal civatte bodies, edema, and superficial dermal pigment incontinence, with no epidermal necrosis, a focal early subepidermal split. the findings are consistent with an interface-type reaction including an interface-type drug reaction and/or a lesion along the spectrum of erythema multiforme/ syndrome. hsv culture of the erosions present in the patient's mouth were negative for hsv. iv acyclovir was initially started empirically, then discontinued, as it was felt that the risk of nephrotoxicity outweighed the ?benefit. rocephin, levaquin, and dilantin were held. per derm, all aromatic anti-convulsants (dilantin, carbamezapine, phenobarbital) should not be given as they cross-react. the pt experienced improvement over a several day course using the following treatments: triamcinolone ointment 0.1% over affected area, bacitracin topically to vulvar erosions., for mucosal lesions and mouth pain- ordered lidocaine mouthwash prn. . # crf: on admission the pt had a left av fistula in place, not yet mature. crcl is <10 so renally dose meds. pt started hd on . received 2 units prbcs and . received another unit prbc on and on . calcitriol, nahco3 (will be corrected in hd) were discontinued. . #. ?history of seizure disorder neuro was consulted for . given history of childhood seizures, pt is at risk for further seizures, although we did have her records from . neuro recommended discontinuing dilantin, and the pt was started depakote 250mg po bid. this was titrated up to 250 mg tid and was subsequently discontinued once it was overlapped with keppra for 2 days (depakote was discontinued in the setting of bleeding as per above, and due to her liver disease). the pt was then continued on keppra. . #fever: pt spiked temp 101 on night of and , low grade temp on subsequent nights. unclear . u cx, c diff neg. cxr had ? lml nodule and possible lll loculated effusion, however ct torso from shows no nodule (nipple shadow on cxr apparently) and small bl pleural effusions, no acute intrab process. pt also c/o diarrhea at this time, but likely due to sjs. pt has large ascites and mild mid-ab pain, but sbp unlikely and pt at risk for bleeding with paracentesis. ua, urine cx, stool cx, and blood cx were all repeated on for continued low grade fevers. a component of the pts ivh could have also been contributing to her fever at that time. . #. elevated pancreatic enzymes: the pt has known chronic pancreatitis, with her enzymes at baseline levels. the pt is currently off haart which has been attributed in the past to causing her pancreatitis. ct torso on was negative for signs of pancreatitis. . 8. anemia: recent anemia w/u consistent with anemia of chronic dz, likely from renal failure. given also has guaiac positive stool, gib is another source though no overt bleeding. patient received 2 units prbcs in hd , 2 units prbcs after hd. baseline 22-25. . #h/o hepatic encephalopathy: no clear signs of encephalopathy during hospitalization. pt showed no asterixis. increased ascites on us of abdomen . patient was continued on lactulose. . #hiv/hepc: off haart therapy since last admission in contributing to elevated pancreatic enzymes. last cd4 was 233 in . also coinfected with hepc, hep b negative. will hold on haart at this time in setting of bleed. last cd4 135 with cd4/cd8 ratio of 0.2. the pt was started on atovaquone for pcp on . . 9. fen: renal heart dm diet. replete all lytes. . 10. ppx: ppi, lactulose, pneumoboots (holding heparin given guiac + stool, low plt) . 11. code: full code -> dnr/dni-> cmo medications on admission: ceftriaxone (d/c ) insulin dilantin (according to notes was not on this ) levaquin colace protonix lactulose calcitrol phoslo bicitra discharge medications: none discharge disposition: extended care discharge diagnosis: 1. altered mental status 2. syndrome 3. end-stage renal failure on hemodialysis 4. conjunctivitis bilateral eyes 5. human immunodeficiency virus 6. hepatitis c 7. cirrhosis 8. type ii diabetes mellitus discharge condition: deceased discharge instructions: none followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Transfusion of packed cells Other incision of skin and subcutaneous tissue Closed biopsy of skin and subcutaneous tissue Transfusion of other serum Transfusion of platelets Transfusion of coagulation factors Diagnoses: End stage renal disease Obstructive hydrocephalus Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic hepatitis C with hepatic coma Acquired coagulation factor deficiency Other convulsions Unspecified fall Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Defibrination syndrome Long-term (current) use of insulin Chronic pancreatitis Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Hydantoin derivatives causing adverse effects in therapeutic use Acute conjunctivitis, unspecified

allergies: penicillins / naproxen attending: chief complaint: ? seizure, delta ms major surgical or invasive procedure: lumbar puncture and history of present illness: 47 year old female with hep c cirrhosis, hiv ( cd4 >1000, vl>916,000), type ii dm, and recently diagnosed chronic renal failure presents following possible seizure. her boyfriend reports that earlier today, he noted that, when she was giving herself insulin her right hand began shaking for a few minutes. she was also complaining of a mild frontal headache, relieved with ibuprofen. boyfriend left the pt at 6am this morning. both pt's mother and boyfriend attempted to call the pt at 10am then at 11am, but pt did not respond to the phone. after returning from work at 3:45 p.m., her boyfriend found her unconscious and covered in stool/urine; she later opened her eyes, but did not seem to recognize him. no known fevers, chills, uri symptoms, abdominal or urinary symptoms. she was brought to the ed, where t 99.8, hr 112, bp 178/101, resp 20 96% 2l nc. she was noted to have eye deviation to the left with nystagmus, followed by deviation to the right with nystagmus. she received ativan 4 mg iv x 1 with resolution of eye deviation. given shallow breathing and diminished gag, she was intubated for airway protection. . the patient was recently admitted after she presented with decreased uop, increased le edema, and increased abdominal girth and was found to be in subacute renal failure (bun 64/5.1). exam/laboratory studies were c/w nephrotic syndrome, and a renal u/s showed lg echogenic kidneys with nl perfusion. initially, her symptoms were fel to be c/w hiv-associated nephropathy. renal bx was c/w diabetic nephropathy +/- iga nephropathy. she was aggressively diuresed with good response; her cr declined to 4.2 at time of discharge. past medical history: 1) hiv diagnosed : off haart since ; cd4 1065 2) hepatitis c: genotype 1; liver bx c/w stage iv fibrosis; s/p ifn and ribaviran , stopped secondary to neutropenia - egd grade i varices at ge jxn, portal htn gastropathy 3) type ii dm: hgba1c 5.4 4) asthma 5) glaucoma 6) h/o pancreatitis 7) h/o etoh abuse social history: no current smoking, alcohol, no drug use.the patient has a prior history of heavy alcohol use and has not drank in over a year. 25-pack-year smoking history. cigarettes daily now. the patient admits to a prior history of cocaine use/ivdu but quit 10 years ago. the patient works at a fast food restaurant. she lives with her boyfriend and son in . family history: mother with type 2 diabetes. physical exam: tc 99.8, hr 92, bp 175/87, resp 18, 100% ac tv 500, rr 16, fio2 0.6 peep 5; abg 7.41/32/223 gen: middle-aged african amirican female, intubated, sedated, not responsive to verbal or tactile stimulus. heent: perrl, anicteric, nl conjunctiva, ommm, ogt in place, ett in place, neck supple, no lad, no jvd cardiac: rrr, no m/r/g appreciated pulm: scatterred ronchi throughout, minimal crackles at bases bilaterally abd: nabs, soft, nt, mildly distended ext: 2+ le edema to knees bilaterally, extremities warm with 1+ dp bilaterally skin: scatterred petechiae over lower extremities bilaterally neuro: moves all 4 extremities in response to noxious stimuli, brisk dtr throughout, toes downgoing bilaterally, normal tone. pertinent results: urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg type-art 7.41/32/223 lactate-2.1 ammonia-84 glucose-108* urea n-55* creat-4.4* sodium-136 potassium-5.7* chloride-109* total co2-20* anion gap-13, alt(sgpt)-30 ast(sgot)-111* alk phos-123* amylase-415* tot bili-0.8, lipase-78*, albumin-2.0* calcium-7.8* phosphate-6.0* magnesium-1.3* wbc-6.0 rbc-3.55* hgb-11.0* hct-33.6* mcv-95 mch-31.1 mchc-32.8 rdw-17.4*, neuts-69 bands-1 lymphs-23 monos-6 eos-0 basos-1 atyps-0 metas-0 myelos-0 nuc rbcs-1* ekg sinus tachycardia, rate 109. probable left atrial abnormality. compared to the previous tracing of sinus tachycardia and left atrial abnormality are new. ct head w/o contrast no intracranial hemorrhage or mass effect. spinal fluid negative for malignant cells. lymphocytes and monocytes. mri/mra head 1. multiple lesions with high t2 signal in the periventricular and subcortical white matter of the cerebral hemispheres bilaterally, which appear nonspecific but may represent infection, chronic microvascular ischemia, or demyelinating disease. 2. flow in all major tributaries of the circle of on otherwise limited mra. cxr improved consolidation with residual consolidation in the posterior basilar segment of the right lower lobe. ct head there is no acute intracranial hemorrhage, mass effect, or shift of normally midline structures. the ventricles are stable in size. there are new small bilateral low density fluid collections over the frontal convexities. abd ultrasound 1. no findings suggestive of acute cholecystitis on ultrasound. 2. questionable subcentimeter area of focal thickening in relation to the anterior gallbladder wall, which could be followed up at interval with focused ultrasound. 3. no intra-abdominal ascites for paracentesis. csf negative for malignant cells. lymphocytes, monocytes, and red blood cells. eeg this is an abnormal routine eeg obtained in stage ii sleep progressing to stage iii sleep with brief periods of wakefulness due to the presence of sharp and spikes bifrontally, left more than right. in addition, the patient is excessively drowsy and sleepy. this finding could either be due to a previous sleep deprivation or could be a medication overdose effect. this can be seen in context of high blood levels of antihistamines, albuterol. no seizure activity recorded. brief hospital course: 47 y/o aaf with pmh significant for hiv, hepatitis c, cirrhosis, type ii dm, htn, and most recent hospitalization for subacute renal failure (dm nephropathy +/- iga nephropathy), presents with altered mental status. 1. mental status changes while her initial mental status changes were thought to be due to hypoglycemia (glucose on admission was 36), the differential regarding this remains broad. acyclovir and levofloxacin, as well as sedatives she was given in the icu may have contributed to her ms given her poor renal and hepatic clearance (propofol, d/c on ; morphine, dosed 2mg on , and ?amt on ). she was also found to have aspiration pneumonia, which also may have aggrevated her mental status. initially, following transfer from the icu, her mental status improved and was thought to be secondary to medications over her stay . hepatic encephalopathy is still a possibility, with her elevated ammonia (84 umol/l), but was not encephalopathic during previous hospital stay and did not receive lactulose at that time; she received lactulose throughout this admission. similarly, uremic encephalopathy was also considered although her bun today was 70, and at prior admission, she was not encephalopathic though in arf with elevated bun/cr. delirium tremens was also considered, however her history and speaking with her family speaks against this. her family states that she did not drink from the time she was discharged to her admission. the time frame was off given her stay in the micu for delerium tremens, and her symptoms were not consistent with this. in addition, a ppd was planted and read as negative on . finally, an htlv1/2 was found to be negative, suggesting her high cd4 count of >1000 did represent true immunocompentency, as htlv1/2 infection can give a false impression of a high cd4 count. two lps failed to reveal a cause for her change in ms, such as active meningitis, thus nondiagnostic. at discharge, crypto was negative but jcv, cmv, and toxo were pending. at discharge, the patient was afebrile, her renal biopsy site was resolving well, her wbc on was 11.2, and she was alert, oriented to person, place and time, and appropriate. . 2. hypovolemic hypernatremia over the course of her admission, the patient had a gradually rising sodium, which peaked at 151 on . this was likely iatrogenic and resolved when she was removed from restraints and put on clears. her sodium normalized at discharge to 137. . 3. ?holosystolic/?outflow tract heart murmur when the patient was hypovolemic, she was found to have a systolic murmur, heard best in the l upper sternal border. prior echo () and repeat echo () revealed no valvular abnormalities, no vegetations. the murmur was judged to be an outflow tract murmur, given the patient's low volume status. the murmur was no longer present on exam at discharge on . . 4. pneumonia: on admission, the patient was intubated in ed for airway protection. she was extubated after her mri but then became hypercarbic likely secondary to volume overload. the patient was diuresed and placed on bipap for one day. upon transfer from the icu, she continued to be stable on room air but was running a low grade fever and did have a chest xray consistent with rll aspiration pneumonia with possible lul pneumonia. she was placed on levofloxacin/flagyl. a repeat cxr on showed improvement in the rll consolidation. given her mental status changes, she was switched from levofloxacin to clindamycin for the final two days of her course. at discharge, she was afebrile and her lung exam was clear to ascultation. . 5. possible seizure: the patient's initial presentation on admission was consistent with a seizure (lateral eye deviation, stool/urine incontinence). the differential diagnosis considered in a patient with hiv, hepc, cirrhosis and dm2 was broad and included hypoglycemia, hepatic encephalopathy, renal encephalopathy, hiv-associated encephalopathy (20% of hiv encephalopathy is first presentation of symptomatic disease), toxins, withdrawal (given her polysubstance abuse), malignancy (lymphoma or primary or secondary tumor) vasculitidites (mixed cryos, microscopic polyarteritis, primary cns vasculitis), hemmorhagic stroke, or oi with hiv (including toxo, crypto, tb, listeria, pml). her mri/mra showed an increase in t2 signal in periventricular and subcortical white matter of both cerebral hemispheres. these findings were nonspecific but consistent with infection, chronic microvascular disease, or demyelinating disease. hypoglycemia, given the boyfriend's history, was considered most likely. alcohol withdrawal may have also precipitated the initial event or the hypoglycemia, but was considered less likely given her recent hospital stay. hepatic or uremic encephalopathy are still possibilities (given mri findings) but may be contributing to her ongoing mental status changes more than precipitating her acute event. the mri showed no mass effect or bleed, ruling out tumor or hemmorhagic stroke. her cd4 count remains high at +1000 (despite her high viral load of 916,000) making hiv encephalopathy still a possibility but any oi unlikely. an eeg during admission was consistent with no epileptiform activity. she was found to be hsv negative on , ppd negative on , htlv1/2 negative on , and crypto negative on . two lps, on and , were negative for polys and microorganisms on gram stain. tte on and showed no vegetiations, with the remainder of the study normal. jcv, cmv and toxo from lp were pending at the time of discharge. . 6. hip/flank pain most likely secondary to hematoma following renal biopsy, visualized on abdominal ct () as 2.7 by 4.8 cm lesion. per id's recommendation, a unilateral hip x-ray was conducted on and showed no evidence of osteomyeolitis. . 7. leukocytosis the patient was started on levofloxacin/flagyl on for rll infiltrate seen on cxr and increasing wbc (see above). the levofloxacin was switched to clindamycin for the 2 remaining days of the course. . 8. renal failure recent progression of cr from 1 to 5 with evidence of nephrotic syndrome. creatinine on discharge was 3.2. pathology from renal biopsy consistent with diabetic nephropathy and possibly iga nephropathy. . 9. hypertension the patient's hypertension was well-controlled over admission. she maintained on metroprolol 37.5 mg po tid, lisinopril 5mg po daily, and restarted on her furosemide 40mg on discharge. . 10. non-ag metabolic acidosis etiologies include diarrhea, type i or type iv rta (given positive uag), renal failure. the patient's acidosis was stable over the course of this and last admission. . 11. diarrhea c. diff negative, judged likely related to hiv . 12. anemia during her last admission, the patient's anemia and iron studies were consistent with anemia of chronic disease. her hematocrit was stable over this admission and discharged at 26.5%. . 13. thrombocytopenia over course of prior admission found to be ttp/hus negative. most likely secondary to liver disease. currently stable and discharged with platelet count of 68. . 14. hep c cirrhosis her ammonia level was found to be 84 on but fell to 40 on . she received lactulose over the course of her admission. hepatic encephalopathy may have been contributing to patient's change in mental status, however she was not receiving lactulose during her entire previous admission, and was not encephalopathic therefore unlikely casue of her delta ms. . 15. code: full code medications on admission: 1) quinine 650 mg po qhs prn 2) reglan 10 mg po bid 3) albuterol 2 puffs q6h prn 4) flovent 2 puffs 5) pantoprazole 40 mg po daily 6) lisinopril 5 mg po daily 7) oxycodone 10 mg po bid prn 8) furosemide 40 mg po bid 9) insulin discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*qs 1 mdi* refills:*2* 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for wheezing. disp:*qs 1 mdi* refills:*2* 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 5. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 6. lasix 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: 1. change in mental status 2. seizure, likely secondary to hypoglycemia 3. aspiration pneumonia 4. chronic renal insufficiency with diabetic nephropathy and iga nephropathy 5. hiv 6. hepatitis c 7. cirrhosis 8. type ii diabetes mellitus 9. asthma 10. anemia of chronic disease 11. hypertension 12. thrombocytopenia discharge condition: good discharge instructions: please go to the ed if you feel confused, disoriented, have palpitations, chest pain, nausea or vomiting. please follow up with pcp as soon as possible (see below for instructions.) followup instructions: 1. please follow up with pcp . at . please call this number as soon as possible to schedule an appointment. 2. provider: , md where: lm center phone: date/time: 9:30 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Thrombocytopenia, unspecified Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Anemia, unspecified Unspecified essential hypertension Unspecified viral hepatitis C without hepatic coma Hematoma complicating a procedure Asthma, unspecified type, unspecified Other convulsions Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Acute respiratory failure Cachexia Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Insulins and antidiabetic agents causing adverse effects in therapeutic use Hepatic encephalopathy Hyperosmolality and/or hypernatremia Asymptomatic human immunodeficiency virus [HIV] infection status

history: baby girl was born on as the 1655 gram product of a 31 week gestation pregnancy to a 34 year old gravida iii, para 0 to i mother with estimated date of confinement of . prenatal laboratory studies included blood type a positive, antibody negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune and group b strep unknown. maternal history notable for clomid assisted pregnancy. the pregnancy was complicated by preterm premature of membranes on , leading to maternal admission to the hospital and maternal treatment with antibiotics and betamethasone. mother developed increasing abdominal pain on the day prior to delivery leading to concerns for infection and prompting induction of labor. delivery was by cesarean section secondary to arrest of dilatation. mother did receive several doses of antibiotics just prior to delivery. infant emerged vigorous with apgar scores of 7 and 8 and was brought to the neonatal intensive care unit on oxygen. initial physical examination: initial examination was notable for a weight of 1655 grams, length of 39 cm, and head circumference of 28.5 cm. examination revealed a well developed premature infant overall consistent with 31 to 32 weeks gestational age. infant exhibited moderate respiratory distress with increased work of breathing and coarse breath sounds. hospital course by systems: 1. respiratory: infant was initially placed on cpap for evidence of hyaline membrane disease. however, secondary to increased oxygen requirement, the infant was intubated at approximately six hours of age and then received a total of two doses of surfactant. the infant did well and was extubated to cpap at 24 hours of age. infant remained on cpap until day of life four at which time she was weaned to room air. the infant has remained on room air since that time without significant evidence of respiratory insufficiency. the infant did exhibit mild evidence of immaturity of respiratory control with occasional apnea, bradycardia and desaturation episodes. the infant was not treated with caffeine and these episodes gradually resolved over time. the infant has not had an apneic or bradycardic episode at rest for approximately two weeks by the time of discharge. the patient did exhibit evidence of discoordination with feedings with occasional desaturations and bradycardic episodes during feeds; however, these also improved by the time of discharge. the infant had no feeding related events for five days. 1. cardiovascular: the infant remained hemodynamically stable throughout admission. the infant did not exhibit hypotension or significant concerns for a patent ductus arteriosus. intermittent murmur was heard over the course of the hospitalization; this was not evaluated in detail and a murmur was not present by the time of discharge. 1. fluids, electrolytes and nutrition: the infant was maintained on intravenous fluids and then begun on parenteral nutrition. enteral feedings were introduced on day of life 2 and were advanced without difficulty. the infant received a parenteral nutrition for a total of five days and reached full enteral feedings by day of life number seven. calories were subsequently increased to a maximum caloric density of 28 calories per ounce of breast with added promod. the feedings were initially given by gavage tube with oral feedings gradually introduced and advanced as tolerated. with excellent weight gain caloric density of breast milk was slowly decreased. by the time of discharge the infant is being given 24 calories per ounce made with similac powder, taking it all by mouth with total intake of 150 to 180 cc per kilogram per day with excellent weight gain. recent growth parameters include weight of 2785 (inc 60g) on , head circumference of 33 cm on and length of 47.5 cm on . electrolytes were periodically monitored throughout admission and remained within normal limits. the infant is on vi-daylin at the time of discharge, 0.1 cc by mouth q. day. 1. hematology/infectious disease: a cbc and blood culture were sent on admission. cbc included a white count of 14.5 thousand with a differential of 23 percent neutrophils and 0 percent bands. the hematocrit was 48.2 and platelet count was 392. the infant was begun on ampicillin and gentamicin; these were discontinued after 48 hours with a negative blood culture and overall benign clinical course. on day of life six an abrasion to the back of the right leg was noted with a small amount of surrounding erythema concerning for early cellulitis. sputum stain growth culture were sent; blood culture returned negative. infant was treated with five days of antibiotics initially with vancomycin and gentamicin and then with keflex with prompt resolution of the lesion. no further infectious disease issues were noted throughout the hospitalization. the infant was begun on iron after reaching full feeds and continues on supplemental iron at the time of discharge. the last hematocrit was on and was 34 percent with a reticulocyte count of 2.6 percent. 1. neurology: the patient has had a normal neurologic examination throughout admission. a head ultrasound on day of life nine was normal. a repeat ultrasound on day of life 29 was also normal. initial ophthalmology examination on revealed immature retinas in zone 3; a follow up examination on revealed mature retinas without evidence of retinopathy. follow up was recommended in nine months. 1. other: the infant was noted to have developed two small hemangiomas over the course of hospitalization. one is on the scalp is the other is on the left leg. these are small hemangiomas approximately 1 to 3 mm in size and have not changed significantly during the hospitalization. 1. routine health care maintenance: the infant received hepatitis b vaccination on . the infant received the first dose of synagis on . the infant passed a hearing screen on . the infant passed a car seat placement test on . newborn screenings have been sent per protocol with the last one done on and have been unremarkable to date. 1. discharge physical examination: weight on was 2725 grams. general: the infant is a well developed premature infant in no distress. the infant is comfortable and active with examination. fontanelles are soft and flat. sutures are appropriately apposed. palate is intact. ears and nares are normal. red reflex is present bilaterally. lungs are clear to auscultation with minimal evidence of increased work of breathing. cardiac examination is regular rate and rhythm without murmur or gallops. abdomen is soft and nontender with active bowel sounds. a small umbilical hernia is present. genitalia was that of normal female without rash or lesions. hips and back are normal. tone and activity are appropriate. moro, grasp and suck reflexes are intact. two small hemangiomas are noted over the scalp and left leg. discharge medications: 1. vi-daylin 1 cc by mouth once a day. 2. fer-in- 0.2 cc by mouth once a day. discharge disposition: the infant is being discharged to care of parents. follow up will be with a visit two days after discharge and with a primary medical doctor visit three days after discharge. primary pediatrician is dr. at pediatrics. the following immunizations are recommended: 1. synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: 1) born at less than 32 weeks. 2) born between 32 and 35 weeks with two of the following risk factors: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age sibling. 3) with chronic lung disease. 2. influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home care givers. discharge diagnoses: 1. prematurity at 31 5/7 weeks gestation. 2. respiratory distress syndrome, resolved. 3. sepsis evaluation, resolved. 4. left leg cellulitis, resolved. 5. hemangiomas of scalp and left leg. 6. apnea of prematurity, resolved. , md dictated by: medquist36 d: 11:53:26 t: 14:19:27 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,500-1,749 grams Hemangioma of skin and subcutaneous tissue 31-32 completed weeks of gestation Cellulitis and abscess of leg, except foot Umbilical hernia without mention of obstruction or gangrene

history of present illness: the patient is a 59 year old female who suffers from insulin dependent diabetes, hyperlipidemia and chronic renal failure. she was found to have a pancreatic mass and was referred to dr. office for surgical management. she initially presented to her primary care physician after being evaluated for liver function tests which were initially found to be elevated and were felt to be due to the starting of lipitor. the statin was subsequently discontinued, however, the elevated lfts remained. on workup she had a right upper quadrant ultrasound and that revealed a mass in the head of the pancreas. this was done in when patient had no complaints of any abdominal symptoms. because of her history of chronic renal insufficiency, she was subjected to a ct scan without contrast that revealed a mass in the head of the pancreas as consistent with ultrasound findings. this mass appears to be necrotic and over 5 cm in size. there also appears to be pathologic retroperitoneal lymph nodes at the level of the pancreas. because of the limits of these studies, she subsequently, in , had an open mri which revealed a 7.4 x 5.2 cm mass in the region of the head of the pancreas with mild enhancement. there were also noted bilateral periaortic adenopathy inferior to and at the level of the renal veins. subsequent ct guided fine needle aspiration fracture was performed which was reported as positive for malignant cells consistent with adenocarcinoma. it was at this point that she was referred to for further management and second opinion. review of systems: essentially patient was always in her usual state of health, although she noted slight fatigue over the past several months, but attributed this to her chronic renal insufficiency and her diabetic status. she is also chronically anemic. she denied history of fever, chills, night sweats, weight loss, cough, chest pain, shortness of breath, abdominal pain, change in bowel habits or change in her urine or stool color. there was no rash, jaundice or swollen lymph nodes. she had a very good appetite. it is of note that she is markedly obese. she also reported that she probably gained some weight in the last year. past medical history: as outlined above. allergies: she is reporting allergy to levaquin and intolerance to the statin class of medications. outpatient medications: include insulin, avapro, synthroid, metoprolol, lasix, erythropoietin. social history: she denied tobacco use and drank alcohol rarely. family history: there is no significant family history of cancer. hospital course: after thorough evaluation including more mr scans and extensive calls between dr. and the patient, she was admitted for a scheduled whipple procedure on the day of admission. on the day of admission patient was taken to the o.r. for a scheduled planned resection of pancreatic mass with whipple procedure. intraoperatively a large mass was found in the center of the pancreas. therefore, a central pancreatomy was performed with roux-en-y pancreaticojejunostomy and open cholecystectomy. blood loss was estimated at 500 cc and patient received 9 liters of crystalloid during the operation. she was moved to the pacu in stable condition, extubated. postoperatively patient made average 20 cc per hour in urine output. her systolic blood pressure was between 100 to 120 for several hours, which was lower than her baseline. she was bolused with normal saline for approximately 2 liters. on post-op day one she was transferred to the intensive care unit for management of her fluid status. over the next several days her renal function started to worsen. her creatinine increased from 3.4 to peak at 5.4 on postoperative day six. renal service was consulted on postoperative day one and these findings were attributed to the transient hypoperfusion of the kidneys and with proper fluid management, her creatinine has been stable and trending down. she has remained afebrile and with her blood pressure returning to her baseline of 130s. she was successfully transferred to the floor on postoperative day eight. subsequently she started to pass flatus and her diet was gradually increased. she tolerated p.o. intake. her serum amylase was stable at 14. her amylase from the drain was also stable at 13 on postoperative day 12. her output from urine was adequate. there was approximately 130 cc of fluid draining from her drain on postoperative day 12. given that she was tolerating p.o. intake well, the drain was discontinued on and her foley was also discontinued on the same day. she continued to improve physically. by the day of discharge she was able to ambulate with a walker. she took an adequate amount of p.o. intake. of note, on postoperative days one to six she was in the intensive care unit and tpn was initiated for three days to increase her nutritional status, which was subsequently discontinued one day after she was transferred to the floor. given that she tolerated the procedure well and recovered well, she is discharged to home with vna services. according to the renal service recommendations, she was discharged without an ace inhibitor. discharge medications: 1. dilaudid 1 mg q.four to six hours as needed. 2. tums one tablet t.i.d. 3. reglan 10 mg q.six hours p.r.n. 4. levothyroxine 75 mcg q.day. 5. metoprolol 25 mg b.i.d. 6. epogen 10,000 units three times per week. her insulin regimen was initiated by the jocelin consulting service with glargine 36 units q.bed time and humalog sliding scale to cover her daily need for insulin. pathology findings from the samples taken intraoperatively showed an endocrine cell neoplasm on the pancreas sample. there was no invasion with free margins of tumor. the tumor expressed cytokeratin and also expressed glucagon and also synaptophasin. it does not express chromogranin gastrin insulin or somatostatin. condition on discharge: good. discharge status: to home with services. , m.d. dictated by: medquist36 Procedure: Cholecystectomy Anastomosis of pancreas Other partial pancreatectomy Diagnoses: Other and unspecified hyperlipidemia Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Chronic cholecystitis Malignant neoplasm of body of pancreas

history of present illness: an 81-year-old male with no history of hypertension or diabetes complaining of chest tightness and shortness of breath on exertion. he had an exercise tolerance test at an outside hospital and was positive and subsequently was catheterized on . the catheterization, in summary, showed an ejection fraction of 55%, left main 85% stenosis, left anterior descending artery was normal, circumflex had 90% stenosis, right coronary artery had 40% stenosis. please see catheterization report for full details. catheterization was done the hospital. the patient was subsequently transferred to for coronary artery bypass grafting. past medical history: the patient had no significant past medical history. past surgical history: past surgical history only significant for hemorrhoidectomy. allergies: he has no know allergies. medications on admission: medications prior to admission included aspirin 325 mg p.o. q.d., atenolol 25 mg p.o. q.d., and altace 5 mg p.o. q.d. physical examination on admission: heent revealed pupils were equally round and reactive to light. neurologically, alert and oriented times three. chest was clear to auscultation bilaterally. heart had a regular rate and rhythm, s1 and s2. no murmurs. no rubs. abdomen was soft, nontender, and nondistended. his extremities revealed no edema. laboratory data on admission: sodium 140, potassium 4.4, chloride 104, bicarbonate 27, bun 18, creatinine 0.8, glucose of 221. cholesterol 42. blood cell count was 7.4, hematocrit 39, platelets 230. ptt 23, pt 12.6, inr 1.1. hospital course: on hospital day two, the patient was brought to the operating room where he underwent coronary artery bypass grafting times three. please see the operative report for full details. in summary, the patient had coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending artery, and saphenous vein graft to right coronary artery, and saphenous vein graft to the obtuse marginal. 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 had a mean arterial pressure of 79, a central venous pressure of 16. he was in a normal sinus rhythm at 82 beats per minute. he had an arterial line and a central venous pressure catheter, two atrial pacing wires, two mediastinal, and a left pleural chest tube. at the time of transfer, the patient's only intravenous medication was a neo-synephrine drip. in the immediate postoperative period the patient did well. he was weaned off of all vasoactive drugs. his anesthesia was reversed. he was weaned from the ventilator and extubated shortly after arrival to the cardiothoracic intensive care unit. he remained hemodynamically stable overnight, and on the morning of postoperative day he was transferred from the intensive care unit to far six for continuing postoperative care and cardiac rehabilitation. on postoperative day two, the patient had an episode of atrial fibrillation with a ventricular response rate of 90 to 100 beats per minute. he maintained a blood pressure of about 100/70 during these episodes. he was treated initially with lopressor and was subsequently started on oral amiodarone, after which he converted to a normal sinus rhythm. on postoperative day three, the patient experienced an episode of confusion following the administration of percocet. as part of the workup for his confusion, he was seen by the psychiatry service who thought it was postoperative delirium, and he had a head ct which was read as negative, and he had a negative metabolic workup as well. he has had no further episodes of confusion since the narcotics were discontinued. over the next two postoperative days the patient remained hemodynamically stable. he was deemed to be ready for discharge to home on postoperative day five. condition at discharge: at the time of discharge, the patient's was stable. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to right coronary artery, and saphenous vein graft to obtuse marginal. 3. hypertension. 4. hypercholesterolemia. physical examination on discharge: the patient's physical examination at the time of discharge revealed vital signs with heart rate 70 sinus rhythm, blood pressure 126/74, respiratory rate 14, oxygen saturation 94% on room air. weight preoperatively was 68.8 kg, at discharge was 70.1 kg. physical examination revealed he was ambulating in room without difficulty. alert and oriented times three. moved all extremities. cardiovascular examination revealed a regular rate and rhythm, s1 and s2. lungs were clear to auscultation bilaterally. the abdomen was soft and nontender with positive bowel sounds. last bowel movement on . the sternal incision was well approximated with steri-strips. no erythema along the wound margins. in the past there had been a small amount of serous drainage from the sternal wound; however, there was none present on the day of discharge. right leg incision with steri-strips was intact, open to air, and well approximated. laboratory data on discharge: laboratory data on revealed a blood cell count of 11.7, hematocrit 24.3, platelets 355. sodium 139, potassium 3.9, chloride 101, bicarbonate 29, bun 27, creatinine 0.9, and glucose was 102. medications on discharge: 1. metoprolol 25 mg p.o. b.i.d. 2. furosemide 20 mg p.o. q.d. times seven days. 3. potassium chloride 20 meq p.o. q.d. times seven days. 4. ranitidine 150 mg p.o. b.i.d. times two weeks. 5. aspirin 81 mg p.o. q.d. 6. amiodarone 400 mg p.o. t.i.d. times two days; then 400 mg p.o. b.i.d. times seven days; then 400 mg p.o. q.d. 7. ibuprofen 400 mg p.o. q.6h. p.r.n. for pain. discharge status: the patient was to be discharged home with to come into his home. die followup: he was to have followup with dr. in three to four weeks and follow up with his primary care physician in three to four weeks. , 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 Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Unspecified transient mental disorder in conditions classified elsewhere

allergies: vancomycin hcl/d5w attending: chief complaint: anuria major surgical or invasive procedure: none history of present illness: 84 vent-dependent m with copd, chf, cad, as, afib, recent prolonged hospitalization for chf complicated by spontaneous retroperitoneal hematoma, referred from vent facility for fevers, altered mental status, and hypoxia/difficulty ventilating, as well as anuria. on the day prior to admission pt, was reportedly febrile, hypoxic on his vent, and alternately agitated and lethargic. cultures were sent and pt received 2 units prbcs on for hct 26, also kayexalate for k 6.1. has grown vre (e faecalis) in blood cultures sent , for which he is on linezolid at care; sputum cultures have grown enterbacter cloacae (sensitive to imipenem, genta, tobra, and amikacin). he became anuric and was transferred to . . in ed, initial vs 99.2, 140/80, 85, abg 7.04/97/60 after bagging in ambulance. labs remarkable for arf with hyperkalemia, rx'd with calcium, insulin + glucose, bicarb. foley placed, pt remained anuric; gu confirmed foley in decompressed bladder. cxr showed opacified l hemithorax--started levo/vanc. abd also distended and tender. surgery consulted and ct thorax obtained, which showed large l pleural effusion, large ascites; surgery did not think any acute surgical pathology. when returned from ct, pt in afib/rvr to 190s. past medical history: 1.aortic stenosis (moderate aortic valve stenosis by echo; aortic valve area 1 cm squared. maximal gradient of 42, with a mean gradient of 26) 2.pvd s/p r fem- bypass 3.carotid artery disease 4.copd 5.htn 6.paraganglionoma diagnosed during ex-lap in 7.s/p tracheostomy, vent dependent 8.s/p peg-j social history: past history of tobacco use, none in past 25 years, no alcohol, no drug use. has been living at vent facility almost one month family history: nc physical exam: 98.5 127/37 59 20 92% on ac 650x20, 40% fio2, 8 peep gen: grimaces to painful stimulus, does not follow simple command heent: nc/at, perrl but sluggish, will not track to allow assessment of eom, poor dentition neck: trach, jugular veins appear flat chest: rhonchorous on l, bronchial breath sounds on r cv: heart sounds obscured by breath sounds abd: marked distension, healing midline surgical scar, peg/j in epigastrium with bilious drainage around site. dull to percussion back/ext: skin tear under l shoulder blade. coccygeal ulcer with eschar and surrounding erythema. #+ pitting edema to mid-thighs skin: thin, weeping skin on arms, with skin tear on l wrist pertinent results: 05:45pm wbc-14.7* rbc-4.00*# hgb-12.5*# hct-38.1*# mcv-95 mch-31.3 mchc-32.9 rdw-16.7* 05:45pm neuts-91.4* bands-0 lymphs-7.2* monos-0.9* eos-0.3 basos-0.1 05:45pm plt smr-normal plt count-155 05:45pm pt-11.1 ptt-23.9 inr(pt)-0.9 05:45pm glucose-112* urea n-140* creat-3.7*# sodium-140 potassium-10.4* chloride-107 total co2-21* anion gap-22* 05:45pm alt(sgpt)-57* ast(sgot)-110* alk phos-107 amylase-110* tot bili-1.4 05:45pm lipase-81* 05:45pm albumin-2.4* calcium-8.4 phosphate-9.8*# magnesium-3.6* 06:00pm lactate-2.1* 06:45pm type-art tidal vol-650 peep-5 o2-100 po2-68* pco2-60* ph-7.22* total co2-26 base xs--4 aado2-599 req o2-96 -assist/con cxr: there has been interval near complete opacification of the left hemithorax when compared to the previous exam. there is apparent slight shift of the mediastinum to the left, indicating a component of volume loss/collapse, possibly secondary to a mucus plug. there is most likely an associated left-sided pleural effusion. the right costophrenic angle has been clipped from the film. the visualized right lung appears within normal limits. the pulmonary vasculature within the right lung is within normal limits. the tracheostomy tube and percutaneous gastrostomy tube appear in unchanged positions. ct abd/pelvis: 1. resolving retroperitoneal hematoma extending along the left posterior pararenal space inferiorly to the left groin. 2. large left-sided pleural effusion with associated atelectasis and collapse of the left lower lobe. small right-sided pleural effusion. 3. large amount of ascites and anasarca. 5. mildly thickened loops of small bowel with evaluation limited by ascites and lack of intravenous contrast. the appearance is similiar to the prior examination. the findings are likely secondary to anasarca. ischemia cannot be completely excluded, especially given the appearance of the heavily calcified sma and close clinical correlation is advised. ruq ultrasound with doppler to assess portal vessels: 1. significantly shrunken liver with nodular contour and increased echogenicity consistent with cirrhosis. significant amount of ascites is also identified. the main portal vein and hepatic veins demonstrate normal flow pattern. 2. cholelithiasis with no evidence of cholecystitis. brief hospital course: 84m with as, cad, copd, vent dependent, now with likely acinetobacter vap, also enterecoccus bacteremia, and oliguric renal failure . # respiratory: trach/vent dependent; continued ventilation to keep sats >90%. l >> r pleural effusion--l effusion was last drained one month ago (3.5l removed) and has reaccumulated, likely sympathetic from ascites. as long as able to oxygenate well, would not drain urgently. maintained copd on alb/atro, inhaled steroids, and continued methylprednisolone with plan to taper. . # cardiovascular: chronic problems include: - as by last echo, so would avoid sudden volume shifts as patient is likely very pre-load dependent - afib--rate controlled with metoprolol . # acute oliguric renal failure, oliguric: cr bumped from 1.0 a month ago to 2.0 three days ago and now up to 3.7. urine lytes showed fena 11%, most likely atn according to renal consultant. renal team offered dialysis to patient's family, but explained that with his other significant co-morbidities, dialysis would not be likely to change his overall prognosis, and healthcare proxy decided that dialysis would not be in keeping with patient's wishes. . # gi: ascites: pt is not known cirrhotic, so cause of cirrhosis not clear, although his chf and hypoalbuminemia. low albumin state vs portal htn. should have diagnostic tap in am (has not had paracentesis before). tense ascites have displaced his peg, contributing to the leak of bilious fluid from the peg site and most likely also contaminating the peritoneum. not clear if this was the source of enterococcus bacteremia, but covered with abx as below. - elevated ast/alt--could be drug effect, infection, shock liver as patient was reportedly hypotensive - chemical pancreatitis--ct did not reveal pancreatitis . # id--reportedly febrile yesterday; wbc 14 with 91% polys, cultures from osh growing vre in blood and enterobacter in sputum. resent blood, urine, sputum cultures. for now, continue ampicillin for enterococcus; enterobacter was sensitive to imipenem (although not tested for meropenem) and aminoglycosides but no others, will use meropenem since less seizure risk in renal failure. . # skin--breakdown on coccyx as well as upper back, and thin skin on arms with tears and ecchymoses. -air bed, wound consult. . # code--full, per daughter ( ]); pt has girlfriend who has been very involved in his care ( ). after several discussions of the futility of additional interventions such as dialysis in the setting of his numerous comorbidities and the low likelihood that he would survive any surgery to address the dehisced peg and peritonitis, his family agreed he would want to focus the goals of his care on comfort. he was made cmo and expired shortly thereafter. medications on admission: apap 650 prn morphine 2mg iv q3 prn albuterol inh 6 puffs q4h ipratropium inh 6 puffs q4h calmoseptine top dakin's solution top xenaderm top colace 100mg + senna fluticasone 110mcg x2puffs imipenem cilastatin 500mg iv q12 cefepime 1gm daily insulin nph (dose not stated) + ssri isordil 20mg tid lansoprazole 30mg daily linezolid 600mg methylprednisolone 40mg q12 metoprolol 75mg tid simvastatin 20mg daily terazosin 2mg daily discharge medications: n/a discharge disposition: expired discharge diagnosis: # enterococcus bacteremia # enterobacter ventilator acquired pneumonia # peritonitis # trach # peg # paraganglionoma # aortic stenosis (moderate aortic valve stenosis by echo; aortic valve area 1 cm squared. maximal gradient of 42, with a mean gradient of 26) # pvd s/p r fem- bypass # carotid artery disease # copd # htn discharge condition: expired discharge instructions: n/a followup instructions: n/a md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other cystoscopy Diagnoses: Acidosis Hyperpotassemia Pneumonia due to other gram-negative bacteria Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Aortic valve disorders Peripheral vascular disease, unspecified Acute and chronic respiratory failure Bacteremia Pressure ulcer, lower back Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Tracheostomy status Dependence on respirator, status Unspecified peritonitis Status of other artificial opening of gastrointestinal tract

allergies: vancomycin hcl/d5w attending: chief complaint: sob/doe major surgical or invasive procedure: evacuation of retroperitoneal hematoma excision of periaortic lymph nodes ligation of repair of iatrogenic splenic lac history of present illness: 84 yo man w/ h/o as, copd, pvd who p/w sob/dyspnea. pt is a poor historian, but per pt, describes decreased functional status over sub-acute time course, with decrease mobility/increased sedentary lifestyle over at least past 1 month due to increased sob/doe. pt states has had "more difficulty" with his breathing over this past month, describes sob at rest and with exertion, to point where he became too uncomfortable so came to ed. otherwise denies cp/pressure, orthopnea, pnd, lower extremity edema, f/c, cough. he presented to with these complaints and was found to have t 99.4, hr 100 (sinus), rr 40-50, bp 165/56, o2 84-86% on ra, 100% on nrb. labs notable for trop (trop 0.218). pt given 80mg iv lasix with good uop, combivent neb x 1, asa 325mg x 1, nitropaste 1 inch, and started on hep gtt and was transferred to for further care. on arrival to 6 , patient was noted to be tachypnic to 40's, visibly using accessory respiratory muscles to breath. he was given another 80mg iv lasix x 1 with good uop, but continued resp distress. abg was 7.34/67/70 on nrb and therefore was transferred to ccu. pt intubated. has had been kept on vent--thought to have copd exacerbation, as well as chf & possible pna. question of pe also raised as d-dimer elevated. lenis (-), though no cta given renal dysfunction, nor v/q given underlying lung disease. also, pt has been in and out of afib (no record of it in past); started on dilt & heparin gtt for this. past medical history: 1.aortic stenosis (moderate aortic valve stenosis by echo; aortic valve area 1 cm squared. maximal gradient of 42, with a mean gradient of 26) 2.pvd s/p r fem- bypass 3.carotid artery disease 4.copd 5.htn social history: past history of tobacco use, none in past 25 years, no alcohol, no drug use family history: nc physical exam: vs: t afebrile bp 125/58 hr 83 rr 32 o2 95% on vent gen: elderly man lying in bed, intubated & sedated neck: supple with jvp of to angle of jaw cv: distant heart sound, s1, s2, with 2-3/6 sem chest: vent sound abd: soft, ntnd. no hsm or tenderness. ext: no c/c/e. no femoral bruits. pertinent results: on admission: 12:26am blood wbc-14.5* rbc-4.29*# hgb-13.1*# hct-38.3*# mcv-89 mch-30.5 mchc-34.1 rdw-13.5 plt ct-307# 12:26am blood pt-13.6* ptt-26.5 inr(pt)-1.2* 05:10am blood d-dimer-2592* 12:26am blood glucose-185* urean-36* creat-1.5* na-140 k-4.5 cl-97 hco3-34* angap-14 06:00am blood alt-46* ast-68* ld(ldh)-478* ck(cpk)-128 alkphos-76 totbili-0.6 09:37am blood lipase-128* 12:26am blood calcium-8.9 phos-4.8* mg-2.3 11:23pm blood type-art po2-70* pco2-67* ph-7.34* caltco2-38* base xs-6 chest (portable ap) the heart size is mildly enlarged but grossly unchanged. the aorta is tortuous and calcified. the lungs are hyperinflated. this most likely represent unlike emphysema. perihilar opacities involving the lower lobes are demonstrated, right slightly worse than left and might represent pulmonary edema with asymmetric appearance due to underlying emphysema. small right pleural effusion cannot be excluded. the slight asymmetry between the lungs might represent underlying right lower lobe infectious process which can be better characterized after resolving of pulmonary edema. on day# 7: when pt. developed acute renal failure/: 05:02am blood glucose-266* urean-105* creat-3.0* na-138 k-7.1* cl-102 hco3-19* angap-24* 11:43pm blood wbc-18.2* rbc-2.38* hgb-7.4* hct-20.5* mcv-86 mch-31.0 mchc-36.0* rdw-14.8 plt ct-86* 11:08am blood wbc-34.1* rbc-2.17* hgb-6.7* hct-19.6* mcv-90 mch-30.7 mchc-34.1 rdw-14.0 plt ct-241 02:08pm blood alt-7470* ast-9415* ld(ldh)-* alkphos-46 amylase-700* totbili-1.0 12:30pm blood type-art po2-389* pco2-65* ph-7.24* caltco2-29 base xs--1 intubat-intubated vent-controlled 05:43am blood lactate-9.3* 08:06pm blood freeca-0.95* abdomen (supine & erect) port impression: no evidence of free air or pneumatosis, however, plain radiograph is insensitive in the evaluation of bowel ischemia and if there remains clinical concern, ct is recommended to further evaluate. further pertinent evaluation: ct abdomen w/o contrast 11:37 am 1. findings are consistent with hemorrhagic ascites; no fresh hemorrhage or definitive source is evident on these images. the hemorrhagic ascites does extend to the aorta and paraaortic region, which were evacuated on the patient's recent surgery. a splenic laceration is felt to be less likely. a mass within the abdomen or underlying lesion cannot be distinguished on this examination; a followup ct examination is recommended. if the patient is stable, mri may also be helpful. 2. thickening of small bowel loops may be incident to ischemia, edema, or hemorrhage. 3. bilateral pleural effusions and pulmonary findings as described above. ct abdomen w/contrast 1:29 pm 1. retroperitoneal hematoma extending along the left posterior pararenal space inferiorly as far as the left groin and has decreased in size when compared with the previous ct from two weeks prior. 2. ascites, which has increased in size when compared to the previous ct. 3. bilateral pleural effusions with associated atelectasis, pleural calcification. 4. splenic cysts. 5. sigmoid diverticulosis without evidence of diverticulitis. 6. anasarca. 2:52 pm bronchoalveolar lavage gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): oropharyngeal flora absent. klebsiella oxytoca. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella oxytoca | ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- 16 i cefuroxime------------ =>64 r ciprofloxacin--------- 1 s gentamicin------------ <=1 s imipenem-------------- <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- =>128 r brief hospital course: this patient had a very protracted and complicated hospital course. below is a review of hospital course by system. in general, mr. arrived at with increasing sob/doe, tx for acute exacerbation of chf, and t/f to for further care. in icu, con't resp failure, intubated and tx for copd, chf, pna, afib, glycemic control, htn and renal issues. on day 7, mr. developed arf, a lactic acidosis, increased ventilatory needs and worsening hemodynamic status. an abdominal us was neg and kub gave no evidence. he developed increased abdominal girth, and it was decided to take him for ex-lap for sepsis, increased abdominal girth, arf and lactic acidosis for possible gut ischemia/infarct. upon exploration, a retroperitoneal hematoma was discovered and evacuated, a large adhesed periaortic ln was excised and sent to path (found to be paraganglioma) along with the the ligated and a iatrogenic slenic lac controlled. post operatively, the patient remained in icu setting on the vent. renal function slowly resumed. he developed a klebsiella pneumonia which was treated w/ appropriate abx. he had difficulty weening from vent and was thus trached. nutrition was maintained w/ tf's and a peg placed. lastly access via picc was established. post op his neuro status improved and on d/c is a/o and following commands. his hospital course included ed eval and tx at , ccu, micu and ultimately the tsicu b/f d/c. neuro: throughout hospital stay, pt was sedated appropriately for ventilation and analgesia was maintained as appropriate. throughout his stay, neuro checks proved a waxing and type picture with propofol for sedation, and haldol for agitation as per the micu team. overall, his neuro status improved throughout with improvement of other medical issues. cv: pt had new issue of atrial fibrillation. during micu stay needed pressors of da and levophed to maintain bp on at same time became olguric and septic as described. this recovered post-operatively. he experienced a bump in tni, likely due to demand ischemia. he was properly anticoagulated and rate controlled with dilt. around day 13-14, per chart review, he reverted back to nsr and was continued on b-, , bp meds, asa and statin. he has runs of htn which responded well to bp meds including metop, hydralazine and clonidine. postoperatively he remained stable on his rx and had no further issues. pulm: with the initiating cc of sob/doe pt was treated for chf exacerbation with lasix, nitro, nebs and t/f to . here he was intubated for increased resp distress, given iv steroids and nebs for copd, diuresed for chf, and started emperically on vanco/zosyn for pna after pan cx. he continued to remain on the vent throughout his stay, with varying vent support. a klebsiella pna was discovered on bal, and tx w/ 2 week course of meropenam. a trach was performed on due to continued vent needs. on d/c he remains on cpap + ps(12) with tv 550, rate 30, fio2 40%, and peep 5. the last week of admission, the patient developed a pleural effusion and 2.5l of fluid that did not grow organisms. this improved resp status and did not recur. gi/fen: pt's fluid and electrolytes were replaced/maintained throughout his hospital stay. early diuresis for chf was aggressive and preceeded arf. pt was given a peg on and continues to receive tf at goal of 65. the question of possible bowel ischemia proved untrue with the ex-lap, but findings as described above. prior to the or he received a abd us, only showing cholelithiasis w/o cholecystitis and nl portal flow. heme/id: pt was treated emperically early in the course for pna with vancomycin and zosyn. he was afebrile but had increased wbc count of 47.9, 29% pmns. throughout his stay, abx included flagyl, linezolid and fluconazole. yeast grew in the urine, blood cx were neg, the pt remained mrsa and c.diff neg, but did grow klebsiella found on sputum and bal, treated with 2 weeks of meropenam ending on the day of d/c. pt had bouts w/ fever, though has been stable and afebrile on d/c. gu/renal: as described, on day 7, pt experienced arf and was evaluated by renal. arf was from atn secondary to decreased renal perfusion from hypotension and retroperitoneal bleed. over the hospital stay this improved and remains at a baseline of bun/cr of 50/1. endocrine: pt has been treated w ssi throughout hospital stay. early in hospital course, glucose rose to 180-200's likely secondary to steroids. has been well controlled and is 80-120 x 7-10 days. prophylaxis: the pt. was maintained on dvt/gi prophylaxis w/ h2 , sqh and scd's throughout. le us was neg for dvt. pt maintained full code. medications on admission: lasix 40 mg p.o. daily advair 50/250 doxazosin 4 mg p.o. daily folic acid 1 mg p.o. daily 81 mg of aspirin p.o. daily lipitor 10mg daily albuterol prn discharge medications: 1. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 2. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 6. zinc oxide-cod liver oil 40 % ointment sig: one (1) appl topical prn (as needed). 7. doxazosin 4 mg tablet sig: one (1) tablet po hs (at bedtime). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 9. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day). 10. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. metolazone 5 mg tablet sig: one (1) tablet po daily (daily). 13. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 14. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 15. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). discharge disposition: extended care facility: northeast - discharge diagnosis: congestive heart failure chronic obstructive pulmunary disease acute renal failure extra-adrenal paraganglioma retroperitoneal hematoma discharge condition: good discharge instructions: during your hospital stay, you were treated for acute exacerbation of congestive heart failure and chronic obstructive pulmonary disease. during your stay you suffered acute renal failure and had to go to surgery for a retroperitoneal hematoma. in the surgery, a large lymph node surrounding your aorta was removed, an artery called the inferior mesenteric artery was tied off in the process, and a small laceration to your spleen occurred and was repaired without complication. the lymph node was described by pathology as a paraganglioma, a type of extra-adrenal tumor. the endocrinologists were unable to definitively diagnose this mass in the setting of your acute illness, and it is suggested that you follow up with this as an outpatient after you rehabilitiation. in your recovery, you have had a pneumonia that has been treated with antibiotics. in addition, it has been difficult to ween your breathing off of the ventilator. consequently, you will be going to a vent rehabilitation center to help you recover and breath without the ventilator. following completion of vent rehab, you will follow up with both the trauma surgery service and with the vascular surgery service as listed below. please continue all medications that you are discharged on as listed below, and continue any home medications that you were on prior to hospital admission once you return home. if you experience any worrisome symptoms including increased shortness of breath or trouble breathing, chest pain, fever, chills, severe abdominal or back pain, or anything else that worries you please seek medical attention. followup instructions: 1. trauma surgery: please call and arrange an appointment for 1-2 weeks. 2. vascular surgery: please call and arrange an appointment with dr. in 2 weeks. 3. endocrinology: please call and arrange an appointment in weeks. Procedure: Venous catheterization, not elsewhere classified 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 Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Incision of abdominal wall Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Other surgical occlusion of vessels, abdominal arteries Other sympathectomy and ganglionectomy Excision of lesion of adrenal gland Low forceps operation with episiotomy Excision of lesion of tendon sheath Excision of lesion or tissue of spleen Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Hematoma complicating a procedure Aortic valve disorders Accidental puncture or laceration during a procedure, not elsewhere classified Diaphragmatic hernia without mention of obstruction or gangrene Occlusion and stenosis of carotid artery without mention of cerebral infarction Acute respiratory failure Septic shock Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Accidents occurring in residential institution Acute vascular insufficiency of intestine Atherosclerosis of native arteries of the extremities, unspecified Surgical or other procedure not carried out because of contraindication Diastolic heart failure, unspecified Chronic vascular insufficiency of intestine Diverticulosis of colon (without mention of hemorrhage) Diabetes with unspecified complication, type II or unspecified type, uncontrolled Neoplasm of uncertain behavior of paraganglia Accidental cut, puncture, perforation or hemorrhage during surgical operation

allergies: gi upset with codeine and percodan. ros: neuro: alert and oriented x 3. mae. able to walk several feet to toilet with assistance. slight unsteadiness. equal strength throughout. gi: reports good appetite. bm this am by report. abdomen soft with bowel sounds. gu: voids spontaneously qs. respiratory: room air sats in high 90's. rr in the high 20s. reportedly some chf. xray repeated this pm. lies flat comfortably. cardiac: stable through 1st half of pheresis(see carevue for objective data). recieving calcium infusion iv by pheresis with q 1/2 hour ionized ca checks. heme: no evidence of bleeding. hct and plts remain low. will need new blood clot tomorrow. social: pheresis rn attempted to reach pt's dgtr to advise her of the transfer, but no answer, and no machine. pt was visited by the catholic priest and received communion. Procedure: Venous catheterization, not elsewhere classified Therapeutic plasmapheresis Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Other and unspecified angina pectoris Pneumonitis due to inhalation of food or vomitus Alkalosis Infection and inflammatory reaction due to other vascular device, implant, and graft Tracheostomy status Other staphylococcal septicemia

history of present illness: this is an 84-year-old female with a past medical history of hypertension, vascular disease, increased cholesterol, laryngeal carcinoma 10 years ago, status post laryngectomy, cervical carcinoma status post tah, angina and appendectomy, who presented to emergency room on . she was transferred from hospital. this whole issue started on when patient presented to hospital for an ischemic right fifth toe. the patient had at that time bilateral iliac stenting. she left the procedure with suprapubic hematoma. she received three units of packed red blood cells and 6 units of platelets and she was discharged home on . the patient was noted to be lethargic over the subsequent days and returned to hospital on . when she got to hospital she was anemic with hematocrit of 24 and thrombocytopenic with a platelet count of 25,000. she received two units of packed red blood cells and 6 units of platelets and she continued to have low counts. hematology was consulted at that point and ldh was increased. the patient was transferred t on for further management of a presumed ttp. on she complained of left hand numbness, paresthesias and a left sided facial droop that lasted 15 minutes, which resolved on its own. neuro consult felt tia was the most likely cause with right mca territory. cat scan of the head was negative. mri and mra demonstrated atherosclerotic changes of intracranial carotids, right greater than left, but no stroke. mrs. began plasmapheresis on , though during her first episode she developed hypotension with systolic blood pressure to the 80's, responded to fluid boluses and she was also hypocalcemic at the time. therefore, patient was transmitted to the micu where plasmapheresis continued there. on she completed a course of plasmapheresis, her platelets had maxed at 238,000 and her ldh was 271. she needed plasmapheresis again on for decreasing platelets, increasing ldh and decreasing haptoglobin. subsequently on she developed a fever to 101. she was cultured and blood cultures grew coag negative staph aureus four bottles and the patient was started on vancomycin. she had a line exchange on . during that time her platelet count was decreasing and there was a question of infection vs dic and hit. she had an hit positive antibody at that time. plasmapheresis continued through the right subclavian catheter placed by ir with completion of plasmapheresis on the . physical examination: she had temperature 98.9, blood pressure 150/70, pulse 85, respirations 20, 95% on room air. she was in no apparent distress. she was normocephalic, atraumatic, equal ocular movements intact. chest clear to auscultation. cardiovascular showed a regular rate and rhythm, normal s1 and s2, no murmurs, rubs or gallops. abdomen was benign. extremities, no clubbing, cyanosis or edema but there was a large ecchymoses in the right groin area. neuro, she is alert and oriented times three, cranial nerves ii through xii grossly intact, muscle strength 5/5 throughout. back without tenderness. past medical history: as previously noted. she has hypertension, vascular disease, increased cholesterol, laryngeal carcinoma 10 years ago, status post laryngectomy, cervical cancer status post total abdominal hysterectomy, angina status post epi. medications: on admission, meclizine 25 mg once a day, atenolol 50 mg once a day, iron 325 mg tid and lipitor 10 mg once a day. allergies: no known drug allergies. laboratory data: she had a white count of 8.3, hematocrit 29.9, platelet count 35, pt 13.6, ptt 26 and inr 1.1, d dimer greater than 1,000, ftp between 10 and 40, sma 10 was within normal limits. head ct on the was negative. head ct on showed no acute blood. hospital course: partially stated during hpi, patient was admitted on to from hospital. the patient had a hematocrit of 29.9 and platelet count 35 and white appeared to be a tia, so it was believed that patient was suffering from ttp. the patient developed a plasmapheresis on at which point she became hypotensive with systolic blood pressure to the 80's and hypocalcemia. therefore, patient was transferred to the micu where she tolerated plasmapheresis very well. the patient's platelets came up to 238,000, ldh came down to 271 on , though it was noted that the patient's platelets were decreasing again. ldh was rising and haptoglobin was low. the patient restarted plasmapheresis on . on subsequent exam on , the patient developed a fever to 101.5 with coag negative staph in bottles from the blood. she was started on vancomycin and her line was exchanged on . when patient had a fever on and the line needed exchanging, the patient was sent to the on the . the patient received right subclavian and continued on vancomycin for one week. a new line was placed on . during that time there was question of infection and dic vs hit. the patient had hit positive lab test results. patient had good renal function throughout the whole hospitalization. creatinine ranged from 0.9 to 1.1. some time on the floor the patient had one episode of chest tightness that resolved with nitroglycerin. cardiology consult believed this to be demand ischemia with minor st-t changes. troponin maxed at 1.7 and patient was treated with increased beta blockers. at that time patient was not a candidate for aspirin therapy. the patient completed plasmapheresis on for a total of 25 sessions of plasmapheresis. upon discharge the patient's platelets normalized at 298,000, ldh remained within the normal limits. the patient was discharged home with home services. condition on discharge: patient is stable at discharge. discharge medications: calcitrol 0.25 mcg q day, insulin sliding scale, prednisone taper, atenolol 100 mg q day, protonix q 40 mg q day, meclizine 12.5 mg q day, folic acid 1 mg q day, iron 325 mg q day and alendronate 5 mg q day. discharge diagnosis: 1. ttp. discharge status: stable. home with services. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Therapeutic plasmapheresis Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Other and unspecified angina pectoris Pneumonitis due to inhalation of food or vomitus Alkalosis Infection and inflammatory reaction due to other vascular device, implant, and graft Tracheostomy status Other staphylococcal septicemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 69 y/o man presents with increasing fatigue and shortness of breath with acitivity. major surgical or invasive procedure: cabg x 2 and aortic valve repair 23mmce history of present illness: mr. is a 69 year old gentleman with a history of increasing fatigue and shortness of breath, especially with activity. the patient underwent echo after diagnosis of a murmur and was found to have critical aortic stenosis. preoperative cardiac catheterization revealed 20 percent left main disease, serial 80 and 100 percent left anterior descending lesions, 50 percent or less diagonal lesion and 80 percent posterior descending artery and 60 percent plv stenosis, in addition to a very stenotic circumflex that arose from the right coronary artery. the patient was seen and evaluated and felt suitable for surgery. past medical history: gout hypercholesterolemia htn cad obesity social history: never smoked tobacco. patient is retired salesman consumes drinks per week for the past 50 years. never used drugs. lives with wife in , . family history: mother died at 88 y/o of natural causes. father died of lung cancer at 66 y/o. physical exam: vitals: 98/84 nsr/140/92/20 height 5'" weight 244lbs gen: wd, wn in nad appearing stated age skin: well hydrated, w/o rash of suspicious lesions neck: supple, no jvd chest: cta-b, no w/r/r heart: rrr, s1s2 abd: obese nt/nd, nabs ext: warm, no edema/cyanosis/ clubbing neuro: cnii-xii grossly intact, no motor/sensory deficits pertinent results: 10:12pm hgb-9.8*# 08:27pm type-art po2-147* pco2-49* ph-7.32* total co2-26 base xs--1 05:28am blood wbc-9.4 rbc-3.48* hgb-10.0* hct-29.4* mcv-85 mch-28.7 mchc-33.9 rdw-14.7 plt ct-155 02:50am blood wbc-11.0 rbc-2.79* hgb-8.2* hct-22.9* mcv-82 mch-29.2 mchc-35.6* rdw-13.6 plt ct-88* 07:59am blood plt ct-139*# 05:28am blood glucose-101 urean-18 creat-1.0 na-141 k-4.2 cl-106 hco3-29 angap-10 05:28am blood calcium-8.6 phos-3.0 mg-2.1 05:15pm blood urean-16 creat-0.7 cl-112* hco3-23 08:05pm blood mg-2.0 03:46pm blood type-art ph-7.48* ospital course: the patient was taken to the operating room on to undergo an aortic valve replacement with a 23 mm - bioprosthetic valve and coronary artery bypassgrafting times two, specifically saphenous vein grafts to the left anterior descending, right posterolateral. the cardiopulmonary bypass time was 168 minutes, cross clamp time was 130 minutes. two atrial and two ventricular wires were place in addition to three chest tubes, one mediastinal, one mediastinal right and one left pleural. the patient tolerated the procedure extremely well and was transferred to cardiac intensive care unit. the patient was extubated shortly after surgery; aterial blood gas post extubation with consistent with good ventilation and perfusion of both lungs. on post op day one the patient remained in the crsu and was delined. his chest tubes were removed, diet was advanced, aggressive pulmonary therapy was employed to improve lung ventilation. the patient worked with physical therapy on transferring from his bed to a chair. the patient's pain was well controlled with intravenous morphine and he was deemed ready for the regular hospital floor. prior to being transferred to the floor the patient experienced some agitation during the night and was treated with haldol. on postop day two the patient continued to be slightly confused while in the crsu however his cordis and pacing wires were removed and he was transferred to the regular hospital floor in stable condition. specifically, his pain was well controlled and he was tolerating a regular diet. on post op day three the patient worked very well with physical therapy and ambulated with minimal assistance. on postop day four the patient was deemed level five after walking up a flight of stairs and around the floor. the patient became progressively less agitated during his hospital stay on the regular floor. he was put back on his home medications while on the floor and tolerated them well without any untoward events. the patient was discharged home on the morning of postop day five with cardiopulmonary nursing services. he has an appointment to see dr. in weeks. he was discharged on all his prior home medications in addition to 4 days of lasix, oral pain meds, metoprolol and amiodarone. medications on admission: lipitor 10 mg tablet sig: one (1) tablet po once a day. probenecid 500 mg tablet sig: one (1) tablet po twice a day. enalapril 10mg po qd tylenol xs discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours): take medication for 4 days. disp:*8 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:*2* 3. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 5. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 6. amiodarone hcl 200 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. potassium chloride 10 meq capsule, sustained release sig: one (1) capsule, sustained release po twice a day: take for 4 days with furosemide. disp:*8 capsule, sustained release(s)* refills:*0* 9. lipitor 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 10. probenecid 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: cad and aortic stenosis. discharge condition: stable discharge instructions: patient to be discharge home. avoid strenous activity for the next 5-6 weeks. if patient experiences acute shortness of breath or chest pain go directly to emergency room. patient can shower with soap and water. avoid soaking in a bath for 3 weeks. followup instructions: provider: , follow-up appointment should be in 1 month provider: cardiologist appointment should be in days Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Gout, unspecified Atrial fibrillation Aortic valve disorders

allergies: ceftriaxone attending: chief complaint: confusion, nausea major surgical or invasive procedure: diagnostic paracentesis under ultrasound guidance central line placement intubation history of present illness: 58 y.o. man with hcv/etoh cirrohosis, 3 recent admissions for encephalopathy of unclear precipitant, p/w increasing somnolence, fatigue. pt was most recently admitted on and discharged on for hepatic enceph. at that time, there was no clear precipitant and he was treated with more aggressive lactulose therapy. he has been very fatigued since discharge but per his wife there was no change in ms until this afternoon. he became very somnolent and disoriented and was brought in to the ed. per his wife, he has not been complaining of increasing abdominal girth, abdominal pain, nausea, vomitting. he has been taking his lactulose, and has been stooling. though he takes morphine chronically, his dose has been less over the last week. denies f/c, cough, sob, dysuria, or any other focal symptoms of infection. has been on cipro for sbp ppx and lactulose, rifaximin. in , pt noted to have gcs of , minimally responsive. he received pr lactulose without much change. then, due to increased hypoxia (93% on nrb), pt intubated for airway protection. past medical history: 1.hcv cirrhosis: contracted hcv from blood transfusion in . no prior treatment. per report, has ulcers found on prior egd. on the liver tranplant waiting list-- being seen by dr. . several recent admits for altered ams. inr peak 2.9 on , with several measurements above 2.0 in the last several months. albumin nadir 2.4 on . alt levels are all below 40 over the last several months. 2. dm2: on inuslin. diagnosed . 3. rheumatoid arthritis 4. alcoholism. 5. ascites. 6. group b strep bacteremia s/p 1 month of iv zosyn . social history: lives with wife. disabled veteran. +tobacco currently. +etoh previously. used to drink 6-12 beers/day. now, no drinks since . used marihuana and intranasal cocaine in the remote past. baseline of moderate activity. family history: family history: father-alive,84 mother died of lung cancer. uncle and aunt- died of cancer. physical exam: t=99.0---p=78---bp 140/74---rr 27---o2 94% on 2l gen: somnolent, decerebrate posturing. heent: ncat, perrl, anicteric. op clear with ett in place. neck: supple, no lad. lungs: cta b/l cv: tachy and regular, nml s1s2, no m/r/g abd: soft, distended, nt, nabs, dullness at flanks ext: no edema, 1+ dp pulses b/l. neuro: decerebrate posturing. skin: abrasion on lue, multiple spiders on trunk. pertinent results: 07:45pm blood wbc-7.4# rbc-3.99* hgb-12.5* hct-36.6* mcv-92 mch-31.4 mchc-34.2 rdw-15.1 plt ct-114*# 07:45pm blood neuts-74.4* bands-0 lymphs-17.5* monos-5.5 eos-2.2 baso-0.4 07:45pm blood pt-15.4* ptt-35.0 inr(pt)-1.6 07:45pm blood plt ct-114*# 07:45pm blood glucose-143* urean-29* creat-0.9 na-137 k-4.9 cl-105 hco3-23 angap-14 08:43pm blood ammonia-234* 07:45pm blood albumin-3.1* calcium-8.3* phos-3.0 mg-1.9 07:45pm blood lipase-101* 07:51pm blood lactate-2.2* k-5.0 brief hospital course: in the micu pt was given aggressive lactulose with improvement in ms. was extubated in the afternoon on , with stable o2 sats and vitals after extubation. a diagnostic paracentesis was performed on which showed 622 wbcs and 12% pmns, no evidence of sbp. cipro was continued for sbp prophylaxis and as his ms was stable and he was afebrile and hemodynamically stable he was transferred to the floor for further care. . on the floor pt. was monitored overnight. as he was hemodynamically stable, with no further changes in mental status he was discharged with f/u by hepatology outpatient. medications on admission: lactulose titrated to 4bms per day morphine 15mg q4 hours ms contin 15mg q8h rifaximin 200mg tid lasix 40mg po bid aldactone 100mg protonix 40mg daily cipro 250mg daily insulin nph 18u + 14u nadolol 20mg daily magnesium oxide 800mg daily discharge disposition: home discharge diagnosis: primary: hepatic encephalopathy secondary: hepatitis c, hepatic cirrhosis discharge condition: pt. was alert and oriented with no further change in mental status. paracentesis showed no evidence of infection and pt. was afebrile. discharge instructions: please take all medications as prescribed. please continue your lactulose at your normal home dose. please call your pcp or go to the er if you have any confusion, fatigue, abdominal pain or distention, fevers, chills, nausea, vomiting, coughing up blood, blood with bowel movements, or any other symptoms that concern you. followup instructions: please call your pcp dr to set up an appointment in the next week. you can reach his office at to make an appointment. provider: . where: lm center phone: date/time: 1:00 - dr. will check your hemocrit at this visit, as it was low in the hospital Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Percutaneous abdominal drainage Diagnoses: Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Rheumatoid arthritis Other specified disorders of stomach and duodenum Personal history of alcoholism

allergies: ceftriaxone attending: chief complaint: fever major surgical or invasive procedure: multiple paracentesis history of present illness: pt is a 59 yo man w/ h/o hep c cirrhosis s/p liver xplant in , w/ chronic rejection (demonstrated on biopsy in ), recurrent hep c on inf and ribavirin, b cell lymphoma, who p/w fevers, abdominal pain, sbp. pt was in usoh until 1 week pta when began feeling fatigued, had n/v approximately 1-2 episodes per day, non-bloody, non-bilious. 3 days pta, pt began to have severe abdominal pain. he also noted increased abd girth, increased le edema, r > l, denied any calf pain. over past 3 days, pt also c/o cough with some sputum production, although difficult to bring up 2/2 abd pain. he also c/o laryngitis starting 3 days ago. ros otherwise negative for brbpr, melena, sob, cp/pressure." . on , the patient saw dr. in clinic, the complained of severe abdomninal pain, was noted to have a fever to 101, and therefore was sent to the ed for further evaluation. . in , pt was noted to be febrile to 102.8, hr 119, bp 104/74, o2 sat 95% on ra, decreased to low 90's on , placed on 2l nc and o2 sat increased to mid-90's. labs notable for wbc 10.7 with 17% bands, t elevated to 20.5 (last t 15 on ), lactate 2.4, inr 1.2 (elevated from 1.0). paracentesis was done that demonstrated 8520 wbc w/ 62% polys, c/w sbp. ct scan report demonstrated no free air, no bowel obstruction, increased ascites, and ?lll pna vs clot in lung vs hepatic vein clot. pt was given levofloxacin 500mg iv x 1, flagyl 500mg iv x 1, morphine. . due to pt's ill-appearance, and severe sbp, he was admitted to micu for further care and monitering. past medical history: 1. hepatitis c (s/p transfusion for bursitis surgery in ' vs. etoh cirrhosis), s/p orthotopic liver transplant on , followed by dr. . post-op complications have been recurrent hepatitis c viremia and development of cholestatic jaundice of uncertain etiology, both occurring four months after liver transplant. 2. b cell lymphoma: nodal marginal zone cd5 positive b-cell lymphoma noted at the time of transplant; bone marrow biopsy performed during hospitalization for pancytopenia and pna in revealed approx. 25% involvement. decision was for no chemo at that time. 3. h/o pna in : pseudomonas and staph. cx positive treated with aztreonam and levofloxacin. 4. headaches: rxn to prograf; was taken off for some time then restarted; ha are throbbing, constant and encompass whole head. responds well to cold compress; refractory to pain medications. 5. iddm 2: diagnosed in , hba1c 5.4 (). 6. arthritis s/p long hospitalization in the 70's. 7. chronic neck pain s/p cervical procedure . 8. r inguinal hernia; unable to operate given recent liver transplant. 9. alpha-1 antitrypsin deficiency - this diagnosis appeared in a prior discharge summary but was denied by the patient. social history: married >30 years. lives with wife and her 10 year old grandson, whom he takes care of. never previously married and never had children of his own. veteran and describes ptsd following 13 months of combat, which he received some counseling for but no formal treatment. he used to work as a custodian in the public schools but is now on disability following a work injury. . pt drank heavily in the past. last drink was >1yr ago, prior to liver transplant. admits to marjuana use and occasional cocaine use in the past. tobacco history, smokes 10 cigarettes daily, reports only taking 2 puffs and then throwing it away; up to one pack daily over the last 45 years. would like to quit, has tried in the past with the patch and been successful for up to 2 weeks. family history: mother died at 76 from lung cancer. father is 85, healthy. brother committed suicide ~10 years ago. two brothers and two sisters alive and healthy. physical exam: vitals - t 100.9/100.9, 102 on at 2pm , hr107 , bp102/58 , rr 14, o2 97% room air general - cachectic, non-toxic, alert, oriented x3 heent - scleral icterus cvs - tachycardic, regular, no noted m/r/g lungs - decreased bs at bases b/l, ?crackles at left base abd - distended, incisional and umbilical hernia noted, reducible, diffuse tenderness, no reboudn or guarding, tap site without focal tenderness, erythema ext - + le edema b/l, r>l--this was noted on admit as well skin - jaundiced neuro - no noted asterixis, oriented x 3 . on discharge, afebrile bp 114/77, hr 85, 97% ra. similar exam. abdomen distended, but soft w/o ttp, rebound, or guarding. pertinent results: on admission: 04:00pm blood wbc-10.7# rbc-3.62* hgb-10.8* hct-30.8* mcv-85 mch-29.9 mchc-35.2* rdw-19.1* plt ct-111* 04:00pm blood pt-13.8* ptt-31.7 inr(pt)-1.2* 04:00pm blood glucose-211* urean-22* creat-0.6 na-137 k-3.3 cl-102 hco3-21* angap-17 03:52am blood caltibc-144* vitb12-greater th folate-18.4 ferritn-247 trf-111* . 04:00pm alt(sgpt)-94* ast(sgot)-109* alk phos-1529* amylase-33 tot -20.5* 04:00pm lipase-27 04:00pm albumin-2.9* . on dishcarge wbc 2.3, hct 22.8, plt 101 na 134, k 3.4, cl 101, bicarb 21, bun 12, cr 0.6 tbili 17.4 ap 960, alt 51, ast 157 rapamycin 8.3 . microbiology: , , blood cx: pending peritoneal fluid cx: gbs, sensitive to levofloxacin sputum: beta strep . imaging: cxr: there is consolidation in the left lower lobe with marked leftward displacement of the mediastinum and elevation of the left hemidiaphragm suggesting complete or almost complete atelectasis of the left lower lobe. there are no other consolidations or masses. there is no sizeable pleural effusion. the heart size is normal. the mediastinal contours are unremarkable. revision of the recent pet/ct and ct abdomen demonstrates intermittent obstruction of the left lower lobe segmental bronchi with subsequent atelectasis. given this intermittent nature of the radiological findings and absence of any endobronchial obstructing lesion on the pet/ct from , , recurrent aspirations are the most likely diagnosis. . ct abdomen and pelvis: impression: 1. increase in abundant ascites. 2. left lower lobe consolidation is likely pneumonia, but pulmonary infarct is a consideration given presence of possible left lower lobe pulmonary embolus. 3. left lower lobe thrombus that is either within the pulmonary arteries or veins. brief hospital course: this is 59 year-old man with hep c cirrhosis s/p liver transplant 10 months ago complicated by recurrent hep c and chronic rejection who presented with abdmonial pain and was found to have severe spontaneous bacterial peritonitis. . due to pt's ill-appearance, and severe sbp, he was admitted to micu for further care and monitering. . while in the micu the patient was started on aztreonam, linezolid, flagyl and levoquin to cover sbp and a possible pneumonia. his antibiotic regimen was changed to vancomycin, levofloxacin, and flagyl when he was found to have group b streptococci growing from peritoneal culture. mr abdominal pain improved rapidly with antibiotic therapy as well as a therapeutic paracentesis. the gbs was found to be sensitive to levoquin and he was eventually transitioned to levoquin monotherapy and was discharged to finish a 14 day course with subsuquent ciprofloxacin sbp prophylaxis. . additionally mr. was briefly hypoxic in the micu (wich resolved). ct scan revealed a question of lll pneumonia versus pulmonary embolus versus atelectasis. the radiologists subsuquent discussions with the primary team indicated that the ct appearance was more consistent with atelectasis and mr. hypoxia resolved without heparin therapy. . mr. is 10 months s/p liver transplant and has both chronic rejection as well as reactivation of his hepatitis c. he was on treatment with interferon and ribavirin for his hepatitis c on admission in addition to his immunosuppressive regimen. he was admitted with an acute rise in his lfts over baseline most likely secondary to his rejection and hcv. his hepatitis c treatment had to be discontinued due to his acute illness, and it was difficult to increase his immunosuppressants to treat rejection due to his reactivation of hepatitis c. he was continued on his home regimen of rapamune, prednisone, and ursidiol. he was not encephalopathic in house and did not require lactulose. . mr also suffered from portal hypertension with resultant chronic ascites and lower extremity edema that were quite symptomatic. his diuretics were originally held in house due to his illness and concern for potentially initiating renal failure in his infected state. he was maintainted on a low sodium diet with one therapeutic paracentesis, which he tolerated. when he clinically improved from an infectious standpoint; lasix 40 and spironolactone 100 were reintroduced without significant renal dysfunction. . mr also received the standard care of a ppi; insulin to treat his diabetes, electrolyte repletion, heparin prophylaxis, nutritional input and physical therapy. . ultimately with regards to his chronic liver failure and difficult to manage ascites the patient initiated conversations with dr. and the hepatology team about his overall prognosis and therapeutic options. because of his ill health and particularly because he was found to have lymphoma in his explanted liver he is not a candidate for a second liver transplant. mr. decided he would prefer to therefore direct the remainder of his medical care to comfort measures. with the palliative care service along with the social workers were very involved in setting up hospice care for the patient at home and he was discharged with that goal in mind. . discharge medications: 1. oxycodone 5 mg tablet sig: six (6) tablet po q4h (every 4 hours) as needed. 2. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone 40 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q12h (every 12 hours). 6. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. sirolimus 1 mg tablet sig: three (3) tablet po daily (daily). 8. hydromorphone 4 mg tablet sig: 1-2 tablets po every 4-6 hours as needed: please do not take if oversedated. disp:*40 tablet(s)* refills:*0* 9. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days: last dose to be on . disp:*8 tablet(s)* refills:*0* 10. norfloxacin 400 mg tablet sig: one (1) tablet po once a day: to start on , after you complete the levofloxacin. disp:*30 tablet(s)* refills:*2* 11. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 12. spironolactone 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna of -east & visiting nurse hospice discharge diagnosis: 1. spontaneous bacterial peritonitis 2. hepatitis c s/p liver transplant 3. chronic liver rejection 4. lymphoma discharge condition: fair. afebrile, vss discharge instructions: you were admitted to the hospital with an infection in your abdomen, you will need to complete a 14-day course of levofloxacin for this, and afterwards you will need to be on a medicine called norfloxacin daily to prevent further infections. you should seek medical attention if you develop fevers, chills, or worsening abdominal pain because this may be a sign that your infection has returned. . to treat your ascites and leg swelling we have started you on lasix 40mg daily and spironolactone 100mg daily. . we are also asking that hospice be involved in your care and they will help you manage things like your pain, encephalopathy, and other comfort measures. followup instructions: provider: , md phone:. thursday ; dr office should contact you with an appoinment time. Procedure: Percutaneous abdominal drainage Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Portal hypertension Personal history of other infectious and parasitic diseases Pulmonary collapse Other malignant lymphomas, unspecified site, extranodal and solid organ sites Complications of transplanted liver Other specified antibiotics causing adverse effects in therapeutic use Spontaneous bacterial peritonitis Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B Alpha-1-antitrypsin deficiency Family history of malignant neoplasm of trachea, bronchus, and lung

service: neonatology history of present illness: the gram product of a 32 and week gestation baby boy number two was born to a 40 year-old g2 p0 now 3 female with prenatal screens of a negative, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, group b pregnancy had an estimated date of confinement of . complicated by cervical shortening for which the mother received a full course of betamethasone at 26 weeks, the pregnancy was subsequently followed with serial ultrasounds given poor growth of number one. by the day of admission number one showed oligohydramnios prompting the decision to deliver by c section. by o2 in the delivery room. apgar scores were 7 at one minute and 7 at five minutes after which the neonate needed cpap for apnea and cyanosis prior to transfer to the neonatal intensive care unit for further evaluation and management. admission physical examination: weight grams (70th percentile), length 43.5 cm (50th percentile), head circumference 29.5 cm (25th percentile). the anterior fontanel is soft, open and flat, the palette is intact, breath sounds are present bilaterally. significant grunting, flaring and retracting are noted on cpap with diminished breath sounds noted bilaterally. cardiovascular there is a regular rate and rhythm without murmur. peripheral pulses are 2+ including the femorals. the abdomen is benign without hepatosplenomegaly or masses. the genitalia are normal male for gestational age with testes palpable in the low canal bilaterally. the skin is pink and well perfused. tone is appropriate and the newborn is responsive. initial dextrose stick is 64. hospital course: 1. respiratory: given the presentation of surfactant deficiency, the baby was intubated and given three doses of surfactant over the next 48 hours. extubated on day of life number three, the newborn tolerated the nasal cannula oxygen and was able to be weaned to room air by day of life five. the newborn was without significant apnea of prematurity and last had a bradycardic episode on . 2. cardiovascular: the newborn was hemodynamically stable throughout the admission. 3. fluids, electrolytes and nutrition: the baby was started on total parenteral nutrition with enteral feeds begun on day of life three. full volume feeds were reached by day of life nine. the highest caloric density was achieved by day of life twelve, which consisted of breast milk and primi enfamil 45 to 26 k calories per ounce. presently the baby has been growing well on breast milk fortified to 24 k calories per ounce using enfamil powder. today the baby was switched to ad lib feeds in the hope that he will maintain weight gain on full po feeds. 4. gastrointestinal: maximum total bilirubin was 8 on day of life three for which phototherapy was continued through day of life eight. follow up bilirubin were in the acceptable range. wt on discharge=3045g. 5. hematology: the initial hematocrit was 43.8%. the infant received no transfusions. the neonates blood type is a negative. 6. infectious disease: treated with ampicillin and gentamycin for 48 hours. the neonate had negative blood cultures when the antibiotics were stopped. 7. neurology: no issues. 8. sensory: audiology, hearing screening was performed with automated auditory brain stem responses. the baby passed on . ophthalmology, the patient was not examined. the patient is due for a first examination at eight months of age given a higher incidence of refractive error in premature infants. 9. psycho/social: the social work team was involved with the family. their contact number is . condition on discharge: good. discharge disposition: the baby is to be discharged to home in the care of the parents. the name of the primary pediatrician is of health care south in . the phone number there is , fax number is . care and recommendations: feedings at discharge are breast milk 45 to 24 k calories per ounce with enfamil powder. medications: fer-in- 0.3 cc po q day and poly-v- 1 cc po q day. car seat position screen is to be arranged before discharge. state newborn screen status: testing was performed on approximately and with results from as all being within normal limits. immunizations received: the newborn received hepatitis b vaccine on . immunizations recommended: rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: 1. born at less then 32 week. 2. born between 32 and 35 weeks with plans for day care during rsv season, with a smoker in the household or with preschool siblings. 3. with chronic lung disease. by these criteria this baby did not warrant rsv prophylaxis. influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other care givers should be considered for immunization against influenza to protect the infant. follow up appointments scheduled and recommended: the family is to follow up with the pediatrician two to three days post discharge. it is also expected that vna services will make a home visit around the same time. discharge diagnoses: 1. preterm (32 and week) newborn appropriate for gestational age male number two. 2. status post respiratory distress syndrome. 3. sepsis ruled out. 4. status post physiologic hyperbilirubinemia. 5. status post circumcision on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Other phototherapy Prophylactic administration of vaccine against other diseases Circumcision Audiological evaluation Diagnoses: Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 2,000-2,499 grams Routine or ritual circumcision Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section

6. immunizations. hepatitis b immune vaccine administered on . 7. hearing screening performed prior to discharge. discharge medications: ferinsol 0.2 cc's po, q day. the patient is to be discharged home with follow-up at , chulmsford center. mother should have an appointment within five days with dr. . visiting nurse to come to home the day post discharge. Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 33-34 completed weeks of gestation

discharge condition: stable. discharge instructions: 1. the patient should have his hematocrit checked within three days of discharge as he was anemic in the hospital without a clear source. 2. the patient should continue to receive heparin subcutaneously until he is therapeutic on coumadin. 3. the patient should have chest physical therapy each day until he is free of secretions. 4. we are sending the patient with a picc line in place so that he may finish his course of clindamycin. after the antibiotics are finished, the picc line should be removed. 4. the patient should have his inr monitored upon admission until coumadin is therapeutic and then monitored thereafter with target range 2.0-3.0. discharge medications: 1. lopressor 25 mg twice a day, hold for systolic blood pressure less than 120. 2. ativan .5 mg every 4-6 hours as needed. 3. albuterol nebulizer every 6 hours as needed. 4. atrovent nebulizer every 6 hours as needed. 5. lansoprazole 30 mg once a day by gastrostomy tube. 6. digoxin 125 mcg once a day 7. clotrimazole 1% cream topically twice a day to affected areas. 8. tylenol 325 to 650 mg every 4-6 hours as needed. 9. heparin sodium 5000 units/ml, injection subcutaneously every 12 hours, until the patient is therapeutic on coumadin 10. scopolamine 2.5 mg every 72 hour, patch q. 72 hours as needed for secretions 11. clindamycin 600 mg intravenously q. 8 hours, last dose on . 12. neutra-phos two packets three times a day for low phosphorus 13. coumadin 5 mg q.o.d. h.s. 14. coumadin 5.5 mg q.o.d. h.s. discharge diagnosis: 1. choledocholithiasis 2. pneumonia 3. aspiration pneumonitis 4. mental retardation 5. atrial fibrillation 6. hepatitis b carrier 7. hypoxia 8. anemia , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Unspecified protein-calorie malnutrition Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Long-term (current) use of anticoagulants Paralytic ileus Infection and inflammatory reaction due to other vascular device, implant, and graft Quadriplegia, unspecified Calculus of bile duct without mention of cholecystitis, without mention of obstruction

history of present illness: this is a 66 year-old severely mentally retarded male who is quadriplegic and blind who was transferred from the intensive care unit at hospital to the here at for an endoscopic retrograde cholangiopancreatography to treat a 1 cm common bile duct stone. a brief summary of the hospital course at is as follows; the patient was admitted to hospital on after developing nausea, vomiting and fever to 101 degrees. in the emergency department there he was tachycardic, tachypneic and febrile with a distended abdomen. at that time the patient was found to be in atrial fibrillation at 127 beats per minute. his inr was found to be supratherapeutic and his coumadin was initially held. the patient was also found to have no output through his ileostomy and a plain film of the abdomen showed air filled large and small bowel proximal to the descending colon raising the question of a bowel obstruction. a ct scan showed an edematous gallbladder with wall thickening and a right upper quadrant ultrasound showed a possible stone at the base of the gallbladder with dilation of the duct to 1 cm. the patient was placed on levaquin and clindamycin at this time. the patient also experienced respiratory failure after having a great deal of difficulty with secretion clearance, he desaturated further requiring a nonrebreather mask and at that time a chest x-ray showed complete opacification of the left hemithorax. at that time the patient was transferred to the intensive care unit at hospital, briefly intubated after discussions with the patient's brother . cultures were negative at that time. over the next several days his respiratory status improved and the patient was continued on 40% aerosol mask. the patient eventually underwent mrcp at hospital revealing 1 cm common bile duct stone. at this time the patient was transferred to for further management. past medical history: 1. atrial fibrillation with an ef in the 50s. 2. status post myocardial infarction. 3. severe mental retardation. 4. quadriplegia. 5. subtotal colectomy with ileorectal anastomosis. 6. hepatitis b carrier. 7. gastroesophageal reflux disease. 8. hiatal hernia. 9. kyphosis. 10. peg tube. outpatient medications: 1. coumadin 5 mg and 5.5 mg alternating days. 2. lopresor 12.5 mg twice a day. 3. protonix q day. 4. simethicone prn. allergies: nystatin. social history: the patient has been in the care of the state for sometime. his brother is his health care proxy. the brother has designated that the patient's code status shall be dnr/dni. physical examination on admission: temperature 98.1. heart rate 63. pressure 134/48. oxygen saturation 96% on face tent 80%. general lying in bed in no acute distress. heent no rash or icterus. lungs limited air movement, low bronchial sounds. heart s1, s2 without murmurs, rubs or gallops. abdomen soft, nontender, nondistended with hyperactive bowel sounds with no rebound or guarding. extremities contracted extremities without clonus. neurological nonverbal quadriplegic. laboratories on admission: white cell 10.8, hematocrit 37.4, platelets 276, inr 1.3, sodium 143, potassium 3.9, bun 13, creatinine 0.6, glucose 68, ast 42, alt 62, alkaline phosphatase 138, bili 1.3, amylase 77. hospital course: this is a 66 year-old severely mentally retarded quadriplegic blind male with multiple medical problems including atrial fibrillation who is admitted to the fiu from an outside hospital for endoscopic retrograde cholangiopancreatography and common bile duct stone removal. 1. common bile duct obstruction: the patient was kept npo prior to the procedure and underwent an endoscopic retrograde cholangiopancreatography on . a biliary sphinchterotomy was performed. the 1 cm stone was extracted and the bile duct was subsequently swept with a balloon catheter and an occlusion cholangiogram revealed no further concretion in the bile duct. the patient was continued on unasyn intravenously for several days. the patient was kept npo after the procedure and tube feeds were gradually restarted in the a.m. the patient will return to state on a seven day course of augmentin. the patient can follow up with dr. as needed. 2. bowel obstruction/ileus: in the end the patient was felt likely to have an ileus relating to irritation from the common bile duct stone. at no time did he appear toxic with respect to his gastrointestinal tract. he tolerated the endoscopic retrograde cholangiopancreatography procedure well. on he was gradually restarted on his tube feedings. 3. pneumonia: it is unclear whether the patient had a pneumonia at hospital or whether he acutely desated from mucous plug requiring intubation. he received antibiotic coverage there for a pneumonia, however, this was not continued at . here he sated in the high 90s on 40% face tent. he did occasionally desat, but responded to aggressive suctioning. it is likely that his oxygen requirement will go down as he recovers from the acute insult of both the common bile duct stone and the sedating medication used during the procedure. 4. atrial fibrillation: the patient apparently has had several episodes of atrial fibrillation in the past with rates to the 120s. at the patient was well controlled on lopressor 25 b.i.d., however, he did appear to remain in atrial fibrillation. recommend continuation of this previously effected and well tolerated medication. the patient's anticoagulation was held for his endoscopic retrograde cholangiopancreatography procedure. on the patient was restarted on his home doses of coumadin to bring his inr back up into the therapeutic range of 2.02 to 3.0. given the patient's reported history of an myocardial infarction the patient may benefit from a baby aspirin a day and also from an ace inhibitor. 5. dermatology: on the patient was noted to have a macular red beefy lesions in his groin, thought to be candidiasis. the patient was started on clotrimazole cream b.i.d. 6. nutrition: on the patient was restarted on gentle tube feeding with his goal to be 60 cc per hour of osmolite hn as he was on at state. 7. code status: during this hospitalization the patient's brother decided it would be appropriate for the patient's code status to be dnr/dni. this was briefly waved both for his acute intubation at hospital as well as for the endoscopic retrograde cholangiopancreatography procedure. this concludes dictation on this patient for the dates through , dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Unspecified protein-calorie malnutrition Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Long-term (current) use of anticoagulants Paralytic ileus Infection and inflammatory reaction due to other vascular device, implant, and graft Quadriplegia, unspecified Calculus of bile duct without mention of cholecystitis, without mention of obstruction

history of present illness: is a former 1.345 kg product of a 30 6/7 weeks gestation pregnancy born by repeat cesarean section due to progressive preterm labor and known triplet gestation. mother is a 29 year old gravida 4, para 1, now 2, intrauterine insemination triplet conception, estimated date of confinement was . prenatal screens revealed blood type 0 positive, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, group b streptococcus negative. the pregnancy was complicated by gestational diabetes. there was preterm labor at 23 1/7 weeks for which mother was admitted and received a complete course of betamethasone. she presented again on the night of delivery with preterm labor and cervical dilatation and was therefore delivered by repeat cesarean section. amniotic fluid was clear. this triplet, #1, emerged with spontaneous cry, requiring only blow-by oxygen and routine care in the delivery room. apgars were 8 at one minute and 9 at five minutes. she subsequently developed mild increased work of breathing and supplemental oxygen requirement. she was transported to the neonatal intensive care unit for further care. physical examination: weight was 1.345 kg, 50th percentile, length 41.5 cm, 50th percentile, head circumference 29.25 cm, 50th percentile. general: nondysmorphic with overall appearance consistent with known gestational age. head, eyes, ears, nose and throat, anterior fontanelle open and flat, red reflexes present bilaterally, palate intact. intermittent grunting with moderate intercostal retractions. chest, diminished air entry bilaterally. cardiovascular, regular heart rate and rhythm, no murmur. 2+ femoral pulses. abdomen: benign with no hepatosplenomegaly. no masses. genitourinary: normal female genitalia for age. musculoskeletal: spine straight with normal sacrum. hips: stable. neurologic: toes and reflexes consistent with gestational age. skin: pink with fair perfusion. hospital course: (by systems including pertinent laboratory data. 1. respiratory - initially was placed on continuous positive airway pressure for her respiratory distress. she developed increased work of breathing. she was intubated and received two doses of survanta. she was extubated to continuous positive airway pressure on day of life #1. she weaned to room nasal cannula oxygen by day of life #2 and was in room air by day of life #4. she remained in room air for the rest of her neonatal intensive care unit admission. she had many episodes of apnea and bradycardia. she was treated with caffeine citrate. the caffeine was discontinued on . she continued to have intermittent episodes of apnea, her last occurred on . at the time of discharge, she was breathing comfortably in room air with a respiratory rate in the 30s to 50s. 2. cardiovascular - required a normal saline bolus for a low blood pressure shortly after addition to the neonatal intensive care unit. she maintained normal heart rates and blood pressures from that time. no murmurs have been noted during admission. 3. fluids, electrolytes and nutrition - was initially npo on intravenous fluids. she started on parenteral nutrition on day of life #1. enteral feeds were started on day of life #2 and gradually advanced to full volume. she received calorie supplementation, to a maximum of 26 cal/oz with added promod. she has been on p.o. feeds since . at the time of discharge she is taking breast milk or enfamil 20, 24 cal/oz breast milk with 4 cal by enfamil powder. serum electrolytes were within normal limits during admission. discharge weight is 2.610 kg with a length of 47 cm and a head circumference of 34 cm. 4. infectious disease - due to her respiratory distress and prematurity, was evaluated for sepsis shortly after admission to the neonatal intensive care unit. a blood culture was obtained prior to starting intravenous ampicillin and gentamicin. the blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. gastrointestinal - peak serum bilirubin was 8.0 total/0.3 mg/dl direct, with an indirect of 7.7. on day of life #2, phototherapy was started and continued for six days. rebound bilirubin was 5.3/0.2 with an indirect of 5.1. 6. hematology - hematocrit at birth was 53.2%. did not receive any transfusions of blood products. most recent hematocrit was on at 31.5%. 7. neurology - head ultrasounds were performed on day of life #7 and at one month of age and both were within normal limits. 8. sensory - hearing, screening was performed with automated auditory brain stem responses, passed in both ears. ophthalmology, retinas were most recently examined on and were found to be immature, zone 3 with a recommended follow up the week of . 9. social - parents have been involved and visited regularly. the other triplet siblings have been discharged home. condition on discharge: good. discharge disposition: home with parents. primary pediatrician: dr. in , , phone . care/recommendations on discharge: 1. feeding - breast milk or enfamil 24 cal/oz breast milk with 4 calories of enfamil powder. 2. medications - ferrous sulfate 25 mg/ml dilution 0.2 ml p.o. q.d. 3. carseat position screening - performed, was observed for 90 minutes in her carseat without any episodes of bradycardia or oxygen saturation. 4. state newborn screens - sent on and , all results were within normal limits. 5. immunizations received - hepatitis b vaccine was administered on . 6. immunizations recommended - influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 7. follow-up with primary pediatrician is planned early the week of . discharge diagnosis; 1. prematurity at 30 6/7 weeks gestation. 2. triplet #1 of triplet gestation. 3. respiratory distress syndrome. 4. suspicion for sepsis ruled out. 5. unconjugated hyperbilirubinemia. 6. apnea of prematurity. , m.d. dictated by: medquist36 Procedure: Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,250-1,499 grams 29-30 completed weeks of gestation Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section

history of present illness: 1345 g female infant, triplet #1, born at 30 and 6/7 weeks gestation delivered by repeat cesarean section due to progressive preterm labor and triplet gestation. prenatal history: mom is a 29 year old, gravida 4, para 1 now 2 (two deliveries, four children), iui triplet conception. estimated date of confinement . prenatal screens 0 positive, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, reportedly gbs negative. pregnancy was complicated by gestational diabetes. question of preterm labor with abdominal discomfort and vaginal pressure at 23 and 1/7 weeks. mom was admitted and received a complete course of betamethasone. she presented again on the night of delivery with preterm labor and cervical dilatation and was, therefore, delivered by repeat cesarean section. amniotic fluid was clear. this triplet emerged with spontaneous cry, requiring only blow-by oxygen and routine care in the delivery room. apgars were eight at one minute and nine at five minutes. she subsequently developed mild increased work of breathing and supplemental oxygen requirement. she was transported to the neonatal intensive care unit for further care. physical examination: weight 1345 grams (50 percentile); length 41.5 cm (50 percentile); head circumference 29.25 cm (50th percentile). non dysmorphic with overall appearance consistent with known gestational age. anterior fontanel open and flat. red reflex present bilaterally. palate intact. intermittent grunting with moderate intercostal retractions. diminished air entry bilaterally. heart with regular rate and rhythm, no murmur. 2+ femoral pulses. abdomen benign with no hepatosplenomegaly. no masses. normal female genitalia for gestational age. normal back. extremities with hips stable. neurologic with appropriate tone. skin pink with fair perfusion. hospital course: 1. cardiovascular: received normal saline bolus on admission for low blood pressure, subsequently cardiovascularly stable with normal blood pressures. no murmur. 2. respiratory: initially placed on cpap. the patient subsequently developed increased work of breathing. was intubated and received surfactant times two doses. extubated to cpap on day of life 1. weaned off cpap to nasal cannula oxygen on day of life 2 and weaned to room air by day of life 4. subsequently breathing comfortably in room air. had episodes of apnea and bradycardia of prematurity. was started on caffeine. caffeine was discontinued on after a period of three days with no spells. continues to be monitored off caffeine. 3. fluids, electrolytes and nutrition: initially n.p.o. on intravenous fluids. started on parenteral nutrition on day of life one. started on enteral feeds on day of life two and advanced on enteral feeds without difficulty. reached full feeds on day of life seven. calories subsequently advanced to breast milk 26 or pe26 plus promod. given feeds gavage over 90 minutes, secondary to spits. on ferinsol and vitamin e supplements. good weight gain. birth weight 1,345 grams. weight on , 1,705 grams. 4. gastrointestinal: bilirubin levels were monitored. phototherapy initiated on day of life two. peak bilirubin of 7.8 total. phototherapy discontinued on day of life six for a bilirubin of 5.0 over 0.2, rebound bilirubin the following day was 5.3 over 0.2. 5. hematology/infectious disease. cbc and blood culture sent on admission. initial cbc with a white count of 7.8 with 4 polys and 0 bands. the patient was started on ampicillin and gentamicin. repeat cbc was obtained secondary to the neutropenia on the initial cbc. repeat cbc improved with white count of 9.4 with 23 polys and 3 bands. blood cultures showed no growth at 48 hours and antibiotics were discontinued. no further infectious disease issues. the patient has had screening and surveillance cultures which were positive for methicillin sensitive staph aureus. 6. hematology: initial hematocrit 53.2; platelets of 259. last hematocrit of 45.2 on day of life 2. the patient is on iron supplementation. 7. neurology: head ultrasound was performed on day of life seven and was negative. 8. sensory: hearing screen will need to be performed prior to discharge home. ophthalmologic examination has not yet been performed. 9. routine health care maintenance: newborn screen sent on day of life three and was normal. repeated on day of life 14 and results pending. no immunizations have yet been given. condition at discharge: stable. medications on discharge: 1. vitamin e. 2. ferrous sulfate. discharge diagnoses: 1. prematurity at 31 weeks gestational age. 2. status post surfactant deficiency. 3. status post hyperbilirubinemia. 4. status post rule out sepsis. 5. feeding immaturity. , m.d. dictated by: medquist36 Procedure: Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,250-1,499 grams 29-30 completed weeks of gestation Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section

history of present illness: baby girl is the 2.925 kilogram product of a 36 and week gestation born to a 31-year-old g2 p0 mom. prenatal screens b positive, antibody negative, rpr nonreactive, rubella immune, hepatitis negative, gbs unknown, no fever at delivery and no prolonged rupture of membranes. mother was insulin dependent diabetic since age 7 and was on an insulin pump during pregnancy. her hemoglobin a1c was 5.7. she has a history of chronic hypertension, retinopathy and nephropathy. mother was treated with dilantin, aldomet, synthroid in addition to her insulin. infant was born by c section secondary to maternal chronic illness. infant received apgars of 8 and 9 at 1 and 5 minute respectively. in the delivery room, she was given some blow by o2, dried and bulb suctioned. initially she was sent to the newborn nursery where she was noted to have a d stick of 38, was fed with a repeat d stick of 58. she had several more d sticks that were hypoglycemic and was transferred to the nicu for further management. physical examination on admission: weight 2.925 grams, 75th percentile, head circumference 33 cm 75th percentile, length 46 cm 50th percentile. normocephalic atraumatic anterior fontanelle open and flat. intact. red reflex deferred. neck supple. lungs clear bilaterally. cardiovascular regular rate and rhythm. no murmur. femoral pulses 2+ bilaterally. abdomen soft with bowel sounds. no masses or distention. extremities warm and well perfused. brisk cap refill. gu normal female. hips stable. clavicles intact. thigh midline. no sacral dimple. neuro, good tone. normal suck and gag. hospital course: respiratory, was in room air throughout her hospital course. she did have several episodes of apnea bradycardia on day of life 3. she has been 5 days apnea and bradycardia free as of . cardiovascular, no issues. fluid and electrolytes. her initial d sticks were hypoglycemia, with a low of 32. required d10 at 40 per kilo and ad lib enteral feedings. she has been off iv fluids since day of life #2 and has been stable with ad lib feedings since that time. gi, peak bilirubin was 9.7/0.2 on day of life #6. she has not required any interventions. hematology, hematocrit on admission was 40.3. infectious disease, cbc and blood culture were obtained on admission and a repeat cbc and blood culture obtained on day of life 3 in light of respiratory apnea and bradycardia. both cbcs and blood cultures were negative and infant has not received any antibiotics. neuro, she has been appropriate for gestational age. hearing screen was performed with automated auditory brain stem responses and the infant passed prior to discharge. condition at discharge: stable. discharge disposition: home. name of primary pediatrician: dr. . the family is going to follow up with dr. . medications: tri-vi- 1 ml po every day. car seat position screening: car seat test was passed prior to discharge. state newborn screen: state newborn screen has been sent per protocol on and . immunizations: infant received hepatitis b vaccine on . immunizations recommended, synagis rsv prophylaxis should be considered from through with infants who meet any of the following 3 criteria; 1)born at less than 32 weeks, born between 32 and 35 weeks with 2 of the following, day care during rsv season a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or with chronic lung disease. influenza immunizations recommended annually in the fall for all infants once they reach 6 months of age. before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. discharge diagnoses: infant of a diabetic mother, hypoglycemia, apnea and bradycardia of prematurity. , md dictated by: medquist36 d: 07:47:29 t: 08:17:58 job#: Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Primary apnea of newborn Neonatal bradycardia 35-36 completed weeks of gestation Other preterm infants, 2,500 grams and over Syndrome of "infant of a diabetic mother"

past medical history: 1. hypercholesterolemia. 2. hypothyroidism. 3. osteoporosis. allergies: sulfa. medications on admission: 1. enteric coated aspirin 81 mg once daily. 2. lovenox one dose. 3. synthroid 0.25 mg once daily. 4. pravachol 10 mg p.o. q.h.s. history of present illness: the patient is a 69 year old female with past medical history significant for hypercholesterolemia, hypothyroidism, osteoporosis, who presented to outside hospital with complaint of one week of right sided chest pain, burning, for one week. the pain was worsened on exertion. the patient was given nitroglycerin by her husband which did not relieve her pain. the patient denied shortness of breath, nausea, vomiting, fever and chills. at the outside hospital, the patient's troponin was 1.68. prevacid did not bring any relief. on the electrocardiogram, she had st depression in leads ii, iii and avf with flipped t waves in lead iii. the patient was given one dose of lovenox at the outside hospital and transferred to for further evaluation and management. physical examination: on admission, temperature is 97.8, pulse 64 and regular, blood pressure 120/80, respiratory rate 18, oxygen saturation 98% in room air. no carotid bruits, no jugular venous distention. heart - regular rate and rhythm with normal s1 and s2, i/vi systolic ejection murmur at the left upper sternal border. the lungs are clear to auscultation bilaterally. the abdomen is soft, nontender, nondistended. extremities are warm and well perfused. no edema. laboratory data: on admission, white blood cell count was 7.1, hematocrit 38.0, platelet count 285,000. inr was 1.2. sodium 141, potassium 4.0, blood urea nitrogen 13, creatinine 0.5. hospital course: the patient was admitted to medicine service on . in addition to her own medications, she was started on a beta blocker and integrilin. the patient underwent cardiac catheterization on , which showed 50% proximal left anterior descending lesion, 60% mid left anterior descending lesion involving the origin of the major diagonal, left circumflex distal 95% involving origin of om3 which is 95% narrowed at origin, 60% om2 origin, right coronary artery 70% origin, 95% mid left to right collateral to posterior descending artery, 1+ mitral regurgitation, left ventricular ejection fraction 45%, moderate inferior hypokinesis. cardiac surgery was consulted and coronary artery bypass graft was recommended for this patient. after appropriate preoperative workup, the patient went to the operating room on , where a coronary artery bypass graft times four was performed (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to om1, saphenous vein graft to posterior descending ii). the operation went without complications. pacing wires, as well as two mediastinal and one pleural chest tubes, were placed. the patient was transferred to post anesthesia care unit without complications. postoperative day number zero, the patient was extubated without complications. postoperative day number one, the patient was doing well. vital signs were stable. she was weaned off drips and started on p.o. lopressor. her chest tube was removed. postoperative day number two, the patient remained afebrile and vital signs were stable. her foley and wire were removed. the patient ambulates and works with physical therapy without any complications. postoperative day number three and four, the patient has no complaints, afebrile, continued to ambulate. no complaints and no active issues. condition on discharge: good. discharge status: the patient is discharged home. follow-up: the patient should follow-up with dr. in four weeks for postoperative check and follow-up. medications on discharge: 1. lasix 20 mg p.o. q12hours for fourteen days. 2. potassium chloride 20 meq p.o. twice a day for fourteen days. 3. enteric coated aspirin 325 mg p.o. once daily. 4. levothyroxine 25 mcg p.o. once daily. 5. pravastatin 20 mg p.o. q.h.s. 6. metoprolol 25 mg p.o. twice a day. 7. percocet one to two tablets p.o. q4-6hours p.r.n. for pain. 8. colace 100 mg p.o. twice a day while taking percocet. discharge diagnoses: 1. coronary artery disease, unstable angina, status post coronary artery bypass graft times four. 2. hypercholesterolemia. 3. hypothyroidism. 4. osteoporosis. , m.d. dictated by: medquist36 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 Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Unspecified acquired hypothyroidism Hematoma complicating a procedure Constipation, unspecified Osteoporosis, unspecified

allergies: nkda meds on admit: fosamax and asa review of systems: neuro: pt intubated an sedated on iv propofol, easily aroused. mae on bed. perrl. nodding appropriately to questions and follows simple commands. if mso4 given for pain/sedation. tls clear and c spine precautions maintained. cv: nsr, 1' avb with hr=60-80s and pt noted to have occasional pauses/missed beats for 1-4 seconds, p waves noted s qrs, slight drop in blood pressures noted. dr aware. ekg obtained. cardiology consulted. a line placed. weakly palpable peripheral pulses. resp: ls dm bilatally. a/c ventilation and pt tol well with adequate abgs and sao2-98-100%. gi: abd soft, +bsx4. npo. iv pepcid started. gu: indwelling foley intact and draining clear yellow urine, fair uo. heme: hct=23.7 (30.1). plan to hold on sq heparin presently 2' bleeding. id: tmax=99.9po. wbc=23(15). iv cefazolin started. endo: no issues. skin: warm and dry, extremities cool to touch. upper back, thoracic spine region with pink/reddened pressure sore area, stage 1. face with edema, periorbital edema and ecchymosis, and oozing blood from mouth and eyes. soc: pt lives with husband in . husband was home when pt fell but did not witness the fall. pt's daughter also present. questions answered and update proveded. they plan to be in later today. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Arterial catheterization Pulmonary artery wedge monitoring Open reduction of maxillary fracture Transfusion of packed cells Control of epistaxis by other means Diagnoses: Congestive heart failure, unspecified Atrial fibrillation Atrioventricular block, complete Acute diastolic heart failure Sinoatrial node dysfunction Closed fracture of malar and maxillary bones Home accidents Pathologic fracture of vertebrae Other accidental fall from one level to another

history of present illness: patient is a 77-year-old female who is complaining of back pain for several days and was experiencing back pain radiating to the chest. at some point the patient had a syncopal episode and fell onto her face. the patient reports a positive loss of consciousness. the patient was found down, bleeding significantly from her face and was brought immediately to the emergency department for further evaluation. patient was normotensive in the 70s and receiving intravenous fluids when she arrived at the emergency department. she was intubated in the emergency department using vecuronium and succinylcholine and was then evaluated using many radiographic modalities which showed multiple facial fractures. the patient was then transferred to the trauma surgical intensive care unit for further evaluation. past medical history: 1. osteoporosis. 2. compression fractures. past surgical history: none. medications: 1. fosamax. 2. aspirin. allergies: no known drug allergies. physical examination: on arrival her temperature is 100.8, pulse of 74, blood pressure 146/68, 14, 100%. the initial settings for the respirator are imv at a tidal volume 500, rate of 14, fio2 60%, and peak of 5. in general, intubated, sedated, paralyzed. heent: traumatic facial fractures with skull depression. bilateral tympanic membranes without blood. pupils pinpoint, sluggish to light. neck: in collar without lad or jugular venous distention. carotids 2+. rectal: guaiac negative, decreased tone. lungs: clear to auscultation bilaterally. heart is regular rate and rhythm; normal s1 and s2. abdomen: soft, nontender, nondistended; no hepatosplenomegaly. extremities: upper extremity full range of passive; left lower extremity full range of movement in passive motion; 1+ pitting edema bilateral knees. vasculature: right and left carotids, radial femorals, and dorsalis pedis all 2+. laboratory data: initial lab results showed a white count of 15, hematocrit of 30, and platelet count of 206. ck was 119, troponin was less than 0.01. urinalysis was negative. urinary electrolytes were unremarkable. summary of hospital course: the patient was transported to the trauma sicu, where she was evaluated by ear, nose, and throat as well as plastics for the facial fractures and epistaxis. the ent service at this point used balloons to tamponade the bleeding from the patient's nose. multiple adjustments were made during the trauma sicu time in order to control the bleeding. the initial evaluation by plastic surgery was that the patient would require in-house surgical repair of the multiple fractures. after a short stay in the trauma sicu the patient was then evaluated by cardiology, who determined that the patient either had sick sinus syndrome or another intermittent arteriovenous block or block below the av node which resulted in four- to five-second pauses on telemetry monitoring. the cardiology service felt the best course of action was to place a pacemaker for the patient. this procedure was done without complication. the patient was extubated and after a short period of time was sent to the trauma floor for further evaluation and possible surgical repair of facial fractures. after a short time on the floor patient was reevaluated by the plastic surgery service, who felt that at this point her facial fractures were non-operative. the ent service also felt that the epistaxis was under control and that no other intervention was necessary. the patient was evaluated by speech and swallow and physical therapy, and it was determined that the patient would leave the hospital to go to rehab prior to going home to ensure the patient's safety. at time of discharge the patient had improving pain symptoms and was improving overall clinically. discharge condition: good. disposition: to rehab. discharge diagnoses: 1. syncope. 2. pacemaker placement. 3. multiple facial fractures. 4. likely repaired intermittent arteriovenous block or block below the arteriovenous node. discharge medications: 1. percocet 325. 2. colace 100 b.i.d. 3. erythromycin ointment, one to two drops ophthalmic q.i.d. 4. famotidine q. 12 hours. 5. bisacodyl 10 mg suppository q. h.s. discharge instructions: 1. follow up with the trauma clinic in one to two weeks. 2. follow up with the clinic in one to two weeks. 3. the patient may also follow up with her outpatient plastic surgeon, dr. , for possible repair of the fractures in the future. , m.d. 2923 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Arterial catheterization Pulmonary artery wedge monitoring Open reduction of maxillary fracture Transfusion of packed cells Control of epistaxis by other means Diagnoses: Congestive heart failure, unspecified Atrial fibrillation Atrioventricular block, complete Acute diastolic heart failure Sinoatrial node dysfunction Closed fracture of malar and maxillary bones Home accidents Pathologic fracture of vertebrae Other accidental fall from one level to another

history of present illness: this is an 80-year old female with respiratory failure and subglottic stenosis versus, tracheomalacia; and with possible subglottic stenosis the patient was trach'ed after a foreign body aspirate and transferred from for a rigid bronch and microdebridement at the . the patient also has a history of a uti. past medical history: notable for chf, afib, hypertension, cva, the patient on a vent is treated for c. diff. past surgical history: notable for a tracheostomy and peg which was placed in . medications at home: include aspirin, diltiazem, lasix, prevacid, thiamin, multivitamin, calcium and vitamin d, heparin subcutaneously, oxycodone, protonix, albuterol, ciprofloxacin and vancomycin p.o.. family history: noncontributory. social history: the patient denies tobacco or etoh. physical examination: the patient was on admission afebrile with vital signs stable. she was in no acute distress. she was awake, and alert, and oriented. she was regular rate and rhythm with no murmurs, rubs or gallops. her airways were clear, but decreased breath sounds. her belly was soft, nontender, nondistended. she had no clubbing, cyanosis or edema of her lower extremities. the patient was admitted for a rigid bronch and t-tube placement. pertinent results: the patient had a chest x-ray which was obtained on after a picc line was placed in the right arm to evaluate subglottic stenosis. the picc was found to terminate in the soft tissue of the axilla 5 cm below the shoulder joint. path tissues were also obtained from the microdebridement which are pending at this point. a chest x-ray was obtained on admission - on - which showed stable bilateral pleural effusions in the lower lobes bilaterally. the patient was admitted on with a white count of 6.3, hematocrit 30.2, platelet count of 327. sodium was 130, potassium was 5.0, chloride was 97, bicarbonate was 23, bun was 14, creatinine 0.6 and glucose 141. all labs remained stable throughout her hospitalization course, and she required no transfusions. hospital course: the patient was admitted under dr. on . she was admitted to the surgical icu at the . she was made n.p.o.. she was given iv fluids. her tube feeds were held. her hematocrit remained stable, which was previously noted. she was started on vancomycin and levofloxacin for c. diff and a uti. a foley was then placed. on , the interventional pulmonary service saw the patient in the morning; at which point a flex bronch was performed at the bedside and a rigid bronch and microdebridement were planned for the following day. the patient was bronch'ed on ; which showed a subglottic stenosis with a right lower lobe endotracheal tube. there was mild supraglottic edema. there was subglottic stenosis with malacia. the patient was then taken to the operating room again on for a rigid bronch, microdebridement and a t-tube placement. the goal of t-tube was to have it capped 24 hours a day/7 days a week. if the patient needs to be uncapped then she should be put on humidified air. a speech and swallow eval was requested. guaifenesin 1200 mg b.i.d. was to be used for t-tube. she was then supposed to be transferred to rehab. the patient was capped with her t-tube, however, she developed desaturations into 80% immediately postop. she was then placed back on humidified air and tolerated it well, and saturations came up into the 90s. the following day - on - the patient was once again transferred to have her t-tube capped. she tolerated it well. kept her saturations in the 90s for several hours, in which case she was then transferred back to her humidified air tracheal collar for increased comfort. discharge medications: she is to be discharged on acetaminophen, aspirin, calcitonin, calcium carbonate, heparin, diltiazem, colace, lasix, hexavitamin, oxycodone, thiamin, vitamin d3, albuterol, pantoprazole, anzemet, morphine, vancomycin, guaifenesin, glycerin suppository. discharge instructions: the patient was told that she had a t-tube placed in the hospital. the goal of her breathing was to have her t-tube clamped 24 hours a day/7 days a week. however, she was told that if she has any shortness of breath that she may go back onto a tracheal collar on humidified until the time at which she can tolerate the tube being clamped. she was told to continue her tube feeds, and that she should remain n.p.o.. she is also to have guaifenesin 1200 mg b.i.d. for care of the t-tube and to receive o2 by nasal cannula. her tube feeds are probalance at 50 cc an hour, which includes 1440 kilocalories and 65 grams of protein. she is to have her abdomen examined on a regular basis and to have her electrolytes checked on a routine basis. the patient was also told to call dr. for a follow-up visit for a flexible bronchoscopy in 2 weeks. discharge condition: good; she is saturating well; she is afebrile; her vital signs are stable. discharge disposition: she is to be transferred to her rehab facility in the morning. , md Procedure: Fiber-optic bronchoscopy Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Replacement of tracheostomy tube Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Intestinal infection due to Clostridium difficile Long-term (current) use of anticoagulants Fitting and adjustment of cardiac pacemaker Chronic respiratory failure Other diseases of trachea and bronchus Mechanical complication of tracheostomy Stenosis of larynx Edema of larynx

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall major surgical or invasive procedure: peg/tracheostomy placement history of present illness: 79 f s/p fall (tripped on her dog), hit countertop w/head. no loc. head ct at osh shows l sdh and l frontal contusion. patient transferred to for further treatment. of note, patient anticoagulated with coumadin for atrial fibrillation. past medical history: -complete heart block, with traumatic fall, s/p pacer -lefort ii fracture -osteoperosis -compression vertebral fractures -atrial fibrillation -h/o repeated falls physical exam: gen: wd/wn, comfortable, nad. heent: nc/at. anicteric. mmm. neck: supple. no masses or lad. no jvd. no thyromegaly. no carotid bruits. lungs: cta bilaterally. no r/r/w. cardiac: rrr. s1/s2. 3/6 systolic ejection murmur at upper sternal border. abd: soft, nt, nd, +nabs. no rebound or guarding. no hsm. extrem: warm and well-perfused. no c/c/e. neuro: mental status: eyes closed when entering the room. opens them briefly to nasal tickle and turns head side to side. no verbal response. does not follow commands. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. blinks to threat bilaterally. iii, iv, vi: extraocular movements with full horizontal ductions (tracked $) but did not track vertically. v, vii: facial symmetric. corneal reflexes present bilaterally. viii: unable to assess. ix, x: +gag. : unable to assess. xii: tongue midline without fasciculations. motor: underlying bulk obscurred by edema. right arm is flaccid. left arm is hypertonic. at rest, right arm extended at side, left arm flexed. no withdrawal of right upper extremity to noxious. triple flexion response in right lower extremity. withdraws purposefully on left. sensation: grimaced to noxious on right, withdrew on left. reflexes: b t br pa ac right 2 2 2 1 1 left 2+ 2+ 2+ 1 1 toes upgoing bilaterally pertinent results: ct tspine: there are multiple compression fractures throughout the thoracic spine and upper lumbar spine. the thoracic compression fractures in aggregate cause marked kyphotic curvature of the thoracic spine. at the level of t4, there is a mild vertebral body compression fracture. at the level of t7, t8 and t9, there are severe anterior wedge-shaped compression fractures. there is a mild compression fracture at the level of t11. there is a mild compression fracture at the level of l1. throughout the thoracic spine, there is no evidence of retropulsion, bony central spinal canal compromise, or significant neural foraminal stenosis. there are bilateral pleural effusions. there are atherosclerotic calcifications within the wall of the aorta. head ct : there has been mild improvement of the left frontal intraparenchymal hemorrhage that measures 4.0 x 3.0 cm, and the second smaller adjacent parietal intraparenchymal hemorrhage is also slightly improved. the mass effect is unchanged with persistent compression of the anterior and subfalcine herniation. surrounding associated edema has slightly progressed from the comparison. blood is no longer seen in the lateral ventricles and small left subdural hematoma is unchanged in size. eeg : this is an abnormal eeg due to the presence of diffuse and slowed background rhythms along with generalized bursts of mixed frequency delta and theta slowing. in addition, the presence of an asymmetry with more triphasic waves seen over the right than left was also noted. no sharp or epileptiform features were observed. this eeg is most consistent with a severe encephalopathy with a question of possible midline lesion, as well, given the bursts of generalized pattern slowing seen. common causes of encephalopathy include medications, metabolic causes, and infectious processes. note is made of an irregular cardiac rhythm. brief hospital course: patient admitted to the trauma service (icu) and started on dilantin with q1 hour neuro checks. exam on admission- asleep but arousable; oriented to place and person. eyes open to command; perrl. eomi. follows commands and mae w/ equal strength. on hospital day #3 the patient was intubated for decreased resp effort/mental status. repeat head ct was unchanged. pt was fitted for tlso brace for thoracic fx which must be on when hob>45 degrees or anytime pt is oob. pt was treated for staph areus coag +/ pseudomonas pneumonia with vanco and cefepime both due to end on . pt persistently febrile and dilantin was weaned and keppra was started. please follow taper up of keppra and taper down of dilantin as directed. on hct down 23-->19 w/ heme (+) stool. pt was transfused 2 units red cells at that time with no further episodes. trach and peg performed on . pt weaned to trach mask with good abg's. last abg on 40% trach mask was 7.46/42/88/ o2sats 99%. current exam-- perrl 3mm-->2mm. eyes open to voice. localizes left upper extremity. withdraws bilateral lower extremities. no movement rue. medications on admission: warfarin asa procrit calcium discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. 2. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 3. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) 5000units injection tid (3 times a day). 6. insulin regular human 100 unit/ml solution sig: one (1) sliding scale injection asdir (as directed). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day): hold hr <60, sbp<100. 9. levetiracetam 100 mg/ml solution sig: ten (10) po bid (2 times a day) for 3 days. 10. levetiracetam 100 mg/ml solution sig: ten (10) po qam (once a day (in the morning)). 11. levetiracetam 100 mg/ml solution sig: fifteen (15) po qpm (once a day (in the evening)). 12. cefepime 2 g piggyback sig: one (1) piggyback intravenous q12h (every 12 hours): dc . 13. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours). 14. vancomycin 500 mg recon soln sig: one (1) recon soln intravenous q 12h (every 12 hours): dc . 15. phenytoin sodium 50 mg/ml solution sig: four (4) intravenous q12h (every 12 hours) for 7 days. 16. phenytoin sodium 50 mg/ml solution sig: two (2) intravenous qam (once a day (in the morning)) for 3 days: start am ; stop after dose 6/17. 17. phenytoin sodium 50 mg/ml solution sig: four (4) intravenous qpm (once a day (in the evening)) for 3 days: start on ; stop after dose on . 18. phenytoin sodium 50 mg/ml solution sig: two (2) intravenous q12h (every 12 hours) for 3 days: start on ; stop after dose on . 19. phenytoin sodium 50 mg/ml solution sig: two (2) intravenous qpm (once a day (in the evening)) for 3 days: start on ; dc after 3 days. discharge disposition: extended care facility: & rehab center - discharge diagnosis: l frontal iph, l parietal sdh, l parietal fracture t4 fracture discharge condition: neurologically stable discharge instructions: please come to the emergency room if you have fever >101.4, nausea or vomiting, shortness of breath or any other symptoms of concern to you. please take your medications as directed. followup instructions: please follow up with dr. in 4 with a head ct. call his office at for an appointment. md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Transfusion of packed cells Electroencephalogram Diagnoses: Abnormal coagulation profile Urinary tract infection, site not specified Atrial fibrillation Acute respiratory failure Pneumonia due to Pseudomonas Alkalosis Osteoporosis, unspecified Methicillin susceptible pneumonia due to Staphylococcus aureus Other encephalopathy Home accidents First degree atrioventricular block Pathologic fracture of vertebrae Other accidental fall from one level to another Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness

history of present illness: ms. is a 41 year-old female who was a bicyclist on when she was hit by an automobile that resulted in a sucking chest wall wound, which was repaired in a severe peroneal injury. the injury required anal sphincter repair and diverting colostomy. she was admitted for repair of her bowel diversion. past medical history: notable for being overall healthy with no history of hypertension, diabetes, asthma, bleeding disorder, shortness of breath or palpitations. past surgical history: notable for colostomy in . allergies: no known drug allergies. medications: none. social history: no smoking and occasional ethanol and no recreational drugs. physical examination on admission: the patient was regular rate and rhythm. nontender, nondistended. lungs clear to auscultation bilaterally. stoma intact and pink. hospital course: on the patient underwent an elective take down colostomy by dr. with 1650 of intravenous fluids and 100 of estimated blood loss with no untoward events during the operation. this operation was performed at 8:00 a.m. at 2:00 p.m. the patient underwent postoperative check, which demonstrated vital signs at 98.7, 122/67, 73, 13 and 94% on room air. the patient was being maintained on a morphine sulfate pca at 1 mg q 6 minutes with a 10 mg hourly maximum. she also received 100 mg of fentanyl in the operating room and received 7 mg of morphine sulfate in the pacu before having her pca begun. in the pacu it was noted that the patient's respiratory rate ranged around the 20s and diminished to the 15s and then 10 while the patient maintained excellent oxygen saturations from 100% down to 92% by 3:00 p.m. the patient was transferred to the floor, but at 7:38 p.m. a respiratory arrest was called. the patient was found unresponsive and not breathing with patent airway. the patient was bag ventilated to raise her saturations to 89 to 100% on room air with a blood pressure of 116/77 and the patient was given narcan .4 mg intravenous and began breathing on her own with improved oxygen saturations. the patient had serial arterial blood gases performed. the first one was 7.00, 103, 335, 27 and negative 7. the second blood gas when the patient was transferred to the unit was 7.32, 43, 326, 23, negative 3. the patient was started on a narcan drip and transferred to the surgical intensive care unit and began on neurological checks and given toradol to help control her pain. that following morning the patient improved. her vital signs the following day, she had heart rate of 66, blood pressure 120/63, respiratory rate 14, 100% on 5 liters nasal cannula. her lungs were clear to auscultation bilaterally and heart was regular rate and rhythm. s1 and s2. the patient also had one set of enzymes, which were negative for cardiac event. the patient did well the following day and was transferred to the floor postoperative day one. postoperative day two the patient did well. she remained stable on the floor with no events. she began passing flatus on postoperative day four. her diet was advanced. she continued to be stable respiratory wise and she remained afebrile. she tolerated a regular diet and diuresed her fluids well. she was mentating well by report. she was discharged home on after being seen and evaluated by dr. for a final time and with follow up with dr. on the thursday of the week for staple removal. she was instructed not to drive or lift greater then 15 pounds and the patient was discharged also because she lived in very close proximity to the hospital and had adequate home assistance. the patient tolerated a regular diet and remained afebrile throughout the remainder of her course. , m.d. dictated by: medquist36 Procedure: Large-to-large intestinal anastomosis Closure of stoma of large intestine Diagnoses: Attention to colostomy Respiratory arrest

history of present illness: the patient is a 41-year-old female bicyclist who swerved to avoid a car door opening and was "run over" by a 30- truck. emergency medical service at the scene reported a sucking chest wound in the field, but hemodynamically stable. a large peroneal laceration. in the emergency department the patient was alert and oriented but there was positive loss of consciousness at the scene. she was moving all extremities. due to chest wound and plans for the operating room, the patient was intubated and a left chest tube was placed with minimal blood return. a ct of the head was negative. a ct of the chest demonstrated a small left apical pneumothorax. a ct of the cervical spine was negative for fracture, dislocation. a ct of the abdomen and pelvis demonstrated a larger peroneal laceration with fat stranding surrounding it. the patient was sent to the operating room with repair of left chest pleural laceration which was a primary repair, and also underwent a diverting sigmoid colostomy procedure. exploratory laparotomy was otherwise negative. she was admitted to the surgical intensive care unit after return from the operating room. past medical history: none. medications on admission: none. allergies: no known drug allergies. physical examination on admission: temperature not recorded on emergency department flow sheet, heart rate 80, blood pressure 110/69, respiratory rate 30, oxygen saturation 100% on 4 liters. heent revealed no abrasions or lacerations noted over the head or face. neck was in a cervical collar, immobilized. no tenderness to palpation over the bony cervical spine. no stepoff or deformities were noted. chest had bilateral equal breath sounds throughout, open sucking left chest wound was noted. heart had a regular s1/s2. no murmurs, gallops or rubs. abdomen was soft and nondistended. there was diffuse abdominal tenderness throughout. pelvis was stable. there was a large peroneal laceration noted. moderate rectal tone with frank red blood. there was a muscle exposed in the perineum. there was a large abrasion over the right buttock. extremities were warm and well perfused, full distal pulses. no gross bony deformity or tenderness to palpation, spontaneously moved all extremities. motor and sensation were intact without focal deficits. neurologically, the patient was awake alert and oriented times three; although, there was a report of loss of consciousness at the scene. her coma scale was 15 on arrival to the emergency department. laboratory on admission: complete blood count revealed a white blood cell count of 8.9, hematocrit 37.3, hemoglobin 12.6, mcv 91, platelets 141. pt 13.3, inr 1.2, ptt 37.6. fibrinogen 241. sma-7 revealed sodium of 140, potassium 3.7, chloride 107, bicarbonate 21, bun 21, creatinine 1, glucose 105. amylase 49, magnesium 1.4. serum toxicology screen was negative. urine toxicology screen was negative. arterial blood gas after intubation in the emergency department revealed 50% fio2 with a tidal volume of 700, a respiratory rate of 8, demonstrated a ph of 7.4, po2 of 233, pco2 of 37, total co2 of 24, and no base excess. radiology/imaging: ct of the head in emergency department without contrast revealed no intracranial hemorrhage or skull fracture. ct of cervical spine revealed no cervical spine fracture or malalignment. ct of the chest with intravenous contrast revealed there was interruption of the left anterior chest wall musculature with large subcutaneous emphysema connected with a trace left pneumothorax, assessment left anterior rib fractures, small focal hemorrhage in the right ischiorectal fossa. on ct of the abdomen, rectum appeared intact. ct of the thoracic and lumbar spine were without evidence of fracture or dislocation. hospital course: immediately postoperatively, the patient was admitted to the surgical intensive care unit for further care. she was successfully extubated post surgery and was awake alert and oriented at that time. a patient-controlled analgesia was set up for pain control, and the patient found that she was unable to push the button. a neurology consultation was obtained in order to evaluate for right hand weakness. the patient was found to have weakness suggestive of an ulnar neuropathy. she had decreased sensation to pinprick in the distal aspect of her later fourth and fifth fingers on the right hand. in order to fully rule out a more proximal injury, an mr of the brachial plexus was obtained which was normal. on hospital day two, chest tube was removed. on hospital day three, - was removed. the function of the patient's right hand continued to improve throughout her hospital course. the patient began occupational and physical therapy on hospital day two. she was transferred to the floor for further care on hospital day three. throughout the remainder of her hospital course she did well. she was out of bed and ambulating without difficulty. her pain was adequately controlled. she was slowly advanced onto a p.o. diet. she did have one episode during her hospital course of nausea and vomiting during which an nasogastric tube was placed, and further abdominal imaging was obtained in order to rule out obstruction. a kub flat and upright was obtained which demonstrated dilated loops of small bowel in the midabdomen. a cat scan of the abdomen demonstrated markedly dilated loops of small bowel with definite transition point. a short segment of wall thickening probably involving the jejunum. no pneumatosis or free air was noted, and no abscess was noted. stoma function gradually improved, and the ileus slowly resolved. on the day of discharge the patient was enjoying a full p.o. regular diet without any difficulty. ostomy was functioning well. she felt well and was ready and eager for discharge to home. she will be followed at home with once a day for ostomy care for the next. she has undergone ostomy training inhouse. she was to follow up with dr. in the first week of in order to evaluate for ostomy takedown. she was to follow up with dr. on thursday, , for followup regarding her chest surgery. medications on discharge: 1. colace 100 mg p.o. b.i.d. 2. tylenol 650 mg p.o. q.4-6h. p.r.n. 3. ostomy care material. discharge diet: diet on discharge was regular. condition at discharge: excellent. discharge status: the patient was to be discharged to home. discharge diagnoses: 1. bicyclist struck by car. 2. one open chest wound, status post repair. 3. open peroneal wound, status post repair. 4. diverting colostomy. , m.d. dictated by: medquist36 Procedure: Temporary colostomy Repair of pleura Suture of laceration of vulva or perineum Diagnoses: Paralytic ileus Closed fracture of one rib Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist Traumatic hemothorax with open wound into thorax Open wound of other and unspecified parts of trunk, without mention of complication Other specified sites, including multiple injury

allergies: codeine attending: chief complaint: pericardial effusion s/p af ablation major surgical or invasive procedure: pericardiocentesis pulmonary vein isolation history of present illness: patient is a 44 yo man with pmh long standing afib, s/p pvi in at which lasted 10 months, htn, hypercholesterolemia, who presented to today for scheduled pulmonary vein isolation/af ablation. procedure was noted to be technically difficult with several attempts at transeptal puncture. ablation was carried out successfully, and on intra cardiac echo, a pericardial effusion was noted (per notes approximately 1cm). it is unclear whether this effusion was present prior to procedure. therefore, a post-procedure echo was obtained that per notes demonstrated pericardial effusion = 2.4cm (no report online yet). patient remained hemodynamically stable throughout procedure and post-procedure. currently patient feels "out of it" from all the sedation medications, c/o mild chest pressure, no other complaints. past medical history: 1.) afib s/p pvi in at , lasted 10 months. followed by dr. and alexi 2.) htn 3.) hypercholesterolemia 4.) ?sss per records, last echo in demonstrated ef=37% social history: sh: no tobacco, occasional etoh, no drug use. lives with wife and 2 children (age 12 and 8) in , currently unemployed mechanic. family history: noncontributory physical exam: vitals - hr 74 nsr, bp 114/59, pulses 7, rr 19, o2 100% 2l nc general - lying supine, appears lethargic but easily arousable, nad heent - perrl, mmm neck - could not assess jvp as pt lying supine cvs - rrr, nl s1, s2, no m/r/g lungs - cta anteriorly and laterally abd - soft, nt/nd, no noted hsm, + bs groin - b/l groin puncture sites - r side covered with dressing w/ some sanguinous drainage, no active bleeding noted, no hematoma noted non-tender to palpation, no bruit ascultated. l side same. ext - no le edema b/l, 1+ dp pulses b/l, 2+ pt pulses b/l pertinent results: pre-procedure ekg: afib at 111, no other noted abnormalities . post-procedure ekg: nsr @ 77, no other noted abnormalities tte conclusions: left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is a moderate sized, circumfirential pericardial effusion. there are no echocardiographic signs of tamponade. tte conclusions: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. there is a moderate to large sized pericardial effusion (greatest posteriorly). there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , there is no definite change (prior study had focused views and underestimated the size of the effusion) . tte 1. 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%). 2. right ventricular chamber size is normal. right ventricular systolic function is normal. 3.there is a large pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. compared with the findings of the prior study (images reviewed) of , the effusion has grown in size. . pericardiocentesis procedure: right heart catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 french pulmonary wedge pressure catheter, advanced to the pcw position through an 8 french introducing sheath. cardiac output was measured by the fick method. pericardiocentesis: was performed via the subxyphoid approach, using an 18 gauge thin-wall needle, a guide wire, and a drainage catheter. conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. comments: 1. baseline hemodynamics demonstrated moderately elevated right sided pressures (mean ra 20 mmhg), pulmonary pressures (pad 20 mmhg), left sided pressures (mean pcwp 20 mmhg) a pericardial pressure of 20 mmhg. 2. pericardiocentesis was performed successfully and 650 ml of bloody fluid was drained. 3. following pericardiocentesis, the ra pressure fell to 15 mmhg, and the pericardial pressure fell to 1 mmhg. 4. echocardiography performed following the procedure showed only a small residual effusion (see echocardiography report). 5. a catheter was left in the pericardium to drain, and the patient left the catheterization laboratory in stable condition. final diagnosis: 1. pericardial effusion. 2. successful pericardiocentesis. . tte post pericardiocentesis conclusions: focused study. 1.left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). 2.there is a trivial pericardial effusion present. . tte conclusions: there is a trivial pericardial effusion. there are no echocardiographic signs of tamponade. . complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:18pm 33.4* 07:05am 8.7 4.04* 12.2* 34.9* 86 30.1 34.8 13.8 268 04:57pm 36.1* 04:08am 10.0 3.96* 12.2* 35.1* 89 30.7 34.6 13.8 182 11:41pm 33.9* 07:20pm 34.1* 12:58pm 33.7* 04:00am 12.0* 3.58* 10.9* 31.2* 87 30.5 35.0 13.7 142* added retic 10:am 10:20pm 33.8* 04:00pm 13.8* 4.03* 12.3* 35.3* 88 30.5 34.8 13.6 134* 04:59am 19.1* 5.04 15.1 43.6 87 30.0 34.7 13.8 210 12:19am 18.9* 5.24 15.6 45.8 87 29.9 34.2 13.7 240 brief hospital course: patient is a 44 year old man with pmh long standing atrial fibrillation, presented for elective pulmonary vein isolation/atrial fibrillation ablation. . patient underwent atrial fibrillation ablation on that was initially successful in converting patient to nsr. however, procedure was complicated by technical difficulties, including new onset pericardial effusion thought to be due to perforation of the posterior/septal wall of left atrium during the procedure. therefore the patient was admitted to the ccu for monitering. the patient was initially in a lot of chest pain following the procedure, which via evaluation was felt secondary to his pericarditis from the procedure and the effusion. this resolved quickly during his hospital course. his pulses and hemodynamics were monitered closely and remained stable. repeat echo's initially demonstrated no change in the size of his effusion, and with his stable hemodynamics, it was felt that his effusion was stable. . however, 2 days following admission, the patient's clinical status changed and he began having transient episodes of hypotension. at this time, he was also noted to have a nearly 10 point hct drop, and had returned again from nsr, which he had been in since his pulmonary vein isolation, to atrial fibrillation/atrial flutter. ep was notified of the patient's return to atrial fibrillation/flutter and opted to start the patient on sotalol, which was titrated up to 120mg po bid by time of discharge. he was also intermittently given diltiazem (po and iv) for rate control. to work up his hct drop and associated transient episodes of hypotension, a femoral artery ultrasound was performed on the patient's femoral arteries bilaterally, which were negative. his stool was guiaced for blood, which was negative. he had an abdominal/pelvis ct scan to rule out a retroperitoneal bleed which was negative. he also underwent another echo after this hct drop was noticed, which demonstrated a 25% increase in the pericardial effusion, no evidence of tamponade, and patient's pulses remained stable at this time. therefore the patient was brought to the cath lab for a pericardiocentesis with drain placement, and successfully underwent drainage of 1 liter of sanguinous fluid from the pericardial sac prior to removal of his pericardial drain. his hct was monitered tid during this time, and remained stable with small amounts of fluctuation. a repeat echo performed following removal of the pericardiocentesis drain, prior to discharge, demonstrating no re-accumulation of his pericardial effusion. the patient's hemodynamics and pulses remained stable. . therefore the patient was re-started on his coumadin with lovenox bridge (given high incidence of clot formation following pulmonary vein isolation) and discharged on sotalol 120mg with instructions to follow up at his primary care physician's office 1 day and 3 days after discharge for both hct checks (to ensure were stable) and inr checks, then follow up as his pcp . he was also instructed to follow up with his cardiologist 1 week following discharge. . of note, the patient's blood sugars were noted to be elevated throughout hospital course. per patient, he stated that he was told that his blood sugar was high prior, by his pcp, that attempts at dietary and exercise modifications were made. given the patient's values of non-fasting glucose greater than 200, the patient meets criteria for likely type 2 diabetes mellitus. management of this was deferred as an inpatient given the patient's other medical conditions described above, but this should be addressed in the outpatient setting, and consideration should be made of starting an oral hypoglycemic . medications on admission: coumadin 7.5mg po qd (last dose ) atenolol 25mg flexoril 10mg prn discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. sotalol 80 mg tablet sig: 1.5 tablets po bid (2 times a day) as needed for aflutter. disp:*90 tablet(s)* refills:*2* 3. warfarin 5 mg tablet sig: 1.5 tablets po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 4. enoxaparin 100 mg/ml syringe sig: one (1) injection subcutaneous (2 times a day): please continue until advised so by your primary care physician (once coumadin level is therapeutic). disp:*30 injection* refills:*2* 5. outpatient lab work hematocrit, inr, ptt - please check on tuesday, 6. outpatient lab work hematocrit, inr, ptt - please check on friday, discharge disposition: home discharge diagnosis: atrial fibrillation status post pulmonary vein isolation atrial flutter hemopericardium pericarditis discharge condition: hemodynamically stable, no chest pain, good discharge instructions: 1. please take all medications as prescribed. 2. please keep all follow-up appointments. 3. please seek medical attention if you develop lightheadedness, chest pain, shortness of breath, nausea, vomiting or have any other concerning symptoms. followup instructions: 1.) please go to dr. office on tuesday and friday after 9am for blood draws to have your hematocrit and inr checked. 2.) please follow up with appointment with dr. () on tuesday at 11am. call to change appointment. 3.) please follow up with dr. in the next 1-2 weeks (). please ensure dr. is communicating with dr. , and you should probably also follow up with dr. in the next 2-4 weeks (can discuss with dr. whom you should be following with) Procedure: Pericardiocentesis Excision or destruction of other lesion or tissue of heart, endovascular approach Right heart cardiac catheterization Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Atrial flutter Unspecified disease of pericardium Other abnormal blood chemistry

history of present illness: the patient is a 53-year-old right handed man with a history of insulin dependent diabetes, angina, status post angioplasty with three stent placements. here today for evaluation from neurosurgery service for brain tumor. his neurologic problem began in when he noted pulsatile tightness. he also experienced poor balance and dizziness. he saw his primary care physician but antibiotics did not help his symptoms. later in mid he began experiencing mid frontal headaches radiating to the back of his head. the headaches were not positional. he has had pressure in his right ear. he underwent physical therapy and saw an ent physician. reported that he had unremarkable ct of the sinuses and his nasal sinus evaluation showed old scarring. he had a gadolinium enhanced mri of the brain on which showed a mass in the right temporal brain. he had a lung and adrenal gland biopsy on . the lung biopsy was non diagnostic and the adrenal biopsy is still pending. physical examination: the patient had a blood pressure of 140/80, heart rate 80, respiratory rate 14. skin had full turgor. heent unremarkable. neck supple, no bruits. cardiac exam reveals regular rate and rhythm, no murmur or s4. lungs are clear. abdomen is soft. extremities show no clubbing, cyanosis or edema. neurologically he is awake, alert and oriented times three, there is no left right confusion, calculation is intact. his language is fluent with good comprehension, naming and repetition. short term memory is at 0 minutes and at 5 minutes. cranial nerve exam, pupils are equal and reactive, 4 mm to 2 mm, extraocular movements are full. visual fields are full to confrontation. his funduscopic exam reveals sharp disc margins bilaterally with venous pulsations. face is symmetric. facial sensation is intact bilaterally. hearing is intact bilaterally. tongue is midline. palate goes up midline. he has no drift. his muscle strength is in all muscle groups with the exception of his left iliopsoas which is 4+/5. he has normal bulk and tone. his reflexes are 0-1 and symmetric bilaterally. ankle jerks are absent. toes are downgoing. sensation is intact to touch and proprioception. coordination exam does not reveal any dysmetria and his gait is normal. hospital course: on he underwent a right temporal craniotomy for resection of tumor. post-op his vital signs were stable, he was afebrile, he was awake, alert, extraocular movements intact, tongue midline, mild symmetric, visual fields full to confrontation, no drift. dressing was removed, his incision was clean, dry and intact. vital signs have remained stable. postoperative white count was 37, hematocrit 43.2, sodium 140, potassium 4.6. he is on depakote 500 mg po tid times one week. for discharge meds, also decadron to be weaned to 2 mg po bid over 1-2 weeks time, zantac 150 mg po bid and percocet 1-2 tabs po q 4 hours. also univasc 7.5 mg po q day, niacin 500 mg po q h.s., atenolol 50 mg po q day, actose 45 mg po q day. patient's vital signs are stable and he was discharged home in stable condition with follow-up in the brain tumor clinic on at 2 p.m. , m.d. dictated by: medquist36 Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Tobacco use disorder Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Other and unspecified angina pectoris Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of bronchus and lung, unspecified Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled

allergies: cephalosporins attending: chief complaint: transfer from osh major surgical or invasive procedure: tracheoplasty tracheostomy history of present illness: 69m with severe tracheobronchial malacia transferred from osh for evaluation for possible surgical intervention for definitive tracheal modification. patient was initially admitted from home to osh (, nh) for fatigue, dehydration and several week h/o daily diarrhea and transferred to . prior to his admission on , the patient was at a rehab facility from early to where he was being treated for a pna with vancomycin and for a uti with ciprofloxacin. given recent courses of antibiotics, patient was treated empirically with flagyl for possible c.diff, but this was later d/c'd when stool cultures returned negative for c. diff x1. diarrhea resolved during most of his hospitalization in , but restarted one day prior to transfer. patient reports that he has been having a non-productive cough at home associated with worsening shortness of breath. he denied fevers and chills. no associated cp/palpitations/n/v/diaphoresis. cxr and chest ct at osh revealed new r pleural effusion, but no evidence of infiltrate suggestive of pna. patient was s/p diagnostic thoracentesis . preliminiary results: glucose 68, ldh 1106, tprot 5.4. thoracentesis was complicated by afib with rvr that was rate controlled with diltiazem. patient later spontaneously converted to sinus rhythm. on transfer to , patient with no specific complaints. reported that respiratory status was close to baseline, but perhaps a little worse. he felt comfortable, denied chest pain/abdominal pain and baseline appetite. he noted 1 episode of diarrhea one day prior to transfer. past medical history: 1. tracheobroncheal malacia, dx ; s/p y stent placement and removal 2. cad 3. hypercholesterolemia 4. htn 5. afib 6. pulm htn 7. lle dvt -> pe ' 8. osa, intolerant to cpap 9. h/o mrsa pna 10. bph (foley changed , needs to be changed q month- will have laser surgery once resp issues resolved.) 11. cva x3 -> l hemiparesis. 12. recurrent bronchitis 13. home o2 (3l at baseline) social history: he has worked as a technical writer, a desk job, lives w/ wife in southern , 3 children, daughter involved/supportive. 6 grandchildren lifelong non-smoker no etoh family history: father died at age , and a history of tias. mother died at age 75 and a history pneumonias, hypertension, and stroke. brother died of an embolic stroke to the brainstem. aunt died of colon cancer. three children, six grandchildren, and one of his daughters has been recently diagnosed with incurable pancreatic cancer. physical exam: t98.9 bp104/60 hr92 rr18 94%3l gen: sitting in bed, nad heent: perrl, eomi, op-clear, mmm neck supple, no lad resp: loud, upper airway sounds. +ronchi throughout, no wheezes, no crackles cv: rr no murmurs/rubs/gallops abd: nt/nd, +bs ext: no edema. teds in place neuro: aox3, grossly normal. pertinent results: 09:20pm wbc-11.0 hgb-11.5* hct-32.8* mcv-85 plt count-368 sodium-143 potassium-3.8 chloride-102 total co2-27 urea n-23* creat-1.4* glucose-148* calcium-8.9 phosphate-3.0 magnesium-2.0 ua pending ekg: sinus rhythm at 91 with frequent atrial and ventricular ectopy. no st-t changes. no significant change from prior (). . studies: p-mibi: conclusion: normal myocardial perfusion study, no evidence for ischemia, normalwall motion with a 65% ejection fraction. . stress: impression: no anginal type symptoms or ischemic ekg changes. nuclear report sent separately. . cxr: portable ap chest radiograph: there are poor inspiratory lung volumes, with pulmonary vascular crowding. the cardiac and mediastinal contours are stable. there is a tortuous aorta. no pneumothorax is seen. there is slight elevation of the right hemidiaphragm which is unchanged from the prior study. additionally, there may be minimal blunting of the right costophrenic angle. there is limited evaluation of the trachea and bronchus, likely due to technical factors. a stent can be seen within the main trachea, however, the distal extent of this into the bronchi is not visualized on this exam. . video swallow: impression: mild residue which cleared with repeated swallows. trace penetration with no aspiration. . chest ct: impression: 1. tracheal stent extending from the thoracic inlet down into the left main stem bronchus. 2. right lower lobe atelectasis. . pleural fluid: 10cc bloody fluid collected, negative for malignant cells. histiocytes and blood. . cxr: since the previous exam, the tracheobronchial stent has been removed. the trachea above the carina shows narrowing. there are bilateral small pleural effusions. there is also pleural thickening along the lateral chest wall. the lungs are clear. there is slight asymmetric aeration of the lungs, which may be due to air-trapping. impression: bilateral small pleural effusions, right greater, and narrowing of the distal trachea. . brief hospital course: 69m with severe tracheobronchial malacia here for surgical evaluation. #. tracheobronchial malacia- awaiting eval and input from dr. and dr. . per ip 2 tracheobronchial metal stents were placed on , initially thought stents would improve breathing. stents were followed with serial cxr and chest ct which showed no migration or stents. however, pt had persistent cough without releif with atrovent nebs, lidocaine ih, and guafenesin. on metal stents were removed per ip for symptomatic relief of persistent cough. ct followed pt throughout course of hospitalization. atrovent nebs qid, ativan qhs, guaifenesin prn, and lidocaine nebs prn per respiratory were continued. : patient was transferred to the thoracic surgery service and underwent a tracheoplasty for his tracheobronchial malacia. postoperatively, he was transferred to the icu intubated. he was restarted on his heparin drip immediately postoperatively. he remained stable overnight and was given intermittent fluid for low blood pressures. pain was controlled using an epidural. pod #1-bronchoscopy was performed on pod #1 and the patient was extubated. on the evening of pod #1, patient became less alert with desaturations despite supplemental oxygen. his creatinine also increased despite gentle fluid resuscitation. anesthesia was called for increasing desaturations and the patient was reintubated at the bedside without complication. pod #2-patient maintained on mechanical ventilation, remained stable throughout the day. pod #3-patient stable on a low neosynephrine drip. he went back to the operating room for an uncomplicated tracheostomy. postoperatively, patient was noted to be unresponsive despite weaning of his anesthetics as well as hypoxic to the low 80's despite mechanical ventilation via his tracheostomy. he experienced episodes of ventricular tachycardia treated with amiodarone and lidocaine. laboratory values at this time demonstrated the patient to be severely acidemic with a bicarbonate of 16 as well as an arterial ph of 7.12. the patient was given bicarbonate supplementation and aggressively ventilated. at this time, the patient remained unresponsive with unequal pupils on exam. he continued to deteriorate with decreasing urine output, continuing acidemia, and elevated transaminases to >1000. a swan ganz catheter was placed at the bedside and the patient's pulmonary artery pressures were noted to be markedly elevated. a stat echocardiogram was performed at the bedside for a presumed pulmonary embolism which demonstrated a dilated, hypokinetic rv. a lactate performed at this time reached it's peak at 9.5. general surgery was consulted for question of ischemic bowel as well as renal for a decreasing urine output. neurology was also consulted for questionable seizure activity. the patient did eventually stabilize hemodynamically and underwent a head, chest and abdominal ct scan. a preliminary read demonstrated a large r sided pulmonary embolism. the patient was started on tpa and managed supportively for his low blood pressure and acidosis. he was maintained on maximal pressor support as well as mechanical ventilation with continuing acidemia. in discussion with the patient's family, the patient was withdrawn from mechanical ventilation as well as pressor support on the evening of pod #3. the patient expired with his family at the bedside. #. id: pt had initially been started on vanc for preop empiric treatment on . of note, urine culture was positive for mrsa at osh. given lack of leukocytosis and fever, patient was thought to be colonized and was not initially treated. however, on ua was +for uti, uculture w/enterobacter and staph aureus, so vanc was continued for enterobacter uti. levo/flagyl was started on for empiric treatment of asp pna. although video swallow study was neg for aspiration, pt aspirated x2 and was continued on levo/flagyl. on pt spiked to 102.7 in setting of levo/flagyl/vanc already on board, repeat cxr did not show consolidation, ua improved from previous ua. id was consulted for further evaluation of persistent fevers in setting of abx coverage. on usensitivities came back for vre uti, vanc was d/c'd, started on linezolid. levo/flagyl were d/c'd on as no clear evidence of asp pna/no consolidation noted on imaging studies cxr/ct. recommended ip to rebronch thich mucous secretions to r/o pulmonary infectious process prior to ct . #. atrial fibrillation-rate controlled with bb. on had an episode of rvr, hr up to 140s and responded to metoprolol 5mg iv x1 which converted back to nsr. throughout hospitalization continued to convert in and out of af/sr. in setting of continual cough and poor po intake, coumadin was discontinued and started on hep gtt for anticoagulation. . #. pleural effusion- osh reported moderate sized pleural effusion with question of underlying infiltrate. patient was evaluated by the pulmonary service, who thought that pna was not likely and thus antibiotic treatment was initially not initiated. patient is s/p diagnostic thoracentesis at osh. follow-up pleural fluid results showed histiocytes and blood, no malignant cells. . #. arf- baseline cr 1.0. likely pre-renal; sent urine lytes. cr slowly trended up from 1.1--1.6--2.0 in setting of continual diuretic use, clots noted in foley c/w post renal/obstruction. fena 0.6% and feun 33% c/w prerenal etiology and diuretic use. diuretics were d/c'd . patient with chronic indwelling foley and prolonged hospitalization. hydrated with ivf o/n. clots resolved w/continuous bladder irrigation per urology. pt cr. started to trend down on to 1.7 from 2.0. . #. gu/foley trauma-pt was noted to have clots in foley bag on , urology was consulted, pt with chronic indwelling foley for bph changed qmonth per urologist. during this admission foley was changed on with continuous bladder irrigation. hep gtt off for 2 days for bleeding. bleeding stopped, urine clear. . #. ?cad- continue bb, statin. echo at osh ef 45-50%. during this admission stress test and p-mibi were normal, therefore ? if true cad. pt has no h/o mi. . #. diarrhea- stool cx neg for c.diff at osh. will re-send stool cultures for c.diff x3. pt did not have diarrhea during this admission. medications on admission: home medications: ativan 0.5mg po qhs zocor 40mg po daily atrovent nebs qid coumadin 7.5mg t,sa; coumadin 5mg other days flomax 0.4mg po qhs metoprolol 75mg po bid proscar 5mg po qam protonix 40mg po daily lasix 40mg po qam, 20mg po qpm guafenisin 600mg po bid medications on transfer: ativan 0.5mg po qhs zocor 40mg po daily atrovent nebs qid coumadin 3mg po daily flomax 0.4mg po qhs metoprolol 75mg po bid proscar 5mg po qam protonix 40mg po daily lasix 20mg po bid guafenisin 600mg po bid discharge disposition: expired facility: discharge diagnosis: tracheomalacia discharge condition: deceased Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Fiber-optic bronchoscopy Injection or infusion of thrombolytic agent Thoracentesis Other intubation of respiratory tract Decortication of lung Temporary tracheostomy Other repair and plastic operations on trachea Other repair and plastic operations on bronchus Transfusion of packed cells Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Injection or infusion of oxazolidinone class of antibiotics Removal of intraluminal foreign body from trachea and bronchus without incision Infusion of vasopressor agent Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Acute and subacute necrosis of liver Unspecified septicemia Severe sepsis Atrial fibrillation Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pulmonary embolism and infarction Cerebral embolism with cerebral infarction Acute vascular insufficiency of intestine Iatrogenic cerebrovascular infarction or hemorrhage Pleurisy without mention of effusion or current tuberculosis Mixed acid-base balance disorder

history of present illness: this is an 87 year old man with a history of etoh abuse, significant for drinking six or seven scotches per night, history of dilated cardiomyopathy, ejection fraction of 30 percent. he awoke two nights prior to admission, had four episodes of brownish ground coffee emesis. the patient was admitted on . no complaints of abdominal pain or retching. he also noted bright red blood, some dizziness, no shortness of breath and no weakness. he went to his primary care physician who sent the patient to the emergency department. in the emergency department, he had two more episodes of coffee ground emesis. nasogastric lavage attempted but it was aborted secondary to a nosebleed. the patient's hematocrit had dropped from 44.0 percent to 35.0 percent. the patient was therefore admitted to the unit for evaluation of upper gastrointestinal bleed. past medical history: etoh history. hypertension. chronic atrial tachycardia with a baseline heart rate of 100 to 110. gout. questionable atypical seizure disorder. dementia. allergies: aspirin sensitivity, nosebleeds. medications on admission: 1. toprol xl 12.5 mg p.o. once daily. 2. digoxin 0.125 mg p.o. once daily. 3. hydrochlorothiazide 25 mg once daily. 4. allopurinol 300 mg once daily. 5. mysoline 250 mg once daily. 6. multivitamin. social history: the patient lives with wife, retired, history of multiple jobs. history of drinking six or seven scotches per day. nonsmoker. physical examination: the patient's vital signs are unremarkable except for heart rate of 108. physical examination is notable for positive dupuytren's contracture. no evidence of hepatosplenomegaly on examination. hospital course: the patient was admitted for observation. hematocrit was stable in the mid 30s overnight. he underwent esophagogastroduodenoscopy which was negative for any source of acute bleed. it was positive for what appeared to be friable esophageal mucosa consistent with barrett's esophagitis as well as a c line which was displaced proximally. no biopsies were taken. at this point, the patient was treated with protonix and discharged home on p.o. protonix with follow-up with his primary care physician in one to two weeks with plans for referral for an outpatient esophagogastroduodenoscopy for biopsies to confirm the visual appearance of barrett's esophagitis. the patient is to follow-up in six to eight weeks. medications on discharge: the patient will be discharged on all his original outpatient medications in stable condition with addition of protonix 40 mg once daily. 1. toprol xl 12.5 mg p.o. once daily. 2. digoxin 0.125 mg p.o. once daily. 3. hydrochlorothiazide 25 mg once daily. 4. allopurinol 300 mg once daily. 5. mysoline 250 mg once daily. 6. multivitamin. 7. protonix 40 mg p.o. once daily. discharge diagnosis: barrett's esophagitis. major procedures: esophagogastroduodenoscopy. , Procedure: Other endoscopy of small intestine Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Gout, unspecified Other convulsions Other specified cardiac dysrhythmias Alcohol abuse, continuous Barrett's esophagus

past medical history: 1. hypertension. 2. hypercholesterolemia. 3. aortic stenosis. 4. hyperthyroidism. 5. osteoporosis. 6. djd to right ureter and kidney resulting in many utis. 7. history of rf at age 12. past surgical history: appendectomy. allergies: the patient has an allergy to hydrochlorothiazide which gives her a rash and sulfa which also gives a rash, and ampicillin gives her a rash. at-home medications: 1. aspirin 81 mg q.d. 2. altace 5 mg q.h.s. 3. toprol 25 mg b.i.d. 4. levoxyl 88 micrograms q.d. 5. fosamax 70 mg q. friday. 6. clonazepam 0.25 mg q.h.s. 7. multivitamin. 8. vitamin e. 9. calcium 1,200 mg q.d. physical examination on admission: general: the patient was in no acute distress. chest: clear to auscultation. regular rate and rhythm. laboratory data/studies: the patient's electrolytes were within normal limits. the white count was 13.4, hematocrit 31.7, platelet count 90,000. coagulations revealed an inr of 1.6, pt 10.6, ptt 58.3. hospital course: the patient underwent cardiac catheterization on which showed #+ moderately severe mitral regurgitation, ejection fraction of 65%, lad 50% at the origin, 80% mid just before major diagonal, and rca with 70% to the origin and 70% proximal. the patient was with significant aortic stenosis with peak-to-peak gradient of 55%. the patient presented for a cabg times three and lima to the lad, svg to the pda, and svg to d1. the patient also had an avr with 21 mm ce and mitral valve repair, 26 mm . the patient tolerated the procedure without complication. postoperatively, on day number four, the patient had an episode of atrial fibrillation which resolved. the patient was subsequently transferred to the floor the evening of postoperative day number four. the patient again had an episode of tachy brady and was transferred back to the unit. cardiology consultation was obtained. it was felt that the patient would likely need a pacer secondary to preexisting conduction problems and the poorly controlled rate on diltiazem drip and on amiodarone. the placement of a pacer was delayed due to some right arm phlebitis that developed. the patient was placed on antibiotics, improved, and subsequently received her pacer on postoperative day number seven. the patient was transferred to the floor on postoperative day number eight and had an uncomplicated hospital course. the patient was able to tolerate a regular diet, ambulating well per physical therapy and felt to be ready for discharge to a rehabilitation facility to be named at a later date. the patient is currently being coumadinized and on a heparin drip for her valve issues. discharge medications: 1. coumadin 5 mg on the evening of . 2. captopril 25 mg p.o. t.i.d. 3. amiodarone 400 mg p.o. t.i.d. 4. vancomycin 1 gram iv q. 12 hours. 5. percocet one to two tablets p.o. q. four hours p.r.n. pain. 6. tylenol 650 mg p.o. q. four hours p.r.n. 7. aspirin 325 mg p.o. q.d. 8. zantac 150 mg p.o. b.i.d. until follow-up with cardiac surgeon. 9. colace 100 mg p.o. b.i.d. 10. lopressor 25 mg p.o. b.i.d. condition on discharge: good. discharge status: to rehabilitation facility. discharge diagnosis: 1. status post coronary artery bypass graft times three. 2. aortic valve replacement. 3. mitral valve repair. fop: the patient is to follow-up with dr. in four weeks and with her primary care provider, . , in one to two weeks, and her cardiologist in two to three weeks. , m.d. dictated by: medquist36 d: 11:50 t: 13:08 job#: Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Open and other replacement of aortic valve with tissue graft Monitoring of cardiac output by other technique Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Osteoporosis, unspecified Mitral valve stenosis and aortic valve stenosis Other specified anomalies of kidney Other specified anomalies of ureter

allergies: latex attending: chief complaint: right renal mass major surgical or invasive procedure: right debulking nephrectomy inferior vena cava thrombectomy internal jugular vein central line placement arterial line placement chest tube placement nasogastric line placement foley catheter placement history of present illness: this is a 59-year-old woman who has been known to be relatively healthy who was admitted on to hospital in with the diagnosis of bilateral pulmonary emboli. she had been feeling weak and fatigued and had had some shortness of shortness leading up to this point. she first noticed these symptoms about a week prior to admission to ohs. ct of the abdomen at osh () showed a 5.5cm right renal tumor with extension into the renal vein and ivc. - pet scan at osh ()showed no increased uptake in the rll 2cm nodule but increased uptake in right kidney and in the left hilum of the lung. - mri of the head with gado at osh ()was unremarkable. - mri of the abdomen at osh (): thrombus locally intrusive into the ivc but does not extend up to the hepatic area or right atrial area. she was anticoagulated at osh, and her inr was noted to be therapeutic upon her discharge and transfer to . at , she was continued on coumadin with therapeutic inrs. upon further evaluation, it was determined that the patient could potentially benefit from debulking surgery. she presented for right renal debulking nephrectomy with ivc thrombectomy. she went to an emergency room there and was found to have an elevated d-dimer, and on cat scan was found to have bilateral pulmonary emboli. she was then admitted to hospital and was begun on anticoagulation and further work-up proceeded. the patient received bilateral duplex ultrasounds that were negative. however, she had a cat scan of the abdomen that showed a 5.5 cm right renal mass with extension to the renal vein and inferior vena cava. there was also noted to be a 2 cm right lung lower lobe nodule. she also had a pet scan there that was noted to show some increased uptake in the hilum of the left lung. in addition to that, in the kidney. an mri of the head was also performed that was found to be unremarkable and to show no signs of metastases. she was anticoagulated at the outside hospital, and her inr was noted to be therapeutic upon her discharge and transfer to . the inr was 2.3 at this time. her history is also significant for depression for which she is treated with klonopin and effexor, and it is noted to be well-controlled by the patient and her family. past medical history: she is a g6 p5 with 1 abortion with a d and c for miscarriage. she has reflux symptoms since age 26. she had a cholecystectomy in her 30s with 2 subsequent episodes of bleeding where she needed to be reexplored. social history: the patient's husband died from primary pulmonary hypertension 20 years ago. the patient works as a nursing unit coordinator at the hospital. family history: mother died of lung cancer and she was a noted smoker. daughter had congestive heart failure in a pregnancy and delivered prematurely. there is no history of dvt or pulmonary emboli noted in the family. physical exam: vitals: 98.7 hr: 93 bp 145/93 rr: 18 o2sat 96% ra alert and oriented x3. no acute distress, comfortable. heart is regular rate and rhythm. no murrmurs, rubs, or gallops. chest with mild end-inspiratory crackles at right base. otherwise clear, no wheezes. abdomen is mildly obese. soft, non-tender except over incisonal site. no rebout tenderness. staples and sutures are in place. no erythema or discharge about the wound. extremities with significant post-operative edema extending to thighes, back, but improving. otherwise warm and well perfused. moving all extremities. pertinent results: 08:05pm glucose-148* urea n-11 creat-0.9 sodium-141 potassium-4.2 chloride-113* total co2-22 anion gap-10 08:05pm albumin-2.5* calcium-8.9 phosphate-4.1 magnesium-2.5 08:05pm wbc-7.5 rbc-4.02* hgb-11.0* hct-29.8* mcv-74* mch-27.5 mchc-37.0* rdw-19.6* 08:05pm pt-12.8 ptt-27.7 inr(pt)-1.1 08:05pm plt count-88* hct: 32.4* 06:01am 4.9 3.46* 9.4* 28.0* 81* 27.2 33.6 18.6* 114* 02:56am 5.7 3.55* 9.9*# 28.5* 80* 27.8 34.6 18.6* 79* basic coagulation (pt, ptt, inr) 07:45am 13.21 24.5 1.2 renal & glucose glucose urean creat na k cl hco3 angap 06:01am 106* 8 0.7 138 4.0 103 27 12 radiology final report chest (pa & lat) 9:24 am chest (pa & lat) findings: comparison is made to the prior study of a day earlier. since the prior study, there has been removal of the right ij line, no evidence of pneumothorax. partial atelectasis involving the right middle lobe is again noted as well as the left lower lobe partial atelectasis. no hiatal hernia is suspected. some left pleural effusion is suspected in the posterior costophrenic angle. impression: interval removal of the right ij line and no evidence of pneumothorax. areas of partial atelectasis involving the lower lobes bilaterally as well as the right middle lobe. ? small left pleural effusion. cardiology report ecg study date of 8:53:56 pm sinus rhythm prominent low lead qrs voltage - consider left ventricular hypertrophy otherwise normal ecg since previous tracing of , qrs voltages more prominent intervals axes rate pr qrs qt/qtc p qrs t 81 168 96 374/411.14 10 -9 5 brief hospital course: dr. performed a right radical nephrectomy, removal of tumor thrombus from the inferior vena cava and reconstruction of inferior vena cava on . in the operating room, the patient received 4600 cc of crystalloid, 14 units of red blood cells, 6 units of ffp, 1 unit of platelets, 750 cc of albumin. the estimated blood loss was 8 liters. post operatively, patient was transferred to the surgical intensive care unit for observation, where she continued to do well. she was extubated and nasogastric tube was discontinued. she was transferred to the floor where her status continued to improve. diet was advanced as tolerated and patient was transitioned to po percocet with oxycodone for breakthrough. on post-operative day 4 her epidural catheter was pulled, as was her chest tube and central line. her home medication regimen was continued once she was able to take pos. chest radiography was obtained and confirmed good re-expansion of lungs without pneumothorax, and atelectasis at the bases bilaterally. her foley catheter was discontinued on the evening of post-operative day 4 and she was able to void. she was re-started on coumadin alternating 5mg/7.5mg qhs. on discharge, inr was 1.2 after one dose of 2mg and one dose of 5mg. she was given strict instructions to follow up with her pcp, . in this friday for inr measurement and adjustment of her anticoagulation. she was discharged home on in good condition. medications on admission: 1. klonopin 2 mg p.o. q. at bedtime 2. warfarin sodium 7.5 mg p.o. at bedtime with follow-up instructions as above. 3. quinine 325 mg p.o. at bedtime. 4. oxybutynin 5 mg p.o. q. a.m. 5. prilosec 20 mg of delayed release p.o. b.i.d. 6. effexor xr 37.5 mg p.o. once daily. 7. fexofenadine 60 mg p.o. at bedtime. discharge medications: 1. warfarin sodium 5 mg tablet sig: one (1) tablet po every other day as needed for sub-therapeutic inr: please altarnate with 7.5 mg coumadin (warfarin) dose, every other day. disp:*15 tablet(s)* refills:*0* 2. coumadin 7.5 mg tablet sig: one (1) tablet po every other day: please alternate with 5 mg coumadin tablet every other day. disp:*15 tablet(s)* refills:*0* 3. quinine sulfate 325 mg capsule sig: one (1) capsule po hs (at bedtime). 4. venlafaxine 37.5 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily). 5. fexofenadine 60 mg tablet sig: one (1) tablet po hs (at bedtime). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*60 capsule(s)* refills:*0* 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 8. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). tablet, delayed release (e.c.)(s) 9. oxybutynin chloride 5 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 10. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 11. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain: take for breakthrough pain as needed. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: renal cell carcinoma ivc thrombus extension bilateral pulmonary emboli discharge condition: stable discharge instructions: patient to be discharged home with follow up with dr. , as well as dr. (see below). please return to the hospital if you experience fevers greater then 101.4, chills, or other signs of infection. also return to the hospital if you experience chest pain, shortness of breath, redness, swelling, or discharge from the incision site. return if you experience worsening or new pain or any other concerning symptoms. avoid straining, excessive activity or lifting heavy objects for at least 3 weeks. do not drive for at least 3 weeks after surgery unless you are otherwise cleared by your surgeon. certain pain medications may have side effects such as drowsiness. do not operate heavy machinery while on these medications. certain pain medications such as percocet or codeine can cause constipation. if needed you can take a stool softner such as colace (one capsule) or gentle laxative (such as milk of magnesia) once per day. restart taking all your regular medications once you arrive at home. alternate coumadin dose between 5 mg and 7.5 mg and have dr. office check your inr on friday, . please follow-up with dr. to check your blood pressure. followup instructions: please go to dr. office on friday, between 9 am and 12 noon to have your coumadin/inr level checked. you can call his office with questions(). please schedule an appointment with dr. during next week to follow up on your mildly elevated blood pressure. please have your staples and sutures removed on unless otherwise directed by your surgeon. please call dr. office at to confirm your follow-up appointment. you should see dr. in weeks. you should also see the onclogist (dr. ) on the same day of your follow-up appointment. Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Arterial catheterization Nephroureterectomy Transfusion of packed cells Transfusion of other serum Transfusion of platelets Incision of vessel, abdominal veins Diagnoses: Acute posthemorrhagic anemia Secondary malignant neoplasm of other specified sites Malignant neoplasm of kidney, except pelvis Old myocardial infarction Long-term (current) use of anticoagulants Other pulmonary embolism and infarction Other venous embolism and thrombosis of inferior vena cava

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: paroxysmal atrial fibrillation major surgical or invasive procedure: pulmonary vein isolation coronary sinus node temporary pacemaker wire insertion. history of present illness: mr. is a 68 yo m with hx of paf for approximately 8 yrs. he has been tried on different medications, had success with amiodarone, however approx 2 yrs ago he began to develop thyroid toxicity. he has been off amiodarone for approx 1.5-2 yrs. currently on metoprolol, diltiazem and anticoagulated with coumadin. however over the course of the past mos he has been having episodes of paf with palpitation and presyncope which have increased in frequency and duration and now happens weekly and lasts hours. . he had a pvi procedure done in ep lab which was complicated by spontanous afib not responding to internal or external dc cardioversion, given iv ibutilide which successfully converted to nsr, however he then began to have bradycardia in 40s, aivr, and long qt. cs lead was kept in place and he was a paced @ 80 bpm and transferred to ccu for monitoring. . ros: no cp/sob/palp/lightheadedness past medical history: afib hypertension hyperlipidemia thyroid toxicity amiodarone social history: married, works part time driving adults with mental illness. family history: mother cad s/p cabg @ age 52 physical exam: gen- lying in bed in nad vs- 98.2 80 bpm paced 101/57 14 98% on 2l heent- nc/at, eomi, perrl, mmm neck- supple, no jvd, no lad, no thyromegaly cv- rrr, no m/r/g, nondisplaced pmi pulm- ctab anteriorly, good air movement abd- mildly obsese, soft, nt, nd extr- no c/c/e. dp, pt pusles 2+ b/l, no groin hematomas, r fem sheath with miniaml oozing. left sheath w/ pacer wire neuro- cn ii-xii intact, no fnds pertinent results: 09:30pm ck(cpk)-94 09:30pm ck-mb-notdone ctropnt-0.68* 06:57pm glucose-133* urea n-13 creat-0.8 sodium-143 potassium-3.9 chloride-108 total co2-27 anion gap-12 06:57pm calcium-8.3* phosphate-2.8 magnesium-1.7 06:57pm wbc-11.1* rbc-4.65 hgb-13.7* hct-39.5* mcv-85 mch-29.5 mchc-34.8 rdw-13.4 06:57pm plt count-214 06:57pm pt-14.3* ptt-31.0 inr(pt)-1.3* 04:30am blood wbc-9.2 rbc-4.17* hgb-12.7* hct-35.0* mcv-84 mch-30.5 mchc-36.3* rdw-13.4 plt ct-203 04:30am blood glucose-126* urean-11 creat-0.8 na-140 k-3.3 cl-105 hco3-29 angap-9 04:30am blood calcium-7.8* phos-2.3* mg-1.8 brief hospital course: 68 yo m with paf s/p succesful pvi with subsequent qt prolongation, aivr in setting of ibutilide usage, temporarily a-paced @ 80 bpm overnight, hemodynamically stable, discharged in sinus rhythm. . 1) rhythm the patient was admitted to the ccu s/p pulmonary vein isolation. during the procedure the patient developed persistent afib refractory to dc cardioversion. intravenous ibutilide successfully converted the patiene to normal sinus rhythm, however he then began to have bradycardia to the 40's, accelerated idioventricular rhythm, and prolonged qt interval. coronary sinus lead was kept in place and he was atrially paced @ 80 bpm overnight. the patient developed a new new right bundle branch block in v4-v6 that was unrelated to pacing. the pacer wire was discontinued the following morning without incident, and the patient remained in sinus rhythm prior to discharge. the rbbb will be followed by the patient's primary cardiologist. his diltiazem was discontinued as a result of his successful conversion to sinus rhythm. no other changes were made to his medication regimen. he was discharged to home on his regular dose of coumadin for follow-up pt/inr with his regular coumadin clinic. he will see his primary cardiologist, dr. , this month for a follow-up evaluation. . 2) ischemia the patient does not have a history of myocardial infarction. serial ekg's did not reveal ischemic changes. serial cardiac enzymes were within normal limits. he was chest pain free. he was continued on his home dosages of aspirin and simvastatin. . 3) hypothyrodism we continued his oupatient dosage of levothyroxine for follow-up tsh monitoring as needed by the patient's primary providers. . 4) anemia the patient had a decrease in hematrocrit from 39.5-35 the morning after admission. this was likely secondary to procedure related blood loss and dilution with iv hydration. stool guaiacs were negative. medications on admission: levothyroxine 0.075mg daily in the am diltiazem 120mg daily in the am warfarin 3mg/4.5 mg metoprolol 25mg simvastatin 10mg daily in the pm discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. warfarin 3 mg tablet sig: one (1) tablet po mon, wed, friday, sunday. disp:*30 tablet(s)* refills:*2* 6. warfarin 2 mg tablet sig: two and tablet po tues, thursday, saturday. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: paroxysmal atrial fibrillation secondary: hypertension hyperlipidemia discharge condition: good. discharge instructions: you had a pulmonary vein isolation performed for atrial fibrillation and needed to stay for overnight observation to assure your heart was working properly. it is important that you take all of your medications as prescribed. it is important you continue taking your coumadin as before and follow up for pt/inr levels with your doctor early next week. followup instructions: you should follow up with dr. within the next month. please call his office for an appointment. Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Insertion of temporary transvenous pacemaker system Atrial cardioversion Cardiac mapping Diagnoses: Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias

history of present illness: this is a 55 year old man with a history of diabetes mellitus, hypertension and hypercholesterolemia, who presents after experiencing left morning of , while playing golf when he noticed that the golf ball suddenly became blurry and appeared as though it was moving. he experienced light-headedness. he decided to play on when he realized that his left arm was wobbling all over; he took his right hand to steady the left. although the blurry vision resolved quickly, the left arm weakness persisted until he went to an outside hospital. the time did not reveal any acute bleed. he was transferred to the for further evaluation. past medical history: 1. diabetes mellitus since , noninsulin requiring. 2. hypertension since . 3. hyperlipidemia for four years. 4. right hip degenerative joint disease. allergies: penicillin causes hives. strawberries cause rash. medications on admission: 1. lipitor 40 mg p.o. once daily. 2. glucovan 2.5-500 two pills p.o. twice a day. 3. accupril 20 mg p.o. once daily. 4. aspirin 325 mg p.o. two pills once daily. social history: dr. is a dentist who is married with two children. he does not drink or smoke. family history: father died at age 58 from myocardial infarction. mother died from a stroke at age 68. he has two siblings who are healthy. physical examination: vital signs revealed temperature 98.6, blood pressure 120/80, heart rate 74, respiratory rate 20, oxygen saturation 94% in room air. general- a middle age man in no acute distress. head and neck - normocephalic, supple. no lymphadenopathy, no bruits. cardiovascular - regular rate and rhythm. pulmonary clear to auscultation bilaterally. abdomen - positive bowel sounds, soft, nontender, nondistended. extremities - positive pulses, no cyanosis, clubbing or edema. neurologic - awake, alert and oriented times three. speech and comprehension are intact. attention is intact as well as memory recalling four out of four objects at five minutes. there was some minor word finding slowness but no apraxia. cranial nerves - the pupils are equal, round, and reactive to light and accommodation. extraocular movements are full. funduscopic examination is normal. visual fields are full. face moves symmetrically as well as palatal elevation. tongue protrudes midline. facial sensation is intact. motor - bulk, tone and power are normal throughout. there is minimal left drift though unclear. reflexes are 2+ and symmetric. plantar reflexes are flexor. sensation is intact to touch, pin prick, temperature and proprioception throughout. coordination - finger to nose is sloppy on the left. finger tap is slow on the left. rapid alternating movement is also slow. heel to shin is difficult to ascertain for old hip injury on the right. laboratory data: mr imaging - there is a diffusion restriction in the right parietal lobe in apparent relenting fashion. mra reveals an occluded left carotid artery with some collateralization in the left mca distribution. the right carotid appears to be diseased but no appreciable flow compromise. hospital course: the patient presents with what is most consistent with an acute ischemic insult leaving some weakness on the right arm. formal strength testing was unremarkable though coordination reveals some weakness. taking together the presentation is very concerning for symptomatic right carotid disease. further evaluation reveals 60 to 70% stenosis of the right internal carotid. transesophageal echocardiography was also performed to evaluate for possible cardiac source of emboli. this did not reveal evidence of thrombus, however, there is a small patent foramen ovale appreciated. based upon these findings, the patient was started on more aggressive antiplatelet regimen including aspirin and plavix. however, the patient's course deteriorated while in house and he experienced another episode of left arm weakness and on examination he had severe weakness of the finger extensors and interossei of the left hand. his triceps and deltoids were also weak on the left. he was started on heparin drip. transcortical doppler revealed intermittent emboli arising from the right carotid stenotic atherosclerosis. therefore, consultants further evaluated and recommended right carotid stenting which was done. he underwent stenting of the right internal carotid with good results. he initially required some pressor support in the intensive care unit but was quickly weaned successfully. his left arm weakness improved dramatically. he was started on a regimen of warfarin, plavix and aspirin. at the time of discharge, the patient was clinically markedly improved with better control of his left hand and arm. he continued to work with occupational therapy to help increase his manual dexterity on the left. we would anticipate that he will continue to make clinical improvement. condition on discharge: improved. discharge status: the patient was discharged home with follow-up and services. discharge diagnoses: 1. right parietal ischemic infarction. 2. symptomatic right internal carotid artery disease, status post successful stenting. secondary diagnoses: 1. hyperlipidemia. 2. diabetes mellitus. 3. hypertension. medications on discharge: 1. warfarin 2.5 mg p.o. once daily with an inr goal of 2.0 to 3.0> 2. glucovan 2.5/500 two tablets p.o. once daily. 3. plavix 75 mg p.o. once daily. 4. aspirin 325 mg p.o. once daily. 5. atorvastatin 40 mg p.o. once daily. follow-up: 1. the patient will follow-up with dr. in stroke/ clinic . 2, he will also follow-up with me in clinic . 3. he will follow-up with his primary care physician, . . 4. we have written a prescription for outpatient occupational therapy. , m.d. attending in neurology dictated by: medquist36 d: 10:43 t: 12:24 job#: Procedure: Other esophagoscopy Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hematoma complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Hemiplegia, unspecified, affecting unspecified side Occlusion and stenosis of carotid artery with cerebral infarction

history of present illness: (per medical intensive care unit admission note) the patient is a 75 year old male with alcoholic cirrhosis, ascites, edema, multiple gastrointestinal bleeds from grade i varices, and lower gastrointestinal bleed from diverticula and hemorrhoids. today, he noted explosive diarrhea, dark and melanotic per patient, about every two hours, and he came to the emergency department. he was started on motrin four times a day times four days for gouty flare. he complained of lightheadedness but denied fever or chills, nausea or vomiting, chest pain, shortness of breath, hematemesis, bright red blood per rectum. he had a colonoscopy on , for bleeding, with polyps. he had a resection at that time and was also noted to have diverticula with internal hemorrhoids. he is quasi-transfusion dependent for packed red blood cells in two days. nasogastric lavage was negative in the emergency department. past medical history: 1. cirrhosis secondary to alcohol. 2. atrial flutter status post cardioversion and arteriovenous node ablation. 3. coronary artery disease status post coronary artery bypass graft, left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal stent /. 4. history of multiple gastrointestinal bleeds. 5. diverticulosis. 6. multiple colonic polypectomies. 7. esophageal varices , grade i. 8. history of telangiectasias stomach. 9. chronic renal insufficiency with baseline creatinine 1.5 to 1.8. 10. history of urosepsis. 11. right esotropia. 12. hemorrhoids. 13. gout. 14. history of peptic ulcer disease in . 15. history of cellulitis of left leg. medications on admission: 1. nitroglycerin patch. 2. protonix 40 p.o. q. day. 3. lactulose 30 mg p.o. q. day. 4. lopressor 50 mg p.o. twice a day. 5. lasix 40 mg p.o. twice a day. 6. aldactone 35 mg p.o. twice a day. 7. 20 mg p.o. q. day. social history: married; quit alcohol. thirty pack year smoking history. family history: noncontributory. physical examination: temperature 97.1 f.; blood pressure 126/44; heart rate 70. in general, an elderly male in no apparent distress. heent: mucous membranes were moist. lungs clear to auscultation bilaterally. cardiovascular is regular rate and rhythm, grade iii/vi systolic murmur at left upper sternal border. abdomen soft, obese, nontender, nondistended, positive bowel sounds. extremities with no pedal edema. neurological: alert, pleasant conversant. laboratory on admission: white blood cell count 3.8, hematocrit 25.5, platelets 106, 72% neutrophils, 18% lymphocytes, 6% monocytes, 2% eosinophils. sodium 135, potassium 4.4, chloride 99, carbon dioxide 26, bun 40, creatinine 3.0 from baseline of 1.5 to 1.8. glucose 122, inr 1.1. hospital course: the patient was admitted to the medical intensive care unit for gastrointestinal bleed and multiple bleeding sources. gastroenterology was consulted who recommended beginning octreotide, taking a right upper quadrant ultrasound and transfusing as needed. the patient had an esophagogastroduodenoscopy performed on , which revealed grade i esophageal varices without evidence of recent bleed. small fundic polyp; biopsy was not performed as he is currently undergoing evaluation for gastrointestinal bleed and this can be re-evaluated at the time of next esophagogastroduodenoscopy. the patient then underwent colonoscopy on , which revealed diverticulosis of the sigmoid colon. there were large nonbleeding rectal veins and varices noted; otherwise normal colonoscopy to the cecum. there was no source clearly obtained from study. the patient was transfused to maintain hematocrit greater than 30. the plan was discussed regarding the possibility of performing capsule endoscopy, however, given the patient's reluctance for surgery, the decision was made to not pursue further work-up and to transfuse only as needed. the patient remained hemodynamically stable with a normal hematocrit. 2. hematology: the patient with a long standing pancytopenia seen evidenced one year ago. he also had acute blood loss anemia as described above. reticulocyte count was performed which revealed an appropriate bone marrow response to ongoing anemia with a reticulocyte index of only 1.5. his platelets remained low but as he had stopped bleeding, he did not require any platelet transfusions. he was not on any heparin products. pt really is against invasive aproach and it was felt that even if aggressive w/u including bone marrow bx, the likelyhood of finding a reversible cause was very unlikely so no further w/u will be pursue. 3. infectious disease: on , the patient spiked a fever to 103.3 f. urinalysis was positive for trace leukocytes, 11 to 20 white blood cells, moderate bacteria with zero to two white blood cell casts, so he was started on levofloxacin 250 mg p.o. q. day times seven day course. he was not on a foley catheter. chest x-ray, blood cultures and urine cultures were obtained prior to initiating antibiotics. blood cultures ultimately revealed staphylococcus aureus. the patient was initially started on vancomycin until the sensitivities returned showing methicillin sensitive staphylococcus aureus and he was changed to oxacillin to complete a two week course. he had a transesophageal echocardiogram which showed no evidence of endocarditis and the decision was made not to pursue a transesophageal echocardiogram given that he is clinically stable. his urine culture initially came showing fecal contamination. a repeat urine culture sent after initiation of levofloxacin ultimately showed no growth. he was given a picc line and sent to rehabilitation for intravenous oxacillin times a two week course. 4. cardiovascular system: the patient has a history of coronary artery disease with coronary artery bypass graft, diastolic dysfunction. his aspirin was held given the bleed. his beta blocker was also held given the bleed, however, it was restarted on discharge to rehabilitation. 5. renal: the patient was admitted with a creatinine of 3.0, however, with intravenous fluids, creatinine improved and ultimately he was discharged with a creatinine of 1.1, below baseline. discharge diagnoses: 1. melena. 2. anemia secondary to blood loss. 3. acute renal failure, prerenal. 4. cirrhosis of liver, alcoholic. 5. esophageal varices, grade i. 6. methicillin sensitive staphylococcus aureus bacteremia. 7. pancytopenia. 8. leukopenia. 9. thrombocytopenia. 10. chronic obstructive pulmonary disease. 11. gout. 12. diastolic congestive heart failure. discharge medications: 1. acetaminophen p.r.n. 2. pantoprazole 40 mg p.o. q. 12 hours. 3. maalox p.r.n. 4. ambien p.r.n. 5. oxycodone p.r.n. gout pain. 6. albuterol inhaler q. six hours. 7. levofloxacin 250 mg p.o. q. 24 hours, last dose 06/09, for a seven day course. 8. lactulose 30 mg p.o. q. day. 9. lasix 20 mg p.o. twice a day. 10. spironolactone 25 mg p.o. twice a day. 11. colchicine 0.6 mg p.o. q. day. 12. oxacillin two grams intravenously q. six hours times 14 days, with last dose . 13. metoprolol 50 mg p.o. twice a day. 14. 20 meq p.o. q. day. , m.d. dictated by: medquist36 d: 17:44 t: 20:44 job#: Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Colonoscopy Injection of antibiotic Other irrigation of (naso-)gastric tube Diagnoses: Alcoholic cirrhosis of liver Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Chronic airway obstruction, not elsewhere classified Bacteremia Blood in stool Diastolic heart failure, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress/hypoxia major surgical or invasive procedure: elective intubation history of present illness: 77 yo old male with pmh significant for dm, htn, high chol, cad s/p stents , chf, afib s/p ppm , ckd who presents to ed because of weakness and collapse at home. patient was found on admission to be febrile, tachypneic with rul pneumonia on chest film. patient complained of chronic cough with increasing sputum production. he denies fevers, chills, shortness of breath, chest pain. he denies any loss of consciousness or head trauma with falls. denies bowel or bladder incontinence or changes in function. denies any weight loss or changes in eating habits. no abd pain/n/v/d. no choking on food reported. patient was admitted and started on ceftriaxone and azithromycin for cap which was then changed to levoflox and flagyl as cxr showed ? evidence for aspiration pna. the patient since admission has remained tachypneic and hypoxic requiring o2 today. he needed a non-rebreather for some time but has since been titrated down. as the patient additionally has a history of chf, a repeat chest film was performed to evaluate for any component of congestion. although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen, now a multilobar pneumonia involving the right upper and middle/lower lung fields. abg 7.43/37/54 at time of transfer to icu, he received 80 mg of lasix with minimal urinary output after 20 mg caused 250 cc of urine output earlier in the day. albuterol nebs with minimal improvement in o2 sat. pt was x-ferred to icu and started on bipap. see additional course below. past medical history: past medical history: 1. congestive heart failure; ejection fraction of 55% in 02/. 2. diabetes mellitus, insulin dependent, complicated by nephropathy and retinopathy. 3. hypertension. 4. history of bradycardia. 5. hypercholesterolemia. 6. chronic renal insufficiency with baseline creatinine 1.9 to 2.1. 7. anemia thought secondary to chronic disease. 8. cad s/p stent of lcx and rca in 9. a fib s/p in social history: lives with wife and 1 daughter. 5 daughters. quit smoking 25 years ago, but 10 year smoking history. no etoh or ivda. family history: nc physical exam: physical exam: 101.7 tm, 65 bp118/93 rr21 o2sat 91% on ra --> 100% 3l nad, +diaphoretic. mmm, jvd elevated around angle of jaw at 45 deg neck from, no lad rrr with 3/6 sem at rusb bronchial breath sounds at rul, rll obese, paradoxical abdominal movements with abdominal grunting, umbilical hernia- no erythema, easy to reduce, +bs trace le edema, no cyanosis. moves all 4 extremeities, 2+ dtrs pertinent results: ekg: paced at 60bpm, no changes from prior . cxr: cardiac, mediastinal, and hilar contours are not significantly changed. there is a right upper lobe opacity. there are mildly increased pulmonary vascular markings indicating mild failure. . ct head: no evidence of acute intracranial hemorrhage. findings consistent with old lacunes. 09:09pm lactate-2.1* 09:05pm glucose-130* urea n-30* creat-2.8* sodium-144 potassium-3.1* chloride-102 total co2-28 anion gap-17 09:05pm wbc-13.2*# rbc-4.12* hgb-12.4* hct-36.9* mcv-89 mch-30.1 mchc-33.7 rdw-15.3 09:05pm neuts-86.0* lymphs-8.4* monos-5.1 eos-0.3 basos-0.2 09:05pm pt-14.5* ptt-27.4 inr(pt)-1.4 09:05pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 4:10 am sputum site: endotracheal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): sparse growth oropharyngeal flora. 12:30 pm bronchoalveolar lavage bronchial lavage test. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~1000/ml oropharyngeal flora. legionella culture (preliminary): no legionella isolated. immunofluorescent test for pneumocystis carinii (final ): pneumocystis carinii not seen. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): viral culture (final ): specimen not processed due to:. duplicate order. refer to for results . patient credited. viral culture: r/o cytomegalovirus (final ): specimen not processed due to:. duplicate order. refer to for results . patient credited. brief hospital course: a/p: 77 year old male with hx of htn, high chol, cad, afib s/p pacer here with lobar pna. . 1. respiratory distress: initially, the patient was started on ceftriaxone and azithro for cap but abx were adjusted to levoflox/flagyl based on patient's continued hypoxia and cxr concerning for aspiration event. the patient became more distressed with his respiratory state over the first 3 days of his hospitalization. it was felt that the most likely source of his resp distress was thought to be his rul pneumonia, perhaps with contribution from his diastolic chf. pe was considered but felt to be very low suspicion given xray findings, febrile state. although the film did not appear to be all that congested, the patient's pneumonia appeared to worsen to a multilobar pneumonia involving the right upper and middle/lower lung fields. the patient was found to be dangerously hypoxic on with increasing work of breathing. abg 7.43/37/54 at that time, patient received 80 mg of iv lasix with minimal urinary output. albuterol nebs resulted in minimal improvement in o2 sat. pt was x-ferred to icu and started on bipap. he was intubated due to continued respiratory distress (it was a difficult intubation). his abx was adjusted again to include vancomycin and levofloxacin to cover mrsa and cap. despite no cx data, it was felt the patient most likely had strep pneum. pneumonia due to clinical course. the pateint was liberated from ventilator slowly due to difficult airway issues and he was extubated on . his sputum culture from bal on showed 1000 oropharyngeal flora; all other cultures were negative. serial cxrs showed clearing of pneumonia. he was transferred to the floor on 4l nc on . he maintained excellent o2 sats and he was weaned to 2l upon discharge. he has been intermittently diuresed with lasix (20mg iv), but his cxrs have not shown congestion and the course of his respiratory status has closely followed that of his pneumonia. he has also received albuterol and atrovent nebs with improvement in his wheeze and dyspena. he has completed 12 days of vancomycin and levofloxacin, and they were continued upon discharge to finish a 14 day course for ? pneumococcal vs staph aureus pneumonia. the patient was given pneumococcal vaccine prior to discharge. no blood cx were positive. . 2. cad: his ekg showed a paced rhythm and old lbbb. he was without chest pain and had no signs of ischemia throughout his stay. cardiac enzymes were cycled to rule out the possibility of silent ischemia, and were negative. he was maintained on his asa, bb, and statin. an outpatient echocardiogram may be considered for future management. . 3. htn: mr. was maintained on metoprolol, and amlodopine and imdur. he will titrate up his htn management with his pcp. bp upon discharge was slightly above goal (sbps 140s). . 4. afib/avnrt: mr. has a for tachy-brady syndrome in the past. he has also had ablation for svt with aberrancy in . at that time he was started on amiodarone. he has a ? history of atrial fibrillation/flutter, but is not on anticoagulation as the history is unclear. was in nsr throughout his stay. he has an appointment in ep device clinic later this month and is also set up for a cardiology appointment in . . 5. dmii: mr. was put on half of his outpatient dose of nph 75/25 and sliding scale insulin during his hospitalization. he maintained good glucose control (fsbg < 150). he was discharged on the half-dose nph 75/25, and should follow up with his pcp/ to adjust as needed. . 6. fen: he was maintained on a cardiac/diabetic diet and 2l fluid restriction. the patient needed prn lasix dosing for volume overload (he responded well to 20-40mg iv lasix). . 7. ckd: baseline creatinine 1.9-2.2. he had some variations in creat throughout stay (likely due to varying volume status and diuresis) but was back to baseline prior to discharge (1.9). his medications were all renally dosed (vancomycin by levels < 15). his kidney disease is related to lond standing diabetes and he is followed at the clinic by dr. for this issue. 8. anemia: patient's baseline hct 27-31 with fe studies consistent with anemia of chronic disease. his hct remained in the range (27-32) throughout his stay and the patient did not receive any prbcs. he would likely benefit from erythropoetin as an outpt as his epo-deficient state from ckd is the likely etiology of his anemia. medications on admission: medications: 1. atenolol 50 mg p.o. q.d. 2. amiodarone 400mg q.d. 3. norvasc 10 mg p.o. q.d. 4. doxazosin 2 mg p.o. q.d. 5. cozaar 50 mg p.o. b.i.d 6. niferex 150 mg p.o. b.i.d. 7. plavix 75mg qd 8. aspirin 325 mg p.o. q.d. 9. humalog 75/25, 12u qam, 10u qpm 10. furosemide 40mg qam, 20mg qpm 11. atorvastatin 10 mg p.o. q.d. 12. imdur 90mg q.d 13. laxatives 14. meclizine 25mg qhs discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po hs (at bedtime). 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 5. albuterol sulfate 0.083 % solution sig: one (1) nebs inhalation q6h (every 6 hours) as needed. 6. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. isosorbide dinitrate 10 mg tablet sig: three (3) tablet po tid (3 times a day). 9. doxazosin 2 mg tablet sig: one (1) tablet po hs (at bedtime). 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 12. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. 13. meclizine 25 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 14. losartan 50 mg tablet sig: one (1) tablet po bid (2 times a day). 15. vancomycin 1,000 mg recon soln sig: one (1) gram intravenous once a day for 2 days: finish . 16. humalog mix 75-25 75-25 unit/ml suspension sig: six (6) units subcutaneous qam: adjust as needed for glycemic control (fsbg 80-120). 17. humalog mix 75-25 75-25 unit/ml suspension sig: five (5) units subcutaneous qpm: adjust as needed for goal fsbg 80-120. 18. amlodipine 10 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: primary: 1. multilobar pna (community-acquired) 2. diastolic chf secondary: 3. htn 4. ? avnrt/aflutter s/p ablation/pacer 5. anemia of chronic disease 6. ckd discharge condition: stable, on 2l nc and improving daily. discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1500ml if you experience any fevers > 101.5, chills, chest pain, followup instructions: 1. provider: call phone: date/time: 10:15 . 2. provider: , m.d. phone: date/time: 9:00 (please consider outpt echocardiogram). . 3. provider: clinic phone: date/time: 10:30 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 Non-invasive mechanical ventilation Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia in chronic kidney disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Unspecified essential hypertension Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Long-term (current) use of insulin Cardiac pacemaker in situ Diastolic heart failure, unspecified Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Pneumonia due to Streptococcus, unspecified

allergies: streptokinase attending: addendum: discharge instruction amended with specifics on followup appointments. discharge medications: 1. brimonidine tartrate 0.15 % drops sig: one (1) drop ophthalmic q8h (every 8 hours). 2. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 3. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. disp:*60 tablet, sublingual(s)* refills:*0* 4. simvastatin 10 mg tablet sig: two (2) tablet po hs (at bedtime). disp:*60 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 8. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 9. keflex 500 mg capsule sig: one (1) capsule po twice a day for 4 days. disp:*8 capsule(s)* refills:*0* 10. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. metoprolol succinate 50 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily). disp:*90 tablet sustained release 24hr(s)* refills:*2* 12. glipizide 2.5 mg tab, sust release osmotic push sig: one (1) tab, sust release osmotic push po at bedtime: this medication replaces glyburide. disp:*30 tab, sust release osmotic push(s)* refills:*2* discharge disposition: home with service facility: vna of rode island discharge diagnosis: ventricular tachycardia/ventricular fibrillation cardiac arrest atriaventricular conduction abnormality coronary artery disease pacemaker implantation discharge condition: good - no further episodes of vt/vf, no chest pain, or shortness of breath, ambulating with assistance. discharge instructions: please take all medications as directed. please follow up with appointments listed below. if you have chest pain that lasts longer than 15 minutes, you need to go to the emergency room for evaluation immediately. stop taking glyburide - you will be starting glipizide instead. followup instructions: 1. please followup with dr. () tuesday at noon. please bring a copy of your discharge summary as well as a list of all your medications. you should have your urine re-checked at your pcp appointment to make sure the blood in your urine has resolved. (this was likely due to trauma from the catheter that was in your bladder). you should also have your creatinine drawn there to evaluate your kidney function. at that point, talk to dr. about your diabetes medication. 2. you will need to return to to have your pacemaker checked approximately 2 weeks after discharge. provider: clinic where: cardiac services phone: date/time: 2:00 3. please follow up with dr. , a cardiovascular surgeon, on at 10am. please call (ext 6508) to confirm time and location. 4. please also follow up with dr. , a cardiologist, on tuesday 4:30 pm. call tuesday morning to confirm the location and time of your appointment. please bring a copy of your discharge summary and a list of all your medications to that appointment. md Procedure: Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of venous thrombosis and embolism Other and unspecified coagulation defects Syncope and collapse Delirium due to conditions classified elsewhere Other second degree atrioventricular block