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history of present illness: mr. is an 85 year old male, with an unknown past medical history. he presented on as a hospital transfer from the . he was initially seen on the afternoon of with complaints of low back pain, syncope and neck pain. work-up there included plain films of the cervical spine revealing a c3 fracture and otherwise with no neurologic changes and hemodynamic stability. he initially had a relatively low hematocrit and was given two units of packed cells for a blood count of 27. it was not understood what the etiology of his dropped hematocrit was; however, he did receive an abdominal ct scan. he was called in as a possible trauma transfer for his c3 neck fracture and for further management. after being transported by ambulance here to , on , he was found to be quite unstable in the trauma bay. he had distended abdomen with absent femoral pulses. a diagnostic peritoneal lavage was done per atls protocol, revealing gross blood. he was transferred to the operating room with the presumed diagnosis of a possible retroperitoneal hemorrhage/ruptured aortic aneurysm. he underwent an exploratory laparotomy confirming a contained retroperitoneal rupture of an infrarenal abdominal aortic aneurysm. intraoperative consultation with the vascular surgeon, dr. was done. the initial surgeon was dr. with the assistance of dr. and . after the intraoperative consultation with dr. was achieved, dr. presumed the remaining care of this patient. after he had his aneurysm repaired with a bifurcated graft, he received seven liters of crystalloid, 14 units of ffp, 19 units of packed cells, two units of platelets, one unit of cryo precipitate, 10 mg of intravenous vitamin k and made approximately 120 cc of urine output, with a blood loss of 8 liters. the only specimens sent for the procedure were aortic plaque. he came out of the operating room, not on any pressors. he was obviously volume requiring. he required ongoing fluid and massive resuscitation. a pa catheter was being used to monitor and guide our therapy. over the ensuing weeks, the patient had continued complications from his ruptured aortic aneurysm repair. he went into renal failure, necessitating hemodialysis. he had continued ventilatory requirements and ultimately developed fevers. he was treated for ventilator associated pneumonia, as well as intermittent bouts of line sepsis. he ultimately got better from these issues. he continued his dialysis through subclavian or internal jugular perma-caths, which were rotated appropriately. he was tolerating tube feedings through a gastric tube and continued to do somewhat poorly over the ensuing weeks. ultimately, after a two month hospitalization, the patient continued to have failure to thrive. he required increasing ventilatory support. over the last several days of his hospitalization, in the intensive care unit, he actually had intermittent low grade temperatures and a climbing white count. he required vasopressor support. he had one event 48 hours prior to expiration where the patient had thick secretions that prompted a possible respiratory mucus plugging event that caused bradycardia and hypotension, necessitating epinephrine and atropine to recover his heart rate and blood pressure. once he recovered, he thereafter, required vasopressor support for blood pressure maintenance and a pulmonary artery catheter had been reinserted for management of his volume status, given his hemodialysis needs. given the fact that the patient had ongoing renal, pulmonary and infectious processes, nor did he completely improve to the point of not requiring intensive care unit monitoring, repeated discussions had been held with the patient's family over several week period between dr. , the intensive care unit staff and the family. ultimately, in the final meeting of , the family decided to make the patient comfort measures only. after being made comfort measures only on the afternoon of , the patient expired at 7:27 p.m. on the evening of . the family was thereafter notified and declined a post mortem examination. the medical examiner declined any kind of autopsy and, thereafter, he was appropriately pronounced and sent to the care of his family. immediate causes of death: 1. cardiac arrest. 2. respiratory failure. chief cause of death: ruptured infrarenal aortic aneurysm with postoperative renal failure and respiratory failure. , m.d. dictated by: medquist36 d: 07:48 t: 19:52 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Percutaneous abdominal drainage Cholecystectomy Temporary tracheostomy Control of hemorrhage, not otherwise specified Incision of vessel, lower limb arteries Other repair of abdominal wall Flexible sigmoidoscopy Resection of vessel with replacement, aorta, abdominal Resection of vessel with replacement, abdominal arteries Peritoneal lavage Reclosure of postoperative disruption of abdominal wall Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acute kidney failure, unspecified Unspecified septicemia Disruption of internal operation (surgical) wound Hemorrhage complicating a procedure Closed fracture of second cervical vertebra Infection and inflammatory reaction due to other vascular device, implant, and graft Urinary complications, not elsewhere classified Abdominal aneurysm, ruptured

allergies: cephalosporins / vancomycin / codeine attending: chief complaint: dysuria, abdominal pain major surgical or invasive procedure: percutaneous ct scan guided drainage of abdominal fluid. history of present illness: patient is a 68 yo f, h/o cervical ca, radiation cystitis, radiation colitis, frequent line infections, recurrent utis who presented after developing acute on chronic severe abdominal pain. four days prior to admission, patient woke with severe abdominal pain that was worsened with movement. she had some dysuria in the days prior. she also complained of nausea and vomiting. her abdominal pain was worsened by movement. she denied fevers or chills. . she was brought by ambulance to an outside hospital. there she had a ct of her abdomen which was notable for mild ascites, but no acute process. she was mildly hypotensive to sbp of 90s and was given 3 l ns. given levofloxacin/flagyl. she was transferred to the ed. on arrival t 100.8, hr 107, bp 100/71. soon thereafter sbp dropped to the 70s and she was bolused a total 5l ns. her ostomy output was heme negative. u/a showed gross blood and + wbc. she was given one dose of meropenem 500mg iv, as this is what she was discharged on previously. her pain was also treated with tylenol and dilaudid. she became mildly hypotensive with dilaudid. pt was then transfer to the micu her vs were t 98, 120/51, 15, 99/ra. . on arrival to the icu, she again become hypotensive and required levophed. she also recieved one unit of prbcs for hct of 22. she was continued on meropenem for presumed urosepsis, and had received a total of 8l of iv fluids while in the icu. she was then transferred to the floor after she stabilized on . . the morning of , she was noted to be in marked respiratory distress. her oxygen saturation at times dropped to 80% on non-rebreather, and was noted to be hypertensive into the 160s systolic. she was given 20mg lasix x 2, her usual dose of dilaudid and hydralazine without marked improvement, and the micu resident was called. examination demonstrated bilateral crackles and jvp elevated to the angle of the mandible. cxr demonstrated marked pulmonary edema. she was given nitroglycerin sl and transferred to the icu for possible initiation of bipap. . when she arrived in the icu, her respiratory status had markedly improved and she denied any shortness of breath or chest pain. she continued however to have abdominal pain. past medical history: 1. cervical ca s/p tah/xrt s/p hysterectomy with recurrence in 2. radiation cystitis 3. urinary retention; straight catheterization ~8x per day 4. r ureteral stricture -- c/b recurrent infections -- s/p right nephrectomy () 5. recurrent utis: (klebsiella (amp resistant) and enterococcus (levo resistant) 6. short gut syndrome since s/p colostomy from radiation enteritis. 7. osteoporosis 8. hypothyroidism 9. migraine ha 10. depression 11. fibromyalgia 12. chronic abdominal pain syndrome 13. multiple admits for enterococcus, klebsiella, infections 14. dvt / thrombophlebitis from indwelling central access 15. lumbar radiculopathy 16. multiple prior picc line / hickman infections -- see multiple surgical notes to date 17. h/o sbo followed by surgery . h/o stemi takotsubo cm, with clean coronaries on cath in . ef down to 20% in setting of illness, but ef recovered to 55-60%, in setting of klebsiella pna. 19. hyponatremia: previously attributed to hctz use social history: she lives with her husband in an . she reports a 80 py smoking history but quit 18 years ago. denies alcohol or drugs. she walks with a walker but has a history of frequent falls. independent of adls. family history: father with etoh abuse, cad. with renal ca, cad. 3 healthy children. physical exam: admission exam: gen: pleasant, comfortable, nad heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: aaox3. cn ii-xii intact. . discharge exam: vs: t 98.8 , bp 120/56 , p 81 , rr 16 , o2 99 % on ra, gen: thin woman in nad heent: normocephalic, anicteric, op benign, mm appear dry cv: rrr, no m/r/g; there is no jugular venous distension appreciated, dp pulses 2+ bilaterally pulm: expansion equal bilaterally, but overall decreased air movement, worst at right lung field abd: soft, nd, bs+, ostomy bag in place. mild tenderness to palpation extrem: warm and well perfused, no c/c/e neuro: a and ox3, strength 3/5 in lower extremities, in upper extremities psych: pleasant, cooperative. pertinent results: admission labs: 08:45pm blood wbc-7.6# rbc-3.20* hgb-9.4* hct-28.5* mcv-89 mch-29.2 mchc-32.9 rdw-13.1 plt ct-175 08:45pm blood neuts-93.8* lymphs-3.5* monos-2.6 eos-0 baso-0.1 08:45pm blood glucose-93 urean-17 creat-1.4* na-134 k-5.2* cl-106 hco3-17* angap-16 08:45pm blood alt-16 ast-26 ld(ldh)-145 ck(cpk)-203* alkphos-81 totbili-0.2 08:45pm blood lipase-27 08:57pm blood lactate-3.2* . icu labs: 04:00pm blood ck-mb-4 ctropnt-<0.01 04:28am blood ck-mb-3 ctropnt-<0.01 probnp-2468* 02:23pm blood anca-negative b 02:23pm blood -negative 02:23pm blood crp-188.2* 02:23pm blood aspergillus galactomannan antigen-pnd 02:23pm blood b-glucan-pnd . discharge labs: 06:00am blood wbc-3.6* hgb-7.4* hct-22.5* mcv-87 mch-28.6 mchc-32.8 rdw-13.2 plt ct-565 06:00am reticulocyte count, manual 1.7* 06:00am ldh 119 t.bili 0.1 direc bili 0.1 indirect bili 0.0 05:44am blood glucose-86 urean-36 creat-1.2 na-136 k-4.5 cl-105 hco3-22 05:44am blood calcium-9.6* phos-4.8 mg-2.1 . microbiology: blood cx: negative urine cx: 10,000-100,000 organisms/ml. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. stool cx: negative blood cx: negative urine legionella ag: negative influenza swab: negative . imaging: cxr: in comparison with the study of , there is some increased opacification at the left base, which does not silhouette the hemidiaphragm or left heart border. although this could conceivably represent a region of pneumonia, it more likely reflects artifact of soft tissues pressed against the cassette. no evidence of vascular congestion or pleural effusion. tip of the central catheter again lies in the mid-to-lower portion of the svc. . ct abdomen/pelvis w/ con: 1. new moderate ascites and small bilateral pleural effusions. no evidence of abscess or pyelonephritis. 2. unchanged fullness of the left renal pelvis, likely due to upj obstruction. 3. stable moderate common bile duct dilation in this patient who is post-cholecystectomy. . ct chest w/o con: 1. extensive fibrotic changes and ground-glass opacity suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity or nsip. 2. no evidence of edema or pneumonia. . echo: the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. mild aortic regurgitation. mild mitral regurgitation. compared with the prior study (images reviewed) of , mild mitral regurgitation is now seen. . chest x-ray: in comparison with the study of , there has been decrease in the diffuse bilateral pulmonary opacifications, consistent with improving pulmonary edema or hemorrhage. blunting of the costophrenic angle on the right persists consistent with a small effusion. increasing opacification at the left base is consistent with pleural effusion and some volume loss. central catheter remains in place. . kub: dilated loops of bowel in the left mid abdomen up to 4.8 cm which raise concern for small-bowel obstruction. ct provides more specific information if clinical concern remains. . kub: supine and upright abdominal radiographs were obtained. a dilated loop of bowel in the left lower quadrant measures 4.8 cm and is essentially unchanged in four hours. surgical clips project over the mid abdomen and pelvis. a calcified right breast implant is seen. dilated bowel loop remains concerning for small-bowel obstruction. . ct abdomen:1. multiple intra-abdominal fluid collections, with rim enhancement and pockets of air, highly suspicious for abscess. 2. interval development of marked left hydronephrosis. 3. status post right nephrectomy. appearance of fluid-filled tubular structure at the expected location and course of the right ureter. if the patient did not have right ureteral resection, this could represent a urine-filled right ureteral stump. recommend clinical correlations. 4. thickened, diffuse bladder wall, likely radiation change such as radiation cystitis. 5. no bowel obstruction. oral contrast has reached the rlq ileostomy bag. . abd us:1. a small subhepatic fluid collection measuring 4.5 cm. previously seen right paracolic gutter and pelvic fluid collections are not well visualized. please note that ultrasound is less sensitive for detecting loculated intra-abdominal fluid collections. 2. stable appearance of the mild intra- and extra-hepatic biliary dilatation. 3. moderate left hydroureteronephrosis, slightly improved since the prior study. . at time of discharge, intraabdominal fluid culture pending (prelim result no growth to date). brief hospital course: micu course: # sepsis of likely urinary origin: upon presentation to on , had blood pressure drop to 70s sytolic. she was given 5l ivf in ed and transferred to micu. cxr was unrevealing. u/a showed increased leuks and wbc on urine micro. was empirically started on meropenem in micu given that patient had recently been on carbapenems for a uti in end of 1/. in micu her bp was intially stable and then fell and patient was started on norepinephrine, which she remained on for approximately 17 hours on . given patient's severe abdominal pain, received a ct abd/pelvis in the ed which showed moderate ascites, though no other acute changes. surgery consult was called and felt that there was no acute surgical intervention indicated and followed the patient's course in the micu. we also trended patient's lactate level, which was 3.2 at presentation and trended down to 1.3 with fluid resuscitation. checked cdiff toxin, which was negative. iv team was called to assist in managment of patient's tunneled double lumen catheter and they suggested ethanol dwells between tpn infusions in order to prevent line infection. blood cultures from and were negative. . # abdominal pain: pain with severe abdominal pain upon presentation. we reassured after ruling out acute intra-abdominal process with ct scan and serial exams. given frequent (q1hour) iv dilaudid requirements on morning of , pain service consult was called; however, prior to pain service seeing patient her pain improved to point that dilaudid could be given less frequently. was felt that we had been behind on pain control after sleeping overnight, possible due to held doses of gabapentin. she was continued on methadone, dilaudid, and gabapentin. . # anemia: hct was found to be 22, pt was transfused 1 unit of prbcs. post-transfusion hct was 26.9. . medicine floor course: : patient was called out from the micu on after she had been normotensive for 24 hours without pressors. she had a new oxygen requirement (94% on 4l) thought volume overload (8 l + for los). overnight, she was hypertensive to 188/80. in the morning she was found to be hypoxic to 81% on 4l. she was put on a non-rebreather with intermittent improvement of her oxygen sats to low 90s but would then drop to low 80s. she was also given iv lasix 20 mg x 2 and she put out 2 l in 2 hours. her blood pressure was treated with hydralazine 20 mg iv x1 and sl nitro. despite these interventions she was still hypoxic in the 80s on a non-rebreather and was transferred back to the micu for positive pressure ventilation and aggressive diuresis. . micu course: : cxr was c/w volume overload, likely from fluid resuscitation she received in the micu. she was diuresed with iv lasix and started on azithromycin for atypical pneumonia coverage. ct chest performed later revealed extensive fibrotic changes and ground-glass opacities suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity, or nsip. pneumonitis workup was initiated. esr =83, crp = 188.2, , anca, beta-glucan, and galactomannan were all negative. she was stable and was transferred to the floor for further evaluation. . medicine floor course: : pt was stable and continued to improved. active issues: . # hypoxemia/pulmonary infiltrates: oxygenation gradually improved and pt was weaned off oxygen supplement gradually. etiology of infiltrates was unclear, possibilities included and medication-induced lung toxicity. pt received 1 course of azithromycin for possible atypical pneumonia. her flu and legionella screenings were negative. she was weaned off o2 and mantained 95%+ saturation on room air at the time of discharge. . # urosepsis: pt remained hemodynamically stable on the floor. she received meropenem for total of 7 days (). she remained without urinary complaints. pt was given hyoscyamine for bladder spasm pain. . #anemia: the patients hematocrit trended down throughout her hospitalization from around 27 to a low of 22. her baseline over the last few months has been 25-28. this was attributed to her ongoing inflammation secondary to her radiation enteritis and cystitis, although the precise etiology remains unclear, and infection and myelodysplasia should be considered as well. her manual reticulocyte count was found to be 1.7 (corrected 0.53), indicating insufficient marrow response. her ostomy output was found to be guiac negative and her c+ ct scan of the abdomen and pelvis demonstrated no evidence of active bleeding. hemolysis labs demonstrated no evidence of ongoing hemolytic process, however corrected retic count was low. this can be due to illness or medication suppression. recent iron studies were all within normal limits. pt was instructed to follow up with primary care physician about this issue, with repeat hct/reticulocyte count and further workup as needed. . # abdominal pain/fluid collections: the patient had known chronic abdominal pain related to cervical cancer and radiation complications. c. diff was been negative. we continued her home medication (methadone and oxycodone), and added dilaudid. pt was able to eat and drink, and did not have any vomiting. she was evaluated with kub for possible obstruction, which showed dilated loops of bowel. ct of abdomen demonstrated multiple fluid collections, enlarged fluid filled bladder, l hydronephrosis, and a dilated fluid filled ureteral stump. urology was consulted, and a foley was placed for decompression. when the patient was taken for ct-guided drainage of the collections, the collections had almost completely disappeared, potentially related to decompression from the foley catheter. fluid from the remaining collection was sampled and sent for culture and analysis, which demonstrated no bacteria and a creatinine of 1.8 (not consistent with urinoma). repeat ultrasound demonstrated interval resolution of the previoulsy noted hydronephrosis and stable appearance of the fluid collections compared to the most recent ct scan. . chronic issues: . # ckd: pt cr remained at her her baseline, and no new acute issues. . # short gut syndrome: we continued pt's tpn and she was also followed by the nutritionist while she was in the hospital. . # anxiety/depression: we continued pt's home meds (alprazolam, fluoxetine). . # chronic pain/fibromyalgia: we continued the pt's home meds (gabapentin, methadone). . # hypothyroidism: we continued the pt's home med (levothyroxine). . # osteoporosis: we continued the pt's home med (vitamin d, calcium). . #htn: we restarted pt's lisinopril on after her blood pressure returned to its chronically high level. medications on admission: 1. alprazolam 0.25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 2. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 5x/week (mo,tu,we,th,fr). 3. fexofenadine 60 mg tablet sig: one (1) tablet po daily (daily). 4. fluoxetine 20 mg capsule sig: one (1) capsule po tid (3 times a day). 5. gabapentin 300 mg capsule sig: one (1) capsule po qid (4 times a day). 6. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. pilocarpine hcl 5 mg tablet sig: one (1) tablet po q4h (every 4 hours). 9. methadone 5 mg tablet sig: one (1) tablet po qid (4 times a day). 10. ertapenem 1 gram recon soln sig: one (1) gram intravenous once a day for 6 days. :*7 grams* refills:*0* 11. oxycodone 5 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 12. pyridium 100 mg tablet sig: one (1) tablet po three times a day as needed for pain. 13. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 14. lisinopril 10 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 15. vitamin b-12 1,000 mcg/ml solution sig: one (1) injection injection once a month. 16. darifenacin 15 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po at bedtime. 17. hyoscyamine sulfate 0.125 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po four times a day as needed for bladder spasm. 18. ativan 0.5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. 19. vivelle-dot 0.0375 mg/24 hr patch semiweekly sig: one (1) transdermal semiweekly. 20. zolmitriptan 2.5 mg tablet sig: one (1) tablet po once a day as needed for headache. 21. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 22. fioricet 50-325-40 mg tablet sig: one (1) tablet po three times a day as needed for headache. 23. optics mini drops sig: 1-2 drops once a day. 24. metrogel 1 % gel sig: one (1) topical twice a day. 25. ethanol 70% catheter dwell (tunneled access line) sig: two (2) ml once a day: 2 ml dwell daily not for iv use. to be instilled into central catheter port (both ports) for local dwell. for 2 hour dwell following tpn. aspirate and follow with normal flushing. discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. gabapentin 300 mg capsule sig: one (1) capsule po q12h (every 12 hours). 3. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. methadone 5 mg tablet sig: one (1) tablet po qid (4 times a day). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po daily (daily) as needed for anxiety. 7. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for headache. 8. fluoxetine 20 mg capsule sig: one (1) capsule po bid (2 times a day). 9. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual qid (4 times a day) as needed for bladder spasm. 10. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 11. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 12. maalox advanced oral 13. vivelle-dot 0.0375 mg/24 hr patch semiweekly sig: one (1) transdermal 2xweek (). 14. salagen 5 mg tablet sig: one (1) tablet po qid (4 times a day). 15. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 16. heparin flush (10 units/ml) 2 ml iv prn line flush tunneled access line (e.g. hickman), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 17. ethanol (ethyl alcohol) 98 % solution sig: two (2) ml injection daily (daily). 18. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 19. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. :*30 tablet(s)* refills:*0* 20. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). discharge disposition: extended care facility: - discharge diagnosis: urosepsis, anemia, pulmonary infiltrates, hydronephrosis, abdominal fluid collections discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - with assistance. discharge instructions: dear ms. , . it was a pleasure taking care of you at . you were admitted for a severe infection of the urinary tract, anemia, low blood pressure and shortness of breath. . -for your urinary tract infection, you were given a course of iv antibiotics and your infection resolved. . -for your low blood pressure, you were given iv fluids and medications to help maintain your blood pressure initially. your low blood pressure was related to your urinary tract infection and improved as this issue improved. after you returned to your baseline blood pressure (high), we restarted your blood pressure medication. . -for your anemia, you were transfused 1 unit of packed red blood cells. you should follow up regarding this issue with your primary care doctor as an outpatient. . -for your shortness of breath, you were given oral antibiotics, supplementary oxygen and diuretics, and you improved. we think that your shortness of breath may have been related to an adverse reaction to a blood transfusion that you received. you will follow up as outpatient at the pulmonary clinic (see below). . -for your abdominal pain, we obtained a ct scan which initially showed multiple fluid collections in your abdominal cavity. these collections resolved spontaneously following placement of a foley catheter, and so we suspect that they were related to your bladder. we took you to interventional radiology to sample fluid from one of these collections, and found no evidecne of infection. you were also followed by urology, who recommended keeping the foley in place until you have an appointment with them in 2 weeks. . we made the following changes to your medications: changed oxycodone 5mg 1-2 tablets by mouth every 6 hours to po dilaudid 2mg 1-2 tablets every 4 hours as needed for pain. . started hyocyamine 0.125mg sl every 6 hours as needed for bladder spasm started clotrimazole 1 troc by mouth 4 times a day. followup instructions: name: , np specialty: urology address: , ste#58 , phone: appointment: thursday at 1:30pm radiology department: wednesday at 11:45 am building: , campus: east best parking: garage ** an order has been placed for you to have a chest x-ray prior to your pulmonary appointments department: pulmonary function lab when: wednesday at 12:40 pm with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: wednesday at 1 pm with: , m.d. building: campus: east best parking: garage department: pft when: wednesday at 1 pm please call your primary care physician when you leave rehab for an appointment. md, Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Unspecified septicemia Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Personal history of tobacco use Sepsis Chronic kidney disease, unspecified Dysthymic disorder Other and unspecified hyperlipidemia Osteoporosis, unspecified Old myocardial infarction Iron deficiency anemia, unspecified Personal history of venous thrombosis and embolism Other ascites Hydronephrosis Acquired absence of kidney Other and unspecified postsurgical nonabsorption Peritoneal abscess Ileostomy status Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Personal history of malignant neoplasm of cervix uteri Irradiation cystitis Late effect of radiation Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute edema of lung, unspecified Transfusion related acute lung injury (TRALI) Natural blood and blood products causing adverse effects in therapeutic use

allergies: codeine / cephalosporins attending: chief complaint: fever, malaise, weakness major surgical or invasive procedure: picc line placement by interventional history of present illness: 61 year old woman with history cervical cancer and multiple line infections. patient has previously undergone radiation therapy for cervical cancer, which led to radiation enteritis requiring bowel resection and subsequent shortgut syndrome. since development of shortgut syndrome, patient has required chronic total parenteral nutrition leading to frequent line infections. patient has a history of two years of pain and paresthesias down her left thigh and and into her leg. she was evaluated by her neurologist and had an emg/ncs which suggested lumbosacral plexopathy bilaterally. this was attributed to radiation. she has noticed in the last two days that she has had more neck pain than usual which can sometimes happen with her migraine headaches but also some pain between the shoulder blades, more on the right. she also noted that two days ago she started having the shooting pain and paresthesias running down her right leg. yesterday or today she tried to get up and walk and she noted that she totally buckled and could not support her weight. she thinks her weakness is worse on the left versus the right. she has chronic diarrhea from the radiation and has an ileostomy. she also self-catheterizes because she has bladder dysfunction from radiation as well. she has a fever and is developing malaise that for her is always suggestive of a line infection. she was referred to the ed for further evaluation. past medical history: 1. cervical cancer status post radiotherapy, radiation enteritis resulting in bowel resection and need for tpn, also with ileostomy 2. history of candidemia. 3. deep venous thrombosis secondary to multiple central lines. 4. chronic abdominal pain secondary to adhesions, incisions, and radiation, on stable doses of pain regimen. 5. chronic incontinence which she attributes to radiation 6. osteoarthritis and osteoporosis 7. cholecystectomy 8. migraines/tension headaches 9. l3-4 herniated disc 10. left upper extremity thrombosis secondary to picc line 11. iron deficiency anemia 12. ureteral stenosis 13. depression social history: married, nonsmoker, no drugs, no history of iv drug use family history: non contributory physical exam: t98.6 p91 bp128/68 rr18 o299% ra gen: no acute distress heent: ncat, perrl, eomi, oral mucus membranes moist neck: supple, no cervical lymphadenopathy lungs: clear, no wheezes, rales or rhonchi heart: nl s1, s2, rrr, no mrg abd: soft, nt, nd, no rebound or guarding ext: no clubbing cyanosis or edema pertinent results: mr w& w/o contrast; mr w & w/o contrast 1. no evidence of discitis, osteomyelitis, or epidural abscess. 2. mild degenerative changes. 3. free fluid in the pelvis. ------- 10:03pm pt-13.4* ptt-31.8 inr(pt)-1.2 08:00pm urine color-amber appear-clear sp -1.011 08:00pm urine blood-lg nitrite-pos protein-100 glucose-neg ketone-neg bilirubin-mod urobilngn-4* ph-7.0 leuk-mod 08:00pm urine rbc-* wbc-21-50* bacteria-mod yeast-none epi- 08:00pm urine amorph-mod 07:23pm comments-green top 07:23pm lactate-2.2* 07:23pm hgb-10.9* calchct-33 07:05pm glucose-112* urea n-26* creat-1.5* sodium-132* potassium-3.4 chloride-95* total co2-24 anion gap-16 07:05pm alt(sgpt)-42* ast(sgot)-43* alk phos-183* amylase-79 tot bili-0.8 07:05pm calcium-8.4 phosphate-2.1*# magnesium-1.5* 07:05pm osmolal-280 07:05pm wbc-11.8* rbc-3.66*# hgb-10.7*# hct-30.1*# mcv-82 mch-29.2 mchc-35.4* rdw-13.9 07:05pm neuts-95.3* bands-0 lymphs-3.4* monos-1.1* eos-0.1 basos-0.2 07:05pm plt smr-normal plt count-181 07:05pm pt-13.1 ptt-29.1 inr(pt)-1.1 06:01pm comments-green top 06:01pm lactate-3.1* 05:40pm glucose-77 urea n-27* creat-1.5* sodium-130* potassium-3.6 chloride-92* total co2-23 anion gap-19 05:40pm wbc-18.2*# rbc-1.63*# hgb-4.8*# hct-13.3*# mcv-82# mch-29.4 mchc-36.0* rdw-14.2 05:40pm hypochrom-3+ anisocyt-1+ poikilocy-occasional macrocyt-normal microcyt-1+ polychrom-normal 05:40pm plt smr-normal plt count-304 brief hospital course: 61f with history of cervical cancer, shortgut syndrome requiring chronic total parenteral nutrition complicated by frequent line sepsis. upon initial evaluation, given patient's symptoms of fever and back pain, neurology and neurosurgery consults were obtained for concern of epidural abscess. however, mri revealed no epidural abscess and as patient became hemodynamically unstable (systolic blood pressure to 60s), patient was initiated on dopamine for pressor support. patient was transferred to the medical intensive care unit, where working diagnosis was considered to be gram negative sepsis secondary to either line infection or urinary tract infection (patient self-catheterizes due to bladder dysfunction from radiation therapy). peripheral intravenous central catheter was removed on hospital day two due to high suspicion of line infection. urine cultures revealed an enterococcus infection, and blood cultures revealed a gram negative rod that ultimately speciated as klebsiella. patient was treated initially with aztreonam, gentamicin, and fluconazole, and later changed to vancomycin, gentamicin, and levofloxacin given enterococcus in urine. by hospital day 4, patient was afebrile and hemodynamically stable following weaning off pressors and was transferred to floor. following transfer, patient's antibiotic regimen was changed to ampicillin sulbactam given the fact that at this point both enterococcus and klebsiella cultures were found to be sensitive to that regimen. surveillance blood cultures continued to be negative following removal of picc, and patient was felt to be stable for placement of a new picc on hospital day eight, required for continued tpn. at the time of discharge, patient had been afebrile for greater than 48 hours, was hemodynamically stable, and had negative surveillance blood cultures. patient was discharged home with services and was to continue additional antibiotic therapy for eight days following discharge. patient was instructed to follow up with her primary care physician 10 days following discharge. medications on admission: 1. prozac 20mg twice daily 2. fiorinal 100mg once to four times daily 3. coumadin 0.5mg once daily 4. xanax 0.5mg once daily 5. ativan 1mg as needed 6. oxycontin 20mg every 12 hours 7. methadone 5mg three times daily 8. b12 once monthly 9. salagem 5mg three times daily (for dry mouth) 10. mobic 7.5mg once daily 11. pyridium 100mg twice daily 12. vivelle dot hormone patch 0.03 once weekly 13. vitamin d 5000mg once weekly discharge medications: 1. fluoxetine hcl 20 mg capsule sig: one (1) capsule po bid (2 times a day). 2. alprazolam 0.25 mg tablet sig: two (2) tablet po qd (once a day). 3. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for anxiety. 4. acetaminophen-caff-butalbital mg tablet sig: tablets po q4-6h (every 4 to 6 hours) as needed for headache. 5. ropinirole hydrochloride 0.25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. phenazopyridine hcl 100 mg tablet sig: two (2) tablet po bid (2 times a day) as needed for bladder pain for 3 days. 8. ampicillin-sulbactam sodium g recon soln sig: 4.5 grams injection three times a day for 8 days. disp:*24 doses* refills:*0* 9. normal saline flush 0.9 % syringe sig: five (5) cc injection sash as needed for picc flush for 1 months. disp:*1 month supply* refills:*5* 10. heparin flush (porcine) in ns 100 unit/ml kit sig: five (5) cc intravenous sash as needed for picc flush for 1 months. disp:*1 month supply* refills:*5* 11. iv infusion pump infusion set sig: one (1) unit miscell. continuous. disp:*1 infusion set* refills:*0* 12. tpn tpn: 50g amino acids 100g dextrose no lipids disp: 30 day supply refills: 5 discharge disposition: home with service facility: tlc staff builders discharge diagnosis: sepsis urinary tract infection shortgut syndrome radiation myelopathy/radiculopathy discharge condition: good discharge instructions: 1) continue tpn daily. make sure to dedicate and mark one lumen of your picc line for tpn only. do not use that lumen for any other medications. tpn orders: - 10 hour cycle - 100 grams dextrose - 50 grams amino acids - 1000cc total electrolytes: nacl 150meq, napo4 10meq, kcl 40meq, kpo4 15meq, mgso4 10meq, cagluc 10meq 2) continue unasyn 4 grams, three times a day for 8 more days. use only the non-tpn lumen for unasyn, and use that same lumen for all other iv medications. 3) call your primary care physician or come to the emergency room if you have fever, chills, sweats, or other signs of infection or bladder infection. 4) continue taking your outpatient medications as directed. followup instructions: please make an appointment to see your primary care physician 7-10 days after discharge. provider: mri where: phone: date/time: 10:45 provider: , md where: lm disease phone: date/time: 11:30 provider: density testing where: medical specialties phone: date/time: 12:20 md, Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Urinary tract infection, site not specified Sepsis Osteoporosis, unspecified Other septicemia due to gram-negative organisms Infection and inflammatory reaction due to other vascular device, implant, and graft Other and unspecified postsurgical nonabsorption Personal history of malignant neoplasm of cervix uteri Displacement of lumbar intervertebral disc without myelopathy Effects of radiation, unspecified

allergies: cephalosporins / vancomycin / codeine attending: chief complaint: chief complaint: lower gi bleed reason for micu admission: hypotension major surgical or invasive procedure: sigmoidoscopy history of present illness: ms is a 67 year old woman with history of cervical cancer, s/p tah/xrt, complicated by radition cystitis, short-gut syndrome from radiation enteritis, rectovesicular fistula, on home tpn via picc with recurrent line infections, presenting with rectovaginal bleeding since 2 am on night prior to admission. patient noted passage of bright red blood around 2 am, when she woke up to self cath. she describes being "covered in blood" and having severe, sharp pain in her left lower quadrant. patien then placed a chux pad however this too became "soaked with blood". patient also reported left hip / flank pain, reports she had a fall approximately one week pta where she hit her left side. reports fever up to 102 at home and shaking chills. denies any vomiting but had nausea. she reports her ostomy output has remained stable and denies have any changes in her diet. in the ed, vital signs were initially: pain, temp 99.2 96 122/53 16 100. patient noted to have small amount of "ooze-like" rectal bleeding and some vaginal bleeding. ostomy bag with normal stool. patient underwent ct scan which revealed likely infectious colitis of sigmoid. blood cultures were collected and patient was noted to have decreasing systolic pressure into 80's and 90's. patient received a total of 3l of fluid with minimal improvement, she was admitted to micu for further management. no antibiotics were given. past medical history: 1. cervical ca s/p tah/xrt s/p hysterectomy with recurrence in 2. radiation cystitis 3. urinary retention; straight catheterization ~8x per day 4. r ureteral stricture -- c/b recurrent infections -- s/p right nephrectomy () 5. recurrent utis: (klebsiella (amp resistant) and enterococcus (levo resistant) 6. short gut syndrome since s/p colostomy from radiation enteritis. 7. osteoporosis 8. hypothyroidism 9. migraine ha 10. depression 11. fibromyalgia 12. chronic abdominal pain syndrome 13. multiple admits for enterococcus, klebsiella, infections 14. dvt / thrombophlebitis from indwelling central access 15. lumbar radiculopathy 16. multiple prior picc line / hickman infections -- see multiple surgical notes to date 17. h/o sbo followed by surgery . h/o stemi takotsubo cm, with clean coronaries on cath in . ef down to 20% in setting of illness, but ef recovered to 55-60%, in setting of klebsiella pna. 19. hyponatremia: previously attributed to hctz use social history: she lives with her husband in an . she reports a 80 py smoking history but quit 18 years ago. denies alcohol or drugs. family history: father with etoh abuse, cad. with renal ca, cad. 3 healthy children. physical exam: vitals: t: 98.9 p: 72 bp: 162/88 r: 20 sao2:100%ra general: awake, alert to team entering room, nad. heent: nc/at, perrla, eomi, sclerae anicteric, mmm, op without erythema or exudate neck: supple, trachea midline, no jvd or lad. no thyromegaly. pulm: nard. ctab. no w/r/r. cardiac: rrr. normal s1 and s2. no m/r/g. abdomen: normal bowel sounds. soft, non-distended. some ttp, especially in llq. no rebound. minimal guarding. no appreciable organomegaly. extremities: mae. extremities are cool to touch but dps and radials 2+ b/l. no c/c/e. neurologic: alert and orient x3. -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact -motor: normal bulk, strength and tone throughout. no abnormal movements noted. -sensory: decreased sensation to light touch in distal les consistent with known lumbosacral plexopathy pertinent results: admission: 02:10pm blood wbc-13.0*# rbc-3.98* hgb-11.0* hct-33.7* mcv-85 mch-27.5 mchc-32.6 rdw-13.6 plt ct-299 02:10pm blood neuts-93.0* lymphs-5.4* monos-1.5* eos-0 baso-0.1 02:10pm blood pt-12.7 ptt-27.1 inr(pt)-1.1 02:10pm blood glucose-90 urean-16 creat-1.5* na-124* k-4.9 cl-94* hco3-21* angap-14 02:10pm blood ctropnt-0.03* 02:10pm blood calcium-8.5 mg-1.9 01:35am blood albumin-3.3* calcium-7.5* phos-2.7 mg-1.8 02:10pm blood osmolal-271* 05:05pm blood lactate-1.2 discharge: 06:20am blood wbc-5.2 rbc-3.92* hgb-10.7* hct-32.9* mcv-84 mch-27.3 mchc-32.5 rdw-13.7 plt ct-285 06:20am blood pt-15.0* ptt-29.5 inr(pt)-1.3* 06:20am blood glucose-97 urean-19 creat-1.4* na-130* k-4.0 cl-96 hco3-25 angap-13 06:20am blood calcium-9.0 phos-3.3 mg-1.5* sigmoidoscopy: findings: lumen: evidence of a previous subtotal colectomy was seen, as the lumen narrows at 12 cm. impression: previous intervention of the colon otherwise normal sigmoidoscopy to 12 cm from anal verge recommendations: review ct scan abd/pelvis with radiologist. question possibility of small bowel source. additional notes: the attending was present for the entire procedure. the patient's reconciled home medication list is appended to this report. ecg : normal sinus rhythm, rate 89. normal tracing. compared to the previous tracing of no significant change. 3 views hip & left hip joint : there is an old healed fracture of the left superior and inferior pubic rami with surrounding callous. there are surgical clips in the pelvis. the sacrum has a mottled appearance which may be secondary to osteopenia or radiation treatment. previously noted sacral fractures are not clearly seen on this study as overlying bowel obscures visualization. no new fractures are noted. impression: chronic fractures of the left superior and inferior pubic rami. no new fractures noted. cxr : comparisons: . findings: since prior examination, there is no significant interval change. the lungs are clear without consolidation, pleural effusions or pneumothorax. the patient is status post right calcified breast implantation and cholecystectomy. a right-sided picc is seen with tip terminating within the low svc. cardiomediastinal contours are normal. the visualized osseous structures are unremarkable. impression: no acute cardiopulmonary process. ct abdomen/pelvis : examination: ct of the abdomen and pelvis with oral and intravenous contrast. comparisons: comparison is made to multiple prior examinations including , , , and . technique: helically acquired axial images were obtained from the thoracic inlet to the pubic symphysis after the administration of oral and 130 ml of optiray intravenous contrast. coronal and sagittal reformations were obtained. findings: ct of the abdomen with intravenous contrast: other than mild linear atelectasis, the lung bases are clear without focal parenchymal consolidation, pleural effusions, or pulmonary nodules. there is stable appearance of central intrahepatic biliary dilatation and extrahepatic biliary dilatation with the common bile duct measuring up to 9 mm. no new focal liver lesions are identified. the spleen, both adrenal glands, pancreas, and left kidney are unremarkable. the patient is status post right nephrectomy. the patient is status post ileostomy. multiple clips are noted within the pelvis. the patient is status post hysterectomy and bilateral oophorectomy. there is a significant amount of retained contrast seen within the cecum stable since multiple remote prior examinations dating back to . contrast is seen to the ileostomy without evidence of obstruction. there is associated mesenteric stranding and fluid and bowel wall thickening and edema involving the rectum, sigmoid colon, transverse colon to the level of the cecum most compatible with a component of colitis, likely infectious in etiology. there is no evidence of associated pneumatosis. transverse colon is noted to be in a stable but abnormal course with kinking and tethering adjacent to the deep left pelvic side wall. there is no intra-abdominal free air. there is no mesenteric or retroperitoneal lymphadenopathy. ct of the pelvis with intravenous contrast: the patient is status post multiple surgeries as described above. a foley is seen with the bladder collapsed about it. known fistulization not clearly apparent on this current study without administration of rectal contrast. bowel wall thickening and edema with associated stranding as described above. no inguinal or pelvic lymphadenopathy. bone windows: stable appearance of extensive post-traumatic deformity. there is stable wedging of the l1 vertebral body. there is post-traumatic deformity with osseous remodeling of the left inferior and superior pubic rami and the left acetabulum. in addition, there is remodeling and extensive degeneration and demineralization involving the left hemisacrum. impression: 1. bowel wall thickening and edema with associated mesenteric stranding and fluid surrounding the entire colon and rectum, new from prior studies, most compatible with colitis, likely infectious in etiology. 2. patient is status post extensive surgeries with ileostomy, all with stable appearance since prior examinations with retained contrast noted within the cecum. 3. stable central intrahepatic and extrahepatic biliary dilatation. 4. stable appearance with wedge compression of l1 and post-traumatic deformity involving the left hip and pelvis. cxr : findings: as compared to the previous examination, there is no relevant change. unchanged course of the right-sided central venous access line. unchanged normal to borderline size of the cardiac silhouette without evidence of pulmonary edema. no pleural effusions. no focal parenchymal opacities suggesting pneumonia. kub : comparisons: comparison is made to ct examination from . findings: nonspecific bowel gas pattern. no dilated loops of small or large bowel. no evidence of pneumoperitoneum. clips are noted to overlie the pelvic inlet and the mid abdomen. the patient is noted to be status post right-sided breast implantation, which now demonstrates rim calcification. lung bases are clear. visualized osseous structures are unremarkable. an ileostomy is noted to overlie the right mid abdomen. impression: no evidence of pneumoperitoneum. brief hospital course: 67 year old woman with complicated medical history, including short gut syndrome, rectovaginal fistula, recurrent urinary tract and line infections, presenting with rectal/vaginal bleeding and hypotension. # hypotension: in setting of recurrent line infections, tpn via picc line and active bleeding, concerning for sepsis vs volume depletion / dehydration. the patient was given ivf and transfused 1u prbc and blood pressures improved. the cause was likely volume depletion in the setting of bleeding. blood pressures were stable on the floor prior to discharge. # rectal/vaginal bleeding: patient with ileostomy and blind rectal pouch with knwn vaginal fistula. blood source difficult to elucidate, however given findings of colitis in ct with normal lactate, most likely due to infectious process. ddx changes in patient with blind loop, however pathogen most likely to be same as isolated strains in prior urinary infections (cipro resistant e. coli, klebsiella) or c diff colitis, although less likely as food products are not processed through rectum. would also keep high in differential radiation changes leading to bacterial infection. the patient underwent a sigmoidoscopy that showed normal mucosa and no evidence of fistula or active bleeding. the patient was continued on iv cipro and flagyl, then converted to po at discharge to complete a 10-day course for suspected infectious colitis. she received her home medications and additional dilaudid for pain control. # chronic renal insufficiency: creatinine 1.5 on admission, (baseline creatinine 1.2 to 1.4), likely in setting of mild dehydration and volume depletion for bleeding. # short gut syndrome: patient continued on chronic tpn throughout this admission. # hypothyroidism: continued on levothyroxine throughout this admission. # depression: continued on prozac 30 mg divided in 3 doses per day. # fibromyalgia: patient with significant pain at baseline, requiring total of 30 mg of oxycodone and 10 mg of methadone daily. in light of active colitis patient was maintained on dilaudid during this admission. pain was improving back close to baseline at the time of discharge. # bladder spasms: foley was removed ~72 hours prior to discharge. patient developed the same bladder spasms that she typically experiences at home, which were associated with abdominal pain and relieved with catheterization. she was re-started on her home bladder medications which were held during the early part of the admission while the foley was in place. medications on admission: alprazolam - 0.5mg tablet - one by mouth at bedtime for insomnia lorazepam - 0.5 mg tablet daily fluoxetine - 60 mg capsule tid gabapentin - 300 mg capsule qid fioricet (butalbital-acetaminophen-caff)- 50 mg-325 mg-40 mg tablet - prn headaches zolmitriptan - 2.5 mg tablet - 1 tablet(s) by mouth at onset of headache . take additional 1 tablet in 2 hours as needed. cyclobenzaprine - 10 mg tablet bedtime lidocaine - 5 % patch oxycodone - 5 mg tablet - one to two tablet(s) by mouth every 4 hr as needed for pain may take up to 9 tabs per day - methadone - 5 mg tablet - 1 tablet(s) by mouth four times a day for pain pilocarpine hcl - 5 mg tablet - one tablet(s) by mouth every four (4) hours . cyanocobalamin - 1,000 mcg/ml solution - 1000 mcg/ml im once a month darifenacin - 15 mg tablet sustained release 24 hr ergocalciferol (vitamin d2) - 50,000 unit capsule daily mon thru fri, skip sat and sun estradiol - 0.0375 mg/24 hour patch semiweekly - apply one patch twice weekly fexofenadine ] - 60 mg tablet once a day hyoscyamine sulfate - 0.125 mg tablet prn bladder spasm iron dextran - 100 mg iv every 2 weeks in tpn for 5 doses (started ) levothyroxine - 50 mcg tablet daily lisinopril - 10 mg tablet - 3 tablet(s) by mouth once a day mvi-13 - - 10 ml iv once daily added to tpn pantoprazole - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day phenazopyridine - 100 mg tablet - 1 tablet(s) by mouth three times a day as needed for dysuria calcium carbonate - 500 mg tablet optics mini drops - 1.4 %-0.6 % dropperette - gtts ou every twelve (12) hours as needed. discharge medications: 1. alprazolam 0.25 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 2. lorazepam 0.5 mg tablet sig: one (1) tablet po once a day. 3. fluoxetine 20 mg tablet sig: three (3) tablet po three times a day. 4. gabapentin 300 mg capsule sig: one (1) capsule po four times a day. 5. fioricet 50-325-40 mg tablet sig: one (1) tablet po once a day as needed for headache. 6. zolmitriptan 2.5 mg tablet sig: one (1) tablet po once a day as needed for headache. 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): 12 hours on, 12 hours off . 8. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 9. methadone 5 mg tablet sig: one (1) tablet po four times a day. 10. pilocarpine hcl 5 mg tablet sig: one (1) tablet po every four (4) hours. 11. cyanocobalamin 1,000 mcg/ml solution sig: one (1) injection once a month. 12. enablex 15 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 13. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po mon-fri. 14. cyclobenzaprine 10 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for back spasm. 15. estradiol 0.0375 mg/24 hr patch semiweekly sig: one (1) transdermal as directed. 16. fexofenadine 60 mg tablet sig: one (1) tablet po once a day. 17. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 18. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual qid (4 times a day) as needed for bladder spasm. 19. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 20. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for dysuria. 21. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 22. tums 500 mg tablet, chewable sig: one (1) tablet, chewable po twice a day. 23. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 10 doses. disp:*10 tablet(s)* refills:*0* 24. cipro 500 mg tablet sig: one (1) tablet po twice a day for 9 doses. disp:*9 tablet(s)* refills:*0* 25. outpatient lab work please draw blood cultures on and fax results to dr. at (. 26. dilaudid 2 mg tablet sig: one (1) tablet po every four (4) hours: take as needed for breakthrough pain if home regimen is ineffective. please do not drive or operate machinery while using this medication. disp:*30 tablet(s)* refills:*0* 27. tpn resume previous home tpn order. discharge disposition: home with service facility: discharge diagnosis: primary: - colitis, likely infectious - rectovaginal bleed (fistula present; suspect gi source) secondary: - h/o cervical cancer s/p radiation - s/p multiple surgeries and bowel removal, s/p ileostomy - radiation cystitis and proctocolitis - short gut syndrome on tpn - known rectovaginal fistula - depression - anxiety - hypothyroidism - anemia - bladder dysfunction discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you were admitted to with vaginal and rectal bleeding. pelvic exam and sigmoidoscopy did not identify a clear source of bleeding. ct scan of the abdomen showed inflammatory changes consistent with infection, so you were started on antibiotics. we have made the following changes to your medication regimen: - begin taking ciprofloxacin 500 mg by mouth twice daily until - begin taking metronidazole 500 mg by mouth three times daily until weigh yourself every morning, md if weight goes up more than 3 lbs. please arrange for follow up as recommended below. followup instructions: 1. primary care - dr. - you have an appointment scheduled with dr. on tuesday, at 9:20am. 2. gastroenterology - dr. -you have an appointment scheduled with dr. on , at 3:20pm. other future appointments: provider: , md phone: date/time: 2:20 provider: , m.d. phone: date/time: 2:00 Procedure: Parenteral infusion of concentrated nutritional substances Flexible sigmoidoscopy Diagnoses: Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Chronic kidney disease, unspecified Osteoporosis, unspecified Old myocardial infarction Abdominal pain, left lower quadrant Other acute pain Other and unspecified postsurgical nonabsorption Myalgia and myositis, unspecified Ileostomy status Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Personal history of malignant neoplasm of cervix uteri Acquired absence of both cervix and uterus Stricture or kinking of ureter Hemorrhage of rectum and anus Infectious colitis, enteritis, and gastroenteritis Digestive-genital tract fistula, female Stenosis of rectum and anus Chronic pain syndrome Other specified retention of urine

allergies: codeine / cephalosporins attending: chief complaint: fever major surgical or invasive procedure: right subclavian central line placement history of present illness: 62 yo woman with h/o of cervical ca s/p tah and xrt complicated by radiation cystitis recquiring straight cathing, s/p colectomy and sb resection, and h/o of ureteral obstructions recquiring stent placement, presents today with fever, flank pain and abdominal discomfort. . per records had recent fall after tripping over vacuum cord and broke wrist and had cast placed, which is making self-cathing difficult. she also notes that her right abdomen is sore agian, which it becomes when she has these utis. of note she had change in right ureteral stent 3weeks ago, complicated by uti. yestrday while she was starting her tpn for short gut syndrome she noticed she was febrile. they stopped the tpn, flushed her picc line which has been in place since and then restarted the infusion and still felt like spiking temp and came in for evalautaion. . in ed, arrived bp 60/40 and t 103, but mentating and recieved 9lns, started on dopa peripherally as refused sepsis/central line and had ct scan of abdomen which was unchanged from last ct scan 3 weeks ago. given levoquin and vanc x1. cast was bivalaved to help with her pain. also with intermitent fleeting cp with burping sensation and hypoxic to 91%2l. repeat cxr with bilateral infiltrates at bases with increased vascular congestion, ct scan with no real change from few weeks ago with continued minimal ascites, but otherwise nothing significant, perirenal cyst. . since arrival here now has 2/4 bottles with gnr, on 10mcg of dopa and continuous fluids at 200cc/hr. past medical history: 1. cervical ca-- s/p hysterectomy , recurrence , xrt, c/b entero-vaginal fistula s/p colectomy and partial small bowel resection 2. short gut syndrome s/p hickman catheter and picc for tpn 3.hx multiple admissions, caused by: enterococcus, klebsiella, parapsilosis, etc.( thought to be from bladder and stool) 4.dvt secondary to multiple central lines 5.radiation cystitis, requiring self-straight catheterization 8 times per day 6.recurrent utis, responding to ciprofloxacin; chronically colonized with yeast 7.right ureteral stenosis s/p stent placement, requiring multiple revisions 8.osteoporosis 9. hypothyroidism ?????? not currently on hormone replacement, last tsh=1.9 in . migraine headaches 11.depression 12.fibromyalgia 13.chronic abdominal pain secondary to multiple surgeries, adhesions, and radiation, on stable doses of pain regimen. social history: lives with husband in , ma. her husband is very involved in her care. no alcohol or tobacco. family history: mother died of brain ca and father died on mi early physical exam: vs: t101.9 p 110 bp 72/42 rr 26 sat 94%on 6lnc gen: aao, nad heent: perrl, mmm, clear op cv: rrr, tachy no murmurs lungs: ctab with bilateral crackles at bases back: + left cvat no right cvat abd: soft, +epigastric tenderness, +bs ext: no edema, 2+dp pulses, left picc in place w/o erythema brief hospital course: sepsis: the patient presented with decreased blood pressure, tachycardia, fever, and signs of distributive shock. she was admitted to the icu. she was found to have gnr in bottles thought initially to be more consistent with urosepsis. she was supported for a short period of time on pressors and then weaned off. she received approximately 14l of fluid for pressure support. on review of cultures, she grew two types of gnr in her blood, nothing from her catheter tip, and enterococcus in her urine. before sensitivities were known, antibiotics were started emperically based on past sensitivities. she most recently had enterococcus which was res to lev, but amp and vanc , was treated with amp iv for her uti. she had also had burkolderia/pseudomonas in , which was ceftaz resistant, but meropenum sensitive and hx of klebsiella pan senstive infectoin 1yr ago. therefore, she was initiated on meropenem as well to treat her gnr sepsis. the urology service was consulted to assess stents and possiblity of stent infections. their perspective was that the stent did not need intervention. stim test showed no adrenal insufficiency. in the meantime, culture sensitivities and id returned. . at this point, the patient was tx to the floor for further management as she had stabilized in the icu. the patient was being appropriately treated with ampicillin for her uti. her gnr bacteremia was identified as two types of enterobacter, both of which were sensitive to levoquin. therefore, meropenem was discontinued and levoquin was initiated with a plan to treat for 14 days after cultures were negative. cultures were taken daily for surveillance and remained negative after the first day in the hospital. the patient had had a subclavian line placed for access after her picc was removed. this remained in place without sign of infection until her final day of hospitalization, when it was removed after ir placed a picc line. the patient had expressed her preference for a hickmann line, but this was thought to carry an increased risk in the time immediately after her infection. it was decided that she would have a picc placed (double lumen) for one month and she could have a hickmann placed thereafter. she has had numerous line infections in the past and a surgical line was to be avoided until she had proved that this infection was cleared successfully. she was continued on her home regimen of 0.5mg of coumadin per day with the thought that it may prevent line clots as she has a history of line clot in the past. inr remained at 1, and the patient was also started on heparin prophylaxis during her stay at the hospital. . arf: the patient presented with an elevated creatinine. it was thought to be due to dehydration and sepsis physiology. as the patient was hydrated, and as the sepsis physiology resolved, the creatinine stablized and then resolved. . hypoxia: in the icu, the patient exhibited some hypoxia. it was thought likley to be related to fluid overload, though initially pna and atelectasis were entertained as well. x ray revealed fluid overload, and as the patient's status improved and she cleared her infection, her pressures returned and she began to auto-diurese. she was net negative 2-3l per day each day for 5-6 days after transfer to the floor and her symptoms of sob and hypoxia resolved. . metabolic acidosis: on presentation, the patient had both gap and non-gap acidosis, likely realted to sepsis and lactate (gap acidosis), with arf and underlying short gut syndrome and acid losses from ostomy output (non-gap acidosis). the patient was monitored closely. her lactic acidosis corrected quickly and the non-gap acidosis also corrected, albeit far more slowly, as the patient's health improved. . short gut: the patient has a long history of short gut syndrome caused by colectomy after radiation to her abdomen for recurrant cervical cancer years ago. this remained stable at this hospitalization. the patient initially had her tpn held as she did not have central access for a number of hours in the icu. once a subclavian line was placed, tpn was restarted and the patient received tpn through this line until the last day of hospitalization when the subclavian was removed after a picc was placed by ir. the plan was to continue her tpn through the picc for one month, whereupon it could be changed to a hickmann catheter for comfort if the patient so desired. . wrist fracture: the patient presented with a short cast on her left arm after a fall at home (see hpi). orthopedics was consulted to evaluate the patient. the cast was removed and replaced with a longer cast to improve alignment. the longer cast was left in place for 3 days and replaced, again, with a short cast after better alignment was confirmed radiographically. the patient complained of decreased mobility with the cast, and the orthopedic service was careful to leave her as much flexibility in her hand as possible, however she was still unable to manipulate her ostomy bag or to self cath after the new short cast was in place. she was seen by pt and found to be mobile and ready for discharge from their perspective. she was seen by ot, who suggested a short rehab stay to ensure that she could conduct her self care after hospitalization discharge. she was instructed to follow up with dr. at orthopedics 2 weeks after discharge for x-rays and re-evaluation of her fracture. . ## preventive antibiotics - the idea of preventive antibiotics in this patient with a history of numerous line infections who is dependent on tpn for nutrition was raised repeatedly at this hospitalization. however, the patient has been evaluated by id as an outpatient numerous times in the past and preventive antibiotics was repeatedly rejected as it tends to prevent infections for a few months and then selects for resistant strains. . ## pain control - pt has complicated pain regimen at home for fibromyalgia and her arm pain. at home, she is on methadone 5 tid, oxycontin 20 , and percoset for breakthrough pain. in addition, she has numerous non-narcotic pain medications. at this hospitalization, her non-narcotic pain regimen was continued, but her narcotics were streamlined to include methadone 5mg tid and msir for breakthrough pain. this was to be continued as an outpatient as she had good pain control. . ## anemia: iron was found to be low, ferritin was wnl, but given her sepsis, it would have been expected to be very high. tibc was low. these labs suggest both iron deficiency and anemia of chronic dz. iron was increased in her tpn as described below. . fen: the patient eats a full diet at home and receives tpn without fat. at home she receives 5mg of iron in her tpn. she was found to be very iron deficient at this hospitalization and her iron was increased to 10mg each night. tpn was cycled over 10 hours and electrolytes were managed as they are at home. at the time of discharge, her tpn was stable and similar in content to her prior formulation with the exception of the increased iron content. medications on admission: mobic 7.5 mg qd xanax 0.5mg qhs prtonix 40mg qd flexeril 10mg qhs coumadin 0.5mg qhs nystatin qhs prozac 40mg qam salagen 5mg tid methadone 5mg tid vitmain d vivelle 0.375patch qweek b12 1000units qmonth aredia q3mos pridium prn fiorecet prn percocet prn zofran prn ativan 1mg tid prn neurotnin 300mg tid oxycontin 20mg q12hrs discharge medications: 1. acetaminophen-caff-butalbital mg tablet sig: tablets po q4-6h (every 4 to 6 hours) as needed for headache. 2. methadone 5 mg tablet sig: one (1) tablet po tid (3 times a day). 3. fluoxetine 20 mg capsule sig: one (1) capsule po bid (2 times a day). 4. pilocarpine hcl 5 mg tablet sig: one (1) tablet po tid (). 5. alprazolam 0.25 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)) as needed. 6. warfarin sodium 1 mg tablet sig: 0.5 tablet po hs (at bedtime). 7. olopatadine 0.1 % drops sig: two (2) drop ophthalmic (2 times a day) as needed. 8. cyclobenzaprine 10 mg tablet sig: one (1) tablet po tid (3 times a day). 9. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 10. vivelle 0.0375 mg/24 hr patch biweekly sig: one (1) patch transdermal once a week. 11. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days: take as instructed until finished with tablets. disp:*4 tablet(s)* refills:*0* 12. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed: use as directed for itching. disp:*1 bottle* refills:*0* 14. zofran 4 mg tablet sig: 1-2 tablets po twice a day. 15. vitamin b12-vitamin b1 100-1 mg/ml solution intramuscular 16. aredia 30 mg recon soln sig: one (1) infusion intravenous q 3 mo: as instructed by physician. 17. neurontin 300 mg capsule sig: one (1) capsule po three times a day. 18. outpatient lab work chem 7 and cbc weekly 19. tpn non-standard tpn: volume 1000 (ml/day amino acid 50 (g/d) branched-chain aa 0 (g/d) dextrose100 (g/d)fat 0(g/d) standard adult multivitamins nacl 90 naac 30 napo4 0 kcl 15 kac 0 kpo4 10 mgs04 10 cagluc 10 heparin(units) 4000 iron 10mg cycle over 10 hrs. start at 1800 (6 pm) stop at 0400 (4 am) plug and flush line 20. picc line iv flush sodium chloride 0.9% flush 3 ml iv qd picc 21. morphine 15 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 22. pilocarpine hcl 5 mg tablet sig: one (1) tablet po qid (). 23. ampicillin sodium 2 g recon soln sig: one (1) gram injection q6h (every 6 hours) for 4 days. 24. aredia 30 mg recon soln sig: one (1) dose intravenous q 3 months. discharge disposition: extended care facility: & rehab center - discharge diagnosis: bacteremia with sepsis complicated by arf uti wrist fracture that was reset secondary diagnoses: osteoporosis hypothyroidism ?????? not currently on hormone replacement, last tsh=1.9 in migraine headaches depression fibromyalgia chronic abdominal pain secondary to multiple surgeries, adhesions, and radiation, on stable doses of pain regimen. discharge condition: stable - afebrile, blood cx ngtd since day after admission. stable baseline chronic pain. discharge instructions: you were admitted with a urinary tract infection and two kinds of bacteria in your blood. these were both serious infections that required a stay in the icu. complicating this, you had the recent fracture of your arm. you were treated with antibiotics and recasting to align your arm better. . you will need to see your primary care physician weeks for a follow-up appointment for lab work and a check-up. . you should follow up with dr. in orthopedics for cast removal and a check-up within 2 weeks. call dr. office at ( to schedule an appointment. . if you develop fever or chills, or severe n/v, or if you have increasing abd pain or pain with urination, if you lose consciousness or feel as though you might, or if you have any other worrisome symptoms, you should seek immediate medical attention. followup instructions: pcp 1-2 weeks. will need chem 7 and cbc. will need checkup with attention to pain, monitoring for c dif (given recent abx), self-cath technique. . ortho for cast removal/check up. call dr. office at ( to schedule an appointment. . provider: , m.d. where: phone: date/time: 3:20 provider: , md where: lm phone: date/time: 1:00 provider: , m.d. where: center phone: date/time: 2:45 md, Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Infusion of vasopressor agent Diagnoses: Acidosis Acute kidney failure, unspecified Severe sepsis Unspecified acquired hypothyroidism Osteoporosis, unspecified Septic shock Iron deficiency anemia, unspecified Other septicemia due to gram-negative organisms Other and unspecified postsurgical nonabsorption Myalgia and myositis, unspecified Personal history of malignant neoplasm of cervix uteri Irradiation cystitis Late effect of radiation Aftercare for healing traumatic fracture of other bone

allergies: pcn, tetracycline, propoxyhene neuro:pt lethargic, easily arouses to voice. aphasic. will not nod, but squeezes left hand approp to yes/no questions. follows commands with left side. left arm , able to bend left leg at knee. rue flaccid, some spont mvmt of right leg noted. left pupil irreg secondary to cataract in past, r pupil 3mm briskly reacts. on dilantin for sz proph- extra 200 mg given this am secondary to level of 6.0. zyprexa d/c;d (was on at home) secondary to extrapyramidial se. cv: parmeters widened to 130-150 this am. hydralizne increased to 30mg po qid, po lopressor 50 tid. hr sr 60-70's. p-boots on. 40 meq kcl given this am for k 3.7. needs pt/ot consults. hob >45 degrees. periph line x2 in left arm benign. poor iv access. ns with 20kcl at 50cc/hour. resp: asthma hx. on inhalers: flovent, serevent, proventil, atrovent a/o. good technique with spacers. ls coarse to clear upper airways, extremely diminshed at bases. pt currently on 3l nc and 40% open face mask. gi:abd large, soft,nt. +bs x4. + loose liquid bm this am- diaper placed on. tol soft solids with no aspiration problems. study done without signs of asp- however rec's for ngt for feeds seocndary to decrease level of alertness to take po's. pt more awake today and able to take in more po's- ngt on hold at this point. pt will need full assist in eaating/drinking. able to take pills whole without problems and once she realizes the straw she will drink freely. gu:foley patent drng clear yellow urine great amoutns. urine lytes sent this am with osm and serum osm secondary to na 132. skin: intact. social: daughter : Procedure: Barium swallow Magnetic resonance imaging of brain and brain stem Diagnoses: Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Intracerebral hemorrhage Unspecified schizophrenia, unspecified Unspecified sleep apnea

history of present illness: the patient is a 67-year-old right-handed woman who presented to an outside hospital with right-handed weakness and difficulty speaking. the history that the patient was behaving strangely and not speaking while on the phone with a friend. sister went to visit her, and found her at home, able to answer yes and no questions, but otherwise nonverbal. additionally, the patient was using her left side despite being right-handed. she was able to stand up with assistance. the patient was taken to hospital, where a ct scan of her midline shift. at that time, the patient was transferred to to the neurosurgery service for further evaluation. the patient was deemed nonsurgical, and was transferred to the neurology service for further evaluation and monitoring. past medical history: asthma, schizophrenia, sleep apnea, hypothyroidism. allergies: propoxyphene, tetracycline, amoxicillin. medications on admission: premarin, proventil, aerobid, serevent, zyrtec, levoxyl, ativan, zyprexa, flovent. social history: the patient is a nonsmoker. family history: unknown. physical examination: temperature 99.1, pulse 108, blood pressure 120/58, respiratory rate 20, oxygen saturation 97% on 2 liters. the patient was lying in bed, in no apparent distress, with her mouth open, tongue constantly moving. the lung examination revealed adventitious sounds, however, there was no wheezing. heart was regular rate and rhythm. the abdomen was soft, nontender, nondistended, with good bowel sounds. neurologic examination: mental status: patient opens eyes to voice, will grasp hand, will wiggle toes. the patient was nonverbal. cranial nerves: left pupil was 2 mm, right pupil was 1.5 mm, both of them were reactive. there was left lid ptosis. the face was symmetric. there was no nystagmus. the patient blinks to threat bilaterally. motor examination showed spontaneous movement of the left arm. the patient moved her left leg and wiggled the toes. there was tremor on the left side, with increased tone. the right side was hemiplegic. reflexes were 2+ throughout. the toe was upgoing on the right and downgoing on the left. sensory: examination was not withdrawing to pain on the right side. laboratory data: on admission, revealed white count of 11.5, with a differential of 79 neutrophils, 13 lymphocytes, 1 atypical cell, 4 monocytes, 1 eosinophil, 2 basophils. hematocrit 35, platelet count 353. chem 7 revealed a sodium of 136, potassium 4.1, chloride 98, bicarbonate 22, bun 12, creatinine 1.3, glucose 143. calcium was 9.6, albumin 3.5, protein 6.7, bilirubin less than 0.5, alkaline phosphatase 93, alt 26, ast 7. ck 48, troponin less than 0.04. an mri angiogram of the head was obtained, which showed left frontoparietal lobe hemorrhage with mild surrounding edema. there was no evidence of abnormal enhancement. no other abnormal areas of enhancement in the brain. normal mra of the head. global hemorrhage could be secondary to the amyloid angiopathy. no enhancing lesion is identified. follow up examination in eight weeks is recommended. hospital course: in summary, mrs. is a 67-year-old white female without known vascular risk factors, who suffered a lobar hemorrhage in the left frontoparietal region. she does not have a history of hypertension or diabetes. the differential for such bleed would include amyloid angiopathy, vascular malformation or hemorrhage into cortical infarct. initially the patient was observed in the intensive care unit, where she did well and was transferred to the neurology service. the patient was started on dilantin, with current dose being 300 mg by mouth daily at bedtime. initially the patient's blood pressure was controlled with nipride, with transfer to lopressor and hydralazine to maintain her blood pressure between 130 and 150 systolic. the patient initially was fed through a nasogastric tube, however, following a swallowing evaluation which revealed microaspirations with thin fluids, however, no aspiration with nectars or pudding, thick liquids, the patient was started on pureed diet with nectar thick liquids. during this hospitalization, the patient's asthma medication was continued. she did not require any nebulizer treatments. physical examination on discharge was slightly improved, with the patient following some midline commands and purposeful movements of her left arm. the patient remained nonvocal, with paralysis of her right arm and leg. the patient is to follow up with our stroke fellow, dr. , as well as her primary care physician. will need a repeat mri scan in four to six weeks. at that time, angiography could also be performed. discharge diagnosis: 1. asthma 2. schizophrenia 3. sleep apnea 4. hypothyroidism 5. left frontal bleed discharge medications: flovent two puffs twice a day, serevent two puffs twice a day, proventil two puffs every six hours as needed, dilantin 300 mg by mouth daily at bedtime, synthroid 75 mcg by mouth once daily, zyprexa 10 mg by mouth every evening, tylenol 650 mg as needed, nystatin swish and swallow 5 cc by mouth four times a day (please stop once thrush resolves), premarin 0.9 every morning, lopressor 50 mg by mouth three times a day and hold for systolic blood pressure of less than 130, hydralazine 20 mg by mouth four times a day and hold for systolic blood pressure less than 130. diet: pureed food, thick nectar. dr., 13-279 dictated by: medquist36 d: 22:09 t: 00:22 job#: Procedure: Barium swallow Magnetic resonance imaging of brain and brain stem Diagnoses: Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Intracerebral hemorrhage Unspecified schizophrenia, unspecified Unspecified sleep apnea

technique: axial images of the abdomen and pelvis were obtained after the administration of 150 cc optiray per history of allergies. ct guided repositioning of pigtail catheter in right abdominal collection was also performed. ct abdomen with oral/iv contrast: comparison with prior study . again seen is a consolidation in the superior aspect oft he right lower lobe which has decreased in size in the interval. there are linear opacities in bilateral lung bases related to subsegmental atelectases. there are small bilateral pleural effusions. there are a few mediastinal nodes. there are no focal liver lesions. again seen is a distended gallbladder with a small gallstone. the pancreas and adrenal glands are normal. there is a low attenuation lesion in the spleen which does not enhance and is unchanged compared to the prior study. it likely represents a cyst or hemangioma. there is a 2 cm high attenuation lesion in the upper pole of the right kidney which compared to prior noncontrast study from has slight enhancement. there are several other low attenuation lesions within the kidneys bilaterally which do not enhancement and are consistent with cysts. the largest one in the mid pole of the right kidney measures 4.1 cm in greatest dimension. other low attenuation lesions are too small to characterize, they likely represent cysts. loops of small bowel are well opacified. again seen is a fragmented mesh in the anterior abdominal wall surrounded by extensive soft tissue and air. anterior to the mesh there is a soft tissue tract and there is extensive fluid accumulated in a bag overlying this area. there is no evidence of high attenuation material within these contents. posterior to the mesh there is a collection of fluid and air which is located adjacent to the greater curvature of the stomach and has decreased in size in the interval. the largest portion approximately measures 1.1 x 7.8 cm. it previously measured 1.7 x 8.7 cm. there is no definite evidence of enteric fistulas. air droplets are seen tracking from the anterior abdominal cavity through a break in the mesh and in the subcutaneous tissues. (over) 4:14 pm ct abdomen w/contrast; ct pelvis w/contrast clip # ct change percutaneous tube reason: s/p colectomy, ostomy, po methylene blue leaking from wound, eval for fistula, collection field of view: 48 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) impression: in the right lower abdomen there is a pigtail catheter within a fluid collection that measures 6.9 x 3.7 cm. compared to the prior study the collection is slightly smaller although it is incompletely drained by the existing catheter. within the left flank there is a tiny collection which measures 1.5 x 2.6 cm and has minimally increased in size in the interval. there is a 4.5 x 4.5 cm fluid collection within the pelvis which previously measured 6.1 x 5.3 cm. there is minimal enhancement surrounding the fluid. contrast is seen in the ostomy. ct pelvis with contrast: there is a foley catheter within the bladder. the ureters are normal. there are degenerative changes in the spine. ct guided repositioning of pigtail catheter in the right lower quadrant collection: using sterile technique saline was flushed via the pigtail catheter and approximately 100 cc of fluid were drained after repositioning the catheter under ct guidance. post procedure ct demonstrates almost complete resolution of collection in the right hemiabdomen. impression: 1. successful repositioning of pigtail catheter in right lower abdominal collection with almost complete resolution. 2. no radiographic evidence of enteric fistula. 3. fragmented mesh in the anterior abdominal wall with surrounding soft tissue density material and free air, the collection anterior to the greater curvature of the stomach has decreased in size in the interval and it is draining into the skin through a well defined tract in the anterior abdominal wall. 4. small pelvic fluid collection which has slightly decreased in size in the interval. 5. tiny collection in the anterior left flank. findings were discussed with the surgery team at the time of the exam. 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 Percutaneous abdominal drainage Arterial catheterization Reopening of recent laparotomy site Peritoneal lavage Removal of foreign body from peritoneal cavity Other immobilization, pressure, and attention to wound Injection or infusion of nesiritide Diagnoses: Acidosis Other postoperative infection Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Acute respiratory failure Other specified septicemias Other and unspecified mycoses Fistula of intestine, excluding rectum and anus

past medical history: 1. status post coronary artery bypass graft in . 2. status post re-do coronary artery bypass graft in . 3. hypercholesterolemia. 4. hypoglycemia. 5. status post ear surgery. allergies: no known drug allergies. preoperative medications: 1. isordil 120 mg po q day. 2. prevacid 15 mg po q day. 3. atenolol 50 mg po q day. 4. altace 10 mg po q day. 5. aspirin 325 mg po q day. 6. lipitor 20 mg po q day. physical examination: vital signs, pulse 74 regular rate and rhythm. blood pressure 128/68. respiratory rate 22. room air oxygen saturation 98%. weight 170 pounds. this is a well appearing 65 year-old male in no acute distress. skin without lesions or rashes. heent is unremarkable. neck is supple. chest lungs are clear to auscultation bilaterally. heart s1 and s2 regular rate and rhythm. abdomen is soft, nontender, nondistended. extremities are warm and well profuse with trace pedal edema. laboratory data: white blood cell count 7.7, hematocrit 42.6, platelet count 159, sodium 143, potassium 4.5, chloride 106, bicarb 27, bun 13, creatinine 1.1. electrocardiogram showed normal sinus rhythm with borderline izcd. ho course: the patient was taken to the operating room by dr. on for a coronary artery bypass graft times three, radial artery to obtuse marginal, saphenous vein graft to diagonal and saphenous vein graft to posterior descending coronary artery. the patient was transferred to the intensive care unit in stable condition. the patient was weaned from mechanical ventilation and extubated on postoperative day number one. the patient required neosinephrine and fusion to maintain adequate blood pressure. the patient was also maintained on a nitroglycerin drip for the radial artery graft. neosinephrine was weaned to off by postoperative day number three. the patient was able to maintain adequate blood pressure. the patient remained in the intensive care unit requiring aggressive pulmonary toilet for what was thought to be an upper respiratory infection or bronchitis. sputum cultures from showed only oropharyngeal flora. chest x-ray showed right lower lobe atelectasis and small left effusion. no identifiable infiltrate. the patient was started on levaquin for presumed bronchitis. the patient had reported being on antibiotics for bronchitis prior to entering the hospital. the patient was requiring around the clock nebulizer treatments with albuterol and atrovent as well as humidified o2 and aggressive chest physical therapy. the patient's coughing and sputum production gradually subsided as o2 requirement decreased and the patient was transferred out of the intensive care unit on postoperative day number four. the patient continued to require aggressive pulmonary toilet with around the clock nebulizer treatments. the patient remained afebrile during this time. the patient's white blood cell count rose to high of 14.7 on postoperative number two, but quickly returned to by postoperative number four. by postoperative number seven the patient was weaned from nasal cannula. the patient was ambulating 500 feet and climbing stairs with physical therapy on room air tolerating activity well. on postoperative day number eight the patient was cleared for discharge. condition on discharge: temperature max 98.2. pulse 80 sinus rhythm with frequent premature atrial contractions. blood pressure 116/60. respiratory rate 20. room air oxygen saturation 98%. weight 78.4 kilograms. neurological intact. cardiovascular regular rate and rhythm without rub or murmur. respiratory breath sounds clear bilaterally, moderately productive cough for yellow sputum. gastrointestinal, positive bowel sounds, soft, nontender, nondistended, tolerating a regular diet although with decreased appetite. sternal incision is clean and dry without drainage or erythema. sternum is stable. left radial artery graft harvest site is clean and dry with minimal erythema. no drainage. saphenectomy sites are clean and dry without erythema. electrocardiogram on showed sinus arrhythmia with a right bundle branch block. chest x-ray from showed small bilateral effusions with right lower lobe atelectasis. laboratory on discharge: white blood cell count 10.6, hematocrit 31.5, platelet count 244, sodium 136, potassium 4.8, chloride 99, bicarb 29, bun 26, creatinine 0.9. the patient is to be discharged to home in stable condition. discharge diagnoses: 1. status post coronary artery bypass graft second re-do. 2. status post coronary artery bypass graft . 3. status post coronary artery bypass graft . 4. hypercholesterolemia. 5. hyperglycemia. 6. status post ear surgery. discharge medications: 1. lopressor 25 mg po b.i.d. 2. lasix 20 mg po q day times seven days. 3. k-ciel 20 milliequivalents po q day times seven days. 4. guaifenesin 400 mg po q.i.d. times seven days. 5. levaquin 500 mg po q day times six days. 6. aspirin 81 mg po q day. 7. lipitor 20 mg po q.h.s. 7. percocet 5/325 one to two tabs po q 4 to 6 hours prn. 8. ibuprofen 400 mg po q 4 to 6 hours prn. 9. combivent mdi with spacer two puffs q.i.d. times one week and then prn. 10. imdur 30 mg po q day times three months. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Diagnoses: Pure hypercholesterolemia Coronary atherosclerosis of autologous vein bypass graft Aortocoronary bypass status Bronchitis, not specified as acute or chronic

allergies: demerol / bactrim / midol attending: chief complaint: non-healing r great toe ulcer major surgical or invasive procedure: peripheral catheterization history of present illness: ms. is an 82 yo woman with a pmh of cerebral palsy, pvd, htn, hyperlipidemia who presented in with critical limb ischemia and ulceration of her r great toe that had not responded to multiple courses of antibx. she was referred to vascular surgery but she declined surgery. access was obtained via a right femoral approach, but there was a complication involving puncture of the inferior epigastric artery. the left external iliac and common femoral arteries were stented and the case was aborted. past medical history: htn hyperlipidemia pvd non-healing right great toe ulcer cerebral palsy social history: lives in . no tobacco. family history: noncontributory physical exam: vss: 98.4, 125, 109/82, 19, 96% 2lnc gen: a+ox1, distressed over l leg pain heent: jvd difficult to assess heart: tachycardic, ns1 s2, no appreciable murmurs lungs: abd: soft, nt, nd, bowel sounds throughout ext: dopplerable dps bilaterally l groin: no ecchymosis or palpable hematoma pertinent results: 09:30pm wbc-10.6 hct-26.2 plt ct-277 05:30am wbc-10.2 hct-31.6 plt ct-249 . 05:30am glucose-120 urean-13 creat-0.6 na-143 k-3.5 cl-101 hco3-32 brief hospital course: 82 yo woman with pmh of non-healing r great toe ulcer, pvd, htn, cerebral palsy presents for lower extremity arteriography and potential intervention which was complicated by puncture of inferior epigastric artery requiring stenting of the left external iliac artery and common femoral artery. . ## cardiac: - ischemia: has cad equivalent. on aspirin 325 mg po qd (increased from 81 mg daily, per dr. , clopidogrel 75 mg po qd. no ischemic issues. - pump: no clinical failure on exam. likely mildly hypovolemic on presentation to ccu. given blood products and small ivf boluses. - valves: no known issues - rhythm: no known issues . ## pvd/access complication: bilateral dopplerable dps. ct revealed retroperitoneal hematoma. required 2 u prbcs. hct stable thereafter. the plan is to return to have repeat angiography with intervention of right lower extremity some time next week. ## htn: not on any po antihypertensives. came to floor on nitro drip for bp control. responded well to metoprolol 25 tid. changed to toprol 75 qd on discharge. ## anuria: the patient's foley was removed a couple of hours prior to transfer to rehab. at that point she had not yet voided. if she hasn't voided by the evening of transfer she should be straight catheterized intermittently as needed, and dr. should be made aware. medications on admission: augmentin 875 oxycodone q4hrs mscontin 45 asa 81 qd clopidogrel 75 qd atorvastatin 20 qd levothyroxine 25 qd furosemide 20 qd iron 325 qd colace 100 qd apap 1000 tid gabapentin 300 tid effexor 187.5 qd senokot qod calcium/vitamin d discharge medications: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 3. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 5. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 6. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qd (): please apply one patch to each shoulderfor 12 hrs qd . 7. morphine 15 mg tablet sustained release sig: three (3) tablet sustained release po q12h (every 12 hours). 8. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po bid (2 times a day). 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 10. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 11. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 12. toprol xl 25 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po once a day. 13. colace 100 mg capsule sig: one (1) capsule po once a day. 14. senna 8.6 mg tablet sig: one (1) tablet po every other day. 15. calcium 500+d 500-400 mg-unit tablet, chewable sig: two (2) tablet, chewable po once a day. discharge disposition: extended care facility: nursing home - discharge diagnosis: peripheral vascular disease with complication: ulcer. retroperitoneal hematoma hypertension hyperlipidemia discharge condition: stable. foley removed, hasn't urinated yet. discharge instructions: resume all of your previous medications. we have started you on a new medication called toprol xl 75 mg once daily. we have increased your aspirin dose to 325 mg daily. let a nurse or doctor know if you experience worsening back pain, abdominal pain, chest pain, shortness of breath. followup instructions: dr. will contact you regarding returning sometime next week for repeat angiography of right lower extremity. his phone number is , should any problems arise. Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Unspecified essential hypertension Hematoma complicating a procedure Accidental puncture or laceration during a procedure, not elsewhere classified Ulcer of other part of foot Other and unspecified hyperlipidemia Atherosclerosis of native arteries of the extremities with gangrene Oliguria and anuria Infantile cerebral palsy, unspecified Unspecified intellectual disabilities

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: decreased exercise tolerance with dypsnea on exertion major surgical or invasive procedure: avr (23mm ce pericardial))/mvr (29mmce, pericardial)/tv repair (32mm ring)/cabg x 1 (svg > om) on history of present illness: 75 y/o african american male with known rheumatic heart disease with recent shortness of breath and hospital admission for congestive heart failure. also c/o decreased exercise tolerance, doe, and fatigue. past medical history: aortic stenosis mitral regurgitation and stenosis tricuspid regurgitation coronary artery disease rheumatic heart disease congestive heart failure hypercholesterolemia diverticulitis ?gerd h/o prostate cancer s/p prostatectomy s/p testicular surgery social history: retired parking officer. lives with wife. quit smoking after 1/2ppd x 35 yrs. rare etoh family history: non-contributory physical exam: vs: 84 20 160/84 160/80 5'" 112# general: 75 y/o male in nad skin: unremarkable, w/d heent: eomi, perrl, nc/at neck: supple, from, -jvd chest: ctab -w/r/r heart: rrr 3/6 syst. murmur abd: soft, nt/nd, +bs ext: warm, well-perfused, -edema, few varicosities bilat r>l neuro: a&ox3, mae, non-focal pertinent results: echo : prebypass: the right atrium is markedly dilated. there is moderate global left ventricular hypokinesis. overall left ventricular systolic function is moderately depressed. resting regional wall motion abnormalities include moderately depressed inferior wall basal and mid portions. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis. moderate to severe (3+) aortic regurgitation is seen. aortic annulus measures 23 mm. the mitral valve leaflets are severely thickened/deformed. the mitral valve shows characteristic rheumatic deformity. there is moderate mitral stenosis. moderate (2+) mitral regurgitation is seen. severe tricuspid regurgitation is seen. moderate sized left pleural effusion. post bypass: biventricular systolic function is unchanged. bioprosthetic valve seen in the mitral position. valve appears well seated and the leaflets move well. trace mitral regurgitation. bioprosthetic valve seen in the aortic position. leaflets move well and the valve appears well seated. trace aortic regurgitation present. annuloplasty ring seen in the tricuspid position. trace to mild tricuspid regurgitation present. cxr : resolution of failure. cardiomegaly persists. 02:05pm blood wbc-17.6*# rbc-2.95*# hgb-8.9*# hct-25.9*# mcv-88 mch-30.3 mchc-34.5 rdw-13.3 plt ct-106* 03:36am blood wbc-19.2* rbc-2.85* hgb-8.6* hct-24.4* mcv-86 mch-30.3 mchc-35.4* rdw-15.2 plt ct-126* 09:00pm blood wbc-10.8 rbc-3.66* hgb-11.2* hct-31.3* mcv-86 mch-30.5 mchc-35.6* rdw-14.0 plt ct-171 02:05pm blood pt-18.8* ptt-58.3* inr(pt)-1.8* 03:17am blood pt-13.0 ptt-30.8 inr(pt)-1.1 03:20pm blood urean-13 creat-0.7 cl-114* hco3-23 06:09am blood glucose-120* urean-16 creat-0.7 na-138 k-3.2* cl-101 hco3-26 angap-14 06:09am blood calcium-8.6 phos-3.2 mg-1.8 ospital course: mr. was seen initially as an outpatient and had his entire pre-operative work-up done prior to hospital admission for surgery. he was a same day admit on and was brought to the operating room where he underwent a aortic valve repair, mitral valve repair, tricuspid valve replacement and coronary artery bypass graft x 1 by dr. . please see op note for surgical details. following surgery patient was transferred to the csru in stable condition receiving epinephrine, milrinone, and propofol. early on post-op day one he was weaned from sedation, awoke neurologically intact and extubated. he was weaned off of all pressors/inotropes by post-op day two. beta blockers and diuretics were started and he was gently diuresed towards his pre-operative weight. he was slightly anemic with a hgb of 24.4 and was transfused 1u prbc's. at time of discharge his hgb was 31. chest tubes and epicardial pacing wires were removed per protocol. had sleep study on post-op day 3 secondary to difficulty swallowing. he became febrile between post-op day 3 and 4 and was empirically started on vancomycin and levaquin. multiple cultures came back negative but was found to have lll consolidation (presumed pna). he was transferred to the cardiac surgery step down unit on post-op day four. his temperature decreased on pod#5, but had elevated wbc. pt worked with patient during entire post-op course for strength and mobility. patient became confused and psychiatric consult was done. infectious disease was also consulted secondary to fever/wbc/pna. over next couple of days patient was stable with normal exam, vital signs, and stable labs. he was discharged home with vna services on post-op day seven and the appropriate follow-up appointments. medications on admission: aspirin 81mg qd, lisinopril 20mg qd, simvastatin 40mg qd, antacids prn discharge medications: 1. simvastatin 40 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. 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: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. disp:*1 mdi* refills:*2* 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*1 mdi* refills:*2* 8. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 9. amiodarone 200 mg tablet sig: two (2) tablet po once a day for 7 days: then 200 mg daily until d/c'd by dr. . disp:*60 tablet(s)* refills:*0* 10. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. potassium chloride 10 meq capsule, sustained release sig: one (1) capsule, sustained release po twice a day for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 12. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. disp:*5 tablet(s)* refills:*0* 13. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: aortic stenosis/mitral regurgitation and stenosis/tricuspid regurgitation/coronary artery disease s/p aortic valve replacement, mitral valve replacement, tricupid valve repair, coronary artery bypass graft x 1 rheumatic heart disease hypercholesterolemia discharge condition: good discharge instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks p instructions: with dr. in weeks with dr. in weeks with dr. in 4 weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Annuloplasty Open and other replacement of mitral valve with tissue graft Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Rheumatic heart failure (congestive) Pneumonitis due to inhalation of food or vomitus Multiple involvement of mitral and aortic valves Diseases of tricuspid valve

service: history of present illness: the patient is an 82-year-old male who presented in emergency department for shortness of breath. he also reported abdominal pain and fevers and chills for one day. his medical history is not completely clear; however, the patient reported a history of failure, arrhythmia, and multiple admissions for pneumonia. he was diagnosed with gastric outlet obstruction status post dilation in . his current symptoms started the day prior to admission with the onset of sharp, right upper quadrant pain. it was not associated with nausea, vomiting, or eating. he continued to bladder habits and had normal bowel movements one day prior to admission. he denied bright red blood per rectum or melena. he does have a history of alcohol abuse and is a former cigarette smoker. at , the patient had a normal chest x-ray and kub and was found to have an amylase of 1200 and lipase of 6900, and total bilirubin of 4.2. his white blood count was significant for 25% bands and a fever to 103??????. presumptive diagnosis was ascending cholangitis, and he was given one dose of rocephin and flagyl and sent to for further work-up, including ercp. of note at hospital, he had a drop in his blood pressure to 75/30 after the administration of morphine. blood pressure responded with intravenous fluids and narcan. past medical history: pacemaker placed over 15 years ago, morbid obesity, congestive heart failure, chronic obstructive pulmonary disease, hypertension, history of h. pylori, gastric outlet obstruction secondary to pyloric stenosis, status post dilation in , gastric ulcer per egd in and , pseudogout, chronic atrial fibrillation, status post bilateral cataracts, benign prostatic hypertrophy, osteoarthritis. family history: noncontributory. outpatient medications: bumex 1 mg p.o. q.d., vioxx 25 mg q.d., zantac 150 b.i.d., combivent 2 puffs q.i.d., pulmicort, dilantin 200 b.i.d., potassium chloride, home oxygen 2 l. social history: tobacco: he smokes three packs per day for 20-30 years, none in the last 15 years. alcohol: heavy use in the past, none in the last 15 years. he works as a retired truck driver. physical examination: vital signs: temperature 97.1??????, blood pressure 100/64, pulse 55, respiratory rate 24. general: the patient was tachypneic, nontoxic-appearing, mild jaundiced. heent: oropharynx clear. mucous membranes very dry. jvp not elevated. neck: supple. mildly icteric sclerae. chest: bilateral expiratory wheezes. coarse breath sounds bilaterally but no appreciable rales or rhonchi. cardiovascular: distant heart sounds. normal s1 and s2. there was a 2 out of 6 systolic murmur. no rubs or gallops. abdomen: obese, distended, soft, exquisitely tender to palpation of right upper quadrant. normoactive bowel sounds. extremities: there was + bilateral lower extremity edema. he had erythematous, scaly, and crusting lesions on bilateral shins consistent with chronic venostasis. neurological: the patient was alert and oriented times three. no gross motor or sensory deficits. rectal: no stool. normal rectal tone. guaiac negative. laboratory data: electrocardiogram was av paced with rate of 55 beats per minute, t-waves present but not conductive, consistent with third degree av block. on admission white count was 12, hematocrit 42.9, platelet count 183; sodium 143, potassium 5.1, chloride 102, bicarb 25, bun 57, creatinine 2.3, glucose 77; bilirubin 4.6, alkaline phosphatase 195, ast 97, alt 111. hospital course: the patient was admitted to the general medical service for emergent ercp. he went to the ercp and was found to have suppurative cholangitis and an impacted stone in the distal common bile duct which was bolting into the major pupilla. he had successful biliary sphincterotomy and successful stone extraction. after the procedure, he was transferred to the intensive care unit for respiratory failure, and he was intubated. in the intensive care unit, he developed acute renal insufficiency with creatinine peaking to 4.1. he also developed pseudomonal pneumonia, and pseudomonas grew from his biliary sample. he had persistently elevated lfts throughout his hospitalization and was intermittently pressor dependent for blood pressure support. he was treated with broad-spectrum antibiotics. he had an ileus for one week postprocedure. he was ultimately started on tube feeds which he tolerated at goal. he had low-grade dic which resolved spontaneously. ultimately the patient showed no evidence of progressing from a respiratory status. a family meeting was held on , to discuss the patient's future course. at this time his daughter and son who were present made it clear that he made his wishes known to not be dependent on a ventilator for a prolonged period. the decision was made to withdraw ventilatory support and concentrate care on his comfort. the patient passed away on at 3:35 a.m. from respiratory failure. condition on discharge: death. , m.d. dictated by: medquist36 d: 14:30 t: 14:43 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Pneumonia due to Pseudomonas Paralytic ileus Cholangitis Acute pancreatitis Calculus of bile duct without mention of cholecystitis, without mention of obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cc: abdominal pain, dyspnea major surgical or invasive procedure: mechanical ventilation history of present illness: hpi: 79 yo poor historian w/chf (ef 24%), afib, cad, pvd, cri. he reports that he was in his usoh one year ago. over the past year with particular crescendo in the past two months, he has experienced increasing doe resulting in decline of functional status to the point that he cannot no longer walk across the rooms in his house w/o sob. over the same period of time, he has experienced central lower abdominal pains with no identifiable character, exacerbants, or relieving factors. he notes diminished volume of urination over the past year with particular exacerbation over the past 72h. . past medical history: pmh: chf (ef24%) cad afib pvd cri psoriasis lupus anticoagulant social history: sh: retired lawyer. quit smoking in following 50pkyr hx. former 2 drinks per day; quit many years ago. no ivda. lives w/wife and son. decrease in adls as above. family history: father died,62, mi. has four brothers. one brother had ?psoriasis, body covered with lesions. physical exam: pe: 97.5 126/57 90 24 100%2l nad perrla, mmm & clear jvd @ 3cm over the clavicle w/patient at 60 degrees; nl s1/s2 ctab w/poor insp effort soft, nt, nd, +bs; prominent and palpable bladder wwp x 4 w/diffuse excoriations; mild bipedal edema prostate smooth and round w/o nodularity; guaic negative . pertinent results: 01:15pm urine hours-random 01:15pm urine gr hold-hold 01:15pm urine color-yellow appear-clear sp -1.019 01:15pm urine blood-neg nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 01:15pm urine rbc-0 wbc-0 bacteria-rare yeast-none epi-0 12:10pm glucose-125* urea n-37* creat-2.1* sodium-141 potassium-4.3 chloride-99 total co2-30 anion gap-16 12:10pm alt(sgpt)-6 ast(sgot)-25 ck(cpk)-34* alk phos-141* amylase-24 12:10pm ctropnt-0.05* 12:10pm ck-mb-notdone 12:10pm albumin-3.2* calcium-9.4 phosphate-1.8*# magnesium-1.6 12:10pm wbc-7.1 rbc-3.81* hgb-10.9* hct-35.2* mcv-92 mch-28.6# mchc-30.9* rdw-17.0* 12:10pm neuts-89.0* bands-0 lymphs-5.5* monos-3.9 eos-1.6 basos-0.1 12:10pm hypochrom-normal anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-normal polychrom-occasional ovalocyt-1+ 12:10pm plt count-231# 12:10pm pt-34.8* ptt-40.9* inr(pt)-3.8* brief hospital course: doe was likely from possible malignancy, pneumonia and pleural effusions. ct chest was obtained demonstrating?????? #pulmonary nodules/splenic nodules. his condition worsened and he was transferred to micu for hypercarbic resp failure. he was mechanically ventilated. he developed renal failure. his malignancy workup was in progress. however his condition continued to deteriorate. upon discussion with family, it was decided to make him cmo. he expired on . medications on admission: meds: asa 325 toprol xl 100 mg qd omeprazole lasix 40 mg qd lisinopril 5 mg . discharge medications: none discharge disposition: expired discharge diagnosis: acute renal failure respiratory failure discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Thoracentesis Transfusion of packed cells Diagnoses: Unspecified pleural effusion Congestive heart failure, unspecified Acute kidney failure, unspecified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Chronic kidney disease, unspecified Acute respiratory failure Old myocardial infarction Long-term (current) use of anticoagulants Retention of urine, unspecified Primary hypercoagulable state Other psoriasis Asbestosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization s/p ptca of previously stented svg to om1-om2-om3 jump graft history of present illness: 76 y/o m with htn, hypercholesterolemia, dm, tobacco use, cad s/p cabg ', ' (svg->d1, svg->pda, svg->0m1-om2-om3, lima->lad), s/p pci/des to svg-om1-om2-om3 jump graft in , s/p tmlr, s/p icd, icm with ef 30%, prostate ca who presented to on with unstable angina. . had onset of sharp, substernal cp when climbing stairs. alleviated w/ 1 sl ntg. took a nap, and awoke with cp, and bilat shoulder pain, similar to prvious mi pain. alleviated with 3 sl ntg. called primary cardiologist, prompting ems transport to osh. . at osh, peak trop i 0.23 (ref range 0.0-0.39). ecg showed twi v4-v6, and 1mm st depression in avl. transferred to for cath. also received 1u prbcs for hct 24. . ros: has had cp w/ sob when going outdoors into cold air, and when climbing stairs. typically uses 1 sl ntg /week. guaiac (+) stools at ~1 week ago, but guaiac (-) on this admission. past medical history: cad as above htn hypercholesterolemia dmii paroxysmal a-fib s/p icd, generator ( dr 7278) replaced in s/p ivc filter for dvt (pt presented with hemoptysis) siadh hx of gib secondary to ulcer trigeminal neuralgia h/o tias cri (baseline cr=1.4) prostate ca social history: he lives in a house with his wife, has 4 children. 2 pack-year history of smoking, quit 20 years ago. drinks 1-3 beers per month. no cocaine use or other drug use. family history: 2 brothers suffered mi in their 50's. physical exam: vs - t 98.1, hr 65, bp 111/49, rr 19, o2 sat 100% 3l nc gen: comfortable, in bed, nad heent: eomi, perrl, op clr, mmm, jvp 4cm above angle cv: rrr w/ ectopy; +2/6 systolic murmur at apex pulm: crackles 1/2 up bilaterally, no wheezes abdomen: nabs, soft, nt, no g/r ext: no edema, 2+ dp/pt pulses bilaterally neuro: non-focal pertinent results: 03:05pm glucose-117* urea n-24* creat-1.6* sodium-138 potassium-4.5 chloride-105 total co2-25 anion gap-13 03:05pm calcium-8.7 phosphate-3.4 magnesium-1.8 06:03am blood wbc-6.3 rbc-3.75* hgb-12.5* hct-34.6* mcv-92 mch-33.4*# mchc-36.1*# rdw-13.8 plt ct-242 03:05pm blood pt-12.7 ptt-44.5* inr(pt)-1.1 . blood ck(cpk)-98 -> 97 -> 101 -> 79 -> 83 -> 90 blood ctropnt-0.03 -> 0.04 -> 0.06 -> 0.07 . chest - portable ap (): no previous films for comparison. status post cabg. there is a dual chamber left-sided icd with atrial and ventricular leads in situ. there is cardiomegaly with tortuosity of the thoracic aorta but no evidence for chf. apart from linear atelectasis at the left lung base, the lungs are clear. . cardiac cath (): 1. selective coronary angiography in this right dominant patient revealed severe native vessel cad. the lad and lcx were proximally occluded and the lcx had some left to left collaterals. the rca was also proximally occluded. the lima-lad graft was known occluded and was not engaged. the svg-rpda was widely patent. the svg-d1 was patent with a slow filling small diagonal that was distally occluded. the svg-om-om-om (lpl) had an occlusion distal to first touchdown just after the previously placed cypher stent. 2. limited resting hemodynamics revealed normal systemic blood pressure of 112/46 with hr 60. 3. successful ptca of the svg-om-om-om with 1.5 mm and 2.0 mm balloons. at the end of the case, there was antegrade flow through the graft into all three anastamosed om's (three touchdown sites). . final diagnosis: 1. three vessel coronary artery disease. 2. patent svg-rpda, patent svg-small d1, occluded lima-lad and newly occluded svg-om-om-om distal to the first touchdown. 3. successful ptca of the svg-om-om-om. . tte (): the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is severe regional left ventricular systolic dysfunction with akinesis of the septum, anterior wall and apex. the inferior wall is hypokinetic. the basal lateral wall moves best. no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . compared with the prior study (images reviewed) of , lv systolic function has decreased. brief hospital course: 1) cardiovascular # ischemia - patient presented with unstable angina. cardiac enzymes were monitored, and remained stable though minimally elevated. he was taken for cardiac catheterization which demonstrated stent restenosis of svg->om1-om2-om3 vein graft. this was angioplastied with plans for stenting in 1 month. he was continued on a medication regimen of asa, plavix, lipitor, toprol xl, and lisinopril. he was changed to a long acting oral nitrate. doses were optimized. . # pump - patient has known depressed ef of 30% by tte in . wma were significant for severe hypokinesis/akinesis of the distal half of the septum and anterior wall. a repeat tte during this hospitalization showed ef 20-25%. patient remained relatively euvolemic by clinical exam. . # rhythm - patient is known to have a history of paroxysmal atrial fibrillation, but was noted to be in a combination of atrial-paced and normal sinus rhythm throughout hospitalization. he is s/p a-v pacer / icd. he is not anticoagulated at home, presumed gib. . 2) anemia: patient has chronic anemia of unclear etiology, presumed secondary to chronic renal insufficiency. he also had a prior ulcer gib, with continued guaiac positive stools. he had documented guaiac positivity on a recent admission at osh, and was guaiac positive on this hospitalization. he was continued on a ppi, and was transfused 1u prbcs prior to his transfer here. his hct was monitored daily, and remained stable. . 3) chronic renal insufficiency: patient has known chronic renal insufficiency with a prior baseline creatinine 1.3-1.4. during hospitalization, his creatinine was stable between 1.6-1.8, likely to represent a new baseline. he received precath and postcath hydration as well as mucomyst for renal protection. . 4) diabetes mellitus: patient has a previously documented diagnosis of dm, but stated on admission that he had been previously told that he was no longer diabetic. he had previously been on metformin, but was not on a oral hypoglycemic or insulin on admission. a hba1c drawn on admission was 5.9%. . 5) prophylaxis: patient received sq heparin, a ppi, and a bowel regimen during hospitalization. code: full, confirmed on admission. medications on admission: asa 81 qd plavix 75 toprol xl 50 cozaar 50 (stopped presyncope) lipitor 10 tricor 145 isordil 20 tid sl ntg prn (usually /wk) iron 325 qd "prostate injections" q4mo discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. 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* 6. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 8. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: non st elevation mi . secondary: cad: s/p cabg ', ' (svg->d1, svg->pda, svg->0m1-om2-om3, lima->lad), s/p pci/des to svg-om1-om2-om3 jump graft in , s/p tmlr, s/p icd, icm with ef 30% htn hypercholesterolemia dmii paroxysmal a-fib s/p icd, generator ( dr 7278) replaced in s/p ivc filter for dvt (pt presented with hemoptysis) siadh hx of gib secondary to ulcer trigeminal neuralgia h/o tias ckd (baseline cr=1.4 prostate ca discharge condition: good. patient is afebrile, hemodynamically stable, mobile, on stable medical regimen. patient has appropriate follow up arranged. discharge instructions: 1. please take all medications as prescribed . 2. please keep all outpatient appointments . 3. please return to hospital immediately for symptoms of shortness of breath, chest pain, nausea/vomiting, dizziness, loss of consciousness or any other concerning symptoms. followup instructions: you have an appointment with your primary care physician, . on monday, at 2:30p.m. his office is located at , ma. please call his office at with any questions or scheduling needs. . please call your cardiologist, dr. , to make an appointment to be seen for follow up within the next two weeks. Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Coronary atherosclerosis of autologous vein bypass graft Atrial fibrillation Personal history of malignant neoplasm of prostate Unspecified deficiency anemia

history of present illness: this is a 56 year-old female who works as a home cleaner who was found on the floor of a bathroom unresponsive with questionable seizure activity. she was brought by ambulance to emergency room and was combative at the time of arrival. the patient reportedly felt dizzy while urinating and weak all over. she screamed out loud and then passed out. on arrival she denied any palpitations, chest pain or shortness of breath. there is no focal weakness or numbness. past medical history: none. allergies: no known drug allergies. medications: none. social history: the patient is creole speaking and arrived nine months ago from to the united states and she is known to be a smoker. physical examination: on examination her temperature was 96.3, heart rate 120, blood pressure 203/120. respirations 25 and 99% on room air. on cat scan the patient was noted to have a subarachnoid hemorrhage and a neurosurgery consult was obtained. hospital course: the patient was brought to the angio suite where the patient was found to have a ruptured anterior communicating aneurysm. the patient was brought back to the neurological intensive care unit where she was monitored overnight, started on nimodipine via nasogastric tube. also her blood pressure was controlled to keep less then 140. her family was told what her diagnosis was and they gave consent for her to have an open craniotomy, which occurred on . the patient was brought to the operating room and underwent a right frontal craniotomy for clipping of the acom aneurysm. she had no intraoperative complications with that procedure. the patient was returned to the neurological intensive care unit where she was monitored very closely. her blood pressure was controlled with intravenous lopressor. she also had been started on dilantin for prophylaxis procedures. nimodipine for prophylaxis, protonix and kefzol 1 gram q 8 hours for her ventriculostomy drain. her blood pressures were kept in the 150s to 180 range. she continued to have both sheaths in place from her angiogram. the patient was kept on the ventilator to keep her co2 within approximately 35. her hematocrit dropped at one point and on the 11th and the 15th she received a total of 3 units of packed red blood cells for a hematocrit below 28. , m.d. dictated by: medquist36 d: 12:16 t: 12:37 job#: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Clipping of aneurysm Arteriography of cerebral arteries Arteriography of cerebral arteries Intravascular imaging of intrathoracic vessels Diagnoses: Anemia, unspecified Unspecified essential hypertension Subarachnoid hemorrhage Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Infection and inflammatory reaction due to other vascular device, implant, and graft Accidents occurring in residential institution

history of present illness: this is an 82 year old female who has a known history of aortic stenosis and coronary artery disease, who reports increasing dyspnea on exertion over the last several years. the patient was referred to for cardiac catheterization. the cardiac catheterization showed an ejection fraction of 55%, left ventricular end diastolic pressure of 20, aortic valve area of 0.5 cm squared, peak aortic valve gradient of 72 and 100% proximal right coronary artery lesion. an echocardiogram of showed moderate concentric left ventricular hypertrophy, ejection fraction of 65%. aortic stenosis with trace aortic insufficiency, peak aortic gradient of 117 mm of mercury and mean aortic gradient of 88 mm of mercury, mild tricuspid regurgitation and mild mitral regurgitation. the patient was referred to dr. for surgery. past medical history: 1. coronary artery disease. 2. aortic stenosis. 3. glaucoma. 4. status post partial colectomy in for colon carcinoma. 5. history of paroxysmal atrial fibrillation. 6. osteoarthritis. 7. status post hernia repair times two. 8. status post tonsillectomy. 9. status post percutaneous transluminal coronary angioplasty to left anterior descending in . preoperative medications: 1. imdur 60 mg p.o. q. day. 2. betapace 80 mg p.o. twice a day. 3. corgard 10 mg p.o. twice a day. 4. lipitor 5 mg p.o. q. day. 5. xanax 0.25 mg p.o. three times a day. 6. enteric coated aspirin 325 mg p.o. q. day. 7. cardizem 60 mg p.o. q. a.m. and 30 mg p.o. q. p.m. and 30 mg p.o. q. h.s. 8. xalatan eye drops, two drops o.u. q. a.m. 9. alphagan eye drops, two drops o.u. three times a day. allergies: no known drug allergies. hospital course: the patient was admitted to on . she was taken to the operating room for an aortic valve replacement with a 19 mm - pericardial valve and a coronary artery bypass graft times one, saphenous vein graft to the right coronary artery with dr. . total coronary pulmonary bypass time was 115 minutes; cross clamp time 88 minutes. please see operative note for further details. the patient was transferred to the intensive care unit in stable condition. on the first postoperative evening, the patient awoke and followed commands; however, the patient was slow to extubate from mechanical ventilation as she was slow to fully awake. postoperatively she was weaned and extubated on postoperative day number one without difficulty. the patient required neo-synephrine on postoperative day one to maintain adequate blood pressure. the patient was started on lasix with good response. on postoperative day number two, the patient had an episode of atrial fibrillation. the patient was started on amiodarone. as the patient was on sotalol preoperatively, an electrophysiology service consultation was obtained and they initially recommended restarting the sotalol. the patient converted to sinus rhythm and maintained sinus rhythm for less than 24 hours and again had an episode of atrial fibrillation. the patient was started on lopressor as well. on postoperative day number three, the patient was transferred from the intensive care unit to the regular part of the hospital. the patient continued to have episodes of atrial fibrillation and the patient's sotalol had been discontinued. electrophysiology service was again consulted and they recommended anti-coagulation and cardioversion if patient remained in atrial fibrillation; however, the patient's platelet count postoperatively had decreased. on postoperative day three, the patient's platelet count had dropped to 62. heparin antibody was sent and it was subsequently negative and the patient's platelet count began to rise. the patient was started on heparin for anti-coagulation. on postoperative day number six, the patient was taken to the electrophysiology service laboratory where she underwent a transesophageal echocardiogram to rule out thrombus in her atria. the echocardiogram showed no clot, normal left ventricular function, mild to moderate mitral regurgitation, mild tricuspid regurgitation and no pericardial effusion. cardioversion was attempted by the electrophysiology service and the patient had a very brief episode of sinus rhythm again converted into atrial fibrillation. it was recommended by the electrophysiology service to load the patient on amiodarone and if the patient continued in atrial fibrillation after a month on amiodarone and anti-coagulation, to again attempt cardioversion. the patient began working with physical therapy. it was recommended by physical therapy that the patient could benefit from a stay at a short term rehabilitation. by postoperative day number seven, the patient was cleared for a discharge to rehabilitation and she will be discharged on postoperative day number eight. condition at discharge: temperature maximum 98.8 f.; pulse 85 in atrial fibrillation; blood pressure 108/58; respiratory rate 18; room air oxygen saturation 94%. the patient's weight is 82.3 kilograms. preoperatively the patient weighed 79 kilograms. neurologically the patient is alert and oriented times three, nonfocal. heart is irregularly irregular. ii/vi systolic ejection murmur, no rub. breath sounds are decreased at bilateral bases. otherwise, clear. abdomen with positive bowel sounds, soft, nontender, nondistended, tolerating a regular diet. sternal incision: staples are intact. there is no erythema and there is no drainage. the sternum is stable. the right lower extremity vein harvest site is clean and dry. there is no erythema or drainage. in the patient's lower extremities, she has one plus pitting edema. discharge diagnoses: 1. coronary artery disease. 2. aortic stenosis. 3. status post coronary artery bypass graft and aortic valve replacement. 4. postoperative atrial fibrillation. discharge medications: 1. lasix 20 mg p.o. twice a day times seven days. 2. potassium chloride 20 meq p.o. twice a day times seven days. 3. colace 100 mg p.o. twice a day. 4. zantac 150 mg p.o. twice a day. 5. enteric coated aspirin 81 mg p.o. q. day. 6. percocet 5/325, one to two p.o. q. four to six hours p.r.n. 7. lipitor 5 mg p.o. q. day. 8. amiodarone 400 mg p.o. three times a day times five days and then 200 mg p.o. three times a day times seven days and then 200 mg p.o. twice a day times 14 days, then 200 mg p.o. q. day. 9. lopressor 50 mg p.o. twice a day. 10. coumadin; the patient should receive a daily dose after checking a pt and inr and adjust coumadin for a goal inr of 2.0 to 2.5. 11. lovenox 60 mg subcutaneously twice a day until inr is greater than 1.5. discharge instructions: 1. the patient will also have of hearts monitor placed with tracings to be transmitted to dr. as directed during the loading phase of her amiodarone. 2. the patient should follow-up with dr. in one to two weeks. 3. she is to follow-up with dr. in one to two weeks. 4. the patient should follow-up with dr. in three to four weeks. disposition: the patient is to be discharged to rehabilitation in stable condition. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Aortic valve disorders Personal history of malignant neoplasm of large intestine

allergies: anzemet / latex attending: chief complaint: abdominal pain, low grade fever and vomiting major surgical or invasive procedure: 1. total abdominal colectomy 2. sternal marrow aspirate 3. fluoroscopy for ivc filter placement 4. inferior vena cava filter 5. partial secondary closure of abdominal wound with vac application 6. tracheostomy 7. ileostomy 8. gastrojejunostomy tube placement history of present illness: 59-year-old woman with all who is receiving chemotherapy. she currently was at the nadir of her white count and she presented today to the emergency room with a white count of 0.1 and abdominal pain with altered mental status and hypotension. she was found to be in septic shock and was resuscitated. ct scan revealed pneumatosis of the colon, a small amount of free air and very extensive portal venous air throughout the liver. she received approximately 9 liters of crystalloid and pressors to reestablish perfusion and urine output in the er. this was done over a period of approximately 45 minutes. she was given antibiotics in consultation with the bone marrow transplant service who follows her (dr. attending). after a discussion with the family, she was taken to the operating room for treatment of presumed dead bowel of unknown origin with progression to infarction and septic shock. past medical history: vancomycin sensitive enterococcus faecium bacteremia from port during induction chemotherapy pcp - not confirmed by culture hypothyroidism hypertension seasonal allergies s/p hysterectomy s/p appendectomy . onchx: (from prior notes) all, precursor b-phenotype (induction with hyper-cvad , negative for chromosome). pt was in usoh until , when she had a cold with dry cough, fevers and chills, all improved by . after a few days, pt had vomiting, abdominal pain, and fatigue increasing for about a week until , when the pt went to for the above symptoms. she was found to have an enlarged spleen and thrombocytopenia. bone marrow biopsy was suggestive of pre-b all. she was discharged in stable condition and followed up with dr. in clinic , and felt the biopsy should be repeated here to confirm the diagnosis and possibly begin treatment if positive for all. social history: unmarried, lives with her mother (85) and brother (64). retired clerk for insurance company. rare etoh use, no smoking, no ivdu. family history: aunts and uncles with breast cancer and asbestos related lung cancer by report. father with diabetes. physical exam: sbp low on 10 dopa/max levophed 63; sbp increased to 134 on dopa 20/max levophed- received 8+l fluid gen: ill appearing, intubated, facial erythema, no scleral icterus cv: tachycardic, no m/r appreciated lungs: occ wheeze on anterior ausculation; bilateral breath sounds noted abd: distended, tender to palp ext: no rashes ph 7.20 pco2 48 po2 223 hco3 20 basexs -9 pertinent results: on admission: . colon pathology: ileo-total abdominal colectomy: colon with extensive transmural ischemic type necrosis, extending to the distal resection margin. ileum with patchy ischemic type necrosis, extended focally to the resection margin. . ct head: impression: 1. 4.2 x 3.5 cm calcified hyperdense mass within the right frontal lobe. differential diagnosis includes calcified meningioma and, much less likely calcified cavernoma. mri is recommended for further characterization. 2. no evidence of intracranial hemorrhage. . ct chest/abd/pelvis: impression: 1. diffuse pneumatosis along the ascending, transverse, and descending colon with dilatation of the ascending and transverse colon, mucosal wall thickening, lack of enhancement, mesenteric and portal venous gas. these findings are consistent with ischemic bowel.the severe stranding around the cecum suggests that this may be perforated locally.there is also a questionable small focus of eccentric extraluminal air here 2. free fluid within the abdominal cavity. 3. basilar airspace consolidations in the dependent portions may represent atelectasis or aspiration pneumonia. 4. no evidence of pe. dilated pulmonary artery suggestive of pulmonary hypertension. 5. tiny cyst within the pancreatic tail, not fully characterized. 6. 2.2 x 2.2 cm soft tissue density mass in left anterior pelvic wall. 7. l1 compression fracture. . brief hospital course: on arrival to the ed, she was confused, tachypneic, cyanotic in septic shock (wbc=0.1). at ct of the abdomen showed pneumatosis of colon with free air. she was immediately intubated; levophed was started for her hypotension, and sent to the operating room. . she underwent emergent exploratory laparotomy on day of admission . colonic necrosis from the cecum to upper rectum without perforation was discovered and total abdominal colectomy and damage control packing of the abdomen was performed. . on she was taken back to the operating room for unpacking of the abdomen, abdominal washout, ileostomy, and gastrojejunostomy. . on she returned to the operating room due to abdominal wound dehiscence, prolonged respiratory failure, need for vascular access, and abdominal fat necrosis. she underwent exploratory laparotomy with incision and drainage and re closure of laparotomy incision, drainage of intraabdominal collection (most likely sterile fat necrosis), tracheostomy, and placement of right subclavian central venous catheter. her open wound was managed by vac therapy. . the patient's post-operative course was also complicated by the development of a gastrocutaneous fistula out of the wound bed, assumedly due to erosion of gastric wall by the g-j tube. this was initially managed by npo and frequent vac changes. as her wound began to granulate, we progressively sutured her wound closed. . neuro: the patient's post-operative course was also complicated by profound upper and lower extremity weakness. the etiologies considered included critical illness myopathy, critical illness neuropathy vs. ? . as part of her work-up for this, she underwent a lumbar puncture on , which was essentially negative. she was treated with a 5-day course of ivig as empiric treatment for -. on the day of discharge she had made significant progress in regaining strength but had not returned to full-strength baseline. . cardiovascular due to anemia, she received several units of prbcs over the course of her hospital stay. she was also started on erythropoietin in consultation with the heme/onc service. she did require repletion of her electrolytes intermittently during her hospital stay. her most recent chemistry panel : glucose urean creat na k cl hco3 angap 143* 12 0.2* 138 3.8 98 32 12 pulmonary as noted above, she suffered from prolonged respiratory failure and required tracheostomy placement. her tracheostomy was removed and her incision site healed without complication. on the day of discharge she was >95% sp02 on room air without respiratory symptoms. . gi as described above. she was started on tube feedings which she has tolerated and at approximately hd #55 she was started on an regular diet which she has tolerated quite well. her tube feeds have been cycled; she will need to be on calorie counts once at rehab with decrease in cycle tube feeds with the goal of eventually having her on a regular diet with supplements as her nutritional support. . musculoskeletal: physical and occupational therapy were consulted and have recommended acute rehab stay given her lengthy and complicated hospital course. . hematology/oncology: on she underwent sternal aspirate by the heme/onc service which did not show evidence of leukemia: (cellular bone marrow with maturing trilineage hematopoiesis. there is no morphologic evidence of leukemia). on discharge she was provided plans for follow-up with hematology/oncology. . id she did have a urinary tract infection on and was treated with zosyn for 7 days once the sensitivities were back. medications on admission: neupogen 480 mcg daily x 10 days acyclovir 400 mg every 8 hours hydralazine 25 mg every 6 hours levothyroxine 75 mcg daily bactrim ds every monday/wed/friday discharge medications: 1. acyclovir 200 mg capsule sig: two (2) capsule po q8h (every 8 hours). 2. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po mwf (monday-wednesday-friday). 3. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 4. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 5. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. hexavitamin tablet sig: one (1) cap po daily (daily). 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 9. calcium carbonate 500 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 12. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 13. epoetin alfa 10,000 unit/ml solution sig: one (1) ml injection qmowefr (monday -wednesday-friday). 14. compazine 10 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 15. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 16. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day): applt to affected areas. 17. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale: see attached sliding scale. 18. reglan 10 mg tablet sig: one (1) tablet po four times a day as needed for nausea. 19. magnesium sulfate replacement sig: four (4) gm once a day as needed for mg <1.2. discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1. acute lymphoblastic leukemia 2. pancolonic ishemia 3. critical illness myopathy/neuropathy vs. - syndrome 4. gastro-cutaneous fistula 5. pancytopenia of malignancy 6. hypothyroidism 7. hypertension discharge condition: good followup instructions: 1. please follow-up with dr. in surgery. please call to make an appointment: 2. please follow-up with dr. in hematology/oncology. please call to make an appointment: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Interruption of the vena cava Enteral infusion of concentrated nutritional substances Other electric countershock of heart Percutaneous abdominal drainage Biopsy of bone marrow Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Reopening of recent laparotomy site Percutaneous [endoscopic] gastrojejunostomy Transfusion of packed cells Transfusion of other serum Other permanent ileostomy Transfusion of platelets Injection or infusion of immunoglobulin Infusion of vasopressor agent Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Severe sepsis Unspecified acquired hypothyroidism Atrial fibrillation Acute respiratory failure Infection with microorganisms without mention of resistance to multiple drugs Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Septicemia due to anaerobes Acute vascular insufficiency of intestine Drug induced neutropenia Unspecified procedure as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Fistula of intestine, excluding rectum and anus Acute lymphoid leukemia, without mention of having achieved remission Critical illness myopathy Critical illness polyneuropathy Disruption of external operation (surgical) wound Peritonitis (acute) generalized Sclerosing mesenteritis Acute infective polyneuritis Anemia in neoplastic disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transferred for further management of tracheal stenosis major surgical or invasive procedure: bronchoscopy with stent placement bronchoscopy history of present illness: 63 y/o f w/hx of breast ca s/p lumpectomy/chemo , who presented to hospital on with shortness of breath. per the pt, she initially noted swelling in her left neck one year ago. her oncologist at presbyterian treated her with femara which made no difference. at that point he told her that her tumor was "receptor negative" and the femara was likely not helping. at this point (approx one month ago) she developed swelling in her right neck as well. she then went to the oasis center in tijuana, in of this year, and was treated with a vaccine of some sort, as well as numerous vitamins. a week after this, she developed shortness of breath which progressively worsened, as well as difficulty speaking/swallowing. she also has a nonproductive cough but no fevers. at the outside hospital, cxr demonstrated a mediastinal mass, no infiltrates or effusions. le dopplers were negative for dvt. she was begun on solumedrol 60 iv q12h and had a ct scan of her chest (r/o pe) and neck (eval for tracheal compression). she also was placed on ceftriaxone and azithromycin. she was evaluated by pulmonary, thoracic surgery, ent, heme-onc, and rad-onc who all agreed that she needed definitive therapy for her extrinsic tracheal compression and she was transferred to for interventional pulmonary evaluation on . she did have a lymph node biopsy of her neck prior to transfer. past medical history: 1. breast ca , s/p lumpectomy. refused xrt. s/p cyclophosphamide and taxol x 6 months in . had recurrence at left supraclavicular node s/p excision, refused chemo. 2. endometrial ca s/p hysterectomy social history: lives alone in , has 3 children who live nearby. no history of tobacco use. no etoh. works as a legal assistant. family history: mother & father w/cva. sister with brain cancer. physical exam: t: 99.1 p: 71 bp: 123/56 r: 16 98%ra gen: alert and oriented pleasant female in no acute distress, but with audible inspiratory stridor and frequent coughing during exam heent: normocephalic, atraumatic, mm dry, anicteric. neck: matted, firm, nontender massive lymphadenopathy in l>r cervical and supraclavicular regions. trachea deviated to left. lungs: bibasilar rhonchi, otherwise no crackles or wheezes cv: regular rate and rhythm, no murmur/rub/gallop breasts: symmetric, no palpable masses abd: soft, nontender, nondistended, normoactive bowel sounds. no hepatomegaly. ext: no edema, 2+ distal pulses skin: warm and dry pertinent results: labs from osh: wbc 9.3 hct 29.2 plt 316 na 138 k 4.4 cl 103 hco3 25 bun 15 creat 0.5 glc 121 pt 11 ptt 27 inr 1.0 ca 8.7 alb 4.2 total protein 8 tot bili 0.3 alk phos 59 alt 12 ast 22 ldh 122 cea 112.4 cxr : large superior mediastinal mass with leftward tracheal deviation, no infiltrate ct neck with contrast : extensive bilateral cervical adenopathy up to 4 cm in diameter, some with moderate central necrosis. moderate extrinsic compression and displacement of the cervico thoracic trachea from adjacent nodal enlargement at this level. low attenuation lesion 1 cm in diameter in left thyroid lobe. ct chest : large 5x7 anterior mediastinal mass continuous with neck masses, with mixed attenuation and contrast enhyancement. extends inferiorly compression the trachea. multiple subcarinal nodes and few right hilar nodes with largest at 1.5 cm. svc patent and displaced anteriorly. 8 mm spiculated pulmonary nodule in right apex. no effusion. ct abd/pelvis : normal, no evidence of metastasis. labs on admission: 05:57pm blood wbc-10.1 rbc-3.71* hgb-10.7* hct-32.1* mcv-86 mch-28.8 mchc-33.3 rdw-13.0 plt ct-334 05:57pm blood pt-11.8 ptt-24.0 inr(pt)-0.9 05:57pm blood calcium-9.4 phos-2.5* mg-2.0 labs on discharge: 06:35am blood wbc-10.4 rbc-3.78* hgb-11.3* hct-33.3* mcv-88 mch-29.9 mchc-34.0 rdw-13.3 plt ct-404 06:30am blood glucose-122* urean-14 creat-0.6 na-140 k-4.5 cl-104 hco3-27 angap-14 procedure date tissue received report date diagnosed by dr. /crxs diagnosis: excised soft tissue, "tracheal tumor versus granulation tissue." fibrinous exudate with admixed inflammatory and scattered atypical cells considered to be reactive. no malignancy is identified. clinical: history of breast cancer. tracheal tumor versus granulation tissue. gross: the specimen is received in formalin-filled container labeled " " and consists of an irregularly shaped tan-white piece of soft tissue measuring 1.9 x 1.1 x 0.9 cm with focal areas of hemorrhage. the specimen is inked in black, serially sectioned and submitted in total in cassettes a-c. brief hospital course: this is a 63 y/o f w/metastatic breast ca who presents with airway obstruction. hospital course was remarkable for the following issues: 1. airway obstruction/sob: per review of outside hospital ct scan, pt's trachea at smallest dimension is 3 mm, and she had audible stridor on admission exam. she was admitted to the icu and went to the or tomorrow the following day for rigid bronch with placement of a y stent by the interventional pulmonary staff. she was monitored in the icu for 1 day. she had a stable airway and was subsequently transferred to the medical floor on . radiation oncology was consulted and the decision was made to initiate radiation therapy locally in order to monitor the patient's airway closely during radiation. she initiated daily radiation treatments on . she tolerated radiation treatments well without evidence of stridor or airway compromise. she underwent repeat bronchoscopy on which revealed boggy/infiltrate arytenoid with narrow glottis and proximal trachea. a tissue flap partially occluding the proximal tracheal stent was excised with forceps. moderate secretions in the mid-tracheal stent were therapeutically aspirated. stent limbs were patent. the patient was also continued on iv dexamethasone while undergoing radiation. the patient is to continue daily radiation therapy to complete a 10 day course. radiation oncologists at contact radiation oncology at hospital and communicated the treatment plan. the patient was continued on an aggressive anti-tussive regimen and continued on pain medications prn. her oxygen saturations were stable in the mid-upper 90's on room air. it is highly recommended that the patient continue to be monitored by the pulmonary staff at methodist (dr. . 2. metastatic breast cancer: hematology/oncology was consulted and recommended that the patient follow up with oncologists in . it was recommended that the patient's her-2-neu status be clarified as to overexpressing or not. if 3+ her-2-neu, then herceptin should be considered as an additional in additional to standard chemotherapy after radiation therapy is completed. 3. fen: the patient was was given a pureed diet and tolerated this very well. 4. prophylaxis: the patient was continued on subcutaneous heparin for dvt prophylaxis and stool softeners while on narcotic pain medications. 5. disposition: the patient repeatedly requested transfer to if possible in order to be closer to her family. the patient was a full code. medications on admission: numerous vitamins and herbal supplements discharge medications: 1. heparin sodium (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 2. lidocaine hcl 1 % solution sig: 2.5 mls injection q1-2h () as needed for cough. 3. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 4. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 6. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 7. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed: hold for diarrhea. 8. acetaminophen-codeine 120-12 mg/5 ml elixir sig: 12.5-25 mls po q4h (every 4 hours) as needed. 9. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 10. morphine 2 mg/ml syringe sig: two (2) mg injection q4h (every 4 hours) as needed. 11. cepacol 2 mg lozenge sig: one (1) lozenge mucous membrane q4h (every 4 hours) as needed. 12. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po tid (3 times a day) as needed. 13. albuterol sulfate 0.083 % solution sig: one (1) nebulizer treatment inhalation q6h (every 6 hours) as needed. 14. dexamethasone 4 mg iv q6h 15. guaifenesin 1,200 mg tablet sustained release 12hr sig: one (1) tablet po twice a day as needed for cough. discharge disposition: extended care discharge diagnosis: metastatic breast cancer tracheal stenosis/compression discharge condition: o2 sats stable on ra, no stridor discharge instructions: follow up with your doctors at methodist followup instructions: you are being transferred to an inpatient facility. Procedure: Other intubation of respiratory tract Other radiotherapeutic procedure Bronchial dilation Local excision or destruction of lesion or tissue of trachea Diagnoses: Personal history of malignant neoplasm of breast Personal history of malignant neoplasm of other parts of uterus Iatrogenic pneumothorax Secondary malignant neoplasm of mediastinum Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck

allergies: dilantin / bactrim attending: chief complaint: seizures major surgical or invasive procedure: intubation insertion of central line. history of present illness: (per report and neuro note): pt is 51 yo male w/ h/o hiv who presents s/p episodes of generalized tonic-clonic seizures. at work today, pt had a witnessed tonic-clonic seizure (no report of how long seizure lasted). ems was called, who found pt unresponsive, but then the pt began seizing again and he was given valium 10mg iv. fs was 156. seizure then ceased. son reports that pt was "not feeling well this morning" and had the "flu". ems was unable to obtain further information from the son as there was no contact information. pt was then transferred to an osh (and remained unresponsive throughout the trip). at the osh, pt was unresponsive on arrival. he had another seizure shortly after arrival, which stopped without intervention. he was intubated, reportedly for airway protection though he was breathing spontaneously with adequate o2 sats. he was given versed 10 mg iv and vercuronium 10 mg iv for intubation. also at the osh, he received ceftriaxone 1 g iv, vancomycin 1 g iv, and dilantin 1 g iv. he had a head ct, which reportedly showed no acute process. cxr was reportedly negative. also, at the osh, he reportedly had a wbc count of 28. he was transferred to for further evaluation. . in the , pt had temp 99. he received 27mg of iv versed (for sedation and ? sz vs. rigors). there was reportedly purposeful movement after sedation was weaned. he received a dose of acyclovir, and underwent an lp. lactate was found to be 3.4. neurology was consulted, who recommended admission to the micu. past medical history: hiv sjs to dilantin toxoplasmosis ?dvt - pt reports being on coumadin for 6-7 months for dvt in setting of hospitalization in past social history: lives in , ma with son and son's wife. employed at factory. family history: nc physical exam: physical exam on transfer to the floor vitals: 98.4 112/68 61 20 100%ra gen: a/o nad, . interacts well, bright, engaged. heent: perrl, eomi neck: supple, no lad noted, no jvd cardio: rrr, s1, s2, soft systolic murmer noted at llsb resp: cta b/l posteriorly abd: soft, nt, nd, +bs ext: no c/c/e. warm. pertinent results: mri: 1) slightly increased t2 signal within the right occipital lobe of unclear etiology. recommend repeat scanning with gadolinium after patient sedation. . mri impression: 1. focal cerebritis/encephalitis in the right occipital lobe with a trapped occipital , versus sequela of treated toxoplasmosis. comparison with previous studies regarding any prior toxoplasmosis in this location would be helpful. 2. small rim-enhancing lesion without associated parenchymal edema in the left frontal region, either in the extra-axial space or in the superficial cortex, which most likely represents active toxoplasmosis. however, other infectious etiologies may be considered if an appropriate clinical suspicion is present. 3. fluid in the sphenoid sinus, which may indicate acute sinusitis. . skin biopsy: skin, right arm; punch biopsy (a): interface dermatitis with basal vacuolar degeneration, dyskeratosis; features consistent with erythema multiforme like drug reaction. . labs on discharge: 06:00am blood wbc-6.2 rbc-3.86* hgb-11.8* hct-34.3* mcv-89 mch-30.7 mchc-34.6 rdw-15.9* plt ct-412 06:00am blood plt ct-412 06:00am blood glucose-88 urean-12 creat-0.9 na-138 k-4.1 cl-105 hco3-27 angap-10 06:00am blood calcium-9.1 phos-3.1 mg-2.5 05:51am blood caltibc-222* ferritn-183 trf-171* brief hospital course: a/p: 51 yo m with hiv, unknown other pmh, who presents with several episodes of seizure activity. . #) respiratory: pt was intubated for airway protection in the setting of frequent seizures/status epilepticus. he was maintained on mechanical ventilation given the need for an ativan drip for control of his seizures. after ativan gtt was discontinued, he self-extubated on hd #4 without incident and maintained oxygen saturations without support. . #) seizures: pt presented from after multiple seizure episodes thought to be secondary to known cns toxoplasma. patient had tonic episode during neurology evaluation on , where flexed both arms at elbows, pupils became dilated, and head turned toward right. he was started on keppra 1500mg , given history of - reaction in the past and recurrent reactino after receiving dilanting at osh. because seizures persisted, he was started on an ativan gtt. he had three seizures noted on . lp appears benign, cultures pending. he was restarted on treatment for toxoplasma w/pyramethamine, clindamycin, and leukovorin. off ativan drip, with 2mg prn for seizure. discontinued standing ativan as patient did not require any for 2 days. need to follow-up ebv from cns, which if negative would suggest against cns lymphoma in hiv patient. neurosurgery aware, in case brain biopsy for lymphoma is a consideration. patient was on continuous eeg monitoring while intubated on ativan gtt, but no further events occurred after monitoring had begun. hsv serologies negative. . #) erythroderma: pt developed diffuse, macular rash with no obvious oral lesions or bullae in setting of receiving dilantin with past history of - reaction that was unknown at the time. dermatology was consulted and a biopsy was done that was indeterminate, but suggestive of a reaction similar to sjs. erythroderma improving. he was started on steroids and given supportive care with frequent skin checks for desquamation and skin separation, but these were subsequently discontinued. ophthalmology was also consulted and did not note any corneal lesions. . #) ? dvt - rn in , patient has been on coumdain for 6-7 months. it is unlikely that he needs further treatment w/coumadin for dvt in leg hospitalization. will d/c without coumadin and have pcp follow up. . after the micu he was transfered to the floor. he remained clinically stable and was cleared by physical therapy for disacharge. follow up was arranged w/his health care facility in (spoke w/ ) as well as with , a specialist in the neurologic manifestations of hiv. free care provided his medications and he has follow up as above. it is very important that he obtain a follow up mri in 3 weeks time prior to his visit w/dr> . . medications on admission: outpatient meds unknown . per patient was taking: hiv medications ?coumadin discharge medications: 1. pyrimethamine 25 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 2. leucovorin calcium 5 mg tablet sig: four (4) tablet po daily (daily). disp:*120 tablet(s)* refills:*2* 3. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. atovaquone 750 mg/5 ml suspension sig: 1500 (1500) mg po daily (daily). disp:*qs mg* refills:*2* 5. lopinavir-ritonavir 200-50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 6. clindamycin hcl 300 mg capsule sig: two (2) capsule po every six (6) hours for 1 months. disp:*240 capsule(s)* refills:*0* 7. keppra 500 mg tablet sig: three (3) tablet po twice a day for 14 days. disp:*84 tablet(s)* refills:*4* discharge disposition: home discharge diagnosis: hiv, aids cns toxoplasmosis severe reaction to dilantin- syndrome discharge condition: ambulating, tolerating pos, mental status @ baseline discharge instructions: please take all medications as prescirbed. it is also very important to attend all follow up appointments. . please have your health care providers follow up the ebv pcr that was sent to r/o cns lymphoma . also: please obtain a follow up mri in 3 weeks time. followup instructions: provider: , m.d. phone: date/time: 1:30 . you are scheduled with an appointment @ w/ dr. and with on monday @ 10:15am. it is very important that you attend this appointment as it will provide the continuity in your care. when you meet with them, it will be very, very important for you to discuss having a brain mri in 3 weeks to follow-up your toxoplasmosis infection. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Closed biopsy of skin and subcutaneous tissue Diagnoses: Human immunodeficiency virus [HIV] disease Grand mal status Toxoplasmosis, unspecified

allergies: sulfasalazine / warfarin / vancomycin attending: chief complaint: edema, dyspnea major surgical or invasive procedure: right and left heart catherizations picc placement history of present illness: 57 yo male with afib, venous insufficiency, significant ugib, who presents to dr. office today with c/o worsening dyspnea and increasing weight gain and edema. he denies orthopnea or pnd. he was told to have a sleep study, but he has not had that. he states he has alot of medical problems, but none of them are to the point where it concerns him. he denies any back or neck pain. he's had venous insufficiency and ulcers associated with that for a while, followed by dr. of vascular for that. in dr. clinic, an echo was performed which showed e/o right heart strain and ? cor pulmonale. he was referred to our ed for further eval. in ed, initial vitals were 61, 112/85, mid 80s on ra, and then increased to 95% on 4l. he was noted to have bilateral crackles and anasarca on exam. a cta was performed which was negative for pe. the patient was then admitted for volume overload. he was not given lasix in the ed in case a cath was to be performed in the am. ecg was afib without any ischemic changes. cardiac enzymes were not very remarkable. on floor, patient was comfortable. he denied chest pain or sob. he confirmed above. on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. past medical history: 1. atrial fibrillation not anticoagulated since significant gib 2. history of alcohol abuse. 3. hypertension. 4. upper gastrointestinal bleed in secondary to prepyloric ulcer. 5. psoriasis. 6. mitral valve prolapse. 7. gastric biopsy in showing esophagitis and gastritis, h-pylori negative. 8. the patient had repeat esophagogastroduodenoscopy in showing evidence of gastritis, however, a healed prepyloric ulcer. 9. adrenal insuffiency diagnosed in and on hydrocortizone replacement therapy. social history: the patient currently works part time as a spanish teacher at middle school. he has smoked a half a pack per day of tobacco times 30 years. he reports occasional alcohol use, but has a history of alcohol abuse in the past. he denies any other drug use. family history: noncontributory physical exam: vs:98 120/81 58 22 95% 4l general: obese male, nad. had "ruddy" look. sleeping, but arousable and answers questions appropriately. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. ruddy appearance of face neck: supple with jvp of 12 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. decreased bs bilateral bases, few bibasilar crackles. no rhonci abdomen: obses, soft tissue edema; large stretch marks throughout abdomen. reddish color. normal bowel sounds extremities: dark feet, erythematous legs, bandaged. 3+ edema bilatearlly up through thighs skin: stasis dermaitits and ulcers present; bandage in place pulses: right: carotid 2+ unable to appreciate femoral pulse body habitus. 1+ dp pulse left: carotid 2+ unable to appreciate femoral pulse body habitus. 1+ dp pulse pertinent results: admission labs: 05:30pm ck-mb-notdone 05:30pm ctropnt-0.06* 05:30pm alt(sgpt)-15 ast(sgot)-35 ld(ldh)-382* ck(cpk)-45 alk phos-188* tot bili-3.0* dir bili-1.6* indir bil-1.4 07:50pm pt-17.4* ptt-32.2 inr(pt)-1.6* . cta : 1. no evidence of pulmonary embolus or aortic dissection. 2. nodular shrunken hepatic contour, could reflect chronic passive congestion and/or liver disease. clinical correlation is advised. 3. unchanged left hepatic lobe hypoattenuation, could reflect a simple cyst. 4. bilateral pleural effusions, anasarca and ascites, in the setting of cor pulmonale is probably secondary to right heart failure. . arterial doppler : doppler evaluation was performed of both lower extremity arterial systems at rest. on the right, doppler tracings are triphasic at the femoral, popliteal and dorsalis pedis. they are absent at the posterior tibial. ankle brachial index is 1.08. pulse volume recordings are mildly decreased at the ankle and metatarsal. left doppler tracings are triphasic at the femoral, popliteal, and posterior tibial levels. they are monophasic at the dorsalis pedis. ankle brachial index is 0.94. pulse volume recordings show mild drop off at the ankle and metatarsal. impression: mild bilateral tibial artery occlusive disease. . abdominal utlrasound : 1. very heterogeneous liver with no solid liver mass identified. 2. hyperdynamic pulsatile bidirectional flow seen in all of the portal veins. large hepatic vein. these findings suggest tricuspid insufficiency. 3. sludge in the gallbladder. 4. small amount of ascites. . cardiac echo : this study was compared to the prior study of . left atrium: moderate la enlargement. right atrium/interatrial septum: markedly dilated ra. the ivc is dilated (>2.5cm) left ventricle: mild symmetric lvh. mildly dilated lv cavity. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). no resting lvot gradient. no vsd. right ventricle: dilated rv cavity. rv function depressed. abnormal diastolic septal motion/position consistent with rv volume overload. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. aortic valve: aortic valve not well seen. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild (1+) mr. tricuspid valve: moderate tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. conclusions: suboptimal image quality. images insufficient to exclude an asd or pfo.the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the aortic valve is not well seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. suboptimal image quality. agitated saline could not be seen in the right atrium after injection. pfts: spirometry 8:00 am pre drug post drug actual pred %pred actual %pred %chg fvc 1.54 4.55 34 1.67 37 +9 fev1 1.01 3.26 31 1.07 33 +6 mmf 0.47 3.19 15 0.44 14 -7 fev1/fvc 66 72 92 64 90 -2 lung volumes 8:00 am pre drug post drug actual pred %pred actual %pred tlc 2.99 6.81 44 frc 1.81 3.82 47 rv 1.59 2.26 70 vc 1.41 4.55 31 ic 1.18 2.99 40 erv 0.22 1.56 14 rv/tlc 53 33 160 he mix time 4.75 . dlco 8:00 am actual pred %pred dsb 11.46 27.09 42 va(sb) 2.21 6.81 32 hb 17.70 dsb(hb) 10.64 27.09 39 dl/va 4.81 3.98 121 . ccath : cath - left clean, right elevated pressures, severe phtn, did not respond to nitric oxide . right foot xray: impression: degenerative changes primarly involving the great toe. no findings to suggest bone destruction . discharge labs: . 140 / 96 / 18 / 107 3.8 / 36 / 0.9 ca: 9.0 mg: 2.0 p: 2.6 wbc 6.6 plt 247 hct 48.6 pt: 16.1 ptt: 34.9 inr: 1.4 . abg : ph 7.38 pco2 62 po2 78 hco3 38 basexs 8 brief hospital course: mr. is a 57 yo m with afib, p/w severe r chf and volume overload as well as c/b ble venous stasis breakdown. r chf cor pulmonae from osa and pulmonary edema and anasarca on lasix ggt and on bipap at night. . since admission, aggressive diuresis has been pursued. began diuresis with iv lasix. abdominal u/s was obtained to evaluate for cirrhosis given distended abdomen and elevated inr and revealed a hetergenous liver. wound care recs obtained. pulmonary consult thought exam / studies consistent with pulmonary htn, obtained pfts, /lung volumes/dlco & obtain hiv, , ds-dna, anti-csl, rf, esr, crp. sleep evaluation recommended supplemental o2, avoid empiric cpap (both cpap and autotitrate bipap with desaturation). he was also being followed by pt. sprinolactone and k were added. dermatology consult for pruritic rash though c/w prurigo nodularis and recommended anti-histamines, clobetasol , d/c neosporin, bactroban to open lesions, if persittent could consider cryothearpy or il sterioids, f/up in 3 months. for his stasis recommneded compression of entire foot and knee if can tolerate, elevation, unna boots. trigger for spreading rash and somnolence, given fenofexadine, on supplemental o2. trigger for hypoxia and altered mental status, pt o2 to 70s on cpap at 10l with patient difficult to arouse. pulmonary reccommended keeping upright, continue lasix and consider adding diamoxx, nebs prn, try auto-bipap. on recommended d/c spironolactone and continuing diuresis. cardiology attending was recommending screening for rehab while continuing lasix gtt. patient triggered for difficulty with arousing, was cultured and abg was sent revealing ph 7.38, pco2 69, po2 66, hco3 42, lactate 1.1. repeat abg ph 7.37, pco2 68, po2 66, hco3 41. patient remained somnolent with some concern for hypotension and bradycardia. he was then transferred to the icu for further evaluation of these complaints. . micu course: patient stabilized clinically on bipap. sleep recommended a special asv machine. we continued aggressive diuresis with lasix 120mg po bid with good effect. he grew mssa from his blood for which he was placed on nafcillin after a brief course of daptomycin (has vanco allergy). a picc was placed . he will need a 2 week course of nafcillin through . vascular changed his le dressings. he will need follow up with vascular and dermatology. we restarted his metoprolol with good effect. . by problem: . 57 yo m with afib, admitted with chf exacerbation cor transferred to icu for ams likely multifactorial pulmonary edema, osa and gpc bacteremia chronic rle ulcer. . mssa bacteremia/rle ulcer: most likely source at this time was rle ulcer, vascular was consulted. foot xray without concern for infection. he was empirically on daptomycin then switched to nafcillin. picc was placed . his surveillance cultures remained ngtd except for 1 culture with coag neg staph was thought to be contaminant. echo was negative for vegetation. he will need 2 weeks of antibiotics through . . obstructive sleep apnea: patient was seen by pulmonary and vasculitis labs sent. during r heart cath, patient had severe phtn and no improvement with nitric oxide. sleep study not tolerated because patient could not tolerate cpap mask. pfts were reflective of restrictive physiology from obesity. he was put on asv machine and tolerated well. he will need to wear this at night and follow up in sleep clinic. he will need a sleep study prior to that appointment. . hypoxia/hypercarbia: - likely multifactorial including some pulmonary edema (as evidenced on cxr), pulmonary hypertension and cor pulmonale. no e/o pe on cta from admission. he is mildly hypercarbic at baseline. he responded well to the above interventions and to lasix. . right heart failure - secondary to cor pulmonae from copd/osa. no significant evidence of alcoholic cardiomyopathy. echo showed normal ef, not major lv dysfunction and showed significant phtn and tr. no improvement with nitric oxide, thus did not start sildenafil or ccb. patient s/p right and left heart cath. no evidence of asd. left heart cath negative for cad. we resumed his lasix at 120mg po bid with very good effect. we re-started his metoprolol with good effect. his lasix will need to be adjusted prn given his volume status, though he likely remains total body fluid overloaded on discharge. . atrial fibrillation: currently not anticoagluated massive gib while on coumadin and ciprofloxacin. rate controlled with metoprolol. no asa due to h/o gib. . prurigo nodularis: dermatology saw patient who recommended applying creams and to follow up with dermatology in 3 months. continue atarax qhs, clobetasol 0.05% ointment , capsaicin cream tid x 4 weeks, mupirocin cream 2% 1 appl tp to open lesions/excoriations . venous insuffiency/rle ulcer: status post apligraf placement on his right leg on . arterial flow studies, good flow until tibia. chronic issue. foot xray without evidence of infection. continued dressings and will need follow up with vascular surgery. . depression ?????? started on citalopram 10mg daily. can uptitrate as needed . access: picc was placed successfully on medications on admission: protonix 40 mg vitamin c 500 mg daily lasix 100 mg daily hydrocortisone 10 mg daily digoxin 250 mcg daily hydroxyzine 25 mg 1-2 tabs ferrous sulfate 325 daily folic acid 1 mg daily metoprolol 100 mg daily discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 5. hydrocortisone 5 mg tablet sig: two (2) tablet po daily (daily). 6. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 11. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 12. multivitamin tablet sig: one (1) tablet po daily (daily). 13. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 14. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 15. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 16. clobetasol 0.05 % cream sig: one (1) appl topical (2 times a day). 17. capsaicin 0.025 % cream sig: one (1) appl topical tid (3 times a day). 18. magnesium oxide 400 mg tablet sig: two (2) tablet po daily (daily). 19. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 20. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day). 21. furosemide 40 mg tablet sig: three (3) tablet po bid (2 times a day): adjusted prn based on fluid status. 22. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 23. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 24. nafcillin in d2.4w 2 gram/100 ml piggyback sig: one (1) injection intravenous q4h (every 4 hours): through for 14 day course after negative cultures. 25. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: hypercarbic respiratory failure obesity hypoventilation syndrome obstructive sleep apnea pulmonary hypertension congestive heart failure bacteremia: methicillin sensitive staph aureus . secondary diagnoses: atrial fibrillation venous insufficiency hypertension adrenal insufficiency discharge condition: good, mentating well, hemodynamically stable, oxygenating well discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1.5 liters . the patient was admitted with multifactorial shortness of breath most likely caused by congestive heart failure and fluid overload, obstructive sleep apnea, and pulmonary hypertension. he was initially aggressively diuresed with a lasix drip on cardiology. however, he was transferred to the micu due to persistent somnolence. while in the icu his asv was adjusted with the help of pulmonology with good effect. he was also diuresed aggressively. he will be discharged to continue his asv mask and to follow up in sleep clinic. he will also need continued diuresis. . he was also followed by vascular surgery for his lower extremity venous insufficiency as well as rash. he will need to follow up with vascular surgery as well as dermatology to track his rash. . he was also diagnosed with mssa bacteremia, for which he will need 2 weeks of iv nafcillin and periodic liver and kidney monitoring . he should also follow up with his cardiologist and pcp as soon as possible. . please continue all of his medications as prescribed and adjust his lasix based on his volume status. please have patient return to the hospital if his shortness of breath worsens, he experiences chest pain, somnolence or any other concerning symptoms followup instructions: vascular surgery: provider: , md phone: date/time: 1:45 . sleep clinic/pulmonology: provider: , md phone: date/time: 11:00 . endocrinology: provider: , md phone: date/time: 1:30 . the patient will need an outpatient sleep study prior to his appointment with dr. . . the patient should follow up with dermatology in the next 3 months to re-evaluate his rash Procedure: Venous catheterization, not elsewhere classified Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnoses: Acidosis Obstructive sleep apnea (adult)(pediatric) Abnormal coagulation profile Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Long-term (current) use of steroids Cirrhosis of liver without mention of alcohol Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Other chronic pulmonary heart diseases Depressive disorder, not elsewhere classified Alcohol abuse, unspecified Acute respiratory failure Cellulitis and abscess of leg, except foot Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Obesity, unspecified Glucocorticoid deficiency Diseases of tricuspid valve Ulcer of other part of lower limb Venous (peripheral) insufficiency, unspecified Lichenification and lichen simplex chronicus Other respiratory abnormalities Polycythemia, secondary

allergies: bactrim / tylenol attending: chief complaint: right lower quadrant bulge with abdominal bloating and crampy pain major surgical or invasive procedure: spigelian hernia repair with mesh history of present illness: 79f with h/o right abdominal bulge x years who presents for herniorrhaphy past medical history: 1. emphysema and ild, with dlco 33%, pfts consistent with rld. 2. status post aortic arch repair for type i dissection (), status post graft repair . on home oxygen. 3. dvt/pe post-op, status post ivc filter placement. 4. hypertension 5. h/o c.difficile colitis 6. atrial fibrillation on coumadin 7. s/p ventral hernia repair 8. s/p ccy 9. osteoarthritis social history: she lives with one daughter and one son, has 6 children, no etoh, 20 pk-year history of smoking, no ivdu. she has the equipment for home oxygen, but has not been using it regularly. she does not use her portable oxygen when she ambulates. family history: non-contributory. physical exam: discharge exam afebrile vss, sat 100% on 4liters nasal cannula heent: nonicteric sclera chest: distant breath sounds with scattered rhonchi cv: irreg abd: soft, incision c/d/i without erythema, mild incision tenderness ext: warm pertinent results: inpatient labs ---------------- 11:50am blood wbc-9.0 rbc-4.41 hgb-13.6 hct-40.0 mcv-91 mch-30.7 mchc-33.9 rdw-14.9 plt ct-168 04:59am blood wbc-9.4 rbc-4.55 hgb-13.6 hct-41.2 mcv-91 mch-29.9 mchc-33.1 rdw-15.0 plt ct-155 09:37am blood pt-17.7* inr(pt)-1.7* 04:59am blood pt-17.1* ptt-33.3 inr(pt)-1.6* 11:50am blood glucose-213* urean-15 creat-1.0 na-134 k-3.3 cl-100 hco3-23 angap-14 04:59am blood glucose-122* urean-13 creat-0.8 na-137 k-4.1 cl-105 hco3-22 angap-14 11:50am blood alt-14 ast-31 ld(ldh)-311* ck(cpk)-67 alkphos-101 amylase-22 totbili-2.2* 11:50am blood ck-mb-notdone ctropnt-<0.01 11:00pm blood ck-mb-notdone ctropnt-0.15* 04:59am blood ck-mb-notdone ctropnt-0.16* 12:32pm blood ck-mb-5 ctropnt-0.10* 11:50am blood albumin-3.7 calcium-8.6 phos-3.5# mg-1.9 uricacd-6.3* 04:59am blood calcium-8.9 phos-3.0 mg-2.1 11:29am blood type-art po2-83* pco2-40 ph-7.35 caltco2-23 base xs--3 operative note ------------------- preoperative diagnosis: right spigelian hernia. postoperative diagnosis: right spigelian hernia. procedure: right spigelian hernia repair with polypropylene mesh. anesthesia: general endotracheal anesthesia and 30 cc of 0.5% marcaine. iv fluids: 700 cc. estimated blood loss: minimal. urine output: no foley was placed in the case. indications: is very pleasant, 79-year-old female with a history of a right lower quadrant bulge. she had an outpatient ct by her primary care doctor that showed a ventral hernia in the spigelian position with terminal ileum and cecum within the hernia. she had had abdominal cramping and obstructive symptoms and was sent for a surgical consultation. despite her multiple medical issues, she was offered repair to prevent strangulation. the risks and benefits of the surgery were discussed, and she signed a consent. preparation: the patient was given intravenous antibiotics and subcutaneous heparin, taken to the operating room, and placed in the supine position. venodyne boots were placed and activated. the patient was then endotracheally intubated in the normal fashion. the patient was shaved and sterilely prepped and draped in the normal fashion. procedure in detail: local anesthesia was infused overlying the palpable mass. an approximately 10-cm incision was made over the mass with a 10-blade scalpel. dissection through the subcutaneous tissue was performed with electrocautery. the hernia sac was encountered and circumscribed with electrocautery dissection. the external oblique fascia had been eroded by this large hernia. flaps of the external oblique fascia were created around the hernia defect. the hernia defect was reduced first by opening the hernia sac and reducing the bowel within the defect and then by dissecting the hernia sac in all quadrants. the sac was then closed and reduced back in the abdominal cavity. the internal oblique muscle and fascia were reapproximated with a running 0 pds suture. a 7.5 x 15-cm mesh was then chosen. it was sutured to the lateral aspect of the pubic tubercle, the inferior aspect, and along the shelving edge of the inguinal ligament inferolaterally. these were done with 2-0 prolene interrupted sutures. the mesh was sutured medially to the anterior abdominal wall and superolaterally to the anterior abdominal wall. there was good overlap of mesh on the defect. there was no further palpable defect. the subcutaneous tissues were irrigated with sterile saline. bleeding was controlled with electrocautery. the external oblique fascia was reapproximated with a running 0 pds suture. the wound was irrigated. additional local was infused. the scarpa layer and camper layer were closed with a running 3-0 vicryl suture. the skin was reapproximated with 4-0 monocryl subcuticular suture. steri-strips and sterile occlusive dressing was placed over the wound. the patient was extubated in the operating room and transferred to the post anesthesia care unit. counts: correct x2 prior to closure. complications: none were apparent. implants: a 15 x 7.5-cm polypropylene mesh. study: cta chest with and without contrast and recons. indication: a 76-year-old female with hypoxic episode. evaluate for pe. comparison: . findings: the major airways are patent down to the subsegmental level. there is a new, small left pleural effusion and trace right effusion. diffuse emphysematous change is again noted in the lungs, especially in the upper lung fields. also noted are interstitial changes and fibrosis in a predominantly peripheral and basilar distribution, most consistent with usual interstitial pneumonitis (uip). these changes are not significantly changed since previous study, . no suspicious nodules or masses are identified within the lung parenchyma. vascular calcifications are again noted within the coronary arteries. the main pulmonary artery measures 2.7cm and right main 2.3cm and left main 2.9cm. large hiatal hernia is again noted and unchanged. ct pulmonary angiogram: respiratory motion limited evaluation of the distal branches in both lower lobes. no pulmonary embolism is identified. no secondray signs of pe are present. please note that given principal concern for pulmonary embolism, bolus timing was optimized for pulmonary arterial enhancement, not for aortic enhancement. patient again noted to be post aortic dissection repair with stent graft in stable position extending from the proximal ascending aorta through the descending aorta terminating just proximal to the aortic hiatus. no gross evidence of leak or graft failure noted. the region of short segment dissection of the right common carotid artery is again noted and stable when compared to previous studies (3:11) although not optimally evaluated on this study. limited views of the abdomen demonstrate no obvious abnormalities within the liver or spleen. impression: 1. no evidence of pulmonary embolism. limited evaluation as above. 2. stable appearance to thoracic aortic stent graft. no evidence of aortic dissection although bolus timing is not optimal for evaluation for dissection as per given clinical history. no periaortic thrombus identified. 3. stable emphysema and fibrotic changes. 4. stable large hiatal hernia. 5. pulmonary arterial hypertension. echo ---------- measurements: left atrium - long axis dimension: *4.1 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.9 cm (nl <= 5.2 cm) right atrium - four chamber length: *5.3 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 1.0 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 3.6 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 2.1 cm left ventricle - fractional shortening: 0.42 (nl >= 0.29) left ventricle - ejection fraction: 60% to 70% (nl >=55%) aorta - valve level: 3.4 cm (nl <= 3.6 cm) aorta - ascending: 2.9 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.2 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.3 m/sec mitral valve - a wave: 0.5 m/sec mitral valve - e/a ratio: 2.60 mitral valve - e wave deceleration time: 145 msec tr gradient (+ ra = pasp): *42 mm hg (nl <= 25 mm hg) interpretation: findings: this study was compared to the prior study of . left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. normal ivc diameter with <50% decrease during respiration (estimated rap 11-15mmhg). left ventricle: normal lv wall thickness, cavity size, and systolic function (lvef>55%). normal regional lv systolic function. no resting lvot gradient. right ventricle: dilated rv cavity. mild global rv free wall hypokinesis. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. normal ascending aorta diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. no as. trace ar. mitral valve: normal mitral valve leaflets. moderate to severe (3+) mr. eccentric mr jet. lv inflow pattern c/w restrictive filling abnormality, with elevated la pressure. lv inflow uninterpretable due to tachycardia and/or fusion of spectral doppler e and a waves tricuspid valve: normal tricuspid valve leaflets. moderate tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: significant pr. pericardium: no pericardial effusion. conclusions: the left atrium is mildly dilated. the estimated right atrial pressure is 11-15mmhg. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. the right ventricular cavity is dilated. there is mild global right ventricular free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. moderate to severe (3+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. impression: right ventricular dilation with mild hypokinesis. preserved left ventricular systolic function. moderate to severe mitral regurgitation. moderate tricuspid regurgitation. moderate pulmonary artery hypertension. restrictive filling pattern consistent with elevated left atrial pressures. compared with the prior study (images reviewed) of , the severity of mitral regurgitation has increased. brief hospital course: was admitted to the surgery service under the care of dr. on . she was taken to the operating room where she underwent a right spigelian hernia repair with mesh. she tolerated the procedure well and was taken the floor after recovery in the pacu. at pod 1 the urinary catheter was replaced for urinary retention. she was tolerating a regular diet. on this day she was assisted to the side of the bed to ambulate and it was reported that she became cyanotic and unresponsive. a nrb was placed with recovery of breathing and o2 saturation. she remained with palpable pulses. ekg showed sinus rhythm. she was transferred the to icu for further monitoring. cxr was negative for acute process. cycled cardiac enzymes were slightly elevated at 0.15; 0.16 with trend to normal at 0.10. on arrival to the icu she was in nad and hemodynamically stable. she had no neurological deficits and denied cp/sob. at pod 2 she remained stable, and was transferred back to the floor. at pod 3 she was afebrile and in good condition. she was tolerating a regular diet. a cta was performed to evaluate for possible pe due to past history of such event. this was negative. on pod 4 an echo was done which showed lvef> 55%; right ventricular dilation with mild hypokinesis; moderate to severe mitral regurgitation; moderate tricuspid regurgitation; and moderate pulmonary artery hypertension. at pod 5 she was doing well, afebrile, tolerating a regular diet. incision was clean, dry and without erythema. cardiology cleared her for discharge. she was sent home in good condition. she was instructed to use her oxygen at all times. she was to follow up with her primary care physician weeks for reevaluation and inr check. medications on admission: asa 81mg colace 100mg prn coumadin hctz 12.5mg prn lipitor 10mg hs toprol xl 25mg prilosec 20mg prn iron mvi discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: spigelian hernia hypoxic event requiring icu admission troponin leak discharge condition: good discharge instructions: please resume your regular medications. take all new medications as directed. please resume your regular activities. avoid heavy lifting for 6 weeks. you may resume your regular diet. you may shower, just allow water to run over the wound. no swimming or baths for 2 weeks. continue to wear the abdominal binder until your follow up appointment. please call or return to the er if you experience: - fever (> 101 f) - worsening redness or drainage from the wound - increased pain - nausea, vomiting, or inability to drink - other symptoms concerning to you followup instructions: please follow up with dr. in weeks. call his office, (, to arrange the appointment. please follow up with your primary care doctor in weeks for reevaluation and to check your inr/coumadin level. Procedure: Insertion of indwelling urinary catheter Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis Diagnoses: Unspecified essential hypertension Gout, unspecified Atrial fibrillation Postinflammatory pulmonary fibrosis Other emphysema Osteoarthrosis, unspecified whether generalized or localized, site unspecified Retention of urine, unspecified Personal history of venous thrombosis and embolism Hypoxemia Acute myocardial infarction of unspecified site, initial episode of care Urinary complications, not elsewhere classified Other ventral hernia without mention of obstruction or gangrene

allergies: tylenol attending: chief complaint: n/v/dizziness major surgical or invasive procedure: 1. hemiarch replacement (28mm gelweave) 2. aorta to innominate artery conduit (6mm graft) 3. aortic valve resuspension history of present illness: hpi: 77yo with hx htn, af with rvr who p/w nausea and dizziness. states that she was walking around in her house and as she went to pull up the shade she fellt sudden onset dizziness, "room spinning around me". went to the couch and sat down, no loc, no trauma. approximately 2h later felt nauseous and had dry heaves. also states she had a "knot" in her chest that felt better with burping. pressure non-radiating, no shortness of breath, no fevers, chills. +productive cough but chronic, +weakness and malaise, +nausea, no vomiting. past medical history: hypertension, atrial fibrillation with rapid ventricular response, s/p ventral hernia repair, s/p ccy, arthritis social history: former smoker, 15pk/yr history, quit 30y ago. no etoh, ivda. family history: cad--> father age 62 physical exam: pe: t98.9 bp123/57 hr 45-->66 rr 18 100%@ra gen: aox3, nad heent: perrl, eomi. dry mm lungs cta bilaterally cv rrr no m/r/g abd soft, bs present, nt/nd ext no edema back ecchymoses l back, no oozing pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:35am 15.9* 3.87* 11.2* 34.6* 89 29.0 32.5 14.7 398 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 05:35am 398 05:35am 18.9*1 2.4 1 note new normal range as of 12 am chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:35am 90 15 1.2* 137 4.6 99 26 17 chemistry totprot albumin globuln calcium phos mg uricacd iron 05:35am 2.0 brief hospital course: 77yo with hx htn, af with rvr who p/w nausea and dizziness. states that she was walking around in her house and as she went to pull up the shade she fellt sudden onset dizziness, "room spinning around me". went to the couch and sat down, no loc, no trauma. approximately 2h later felt nauseous and had dry heaves. also states she had a "knot" in her chest that felt better with burping. pressure non-radiating, no shortness of breath, no fevers, chills. +productive cough but chronic, +weakness and malaise, +nausea, no vomiting. patient was evaluated by cardiac surgery on . after appropriate pre-operative work-up, she was taken to the or on for hemiarch replacement (28mm gelweave), aorta to innominate conduit, av resuspension. post-operatively, she was transferred to the csru where she had peri-operative atrial fib with hypotension. she was electrically cardioverted pod 3, however did not stay in a sinus rhythym. her hemodynamics did improve, though, and she was eventually extubated on pod 5, chest tubes and wires were removed per protocol. she had some serous drainage from her sternum which resolved without intervention. patient was also anti-coagulated with heparin and coumadin for atrial fib. she was transferred to the floor on pod 8, where she did well. she was evaluated by pt and they recommended short term rehab. on pod#12 she was noted to have an elevated wbc. her central line was d/c and her wbc began to decrease. she was started on bactrim for a positive ua. she thrn developed a rash and had a negative urine culture, so the bactrim was discontinued. she continued to improve and was discharged to rehab on pod#17 in stable condition. medications on admission: 1. coumadin 2.5 mg po qd 2. atenolol 25 mg po qd 3. lisinopril 10 mg po qd discharge medications: 1. multivitamin capsule sig: one (1) cap po daily (daily). 2. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 6. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. potassium chloride 20 meq packet sig: two (2) packets po q12h (every 12 hours) for 1 weeks. disp:*28 packets* refills:*0* 8. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 weeks. disp:*14 tablet(s)* refills:*0* 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. amiodarone hcl 200 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 11. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 weeks. disp:*14 tablet(s)* refills:*0* 12. coumadin 1 mg po qhs for inr goal of .5 discharge disposition: extended care facility: senior healthcare - discharge diagnosis: 1. atrial fibrillation 2. ascending aortic dissection 3. uti 4. hypertension discharge condition: good discharge instructions: 1. medications as directed. 2. please follow inr, goal of .5. 3. call office or go to er if fever/chills, drainage from sternal incision, chest pain, or shortness of breath. p instructions: call for an appointment with dr. in weeks. dr. , 4 weeks, please call for appointment. make an appointment with dr. for 2-3 weeks. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Enteral infusion of concentrated nutritional substances Other electric countershock of heart Resection of vessel with replacement, thoracic vessels Closed [endoscopic] biopsy of bronchus Other repair of vessel Operations on other structures adjacent to valves of heart Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Dermatitis due to drugs and medicines taken internally Diarrhea Other and unspecified coagulation defects Dissection of aorta, thoracic Hemopericardium Sulfonamides causing adverse effects in therapeutic use Unspecified sinusitis (chronic)

allergies: tylenol / bactrim attending: chief complaint: chest and back pain major surgical or invasive procedure: stent graft repair of thoracic aortic aneurysm/dissection right-to-left, carotid-to- carotid bypass with 6 millimeter dacron graft. history of present illness: this is a 78 year old female who recently underwent an ascending aorta and arch replacment with 28 millimeter conduit and ascending aorta to inominate conduit on by drs. and for type i aortic dissection. her postoperative course was complicated by a pulmonary embolus for which she underwent placement of an ivc filter. she was treated with lovenox and eventually discharged to rehab. on the day of admission, she complained of acute onset of back pain. there were no alleviating factors. she denied shortness of breath, syncope, palpitations. she states her symptoms were very similar to her previous aortic dissection. she also complained of mild "bloating" but denied abdominal discomfort. no history of fever, chills or night sweats. she also admitted to normal bowel habits. past medical history: 1)type i aortic dissection - s/p asc aorta and arch replacment with 28 millimeter conduit; asc aorta to inominate with 8 millimeter conduit(), postop course complicated by pulmonary embolus - s/p ivc filter placement 2)history of c. difficile colitis 3)hypertension 4)history of atrial fibrillation 5)ventral hernia repair 6)cholecystectomy 7)arthritis 8)history of small bowel obstruction - s/p exlap social history: currently has been at rehab but lives in with daughter and son. for many years. former smoker, 15pk/yr history, quit 30y ago. no etoh or ivda. family history: father diagnosed with coronary artery disease at age 62 physical exam: temp 96.8, bp 180-190/ 80-90, pulse 72, resp 16 general: elderly female in no acute distress chest: lungs clear to auscultation heart: regular rate and rhythm, no murmur or rub abdoment: soft, nontender, nondistended; nabs ext: warm, well perfused pulses: 2+ distally rectal: heme negative neuro: alert and oriented; no focal deficits noted pertinent results: 05:40am blood wbc-16.2* hct-34.0* 06:05am blood wbc-15.0* rbc-3.99* hgb-10.9* hct-33.3* mcv-83 mch-27.2 mchc-32.6 rdw-15.9* plt ct-505* 05:40am blood pt-17.8* inr(pt)-2.1 05:40am blood k-4.8 12:45pm blood glucose-93 urean-5* creat-0.7 na-137 k-3.9 cl-99 hco3-25 angap-17 05:40am blood mg-1.8 brief hospital course: on admission, a full body ct scan was notable for aortic dissection distal to the origin of the left subclavian artery extending to the 8th thoracic verterbral level. there was contrast in the false lumen. she was admitted to the csru and placed on intravenous labetolol to maintain sbp less than 110 mmhg. she remained pain free. plans were made to repair the aneurysm with a thoracic stent graft device. because of that, she was initially evaluated for a right-to-left carotid to carotid bypass given that the thoracic stent graft device will require placement covering the left carotid and subclavian arteries. this procedure will ensure flow to her left carotid system. a preoperative carotid ultrasound was obtained, showing widely patent common and internal carotid arteries bilaterally. as a side note, the ent service was consulted for persistent hoarseness since her initial operation in . examination revealed left vocal cord paralysis. subsequent swallow evaluation found no signs of aspiration. diet as tolerated was recommended along with whole pills in puree. she will eventually require outpatient medialization laryngoplasty. on , dr. performed a right-to-left, carotid-to-carotid bypass utilizing a 6 millimeter dacron graft. surgery was uneventful. she remained neurologically intact. she remained stable on medical therapy while in the csru with strict bp control. she was eventually started on levofloxacin for a proteus mirabilis urinary tract infection. on , drs. and performed a stent graft repair of her thoracic aortic aneurysm/dissection. she returned to the csru in stable condition. within 24 hours, she awoke neurologically intact and was extubated. she maintained stable hemodynamics as she was transitioned to po antiphypertensives. on , she transferred to the sdu. repeat swallow examination on again showed no signs of aspiration. her diet was therefore advanced to thin liquids and regular consistency solids. she completed a course of levofloxacin for her preoperative urinary tract infection. she had a mild leukocytosis postop with negative blood cultures. all access lines were changed and monitored. her white count peaked to 19k on and slowly improved by time of discharge. she was eventually diagnosed with c. difficile and started on appropriate antibiotics and placed on contact precautions. she concomitantly experienced persistent hypokalemia for which the renal service was consulted. k and mg levels were followed closely and repleted per protocol. a cta showed no evidence of renal artery stenosis. a potassium sparing diuretic was eventually started and titrated accordingly. acth level was slightly elevated at 29. given her history of atrial fibrilllation and pulmonary embolus, she remained on warfarin which was dosed daily for a goal inr between 2.0 - 2.5. of note postoperatively, she remained in a normal sinus rhythm. no atrial or ventricular dysrhythmias were noted. over her remaining days, she made steady, clinical improvements as medical therapy was optimized. she worked daily with physical therapy and continued to make steady progress. she was ambulating off supplemental oxygen. her postoperative course was otherwise uneventful and she was discharged to home on . she is scheduled to followup with the renal, cardiac and vascular surgery services shortly after discharge. medications on admission: mvi, aspirin 81 qd, protonix 40 qd, lipitor 10 qd, lopressor 50 , amiodarone 400 qd, warfarin - variable discharge medications: 1. atorvastatin calcium 10 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. 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. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. disp:*7 tablet(s)* refills:*0* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*30 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. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. disp:*120 tablet(s)* refills:*0* 9. lisinopril 20 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 10. amiloride 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 11. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 14 days. disp:*42 tablet(s)* refills:*0* 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 13. coumadin 1 mg tablet sig: one (1) tablet po once a day: take as directed by dr. for an inr goal of .5. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: thoracic aortic aneurysm/dissection - s/p stent graft repair; type i aortic dissection - s/p asc aorta and arch replacment with 28 millimeter conduit; asc aorta to inominate with 8 millimeter conduit(), postop course complicated by pulmonary embolus - s/p ivc filter placement; history of c. difficile colitis; hypertension; history of atrial fibrillation; ventral hernia repair; cholecystectomy; arthritis; history of small bowel obstruction - s/p exlap discharge condition: good, stable discharge instructions: patient may shower. no baths. no lotions, creams or ointments to incisions. no driving for at least one month. no lifting no more than 10-12lbs for 10-12 weeks. take warfarin as directed for goal inr between 2.0 - 2.5. followup instructions: dr. in 4 weeks dr. in 1 week. call dr. in clinic at 3:30 pm 7 dr. @1pm dr. in weeks. Procedure: Venous catheterization, not elsewhere classified Laryngoscopy and other tracheoscopy Other endovascular procedures on other vessels Aorta-subclavian-carotid bypass Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Atrial fibrillation Hypopotassemia Dissection of aorta, thoracic Mechanical complication of other vascular device, implant, and graft Unilateral paralysis of vocal cords or larynx, partial

history of present illness: the patient is a 20 year old male, status post high speed motor vehicle accident, unrestrained driver, who hit a pole, resulting in car fire, extraction time approximately 30 minutes, but the patient suffered no burns in the fire. the patient was intubated in the field, with a questionable unknown down time. the patient arrived intubated, sedated and paralyzed, hypotensive and tachycardiac. he had received two liters of crystalloid upon arrival. the patient had an open right femur fracture. he went to the oropharynx clear for repair. the patient was fully evaluated in the trauma bay, with a ct scan of the head showing a small subdural hematoma and frontoparietal hemorrhage. a ct scan of the abdomen showed a grade iv liver laceration with blood around the liver and in the pelvis. a ct scan of the neck was initially concerning for c1-2 injury, subsequently ruled out. a ct scan of the abdomen saw a left lower lobe infiltrate versus aspiration. past medical history: initially unknown but later revealed -parkinson-white syndrome with ablation. medications on admission: initially unknown but, upon talking with the family, the patient was on celexa. allergies: the patient has no known drug allergies. physical examination: on physical examination, the patient was sedated, intubated and paralyzed. head, eyes, ears, nose and throat: pupils 2 mm, equal and reactive, mid-face stable, endotracheal tube in place, left upper lip laceration, no head or scalp lacerations. neck: tracheal midline. chest: clear to auscultation bilaterally with chest wall intact. cardiovascular: regular rate and rhythm. abdomen: flat, firm, nondistended, pelvis stable. rectal: vault full of stool, heme negative, normal prostate. extremities: right lower extremity with open femur fracture and exposed bone, right foot mottled. neurologic: coma score of 3t, paralyzed, sedated. laboratory data: admission white blood cell count was 27.3, hematocrit 32.1, platelet count 281,000, prothrombin time 15.4, partial thromboplastin time 58, inr 1.6, fibrinogen 116.5, amylase 66, sodium 143, potassium 3.5, chloride 110, bicarbonate 18, bun 18, creatinine 1 and blood sugar 301 and lactate 5.7. alcohol level was 187. ct scan of the head showed a small right subdural hematoma. ct of the abdomen showed left lower lobe developing infiltrate, questionable aspiration, liver laceration grade iv with blood around the liver and pelvis, right back hematoma. ct of the neck could not rule out c1-2 atlantoaxial injury initially; further evaluated to be negative. hospital course: prior to going to the operating room, the patient received an additional liter of intravenous fluids, four units of unmatched packed red blood cells and a left femoral trauma line. a trauma ultrasound was performed and suggested fluid in pouch. the patient went for a ct scan to rule out intra-abdominal injury, at which point it was felt there was no injury and the patient could go to the operating room for fixation of the right femur. the patient was given kefzol for the right open leg and started on levaquin and flagyl for potential aspiration pneumonia. the patient went to the operating room by the orthopedic surgeons for an open reduction and internal fixation of the right femur and then the patient was admitted to the surgical intensive care unit for continued evaluation. the neurosurgeons saw the patient for the right frontoparietal temporal and subdural, with questionable slight, 1 to 2 mm, midline shift. nonoperative intervention was deemed appropriate. a systolic blood pressure of less than 140 was desirable. the patient was loaded on dilantin with a repeat head ct in 24 hours showing no progression of bleeds. it was also desirable to keep the inr below 1.7. on postoperative day number two, the patient was extubated within difficulty. the patient did spike a temperature to 101.5 with panculture. he received two units of blood for a hematocrit of 23. all antibiotics were stopped at this point. at this point, considering the dirty nature of the right femur fracture and fever spike, the patient was brought back to the operating room for a cleanout of the right leg. this was performed without complication. the patient was seen by the psychiatry service due to the patient's depression and polysubstance abuse. the patient was thought to be increasingly paranoid and that the nursing staff was invasive. he was pulling out his tubes saying that he wanted to die, "and i can make things easier for you, why don't you just kill me". the patient was maintained on a one-to-one observer with ciwa protocol. he was written for haldol 2 to 3 mg hourly until desired effect. liver function tests, tsh, t4, b12 and folate were all evaluated. on hospital day number four, postoperative days one the three, the patient was transferred to the floor for continued monitoring. the patient remained completely unaware of surrounding events, with perseveration regarding the accident and inappropriate questions about paying hospital bills. he was very anxious. he had no other complaints at this time, with stable vital signs. his short term memory was certainly impaired, with no recollection of previous visits by the team. this mental status slowly improved, with his diet being advanced and physical therapy started. the patient was seen by the neurology rehabilitation service on who felt that his behavior was consistent with a left frontal contusion. it was at this point that the patient was referred to an acute head injury program for rehabilitation. the patient remained stable from the standpoint of his liver laceration and femur fracture. by hospital day eight, his mental status had markedly improved, with behavior resolution. one-to-one sitter was removed without subsequent difficulties. the patient was started on physical therapy, bedside and with ambulation, without difficulty. on hospital day nine, the patient remained on a full diet and had no complaints. the patient was started on lovenox on hospital day eight after consultation with the neurosurgeons regarding the intraparenchymal bleeds. the patient remained on keflex for his right leg. at the time of discharge, the patient is partial weightbearing with his right leg and ambulating with a walker per physical therapy. at this point, it is felt that the patient is appropriate for continued rehabilitation. discharge medications: colace 100 mg p.o.b.i.d. lovenox 30 mg s.c.b.i.d. keflex 500 mg p.o.q.i.d. to continue until . celexa 20 mg p.o.q.d. ativan 1 mg p.o.q.6h.p.r.n. morphine 1 to 4 mg s.c./p.o.q.4h. percocet one to two tablets p.o.q.4-6h.p.r.n. discharge instructions: the patient will need to follow up with the orthopedic service at in one week. he will also need to follow up with the trauma clinic at in one week. discharge diagnosis: subdural hematoma, left frontal occipital parenchymal hemorrhage, grade iv. liver laceration. right femur fracture. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Open reduction of fracture with internal fixation, femur Debridement of open fracture site, femur Debridement of open fracture site, femur Diagnoses: Depressive disorder, not elsewhere classified Other and unspecified coagulation defects Other and unspecified alcohol dependence, unspecified Open fracture of shaft of femur Injury to liver without mention of open wound into cavity laceration, unspecified Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, unspecified state of consciousness Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle

allergies: penicillins / cephalosporins / erythromycin base / codeine / nsaids / aspirin / sulfa (sulfonamides) / vancomycin / levaquin / clindamycin / sensipar attending: chief complaint: s/p vt/vf arrest major surgical or invasive procedure: parathyroidectomy et during surgery right a line right femoral line history of present illness: 57 yo female with pmh esrd, afib (on sotalol), baseline qtc prolongation, lupus, diverticulitis (s/p resection and ileostomy) had elective parathyroidectomy today c/b vt arrest. pt has a baseline pth of 2500 with bony pain and difficulty walking which prompted this surgery. she took sotolol this am. during the procedure, pt developed ventricular bigeminy. she then developed a prolonged episode of vt/vf which lasted for minutes. she became pulseless and cpr was initiated. the vt spontaneously terminated. pt was given amio 150mg bolus. she had recurrent episode of sustained vt which terminated and was given another amio 150mg and started on amio gtt at 1mg/min. also started on proporol gtt. of note, the parathyroidectomy was completed with removal of left upper/lower gland, right upper/lower gland (total 3.5 glands) and thyroid. pth was ; no repeat performed in setting of acute event outlined above. . on arrival to , pt was hemodynamically stable. started on magnesium. past medical history: hyperparathyroidism (baseline pth >2500; severe bone pain and inability to walk) lupus (diagnosed ) esrd ( lupus; hd mwf) afib (on sotalol and coumadin) diverticulitis (s/p resection-ileostomy) l knee surgery ( septic knee in c/b mult re-do surgeries. unable to bend knee at baseline) benign cyst removal from right knee () benign tongue growth removal () burst left arm aneurysm htn multiple avf surgeries hx of multiple cdiff infections mr social history: functional capacity limited pain, wheelchair-bound. family history: nc physical exam: vs: 98.2, p55, 107/49, rr18, 99% on ac 400 (spont 424)/16/5/.60 gen: intubated and sedated heent: perrl, clear op, et tube in place cvs: rrr, nl s1 s2, holosystolic murmur at base lungs: coarse bs bilaterally anteriorly abd: soft, nd, decr bs ext: no edema msk: deformed right elbow with effusion and no warmth or redness, bilateral ankle joint swelling w/o evidence of infection pertinent results: ekg: nsr@59, leftward axis, qtc prolongation of 497, slight std lead 2 (new), lvh by voltage criteria. . rhythm strips: unable to obtain strip of sustained vt. strip of episode of nsvt reveals short runs of polymorphic vt preceded by long pauses with significantly increased rr intervals. . echo: () normal lv size and function. ef 65%. mild concentric lvh. no regional wall motion abnl. 2+ mr. tr. biatrial enlargement. . echo: the left atrium is mildly dilated. the estimated right atrial pressure is 11-15mmhg.. 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. the aortic valve leaflets are moderately thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild aortic valve stenosis. moderate mitral regurgitation. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. pulmonary artery systolic hypertension. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . cxr: change in lung opacities. there has been interval extubation and removal of a nasogastric tube. cardiac silhouette remains enlarged with vascular engorgement and perihilar haziness, which may be due to chf or volume overload. homogeneous opacity in left retrocardiac region and adjacent left pleural effusion are again demonstrated with interval increase in size of left effusion. air space opacity in right lower lobe is difficult to compare due to positional differences but may be slightly worse, and there is also apparent slight increase in adjacent right pleural effusion. bones are heterogeneous in appearance with a lucent lesion of the left humeral head as described on the recent study. . ecg: technically difficult study sinus rhythm with pvcs with pacs qt interval prolonged for rate extensive st-t changes are nonspecific since previous tracing of the same date, premature beats are new, precordial voltage lower . ecg: sinus rhythm long qtc interval inferior/lateral st-t changes are nonspecific low limb lead voltage since previous tracing of , premature beats not seen, precordial voltage higher . cxr: probably no change in the left pleural effusion and underlying opacity in the left retrocardiac region. slight decrease in the right pleural effusion, as well as airspace opacity in the right lower lobe. slightly improved degree of vascular engorgement and perihilar haziness. . ecg: sinus rhythm, rate 70. since the previous tracing of minimal shortening of the q-t interval is present, though it remains prolonged. technical artifacts are noted over the lateral precordium. . ecg: sinus rhythm. left atrial abnormality. prolonged qtc interval. clinical correlation is suggested. compared to the previous tracing of no significant change. . cxr: worsening fluid status with features of chf and larger effusions. new right airspace disease which is nonspecific in nature requiring clinical correlation and additional imaging followup. . ecg: atrial flutter with rapid ventricular response. since the previous tracing of atrial flutter is now present. . ecg: sinus rhythm left atrial abnormality possible left ventricular hypertrophy since previous tracing of , sinus rhythm restored . ecg: atrial fibrillation with a rapid ventricular response. low limb lead voltage. compared to the previous tracing of atrial fibrillation with a rapid ventricular response has appeared. . ecg: sinus rhythm. non-specific t wave inversion in lead iii. baseline artifact in leads v5-v6 makes interpretation difficult. compared to the previous tracing of sinus rhythm is now present. . brief hospital course: 57 yo female with pmh af (on sotalol), baseline prolonged qtc, esrd on hd, lupus (on chronic steroids), now s/p parathyroidectomy c/b vt/vf arrest. . 1. vt/vf arrest: most likely secondary to torsade de pointes in setting of alkalemia and hypocalcemia in this patient with baseline prolonged qtc sotalol. pt had ventricular bigeminy preceding event, and pvc with post-pvc compensatory pause likely initiated torsades. we discontinued amio, sotalol(esp since it's renally cleared) and plaquenil, all of them prolonged qt; continued her tele and repeat ekg qam; monitored and repleted lytes aggressively. no further events in house. . 2. hyperparathyroidism (s/p parathyroidectomy): likely secondary hyperparathyroidism esrd vs. tertiary hyperpara. pth 58 post surgery. received hydrocortisone 100mg x 1 in or. developed subsequent hungry bone syndrome requiring a calcium drip, calcitriol, and po calcium supplement. she was weaned off the drip but is still requiring large amounts of po calcium to maintain her levels. renal and endocrine were consulted and assisted with her management. she will have calcium checked with hemodialysis to follow for weaning of her po supplement. . 3. abnl cxr: rll opacity, lll collapse vs. atelectasis. patient received 7 days of antibiotics for treatment. . 4. afib: patient was in sinus prior to surgery. her sotalol had to be discontinued. cardiology recommended starting lopressor for rate control. her rate has been well controlled on this medication. she is on coumadin for anticoagulation. she will have her inr checked with hemodialysis until it is stable. . 5 esrd: renal was consulted, she was to continue on hd on mwf. continue nephrocaps. . 6. lupus: no evidence of acute infection/inflammation. continued her prednisone 6mg daily (home dose), but stopped her plaquenil as plaquenil prolongs qt and discussed with her outpt rheumatologist (dr. , ) who agreed with stopping her plaquenil and continuing the prednisone. 7. hypertension: normotensive. hold captopril and stopped sotalol given prolongation of qt. currently on lopressor. . 8. drug rash: thought possible due to ceftriaxone for pneumonia so this was stopped after 6 days. she received a 7th day of antibiotics, with doxycycline. . 9. full code . 10. comm: medications on admission: hydroxychloroquine 200mg qhd prednisone 6mg qd nephrocaps qd captopril 12.5 mg qd sotolol ? dose ( tab qd) protonix 40mg qd coumadin 1 mg daily qd tylenol prn discharge medications: 1. prednisone 1 mg tablet sig: six (6) tablet po daily (daily). 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. warfarin 1 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. calcium citrate 950 mg tablet sig: six (6) tablet po qid (): you must have your calcium closely followed when taking this. disp:*336 tablet(s)* refills:*0* 6. calcitriol 0.5 mcg capsule sig: three (3) capsule po bid (2 times a day). disp:*84 capsule(s)* refills:*0* 7. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po q mon (). disp:*4 capsule(s)* refills:*0* 8. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 9. outpatient lab work please draw calcium and inr with every hemodialysis, until stable. please contact dr. with the results, phone: discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary: cardiac arrest secondary to ventricular fibrillation ventricular tachycardia hypocalcemia atrial fibrillation hyperparathyroidism s/p parathyroidectomy community acquired pneumonia secondary: systemic lupus erythematous end stage renal disease discharge condition: good: calcium stable, no significant arrhythmias discharge instructions: please call your doctor or go to the emergency room if you experience chest pain, palpitations, shortness of breath, cramping in your muscles or abdominal area, or other concerning symptoms. please note that your sotalol and hydrochloroquine have been discontinued due to a life-threatening heart rhythm. please do not take this medication anymore. you have been started on 3 new medications, please take them as prescribed. you must have your calcium and coumadin level checked with every hemodialysis until it is stable. followup instructions: 1. you have an appointment scheduled with your primary care doctor, dr. , on friday at 12:30. 2. you have a follow-up appointment scheduled with dr. on thursday at 12:45. 3. you have a follow-up appointment scheduled in the endocrine clinic at with dr. on , at 8:20 am. 4. you have an appointment scheduled in the cardiology clinic at . provider: , m.d. phone:. date/time: 9:00. location: , building, . 5. please call to schedule a follow-up appointment with your ent doctor within 1-2 weeks. Procedure: Venous catheterization, not elsewhere classified Hemodialysis Arterial catheterization Cardiopulmonary resuscitation, not otherwise specified Other parathyroidectomy Other and unspecified hysterectomy Diagnoses: Pneumonia, organism unspecified Chronic glomerulonephritis in diseases classified elsewhere Acidosis Systemic lupus erythematosus Other iatrogenic hypotension End stage renal disease Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Atrial fibrillation Atrial flutter Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Ventricular fibrillation Secondary hyperparathyroidism (of renal origin) Accidents occurring in residential institution Disorders of magnesium metabolism Long QT syndrome

please see carevue for all objective data. please see fhpa for list of multiple allergies and complicated pmh. essentially, this is a very ill appearing 57 year old woman admitted from the or. she had an elective parathyroidectomy done and the procedure had been completed. she developed vea (bigeminy), which progressed to vt. cpr was initiated and nsr resumed without any medications, then started on amiodarone.(?qtc prolongation at baseline, ?vea with r on t phenomenon causing polymorphic vt). pt transferred to for monitoring and electrolyte replacement. cvs: heart rate has been sb without vea since admission with b/p 90-120/systolic. amiodarone dc'ed. pt. is being ruled out for an mi...echo done with results pending. k+=4.2, mg=1.9 (prior to replacement with 4grams), ionized ca of 1.08 (prior to replacement of 2 grams). repeat bloods will be sent at 1830. resp: lungs with diminished breath sounds, rhonchi throughout. suctioned x 1, no secretions. respiratory alkalosis ( 7.52, 39 170, 33) on a/c 60% 400 x 16 with 5 of peep. rate decreased to 14 with abg to be repeated at 1830. cns: pt. sedated with propofol at 80mcg/kg/min. she does appear uncomfortable with noxious stim and attempts to open eyes on command. +hand grasps. soft wrist restraints on for safety. gi: abdomen is soft and distended with active bowel sounds throughout. no stool. ogt passed and placement has been confirmed on cxr. id: afebrile, no antibiotic therapy at this time. renal: pt. on hd q monday/wed/fri. foley catheter passed, with no urine output at this time. unclear as to how much pt. usually voids. skin: intact, but pt's right arm is deformed with +effusion at the elbow. lines: right radial art line present (no sutures). left femoral quad lumen present with +bleeding at the insertion site. +fistula lue. old fistula present rue. post-op: surgical incision site clean and dry, staples present, covered with sterile towel per surgery instructions. social: husband and in to visit and have spoken with nursing, housestaff, surgery and anesthesia. social: follow for any arrythmias as indicated, replete lytes. probable extubation in am Procedure: Venous catheterization, not elsewhere classified Hemodialysis Arterial catheterization Cardiopulmonary resuscitation, not otherwise specified Other parathyroidectomy Other and unspecified hysterectomy Diagnoses: Pneumonia, organism unspecified Chronic glomerulonephritis in diseases classified elsewhere Acidosis Systemic lupus erythematosus Other iatrogenic hypotension End stage renal disease Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Atrial fibrillation Atrial flutter Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Ventricular fibrillation Secondary hyperparathyroidism (of renal origin) Accidents occurring in residential institution Disorders of magnesium metabolism Long QT syndrome

allergies:nkda. social:married lives w wife. children in area. crf:wo hx cad. distant smoker. elevated cholesterol. wo htn/dm. presnet hx: onset substernal cp. admitted to w unstable angina-ri w nstemi 534/68 w +troph. card cath=sever lm w 3vd, sever lv duastolic dysfunct, & antlat/anfapical hk. plan cabg. recurrance cp-pre op iabp placed & transfered to ccu. awaiting planned cabg . o:neuro=a/a/o. cooperative. pulm=o2 2l nc w sats upper 90's. breath sounds=clear. cv=1 episode cp-ekg wo acute chgs-rxed w increase iv ngt w resolution. rhtyhm-1st degree avb w freq pac's. rate 60-80. iabp maps-81-103. gtss-heparin presentlyy @ 900u/ am ptt & ntg @ 0.75mcg/kg/min. 2200 ck/mb-437/37. iapb-r fem--dp +1 on r, rest wo-sl ooze @ site--pt unable to stay still. gi=npo after mn. gu=foley. adeq uo. id=afebrile. social=son in to visit-given # of csru. misc=glass 7 dentures w pt. labs=am sent. a:1 episode of cp-resolved w increase in iv ntg. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Cardiac complications, not elsewhere classified Atrial fibrillation Unspecified disorder of kidney and ureter Anomalous atrioventricular excitation

history of present illness: this is a -year-old male with no known coronary artery disease who presented with chest pressure and abdominal pressure who has reportedly had a several month history of exertional angina relieved with rest. on the evening prior to admission, this anginal occurred with minimal exertion and prevented him from sleeping. he also had mild shortness of breath with this pain. he contact emergency medical service who administered aspirin and nitroglycerin with good relief. past medical history: (this is a -year-old male with a past medical history significant for) 1. atrial flutter (status post ablation of ). 2. gastroesophageal reflux disease. 3. spinal stenosis. 4. status post prostatectomy. 5. status post herniorrhaphy. allergies: no known drug allergies. medications on admission: medications on admission were colace, celebrex, tylenol, and fibercon. social history: the patient has a known history of tobacco use with rare alcohol use. hospital course: the patient underwent cardiac catheterization on which revealed severe left main and 3-vessel disease with 80% proximal and 60% distal stenosis of the left main coronary artery, diffusely diseased proximally, and with 60% stenosis of the left anterior descending artery, and 70% proximal, and total occlusion after second obtuse marginal of the left circumflex, and 50% ostial and 90% medial stenosis of the right coronary artery. left ventriculography revealed 1+ mitral regurgitation, and anterolateral and inferoapical hypokinesis, with an ejection fraction of 40%. the patient underwent coronary artery bypass graft times three on with an intra-aortic balloon pump placed preoperatively. the patient had left internal mammary artery to the left anterior descending artery, saphenous vein graft to the diagonal, and saphenous vein graft to the right posterolateral. the total cardiopulmonary bypass was 50 minutes. total cross-clamp time was 40 minutes. the patient was transferred in stable condition, in a normal sinus rhythm at 80 beats per minute, to the coronary recovery unit on propofol 30 mcg/kg per minute, and milrinone 0.25 mg/kg per minute, and nitroglycerin at 0.5 mcg/kg per minute. on postoperative day one, 24-hour events included the patient receiving another swan-ganz catheter as well as extubated. the patient was in atrial fibrillation at 99 beats per minute with a low-grade temperature (with a temperature maximum of 100.8, peak temperature current of 99). on physical examination, the patient had decreased breath sounds at the bilateral bases. otherwise unremarkable. the plan was to wean the patient's dobutamine, and to discontinue the intra-aortic balloon pump if stable, and to continue with the amiodarone. the renal service came by to see the patient on postoperative day one for complaints of labored breathing; at which time they recommended checking chemistry-7, magnesium, phosphorous, and calcium levels, and to continue gentle diuresis if the patient continued to be dyspneic and requiring increased oxygen. they also suggested using lasix as needed for his clinical condition. on postoperative day two, the patient was still a temperature maximum with a low-grade temperature of 100.6. the patient was still in atrial fibrillation; rate controlled. twenty-four events included the intra-aortic balloon pump being discontinued, and administration of lasix overnight with good effect. on physical examination, the patient still had coarse breath sounds with expiratory wheezing. the plan was to administer heparin for the atrial fibrillation, to discontinue the amiodarone, and to administer oral lopressor, and to transfer the patient to the floor. the renal service came by to see the patient again on postoperative day two; at which time they recommended to avoid the lasix for the rest of the day, and his oxygen saturation was fine with good urine output, and to continue the lasix as needed for dyspnea. they also recommended that we could packed red blood cells. they also recommended to follow up on sodium for worsening hyponatremia, but they felt that this hyponatremia would improve as his diet was advanced. on postoperative day three, the patient was afebrile. vital signs were stable, with no events acutely over the last 24 hours. on postoperative day four, the patient was still in atrial fibrillation, rate controlled. on physical examination, he had improved coarse breath sounds bilaterally, and the plan was to increase the patient's lopressor dose. electrophysiology service came by and saw the patient; at which time they recommended proceeding with anticoagulation and rate control. they also stated that they would cardiovert if the patient became hemodynamically intolerant. later on that day, on postoperative day four, the patient was noted to have a distended abdomen with a decreased urine output of about 20 cc to 30 cc that evening. a foley catheter was placed with 600 cc of urine drained, with relief of the patient's abdominal discomfort. on postoperative day five, the patient was afebrile, still in atrial fibrillation at 105 beats per minute. on physical examination, the patient still had decreased breath sounds at both bases which were coarse. his abdomen was still somewhat distended without tympany with decreased breath sounds. the plan was to continue the heparin for the patient's atrial fibrillation, and to start the coumadin, and to continue the lopressor. cardiology service came by to see the patient on postoperative day five at which time they agreed with the anticoagulation, and the coumadin administration, as well as the beta blockers. on postoperative day six, the patient with no acute events overnight. the patient was still in atrial fibrillation at 70 beats per minute and still with coarse breath sounds bilaterally. the plans were to get the patient ready for rehabilitation. on postoperative day seven, the patient was still in atrial fibrillation at 60 beats per minute. otherwise, hemodynamically stable, saturating at 95% on room air. the patient's preoperative weight was 77 kg; currently at 83.3 kg, with 2+ pitting edema bilaterally of the lower extremities. the plan was to continue the lasix for the patient's edema and coarse breath sounds. discharge disposition: the patient's expected day of discharge was . medications on discharge: (the patient to be sent home on the following medications) 1. coumadin. 2. flomax 0.4 mg p.o. q.h.s. 3. percocet one to two tablets p.o. q.4h. as needed (for pain). 4. metoprolol 12.5 mg p.o. b.i.d. 5. lasix 20 mg p.o. q.12h (for two weeks). 6. potassium chloride 20 meq p.o. q.12h. (for two weeks). 7. colace 100 mg p.o. b.i.d. as needed (for constipation). 8. aspirin 325 mg p.o. q.d. discharge instructions/followup: 1. to follow up with his primary care physician in two to four weeks. 2. to follow up with dr. in four weeks. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting times three. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Cardiac complications, not elsewhere classified Atrial fibrillation Unspecified disorder of kidney and ureter Anomalous atrioventricular excitation

service: cardiothoracic history of present illness: this is a -year-old male with known coronary artery disease presenting with chest and abdominal pressure. he has had several month history of exertional angina that was relieved with rest. he did not take anything for it. last night pain occurred with minimal exertion and kept him from sleeping. he has mild shortness of breath. no nausea, vomiting, diaphoresis or palpations. no radiation. he had been feeling well prior to the onset of this pressure. the patient call ems. pain relieved with aspirin and nitroglycerin. pain entirely relieved in the emergency room after two sublingual nitroglycerin. due to diffuse precordial st depressions, the patient was started on heparin. pertinent laboratory: patient's admission creatinine was 1.7, troponin i was 3.3, ck mb was 11. ekg showed st depressions in v2 through v6 (3 to 5 mm) and t wave inversion in i and avl. hospital course: patient was admitted on with complaints of chest pain and sob. in the emergency room, the patient was started on heparin drip for st elevations noted on ekg and elevated troponin i and ck mb. patient also received a cardiology consult at which time it was decided to continue with the heparin drip and add on aspirin once a day. to start catheterization. subsequent cardiac catheterization showed severe left main and three vessel disease. the lmca was 80% stenosed proximally and 60% distally. lad diffuse disease with 60% stenosis. left circumflex 70% proximal and total occlusion after the om2. the distal lcx fills via right to leg collaterals. rca of 50% stenosis and osteal; 90% in mid. at that time, it was advised because of the patient's three vessel and left main disease to proceed with a coronary artery bypass graft. cardiothoracic surgery was called and the risk and benefits of coronary artery bypass graft were discussed with the patient. an iabp was placed in the cath lab because of increased pain. he underwent successful underwent cabg x 3 on . the lima was placed to the lad, veins were placed to the diagonal branch and the pl branch of the rca. the circumflex could not branch and the pl branch of the rca. the circumflex could not be grafted. intraop tee showed pre cpb ef of 30% with 2+ mr. function was slightly improved. post operatively he did well. he was extubated and the iabp was removed. he progressed slowly but well on the floor. the patient in being transferred to rehab in good condition, tolerating a diet well and ambulating with a walker. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Cardiac complications, not elsewhere classified Atrial fibrillation Unspecified disorder of kidney and ureter Anomalous atrioventricular excitation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pneumonia major surgical or invasive procedure: none history of present illness: hpi: yom w/ h/o cad s/p cabg, af on coumadin, htn presents to ed s/p fall. this a.m., pt reports he "slipped" while going to the bathroom, falling between his bed and the dresser. his wife called ems, who found the pt coughing up pink sputum, lying on his left side, initially "mottled" improving w/ o2 administration. in ed, he was hypotensive w/ sbp 80s-90s, o2 sat 86% ra, improving to 95% on 5l nc. cxr showed rll infiltrate w/ ?rml mass and pt received levofloxacin 500 mg iv x 1, flagyl 500 mg iv x 1 and 1l ns. the pt reports mild shortness of breath and cough productive of yellow sputum (denies hemoptysis) x 3 days. he denies chest pain, lh, palpitations, f/c, myalgias. he reports he vomited several times yesterday (no hemetemesis); denies abd pain, diarrhea. no recent sick contacts or recent travel. past medical history: 1) atrial flutter: s/p ablation 2) cad: s/p nstemi - cardiac cath: lm 80% prox and 60% distal, lad 60%, rca 50% prox and 90% mid, lcx 70% prox and 100% distal, ef 30% w/ severe anterolateral, apical and inferior hypokinesis w/ 2+ mr - pmibi: no angina or ischemic ekg changes. no myocardial perfusion defects ef 68% - tte: la and ra mod dilated, asymmetrical lvh, lvef 50-55%, aortic root moderately dilated, trace ar, 1+ mr 3) gerd 4) spinal stenosis 5) s/p prostatectomy 6) squamous bladder metablasia 7) htn 8) hyperlipidemia 9) cri: baseline cr 1.4-1.7 social history: lives with wife, ambulates with walker. former tob 100 pk-yrs, quit 20 yrs ago. no etoh or other drug use family history: nc physical exam: pe: tc 97.1, pc 70, bpc 90/49, resp 25, 95% 5l gen: elderly male, alert, ox3, although slightly confused, tachypnic, (+) accessory muscle use heent: perrl, eomi, anicteric, pale conjunctiva, omm dry, op clear, neck supple, (+) right anterior cervical lad, mildly tender, jvp 15 cm cardiac: rrr, ii/vi sm at apex pulm: crackles at bases bilaterally up 1/3. no wheezes abd: nabs, soft, nt/nd, no masses ext: no c/c/e, 2+ dp bilaterally neuro: cn ii-xii grossly intact and symmetric bilaterally, strength throughout, symmetric bilaterally, 2+ dtr and bilaterally, sensation intact to light touch proximally and distally in upper and lower extremities bilaterally. brief hospital course: yom w/ cad s/p cabg, af and htn who presented s/p mechanical fall and was found to have hypotension which resolved with 1 l of ns and pna. pneumonia: crx concerning for rml mass on top of pna which may be multilobar with also lll involvement. responding to levofloxacin with rapid clinical imporvement and now nl room air oxygen. - continued on levofloxacin renally dosed - a ct was performed which did not reveal a mass, but showed a large aaa. sepsis: resolved. lactate improved from 8.3 -> 1.8 and his bp normalized with only 1 l ns and early antibiotic tx suggesting that volume depletion may have been the main culprit. blood cx negative to date. s/p fall: pt had witnessed mechanical fall w/o loc or head trauma. head ct and c-spine ct were also negative for new acute pathology including bleed or fx. most likely etiology was weakness from underlying infection. -fall precautions were instituted. he was evaluated by pt who assessed him able to go home from the hospital without any further rehab. cad: minimal lateral st depressions on ekg with positive ck mb and trop leak, asymptomatic. possibly demand ischemia caused by transient hypotension and infection. - continued on asa, lipitor, and bb htn: normotensive now. pt usually on aldactone and bb. he ignores the doses. -he was restarted on a low dose of aldactone and lopressor. cri: cr was initially elevated at 1.8 from a baseline of cr 1.4-1.7. this resolved over 24 hours with hydration and it was attributed to prerenal etiology af: anticoagulation was held for possible procedure upon arrival to micu. inr therapeutic at 2.7 -restart on coumadin at 5mg po qd in am. at d/c his inr was 3.2 medications on admission: metoprolol, aspirin, aldactone, coumadin discharge medications: 1. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 2. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 10 days. disp:*10 tablet(s)* refills:*0* 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. warfarin sodium 2.5 mg tablet sig: one (1) tablet po once a day: do not take on day of discharge. discharge disposition: home with service facility: family & services discharge diagnosis: fall multilobar pneumonia afib constipation discharge condition: good- at baseline followup instructions: please see your primary care doctor (dr. in 1 week Procedure: Arterial catheterization Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Esophageal reflux Unspecified essential hypertension Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Unspecified fall Constipation, unspecified Other and unspecified hyperlipidemia Hypotension, unspecified Old myocardial infarction Unspecified disorder of kidney and ureter Abdominal aneurysm without mention of rupture Other disorders of neurohypophysis Other nonspecific findings on examination of blood

history of present illness: this is a 59 year old male with a history of coronary artery disease status post multiple stents, hypertension, hyperlipidemia, and diabetes mellitus type 2, who presents with an episode of choking sensation, discomfort with radiation from the stomach to the chest, worse with exertion. it started the evening prior to admission. it was relieved with two sublingual nitroglycerin and the chest discomfort recurred with nausea and diaphoresis with a mild headache. he took two aspirin and went to sleep. later that morning, the patient noted a left sided chest discomfort which had returned and presented to the emergency department. he was given sublingual nitroglycerin which relieved the pain. the patient was started on a heparin drip. he had already taken his beta blocker and aspirin at home. the patient noted episodes exactly the same of this prior anginal episode denied. past medical history: 1. coronary artery disease status post right coronary artery stents in , . status post left circumflex in and . cardiac catheterization in showed left anterior descending, proximal and medial 80 to 90% stenosed, d1 90% stenosed and left circumflex stents patent; obtuse marginal 90%, right coronary artery mid 95%. ptc and stented. the erca stent patent. ejection fraction 44%. 2. posterior basilar hypokinesis. anterior lateral inferior hypokinesis. 3. hypertension. 4. hyperlipidemia. 5. diabetes mellitus. allergies: the patient has no known drug allergies. medications at home: 1. toprol xl 150. 2. plavix 75. 3. cozaar 25. 4. glucotrol 10 twice a day. 5. prilosec 20. 6. lipitor 10. 7. aspirin. 8. flogard 1. social history: the patient had quit smoking 35 years ago and used only occasional alcohol. laboratory: on admission the patient's white blood cell count was 8.3, hematocrit 40.7, platelets 164. electrolytes were within normal limits. ck 49, troponin less than 0.3. chest x-ray showed no congestive heart failure, no infiltrates. stress test on , stress mibi showed moderate partially reversible defects involving inferior and lateral walls, improved when compared to which was stress test prior to the second right coronary artery stent. physical examination: on examination, the patient was afebrile, vital signs were stable. regular rate and rhythm. clear to auscultation. hospital course: the patient underwent a catheterization on which showed lmca mild ostial plaquing, left anterior descending proximal eccentric 80 to 90%, mid-serial 80% and apical 90%. high diagonal ramus diffuse disease to 80 to 90%. d2 small with diffuse disease 80 to 90%. l6 single large bifurcating along with diminutive arteriovenous groove circumflex. obtuse marginal one upper pole diffuse disease to 60%, obtuse marginal one lower pole diffuse disease to 80 to 90% in multiple places. right coronary artery diffuse mild disease with mild in-stent restenosis. patent ductus arteriosus diffusely diseased to 50%. the patient underwent coronary artery bypass graft times four with a left internal mammary artery to left anterior descending, saphenous vein graft to right coronary artery, saphenous vein graft to the obtuse marginal and saphenous vein graft to the diagonal on . the patient tolerated the procedure without complications. he was extubated on postoperative day one and transferred to the floor where he continued to do well with only minimal sternal drainage overnight on postoperative day number three, but the incision which was monitored continued, but was very minimal. the patient was felt to be ready for discharge on postoperative day number four. he was on a regular diet, ambulating well, had good p.o. and pain control. discharge status: the patient was to be sent home with visiting nurses association for dressing changes and wound checks. discharge instructions: 1. the patient to follow-up with dr. in four weeks. 2. to follow-up with his primary care physician, . , in one to two weeks. 3. the patient to see cardiologist in two to three weeks. discharge medications: 1. lopressor 75 mg twice a day. 2. ibuprofen 400 mg q. six hours p.r.n. 3. glipizide 10 mg twice a day. 4. atorvastatin 10 mg q. day. 5. plavix 75 mg q. day. 6. percocet one to two tablets p.o. q. four to six hours p.r.n. 7. tylenol 650 mg q. four hours p.r.n. 8. aspirin 325 mg q. day. 9. zantac 150 mg twice a day and to follow-up with cardiac surgeon. 10. lasix 20 mg twice a day times seven days. 11. potassium chloride 20 meq twice a day times seven days. 12. colace 100 mg twice a day. 13. milk of magnesia 30 ml q. h.s. p.r.n. 14. insulin sliding scale as needed. condition on discharge: good. discharge status: home. discharge diagnoses: status post coronary artery bypass graft times four. , m.d. dictated by: medquist36 d: 12:58 t: 16:50 job#: Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Monitoring of cardiac output by other technique Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Other complications due to other cardiac device, implant, and graft Other nonspecific abnormal results of function study of cardiovascular system

history of present illness: the infant is a former 27 and week gestation, twin number 2, admitted to the nicu for respiratory distress and prematurity. on the day of transfer, the infant corrected to 35 and 3/7 weeks. maternal history: the mother is a 38-year-old, gravida 1, para 0-2, woman, with a past medical history notable for infertility and hypothyroidism treated with levothyroxine. prenatal screens include blood type a positive, dat negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, group b strep unknown. antenatal history: pregnancy was conceived through ivf resulting in diamniotic-dichorionic twin gestation with of . pregnancy was complicated by cervical shortening and preterm labor leading to admission in . the mother was readmitted earlier the week prior to delivery with cervical shortening and received betamethasone with a course completed four days prior to delivery. delivery was by cesarean section for progressive labor with a breech twin presentation. membranes were ruptured at delivery yielding clear amniotic fluid. there was no intrapartum fever or other clinical evidence of chorioamnionitis. cord prolapse of twin number 1 occurred through the operative incision. neonatal course: this infant emerged hypotonic and apneic with a heart rate of 90. he was orally and nasally bulb suctioned, dried, and given bag mask ventilation for 1-2 minutes followed by the onset of spontaneously respirations and resolution of bradycardia. apgar scores were 4 at one minute and 8 at five minutes. the baby was transferred uneventfully to the nicu in free-flow 100 percent oxygen and intubated on admission for the onset of intercostal retractions and grunting respirations. admission physical exam: general: birth weight 1045 g, 50th percentile, head circumference 25 cm, 25th percentile, length 36 cm, 25th percentile. vital signs: temperature 96.7 which improved to 98.6 with appropriate warming. heart rate 156, respiratory rate 44, blood pressure 51/33, with a mean of 39, oxygen saturation 98 percent in 40 percent oxygen. heent: physical examination included an anterior fontanel open and flat, nondysmorphic features. palate intact. neck and mouth normal. moderate nasal flaring. normocephalic. chest: moderate retractions on spontaneous breaths. fair excursion with intermittent mechanical ventilation. breath sounds clear and symmetric with endotracheal tube traction. cardiovascular: the infant appeared well perfused. he had a regular, rate, and rhythm. no murmur. normal s1 and s2, split. femoral pulses normal. abdomen: soft and nondistended. no organomegaly. no masses. active bowel sounds. three-vessel cord. patent anus. gu: normal male genitalia. testicles undescended bilaterally. central nervous system: active and responsive to stimulation. appropriate tone for gestational age. moves all extremities symmetrically. intact gag. integument normal. musculoskeletal: normal spine, limbs, hips, and clavicles. hospital course: cardiovascular: the infant required two normal saline boluses followed by a dopamine infusion with a maximum rate of 7.5 mcg/kg/min to maintain blood pressures in the normal range. dopamine was discontinued after 24 hours, and blood pressures remained stable. an echocardiogram was performed on day of life 17 to rule out a patent ductus arteriosus. this echocardiogram revealed normal heart structure and no pda. central axis was performed with an umbilical arterial catheter and an umbilical venous catheter, both of which were in place until day of life 6, at which time a picc line was placed, and uauvc lines were discontinued. the picc remained in place until day of life 16. current blood pressure is 78/38 (51). respiratory: the infant required surfactant replacement times three doses and was on mechanical ventilation with maximum settings of 18/5 and a rate of 30. he was extubated to cpap of 7 cm on day of life 5 following a loading dose of caffeine. he remained extubated until day of life 11, and due to progressive apnea and desaturations and work of breath, was reintubated. he remained reintubated until day of life 18 when he was again extubated to cpap. the infant continued on caffeine until day of life 28, at which time it was discontinued. he was transitioned from cpap to nasal cannula on day of life 42 which was . he continues on nasal cannula with 300 cc flow and 40 percent oxygen with respiratory rates of 50s to 70s and saturation 93%. he continues to have occasional drifts in his oxygen saturation requiring increased concentration of his fio2. overall he has comfortable work of breathing and has clear and equal breath sounds. the infant had lasix on two occasions following blood transfusions but did not require diuretic therapy. fen: the infant was npo until day of life 7. he was maintained on parenteral nutrition and intralipids and was euglycemic upon admission and remained so on his intravenous fluids. electrolytes were monitored and remained in the normal range on pn. he did require the administration of neut bicarbonate times two on day of life 6 and 7 for metabolic acidosis which improved. he was started on enteral feeds at day of life 7 with mother's milk and advanced 10 cc/kg b.i.d.. he achieved full enteral feedings by day of life 16. at this time, he was advanced on calories to a maximum of breast milk 30 with promod. he currently receives breast milk 30 with promod at 130 cc/kg/day. his weight gain has averaged 20 g/kg/day over the last week. the infant is also on vitamin e and iron which was started on day of life 18. weight at the time of discharge is 2195 g. head circumference is 30.5 cm. length is 44 cm. the infant started to p.o. feed and breast feed about one week ago. the mother has been meeting with lactation and putting the infant to breast with good success. gastrointestinal: the infant is status post phototherapy for physiologic jaundice which peaked on day of life 9 with a serum bilirubin of 5.0/0.3. phototherapy was discontinued on day of life 12, and this is a resolved issue. due to concern for a gastroesophageal reflux, the infant was started on reglan and zantac on day of life 46, . there was noted to be clinical improvement. he continues on reglan and zantac at the time of transfer. as mentioned, he continues on vitamin e and iron. he had nutrition labs which were last noted on with a calcium of 9.5, phosphorus of 5.9, and alkaline phosphatase of 409. the infant has a normal voiding and stooling pattern and has had occasional heme positive stools which were felt to be due to aphagia. hematologic: initial cbc was notable for a white count of 5.0 with 28 polys and 0 bands, a hematocrit of 44.9, and platelets of 265,000. the infant received three blood transfusions of packed red blood cells, the first on day of life 5, which was ; the second of which was on day of life 27, and the last was received on day of life 45, which was for a hematocrit of 25.7, and a retic of 5.3 percent. infectious disease: initially course of ampicillin and gentamicin continued for 48 hours with negative cultures. on day of life 15, a sepsis evaluation was performed for increased spells and lethargy. vancomycin and gentamicin were administered for 48 hours and were stopped with negative cultures. the infant experienced excoriation of his nose due to prolonged treatment with cpap and was treated with bactroban. he also had some eye drainage associated with that and received erythromycin ointment for five days which ended on . due to concern for cellulitis of the nose, orl was consulted, and the infant received oxacillin and gentamicin for three days. the oxacillin was discontinued, and vancomycin was started in its place, and the infant received a full seven- day course of vancomycin and gentamicin for cellulitis of his nose. levels were obtained and noted to be in the normal range for both vancomycin and gentamicin. he completed the seven-day course on day of life 43 which was . his nose is much improved without excoriation or erythema. neurologic: head ultrasounds were obtained screening for ivh on day of life 1, 7, and 30, all of which were normal. it is recommended that an ultrasound or mri is obtained at term or prior to discharge. audiology: hearing screen has not yet been performed but is recommended prior to discharge. ophthalmology: the infant had his initial screening ophthalmology examination on and was found to have immature retinas to the zone ii. a follow-up exam on revealed stage i, zone ii rop with 8 clock hours and 7 clock hours on the left. follow-up exam today also showed zone 1, stage 1, now with 12 clock hours bilaterally. psychosocial: social worker, , has been involved with this family. she may be reached at . the infant's twin died at approximately day of life 6, and this family was appropriately saddened, and services were attended by the family. the family is greek-speaking. the father has been the primary communicator. the mother does not speak english and requires a greek interpreter for lactation consulting, newborn care, and basic infant care. the father likes to be contact with any change in the baby's care and condition so that he is up-to-date with all events. his cell phone number is (. condition on discharge: stable. discharge disposition: to level ii nursery. primary pediatrician: has not yet been identified. the family lives in . care and recommendations: feedings at the time of discharge: breast milk 30 calories with promod, that is made with human milk fortifier, mct oil, and polycose with the addition of promod by p.o. or pg. pg feeds are over one hour. at the time of transfer, the infant is approximately half p.o. and half pg, plus breast, 130 cc/kg/day, total fluids. discharge medications: 1. iron 2 mg/kg/day (0.2ml once daily) 2. vitamin e 5 iu po/pg daily, 3. metaclopromide 0.2mg q8h pg 4. zantac 4.54 mg q8h pg. car seat position screening: has not yet been performed. state newborn screening: has been performed according to the recommended intervals and have been normal to date. immunizations received: none at this time. the infant is approaching two months of age and will be eligible for his two-month vaccine. immunizations recommended: 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: daycare during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, and 3) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age (and for the first 24 mos of the child's life), immunization against influenza is recommended for household contacts and out-of-home caregivers. follow up: recommended with primary care physician, yet to be determined, and ophthalmology. discharge diagnosis: 1. surviving twin, prematurity at 27 and 3/7 weeks. 2. respiratory distress syndrome 3. chronic lung disease. 4. rule out sepsis. 5. cellulitis of the nose. 6. apnea of prematurity. 7. anemia of prematurity. 8. physiologic jaundice. 9. retinopathy of prematurity. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Non-invasive mechanical ventilation Arterial catheterization Laryngoscopy and other tracheoscopy Other phototherapy Transfusion of packed cells Umbilical vein catheterization Diagnoses: Acidosis Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery 27-28 completed weeks of gestation Neonatal bradycardia Anemia of prematurity Other specified conditions originating in the perinatal period Retrolental fibroplasia Other diseases of lung, not elsewhere classified Other preterm infants, 1,000-1,249 grams Other and unspecified atelectasis Other apnea of newborn Neonatal conjunctivitis and dacryocystitis

history of present illness: 77-year-old woman reports being diagnosed with a heart murmur at least 20 years ago. over recent years she has been followed by serial echocardiograms, the most recent echocardiogram was from at which time she had a 60% ejection fraction with normal contraction lvh, peak aortic gradient of 117 mmhg and a mean gradient of 63 mmhg, aortic valve area was 0.6 cm sq with 1+ mr. the patient states that she generally feels well with normal daily activities of living. it is only when she walks up that she becomes shortly dyspneic with chest heaviness. she denies any history of prior cad. denies claudication, orthopnea, edema, pnd and lightheadedness. past medical history: significant for primary hyperparathyroidism, aortic stenosis, thyroid disorder, osteoporosis, hypertension, hyperlipidemia. past surgical history: status post cholecystectomy. allergies: no known drug allergies. medications: prior to admission include procardia xl 90 mg q d, lipitor 10 mg q d, e-vista 60 mg q d, tapazole 5 mg q d, caltrate 600 mg q d and centrum one q d. laboratory data: white count 12.4, hematocrit 42.9, platelet count 342,000, sodium 144, potassium 4.4, chloride 103, co2 27, bun 20, creatinine 1.1, inr 1.0. social history: patient is widowed and lives alone. her daughter is a neurologist at . hospital course: the patient was admitted to and following admission went for cardiac catheterization. please see cath report for full details. summary of the cath showed calcific aortic stenosis with mitral annular calcification and an 80% proximal rca lesion. the patient did well following cardiac catheterization. she was followed by the medical service for the next two days and on was brought to the operating room. please see the or report for full details. in summary, the patient underwent coronary artery bypass grafting times one with a saphenous vein graft to the rca and an aortic valve replacement with a #23 aortic valve. she tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit and at the time of transfer the patient's mean arterial pressure was 82, cvp 13, pa 25/16. she was a paced at a rate of 80 and she had propofol drip infusing. she did well in the immediate postoperative period but she was noted to have a moderate metabolic acidosis and therefore the patient remained intubated for several hours following her surgery. during the night of postoperative day #1 she was successfully extubated and following extubation, the patient did well. postoperative day #1 the patient was weaned from all cardioactive iv drips. her swan ganz catheter was discontinued. on postoperative day #2 it was noted that the patient's preoperative urine had e. coli greater than 100,000. she was therefore started on bactrim at that time. also on postoperative day #2 it was felt that the patient was stable and ready to be transferred to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor, the patient's activity level was slowly increased with the assistance of the nursing staff and physical therapy. she remained hemodynamically stable and on postoperative day #5 it was felt that she was stable and ready to be transferred to rehabilitation for continuing postoperative care and cardiac rehabilitation. at the time of transfer patient's physical exam is as follows: vital signs, temperature 98.3, heart rate 89, sinus rhythm, blood pressure 128/70, respiratory rate 18, o2 saturation 94% on room air. weight preoperatively was 72.4 kg, at discharge is 74.6 kg. lab data: white count 10.8, hematocrit 29.2, platelet count 250,000, sodium 142, potassium 4.4, chloride 106, co2 30, bun 28, creatinine 1.2, glucose 87. physical exam, alert and oriented times three, moves all extremities, follows commands. respiratory clear to auscultation bilaterally. heart sounds regular rate and rhythm, s1 and s2, no murmurs. sternum is stable with no click. incision with steri-strips, open to air, clean and dry. abdomen soft, nontender, non distended with normoactive bowel sounds. extremities are warm and well perfused. left lower extremity incision is open to air, clean and dry. discharge medications: aspirin 325 mg q d, lasix 20 mg q d times 14 days, potassium chloride 20 meq q d times 14 days, metoprolol 25 mg and bactrim one tablet q d through . patient's prn medications include percocet 5/325 1-2 tabs q 4 hours prn and ibuprofen 400-600 mg q 6 hours prn. condition on discharge: stable. she is to be transferred to the . she is to have follow-up with dr. in weeks and follow-up with her primary care provider 4 weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Aortic valve disorders Family history of ischemic heart disease Unspecified disorder of thyroid

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sepsis major surgical or invasive procedure: placement of arterial line, femoral tlc, subclavian tlc. history of present illness: hpi: 78yo woman with history of htn, dm2, gi bleeding, and spinal stenosis presented to hospital with nausea/vomiting/diarrhea for 3 days. on admit to caritas ed, her vitals were 97.3, 65, 20, 134/51, and 100% on ra. there, she underwent ct of abdomen with oral contrast, which was read as significant for the following: small hiatal hernia, markedly distended stomach with distal gastric wall thickening (inflammation vs. infectious process), small amount of ascites, s/p cholecystectomy, moderate amt of stool in colon, apparent thickning of rectal wall, "possible thickening of the large bowel wall, but not certain due to lack of oral contrast". she was also diagnosed with urinary tract infection. at caritas ed, she was given volume resuscitation with ns 2l, levaquin 500mg, dilaudid 0.5mg x 2, reglan, pepcid, and ativan. she had wbc count of 23.9, ua with mod blood, 30 prot, lg le, numerous wbc. . on transfer to ed, she was afebrile, hemodynamically stable and a/o x 3. . upon arrival to ed, she quickly was noted to be apneic, with right facial droop, and slumping over to right side. she was apneic and cyanotic. she was intubated. given 3l ns for hypotension. given vancomycin 1g, levaquin 500mg iv, and flagyl 500mg iv. she was given 3amps of bicarbonate. given insulin, d50, kayexalate, hco3 for hyperkalemia. . abdominal ct reviewed by surgery and radiology, who both feel that the ct clearly reveals some mucosal thickening, which could be consistent with c. diff colitis. . discussion with her family reveals that she has been in and out of hospital and rehab for significant gi bleed from ugi ulcer one month ago, has had chf, and has had c. diff colitis; has completed 8 day course of flagyl. she had returned to home from rehab and was doing well, but then complained of mild nausea/vomiting/diarrhea for past 3 days. past medical history: past medical history: 1. dm2 2. hypertension 3. spinal stenosis 4. congestive heart failure 5. h/o gi bleeding social history: - family history: - physical exam: . physical exam: 92.9, 76, 122/56, 100% on mech vent (ac, 24 x 600, fio2 100%) gen: intubated, sedated; following commands heent: perrla, eomi neck: no jvd cv: irregular; regular rate; no m/r/g resp: clear to auscultation bilaterally abd: soft, minimally distended; hypoactive bowel sounds; no peritoneal signs. guaiac negative in ed. extr: cool extremities; no peripheral edema neuro: no focal deficits per limited exam pertinent results: 08:30am type-art temp-32.8 rates-24/ tidal vol-600 peep-5 o2-50 po2-177* pco2-12* ph-7.08* total co2-4* base xs--24 intubated-intubated 08:13am lactate-17.7* 07:57am glucose-136* urea n-30* creat-1.8* sodium-138 potassium-6.5* chloride-110* total co2-less than 07:57am alt(sgpt)-137* ast(sgot)-427* ld(ldh)-2423* alk phos-355* tot bili-0.5 07:57am albumin-1.5* calcium-7.8* phosphate-6.6* magnesium-2.1 07:57am wbc-35.5* rbc-2.70* hgb-7.5* hct-25.0* mcv-93 mch-27.9 mchc-30.1* rdw-19.2* 07:57am pt-20.9* ptt-90.8* inr(pt)-3.1 07:57am fibrinoge-413* 07:07am lactate-16.6* 06:11am lactate-15.6* 06:10am lactate-15.8* 06:10am o2 sat-52 05:06am lactate-15.3* 02:56am wbc-34.5* rbc-2.75* hgb-7.6* hct-25.0* mcv-91 mch-27.8 mchc-30.6* rdw-19.3* 02:56am plt count-258 02:56am fdp-160-320* 02:56am fibrinoge-487* 02:56am ret aut-3.4* 01:12am type-art po2-536* pco2-22* ph-7.18* total co2-9* base xs--18 01:12am lactate-15.0* na+-136 k+-4.7 cl--107 tco2-9* 10:44pm alt(sgpt)-15 ast(sgot)-38 ld(ldh)-401* ck(cpk)-28 alk phos-140* amylase-128* tot bili-0.4 10:44pm neuts-30* bands-15* lymphs-34 monos-5 eos-1 basos-0 atyps-0 metas-13* myelos-2* 10:44pm hypochrom-3+ anisocyt-2+ poikilocy-1+ macrocyt-2+ microcyt-normal polychrom-1+ schistocy-1+ burr-1+ teardrop-1+ 10:44pm plt smr-normal plt count-343 pltclm-1+ 10:44pm pt-18.2* ptt-85.7* inr(pt)-2.3 10:46pm ctropnt-0.01 10:44pm alt(sgpt)-15 ast(sgot)-38 ld(ldh)-401* ck(cpk)-28 alk phos-140* amylase-128* tot bili-0.4 10:44pm lipase-19 10:44pm albumin-2.1* calcium-8.4 phosphate-7.0* magnesium-2.5 10:44pm wbc-38.4* rbc-3.41* hgb-9.6* hct-33.1* mcv-97 mch-28.3 mchc-29.1* rdw-19.2* 10:44pm hypochrom-3+ anisocyt-2+ poikilocy-1+ macrocyt-2+ microcyt-normal polychrom-1+ schistocy-1+ burr-1+ teardrop-1+ 10:44pm plt smr-normal plt count-343 pltclm-1+ 10:44pm pt-18.2* ptt-85.7* inr(pt)-2.3 10:35pm lactate-13.9* brief hospital course: 78yo woman with complicated medical history presented from outside hospital with sepsis, and likely lactic acidosis from bowel ischemia. she was aggressively managed with volume resuscitation, pressors, broad spectrum antibiotics, and mechanical ventilaiton in the intensive care unit. . over her course, she had worsening hypotension and increasing pressor requirements. ultimately, family meeting was held, and it was decided to make her comfort measures only. she thereafter passed away. a post-mortem examination will be performed per the family's request. medications on admission: medications: atenolol 100mg lisinopril 40mg qd mvi effexor 75mg qd allopurinol 100mg kcl 40 qd hydralazine 10mg tid ativan 0.5mg prn (flagyl 250mg tid x 8 days - done) anusol lasix 40mg qd protonix 40mg qd procardia xl 30mg qd vicodin prn duragesic 50mcg q72hrs discharge disposition: expired discharge diagnosis: deceased; sepsis discharge condition: - discharge instructions: - followup instructions: - Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Septic shock

allergies: codeine attending: chief complaint: chest pain, positive blood cultures major surgical or invasive procedure: picc line placement dialysis catheter removal and replacement history of present illness: 49 yo female, h/o recent admission for complicated enterococcus endocarditis (initially with vegetation on aortic valve with possible migration to mitral valve), bilateral knee replacements, iv cocaine abuse, presenting now with blood cultures positive for enterococcus from 1 week ago and right-sided pleuritic chest pain. upon discharge from on , she went to rehab where she stayed until before returning home. she was receiving dialysis at that time (gentamicin initiated last admission for endocarditis caused acute renal failure) and was having surveillance blood cultures drawn weekly at hd. cultures from grew enterococcus, (sensitive to amp, vanco, cipro). for this, she was started on vancomycin, ceftaz, and ampicillin. additionally, she developed acute, pleuritic chest pain on the night prior to admission. she described it as occurring with deep breaths, radiating to the back, , relieved by sitting forward, without radiation to arm/jaw, no n/v/diaphoresis. she states she does not usually get chest pain/angina and has not experienced pain like this in the past. the pain has been getting worse and now is constant (still worse with deep breathing). she states she has been having 'chills,' but denies subjective fevers, night sweats. she has a stable pillow orthopnea and has pnd (not increased or worse recently). she states that since she was started on hemodialysis, she has had le swelling, sometimes asymmetric (usually l>r). on presentation to the ed, she was uncomfortable, afebrile with stable vitals, saturating adequately on ra (but placed on nc o2). vanco level was checked, cr was 2.5 (baseline wnl, s/p gent was up to 6, 3.1 on discharge last admission), blood cultures were sent, and 1 set of ce's were sent (troponin t 0.03; was 0.05 on last discharge). chest x-ray showed some upper zone redistribution, and leni's/tte were ordered. she was admitted to medicine for further workup of this chest pain and positive blood cultures. past medical history: 1. endocarditis recently, initial vegetation on aortic valve, with migration to mitral valve; treated with amp/gent. most recent tte on showed 4+ ar with small veg on av, 2+ mr e-sized vegetation on mv, ef=55% 2. gentamicin-induced renal failure last admission. on hemodialysis. 3. osteoarthritis r hip ?????? scheduled of thr in , but missed appointment, now with no plans to pursue surgery. 4. s/p l knee replacement ?????? , complicated by septic knee, hardware removed and then replaced 1 year later. 5. s/p r knee replacement ?????? 6. asthma ?????? diagnosed years ago, no hospitalizations, no intubations, no attacks in 1 year 7. bipolar disorder ?????? scheduled to begin valproic acid therapy soon 8. anxiety disorder ?????? treated with klonopin 9. iv cocaine abuse ?????? last use was months ago by her report social history: pt was at rehab from , then returned home. she lives with her husband and daughter (age 19) in ; tobacco: 1/2ppd x 30 yrs no alcohol use + iv cocaine use few months ago denies any recent ivdu does not work family history: non-contributory physical exam: vs: t:98.4; p: 98; bp: 106/42; rr: 20; o2: 99% 4l gen: mild distress, relatively comfortable, obese female : perrl, no spots, eom grossly intact op clear cnii-xii intact neck: ?jvd (9cm noted in ed), on lad cv: 3/6 sem rusb with radiation to carotids bilaterally, ?diastolic murmur (soft), no r/g chest/back: reproducible chest pain to palpation on right paraspinal area, right mid-chest, right side lungs: + crackles at bases bilaterally, poor air movement throughout, no w/r appreciated abd: obese, nabs, nt/nd, no reb/guard extr: 2+ pitting edema bilaterally, r>l, pt 1+ bilaterally, negative sign bilaterally neuro: strength and sensation intact to light touch and temperature bilaterally and symmetrically, no focal deficits skin: right ij hd catheter-no erythema, discharge, no tenderness to palpation around site on catheter. no splinter hemorrhages, lesions noted pertinent results: labs on admission: lactate:1.7 vanco: 2.0 grossly hemolyzed specimen 136 96 28 94 ------------ 4.3 28 2.5 ck: 63 mb: notdone trop-*t*: 0.03 lip: 38 mcv= 90 wbc= 11.3 hgb= 10.4 plts= 460 hct= 32.3 n:77.2 l:16.2 m:2.7 e:3.8 bas:0.1 hypochr: 3+ anisocy: 1+ poiklo: 1+ macrocy: 1+ pt: 13.2 ptt: 25.7 inr: 1.1 _________________________________ radiology leni's: impression: limited study. no evidence of dvt. - lung scan-) central deposition of radiotracer with heterogeneous ventilation to the upper lobes. 2) patient refused perfusion images, therefore, this is anincomplete ventilation/perfusion study. cxr: again demonstrated is a right ij double- lumen catheter, unchanged in position. there is stable lv enlargement. there is upper zone redistribution of the pulmonary vasculature with a small left- sided pleural and questionable right-sided pleural effusion consistent with mild left heart failure. the mediastinal and hilar contours are stable. there is no pneumothorax. ekg: nsr 91, left axis deviation, with t-wave inversions in iii, avf, v1-v5; unchanged from ekg from - tte-conclusions: 1. the left atrium is moderately dilated. 2. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3. the aortic valve leaflets (3) are mildly thickened. there are at least 2 small, fibrotic masses on the aortic valve, which may represent healed or active vegetations. severe (4+) aortic regurgitation is seen. 4. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. two mitral regurgitation jets are seen, one of which probably represents a small hole in the anterior leaflet. 5. compared with the findings of the prior study (tape reviewed) of , the aortic mass is evolving and the mitral mass is gone. left upper extremity u/s-impression: no dvt on this somewhat limited study. - ct abd/pelvis with contrast-impression: 1) new pericardial effusion, otherwise unremarkable ct of the chest. no identifiable source of infection within the abdomen or pelvis. 2) soft-tissue fullness within the pancreatic head, worrisome for pancreatic neoplasm. an mri of the pancreas is advised. echo-conclusions: the left atrium is dilated. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular systolic function is normal with borderline preserved right ventricular systolic function. the aortic valve leaflets are mildly thickened. there are echo dense masses associated with the aortic valve which likely represent vegetations. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen (not fully assessed). there is a pericardial effusion that is small to moderate anteriorly and large inferolaterally (upto 2.7-3.0 cm wide). there are no echocardiographic signs of tamponade. compared to the prior study of , the pericardial effusion is now larger. - ap cxr-a single ap supine image. comparison study dated . a new endotracheal tube is noted, its tip at the level of the thoracic inlet. the right ij swan catheter tip remains well positioned in the right pulmonary artery. the right ij double-lumen catheter tip appears to be in the mid right atrium. the cardiac silhouette remains markedly enlarged, though possibly slightly improved since the prior study. there appears to be a drain overlying the cardiac silhouette following the pericardial window procedure. the lungs appear slightly better inflated than before, but there appears to be a left lower lobe collapse/consolidation behind the heart. no definite pleural effusions are demonstrated on this supine view. pericardial fluid-no malignant cells. - echo the right ventricular cavity is dilated. right ventricular systolic function appears depressed. there is a trivial/physiologic pericardial effusion subtending the lateral wall and apex of the left ventricle. there are no echocardiographic signs of tamponade. no right atrial or right ventricular diastolic collapse is seen. _______________________________ microbiology: - bcx- no growth - bcx- no growth - ucx- mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination bcx- no growth bcx- no growth bcx- no growth r subclavian tip culture -no growth - pericardial tissue-gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): no growth. anaerobic culture (final ): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): fungal culture (preliminary): no fungus isolated. pericardial tissue swab-gram stain- no pmns. no microorganisms. no anaerobic growth. - bcx x 2- no growth to date - bcx x2- pending bcx- pending ___________________________________ labs on discharge : wbc rbc hgb hct mcv mch mchc rdw plt ct 13.1* 3.20* 9.1* 28.3* 89 28.4 32.1 17.7* 338 glucose urean creat na k cl hco3 118* 28* 3.2* 138 3.4 101 28 alb-3.0* ca-9.3 ph-2.6* mg-2.0 _____________________________________ other labs: - esr -22; - crp 18.31 caltibc hapto ferritn trf 207* 314* 468* 159* - t3-56; t4-0.6; tsh-14 _____________________________________ brief hospital course: 1. chest pt developed new, right-sided, initially pleuritic chest pain with radiation to the back. she also has ?new le edema, asymmetrical at times, and positive blood cultures. she has no history of cad, had no evidence of perivalvular abscess on tte from last admission, and all of her surveillance blood cultures up until now had been negative. perivalvular abscess and/or pericarditis +/- effusion was in the differential given her known vegetations on last admission (she did complete ampicillin course, no pr prolongation on ekg). her symptoms did not sound like a cardiac ischemic event, but that was also a possibility (ekg not really consistent with ischemia, tnt elevated in setting of renal insufficiency). she had some chest pain on last admission that was thought to be musculoskeletal in origin, so this was also a possibility. while in-house, she had a tte which showed at least 2 small vegetations on the av and 4+ ar. no vegetations were seen on the mv. these findings were thought to be an evolution of the original process (vs. new vegetations?). tee did not show any perivalvular abscess or aortic abnormality. she had the onset of some new afib and rbbb discovered on ekg/telemetry, and cardiology was consulted. id was additionally consulted and recommended treating for an additional 8 weeks with ampicillin with close follow up and serial tte's to monitor for improvement in vegetations. open mri was recommended to rule out epidural abscess as a source for the persistent bacteremia. bilateral leni's were negative for dvt, v/q was not able to be obtained (pt refused q portion), and cta was not an option given her renal insufficency. non-contrast ct was obtained, however. it showed a new pericardial effusion. 2. pericardial effusion- a new small pericardial effusion was noted on a follow up tte done on . a ct scan on done to further evaluate for a source of the persistently positive blood cultures incidentally confirmed a moderate sized pericardial effusion and a tte on showed a small to moderate anterior and large inferolateral effusion without echocardiographic signs of tamponade. over the next couple of days, however, the patient became progressively short of breath. on the floor team noted a mild pulsus paridoxicus of 12, and increasing dyspnea with pao2 62 on abg, hr increased to 90, bp decreased to 100, and the patient was therefore evaluated for transfer to the ccu, which was thought appropriate given concern for tamponade. an echo that day now demonstrated a large pericardial effusion (increased in size from previous echo) without the typical echocardiographic signs of tamponade. the patient had a swan-ganz catheter placed on which demonstrated markedly elevated right and left sided pressures. a repeat echo on the next day () again showed a large pericardial effusion, again quite prominent around the right atrium (>2.5cm), with possibly some organized/stranding. in light of this, plus a finding of a pulsus paradoxicus of 25 that morning, it was decided to proceed with pericardiocentesis/pericardial window. ms. had window creation by ct surgery on , at which time 1 l of serosanguinous fluid was drained from the pericardial sac. her hemodynamics immediately improved, with systolic blood pressure increasing to as high as 160 on arrival to the floor (previously running around 110), and increased ci, to 2.5-2.8, with mildly lowered filling pressures. it is felt that ms. was indeed in tamponade, however it was masked on the echocardiogram secondary to the elevated right sided pressures, which were/are likely secondary to her severe ai/mr, with resultant backpressure to the right side of the heart. she was intubated for the procedure. she was placed on pressure support overnight and was successfully extubated on the morning of . she was restarted on captopril for afterload reduction for her severe ai on as it had been previously held secondary to low blood pressures. pericardial aspirate showed no pmns, no organisms, and serosanguinous fluid from her jp drain. a repeat echo on showed only trivial effusion. the thoracic surgery team pulled the jp drain on . the cause of pericardial effusion was likely from endocarditis, bacteremia, and pericarditis. other possibilities include pt's hypothyroidism (though not severe), uremia, or hemodialysis as they are also all known causes. a ppd was planted on and was negative. pt is (+). 3. bacteremia/endocarditis pt had positive blood cultures (enterococcus) on with vegetations on aortic valve (migration to mv). all of her follow up surveillance cultures had been negative, but she has cultures again positive from . she was doing well on ampicillin monotherapy (gent for synergy had caused renal failure). she was recently started on vanco/ceftaz for these positive cultures. likely sources of this infection include the valves, ?line infection from her hd catheter, ?her prosthetic knee hardware. given that she still had vegetations on tte, it was thought that this was the most likley source of the bacteremia. open mri was recommended to r/o epidural abscess (pt too large to fit into mri machine). hd line did not appear to be the source of infection and was left in place. as per id, ampicillin will be continued for a total of 12 additional week(was endocarditis undertreated the first time or did these vegetations represent a new occurrence). hd catheter was changed over a wire on this hospitalization. ampicillin was started on . surveillance cultures were negative so far at . ekg was done daily to assess for pr prolongation and to see if the conduction system was affected. she has maintained normal pr intervals here. 4. aortic insufficiency- per surgery, pt is not a surgical candidate as she is still abusing drugs. this should be continually assessed. pt had a large pulse pressure ~60-70 secondary to ai. 5. pt with ef=55% on last admission but with 4+ ar and 2+ mr. cxr on admission shows upper zone redistribution, small bilateral pleural effusions. she has had some volume issues since initiation of hd. repeat tte continued to show a preserved ef, and her volume issues were managed in-house with hd. 6. renal failure- ms. has gentamicin-induced renal failure. the hope was that she would eventually not require hd when her gentamicin-induced renal failure resolved. however, it appears to be persisting and per renal is likely permanent. pt was maintained of tiweek hemodialysis here (m,w,f). she continued nephrocaps. ampicillin was started and continued at 2 grams q6 hours. 7. anemia: pt with anemia of chronic disease by labs. hct remained in the upper 20s/lower 30s. she required 2 units prbcs post pericardiocentesis/window and hct was then stable afterwards. 8. pt is on oxycontin at home with morphine for breakthrough and was also on fentanyl patch; this was bilateral knee pain, right hip pain, and in the hospital chest pain. pt with history of opiod use, though serum and urine toxicity screens were negative on this admission. in the hospital, we maintained pt on oxycontin. we switched from morphine to oxycodone prn at the end of the hospital stay while maintaining pt on long acting oxycodone. this achieved good results. we also added tylenol prn. we are avoiding nsaids given renal failure. 9. pancreatic mass- a soft-tissue mass was noted in the pancreatic head discovered incidentally on ct, concerning for inflammatory mass vs neoplasm. will need to get this followed up as an outpatient and possible mri. 10. asthma-this was well controlled with albuterol and fluticasone. 11. pt with increased tsh- tsh 14, t3-56; free t4- 0.6 on . started levothyroxul 25 mcg qday. she will need repeat checks in weeks from starting her levothyroxine. 12. bipolar disorder- we continued outpt seroquel and citalopram. 13. pt was on subcutaneous heparin and a ppi. 14. f/e/ pt was on a low sodium diet renal diet; electrolytes were monitored. 15. code status- code status was full code. medications on admission: meds on admission: fentanyl patch 50 mcg albuterol mdi fluticasone protonix celexa 20 mg daily seroquel; 100 mg qam, 200 mg qhs imdur 30 mg daily hydralazine 10 mg tid on non-hd days morphine 15 mg prn oxycontin 50 mg vanco: 1gm , 500 mg , ceftaz 2gm discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 2. quetiapine fumarate 100 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 3. quetiapine fumarate 200 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. oxycodone hcl 5 mg tablet sig: 2-3 tablets po q4h (every 4 hours) as needed. 6. oxycodone hcl 20 mg tablet sustained release 12hr sig: two (2) tablet sustained release 12hr po qam (once a day (in the morning)). 7. oxycodone hcl 20 mg tablet sustained release 12hr sig: three (3) tablet sustained release 12hr po hs (at bedtime). 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for nasal congestion. 12. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po daily (daily). 13. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day): hold for sbp <100. 14. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po hs (at bedtime). 15. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 16. ampicillin 2 gm iv q6h 17. levothyroxine sodium 25 mcg tablet sig: one (1) tablet po daily (daily). 18. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 19. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 20. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 21. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 22. heparin sodium 5,000 unit/0.5 ml syringe sig: one (1) injection three times a day: while pt is immobile. discharge disposition: extended care facility: hospital discharge diagnosis: primary diagnosis: enterococcal bacteremia aortic valve endocarditis complicated by severe aortic regurgitation pericardial effusion pericarditis hypothyroidism secondary diagnosis: renal failure secondary to gentamicin toxicity requiring dialysis asthma bipolar discharge condition: chest pain has greatly improved, pericardial effusion has been drained. pt is afebrile with negative blood cultures since admission. discharge instructions: -call your primary care doctor and/or return to the hospital if you experience any fevers, chills, sweats, worsening shortness of breath , chest pain, or any other health concern. take all of your medications, including iv antibiotics, and follow up with your doctors as listed below. -iv antibiotics should be continued until for a total course of 12 weeks (started on ) - followup instructions: 1. call your primary care doctor for an appointment in the next 1-2 weeks. you should have a repeat echocardiogram in 2 weeks to assess your pericardial effusion. 2. provider: , md where: lm disease phone: date/time: 11:00 -pt needs a follow-up appointment made with thoracic surgery dr. in ~ 1 week. please call within 3 days of discharge to see when he wants to see you. also, ms. will need to have her staples removed around . please ask dr. first if that will be done at the appointment or when he would like them removed. -tsh was elevated and levothyroxine was started on (see d/c summary). will need follow-up levels in weeks -pt had a pancreatic mass seen on ct. will need to get this followed up as an outpatient with possible mri. Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Pericardiotomy Incisional hernia repair Diagnoses: Anemia, unspecified Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Unspecified disease of pericardium Bacteremia Morbid obesity Acute and subacute bacterial endocarditis Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Incisional ventral hernia with obstruction

allergies: codeine attending: chief complaint: fever, hypotension major surgical or invasive procedure: rsc dialysis cath endotracheal intubation history of present illness: 50 yo f with h/o esrd on hd, chronic pes, pvd, ar/mr medically treated, chf p/w fever, hypotension. pt reported to the ed after dialysis catheter accidentally "fell out." found by the ed to have mental status changes. fever to 103.6, sbps in the 60s. pt noted to have a lactate of 3.3, wbc 7. pt was intubated given concern over airway protection (pt alternately somnolent/ agitated) and a r femoral tlc was placed. levophed started. given 3 l ns. pt given vanc 1000 mg x1 and cefepime 2 gm iv x1. in the pt defervesced and systolics stabilized to 100s on pressor/fluid as above. in the ed no clear source of infxn identified. cxr negative, pt unable to make urine. . transferred to micu for further management. past medical history: 1. chf--ar and mr endocardidtis () with medical tx, not surgical candidate for valve repair. echo showed lae, dilated rv/lv, lvef >60% (intrinsic depression given regurg). 4+ ar, 3+ mr, 2+ tr. pa systolic htn. 2. esrd on hd qt, r, sat --due to mixed gent and contrast-induced nephrotoxicity 3. chronic pe s/p ivc filter on lifelong coumadin 4. pvd s/p fem-post tib nonreversed saphenous vein graft -- c/b wound hematoma --> exploration /evacuation, ivc filter placed; chronic venous stasis ulcers 5. hbv and hcv 6. hypothyroidism 7. oa s/p bilateral tkr () c/b r septic joint --> redo 8. multiple psych issues including bipolar d/o with psychosis, narcotic dependence, anxiety d/o 9. hx of pericardial effusion with tamponade - resolved 10. mrsa carrier other psh: 1. s/p ccy 2. s/p c-section social history: lives at home in with her husband, who spends his time taking care of her. she is on ssi. she is not able to walk, is transported in wheelchair by her husband, whom she cites as a strong support. no alcohol or drugs. ppd x 40 years tobacco. she says she feels that "life is not worth living" and has thought about comitting suicide, although she has never formulated a plan. she is catholic and says she prays a lot, and that is why she is "still here." she does not have a therapist she sees regularly. family history: nc physical exam: t 100 bp 150-160/60-70 p 55-80 r 23 o2 97 on fio2 40% vent: ps 10/5 on rate of 23 tv 375 gen: intubated, obtunded eyes: perrl, sclerae anicteric mouth: mmm, intubated neck: supple, no lymphadenopathy chest: scattered crackles at bases, fair air movement heart: rr, no murmur abd: obese, no bowel sounds. ext: no edema neurol: toes mute, some spontaneous movement of lower extremities. could not elicit reflexes, no clonus skin: no rash. pertinent results: admit labs: ======== wbc-7.3 rbc-3.88* hgb-11.9* hct-36.1 mcv-93 mch-30.6 mchc-32.8 neuts-84* bands-0 lymphs-12* monos-2 eos-1 basos-0 pt-43.2* ptt-40.7* inr(pt)-4.9* glucose-66* urea n-32* creat-5.4*# sodium-138 potassium-5.0 chloride-97 total co2-24 anion gap-22* . admission to floor: 147 107 12 -------------< 101 agap=16 4.2 28 3.3 ca: 9.1 mg: 2.1 p: 2.7 vanco: 23.7 wbc 9.5 hgb 9.7 hct 29.8 plt 177 pt: 41.8 ptt: 38.0 inr: 4.7 . micro: ===== - blood cx ngtd urine cx yeast < 10,000 - blood cx ngtd - o&p, cdiff negative - urine cx <10,000 yeast - sputum: gram stain (final ): negative rpr pending . radiology: ========= cxr : the et tube is 2.8 cm above the carina. ng tube tip is in the stomach. there continues to be volume loss/infiltrate in the left lower lobe in the retrocardiac region. there are also patchy areas of volume loss/infiltrate obscuring the right hemidiaphragm and right heart border. . cxr: 1. retraction of endotracheal tube, now located 5.8 cm above the carina. 2. stable left lower lobe and right hilar opacities, which may represent atelectasis or less likely consolidation. . - portable cxr: acutely occurring left-sided total pulmonary whiteout most likely related to mucous plugging and atelectasis . head ct: there is no evidence of an intracranial hemorrhage. there is no midline shift, mass effect or hydrocephalus. the -white matter differentiation is preserved. . tte: the left atrium is moderately dilated. the right atrium is moderately dilated. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. there is a large vegetation on the aortic valve (right cusp). severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , findings are similar. brief hospital course: 50 yo f with h/o esrd on hd, chronic pes, pvd, ar/mr medically treated, chf p/w sirs/sepsis from presumed line infection and persistent mental status changes. . # sirs/sepsis: on admission presented with fever, hypotension (sbp 60's), lactate of 3.3. cxr showed an infiltrate in lll, ua shows many white cells, positive nitrites, < 1 epi, but ucx was negative. line infection was thought to be most likely possibility. line had been removed by patient at home. she was started on antibiotics with vanco/cefepime for presumed sepsis and volume resucitated with ns ivf. admitted to icu, where she was transiently placed on pressors. a new dialysis catheter was placed, in addition to a picc to complete a 2 week course of vanco/cefepime. she subsequently remained hemodynamically stable and afebrile. blood cultures have been negative this entire admission. patient is afebrile with normal white count. sbp at baseline low 90s to low 100's. c. diff and ova/parasites, rpr, and sputum gram stain were negative. blood cultures have remained negative. vancomycin and cefepime were given for a 14-day course. . # mental status changes: during micu course and after admission to floor, patient was noted by staff and husband to have waxing and mental status, most notably decreased attention and perseverative/repetitive speech. although she was oriented x 3, she would repeat "the 20th" several times before being able to move on the next question. her mental status was observed for several days to determine if there was any improvement, with the thought that resolving infection may have been a factor. other possible etiologies included ischemia/hypoperfusion from poor cardiac output or uremia from renal failure. oversedation with drugs was also considered--pain medications were held, trazodone was d/c'ed. hypothyroidism was considered as well, and levothyroxine was increased from 25 -> 50 -> 100 mcg daily. this should be checked in 2 weeks. additionally head ct was done that showed no abnormalities. the patient had some improvement in mental status, though not completely at baseline per husband. pt was alert and oriented x 3 on day of discharge and appropriate. . # esrd on hd: secondary to gentamicin-induced renal failure during endocarditis admission. new hd catheter placed. currently on mwf hd schedule, although recommended 4x/weekly (as outpatient due to the fact that she does not fluid restrict). on renal diet with 1.5l fluid restriction, although noncompliant. not currently on lanthanum, sevelamer. nephrocaps, epogen given at hd . # chf: severe mr/ar endocarditis, lvef >55% by echo ( and ) but physiologically decreased given severe ai. no fluid overload on last cxr or on clinical exam, although patient has felt subjectively short of breath that improves with dialysis. her bp was consistently hypotensive with baseline sbp 90s. . # chronic pain: stable on methadone 20 mg po tid, hydromorphone prn, and topamax, although these meds were held temporarily for oversedation, but then restarted. she is currently on them and still complains of pain. . # chronic pes: ivc filter in place since , came in supratherapeutic on coumadin. coumadin was restarted at home dose of 5 mg po daily when inr was within goal 2.0-3.0, at goal. . # pvd: stable, has non-healing wound over left thigh and shins b/l. s/p vein graft in . baby aspirin was continued. she was seen by vascular surgery on admission in early and by wound care nursing during her last admission, who recommended continuing her current regimen of duoderm/moistened gauze/4x4/hy tape/abd. . # hypothyroidism: tsh was elevated, but significance in setting of acute illness was unclear. icu team increased levothyroxine from 25 to 50. on the floor, given her lethargy, hypothyroidism was thought to be a potential contributing factor. levothyroxine was further increased to 100 mcg daily for this reason, despite having only been on 50 mcg daily for several weeks. will need tsh check in 2 weeks . # psych issues--stable. bipolar with psychotic features, narcotic dependence, anxiety d/o. her psych meds were held while in the icu, then restarted on admission to the floor at her outpatient doses of topirimate, citalopram, and quetiapine. as mentioned above, trazodone was d/c'ed secondary to concerns of oversedation. . # ppx: coumadin, pneumoboots, ppi were given. . # fen/gi-she was tolerating pos well, kept on a renal diet with 1.5l fluid restriction, and given a bowel regimen. # access: picc . # communciation: with husband . # full code medications on admission: 1.ascorbic acid 500 mg tablet sig: one (1) tablet po bid 2.aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily . 3.levothyroxine 25 mcg tablet sig: one (1) tablet po daily 4.quetiapine 25 mg tablet sig: one (1) tablet po bid 5.sevelamer 800 mg tablet sig: one (1) tablet po tid 6.lanthanum 250 mg tablet, chewable sig: two (2) tablet, chewable po tid 7.docusate sodium 100 mg capsule sig: one (1) capsule po bid 8.senna 8.6 mg tablet sig: 1-2 tablets po bid prn 9.lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 10.simethicone 80 mg tablet, chewable sig: tablet, chewables po qid prn 11.lisinopril 10 mg tablet sig: one (1) tablet po daily 12.warfarin 10 mg tablet sig: one (1) tablet po at bedtime. 13.topiramate 100 mg tablet sig: one (1) tablet po hs (at bedtime). 14.trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime). 15.citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 16.hydromorphone 4 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed for pain for 7 days. 17.acetaminophen 325 mg tablet sig: two (2) tablet po qid (4 times a day) as needed for pain, fever. 18.methadone 10 mg tablet sig: two (2) tablet po tid (3 times a day). discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 4. topiramate 100 mg tablet sig: one (1) tablet po daily (daily). 5. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 6. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 7. hydromorphone 2 mg tablet sig: two (2) tablet po q3-4h (every 3 to 4 hours) as needed for pain. 8. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 11. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 12. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 13. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 14. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 15. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 16. methadone 10 mg tablet sig: two (2) tablet po tid (3 times a day). 17. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal (2 times a day) as needed for hemorrhoid pain. 18. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 19. dolasetron mesylate 12.5 mg iv q8h:prn nausea discharge disposition: extended care facility: hospital discharge diagnosis: sepsis, likely hd catheter infection chf severe valvar disease esrd on hd chronic pain chronic pe pvd nonhealing left thigh wound hypothyroidism bipolar disorder discharge condition: stable, afebrile, continued hd requirement discharge instructions: please take all your medications as directed. we have not added any new medications. . please follow up with , your np, after you leave your rehab facility. . if you experience fever > 100.5, shaking chills, nausea, vomiting, lightheadedness, dizziness, or any other symptoms, or if your mental status worsens, please contact your health care provider. followup instructions: please follow up with , you leave your rehab facility. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Diagnoses: End stage renal disease Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Mitral valve insufficiency and aortic valve insufficiency Acute respiratory failure Septic shock Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Infection and inflammatory reaction due to other vascular device, implant, and graft Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Ulcer of other part of lower limb

allergies: codeine attending: chief complaint: cardiac arrest major surgical or invasive procedure: arterial line cvvhd history of present illness: 51 yo female with mmp including h/o pe (s/p permanent ivc filter), pvd (fem/ bpgs), esrd ( gent), valv dz (ai, mr - not cand) and endocarditis, pvd, dvt, narc abuse, admitted to the icu s/p cardiac arrest at home. apparently, as relayed by pt's husband, pt has been sob x 1 days. pt went to bathroom said that "she felt she was going to die" and collapsed. , documentation from ems mostly absent, so story per husband and reconds. apparently, pt was complaining of worsening sob over thpast day, went to go to bathroom and said she felt like she was dying and then collapsed. husband called ems, ems arrived approx 8 min later and found the patient in asystole. pt intubated in field, cpr started, total 8 rounds of epi, 3 of atropine, got bp of started cpr given 6 rounds of epi, 3 of atropine and 1 nabicarb. had bp of 90/p at one point. total field code time was 30 minutes. lost bp short time later, hr on monitor read to be 140s with no pulses. when rolling into the ed, bounding femoral pules felt, with hr of 130's. bp then 130/p. total coding time about 30 mins. . in ed femoral catheter placed, ? arterial placement but line gas and abg from radial artery obviously different lab results so appears to be in appropriate vein. cta was not ordered high ptt in the eds and ivc filter placed. pt never really hypotensive per ed records with lowerst bp recorded as 99/33. . of note, seroquel was recently increased to 50mg by np on and dilaudid 2mg to be taken tid was prescribed during this visit too due to poor pain control . unable to obtain ros as patient is intubated and unresponsive. . . in the ed, vs returned hr 110-130s; bp 110/50. past medical history: 1. chf--ar and mr endocardidtis () with medical tx, not surgical candidate for valve repair. echo showed lae, dilated rv/lv, lvef >60% (intrinsic depression given regurg). 4+ ar, 3+ mr, 2+ tr. pa systolic htn. known veg ao valve, coronary cusp--stable since 2. esrd on hd qt, r, sat --due to mixed gent and contrast-induced nephrotoxicity 3. chronic pe s/p ivc filter on lifelong coumadin 4. pvd s/p fem-post tib nonreversed saphenous vein graft -- c/b wound hematoma --> exploration /evacuation, ivc filter placed; chronic venous stasis ulcers 5. hbv and hcv 6. hypothyroidism 7. oa s/p bilateral tkr () c/b r septic joint --> redo 8. multiple psych issues including bipolar d/o with psychosis, narcotic dependence, anxiety d/o 9. hx of pericardial effusion with tamponade - resolved 10. mrsa carrier 11. prior aspiration events. 12. deep ulcers l leg 13. atrial fibrillation on anti-coagulation/rate control 14. multiple micu admissions to the micu for respiratory depression due to overnarcotizing 15. multiple aspiration pneumonias social history: lives at home in with her boyfriend, who spends his time taking care of her. she is on ssi. she is not able to walk, is transported in wheelchair by her husband, whom she cites as a strong support. no alcohol or drugs. ppd x 40 years tobacco. recently dc'd from rehab family history: nc physical exam: vs: t 98.3 (not recorded in other ed documentation), tc 98.6; bp 132/49; hr 100-120; rr 16-32; o2 sat 100% on abg: 7.28/31/348. ac 550*16, fio2 of 1.00; peep 5. gen: intubated, unresponsive. heent: perrla, sclera icteric, scleral edema. r ej in place. fast, rhythic jaw fasiculations. rigid platysma. no jvp cv: regular, nl s1, s2,3+systolic murmur, 2+diastolic murmur. lv heave. pulm: ctab, coarse inspiratory breath sounds abd: soft, obese, multiple scars, +bs. no organomegaly. ext: rle. no edema. weak dopp pulses. no pulses dopplerable lle. multiple ulcers on the lle, some down to the bone. necrotic tissue present. neuro: intubated, unresponsive without sedation. does not withdraw to pain. pertinent results: labs: 12:58pm blood wbc-9.4 rbc-3.63* hgb-11.2* hct-38.6 mcv-106*# mch-30.8 mchc-28.9* rdw-21.2* plt ct-155 04:19am blood wbc-9.7 rbc-3.34* hgb-10.3* hct-33.4* mcv-100* mch-30.9 mchc-31.0 rdw-22.3* plt ct-84* 12:58pm blood neuts-78* bands-0 lymphs-18 monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 nrbc-8* 12:58pm blood pt-22.5* ptt-150* inr(pt)-2.2* 12:58pm blood glucose-182* urean-26* creat-3.7*# na-131* k-4.7 cl-92* hco3-15* angap-29* 04:19am blood glucose-102 na-132* k-4.5 cl-97 hco3-20* angap-20 12:58pm blood ck(cpk)-33 07:25pm blood alt-29 ast-58* ld(ldh)-348* ck(cpk)-92 alkphos-277* amylase-65 totbili-1.1 02:36am blood alt-1066* ast-1522* alkphos-220* totbili-2.4* 07:25pm blood lipase-22 07:25pm blood ck-mb-notdone ctropnt-0.21* 04:00am blood ck-mb-16* mb indx-1.6 ctropnt-0.72* 07:25pm blood albumin-3.8 calcium-9.3 phos-5.1* mg-1.7 07:25pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:22pm blood type-art tidal v-550 fio2-100 po2-478* pco2-33* ph-7.19* caltco2-13* base xs--14 aado2-201 req o2-42 -assist/con intubat-intubated 02:30pm blood rates-16/0 tidal v-550 peep-5 fio2-100 po2-57* pco2-65* ph-7.04* caltco2-19* base xs--14 aado2-590 req o2-97 -assist/con intubat-intubated comment-green top 01:13pm blood glucose-167* lactate-8.6* na-130* k-5.7* cl-96* calhco3-18* . cxr on admission: no acute cardiopulm process . ekg on admission: aflutter 150, regular, borderline qt, leftward axis, st-t changes laterally. . ekg on floor: sinus arrythmia, rate 102. q's in iii. leftward axis. qtc 0.51 . ct head: 1. no hemorrhage. 2. poor differentiation of the grey-white matter may be seen in the setting of anoxic brain injury. correlate clinically. brief hospital course: 51f esrd on hd, pvd, valvular heart disease admitted to the micu s/p asystolic arrest of unknown etiology. . #s/p asystolic arrest: the patient was found down at home; 8 mins until cpr and then at least 30 mins until return of circulation. etiology. differential includes arrythmia (hyperkalemia, prolonged qt), large pe, overnarcosis, mi. cardiac enzymes are elevated but more likely demand than acs. serum and urine toxicology screens were negative. based upon her neuro status, in discussion with her family, the patient was made cmo after >72 hrs of observation. she expired shortly after extubation. . #neuro: unresponsive. s/p prolonged downtime (~8mins) with long resuscitation (30 min). evidence of severe anoxic brain injury on examination and head ct with loss of grey-white differentiation. neurology was consulted and recommended repeat examinations at initial time point and 72 hours after presentation given renal failure, fevers, and possibly effects of narcotics. there was no improvement and thus the prognosis for any neurologic recovery was extremely grim. . #respiratory: intubated due to asystolic arrest. overbreathing the vent due to acidosis. continue mechanical ventilation until terminally extubated. . #cv: . ischmemia: no cp per witness but did c/o sob which may be anginal equivalent. +trops but s/p cpr (no shocks), and st changes laterally when going 150 (? rate related). no cath in our system but abnormal stress test. cardiac enzymes were trended and troponin leak likely from hypotension during arrest rather than ruptured plaque. . pump: preserved ef. known chronic aortic valve vegetation but not a surgical candidate per multiple evaluations. . rhythm: h/o afib on anticoagulation. patient was in sinus arrhythmia at presentation with long qt. initial arrest may have been due to torsades and notably she is on seroquel and topamax as an outpatient. maintained k>4, mg>2. avoided qtc prolonging drugs. . #pvd: multiple non-healing chronic lle wounds. wound care team was consulted. . #id: ? infected ulcers given elevated wbc count and fevers. colonized by mrsa and esbl kliebsiella. also with uti and likely aspirated during arrest. she was treated with vanco/ceftriaxone for broad spectrum coverage. . #hematology: anticoagulated with coumadin for pe and chronic aortic valve vegetation. she was therapeutic on admission and then became supratherapeutic likely due to severe hepatic failure. coumadin was held. . #endocrine: riss. continued iv levothyroxine. . #renal: esrd on hd contrast/toxin nephropathy. renal was consulted and she was placed on cvvhd for management of anion gap lactic acidosis due to hypoperfusion. her ph on admission was 7.19 and normalized. she was removed from cvvhd given the stability of her metabolic status, poor prognosis due to severe brain injury, and decision to make cmo by family. . # contact: (daughter/hcp) #dispo: expired medications on admission: warfarin 2.5 mg po hs folic acid qday synthroid 150mcq q am trazadone 150mg qhs thiamine 100 qd topamax 100 qd cymbalta 30mg qd colace 100 mg asa 81mg qd lopressor 50mg tid seroquel 50mg oxycodone 20mg oxycodone 5mg q 4 hrs flovent 220mcg 2puffs combivent 2puffs quid senna prn discharge medications: none discharge disposition: expired discharge diagnosis: cardiac arrest hypoxic brain injury end stage renal disease discharge condition: expired discharge instructions: expired followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: End stage renal disease Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Atrial fibrillation Mitral valve insufficiency and aortic valve insufficiency Ulcer of other part of foot Cardiac arrest Anoxic brain damage Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta

allergies: codeine attending: chief complaint: mental status changes major surgical or invasive procedure: picc placement history of present illness: icu issue: hypotension . pcp: at health. . hpi: 51f with esrd on hd, valvular heart disease(4+ar, 3+mr), dvt on coumadin, now with hypotension on the medical floor starting this morning. she initially presented with fever and weight gain from dialysis. she was started on vanc/unasyn empirically to cover possible line infection or infxn from le ulcers. in ed, she had fever to 100.7, wbc 12.2, lactate was 2.0. at dialysis prior to admission, she had 6l dialyzed off with pre wt 111kg, post 105. bp pre, 128/78 post. the pt denies fevers, chills, cough, abd pain, she makes no urine. over the course of the night bp was trending down. at 11pm it was noted to be 98/47, in the morning rounds was 85/43. the pt has had no fevers since the ed, wbc down to 9.4 this am from 12.2. of note, the pt received lisinopril 20' this am at 0800. pt was clinically alert and oriented while sitting up in a chair. vitals on icu arrival: t 98.2, 97/38 p92 rr 15 100 on 3l. her sats were 94% on ra on floor. . micu course: : admitted for hypotension. received ivf. bp stable. . abx: ceftaxadime . ros: all systems were reviewed and were negative except for aforementioned in the hpi. . . past medical history: 1. chf--ar and mr endocardidtis () with medical tx, not surgical candidate for valve repair. echo showed lae, dilated rv/lv, lvef >60% (intrinsic depression given regurg). 4+ ar, 3+ mr, 2+ tr. pa systolic htn. 2. esrd on hd qt, r, sat --due to mixed gent and contrast-induced nephrotoxicity 3. chronic pe s/p ivc filter on lifelong coumadin 4. pvd s/p fem-post tib nonreversed saphenous vein graft -- c/b wound hematoma --> exploration /evacuation, ivc filter placed; chronic venous stasis ulcers 5. hbv and hcv 6. hypothyroidism 7. oa s/p bilateral tkr () c/b r septic joint --> redo 8. multiple psych issues including bipolar d/o with psychosis, narcotic dependence, anxiety d/o 9. hx of pericardial effusion with tamponade - resolved 10. mrsa carrier other psh: 1. s/p ccy 2. s/p c-section social history: lives at home in with her husband, who spends his time taking care of her. she is on ssi. she is not able to walk, is transported in wheelchair by her husband, whom she cites as a strong support. no alcohol or drugs. ppd x 40 years tobacco. family history: nc physical exam: t 98.2, 97/38 p92 rr 15 100 on 3l. her sats were 94% on ra on floor comfortable at rest. neck supple, jvd elevated carotid upstroke nl, no bruit heart: rrr, loss of s2 with ii/vi systolic murmur as well as early diastolic murmur. chest: coarse bs throughout crackly at bases. soft, non tender, nl bs. extreme: thick, scaly dry cracked skin with multiple ulcers bilateral le. neuro: alert&oriented x 3, maew pertinent results: . cxr: (prelim read) worsening mild pulmonary edema. r ij dialysis cath in good position. . ecg: sr at 90 bpm with nl axis/intervals, non-specific tw changes . ct head: ct of the head with contrast: the examination is slightly limited by patient motion, particularly in the posterior fossa. the presence or absence of acute hemorrhage cannot be assessed in the presence of contrast, though no gross hemorrhages are apparent. there is no shift of the normally midline structures. the ventricles and cisterns are unchanged. the density values of the brain parenchyma are normal, without definite areas of pathologic enhancement. there is appropriate opacification of the intracerebral structures. the visualized paranasal sinuses are well aerated, with a tiny mucus retention cyst versus polyp in the medial aspect of the left maxillary antrum. the mastoid air cells are clear. osseous and soft tissue structures are unremarkable. impression: no areas of pathologic enhancement within the brain are detected on this limited exam. please note that mri with diffusion weighted imaging and gadolinium administration is more sensitive for the detection of intracranial pathology, including infarction. .. echo: conclusions: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated. there is mild global right ventricular free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened. there is a moderate-sized vegetation on the aortic valve (right coronary cusp). there is no valvular aortic stenosis. the increased transaortic gradient is likely related to aortic regurgitation. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. moderate to severe (3+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the prior study (images reviewed) of , no major change. 06:00pm blood wbc-12.2*# rbc-3.57* hgb-11.2* hct-35.7*# mcv-100* mch-31.3 mchc-31.3 rdw-18.4* plt ct-290# 06:00pm blood pt-22.2* ptt-69.7* inr(pt)-2.2* 06:35am blood fibrino-420* 06:00pm blood glucose-94 urean-10 creat-2.5*# na-137 k-4.1 cl-94* hco3-31 angap-16 06:00pm blood alt-11 ast-16 ld(ldh)-218 alkphos-243* totbili-0.4 06:00am blood calcium-8.4 phos-2.9 mg-1.5* 06:00pm blood acetone-negative 06:00am blood tsh-5.5* 06:17am blood free t4-0.90* 06:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 05:52am blood wbc-7.8 rbc-3.89* hgb-11.8* hct-38.4 mcv-99* mch-30.5 mchc-30.9* rdw-18.1* plt ct-235 05:56am blood pt-23.3* ptt-36.6* inr(pt)-2.3* 05:52am blood glucose-86 urean-23* creat-6.1* na-134 k-4.3 cl-96 hco3-25 angap-17 06:00am blood tsh-5.5* 06:30am blood pth-103* brief hospital course: assessment/plan: 51f with esrd on hd, valvular heart disease(4+ar, 3+mr), dvt on coumadin, with mental status changes. . micu course: patient initially admitted to with volume overload but transferred patient with hypotension and hypoxia to the micu. was treated with ivf as necessary as well as empiric abx (vancomycin and ceftazadime) for seven days. improved without knowing source of infection but also without pressor need. . on floor, # mental status- waxed and waned throughout stay, thought to be better with lightening of narcotics and continued dialysis. multiple ct heads negative.she did have two episodes of aspiration pna associated with starting pos during which her mental status declined. her mental status improved, however with tx. with vanc/ceftazadime/flagyl. upon discharge, she still has some transient episodes of confusion +/- myoclonus, which husband reports she has had longstanding prior to admission, likely narcotics, but risks and side effects explained to pt. and will tolerate given pain needs. # line infection: blood cx. now growing staph coag negative, ?contamination, but given h/o endocarditis, indwelling line, must assume it is real and treated for bacteremia through line x 10d. last day vanc was . she was afebrile and follow up cultures negative at time of discharge. . # hypotension: basline bps in 80s-100s, stable throughout her stay on the floor . # mild hypoxia: concern for aspiration initially, temporary mild o2 requirement, which resolved with reatment of aspiration pneumonia . #. esrd - second to gent and contrast induced nephropathy. history of missing dialysis. she received dialysis on tuthsa cycle. she will receive outpt. dialysis similarly. . # tenderness at catheter site: no pus, erythema, but some focal tenderness along site, which may represent simple pain from line itself. cx. off line, which is still ngtd upon discharge. . # endocarditis: echo shows a moderate-sized vegetation on the aortic valve (right coronary cusp). this is old and unchanged from previous echo in . pt is not a surgical candidate and is on chronic anticoagulation. blood cultures were all negative during hospitalization other than 1 coag negative staph, which was treated as line infection through line. her inr was labile given concurrent antibiotic use. she was discharged on 7.5 mg coumadin with a therapeutic inr, furhter inrs to be drawn at dialysis. . # leg wounds/pvd - /plastics consulted and patient not a candidate for surgery. wound care consulted and appreciate recs. - dilaudid prn as needed for severe pain, otherwise will limit narcotics to improve mental status. . # pain control- with improved mental status and activity, feeling some increased pain overall during day. transitioning to pos as pt. will need to be on pos for discharge. stable pain control on current regimen with occasional episodes of confusion and myoclonus - oxycontin to 30, 30, 60 to cover night a bit better. - 4mg po hydromorphone prn breakthrough . # psych issues: bipolar d/o with psychosis, narcotic dependence, anxiety d/o - continue topirimate, quetiapine # hypothyroidism: continue home meds. # fen/code status: spoke for a long time with family as did dr. (see omrnote) and pt. is firmly focused on quality of life, of which food is a big part. her husband, who is hcp and she understand risks of aspiration and would still like to eat. liberalized diet as has been tolerating, and husband was bringing her food anyways. she and her husband agreed during these discussions that given her high risk for aspiration and possibility of needing future intubation should she aspirate, that she would like to be dnr/dni and focus on quality of life, which was to include antibiosis, dialysis and the possibility of short future hospitalizations, but would also include continued pos. she was discharged home with services with outpt. dialysis medications on admission: meds: 1. aspirin 81 mg tablet qd 2. docusate sodium 100 mg 3. folic acid 1 mg tablet qd 4. albuterol sulfate 0.083 % solution q6h prn 5. pantoprazole 40 mg tablet qd 6. duloxetine 30 mg capsule, delayed release(e.c.) qd 7. topiramate 100 mg tablet qd 8. warfarin 5 mg tablet qhs 9. combivent 1 puff qid prn 10. b complex-vitamin c-folic acid 1 mg capsule qd 11. gabapentin 300 mg capsule qd 12. quetiapine 25 mg tablet 14. levothyroxine 150 mcg tablet qd 15. ascorbic acid 500mg qd 16. thiamine 100mcg qd 17. lisinopril 20mg qd 18. metoprolol 12.5mg 19. spiriva 1 puff qd 20. trazodone 150mg qd 21. dilaudid 2mg qd discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. duloxetine 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* 4. topiramate 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. trazodone 50 mg tablet sig: three (3) tablet po hs (at bedtime). disp:*90 tablet(s)* refills:*0* 8. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 9. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). disp:*30 cap* refills:*2* 11. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. disp:*60 nebs* refills:*2* 13. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. disp:*1 bottle* refills:*2* 14. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 15. gabapentin 300 mg capsule sig: one (1) capsule po at bedtime. disp:*30 capsule(s)* refills:*2* 16. cortisone 1 % cream sig: one (1) appl topical qid (4 times a day): to affected area. disp:*1 tube* refills:*2* 17. oxycodone 10 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qam and qpm (). disp:*56 tablet sustained release 12hr(s)* refills:*0* 18. oxycodone 20 mg tablet sustained release 12hr sig: three (3) tablet sustained release 12hr po qhs (once a day (at bedtime)). disp:*56 tablet sustained release 12hr(s)* refills:*2* 19. hydromorphone 4 mg tablet sig: one (1) tablet po q3-4h as needed. disp:*90 tablet(s)* refills:*0* 20. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. disp:*1 bottle* refills:*2* 21. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 22. folic acid 1 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 23. warfarin 2.5 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*0* 24. oxycontin 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qam and qpm: take together with 10mg dose in am and pm for a total dose of 30mg each qpm and qam. disp:*56 tablet sustained release 12hr(s)* refills:*0* 25. hexavitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: hypotension esrd aspiration pneumonia . chf hepatitis endocarditis chronic anticoagulation skin ulcers, non-healing discharge condition: fair, mental status improved, tolerating pos, satting well on ra, mobile in wheelchair without assistance discharge instructions: you were admitted for suspected infection and aspiration pneumonia. you have gotten dialysis and antibiotics and have improved. we have also adjusted your pain regimen to optimize your wakefulness and pain control while minimizing your chances for aspiration. . you should return to the ed if you have any vomiting, fever, chills, chest pain, shortness of breath, confusion, or any other concerning symptoms. take all medications exactly as prescribed and follow up as below take your coumadin as directed and adjust per your pcp. followup instructions: you should follow up with your primary care physician weeks by calling (dr. . you will need to have your inr checked at that time. Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Hemodialysis Diagnoses: End stage renal disease Congestive heart failure, unspecified Toxic encephalopathy Chronic hepatitis C without mention of hepatic coma Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Pneumonitis due to inhalation of food or vomitus Bacteremia Infection and inflammatory reaction due to other vascular device, implant, and graft Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Ulcer of other part of lower limb Endocarditis, valve unspecified, unspecified cause

history of present illness: the patient is a 76-year-old male who presented to the emergency room with worsening abdominal pain, nausea, and vomiting x 4. the patient had recently been undergoing an evaluation for painless jaundice. in early the patient had an abdominal ct at an outside hospital which demonstrated intrahepatic ductal dilatation. on the patient came to and underwent an ercp by the gi team which demonstrated a pancreatic duct stricture, which was compatible with a mass, a biliary stricture, and a stent placement in the biliary system. the patient tolerated this procedure well and during the admission when told that the most likely was cancer, signed out against medical advice. at home over the next several days the family reported the patient developed worsening abdominal pain accompanied with nausea and vomiting. when this continued to worsen the family brought the patient to the emergency room for further evaluation. past medical history: 1. hypertension. 2. hypercholesterolemia. past surgical history: none. allergies: the patient has no known drug allergies. medications on admission: unknown. physical examination: on admission the patient was tachycardic with a blood pressure of 110/41. he was alert but agitated. the chest was clear. heart was regular but tachycardic. he had diffuse abdominal tenderness with guarding and rebound. the rectal examination was normal and guaiac negative. laboratory data: white count 13, hematocrit 46, inr 2.1, bun 80, creatinine 4.9, bicarbonate 11, alt 84, ast 91, alkaline phosphatase 545, bilirubin 10. chest x-ray demonstrated the possibility of free air overlying the epigastrium. hospital course: due to the presentation of an acute abdomen following an ercp and the possibility of free air the patient was emergently taken to the operating room where he underwent an exploratory laparotomy. a duodenal perforation was discovered and repaired with oversewing and patch. at that time also a jejunostomy tube was placed. the biliary stent was removed and a t tube was placed as well. a liver biopsy was taken as well. the patient remained tenuous during the perioperative period. in the operating room he received two units of packed cells, three units of fresh frozen plasma, 3,000 of crystalloid. he did continue to make urine and was postoperatively taken to the surgical intensive care unit for close hemodynamic monitoring. during the early postoperative course the patient's hemodynamics were maintained with neo-synephrine pressor support. the patient demonstrated improvement over the ensuing days and the pressor support was weaned. the hematocrit remained stable. the patient's renal function improved with a significant drop in the creatinine. as the patient improved, the respiratory support was weaned as well as tolerated. during this time with the sedation weaned the patient would follow commands and appeared to be neurologically intact. by postoperative day three the patient was extubated. the jejunostomy tube feeds were started and advanced to goal. the patient was maintained on broad-spectrum antibiotics. on postoperative day number six the patient was transferred to the floor. on the floor the patient had a temperature spike which prompted a work-up and a cat scan was performed. the patient demonstrated multilocular retroperitoneal fluid collection. he underwent a ct-guided drainage and the cultures demonstrated from this collection. the patient was started on ambisome iv. infectious disease was consulted and the patient was maintained on the broad-spectrum antibiotics as before as well. the patient defervesced and a follow-up cat scan done prior to discharge demonstrates that the fluid collections have decreased in size. the patient will be discharged with drains in place. the patient was evaluated by physical therapy, has been ambulating with no assistance and will not require intensive rehabilitation. the patient's tube feeds have been cycled at night and the patient has been allowed to advance to a house diet which he has tolerated. the patient prior to discharge underwent a t-tube cholangiography to examine the placement of the t-tube and the anatomy of the biliary tree. this was normal with good contrast entering the duodenum and the t-tube was capped prior to discharge, which he has tolerated. the patient's family had multiple meetings with his doctors regarding the of presumed cancer. the patient's family and the patient understand that without definitive tissue , the prognosis is unclear. the patient also does not want any further invasive therapy at this time. the family would rather have the patient be discharged to home, recover from his current illness, and reassess the situation at a later time during a follow-up visit. arrangements are being made for a visiting nurse. the patient will be discharged home with vna and cycled tube feedings at night. discharge diagnoses: 1. biliary stricture which is presumably a carcinoma but with no definitive tissue . 2. duodenal perforation and repair. 3. malnutrition. 4. abdominal fungal abscess. 5. hypertension. discharge medications: 1. levofloxacin 500 mg p.o. q.d. to be continued for one week after drains have been removed. 2. flagyl 500 mg p.o. t.i.d. to be continued for one week after drains have been removed. 3. fluconazole 400 mg p.o. q.d. to be continued until the drains have been removed. 4. lansoprazole 30 mg p.o. q.d. 5. flomax 0.4 mg p.o. q.d. 6. albuterol inhaler 4 puffs q. 6 hours p.r.n. 7. dilaudid 2 mg p.o. q. 4 hours p.r.n. 8. colace 100 mg p.o. b.i.d. 9. the patient will continue on medications as before. discharge instructions: 1. wet-to-dry dressing changes to the abdominal wound b.i.d. 2. drainage catheters #1 and #2 to gravity with daily volume recording. 3. tube feedings from 7 pm to 7 am which would be promod with fiber 70 ml per hour. 4. two cans of boost per day. 5. diet as tolerated. 6. jejunostomy tube should remain clamped during the day. 7. t-tube should be capped and remain underneath the dressing. 8. no showers, but sponge baths as tolerated. 9. activity as tolerated. 10. continue antibiotics and antifungals as directed. follow up: the patient will follow up with dr. in the clinic in one week. condition on discharge: stable. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other enterostomy Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Removal of T-tube, other bile duct tube, or liver tube Suture of duodenal ulcer site Other cholangiogram Open biopsy of liver Exploration of common duct Diagnoses: Pneumonia, organism unspecified Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified protein-calorie malnutrition Iatrogenic pneumothorax Other specified disorders of biliary tract Mechanical complication due to other implant and internal device, not elsewhere classified Cholangitis Malignant neoplasm of pancreatic duct

technique: multiple axial images from the lung bases to the pubic symphysis were obtained following the administration of oral contrast as well as 150 cc of optiray due to patient history of allergies. abdomen with contrast: small bilateral pleural effusions are slightly decreased in size in the interval. there is minimal dependent atelectasis bilaterally. slight prominence of the central biliary tree is again noted. there are several tiny foci of gas within biliary tree in the left lobe of the liver, and a biliary stent is seen. the spleen, pancreas, gallbladder, adrenal glands and kidneys are unchanged in appearance in the interval. a moderate amount of fluid persists within the abdomen, not substantially changed in quantity or configuration since the previous exam. the larger of the two right upper quadrant drains has been removed in the interval, and the smaller is in unchanged position. percutaneous feeding tube is present. pelvis with contrast: two right lower quadrant pig-tail drains are new in the interval and reside within the largest of the extensive, loculated rim- enhancing fluid collections, slightly decreased in size in the interval. soft tissue surrounding the aorta and iliac branches is unchanged. the bladder is unremarkable. bone windows: there are no suspicious lytic or sclerotic bony lesions. impression: perhaps slight improvement in degree of extensive enhancing fluid collections within the pelvis after pig-tail drain placement. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other enterostomy Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Removal of T-tube, other bile duct tube, or liver tube Suture of duodenal ulcer site Other cholangiogram Open biopsy of liver Exploration of common duct Diagnoses: Pneumonia, organism unspecified Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified protein-calorie malnutrition Iatrogenic pneumothorax Other specified disorders of biliary tract Mechanical complication due to other implant and internal device, not elsewhere classified Cholangitis Malignant neoplasm of pancreatic duct

history of present illness: this is a 77 year old man with a history of obstructive jaundice since . in , the patient was discovered to have painless jaundice. a endoscopic retrograde cholangiopancreatography was performed and stent was placed. several days later, the stent eroded and the patient developed an acute abdomen. he underwent an exploratory laparotomy by dr. , during which the stent was removed and a repair of the duodenal perforation was performed as well as placement of an 8french t-tube. the patient was in his usual state of health until one day prior to admission when his t-tube accidentally fell out of his side. he also complained of some low grade fevers while he was at home. so the patient had been in his usual state of health until one day prior to admission when apparently the t-tube came out. he denies any pain and he did have the low grade fevers up to 101.7. he denies any nausea, vomiting, diarrhea or constipation. past medical history: in addition to the suspected ampullary adenocarcinoma, the patient also has hypertension and hypercholesterolemia. he has the prior surgical history of the exploratory laparotomy in . medications on admission: he takes no medications at home. allergies: he has no known drug allergies. social history: he lives with his wife and daughter. does have a positive smoking history. no alcohol use. physical examination: the patient on presentation was afebrile with a heart rate of 112, blood pressure 99/69, respiratory rate 18, oxygen saturation 96%. the patient did not seem in any acute distress. he had a regular rate and rhythm and lungs were clear to auscultation bilaterally. his abdomen was soft, nontender, nondistended. the right upper quadrant t-tube site was in place without any drainage. he did have a j-tube in the left upper quadrant. his extremities were warm with no edema. laboratory data: his laboratories showed a white blood cell count of 8.9, hematocrit 35.3, platelet count 345,000. he did a left shift of his white blood cell count with 90% neutrophils. sodium was 133, potassium 4.1, chloride 96, bicarbonate 25, blood urea nitrogen 38, creatinine 1.4 and glucose 145. his current liver function tests revealed alt 193, ast 182, alkaline phosphatase 640, total bilirubin 1.1, amylase 55, lipase 41. coagulation factors showed prothrombin time 12.4, partial thromboplastin time 26.6, inr 1.0. incidentally, his ca19-9 level is 82. hospital course: the patient was admitted to surgery and given intravenous antibiotics, linezolid, fluconazole and levofloxacin and a cat scan was performed. the cat scan showed a significant amount of intrahepatic ductal dilatation with a persistence of the mass in the porta hepatis compressing the hepatic duct. there were no fluid or air collections indicating abscesses and stable abdominal aortic aneurysm. the patient was followed with serial examinations over the next 24 hours but unfortunately on hospital day two, the patient acutely decompensated with shortness of breath, decreasing oxygen saturation with increasing heart rate to approximately 160. on physical examination, the patient had wet sounding lungs and looked in significant distress. he was transferred to the intensive care unit where a swan-ganz catheter was placed. the patient was also intubated. an echocardiogram at this time revealed an ejection fraction of only 25% with diffuse left ventricular hypokinesis. troponin levels were increased at this time. a chest x-ray showed marked bilateral pleural effusions which was confirmed in a cta that was performed afterwards that also showed the bilateral pleural effusions but did not show any sign of pulmonary embolus. over the next few days, the patient received multiple transfusions with packed red blood cells and required pressors for hemodynamic stabilization. on , which was hospital day seven, the patient was doing better hemodynamically and was finally extubated which he tolerated well. in addition, tube feeds were begun at this time. on , hospital day twelve, the patient was transferred to the floor. at this time, he was already on goal tube feeds. he appeared well. he appeared chronically ill but was stable with respect to his pulmonary status and his respiratory status, his pulmonary status and cardiovascular status and hemodynamically he was also stable. on , cholangiography was performed. this revealed an obstructive stricture in the common bile duct with associated dilation of the intrahepatic ducts. multiple biopsies were sent that did not reveal any tumor. a percutaneous biliary drain was placed traversing the strictured area. this drain was left to drainage and drained well. it drained bilious material afterwards. the bilious material was sent for culture and grew back enterococcus. this enterococcus was sensitive to vancomycin. it should be noted that this is the only positive culture that the patient had during his hospital stay. on the day of discharge, the patient appeared well and was tolerating his tube feeds without complication. his heart rate was regular rate and rhythm, lungs were clear to auscultation bilaterally. the abdomen was soft, nontender, nondistended with the drain in place draining bilious material. the patient's extremities were warm with no cyanosis, clubbing or edema. although the patient had been seen by physical therapy and was recommended for rehabilitation, the patient and his family refused rehabilitation and the patient was discharged home in stable condition on , hospital day number seventeen. final diagnoses: 1. status post percutaneous transhepatic catheter placement. 2. hypoxia and respiratory distress requiring intubation. 3. congestive heart failure. 4. myocardial injury. 5. atrial fibrillation. 6. chronic blood loss anemia requiring transfusion. 7. hypokalemia. 8. hypomagnesemia. 9. hemodynamic monitoring with swan-ganz catheter. medications on discharge: 1. levofloxacin 500 mg p.o. q24hours for one week. 2. fluconazole 400 mg p.o. once daily for one week. 3. he was also recommended to start his prior medications that he was taking before admission. he could not remember these so he was recommended to follow-up as soon as possible with his primary care physician to coordinate his home medication regimen for hypertension and hypercholesterolemia. in addition, he was recommended to follow-up with dr. office to arrange a follow-up appointment in about two weeks. the patient was recommended to continue his tube feeds at home with the same rate that he was taking before this admission. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Pulmonary artery wedge monitoring Other percutaneous procedures on biliary tract Percutaneous biopsy of gallbladder or bile ducts Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Other primary cardiomyopathies Mitral valve disorders Congestive heart failure, unspecified Unspecified septicemia Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Other shock without mention of trauma Acute myocardial infarction of unspecified site, initial episode of care Cholangitis

history of present illness: the patient is a 48 year old female with past medical history of ethanol abuse, hypertension, chronic pancreatitis, narcotic abuse, recurrent falls. on , she was found at home on the floor unresponsive with agonal breathing and diffuse bleeding. she was brought to the emergency department where she was intubated for airway protection and treated for possible drug overdose. on head ct she was found to have a subarachnoid hemorrhage, subdural hemorrhage with midline compression and a large intraparenchymal pontine hemorrhage. physical examination: on examination on admission, she was found to be unresponsive to verbal stimuli. head, eyes, ears, nose and throat examination revealed a left facial and periorbital edema, left subconjunctival hemorrhage. the pupils are 2.0 millimeters, fixed and nonreactive, no doll's eyes, positive corneal reflex, slight gag reflex. neurologically, she had posturing of bilateral arms plus left lower extremity to painful stimuli. toes were bilateral upward. left ankle clonus greater than right ankle clonus. cardiovascular - regular rate and rhythm. respiratory was clear to auscultation bilaterally. the abdomen was soft. laboratory data: her laboratories were unremarkable. serum ethanol 136. positive urine benzodiazepine. the rest of the toxicology screen was negative. hospital course: neurosurgery was consulted and it was determined that there were no therapeutic options at this time. family decided that under the circumstances, this patient should be made comfort measures only, no fluids, no blood draws, will keep comfortable. her hospital course was uneventful. the patient was comfortable throughout hospitalization. over the course of days, she was in the micu in the beginning and transferred from the micu to the floor. she was kept comfortable with intravenous morphine. she also had a scopolamine patch placed q72hours for reduction of airway secretions. on , her respirations started to slow and on , this patient passed away. the family was present. the attending was notified. cause of death: respiratory arrest secondary to dehydration and sepsis and renal failure. the precipitating cause of death was severe brain injury secondary to fall and/or seizure at home. dr., 11-398 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Acute respiratory failure Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Chronic pancreatitis Other and unspecified alcohol dependence, unspecified Fall from roller skates

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p pedestrian struck by auto major surgical or invasive procedure: orif right knee reconstruction ivc filter placement history of present illness: 23 yo female pedestrian who was struck by auto traveling at unknown rate of speed; initialy combative at scene requiring intubation for airway protection. she was transferred to via for continued trauma care. past medical history: none known family history: noncontributory physical exam: upon admission: hr 65 bp 141/72 rr16 paralyzed, intubated heent: perrla neck: c-collar chest: cta bilat cor: rrr abd: soft, nd fast negative rectum: tone decreased pelvis; blood out of vagina; stable extr: left femur fracture; pulses palp lle; right unstrable knee with palp pulses rle pertinent results: 07:10am glucose-107* urea n-7 creat-0.5 sodium-136 potassium-3.9 chloride-112* total co2-24 anion gap-4* 07:10am calcium-8.0* phosphate-4.0 magnesium-1.6 07:10am wbc-13.2* rbc-3.22* hgb-8.6* hct-24.9* mcv-77* mch-26.8* mchc-34.7 rdw-17.7* 07:10am plt count-310 07:10am pt-14.8* ptt-30.5 inr(pt)-1.3* ct pelvis: impression: 1. multiple fractures are seen involving the pelvis, as described above. 2. there is no evidence of intra or extraperiotneal contrast extravasation from bladder injury. however, there is a tiny amount of fluid anterior to the bladder in the region of the pubic symphysis, and given the presence of pelvic fractures, even though contrast extravasation is not identified, a small extraperitoneal bladder injury is not definitely excluded. 3. there is an area of low attenuation along the medial aspect of the kidney, which may represent a small laceration. there is no significant perinephric fluid or evidence of hematoma. 4. there is some dense material within the region of the vagina, and may represent a small amount of blood - correlation with clinical examination is recommended. 5. small areas of lung parenchymal opacity which may reflect aspiration or contusion. femur (ap & lat) left 1:46 am lower extremity fluoro without; femur (ap & lat) left reason: left femur fx repair left femur, seven views. indication: left femur fracture repair. findings: comparison to at 1:20 a.m. seven intraoperative radiographs of the left femur demonstrate open reduction and internal fixation of a comminuted left proximal femoral diaphyseal fracture with an intramedullary rod and gamma nail. two distal interlocking screws are seen. no immediate hardware complication is noted. there is gas in the soft tissues. impression: intraoperative radiographs demonstrating open reduction internal fixation of a comminuted proximal left femoral fracture with intramedullary rod and gamma nail. ct low ext w/o c bilat 12:13 am ct low ext w/o c bilat reason: s/p struck by car; evaluate femoral, pelvic fx's medical condition: 20 year old woman s/p struck by car reason for this examination: l. femur fx contraindications for iv contrast: none. indication: struck by car. left femur fracture. comparison: none. technique: mdct-acquired images of the pelvis and femurs were obtained with coronal and sagittal reformatted images. preliminary report: "comminuted intertrochanteric fracture of the left femur. right lateral tibial plateau and fibular head fracture. left sacral ala fracture. bilateral pubic rami fractures. discussed with dr. at 1 a.m. on . " ct of the pelvis and bilateral femurs: there is a fracture of the left l5 transverse process with 3 mm of separation. there is a fracture of the left sacrum that extends in an antero-postero direction with involvement of the left s1 neural foramen. there is a comminuted fracture of the left superior pubic ramus and a comminuted, segmental fracture of the left inferior pubic ramus that is minimally displaced. there is a minimally displaced comminuted fracture of the right superior pubic ramus at the level of the symphysis pubis. the femoral heads are normally seated in the acetabula bilaterally. there is a complex, comminuted fracture of the left femur with at least two butterfly fragments with extension through the superior aspect of the greater trochanter, through the intertrochanteric and subtrochanteric regions. there is external version of the left distal femur and proximal tibia and fibula. no definite left knee effusion is demonstrated. there is a right knee lipohemarthrosis. there is a fracture of the right lateral tibial plateau with fragment measuring approximately 7 mm that is distracted in a superior and lateral orientation by approximately 6 mm. there is a comminuted fracture of the right fibular head. there is a large soft tissue defect in the left superior thigh musculature with multiple of air in this region within the surrounding soft tissues. there is packing material within this defect. there is a foley catheter present within the bladder. the bladder is better evaluated on the contrast- enhanced ct torso performed on the same day. impression: 1. left sacral fracture with an antero-postero orientation involving at least the left s1 neural foramen. 2. bilateral superior pubic rami fractures and left segmental inferior pubic ramus fracture. 3. complex comminuted left femur fracture with external version of the distal femur and tibia-fibula. 4. right lateral tibial (likely avulsion-type) fracture with comminuted right fibular head fracture and right lipohemarthrosis. this constellation of findings raises the possibility of a posterolateral corner injury. 5. left l5 transverse process fracture. radiology final report knee (2 views) left 5:22 pm knee (2 views) left reason: r/o fracture or other process medical condition: 20 year old woman s/p struck by car, now post op from r knee ligamentous repair , now with left knee pain with wb and point tenderness reason for this examination: r/o fracture or other process left knee, two views. indication: 20-year-old woman struck by car, now postoperative from ligamentous repair. left knee pain. findings: distal aspect of a left femoral intramedullary rod and two distal interlocking screws is visualized. skin clips are noted laterally. no acute fracture or dislocation is seen. no lytic or sclerotic lesion is seen. the soft tissues are unremarkable. no joint effusion is noted. impression: no acute fracture or dislocation. distal aspect of left femoral intramedullary rod is incompletely visualized. brief hospital course: patient admitted to the trauma service. orthopedic trauma surgery was consulted for a left open pelvic fracture, left sacral fracture, left femur fracture, l5 transverse process fracture, and fracture of the right lateral tibial plateau and fibular head found on x-ray. orthopedic surgery performed an orif of left femur, repair of left pelvis, and placement of ivc filter. she required 2 units prbc's on for a hematocrit of 19, her most recent cbc from shows a stable hematocrit of 28. on orthopedic surgery performed re-construction of her right knee dislocation with irrigation and debridement. post operatively her pain was managed with a morphine pca, she is now taking percocet around the clock with improvement of pain control. she is to remain non-weight bearing on right lower extremity for 6-8 weeks, with weight bearing as tolerated on left leg. she experienced intermittent fevers and cultures were sent. culture from left hip wound showed enterococcus, which was sensitive to ampicillin; she will require antibiotic treatment for 10 days, stop date . she had difficulties voiding when foley catheter was initially removed and needed to be replaced, subsequently she is complaining of dysuria, urinalysis was sent and results are pending at the time of this dictation. physical therapy has been consulted and recommends short term rehab. medications on admission: none discharge medications: 1. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q12h (every 12 hours) for 4 weeks. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools. 3. ampicillin 500 mg capsule sig: one (1) capsule po every six (6) hours for 6 days. 4. dulcolax 5 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po twice a day as needed for constipation. 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours): give around the clock. 7. oxycodone-acetaminophen 5-325 mg tablet sig: two (2) tablet po once mr1 (once and may repeat 1 time): give prior to rehab sessions. 8. milk of magnesia 800 mg/5 ml suspension sig: po twice a day as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: s/p pedestrian struck left femoral shaft facture right tibial plateau fracture right fibular head fracture extrperitoneal bladder rupture left renal laceration left pubic ramus fracture left sacral ala fracture left l5 transverse process fracture discharge condition: stable discharge instructions: follow up with dr. , othopedics in 2 weeks. do not bear any weight on your right leg. you may bear weight as tolerated on your left leg. continue with your antibiotics until and then discontinue after your last dose on that day. continue with your lovenox injections for a total of 4 weeks. followup instructions: call for an appointment with dr. to be seen in 2 weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Open reduction of fracture with internal fixation, femur Debridement of open fracture site, femur Transfusion of packed cells Closed reduction of fracture without internal fixation, tibia and fibula Other repair of the collateral ligaments Other repair of the cruciate ligaments Diagnoses: Other postoperative infection Acute posthemorrhagic anemia Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Retention of urine, unspecified Urinary complications, not elsewhere classified Closed fracture of lumbar vertebra without mention of spinal cord injury Open fracture of subtrochanteric section of neck of femur Open fracture of pubis Closed fracture of sacrum and coccyx without mention of spinal cord injury Injury to kidney with open wound into cavity, laceration Closed fracture of upper end of fibula with tibia Closed fracture of shaft of femur

history of present illness: the patient is an 83-year-old female, nursing home resident status post a fall on with left hip and left knee pain. the patient has had a left hip replacement and revision in the past, is now here with a left acetabular shell loosening. past medical history: coronary artery disease, status post cabg in , status post aortic valve replacement in , status post tah bso, history of dvt, history of increased inr on coumadin with a history of a left leg hematoma, history of lymph node cancer in the abdomen, diverticulitis, falls, possible hypertension. allergies: no known drug allergies. medications: upon presentation to hospital, coumadin, lopressor, lasix, zestril, aleve. social history: the patient supposedly lives at home with home health aide and uses a motorized wheelchair. the patient has a 10 pack year smoking history and quit 40 years ago. physical examination: upon presentation to the hospital, patient's temperature was 97.9, blood pressure 108/96, pulse 64, respirations 16, 98% on room air. patient with no apparent distress. pupils were equal, round and reactive to light. neck was supple. lungs clear to auscultation bilaterally. tenderness over left knee, not thigh. hip, range of motion was limited, lower left extremity with shortening, sternally rotated. patient's dorsalis pedis and posterior tibial pulses were not palpable. needed to be evaluated by doppler. x-ray upon presentation showed a loose acetabular shell with a question of a loose femoral head. the patient was on anticoagulation due to her aortic valve replacement, thus was waiting for her coagulation factors to be more optimal for operative management of her hip. during the waiting period for this, patient suddenly started complaining of right lower quadrant abdominal pain with slight nausea but no vomiting. the patient also began to have some guaiac positive diarrhea. on exam the patient had newly noted right lower quadrant mass 6 by 6 cm. the patient was also diaphoretic and cool. patient's temperature dropped to 94, lactate was 17.5, hematocrit 20 which dropped earlier in the day on from 29.3. the patient was transferred to the micu for evaluation for decreased hematocrit, decreased blood pressure. the patient at that point in time also had an ng tube that elicited approximately 200 cc of coffee ground emesis that cleared with 200 cc of saline. it was found upon further evaluation that patient was having a brisk lumbar artery bleed secondary to her fall. she is currently status post an embolization by interventional radiology for the fall. patient remained in the micu from to and then was transferred to the medicine floor. laboratory data: upon presentation to the hospital, white count was 13, hematocrit 29, inr 4.3, ptt 150, esr 77, crp 2.1. urinalysis was negative for nitrites, white blood cells per high power field. chem 7, sodium 136, potassium 4.9, chloride 100, co2 24, creatinine 2.0, glucose 230. hospital course: 1. ortho: the patient is status post fall on with an acetabular shell slippage and a question of a fem loosening. this fall was complicated by a retroperitoneal bleed from lumbar artery bleed. she is currently status post embolization, interventional radiology. the patient's orthopedic issues have not been fully treated due to patient's more acute issues during . upon discharge from hospital patient's orthopedic issues still were not treated due to patient's need for continued rehabilitation secondary to hypovolemic shock. for questions concerning orthopedic follow-up, please call dr. at . 2. cardiovascular: 1) hypovolemic shock - patient was found to have a lumbar artery bleed, was found to be hypotensive, diaphoretic. patient's hematocrit fell from 29 to 23.4 on to 16. the patient was resuscitated with crystalloid, 5 units of packed red blood cells, 4 units of ffp. the patient was started on dopamine 4 mcg/kg/minute while patient was fluid resuscitated. while patient was fluid resuscitated, the patient required less pressors and ultimately was weaned off pressors completely. the patient has remained hemodynamically stable after pressors were taken off and patient was adequately fluid resuscitated. the patient's blood pressures during the last week of were in the 140's to 160's/80's to 90's, not requiring fluid resuscitation, not requiring pressors for majority of hospital stay. 2) aortic valve replacement - patient was on coumadin with a questionable dose of 4 mg upon presentation to the hospital. the patient has been on an iv heparin drip since her presentation to the hospital. the patient's heparin orders were weight based upon 55 kg with an ideal ptt between 60 and 100. on the patient was switched from heparin drip to lovenox 30 mg subcu . this should continue for one week and then patient should be reevaluated to whether patient can be started back on coumadin with a question of 4 mg dose. with questions of coumadin dose, please call which was patient's nurse practitioner . 3. respiratory: patient went into respiratory failure after patient went into hypovolemic shock secondary to lumbar artery bleed. the patient was intubated and then weaned appropriately and extubated on . the patient's respiratory status remained stable after extubation. the patient's respiratory rate remained anywhere between 22 and 28 after patient's extubation. the patient's oxygen requirements were decreased from 50% face tent to 35% face tent. the patient's oxygen status was always greater than 92% on 30% face tent. on it was found that patient's oxygen status was greater than 92% without face tent, thus oxygen was weaned appropriately. 4. gi: the patient had guaiac positive stool with her right lower quadrant pain and her hypovolemic shock due to lumbar artery bleed. the patient had an acute increase in lfts during her hypovolemic shock. the patient's alt, ast went from respectively to 448 and 524. patient's ldh went up to 1806. patient's amylase went from 58 to 123. this acute increase in liver function tests were most likely secondary to shock liver due to hypoperfusion. after patient became hemodynamically stable, adequately fluid resuscitated, patient's liver function tests improved dramatically. the patient's liver function tests decreased slowly during hospital course and on day of discharge patient's alt was 53, ast 27, alkaline phosphatase 105, bilirubin 1.7. the patient was complaining of some right upper quadrant pain the last week of her . a right upper quadrant ultrasound was done which showed cholelithiasis and no evidence of cholecystitis. 5. renal: acute renal failure. patient's base creatinine was 2.0. patient went into acute renal failure secondary to hypoperfusion due to hypovolemic shock. the patient's creatinine crept up to 3.5. patient's zestril was held at that point in time. after hypovolemic shock patient did have inadequate urine output secondary to decreased blood pressure. as patient lives adequately fluid resuscitated and improved during the hospital stay, patient's urine output became adequate and patient's creatinine began to creep downward slowly and on hospital day #16, , patient's creatinine reached a nadir of 1.6. patient was started on captopril on , a low dose of 6.25, po tid which was increased slowly to 25 mg po tid to help patient's renal function. the patient was discharged to home on captopril 25 mg po tid. 6. id: the patient has remained afebrile during hospital course. the patient actually was hypothermic during patient's hypovolemic shock with a temperature nadir of 94 degrees. the patient was empirically started on ceftriaxone, flagyl and vancomycin on for a question of bowel sepsis vs pneumonia seen as an infiltrate on chest x-ray. the patient's flagyl and vancomycin were discontinued on at first respectively. patient was continued on a 14 day course of ceftriaxone for a question of pneumonia. the patient did have an increase in white cell count during with a max of 28.9 with an unclear source of why the white cell count went up. there is question of acute phase vs pneumonia. right upper quadrant ultrasound showed no evidence of cholecystitis. there is a question of sinusitis with ng tube placement and tube feeds. sinus films were not done. patient's white cell count did start to go down on day of discharge, . it went down gradually to 23.1. patient remained afebrile. a c. diff culture for stool was sent which was negative. the patient's central line tip was sent for culture which is still pending upon discharge. patient's white cell count most likely due to pneumonia. 7. neuro: the patient had a slow return to consciousness after hypovolemic shock, probably secondary to sedation in micu stay, hypotension, metabolic derangement. there was a question of a stroke but a head ct was negative for evidence of stroke. patient continued to improve and improved dramatically from until discharge, going from being mildly sedated to being able to answer questions intelligently, being alert and oriented times three and able to follow commands. during patient's micu stay it was thought that an mri and eeg would be needed but with patient's improvement an mri and eeg were not done. neurology felt that those did not need to be done as well. the patient will continue to improve as outpatient most likely. 8. fluids, electrolytes & nutrition: upon patient's hypovolemic shock patient was made npo. an ng tube was placed. tube feeds were started on . the patient was started on tube feeds with a goal of 40 cc per hour and held for residuals of greater than 100 cc per hour. nutrition continued to follow patient's course and patient's tube feeds were changed to ultracal 4% to a goal of 55 cc per hour as tolerated. due to patient's hypovolemic shock and metabolic derangement and slow return to base function, there was a question of whether patient was an aspiration risk. speech therapy began to see patient on and on and patient was felt to be an aspiration risk and the ng tube and tube feeds were continued. patient improved on and a video swallowing study was scheduled. video swallowing study was done on which showed that the patient still had risk of aspiration, thus speech pathology recommended that patient continue on tube feeds with ng tube for one week and then retry with an other video swallow to see whether patient is less of an aspiration risk. the patient became hypernatremic during hospital stay with sodium in the max of 150. at that point in time the patient was started on free water boluses. ultimately 200 cc boluses done q 4 through ng tube was done and patient's sodium normalized. 9. access: a right subclavian central line was placed. a foley catheter was placed. an ng tube was placed upon micu admission. all of these things have been removed except patient's foley catheter. an ng tube needs to be placed upon patient's admission to rehab for tube feeds to continue. patient's right subclavian line was pulled and two peripheral iv's are now present for access. 10. code status: on it was discussed with patient's daughter. at that point in time was dnr, not dni. on after patient became lucid and was able to answer questions for herself, the patient wanted to be full code so thus patient is full code at this point in time. discharge diagnosis: 1. status post fall with acetabular head dislocation, complicated by lumbar artery bleed, status post embolization for hypovolemic shock. discharge condition: fair. discharge status: patient is to be discharged to rehabilitation. dr. will not follow patient while patient is in . patient should continue on tube feeds, the ultracal at 55 cc per hour to be held for residuals of greater than 100 cc. patient should continue on medications on page 1 and should be evaluated for coumadin use, change from lovenox in approximately one week. for questions concerning patient's coumadin, please call . for questions regarding patient's orthopedic issues, call dr. at . , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Other irrigation of (naso-)gastric tube Diagnoses: Acute posthemorrhagic anemia Acute and subacute necrosis of liver Acute kidney failure, unspecified Hyperosmolality and/or hypernatremia Fall from other slipping, tripping, or stumbling Traumatic shock Closed fracture of shaft of femur Injury to abdominal aorta

history of present illness: this is a 37-year-old man with a history of ulcerative colitis, who is status post a proctocolectomy in complicated by pouchitis. he had an ileocolostomy in complicated by wound dehiscence, a small bowel obstruction. he had an exploratory laparotomy and small bowel resection also in . in , he developed stool leakage by an enterocutaneous fistula. he most recently underwent an ostomy takedown and j-pouch formation. he presented to the emergency room on after developing acute onset of severe abdominal pain, nausea, vomiting, a fever to 102.7, and pain around his wound. past medical history: 1. pouchitis. 2. wound dehiscence. 3. enterocutaneous fistula. 4. partial small bowel obstruction. 5. ulcerative colitis. past surgical history: 1. proctocolectomy. 2. exploratory laparotomy. medications at home: 1. prednisone 10 mg once a day. 2. ibuprofen. 3. imodium prn. physical examination on admission: his vital signs included a temperature of 101.7, heart rate of 124, blood pressure of 101/56, respirations of 20. his oxygen saturation was 100% on room air. his mucous membranes were moist. his pupils are equal, round, and reactive to light. extraocular motions were intact. his heart examination was tachycardic with regular rhythm, and no murmurs, rubs, or gallops. his lungs were clear to auscultation bilaterally. his abdomen was minimally distended, very tender with positive rebound. the pain was localized to bilateral lower quadrants. his wound contains serous discharge particularly on the left side. his extremities were warm and well perfused with no clubbing, cyanosis, or edema. laboratories on admission: complete blood count with white blood cell count 9.1, 77% neutrophils, 10% bands, neutrophils. his hematocrit was 31.1, platelets 434. his electrolytes were sodium of 136, potassium 3.7, chloride 100, total co2 25, bun 13, creatinine 1.0, glucose 107, calcium 9.5, magnesium 1.5, phosphorus 3.2. liver function tests were ast of 8, alt 9, alkaline phosphatase 78, total bilirubin 0.6, amylase 103, lipase 71. blood cultures sent at the time x2 were negative for bacterial growth. wound cultures were positive for sparse growth of gram-negative rods, rare growth of enterococcus, and rare growth of coagulase-negative staphylococcus species. radiologic findings: ct scan demonstrating ill-defined fluid and bubbles of gas within the mid mesentery that could not be constantly connected with the bowel and not suspicious for perforation. persistent abdominal wall air which was slightly improved since prior study. infection fistula with bowel or possible considerations. no evidence of abscess was noted. please see full report of ct scan on admission for details. the patient was admitted to the surgical intensive care unit for possible septic shock with a likely perforated viscus. the patient was taken to the operating room on for a ruptured small bowel. he underwent a drainage of abscess x2, drainage of intraloop abscess, and a repair of small bowel. please see full dictation of procedure for details. following this procedure, the patient was transferred to the intensive care unit, where he remained intubated postoperatively. he was started on total parenteral nutrition. in addition, he was started on antibiotics including levofloxacin, linezolid, metronidazole, fluconazole, as well as morphine sulfate. for pain, hydrocortisone and pepcid. the patient remained afebrile with stable vital signs overnight in the intensive care unit, and was extubated the following morning on postoperative day one. his intensive care unit course was uncomplicated, and the patient resumed normal hemodynamic status as well as stable vital signs and urinary output. on postoperative day two, he was deemed in stable enough condition to be transferred to the surgical floor. he remained afebrile with stable vital signs. continued to have an unremarkable physical examination. his abdominal wounds were left open and two - drains were left in place postoperatively draining serosanguinous fluid. the patient continued on total parenteral nutrition, and maintained stable electrolytes. his pain was controlled by morphine sulfate patient controlled anesthesia. his postoperative course was complicated by slow resumption of bowel function as well as periodic nausea and several episodes of emesis. on postoperative day six, the patient had an episode of elevated blood pressure and decreased pulse oxygenation at which time, it was felt he had mild pulmonary congestion and was treated with 20 mg of lasix iv with good diuresis response. following this event, the patient resumed normal pulmonary function and had no further issues. he complained of hiccups on postoperative day seven, however, these were resolved with passage of flatus and bowel movements, and resumption of bowel function. on postoperative day eight, his total parenteral nutrition was weaned to off. his - drains were draining minimal amounts of serosanguinous fluid and were discontinued. on postoperative day nine, he was deemed in stable enough condition to return to home with visiting nurse services. condition on discharge: good and stable. discharge status: home with services. discharge diagnosis: perforated small bowel. secondary diagnoses: 1. ulcerative colitis. 2. septic shock. discharge medications: 1. loperamide 2 mg capsules one capsule po qid prn. 2. hydromorphone 2 mg tablet 1-2 tablets po q3-4h as needed for pain. follow-up plans: an appointment with dr. within 7-10 days. the patient is given the office telephone number to contact to schedule this appointment. in addition, he is scheduled for visiting nurses for abdominal wound care with normal saline wet-to-dry dressing changes twice a day. his diet is regular. his activity level is full. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other laparotomy Suture of laceration of small intestine, except duodenum Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Other postoperative infection Other shock without mention of trauma

allergies: azithromycin / zosyn attending: addendum: tacrolimus level 10.6-please give 3mg in the pm , 3 mg in the am and obtain a trough daily. discharge disposition: extended care facility: - md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed (percutaneous) [needle] biopsy of liver Closed (percutaneous) [needle] biopsy of liver Closed (percutaneous) [needle] biopsy of liver Percutaneous abdominal drainage Percutaneous abdominal drainage Cholecystectomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Other incision of brain Other transplant of liver Total splenectomy Therapeutic plasmapheresis Other diagnostic procedures on brain and cerebral meninges Other immobilization, pressure, and attention to wound Other operations on lacrimal gland Transplant from cadaver Diagnoses: Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified essential hypertension Acute posthemorrhagic anemia Acute and subacute necrosis of liver Acquired coagulation factor deficiency Severe sepsis Unspecified acquired hypothyroidism Defibrination syndrome Acute and chronic respiratory failure Other specified septicemias Pressure ulcer, other site Hepatic encephalopathy Complications of transplanted liver Cytomegaloviral disease Visceral herpes simplex Intracranial abscess Aspergillosis Pneumonia in aspergillosis

allergies: azithromycin / zosyn attending: chief complaint: fulminant hepatic failure secondary to hsvii major surgical or invasive procedure: emergent abo incompatible olt w/splenectomy for hsv/fulminant hepatic failure sp icp monitor placement sp liver biopsy x 2 sp bronchoscopy sp tracheostomy ct guided drainage of intra abd fluid collection sp brain biopsy history of present illness: 41 y/o f w/past med hx of recently diagnosed htn, who went to the ed last night with nausea, vomiting, and diarrhea. her illness began 6 weeks ago with only watery, non-bloody diarrhea (7-8x/day). she attributed this to stress as she's been going through a divorce. however, 9 days ago (on ), she began to feel worse, with generalized body aches, chills, sweats and a cough. she saw her pcp who felt she had bronchitis and gave her zithromax. this was on . she took the zithromax that night and the next morning, and subsequently developed nausea and vomiting 4-5x/day (and diarrhea continued). she went to the on , and she was tachycardic at 120, febrile to 100.5. they felt she had gastroenteritis. at that time, her wbc count was 10, ast 163, alt 116, and k 2.6. her bun was 7, creatinine 1.0, bicarb 19. she was given iv fluid, reglan, and was discharged home on levaquin 250 mg daily and potassium 20 meq daily. all of last week, she continued to feel poorly with continued nausea, vomiting, fevers, chills, and vague abdominal pain. she also had some low back pain and for this took 12 tablets of ibuprofen/day for 4-5 days. she also c/o left knee pain and a lower extremity rash. on friday she went to for work, and came back last night. upon returning home, she went immediately back to the emergency room as she still felt terrible. at , she was noted to have acute renal failure with a bun 36, creatinine 7.6, ast 1500, alt 800, (nl bili), ph 7.22, bicarb 18, esr 55, wbc 1.9 with 81% polys, hgb 10.4. urine sediment examined by physician at (who is also a renal fellow) demonstrated many wbcs, many rbcs, many squamous epithelial cells, many renal tubular epithelial cells, many coarse granular casts, and no red cell casts. she had a stool culture from which grew abundant staph and did not grow normal gram negative enteric flora. o&p neg, stool cx neg for salmonella, campylobacter, shigella, or ecoli o157:h7. they felt she had atn due to nsaids as well as a necroinflammatory hepatitis, and transferred her to for further care. on further review of systems, she denies recent travel to anywhere other than the recent trip to . she denies any sick contacts, ivdu, tattoos, or eating anything out of the ordinary. she does report unprotected sexual intercourse approximately 2 weeks ago. she had a d&c on for abnormal uterine bleeding, but denies any abnl vaginal discharge. past medical history: 1. htn, diagnosed 2 months prior to admission 2. hypothyroidism 3. depression 4. d&c for abnl uterine bleeding 5. h/o syncope one month prior to admission social history: lives in , in the middle of a very stressful divorce. has 3 children, ages 6, 7, and 9 years old (6 and 9 year old girls adopted from , 7 year old boy biological). works as a writer and speaker. drinks 2-3 alcoholic drinks one night per week. denies tobacco or ivdu. no tattoos or piercings. no recent travel. one pet at home (rabbit). family history: htn dm physical exam: t: 98.9 bp: 113/53 p: 108 rr: 43 o2 sat 100% ra gen: awake/alert pleasant female, appears anxious, uncomfortable, and in mild distress heent: face flushed, sclerae anicteric, conjunctivae noninjected, mucous membranes dry neck: + tender anterior cervical lymphadenopathy on l, approx 1 cm lungs: decreased breath sounds at left base, mild inspiratory crackles at r base, o/w clear to auscultation bilaterally cv: tachycardic, regular, no murmurs, rubs, or gallops abd: + ttp ruq without rebound or guarding, nondistended, soft, with normoactive bowel sounds. liver edge palpable approx cm below costal margin. mild left cva tenderness. no vertebral tenderness. ext: toes are cold, 2+ dorsalis pedis pulses bilaterally skin: vague livedo reticularis rash on lower extremities, good skin turgor pertinent results: admission: pt-14.5* ptt-31.5 inr(pt)-1.4 plt count-274 wbc-2.0* rbc-3.65* hgb-10.7* hct-31.2* mcv-86 mch-29.4 mchc-34.3 rdw-14.0 albumin-3.0* calcium-6.1* phosphate-4.0 magnesium-1.4* alt(sgpt)-882* ast(sgot)-1865* alk phos-313* tot bili-0.2 glucose-120* urea n-38* creat-7.3* sodium-136 potassium-3.1* chloride-105 total co2-9* anion gap-25* type-art po2-95 pco2-19* ph-7.19* total co2-8* base xs--18 hospital course: cbc: 07:45pm blood wbc-1.9* rbc-3.51* hgb-10.7* hct-29.8* mcv-85 mch-30.6 mchc-36.0* rdw-14.2 plt ct-144* 03:12pm blood wbc-5.1 rbc-3.33* hgb-10.1* hct-28.9* mcv-87 mch-30.5 mchc-35.1* rdw-14.5 plt ct-43* 08:25pm blood hct-23.8* plt ct-65* 08:15pm blood wbc-7.1 rbc-3.53* hgb-10.3* hct-29.0* mcv-82 mch-29.2 mchc-35.6* rdw-16.4* plt ct-84* 09:13pm blood wbc-11.7* rbc-3.63* hgb-10.9* hct-29.9* mcv-82 mch-30.2 mchc-36.6* rdw-14.6 plt ct-180 03:00pm blood wbc-9.0 rbc-3.70* hgb-11.1* hct-32.4* mcv-88 mch-29.9 mchc-34.1 rdw-16.8* plt ct-123* 02:30am blood wbc-25.0* rbc-2.79* hgb-8.6* hct-25.9* mcv-93 mch-30.7 mchc-33.1 rdw-23.6* plt ct-109* 08:23pm blood wbc-30.5* rbc-3.28* hgb-9.9* hct-30.0* mcv-91 mch-30.2 mchc-33.0 rdw-22.0* plt ct-79* 05:17pm blood hct-25.1* 03:12am blood wbc-18.5* rbc-3.37* hgb-10.2* hct-30.7* mcv-91 mch-30.3 mchc-33.3 rdw-19.6* plt ct-204 03:50am blood wbc-17.6* rbc-3.70* hgb-11.1* hct-34.1* mcv-92 mch-30.0 mchc-32.6 rdw-16.4* plt ct-565* coags: 01:12pm blood pt-14.9* ptt-27.7 inr(pt)-1.5 10:00am blood pt-13.2 ptt-22.2 inr(pt)-1.2 02:00am blood pt-14.4* ptt-21.5* inr(pt)-1.4 02:05am blood pt-13.6* ptt-19.9* inr(pt)-1.2 02:07am blood pt-12.7 ptt-23.7 inr(pt)-1.1 01:41am blood pt-12.5 ptt-22.3 inr(pt)-1.0 chemistries: 08:00am blood urean-44* creat-2.6* 10:00am blood glucose-87 urean-59* creat-3.3* na-143 k-5.4* cl-100 hco3-31* angap-17 08:45am blood glucose-95 urean-92* creat-3.2* na-149* k-2.9* cl-108 hco3-28 angap-16 10:00am blood glucose-117* urean-115* creat-2.1* na-145 k-4.4 cl-117* hco3-16* angap-16 05:22am blood glucose-175* urean-94* creat-1.5* na-143 k-5.6* cl-112* hco3-20* angap-17 06:11pm blood glucose-131* urean-94* creat-1.3* na-143 k-3.4 cl-107 hco3-23 angap-16 03:14am blood glucose-128* urean-88* creat-1.2* na-142 k-3.9 cl-109* hco3-21* angap-16 10:45am blood glucose-90 urean-83* creat-1.1 na-142 k-3.6 cl-111* hco3-21* angap-14 02:08am blood glucose-111* urean-63* creat-0.7 na-144 k-4.0 cl-111* hco3-22 angap-15 02:07am blood glucose-179* urean-27* creat-0.3* na-142 k-3.7 cl-108 hco3-22 angap-16 02:08pm blood alt-882* ast-1865* ck(cpk)-91 alkphos-313* amylase-881* totbili-0.2 06:12am blood alt-1240* ast-3103* alkphos-416* totbili-0.4 04:14am blood alt-1549* ast-4278* ld(ldh)-3935* alkphos-628* amylase-795* totbili-0.7 07:45pm blood alt-1804* ast-5595* ld(ldh)-4960* alkphos-783* amylase-437* totbili-1.4 04:05am blood alt-1608* ast-5716* ld(ldh)-5590* alkphos-950* totbili-3.1* dirbili-2.4* indbili-0.7 01:41pm blood alt-805* ast-3214* ld(ldh)-2638* alkphos-599* totbili-4.0* 04:00pm blood alt-427* ast-1469* ld(ldh)-1730* alkphos-464* amylase-470* totbili-5.0* 03:48pm blood alt-282* ast-800* alkphos-357* totbili-5.6* 06:10pm blood alt-109* ast-304* ld(ldh)-516* alkphos-161* amylase-248* totbili-4.0* 08:00am blood alt-1022* ast-2252* alkphos-95 amylase-219* totbili-2.3* 04:43am blood alt-112* ast-185* alkphos-134* amylase-163* totbili-3.3* 12:00am blood alt-83* ast-133* alkphos-88 totbili-2.4* 02:38am blood alt-61* ast-33 alkphos-181* totbili-0.4 07:00am blood alt-56* ast-44* alkphos-155* totbili-0.3 03:54am blood alt-111* ast-48* alkphos-140* totbili-0.3 02:08pm blood caltibc-187* vitb12-> folate-greater th hapto-457* ferritn-> trf-144* 02:38am blood caltibc-159* trf-122* 08:23pm blood tsh-5.9* 11:30am blood tsh-7.4* 03:25pm blood tsh-3.1 12:25pm blood tsh-6.2* 05:25pm blood hbsag-negative hbsab-negative hbcab-negative hav ab-positive igm hbc-negative igm hav-negative 05:25pm blood hiv ab-negative micro: - pan ctx'd sputum- gpc, gnr cmv pending. aline neg. cmv neg. brain abscess neg. abd-wound - staph, enterococcus, diphtheroids. r scl cath tip ng. r scl cath tip ng. sputum: aspergillus, bcx: coag neg staph, ucx: yeast < 10^5. sputum: enterobacter, aspergillus. cath tip neg. spcx aspergillus, ucx <10^5, bcx diphteroids brief hospital course: ms. was sent to the for further evaluation. she was on the tranplant surgery service awaiting transplantation with fulminant hepatic failure secondary to herpes virus. a bolt was placed on for encephalopathy and she was intubated. broad spectrum antibiotics were started. a liver biopsy performed on revealed 40-50% necrosis with viral changes consistent with herpes virus. patient was taken to the operating room on to have an abo incompatible piggyback liver transplant. 19 units of prbc, 17 units ffp, 6 units platelets, and 3 units ffp were given. initially she received okt3, methylprednisolone, and mmf for immunosupression. the regimen that she is currently on is mmf, tacrolimus, and prednisone. an ultrasound of the liver on showed hepatic vessels with good flow. her bolt was removed on . ms. had a prolonged postoperative course with multiple issues. some of her most important issues are described below. it was discovered that she had an aspergillus pneumonia for which she was started on caspofungin . she had the development of ascites and had ct guided drainage on . she had further a further luq collection which was drained . it was decided at this point to perform a tracheostomy on . a brancheoalveolar lavage was performed on which revealed enterobacter sensitive to aztreonam. a repeat head ct performed on revealed an abscess from her prior burr hole site. she was taken to the operating room by the neurosurgery service for abscess drainage. a repeat head ct scan show improvement of the abscess on . patient also had a positive cmv viral load for which she was started on ganciclovir. tube feeding was started and was tolerated well through a dobhoff tube. a gradual vent wean was performed throughout the month of . by the time of discharge, she was on trach mask. the weekend of , the was a temperature spike with a rising wbc count. after her central line was change, her clinical status improved.the patient was on mulitple antibiotic regimens throughout her hospital course which we tailored in consultation with the infectious disease service. her final regimen in listed below in the discharge medications. pt should get fk levels checked daily and called into the transplant center. medications on admission: atenolol lisinopril levothyroxine discharge medications: 1. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 2. artificial tear ointment 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 3. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 4. acetaminophen 160 mg/5 ml solution sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 5. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 6. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 7. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 8. mycophenolate mofetil 200 mg/ml suspension for reconstitution sig: two y (250) po bid (2 times a day). 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 10. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 11. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 12. lansoprazole oral 13. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). 14. caspofungin 50 mg iv q24h start: in am 15. levothyroxine sodium 175 mcg tablet sig: one (1) tablet po daily (daily). 16. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 17. vancomycin hcl 750 mg iv q 12h check trough before 4th dose please 18. haloperidol 2 mg iv bid:prn 19. lorazepam 1 mg iv q12h prn please do not give unless directed by the transplant team. thanks 20. ganciclovir 350 mg iv q12h handle as for chemotherapy. 21. insulin fixed/sliding scale sig: see attached subcutaneous once a day. 22. tacrolimus 5 mg capsule sig: one (1) capsule po 2 doses (): dosed per level daily. discharge disposition: extended care facility: - discharge diagnosis: fulminant hepatic failure secondary to hsvii s/p abo incompatible olt w/splenectomy discharge condition: stable discharge instructions: please call the transplant center if experiencing fevers/chills, nausea/vomiting, redness/drainage from your wound, chest pain, shortness of breath, lightheadness/dizziness, or any questions or concerns. followup instructions: please follow up at the transplant clinic as instructed by the transplant coordinator. follow up with dr. (neurosurgery) after repeat head ct in weeks. follow up with dr. in clinic on at 2pm. md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed (percutaneous) [needle] biopsy of liver Closed (percutaneous) [needle] biopsy of liver Closed (percutaneous) [needle] biopsy of liver Percutaneous abdominal drainage Percutaneous abdominal drainage Cholecystectomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Other incision of brain Other transplant of liver Total splenectomy Therapeutic plasmapheresis Other diagnostic procedures on brain and cerebral meninges Other immobilization, pressure, and attention to wound Other operations on lacrimal gland Transplant from cadaver Diagnoses: Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified essential hypertension Acute posthemorrhagic anemia Acute and subacute necrosis of liver Acquired coagulation factor deficiency Severe sepsis Unspecified acquired hypothyroidism Defibrination syndrome Acute and chronic respiratory failure Other specified septicemias Pressure ulcer, other site Hepatic encephalopathy Complications of transplanted liver Cytomegaloviral disease Visceral herpes simplex Intracranial abscess Aspergillosis Pneumonia in aspergillosis

allergies: lipitor attending: chief complaint: occluded coronary vessels found on work-up for elective hip replacement. major surgical or invasive procedure: 1. redo coronary artery bypass grafts x2, saphenous vein grafts to posterior descending artery and obtuse marginal artery. 2. mitral valve replacement with a . porcine prosthesis. history of present illness: this is a 70-year-old patient who has had coronary artery bypass grafts x2 in with a left internal mammary artery to the left anterior descending and saphenous vein graft to obtuse marginal artery. he was essentially asymptomatic. as a preoperative workup for hip replacement, he had a stress test done which was positive. further investigations revealed patent left intramammary artery, but blocked circumflex vein graft and also native right coronary disease. he also had severe mitral regurgitation with preserved left ventricular function. he was electively admitted for redo coronary artery bypass grafts and mitral valve replacement. past medical history: pmh: hypercholesterolemia hypertension gerd h/o mi in esophageal strictures pud w/ h/o gi bleed osteoarthritis pyloric stenosis spinal chord compression gout psh: cabg x2 (lima->lad, svd->lcx/om) unsuccessful ptca of pda esophageal dilation x2 (, ) laporascopic cholecystectomy laminectomy incisional hernia repair social history: retired neurophysiologist/psychologist denies smoking social etoh family history: father died of mi at age 71 physical exam: afebrile, hr 54, bp r138/60 l132/60, ht 72", wt 158lbs gen: elderly male in nad, appears frail and deconditioned heent: ncat, perrl neck: supple, full rom, no jvd lungs: cta b/l, well-healed previous sternotomy cv: irregular, +1-2/6 sem abd: soft, nt/nd, nabs ext: warm, 2+ le edema b/l pulses: 1+ dp/pt pulses b/l pertinent results: 03:49pm blood wbc-8.9 rbc-3.97* hgb-12.8* hct-37.2* mcv-94 mch-32.3* mchc-34.4 rdw-14.2 plt ct-221 03:49pm blood pt-12.2 ptt-27.6 inr(pt)-1.0 03:49pm blood glucose-83 urean-16 creat-1.0 na-145 k-4.3 cl-107 hco3-28 angap-14 03:49pm blood alt-16 ast-17 ld(ldh)-181 alkphos-125* amylase-210* totbili-0.5 03:49pm blood mg-1.9 03:49pm blood %hba1c-5.6 -done -done brief hospital course: the patient was admitted to the hospital and taken to the operating room, where he underwent a redo cabg x2 vessels with mitral valve replacement (see operative note for full details). the patient tolerated this procedure well. he was transferred to the csru immediately post-op. he was extubated that night. on post-op day #1, his pressors were weaned to off. on post-op day #2, the mediastinal chest tubes were removed. the patient was given lasix and lopressor. he was seen by the physical therapy service and moved to a chair for ambulation. on post-op day #3, the patient underwent a swallow evaluation, which he failed. therefore, a post-pyloric feeding tube was placed by interventional radiology. the patient was transferred to the floor. on post-op day #4, the patient underwent a repeat swallow study, which was inconclusive. he was seen by the wound care team for bilateral heel pressure ulcer treatment. on post-op day #5, the patient's hematocrit was found to be 27.1, and he was given one unit of prbc's. on post-op day #6, the patient underwent a video-assisted swallow study, which showed mild-moderate pharyngeal dysphagia. however, the patient was cleared to start a soft-solid consistency diet. because of a persistent pnumothorax, the patient's chest tube was left in place until post-op day #8. he was seen by the electrophysiology service for a 6 second spell of nsvt and a 3 second pause on telemetry. their only recommendation was to discharge the patient to rehab with telemetry and to stop his beta-blockade. on post-op day #9, his feeding tube was removed. the patient failed repeat void trials, and therefore had to be discharged with a foley catheter and leg bag in place. he was started on flomax. medications on admission: celebrex 100 mg po bid, nexium 40mg po bid, toprol 50mg po qdaily, ecasa 81mg po qdaily, allopurinol 150mg po qdaily, atacand 16mg po qdaily, baclofen 10mg po qid, colchicine 0.6mg po qdaily, tramadol 50mg po qid, cholestyramine discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. baclofen 10 mg tablet sig: one (1) tablet po tid (3 times a day). 3. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 6. allopurinol 100 mg tablet sig: 1.5 tablets po daily (daily). 7. cholestyramine-sucrose 4 g packet sig: one (1) packet po bid (2 times a day). 8. docusate sodium 150 mg/15 ml liquid sig: ten (10) ml po bid (2 times a day). 9. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). 10. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 11. protonix 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 redo of cabg x2 discharge condition: stable ge instructions: please return to the hospital or call dr. office if you experience chills or fever greater than 101 degrees f. please call if you notice redness, swelling, or tenderness of your chest wound, or if it begins to drain pus. p instructions: please follow up with dr. in 4 weeks. call for an appointment. follow up with dr. in 4 weeks. call for an appointment. Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Enteral infusion of concentrated nutritional substances Open and other replacement of mitral valve with tissue graft Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Gout, unspecified Paroxysmal ventricular tachycardia Old myocardial infarction Pressure ulcer, elbow Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh

history of present illness: is the former 2.175 kg product of a 32-week gestation pregnancy, born to a 35-year-old, g4, p2, now 3, woman. prenatal screens: blood type a positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status unknown. the mother's prior obstetrical history is notable for a spontaneous vaginal delivery at 34 weeks in and 35 weeks in . her past medical history is notable for nephrolithiasis x2 with no active issues currently. this pregnancy had an estimated date of confinement of by first trimester ultrasound. fetal surveys were within normal limits. the pregnancy became complicated by preterm labor with premature rupture of membranes 3 days prior to delivery. mother was admitted at and transferred to . she received a complete course of betamethasone, was treated with magnesium sulfate and antibiotics. amniotic fluid was clear. the mother had an intrapartum fever to 99.6 degrees fahrenheit in labor. on the day of delivery, preterm labor progressed. the infant was born by spontaneous vaginal delivery under epidural anesthesia. he required only nasal suction and drying and tactile stimulation. apgars were 9 at one minute and 9 at five minutes. he was admitted to the neonatal intensive care unit for treatment of prematurity. admission growth percentiles: weight 2.175 kg, 90th percentile; head circumference 30.5 cm, 50th-75th percentile; length 43.5 cm, 50th-75th percentile. discharge physical examination: general: nondysmorphic, nondistressed, preterm male in room air requiring isolette for temperature control. weight 2.l6 kg, head circumference 32 cm. skin: warm and dry. color pink. no rashes or lesions. heent: anterior fontanel soft and flat, sutures open and apposed. symmetric facial features. chest: breath sounds clear and equal. no respiratory distress. cardiovascular regular rate and rhythm. no murmur. pulses +2. abdomen: soft, nontender, nondistended, no masses, no organomegaly, positive bowel sounds. cord on and drying. gu: normal preterm genitalia, testes descending bilaterally. extremities: moving all with normal tone. neuro: appropriate tone and reflexes consistent with gestational age. hospital course by systems including pertinent laboratory data: 1. respiratory: has been in room air for his entire neonatal intensive care unit admission. he has had approximately 2-6 episodes of spontaneous apnea and bradycardia per day, most of these episodes are self- resolved and not requiring stimulation. his baseline respiratory rate is 30-40 breaths per minute. 2. cardiovascular: has maintained normal heart rates and blood pressures. no murmurs have been noted. baseline heart rate is 140-160 beats per minute with a recent blood pressure of 78/335 mmhg, mean arterial pressure 46 mmhg. 3. fluids/electrolytes/nutrition: was initially npo and maintained on intravenous fluids. enteral feeds were started on day of life #2 and gradually advanced to full volume. at the time of discharge he is receiving 140 ml/kg per day of similac special care 24 calorie per ounce formula. he receives his volume every 4 hours by gavage over 2 hours. serum electrolytes were checked at 24 hours of life and were within normal limits. he has experienced occasional aspirates and emesis, requiring slow infusion of gavage feedings. exam has been reassuring; kub was performed that was initially with mild intestinal loop dilations, but follow-up was normal. 4. infectious disease: due to the premature rupture of membranes and the unknown group b beta strep status of the mother, was evaluated for sepsis upon admission to the neonatal intensive care unit. a complete blood count and white cell differential were within normal limits. 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. hematological: hematocrit at birth is 53.1%. did not receive any transfusions of blood products. 6. gastrointestinal: peak serum bilirubin occurred on day of life #4, a total of 9.0 mg/dl. most recent serum bilirubin on had a total of 2.1 mg/dl. he did not require any treatment. 7. neurological: has maintained a normal neurological exam during admission. there are no neurological concerns at the time of discharge. 8. sensory/audiology: hearing screening is recommended prior to discharge. 9. psychosocial: this mother has been very involved in this infant's care but has difficulty visiting at the . she has requested transfer to for her infant. condition at discharge: good. discharge disposition: transfer to for continuing level ii care. primary pediatrician has not yet been identified. care and recommendations at the time of discharge: 1. feeding: similac special care 24 calorie per ounce formula at 140/g/kd per day. 2. no medications. 3. iron and vitamin d supplementation: iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. all infants fed predominantly breast milk should receive vitamin d supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. car seat position screening is recommended prior to discharge. 5. state newborn screen was sent on with no notification of abnormal results to date. 6. no immunizations have been administered. discharge diagnoses: 1. prematurity at 32 weeks gestation. 2. suspicion for sepsis, ruled out. 3. apnea of prematurity. , md Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Primary apnea of newborn Neonatal bradycardia Other preterm infants, 2,000-2,499 grams 31-32 completed weeks of gestation

history of present illness: the patient is a 68 year old right handed man who, a couple of days prior to admission, was a paper and developed blurry vision and felt lightheaded with bilateral arm heaviness. he tried to pick up a coffee cup with both hands but his arms felt weak. he tried to stand but again his legs felt weak and he could not move well. he felt lightheadedness. he called 911 and says his speech was slurred. he could understand what was being said to him. this episode came on suddenly and resolved within one hour. he had a similar episode of this approximately three weeks prior that occurred while walking when he felt lightheaded at that time as well. past medical history: 1. hypertension. 2. chronic obstructive pulmonary disease. 3. left femoral-popliteal bypass. 4. pneumonia. 5. vertigo. 6. headache. 7. benign prostatic hypertrophy. 8. status post appendectomy. 9. status post tonsillectomy. medications: 1. zestril 30 mg p.o. q. day. 2. hydrochlorothiazide 25 mg p.o. q. day. 3. lipitor 10 mg p.o. q. day. allergies: no known drug allergies. social history: smokes two packs of cigarettes per day since age of eight. takes two to three drinks of alcohol per day. has a second marriage currently. physical examination: on physical examination, the patient is afebrile, vital signs are stable. he is awake and alert; he answers questions appropriately with fluent speech. memory registers three out of three. recall three out of three at five minutes. no right to left confusion. no apraxia. face is symmetric without ptosis. extraocular muscles are intact. pupils 4 to 3 bilaterally. the patient's upper extremities were full strength. left lower extremity full strength as well. laboratory: an mri / mra was done that showed right vertebral artery stenosis. white blood cell count 8.5, hematocrit 47, platelets 162. sodium 133, bun 27, creatinine 1.1. hospital course: the patient was admitted to dr. service. he underwent an angiogram on . this showed intracranial stenosis of the right v4 vertebral segment. this was discussed with the patient. the risks and benefits of this procedure were explained to the patient. he wished to proceed. preoperative diagnosis again was right intracranial vertebral artery stenosis. procedure that the patient underwent was: 1. cerebral angiogram. 2. angioplasty and stent deployment within the right vertebral artery stenosis segment. this operation was performed by dr. and was characterized by a prolonged decreased right vertebral flow because of the need for the guide catheter to be high enough in the neck to allow pta balloon and stent navigation to the site of stenosis. the patient awoke with right arm and leg hemiplegia. a stat head ct scan was performed to rule out hemorhhage and that was negative. over the next couple of hours, the patient recovered excellent strength in the right arm and leg back to normal baseline strength, a finding most consistent with relative reversible hypoperfusion of his brainstem intra-procedurally because of the guide catheter position. the patient was continued on heparin, plavix and aspirin post procedure. the heparin was discontinued on . the patient's arterial sheath was also discontinued on . the patient did well. he was transferred out of the intensive care unit. he was continued on aspirin and plavix and did well on the floor and was stable for discharge to home on . discharge instructions: 1. the patient will follow-up with dr. in one month. discharge medications: the patient will be discharged on all his preoperative medications. 1. zestril 30 mg p.o. q. day. 2. hydrochlorothiazide 25 mg p.o. q. day. 3. lipitor 10 mg p.o. q. day. 4. he will also be discharged on plavix 75 mg p.o. q. day. 5. add aspirin 325 mg p.o. q. day. it has been explained to the patient the absolute necessity that he take these medications every day. , m.d. dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Other irrigation of (naso-)gastric tube Diagnoses: Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Hematoma complicating a procedure Peripheral vascular disease, unspecified Other nervous system complications Hematemesis Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction

allergies: aspirin / cefazolin attending: chief complaint: fever x 2 days, chest congestion x 1 week major surgical or invasive procedure: picc placement peg placement history of present illness: history obtained from son and daughter. 80 yo f with severe alzheimer's dementia (non-verbal at baseline) who presents with 1 week of increased respiratory secretions, cough, sob and lethargy. one week ago, pt was started on levofloxacin by her pcp, . . yesterday, pt developed a fever >100. of note pt has multiple areas of skin breakdown as well. . in ed, found to be febrile to 102, tachy to 130s with leukocytosis, elevated lactate consistent with sepsis. pt's code status was discussed with daughter and who confirmed that pt is dnr/dni. given ivf, acetaminophen with some improvement in tachycardia. started on vanco, levo, flagyl empirically for pna, cellulitis, ? osteo. . ros: no n/v/abd pain, diarrhea. no ha. per family, no coughing or choking after eating. family reports pt has pcn allergy- unclear whether this is documented allergy to cefazolin or other allergy. past medical history: severe alzheimer's dementia x 10 years aspiration htn gerd decubitus ulcers h/o gi bleeding secondary to aspirin chronic l lateral malleolus ulcer af social history: lives with daugher in , non-verbal and non-ambulatory at baseline. has 2 pcas who help care for her. per family, sometimes seems to be able to understand commands but not consistently. h/o tobacco (quit 25 yrs ago, only few cigarettes/day before that), no etoh. dnr/dni family history: n/c physical exam: 98.7 138/86 102 22 95% (3l) gen: lying in bed, non-verbal, eyes closed, groans with passive movement, gurgling noises from back of throat heent: dry mm, op clear, no stridor cv: reg, s1, s2, no m/r/g lungs: limited exam, rales at bases bilaterally abd: soft, nt/nd, +bs ext: warm, area of edema over r hip without erythema, fluctuance skin: 6 x 4 cm area of skin breakdown with central and surrounding necrosis over l lateral malleolus. 5 x 3 cm deep ulcer over l elbow with surrounding necrosis. skin tear on r deltoid. healed ulcerations over r hip/buttocks. neuro: non-responsive, groans with passive movement pertinent results: ekg: sinus tach @ 120, l axis, rbbb, inf q waves (old), twi v1-v3 (old), no acute ischemic changes c/w . 03:15pm wbc-16.2*# rbc-5.51*# hgb-13.9# hct-42.9# mcv-78* mch-25.3* mchc-32.5 rdw-17.1* 03:15pm neuts-84.2* lymphs-9.5* monos-5.4 eos-0.3 basos-0.6 03:15pm plt count-464* 03:15pm pt-13.8* ptt-24.9 inr(pt)-1.2* 03:15pm glucose-264* urea n-42* creat-1.3* sodium-150* potassium-4.5 chloride-117* total co2-22 anion gap-16 03:15pm alt(sgpt)-41* ast(sgot)-66* ck(cpk)-3182* alk phos-121* amylase-29 tot bili-0.4 03:15pm calcium-8.8 phosphate-2.7 magnesium-2.4 03:23pm lactate-4.2* 05:53pm lactate-2.3* 03:15pm ck-mb-3 03:15pm ctropnt-0.03* 03:26pm urine color-yellow appear-clear sp -1.026 03:26pm urine blood-tr nitrite-neg protein-tr glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 03:26pm urine rbc-0-2 wbc-0-2 bacteria-occ yeast-none epi-0-2 cxr : no acute cardiopulmonary abnormality. mild cardiomegaly. l ankle x-ray : soft tissue defect adjacent to left lateral malleolus. indistinct lateral malleolus cortex is worrisome for osteomyelitis. further evaluation with three-phase bone scintigraphy or mri can be performed. , mri lle : 1. edema and enhancement in the distal fibula. although this is a nonspecific finding, it lies immediately deep to the patient's soft tissue ulcer and is therefore concerning for osteomyelitis. no interosseous or deep soft tissue abscess is identified. 2. degenerative splits of peroneus brevis and longus tendons, with minimal associated edema enhancement, which is most likely reactive. 3. ptt tendon degenerative changes. 4. extensive muscle atrophy. . mri lue : 1. edema and associated enhancement in the subcutaneous fat overlying the olecranon and lateral epicondyle and in the anconeus muscle. differential diagnosis includes both edema and cellulitis/muscle infection. 2. no abscess collection, joint effusion, or abnormal marrow signal to indicate osteomyelitis is identified. 3. patient unable to extend arm, arm imaged in flexed position. . cxr : moderate cardiomegaly is longstanding. small opacity just above the eventrated right hemidiaphragm developed between and consistent with pneumonia. when feasible routine radiographs should be performed to exclude the possibility that this is, instead, a longstanding nodular abnormality seen in the lower lungs on an abdomen ct . no appreciable pleural effusion or pneumothorax. tip of the left picc line projects over the junction of the brachiocephalic veins. . cxr : left picc line remains in place. new focal right basilar opacity is without change allowing for patient rotation. there is also a questionable new area of opacity in the left retrocardiac region, which could be due to aspiration or atelectasis. . tte : 1. the left atrium is normal in size. 2. there is mild symmetric lvh. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). 3. right ventricular chamber size is normal. right ventricular systolic function is normal. 4. the ascending aorta is mildly dilated. 5. the aortic valve leaflets are mildly thickened. there is mild aortic valve stenosis. no aortic regurgitation present. 6. the mitral valve leaflets are mildly thickenedl. mild (1+) mitral regurgitation is seen. 7. there is moderate pulmonary artery systolic hypertension. 8. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. . cxr : 1. left lower lobe atelectasis-infiltrate, which is recurrent and might be related to aspiration. 2. there is no evidence of congestive heart failure. . ct abd : 1. no evidence of abscess or bowel perforation. 2. improvement in right lower lobe opacities. 3. stable hypoattenuating lesion in the right lobe of the liver most likely representing a cyst. 4. cholelithiasis without evidence of cholecystitis. 5. diverticulosis without evidence of diverticulitis. 6. moderate sized hiatal hernia. 7. soft tissue density opacities in both breasts. correlation with mammography is again recommended. 8. umbilical hernia containing small bowel loops without evidence of incarceration. . discharge labs: wbc 13 hct 28.9 plt 568 bun 13 cr 1.0 alt/ast ap 85 tbili 0.2 : esr 113 crp 120 brief hospital course: 80 yo f with severe alzheimers dementia, multiple areas of skin breakdown presents with fever, cough, lethargy and found to have sepsis. hospital course by problem as below: . # sepsis: she was thought to have aspirated, and was started on vancomycin/ levofloxacin/ flagyl. her family refused central line at this time and the patient was admitted to the floor, rather than the icu. she was also noted to have a large ulcer on her left lateral maleolus (decubitus) and left elbow. mri of the left ankle revealed possible osteomyelitis. id was consulted to help with antibiotic regimen. mri of the elbow showed soft tissue changes, but no definitive osteo. id recommended 6 week-course of vanco/levo empirically, since she was not a good candidate for bone biopsy. a peg tube was placed, with family understanding the continued risk of aspiration. . her course was complicated when she developed fever to 103 with transient hypotension and respiratory distress on . blood cultures drawn from picc line grew e. coli (resistant to levo), so she was broadened to zosyn. her fevers and hypotension resolved on this regimen. her picc line was changed over a wire (ir was unable to resite it since she has difficult access). abdominal ct scan did not reveal another source for the bacteremia. she had recurrnt fever and respiratory distress overnight , possibly due to re-aspiration. the likely source of the e. coli bacteremia was aspiration event. her peg tube feeds were stopped. the patient was then changed from zosyn to ceftriaxone once culture data returned. she tolerated the ceftriaxone well and remained afebrile. she was given a 2 week total course of gram negative coverage for bacteremia. she will need a total of 6 weeks coverage for osteomyelitis with vancomycin and ceftriazone/levofloxacin. she will need weekly labs for monitoring. . # anemia: patient had a questionable episode of coffee ground emesis transfer to the icu. she also intermittently had guaiac positive stools, in the setting pf peg placement. her hct fluctuated but overall was stable. iron studies were consistent with anemia of chronic disease. there was thought to be no role of colonoscopy for cancer work-up, as patient is not a treatment candidate. she received one unit of blood during her stay. . # arf: she initially had a bump in her cr, but it improved to a cr of 1.0 on discharge. vanco troughs were checked and she did well with daily dosing. . # fen: the patient had a peg placed on to help with her nutritional status. risks of aspiration were discussed with the family. she was kept npo while in-house. speech and swallow consultants recommended honey-thickened liquids and pureed diet as outpatient, if the family chooses to feed her. her family was trained in peg care. . # wound care: the wound care consultants evaluated her while she was here and made many recommendations management of her ulcers. she was treated with zinc and vitamin c while in house to facilitate wound healing. . # code/communication: she was maintained as dnr/dni during her admission. her contacts are as follows: -granddaughter ; bilingual): -daughter ( ) (hcp): -son : -son ) (cell); medications on admission: mvi levoflox x 7 days tylenol prilosec discharge medications: 1. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 5 weeks. disp:*qs 35 days worth* refills:*0* 2. nutrition tubefeeding: promote w/ fiber (or equivalent) full strength at 45 ml/hr q4h hold feeding for residual >= 100 ml flush w/ 200 ml water q8h # quanitity sufficient for life 3. nutrition kangaroo 324 pump (for tube feeds) #1 4. normal saline flush 0.9 % syringe sig: one (1) injection as directed: flush picc line 5cc ns pre and post vancomycin infusion per picc protocol. disp:*100 syringes* refills:*2* 5. heparin flush 100 unit/ml kit sig: one (1) intravenous as directed below: flush picc with 3cc after antibiotic infusion. disp:*50 synringes* refills:*2* 6. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 7. docusate sodium 150 mg/15 ml liquid sig: fifteen (15) ml po bid (2 times a day) as needed for constipation. 8. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po bid (2 times a day). 9. ascorbic acid 90 mg/ml drops sig: five (5) ml po daily (daily). 10. ipratropium bromide 0.02 % solution sig: one (1) neb treatment inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 11. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 12. ceftriaxone-dextrose (iso-osm) 1 g/50 ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 7 days. disp:*7 grams* refills:*0* 13. levofloxacin 250 mg tablet sig: one (1) tablet po once a day for 4 weeks: please start on . administer via peg tube. disp:*28 tablet(s)* refills:*0* 14. outpatient lab work please draw weekly vancomycin trough, cbc, esr, crp, lfts, bun, cr starting on thursday, . fax results to dr at (phone) discharge disposition: extended care facility: - discharge diagnosis: osteomyelitis, left ankle aspiration pneumonia e. coli bacteremia advanced dementia .. dm htn discharge condition: medically stable, baseline mental status discharge instructions: contact md if patient develops fever/chills, difficulty breathing, or other concerning symptoms. . please take all medications as directed. you have been prescribed 2 antibiotics to take for the next 5 weeks. followup instructions: please follow-up with dr within one week at . Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Diagnoses: Anemia of other chronic disease Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Other pulmonary insufficiency, not elsewhere classified Severe sepsis Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Septic shock Infection and inflammatory reaction due to other vascular device, implant, and graft Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Dehydration Hyperosmolality and/or hypernatremia Septicemia due to escherichia coli [E. coli] Pressure ulcer, elbow Pressure ulcer, ankle Unspecified osteomyelitis, upper arm

allergies: aspirin / cefazolin attending: chief complaint: hypoxia major surgical or invasive procedure: intubation history of present illness: 80 yo f with severe alzheimer's dementia (non-verbal at baseline, bedridden x 10 yrs) and h/o multiple decubitus ulcers was noted to have shaking activity, moaning and in obvious respiratory distress with ronchorous breath sounds this morning. her sats were 60% ra--> 70-80% 5l. she was given morphine 5 mg, albuterol neb, and emts were called. per documentation had "tonic-clonic activity", but in speaking with rn on floor and emts who spoke w/ rn directly, may have had hypoxic myoclonus. she was thought to have aspirated. pt's code status was discussed with daughter, who reversed the dnr status. . in ed, initial vitals t 99.6, hr 150, bp 104/50, rr 24, 100% on nrb. she was intubated for labored breathing and appearing as though she was tiring. she had a leukocytosis to 20 with left shift. she was given vanco, levo, flagyl empirically for presumed aspiration pneumonia, and possible cellulitis given multiple pressure ulcers on the skin. . of note, pt was d/c from for likely aspiration pna treated with vanc/levo/flagyl, and a 6 week course of vancomycin for a presumed osteomyelitis of the l lat malleolus which ended . her wbc were monitored as an outpt, and because of a rise to 18 on and increased "gurgling" in the lungs, she was started on levo/flagyl on for a presumed chronic repeated aspiration pneumonia, due to end on . past medical history: severe alzheimer's dementia x 10 years aspiration htn gerd decubitus ulcers h/o gi bleeding secondary to aspirin chronic l lateral malleolus ulcer af social history: lives at nursing home, non-verbal and non-ambulatory at baseline. has 2 pcas who help care for her. h/o tobacco (quit 25 yrs ago, only few cigarettes/day before that), no etoh. family history: n/c physical exam: physical exam on admission vitals: t 98.7, bp 140/88, hr 134, rr 22, o2 sat 100% on ac 550/14/5/1. gen: elderly female lying in bed, tachypneic, unresponsive to voice or touch heent: anicteric, op dry mucous membrane. cv: tachy, difficult to hear s1 s2, no m/r/g lung: diffuse rhonchi bilat. abd: soft, nt/nd, +bs ext: has multiple skin breakdown both in left elbow (covered), left lateral malleolus 2 cm, and sacrum with 7x7 cm ulceration which extends to bone pertinent results: laboratory studies on admission wbc-20.4 rbc-4.34 hct-31.7 mcv-73 rdw-16.7 plt count-778 neuts-78 bands-1 lymphs-14 monos-4 eos-1 basos-0 atyps-0 metas-1* myelos-1* pt-12.6 ptt-26.6 inr(pt)-1.1 tot prot-7.0 calcium-8.6 phosphate-4.7* magnesium-2.2 ck-mb-notdone probnp-474 ctropnt-0.03* glucose-142 urea n-29 creat-0.8 sodium-133 potassium-5.0 chloride-99 total co2-17 alt(sgpt)-29 ast(sgot)-29 ck(cpk)-51 alk phos-149* amylase-69 tot bili-0.3 lactate-4.7 type-art temp-36.7 po2-102 pco2-34* ph-7.35 total co2-20* base xs--5 intubated radiology cxr: intubated patient, right lower lobe posterior segment small-sized infiltrate, most likely representing an aspiration pneumonia. ekg : probable sinus tachycardia, left axis deviation, rbbb with left anterior fascicular block. inferior infarct. since previous tracing, rate faster. rue leni: no evidence of dvt brief hospital course: 80 yo f with end stage alzheimers dementia presents with episode of sudden hypoxia and likely aspiration leading to aspiration pna. the patient was initially admitted intubated to the icu, where she was treated with aspiration pneumonia with cefepime, vancomycin, and flagyl to cover for noscomial organisms, including pseudomonas. icu course also notable for lactic acidosis and intermittent hypotension, responsive to iv fluids given continued worsening respiratory status, a family meeting was held and the decision was made to withdraw care and make the patient dnr/dni with comfort care only. she was extubated, her tube feeds held, and started on a morphine drip, scopolamine patch, and ativan prn. she was transferred to the floor, where she passed away early a.m. medications on admission: levoflox 500 qd, flagyl 500 q8h, colace, prevacid, mvi discharge disposition: expired discharge diagnosis: aspiration pneumonia discharge condition: deceased md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Acidosis Esophageal reflux Unspecified essential hypertension Hyposmolality and/or hyponatremia Atrial fibrillation Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pressure ulcer, lower back Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Pressure ulcer, elbow Pressure ulcer, ankle

allergies: flagyl attending: chief complaint: etoh cirrhosis major surgical or invasive procedure: liver transplant re-exploration for decreased hepatic flow noted on duplex history of present illness: 60 y.o. male with etoh cirrhosis. last etoh drink 2 years pta. denies fevers, or chills, problems or recent illness. admitted for liver transplant past medical history: 1. dm2: dx 10 years ago, treated w/ glucophage until 1 year ago when bg normalized, likely weight loss, now not requiring medication. 2. htn: treated w/ diovan until 1 year ago, when bp normalized, presumably weight loss. 3. lumbar djd w/ chronic low back pain 4. h/o c.diff difficulty swallowing s/p esoph dilatation basal cell ca htn failure to thrive last tap encephalopathy oral surgery for dentition social history: lives with wife in , ; retired salesman; drank beers per day for 40 years but quit 6 months ago; smoked 2 cigars per day for 20 years; no iv or recreational drug use. family history: 1. cad: father died of mi 2. gastric ca: brother died physical exam: a&o, nad cta bilat sem abd-nt/nd, minimal ascites, no scars ext-wll, lle ankle deformity pertinent results: 01:30am fibrinoge-402* 01:30am pt-12.9 ptt-30.3 inr(pt)-1.2* 01:30am plt count-226 01:30am wbc-9.0 rbc-3.08* hgb-10.0* hct-27.6* mcv-90 mch-32.4* mchc-36.2* rdw-13.6 01:30am albumin-3.0* calcium-8.6 phosphate-2.7 magnesium-1.9 01:30am alt(sgpt)-6 ast(sgot)-12 alk phos-97 tot bili-0.4 01:30am glucose-120* urea n-17 creat-1.2 sodium-140 potassium-3.4 chloride-103 total co2-28 anion gap-12 02:23am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 02:23am urine color-yellow appear-clear sp -1.010 brief hospital course: he was taken to the or on by dr. for orthotopic liver transplant, piggyback technique,with portal vein to portal vein anastomosis, donor celiac artery to recipient hepatic artery, anastomosis with donor replaced left hepatic artery and bile duct to bile duct anastomosis. assisting surgeon was dr. . please see operative report for further details. estimated blood loss was about cc. 250 cc were given as cell . the patient received 8000 units of crystalloid, 6units of ffp, 11 units of packed rbcs, no platelets. two drains were place with one below the right lobe of the liver and the other behind the hilum of the liver. he received induction immunosuppression consisting of solumedrol and cellcept. postop, he was transferred in stable condition to the sicu where he remained intubated. lfts increased from preop ast 12, alt 6, apk phos 97 and t.bili 0.4 to postop ast 3274, alt , alk phos 109, and t.bili 10.1. on a liver duplex demonstrated the following: 1) non-visualized right hepatic artery, normal arterial waveform identified within the left hepatic artery. 2) fatty liver. 3) blunted hepatic vein waveforms suggesting "stiff" liver or an element of narrowing at the ivc anastomosis. 4) small amount of ascites. he was taken back to the or on by dr. for compartment syndrome and exploratory laparotomy, liver biopsy and closure of fascia with mesh under general anesthesia. there was good flow in the hepatic artery, portal vein and hepatic veins. he was readmitted to the sicu postop where he was weaned off propofol and extubated on . lfts trended down to ast 26, alt 87, alk phos 182 and t.bili 1.2. prograf was initiated on postop days 2 and 1. prograf was adjusted to 2mg per levels 7.7. subsequent levels were 9.9 and 11 by pod 7. solumedrol was tapered to prednisone 20mg qd. he will continue slow taper per transplant clinic over the next 3 months. cellcept 1gram po bid continued. creatinine increased to 1.9 on pod 5 and 4 then decreased to 1.3 by pod . diet was gradually advanced. nutrition followed making recommendations for his diet given recent esophageal dilatation. this included a speech and swallow eval. findings included no evidence of aspiration with suggestion to continue on the current po diet of thin liquids and regular consistency solids. he experienced some nausea and vomiting on post op day after taking am meds. a kub was done for mild abd distension and hypoactive bowel sounds. this revealed relatively markedly distended segment of small bowel over the mid abdomen with air seen in the distal colon and rectum of uncertain significance. he was given a dulcolax suppository with passage of bm. n/v resolved. po intake was only fair and calorie counts were ~1500 kcal. on his wbc increased to 22. a urine culture was negative. an abdominal ct was done to rule out intra-abd abscess. this revealed moderate abdominal/pelvic fluid, moderate bilateral pleural effusions with associated atelectasis and right adrenal hematoma. a cxr showed bibasilar atelectasis left greater than right. he also had some uri symptoms that improved. levaquin was started on for a ten day course. on he complained of a sore mouth. several 4mm punctate ulcerations (aphthous appearing) were noted on his tongue and gum. this was cultured for bacterial and viral organisms. maaolox/benadryl/lidocaine swish was ordered. pt followed and recommended rehab. he experienced serosanguinous leaking via the right side of his incision. several staples were removed and a gauze dressing was loosely packed into the wound. the medial jp was removed on pod and the lateral jp remained in place given outputs of 200cc. his hct trended down slightly each day to 24 on . he was ordered for 2 units of prbc. he continued on lasix 80mg for edema. condition is stable. he is alert and oriented. he remained in the hospital pending a bed at rehab with labs every monday and thursday for cbc, chem 10, lfts, and trough prograf levels with results fax'd to the transplant office attn: rn (). he is scheduled to f/u in the clinic. patient was discharged home on after being deemed capable by team. medications on admission: lactulose 30''', lasix 80', protonix 40', spironolactone 100', zoloft 100', iron, mycelex, propranolol 10'', sertraline 100', lasix 80', ativan prn discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 2. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) ml po daily (daily). 3. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 4. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 5. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. sertraline 100 mg tablet sig: one (1) tablet po daily (daily). 9. furosemide 40 mg tablet sig: two (2) tablet po bid (2 times a day). 10. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 11. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 12. insulin regular human 100 unit/ml solution sig: follow sliding scale injection every six (6) hours. 13. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po hs (at bedtime). 14. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. 15. tacrolimus 1 mg capsule sig: one (1) capsule po bid (2 times a day). 16. maalox/benadryl/lidocaine 5ml po prn qid for sore mouth ulcers discharge disposition: home with service facility: & rehab center - discharge diagnosis: h/o etoh abuse dm ii discharge condition: stable discharge instructions: call if fevers, chills, nausea, vomiting, inability to take medications, jaundice, redness/bleeding/pus from incisions or increased drainage, abdominal pain or any questions. labs every monday and thursday for cbc, chem 10, ast, alt, alk phos, t.bili,albumin, and trough prograf level. fax results to transplant office followup instructions: please call transplant office to schedule follow up appointment provider: phone: date/time: 1:15 provider: , md phone: date/time: 1:00 Procedure: Closed (percutaneous) [needle] biopsy of liver Cholecystectomy Other transplant of liver Other repair of abdominal wall Transfusion of packed cells Perioperative autologous transfusion of whole blood or blood components Other operations on lacrimal gland Transplant from cadaver Diagnostic ultrasound of abdomen and retroperitoneum Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Alcoholic cirrhosis of liver Unspecified protein-calorie malnutrition Pulmonary collapse Constipation, unspecified Personal history of other malignant neoplasm of skin Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Other disorders of plasma protein metabolism Complications of transplanted liver Other and unspecified diseases of the oral soft tissues Stricture and stenosis of esophagus Acute alcoholic intoxication in alcoholism, in remission Lumbosacral spondylosis without myelopathy

allergies: flagyl attending: addendum: please note that patient was given stress dose steroids while in the icu for a cosyntropin stim test that showed a flat response, with baseline cortisol 3.1, 1/2 hour 4.1 and 1 hour 4.3. patient was switched to prednisone taper and was sent out on 7.5 mg prednisone daily. will need final taper recommendations in clinic. discharge disposition: extended care facility: & rehab center - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Other enterostomy Other endoscopy of small intestine Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Pulmonary artery wedge monitoring Central venous pressure monitoring Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Insertion of (naso-)intestinal tube Injection or infusion of oxazolidinone class of antibiotics Infusion of vasopressor agent Diagnoses: Acidosis Thrombocytopenia, unspecified Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Severe sepsis Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Septic shock Metabolic encephalopathy Hyperosmolality and/or hypernatremia Liver replaced by transplant Adult failure to thrive Hypercalcemia

allergies: flagyl attending: chief complaint: increasing creatinine value on labs, increasing confusion, nausea and diarrhea since d/c from hospital on major surgical or invasive procedure: open j tube on placed after several attempts at -duodenal tubes pulled or clogged history of present illness: 60 y/o male s/p olt on with several hospitalizations since transplant for incisional wound issues, nausea, poor appetite and confusion who now presents 11 days post last admission with increasing creat on labs, increasing confusion and still having nausea and diarrhea in spite of switching from cellcept to myfortic. on last admission, confusion slowly resolved. a neuro consult had been obtained at that time and he was ruled out for cerebral bleed. iv vitamins, hydration, decreased prograf dosing and starting thyroid replacement for tsh of 12 were also done and improvement in ms was seen. since the discharge, he has continued with nausea, poor po intake (feeding tube was self d/c'd by patient)and has seen an increase in creatinine to 2.7. liver enzymes have been stable, uc negative. no fever or chills. past medical history: etoh cirrhosis, s/p olt (with mesh closure) dm ii htn h/o c diff s/p esophageal dilatation basal cell ca lumbar djd failure to thrive social history: lives in with wife in single family home h/o etoh abuse family history: non contrib physical exam: on admission: vs: 96.9, 105, 135/65, 20, 96% ra gen: appears confused oriented x1 cv: rrr, 2+ radial pulses pulm: cta bilaterally abd: diffusely tender with guarding pertinent results: 11:00pm glucose-91 urea n-10 creat-2.6*# sodium-138 potassium-4.2 chloride-107 total co2-19* anion gap-16 11:00pm alt(sgpt)-23 ast(sgot)-51* alk phos-107 amylase-16 tot bili-0.3 11:00pm lipase-15 11:00pm wbc-3.4* rbc-3.40* hgb-9.9* hct-28.8* mcv-85 mch-29.1 mchc-34.3 rdw-15.7* 11:00pm plt count-192 11:00pm pt-13.9* ptt-34.3 inr(pt)-1.2* brief hospital course: patient admitted with increasing confusion from baseline, increasing creat, nausea and diarrhea. s/p olt in for etoh cirrhosis and coming from rehab center where he has been a patient since discharge . initial therapy was given with iv fluids for likelydehydration, head ct done showing no acute intracranial hemorrhage or mass effect. abd/pelvis ct were done showing bilateral pleural effusions, pericardial effusions, status post olt, reduced size of anterior abdominal wall collection and reduction in size of right adrenal hematoma. liver u/s showed patent vessels, normal blood flow. it was noted that patient was having difficulty swallowing pills, and in general was "orally defensive". swallow eval not done as patient confused and could not cooperate with testing. kept npo. egd on showed normal esophagus, normal stomach and normal duodenum and an nj tube was placed for feeding at this time. on the evening of patient found to be coughing and then vomited mucous, coarse breath sounds noted. increased resp rate with low o@ sats and tachycardia noted with slight fever and when not improved the patient was moved to icu, intubated. bronchoscopy on showed normal secretions and no gross mass. vanco and meropenem started for coverage after pan-culture. sputum cultures, and bronchalveolar lavage did not grow significant organisms. in light of illness at that time patient continued with meropenem, vanco and addition of ambisome and cipro. while in icu patient received cvvh for worsening kidney function/metabolic acidosis. lp also performed which was negative. by patient off pressors, cvvhd stopped for one day and then restarted on for fluid management. creat maximum value 2.8 patient noted to continue to have pulmonary edema with bilateral pleural effusions. antibiotics changed to vanco, meropenem, and prophylactic fluconazole, gancyclovir and bactrim. patient continued on tube feeds. initially failed weaning, and then was successfully extubated on and then transferred back to floor on . mental status slowly improving at this time. creat slowly falling. swallow eval done at this time and this time diet advanced to regular solids and thin liquids, calorie counts and aspiration precautions. pt evaluated and found to require pt training 2-3x/week and recommended d/c to rehab as part of planning. due to patient pulling out several dobhoff feeding tubes, a j tubes was surgically placed on . on , patient again transferred to icu following episode of vomiting with tachycardia and question of aspiration. patient also intermittently confused. at this time patient on vanco and zosyn for questionable aspiration pna. short stay in icu and then transferred back to regular floor. tpn was started in addition to tube feed through j tube. patient is to continue on strict aspiration precautions. received 5 units packed rbcs over the hospital course for anemia. continues on po iron and erythropoietin zoloft, which had been d/c'd on admission due to confusion was restarted. mental status continued to improve, patient assessed by social work and may require further outpatient evaluation. will complete antibiotic course with 2 days of po augmentin, all other antibiotics have been completed. tpn was weaned as of and he will continue on tube feeds. liver enzymes remained normal during this hospitalization. immunosuppression regimen stable. medications on admission: , mmf750'', protonix 40', valcyte 450', bactrim ss', fluc 400', colace 100", zoloft 100', levaquin 500 x 4 more days, iss discharge medications: 1. epoetin alfa 3,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 2. albuterol 90 mcg/actuation aerosol sig: 2-4 puffs inhalation qid (4 times a day) as needed. 3. ferrous sulfate 300 mg/5 ml liquid sig: one (1) po daily (daily). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 5. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed): see sliding scale. 6. sirolimus 1 mg tablet sig: four (4) tablet po daily (daily). 7. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 8. mycophenolate sodium 180 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 9. trimethoprim-sulfamethoxazole 40-200 mg/5 ml suspension sig: ten (10) ml po daily (daily). 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 11. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 12. prednisone 2.5 mg tablet sig: three (3) tablet po daily (daily). 13. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 14. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 15. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 16. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 17. amoxicillin-pot clavulanate 250-62.5 mg/5 ml suspension for reconstitution sig: one (1) po q8h (every 8 hours) for 2 doses. 18. potassium chloride 10 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day: please check potassium level q monday and thursday with transplant labs. discharge disposition: extended care facility: & rehab center - discharge diagnosis: s/p olt aspiration pneumonia sepsis failure to thrive atn (resolving) discharge condition: stable discharge instructions: call if you experience any of the following symptoms: fever,chills, nausea, vomiting, diarrhea, pain over the liver or at the feeding tube site, jaundice, an increase in abdominal girth or any other symptoms concerning to you. have labs drawn every monday and thursday and have them faxed to . cbc, chem 10, ast,alt, alk phos, albumin, t bili and trough rapamune level continue tube feeds per order Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Other enterostomy Other endoscopy of small intestine Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Pulmonary artery wedge monitoring Central venous pressure monitoring Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Insertion of (naso-)intestinal tube Injection or infusion of oxazolidinone class of antibiotics Infusion of vasopressor agent Diagnoses: Acidosis Thrombocytopenia, unspecified Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Severe sepsis Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Septic shock Metabolic encephalopathy Hyperosmolality and/or hypernatremia Liver replaced by transplant Adult failure to thrive Hypercalcemia

past medical history: 1. copd. 2. hypertension. 3. end-stage renal disease. 4. congestive heart failure with an ejection fraction of 25% on an echocardiogram done in , inferior lateral wall motion abnormalities, mitral regurgitation, and severe aortic stenosis. 5. bph. 6. cholecystectomy. allergies: the patient is allergic to bactrim and sulfa. admission medications: 1. prednisone. 2. pepcid. 3. rofecoxib. 4. docusate. 5. vitamin e. 6. quinine. 7. glucotrol 5 mg p.o. q.d. 8. nephrocaps. social history: the patient lives with his wife. reportedly has a 300 pack year smoking history. his primary care physician is . , whose telephone number is . physical examination on admission: vital signs: the patient's temperature was 103.8, heart rate 122, blood pressure 120/78, respiratory rate 24, and oxygen saturation 96% on room air. he was somnolent and in no acute distress. his head was normocephalic, atraumatic. perrl, and eomi. heart: there was a systolic ejection murmur, rating ii/vi at the right upper sternal border and iii/vi mitral regurgitation murmur was heard at the apex. pulmonary: there was decreased air movement throughout his lung fields on pulmonary auscultation; there were no crackles or rhonchi. abdomen: soft, nontender, nondistended, and there were decreased bowel sounds. rectal: no stool in the rectal vault. he had no clubbing, cyanosis or edema of his extremities. neurologic: difficult to assess due to the patient's somnolence. laboratory/radiologic data: the patient's white blood cell count was 7.7 (with a differential of 87% neutrophils, 7% lymphocytes and 6% monocytes), hematocrit 46.1, and platelet count of 159,000. his pt was 13.8, ptt 25.5, and inr 1.3. serum chemistries demonstrated a sodium of 133, potassium 5.7, chloride 90, bicarbonate 27, bun 21, creatinine 5.4, glucose 126, calcium 10.3, magnesium 1.9, and phosphate 3.2. his alt was 34, ast 46, amylase 87, alkaline phosphatase 105, total bilirubin 0.6, and albumin 4.0. initial ck was 59 and troponin 1.9. his initial ekg demonstrated sinus tachycardia at 118 beats per minute, normal axis, normal intervals, st segment elevations in leads v1 and v2 and t wave inversions in leads v4 through v6. this ekg was reportedly similar to an ekg that was obtained on . initial chest x-ray demonstrated a right-sided pleural effusion with cephalization of the vasculature consistent with congestive heart failure. an initial abg demonstrated a ph of 7.33, pc02 of 61, and p02 of 96 on 4 liters of oxygen by nasal cannula. initial head ct was negative for an acute process. initial lumbar puncture demonstrated 11,000 white blood cells in tube one and 850 red blood cells in the same tube. in tube two, there were 8,250 white blood cells, 575 red blood cells, glucose 26, and protein 635. hospital course: the patient's initial lumbar puncture was clear consistent with an infectious bacterial meningitis. the blood cultures that were obtained in the emergency department ultimately grew out alpha hemolytic streptococcus. on hospital day number six, the patient obtained a tee that demonstrated a small, mobile, and filamentous vegetation on the atrial surface of the anterior mitral valve leaflet. given this finding, in the context of the patient's bacteremia and meningitis, it was felt that the patient's primary source of infection was his bacteremia and endocarditis, and that he subsequently seated his meninges. it was felt that the patient's hypotension on admission was due to this overwhelming infectious process. as noted above, the patient was admitted to the micu. he was continued on ceftriaxone, and vancomycin and ampicillin were added for empiric antibiotic coverage initially. once his bacteremia was speciated as alpha hemolytic streptococcus, the ampicillin was discontinued. throughout the patient's hospitalization, the patient was managed in conjunction with the infectious disease service as well as the renal service for management of his hemodialysis. despite appropriate antibiotic coverage, and despite a brief period of improvement in the patient's mental status, his mental status remained poor throughout his hospitalization. on hospital day number four, a head ct scan was obtained to evaluate for possible etiology of his altered mental status. the study was limited by motion artifact but demonstrated no evidence of hemorrhage or mass affect, normal cisterns were seen. the paranasal sinuses were unremarkable. no enhancing lesions were seen. overall, this was felt to be a negative head ct scan. also, on hospital day number four, the patient had a repeat chest x-ray that demonstrated no new infectious process. he had a lumbar puncture done on that day; the results were consistent with resolving bacterial meningitis. by hospital day number five, the patient's levophed, which had been started on hospital day number one due to his pervasive hypotension, was discontinued, as the patient remained normotensive without any blood pressure support. a transthoracic echocardiogram was also done on hospital day number five. this study did not demonstrate any evidence of a vegetation but, as noted above, the patient had a tee done the next day that did demonstrate a mitral valve vegetation. also, on hospital day number six, the patient's bacteremia was identified as alpha hemolytic streptococcus, and at this time, his vancomycin was discontinued. on hospital day number six, an mri of the head was obtained to evaluate for possible etiology of the patient's persistently altered mental status. this study was also limited due to motion artifact but demonstrated no definitive evidence of an intracranial mass, mycotic aneurysm, or abnormal enhancement. on hospital day number seven, a repeat chest x-ray was obtained. this study raised the question of a possible new right middle or lower lobe pneumonia, so the patient was started on metronidazole for a coverage of a possible aspiration pneumonitis. on hospital day number eight, the patient had his third lumbar puncture, this time to rule out the possibility of communicating hydrocephalus. his opening pressure of made this possibility unlikely. by hospital day number ten, the patient's vital signs had been stable for several days, although his white blood cell count remained persistently elevated. in addition, his mental status remained poor. the patient was intermittently agitated. he was also persistently somnolent and difficult to arouse. in order to evaluate for possible etiologies of his ongoing altered mental status, an abdominal ct scan was obtained on hospital day number ten. this study demonstrated bilateral pleural effusions on the right greater than on the left associated with compressive atelectasis. also seen were a few small areas of hypodensity peripherally within the spleen, likely related to early mixing, although septic emboli could not be excluded as delayed images were not obtained. in addition, multiple sigmoid diverticula with apparent evidence of diverticulitis were seen. given the patient's history, these diverticuli were thought to be possibly related to ischemia. finally, smooth, colonic, intraluminal wall thickening of the cecum was seen. in addition, an mri scan of the head and spine was obtained on hospital day number ten given the patient's ongoing altered mental status. this study demonstrated small, bilateral, subdural effusions which could be related to the patient's history of meningitis. also seen were mildly prominent ventricles. cervical spinal mri was limited due to motion artifact but demonstrated multiple levels of degenerative changes without spinal stenosis, external cord compression, or extrinsic scarring. in the context of these new findings, as well as given his persistently elevated white blood cell count and altered mental status, the patient's antibiotics were broadened to piperacillin/tazobactam on hospital day number 12. overall, despite exhaustive imaging studies, as noted above, as well as extensive laboratory evaluations, no clear etiology of the patient's persistently altered mental status was obtained at any point. on hospital day number 13, the patient's blood pressure began to drop. his systolic blood pressure ranged from 65-100 throughout the afternoon, but remained at a level of 65 after a total of 750 milliliters of intravenous fluid via bolusing. when the patient's systolic blood pressure remained low following these intravenous fluid boluses, the available treatment options were reviewed at length with the patient's family. the possibility of pursuing full resuscitative efforts, including cpr with pressors versus maintaining the patient's dnr/dni status with pressors, versus continuing the current level of care with intravenous antibiotics, intravenous medications, tube feeds, and intravenous fluids as needed for blood pressure support were all reviewed with the family. after a lengthy consideration, the family elected to withdrawal all medical care except for any measures that might ensure the patient's comfort. the family indicated that they felt that they were acting in accordance with the patient's wishes. as a result, on hospital day number 13, all medications were withdrawn, as noted above. the only medications that were continued were to ensure the patient's comfort. he then died on hospital day number 14. time of death was 22:50. discharge diagnosis: 1. endocarditis due to alpha hemolytic streptococcus. 2. alpha hemolytic streptococcus bacteremia. 3. secondary bacterial meningitis. 4. sepsis. 5. persistently altered mental status. 6. chronic obstructive pulmonary disease. 7. hypertension. 8. end-stage renal disease, on hemodialysis. 9. congestive heart failure with an ejection fraction of 25%. 10. mitral regurgitation. 11. severe aortic stenosis. , m.d. dictated by: medquist36 Procedure: Spinal tap Incision of lung Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Hemodialysis Diagnoses: Rheumatic heart failure (congestive) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Pneumonitis due to inhalation of food or vomitus Bacteremia Mitral valve insufficiency and aortic valve stenosis Acute and subacute bacterial endocarditis Encounter for palliative care Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Streptococcal meningitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left hemiplegia major surgical or invasive procedure: pacemaker placement mri of head history of present illness: the patient is a 56 year old man with a history of a right mca infarction on possibly secondary to a right mca stenosis (70%) now presenting with increased left sided weakness. the patient is a poor historian so details were gathered from him and his from his brother who discovered him "half out of bed" this morning. the patient tells me he awoke early this morning and couldn't get out of bed (awoke around 5am). the brother heard a noise around 8am and went to the patient's room to find him partly in the bed, moaning a bit, with "slurring of his speech". he wasn't able to get him back into bed, so about an hour later, he dragged him into the kitchen and called ems. he was taken to hospital (details of treatment there unclear at this point) and ultimately transferred to for further management. he arrived in our er at 2:43 pm. the patient currently has no other complaints including headache, chest pain, shortness of breath, or diarrhea. past medical history: 1. diagnosed in his early years with bilateral uveitis, clinically had bilateral uveitis significant with loss of vision and sarcoid floaters in both eyes. he was seen in follow-up by dr. and, later, dr. . his vision has not dramatically changed through the years and he had some laser surgery bilaterally. he was just recently diagnosed with bilateral cataracts in . 2. , presented with episodic right body numbness lasting several minutes, the longest episode was one hour. in the same year, he was admitted with right face, hand and foot weakness. his workup at that time included an electroencephalogram which was normal. conventional left carotid angiogram showed tortuous carotid arteries ("congenital anomaly"). echocardiogram showed mild enlargement of the left atrium. head ct showed right thalamic lacune. the discharge diagnosis was "embolic stroke secondary to congenital anomaly of the right internal carotid artery". 3. , presented with several falls with left arm and leg weakness, which was initially minimal and progressed during the hospital course. the workup at this time included a conventional angiogram showing some irregularity of the left middle cerebral artery and, from the angiogram, the diagnosis of vasculitis was thought. a head ct showed a small lacunar infarction in the right thalamus. chest x-ray was negative. temporal artery biopsy with negative results. laboratory tests included , rpr, rf, anti-cardiolipin antibody, lupus anticoagulant, anca, mitochondrial dna, all normal. lactic acid was elevated from serum at 2.7. erythrocyte sedimentation rate was between 40 and 50. at this point, the working diagnosis was bechet's disease versus vogt-koyanagi- syndrome. uveomeningioencephalitic syndrome. he was treated with 50 mg of prednisone daily as well as started on 150 mg of cytoxan and improved after that treatment. from the records, it seems that his left-sided weakness improved and he was able to walk without assistance. 4. , presented with one week history of memory problems, was repeating questions again and again but did not have any other neurological findings and no more weakness. his neurological examination described that he was oriented by date, person and place, followed three-step mathematical calculation but his memory was poor, bilateral upward going toes and mild left-sided weakness. hypercoagulable workup was done which was negative. transesophageal echocardiogram showed no vegetation. mri/mra, left temporal lobe "lesions" believed to be responsible for acute memory problems. the description of the lesions is very vague, not clear if visible on t1 or t2 but differential diagnosis included demyelinating lesion versus stroke. head ct, on the other hand, reported as a left pca stroke. additional workup, lumbar puncture negative, lyme negative, oligoclonal bands hiv sent, however, results not included in discharge summaries. diagnosis at that time per neurologist, dr. , was demyelinating versus stroke. he was started on aspirin at that time. seen by rheumatologist, again results of that consultation not clear. 5. subacute right mca infarction discovered after patient presented with increased falls at home; 70% right mca stenosis present 6. noninsulin dependent diabetes mellitus. social history: -lives with brother and mother -smokes about ppd -no alcohol use -at his baseline he can walk about his home without a cane (although has used one in the past) family history: -mother with diabetes -father with ? cancer physical exam: vitals: 98.8 75 126/74 23 99% on room air general: middle-aged man forcefully looking to the right. neck: supple lungs: decreased breath sounds at the bases b/l cv: regular rate and rhythm abdomen: non-tender, non-distended, bowel sounds present ext: warm, no edema neurologic examination: mental status: awake and alert, cooperative with exam, flattened affect oriented to person, place, month and president attention: can say months of year backward with 2 errors in 60 seconds language: fluent, mild dysarthria, no paraphasic errors, naming intact. speech was aprosodic. left sided neglect cranial nerves: no blink to threat on left; surgical pupil on right, 1mm on left and minimally reactive; eom shows difficulty looking toward left, no nystagmus; left facial droop; hearing intact to finger rub bilaterally. tongue midline, no fasciculations. motor: flaccid left arm. increased tone in left leg. no tremor. d t b wf we fif ip gl q h af ae tf te right 1 1 4+ 0 0 0 0 3 3 4 3 2 2 2 2 left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 sensation was decreased to all modalities on left arm and leg reflexes: b t br pa pl right 2 2 2 2 1 left 2 2+ 2+ 2+ 1 toe upgoing on left, mute on right coordination is normal on finger-nose-finger on right, unable to perform on left gait exam deferred. pertinent results: on admission, mr. had an elevated white count of 12.4 but otherwise normal cbc, normal electrolytes, normal tox screen, normal coauglation profile, and normal urinalysis. an mri demonstrated occlusion of the right internal carotid artery and right hemispheric infarction. brief hospital course: 1. stroke - the patient's mri demonstrate a large right hemispheric infarction. stroke workup revealed negative tox screen. lipids showed tg 116, hdl 31, ldl 94. echo showed left atrial elongation, no pfo or vegetations. ef low normal (lvef 50%). carotid ultrasounds normal duplex ultrasound examination of the extracranial carotid arteries bilaterally. note is made of high carotid bifurcations. head ct's were followed and did not show signs of worsening edema or shift. he was started on asa and lipitor for stroke prophylaxis. 2. bradycardia - the patient had sick sinus syndrome and a pacemaker was placed on . he will follow up with cardiology pacer clinic next week. 3. vasculitis - because he had a bilateral history of uveitis and a diagnosis of , esr/crp was checked and both were found to be elevated at 50 mm/hr and 1.31. however, it is often possible that acute stroke itself was the etiology of the elevated inflammatory markers, therefore these labs should be repeated. the records from his prior admission were reviewed and his primary care physician was consulted. to summarize, he has had bilateral uveitis and was treated with high-dose steroids in the past. he was noncompliant with these medications and discontinued them. with regards to further workup of this possible vasculitis he should have an esr and crp checked in 1 week. 4. dispo: he was evaluated by pt and ot and a plan was made for inpatient rehab. he was tolerating a regular diet at the time of discharge on . medications on admission: not on any medications although he is supposed to be taking prednisone and lipitor according to the brother discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. nicotine 21 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 3. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 6. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 2 days. 7. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 8. insulin regular human 100 unit/ml solution sig: per sliding scale units injection asdir (as directed). 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 12. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: - discharge diagnosis: r mca infarct, likely cardioembolic discharge condition: stable, with l sided hemiparesis and improved neglect discharge instructions: please take all medications prescribed daily have your esr and crp checked in your rehab in 1 week followup instructions: provider: clinic where: cardiac services phone: date/time: 1:00 clinic with dr. : call to update registration and make appointment md, Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Artificial pacemaker rate check Diagnoses: Tobacco use disorder Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of other diseases of circulatory system Unspecified iridocyclitis Obesity, unspecified Cerebral embolism with cerebral infarction Sinoatrial node dysfunction Hemiplegia, unspecified, affecting unspecified side Legal blindness, as defined in U.S.A.

history of present illness: the patient is a 47 year old male without any significant cardiovascular history who, while exercising this morning on the exercise bike at the gym, slumped over and, according to eyewitnesses, was caught and lowered by his neighbor. was given chest compression when found to be pulseless by a witness and was defibrillated times two by a portable defibrillator sensing probably ventricular fibrillation. estimated time to defibrillation was five to 10 minutes. he was intubated and transported to center. in the e.d. he was found to be agitated, dyspneic and unresponsive to commands. he was given lopressor and nitroglycerin. his agitation and difficulty ventilating were improved with vecuronium and ativan. he apparently had an exercise tolerance test earlier this year, exercising to stage 4 without any symptoms. it was unclear at the time of admission why this test was obtained. his cardiovascular risk factors included use of tobacco, hypertension and hypercholesterolemia. past medical history: hypertension. hypercholesterolemia. outpatient medications: buspar. allergies: unknown. family history: unknown. physical examination: on admission the patient was sedated and intubated. vital signs were blood pressure of 102/57, pulse 90, afebrile, o2 sat 98% to 100% on assist control ventilation with fio2 of 60%. laboratory data: on admission sodium was 139, potassium 4.4, chloride 101, bicarb 21, bun 16, creatinine 1.5, glucose 196. white blood cell count was 15, hematocrit 48.6, platelets 380. hospital course: the patient was emergently taken to the cath lab where coronary angiography was done which showed a right dominant system with two vessel coronary artery disease. the left main coronary artery was angiographically normal. the proximal lad had discrete 99% stenosis with some haziness at the distal pole of the lesion suggesting thrombus. the remainder of the lad had mild luminal irregularities as well as focal 50% stenosis in the mid-lad. the first diagonal branch had 50% proximal stenosis. the left circumflex artery had mild luminal irregularities and produced a first obtuse marginal that was of moderate caliber and had 90% proximal stenosis. the rca had mild luminal irregularities and 30% to 40% mid-rca stenosis. the lad was stented without dissection and without residual stenosis and timi 3 flow. over the course of his stay in the hospital the patient remained hemodynamically stable and was successfully extubated. he was continued on aspirin and plavix. lopressor and captopril were added to his regimen as tolerated by his blood pressure. repeat echocardiogram showed left ventricular cavity size to be normal. overall left ventricular systolic function was mildly depressed with mild septal hypokinesis. no lv thrombus was seen. aortic valve leaflets were mildly thickened and mitral valve leaflets were also mildly thickened with 1+ mitral regurgitation. in comparison with the previous study there was marked improvement in lv function. in light of questionable thrombus on the first echocardiogram, the patient was started on coumadin with cross coverage with heparin. on day of discharge the patient's inr was therapeutic at 2.3 and heparin was discontinued. during the course of his stay the patient was also started on lipitor 10 mg q.day. during his stay in the hospital the patient reported some short term memory loss and was scheduled to follow up with dr. in behavioral neurology clinic. the patient was discharged home with vna to help with medication education and monitoring of inr levels for anticoagulation. discharge medications: 1. aspirin 325 mg p.o. q.day. 2. lopressor 25 mg p.o. b.i.d. 3. buspar 5 mg p.o. t.i.d. 4. lipitor 10 mg p.o. q.day. 5. benadryl 25 mg p.o. q.six hours p.r.n. 6. plavix 75 mg p.o. q.day for one month. 7. sublingual nitroglycerin 0.4 mg p.r.n. for chest pain. 8. zestril 2.5 mg p.o. q.day. 9. coumadin 3 mg p.o. q.h.s. discharge diagnosis: acute mi with v-fib arrest status post cath and stent to lad. discharge status: discharged home. condition on discharge: stable. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Cardiac arrest

pmh: elevated cholesterol. on zocor and wellbutrin. pt is adopted so family history unclear. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Cardiac arrest

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fevers and severe neck pain. major surgical or invasive procedure: aortic valve replacement on . c3-c4 laminectomy on . history of present illness: mr. is a 53 yo male patient who began feeling poorly 2 weeks prior to admission with fevers, neck pain, myalgias, and arthralgias. laboratory work at his primary care provider's office revealed a thrombocytopenia for which he was referred to the oncology clinic. upon eval at oncology clinic, mr. was confused and lethargic for 1-2 days and he was sent to an osh ed for evaluation. blood cultures at this osh grew gpc for which he was initially treated with vancomycin and clindamicin. he later grew group b strep and his antibiotics were changed to gentamicin and pencillin. a tran-thoracic echocardigram revealed a 1.5 cm vegetation on his aortic valve and at this time he was transferred here for management of his endocarditis. past medical history: asthma. copd. atrial fibrillation. surgery for rectal fissure and hemorrhoids. social history: married, lived with wife in . works as real estate attorney. current smoker with 60 pack year history. also reporst etoh use of approximately 8 beers/day. physical exam: pe on presentation: vs: t 104.5; hr 121; bp 131/20; rr 39; spo2 96% on 2l. skin: no visible rashes. heent: anicteric. conjunctiva without hemmorhages. neck very stiff and painful with movement. tender to palpation from c5-t2. positive kernig's and brudzinski's. no jvd. lungs: bilateral diffuse rhonchi. cardiovascular: tachycardic. ii/vi diastolic murmur at right usb. abd: benign. extremities: warm, well perfused. no osler nodes, petechiae, lesions, or splinter hemmorhages. neuro: minimally arousable to sternal rub. genreally agitated. neuro exam as of : mental status alert, and oriented to place, date, and person. no signs of problems w . pt cooperates well with the examination. attention intact w moyb and dowb. language flow, content, repetition, and comprehension normal. has problem w twister jargons. no paraphasic errors. patient can register and recall after one and five minutes. naming intact for frequent or infrequently used objects. no problems calculating. apraxia. prosody of speech intact. cranial nerves: visual fields full. dipolpia not present. pupils are equal and reactive. accomodation intact. gaze midline at rest. no ptosis. eoms intact. no nystagmus. facial sensation intact for fine touch, pinprick and temperature. no facial droop. palate elevates symmetrically. shrug . head version in all directions . movement strong, and protrudes at midline. motor: normal tonus. pronator drift not present. upper extremities: deltoid r(c)-l(4); triceps r(3+)-l(4); biceps r(4-)-l(4+); extensor digitorum r(4)-l(4); lower extremities: iliopsoas r(4+)-l(4+); quadriceps r(4)-l(4); adductors r(4+)-l(4)hamstrings r(4)-l(4); anterior tibialis r(5-)-l(5-); r(4+)-l(4+). coordination: no tremor. finger to nose normal. heel-to-shin affected by leg weakness but non-ataxic. normal. reflexes: normal and symmetric in ue and le except absent achilles no clonus. plantar reflexes downgoing on left and right. sensation: fine touch, pin prick and temperature intact in all limbs. romberg: positive. gait: patient can rise from bed without assistance but with difficulties. the initiation and the performance of the gait are normal but the pt has wide based gait. has tendency to fall if unsupported. pertinent results: 12:32am blood wbc-11.4* rbc-3.26* hgb-9.9* hct-29.7* mcv-91 mch-30.4 mchc-33.4 rdw-15.6* plt ct-275 03:53am blood neuts-78.8* lymphs-14.7* monos-1.5* eos-4.6* baso-0.3 12:32am blood plt ct-275 02:56am blood pt-14.2* ptt-32.0 inr(pt)-1.3 12:32am blood glucose-141* urean-14 creat-1.1 na-127* k-3.9 cl-95* hco3-23 angap-13 03:00am blood alt-46* ast-92* alkphos-160* totbili-0.4 12:32am blood calcium-7.8* phos-2.8 mg-1.6 brief hospital course: mr. was transferred from an osh on . he was initially evaluated by cardiology and neurology. head ct and mri rose question of epidural abscess and neuro-surgery was consulted. an infectious disease consult was also initiated immediately with recommendation for ongoing gent and pen g. a c3-c6 epidural abscess was suspected with associated meningitis and sepsis and he was taken emergently to the or for c3-c6 laminectomy on . addional findings of "weak bone" associated with osteo but no findings of focal abscess. the cardiac surgery team was consulted on . tee on supported diagnosis or endocarditis. over the next several days, mr. went through a pre-operative evaluation and was followed by neurology, neuro surgery, and infectious disease. he continued to be in the icu, intubated, and confused/agitated. it was felt that he was not ready for surgery and that the longer antibiotics could be continued prior to surgery the better mr. outcomes would be. he was also treated for pneumonia. he was successfully extubated on and remianed extubated through however he remained in the icu for hemodynamic monitoring. ongoing chf with inability to obtain optimal hemodynamics pushed mr. to surgery emergently on . on he proceeded to the or with dr. and underwent an aortic valve replacement with a 25 mm perimount pericardial valve. please see or report for full details. on pod 1, mr. failed to from the ventilator. infectious disease continued to follow mr. with ongoing recs for vancomycin and levofloxacin. on pod 2 he was succcessfully weened and extubated. id discontinued his fluconazole. he continued with an altered mental status. pod 3 through 7 he continued with hemodynamic monitoring and abx administration. he continued to be confused in the icu. a neuro consult on pod 7 stated significantly improved mental status. he was continued on haldol but began to from it. on pod 9 he was transferred to the inpatinet floor for ongoing recovery and rehabilitation. his haldol was weened over the next three days with ongoing dosing only at bedtime with significant clearing of mental status to. neuro surgery was again consulted to eval need for ongoing use of cervical collar that mr. had been wearing since his laminectomy and it was decided that he did not need to continue wearing it. on pod 10 he was noted to have a worsening heart murmur and tte was obtained showing a ventricular septal defect. further evaluation of this vsd (as a tee) was declined as no surgical intervention was felt to be necessary. he continued with physical therapy through pod 15 and it was felt that mr. would benefit greatly from rehabilitation. medications on admission: pencillin g 4 million units iv q4h. acyclovir 400 mg iv tid. protonix 40 mg iv daily. gentamicin 50 mg iv q 12 hours. discharge medications: 1. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 6. tamsulosin hcl 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 7. penicillin g potassium 20,000,000 unit recon soln sig: one (1) recon soln injection q4h (every 4 hours) for 4 weeks. discharge disposition: extended care facility: & rehab center - discharge diagnosis: endocarditis with severe aortic regurgitation, s/p aortic valve replacement. cervical spinal stenosis/cervical spine infectious process, s/p c3-c6 laminectomy for decompression of spinal cord. discharge condition: stable. discharge instructions: shower and wash incisions daily with soap and water. rinse well. do not apply any creams, lotions, powders, or ointments. no bathing in a tub or swimming. no heavy lifting greater than 10 pounds. followup instructions: schedule appointment with dr. in 4 weeks (). schedule appointment with dr. with infectious disease within 4 weeks (). will need to have cervical spine mri prior to that visit. schedule an appointment with dr. with neurology within 4 weeks (). schedule appointment with dr. with neuro-surgery in weeks (). echocardiogram at one month, three months, six months, and 1 year post discharge to be followed by dr. . please check weekly cbc, lfts, and creatinine. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Open and other replacement of aortic valve Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Pulmonary artery wedge monitoring Transfusion of packed cells Transfusion of other serum Transfusion of platelets Injection or infusion of nesiritide Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Asthma, unspecified type, unspecified Alcohol abuse, unspecified Acute and subacute bacterial endocarditis Intraspinal abscess Streptococcal septicemia Streptococcal meningitis Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Spinal stenosis in cervical region Methemoglobinemia

history of present illness: the patient is a 50 year old right-handed armenian man with a history of a left middle cerebral artery stroke in as well as a history of one prior seizure in while taking aricept and wellbutrin. the patient has no history of seizures prior to his stroke. his prior seizure occurred in the shower. his family heard him cry out and fall and when they opened the door he was awake but slightly confused. he, at that time, had an electroencephalogram which showed no evidence of epileptiform activity. it did show some left temporal slowing with drowsiness. he was not started on any antiepileptic medication at that time. he has been in his usual state of health recently. he denies any fevers, chills, abdominal pain, nausea, vomiting, new weakness. he has a mild residual right hemiparesis, his arm more than leg at baseline. he was recently increased several days prior to presentation on a dose of reminyl which was tripled. however, otherwise he has had no new medications. on the day of admission, his mother-in-law found him sitting on the couch, slumped to one side, unresponsive possibly, shaking all four extremities. there was no report of any focal activity. the patient reportedly stopped shaking in two to three minutes. the family called 911. the patient was still somewhat unresponsive. he began to vomit enroute to the emergency room and was intubated. at emergency room he had a head computerized tomography scan which just showed evidence of an old left frontotemporal infarct with encephalomalacia but no evidence of acute infarct. he was loaded with dilantin in the emergency room and transferred to the intensive care unit for ventilator management. past medical history: 1. left middle cerebral artery stroke in ; 2. one prior seizure in ; 3. hemorrhoids; 4. depression; 5. hepatitis a. medications on admission: 1. aspirin 325 mg p.o. q. day; celexa; 2. celexa 20 mg p.o. q. day; 3. buspirone 10 mg p.o. b.i.d.; 4. reminyl 8 mg p.o. q. am, 4 mg p.o. q. pm. allergies: no known drug allergies. social history: the patient is from originally. he has lived in the united states for 11 years. he apparently used to know english, however, after his stroke he forgot english and now only speaks russian. he used to work as a gymnastics coach as well as used to drive a cab. he is no longer working after his stroke. he lives with his wife who speaks english well. he has one son, age 23 and one daughter age 16. used to be a heavy smoker and quit for one and half years after his stroke, however, he recently restarted. his mother-in-law still lives with the family. he only drinks alcohol at special occasions. family history: there is no history of seizures or stroke. his father died at age 84 from coronary artery disease. his mother died from stomach cancer. physical examination: at time of the transfer to the floor, his temperature was 98.8, blood pressure was 100/55, pulse 91. he was breathing at 23, sating 100% on blow-by oxygen. he was extubated, awake but sleepy with an nasogastric tube in place, normocephalic, atraumatic with dry mucous membranes. lungs were slightly coarse at the bases. cardiac examination was regular rate and rhythm with no murmurs, rubs or gallops appreciated. abdomen was soft, nontender, nondistended with positive bowel sounds. extremities revealed no edema. mental status examination: he would speak only in russian through a translator. he was able to state his age, state that he was in the hospital. he would follow commands somewhat although he was somewhat uncooperative and had some poor understanding of what was asked of him. his wife reported that his speech was not dysarthric in russian. cranial nerve examination revealed pupils were 4 mm to 2 mm, round and reactive to light. extraocular movements were full. he initially very poorly cooperative to visual field testing but blinks to threat on both eyes. he initially would not smile but had no obvious facial asymmetry. on motor examination, left arm and leg had full strength. he cooperated poorly initially with examination on the right side, but on re-examination was found to have 4+/5 right finger extensors and right triceps. his right lower extremity was full strength. sensation was intact to light touch throughout. coordination initially was uncooperative but later finger-nose-finger testing revealed no evidence of dysmetria. reflexes were 3+ in the right upper extremity and 2+ in the left upper extremity, he had 3+ reflexes at both patella bilaterally and his plantar response was flexor bilaterally. laboratory data: at the time of admission his white count was 17.9, hematocrit of 37.5, platelets 201, inr 1.0, sodium 140, potassium 4.1, bun 10, creatinine 1.0. his creatinine kinase was 62, troponin less than 0.3. he had a urinalysis which showed no evidence of infection. hospital course: the patient is a 50 year old right-handed armenian male with a history of a prior left middle cerebral artery infarct as well as a history of one prior seizure in . he was admitted with a recurrent seizure in the setting of recently increased reminyl dose. the patient likely aspirated during his initial vomiting in the ambulance. he was extubated successfully but continued to have low grade fevers and a mild cough. he had blood cultures unremarkable. his chest x-ray showed evidence of bibasilar atelectasis versus infiltrates. he was started on antibiotics and defervesced. he was also continued on dilantin. his mental status improved significantly over the first several days. he also had an magnetic resonance imaging scan of the head which showed no evidence of acute infarct and evidence of an old left middle cerebral artery infarct. the patient began to eat and had no other complications and is to be discharged to home. he was instructed on not driving for six months, no standing in high places, no swimming alone, no bathing and he will follow up with dr. on . discharge diagnosis: 1. old left middle cerebral artery infarct 2. seizure disorder 3. depression discharge status: stable. discharge disposition: to home. discharge medications: 1. aspirin 325 mg p.o. q. day 2. celexa 20 mg p.o. q. day 3. dilantin 330 mg p.o. q.h.s. 4. amoxacillin 500 mg p.o. t.i.d. for 60 days and then discontinue , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Other convulsions Pneumonitis due to inhalation of food or vomitus Other late effects of cerebrovascular disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 82yo m w/ a pmhx significant for rul stage 3a vs 3b nsclc s/p chemo/xrt with good response found to have a 2nd primary in the rll after wedge resection 1/' represented with a persistent right pleural effusion and suspicious cytology from prior pleurocentesis. he was referred to the interventional pulmonology service for pleuroscopy, biopsy, evacuation of a probable malignant pleural effusion, and talc pleurodesis . major surgical or invasive procedure: 1- s/p right chest thoracoscopy, pleurodesis() history of present illness: 82yo m who typically lives with his wife in , well known to the thoracic oncology group after treatment for a previous rul stage 3a, possibly stage 3b nsclca (?scca) with almost complete response 4 years ago. his functional status did not allow for surgical management of his disease previously. he was being followed serially by dr. in the multidisciplinary thoracic clinic and serial imaging revealed a persistent, and possibly enlarging right pleural effusion. additionally, the patient was known to have a moderately differentiated adenocarcinoma of the rll and was s/p vats/wedge resection of this lesion with dr. in 1/'. after serial pleural cytologic analysis was persistently suspicious for malignancy but no definitive pathologic diagnosis could be rendered, he was referred for pleuroscopy, pleurodesis and biopsy with dr. . past medical history: hypertension gout s/p cholecystectomy lung cancer (likely 2 primaries, see hpi) social history: he has three children, 8 grandchildren and no great grandchildren. he smoked one pack a day for 20 years, he quit 36 years ago. family history: father-- coronary artery disease mother- breast cancer physical exam: vs t= 98.2 hr= 78 (regular) bp = 132/76 rr = 20 spo2 = 96%ra heent- elderly male, nad, aaox3, anicteric, no cervical/supraclavicular adenopathy, no bruit cor- regular, no murmur pulm- decreased bs on r-lung with dullness to percussion half way up the right posterior hemithorax, left lung is clear abd- soft, non-tender, no hernia/mass, no hsm ext- cool, dry, distal pulses dopplerable only, calves soft pertinent results: 11:48am pleural tot prot-4.5 ld(ldh)-194 albumin-2.5 04:15pm pt-11.8 ptt-28.5 inr(pt)-1.0 04:15pm plt count-226 04:15pm wbc-9.3 rbc-5.27 hgb-15.6 hct-45.7 mcv-87 mch-29.6 mchc-34.2 rdw-15.8* 04:15pm osmolal-271* 04:15pm calcium-8.5 phosphate-3.4 magnesium-2.1 04:15pm glucose-123* urea n-12 creat-0.8 sodium-126* potassium-5.0 chloride-91* total co2-24 anion gap-16 08:55pm calcium-8.3* phosphate-4.2 magnesium-2.0 08:55pm glucose-156* urea n-17 creat-1.0 sodium-128* potassium-4.5 chloride-95* total co2-23 anion gap-15 brief hospital course: mr. was admitted to the ip service on after undergoing a right chest pleuroscopy, biopsy, pleurodesis, and placement of a right chest tube thoracostomy. initially post-operatively, his chest tube outputs were serosanguinous with no evidence of airleak on suction. interval fimls confirmed improved aeration of the right hemithorax after evacuation/pleurodesis of the right chest. by pod#1, the patient had an symptomatic bout of afib with a rvr necessitating transfer to the csru. he was not cardioverted, however, amiodarone iv load with transition to an oral regimen was utilized in conjunction with beta blockade. a surface echo revealed no tamponade physiology and a stable peri-cardial effusion. no significant decrement in ef or wall motion abnormalities were noted on this study as well. over the ensuing days, he did have a change in character of his ct outputs and serial h/h revealed a 15 point hct drop. a ct chest done on revealed a moderate to large hemothorax (as described by houdsfiled signature of the complex right pleural effusion in the background of bloody chest tube outputs). he was managed conservatively and no transfusion requirement occured. he did have eventual transfer to the floor (far 2.thoracic floor). intermittently, the patient had burst of afib that converted to sr necessitating advancement of his lopressor medication. he was continued on diltiazem and after clearance with pt was cleared for disposition to rehabilitation. medications on admission: allopurinol 300mg qd, protonix 40mg qd, cardura 0.4mg qd discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 5. hydromorphone 2 mg tablet sig: one (1) tablet po q3-4h (every 3 to 4 hours) as needed. 6. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day). 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for tachycardia. 8. doxazosin 4 mg tablet sig: one (1) tablet po hs (at bedtime). 9. albuterol 90 mcg/actuation aerosol sig: one (1) inhalation every six (6) hours. discharge disposition: home with service facility: discharge diagnosis: 1- right pleural effusion (malignant)s/p thoracoscopy with talc pleurodesis 2- post-operative atrial fibrillation 3- hypertension (controlled) 4- gout (controlled) 5- prior history of right upper lobe (?scca/stage 3a vs3b w/ complete response to chemoxrt) and right lower lobe non-small cell lung cancer (moderately differentiated adenocarcinoma) s/p chemotherapy and radiation discharge condition: stable, afebrile, sinus rhythm, with adequate pain control with good room air saturations, wounds healing well discharge instructions: please resume your pre-admission medications as directed. some changes have been made to your heart medications to help control your heart rate after the procedure. no heavy lifting greater than 15-20lbs for 2-3 weeks. you may shower and pat your wound dry but no bath-tub/swimming/whirlpool for 2 weeks. followup instructions: see dr. in the pulmonary clinic within 2 weeks of dismissal. you should follow-up with dr. of the heme-onc service as well by making an appointment in the next 2 weeks. Procedure: Insertion of intercostal catheter for drainage Other incision of pleura Injection into thoracic cavity Diagnoses: Unspecified essential hypertension Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Secondary malignant neoplasm of pleura Hemorrhage complicating a procedure

allergies: nkda assessment: neuro: pt alert and oriented. follows complex commands. pulm: pt po >90% on 3-4lnc. bs clear and = bilateral. cv: pt currently sinus with frequent pvc's. gi/gu: u/o >30cc/hr, clear yellow urine (see i&os). abd. soft, non tender and non distended. lines: pt with bilateral groin sheaths. left groin, arterial. right groin, vein. wounds: left groin site intact with sheath inplace. no bleeding or hematoma noted. right groin sheath also intact. small fist size hematoma noted with some brusing. no active visual bleeding noted. bilateral le's with palp. pulses (+1), pink, warm and dry. cap refill +2. family teaching: family at bedside. pt and family (wife and daughter) updated on and pt condition. verbalizes understanding but needes reinforcement. spoke with cardiology with regards pt condition. pain: pt c/o chest pain since cath procedure. md's aware of pt chest pain. pt states pain, "gets worse with deep inspiration.." no jaw or arm pain noted. ekg done upon admission into unit (see ekg's). no acute changes noted. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Acute myocardial infarction of other inferior wall, initial episode of care

history of present illness: this is a 70-year-old male with known coronary artery disease status post coronary artery bypass grafting 11 years ago who presented with one hour of substernal chest pain, 10 out of 10 in severity. he went to hospital where electrocardiogram showed acute inferior myocardial infarction. he received ................., intravenous heparin, intravenous nitroglycerin, and plavix. while he was chest pain free after these interventions, he was still noted to have st elevations on electrocardiogram. he was therefore transferred to for cardiac catheterization. left heart catheterization showed three-vessel disease with 80% left main, 80% proximal left anterior descending, patent ramus but subtotal circumflex occlusion, and totally occluded right coronary artery. there was a saphenous vein graft to the right coronary artery with diffuse 80% thrombosis and 80% occlusion after the posterior descending artery anastomosis. the lima was patent to the left anterior descending. proximal vein graft thrombus was cleared with an export catheter, and then a stent was deployed. attention was next turned to the distal vein graft lesion upon which an additional stent was placed. there was no residual stenosis seen, and timi3 flow was achieved. right heart catheterization showed a cardiac output of 3.3 with an index of 1.63, mean wedge pressure of 12, pulmonary artery pressure of 20/9, right atrial pressure of 11. following the procedure, the patient became bradycardiac and hypotensive requiring atropine and dopamine drip and was thus transferred to the coronary intensive care unit for further management. past medical history: coronary artery disease, coronary artery bypass grafting in at , mild hypertension, hypercholesterolemia. medications on admission: atenolol 50 mg p.o. q.a.m. and 25 mg p.o. q.p.m., colestipol 5 g p.o. q.d., zocor 20 mg p.o. q.d., aspirin 81 mg p.o. q.d. allergies: protamine. social history: no tobacco. no alcohol. physical examination: vital signs: on admission temperature was 96.6??????, pulse 86, respirations 22, blood pressure 104/63, oxygen saturation 98%. he was on a dopamine and integrilin drip. general: he was a pale, elderly male lying in bed complaining of nausea and chest pain, but he was in no acute distress. he was alert and oriented times three. heent: pupils equal, round and reactive to light. extraocular movements intact. normocephalic, atraumatic. moist mucous membranes. neck: jvp was not seen. supple. no lymphadenopathy. pulmonary: clear to auscultation bilaterally listening only anteriorly. cardiovascular: there was a distant s1 and s2. no s3 or s4. regular, rate and rhythm. no murmurs, rubs or gallops. abdomen: soft, nontender, nondistended. positive bowel sounds. groin: there was a right venous sheath and a left arterial sheath. there was no hematoma. no oozing. no bruits heard. extremities: distal lower extremity pulses were not palpable, but dorsalis pedis and posterior tibial pulses were heard on doppler. the feet were warm and seem well perfused. there was no clubbing, cyanosis, or edema. neurological: cranial nerves ii-xii intact. strength and motor was not tested. laboratory data: sodium 141, potassium 3.8, chloride 104, bicarb 26, bun 17, creatinine 1.0, glucose 136, ck 108, mb 9, troponin t 0.21 at the outside; cbc showed a white count of 8.9, hematocrit 47.2, platelet count 198, differential of the white count was 50% polys, 40% lymphocytes, 5% monocytes, 4% eosinophils; total protein 7.1, albumin 3.9, bilirubin 0.5, alkaline phosphatase 68, alt 20, ast 50; inr less than 1.0, ptt 26, pt 9.9. electrocardiogram at the hospital showed st elevations in leads ii, iii, and avf. there was st depression in leads i and avl. there were q-waves in leads iii and avf. there were t-wave inversions in leads ii, iii, and avf, i, avl, and v5-v6. there was frequent ectopy. after cardiac catheterization at our hospital, the electrocardiogram showed sinus tachycardia at 127 beats per minute. there was a elevation in lead ii and avf. there was elevations in lead iii. there was 1- depression in leads i and avl, with t-wave inversion in all limb leads, v5 and v6. impression: this is a 70-year-old male with coronary artery disease and coronary artery bypass grafting 11 years ago who presented with an st elevation myocardial infarction, who received .................. heparin, plavix, aspirin, and lopressor at the outside hospital resulting in persistent st elevations despite becoming chest pain free. he was transferred here for cardiac catheterization and received two stents to thromboses in the saphenous vein grafts to the right coronary system. hospital course: 1. cardiac: the patient was continued on aspirin, plavix, and statin. integrilin was continued for 18 hours after catheterization. initially given the patient's hypotension, he was continued on dopamine for approximately 36 hours to keep his mean arterial pressure above 60. he was given aggressive fluid repletion, as well as 1 u packed red blood cells for a hematocrit of 28. the dopamine was eventually weaned off, and we initiated low-dose beta-blockade, as well as ace inhibitor. the patient noted some orthopnea and paroxysmal nocturnal dyspnea. although his lungs were clear, we presumed that he had become hypervolemic from aggressive fluid repletion during his episode of hypotension. we therefore initiated low-dose lasix with improvement in his symptoms. finally we performed an echocardiogram on hospital day #3. this showed normal left atrium, normal left ventricular wall thickness and cavity size, an ejection fraction of 40%, with inferior and inferoseptal akinesis, with normal right ventricular chamber size and wall motion. there was no mitral regurgitation or aortic regurgitation seen. we discharged the patient on low-dose beta-blocker and ace inhibitor. these should be increased as tolerated as an outpatient. cardiology follow-up was arranged with dr. at hospital. hematology: the patient was transfused 1 u of blood cells for a hematocrit of 28. following this, his hematocrit remained stable at approximately 32. gastrointestinal: the patient had considerable nausea with his hypotension which was treated with zofran which provided symptomatic relief. he was also provided with protonix for gi prophylaxis. discharge medications: aspirin 1 p.o. q.d., zocor 20 mg p.o. q.d., colestid 5 g p.o. q.d., plavix 75 mg p.o. q.d., atenolol 25 mg p.o. q.d., lisinopril 2.5 mg p.o. q.d., lasix 20 mg p.o. q.d., this should be taken for 7 days, then stopped. potassium, bun, and creatinine should be checked prior to redosing lasix. follow-up: the patient will follow-up with his primary care physician . and with his new cardiologist dr. . discharge status: to home. condition on discharge: good. discharge diagnosis: 1. myocardial infarction. 2. anemia. 3. hypotension. 4. status post two stents to existing saphenous vein graft. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Acute myocardial infarction of other inferior wall, initial episode of care

discharge status: to home. discharge diagnosis: pericardial tamponade. , m.d. dictated by: medquist36 Procedure: Pericardiocentesis Thoracentesis Diagnoses: Secondary malignant neoplasm of other specified sites Secondary malignant neoplasm of pleura Malignant neoplasm of bronchus and lung, unspecified Secondary malignant neoplasm of other parts of nervous system

history of present illness: the patient is a 62 year-old female with nonsmall cell lung cancer metastatic to pleura, paracardium and ocular stage four disease diagnosed in with increasing shortness of breath and was status post her second therapeutic thoracentesis on when outpatient echocardiogram revealed tamponade. , m.d. dictated by: medquist36 Procedure: Pericardiocentesis Thoracentesis Diagnoses: Secondary malignant neoplasm of other specified sites Secondary malignant neoplasm of pleura Malignant neoplasm of bronchus and lung, unspecified Secondary malignant neoplasm of other parts of nervous system

history of present illness: baby girl is a now 12 day-old ex-29-3/7 week infant (corrected gestational age 31- 1/7 weeks) who was born at a weight of 1015 grams as part of a set of twins, twin b. this infant was born by cesarean section of a 29-year-old g1, p0-2, a positive, antibody negative, rpr nonreactive, rubella immune, mom with an estimated date of confinement of . her pregnancy was the result of in fertilization and was complicated by insulin-dependent diabetes mellitus and hypertension. she was treated prenatally with nifedipine and labetalol. when she went into pre-term labor, she also received magnesium sulfate and intrapartum antibiotics. in addition, she was beta complete with two doses prior to delivery. mom was c-sectioned for pre-term labor. prior to delivery the family had consented to participate in the network delivery room management study. as a result, this infant was randomized to prophylactic surfactant administration. this infant was active at resuscitation with apgars of 9 and 9 with normal newborn resuscitation. she was subsequently intubated at approximately 8 minutes of life. at that point surfactant was administered without complication. the patient was subsequently transferred to the neonatal intensive care unit for additional care. physical examination: weight: 1015 grams (25th percentile). length: 37 cm (25th percentile). head circumference: 26 cm (25th percentile). normocephalic, atraumatic. anterior fontanelle open and soft. regular rate and rhythm without murmur. two plus pulses with brisk capillary refill. respiratory clear to auscultation bilaterally. abdomen non- tender, non-distended, soft. bowel sounds present. genitourinary: normal female genitalia. neurological: non- focal examination appropriate for gestational age. hospital course by system: respiratory: this infant was intubated and received prophylactic surfactant administration. she was subsequently started on caffeine and extubated to bubble cpap at approximately 8 hours of life. she remained on cpap for a total of 72 hours post-natally after which she transitioned easily to room air. during this time she remained quite stable with minimal spells. she remains on caffeine for apnea of prematurity but has, at most, two to three spells in a 24 hours period. cardiovascular: the patient has been stable from a hemodynamic standpoint over the past week. she has intermittently had a soft murmur most consistent with pps. we are just following this clinically and have not felt additional workup indicated at this point. fluids, electrolytes and nutrition: the patient was originally npo with initiation of feeds on day of life one. she gradually advanced up to full volume feeds of 150 cc/kilogram/day. at present she is on breast milk 26 kcal/ounce and gaining weight. in addition, we started her on vitamin e 5 units p.o. q. day and ferrous sulfate 0.1 cc p.o. q. day. gastrointestinal: the patient had mild hyperbilirubinemia with a peak bilirubin on day of life two of 5.5. she received a brief course of phototherapy with a rebound of 3.4/0.3. hematology: admitting cbc had an hematocrit of 55.8 with a platelet count of 183,000. subsequent cbc on day of life one found similar results with hematocrit of 51.9 and platelet count of 195,000. no additional cbc's have been necessary. infectious disease: the patient had a rule out sepsis at the time of delivery. white count at that time was low (4.5 with 29 percent polys, 0 bands) with an anc of 1170. due to this laboratory finding, a follow-up cbc was obtained. the second cbc had a white count of 6.5 with 45 neutrophils. with her stable clinical status and reassuring second cbc, decision was made to discontinue antibiotics. in addition, culture remained negative at 48 hours. no additional rule out sepsis evaluations have been indicated. neurology: this patient had a head ultrasound on day of life six (). this study was normal. audiology: hearing screen should be obtained prior to discharge. ophthalmology: patient qualifies for rop screening but is not of age to have been checked yet. psychosocial: a social worker was involved with this family. the contact social worker is and she can be reached at . condition on transfer: stable. transfer disposition: to . primary pediatrician: information not available. care and recommendations: feeds at discharge: breast milk 26 kcal at 150 cc/kilogram/day p.g. medications: caffeine 7 mg p.g. q. day, vitamin e 5 units p.g. q. day, ferrous sulfate 0.1 cc p.g. q. day. car seat position screening: will need. state newborn screening: sent. immunizations: none to date. transfer diagnoses: 1. prematurity at 29-3/7 weeks' gestation. 2. twin b. 3. mild hmd, status post surfactant (on protocol). 4. apnea of prematurity, on caffeine. 5. hyperbilirubinemia, resolved. 6. rule out sepsis, negative. 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 Arterial catheterization Other phototherapy Umbilical vein catheterization Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn 29-30 completed weeks of gestation Stenosis of pulmonary valve, congenital Other preterm infants, 1,000-1,249 grams

history of present illness: this is a -year-old male with non-hodgkin's lymphoma currently on rituxan, who presented from rehab on with fevers to 101.2, heart rate of 160 found to be in rapid afib, and hypotension with a systolic blood pressure in the 70s. patient was started on diltiazem drip for rapid atrial fibrillation, given iv fluids for hypotension, and was transiently on pressors to maintain his blood pressure. patient was also found to be neutropenic. chest x-ray showed evidence of right chest wall mass with increased effusion and increased right-sided infiltrate thought to be progression of his lymphoma. patient was initially transferred to the icu, where he was weaned off the diltiazem and levophed drips. his hypotension improved, heart rate was controlled. patient was placed on antibiotics for coverage of gram-negative rods and his mental status improved. on , patient was transferred to the medical floor for further care. at that time, patient denied any shortness of breath or pain, just expressed that he was tired. past medical history: 1. non-hodgkin's lymphoma, large b-cell lymphoma diagnosed in receiving rituxan treatment. history of chop times three cycles. 2. atrial fibrillation noted in . 3. status post gastrectomy. 4. status post cholecystectomy. 5. status post turp. allergies: no known drug allergies. medications on admission: 1. lasix 40 q.d. 2. tolterodine 2 mg q.d. 3. lopressor 25 q.d. 4. oxycontin 20 b.i.d. 5. percocet prn. 6. protonix 40 q.d. 7. flagyl 500 t.i.d. (for recent clostridium difficile infection). 8. calcium carbonate. 9. neurontin 300 t.i.d. 10. pravachol 30 q.d. current medications on transfer to medical floor: 1. cefepime 2 grams q8. 2. levofloxacin 250 q.d. 3. colace. 4. senna. 5. neurontin 300 t.i.d. 6. protonix. current vital signs: temperature 98.8, heart rate 89 and irregular, blood pressure 105/48, respiratory rate 16, and saturating 94-98 percent on 4 liters o2 by nasal cannula. patient was calm and conversant in no acute distress. pupils are equal, round, and reactive to light, no lymphadenopathy. cardiovascular: irregularly, irregular s1, s2. lungs are clear to auscultation anteriorly, but decreased breath sounds at the bases. abdomen with bowel sounds, soft, nontender, mildly distended. extremities: plus edema throughout. pulses are 2 plus bilaterally. neurologically: alert and oriented times three. cranial nerves ii through xii are intact, although mild hearing loss and sensation intact bilaterally. strength and gait not assessed secondary to weakness. labs on transfer to floor: white count of 3.4, hematocrit 29.4, platelets 11. chemistries within normal limits. digoxin level 1.7. hospital course by systems: 1. atrial fibrillation: patient was rate controlled initially on diltiazem and transitioned to digoxin. patient received digoxin for approximately two days and then was maintained on low-dose diltiazem without further episodes of hypotension. 1. mental status: patient's decline in mental status was likely thought to be secondary to medications, versus infection, versus transient hypotension. patient's mental status on transfer to floor was currently improved, and per family, he was close to his baseline. 1. pneumonia/pleural effusion: this is thought to be secondary to his lymphoma. patient was continued on levofloxacin. he was given prn nebulizers and incentive spirometry. placed on aspiration precautions. patient underwent a speech and swallow evaluation, which he failed at the bedside. patient was thought to be a silent aspirator. was started on nectar-thick liquids. 1. hypotension: currently resolved. patient is restarted on lasix for gentle diuresis. 1. thrombocytopenia thought to be side-effect of chemotherapy. there is no current active signs of bleeding. patient did not require blood products. 1. neutropenia thought to be functional versus chemical. patient's neutropenia improved. cefepime was d/c'd. 1. lymphoma: patient with known diagnosis of non-hodgkin's lymphoma currently not responding to further therapy. by time of transfer to the floor, the patient denied any pain, symptoms of worsening of lymphoma. however, during this hospital course, patient recognized his cancer was untreatable. patient made specific request to have his end of life care in the hospital. on , patient began to develop increased pain and dyspnea. patient was initially started on nsaid therapy, however, is not responded. patient was then started on narcotics with morphine initially. multiple family discussions were held as to how to satisfy patient's wishes for end of life care. patient's code status was changed to comfort measures only. the patient was started on a morphine drip to titrate to alleviate pain. pain was primarily rib pain whereas penetrating through his bones. on , patient expired. family was notified. postmortem was declined. dr., 12-766 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Thrombocytopenia, unspecified Atrial fibrillation Other malignant lymphomas, unspecified site, extranodal and solid organ sites Hypotension, unspecified Pneumonia due to Klebsiella pneumoniae Disorder of bone and cartilage, unspecified

allergies: mezlocillin / oxacillin attending: chief complaint: change in mental status major surgical or invasive procedure: ngt tube temporary dialysis catheter lij tunnelled dialysis catheter lij history of present illness: this is a 50 year old male with history of hypertension, osteomyelitis, chronic pain and depression who was brought in from home after an attempted suicide by narcotic overdose. per patient's wife, she heard a thud in the other room and found the patient "jerking" on the ground. ems was called and found the patient to be in cardiac arrest, administered epinephrine with return of sinus rhythm (no shock given) and subsequently intubated the patient for airway protection. patient was found with an empty bottle of dilaudid. patient takes methadone and dilaudid for chronic ankle pain. wife noted that he had been very depressed and crying at times over the past few months. . in the ed, vitals 101.8, 110, 75/20, 19, 99%. toxicology screen was positive for methadone/opiates and etoh (level 88), otherwise negative for aspirin and tylenol. stat head ct was negative for bleed or emboli. chest x-ray showed no acute infiltrate. ekg showed sinus tach with 1/2mm st depressions in v3-v4. patient's initial lactate 27 and he was given 3 amps of hco3 with repeat lactate 10. patient's initial abg 6.65/91/348-bicarb 12. repeat abg 7.11/44/142/15. . toxicology was consulted. patient admitted to taking double his usual methadone dose, but denied asa, tylenol or other agents. toxicology did not fell that patient's presentation was consistent with narcotic overdose as patient improved without narcan. . patient was started on vancomycin, levofloxacin and flagyl. he was bolused 4 liters normal saline. three pivs were placed and levophed was started peripherally. patient's sbp increased to sbo 100s and levaphed was weaned. patient's levophed stopped prior to transfer to the micu. past medical history: 1. chronic pain 2. depression 3. osteomyelitis 4. tr/small asd 5. htn 6. microcytic anemia 7. ? osa 8. pulm nodules-has abnormal nodules on cxr and ct. ? granulomas vs. metastatic dz. had bronch and bx which showed inflammatory lesions like granulomas around airways. no definite cause. pfts normal and patient generally asymptomatic. 9. melanoma s/p resection social history: patient is married with no children. he works as a speech pathologist for special children. he drinks 2 beers per night 7 days a week for years, but he and his wife quit 1 month ago. patient does not currently use tobacco and quit in college. family history: parents are alcoholics. physical exam: vital signs: t 101.8 bp 136/81 rr 26 hr 93 o2 sat 97% vent: ac 0.6/ 700/ 5/ 26 general: alert, responding to commands, intubated heent: ncat, epmi, pupils mid size, equal and responsive, neck supple cv: rrr 2/6 sm at rusb lungs: + rhonchi bilat abd: +bs, soft, nt, nd ext: no c/c/e, + healing scars on rle neuro: maew, nonfocal skin: c/d/i- no rash pertinent results: labs on admission: glucose-162* urean-20 creat-1.3* na-138 k-2.8* cl-103 hco3-19* angap-19 calcium-5.9* phos-6.5*# mg-3.0* . wbc-8.1 rbc-5.35 hgb-17.0 hct-52.2* mcv-98 mch-31.8 mchc-32.6 rdw-12.8 plt ct-262 . neuts-89.6* bands-0 lymphs-7.5* monos-2.1 eos-0.7 baso-0.1 hypochr-normal anisocy-normal poiklo-1+ macrocy-normal microcy-normal polychr-normal ovalocy-occasional tear dr ret aut-1.1* . d-dimer-6501* fdp-40-80 . alt-318* ast-1765* ld(ldh)-2396* ck(cpk)-* alkphos-51 totbili-0.4 lipase-74* ggt-92* albumin-2.9* uricacd-15.7* hbsag-negative hbsab-negative hbcab-negative igm hbc-negative igm hav-negative smooth-negative -negative igg-560* hcv ab-negative heparin dependent antibodies-neg herpes simplex (hsv) 2, igg-test neg herpes simplex (hsv) 1, igg-test neg ceruloplasmin-test wnl . pt-16.4* ptt-52.8* inr(pt)-1.5* fibrino-282 lactate-27.1* . 01:37pm blood ck-mb-4 ctropnt-<0.01 05:15pm blood ck-mb-17* mb indx-0.1 ctropnt-0.02* 09:42pm blood ck-mb-20* mb indx-0.1 ctropnt-0.02* 02:00am blood ck-mb-23* mb indx-0.0 ctropnt-0.03* . iron-18* caltibc-215* hapto-143 trf-165* ferritn-595* vitb12-339 folate-15.9 . osmolal-289 tsh-4.2 cortsol-28.5* . blood asa-neg ethanol-88* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg . art po2-348* pco2-91* ph-6.65* calhco3-12* base xs--31 art po2-322* pco2-70* ph-6.86* calhco3-14* base xs--23 -assist/con intubat-intubated comment-vent 700/2 cohgb-0 methgb-1 . urine color-yellow appear-clear sp -1.016 blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirub-neg urobiln-neg ph-6.5 leuks-neg rbc-0-2 wbc-* bacteri-many yeast-none epi-0-2 sperm-few . urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-pos . 04:12am urine color-yellow appear-cloudy sp -1.010 blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-tr rbc-0-2 wbc-0-2 bacteri-mod yeast-none epi-0-2 amorphx-many myoglob-presumptiv . cerebrospinal fluid (csf) wbc-1 rbc-0 polys-0 lymphs-44 monos-56 totprot-51* glucose-105 . catheter tip-iv wound culture-no growth serology/blood rapid plasma reagin test-nonreactive mrsa screen mrsa screen-negative ebv igg/igm/ebna antibody panel - virus vca-igg ab-final; - virus ebna igg ab-postiive; - virus vca-igm ab-negative cmv antibodies cmv igg antibody-negative; cmv igm antibody-negative serology/blood varicella-zoster igg serology-negative swab r/o vancomycin resistant enterococcus-negative mrsa screen mrsa screen-negative sputum gram stain-oropharyngeal flora; respiratory culture-final oropharyngeal flora blood culture aerobic bottle-no growth; anaerobic bottle-no growth blood culture aerobic bottle-no growth; anaerobic bottle-no growth urine urine culture-no growth csf;spinal fluid gram stain-negative; fluid culture-no growth urine urine culture-no growth blood culture aerobic bottle-no growth; anaerobic bottle-no growth blood culture aerobic bottle-no growth; anaerobic bottle-no growth . . studies: head ct: : no acute intracran process extensive fluid in nasal cavity, post nasopharynx and r sph sinus, likely rel to supine position and intubation pre-exist mild sinus inflamm chgs . c-spine ct: no acute fx/alignmt abnlty, poss old compr'n, sup endplate c6, chgs c5/6, w/mod l nf narrowing, et/ngts . cxr: no acute cp procedd, ngt and ett in appropriate position . ekg sinus tachycardia possible left atrial abnormality incomplete right bundle branch block poor r wave progression - probably a normal variant but consider old anteroseptal infarct no change from previous intervals axes rate pr qrs qt/qtc p qrs t 117 168 114 300/ 6 . mr head w & w/o contrast; mra brain w/o contrast findings: brain mri: impression: signal abnormalities at both posterior frontal and parietal convexity region on flair and t2-weighted images without corresponding enhancement or diffusion abnormalities. these findings could be secondary to previous infarcts. no enhancing lesions are seen. if the patient has prior mri examinations, comparison would be helpful. the appearances are not typical for reversible encephalopathy. small areas of microhemorrhages are seen in both cerebral hemispheres near the convexity indicating old hemorrhages. no enhancing lesions are seen. mra of the head: normal mra of the head: mrv of the head: normal mrv of the head. . duplex liver or gallbladder us : 1. normal doppler study. 2. extrahepatic biliary ductal dilatation with mild intrahepatic biliary ductal dilatation. an mrcp would be helpful in order to assess for any obstructive process. 3. marked wall thickening of the gallbladder with intramural edema. this can be seen in several clinical scenarios, including cholecystitis but other features of cholecystitis are not present such as stones and distention. if however this diagnosis is strongly suspected clinically a hida scan could be performed. the appearance can be seen in acute hepatic disease and hypoalbuminemia as well. 4. possible edema around the head of the pancreas. correlation with pancreatitic enzymes to exclude coincident pancreatitis is recommended. . eeg : background: consisted of a 10 hz posterior predominant rhythm bilaterally. at times, faster beta rhythms were observed. this may be due to medications. hyperventilation: could not be performed as the patient could not comply. intermittent photic stimulation: could not be done as this was a portable eeg. sleep: the patient progressed from wakefulness into drowsiness but no stage ii sleep was seen. cardiac monitor: showed a generally regular rate and rhythm with a rate of approximately 70 bpm. impression: this is a normal eeg in the awake and drowsy states. no focal or epileptiform features were observed. . echo : the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). the right ventricular cavity is mildly dilated. right ventricular systolic function is normal. the ascending aorta is moderately dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , there is less tricuspid regurgitation, pulmonary pressures are lower . mri abdomen w/o contrast : 1. underdistended gallbladder with no apparent stones. gallbladder wall edema/pericholecystic fluid is not a specific finding. if clinical concern exists for chronic cholecystitis, a hida scan would be the study of choice. 2. prominent extrahepatic bile duct tapers normally and demonstrates no evidence of choledocholithiasis. 3. extensive subcutaneous edema. 4. bilateral small-to-moderate pleural effusions. of note, technical issues prevented complete normal study and no gadolinium was administered. . chest (pa & lat) : pa and lateral radiographs of the chest are reviewed, and compared with the previous study of . the patient has been extubated. the previously identified congestive heart failure has been improving. there is continued cardiomegaly and small right pleural effusion associated with bilateral lower lobe patchy atelectasis. note is made of a question of nodular opacity in the right apex, which can be composite shadow. when patient is better, evaluate with repeated pa, bilateral shallow oblique radiographs of the chest. impression: 1. improving congestive heart failure with remaining cardiomegaly and small right pleural effusion. 2. question of nodular opacity in the right apex. . unilat up ext veins us right : dvt within one of the distal right brachial veins as well as cephalic vein. basilic vein was not visualized. no evidence of hematoma within the right upper neck. . c1894 int.shth not/guid,ep,nonlaser : successful placement of a 14-french 20-cm double-lumen hemodialysis catheter by way of the left internal jugular vein with tip in the superior vena cava. the catheter can be used immediately. . unilat lower ext veins right : no evidence of dvt in the right lower extremity. . fluoro 1 hr w/radiologist : successful conversion from a temporary left internal jugular to a tunneled hemodialysis catheter (27 cm from cuff to tip). the catheter is ready for immediate use. brief hospital course: briefly, this is a 50 year old man with history of hypertension, depression, chronic pain and osteomyelitis who presented with likely cardiac arrest secondary to opioid overdose and possible associated seizure. on admission to the emergency department, patient was only briefly hypotensive with systolic in 70's which responded to iv fluid resuscitation and required transient peripheral levophed. patient was also empirically started on broad spectrum antibiotics and given po charcoal. a lp was performed to rule out meningitis in setting of witnessed seizure. also, of note, patient was in severe lactic acidosis with ph <7.0 which responded to stat administration of 3 amps of sodium bicarbonate. patient's mental status improved after ed resuscitation and he was transferred to the micu for further care. . in the micu, patient subsequently developed elevated lfts, rhabdomyolysis and acute renal failure. patient remained intubated for airway protection. initially, patient had a severe anion gap and non-anion gap metabolic acidosis and respiratory acidosis. metabolic acidosis was likely secondary to lactic acidosis in setting of cardiac arrest decreased organ perfusion and possible seizure. etiology of non-gap acidosis was unclear. patient's mental status and respiratory acidosis improved and he was extubated on after a rsbi ~10. patient sating 94% on 5l nasal cannula after extubation. repeat cxr was improved but continued to show pulmonary edema. patient remained stable and was subsequently transferred to the floor. . #. ?seizure: patient was initially worked up for seizure with a differential diagnosis of opiate overdose, vasovagal induced, infection induced or etoh withdrawal induced. mri/mra/mrv were negative for emboli or other abnormalities. repeat echo this admission largely unchanged from prior if not improved. lp was performed and not consistent with meningitis. patient with positive tox screen for alcohol and opiates. patient admitted to drinking cough syrup at home. he and his wife had quit drinking alcohol approximately 1 month ago. patient was placed on ciwa scale while on the floor. unclear whether patient actually seized or had post cardiac arrest movements however if patient did seize the likely etiology was either alcohol withdrawal or opiate overdose induced metabolic derangement. patient's mental status returned to baseline and no recurrence of seizures occurred while in hospital. eeg was negative for seizure. nonspecific vascular findings on mri, per neurology were old and would not have contributed to current presentation. plan is to have patient follow-up with a repeat mri and see neurology as an outpatient in weeks time. . #. rhabdomyolysis: etiology likely secondary to immobilization and ischemic compression of muscle induced by opioid overdose versus drug induced seizures or hyperthermia associated with excess muscle energy demands. also, metabolic derangement including hypokalemia (2.8 on admission) and hypocalcemia (5.9) may have contributed or caused the rhabdo but unclear etiology of electrolyte abnormalities ?opioid overdose. cpk peaked at 150,000 on and then continued to downtrend. calcium was repleted aggressively while alkalinizing his urine to prevent further renal damage. . #. arf: on admission, cr 1.0 increaed to 4.8 on and continued to increase to peak of 10.3 on . etiology of acute renal failure likely secondary to hypovolemia during cardiac arrest and rhabdomyolysis. patient was intially aggressively hydrated and his urine was alkalinized with hco3 to avoid further renal damage from myoglobin. he was also given mannitol to osmotically diurese which was eventually held on . there was an unsuccessful rij line placement on , no hematoma was seen on neck us. ir placed temporary dialysis catheter in lij on and then switched over a tunnelled cath into lij on . patient initally required daily dialysis and then three times a week. at time of discharge, patient had gone for 5 days without dialysis and was making large volumes of urine. electrolytes were followed carefully and phosphate binders were used as needed. he will need to have his electrolytes (chem 7, calcium, magnesium, phosphate) checked in 48 hours, 1 week, and two weeks to ensure recovery of kidney function. he will need removal of his tunneled hemodialysis catheter in two days, on , to be done by interventional radiology. a renal consult should be obtained for follow up of chemistries. the renal consult service will decide when patient will be able to have his tunneled catheter removed by interventional radiology. . #. chronic pain/r le pain: patient with history of right ankle injury requiring multiple surgeries between -. it was recommended in that he have his r ankle amputated however patient decided not to have the amputation and to medically treat his chronic pain. had been on methadone and dilaudid po as an outpatient. pain medications were held until patient's mental status was at baseline and then he was started and gradually titrated up on a fentanyl patch with oxycodone prn for breakthrough. iv diladudid was used as breakthrough which was subsequently switched to po dilaudid and then discontinued due to adequate pain control. please obtain pain management consult for pain control if pain is unable to be controlled with fentanyl patch with oxycodone. . #. depression: patient now at baseline mental status however severely depressed. psychiatry was consulted regarding the opiate overdose and felt that patient required inpatient admission for suicide attempt. continued to hold zoloft. continued 1:1 sitter. as patient was medically stable, he was transferred to an inpatient psychiatry floor for further care. . #. anemia: unclear etiology. hct baseline 29.0. paitnet received 2 units in hemodialysis on . hct remained stable thereafter. guaiaced all stools which have been negative. . #. r ue brachial dvt: patient received anti-coagulation for 1 week with iv heparin and then for a short period of time on coumadin. review of us with radiology showed distal location of possible clot and low risk for embolization and so no further anti-coagulation was planned. decision not to anticoagulate was approved by dr. . patient will not need to have heparin sc injections for dvt prophylaxis if he continues to ambulate. . #. increased lfts: most likely secondary to acidemia, possibly shock liver. initially, ruq us suggestive for cholecystitis however subsequent abdominal mri showed prominent extrahepatic bile duct tapers normally and demonstrates no evidence of choledocholithiasis. liver was consulted and recommended the following tests: vzv igg negative, cmv negative, ceruloplasmin wnl, hep a, b, c negative, and anti-smooth ab negative, igg low, hsv1 igg-, hsv2 igg-, ebv igg+ igm-. alkaline phosphatase and total bilirubin began to downtrend without intervention and so no hida/mrcp was pursued. near resolution of elevated lfts at time of discharge. . #. id: patient with very high temp in ed. differential diagnosis included seizure versus infectious etiology. patient was pan-cultured in ed with no growth. patient was only briefly hypotensive and on transient levophed. patient initially empirically covered with vanco, levo and flagyl. lp negative for organisms and not consistent with meningitis. on , antibiotics were discontinued given low suspicion for infection. . #. htn: continued to hold bp agents and follow sbp closely. . #. obstructive sleep apnea: unclear whether patient suffers from this but he can schedule a sleep study as outpatient. . #. abnormal chest x-ray findings: patient will need to follow-up with chest x-ray with pa/lat/bilateral shallow oblique views to re-evaluated possible nodular opacity in right apex of lung seen on chest x-ray . however this admission, no definite opacity in right apex of lung was seen in subsequent chest x-rays. patient has a remote history of pulmonary nodules of unclear etiology. he would likely benefit from repeat imaging. . #. fen: patient is no longer requiring dialysis, watch for electrolyte abnormalities . #. ppx: sc heparin, encouarge ambulation, pneumoboots . #. access: tunneled hemodialysis catheter. peripheral ivs . #. communication: wife: (c) and (h) . #. code: full . #. patient is medically stable to be discharged from the medical floor for transfer to psychiatry. medications on admission: 1. aspirin 235mg po qd 2. methadone 40mg po tid 3. hctz 25mg qd 4. lisinopril 10mg qd 5. zoloft 100mg qd 6. dilaudid 4mg q4h:prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. trazodone 50 mg tablet sig: 0.5-1 tablet po at bedtime as needed for insomnia. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 7. fentanyl 100 mcg/hr patch 72hr sig: one (1) patch transdermal every seventy-two (72) hours. 8. sevelamer 800 mg tablet sig: two (2) tablet po tid (3 times a day). 9. epoetin alfa 10,000 unit/ml solution sig: 10,000 units injection qmowefr (monday -wednesday-friday). 10. oxycodone 5 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for breakthrough pain. 11. outpatient lab work chem 7, calcium, magnesium, phosphate to be checked on: . . . this should be followed by the renal consult service. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: opiate overdose alchohol abuse/dependence cardiac arrest rhabdomyolysis acute renal failure depression nos . secondary diagnosis: chronic right ankle pain history of osteomyelitis hypertension discharge condition: good discharge instructions: please take medications as prescribed. consider restarting blood pressure medications once renal function improves. . please get repeat chest x-ray (pa/lat/bilateral shallow oblique views) to re-evaluated possible nodular opacity in right apex of lung seen on chest x-ray . . please remember to get a repeat brain mri as scheduled by dr. . . if you have any change in mental status, shortness of breath, chest pain, nausea/vomitting, decreased urine output, return to the emergency department. . if pain is not well controlled on the fentanyl patch with oxycodone, obtain pain management consult. . patient does not need heparin sc for dvt prophylaxis if he is able to ambulate. . obtain renal consult for follow up of acute renal failure. please have your blood work checked for recovery of your renal function. you will need the following labs checked on , , , and . chem 7, calcium, magnesium, phosphate. this will be followed by the renal consult service. . you will need to have your hemodialysis catheter removed by interventional radiology. this should happen in days. the renal consult service will determine when this happens. followup instructions: provider: np/ md date/time: 1:20pm locations: clinical center phone: . provider: , md (neurology) date/time: 8:00am location: clinical center phone: . provider: , m.d. (cardiology) phone: date/time: 3:15 . please follow-up in clinic by calling and scheduling an appointment with dr. . . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Venous catheterization for renal dialysis Venous catheterization for renal dialysis Diagnoses: Acidosis Anemia, unspecified Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Other convulsions Depressive disorder, not elsewhere classified Poisoning by opium (alkaloids), unspecified Acute respiratory failure Hypovolemia Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics Rhabdomyolysis Other and unspecified alcohol dependence, continuous Pain in joint, ankle and foot

past medical history: 1. charcot--tooth disease. 2. -parkinson-white status post ablation. 3. asthma. 4. mitral valve prolapse. 5. depression on paroxetine 30 mg per day and p.r.n. lorazepam. 6. nephrolithiasis with chronic pain during pregnancy; initially treated with percocet progressing to hydromorphone infusion at 2.5 mg per hour in the week prior to delivery. also receiving dolasetron. prenatal screens: blood type a-positive, dat negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, group b strep status unknown. antenatal history: estimated date of delivery is for an estimated gestational age of 35-5/7 weeks. pregnancy complicated by maternal conditions and medications as detailed above and by preterm labor at 25 weeks which was treated with magnesium sulfate and betamethasone at that time. mother presented in spontaneous labor leading to a cesarean section under epidural anesthesia. membranes were ruptured at time of delivery yielding clear amniotic fluid. there were no intrapartum fever or other clinical evidence of chorioamnionitis. she did not receive intrapartum antibiotic therapy. neonatal course: infant cried at delivery, orally and nasally bulb suctioned, dried. free-flow oxygen administered. apgars 7 and 9 at 1 and 5 minutes. in the nicu, infant was noted to have grunting respirations, intercostal retractions, and occasional apnea. physical exam upon admission: birth weight 2.595 kilograms, ofc 34.5 cm, length was undocumented at that time. heent: anterior fontanel is soft and flat, nondysmorphic. intact palate. mouth and neck: normal. nasal flaring. red reflex visualized bilaterally. chest: with grunting respirations, moderate intercostal retractions, improved with nasal cpap. clear breath sounds bilaterally with few scattered coarse crackles. cardiovascular was well perfused with regular rate and rhythm. femoral pulses: normal. normal s1, s2, no murmur. abdomen: soft nondistended. liver 2 cm below the right costal margin. no splenomegaly, no masses. bowel sounds: active. anus appears patent. gu: normal penis. testes descended bilaterally. cns: active, responsive to stimuli. tone: appropriate for gestational age and symmetric. moves all extremities. suck, root, and gag: intact. integument: erythema toxicum over neck and trunk. musculoskeletal: normal spine, limbs, and hips and clavicles. hospital course by systems: respiratory: due to increased work of breathing on cpap, infant progressed to intubation and surfactant administration. peak ventilator settings were 25/5 with a rate of 25 and 40% with a blood gas of 7.36, 40, 95, 24, and -2. he received 1 dose of surfactant and was extubated at 24 hours of age, and has been room air breathing comfortably since that time. there has been no evidence of apnea or prematurity. currently breathing 30s-40s with o2 saturations 95-97%. cardiovascular: infant has remained hemodynamically stable throughout without need for cardiovascular support. fen: infant was initially npo until cardiorespiratory stability was achieved, and had normal glucose screens and electrolytes. on iv fluid and normal electrolytes as well. enteral feedings were introduced on day of life 2 with enfamil 20, and advanced gradually to 120 cc/kg/day. infant is currently feeding mostly pg with gradually improving po intake. breast feeding and breast milk were initially held due to maternal medication use, but could be initiated in the future if desired. infant has been voiding and stooling normally, and ast electrolytes were on with a sodium of 142, a k of 4.9, chloride 114, and a bicarbonate of 15. further increase in feeding volumes and/or calories is anticipated. gi: a serum bilirubin was obtained on day of life 3 with a state screen which was 10.5/0.3. it peaked on day of life 4 at 13.5/0.3 at which time the baby was placed under phototherapy. the phototherapy remained in place for 24 hours and was discontinued for a bilirubin of 7.9/0.3, with a rebound level of 8.7/0.3 on the day of transfer. due to concern for one mucousy stool and several heme-positive stools, a kub was obtained on which was reassuring, although with a paucity of bowel gas. repeat kub on was normal. physical exam revealed a soft, flat belly with no distention, active bowel sounds, and baby continued to feed without difficulty. hematologic/id: a cbc and blood culture were obtained upon admission due to the respiratory distress. the white blood cell count was 11.2 with 21 polys and 1 band, hematocrit 44.9 and platelets 359,000. the blood culture remains negative. the antibiotics of ampicillin and gentamicin were administered for 48 hours. baby has remained clinically well since the discontinuation of the antibiotics. neurologic: the baby was followed for neonatal abstinence syndrome in view of maternal narcotic use for chronic pain and due to increasing scores on day of life 2, the baby was started on neonatal opium solution (equivalent 0.4 mg morphine per ml) with the initial dose being 0.35 ml by mouth every 4 hours. this was increased to 0.4 ml every 4 hours later on day 2 of life due to persistently elevated nas scores, but since then scores have remained stable at 4-6. dose of neonatal opium remains 0.4 ml po q 4 hours. on examination, coltson had some irritability and some mild tremors, mildly increased tone, and a high-pitched cry. this has improved with the neonatal morphine. he does have an excoriated buttock. social: parents are married. mother has a complex medical history and has a supportive family in place. plans for transfer to for continued convalescent care and weaning of neonatal morphine and maturation of feeding skills is planned, and parents are in agreement with that at this time. condition at discharge: good. discharge disposition: level ii nursery at . name of primary pediatrician: in . care and recommendations: feedings currently are enfamil 20 at 120 ml per kilogram. medications are neonatal morphine, neonatal opium solution 0.4 ml p.o. pg every 4 hours which is a total dose of 0.9 ml per kilogram per day. car seat position screening is recommended before discharge. state newborn screen was obtained on day of life 3 and was noted to have an increased 17ohp, and a repeat will be sent on prior to transfer to . immunizations received are none to date. immunizations recommended are 1. synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks; 2) born between 32-35 weeks with 2 of the following: daycare during rsv season, smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) infants with chronic lung disease. 2. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age and for the 1st 24 months, immunization against influenza is recommended for household contacts and out-of-home caregivers. follow-up appointments scheduled will be primary care pediatrician after discharge. discharge diagnoses: prematurity at 35-5/7 weeks, surfactant deficiency, rule out sepsis, feeding immaturity and neonatal abstinence syndrome. , md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Observation for suspected infectious condition Neonatal jaundice associated with preterm delivery Other preterm infants, 2,500 grams and over Other respiratory problems after birth 33-34 completed weeks of gestation Rash and other nonspecific skin eruption Other specified conditions involving the integument of fetus and newborn Narcotics affecting fetus or newborn via placenta or breast milk

history of present illness: the patient is a 71-year-old male, who had an episode of chest pain on . he was admitted to an outside hospital and ruled out for myocardial infarction. he stated that he had increased dyspnea on exertion starting in . he saw his primary care physician who referred him to a cardiolgoist. his exercise tolerance test showed ischemia. an echocardiogram was done at dr. office. cardiac catheterization was performed on the 13th which showed a calcified left main, calcified left anterior descending with a 70% lesion at the diagonal i, circumflex lesion of 80%, right coronary artery totally occluded at 100%, with an ejection fraction of 65-70%. please refer to the official cardiac catheterization report. past medical history: 1. hypertension. 2. hyperlipidemia. 3. peripheral vascular disease with known carotid disease. 4. bilateral cea, left and right, in . 5. gastroesophageal reflux disease. 6. squamous cell carcinoma in status post radiation therapy and chemotherapy. medications on admission: nifedipine 60 mg p.o. q.d., metoprolol 50 mg p.o. b.i.d., norvasc 2.5 mg p.o. q.d., isosorbide 60 mg p.o. q.d., gemfibrozil 600 mg p.o. b.i.d., lovastatin 40 mg p.o. b.i.d., folic acid p.o. q.d., pepcid a.c. 10 mg p.o. q.d. allergies: no known drug allergies, but he stated that nitroglycerin sometimes drops his heart rate. social history: he discontinued smoking 22 years prior. he drinks alcohol only on social occasions. physical examination: vital signs: height 5 ft 7 in, weight 175 lb. heart rate 76, respirations 20, blood pressure 160/80. neck: no jugular venous distention or bruits. chest: clear. there was an old healed permcath site on his chest wall. heart: regular, rate and rhythm. abdomen: positive bowel sounds. no hepatosplenomegaly. extremities: no clubbing, cyanosis, or edema. peripheral pulses were present throughout. no varicosities. neurological: nonfocal. the patient was referred to dr. for coronary artery bypass grafting. imaging: preoperative chest x-ray showed minimal atelectasis or scar in the right middle lobe with no other cardiopulmonary abnormality. laboratory data: preoperative lab values revealed a white count of 8.9, hematocrit 44.1, platelet count 194,000; pt 13.4, ptt 27.8, inr 1.2; negative urinalysis; sodium 140, potassium 4.2, chloride 102, bicarb 27, bun 16, creatinine 1.0, blood sugar 90, anion gap 15; alt 15, ast 15, alkaline phosphatase 115, total bilirubin 0.6, total protein 8.2, albumin 4.6, globulin 3.6. ho course: on , the day of admission, the patient underwent coronary artery bypass grafting times three by dr. with a lima to the left anterior descending, vein graft to the obtuse marginal and a vein graft to the posterior descending artery. the patient was transferred to the cardiothoracic intensive care unit in stable condition. on postoperative day #1, the patient had been extubated at 11 p.m. the night prior. he was on a nitroglycerin drip at 0.3 mcg/kg/min. he started his aspirin. his incision drip, which was at 2 u/hr was weaned to off. he was receiving morphine and percocet for pain. he continued his perioperative kefzol. his pulse was 83 in sinus rhythm with a blood pressure of 120/46. his arterial blood gases was 7.36, 40, 119, 24, -2. he had an oxygen saturation of 100% on 4 l nasal cannula. he was alert and oriented. postoperative labs revealed a white count of 17.1, hematocrit 27.7, platelet count 172,000; sodium 142, potassium 4.1, chloride 114, bicarb 23, bun 16, creatinine 0.9, blood sugar 104. he was awake and in no apparent distress. heart was regular, rate and rhythm. his sternal incision was clean, dry, and intact. chest tubes were in place. his lungs were clear bilaterally. his left leg dressing was clean, dry, and intact. he was transferred out to the floor on the morning of postoperative day #1. he was seen by case management. he received pain medication for discomfort. on postoperative day #2, he began lasix diuresis and began beta-blockade with metoprolol 12.5 mg p.o. b.i.d. he was also started on aspirin. he finished his perioperative kefzol. he started his percocet and ranitidine. his blood pressure was 160/66. he was in sinus rhythm, tachycardiac at 114, with an oxygen saturation of 96% on 2 l nasal cannula. his chest tubes remained in place for some drainage. they were switched to water seal. he continued to have a little bit of hematuria. the issue was raised of whether to obtain a gu consult. he began to work with physical therapy on his ambulation and continued to do well on the floor managing his pain with p.o. medications and some dilaudid, in addition to percocet. he went into atrial fibrillation once which resolved within 15 min with intravenous lopressor, and p.o. lopressor was given in addition to his morning dose. on postoperative day #3, his chest tubes were pulled, and he had a pneumothorax on chest x-ray. he was breathing comfortably. he had no other events over night. he was started on amiodarone and was on 400 t.i.d. for his atrial fibrillation. he was back in normal sinus rhythm in the morning with a heart rate of 79 and a pressure of 110/58 and was hemodynamically stable. he continued on his aspirin, lasix, and metoprolol which was increased to 50 mg p.o. b.i.d., as well as pain control medication. he had an oxygen saturation of 97% on room air with a respiratory rate of 20. hematocrit was 26.3, white count 14.3, potassium 4.9, bun 24, creatinine 1.2. his lungs were clear bilaterally. his wounds were clean, dry, and intact. his abdominal exam was benign. his heart was regular, rate and rhythm. he was not in any distress. a chest x-ray was ordered. metoprolol was increased to 75 p.o. b.i.d., and a rehabilitation screen was begun. he was seen by gu on urology consult on who recommended sending urine for cytology to rule out any malignancy and recommended follow-up ct of the abdomen and pelvis to rule out malignancy and checking psa level. the patient was assigned to dr. for follow-up postoperatively as an outpatient. the patient was also seen and continued to work with physical therapy on postoperative day #4. the patient continued with his beta-blockade and amiodarone with normal sinus rhythm at 70 with a blood pressure of 128/51. his chest x-ray did show a bilateral pneumothorax with right greater than left. he had an oxygen saturation of 94% on room air with a stable white count of 11.3 and hematocrit of 23.7, bun of 30, and creatinine of 1.2. his exam was benign. his chest was stable. his heart was regular, rate and rhythm. his lungs were clear. incisions were clean, dry, and intact. he was transfused 1 u packed red blood cells for a hematocrit of 22. rehabilitation screen continued. on postoperative day #5, chest x-ray showed that the pneumothorax was stable. he was hemodynamically stable in sinus rhythm at 70 with a blood pressure of 121/44, with an oxygen saturation of 95% on room air with adequate urine output. his cbc from the day prior showed a white count of 10.4, hematocrit 23.0, and a platelet count of 131,000. he was at level 4. his telemetry was discontinued, and the patient was discharged to home in stable condition with vna services on . discharge diagnosis: 1. coronary artery disease status post coronary artery bypass grafting times three. 2. hypertension. 3. hyperlipidemia. 4. peripheral vascular disease. 5. status post bilateral carotid endarterectomies in . 6. gastroesophageal reflux disease. 7. squamous cell carcinoma in status post radiation therapy and chemotherapy. fop: the patient was instructed to make a follow-up appointment with dr. and see him in the office four weeks postdischarge and follow-up with his cardiologist and internist, dr. .................., and also to follow-up with dr. of urology. discharge medications: aspirin enteric coated 325 mg p.o. q.d., colace 100 mg p.o. b.i.d., lasix 20 mg p.o. b.i.d. for 5 days, potassium chloride 20 meq p.o. b.i.d. for 5 days, dilaudid 2 mg p.o. p.r.n. q.3-4 hours as needed for pain, amiodarone 400 mg p.o. t.i.d. for 1 week, followed by amiodarone 400 mg p.o. b.i.d. for 1 week, followed by amiodarone 200 mg p.o. b.i.d. x 1 week, and then per the instructions of the cardiologist for further amiodarone therapy, metoprolol 75 mg p.o. b.i.d. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atherosclerosis of native arteries of the extremities with intermittent claudication Other and unspecified angina pectoris Personal history of other malignant neoplasm of skin Iatrogenic pneumothorax Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

allergies: keflex and cephalosporins. neuro: arrived sedated on propofol. pupils 8mm and unreactive bilat. md aware. will continue to monitor. cv: nsr with pvc's noted. k+ 3.2->potassium repletion started. ci's greater than 2.0. epi weaned and ntg increased by anesthesia shortly after arrival for htn. continue to increase ntg for bp control->team aware. right femoral site with large area of soft eccymosis. feet warm bilat with intact pp's. resp: simv on arrival. initial abg wnl. coarse bs throughout. gi: abd soft. ogt with minimal pink tinged secretions. mouth suctioned for blood tinged secretions. had large amt blood suctioned from oropharyngeal area in or. gu: adequate u/o. endo: insulin gtt started for hyperglycemia. skin: intact to anterior inspection. large area of eccymosis noted mid sternally. a: htn. pvc's. dilated unreactive pupils. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Other electric countershock of heart Arteriography of femoral and other lower extremity arteries Transfusion of packed cells Repair of blood vessel with synthetic patch graft Diagnostic ultrasound of other sites of thorax Transfusion of other serum Transfusion of platelets Endoscopic excision or destruction of lesion or tissue of lung Extracorporeal membrane oxygenation [ECMO] Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Unspecified essential hypertension Aortocoronary bypass status Hematoma complicating a procedure Acute respiratory failure Cardiac arrest Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Malignant neoplasm of middle lobe, bronchus or lung Air embolism as a complication of medical care, not elsewhere classified

allergies: cephalosporins / ace inhibitors attending: chief complaint: shortness of breath major surgical or invasive procedure: s/p rigid bronch with argon plasma coagulation/cardiac arrest/ecmo/removal of ecmo history of present illness: mrs. has a previously diagnosed right middle lobe carotenoid and presented for ablation due to recurrent hemoptysis. due to the patient's frailty, pat and other examinations were performed for the endoscopy. past medical history: s/p rigid bronch with argon plasma coagulation/cardiac arrest/ecmo/removal of ecmo pmhx: carcinoid tumor, asthma, lul adenoca, s/p cabg, dilated cardiomyopathy, lvef:30% physical exam: general- ill appearing female heent- perrla, wnl resp- clear, coarse right cor- rrr abd-+bs, nt, nd, soft ext- no edema, pertinent results: cardiology report c.cath study date of brief history: is a 75 year old woman with hypertension, hyperlipidemia, prior tobacco use and positive family history of cad. she has a prior history of cabg (lima to ramus, svg to lad, svg to om). while undergoing a bronchoscopic procedure for ablation of a bronchial carcinoid tumour, the patient suffered a cardiac arrest. resuscitation was begun, tee revealed that there was air in the left ventricle. the patient was placed on extra-corporeal membrane oxygenation and transferred emergently to the cath lab. final diagnosis: 1. two vessel coronary artery disease. 2. patent svgs to lad and om2. 3. air in left ventricle hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:25am 13.3* 3.49* 10.6* 31.8* 91 30.2 33.2 14.1 387# differential neuts bands lymphs monos eos baso atyps metas 01:11pm 93.3* 0 3.5* 2.8 0.3 0.1 red cell morphology hypochr anisocy poiklo macrocy microcy polychr 01:11pm normal1 normal normal normal normal normal 1 normal manual basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 05:23pm 41.7* heparin dose: 800 06:25am 387# 06:25am 12.91 116.0* 1.1 radiology final report unilat up ext veins us left 10:37 am unilat up ext veins us left reason: lue swelling medical condition: 75 year old woman with new onset of left upper ext swelling with history of cvl on that side reason for this examination: ? left upper extrem dvt indication: 75-year-old female with history of new-onset left upper extremity swelling and history of central venous catheter on that side. comparison: left upper extremity ultrasound dated . left upper extremity ultrasound: grayscale, color flow and doppler ultrasound of the left internal jugular, subclavian, brachial, cephalic and basilic veins were obtained. color flow and doppler ultrasound only of the axillary vein was performed. although compression of the axillary vein was not performed, relative loss of color flow was demonstrated within the axillary vein. normal flow, augmentation, compressibility and waveforms were demonstrated in the right internal jugular, brachial veins were seen. the cephalic vein was not previously imaged and demonstrates non-compressibility consistent with intraluminal thrombus. impression: 1. no evidence of left axillary dvt extension. 2. limited exam of the left axillary vein. no visualized thrombus is seen, with demonstrated normal wall- to wall flow. if clinical concern persists, reimaging with axillary vein could be performed at no additional charge for the patient. 3. intraluminal thrombus of the left cephalic vein, which was not previously imaged. radiology final report bilat lower ext veins 10:37 am bilat lower ext veins reason: lle clot medical condition: 75 year old woman with new onset of left lower ext swelling with history of cvl on that side reason for this examination: ? left lower extrem dvt indication: 75-year-old female with new onset of left lower extremity swelling, and history of central venous catheter placement. evaluate for left lower extremity dvt. comparison: left lower extremity ultrasound dated . left lower extremity ultrasound: grayscale, color flow, and doppler imaging of the left common femoral, superficial femoral, and popliteal veins were performed. as previously indicated, thrombus is seen extending from the popliteal vein through the superficial femoral vein, and into the common femoral and greater saphenous vein. there has been no significant interval resolution or progression of the identified thrombus. although a normal waveform is demonstrated within the mid and distal superficial femoral vein, no visualized color flow is demonstrated, and no compression was visualized. impression: essentially occlusive thrombus extending from the popliteal vein through the mid superficial femoral vein. partially occlusive thrombus in the greater saphenous, and common femoral veins. these findings are unchanged from prior study dated . brief hospital course: brief history: is a 75 year old woman with hypertension, hyperlipidemia, prior tobacco use and positive family history of cad. she has a prior history of cabg (lima to ramus, svg to lad, svg to om). while undergoing a bronchoscopic procedure for ablation of a bronchial carcinoid tumour, the patient suffered a cardiac arrest. resuscitation was begun, tee revealed that there was air in the left ventricle. the patient was placed on extra-corporeal membrane oxygenation and transferred emergently to the cath lab. there was a visible pocket of air in the left ventricular cavity. a pigtail catheter was advanced into the lv and used to aspirate the air. there was reduction in the appearance of the air pocket on fluoroscopy. when maximal efforts to aspirate the air were completed, the patient was defibrillated with one shock and sinus rhythm was restored. small doses of levophed were used to maintain blood pressure. the patient was placed on the ventilator with good oxygenation and co2 exchange. uncrossmatched blood was administered with improvement in filling pressures. fluroscopy did not reveal any evidence of pneumothorax. the patient was transferred to surgery for removal of the ecmo cannulas. patient supported in icu and successfully extubated and weaned of pressors and transferred to floor. pt made dnr/dni per her wishes in agreement w/ family. was recovering well and approaching discharge to previous inpatient facility. pod#8- pt found unresponsive w/ agonal respirations with stable hemodynamics. family wished no further intervention and comfort measures to be a priority and were initiated. pt expired at 1806 with family at bedside. pronounced by thoracic team. attending physician . medications on admission: singulair, duoneb, lasix, lovastatin, coreg, fosomax discharge medications: none discharge disposition: expired discharge diagnosis: s/p rigid bronch with argon plasma coagulation/cardiac arrest/ecmo/removal of ecmo pmhx: carcinoid tumor, asthma, lul adenoca, s/p cabg, dilated cardiomyopathy, lvef:30% discharge condition: pateint expired followup instructions: none Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Other electric countershock of heart Arteriography of femoral and other lower extremity arteries Transfusion of packed cells Repair of blood vessel with synthetic patch graft Diagnostic ultrasound of other sites of thorax Transfusion of other serum Transfusion of platelets Endoscopic excision or destruction of lesion or tissue of lung Extracorporeal membrane oxygenation [ECMO] Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Unspecified essential hypertension Aortocoronary bypass status Hematoma complicating a procedure Acute respiratory failure Cardiac arrest Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Malignant neoplasm of middle lobe, bronchus or lung Air embolism as a complication of medical care, not elsewhere classified

allergies: sulfa (sulfonamides) / amoxicillin / latex / shellfish attending: chief complaint: chest pain major surgical or invasive procedure: s/p cardiac cath with pci to lad x3 intra-aortic balloon pump history of present illness: 87 yo female with pmh cad, htn, hyperlipidemia, dm admitted to hospital with complaints of intermittent chest pain for several days preceding admission. six months ago, she had chest pain and was admitted to the hospital where she said she was exercised and was told she should have a cardiac cath but refused it at her age. this time, pt complained of severe chest pain at lower substernal area with sob, lightheadedness, and n/v when doing housework 6 days ago. unable to determine pain rate. chest pain radiated to left arm, lasted more than 30 minutes. did not take medicine, diminished by resting. denied palpitations, orthopnea, or edema. she called her grandson who suggesting going to the hospital. she called an ambulance and was taken to hospital where they found anterolateral st elevation and +trop 2.9 consistent with anterior st elevation mi. pt was initially medically managed. was started on lovenox and transferred here for cardiac cath. past medical history: cad s/p mi, refused cardiac cath in the past htn hyperlipidemia niddm gerd barrett's esophagus diverticular disease hiatus hernia with skin ca with s/p cytectomy s/p colectomy tah bilateral salphingo-oopherectomy right cataract surgery mva in social history: denies tobacco, etoh lives alone, able to perform adl family history: mother died at 81 due to mi physical exam: vs: t91.1 (oral), p111, 90/37, rr20, 92% on ac fio2 1, tv 500, rr28 gen: sedated and intubated cvs: rrr, nl s1 s2, no murmurs appreciated lungs: course breath sounds bilaterally abd: soft, nt, nd, +bs groin: no hematoma or bruit ext: no edema bilaterally pertinent results: 07:37pm wbc-30.8* rbc-4.28 hgb-13.5 hct-39.8 mcv-93 mch-31.6 mchc-34.0 rdw-13.1 07:37pm neuts-83* bands-5 lymphs-3* monos-5 eos-0 basos-0 atyps-4* metas-0 myelos-0 07:37pm plt smr-normal plt count-258 . 07:37pm glucose-732* urea n-27* creat-1.2* sodium-125* potassium-4.0 chloride-94* total co2-14* anion gap-21* 07:37pm calcium-7.1* phosphate-4.7* magnesium-1.4* . 05:27pm type-art tidal vol-450 o2 flow-1 po2-83* pco2-46* ph-7.21* total co2-19* base xs--9 -assist/con intubated-intubated . 07:50pm type-art po2-65* pco2-44 ph-7.18* total co2-17* base xs--11 07:50pm glucose-741* lactate-4.4* 07:52pm o2 sat-62 . 09:40pm type-art temp-36.1 po2-117* pco2-39 ph-7.31* total co2-21 base xs--6 09:40pm lactate-4.6* . 11:57pm type-art temp-35.0 po2-94 pco2-29* ph-7.43 total co2-20* base xs--3 11:57pm o2 sat-98 . 10:51pm urine blood-mod nitrite-neg protein-neg glucose-250 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 10:51pm urine rbc-0 wbc-0-2 bacteria-none yeast-none epi-0-2 . 07:37pm blood ck(cpk)-1146* 07:37pm blood ck-mb-233* mb indx-20.3* ctropnt-3.95* 11:47pm blood ck(cpk)-1495* 11:47pm blood ck-mb-312* mb indx-20.9* ctropnt-4.94* 04:58am blood ck(cpk)-1864* 04:58am blood ck-mb-314* mb indx-16.8* ctropnt-5.92* 10:16am blood ck(cpk)-1580* 10:16am blood ck-mb-205* mb indx-13.0* 03:10pm blood ck(cpk)-1279* 03:10pm blood ck-mb-142* mb indx-11.1* ctropnt-4.75*1 01:19pm blood ck(cpk)-355* 01:19pm blood ck-mb-10 mb indx-2.8 ctropnt-3.74* 08:08pm blood ck(cpk)-263* 08:08pm blood ck-mb-18* mb indx-6.8* ctropnt-3.88* 08:30am blood ck(cpk)-231* 08:30am blood ck-mb-23* mb indx-10.0* ctropnt-4.98* . tte: conclusions: there is symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (ejection fraction 20-30 percent) secondary to akinesis of the anterior free wall, apex, and interventricular septum; the basal and midventricular segments of the inferior, posterior, and lateral walls contract normally. right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. . cxr: interval decrease in bilateral diffuse pulmonary infiltrates. consistent with resolving pulmonary edema. . tte: overall left ventricular systolic function is severely depressed (ejection fraction 20-30 percent) secondary to severe hypokinesis/akinesis of the anterior septum, anterior free wall, and apex; the inferior free wall is hypokinetic as well. there is no ventricular septal defect. the right ventricular cavity is dilated. there is focal hypokinesis of the apical free wall of the right ventricle. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are mildly thickened. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is a moderate sized pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. the effusion appears loculated around the right ventricular free wall. there are no echocardiographic signs of tamponade. no right ventricular diastolic collapse is seen. . cxr: : no pneumothorax. left lower lobe atelectasis/consolidation. small focal opacity consistent with consolidation in right mid-zone. probable small bilateral pleural effusions. . tte: left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with near akinesis of the septum, distal inferior wall and apex and hypokinesis of the distal half of the anterior wall. no aneurysm or masses or thrombi are seen in the left ventricle. masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets appear structurally normal with good leaflet excursion. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a small pericardial effusion. . tte: severe left ventricular systolic dysfunction with small apical aneurysm. moderate mitral regurgitation. very small circumferential pericardial effusion. . cxr: there are small bilateral pleural effusions. there is mild pulmonary edema. there are left lower lobe opacifiactions which are improving. again seen is biapical pleural thickening. . cxr: improvement in bilateral pulmonary vascular congestion. bilateral pleural effusion also have decreased in size since the prior study. the left lower lobe remains atelectatic. there is no evidence of pneumothoraces. . brief hospital course: 1. cad: pt started on lovenox and transferred here for elective cath. left heart ventriculography showed mild mitral regurgitation; severely hypokinetic anterolateral, anteroapical, and mid to distal inferior walls; and lvef 25%. coronary angiography showed a right dominant system with lad with tandem 95% and 90% mid vessel lesions with timi 2 flow at the start of the case, 60% ostial lesion of lcx, large branching om1 with 80% stenosis in the upper pole and 85% stenosis in the lower pole at the birfurcation, and proximally occluded rca that filled by left to right collaterals. pt was s/p anterior mi. ct surgery was consulted who refused the pt as an operative candidate. the lad lesions were stented: 1 cypher stent in the proximal lesion and 2 pixel stents in the distal lesions, with resulting timi 3 flow. . at the end of the case, the pt developed respiratory distress requiring 100 nrb mask, iv lasix 80mg, and iv ntg. this progressed to fulminant respiratory failure requiring intubation with mechanical ventilation. following induction, the pt became progressively hypotensive refractory to wide-open dopamine. pt as given iv solumedrol, iv benadryl, and iv pepcid for possible allergic reaction as contributing factor for hypotension. the pt was taken back to the cath lab and found to have widely patent lad stents and no change in anatomy in the lcx and rca by collaterals. a iabp was placed in the right fa with diastolic augmentation to 140mm hg on wide open da and neo gtt. right heart cath showed only mildly elevated right heart pressures with pcw 18mmhg and entry into the la by pfo or asd confirmed by sats. bedside echo demonstrated known ef 20-25% and no hemodynamically important pericardial effusion. there was mild ai. pt suffered a large infarction peri-cath secondary to distal embolization. . on hd2, ck peaked at 1864 (tn 5.92) and trended down. pt was continued on asa, plavix, heparin, statin. beta blocker was held and ace was not started in the setting of hypotension. echo showed severely depressed left ventricular systolic dysfunction with ef of 20-30%. echo on found small apical aneurysm. pt was taken off heparin for a couple of days when her platelets decreased. platelets normalized. on hd7, heparin was restarted for her severely depressed ef and apical aneurysm. . 2. chf: pt was transferred to the ccu in cardiogenic shock, as demonstrated by co of 2.7 and ci of 1.9 using the swan. pt was continued on dopamine and 1:1 iabp. pt was making good urine output. neosynephrine was weaned off and levophed was added. pt presented in heart failure as seen on chest x-ray. echo performed on showed severely depressed left ventricular systolic dysfunction with ef of 20-30%; no pericardial effusion was seen. repeat echo on showed a new moderate sized pericardial effusion which was echo dense, consistent with blood, inflammation or other cellular elements. there are no echocardiographic signs of tamponade. serial echos showed decrease in pericardial effusion. pt was weaned off of both dopamine and levophed. on hd4, iabp was removed. pt was off pressors for 14 hours prior to restarting dopamine. dopamine was weaned off. pt was off pressors for 15 hours prior to requiring levophed. during this time, pt was diuresed with prn iv lasix with good urine output. on hd7, swan was resited in setting of new fevers and question of infection. swan numbers with pcw of 27 were consistent with continued heart failure. pt remained on levophed. pt had multiple episodes of sinus tachycardia with rate-related left bundle branch block. on hd7, pt became progressively hemodynamically unstable requiring increasing doses of levophed, up to 0.400. swan numbers showed significantly depressed cardiac index of 1.5 and increased svr of 2200. pt was started on milronone. she became tachycardic during milronone bolus. bolus was stopped and milronone drip started. repeat swan numbers revealed ci and svr back to 2.7 and 1032. on hd8, milronone discontinued. pt continued to have tenuous hemodynamics, very pressor dependent, with little progress. family meeting took place on hdi and decision was made to make pt dnr. no progress made overnight. on hd9, family meeting took place and decision was made to make pt . pressors were discontinued and pt was extubated. she passed away shortly thereafter. . 3. rhythm: pt had transient episodes of sinus tachycardia with rate-related left bundle branch block, related to even the smallest amount of stimulation and manipulation. hr would spontaneously decrease to 80-90s. . 4. id: initially, sepsis was considered as source of hypotension given elevated wbc of 30. however, pt was afebrile without source of infection. initially, pt was pan-cultured and started on broad spectrum empiric antibiotics, which were discontinued on hd3, after patient remained afebrile and cultures remained negative. on hd6, pt developed fevers to 101.4. blood cultures sent off and pt started on empiric levofloxacin and flagyl. cultures continued to remain negative. on hd7, pt continued to spike temperatures, had elevated bs, and hypotension requiring slight increase in levophed. swan numbers were not consistent with septic physiology. vancomycin was added for additonal coverage. initial swan was removed and new swan was placed. given lll consolidation suggestive of pna seen on cxr, levo was discontinued and switched to ceftazidime for coverage of pseudomonas. sputum culture grew gram positive cocci in pairs/chain, gpc in clusters, and gram negative rods. blood and urine cultures remained without growth and no definite source of infection identified. . 5. respiratory failure: pt developed acute respiratory failure after cardiac catheterization most likely secondary to acute heart failure. pt was intubated on hd1. pt remained intubated. on hd5, attempt made to wean to pressure support, which she did not tolerate as she become tachycardic. pt remained on assist control with adequate ventilation. pt was extubated on hd9 and pt passed away shortly after. . 6. heme: on admission to ccu, pt's hct was 32. hct dropped to 27 on , for which she got 1 unit with appropriate increase to 30. platelets on admission to ccu was 258. pt had transfused 1 unit of platelets on hd1 prior knowing platelet value. platelet counts subsequently steadily decreased to nadir of 60s on hd4 when it was decided to discontinue heparin. platelet counts steadily increased. hit antibodies were found to negative. decrease in plt felt to likely to be from integrillin and shearing by iabp. heparin was restarted on hd7. hct remained between 27-30. . 7. dm: pt initially presented with hyperglycemia of 732. possible etiologies include recent steroids, sample drawn from vein close to drips containing dextrose, acute stress. less likely from dka, given the fact that glucose quickly normalized. pt was continued on insulin drip with good blood glucose levels. on hd7, pt went up on insulin requirements with bs in 200s. . 8. metabolic acidosis: pt initially presented with elevated lactate of 4.4. most likely secondary to decreased tissue perfusion. by hd2, acidosis was significantly improved. pt had no further issues. . 9. hyponatremia: pt initially presented with hyponatremia with sodium of 125. this is most likely secondary to chf and hyperglycemia of 732. sodium subsequently normalized. . 10. fen: pt was given tube feeds during this hospitalization. medications on admission: metoprolol 50mg asa 81 mg qd lipitor 80mg qd plavix 75mg qd lovenox 50mg sc bid imdur 60mg po qd discharge medications: pt made on morphine drip. . meds prior to : lasix 100mg iv prn norepinephrine 0.25 mcg/kg/min heparin 400 fentanyl citrate 50 mcg/hr midazolam hcl 1.5 mg/hr iv insulin 5 unit/hr iv ceftazidime 1gm q24 metronidazole 500 mg iv q8h vancomycin hcl 1000 mg iv q24h atorvastatin 80 mg po daily pantoprazole 40 mg iv q24h clopidogrel bisulfate 75 mg po daily aspirin ec 325 mg po daily atropine prn tylenol prn senna docusate discharge disposition: expired discharge diagnosis: s/p anterior mi cardiogenic shock respiratory failure discharge condition: pt passed away on . discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Implant of pulsation balloon Transfusion of packed cells Transfusion of platelets Nonoperative removal of heart assist system Injection or infusion of nesiritide Insertion of drug-eluting coronary artery stent(s) Diagnoses: Other primary cardiomyopathies Thrombocytopenia, unspecified Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Cardiogenic shock Encounter for palliative care Pneumonia due to other specified bacteria

history of present illness: baby , twin number 2, delivered at 31 and 0/7 weeks gestation. he was admitted to the newborn icu for management of respiratory distress and prematurity. birth weight was 1530 grams. the mother is a 34 year-old, gravida i, para 0 now ii mother, with in- fertilization, diamniotic, dichorionic twin gestation. her prenatal screens included blood type a positive, antibody screen negative, hepatitis b surface antigen negative, rubella immune, rpr nonreactive and group b strep unknown. maternal medications during pregnancy included prozac 40 mg daily and pepcid ac. she presented with preterm labor and bleeding on the day of delivery. she was treated with magnesium sulfate and received a dose of betamethasone shortly prior to delivery. due to increased bleeding, delivery was by emergency cesarean section with abruption noted at delivery. this twin emerged breech, was cyanotic and limp with apnea in the delivery room. he was given positive pressure ventilation for several seconds. his apgar scores were 5 at 1 minute and 8 at 5 minutes. physical examination: in general, infant with respiratory distress. weight 1530 grams (50th percentile). length 43 cm (50th percentile). head circumference 29 cm (50th percentile). head: normocephalic, atraumatic. anterior fontanel open and flat. palate intact. red reflex present bilaterally. neck supple. chest: shallow respirations with deep intercostal retractions and grunting. cardiovascular: regular rate and rhythm. no murmur. femoral pulses 2+ bilaterally. abdomen soft with active bowel sounds, no masses, no hepatosplenomegaly. extremities: warm, well perfused, brisk capillary refill. genitourinary: normal preterm male. testes not palpable. anus patent. spine midline with no sacral dimple. clavicles intact. neuro: decreased tone. hospital course: 1. respiratory: he was intubated and placed on assisted ventilation for respiratory distress syndrome. he received 1 dose of surfactant. he was extubated to nasal continuous positive airway pressure on day of life 1, requiring room air to 28%, weaned off continuous positive airway pressure to room air on day of life 4. has remained in room air since with comfortable work of breathing. respiratory rate in the 30's to 50's. he was started on caffeine citrate for apnea of prematurity. he has occasional apnea of bradycardia episodes.caffeine d'cd on . 2. cardiovascular: he has been hemodynamically stable since admission. no murmur. heart rate ranges in the 120's to 170's. recent blood pressure 76/51 with a mean of 60. he had an echocardiogram on for a grade murmur, no longer audible, that revealed a tiny pda. 3. fluids, electrolytes and nutrition: he was initially n.p.o. and received iv fluids and parenteral nutrition through a double lumen umbilical venous catheter. he started enteral feeds on day of life 2 with breast milk or premature enfamil. he gradually increased on feeds and reached full volume feeds on day of life 8 without problems. the caloric density has gradually increased and he is currently he on breast milk 28 calories per ounce with promod, receiving his feeds over 1 hour . his electrolytes were followed and were all within normal limits. he is on 150 ml per kg per day breast milk 26 with promod every 4 hours over 2 hours. 4. gastrointestinal: he received phototherapy for indirect hyperbilirubinemia. his highest bili was on day of life 8. total of 8.7; direct .4. his phototherapy was discontinued on day of life 11. a rebound bilirubin on day of life 12 was total of 4.5 and 0.3. 5. hematology: his hematocrit on admission was 46.2%. he received 1 prbc transfusion and his hct prior to discharge was 29 with a retic count of 1.9. 6. infectious disease: cbc and blood culture was drawn on admission. he received 48 hours of ampicillin and gentamycin for rule out sepsis. he had a normal cbc. blood culture was negative. on he had a period of tempature instability with increasing aop and guiac positive stool. cbc was benign and blood culture negative, antibiotics d'c at 48 hours with benign cbc, negative cultures and normal kub. he had occasional guiac positive stools since that time, but has remained clinically stabile. on he had blood streaks in his stool with an abdominal film that demonstrated non specific bowel distension. at that time he was transferred to the neonatology service and kept npo for 14 days and treated with amp/gent and clindamycin or zosyn. 7. neurology: head ultrasound on day of life 6 was normal. a follow-up head ultrasound at 1 month of age was normal. 8. hearing screen:passed 9. immunizations:hep b given on . synagis given on because of infant on unit having contracted rsv. name of primary pediatrician: , , ma /dr. . discharge medications:ferinsol 0.2 cc po q day to be given at home. discharge diagnoses: 1. appropriate for gestational age 31 week preterm male infant, twin #2. 2. respiratory distress syndrome, resolved. 3. colitis presumed nec/allergic colitis. 4. apnea of prematurity. vna to come to home day postdischarge. f/u with dr. within 2 days of discharge. , Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified 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 Transfusion of packed cells Umbilical vein catheterization Other vaccination and inoculation Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Neonatal bradycardia Other preterm infants, 1,500-1,749 grams 31-32 completed weeks of gestation Nonspecific abnormal findings in stool contents Examination of participant in clinical trial Undiagnosed cardiac murmurs Need for prophylactic vaccination and inoculation against other viral diseases

history of present illness: (baby girl #2), is a second born of twins, birth weight 1.605 kg, born at 31 weeks gestation to a 32-year-old g2, p0, woman. prenatal screens: blood type o positive, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, group beta strep status unknown. the pregnancy was complicated by dichorionic, diamniotic twins with discordant growth. there was also cervical shortening noted. the mother was betamethasone complete at the time of delivery. the infants were born by elective cesarean section due to increasing concerns for discordant growth. this twin, no. 2, emerged active with spontaneous respirations. apgars were 7 at 1 minute and 8 at 5 minutes. after delivery and stabilization, she was transferred to due to census issues at the . she was transferred back to the on day of life no. 12. her medical course at children hospital was notable for respiratory distress syndrome requiring intubation and surfactant. she transitioned to cpap by dol , and was in room air by day of life no. 8. she had mild apnea of prematurity, treated with caffeine, gradual advancement of enteral feeds to full feeds without difficulty, mild hyperbilirubinemia treated with phototherapy from day of life no. 1 through 3, and a 48-hour course of antibiotics ruling out sepsis. physical examination: physical examination upon readmission to the showed weight of 1.74 kg. general: nondysmorphic, preterm female in room air. skin warm and dry. color pink. heent: anterior fontanel open and flat. symmetric facial features. positive red reflex bilaterally. chest: breath sounds clear and equal. cardiovascular: regular rate and rhythm without murmurs. femoral pulses +2. abdomen: soft, full, nontender. no masses. genitourinary: normal preterm female. extremities: moving all well with normal digits, nails and creases. neuro: appropriate tone and reflexes. hospital course by systems including pertinent laboratory data: respiratory: remained in room air for her neonatal intensive care unit admission at the . she was treated with caffeine for apnea of prematurity through day of life no. 19, discontinued on . after cessation of the caffeine she had one episode of spontaneous apnea bradycardia. she has had no episodes for greater than 5 days prior to discharge. at the time of discharge she was breathing comfortably with a respiratory rate of 30 to 40 breaths per minute. cardiovascular: has remained normotensive with normal heart rate. no murmurs have been noted. recent blood pressure is 64/37 with a mean of 41. fluids, electrolytes and nutrition: maximum caloric intake was breast milk 28 calories per ounce. she is being discharged home on breast milk 24 calories per ounce, 4 calories by neosure powder. serum electrolytes were checked on day of life no. 28 and were within normal limits. weight at the time of discharge is 2.455 kg with a length of 44.5 cm and head circumference of 32.5 cm. infectious disease: there have been no other infectious disease issues since re admission. hematology: most recent hematocrit was on , and was 33.6 percent with a reticulocyte count of 2.4 percent. she did not receive any transfusions of blood products. neurology: head ultrasounds were obtained on , and . both of these results were within normal limits. has maintained a normal neurological examination during admission and there were no neurological concerns at the time of discharge. audiology: hearing screening was performed with automated auditory brain stem responses. passed in both ears. ophthalmology: eyes were most recently examined on , showing mature retinas bilaterally. ophthalmology follow up is recommended in 9 months. psychosocial: social work was involved with this family. the contact social worker is and she can be reached at . case manager, , was also involved with this family. she can be reached at . the baby's surname after discharge will be cisler. condition on discharge: good. discharge diagnosis: sent home with the parents. name of primary pediatrician: dr. , , . phone no. . care recommendations: 1. feeding ad lib po breast feeding or breast milk fortified to 24 calories per ounce with neosure powder. the neosure is recommended until 6 to 9 months of corrected age. 2. medications - ferrous sulfate 25 mg per ml, 0.4 ml, once daily, vi-daylin 1 ml po once daily. 3. car seat position screening was performed. was observed in her car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. state newborn screens were sent on , , and . all results are within normal limits. a repeat screen was sent on , with results pending at the time of this dictation. 5. immunizations received - hepatitis b was given on . 6. immunizations recommended - synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria. a. born at less than 32 weeks. b. born between 32 and 35 weeks with two of the following: daycare during the rsv season. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. c: chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. follow up appointments scheduled or recommended: 1. appointment with dr. on , . 2. pediatric ophthalmology at 9 months of age. discharge diagnosis: 1. prematurity at 31 weeks gestation. 2. twin no. 2 of twin gestation. 3. apnea of prematurity. , md dictated by: medquist36 d: 23:57:30 t: 00:55:16 job#: Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Primary apnea of newborn Other preterm infants, 1,500-1,749 grams 31-32 completed weeks of gestation Diaper or napkin rash

allergies: iodine / inderal attending: chief complaint: 1. acute bleed 2. acute on chronic renal failure 3. hypernatremia/diabetes insipidus major surgical or invasive procedure: thoracentesis, left pleral space history of present illness: 72yo male with h/o a fib, htn, aaa, cri, l renal cysts, recent urosepsis treated with levofloxacin, who p/w an acute bleed from l kidney when inr was 4.6. since admission, pt??????s inr and hct have stabilized, has had acute on chronic renal failure which is resolving, had hypernatremia which is resolving, and had a l pleural effusion which was tapped on , results c/w tracking of l renal bleed. elevated wbc, chronic cough. past medical history: ?????? atrial fibrillation/flutter: rate controlled?????? hypertension?????? aaa (6 x 6.5cm): being watched?????? cri: baseline cr ~2.5?????? bipolar d/o: tx??????d w/li for many yrs?????? renal cysts/unidentified lesions: dx??????d 3y pta by dr. , pt refused further w/u?????? gout?????? urosepsis (recent): treated with levofloxacin social history: sh: lawyer 50 pack-year habit etoh 14 drinks/week family history: fh brother ?????? ? rccfather ?????? cva physical exam: pe vitals t 9 p 71, reg bp 140/80 resp 20, 98% on ra gen obese patient lying in hospital bed with mild sob, a+o x 3 heent perrl, eomi neck obese, no lad thorax bibasilar rales, cough cv rrr, nl s1s2, no murmurs/gallops/rubs abd obese, nondistended, normoactive bs, no rebound/guarding ext no clubbing/cyanosis/edema, nontender neuro nonfocal; pleasant affect, a+o x 3 pertinent results: 07:47am blood wbc-14.7* rbc-3.35* hgb-10.2* hct-31.9* mcv-95 mch-30.4 mchc-32.0 rdw-15.4 plt ct-393 07:47am blood neuts-pnd lymphs-pnd monos-pnd eos-pnd baso-pnd 07:47am blood plt ct-393 07:47am blood pt-15.0* ptt-32.1 inr(pt)-1.5 07:47am blood glucose-111* urean-53* creat-3.0* na-145 k-4.5 cl-111* hco3-23 angap-16 07:20am blood ld(ldh)-241 07:20am blood totprot-5.2* 07:50am blood vitb12-358 folate-greater th 07:00am blood tsh-1.8 brief hospital course: a/p 72yo caucasian male with h/o afib, htn, aaa, cri, left renal cysts and unidentified lesions, recent urosepsis treated with levofloxacin, who p/w left flank and abdominal pain, hct 22 and inr 4.6 and evidence of an acute bleed into his left kidney. since admission, pt??????s inr and hct have stabilized, has had acute on chronic renal failure which is resolving, had hypernatremia which is resolving, and had a l pleural effusion which was tapped on , results c/w tracking of l renal bleed. slightly elevated wbc, chronic cough. 1.increased wbc, cough with sputum, no f/c: possible mild tracheobronchitis, cont to follow 2. arf: resolving 3. neuro: gait disturbance, unchanged since . suggest mri for eval of head and spine, as per neuro consult; pt refuses 3. ? bipolar d/o: hold li, f/u with outpt psych 4. aaa (last measured at 6.5cm x 6.3cm): f/u as outpt with cards 5. hypernatremia: resolving 9. fen: liberal po fluid intake; d5w 10. dispo: short term rehab facility will be required prior to return to home; possible d/c home tomorrow if stable, wbc decreases medications on admission: meds ?????? riss?????? pantoprazole 40 mg po q24h ?????? acetaminophen 650 mg po q6h ?????? docusate sodium 100 mg po bid ?????? senna 1 tab po bid:prn ?????? diazepam 5 mg po q6h:prn ?????? morphine sulfate 2 mg iv q4h:prn ?????? metoprolol 25 mg po tid ?????? 1000 ml d5w continuous at 100 ml/hr for ml?????? lithium (held) discharge medications: 1. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 5. diazepam 2 mg tablet sig: one (1) tablet po q hs prn (). 6. diazepam 2 mg tablet sig: 0.5 tablet po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). discharge disposition: extended care facility: knoll nursing & rehabilitation - discharge diagnosis: 1. acute blood loss 2. acute on chronic renal failure 3. pleural effusion 4. hypernatremia 5. gait disturbance discharge condition: stable discharge instructions: follow up with dr. in one month. followup instructions: follow up with dr. in one month. md, Procedure: Thoracentesis Transfusion of packed cells Diagnoses: Unspecified pleural effusion Urinary tract infection, site not specified Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Candidiasis of mouth Vascular disorders of kidney Nephrogenic diabetes insipidus

history of present illness: was born at 27 and 5/7 weeks gestation to a 42 year old, gravida ii, para 0, now i woman. prenatal screens are blood type 0 positive, antibody negative, rubella immune, rpr nonreactive, hepatitis surface antigen negative and group b strep unknown. pregnancy was complicated by preterm labor. the infant was delivered by cesarean section for a breech presentation and progressive preterm labor. the mother did receive a complete course of betamethasone prior to delivery. the apgars were 6 at one minute and 8 at five minutes. the birth weight was 1,225 grams. the birth length was 37.5 cm and the birth head circumference was 26.75 cm. physical examination: admission physical examination revealed an active preterm infant; anterior fontanel soft and flat. moderate respiratory distress. breath sounds equal. heart was regular rate and rhythm. no murmur. well perfused. femoral pulses present. age appropriate tone and reflexes. hospital course: neonatal intensive care unit course by systems: respiratory status: was intubated soon after delivery. he received one dose of surfactant and then weaned to nasopharyngeal continuous positive airway pressure on day of life number one and successfully weaned to nasal cannula on day of life 40 and then to room air on day of life 42, where he has remained. he was treated with caffeine for apnea of prematurity from day of life one to day of life 46. his last episode of significant bradycardia at rest occurred on . on examination, he has very mild subcostal retractions. breath sounds are clear and equal. cardiovascular status: he has remained normotensive throughout his neonatal intensive care unit stay. he has an intermittent grade i over vi systolic ejection murmur at the left upper sternal border, axilla and back, consistent with peripheral pulmonic stenosis. this should be followed clinically for resolution. fluids, electrolytes and nutrition: the discharge weight is 3,285 grams. the discharge length is 50 cm. the head circumference is 36.5 cm. enteral feeds were begun on day of life two and reached full volume feeding by day of life 10. he then advanced to a maximum of 30 calories per ounce enhanced breast milk. at the time of discharge, he is breast feeding and taking supplement 24 calorie per ounce breast milk. the mother plans to breast feed three times a day and then her goal is to move towards exclusive breast feeding. gastrointestinal status: he was treated with phototherapy for hyperbilirubinemia of prematurity from day of life one to day of life number six. his peak bilirubin occurred on day of life number two and was a total of 6.2, direct of 0.3. hematology: he had never received any blood transfusions. his hematocrit on was 29.9. infectious disease: was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. he completed a seven day course of antibiotics for presumed sepsis. his blood and cerebrospinal fluid cultures remained negative. he has remained off antibiotics since that time. he was found to be colonized with methicillin resistant staphylococcus aureus on routine surveillance surface cultures done in the neonatal intensive care unit. neurology: head ultrasound done on and was functionally normal except for a small right choroid plexus cyst. on , the head ultrasound was read as within normal limits. audiology: hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. ophthalmology: the eyes were examined most recently on , revealing retinopathy of prematurity, stage one bilaterally, five clock hours in the right eye and five clock hours in the left eye. a follow-up examination was planned for the week of discharge. the parents will call to make an appointment. psychosocial: this is a two mother couple. the birth mother is and her partner is . they have been very involved in the infant's care throughout his neonatal intensive care unit stay. the infant is being discharged home in good condition. primary pediatric care will be provided by dr. of pediatrics. telephone number . recommendations: recommendations after discharge: 1. feeding: breast feeding at least three times in 24 hours, with additional feedings of 24 calorie per ounce breast milk made with adding similac powder to the breast milk. the goal of this mom is to exclusively breast feed. medications: iron sulfate (25 mg per ml) 0.5 ml p.o. daily. vi-day- 1 ml p.o. daily. the infant has passed a car seat position screening test. the last state newborn screen was sent on . the infant has received the following immunizations: hepatitis b number one on . hepatitis b number two on . dtap . hib . ipv on . prevnar . recommended immunizations: synagis rsv prophylaxis should be considered from to for infants who meet any of the following three criteria: 1. ) born at less than 32 weeks. 2.) born between 32 and 35 weeks with two of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. or, 3.) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. follow up: follow up appointments for this infant include: 1. early intervention through minute man early intervention, telephone number . 2. infant follow-up program, telephone number . 3. ophthalmology appointment with dr. in , , telephone number . discharge diagnoses: 1. status post extreme prematurity at 27 and 5/7 weeks gestation. 2. status post respiratory distress syndrome. 3. status post apnea of prematurity. 4. sepsis, ruled out. 5. retinopathy of prematurity. 6. status post choroid plexus cyst. 7. chronic lung disease. 8. status post hyperbilirubinemia of prematurity. 9. anemia of prematurity. 10. status post presumed sepsis. 11. intermittent murmur consistent with peripheral pulmonic stenosis. reviewed by: , dictated by: medquist36 d: 04:40:07 t: 05:10:46 job#: Procedure: Insertion of endotracheal tube Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery 27-28 completed weeks of gestation Primary apnea of newborn Anemia of prematurity Retrolental fibroplasia Septicemia [sepsis] of newborn Other preterm infants, 1,000-1,249 grams

past medical history: 1. history of alcohol abuse with alcoholic cirrhosis. 2. arthritis. 3. hypertension. 4. history of nephrolithiasis. allergies: none. medications: 1. naprosyn. 2. lopressor. 3. procardia. physical examination: the patient was afebrile with a blood pressure of 95/40. she was awake, but sleepy. she appeared uncomfortable. the chest was clear. abdomen was obese with voluntary guarding and tenderness in the upper abdomen. rectal examination showed guaiac-positive stool. laboratory data: data revealed the following: the admission wbc was 21,000 with hematocrit of 33.5. the bicarbonate was 18, bun 39, creatinine 4.3, alt 63, ast 74, alkaline phosphatase 569, total bilirubin 4.2 with the direct component being 3.8. amylase 35, and lipase 132. the urinalysis was unremarkable. chest film showed free air under the right hemidiaphragm. hospital course: contrast upper gi was obtained showing a perforation of the first portion of the duodenum. the patient was aggressively fluid resuscitated. she was taken to the operating room that evening for laparotomy. at that time she was found to have a perforation in the anterior duodenal bulb. we closed this perforation primarily and placed patch. postoperatively, the patient did poorly. she was persistently septic in the intensive care unit with a very large fluid requirement. she essentially developed progressive ascites and findings of end-stage liver disease. bilirubin remained elevated. she required prolonged ventilatory support. she developed progressive anuric renal failure. consultation with the renal medicine service was obtained. she was maintained on broad-spectrum antibiotics and iv nutrition. she was extremely somnolent. she developed progressive severe ards. fungal coverage was added to her drug regimen. intensive consultations were had with the son and with the healthcare proxy. ultimately, decision was made to withdrawal support due to the patient's lack of progress and wishes that had been expressed by her, prior to surgery. accordingly, the patient was made comfort-measures only and expired on . disposition: deceased. condition on discharge: deceased. discharge diagnosis: cirrhotic liver failure with ascites, sepsis, severe acute respiratory distress syndrome, disseminated intravascular coagulation, perforated duodenal ulcer. , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Suture of duodenal ulcer site Diagnoses: Acidosis Unspecified essential hypertension Unspecified protein-calorie malnutrition Acute respiratory failure Defibrination syndrome Other shock without mention of trauma Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction

history of present illness: a 48 year old male with hepatitis b cirrhosis, segment 2 hepatoma measuring 2.1 x 1.8 cm noted on mri . history of asthma, emphysema, paralyzed left hemidiaphragm, gastropathy, esophageal varices, received phototherapy approximately 1 week prior to hospitalization, history of leg cellulitis, presents for potential liver transplant. the patient was feeling well, recently in the hospital from , to , for left leg cellulitis that was treated with iv cefazolin. he has been on keflex 500 mg q.i.d. since . he denied fevers, chills, left leg greatly improved, left leg negative for dvt. he is usually followed by dr. for hepatitis b virus. last viral load suppressed lamivudine. past medical history: hepatitis b virus cirrhosis with a delta coinfection, hepatoma segment 2, asthma, emphysema, paralyzed left hemidiaphragm, status post pneumonia 1 year ago, gastropathy, status post phototherapy, egd , anemia, obesity, history of latent syphilis, barrett esophagitis, herpes simplex, left leg cellulitis , to . past surgical history: l2 to l3 disc herniation, status post discectomy, hemilaminectomy, right inguinal hernia repair. allergies: morphine causes severe nausea and oxacillin. medications on admission: spironolactone 100 mg b.i.d., lasix 80 mg once a day, clotrimazole 10 mg 4 times a day, protonix 40 mg twice a day, keflex 500 mg q.i.d., nadolol 40 mg daily, zofran 8 mg twice a day, lactulose 30 cc 5 times a day, carafate 1 gram t.i.d., epivir 150 mg once a day, tiotropium bromide mdi inhaler at bedtime. review of symptoms: denied encephalopathy, fevers, chills, nausea, vomiting/indigestion/chest pain/dizziness/dysuria/cough. positive shortness of breath going up stairs. positive dark stools. reports stools guaiac positive today on a rectal exam in the transplant office. physical examination: vital signs 97.1, 64, 20, 120/64, 98% in room air, weight 99 kilograms, height 5 feet 10 inches. the patient was mildly jaundiced, obese, mildly anxious. sisters were present. heent: positive icterus, eom intact. perrla. pharynx within normal limits. no thrush. neck no jvd, 2+ carotids, no lad. lungs diminished left lower lobe, decreased excursion on the left side, clear on the right, nonlabored. cor: s1, s2 normal, no murmurs, rubs, gallops. the abdomen is soft, positive bowel sounds, nontender, nondistended, no bruits, no hepatosplenomegaly. extremities: bilateral edema, left greater than the right, to the knees. vascular: 2+ right femoral pulse, trace left, 2+ dorsalis pedis pulses. skin: left lower leg brawny changes, no erythema, no open skin, no pain. neurologic: alert and oriented x3. strength symmetric, no flap, toes down. social history: the patient lives alone on the , never married, no children, has 2 sisters who are supportive. he works full time for the city of as a supervisor of recycling. habits: quit smoking 1 year ago, smoked 1 pack per day x20 years. rare history of alcohol, none now. no recreational drug use or history of recreational drug use. family history: father died of emphysema at age 72. mother died of complications from biliary surgery at age 38. had 6 siblings, 1 brother died at 49 secondary to sudden cardiac death with 1 sibling with hypertension, and another sibling with diabetes. hospital course: the patient was admitted for liver transplant. the patient was taken to the or on , for a piggy back liver transplant for cirrhosis and hepatoma. surgeons were dr. and dr. , assistants dr. and dr. , general anesthesia. the patient received 5800 cc of crystalloid, 2 units of ffp, 1 unit of packed red blood cells, ebl was approximately 300 cc. the patient was stable and transferred to the surgical intensive care unit, sicu. the patient was intubated upon entrance to the icu with 2 j-p drains and ng tube and a foley catheter. the patient's vital signs were stable. postop labs: white blood cell count 9.3, hematocrit 30.6, platelets 112,000. creatinine 0.8 with a bun of 21 and a potassium of 4.5. abgs were stable. the patient did well postoperatively. the patient was extubated on postop day 2. a liver duplex on postoperative day 1 was normal. the patient was started on prograf on postoperative day 1. the patient received induction immunosuppression intraoperatively. this consisted of 500 mg of solu-medrol, 1 gram of iv cellcept. on postoperative day 1, hematocrit was 26.9 with a platelet count of 85,000. the patient was transfused with 3 bags of packed red blood cells, 5 bags of ffp and 3 bags of platelets. urine output was excellent with a creatinine of 0.8. lfts postoperatively, ast was 2916, alt 1069 and alkaline phosphatase 94 with a total bilirubin of 9.2. the patient was extubated on postoperative day 2. preoperative the patient's b viral load was negative. he received hepatitis b immunoglobulin hospital days 1 through 8 as well as lamivudine 100 mg p.o. daily. hepatitis b titers were followed throughout the hospital course. they were nondetected up until postoperative day 5 when viral load is greater than 450. the patient remained shb-sag negative throughout this hospital course. mr. did well. he was transferred from the sicu to the transplant medical surgical unit on postoperative day 4 with stable vital signs. liver function tests had trended down with an ast of 247, alt of 458 and an alkaline phosphatase of 70 with a total bilirubin of 2.6. pathology results from intraoperative hepatectomy revealed hepatocellular carcinoma with a 2 x 1.8 cm lesion. there was no vascular invasion, positive cirrhosis with grade ii inflammation. there were no vascular or biliary margins detected. chest x-ray on postoperative day 1 revealed left base density. preoperatively it was noted that the patient had a left hemidiaphragm paralysis. on postoperative day 2, it was noted that the patient's platelets were lower at 68,000. heparin antibody was sent off. this was subsequently detected as positive. the patient underwent a line change on postoperative day 4, a nonheparin coated line. chest x-ray confirmed placement. there was no chf or pneumonia noted at that time. the patient's diet was advanced slowly. abdomen remained soft with 2 j-ps. medial j- p was removed on postoperative day 5 as well as the lateral j- p for 35 and 55 cc, respectively. throughout the hospital course, the patient's blood sugars fluctuated according to the solu-medrol taper. was consulted. sliding scale insulin was used to treat the high or elevated glucoses. pain was managed with iv dilaudid with good results. breath sounds remained diminished at the bases with o2 saturations in the mid 90s on 2 liters nasal cannula. on postoperative day 4, iv medications were switched to p.o. medications. the patient was ambulatory and doing well. physical therapy was consulted for assessment. the patient was passing flatus and tolerating a regular diet, voiding large amounts of yellow urine. lasix was started on postoperative day 4. the patient's weight had increased 10 kilograms. the patient slowly began to diurese throughout the hospital course on iv lasix. hepatology followed along closely throughout this hospitalization. the patient was converted to im hepatitis b immunoglobulin on day 8. clinical nutrition was consulted for assessment of fair intake. the patient was given boost supplements, 2 cans per day, and encouraged to drink at least 3 cans per day. abdomen remained soft with positive bowel sounds and he was passing flatus. physical therapy saw the patient and encouraged the patient to ambulate about the unit with supervision. the patient received pt daily until discharge for pulmonary care, gait and balance, and stair negotiation. throughout this hospital course, the patient remained on iv cellcept 1 gram twice a day. solu-medrol was tapered down over the course of 10 days to a dose of 20 mg p.o. daily. prograf was adjusted to levels. on postoperative day 4, prograf level had increased to 17.9. prograf was decreased to 2 mg twice a day and subsequently increased when prograf level dropped down to 5.3 on postoperative day 7. the patient received another chest x-ray on hospital day 7. no chf or pneumonia was noted. a repeat chest x-ray was again done on postoperative day 8. this was negative as well. breath sounds were diminished on the left side. albuterol nebs were switched over to tiotropium. iv dilaudid was converted to p.o. percocet. this was subsequently changed to p.o. dilaudid with better results in pain management. the patient was discharged on postoperative day 11. vital signs were stable. hematocrit was 24.8. white blood cell count 3.7. creatinine of 1.1 with a bun of 28. lfts had trended down nicely with an ast of 20, alt of 50, alkaline phosphatase 79 and total bilirubin of 1.6. the patient was discharged to home. discharge medications: lamivudine 100 mg tab 1 a day, fluconazole 400 mg p.o. daily, protonix 40 mg once a day, cellcept 1 gram p.o. b.i.d., prednisone 20 mg p.o. daily, lasix 40 mg p.o. b.i.d., prograf 10 mg p.o. b.i.d. valcyte 900 mg p.o. b.i.d., bactrim single strength 1 tab p.o. daily. discharge diagnoses: piggy back liver transplant , placement of central venous catheter . hepatitis b virus. emphysema. asthma. left paralyzed hemidiaphragm. peptic ulcer disease with gastropathy. anemia. obesity. positive heparin induced thrombocytopenia. discharge instructions: discharge medications as above. the patient was instructed to follow-up with the transplant surgeons 1 week postoperatively. labs were scheduled to be drawn twice a week for cbc, chem10, lfts and trough prograf level. the patient was instructed to avoid any heavy lifting. the patient was stable upon discharge, ambulatory, tolerating regular diet, using his incentive spirometer. the patient was sent home with visiting nurse services for medication management. discharge condition was stable. , Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Other transplant of liver Transfusion of packed cells Transfusion of platelets Other operations on lacrimal gland Transplant from cadaver Diagnoses: Long-term (current) use of steroids Other specified disorders of pancreatic internal secretion Adrenal cortical steroids causing adverse effects in therapeutic use Cirrhosis of liver without mention of alcohol Acute posthemorrhagic anemia Acute and subacute necrosis of liver Portal hypertension Other emphysema Obesity, unspecified Anticoagulants causing adverse effects in therapeutic use Esophageal varices in diseases classified elsewhere, without mention of bleeding Malignant neoplasm of liver, not specified as primary or secondary Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Splenomegaly Disorders of diaphragm

history of present illness: the patient is an 84-year-old woman with a history type 2 diabetes and hypertension who was admitted to the coronary care unit on as a transfer from for bradycardia with an idioventricular rhythm. the patient gave a vague history of one to two days of doing poorly at home with diminished p.o. intake, increased dyspnea, and assessment mental status changes. on , emergency medical service was called, and the patient was found bradycardic at home with a heart rate in the 20s with an idioventricular rhythm and associated hypotension. the patient received external pacing in the field and was brought to . in the emergency department, her heart rate remained in the 20s. a chest x-ray was consistent with congestive heart failure. her potassium was 6.5, glucose was 350, creatinine of 2.8. there were no ketones in the urine. ast and alt were elevated, consistent with shock liver. at , the patient received calcium gluconate 1 amp, and 10 units of insulin, and 1 unit of d-50, 1 amp bicarbonate, and 2 g of kayexalate. she was subsequently wrapped in warm blankets for hypothermia and intubated for comfort. she was subsequently transferred to the , and upon transfer the external pacer temporarily failed. heart rate at that time was in the 20s with a systolic blood pressure in the 70s. the patient required temporary dopamine. she was then found to revert back to normal sinus rhythm in the 50s, and the dopamine drip was discontinued. on arrival to the medical intensive care unit at , electrocardiogram was consistent with sinus bradycardia at 40 beats to 50 beats per minute with a left bundle-branch block. the patient was still intubated on arrival. initial arterial blood gas was 7.36/28/590. she was maintained on cpap 10/5 with 50% fio2. alt, ast, and lactate were elevated as noted above. inr was 1.4. the patient received 10 mg of subcutaneous vitamin k. the patient was given aggressive intravenous fluids for acute renal failure thought secondary to prerenal azotemia. a temporary pacing wire was placed on arrival which was set at 40 beats per minute. given question of sepsis and active sputum, the patient was started on levaquin for a question of pneumonia. blood cultures were sent. the heart rate was then stable in the 90s on , and the pacing wire was discontinued. the following day, with improvement in the patient's blood pressure, she was restarted on her atenolol. physical examination on presentation: vital signs at the time of transfer from the medical intensive care unit to the floor revealed temperature afebrile, blood pressure 166/80, pulse 91, respiratory rate 18, pulse oximetry 98% on 5 liters. appearance revealed the patient was awake, alert, and following commands. did not speak english. head, ears, nose, eyes and throat revealed dry oral mucosa. nasogastric tube was in placed. neck revealed no jugular venous distention, though difficult to assess. cardiovascular revealed a regular rate and rhythm. normal first heart sound and second heart sound. no murmurs. lungs had crackles halfway up bilaterally. the abdomen was soft, nontender, and nondistended, with active bowel sounds. extremities revealed trace pedal edema. neurologic examination revealed the patient followed commands, moved all four extremities, and equal bilaterally in her upper extremities. pertinent laboratory data on presentation: white blood cell count was 17.8, hematocrit 25.5, platelets of 322. sodium of 131, potassium 4.2, chloride 98, bicarbonate 20, blood urea nitrogen 22, creatinine 1.2 (down from an admission creatinine of 2.4), glucose of 184. alt was 870, ast 701, ldh 691, alkaline phosphatase 78, total bilirubin 0.6, amylase 170, lipase 588. calcium 8.3, magnesium 1.4, phosphate 2.2. inr was 1.3, albumin 3.5. sputum gram stain showed greater than 25 polys, 4+ gram-positive cocci, 3+ gram-negative rods, 1+ gram-negative rods. respiratory culture was pending. urine and blood cultures were also pending. urinalysis was negative. creatine kinases were negative to date. troponin maximum at 1.3. iron was 18. radiology/imaging: chest x-ray on the day of transfer revealed congestive heart failure with underlying chronic interstitial disease with evidence of increased cephalization compared to the prior study with the question of a left lower lobe process. hospital course by system: 1. cardiovascular: the patient presented with bradycardia thought secondary to prerenal state, perhaps brought about by hyperglycemia and/or infection. prerenal state may have resulted in acidosis hyperkalemia with possible poor clearance of her atrioventricular nodal blockers which included verapamil and atenolol at the time of presentation. the patient had no known cardiac history; although, her son later admitted that she had a heart attack years earlier. she was noted to have a troponin leak in the setting of congestive heart failure and poor perfusion. otherwise, she ruled out for a myocardial infarction. the patient was placed on telemetry with no acute arrhythmias; however, she was noted to be in sinus tachycardia consistently status post transfer from the medical intensive care unit. she was put back on her atenolol and verapamil; although, verapamil was ultimately discontinued and beta blocker was titrate upward. the patient underwent an echocardiogram which revealed evidence of global hypokinesis with an ejection fraction of approximately 35% and a partially reversible inferolateral defect. the cardiology service was consulted to evaluate regarding the echocardiogram and the patient's persistent tachycardia. the cardiology service felt that because it was only a partially reversible defect, given the patient's other complicating medical issues, a cardiac catheterization was not indicated at this time. instead, the patient's cardiac regimen was aggressively titrated up until the time of discharge. 2. pulmonary: the patient was maintained on levaquin for presumed pneumonia and completed a 10-day course with a normalization of her white blood cell count and no fevers. she initially underwent some gentle diuresis for congestive heart failure but did not require further diuresis for the duration of her hospital stay. however, she was maintained on aggressive ace inhibitor for afterload and preload reduction. 3. renal: the patient with a history of acute renal failure on presentation, consistent with generalized hypoperfusion in the setting of her bradycardia. her creatinine gradually normalized. she experienced no recurrent hyperkalemia. 4. gastrointestinal: the patient's hematocrit was noted to trend down; although, she was guaiac-negative. she should likely be evaluated for an outpatient colonoscopy given her iron deficiency anemia. 5. hematology: the patient's hematocrit was noted to hover at 25 to 27; which appeared to be her baseline. as noted, she was guaiac-negative. she was found to be iron deficient and was repleted during this hospitalization. her inr was elevated on admission, and this improved with vitamin k times one. 6. endocrine: the patient with a history of type 2 diabetes. she was put back on her glucophage and glipizide with the addition of an insulin sliding-scale for better glycemic control. 7. physical therapy: the patient was aggressively managed by the physical therapy team given the fact that she had no insurance and could not participate in acute rehabilitation. she was ultimately cleared by physical therapy who will also be making several home safety visits via the free care program. discharge diagnoses: 1. bradycardia. 2. hyperkalemia. 3. acute renal failure. 4. pneumonia. 5. cardiomyopathy. 6. type 2 diabetes. 7. iron deficiency anemia. medications on discharge: 1. prevacid 30 mg p.o. q.d. 2. colace 100 mg p.o. q.d. 3. enteric-coated aspirin 325 mg p.o. q.d. 4. timoptic eyedrops to the right eye q.d. 5. iron sulfate 325 mg p.o. t.i.d. 6. glucophage 850 mg p.o. q.d. 7. zestril 40 mg p.o. q.d. 8. atenolol 100 mg p.o. q.d. 9. glipizide 10 mg p.o. b.i.d. 10. norvasc 2.5 mg p.o. q.d. discharge instructions: 1. the patient was to receive physical therapy at home. 2. a speech pathologist will evaluate her swallowing in order to evaluate her diet. 3. recommend a puree diet to avoid aspiration. 4. recommend outpatient colonoscopy to evaluate for iron deficiency anemia. discharge followup: the patient was to follow up with her primary care physician at hospital. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Insertion of temporary transvenous pacemaker system Diagnoses: Pneumonia, organism unspecified Acidosis Hyperpotassemia Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Iron deficiency anemia, unspecified Sinoatrial node dysfunction

past medical history for mother: notable for chronic hypertension, tobacco use, factor v leiden heterozygosity. family history: negative. social history: notable for cigarette use but negative for alcohol during pregnancy. father of baby is involved. this pregnancy complicated by thin lower uterine segment, full fetal survey within normal limits at 16 weeks. underwent repeat cesarean section under spinal anesthesia. no intrapartum fever or other clinical evidence of chorioamnionitis. intrapartum antibiotics were given only intraoperatively. rupture of membranes occurred at delivery yielding clear amniotic fluid. infant was vigorous at delivery, was orally and nasally suctioned, dried, and a supplemental flow of o2 was administered. apgars were 8 at one minute and 8 at five minutes. infant was transferred to the newborn intensive care unit. discharge exam: active with good tone. anterior fontanel open and flat. pink, well perfused. no murmurs auscultated. comfortable in room air. breath sounds clear and equal. tolerating enteral feedings with a soft abdominal exam. active bowel sounds. moving all extremities. history of hospital course by system: 1. respiratory: was admitted to the newborn intensive care unit, placed on cannula briefly with progressive grunting, flaring and retracting. chest x-ray revealing transient tachypnea of the newborn versus respiratory distress syndrome. infant was placed on cpap. he remained on cpap for a total of 72 hours at which time he transitioned to nasal cannula o2. he remained on nasal cannula o2 until at which time he transitioned to room air and has been stable in room air since that time. he has not required methylxanthine therapy and he has had no documented episodes of apnea and bradycardia. 2. cardiovascular: has an audible murmur. cardiac workup was within normal limits. ekg was normal. chest x- ray showed normal cardiac silhouette, pre and post ductal sats within normal limits and 4 extremity blood pressures within normal limits. murmur felt to be pps in quality. 3. fluids/electrolytes: birth weight 2.375 kg, discharge weight is 2390g; discharge head circumference was 32.5 cm, length was 46 cm. infant was initially started on 80 cc per kilo per day. enteral feedings were initiated on day of life #3. full enteral feedings were achieved by day of life #8. he is currently ad lib feeding similac 24- calorie, taking in adequate amounts. 4. gi/gu: peak bilirubin was, on day of life #3, 11.8/0.3, responded nicely to phototherapy, and his most recent bilirubin was 8.5/0.3 on . 5. hematology: the patient's blood type is o positive, direct coombs' negative. initial hematocrit was 46.8. 6. infectious disease: cbc and blood culture obtained on admission. cbc was benign. blood culture remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. infant is currently receiving nystatin ointment to a monilial rash in his diaper area. 7. neuro: infant has been appropriate for gestational age. 8. sensory: hearing screen was performed with automated auditory brainstem responses and the infant passed. condition at discharge: stable. discharge disposition: to home. primary pediatrician: , md, telephone number (. care recommendations: continue ad lib feeding similac 24- calorie. medications: not applicable. car seat position screening was performed for a 90-minute screening and the infant passed. state newborn screen was sent most recently on . initial screening was done on with an elevated 17-ohp, with repeat screen requested. immunizations received: infant received hepatitis b vaccine on . discharge diagnoses: 1. premature infant born at 35-3/7 weeks. 2. respiratory distress syndrome. 3. rule out sepsis with antibiotics. 4. hyperbilirubinemia. 5. monilial rash. 6. pps murmur. Procedure: Non-invasive mechanical ventilation Prophylactic administration of vaccine against other diseases Circumcision 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 35-36 completed weeks of gestation Routine or ritual circumcision Other preterm infants, 1,250-1,499 grams Rash and other nonspecific skin eruption Other specified conditions involving the integument of fetus and newborn

infant born at 33 1/7 weeks gestation to a 35-year-old gravida i, para 0 now i mother. prenatal screens: a positive, antibody negative, hepatitis b surface antigen negative, rpr nonreactive, gbs unknown. past medical history remarkable for insulin-dependent diabetes mellitus with recent hemoglobin a1c of 7, depression treated with prozac, and chronic hypertension treated with diltiazem hydrochloride. normal fetal survey, including echocardiogram. admitted four days prior to delivery with pre-term rupture of membranes. treated with ampicillin and erythromycin. no fever noted. progressive cervical dilatation. normal spontaneous vaginal delivery with apgars of 7 at one minute and 8 at five minutes. physical examination: birth weight 2495 grams (90th percentile), length 49.5 cm (greater than 90th percentile), head circumference 30 cm (50th percentile). examination remarkable for pre-term infant with intermittent grunting, soft anterior fontanel, intact palate, mild retractions, good air entry, no murmur, present femoral pulses, flat, soft, nontender abdomen without hepatosplenomegaly, normal perfusion, normal tone and activity for gestational age. hospital course by system: 1. respiratory: the infant remained in room air throughout this hospitalization, with respiratory rates of 40 to 50. the infant initially had some intermittent grunting on admission, which resolved after one to two hours of life. the infant has not had any apnea or bradycardia this hospitalization. the infant was not treated with methylxanthine therapy. 2. cardiovascular: the infant has remained hemodynamically stable this hospitalization, no murmur, heart rate 120 to 140. 3. fluids, electrolytes and nutrition: the infant was initially no food by mouth on admission, receiving 80 cc/kg/day of d-10-w. the infant received one d-10-w bolus for an initial glucose of 28. the glucoses have remained stable in the 60s and 70s throughout this hospitalization. enteral feedings were started on day of life one of premature enfamil 20 calories/ounce. the infant advanced to full volume feedings by day of life two, and advanced to 140 cc/kg/day by day of life four. the infant is currently receiving breast milk 20 calories/ounce at 140 cc/kg/day by mouth. the current weight is 2575 grams. 4. gastrointestinal: the infant was placed on double phototherapy on day of life two for a bilirubin of 16.1/0.3. phototherapy was discontinued by day of life five, and the rebound bilirubin was 12.7/0.5. 5. hematology: the infant did not receive a blood transfusion this hospitalization. the most recent hematocrit on day of delivery was 49.9%. 6. infectious disease: the infant received 48 hours of ampicillin and gentamicin due to respiratory distress. the white blood cell count was 17.2, hematocrit 49.9%, platelets 240,000, 30 neutrophils, 0 bands, 51 lymphocytes. the blood cultures remained negative to date. 7. neurology: the infant does not meet criteria for head ultrasound. 8. sensory: audiology screening was performed with automated auditory brain stem responses. the infant passed both ears. 9. psychosocial: social worker involved with the family. the contact social worker can be reached at . the parents are involved. condition at discharge: former 33 week gestation, stable in room air. discharge disposition: home with parents. name of primary pediatrician: care recommendations: 1. feedings at discharge: breast milk 20 calories/ounce breast feeding by mouth ad lib 140 cc/kg/day. 2. medications: none. 3. car seat position screening was performed. the infant passed. 4. state newborn screens were sent on , results are pending. 5. the infant received hepatitis b vaccine on . 6. follow-up appointments: a. follow-up appointment with pediatrician in one to two days. b. vna, phone number . discharge diagnosis: 1. pre-term 33 week gestation female 2. status post mild respiratory distress 3. status post rule out sepsis 4. status post hyperbilirubinemia , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other respiratory problems after birth 33-34 completed weeks of gestation Unspecified fetal and neonatal jaundice Syndrome of "infant of a diabetic mother"

infant born at 33 1/7 weeks to 35 yo g1 a+, ab-, hbsag-, rpr-nr, gbs? woman. past medical history remarkable for insulin-dependent diabetes mellitus with recent hgba1c=7, depression treated with prozac, and chronic hypertension treated with diltiazen hydrochloride. had normal fetal survey, including echocardiogram. admitted 4 days ptd with pre-rom. treated with ampicillin and erythromycin. no fever noted. progressive cervical dilatation. nsvd with apgars 7, 8. exam remarkable for preterm infant with intermittent grunting, vital signs as noted, soft af, intact palate, mild retractions, good air entry, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl perfusion, nl tone/activity for gestational age. preterm infant with known sepsis risk, presenting with minimal respiratory symptoms. will check cbc, blood culture. given risks- pre-rom, prom, prematurity- will start ampicillin and gentamicin. current respiratory status suggestive of retained fetal lung fluid. will monitor cardio-respiratory status closely with non-invasive monitoring and blood gases, if needed. will monitor hemodynamic status closely. will make npo for now. will infuse iv dextrose. will require close monitoring of blood glucose, temperature, and bilirubin, given prematurity. parents aware of current clinical status and immediate plan of care. Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other respiratory problems after birth 33-34 completed weeks of gestation Unspecified fetal and neonatal jaundice Syndrome of "infant of a diabetic mother"

allergies: sulfa (sulfonamides) / erythromycin base / ampicillin attending: chief complaint: chest tightness major surgical or invasive procedure: coronary artery bypass graft x 4 (lima to lad, svg to om, svg to ramus, svg to diag) history of present illness: 65 y/o female with chest tightness during walking and exercise over the last month. along with associated dyspnea. she had a +ett and then underwent a cardiac cath at osh. cath revealed severe three vessel disease along with lm disease and she was transferred to for surgical intervention. past medical history: diabetes mellitus, hyperlipidemia, chronic gastritis, s/p l tk replcament, s/p tubal ligation, s/p appendectomy, s/p t&a, s/p herniated disc repair x 2, s/p right carpal tunnel surgery, s/p right trigger finger release social history: tob: quit 2 yrs ago after 3ppd x 30 yrs etoh: occ. on holidays retired from customer service lives with spouse family history: father pacemaker physical exam: vs: 82 20 140/80 gen: nad, wd female skin: unremarkable with right groin cath site ecchymotic, -hematoma heent: eomi, perrla neck: supple, from, -jvd, -carotid bruit chest: ctab -w/r/r heart: rrr -c/r/m/g abd: soft nt/nd +bs ext: warm, well-perfused -edema, -varicosities, 2+ pulses throughout neuro: mae, non-focal, a&o x 3 discharge neuro a/ox3 nonfocal pulm cta cardiac rrr sternal inc no drainage/erythema, sternum stable abd soft, nt, nd +bs ext warm edema +1 left leg evh cdi pertinent results: 06:40am blood wbc-6.8 rbc-3.47* hgb-10.7* hct-31.4* mcv-90 mch-30.9 mchc-34.2 rdw-14.7 plt ct-232# 07:36pm blood wbc-7.3 rbc-4.17* hgb-13.1 hct-37.1 mcv-89 mch-31.5 mchc-35.4* rdw-14.8 plt ct-154 06:40am blood plt ct-232# 02:07am blood pt-12.3 ptt-30.0 inr(pt)-1.1 07:36pm blood plt ct-154 07:36pm blood pt-12.0 ptt-31.4 inr(pt)-1.0 06:40am blood glucose-92 urean-19 creat-0.5 na-140 k-4.3 cl-103 hco3-29 angap-12 07:36pm blood glucose-89 urean-16 creat-0.6 na-139 k-4.0 cl-102 hco3-28 angap-13 07:36pm blood alt-25 ast-24 ld(ldh)-188 alkphos-114 amylase-93 totbili-0.7 04:06am blood calcium-8.2* phos-3.9 mg-2.4 07:36pm blood albumin-4.5 calcium-9.6 phos-3.7 mg-2.1 07:36pm blood %hba1c-6.3* -done -done cxr comparison is made to prior radiograph dated and . pa and lateral chest radiograph. since prior radiograph, there has been interval removal of right-sided central venous line. there are small bilateral pleural effusions, however, no parenchymal consolidation is identified. no pneumothorax. heart size is again identified to be enlarged in this patient status post median sternotomy and cabg. stabilization plate from prior left-sided humeral fracture in incompletely visualized. impression: bilateral pleural effusions, left greater than right side. no evidence of focal pulmonary consolidation.. tee measurements: left ventricle - inferolateral thickness: *1.2 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.6 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 3.9 cm left ventricle - fractional shortening: *0.15 (nl >= 0.29) left ventricle - ejection fraction: 55% (nl >=55%) aorta - valve level: 2.7 cm (nl <= 3.6 cm) aorta - ascending: 3.0 cm (nl <= 3.4 cm) aorta - arch: 2.4 cm (nl <= 3.0 cm) aorta - descending thoracic: 2.0 cm (nl <= 2.5 cm) interpretation: findings: right atrium/interatrial septum: normal interatrial septum. no asd by 2d or color doppler. left ventricle: normal lv wall thicknesses and cavity size. mild symmetric lvh. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. focal calcifications in ascending aorta. normal aortic arch diameter. simple atheroma in aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. no as. no ar. mitral valve: no ms. trivial mr. tricuspid valve: normal tricuspid valve leaflets. mild tr. pulmonic valve/pulmonary artery: physiologic (normal) pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the procedure. the patient appears to be in sinus rhythm. resting tachycardia for the patient. see conclusions for post-bypass data conclusions: pre-bypass: 1. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular cavity size is normal. there is borderline mild left ventricular hypertrophy. .overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. there is no aortic valve stenosis. no aortic regurgitation is seen. 6. trivial mitral regurgitation is seen. post-bypass: pt is in sinus tachycardia on an epineprhine infusion. 1. bi ventricular systolic function is preserved 2. aorta is intact post decannulation 3. other findings are unchanged brief hospital course: ms. was transferred from osh and immediately underwent routine pre-operative testing for surgery. on she was brought to the operating room where she underwent a coronary artery bypass graft x 4. please see operative report for surgical details. she tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition. later on op day she was weaned from sedation, awoke neurologically intact and was extubated. on post-op day one she was transfused with one unit of prbc's and started on beta blockers and diuretics. she was gently diuresed towards her pre-op weight. chest tubes were removed on post-op day two and epicardial pacing wires on post-op day three. on post-op day three she was transferred to the telemetry floor where she received the remainder of her care while in the hospital. physical followed patient during entire post-op course for strength and mobility. she continued to make steady process without any post-op complications and was discharged home with vna services on post-op day six. medications on admission: atenolol 25mg qd, neurontin 100mg tid, 30mg , avandia 8mg qd, zocor 40mg qd, mobic 7.5mg qd, ultracet t tabs q6h prn, zantac 300mg qd, aspirin 81mg qd, mvi, mineral oil prn, oscal, osteo bioflex, glucosamine 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. ranitidine hcl 150 mg tablet sig: two (2) tablet po once a day. disp:*60 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. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*0* 6. fexofenadine 60 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 7. rosiglitazone 8 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. furosemide 20 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 9. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po twice a day for 10 days. disp:*40 capsule, sustained release(s)* refills:*0* 10. 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* 11. metoprolol tartrate 100 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*0* discharge disposition: home with service facility: hh discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 4 pmh: diabetes mellitus, hyperlipidemia, chronic gastritis, s/p l tk replcament, s/p tubal ligation, s/p appendectomy, s/p t&a, s/p herniated disc repair x 2, s/p right carpal tunnel surgery, s/p right trigger finger release discharge condition: good discharge instructions: shower, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: dr. in 4 weeks dr. in weeks dr. in weeks please call for appointments Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Transfusion of packed cells Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest burning major surgical or invasive procedure: cabg x 4 history of present illness: 57 y/o male with new onset chest burning, +ett, referrred for cardiac cath which revealed 3vcad. past medical history: htn elev. cholesterol osa basal cell ca elbow keratosis arm, forehead s/p bilat. ing. hernia repair penile artery bpg social history: married non-smoker family history: non-contrib physical exam: unremarkable pre-op exam pertinent results: 05:40am blood wbc-7.6 rbc-3.65* hgb-11.2* hct-31.8* mcv-87 mch-30.8 mchc-35.3* rdw-13.4 plt ct-152 05:40am blood glucose-126* urean-25* creat-1.2 na-135 k-3.8 cl-99 hco3-32 angap-8 brief hospital course: admitted to the pre-op holding area on , taken to the or where he underwent a cabg x 4 (lima>lad, svg>om, svg>diag, svg>pda), transferred to the csru in stable condition, on propofol and neosynephrine gtts. he was extubated on the day of surgery. he remained in the csru for 2 days due to some hypotension which required continued neosynephrine gtt. he had some atrial fibrillation, was started on amiodarone, and lopressor. he converted to nsr, and has not had further afib. he has progressed well with ambulation, and has remained hemodynamically stable, and in nsr. he is ready to be discharged home. medications on admission: zebeta cardura lipitor nexium asa motrin norvasc discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. disp:*14 tablet(s)* refills:*0* 2. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours) for 7 days. disp:*14 packet(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. 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 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 7 days: then 2 tabs (400 mg) daily for 1 week, then 1 tab daily until d/c'd by dr. . disp:*60 tablet(s)* refills:*0* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: cad discharge condition: good discharge instructions: may shower, no bathing or swimming for 1 month no lifting > 10# for 2 months no creams, lotions or ointments to any incisions p instructions: with dr. in 4 weeks with dr. in 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 Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Other and unspecified angina pectoris

history of present illness: this is a 79-year-old female with a past medical history significant for coronary artery disease, status post myocardial infarction in , osteoporosis, cataracts, asthma, osteoarthritis, who presented to the emergency department from rehabilitation after being found unresponsive. she was reportedly not using her left arm, and had left neglect, at which time the physician left the room for help, and when he returned, the patient was on the floor suffering from left-sided tonic-clonic seizure activity. the patient did not syncopize per report. according to the patient, she recalls having indigestion, vomited bile, she denied headache, dizziness, palpitations, shortness of breath. she did not recall falling, denied fainting in the past. she had no other complaints. past medical history: 1. osteoarthritis. 2. asthma. 3. coronary artery disease status post myocardial infarction in . 4. osteoporosis. 5. cataracts. allergies: penicillin. medications: 1. albuterol metered dose inhaler. 2. atrovent metered dose inhaler. 3. fluticasone 2 puffs b.i.d. 3. theophylline 300 mg b.i.d. 4. aspirin 81 mg p.o. q.d. 5. colace p.r.n. 6. levaquin 500 p.o. q.d. to . 7. indocin 25 mg p.o. q. 8 hours to . social history: at nursing home rehabilitation, previously lived alone in . physical examination: vital signs showed a fingerstick of 131, blood pressure 123-153/45-69, 100% on one liter nasal cannula, respiratory rate 15, heart rate in the 40s. in general she was lying in bed, pleasant in no apparent distress. heent: pupils were equal, round, and reactive to light, extraocular movements intact, no nystagmus, oropharynx was clear with symmetric palate elevation. neck: jugular venous pressure was irregular due to av dissociation, supple. cardiovascular: there was a 2-3/6 systolic ejection murmur at the left and right sternal borders, no rubs or gallops. lungs: decreased breath sounds at the left base, occasional crackles in the bases bilaterally. abdomen: active bowel sounds, soft, nontender, nondistended, no organomegaly. extremities: no edema. mental status: alert to month, year, not place, stated she was in at rehabilitation. neurologic: examination was nonfocal. palate raised symmetrically. there was 3+/5 strength in the intrinsic hand muscles on the left; 4+/5 on the right intrinsic hand muscles. upper and lower extremity strength was bilaterally and symmetric. nonfocal examination, no facial asymmetry, no word-finding difficulty, no pronator drift. laboratory data: on admission white count was 8.3, hematocrit 31.9, baseline 31., platelet count 559, mcv 81, neutrophils 69%, bands 0%, lymphocytes 14%, monocytes 6%. inr was 1.1. ptt 27.3, pt 12.8. sodium 127, down from baseline 135, potassium 4.7, chloride 89, bicarbonate 23, bun 11, creatinine 1, glucose 116, ck 135, ck mb 2, troponin less than 0.3. head ct without contrast showed no intracranial hemorrhage, no mass effect, a large foci versus small infarction in the right occipital lobe, lacunar infarct in the left basal ganglia region. ekg showed complete heart block, ventricular rate of 61, atrial rate of 90, normal axis, qtc 454, qrs 86. carotid ultrasound from showed mild 60-65% stenosis proximal left right coronary artery, no hemodynamically significant plaque in the right bulb or proximal internal carotid artery. hospital course: the patient is a 79-year-old woman with a history of coronary artery disease status post myocardial infarction. she was admitted after an episode of emesis, left-sided neglect and seizure activity who was found to be in complete heart block. the patient was noted to be hemodynamically stable during the time in the emergency department with systolic blood pressures in the 120s to 150s and a ventricular rate ranging from the 40s to the 60s, without any evidence of distress. since it couldn't be determined as to whether the patient had complete heart block as the cause of a possible global ischemia leading to the unmasking of a focal brain lesion leading to the one-sided deficit, the patient was transferred to the coronary care unit for a temporary transvenous wire pacer placement. this was done on the evening of admission. the patient had a right internal jugular placed for this purpose and the transvenous wire was placed into the right ventricle without difficulties. the patient was monitored overnight, and did not have any hemodynamic instability requiring the pacer to be utilized. in the meantime, av nodal blocking agents including phenytoin were avoided. the patient had an ekg done the following morning and had a transthoracic echocardiogram. the transthoracic echocardiogram demonstrated a left ventricular ejection fraction of greater than 55%, a sclerotic aortic valve, and some trace mitral regurgitation. it was noted that this may be underestimated due to cardiac echo shadows during the examination. on the 25th the patient was taken for pacemaker implantation. the patient had a ddd pacer placed, model 5370, serial #, serial lot #. the patient withstood the procedure without difficulty, and subsequent to pacer placement, had a chest x-ray which demonstrated the leads to be in the appropriate position. the pacer was interrogated and found to be in good working condition. subsequent to pacer placement, the patient's heart rate elevated to the 80s and 90s, and her systolic blood pressure was consistently in the 140s to 160s. thus it was determined in the setting of this new hypertension, the patient was initiated on a beta blocker on . she was started on atenolol 25 q.d. as for the potential seizure, neurology was consulted in the emergency department. it was determined that the complete heart block would take precedence over the possible neurological event. as stated previously on admission, a ct of the head did not demonstrate any new evidence of infarct or bleed, and even in the emergency department there was no evidence of left-sided neglect, and only possible mild decreased strength in the intrinsic hand muscles on the left, otherwise her examination was nonfocal. she was scheduled for an eeg. due to the evidence of possible lacunar infarcts in the past in addition to a possible transient ischemic attack which could have explained the brief period of left-sided neglect as well as seizure activity, it was determined to start the patient on pravastatin 20 mg q.d. since the patient was likely at risk for microvascular disease, especially in light of her previous myocardial infarction. a lipid panel was sent, and demonstrated levels within normal limits such as triglycerides 83, hdl 51 and ldl 96. of course it may be slightly depressed in the setting of an acute event. the patient also had carotid dopplers performed, at this time the final is not available, but suggested that there was still significant plaque in the left internal carotid artery with narrowing of approximately 60-69%, but no significant plaques in the right internal carotid artery. there was also normal antegrade flow in the vertebral arteries. any further neurological work-up was deferred as an outpatient. also in this setting there was concern that the hyponatremia, if it occurred rapidly, could have also played a role in her seizure activity. but her baseline sodium had previously been low, approximately 135. urine and electrolytes were sent and a tsh was sent, though it was assumed that the patient had recently had a few days of lasix in the past and may have just been volume depleted. she was thus given normal saline with appropriate correction of her sodium to the mid-130s. for her asthma the patient was continued on the flovent metered dose inhalers b.i.d., albuterol and atrovent p.r.n., and her theophylline was held briefly due to mildly elevated theophylline. it was reinitiated at discharge. the patient was then discharged back to rehabilitation after being deemed unsafe to return home by physical therapy and occupational therapy. discharge diagnoses: 1. third degree heart block status post ddd pacemaker placement. 2. transient ischemic attack versus seizure. follow-up appointment: device clinic on , 9:30 am; and with primary care physician, . . discharge medications: 1. atenolol 25 mg p.o. q.d. 2. cepacol lozenges p.r.n. 3. pravastatin 20 mg p.o. q.d. 4. levofloxacin 250 mg p.o. x 1 day. 5. dipyridamole aspirin one capsule b.i.d. 6. tylenol p.r.n. 7. fluticasone 2 puffs b.i.d. 8. albuterol metered dose inhaler and atrovent metered dose inhaler p.r.n. 9. aspirin 81 mg p.o. q.d. 10. theophylline 300 mg b.i.d. 11. colace 100 mg b.i.d. p.r.n. , m.d. dictated by: medquist36 Procedure: Catheter based invasive electrophysiologic testing Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Hyposmolality and/or hyponatremia Asthma, unspecified type, unspecified Other convulsions Atrioventricular block, complete Osteoporosis, unspecified Osteoarthrosis, unspecified whether generalized or localized, site unspecified Unspecified transient cerebral ischemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - three vessel coronary artery bypass grafting utilizing the left internal mammary to left anterior descending, vein graft to obtuse marginal and vein graft to posterior descending artery history of present illness: this is a 75 year old female with recent complaints of chest pain. of note, patient has dementia and is a poor historian. a myocardial perfusion scan back in mid showed anteroseptal ischemia with an ejection fraction of 45% - no official report. she subsequently underwent elective cardiac catheterization at on . angiography revealed a 70% left main lesion; 60% stenoses of the right coronary and obtuse marginal with a 70% pda lesion. her lvef was estimated at 60%. given her critical left main stenosis, she was transferred to the for further evaluation and treatment. past medical history: coronary artery disease; hypertension; elevated cholesterol; diabetes mellitus; dementia; anemia; hypothyroidism; sarcoidosis; prior knee replacement social history: no significant tobacco or etoh history. she lives with her son. family history: no premature coronary artery disease physical exam: vitals: t 99.5, bp 186/57, p 69, rr 18, sat 94% on ra general: elderly female in no acute distress heent: perrla, oropharynx benign neck: supple, no jvd heart: regular rate, s1s2, systolic murmur noted to radiate to carotids lungs: clear bilaterally abdomen: soft, nontender, nondistended. normoactive bowel sounds. ext: warm, trace edema. no varicosities. pulses: 1+ distally. transmitted carotid bruits vs murmurs. neuro: alert and oriented. cranial nerves grossly intact. no focal motor deficits noted. pertinent results: 05:30am blood wbc-11.0 rbc-4.06* hgb-10.8* hct-32.2* mcv-79* mch-26.6* mchc-33.6 rdw-17.1* plt ct-249 09:35pm blood wbc-7.2 rbc-3.62* hgb-8.8* hct-26.3* mcv-73* mch-24.5* mchc-33.7 rdw-17.2* plt ct-349 07:00am blood urean-21* creat-1.3* k-4.2 09:35pm blood glucose-137* urean-17 creat-1.2* na-141 k-3.9 cl-103 hco3-28 angap-14 07:00am blood calcium-9.6 phos-2.6* mg-1.7 09:35pm blood %hba1c-7.9* -done -done 06:05am blood hct-33.8* 05:30am blood wbc-11.0 rbc-4.06* hgb-10.8* hct-32.2* mcv-79* mch-26.6* mchc-33.6 rdw-17.1* plt ct-249 05:30am blood plt ct-249 05:30am blood glucose-92 urean-20 creat-1.2* na-139 k-4.4 cl-102 hco3-27 angap-14 cxr 1. mediastinal and bilateral hilar lymphadenopathy. further evaluation with a contrast- enhanced chest ct is recommended. 2. no evidence of pneumonia or overt chf. cxr comparison made to prior study of . there has been interval removal of the right internal jugular central venous line and the right chest tube. the opacity in the right lower lobe has improved in the interval, with minimal residual band-like atelectasis. there is improved aeration of the left lung, with residual atelectasis and small left pleural effusion. the cardiomediastinal silhouette is unchanged in appearance. there is no pneumothorax. chest ct 1. extensive mediastinal and symmetric hilar lymphadenopathy as well as few scattered perilymphatic nodules. this distribution of findings is in keeping with the submitted history of sarcoidosis. periportal and celiac lymphadenopathy is seen as well. however, unilateral right supraclavicular and right internal mammary lymphadenopathy is atypical for sarcoidosis, and underlying malignancy such as lymphoma or breast carcinoma cannot be excluded. further assessment with mammography is recommended if clinically indicated. 2. small pericardial effusion. 3. coronary artery atherosclerosis carotid duplex ultrasound moderate plaque with bilateral 40-59% carotid stenosis. of note, on the right, the degree of stenosis will fall to the lower end of the range whereas on the left it will be closer to the higher end of the range. echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid-anterior septal wall. the remaining segments contract well. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a fat pad. ekg normal sinus rhythm, rate 82. borderline first degree a-v block. possible old anteroseptal myocardial infarction. non-specific repolarization changes. compared to the previous tracing of sinus bradycardia has given way to normal sinus rhythm. brief hospital course: mrs. was admitted and underwent further preoperative evaluation. routine chest x-ray was notable for mediastinal and bilateral hilar lymphadenopathy for which a chest ct scan was obtained. this confirmed extensive bulky mediastinal lymphadenopathy. this appearance was compatible with a submitted history of sarcoidosis. there was however two mildly enlarged right supraclavicular and single right internal mammary lymph nodes, atypical for sarcoidosis. underlying malignancy such as lymphoma or breast carcinoma could not be excluded. other studies included an echocardiogram and carotid ultrasound. the echo showed only mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction consistent with coronary artery disease. lvef estimated at 55%. there was mild mitral regurgitation. the carotid ultrasound revealed moderate plaque with bilateral 40-59% carotid stenoses. she otherwise remained pain free on medical therapy and was cleared for surgery. on , dr. performed three vessel coronary artery bypass grafting. see operative note for details. following the operation, she was brought to the csru. within 24 hours, she awoke neurologically intact and was extubated. she weaned from intravenous therapy without complication. low dose beta blockade was initiated. she maintained stable hemodynamics and transferred to the sdu on postoperative day two. beta blockade was advanced as tolerated. she remained in a normal sinus rhythm. an acei was eventually resumed for hypertension. over several days, she continued to make clinical improvements. she responded to diuretics and by discharge, she was close to her preoperative weights with room air saturations of 97%. mrs. continued to make steady progress and was discharged home on postoperative day six. she will follow-up with dr. , her cardiologist and her primary care physician as an outpatient. results of her chest ct scan to be followed up by her primary care physician. medications on admission: lisinopril 20 qd, lipitor 20 qd, levoxyl 112 mcgs qd, metformin 1000 , glipizide 10 , aricept 10 qd discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 5. levothyroxine sodium 112 mcg tablet sig: one (1) tablet po daily (daily). 6. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 7. glipizide 5 mg tablet sig: two (2) tablet po bid (2 times a day). 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 9. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 10. captopril 12.5 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* 11. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 12. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 2 weeks. disp:*56 capsule, sustained release(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: coronary artery disease - s/p coronary artery bypass graft x 3 hypertension hypercholesterolemia diabetes mellitus dementia anemia hypothyroidism sarcoidosis prior knee replacement carotid disease mediastinal lymphadenopathy secondary to ? sarcoidosis discharge condition: good discharge instructions: patient may shower. no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks. please call with concerns. followup instructions: dr. in 4 weeks call cardiologist in weeks for appt, dr. () call pcp weeks for appt, dr. (have pcp with ct findings of mediastinal lymphadenopathy (?sarcoidosis vs. breast cancer vs. lymphoma) 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: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Sarcoidosis Other persistent mental disorders due to conditions classified elsewhere Occlusion and stenosis of carotid artery without mention of cerebral infarction Lung involvement in other diseases classified elsewhere

history of present illness: the patient is a 79 year-old male with coronary artery disease, congestive heart failure, porcine aortic valve placed in who presents to on with a day and a half history of shortness of breath and dyspnea on exertion with chest pressure. he denies any nausea, vomiting, diaphoresis, cough, fevers or chills at that time. he denies any changes in diet, no melena, no bright red blood per rectum. chest x-ray on admission showed mild congestive heart failure. he was gently diuresed. he was found to have a troponin leak of 2.2. the patient was taken to cardiac catheterization where his o2 sat dropped to the 70% when he laid down and he was intubated. on cardiac catheterization no hemodynamically significant lesions were found. the patient became hypotensive with a systolic blood pressure in the 60s and a low cardiac output and low cardiac index. an intraaortic balloon pump was placed. the patient's cardiac index dropped even further. an emergent echocardiogram was done showing 3+ aortic insufficiency to 3+ mitral regurgitation. the intraaortic balloon pump was removed. cardiothoracic surgery was consulted, pressors were started. the patient was transferred to the cardiac care unit for stabilization. during cardiac catheterization the wedge pressure was 36, right atrial pressures the mean was 18, pulmonary artery pressure mean of 27, right ventricular pressure was 63 and 4 with a mean of 19. past medical history: coronary artery disease, the patient underwent a coronary artery bypass graft in with saphenous vein graft to obtuse marginal one and right coronary artery. during that time he also had his aortic valve replaced with a porcine valve in . he had a myocardial infarction with three stents placed to the right coronary artery and saphenous vein graft. he was again stented in . in he was found to have atrial flutter and a pacemaker was placed. he was diagnosed with congestive heart failure in . recent echocardiogram in showed an ejection fraction of 30% with 1+ aortic regurgitation, 3+ mitral regurgitation. basal inferior and inferior lateral hypokinesis with septal hypokinesis, apical hypo and akinesis. he had chronic anemia with a baseline hematocrit of 29. he has a hiatal hernia that was repaired, lower gastrointestinal bleed, benign prostatic hypertrophy, chronic renal insufficiency with a baseline creatinine of 1.0 to 1.5. allergies: niacin. sulfa, but tolerates lasix. medications at home: 1. aspirin 325 q.d. 2. plavix 75 mg q.d. 3. isosorbide 5 mg po b.i.d. 4. carvedilol 25 mg po b.i.d. 5. lipitor 10 mg po q.d. 6. aldactone 12.5 mg po b.i.d. 7. losartan 15 mg po q.d. 8. lasix 20 mg po q.d. 9. coumadin monday, wednesday and friday for atrial fibrillation. 10. terazosin 5 mg po q.h..s 11. multivitamin. 12. folate. 13. colace. 14. senna. medications on transfer from the floor: 1. mucomyst. 2. plavix 75 mg po q.d. 3. protonix 40 mg po q.d. 4. heparin drip. 5. terazosin 5 mg po q.d. 6. losartan 50 mg po q.d. 7. aldactone 12.5 mg po b.i.d. 8. lipitor 10 mg po q.d. 9. isordil 5 mg po b.i.d. 10. carvedilol 25 mg po b.i.d. 11. aspirin 325 mg po q.d. 12. morphine. 13. colace. 14. senna. 15. tylenol. 16. maalox prn. social history: his health care proxy is his daughter. lives with his wife. has no tobacco, alcohol or drug history. physical examination: he was afebrile on transfer to the cardiac care unit, blood pressure 125/47 on dopamine and levophed. heart rate 76. respiratory rate 11. he was on assist control at 100% fio2, tidal volume of 700, respiratory rate 12, peep of 5 sating 100%. he was sedated elderly male. jugulovenous distention up to the jaw. he had crackles anteriorly bilaterally in the lung bases. his heart was irregularly irregular with 3 out of 6 diastolic murmur and systolic murmur. his abdomen was soft, normoactive bowel sounds. extremities were cold with 1+ pitting edema. he had 1+ posterior tibial pulses, dopplerable dorsalis pedis pulses bilaterally. he was sedated. laboratory: white blood cell count 5.7, hematocrit 34.9, 44% neutrophils, 28% lymphocytes, inr 2.2, platelets 142, ptt 132.4. chemistries sodium 138, potassium 4.9, chloride 102, bicarbonate 26, bun 55, creatinine 2.1, glucose 129, calcium 8.9, phos 5.9, magnesium 2.3. cks during the hospital course were 197 to 144 to 126 with troponin less then 0.3, 0.8 and then third set 2.2. arterial blood gas 7.40, co2 33, o2 of 217 on fio2 of 100% on assist control. hospital course: the patient was admitted to the cardiac care unit. his pressor regimen was switched to milrinone for the inotropic and vaso dilatation effect as well as neo-synephrine for the pressor effect. his map was maintained above 60 throughout the first night. blood cultures were sent, urine cultures and urinalysis were sent. cardiothoracic surgery reevaluated the patient and still felt that the patient was unstable for the operating room. he underwent a transesophageal echocardiogram, which showed no atrial septal defect, mild focal left ventricular systolic dysfunction with inferior hypokinesis, no aortic dissection and a flailing of aortic leaflet with 3+ aortic regurgitation, 2 to 3+ mitral regurgitation. no vegetations were seen. the patient was also started on a lasix drip for diuresis given his high wedge pressure. his fio2 was weaned down to 60% as tolerated. a chest x-ray showed a left lower lobe infiltrate. he was started on levofloxacin. the patient proceeded to develop splinter hemorrhages and what seemed like septic emboli to his toes and fingers. he was started on vancomycin to cover him for endocarditis. serial blood cultures were sent. the patient remained in critical condition on two pressors. infectious disease service was consulted who recommended covering with vancomycin, continuing to follow up with the blood cultures. the grim prognosis was discussed with the family. the family expressed that the patient expressed clearly prior to this episode that he would not want to be on a machine and he would not want any aggressive measures. the family decided to make the patient do not resuscitate, do not intubate. the plan was to extubate him on the morning of with the family present and to withdraw care at that point, however, on the night of the patient extubated himself. the decision was made to not reintubate the patient and the patient expired on during early morning around 5:30 a.m. discharge diagnoses: 1. cardiac arrest secondary to severe aortic regurgitation secondary to blown aortic valve. 2. history of hypertension. 3. coronary artery disease. 4. acute renal failure secondary to acute tubular necrosis. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Diagnostic ultrasound of heart Other esophagoscopy Insertion of endotracheal tube Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Right heart cardiac catheterization Diagnoses: Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Unspecified septicemia Cardiac complications, not elsewhere classified Atrial fibrillation Mechanical complication due to heart valve prosthesis Cardiac arrest Cardiogenic shock Acute diastolic heart failure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from osh with hypoxic respiratory failure major surgical or invasive procedure: endotracheal intubation history of present illness: patient is a 40 yo male with h/o asthma transferred from osh after intubation for hypoxic respiratory failure. per report, patient went to work and was on break when he came out of the bathroom with his inhaler, passed out, was reportedly apneic by his co-workers and subsequently vomited feculant appearing vomitus. he could not be intubated in the field, so he was bagged and had ? seizure described as rhythmic movements arm and head and was incontinent of urine. on arrival to the ed at osh, t 96.1, hr 140s, bp 198/112, o2 sats 86% on ambu bag. he was sedated and intubated and an ng tube was placed which yielded ? feculent material. ct head, cta chest and ct abd were performed. he received levofloxacin 500 iv x1, flagyl 500 iv x1, ativan 2 mg ivx3, morphine 10 mg ivx3 and was started on propofol drip and transferred to . . on arrival to he was intubated and sedated satting 100 % on ac tv 560/16 100% fio2 and peep 5. ng tube in place with hemeoccult positive output. on speaking with his wife, over the past 2 months has has been using his inhalers increasingly, at times multiple times per day. he saw his pcp 5 days ago at which time he was started on advair and prednison taper x 7 days. she reports that he had no fevers, chills, cough, uri sx, abd pain, n/v, diarrhea or any other symptoms. he did have a coughing spell 2 days ago during which he nearly vomited. his only recent travel was to from . no sick contacts. of note, they have been remodeling their home and paiting and sanding which may have made his asthma symptoms worse. denies use of nsaids. past medical history: asthma- never hospitalized, only on steroid a couple of times per wife. until recently only used inhalers occasionally occasional gerd treated with prn tums social history: lives with wife. as corrections officer. has been using chewing tobacco for the past 9 months. occasionally smokes cigars. no cigarette. drinks socially. no other drugs. (all history from wife) physical exam: vitals: t 96.4 bp 128/89 hr 98 rr 16 % o2 sats 100% on ac tv 560/16 100% fio2 and peep 5 general: intubated and sedated heent: perrl, ng tube in place with hemoccult positive drainage cv:rr, nl s1, s2, no m/g/r lungs: cta anteriorly with few crackles at left base, no wheezes abd: distended, positive bs, soft, non-tender, no hepatosplenomegaly ext: no edema, 2+ dp pulses neuro: intubated and sedated, before sedation was following commands per osh report skin:no rashes pertinent results: (osh) ct head: negative for bleed or mass effect (osh) cta: not optimal pe is study, but no obvious pe, minimal atelectasis on right, evidence of aspiration versus aspiration pna ct abd (prelim): no acute pathology . ekg: sinus tachy 125, nl axis, nl intervals, no st t wave changes brief hospital course: mr. is a 40 yo male h/o asthma with recent exacerbation transferred from osh intubated after hypoxic respiratory failure possibly secondary to aspiration event in the setting of asthma exacerbation. . # hypoxic respiratory failure: given recent events with increasing need for mdis and coughing fit 2 days ago with near vomiting, it is possible that the patient had an asthma exacerbation, hyperventilated, fainted, and had an aspiration event leading to his intubation. he had no wheeze on exam on arrival to and does not seem acutely bronchospastic which doesn't support this picture. there is evidence of pneumonitis on ct scan at . no evidence of pe, although not an optimal study, although this is lower on the differential given his history. the patient was successfully extubated on and was stable on 3 l nc, later weaned to ra without problem. was conservatively treated with levofloxacin and flagyl for possible aspiration pna, although he may in fact have only aspiration pneumonitis. he was also treated with aggressive nebs, singular, and a slow steroid taper to continue over 2 weeks after discharge. he will follow up with dr. in pulmonary clinic in the next available appointment slot. he will have outpatient pfts checked at that time. - interestingly, the patient had continued tachycardia throughout his stay even after marked improvement with the above treatment. given his recent plane ride to we decided to repeat his cta chest. this study revealed a segmental pe. the patient was started on lovenox and was discharged with this treatment with instructions to call his pcp on to set up a coumadin regimen. he should take lovenox as a bridge to anticoagulation, then should be anticoagulated on coumadin for a total of at least 6 months. . # hemoccult positive ng output: on admission the patient was found to have ng tube output which was hemoccult positive. his hct remained stable. he has no history of gi bleed, does have some mild gerd, denies nsaid or excessive alcohol use. he was on steroids, which increases his risk of gastritis. the patient was kept on a twice daily ppi while in house and is discharged on a daily ppi for gastritis. this may be further worked up as an outpatient if indicated when he follows up with his pcp. . at the time of discharge the patient was able to ambulate while on room air without desaturation. he will follow up with his pcp and in our pulmonary clinic as above. medications on admission: home meds: advair albuterol inhaler prednisone taper . meds on transfer: levofloxacin 500 mg iv x1 flagyl 500 mg iv x1 solumedrol 125 mg iv x1 morphine 10 mg iv x3 ativan 2 mg iv x3 magnesium sulfate 2 g x1 propofol drip discharge medications: 1. montelukast 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*3* 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation (2 times a day). disp:*1 disk* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*3* 4. levofloxacin 750 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. disp:*7 tablet(s)* refills:*0* 5. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 7 days. disp:*21 tablet(s)* refills:*0* 6. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). disp:*1 inhaler* refills:*3* 7. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours): take 2 puffs at least every 4 hours without fail. you may take it every 2 hours if needed. disp:*1 inhaler* refills:*3* 8. prednisone 20 mg tablet sig: two (2) tablet po daily (daily) for 6 days: take 2 daily for 3 days, then decrease to 1 daily for 3 days, then change to 5mg dose pills. disp:*9 tablet(s)* refills:*0* 9. prednisone 5 mg tablet sig: three (3) tablet po once a day for 9 days: after finishing 20mg dose: take 3 daily for 3 days, then decrease to 2 daily for 3 days, then decrease to 1 daily for 3 days then stop. disp:*18 tablet(s)* refills:*0* 10. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours): 100mg sc q12h. disp:*10 syringes* refills:*2* discharge disposition: home discharge diagnosis: asthma exacerbation aspiration pneumonia pulmonary embolus discharge condition: stable. able to ambulate without desaturating. discharge instructions: please call the pulmonary clinic at and ask for the next available appointment with dr. . . please call your primary care physician on for an immediate appointment. he will start you on a medication called coumadin to thin your blood. you will have your levels of this medication checked and lovenox should be taken until your levels of coumadin are appropriate. . please take all of these medications as directed until told to change or do otherwise by dr. . please take your antibiotics for 7 more days only. all other medications should be ongoing. . * it is very important that you use your lovenox injections twice per day. do not stop this until told to do so by your pcp. . **note that your prednisone should be decreasing over the next 15 days. you have prescriptions for 20mg tabs and for 5mg tabs to make this easier for you. please take 40mg (2 of the larger tabs) for the next three days, then decrease to 20mg (1 of the larger tabs)for three days. then take 15mg (3 of the smaller tabs) for three days, then 10mg (2 of the smaller tabs) for three days, then decrease to 5mg (1 small tab) for three days, then stop. this should take a total of 15 days. . if you have fever, chills, trouble breathing or other concerning symptoms please call your physician, . , or come to the emergency room. followup instructions: please call the pulmonary clinic at and ask for the next available appointment with dr. . . please call your primary care physician for the next available appointment as above. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Esophageal reflux Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other pulmonary embolism and infarction Asthma, unspecified type, with (acute) exacerbation

allergies: not known medications: ? klonopine pmh: not known review of systems neuro: pt is sedated w/ propofol. currently on 30mcg/kg/min. pt rouses to voice and becomes restless. maes w/ normal strength. follows commands inconsistently. showing two fingers when asked and nodding head to questions. perrl. 4mm bilaterally. (+) cough and gag reflex. cervical collar intact. resp: intubated w/ 7.5 ett. bs are cta bilaterally. when calm pt not breathing over vent. cv: hr 60s. nsr. no ectopy. pt received 500cc ns bolus for sbp in the 80s. now bp=94/36. gi: npo w/ ns infusing at 80cc/hr. ogt to lis draining light pink drainage. abdomen is soft and nondistended. gu: foley to gravity. urine clear yellow. heme: hct from ew =37.5. hct at 9:30pm=33.2. endo: blood sugar=82 from 76. skin: road rash present on left buttock. no other wounds visible. social: no family or friends have been in touch. a: 40yo pedestrian struck by car c/ (+) loc. p: neuro checks q 1hr. keep sedated and intubated overnight. serial hct checks. contact social services in am . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Alcohol abuse, unspecified Cocaine abuse, unspecified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Bipolar I disorder, most recent episode (or current) unspecified Sedative, hypnotic or anxiolytic abuse, unspecified

history of present illness: a 76-year-old male with a history of mi with systolic dysfunction, ef less than 20%, hyperlipidemia, afib, and chronic renal insufficiency, who is seen in advanced heart failure clinic and sent to for nesiritide tailored therapy. patient had gone to for the winter in decompensated heart failure with recurrent atrial fibrillation. despite promising to seek medical care, he had not sought cardiology followup in , while decompensating further. patient went up 30 pounds in weight in . creatinine was found to be worsening. patient walks 10 yards and is short of breath. patient was on admission not on an aspirin or beta-blocker. complains of moderate-to-low sodium diet. allergies: no known drug allergies. current medications: 1. amiodarone 200 mg q.d. 2. folic acid 1 mg q.d. 3. atorvastatin 10 mg q.d. 4. coumadin. 5. furosemide 80 mg q.d. 6. lisinopril 5 mg q.d. 7. started nesiritide past medical history: 1. chf: systolic ef of less than 20%. 2. coronary artery disease status post mi in . 3. afib status post on coumadin. 4. chronic renal insufficiency. 5. hypothyroid. social history: patient dates the owner of in . history of smoking. no alcohol use recently. physical exam: temperature 96.3, blood pressure 90/62, heart rate 76, respiratory rate 18, and 95% on room air. weight 70.6 kg. lungs with decreased breath sounds at the right base half the way up the left base, but not as pronounced, diffuse crackles. irregularly, irregular s1, s2 normal, no murmur. abdomen: markedly distended and firm, nontender, positive bowel sounds, positive fluid wave. no lower extremity edema. mild non-pitting edema on the left, mild non-pitting edema on the right. 2+ pulses bilaterally. laboratories: creatinine found to be 3.6 on admission, hematocrit 33.4. lfts unremarkable. tsh greater than 100. chest x-ray showed heart failure. hospital course: 1. chf: the patient was markedly decompensated and up approximately 30 pounds. patient was on natrecor 0.15, lasix drip of 7, and dopamine of 3 mcg to maintain pressure and kidney perfusion. patient had a picc line placed for these medications. patient was still having difficulty diuresing and his weight was still around 70 kg at this time. 2. anemia: the patient's hematocrit had been stable at approximately around 33. 3. ascites: plans were to do a paracentesis. the coumadin was discontinued and the inr allowed to drift down. this was going slowly so vitamin k 5 mg subq was given. 4. coronary artery disease: we continued his aspirin, atorvastatin. the beta-blocker and ace inhibitor were not started because he was in such decompensated heart failure and was so hypotensive. 5. hyperlipidemia: we increased his lipitor to 80 mg q.d. 6. hypothyroid: tsh was greater than 100 most likely from amiodarone toxicity. we restarted the patient on low-dose levothyroxine at 25 mcg so that as not to cause any ischemia to the patient. 7. atrial fibrillation: we discontinued the amiodarone because of thyroid dysfunction, the patient not staying in sinus rhythm. we discontinued the coumadin because of the hopes of paracentesis next week. spoke with the attending and there was no reason to place the patient on heparin for anticoagulation. 8. chronic renal insufficiency: baseline creatinine 1.2-1.7 has been slowly decreasing from 3.6-3.0. it has not gone back towards baseline. 9. full code: i spoke with the patient and his girlfriend, who wishes to be his healthcare proxy. they wish all measures to be performed. 10. diet: he was on a 2-gram sodium diet and restricted to 1 liter of fluid per day. electrolytes were repleted as needed. the rest of this discharge summary will be dictated at the time of discharge. dr 12.abz dictated by: medquist36 d: 11:49 t: 05:32 job#: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Arterial catheterization Pulmonary artery wedge monitoring Transfusion of packed cells Transfusion of other serum Injection or infusion of nesiritide Diagnoses: Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Systolic heart failure, unspecified Other sequelae of chronic liver disease Other and unspecified coagulation defects

discharge status: the patient was discharged to home. discharge instructions/followup: 1. the patient was discharged to home with instructions to follow up with a new primary care physician in one week status post discharge. the primary care physician was arranged by dr. with direct communication. 2. the patient was to continue with outpatient physical therapy through an outpatient rehabilitation program. 3. the patient was also to continue with outpatient counseling and therapy; initially through . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Thoracentesis Diagnoses: Acidosis Hyperpotassemia Acute kidney failure, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Intestinal infection due to Clostridium difficile Drug withdrawal Opioid abuse, continuous Electrolyte and fluid disorders not elsewhere classified

history of present illness: this is a 23-year-old male with a history of anxiety and heroin use who was found unresponsive at home. he was last seen 48 hours previously. there was a serax bottle with 13 pills missing found at the bedside, as well as some unknown substance in his safe. he was taken to an outside hospital where his temperature was 92.9, pulse was 130, respiratory rate 12, blood pressure was 133/113, saturating 88% on room air with a 100% nonrebreather. at that point, he was found to have a creatine kinase of 50,000, potassium was 7.4, and a creatinine was 3.2. he had a minimal response to narcan. he was started on ceftriaxone secondary to a chest x-ray showing a left-sided aspiration pneumonia. a head ct was also obtained and was negative. an electrocardiogram had peaked t waves which improved once at the emergency department. at this point, the patient was transferred to . here his temperature was 98.6, pulse was 83, respiratory rate was 18, blood pressure was 100/53, with an oxygen saturation of 97% on 100% nonrebreather. while in the emergency department, his blood pressure dropped to 60/palpable, and he was given dopamine and fluids. his oxygen saturations dropped. at this point, his arterial blood gas was 7.16, co2 was 52, o2 was 110 on the 100% nonrebreather. intravenous fluids were given in the emergency department in combination with the renal failure which prompted respiratory hypoxia; therefore, the patient was intubated. with the chest x-ray showing a left-sided aspiration pneumonia; medications of levofloxacin and flagyl were started. physical examination on presentation: head, eyes, ears, nose, and throat revealed pupils were 2 mm bilaterally. sclerae were anicteric. cardiovascular examination revealed a regular rhythm, tachycardic. no murmurs. pulmonary was positive for rales at the left base with decreased breath sounds. the abdomen was soft, nontender, and nondistended, positive bowel sounds. extremities revealed 1+ lower extremity edema and 2+ pules throughout. pertinent laboratory data on presentation: laboratories revealed white blood cell count was 21.2, hematocrit was 47.1, platelets were 168. sodium was 138, potassium was 7.2, chloride was 105, bicarbonate was 18, blood urea nitrogen was 40, creatinine was 2.9, blood glucose was 156. calcium was 5.3, magnesium was 1.6, phosphate was 5.6. alt was 170, ast was 608, alkaline phosphatase was 62. creatine kinase was 101,860; creatine kinase peaked at 120,000. mb fraction was 0.8%. troponin i was 8.3. inr was 2, pt was 16, and ptt was 32.6. urinalysis was amber with a ph of 5, with a specific gravity of 1.03, a large amount of blood, 100 protein, small bilirubin, trace leukocytes, many bacteria; otherwise negative. toxicology screen was positive for opiates only. radiology/imaging: abdominal film had no free air. electrocardiogram had no signs of ischemia. hospital course: the patient was admitted to the medical intensive care unit. he received emergent hemodialysis which corrected the metabolic acidosis and the electrolyte abnormalities. the patient was also diuresed. his course was complicated by bilateral pulmonary infiltrates consistent with acute respiratory distress syndrome. dopamine was discontinued on hospital day four. a sputum culture at this time returned methicillin-resistant staphylococcus aureus positive. he was given 12 days of vancomycin. he was able to be extubated on hospital day seven. once extubated the patient had withdrawal from benzodiazepines, and maintenance clonidine was begun and was eventually tapered off. he was oxygenating well; however, he continued to spike temperatures along with an elevated white blood cell count that resolved over a few days without antibiotics. a pleurocentesis was performed prior to the resolution, and it showed 201 white blood cells and red blood cells, but no growth on culture. also, during the course, he had upper and lower extremity edema. an ultrasound ruled out deep venous thrombosis. neurology was consulted secondary to decreased mental status. a magnetic resonance imaging of the head was obtained which was negative for blood, infection, or edema. electroencephalogram was also negative. psychiatry came in and felt that his mental status change was delirium. neurology was also involved with the patient's left-sided weakness that was found once awake and alert. electromyogram showed a l5-s1 plexopathy, which did not explain the entire physical examination picture. therefore, a magnetic resonance imaging of the lumbar spine was obtained. this showed no osteomyelitis, but there was a 5-cm region suspicious for a hematoma in the left gluteal region. an ultrasound was obtained to rule out an abscess in this area. it showed no focal fluid collection, and no evidence of an abscess. it was positive for a left gluteal hematoma; although, a mass could not be ruled out. a magnetic resonance imaging of the thoracic and cervical spine was obtained when the weakness persisted. it showed no spinous central canal stenosis or neuroforaminal narrowing. he has continued with physical therapy to regain function. over the course of his hospital stay, his renal function improved. creatine kinase trended down; last checked was 6274, and his electrolyte abnormalities resolved. condition at discharge: condition on discharge was stable. discharge diagnoses: 1. status post rhabdomyolysis. 2. acute renal failure. 3. left-sided weakness. 4. depression. 5. left gluteal hematoma. medications on discharge: 1. celexa 20 mg p.o. q.d. 2. remeron 15 mg p.o. q.h.s. 3. protonix 40 mg p.o. q.d. 4. heparin 5000 units subcutaneous b.i.d. (to continue until the patient has a moderate amount of activity). discharge status: he was to be discharged to a rehabilitation facility. discharge followup: he was to follow up with neurologist (dr. in about four weeks, as well as seeing a nephrologist, and primary care physician (dr. ). discharge recommendations: between two to four months the patient should have a repeat ultrasound of the left gluteal region to assess for absorption of hematoma versus a mass that would prompt an outpatient workup. , j. m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Thoracentesis Diagnoses: Acidosis Hyperpotassemia Acute kidney failure, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Intestinal infection due to Clostridium difficile Drug withdrawal Opioid abuse, continuous Electrolyte and fluid disorders not elsewhere classified

history of the present illness: this is a 59-year-old male with a past medical history of coronary artery disease, status post cabg in and hypercholesterolemia who was admitted to the service on . the patient initially presented to with a three week history of intermittent band-like chest pain radiating down both arms with some associated numbness and tingling in his fingertips bilaterally. the patient also complained of associated fatigue, and mild shortness of breath. the patient claimed that each episode of pain lasted approximately three to four minutes. the patient additionally complained of approximately a weeks history of nausea, vomiting, and diarrhea, which he attributed to a "flu-like illness". the ekg at the outside hospital reportedly demonstrated t wave depression in leads v1 through v3 and st depression in leads v2 and v3. the patient's ck was negative but he did demonstrate elevated troponin to 1.2. transthoracic echocardiogram conducted at the outside hospital reportedly demonstrated an inferior wall reversible defect and the patient was subsequently transferred to the on for further evaluation and treatment. past medical history: 1. hypercholesterolemia. 2. coronary artery disease, status post cabg in with anastomoses from the lima to the lad and rsvg to the om and pda. 3. rectal prolapse. 4. nasal polyps. 5. status post pelvic fracture in . 6. chronic lower back pain and arthritis. admission medications: 1. cardizem. 2. aspirin. 3. lopid. 4. lipitor. 5. k-dur. allergies: penicillin causes anaphylactic shock. social history: the patient lives mainly in with his girlfriend but has a home in , and is here for approximately two months of the year. the patient has a four pack year history of smoking but is currently abstinent. the patient consumes occasional alcohol. there is no history of iv drug use but does reportedly smoke marijuana as an adjunct to his low back pain therapy. hospital course: the patient was admitted to the service on under the direction of dr. . cardiac catheterization conducted on demonstrated three vessel coronary artery disease with complete occlusion of the saphenous vein graft to the pda. in addition, the saphenous vein graft to the om1 was diffusely diseased. as well, the lad was noted to have a 95% stenosis just after d1 and mild diffuse disease in its proximal segment. the patient's ejection fraction was noted to be 52%. the patient was treated medically with beta blockers and aspirin for hospital days number one and two, after which point, a prolonged discussion was held with the patient regarding surgical options. following a discussion of the relative risks and benefits of cardiac surgery, the patient agreed to a coronary artery bypass graft to be scheduled on . on , the patient underwent a re-do coronary artery bypass graft. anastomoses included svg to lad, svg to pda, and svg to om. the patient tolerated the procedure well with a bypass time of 85 minutes and a crossclamp time of 57 minutes. the patient's pericardium was left open; lines placed included an arterial line and a swan-ganz catheter; both ventricular and atrial wires were placed; mediastinal and bilateral pleural tubes were placed. the patient was subsequently transferred to the cardiac surgery recovery unit, intubated, for further evaluation and management. on transfer, the patient's mean arterial pressure was 78, cvp 11, pad 20, and his was 27. the patient was noted to be in normal sinus rhythm with a heart rate of 85 beats per minute. on transfer, active drips included neo-synephrine and propofol. in the hour shortly following his arrival in the csru, the patient was noted to have a hypotensive episode which was responsive to additional neo-synephrine and aggressive fluid resuscitation. the patient's postoperative hematocrit was noted to be 25.4. on postoperative day number one, the patient was successfully weaned and extubated in the csru. he was subsequently advanced to p.o. intake, which he tolerated well, and tolerated removal of his chest tubes and foley catheter well. the patient was subsequently noted to be independently productive of adequate amounts of urine for the duration of his stay. on the evening of postoperative day number two, the patient was cleared for transfer to the floor and was subsequently admitted to the cardiothoracic service under the direction of dr. . postoperatively, the patient had an uneventful clinical course. the patient was evaluated by physical therapy, who deemed him an acceptable candidate for discharge home following a course of acute medical treatment. the patient's epicardial wires were successfully removed without complication and he was noted to remain in sinus rhythm for the duration of his stay. the patient was advanced to a full regular diet, which he tolerated well, and was noted to have adequate pain control via oral pain medications. by postoperative day number five, the patient was noted to be independently ambulatory with good oxygen saturations on room air. his dressing was noted to be clean, dry, and intact, and his sternal incision was noted to be intact with steri-strips neatly in place. no evidence of erythema or purulence was noted in any of his surgical regions. the patient was subsequently cleared for discharge to home with instructions for follow-up on postoperative day number five, . condition at discharge: the patient is to be discharged to home with instructions for follow-up. status at discharge: stable. discharge medications: 1. lasix 20 mg p.o. q. 12 hours times ten days. 2. potassium chloride 20 meq p.o. q. 12 hours times ten days. 3. colace 100 mg p.o. b.i.d. 4. aspirin 325 mg p.o. q.d. 5. percocet 5/325 mg one to two tablets p.o. q. four to six hours p.r.n. pain. 6. lipitor 60 mg p.o. q.d. 7. gemfibrozil 600 mg p.o. b.i.d. 8. lopressor 75 mg p.o. b.i.d. discharge instructions: the patient has been instructed to maintain his incisions clean and dry at all times. the patient may shower but should pat dry incisions afterwards. no bathing or swimming until further notice. the patient is to resume a cardiac diet. the patient is to limit physical exercise; no heavy exertion. no driving while taking prescription pain medications. follow-up: the patient is to follow-up with his primary care provider within one to two weeks following discharge. the patient is to follow-up with dr. four weeks following discharge. the patient is to call to schedule an appointment. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Coronary atherosclerosis of autologous vein bypass graft

allergies: patient recorded as having no known allergies to drugs attending: addendum: hospital course the pt. was admitted after undergoing an open repair of an abdominal aortic aneurysm. the pt. tolerated the procedure well and spent the evening in the pacu under icu observation. the following day he was taken to the icu. please see operative report for further details. propofol / vented atn noted lytes followed / replenished / fluid management ativan for etoh use vent wean with atteept to decrease peep prbc vent wean with attept to decrease peep lytes followed / replenished / fluid management ekg changes with elevated cpk / mb - cardiology consulted. vent wean with attept to decrease peep lytes followed / replenished / fluid management tf started and advanced vent wean with attept to decrease peep lytes followed / replenished / fluid management tf pt experiences agitation on atttempted wean vent wean with attempt to decrease peep lytes followed / replenished / fluid management tf sinusitis with pos cx'x iv antibiotics started increase sodium / free water given creat improves vent wean with attept to decrease peep lytes followed / replenished / fluid management tf pt bronched for therapeutic aspiration - vent wean with attept to decrease peep lytes followed / replenished / fluid management tf h-flu / ab adjusted pt extubated ab / creat improved pnuemonia / chest pt pt oob pt transfered to the vicu lytes followed / replenished / fluid management tf creat continues to improve - oob / diet advanced / tf dc'd lytes followed / replenished / fluid management mentation improves / wbc decreases / creat improves lines dc'd pt consult pt transfered to the floor pt clears to go home with monitering pt stable for dc to follow-up with dr wife agrees discharge disposition: home with service facility: inc. md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other bronchoscopy Other lavage of bronchus and trachea Resection of vessel with replacement, aorta, abdominal Resection of vessel with replacement, lower limb arteries Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Aortocoronary bypass status Other and unspecified angina pectoris Abdominal aneurysm without mention of rupture Hyperosmolality and/or hypernatremia Urinary complications, not elsewhere classified Aneurysm of iliac artery Alcohol withdrawal Other chronic sinusitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal aortic aneurysm major surgical or invasive procedure: - aorto-biliac aortic aneurysm repair with supraceliac cross clamping - insertion of swan catheter - cvl placement history of present illness: 59 y/o m underwent a cardiac evaluation early in that showed a 5.6cm aortic aneurysm. this was confirmed on a ct scan just days later. he had no previous history of this aneurysm. past medical history: 1. cad s/p cabg in a. cardiac catheterization - torturous right iliac, unable to evaluate the graft site for aaa surgery. the lm had a 100% stenosis and is s/p cabg (lima-lad, svg-om) at . b. stress test - exercised 5'" of protocol to 60% apmr stopping d/t leg pain. ekg showed 1-2.5mm info lateral st depressions which resolved 10 minutes into recovery. nuclear images showed a significant inferoapical and posterior, mostly reversible defect. c. echo -concentric lvh with no wall motion abnormalities. ef 60-65%. trace mr. . la enlargement. there is a 5.4cm aaa. cabg - (lima-lad, svg-om) 2. high cholesterol 3. htn 4. aaa 5.6 cm, last us 5. obesity 6. tobacco abuse social history: married for 10+ with two from a previous marriage. he works full time night shifts as a security guard. his wife will drive him to and from the hospital. 50 pyr smoking hx, occ etoh (beers), no ivdu family history: cad father had angina at age 59 and died at age 69 of mi, stroke. m died at 71 from liver cancer physical exam: vitals: 98.7 58 116/54 20 95% generally well appearing in no acute distress oriented to place and person, flat affect ctab, no w/c/r rrr, no m/r/g soft, nt, nd, nabs, incision clean/dry/intact and well healed no c/c/e, pulses 2+ x4 pertinent results: 07:05am blood wbc-11.3* rbc-3.39* hgb-9.9* hct-30.0* mcv-89 mch-29.2 mchc-33.0 rdw-13.4 plt ct-678* 01:56am blood neuts-78.7* lymphs-9.7* monos-5.0 eos-6.5* baso-0.1 07:05am blood plt ct-678* 03:08am blood pt-14.2* ptt-26.3 inr(pt)-1.3* 08:08pm blood fibrino-100* 07:05am blood glucose-85 urean-33* creat-1.6* na-140 k-5.1 cl-105 hco3-22 angap-18 08:35am blood alt-112* ast-60* alkphos-229* amylase-93 totbili-0.7 09:05am blood ck(cpk)-121 08:35am blood lipase-104* 08:35am blood albumin-3.3* 07:05am blood calcium-9.2 phos-3.6 mg-1.7 08:35am blood vitb12-1105* folate-18.6 03:00am blood tsh-1.5 03:32am blood freeca-1.25 radiology final report ct head w/o contrast 5:15 pm reason: please eval for focal infarct / bleed medical condition: 59 year old man s/p aaa repair pod 19 with mental status changes and overall decreased mentation reason for this examination: please eval for focal infarct / bleed contraindications for iv contrast: none. indication: 59-year-old male status post aaa repair, postoperative day #19, presenting with mental status changes. comparisons: none. technique: non-contrast head ct. findings: study is limited secondary to motion artifacts. allowing for this factor, there is no evidence of acute intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. - white matter differentiation appears well preserved. basal cisterns are patent. ventricles, cisterns and sulci are unremarkable. there are calcifications within the vertebral and internal carotid arteries, atherosclerotic in origin. the basilar artery appears tortuous without definite aneurysmal dilatation. there is opacification within the visualized superior aspect of the maxillary sinuses with frothy secretion component. no fractures are identified. the mastoid air cells are well aerated. impression: 1. no evidence of acute intracranial hemorrhage or mass effect. 2. prominent, tortuous basilar artery without definite aneurysmal dilatation. 3. likely maxillary sinus disease. the maxillary sinuses are not completely imaged on this head ct scan. the study and the report were reviewed by the staff radiologist. dr. dr. approved: 8:31 am brief hospital course: the pt. was admitted after undergoing an open repair of an abdominal aortic aneurysm. the pt. tolerated the procedure well and spent the evening in the pacu under icu observation. the following day he was taken to the icu. please see operative report for further details. the pt. initially had an episode of hypostension with a sbp of 80s and map of 60 which resolved with fluid and a dopamine gtt. this gtt was quickly weaned and pt. was able to maintain satisfactory sbps on his own. discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed. disp:*30 tablet(s)* refills:*0* 3. irbesartan 300 mg tablet sig: one (1) tablet po once a day. 4. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po once a day. 5. lipitor 80 mg tablet sig: one (1) tablet po once a day. 6. zetia 10 mg tablet sig: one (1) tablet po once a day. 7. metoprolol succinate 200 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po once a day. discharge disposition: home with service facility: inc. discharge diagnosis: - s/p open aaa repair - post operative delerium - post-operative hypotension - post-operative anemia - poast-operative acute renal failure discharge condition: - stable discharge instructions: discharge instructions following aortic surgery . this information is designed as a guideline to assist you in a speedy recovery from your surgery. please follow these guidelines unless your physician has specifically instructed you otherwise. please call our office nurse if you have any questions. dial 911 if you have any medical emergency. . activity: . there are no specific restrictions on activity other than no lifting an object heavier than twenty-five (25) pounds for the first three (3) months. gradually increase your level of activity back to normal depending on how you feel. fatigue is normal, especially for the first month postoperative. resume driving when you feel strong enough and comfortable enough without needing pain medication. . please call us immediately for any of the following problems: . severe and worsening abdominal pain . . pain or swelling in one of your legs. . increasing pain, redness or drainage related to your incision(s) . . watch for signs and symptoms of infection. these are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. if you experience any of these or bleeding at the incision site, call the doctor. . exercise: . limit strenuous activity for 8 weeks. . resume driving when you feel strong enough and comfortable enough without needing pain medication . . no heavy lifting greater than 20 pounds for 8 weeks. . avoid excessive bending at the hips and stooping for 4 weeks. . bathing/showering: . you may shower immediately if the incision is dry upon coming home. no baths until sutures / staples are removed. dissolving sutures may have been used. in either case, you can wash your incision gently with soap and water. . wound care: . suture / staples may be removed before discharge. if they are not, an appointment will be made for you to return for staple removal. . when the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. these will stay on about a week and you may shower with them on. if these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. . medications: . you may resume taking medication you were on prior to your surgery unless specifically instructed otherwise by your physician will be given a new prescription for pain medication, which should be taken every three (3) to four (4) hours only if necessary. . remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (check with your physician if you have fluid restrictions.) if you feel that you are constipated, do not strain at the toilet. you may use over the counter metamucil or milk of magnesia. appetite suppression may occur; this will improve with time. eat small balanced meals throughout the day. . cautions: . no smoking! we know you've heard this before, but it really is an important step to your recovery. smoking causes narrowing of your blood vessels which in turn decreases circulation. if you smoke you will need to stop as soon as possible. ask your nurse or doctor for information on smoking cessation. . avoid heavy lifting (over 20 pounds) for 8 weeks after surgery. . no strenuous activity for 4-6 weeks after surgery. . diet: . there are no special restrictions on your diet postoperatively. poor appetite is expected for several weeks and small, frequent meals may be preferred. . for people with vascular problems we would recommend a cholesterol lowering diet: follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and ldl (low density lipoprotein-the bad cholesterol). exercise will increase your hdl (high density lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. you may be self-referred or get a referral from your doctor. . if you are overweight, you need to think about starting a weight management program. your health and its improvement depend on it. we know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. if interested you can may be self-referred or can get a referral from your doctor. . if you have diabetes and would like additional guidance, you may request a referral from your doctor. . follow-up appointment: . be sure to keep your medical appointments. the key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. don't let them go untreated! . please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. this should be scheduled on the calendar for seven to fourteen days after discharge. normal office hours are 8:30-5:00 monday through friday. . please feel free to call the office with any other concerns or questions that might arise. followup instructions: - you should call dr. office to schedule a follow-up appointments. please call his office at ( to schedule a post-op check up. - you should also follow-up with your primary care physician for medication, blood pressure, blood sugar, and routine follow-up care. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other bronchoscopy Other lavage of bronchus and trachea Resection of vessel with replacement, aorta, abdominal Resection of vessel with replacement, lower limb arteries Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Aortocoronary bypass status Other and unspecified angina pectoris Abdominal aneurysm without mention of rupture Hyperosmolality and/or hypernatremia Urinary complications, not elsewhere classified Aneurysm of iliac artery Alcohol withdrawal Other chronic sinusitis

allergies: aspirin attending: chief complaint: sob and respiratory failure major surgical or invasive procedure: none history of present illness: the pt is an 83-year-old woman w/ h/o copd fev1 0.93 fev1/fvc 89% fvc 40% pred (pfts ). she is on home o2 and bipap at night. pt has h/o hypercapnic resp failure c multiple admissions for high copd up to 125. last admitted last time at . she was intubated at that time for 36 hours. she presents w/ fever and productive cough x 4 days. pt was seen by her primary pulmonologist and given levofloxacin. she had taken it for 4 days without noticing improvement in her symtpoms. micu team was called to evaluate pt for progressive hypoxemia in ed. in pt was clearly tachypneic rr 35 bpm, spo2 99% on 100% nrb, t 100. her bp was elevated up to 140/72. she was given solumedrol 125, ceftriaxone, zithromax, and started on ntg drip. she has also been on bipap 12/5 and 4 lt c spo2 95%. abgs in ed 7.29/72/81/36 past medical history: 1. copd with hypoxia and co2 retention, on home o2, patient aware of symptoms of hypoxia and co2 retention. 2. sleep apnea, using bipap at night. 3. chronic lower back pain. 4. osteoporosis. history of gi bleed 5. cad 6 gerd 7. afib, not on coumadin for ~3 months per patient social history: patient has a 60-pack year history. lives in same building as daughter. etoh family history: nc physical exam: hr 119---99 bp 140/112 ---100/52 (ntg drip) rr 35 spo2 99% t 100 . gen: obese lady on facial mask , not able to , somnolent but arousable neck no jvp chest: decresed bs bilaterally , no clear crackles. cv: rrr no m/r/g abdomen: large peiumbilical hernia, c no signs of strngulation ext: + + edema brief hospital course: 1. copd: the pt presented w/ severe hypoxemia and hypercarbia. elevated hco3 indicates longstanding hx of copd. in the micu, she was maintained on bipap at night. iv steroids were continued and changed to po prednisone on . her mental status returned to normal as her respiratory status improved, and she was maintaining good sao2 on nc. by the time she was called out of the micu, she was maintaining sao2 of 88-92% on 2l nc, her baseline at home. bipap was continued overnight for episodes of apnea (pt had her own machine). she was continued on her prednisone taper and nebulizers. patient is to continue with prednisone 40 mg qd for next 7 days and then continue the taper with decrease by 10 mg over next 7 days to her baseline of 10 mg qd . 2. possible cap: cxr is negative although poor quality pt's body habitus. a repeat pa and lateral was unremarkable. she was started on ctx and azithro in the ed and the ctx was discontinued on . empiric treatment for cap w/ azithro for 5 days was continued. her dfa was positive for influenza a on after which she was maintained on droplet precautions. tamiflu was not started as the diagnosis was made 24-48 hr after the onset of symptoms. . 3. cv # pump: pt w/ hx of severe htn. she was diuresed for mild fluid overload in her legs with iv lasix in the micu and then switched to her po lasix home dose of 120mg after being transferred to the floor. a tte showed normal ef. patient was subsequently discharged with a lower dose of 80 mg of lasix as she appeared to have contraction alkalosis. patient's edema appears to be at baseline as far as her lower extremity edema. the etiology of her total body volume remains unclear after discussion with patient's pcp . as she does not have overwhelming largepa pressures and no evidence of severe diastolic and nl systolic function. . # ischemia: pt not on asa prior hx of bleeding. no bb copd. . # rhythm: - h/o paf - not while in house, stable. patient is on amiodarone which was continued. she states she has not been on coumadin for the last several months due to presumed gib. - h/o mat - patient appeared to be in intermittent mat. she was rate controlled with diltiazem xr. which she tolerated well. . # gi: pt has hx of gerd. no signs of active gi bleeding. ppi was continued. . # alkalosis and hypochloremia - patient with alkalosis to hco3 of 48, but her baseline pco2 is in 70s. this perhaps was further exacerbated by aggressive diuresis with iv lasix. patient's hypochloremia corrected while her lasix was held and reduced however restarting home dose she worsened again. patient is thus being discharged on lower than her home dose in order to correct contraction alkalosis that may be contributing to her elevated bicarb. . dispo - patient is to follow up with dr. her pcp, patient, she has an appointment on . . medications on admission: 1. -vent 2 puffs b.i.d., 2. serevent 2 puffs b.i.d. 3. albuterol 2puffs b.i.d., 4 atrovent, 5. theophylline 600 mg p.o. q.d., 6. fosamax 35 mg q. sunday, 7. calcium carbonate 8. lasix 80 mg p.o. q.d. 9. kcl 40 10.advair 11.diltiazem 30 qd 12.lt4 50 qd 13.prednisone 40 14.amiodarone 100 15.pantoprazole 40 qd discharge medications: 1. furosemide 40 mg tablet sig: two (2) tablet po bid (2 times a day). 2. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. cepacol 2 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed). 8. insulin regular human 100 unit/ml cartridge sig: units injection four times a day: as directed per insulin sliding scale. 9. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 10. albuterol sulfate 0.083 % solution sig: one (1) puff inhalation q2h (every 2 hours) as needed. 11. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 12. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 13. prednisone 10 mg tablet sig: four (4) tablet po daily (daily): x 7 days, then 30 x 7 days, then 20 x 7 days then maintenance @ 10, unless instructed otherwise after her appt with dr. on . 14. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 15. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 16. outpatient lab work please follow chem 7 over next 3 days as her lasix getting adjusted discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: 1. influenza a infection 2. copd - severe, oxygen dependent, on nocturnal bipap secondary: 3. diastolic chf 4. right heart failure 5. diabetes mellitus - type 2, controlled with complications 6. hypertension 7. chronic kidney disease, stage iii 8. osteoporosis 9. multifocal atrial tachycardia 10. report of history of gi bleed in past discharge condition: stable. ambulating on 2l with sats of 95%. tolerating po. no fever. discharge instructions: please take all your medications as instructed. your prednisone is decreased today to 40 and you should continue @ 40 for next 7 days. it should be then further decreased by another 10 every 7 days until your baseline dose or as determined by your pulmonologist/pcp . . it's important that you follow up with him on and that appropriate transportation be arranged for your visit with him. . please follow patient's chemistry 7 as her lasix gets adjusted. patient is getting d/c on a lower than home dose of 120mg . she is to continue on 80 mg qd in order to correct presumed contraction alkalosis. please follow patient's chemistry 7: including chlrodie and bicarbonate over next few days as her lasix is getting titrated. followup instructions: please follow up dr. on . please make sure you keep that appointment and arrange appropriate travel arrangements. md Procedure: Non-invasive mechanical ventilation Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Obstructive chronic bronchitis with (acute) exacerbation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Chronic kidney disease, Stage III (moderate) Acute respiratory failure Diastolic heart failure, unspecified Influenza with other respiratory manifestations

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxic respiratory failure major surgical or invasive procedure: cvl insertion mechanical intubation bronchoscopy with bal og tube insertion replacement therapy history of present illness: 50 yo m with mixed connective tissue/vasculitis with history of pulmonary hemorrhage and lupus nephritis currently being treating with prednisone and cytoxan who presented to osh complaining of days of worsening sob. per report, the patient had no recent fevers, wheezing, coughing, chest pain or nausea but did complain of worsening le edema. in the ed there he was hypoxic to 76% on ra, rr37, hr 130s, bp 94/65. he was placed on nrp and o2 sat improved to 88% but he continued to appear cyanotic. he was emergently intubated and intial abg following intubation was 7.34/32.6/48.6. he was given 80 iv lasix, hydrocortisone 100, phenylephrine 50 mg iv push x 2, ketamine 100 mg iv, succinylcholine 150 iv, and vecuronium 10 mg iv. he was transferred to , where he receives the majority of his care. . on arrival to the ed, the patient's intial vitals were hr 132, bp 109/67, rr 22, sao2 98%. initial abg on 100% fio2 was 7.14/54/85/19. labs were notable for wbc of 19.9 with a left shift (11% bands), hct 31.1 (range in omr 28-36), cr of 2.5 from baseline 1.0, and lactate 1.0. blood and urine cultures were sent, and he was given 2l ns, vanco 1 g iv, zosyn 4.5 mg iv. he was initially started on propofol drip but then changed to fentanyl/versed drip. cxr showed multifocal bilateral pulmonary infiltrates, and ventilator settings changed to ardsnet protocol and admitted to the micu for further management. . on arrival to the micu, patient was hypotensive to 80s/60s, hr 120-130s, sao2 92%, and appeared dyssynchronous with the ventilor. he was started on peripheral neosynephrine and paralyzed with vecuronium. . notably, patient had a recent admission for hemoptysis (). during that admission, he had a cavitaory lul lesion for which extensive testing failed to identify specific diagnosis. during that admission, he had a ct scan, was ruled out for tb with multiple sputum tests and serologic sputum testing for nocardia histo, coccidioidomycosis, aspergillosis were all negative. he did have an "indeterminate" quantiferon test at that time, of unclear , and has several afb cultures still pending currently (from , , ). anca testing was negative and lung biopsy was considered and discussed but not done. past medical history: - mixed connective tissue//vasculitis: characterized by fluctuating lymph nodes, raynaud's phenomenon, skin ulcerations, neuropathy, arthralgias, alopecia, and prior history of thrombocytopenia, hemolytic anemia - history of chronic inflammatory demyelinating polyneuropathy, status post four plasmapheresis sessions in . - bilateral hip avascular necrosis in the setting of steroid therapy, status post bilateral hip replacements. -hypertension -hypogonadism -iv-g v lupus nephritis and class v membranous nephritis with impairment, high-grade proteinuria and nephrosis -- currently receiving cytoxan/mesna monthly, has received 5 cycles, last dose 9/3 -cavitary lul lesion with extensive id workup neg except for indeterminate quantiferon test social history: he denies cigarette use and uses alcohol very rarely. he denies any recent history of cocaine, iv drug, or marijuana use. family history: his sister also has an undiagnosed autoimmune condition, currently in remission. he denies any history of diabetes, hypertension, or kidney disease in the family. physical exam: general appearance: pale, ill-appearing eyes / conjunctiva: perrl head, ears, nose, throat: endotracheal tube, alopecia cardiovascular: tachycardic and regular, no murmur appreciated peripheral vascular: (right radial pulse: diminished), (left radial pulse: diminished), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: (breath sounds: no(t) rhonchorous: ), coarse and rhonchorus lying flat, improved upright abdominal: soft, distended, hypoactive bs extremities: right lower extremity edema: 2+, left lower extremity edema: 2+, cyanosis skin: cool, multiple deep, prurlent ulcers on le b/l neurologic: responds to: not assessed, movement: not assessed, sedated, paralyzed, tone: not assessed pertinent results: ct head: 1. hemorrhagic transformation of the previously seen right mca and pca territorial infarct with significant mass effect causing uncal and subfalcine herniation. 2. new right thalamic infarct. 3. mass effect effacement of ipsilateral right lateral ventricles with trapping of the left lateral ventricles. 9:52 am sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. aspergillus fumigatus. rare growth. identification performed on culture # . yeast. rare growth. cunninghamella sp.. identification performed on culture # . brief hospital course: 50 yo m with history of vasculitis including prior pulmonary hemorrhage and lupus nephritis being treated with prednisone and cytoxan who presented to on with hypoxic respiratory failure and shock. . # hypoxic respiratory failure: the differential diagnosis for acute respiratory failure in this significantly immunocompromised patient included bacterial infection, fungal/pcp infection, pulmonary hemorrhage, cytoxan-induced pneumonitis. id, rheum, and nephrology were consulted. the patient was intubated and had an esophageal balloon for transplerual pressure monitoring placed. rheum thought that a vasculitic process was unlikely given that the patient was on cytoxan and prednisone as an outpatient and there was no benefit from plasmapheresis. he was treated with pulse steroids for 4 days, then tapered back to a standing dose of prednisone, which was later discontinued. initiated cvvh given the and tenuous clinical picture, and this was later discontinued as his function improved. per id, the patient was initially started on vancomycin, meropenem, iv bactrim, ambisome, and ciprofloxacin. cultures and studies to look for cmv, crypto, pcp, , and fungi were sent. a sputum culture grew back yeast and mold - later identified as zygomycetes/cunninghamella and aspergillus. . # stroke: as mr. was weaned from sedation, it was noted that his mental status did not improve as expected. head ct showed a large right mca and pca stroke, which was later better characterized with mri. stroke team was consulted and provided prognostic information to the family regarding the deficits mr. could expect if he recovered from his acute illness. on , he was noted to have a blown pupil, and repeat head ct showed hemorrhagic conversion of the stroke with uncal and subfalcine herniation. . # tachycardia/hypertension - this was thought to be in part from benzo withdrawal and also from heart failure. an echo obtained on admission showed an ef of 20-25% with moderate to severe mr. the patient was diuresed with cvvh as above with improvement in his hypoxia. however, he remained tachycardic and hypertensive. his benzo withdrawal was treated as above, and he was given some fluid back. . # hct drop: most concerning for pulmonary hemorrhage in setting of known vasculatis with significant lung lesion. no indication of gi bleed or other source of blood loss, although dilution could certainly be contributing to decreased counts. stabilized. . # acute on chronic failure - the patient's creatinine on admission was 2.5, up from a baseline of 1.0. he was started on cvvh, which was stopped after 4 days. his urine output significantly improved after he was stabilized. . # goals of care: multiple family meetings were held with the family and with the primary micu team as well as consultants from id, rheum, and stroke. the family was clear that mr. would not have wanted invasive measures to prolong his life without meaningful hope of recovery, and decided to move to dnr/cmo. he was terminally extubated on , and passed away shortly thereafter in the presence of his family. his son, the next of , was notified, and requested an autopsy. medications on admission: alendronate clotrimazole cyclophosphamide furosemide mesna mvi w/ caffeine nifedpine ondansetron prednisone bactrim testosterone discharge medications: n/a discharge disposition: expired discharge diagnosis: 1. respiratory failure 2. invasive fungal infection 3. brain herniation discharge condition: deceased. discharge instructions: - followup instructions: - Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Long-term (current) use of steroids Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Intracerebral hemorrhage Chronic kidney disease, unspecified Compression of brain Acute respiratory failure Other shock without mention of trauma Septic shock Other constipation Other diseases of lung, not elsewhere classified Acute systolic heart failure Hyperosmolality and/or hypernatremia Unspecified hereditary and idiopathic peripheral neuropathy Drug-induced delirium Drug withdrawal Delirium due to conditions classified elsewhere Raynaud's syndrome Leukocytosis, unspecified Aspergillosis Hip joint replacement Other and unspecified mycoses Ulcer of other part of lower limb Coma Zygomycosis [Phycomycosis or Mucormycosis] Pneumonia in other systemic mycoses Chronic inflammatory demyelinating polyneuritis Mixed acid-base balance disorder Other specified diseases of pulmonary circulation Autoimmune disease, not elsewhere classified Unspecified diffuse connective tissue disease Other testicular hypofunction

history of present illness: mr. is a 42-year-old male with a past medical history significant for lupus diagnosed one year prior to admission, raynaud's syndrome diagnosed one year prior to admission, positive antinuclear antibody titer of 1:1280 in a speckled pattern, and a history of an elevated prostate-specific antigen who initially presented to an outside hospital with severe anemia and thrombocytopenia. approximately seven months prior to admission, the patient developed malaise, episodic subjective tactile fevers, drenching night sweats, shaking chills, and a 2-pound weight loss over a 4-month period. he took six to eight ibuprofen per day for symptomatic relief. he experienced approximately two week cycles of feeling poorly associated with feeling better. his primary care physician administered empiric azithromycin without relief of symptoms. he denied any headaches; however, he described a shooting "heat and pain" radiating up his posterior neck to his occiput; left greater than right. he denies any photophobia or visual changes. he reports mild dry eyes, mild peripheral edema, and increased burping. he saw a rheumatologist in who, according to the patient, felt lupus was reasonably well controlled at that time. in the middle of through he felt better, and he took a cruise to the caribbean. over the past four weeks prior to admission he developed the onset of progressive fatigue, malaise, and dyspnea in the absence of cough, more frequent fevers, dry mouth, and worsening dysphagia with dry foods. he denied any odynophagia. he developed a pruritic rash over his thighs, abdomen, and arms which was worse at night and lasted approximately one week. his fatigue was so severe that he had to rest after inserting his contact lenses. reports dry heaves approximately five days prior to admission. he denies any nausea, abdominal pain, chest pain, diarrhea, or constipation. he denies any light or -colored stools, blood per rectum, and dysuria. he does note some urine. his symptoms progressed to the point which, on the day prior to admission, he sought medical attention at . a , he was febrile to 104 degrees fahrenheit. he was started on ampicillin, and sulbactam, and empirically. he was found to have elevated liver function tests with a total bilirubin of 7.5, alt of 105, ast of 106, and alkaline phosphatase of 325. his direct coombs test was positive. his hematocrit was 24%. his platelet count was less than 10. his sodium was 127. he received a platelet transfusion at . he was transferred to the for further workup. past medical history: 1. lupus; diagnosed one year prior to admission. 2. raynaud's syndrome, diagnosed one year prior to admission. 3. hypertension. 4. meningitis 12 years prior to admission. he was in a coma for 36 hours. positive antinuclear antibody with titer of 1:1380 in a speckled pattern. 5. elevated prostate-specific antigen of approximately 5.4 in and . a biopsy in demonstrated high-grade prostatic intraepithelial neoplasia. a subsequent biopsy in demonstrated chronic inflammation only. 6. erectile dysfunction. medications on admission: procardia-xl 90 mg p.o. q.d., viagra as needed, advil as needed, multivitamin, vitamin e. allergies: no known drug allergies. social history: he denies any tobacco, alcohol, or illicit drug use. he works as a teacher at a college. he owns a book store. he lives with his wife and son. has two parrots at home. one of the parrots died of an unknown causes three weeks prior to admission. family history: there is no family history of blood dyscrasias. his father has prostate cancer. his mother has osteoporosis but is otherwise in good health. his sister has lupus. another brother and sister are in good health. physical examination on presentation: he was a pale nontoxic-appearing male in no apparent distress. temperature was 98.4, blood pressure was 108/70, heart rate was 108, respiratory rate was 20, oxygen saturation was 99% on 2.5 liters of oxygen. pupils were equal, round, and reactive to light. extraocular movements were intact. scleral were icteric. the oropharynx was benign with moist mucous membranes. the neck was supple. there was a 1.5-cm lymph node in the cervical chain on the right side and small posterior cervical lymph node on the right side. there was some small cervical chain lymph nodes on the left side. the heart was regular with normal first heart sound and second heart sound. no murmurs, rubs or gallops. lungs were clear to auscultation bilaterally. the abdomen was soft. the right upper quadrant was tenderness to palpation. there was no rebound or guarding. the liver edge was palpable as was the spleen tip. there were normal active bowel sounds. there were bilateral tender lymph nodes on the right axilla. the groin had a 1.5-cm lymph node in the right inguinal area. the extremities were without clubbing, cyanosis or edema. there was diffuse macular rash on the chest, arms, and abdomen. the reflexes were 1+ throughout. pertinent laboratory data on presentation: data revealed white blood cell count was 12.2 (with 15% neutrophils, 7% bands, 64% lymphocytes, 2% monocytes, 1% eosinophils, 10% atypical lymphocytes, 1% metamyelocytes), hematocrit was 18%, platelet count was 9. pt was 13.5, ptt was 31.8, d-dimer was 1000 to . sodium was 132, potassium was 4, chloride was 99, bicarbonate was 22, blood urea nitrogen was 16, creatinine was 0.8, blood glucose was 175. alt was 85, ast was 89, ldh was 885, alkaline phosphatase was 306, total bilirubin was 6, direct bilirubin was 3.9, indirect bilirubin was 2.1. calcium was 7, magnesium was 2, phosphate was 3.7. uric acid was 5.7. a blood smear demonstrated microspherocytes, larger basophilic stippled cells, anisocytosis with minimal poikilocytosis. there were numerous plasmacytoid cells and large atypical cells as well. there was a paucity of platelets with giant formed platelets seen. hospital course: he was initially admitted to the medicine service for further management and workup for possible leukemia or lymphoma. given the extent of hemodynamic monitoring that would have been required initially, he was transferred to the medical intensive care unit for further management. he was in the medical intensive care unit for one day and then was subsequently transferred to the bone marrow transplant service as a diagnosis of leukemia was lymphoma was continued to be worked up. 1. hematology: he underwent a bone marrow biopsy at the time of admission. the bone marrow biopsy demonstrated a markedly hypercellular marrow for his age group with lymphoplasmacytic hyperplasia with scattered large immunoblasts. diagnostic features of a lymphoproliferative disorder were not seen. the immunopotentiating demonstrated no phenotypic evidence of leukemia or lymphoma. mr. was a difficult cross match in the blood bank and had evidence of regular antibodies. he underwent a thorough workup by the blood bank. his blood demonstrated evidence of both cold and warm autoantibodies. he received a total of 5 units of packed red blood cell blood transfusion and 4 units of platelets blood transfusion. due to the likelihood of autoimmune warm hemolytic anemia, autoimmune cold hemolytic anemia, and autoimmune thrombocytopenia he was started on stress-dose steroids. he also received 150 of ivig in four doses of 40 each. his platelet counts were initially unresponsive to the platelet transfusion, corticosteroids, and ivig. however, several days after he revealed his last dose of ivig, his platelet count began to rise. after reaching a nadir of 6000, the platelet count was 92,000 at the time of discharge. his hematocrit did show some response to blood cell transfusions and corticosteroids. it rose from 18% on admission to 30% at the time of discharge. he underwent radiologic screening to evaluate for evidence of leukemia or lymphoma. a liver and gallbladder ultrasound demonstrated evidence of a simple hepatic cyst with no intrahepatic ductal dilatation. the gallbladder was normal. there was splenomegaly present. a ct of the torso demonstrated bilateral extensive cervical, axillary, anterior mediastinal, and precordial lymphadenopathy of which the largest lymph nodes were in the left axilla. the spleen was markedly enlarged and contained numerous wedge-shaped regions of hypoattenuation and calcific fossae. there were multiple small lymph nodes in the abdomen around the pancreatic tail, superior mesenteric artery, and in the retroperitoneum. the largest abdominal lymph node was at the level of the aortic bifurcation and measured 1.6 cm in diameter. there was no evidence of bony destruction. a ct of the neck to evaluate his cervical lymph nodes demonstrated abnormal parotid glands which were slightly enlarged within an irregular cystic pattern, question representative of mikulicz syndrome. it should be noted that he had been started on intravenous corticosteroids prior to the ct scan of the neck and torso and that his palpable lymph nodes had shrunk dramatically by the time that the radiographic studies had been done. he underwent an excisional biopsy of a right axillary lymph node. no definitive morphologic immuno definitive features of the lymph node or proliferative disorder were seen. at the time of discharge, the etiology of his autoimmune warm hemolytic anemia, autoimmune cold hemolytic anemia, and autoimmune thrombocytopenia had not been elucidated. 2. rheumatology: he had a rheumatology evaluation for the possibility that these symptoms were all related to a rheumatologic disorder. the differential diagnosis included lupus, syndrome, a viral infection, lymphoproliferate disorder, and thrombotic thrombocytopenic purpura. a rheumatologic series of tests were ordered to further determine the possible nature of his symptoms. erythrocyte sedimentation rate was initially 100 but had decreased to 17 by the week after discharge. his absolute cd4 count was greater than 2500. his serum viscosity was 1.8 which was at the upper limit of normal. his lupus anticoagulant was negative. there was no evidence of glomerulonephritis in sever urinalyses. antinuclear antibody was positive as a titer of 1:320 in a speckled pattern. anti-double-stranded dna antibodies were negative. rheumatoid factor was negative. a spep demonstrated evidence of a polyclonal hypogammaglobinemia with no evidence of a monoclonal immunoglobulin. a c3 was 30 (normal range 65 to 163). c4 was 2 (normal range 12 to 36). human immunodeficiency virus antibody test was negative. hepatitis c antibody was negative. a upep demonstrated some albumin, but no evidence of a bence- protein. - virus immunoglobulin g antibodies were positive. - virus immunoglobulin m antibodies were positive. these results were evidence of an infection with - virus at an indeterminate time in the past. a monospot test for acute - virus infection was negative. a rapid plasma reagin test for syphilis was nonreactive. a test for cytomegalovirus immunoglobulin g antibody was negative. cultures of the right axillary lymph node were negative for evidence of aerobic bacterial infection, anaerobic bacterial infection, or mycobacterial, or fungal infection. a further test for - virus early antigen was positive at 1.47 (negative is less than 0.9 with equivocal being 0.91 to 1.09). a test for - viral capsid antigen immunoglobulin m antibody was negative. a test for brucella immunoglobulin g antibody was negative. a test for brucella immunoglobulin m antibody was negative. a test for anticardiolipin immunoglobulin m antibody and immunoglobulin g antibody were both positive. a test for mycoplasma pneumoniae immunoglobulin g antibody was positive. a test for parvovirus b19 immunoglobulin g antibody was positive. a test for parvovirus b19 immunoglobulin m antibody was negative. a test for anti-ro antibody was negative. a test for anti- was negative. a test for anti- antibody was negative. a test for anti-rnp antibody was positive. a test for beta-2 microglobulin was abnormal at 5.7 (normal 0.7 to 1.8). the rheumatology service was unable to come up with a unifying diagnoses for all of these findings at the time of discharge. 3. infectious disease: an infectious disease consultation was also sought. they recommended many of the viral and bacterial tests detailed in the section entitled rheumatology. at the time of discharge, there was no obvious infectious etiology for his presenting signs and symptoms. 4. dermatology: due to his rash and the possibility that this represented a cutaneous manifestation of his systemic disease, he had a dermatology consultation. their impression was that although he had evidence of a background-benign livedo reticularis on his inner thighs, it was not to a degree suggestive of vasculopathy. their impression was that his cutaneous findings were most consistent with a viral exanthem. despite workup as an inpatient, at the time of discharge, no unifying diagnosis could be found for the constellation of symptoms, signs, and laboratory abnormalities in mr. . condition at discharge: condition on discharge was stable. discharge followup: he was to follow up as an outpatient two days after discharge for repeat hematocrit and platelet count. he was to further follow up in the outpatient clinic with dr. and dr. . discharge diagnoses: 1. autoimmune warm hemolytic anemia. 2. autoimmune cold hemolytic anemia. 3. autoimmune thrombocytopenia. 4. hypertension. 5. question systemic lupus erythematosus. medications on discharge: 1. prednisone 120 mg p.o. q.d. 2. nystatin swish-and-swallow q.i.d. 3. protonix 40 mg p.o. q.d. 4. procardia-xl 90 mg p.o. q.d. 5. folic acid 1 mg p.o. q.d. 6. calcium carbonate 500 mg p.o. t.i.d. with meals. 7. multivitamin one tablet p.o. q.d. , m.d. dictated by: medquist36 Procedure: Biopsy of bone marrow Biopsy of lymphatic structure Diagnoses: Systemic lupus erythematosus Thrombocytopenia, unspecified Unspecified essential hypertension Autoimmune hemolytic anemias