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history of present illness: this was a 78-year-old woman with a history of atrial fibrillation, hypertension, and depression who was admitted to with a subdural hematoma on . two days prior, she had a fall. she did not seek medical attention. at that point, she was intubated at an outside hospital on , and she was transferred to . at the outside hospital, she had a head ct that showed a large left subdural hematoma measuring 2.2 cm x 12 cm. she had a 2-cm midline shift, and she had uncal herniation. at , she was made do not resuscitate and comfort measures only after neurosurgery discussed her prognosis with the family. on , the family decided to withdraw care. physical examination on presentation: the patient had fixed and dilated pupils, negative corneal reaction on the right side, positive corneal reaction on the left side. the patient did not move or grimace to pain. the patient had upgoing babinski signs bilaterally. no other physical examinations were pertinent for the diagnosis. radiology/imaging: the patient had a cat scan at the outside hospital that showed the left large subdural hematoma measuring 2.2 cm x 12 cm and a 2-cm midline shift, and the uncal herniation. the patient also had a chest x-ray that demonstrated the endotracheal tube was in the correct location, and no cardiopulmonary disease. hospital course: the patient was admitted on , made comfort care by the family because of her poor prognosis. on the morning of , the family decided to remove care. the patient was extubated, and she passed away later that evening. condition at discharge: her discharge condition was that she passed away. discharge status: her discharge status was that she passed away. diagnoses (on passing): she had a large left subdural hematoma. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Unspecified essential hypertension Atrial fibrillation Compression of brain Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Fall from other slipping, tripping, or stumbling

history of present illness: patient is an unfortunate 80-year-old female with a prior medical history of hypertension, osteoporosis, prior left carotid stenosis, and had subsequent left carotid endarterectomy as well as history of polymyalgia rheumatica, who was involved in a motor vehicle accident as an unrestrained driver with possible loss of consciousness. she was initially seen at an outside facility on , the date of her accident. she was doing well, hemodynamically stable, however, she was complaining of left-sided chest pain. she was diagnosed with multiple left sided rib fractures and evidence of crepitus. her saturations were okay. however, she was quite tachypneic. she additionally had dropped her systolic blood pressure into the 90s at the outside facility from an admission blood pressure in the 130s, and was found to have a hematocrit of 22. she was given 2 units of packed cells, and transferred here. presentation to the trauma bay showed her to have extensive work of breathing requiring subsequent intubation. initial trauma survey revealed crepitus in the left chest and decreased breath sounds necessitating insertion of a left chest tube. chest x-ray had confirmed that she had a large left-sided effusion and multiple rib fractures with no obvious pneumothorax. subsequent to this, the patient was stabilized and received her protocol imaging. her ct of the head was otherwise unremarkable. her ct of the chest revealed a large left hemothorax with no evidence of pneumothorax. a large left pulmonary contusion. additionally, the scan of the chest revealed a right distal clavicular fracture and left scapular fracture. her ct of the neck was unremarkable. her ct of the head was negative. ct of abdomen with intravenous contrast on initial survey additionally showed no evidence of parenchymal or abdominal visceral injury. she was admitted to the trauma critical care unit for further resuscitation. her admission examination was notable for a temperature of 95.3 rectally, heart rate of 107, sinus tachycardia. her blood pressure is 104/39, the respiratory rate of 14, and saturating 100% and vented. she was intubated, however, she was awake and following commands. she had coarse breath sounds bilaterally. on the left, she was markedly diminished. she was tachycardic, but had no murmurs, rubs, or gallops. her left chest had some mild crepitus, but there was no evidence of instability or flail segment. her abdomen was soft and nontender. there was no ecchymosis or abrasion. her pelvis was stable. the rectal examination had loose tone, guaiac negative, no masses. her flanks and back were otherwise normal without obvious deformity or injury. her extremities showed no obvious deformity. there was some minor cuts and scrapes over the knees and right elbow. she was able to move all extremities. her right upper extremity and left upper extremity were somewhat limited by pain, however. over the ensuing hours of her admission, however, she became hemodynamically unstable despite being aggressively resuscitated. the patient was profoundly acidotic and dropped her hematocrit to 26. her abdomen became progressively more distended and had hemodynamic instability requiring high dose of dopamine and levophed. upright chest x-ray had been repeated showing no evidence of intraabdominal free air. she had a transthoracic echocardiogram by the oncall cardiology fellow that night of injury revealing a hyperdynamic left ventricular function with an ef greater than 75%, a normal rv systolic function, no mitral regurgitation, no evidence of pericardial effusion. there was spontaneous collapse of the inferior vena cava and the mechanically ventilated patient, which suggested profound hypovolemia, and her tachycardia precluded adequate evaluation of any wall motion abnormalities. due to the fact that the patient had initial survey on abdominal ct showing no evidence of visceral injury and the rapidly progressing abdominal distention with acidosis and somewhat collapsed ivc, it was thought that the patient may in fact be suffering from an abdominal compartment syndrome. she was thereafter sent to the operating room on the early morning hours of . dr. took her to the or, performed a trauma laparotomy. there was no obvious injury to the viscera. however, after opening the abdomen, the patient profoundly improved confirming the likely diagnosis of abdominal compartment syndrome. she only had 100 cc estimated blood loss during this procedure. received 1200 cc of intravenous fluids and urine output was 700 cc for the case. patient left the operating room intubated, sedated. over the ensuing days, the patient progressed into acute respiratory distress syndrome as defined by her pao2:fio2 ratio being less than 200 with bilateral infiltrates particularly worse on the left side, where she had a confirmed contusion and left hemothorax. there was no obvious persistent pneumothorax, however, as her daily chest x-ray evaluation confirmed this with a left chest tube being repositioned. she was given maximal lung protective ventilation strategy including paralysis, low tidal ventilation, and permissive hypercapnia and permission hypoxia. over the ensuing days she improved. her tube feed regimen was serially increased. she had a pulmonary artery catheter that had been placed during her postoperative course for guidance of her fluid and electrolyte therapy. ultimately, the patient actually somewhat rallied and improved. we were able to dial back her intravenous fluids, titrate up her tube feedings to a goal. ultimately, her ards seemed to improve and she was actually switched from an assist control setting into a pressure support ventilatory mode. her pain control was a problem. we had attempted an epidural twice, were unsuccessful at placement. she did receive a left-sided rib block several times during her icu course to enhance her pain control and to give her an opportunity to participate in her pulmonary rehab and vent wean. we utilized a variety of agents including nsaid therapy with vioxx as well as roxicet elixir to control her pain. however, there was a significant component of pain and overall deconditioning that made her ventilatory wean prolonged. she ultimately necessitated placement of an open tracheostomy tube, which was performed on under the care of dr. . therefore the patient had a speech and swallow evaluation, and at the time of this discharge summary, the final report of the speech and swallow evaluation was indeterminate. the plan was to place a discharge summary addendum with the results of this were back if she were able to pass her speech and swallow evaluation, she will be titrated on an oral regimen and serially advanced accordingly with tube feeds being cycled at night and dialed back as needed as she took adequate p.o. intake. however, if she failed her speech and swallow evaluation, she will likely need a percutaneous endoscopic gastrostomy tube for feeding access and then a repeat speech and swallow evaluation as an outpatient can be performed in a couple of weeks when her aspiration risk was reduced, and that her mental status has improved. follow-up plans by system: neurologically: she had a negative head ct and negative ct c spine. no mr films were done. she wore the collar for more than two weeks. this was ultimately removed. she was able to interact, although not at a very robust fashion, but could certainly localize her gaze to the examiner, able to move her upper extremities with limited range of motion. able to make weak grasp with bilateral upper extremities. able to wiggle toes and intermittently move her legs. therefore, she was following simple commands. she appeared to have somewhat blunted affect despite being on a ventilator, the assessment was whether she may or may not have been suffering from a mild degree of depression as well as some intermittent waxing and consciousness confirming the likely low grade delirium. however, this was florid and did not necessitate antipsychotic regimen or one-to-one sitter or any restraining mechanism. pulmonary wise: the patient was on pressure support ventilation approximately anywhere from 18 to 20 mmhg being utilized. she will continue prolong ventilatory wean. chest x-ray showed no evidence pneumothorax. she had mild cephalization and evidence of mild overload, and she had bilateral effusions left greater than right, but nothing that seemed to be tapable at this time. she had multiple left sided rib fractures, left scapular fracture, and right distal clavicular fracture, and her analgesic regimen will be key to control so that she can participate in her ventilatory wean and have adequate strength and analgesia to pull an adequate tidal volume to allow appropriate weaning as needed. she will receive standard trach care as needed. she had a #6 shiley trach tube placed at the time of surgery on . cardiovascular wise: the patient was stable on a beta-blocker 25 mg p.o. b.i.d. this can be titrated as needed to control her blood pressure and heart rate. she did not have any specific parameters, however, it would be nice to keep her systolic pressures at least under 160 with a heart rate in the 70-80 range. her transthoracic echocardiogram results were stated on the night of admission. her baseline cardiac medications included a beta-blocker and aspirin. aspirin can be added back as needed on an outpatient basis in the vent rehab facility. fen and gi: patient had speech and swallow evaluation pending at the time of this dismissal. if she were to fail this evaluation, she will get a peg tube placed, and continued on impact with fiber full strength at 60 cc per hour. this can be cycled serially at night as needed. ultimately, she can be reassessed for possible swallowing function in the rehab setting so that she can ultimately hopefully be weaned off a tube feeding regimen. she was not receiving any additional motility agents such as reglan at the time of this dismissal note. her electrolytes were otherwise stable. heme/id: she had no infectious issues. she had some yeast that had grown out from a sputum sample at the end of , however, she did not have any florid infiltrate on chest x-ray. her sputum was somewhat tan colored in nature, but ultimately it was not felt that she was suffering from a ventilator-associated pneumonia. at this time, she was not on any antibiotics. she had a hematocrit of 28.6 and a white count was 7.8 on with a normal platelet count of 407. for endocrine: she should be on a sliding scale regimen. she should be placed on a nph regimen and tighten her sliding scales for normoglycemia with goal blood sugars of 120-140 can be achieved. this should be continued indefinitely. the patient almost certainly has some component of insulin resistance or perhaps undiagnosed type 2 diabetes mellitus. gu/renal: she had a foley catheter for urine output monitoring. she had no significant urinary cultures. her creatinine was 0.5 on with a bun of 23. she was making approximately 1-1.5 liters of urine per day. tubes, lines, and drains: at the time of this dismissal, discharge summary, she did have a left subclavian, which was a triple lumen catheter, which had been in place for 15 days as well as a left radial a line. ultimately on dismissal, she likely will not have her radial arterial line unless deemed appropriate by the ventilatory rehab facility. additionally, she was receiving feedings through a nasogastric tube pending the speech and swallow evaluation. she may not end up with a peg tube, thereby removing that nasogastric tube accordingly. prophylaxis: she should continue on prevacid 30 mg/ng q.d. or per peg as needed if she ends up with a peg. she can be on lovenox 30 mg subq b.i.d. for dvt prophylaxis, lopressor 25 mg p.o. b.i.d., aspirin 81 mg p.o. q.d., roxicet elixir as needed, vioxx 12.5 mg p.o. b.i.d., colace 100 mg p.o. b.i.d., dulcolax suppository 10 mg p.o./p.r. one tablet q.d. prn. her followup plans will be to see dr. in approximately one month from time of dismissal. call this clinic for this follow-up appointment. additionally, she should follow up in the trauma clinic in approximately 3-4 weeks from time of dismissal if she has been appropriately weaned from the ventilator. if she is still vent dependent, then she will stay at the rehab until which time, she has been weaned from the ventilator and then she may follow up on a prn basis to the trauma clinic. treatments and frequencies: she will continue on aggressive enteral feeding regimen her speech and swallow evaluation will proceed. if her swallowing is poor, then she will receive a peg tube for enteral access and feeding, and this can be reassessed as an outpatient in the ventilatory rehab setting to see if she can ultimately be started on an oral regimen. she was not requiring any motility agents at this time to assist her with her tube feeding tolerance. she should be on aggressive bowel regimen. her blood pressure control is as stated above. she will need aggressive physical therapy. she can be full weightbearing on her lower extremities as tolerated despite the pelvic fracture as previously noted. additionally, she should continue aggressive physical therapy, be out of bed, get a chest physiotherapy and incentive spirometry, and trach care as standard fashion. discharge diagnoses: 1. status post motor vehicle crash with multiple injuries including multiple left-sided rib fractures, left hemothorax, left sided pulmonary contusion, right distal clavicular fracture, left scapular fracture, left superior and inferior pubic rami fracture. 2. abdominal compartment syndrome resolved. 3. status post exploratory laparotomy. negative for any visceral injury, however, patient was profoundly improved after her abdomen was opened. 4. status post acute respiratory distress syndrome now resolved. 5. respiratory failure with failure to wean from ventilator. 6. status post tracheostomy. other diagnoses: 1. hypertension. 2. peripheral vascular disease. 3. status post left carotid endarterectomy. 4. osteoporosis. 5. polymyalgia rheumatica. , m.d. dictated by: medquist36 d: 12:26 t: 12:50 job#: Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Exploratory laparotomy Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Pulmonary artery wedge monitoring Transfusion of packed cells Injection of anesthetic into peripheral nerve for analgesia Proctostomy Diagnoses: Acidosis Pulmonary collapse Acute respiratory failure Subdural hemorrhage Contusion of lung without mention of open wound into thorax Traumatic hemothorax without mention of open wound into thorax Closed fracture of three ribs Closed fracture of acromial end of clavicle

history of present illness: the patient is a 44-year-old female who is postoperative day five status post coiling for a right vertebral aneurysm. the patient awoke on with the sudden onset of a headache. over the next two days she took flexeril, tylenol, and naprosyn without relief. she then developed photophobia, nausea, and vomiting. she presented to the emergency department. at that time, she underwent a lumbar puncture and magnetic resonance imaging/magnetic resonance angiography which were both negative. she then underwent an angiogram which showed a dissecting right vertebral aneurysm. past medical/surgical history: (past medical history includes) 1. multiple sclerosis; treated with avonex. past flares have included numbness from the waist down and blurred vision. per the patient, no spinal cord lesions. 2. avascular necrosis of the bilateral shoulders; status post shoulder replacement. 3. tubal ligation. 4. two successful pregnancies and one miscarriage. 5. gallstones. 6. a recent history of pancreatitis. brief summary of hospital course: on , she underwent coiling of her aneurysm. her perioperative course was uneventful except for a persistent headache. she has now been out of bed ambulating and tolerating oral intake. she was seen by physical therapy and cleared for a home safety evaluation. she is now ready for discharge. discharge instructions/followup: 1. the patient was instructed to follow up in one to two weeks with dr. . 2. the patient was instructed to follow up with the pain clinic evaluation for her headaches. medications on discharge: (her discharge medications included) 1. percocet 5/325-mg tablets. 2. aspirin 325 mg by mouth once per day. 3. flexeril 10 mg by mouth at hour of sleep. 4. diazepam 5 mg by mouth q.6h. as needed (for pain). 5. metoprolol 50 mg by mouth twice per day. 6. wellbutrin sustained release 75-mg tablets two tablets by mouth every day. 7. interferon beta-1a every sunday. , m.d. dictated by: medquist36 Procedure: Spinal tap Incision of lung Spinal tap Incision of lung Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Spinal blood patch Diagnoses: Cerebral aneurysm, nonruptured Multiple sclerosis

history of present illness: this is a 44 year-old woman with history of multiple sclerosis diagnosed in , maintained on avonex, who was in her usual state of health until one week ago when she went in for an endoscopic retrograde cholangiopancreatography for gallstones. two days after her endoscopic retrograde cholangiopancreatography, she woke up in the middle of the night with an acute headache involving the back of her head. this was very maximal onset and felt like a punch in the back of the head. the head pain was dull and not throbbing. this did not let up at all and two days later she had some nausea and neck stiffness. she did not have any fever, chills, eye pain or bloody vision or other visual symptoms. she states that the headache is worse when she cough or strains. she has had vertigo in the past but this is not the case now. she went to the emergency room yesterday for evaluation and received demerol 25 mg times six as well as versed, phenergan, dilaudid. she had a normal ct scan and a lumbar puncture which showed 0 white cells (tube number four had 10 white cells), 400 red cells (tube four had 240 red cells), glucose 49 and protein 55. no opening pressure was recorded. afterward she felt worse with the headache and it extended to the bifrontal region. she also received one dose of ceftriaxone for meningitis coverage. she currently has a 7 out of 10 headache pain. she does report having occasional headaches around her period located in the occiput. there are no fevers, chills, problems breathing or diarrhea. past medical history: 1) multiple sclerosis treated with avonex with past flares including numbness from the waist down, blurred vision. per patient there were no spinal cord lesions on imaging. 2) avascular necrosis of bilateral shoulders, status post shoulder replacement. 3) tubal ligation. 4) two successful pregnancies, one miscarriage. 5) gallstones. medications at home: effexor 150 mg p.o. q.d., avonex 30 mcg intramuscularly q weekly, flexeril 1 tablet p.o. q..s., percocet p.r.n., protonix 30 mg q.d., ativan 1 mg p.o. b.i.d. p.r.n. allergies: rifampin. social history: she lives at home with her husband. she is a nonsmoker and does not drink alcohol. family history: there is no history of migraines. physical examination: upon admission patient is afebrile, blood pressure 110/80, heart rate 97, 100 percent on room air. this is a well appearing obese female in mild distress. head, eyes, ears, nose and throat: mucous membranes moist, no carotid bruits are noted. lungs are clear to auscultation bilaterally. cardiovascular regular rate and rhythm, no murmur, rubs or gallops heard. abdomen soft, nontender, nondistended. extremities no edema noted. skull and spine neck movements are somewhat limited on lateral rotation, very painful to palpation of the paraspinous soft tissue pressure on the left. on neurologic examination patient is attentive, recalls three out of three objects at three minutes. has good knowledge of her medical history. her language was intact to naming, repetition and comprehension. there is no apraxia or agnosia. on cranial nerve examination visual acuity is 20 out of 25 in od, os and ou. visual fields are full to confrontation. optic disks are extremely difficult to visualize given her discomfort and inability to keep the eyes still. there is no red desaturation. eye movements are normal with deep pupil suggested in the left eye. pupils react normally to light, good direct and consensual. sensation on face is intact to light touch and pinprick. facial movements are normal and symmetric. hearing is intact throughout. there is no nystagmus. the palate elevates in the midline. the tongue protrudes in the midline and is of normal appearance. the sternocleidomastoid and trapezius muscle are strong bilaterally. on motor examination the patient has normal tone and bulk. she had full power 5 out of 5 throughout. there is no pronator drift. on coordination examination there is no ataxia. the finger to nose and heel to shin test are performed accurately. on reflexes are symmetrical and trace in upper extremities and lower extremities bilaterally. there is no ankle clonus. plantar responses are mute. on sensory examination she is intact to light touch, pinprick, temperature and joint position of all extremities. on the gait examination she had narrow base gait. imaging: ct of the head at shows no obvious hemorrhage. hospital course: patient was had another lumbar puncture done in the emergency room at . opening pressure was 9 cm water which was normal. she has 518 red cells and the first two which decreased to 379 red cells in the fourth tube. there were three white cells with 35 percent neutrophils, 58 percent lymphocytes, 7 percent monocytes. protein was normal at 15, glucose normal at 56. an mri-mra was done which revealed no evidence of aneurysm or infarct. she did have a temperature of 100.4 and complained of some paraspinal tenderness around the l4. at the encouragement of her primary care doctor, an mri of the thoracic and lumbar spine was done revealing no evidence of epidural abscess. patient's headaches were managed with morphine and percocet and later switched over to percocet given the nausea secondary to the morphine. she was also given reglan and compazine for her nausea. after four days of hospitalization, patient was taken by the anesthesiology pain service for a lumbar puncture and blood patch under fluoroscopy. the cerebrospinal fluid taken at this time showed 10 white cells with 84 percent lymphocytes and 1 percent neutrophils. there were 689 red cells, protein 46 and glucose of 49. given that the patient still had some persistent red cells in her spinal fluid, we could not definitively rule out a subarachnoid hemorrhoid or aneurysm. patient was then taken to angiography which revealed an intracranial dissecting right vertebral artery aneurysm proximal to the vertebrobasilar junction. she was then transferred over to the neurosurgery service for management of the aneurysm. upon transfer the diagnosis was a right vertebral dissecting aneurysm. transfer condition: stable. transferred to neurosurgery on . dr., 14-133 dictated by: medquist36 d: 14:13 t: 15:26 job#: Procedure: Spinal tap Incision of lung Spinal tap Incision of lung Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Spinal blood patch Diagnoses: Cerebral aneurysm, nonruptured Multiple sclerosis

allergies: bactrim meds: lopressor sh: pt has wife and 2 who have called and spoken w/ ccu resident. spokesperson/health care proxy is : . pt arrived in sicu abt 10pm. aline and central line in place. hemodynamics labile, ntg and iv heparin off. labile bp on and off dopamine 5-10mcg/kg/min. fluid resuscitated abt 1l to support bp. repeat ekg improved. cardiac enzymes elevated. mb index=13.7, troponin = 42.7.fully vented on imv 700x14, 60% 7peep w/ stable abg, 02sats. sxned for copious frothy bld tinged and tan secretions. md spoke w/ pt' who has made pt a full tx but dnr if he should arrest. wife will be in tomorrow. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Acute respiratory failure Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Other specified hypotension

history of present illness: this is a year old male with a history of advanced alzheimer's disease who was brought to the emergency department by his day care center as the patient was having a temperature of 99.7 outside and was becoming combative and tachypneic as well as having new cough which was nonproductive. when the patient came to the emergency department he had cough, sputum production, fever to 102, white blood cell count of 12.1 and a chest x-ray showing a right middle lobe infiltrate. he was hydrated with 2 liters of intravenous fluid. two sets of blood cultures were taken, levaquin 500 mg was given. the patient was also found to be hypertensive. his electrocardiogram showed st depressions in v3 through v6 which were new. the initial ck and troponin were flat. he was started on heparin drip, nitroglycerin drip and desaturation to 70% on 2 liters of nasal cannula. he was subsequently intubated on pressure support ventilation with pressure support of 12 and a positive end-expiratory pressure of 5. his oxygen saturations were 88% on fio2 of 100%. arterial blood gases was 7.35/39/63. he was changed to ac ventilation with improved saturation. he was given lasix 40 mg intravenously times two. the patient received sedation with his intubation and soon after stopped his systolic blood pressure to the 60s. the nitroglycerin drip was stopped. the patient was given intravenous fluid boluses which brought his pressure up. he brought up some pink frothy secretions during this time which resolved on their own after fluid boluses were stopped. in the intensive care unit the patient required dopamine drip and this along with the intravenous fluids resulted in improvement in the systolic blood pressures to the 120s. an arterial and right internal jugular lines were placed. the patient was stabilized on dopamine drip at 6 mcg and intravenous normal saline at 100 cc/hr. physical examination: on physical examination temperature was 100.9, blood pressure 110/50, heartrate 102, respirations 14, sating 94% on ac ventilation. fio2 0.6, table volume 700, respiratory rate 14, positive end-expiratory pressure 7, peak inspiratory pressure 32.1, 23 minute volume. general: the patient intubated and sedation in no apparent distress. head, eyes, ears, nose and throat, right pupil minimally reactive. surgical left pupil. plump external jugular. no lymphadenopathy. cardiovascular: s1 and s2 normal, distant heartsounds, no murmurs. lungs: crackles, left greater than right, posteriorly. abdomen, soft, nontender, nondistended with bowel sounds. extremities, no cyanosis, clubbing or edema. axis: right internal jugular, right arterial line. laboratory data: white count 12.1, hematocrit 41.1, platelets 240, 4% neutrophils. chem-7 as follows, 137, 4.1, 98, 27, 19, 1, 79. urinalysis, 100 protein, greater than 50 red blood cells, rare bacteria, trace ketones, 0-2 white blood cells, no epithelial cells. ck #1 96, troponin #1 less than 0.4, mb #1 not done. ck #2 416, troponin #2 42.7, mb #2 57. calcium 8.9, phosphorus 2.1, magnesium 1.9. pt is 13.4, ptt 34, inr 1.3. electrocardiogram, st depressions v3 through v6, 2 to 3 mm in size, ms and u. repeat electrocardiogram four hours after initial, more prominent st depression in v2. repeat electrocardiogram nine hours after the first, improved st depression, (.5 to 1 mm) after extubation. chest x-ray #1 revealed right middle lobe opacity, pneumonia versus aspiration. chest x-ray #2 revealed worsened pulmonary edema. chest x-ray #3 pulmonary edema. arterial blood gas: 7.35, 39, 63 on pressor support 12.5 positive end-expiratory pressure 15, title volume 700. hospital course: this is a year old male with a past medical history of alzheimer's and hypertension who presented with a likely large anterolateral myocardial infarction, acute respiratory failure in the setting of pneumonia and likely cardiogenic pulmonary edema and cardiac hypotension and possible sepsis. 1. coronary artery disease - the patient's initial electrocardiograms showed st depression in v3 through v6 concerning for ischemia. when the second set of enzymes came back markedly positive, the patient was classified as having non-q wave myocardial infarction. in the meantime, heparin and nitroglycerin had been started appropriately and the patient was given an aspirin. given the patient's baseline dementia and poor prognosis there was no intervention elected by the family and intensive care unit team. the cardiac enzymes by ck mb decreased from a high of 115 on , at 2:30 am steadily to 27 by 12:40 pm on . 2. pulmonary edema - decreased oxygen saturation. the patient had likely cardiogenic pulmonary edema which was exacerbated by fluid that was given in the emergency department (2 liters of intravenous fluids plus heparin and nitroglycerin drip). it is likely that this occurred in the setting of a stunned myocardium. the patient was appropriately given lasix to diurese him, however, this patient developed some problems with hypotension after his intubation and diuresis had to be taken more carefully. 3. hypotension - this was initially seen after intubation. this was most likely a cardiogenic plus septic plus sedative induced hypotension. the patient was started on dopamine, however, this was weaned quickly. additional intravenous fluids had to be used to maintain the blood pressure which made it thus easy for the patient to be extubated. however, this was accomplished by the medicine intensive care unit team within a short timeframe, nonetheless. 4. pneumonia - the patient had two blood cultures taken in the emergency department and was also given levofloxacin. both of the blood cultures were negative at the time of discharge and this was a final report. the levofloxacin was continued during the course of this stay. 5. nutrition - the patient was npo while in the intensive care unit and some slow feeding was started p.o. with much difficulty near the time of his transfer from the unit to the floor. for these reasons, the patient had a swallowing study which showed he was grossly aspirating and had complete failure of the swallowing mechanism. the family was adamant about not having the patient fed through a percutaneous tube, hence the family's wishes were fully respected. given the patient's dementia and poor prognosis, the family, social work and palliative care ( kanofsky, nopp) as well as the patient's attending, dr. decided that it would be best to hold a meeting to determine the patient's status. 6. code status - the patient was initially do-not-resuscitate, do-not-intubate. after the family meeting, the patient was made comfort measures only. comfort was determined to be the ultimate goal and a central line and catheter were removed. they understand that restraint removal may not be possible outside because of safety concerns, but as the patient has family and caregivers in attendance restraints can be off at that time. this will have to be worked out as the patient is being discharged today. they agree that the use of oxygen should only occur if the patient does not pull out the oxygen tube. the patient will be discharged to home. they will receive the following orders of care being given here: 1. morphine elixir 20 mg/ml give .1 cc (2 mg), sublingual/p.o. q. 2 hours prn discomfort 2. give sublingual ativan or p.o. ativan q. 2 hours prn agitation 3. tylenol 650 mg p.r. q. 6 hours 4. scopolamine 1.5 mg transdermal q. 72 hours no intravenous fluids or intravenous antibiotics will be possible at once the line is pulled. the family will continue to follow. discharge status: to heathwood. condition on discharge: fair. code status: see medical orders. dr., 12-207 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Acute respiratory failure Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Other specified hypotension

allergies: patient recorded as having no known allergies to drugs attending: addendum: medication change discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. 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:*2* 4. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 10 days. disp:*10 tablet(s)* refills:*0* 7. potassium chloride 10 meq tablet sustained release sig: one (1) tablet sustained release po once a day for 10 days. disp:*10 tablet sustained release(s)* refills:*0* 8. zocor 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 9. fosamax plus d 70-2,800 mg-unit tablet sig: one (1) tablet po once a week. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: home and health vna md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Osteoporosis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - cabgx3 (lima->lad, svg->om, svg->ramus) history of present illness: splendid 83 year old female who has been experiencing exertional jaw discomfort over the past few weeks. she underwent an ett which was positive for ischemia. a cardiac catheterization was performed on shich revealed severe 3 vessel disease. she was subsequently transferred to the for surgical revascularization with dr. . past medical history: hypercholesterolemia htn nephrolithiasis osteoporosis hyperthyroid varicose veins vertigo dislocated left rib one year ago social history: lives with husband. married this past . denies smoking and occassionally drinks wine. works as a hospital volunteer. family history: none physical exam: 77 123/57 neuro: a+ox3 heent:perrl, anicteric sclera, op benign lungs: clear heart: rrr, no murmur abd: benign ext: warm, well perfused + pulses, bilat varicosities pertinent results: 10:21pm urine color-straw appear-clear sp -1.010 10:21pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 09:03pm glucose-111* urea n-18 creat-0.6 sodium-141 potassium-3.5 chloride-103 total co2-29 anion gap-13 09:03pm alt(sgpt)-26 ast(sgot)-32 ld(ldh)-193 alk phos-100 amylase-90 tot bili-0.5 09:03pm %hba1c-5.5 -done -done 09:03pm wbc-7.3 rbc-4.26 hgb-13.5 hct-38.9 mcv-91 mch-31.8 mchc-34.8 rdw-13.2 09:03pm pt-12.0 ptt-24.6 inr(pt)-1.0 06:10am blood wbc-6.1 rbc-3.36* hgb-10.6* hct-30.6* mcv-91 mch-31.6 mchc-34.7 rdw-14.1 plt ct-203# 06:10am blood plt ct-203# 06:10am blood glucose-88 urean-13 creat-0.5 na-135 k-4.2 cl-99 hco3-28 angap-12 09:03pm blood %hba1c-5.5 -done -done , m: radiology detail - ccc record # final report history: 83-year-old woman, status post cabg. comparison: . chest, pa and lateral: cardiac, mediastinal, and hilar contours are stable, status post cabg and median sternotomy. the aorta is calcified. pulmonary vasculature is mildly congested. there are small-to-moderate bilateral pleural effusions and associated basilar atelectasis. the lungs are otherwise clear. the right ij introducer has been removed. osseous and soft tissue structures are unchanged with thoracic spine osteophytes again noted. impression: small-to-moderate bilateral pleural effusions. mild pumonary vascular congestion. the study and the report were reviewed by the staff radiologist. dr. tham dr. approved: tue 11:29 pm procedure date: echocardiography report , (complete) done at 11:21:12 am final referring physician information , r. division of cardiothoracic , status: inpatient dob: age (years): 83 f hgt (in): 63 bp (mm hg): 178/78 wgt (lb): 117 hr (bpm): 69 bsa (m2): 1.54 m2 indication: coronary artery disease. left ventricular function. evaluate aorta intraoperative cabg icd-9 codes: 440.0 test information date/time: at 11:21 interpret md: , md test type: tee (complete) son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: adequate tape #: 2006aw1-: machine: 1 echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.9 cm <= 4.0 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.0 cm <= 5.6 cm left ventricle - systolic dimension: 2.2 cm left ventricle - fractional shortening: 0.45 >= 0.29 left ventricle - ejection fraction: 50% to 55% >= 55% left ventricle - peak resting lvot gradient: 2 mm hg <= 10 mm hg aorta - valve level: 2.2 cm <= 3.6 cm aorta - ascending: 2.5 cm <= 3.4 cm aorta - arch: 2.4 cm <= 3.0 cm aortic valve - peak velocity: 0.8 m/sec <= 2.0 m/sec aortic valve - peak gradient: 2 mm hg < 20 mm hg aortic valve - mean gradient: 1 mm hg aortic valve - valve area: *2.7 cm2 >= 3.0 cm2 findings left atrium: normal la size. right atrium/interatrial septum: secundum asd. left ventricle: normal lv wall thickness. low normal lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal descending aorta diameter. there are complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. s. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: trivial/physiologic 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. conclusions pre bypass: 1. the left atrium is normal in size. a secundum type atrial septal defect is present. 2. left ventricular wall thicknesses are normal. overall left ventricular systolic function is low normal (lvef 50-55%). 3. right ventricular chamber size and free wall motion are normal. 4. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is no aortic valve stenosis. no aortic regurgitation is seen. 5. the mitral valve appears structurally normal with trivial mitral regurgitation 6. ascending aorta is calcified without atheroma, aortic arch and descending aorta has complex atheroma (>4mm) post bypass: no pacing currently, during the study patient was a paced. on phenylephrine drip. preserved biventricular systolic function. mv - trivial regurgitation tv - mild to moderate regurgitation av - no ai pv - physiologic pr aorta: ascending aorta callcified, no dissection noticed. aortic arch - no dissection, complex atheroma present. descending aorta with complex atheroma. asd is present and unchanged. remaining exam unchanged from pre-bypass period. all findings discussed with the attending surgeon in or while the study is being performed. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician ?????? caregroup is. all rights reserved. brief hospital course: mrs. was admitted to the on via transfer from for surgical management of her coronary artery disease. she was worked-up in the usual preoperative manner. on , she was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. postoperatively she was taken to the intensive care unit for monitoring on neosynephrine and propofol drips. by postoperative day one, she was awake, extubated and neurologically intact. her pressors were slowly weaned. aspirin and a statin were resumed. later on postoperative day two, she was transferred to the step down unit for further recovery. mrs. was gently diuresed towards her preoperative weight. the physical therapy service worked with her daily to help increase her postoperative strength and mobility. chest tubes and pacing wires removed. she was cleared for discharge to home with vna on pod # 5. pt. is to make all follow up appts. as per discharge instructions. medications on admission: asa 162 mg daily lopressor 50 mg zocor 40 mg daily fosamax 70 mg q weekly triamterene 37.5 mg/hctz 25 mg daily tums 2 tabs daily vit.d discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. 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:*2* 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 7. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 10 days. disp:*10 tablet(s)* refills:*0* 8. potassium chloride 10 meq tablet sustained release sig: one (1) tablet sustained release po once a day for 10 days. disp:*10 tablet sustained release(s)* refills:*0* discharge disposition: home with service facility: home and health vna discharge diagnosis: s/p cabg x3 hypercholesterolemia htn osteoporosis vertigo varicose vein nephrolithiasis dislocated left rib one year ago discharge condition: stable discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5)no lifting greater then 10 pounds for 10 weeks. 6)no driving for 1 month. followup instructions: follow-up with surgeon dr. in 1 month. ( follow-up with cardiologist dr. in weeks. follow-up with pcp . in weeks. please call all providers for appointments. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Osteoporosis, unspecified

code: full allergies: nkda events: endoscopy done this shift, no significant findings. colonoscopy also done, no signs of active bleeding, diverticuli visualized by md. last crit 32.7, received 2 units prbc, next crit will be drawn at 1500. neuro: pt alert and oriented x 3, very pleasant, interacts appropriately with staff. denies pain. able to use bedside commode for bms. cv: hr nsr 63-83 with no ectopy noted, nbp 99-117/59-75. transfused with 2 units prbc for crit of 32.7, next crit due to be drawn at 1500. resp: pt satting >95% on ra, rr 10-20. lung sounds clear bilaterally gag/cough intact. gi: bowel sounds x 4, abdomen soft and non-tender. passing brown, liquid stool in commode. gu: voids using urinal. access: piv #18 x 2 social: wife at bedside most of day, updated by rn on pt's condition and plan of care. plan: follow up hct monitor for any signs of active bleeding Procedure: Other endoscopy of small intestine Colonoscopy Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Diverticulosis of colon with hemorrhage Personal history of colonic polyps

allergies: aspirin attending: addendum: will stop plavix while on coumadin, to restart plavix after coumadin is discontinued, spoke with np at tcu to update discharge medications discharge disposition: extended care facility: tcu - md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Atrial cardioversion Open and other replacement of aortic valve with tissue graft Other surgical extraction of tooth Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Aortic valve disorders Cardiac pacemaker in situ Dental caries, unspecified

allergies: aspirin attending: chief complaint: transfer from /referring dr. major surgical or invasive procedure: s/p cardiac catherization s/p dental extractions s/p avr(19mm mosaic porcine tissue valve)/cabgx1(lima->lad) s/p cardioversion history of present illness: this is a 74 yo woman with hypertension and moderate-to-severe aortic stenosis with valve area of 0.8cm2 (gradient 78.3) presented to on with sob and left sided chest pain that radiated down her left arm associated with nausea and vomiting. ekg demonstrated t wave inversion in inferior leads (new). she was treated with sublingual nitro, maalox and tylenol. she ruled out for mi by cardiac enzymes. transferred to for cardiac catherization past medical history: coronary artery disease aortic stenosis hypothyroidism ^chol. djd gerd s/p chole s/p r shoulder surgery osteoporosis htn ddd ppm social history: son lives with her and she functions independently. walks without a walker. never smoked, no alchohol. family history: mother died of mi at 68. father died healthy at 97. physical exam: vitals: t: 97.9 p: 76 bp: 134/60 r: 18 sao2: 96% on ra general: awake, alert, nad. heent: nc/at, perrl, eomi without nystagmus, no scleral icterus noted, mmm, no lesions noted in op neck: supple, no jvd appreciated pulmonary: lungs cta bilaterally (anteriorly) cardiac: rrr, nl. s1s2, iii/vi systolic murmur heard best over lusb abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses b/l. skin: dry skin in le. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. discharge 98.5, sr w/ vpacing 60, 115/59, 20, ra sat 94% neuro a/ox3 nonfocal pulm cta bilat cardiac rrr no m/r/g abd soft, nt, nd +bs ext warm, +1 edema inc sternal no drainage/erythema, sternum stable pertinent results: 06:45am blood wbc-7.6 rbc-3.61* hgb-9.9* hct-30.3* mcv-84 mch-27.5 mchc-32.7 rdw-14.7 plt ct-282 01:00pm blood wbc-4.6 rbc-3.76* hgb-10.4* hct-30.1* mcv-80* mch-27.6 mchc-34.5 rdw-14.0 plt ct-188 01:00pm blood neuts-61.8 lymphs-31.3 monos-4.5 eos-2.1 baso-0.3 06:45am blood plt ct-282 06:45am blood pt-18.6* ptt-98.4* inr(pt)-1.8* 01:00pm blood plt ct-188 01:00pm blood pt-12.9 ptt-31.4 inr(pt)-1.1 06:45am blood glucose-96 urean-20 creat-1.2* na-139 k-4.0 cl-99 hco3-31 angap-13 01:00pm blood glucose-122* urean-20 creat-0.8 na-137 k-3.6 cl-103 hco3-28 angap-10 01:00pm blood alt-10 ast-20 ck(cpk)-50 alkphos-59 amylase-41 totbili-1.4 dirbili-0.4* indbili-1.0 06:35am blood calcium-8.6 phos-4.6* mg-2.3 01:00pm blood caltibc-277 vitb12-276 folate-greater th ferritn-138 trf-213 01:00pm blood %hba1c-6.4* -done -done 05:55am blood tsh-2.9 cxr indication: 85-year-old woman status post aortic valve replacement. evaluate effusions. comparison: . frontal and lateral chest: a left-sided pacemaker with leads are in unchanged positions. the patient is status post median sternotomy. skin staples remain in place. the cardiac and mediastinal contours are similar in appearance. the lungs remain clear with minor atelectasis in the left base. there is a small left-sided pleural effusion that appears roughly similar compared to the prior study. pulmonary vascularity remains within normal limits. hardware in the right humerus is unchanged. the thoracic spine demonstrates extensive degenerative change with a marked kyphosis. impression: small left-sided pleural effusion and minimal left basilar atelectasis. tee measurements: left ventricle - ejection fraction: 55% (nl >=55%) aorta - ascending: *3.5 cm (nl <= 3.4 cm) aortic valve - peak velocity: *2.7 m/sec (nl <= 2.0 m/sec) aortic valve - peak gradient: 45 mm hg aortic valve - mean gradient: 30 mm hg aortic valve - lvot diam: 1.6 cm aortic valve - valve area: *0.5 cm2 (nl >= 3.0 cm2) mitral valve - peak velocity: 0.9 m/sec mitral valve - mean gradient: 2 mm hg mitral valve - mva (p t): 1.8 cm2 interpretation: findings: right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. left-to-right shunt across the interatrial septum at rest. small secundum asd. left ventricle: normal regional lv systolic function. overall normal lvef (>55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. mildly dilated ascending aorta. simple atheroma in ascending aorta. normal aortic arch diameter. there are complex (>4mm) atheroma in the aortic arch. normal descending aorta diameter. there are complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: three aortic valve leaflets. severely thickened/deformed aortic valve leaflets. severe as (aova <0.8cm2). mild (1+) ar. mitral valve: moderately thickened mitral valve leaflets. moderate mitral annular calcification. mild ms (mva 1.5-2.0cm2). moderate (2+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. physiologic (normal) pr. 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. results were personally conclusions: prebypass 1. a left-to-right shunt across the interatrial septum is seen at rest. a small secundum atrial septal defect is present. 2. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3.right ventricular chamber size and free wall motion are normal. 4.the ascending aorta is mildly dilated. there are simple atheroma in the ascending aorta. there are complex (>4mm) atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. 5.there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (area <0.8cm2). mild (1+) aortic regurgitation is seen. 6. the mitral valve leaflets are moderately thickened. there is mild mitral stenosis (area 1.5-2.0cm2). moderate (2+) mitral regurgitation is seen. 7. the tricuspid valve leaflets are mildly thickened. post bypass 1. patient is receiving an infusion of phenylephrine. 2. bioprosthetic valve seen in the aortic position. leaflets move well (demonstrated on deep gastric views) and valve appears well seated. peak gradient across the aortic valve is 30 mm hg. trace aortic insufficiency. 3. moderate mitral regurgitation persists. 4. aorta intact post decannulation. 5. biventricular systolic function is unchanged path diagnosis: aortic valve leaflets: valve leaflets with extensive calcifications. brief hospital course: the patient underwent cardiac catheterization which revealed: calcified lm, 70% prox. lad, 70% prox lcx. heavily calcified rca, tr. mr, and an ef of 60%. she had aortic stenosis with an av gradient of 44 and of 0.71 cm2. dr. was consulted and then a dental consult recommended extraction of 7 teeth. she underwent extraction of 7 teeth on , and on she had avr(19mm mosaic tissue valve)/cabgx1(lima->lad). the cross clamp time was 86 mins., total bypass time 115 mins. please see operative report for further details. she tolerated the procedure well and was transferred to the csru in stable condition on neo and propofol. she was extubated on the post op night and was transferred to the floor on pod#2. she slowly progressed and was diagnosed with a uti which is being treated with cipro. she went into rapid af on pod#5 and did not convert with beta blockers or amiodarone. she was started on anticoagulation and ep consulted and had cardioveriosn resulting in sr with intermittent pacing. she continued to progress and was ready for discharge to rehab . she continues on coumadin with target inr 2.0-2.5 for atrial fibrillation. medications on admission: lipitor 10 mg po daily synthroid 0.05 mg daily zantac 150 mg po daily protonix 40 mg po daily lisinopril 10 mg po daily hctz 25 mg po daily? discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): on plavix instead of asa per pt request. 8. furosemide 40 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 9. amiodarone 200 mg tablet sig: one (1) tablet po tid (3 times a day): 200 mg tid x 1 week per ep, then 200 mg daily until dc'd at one month by dr. ; do not stop until seen by cardiologist. 10. warfarin 2.5 mg tablet sig: one (1) tablet po once (once): please check inr for dosing goal inr 2-2.5 for atrial fibrillation . discharge disposition: extended care facility: tcu - discharge diagnosis: coronary artery disease aortic stenosis hypothyroidism ^chol. djd gerd s/p chole s/p r shoulder surgery osteoporosis htn ddd ppm discharge condition: good. discharge instructions: follow medications on discharge instructions. do not drive for 4 weeks. do not lift more than 10 lbs for 10 weeks. shower daily, let water flow over wounds, pat dry with a towel. do not use lotions, creams, or powders on wounds. call our office for temp>101.5, sternal drainage. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 2-3 weeks. make an appointment with dr. for 4 weeks. pt/inr as needed first check with goal inr 2-2.5 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Atrial cardioversion Open and other replacement of aortic valve with tissue graft Other surgical extraction of tooth Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Aortic valve disorders Cardiac pacemaker in situ Dental caries, unspecified

history of present illness: this is a 53 year old male patient with known coronary artery disease and chest pain ten years ago with catheterization and percutaneous transluminal coronary angioplasty. he has had five catheterizations since that time. more recently he has had episodes with chest pain, now severely affecting his quality of life. he has a strong family history of aortic dissection and early cardiac death. he has a long history of heart murmur with bicuspid aortic valve. he complains also of increased shortness of breath, fatigue even at rest, diaphoresis, nausea and presyncopal episodes. cardiac catheterization on , showed left main 20 percent lesion, left anterior descending coronary artery 20 percent lesion, left circumflex and right coronary artery normal, ejection fraction 55 percent, no mitral regurgitation, no aortic insufficiency, moderately dilated aortic root. echocardiogram showed trace aortic insufficiency, trace mitral regurgitation, 4.1 centimeter ascending aorta with an ejection fraction of 65 percent and mild left ventricular hypertrophy. past medical history: coronary artery disease with percutaneous transluminal coronary angioplasty of left anterior descending coronary artery in . hypertension. hyperlipidemia. liver cyst. gastroesophageal reflux disease. thoracolumbar degenerative disc disease. past surgical history: right leg cyst removal. medications on admission: 1. lipitor 20 mg once daily. 2. lisinopril 2.5 mg once daily. 3. protonix 40 mg once daily. 4. atenolol 12.5 mg once daily. 5. diltiazem 120 mg once daily. 6. aspirin 81 mg once daily. allergies: no known drug allergies. physical examination: vital signs revealed heart rate 76 beats per minute and regular, blood pressure right 142/88, left 128/84, height five feet eight inches tall, weight 185 pounds. in general, a stalky young man with slight shortness of breath on examination. skin - no obvious lesions. head, eyes, ears, nose and throat examination - the pupils are equal, round and reactive to light and accommodation. extraocular movements are intact. anicteric, not injected. neck - no jugular venous distention, no bruits. chest is clear to auscultation bilaterally. the heart is regular rate and rhythm, s1 and s2, faint i/vi systolic ejection murmur without radiation. the abdomen is soft, nontender, nondistended, positive bowel sounds, no costovertebral angle tenderness. extremities are warm, well perfused. varicosities in the right posterior calf. neurologically, cranial nerves ii through xii are grossly intact. nonfocal examination. excellent strength in all four extremities. hospital course: the patient was admitted on , with diagnosis of dilated ascending aorta and bicuspid aortic valve. he underwent a supracoronary ascending aortic graft with a 24 millimeter gel weave graft and a resuspension of the aortic valve under general anesthesia. cross clamp time was 53 minutes. cardiopulmonary bypass time was 70 minutes. he was transferred out of the operating room to the cardiac surgery recovery unit in normal sinus rhythm with a rate of 84 and propofol drip with a mean arterial pressure of 70, cvp 10, pat 13. postoperative day number one was uneventful with a small amount of neo-synephrine continued for blood pressure support. he was extubated also on postoperative day number one. on postoperative day number two, his hematocrit was down to 21. he was transfused two units of packed red blood cells with increase in hematocrit to 27.3. he was transferred to the inpatient unit on postoperative day number two. he continued without any events on postoperative day number three. his atrial and ventricular pacing wires were discontinued. he had a brief episode of supraventricular tachycardia that resolved spontaneously and did not recur. his mediastinal chest tubes were also discontinued on postoperative day number three. he was followed by physical therapy throughout his hospital course and was found to be safe for home on . he was discharged home with visiting nurse at that time. condition on discharge: on physical examination, his lungs were clear to auscultation. cardiovascular examination - regular rate and rhythm, s1 and s2, no murmurs, rubs or gallops. incisions are clean, dry and intact. sternum is stable. abdomen reveals positive bowel sounds, positive bowel movement. laboratories on discharge revealed white blood cell count 8.6, hematocrit 27.5, platelet count 168,000. sodium 139, potassium 4.1, chloride 103, bicarbonate 29, blood urea nitrogen 13, creatinine 0.9, glucose 110. chest x-ray on the date of discharge showed small bilateral pleural effusions, left greater than right, patchy atelectasis within the left base, no pneumothorax. discharge status: to home with . discharge diagnoses: coronary artery disease, status post percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery in . hypertension. elevated cholesterol. status post ascending aortic graft and resuspension of the aortic valve. medications on discharge: 1. colace 100 mg p.o. twice a day. 2. aspirin 325 mg p.o. once daily. 3. percocet one to two tablets p.o. q4-6hours p.r.n. 4. lipitor 20 mg p.o. once daily. 5. protonix 40 mg p.o. once daily. 6. ferrous sulfate 325 mg p.o. once daily. 7. vitamin c 500 mg p.o. twice a day. 8. ibuprofen 600 mg p.o. q6hours p.r.n. 9. lopressor 50 mg p.o. twice a day. 10. lasix 20 mg p.o. once daily for seven days. 11. potassium chloride 20 meq p.o. once daily for seven days. fop: appointment with dr. in one to two weeks. appointment with dr. in four weeks. , m.d. Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Resection of vessel with replacement, thoracic vessels Transfusion of packed cells Operations on other structures adjacent to valves of heart Diagnoses: Esophageal reflux Unspecified essential hypertension Thoracic aneurysm without mention of rupture Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Family history of ischemic heart disease Congenital insufficiency of aortic valve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: tia/palpitations major surgical or invasive procedure: - pfo closure via right mini thoracotomy history of present illness: this 53-year-old with a history of multiple transient ischemic attacks in the past was investigated and was found to have a small patent foramen ovale, and he was electively admitted for closure of the same. his preoperative investigations with coronary angiogram showed normal coronary arteries. his left ventricular function was well preserved. he had no valvular disease. past medical history: right upper lobe nodule tia's childhood skull fracture pfo social history: lives with wife. 1 eto drink daily. quit smoking 30 years ago after smoking 1ppd. retired. family history: brother with mi at age 35 father with mi/cabg died at age 60. physical exam: vitals: bp 144/90, hr 64, rr 14 general: well developed male in no acute distress heent: oropharynx benign, poor dental health neck: supple, no jvd heart: regular rate, normal s1s2, no murmur lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, no varicosities pulses: 2+ distally neuro: nonfocal pertinent results: 07:30am blood hct-25.9* 07:05am blood wbc-5.9 rbc-2.72* hgb-8.6* hct-25.2* mcv-93 mch-31.5 mchc-34.0 rdw-13.0 plt ct-150 07:05am blood plt ct-150 07:30am blood urean-11 creat-0.8 k-4.4 echo no spontaneous echo contrast is seen in the body of the left atrium. no mass/thrombus is seen in the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. a patent foramen ovale/secundum asd is present. a left-to-right shunt across the interatrial septum is seen at rest. a right-to-left shunt across the interatrial septum is seen at rest with injection of agitated saline contrast. the inferior vena cava is dilated (>2.5 cm). left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). left ventricular wall thicknesses are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the mitral valve leaflets are structurally normal. there is no pericardial effusion. post bypass flow across the interatrial septum is no longer visualized with color flow doppler or with injection of agitatated saline at rest or with valsalva. the study is otherwise unchanged from pre-bypass. cxr previous right pneumothorax has resolved except for what is either a small fissural component or a bulla adjacent to the minor fissure. be a small right pleural effusion. right apical pleural tube in place. left lung clear from basal atelectasis. paratracheal mediastinal hematoma is resolving. heart size is normal. tip of the left internal jugular line projects over the svc. ospital course: mr. was admitted to the on for surgical management of his pfo. he was taken to the operating room where he underwent a mini-thoracotomy with closure of his patent foramen ovale (pfo). postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. within a few hours, he woke neurologically intact and was extubated. aspirin was resumed. on postoperative day one, he was transferred to the cardiac surgical step down unit. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. iron and vitamin c were started for postoperative anemia. mr. maintained stable hemodynamics with a normal sinus rhythm throughout his postoperative course. he continued to make steady progress and was discharged home on postoperative day three. he will follow-up with dr. , dr. , his cardiologist and his primary care physician as an outpatient. medications on admission: plavix 75mg daily aspirin 81mg daily discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 5 days. disp:*10 capsule, sustained release(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*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. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily): take for one month then stop. disp:*30 tablet(s)* refills:*0* 6. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed. disp:*qs qs* refills:*0* 7. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day): take for one month then stop. disp:*60 tablet(s)* refills:*0* 8. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. disp:*10 tablet(s)* refills:*0* discharge disposition: home with service facility: tba discharge diagnosis: pfo tia lung nodule (followed by dr. s/p fissurectomy/skull fx discharge condition: good discharge instructions: 1) shower, wash incisions with mild soap and water and pat dry. no lotions, creams or powders to incisions. 2) call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. 3) no driving while on narcotics. 4) take lasix twice daily with potassium for five days then stop. 5) take vitamin c with iron for one month then stop. 6) call with any questions or concerns. followup instructions: follow up with dr. in four weeks, follow up with dr. in weeks, follow up with dr. in weeks, call all providers for appointments. cat scan phone: date/time: 9:15 , md phone: date/time: 2:30 Procedure: Other and unspecified repair of atrial septal defect Diagnoses: Ostium secundum type atrial septal defect

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status, hypoxia major surgical or invasive procedure: intubation x 2, central line insertion, tracheostomy , peg placement history of present illness: ms. is an 89 yo female with pmh of alzheimer's disease, depression, hypernatremia, paroxysmal afib who presents from her nh. her son was called by the nursing home reporting a fever to 101 and o2 sat 84-86%. she was then sent to the ed. . in the ed, she was noted to have altered mental status. she was nonverbal but responded to pain. exam was reported as otherwise unremarkable other than rhonchi. she was noted to be hypoxic to 89%. her cxr was ok. her abg at that time was 7.37/58/178. subsequent abg showed worsening hypercarbia at 66, so she was intubated. she was transiently hypotensive after intubation. this improved with fluid. her hct was in the 50s and her serum sodium was 170. she received 2l ns in the ed with 2 more hanging upon transport to the icu. she was noted to have pyuria and was givne vanc and zosyn. lactate in the ed was 1.4. vs in the ed: t 103.6 rectal 115/60 hr 52 rr 16 98% on 100%fio2, peep 5 tv 400. past medical history: alzheimer's depression hypernatremia paroxymal afib h/o urinary tract infections cholelithiasis h/o influenza a/b social history: permanent resident of manor. chinese speaking only, son and daughter active in her life and visit daily. family history: n/a physical exam: admission pe: vitals: 97.3 89/49 99% on 100% fio2 gen: resting, ill appearing heent: ncat, mmd, pupils 2mm neck: no elevated jvd pulm: ctab, no w/r/r cv: brady, 2/6 sem, no r/g abd: s/nt/nd/nabs extr: no c/c/e, pulses thready neuro: intubated, sedated. does not respond to voice. withdrawals from pain. pertinent results: 10:30am blood wbc-9.1 rbc-5.03# hgb-16.7*# hct-52.6*# mcv-105*# mch-33.3* mchc-31.8 rdw-15.3 plt ct-242 10:30am blood neuts-85.3* bands-0 lymphs-8.3* monos-5.8 eos-0.1 baso-0.6 03:00pm blood pt-17.4* ptt-39.3* inr(pt)-1.6* 10:21am blood type-art po2-178* pco2-58* ph-7.37 caltco2-35* base xs-6 intubat-not intuba 10:21am blood lactate-2.0 10:30am blood esr-31* 10:30am blood glucose-128* urean-82* creat-2.7* na-170* k-4.6 cl-128* hco3-33* angap-14 10:30am blood alt-30 ast-26 ck(cpk)-257* alkphos-55 amylase-53 totbili-1.3 10:30am blood ck-mb-3 ctropnt-0.05* 10:30am blood albumin-3.6 calcium-9.4 phos-4.1# mg-3.7* . 10:10am blood fdp-0-10 10:10am blood fibrino-397 thrombn-14.3* . 05:09pm blood type-art temp-37.2 rates-18/0 tidal v-380 peep-5 fio2-40 po2-128* pco2-38 ph-7.45 caltco2-27 base xs-3 -assist/con 05:09pm blood lactate-1.4 . 03:16am blood cortsol-20.1* . 03:26am blood wbc-7.8 rbc-2.55* hgb-8.5* hct-25.3* mcv-99* mch-33.4* mchc-33.7 rdw-16.1* plt ct-354 03:26am blood pt-13.7* ptt-35.3* inr(pt)-1.2* 03:26am blood glucose-99 urean-13 creat-1.0 na-139 k-4.3 cl-104 hco3-28 angap-11 03:26am blood calcium-8.2* phos-3.6# mg-2.2 . radiographic studies: . cxr : interstitial edema increased. left retrocardiac atelectasis also worsened. small bilateral pleural effusions, more marked on the left are unchanged. calcifications of the aortic arch and old right rib fractures are stable. heart size remains normal. hilar contours are unchanged. . cxr : findings: endotracheal tube, right internal jugular central venous catheter and nasogastric tube appear unchanged. there has been an interval worsening of the bilateral perihilar opacities and probable slight increase in the layering bilateral large pleural effusions. this could reflect developing pulmonary edema although multifocal infection cannot be entirely excluded. . echo : the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. pulmonary artery systolic hypertension. mild mitral regurgitation. . micro data: : ucx w/proteus, sputum w/mrsa : sputum w/stenotrophomonas bcx negative bcx , , , pending r ij tip culture negative ucx x2 negative 3x cdiff negative (, , ) brief hospital course: a/p: 89 yo with pmh of alzheimer's dementia, hypernatremia, uti presents with ams, sepsis physiology, uti, and impressive hypernatremia . #1 sepsis: initially presenting with fever, hypotension, hypoxia. source was likely urine given pyuria, though may have pneumonia as well given mrsa in sputum. ucx grew out pan sensitive proteus mirabilis, initial sputum grew mrsa. bcx from , negative. bcx from , , , all pending. patient had short additional time in micu when required pressors for approx 48 hours. started on empiric zosyn and gent for vap. ucx during this time were negative and sputum grew out stenotrophomonas sensitive to bactrim. iv bactrim started and zosyn/gent d/c. although blood pressure is low at baseline, patient always makes urine. stool tests for c. diff negative x 3 & flagyl stopped . - completed 15d of vanco, was treated for 14d total for uti starting w/cipro/unasyn and switching to gent/zosyn (to double cover for vap) - iv bactrim 250mg q8h for 14 days, starting and finishing on . . #2 respiratory failure: hypoxia and hypercarbia with spontaneous breathing trials. now be volume overloaded due to fluid resuscitation. pnas and deconditioning likely also contribute. patient failed sbts due to rsbis >130 and increasing acidosis. unclear why patient unable to be weaned off vent. patient with slightly hyperinflated s and co2 retention without acidosis on admission. no hx of copd given but may be undiagnosed thus far. nif poor at 16 with large amount of dead space ventilation (70% on psv). difficulty of weaning from the vent likely a mix of decreased respiratory muscle strength combined with underlying intrinsic disease. - continue on pressure support as tolerated and wean as tolerated. . #3 hypernatremia: likely from extreme dehydration. now resolved. patient is currently getting free water boluses 100ml every 6 hours with tube feeds. continue to monitor sodium and adjust as necessary. . #4 ams: likely toxic/metabolic, though other etiologies could include stroke, and underlying dementia. patient increasingly alert as she is treated . #5 hypotension: resolved currently. dopamine drip weaned off. echo relatively unremarkable given patient??????s age and does not explain hypotension or bradycardia. unclear etiology. lactate and mixed venous do not suggest infection. pt did not respond to fluid boluses and cvps do not point to hypovolemia. repeat echo w/normal biventricular cavity sizes with preserved global and regional biventricular systolic function. pulmonary artery systolic hypertension. mild mitral regurgitation. also be unable to mount hr response with conduction disorder. ep consulted twice and do not want to intervene given her hx of sepsis. adrenal insufficiency also a possibility but am cortisol was normal. . fluid balance should be maintained. she has been both very hypervolemic and exterienced flash pulmonary edema during her stay, and fluid balance has been difficult. any prn ivf should be given with caution and extubation was probably in part limited to pulm edema. her sodium and other electrolytes should be monitored every other day until stable and po intake of fluids encouraged. . would reassess fluid status daily and give small doses of lasix as tolerated by blood pressure. the patient has been hypotensive with lasix in the past, therefore small doses should be given. . #6 bradycardia, hr consistently in 50's but asymptomatic: not new ?????? old records show ekg w/nsr at 65 w/1st degree av block 3 years ago. initially ep commented that her rhythm could be a variation of normal or tied to her underlying illness and recommended treating her sepsis and re-evaluating once she has recovered or becomes unstable. . #7 paroxysmal afib: not on anticoagulation on admission for unclear reason (fall risk?) the reason for this should be followed up with her pcp. was not investigated during this stay. . #8 alzheimer's: cont home meds of namenda and aricept. . #9 anemia: hemoconcentrated upon admission, hct trended to mid to upper 20s during here stay. further workup should be initiated by her pcp. monitor her hct every other day until stable. . # ppx: h2 blocker, sc heparin, bowel regimen . # fen: tolerated tf at goal. . # code: full code. discussed with patient??????s son who wants ??????everything done?????? including reintubation if patient fails extubation. medications on admission: bisocodyl supp 10mg daily prn albuterol q 6 prn ipratropium q 6 prn tylenol 500 q 6 prn guiatuss q 6 prn tylenol suppos 650mg q 6 prn lactulose 15ml po daily vit e 800 po daily caltrate 600 + d aricept 10mg po daily colace 100 qday zyprexa 5mg qday namenda 10mg discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 5. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 8. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4hrs prn as needed. 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 10. donepezil 5 mg tablet sig: two (2) tablet po daily (daily). 11. memantine 5 mg tablet sig: two (2) tablet po bid (2 times a day). 12. trimethoprim-sulfamethoxazole 80-400 mg/5 ml solution sig: two y (250) mg intravenous q8hrs for 13 days: through . 13. vitamin e 800 unit capsule sig: one (1) capsule po once a day. 14. caltrate-600 plus vitamin d3 600-400 mg-unit tablet sig: one (1) tablet po twice a day. 15. lactulose 10 gram/15 ml solution sig: fifteen (15) ml po once a day. 16. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) puff inhalation prn (as needed) as needed for shortness of breath or wheezing. discharge disposition: extended care facility: discharge diagnosis: primary: proteus mirabilis urosepsis bradycardia stenotrophomonas pneumonia . secondary: alzheimer's depression hypernatremia paroxymal afib h/o urinary tract infections cholelithiasis h/o influenza a/b discharge condition: good, afebrile discharge instructions: ms. was seen at for urosepsis for which she finished a course of vanc, gent, zosyn. she required pressors intermittently for hypotension. she was also extremely hypernatremic. she also was bradycardic with a mid-grade block. she is receiving bactrim for stenotrophomonas pna. she will need bactrim until . she will need ongoing nebulizers, sc heparin, and bowel regimen per medication orders. please see discharge for full details. . vital signs should be monitored daily. fluid balance should be maintained. she has been both very hypervolemic and exterienced flash pulmonary edema during her stay, and fluid balance has been difficult. . she has not been anticoagulated for her paf in the past. the reason for this should be followed up with her pcp as below. this was not investigated during this stay. . she will need every other day electrolytes and cbc checked until stable. other discharge orders per medication sheet and page 1 referral. . she should return to the ed if she develops altered mental status, fever, hypotension, bradycardia. followup instructions: she should follow-up with her primary care provider, , in the next 1-2 weeks. his office number is . 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 Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Diagnoses: Pneumonia due to other gram-negative bacteria Urinary tract infection, site not specified Toxic encephalopathy Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Hypopotassemia Acute respiratory failure Other specified cardiac dysrhythmias Pressure ulcer, lower back Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Other second degree atrioventricular block Pressure ulcer, stage I

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status, fevers major surgical or invasive procedure: central line placement history of present illness: ms. is an 85 year old nursing home resident, chinese speaking, s/p hospitalization at for influenza a, has been on o2 since with baseline ra sats 88% and 92% on 2l nc. she presented to the with altered mental status and fevers. she is very demented at baseline but is verbal. on the morning of admission, she had a small amount of her usual breakfast but was very lethargic and according to her nurses, may have aspirated some of her meal. vs there were t 103.8. bp 141/94 hr 99 o2 sat 87% on 2lnc. when ems arrived, her vs were 92/68 hr 95 (irregular) rr 42 sat 94% on bvm 100%. . in the ed, she was noted to also be febrile so code sepsis was initiated. her code status was confirmed to be full code. a left subclavian line was placed, and iv normal saline were administered. intravenous ceftriaxone, vancomycin, levaquin and clindamycin were administered. levophed was also started. prior to transfer to the floor her svo2 was 71%. . in the micu, the levophed was weaned. the patient was maintained on vanco and zosyn. cxr showed a flourishing rul pna. her mental status improved on time of transfer. past medical history: alzheimer's depression hypernatremia paroxymal afib h/o urinary tract infections cholelithiasis h/o influenza a/b social history: permanent resident of manor. chinese speaking only, son and daughter active in her life and visit daily family history: n/a physical exam: vs: tm 103.9 tc bp 117/49 (88-121/34-49) hr 84 rr 30 sat 100% nc gen: elderly asian woman in bed sedate and difficult to arouse, breathing comfortably. daughters at bedside. heent: dry mm, eyes closed, no scleral icterus. neck: supple, no masses cv: irregular, normal s1/s2 pul: coarse upper airway sounds abd: diffuse ttp, +bs, no rebound or guarding. ext: no edema neuro: sedated, arousable, but non-verbal with eyes closed. pertinent results: ekg: normal axis, 1st degree a-v block, lvh, qv1-2, lateral j-point depression . initial cbc: 11:38am wbc-13.1*# rbc-4.56 hgb-14.7 hct-45.4 mcv-100* mch-32.1* mchc-32.3 rdw-15.3 11:38am neuts-80.7* lymphs-9.9* monos-6.4 eos-0.5 basos-2.5* 11:38am plt count-402# . lactate: 4.8 () . ua negative. . cxr : again seen is mild cardiomegaly, unchanged from prior study. mediastinal and hilar contours appear unchanged with calcification again seen within the aorta. pulmonary vasculature appears within normal limits. there is no evidence of focal consolidations. diffuse opacity over the right upper lobe could be consistent with aspiration. again noted are healed rib fractures on the right side. impression: diffuse increased opacity over the right upper lobe which could be consistent with aspiration. no focal consolidations seen. . micro blood culture x 2 sets: ngtd urine urine culture-final {yeast} blood culture aerobic bottle & anaerobic bottle-preliminary {staphylococcus, coagulase negative) blood culture aerobic bottle-pending; anaerobic bottle: ngtd brief hospital course: 86f with history of severe dementia, presents with fever and altered mental status, code sepsis in ed. the patient was resuscitated and admitted to the micu. she was diagnosed with pneumonia and treated with zosyn and vancomycin for broad coverage. after she was stabilized and weaned off of pressors, she was transferred to the regular medical floor where she remained stable. she was discharged back to her nh in stable condition. . # ams/infection: the patient is severely demented at baseline. a head ct completed in the ed was negative, and she did not have any focal neurological deficits on exam (although it was limited by the language barrier). on admission to the icu, she had a clean ua but a rul consolidation consistent with aspiration pneumonia. she was also hypernatremic which would also account for ams. she was repleted with free water to correct her sodium, and she was continued on both vanc and zosyn for antibiotics. given that she was recently hospitalized for influenza earlier in the month, it was thought she was at high risk for a nosocomial pneumonia, (also staph a. pneumonia post influenza). she had a repeat cxr the following day, which showed a more definitive infiltrate to suggest pneumonia. bottles from her blood cultures grew coag negative staph. on the morning following admission, she became much more alert and talkative, demonstrating echolalia. her family confirmed that her mental status was close to baseline on discharge. a picc line was placed by ir on without complication. she was discharged on 10 days of vancomycin and zosyn therapy. her home medications for alzheimer's were intially held while she was npo but were restarted on transfer to the floor. . # f/e/n: she was initially kept npo out of concern for sepsis and altered mental status. she had recently undergone a speech and swallow eval at ; these results were obtained, which recommended the patient be kept on a pureed diet with honey thickened liquids. she was fed under aspiration precautions. medications on admission: aricept 10mg daily vitamin e 80u qpm zyprexa 5mg qpm namenda 5mg qpm tylenol 650 supp q6:prn discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 3. memantine 5 mg tablet sig: one (1) tablet po qpm (). 4. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 5. vancomycin 1,000 mg recon soln sig: 1000 (1000) mg intravenous twice a day for 10 days. 6. levofloxacin 500 mg tablet sig: one (1) tablet po once a day for 10 days. discharge disposition: extended care facility: manor - discharge diagnosis: pneumonia hypernatremia sepsis bacteremia severe dementia paroxysmal afib discharge condition: stable, back to baseline mental status. afebrile and normotensive. discharge instructions: please return if you experience shortness of breath, fever >101.5, loow blood pressure, chest pain, lethargy, or any other worrisome symptoms. please take all medications as directed. you have been prescribed 2 antibiotics to take for your pneumonia. followup instructions: please follow-up with dr within 1-2 weeks at . Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Depressive disorder, not elsewhere classified Methicillin susceptible Staphylococcus aureus septicemia Pneumonitis due to inhalation of food or vomitus Septic shock Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Hyperosmolality and/or hypernatremia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: blood from trach major surgical or invasive procedure: bronchoscopy (bedside): small area of injury at main carina without active bleeding. blood seen in all segments and cleared fully. upon re-inspection return of blood seen and with bal progressive bloody return seen. history of present illness: hpi: ms. is an 89 yo female with pmh notable for alzheimer's disease, depression, paroxysmal afib on coumadin and recent admission to micu for mrsa pneumonia, proteus urosepsis and stenotrophomonas vap who presents from her rehab facility with bright red blood from her trach. on at 1400, the patient was noted to have blood-tinged secretions. at that time, labs were obtained and heparin was held. lasix was also increased to 40 mg iv bid. at 1500, nurse blood from trach. inr noted to be 5.4 with hct 29.1. later in the evening (2300), her nurse hemoptysis with hct down to 23.8; vent settings at that time ac 12x350, peep 5, fio2 40% with oxygen saturation 93%. cxr showed worsening bilateral infiltrates by report; she had a ct scan of the chest which showed at midnight, she was seen by the icu resident that she had been treated with 2 u ffp and 5 mg vitamin k. abg at that time demonstrated ph 7.46 / pco2 59 / po2 77. due to hemoptysis, the patient was transferred back to the icu for further evaluation and treatment. . on arrival to the ccu, the patient has blood secretions from her et tube. she opens eyes to voice and actively opposes eye opening but otherwise is nonverbal at present. past medical history: alzheimer's depression hypernatremia paroxymal afib h/o urinary tract infections cholelithiasis h/o influenza a/b social history: permanent resident of manor. chinese speaking only, son and daughter active in her life and visit daily. family history: n/a physical exam: vitals: t 98.9, hr 108, bp 171/88, rr 37, o2 100% on ac 12x400, peep 5, fio2 60% gen: lying still with eyes closed, trach in place, no distress heent: actively opposes eye opening, tongue slightly dry neck: trach in place with mild bright red ooze surrounding insertion site pulm: coarse breath sounds bilaterally, expiratory wheeze r>l cv: rrr, difficult to hear due to vent noise abd: firm, no guarding or rebound, hypoactive bowel sounds, no specific areas of palpation which elicit grimace, peg tube in place in luq with minimal surrounding erythema extr: extremities warm, 3+ pitting edema to thighs, bruise on right hand, r picc in place neuro: trached, opens eyes to sound occasionally, actively opposes eye opening and does not follow other commands pertinent results: 02:37am blood wbc-10.8# rbc-2.09* hgb-7.2* hct-20.9* mcv-100* mch-34.6* mchc-34.6 rdw-18.2* plt ct-271 03:54pm blood hct-25.4* 04:00am blood wbc-8.9 rbc-2.49* hgb-8.1* hct-23.5* mcv-94 mch-32.3* mchc-34.3 rdw-19.5* plt ct-228 10:53am blood hct-22.8* 10:53am blood hct-22.8* 10:00pm blood hct-25.4* 03:32am blood wbc-8.7 rbc-2.65* hgb-8.5* hct-24.0* mcv-91 mch-32.0 mchc-35.4* rdw-18.4* plt ct-207 03:32am blood wbc-8.7 rbc-2.65* hgb-8.5* hct-24.0* mcv-91 mch-32.0 mchc-35.4* rdw-18.4* plt ct-207 03:34am blood wbc-13.5* rbc-2.80* hgb-9.0* hct-26.6* mcv-95 mch-32.0 mchc-33.7 rdw-18.3* plt ct-280 03:56am blood wbc-11.6* rbc-2.28* hgb-7.5* hct-21.6* mcv-95 mch-33.1* mchc-35.0 rdw-18.1* plt ct-249 05:23am blood hct-20.7* 03:19pm blood wbc-11.0 rbc-2.83* hgb-9.1* hct-25.4* mcv-90 mch-32.0 mchc-35.7* rdw-18.7* plt ct-198 03:35am blood wbc-11.8* rbc-3.38* hgb-10.5* hct-30.4* mcv-90 mch-31.0 mchc-34.5 rdw-17.4* plt ct-192 02:37am blood neuts-91.5* lymphs-2.6* monos-4.2 eos-1.5 baso-0.2 02:37am blood pt-23.6* ptt-41.5* inr(pt)-2.3* 03:54pm blood pt-16.7* inr(pt)-1.5* 04:00am blood pt-16.1* ptt-34.5 inr(pt)-1.4* 03:32am blood pt-20.9* ptt-35.8* inr(pt)-2.0* 03:34am blood pt-25.3* ptt-32.2 inr(pt)-2.5* 03:56am blood pt-16.4* ptt-28.8 inr(pt)-1.5* 03:54am blood pt-15.5* ptt-30.1 inr(pt)-1.4* 03:35am blood pt-16.5* ptt-28.4 inr(pt)-1.5* 05:23am blood ret aut-2.4 02:37am blood glucose-161* urean-32* creat-1.4* na-134 k-4.6 cl-90* hco3-40* angap-9 04:00am blood glucose-76 urean-34* creat-1.4* na-136 k-4.8 cl-91* hco3-39* angap-11 03:34am blood glucose-132* urean-38* creat-1.9* na-134 k-5.0 cl-89* hco3-42* angap-8 03:56am blood glucose-71 urean-43* creat-2.0* na-134 k-4.6 cl-90* hco3-38* angap-11 03:35am blood glucose-120* urean-44* creat-1.8* na-137 k-4.0 cl-93* hco3-38* angap-10 06:55pm blood glucose-133* urean-44* creat-1.7* na-140 k-4.2 cl-97 hco3-40* angap-7* 02:37am blood alt-18 ast-25 ld(ldh)-209 alkphos-88 totbili-0.2 02:37am blood lipase-54 02:37am blood albumin-2.6* calcium-8.5 phos-4.0# mg-2.5 03:56am blood hapto-142 03:54pm blood anca-negative b 06:29pm blood vanco-15.0 06:06pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-sm urobiln-neg ph-5.0 leuks-mod 06:06pm urine rbc-21-50* wbc-* bacteri-mod yeast-none epi-0-2 renalep-1 06:06pm urine color-yellow appear-hazy sp -1.017 06:06pm urine casthy-<1 03:02pm urine eos-positive 10:27am urine hours-random urean-440 creat-64 na-18 cl-less than uric ac-23.9 10:27am urine osmolal-336 . micro data: 3:56 am bronchial washings **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): ~/ml oropharyngeal flora. . 9:57 pm catheter tip-iv source: r arm picc. **final report ** wound culture (final ): no significant growth. . 2:51 pm stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). . radiographic studies: cxr: impression: 1. developing right upper lobe infiltrate. 2. continued bilateral pleural effusions with bibasilar atelectasis. 3. findings concerning for mild congestive failure. . ct: impression: 1. migration of gastric tube into the rectus sheath. there is a clear connection, however, into the stomach and no evidence for free air or free fluid. repositioning of tube is recommended. 2. no radiographic explanation for falling hematocrit. 3. multiple incidental findings including right staghorn calculus, porcelain gallbladder, anasarca, bilateral pleural effusions with associated atelectasis, and severe atherosclerotic disease. . cxr: compared to the study from the prior day, there is increased vascular congestion and increased volume loss in both lower s. an underlying infectious infiltrate cannot be excluded. diffuse alveolar opacities are again seen. . brief hospital course: a/p: 89 yo with pmh of alzheimer's dementia, hypernatremia, uti presents with ams, sepsis physiology, uti, and impressive hypernatremia. . # blood from trach: seems from clinical history provided by rehab that patient's secretions initially were "blood tinged" and progressed to frankly blood over the course of the day on . her hematocrit in the same time period has decreased from 29-->23.8. bronchoscopy on arrival to the icu demonstrated bloody secretions which did not clear but became progressively bloodier making diffuse alveolar hemorrhage most likely diagnosis. however, could also represent lesion near trach insertion but this is less likely given bronch findings. was given 2u prbc x1 at initial presentation. held aspirin and coumadin, reversed inr with ffp, vitamin k po, and then vitamin k iv for refractory elevated inr. once inr reversed trach oozing stoped. anca negative, anti-gbm negative. . # anemia: hct drop x3 since admission. transfused 3x with 2u of blood. initial drop explained by dah. hct did not bump appropriately, found to have melena x1 and repeatedly giauac pos stool. melena explained by the peg gastric wall erosion. hemolysis labs negative. enlarging hematoma in l arm, axilla, and anterior chest, but likely source of hct drop. ct showed no intraperitoneal or retroperitoneal hemorrhage. hct has been stable as of . . # respiratory failure: initial decompensation likely due to diffuse alveolar hemorrhage, although contribution of underlying pneumonia, fluid overload, and baseline disease (?) likely contribute. of note, during prior admission patient was unsuccessfully extubated twice and could not be weaned off the vent after several attempts due to high risbis and acidemia. the patient continued to be ventilator dependent at her rehab facility and has failed trach mask and low pressure support ventilation during this admission b/c of very low tidal volumes (down to 130??????s) which improved after pressure support was increased from 10 to 20. patient??????s air movement also did improve after albuterol nebulizer treatment as per nursing staff. lasix boluses initially attempted without much improvement in uop and stopped because of rising cr. stenotrophomonis pneumonia treatment course completed. 3+gnr in sputum stain, sputum culture growing ceftriaxone-sensitive e.coli. ecoli also isolated for peg site culture and urine culture. her antibiotic regimen was adjusted. lasix drip was again attempted later in the hospital course with good response in urine output but not significant improvement in respiratory status. lasix converted to iv 60mg tid. cr and fluid status should continue to be monitored. . # acute renal failure: likely related to volume depletion secondary to blood loss and up titration of lasix at rehab and in micu as creatinine has trended up over the past week per their records higher bicarbonate level and feurea of 34% would support volume depletion as well. ua w/few eos, rare hyaline casts reported. did have hematuria, but difficult to interpret in setting of indwelling foley, elevated inr. on urine culture grew ceftriaxone-sensitive e.coli and antibiotic regimen was adjusted to cover. last day of ceftriaxone treatment should be . could also represent component of systemic process if dah associated with goodpasture's or wegener's (however anti-gbm negative). staghorn r kidney stone noted on ct could be contributing. urine has been progressively more clear and her urine output has improved on lasix drip. with improved urine output, lasix drip was stopped and she was started on lasix po 60mg tid. . #uti: ecoli with same sensitivity profile as the peg swab culture and sputum isolated in urine. treatment with ceftriaxone as above. vre colonized in urine as well. . # peg complications: erythema/ pus around peg likely combination of dermatitis/skin breakdown from pressure of peg on skin w/some cellulitic component. initially improved after 3 days on vanco and after padded bandage placed between peg and skin but has worsened over last 48 hours with increasingly purulent exudate around the tube. patient also with erosion of gastric wall around peg site. endoscopy by ip showed that peg balloon still in stomach, was re-positioned to decrease pressure on wall to better allow for healing. no free intraperitoneal air was noted on ct. repeat egd showed dobbhoff still post pyloric. erosion around peg greatly improved. peg ballon in place. no stiches needed. cultures of discharge shown to be e.coli, also sensitive to ceftriaxone. vanco was continued to treat cellulitis- last day for 10 day course. as per ip recommendations, peg to low intermittent suction. ct confirmed peg placement, dobhoff placement and r/o free air (final read pending). per ip peg tip is 2cm from stomach wall and should not be moved for 3 weeks. tube feeds were restarted via peg and well-tolerated. . # paroxysmal afib: the patient was recently started on coumadin at the rehab facility with inr now > 5 on coumadin 5 mg daily. chads-2 score by my calculation only 1 due to age-not clear that patient has h/o hypertension or chf and no documented h/o stroke or dm. aspirin and coumadin were held. she has not been on anti-arrhythmic medications and maintained a good heart rate. futher anticoagulation should be avoided . # abdominal distension: nttp. has been intermittently present since admission. usually resolves with bowel movement. lfts and lipase normal. ct w/peg findings discussed above and porcelain gallbladder, but no evidence of intraperitoneal bleed or other intraabdominal process. further work up of porcelian gallbladder as outpatient as this is often associated with adenocarcinoma. . # recent stenotrophomonas vap: treated with bactrim 250 mg iv q8h, stop date 12/5 per prior d/c summary. . # alzheimer's: cont home meds when using peg tube. during admission pt mouths words but will not follow commands. pt non-english speaking. . # ppx: ppi, heparin sq& pneumoboots, bowel regimen prn . # fen: tf via peg. . # code: dnr/dni, confirmed with son who is hcp . # access: right-sided picc (placed at during previous admission) . # communication: with patient and son ( cell . # dispo: icu level care given vent requirement medications on admission: meds: coumadin 5 mg daily bactrim 250 mg iv q8h (until ) lasix 40 mg iv qam, 20 mg iv qnoon, 40 mg iv qpm dulcolax 10 mg po daily miralax 17 g daily chlorhexidine mouth wash colace 100 mg ranitidine 150 mg daily xopenex nebs q4h and q2h prn atrovent nebs q4h & q2h prn neutraphos 1 cap 4x/day x 3 days k-phos 1 packet q6h x 3 days vitamin k 5 mg po x 1 aricept 10 mg daily memantine 10 mg vitamin e 800 u daily hep sc tid lactulose 15 ml po daily asa 325 mg po daily miconazole powder prn caltrate with vit d 600 u po bid discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 2. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 3. ipratropium bromide 17 mcg/actuation aerosol : six (6) puff inhalation q6h (every 6 hours). 4. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. docusate sodium 50 mg/5 ml liquid : two (2) po bid (2 times a day) as needed. 6. polyethylene glycol 3350 100 % powder : seventeen (17) g po daily (daily) as needed. 7. albuterol 90 mcg/actuation aerosol : 2-4 puffs inhalation q4h (every 4 hours) as needed for wheezing. 8. lactulose 10 gram/15 ml syrup : thirty (30) ml po q8h (every 8 hours) as needed. 9. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 10. heparin (porcine) 5,000 unit/ml solution : one (1) 5000 unit dose injection tid (3 times a day). 11. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 12. metoclopramide 5 mg iv q6h:prn 13. 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. 14. ceftriaxone 1 g iv q24h day 1 15. 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. 16. furosemide 60 mg iv q8h 17. insulin lispro 100 unit/ml solution : 2-10 units subcutaneous asdir (as directed): per humalog isulin sliding scale. discharge disposition: extended care facility: northeast - discharge diagnosis: diffuse aveolar hemmorrhage acute on chronic respiratory failure acute renal failure gastric erosion secondary to peg tube ecoli pneumonia ecoli uti abdominal cellulitis end stage dementia anemia paroxysmal atrial fibrillation discharge condition: stable, vent dependent. discharge instructions: you were admitted to the hospital for bleeding from your tracheotomy tube. you were found to have diffuse injury termed diffuse aveolar hemmorhage. the bleeding in your s was stoped with reversing your coumadin. you were given blood for your anemia. we have not been able to wean you off the ventilator. . you had acute renal failure from overdiuresis and blood loss. it has gradually improved. we are now trying to take fluid off with diuretics. . you peg tube was found to be eroding through your stomach wall. the tube was repositioned and the erossion has improved. tube feeds were resumed. . you were found to have e. coli present in your , over the peg, and in the urine. you are being treated with antibiotics for the infection. . the following pertinent changes were made to your medications. coumadin was stoped. bactrim course was completed you were started on ceftriaxone . please follow up with your doctor as detailed below . if you develop presistant fever, return of bloody secretions from your , abdominal pain or return of pus from around the peg site, dirrhea, please seek urgent medical attention. followup instructions: please call your pcp for follow up within 1-2 weeks after discharge from rehab. md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Transfusion of other serum Diagnoses: Abnormal coagulation profile Cellulitis and abscess of trunk Urinary tract infection, site not specified Acute posthemorrhagic anemia Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Depressive disorder, not elsewhere classified Acute and chronic respiratory failure Pressure ulcer, other site Other complications due to other vascular device, implant, and graft Long-term (current) use of anticoagulants Pneumonia due to escherichia coli [E. coli] Anticoagulants causing adverse effects in therapeutic use Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Calculus of kidney Tracheostomy status Infection of gastrostomy Mechanical complication of gastrostomy Pressure ulcer, stage II Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms

history of present illness: the patient is a 57 year old woman who was walking on her treadmill the evening of admission, when she developed a sudden onset of severe 10 on 10 headache, worse than any previous headache she had ever had. she had to get off the treadmill and lay down. she took 3 ecotrin and continued with headache for approximately 4 hours until she awoke her husband and then asked to go to the emergency room. she had positive nausea, denies any neck pain, visual changes, shortness of breath, chest pain or abdominal pain. past medical history: osteopenia and headaches. allergies: no known allergies. medications: evista. physical examination: temperature is 97.1, 140/70, 88, 20, 99% on room air. heent: mucous membranes moist. pupils equal, round and reactive to light. eoms full. pulmonary: lungs clear bilaterally. cardiovascular: regular rate and rhythm. extremities: no cyanosis, clubbing or edema. neuro: awake, alert and oriented times 3 with no drift. smile symmetric. eoms full. pupils equal, round and reactive to light. visual fields full. strength 5/5 in all muscle groups. reflexes 2+ throughout. toes are mute. hospital course: the patient was admitted to the icu for close neurologic observation headache. cta to rule out aneurysm or vascular malformation. she had an angiogram on that showed a left ophthalmic aneurysm, which was coiled without complication. she was monitored in the icu. postop her vital signs remain stable. she was neurologically intact. pupils equal, round and reactive to light. eoms full. chest clear to auscultation. her head ct on admission showed no obvious bleeding. on she had a central line place to monitor cvps. her blood pressure was kept initially less than 140 and then liberalized to the 150s. she remained neurologically intact. she was transferred to the step down unit on . she remains neurologically stable, was transferred to the regular floor on , where she also remained neurologically intact. she was discharged to home on with follow up with dr. in one week. discharge medications: her medications at the time of discharge include: 1. levofloxacin 500 mg po q.24h for a uti. 2. restarting her evista, which was her pre-hospital medication. condition on discharge: her condition remains stable at the time of discharge. , Procedure: Venous catheterization, not elsewhere classified Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Subarachnoid hemorrhage Disorder of bone and cartilage, unspecified

history of present illness: patient is a 68-year-old gentleman with a past medical history significant for severe copd, afib, anxiety and depression, who was transferred from hospital on to for further evaluation of his copd. specifically, the patient was admitted to the ct surgery service for evaluation for potential lung volume reduction surgery. the patient's primary pulmonologist at hospital is dr. and he referred the patient specifically to dr. , a ct surgery attending at . the hospital course from up until has been dictated previously by a ct surgeon on dr. team. to briefly summarize their report, the patient was transferred on with issues including failure to thrive, copd, cachexia with severe malnutrition, and a small/medium vessel vasculitis resulting in multiple skin erosions on all four of the patient's extremities. while on the ct surgery service, the patient was evaluated by multiple services, including dermatology, plastic surgery, vascular surgery, infectious disease, rheumatology, pulmonary, nutrition, and physical therapy. the pulmonary service recommended inhaled steroids as well as around-the-clock mdis including atrovent and albuterol for his pulmonary disease. he had pulmonary function testing on that revealed a svc of 2.98, which is 70% of predicted, a fev1 of 0.96, which is 33% predicted, and a fev1:fvc ratio of 32, which is 47% predicted. this is consistent with very severe copd. the patient had a ct of the chest with and without contrast on that showed no lymphadenopathy, extensive emphysematous changes bilaterally, and multiple small bilateral vague patchy areas of nodularity of uncertain significance. there were no pleural or pericardial effusions, no infiltrates. an incidental finding was made of an infrarenal aortic stenosis and extensive vascular calcifications. because of this incidental finding, the patient had bilateral pvr testing that revealed significantly decreased flow to the right leg and a normal pvr of the left leg. the patient subsequently had bilateral lower extremity angiograms on , which revealed near total occlusion of the right common iliac artery and therefore, the patient underwent two stents by dr. being placed in that artery. as far as further significant events during his ct surgery hospital course, the patient was evaluated by dermatology and had multiple biopsies of the skin ulcerations. he was diagnosed with a medium vessel vasculitis thought to be secondary to medications. the most likely culprit is amoxicillin, which the patient had been taking for a copd flare prior to his hospitalization at hospital. there was no evidence of a systemic vasculitis or rheumatologic issue based on multiple testing including negative , negative rheumatoid factor, negative anca, and negative rpr. of note, infectious disease was also consulted as mentioned above at the outside hospital. these ulcers secondary to vasculitis on the patient's extremities grew out both mrsa and enterococcus, therefore the patient was placed on linezolid and ciprofloxacin to cover these organisms. the reason antibiotics were started was that the patient had a leukocytosis with a peak white blood cell count of 28,000 while on the ct surgery service team. also from an id perspective, the patient was treated empirically for clostridium difficile infection because of profuse diarrhea, which improved with flagyl. this describes the hospital course on the ct surgery service as noted in a previous dictation. it was felt that because of the patient's multiple comorbidities including malnutrition and this vasculitis, he was not currently a candidate for lung volume reduction surgery. the patient was transferred to the micu green team resident only service on for hypercapnic respiratory failure. for 24 hours prior to transfer, the patient had been having difficulty breathing and was somnolent on the floor. serial abgs showed a worsening hypercapnia. his abg on the evening of was 7.3, 60, and 80. the next morning the patient was still having difficulty. was noted to be somnolent, and his abg was 7.21 ph, 80 pco2, and 80 o2. therefore, the micu team was called. the patient on examination was noted to have diffuse expiratory wheezes and was found to be in hypercapnic respiratory failure. he was transferred immediately to the micu. a trial of bipap was initiated as the patient had responded to this in the past. an a-line was placed in the patient's right arm immediately. after 15 minutes on bipap, repeat abg was ph 7.19, pco2 87, and po2 had dropped to 52. therefore, anesthesia was called for an elective intubation. the patient was sedated with fentanyl, versed, was intubated and placed on assist control 550/16 100 fio2. repeat blood gas immediately after intubation was 7.23, pco2 of 70, and po2 of 367. the vent was therefore changed to ac at 50% fio2, 550 tidal volume by 20% respiratory rate with a repeat abg of ph 7.32, pco2 of 55, and po2 of 101. of note, immediately after intubation, the patient was noted to become hypotensive with mean arterial pressures between 40 and 50 and required the use of levophed as a pressor. a chest x-ray was obtained post intubation that showed no evidence of infiltrate, no new pneumothoraces, and no obvious explanation for why the patient had a hypercapnic respiratory failure. past medical history: 1. copd: patient has had heavy tobacco use for 30 plus years. of note the patient had recently been hospitalized in for a pneumonia and a copd flare requiring bipap use. prior to this hospitalization at , however, the patient had never required intubation. a month prior to admission, the patient had been on p.o. prednisone for copd flare. baseline sats were 93% per outside hospital records. patient was not on home o2. 2. paroxysmal atrial fibrillation, not anticoagulated. 3. mrsa wound infections in the lower extremities, also enterococcus, and gram-negative rods in the wound infection/vasculitis. social history: the patient lives on . he lives by himself. he is a retired air force pilot. he was a prior competitive swimmer. he is separated from his wife since . has two children, who are very involved in his care, a son who lives on , and a daughter, who lives in . medications on transfer from the ct surgery service: 1. protonix 40 iv q.d. 2. thiamine 50 p.o. q.d. 3. lovenox 40 subq q.d. 4. toradol 15 iv q.6h. prn. 5. vancomycin 500 mg iv q.d. 6. ciprofloxacin 500 mg p.o. b.i.d. 7. doxycycline 100 mg iv q.d. 8. solu-medrol 30 mg q.8h. 9. albuterol prn. allergies: procaine, novocaine, anesthetics, and penicillin. physical exam on admission to the micu: the patient was afebrile. blood pressure was quite labile ranging from systolic blood pressure of 60-190/diagnostic of 40-100, pulse was 70-120 and was regular. in general, the patient prior to intubation appeared very labored from a breathing perspective. he was quite somnolent and only responded to questions with a lot of prompting and shaking. patient is very cachectic. heent: pupils are equal, round, and reactive to light and accommodation. extraocular muscles are intact. oropharynx is clear. heart: s1, s2, regular, no murmurs, rubs, or gallops. lungs: diffuse expiratory wheezes bilaterally, no crackles. abdomen was soft, nontender, and nondistended, positive bowel sounds. extremities: multiple ulcers in the legs and arms and some areas of modeling in the legs. neurologically: the patient was responsive to commands, but otherwise quite somnolent and was subsequently intubated. data on admission: hematocrit was 31.6, white count was 17.5 with 96% neutrophils and 0 bands. inr is 0.8. ptt 28, pt 11. platelet count was 413. chemistries: sodium 140, potassium 5, chloride 103, bicarb 28, bun 43, creatinine 0.5, glucose 127, calcium 8.9, magnesium 1.7, phosphorus 4.9. urine electrolytes were significant for a fena of 0.1%. clostridium difficile was negative x2. blood cultures from admission and showed no growth to date. ekg was normal sinus rhythm, rate 100, normal axis, prominent p waves. old q waves in the inferior leads and slightly early r-wave progression. these ekg changes were old. assessment and plan: patient is a 68-year-old gentleman with severe copd initially admitted to the ct surgery service on for evaluation for potential lung volume reduction surgery. as the patient had multiple other comorbidities as noted including a medium vessel vasculitis thought to be secondary to medication, extreme cachexia from his copd and malnutrition, and likely clostridium difficile colitis, the surgery was deferred. the patient had an episode of hypercapnic respiratory failure and therefore was transferred to the micu for further care and was intubated. hospital course: 1. respiratory failure: on initial admission, it was unclear as to the etiology of the patient's hypercapnic respiratory failure. initial chest x-ray on admission showed no evidence of pulmonary infiltrates, and no evidence of pneumothoraces. status post intubation, the patient became more and more hypotensive and pressor dependent. while a central line was being placed in the right internal jugular vein, the patient became severely bradycardic and eventually asystolic. a cardiac arrest code was called, and the patient went from asystole to a pea arrest requiring epinephrine and atropine dosing. the patient then entered a ventricular fibrillation and was shocked multiple times. the patient then returned to sinus rhythm in the 80s with a blood pressure that rose using multiple pressors. in this setting, a repeat chest x-ray was obtained. this showed a very large right-sided tension pneumothorax. a needle decompression was performed and a chest tube was immediately placed by the surgery service. based on the above description, it was felt that the patient's hypotension post bipap and intubation likely reflected the beginnings of a pneumothorax and that with subsequent peep as well as auto peep, this developed into a tension pneumothorax leading to a pea arrest. although this occurred in the setting of a right ij placement, it was not felt that the pneumothorax was due to the right ij being placed, although this is a possibility. as the patient became hypotensive immediately after intubation, however, it is most likely that the patient had an apical bleb then ruptured with intubation. the patient's pneumothorax resolved with needle decompression and placement of a chest tube. he was intubated and weaned until at which time the patient was extubated. however, over the next 24 hours, the patient began more and more hypercapnic and required reintubation on . the right apical pneumothorax was stable and this decompensation was felt to be due to extremely severe copd. as the patient was becoming difficult to wean, it was decided that it would be in the patient's best interest to have a tracheostomy placed for further weaning and for patient's safety. therefore, a tracheostomy was placed on tuesday, . at the same time, a peg was also placed. these are both done by dr. with the patient's consent and the family were also very involved in the decision and agreed with these procedures. the patient tolerated the tracheostomy without complications. he was able to be weaned to cpap with pressure support and on the day of discharge to the pulmonary rehab facility, he was requiring 0 peep and a pressure support of 8 with excellent oxygenation and no signs of hypercapnia. the patient was continued on intravenous solu-medrol that was eventually tapered. the day of discharge he was to be discharged to prednisone 12.5 mg p.o. q.d. as this correlated to his solu-medrol dose of 10 iv q.d. it was decided to change to p.o. as the patient no longer had any iv access as these were all removed to prevent line-related infection, and as the patient was clinically was much more stable. the patient was continued on albuterol and atrovent mdis as well. chest x-ray prior to admission showed no pneumothorax, no infiltrates. furthermore, the patient was fitted with a passy-muir valve on two days prior to discharge and was able to use this without any respiratory difficulty. 2. cardiovascular: as noted above, the patient was hypotensive immediately post bipap and post intubation likely secondary to the tension pneumothorax on the right side. levophed pressor was required to maintain adequate blood pressure during the patient's first 24 hours within the micu, but then this was quickly weaned with decompression at the right pneumothorax. after the patient's cardiac arrest, which as stated above included asystole, then pea, then ventricular tachycardia and ventricular fibrillation, he was placed on an amiodarone drip for 24 hours. this was then discontinued. the patient does have a history of paroxysmal atrial fibrillation, however, the patient remained in normal sinus rhythm during his hospital course. the patient had no other cardiac issues during his hospital stay. he was noted at times to have some hypertension once he was weaned off the pressors. the highest blood pressure was 150 systolic with a heart rate in the high 90s. therefore, he was placed on lopressor for a short period of time. however, he did not tolerate this longterm and became somewhat hypotensive with the use of lopressor. the patient has no history of essential hypertension, and therefore he was not rechallanged with lopressor. 3. thrombocytopenia: when the patient was admitted, he had a reactive thrombocytosis most likely with platelets up to 600,000. this came down throughout his hospital course and on , the patient's platelet count had dropped to 34,000. the patient had been receiving subq heparin since admission to . at the outside hospital, he had been on lovenox for prophylaxis. the degree of drop in platelets as well as the time course was highly consistent with heparin-induced thrombocytopenia. therefore, the test for hit was sent, and this returned negative. however, with the high clinical suspicion, the patient was kept off all heparin products. as the patient's platelet count continued to drop off of heparin, hematology consult was obtained. they agreed with the high clinical suspicion for hit and recommended sending a second hit test. the second test also returned negative as this is a highly sensitive test for heparin dependent antibodies and the hit syndrome, it was felt that he does not have heparin-induced thrombocytopenia. rather, it was felt that the patient's thrombocytopenia was medication induced, most likely secondary to linezolid. the patient had an extensive workup for this thrombocytopenia before this conclusion was made, however, including he was ruled out for dic, ruled out for ttp, and ruled out for itp with a negative platelet antibody test. while entertaining the diagnosis of hit, it was decided to ultrasound all four of the patient's extremities as hit can also cause clinically significant clots. the patient was noted to have old clots within his left femoral artery as well as in his left upper extremity. therefore, once the patient's platelet count returned to within normal limits and showed upward trend, based on recommendations from the hematology service, the patient was started on prophylaxis for further clots of lovenox 30 subq b.i.d. he tolerated this medication well and his platelets remained quite stable with a platelet count in he 300's upon discharge. the patient was placed on plavix while in the ct surgery service after the two stents had been placed in the right ileac artery. even with the patient's thrombocytopenia, the plavix was continued as the risk for instent thromboses quite high within the first month of stent placement. his aspirin was held while he was severely thrombocytopenic, but then reinitiated when his platelet count returned to . 4. fen: as stated above, the patient had a peg tube placed on at the same time of tracheostomy placement. he tolerated this well, and his tube feeds were at goal 24 hours post placement of the peg. the patient had a speech and swallow evaluation on two separate occasions, once immediately pre-peg placement and one on the day prior to discharge to rehab. on both occasions, the patient failed the speech and swallow evaluation and was noted to aspirate thin liquids. a decision was made that the patient could have ice chips, but nothing else p.o. at the time of discharge. the patient had fairly normal electrolytes and only required repletion of potassium and magnesium on an infrequent basis. even with his profound nutritional deficiency, his coags including inr were within normal limits. 5. infectious disease: the patient did have a leukocytosis as mentioned above with a peak white blood cell count of 28,000. this was felt to be due to both steroid use as well as the infection in the vasculitic ulcers in the patient's extremities. the patient was placed on linezolid and ciprofloxacin for these ulcers. these medications were discontinued on the micu service as the patient no longer had a white count, was afebrile, and his skin lesions were much improved. of note, the linezolid was discontinued prior to the development of thrombocytopenia. as this patient not infrequently causes thrombocytopenia, the drop in platelets was attributed to this medication. the patient was empirically treated for clostridium difficile for a 14-day course. three clostridium difficile toxins were negative, however, with cessation of flagyl on the ct surgery service, the patient developed severe diarrhea and with reinitiation of flagyl, this stopped. once he finished his flagyl course, he had no recurrence of diarrhea. there were no other infectious issues throughout the rest of the hospital course. he remained afebrile with no evidence of pneumonia, no line infections, and his skin lesions did not become reinfected. 6. vasculitis: as above, this was diagnosed as a small to medium vessel vasculitis that was medication related. it is recommended that the patient not receive amoxicillin or other penicillin products for this reason in the future. 7. code: the patient remained full code throughout his hospital course as this was his wish as communicated by the patient on numerous occasions and as affirmed by his family. his daughter is his healthcare proxy. 8. communication: the patient's family is very involved and were present every hospital day of the patient's stay. his daughter is his healthcare proxy. the family should be contact before any changes are made in the patient's care. the daughter's name is . the patient's wife's name is , her work phone is . her home phone is . the patient's son is , who also lives on , his work phone is . his home phone is . 9. the psychiatry service did see the patient for his history of depression and anxiety, and followed him throughout his hospital course. they recommended avoiding benzodiazepines and narcotics as much as possible as they resulted in paradoxical reactions with the patient's mood. specifically, benzodiazepines resulted in hallucinations and altered sensorium. therefore, the psychiatrist recommended the use of haldol or other antipsychotics on a prn basis. 10. pneumothorax. the chest tube was kept on suction until . when the air leak subsided, chest tube was place to waterseal. chest tube was then pulled out on . discharge medications: 1. prednisone 12.5 mg p.o. q.d. to be tapered as per pulmonary rehab. 2. aspirin 325 p.o. q.d. 3. lovenox 30 subq b.i.d. for clot prophylaxis. 4. multivitamin q.d. 5. albuterol mdi q.4h. standing. 6. atrovent mdi q.6h. standing. 7. albuterol inhaled mdi q.2h. prn wheezing. 8. regular insulin-sliding scale while on prednisone. 9. haldol 1-2 mg q.4h. prn agitation. this is recommended by a psychiatry service consult. 10. neurontin 300 mg p.o. b.i.d. 11. plavix 75 p.o. q.d. 12. folic acid 1 mg p.o. q.d. 13. silver sulfadiazine 1% cream one application tp b.i.d. to the legs and arms specifically to the ulcers. 14. thiamine 100 mg p.o. q.d. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage 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 Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Cardiopulmonary resuscitation, not otherwise specified Closed biopsy of skin and subcutaneous tissue Diagnoses: Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Iatrogenic pneumothorax Cardiac arrest Intestinal infection due to Clostridium difficile Emphysematous bleb Nutritional marasmus Arteritis, unspecified

history of present illness: the patient is a 68 year old male, retired fighter pilot, with a medical history significant for advanced chronic obstructive pulmonary disease, anxiety and depression who has deteriorated significantly over the past two months requiring hospitalization. he was separated from his wife in and has been living alone on in an isolated situation, diagnosed with depression several years ago by his primary care physician and has undergone a slow decline over the past several years. he has had several episodes of pneumonia but was doing reasonably well until of last year when he developed bronchitis which progressed to pneumonia and he was admitted to hospital. since that point his decline has resulted in traumatic weight loss and the development of skin necrosis and ulceration in the bilateral lower extremities and tips of his fingers during his last hospital stay. despite an aggressive workup during the involvement of many specialists, they were unable to pinpoint the exact etiology of the problem. the patient denied any fevers, chills or sweats, hemoptysis, new neurological, musculoskeletal or gastrointestinal complaints. he denies issues with his kidneys, pancreas, liver, gallbladder and heart. past medical history: 1. history of atrial fibrillation; 2. anxiety/depression; 3. chronic obstructive pulmonary disease. past surgical history: unremarkable. medications on admission: 1. protonix 40 mg p.o. q. day 2. thiamine 50 mg p.o. q. day 3. lovenox 40 mg p.o. q. day 4. toradol 15 mg intravenously q. 6 hours prn for pain. 5. vancomycin 500 mg intravenously q. day 6. ciprofloxacin 500 mg p.o. b.i.d. 7. doxycycline 100 mg p.o. q.i.d. 8. solu-medrol 30 mg intravenously q. 8 hours 9. albuterol inhaler allergies: the patient has an allergy to procaine, novocaine, anesthetics and penicillin. social history: significant for a 45 year pack year history of smoking. family history: unremarkable. physical examination: on physical examination the patient was afebrile with vital signs stable, sating 93% on room air. the patient was a thin cachectic male who appeared in minimal to moderate distress. head was atraumatic, normocephalic. sclera were anicteric. neck was soft, supple with no masses noted and no carotid bruits. lungs were clear to auscultation bilaterally, however, breath sounds were slightly decreased, no wheezes noted. heart was regular rate and rhythm with no murmur. thorax was symmetrical without any lesions. abdomen was scaphoid, soft, nontender, nondistended. extremities showed no cyanosis, clubbing or edema, however, they did show larger areas of ulceration and necrosis, right greater than left in the lower extremities, upon which the skin appeared to be sloughing off of his body. the patient also had some areas of punctate ulceration necrosis on his hands as well. neurologically, the patient had no deficits. further detailed lower extremity ulcerations, the patient had two large necrotic ulcerations directly inferior to the right kneecap and then from approximately mid calf down the patient had large reddish ulcerations with minimal bleeding in a patchy distribution. on the left lower extremity the patient had minimally bleeding ulceration on the left forefoot that did not extend superiorly to the ankle. hospital course: the patient is a 68 year old male with severe chronic obstructive pulmonary disease, malnutrition, lower extremity ulcerations of unknown etiology who presented to the thoracic surgery service for further evaluation and treatment of multiple problems. on hospital day #2, the patient went for chest x-ray which demonstrated no definite pneumonia or cardiac failure, prominence of the right aortic contour concerning for ascending aortic aneurysm. the patient then went for a computerized tomography scan on hospital day #3 which revealed head computerized tomography scan which showed no intracranial pathological process, computerized tomography scan of the torso which demonstrated no evidence of malignancy, diffuse extensive emphysema with small peripheral patchy opacities, extensive vasculopathy with suggestion of infrarenal aortic stenosis and post traumatic dilatation, an ascending aortic aneurysm measuring 4.2 cm and a prominent left adrenal gland. at this time multiple consultations were obtained. pulmonary consultation evaluating the patient's pulmonary function tests were performed which demonstrated severe emphysematous pattern consistent with the patient's disease process. pulmonary then recommended various nebulizer treatments which were enacted. on , the patient was seen by psychiatry for increasing anxiety, depression and possible delirium change in mental status. psychiatry recommended haldol prn for agitation and also recommended checking tsh, b12 and folate levels which were all normal. there were no further recommendations made at this time, and the patient's mental status had improved over the course of the hospital stay. on , the patient was also seen by nutrition consultation which recommended boost supplements t.i.d. and calorie counts and q. day weights to monitor nutritional status. also on , the patient was seen by the dermatology service who made an assessment of vasculitis of unknown origin or an embolic phenomenon. two punch biopsies were taken at this time, one from the right lower extremity and one from the left index finger and these were sent to pathology for further analysis. also on , neurology saw the patient. they reviewed the computerized tomography scan which was normal and had no recommendations at this time. on , vascular surgery saw mr. , recommendations included noninvasive arterial studies of the lower extremities which demonstrated significant arterial disease on the right lower extremity with flexions of 9 and 6 at the ankle and metatarsal areas respectively on the right lower extremity. in addition, computerized tomography scan was evaluated and infrarenal narrowing of the aorta was noted but thought to be subclinical. dr. , the vascular surgeon at this time, recommended bilateral lower extremity angiogram with possible intervention. in addition vascular surgery recommended silvadene and adaptic dressings to the lower extremity ulcerations b.i.d. on , the patient was seen by nutrition again. the patient was taking in approximately 44 gm of protein and 1400 cal/day which was sufficient for the patient's nutritional needs. the patient was demonstrating a steady weight gain. on , the patient went for bilateral lower extremity angiogram by dr. in the cardiac catheterization laboratory. the patient was found to have near total occlusion of the right common iliac artery and two stents were placed after angioplasty of this area as well as two stents placed in the left common iliac artery. the patient did well post procedure with no groin hematoma, no bruit in the groin. immediately post procedure the patient reported feeling much better in the lower extremities than prior. up until this point the patient had a white count that was hovering between 20 and 24. skin cultures at this point came back only positive for corynebacteria. blood cultures have been negative to date. on , infectious disease saw the patient. recommendations included discontinuing the vancomycin which the patient was on and changing it to linezolid 600 mg p.o. q. 12 hours and continuing the ciprofloxacin. the patient was also recommended to have clostridium difficile sent off which all were negative. on , the patient's punch biopsy by dermatology returned negative for vasculitis in the lower extremity biopsy sample, but the left index finger was positive for vasculitis with definite changes in the small/medium sized arteries. at this time, differential diagnosis included systemic vasculitis or drug vasculitis. multiple systemic laboratory data were sent off including cryoglobulin, c3, c4 which all returned negative. the patient was seen by plastic surgery on for possible skin graft treatment for her lower extremity ulcerations which were somewhat improving. plastic surgery evaluated the patient and made no recommendations at this time, hoping for the patient's ulcerations to heal slightly prior to repeat evaluation assessment as an outpatient. secondary to the patient's persistent high white count the patient was sent for bone scan to rule out osteomyelitis and on the patient was sent and test was negative. post intervention pvrs demonstrated increased flow of arterial supply in the right lower extremity. on , the patient was seen by rheumatology for assessment of vasculitis. additional laboratory data were sent off including esr, crpna which were all negative. tentative diagnosis at this time of the etiology of lower extremity ulceration was drug vasculitis due to vancomycin. on hospital day #13, the patient was seen as fit to be transferred to a rehabilitation center. unfortunately, he was then was found down and hypotensive and required intubation and resusitation and transfer to the icu. the details of which are in a followup addendum. discharge status: to rehabilitation. discharge condition: stable. discharge diagnosis: 1. drug vasculitis. 2. severe pulmonary emphysema. 3. anxiety, depression. 4. peripheral vascular disease. follow up: the patient is to follow up with multiple services, plastic surgery, dr. , infectious disease, dr. , rheumatology, dr. , surgery, dr. in one to two weeks, please call for an appointment, vascular surgery, dr. . medications on discharge: 1. protonix 40 mg p.o. q. day 2. thiamine 100 mg p.o. q. day 3. heparin 5000 units subcutaneously b.i.d. while in bed. 4. combivent inhaler 1 nebulizer q. 6 hours. 5. serevent inhaler 1 disc q. 12 hours. 6. silver sulfadiazine cream apply topically b.i.d. 7. folic acid 1 mg p.o. q. day 8. multivitamin one tablet p.o. q. day 9. aspirin 325 mg p.o. q. day 10. plavix 75 mg p.o. q. day 11. albuterol inhaler one nebulizer q. 6 hours prn 12. ultram 50 to 100 mg p.o. q. 6 hours prn for pain 13. ibuprofen 600 mg p.o. q. 6 hours 14. neurontin 300 mg p.o. q.h.s. 15. solu-medrol 30 mg, 20 mg and 30 mg q. day until mg, 10 mg and 30 mg until mg, 30 mg until mg 20 mg until mg then 10 mg until mg until mg until and 10 mg until , intravenously as directed. 16. linezolid 600 mg p.o. q.12 hrs to be adjusted at follow up. 17. ciprofloxacin 500 mg p.o. q. 12 hours to be adjusted at further follow up. discharge instructions: the patient is to have wound care as directed, silvadene adaptic dressings to lower extremities b.i.d. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage 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 Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Cardiopulmonary resuscitation, not otherwise specified Closed biopsy of skin and subcutaneous tissue Diagnoses: Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Iatrogenic pneumothorax Cardiac arrest Intestinal infection due to Clostridium difficile Emphysematous bleb Nutritional marasmus Arteritis, unspecified

history of present illness: the patient is a 72-year-old female who was recently discharged from from the vascular surgery service on during which she was being worked up for left calf claudication and a non healing ulcer. the angiography had revealed left superficial femoral artery stenosis at the adductor canal and during the work up for surgical treatment, the stress test was found to be positive. the cardiac catheterization was performed on which revealed severe two vessel disease. the lad had moderate diffuse disease with 80% stenosis in the proximal portion. the rca had an 80% mid lesion and a 90% distal followed by serial severe lesions distally and it was noted that she had severe left ventricular diastolic dysfunction. she was evaluated by the cardiothoracic surgery service and it was deemed that she would coronary artery bypass graft prior to having her sfa bypass by the vascular surgery service. she was discharged home and was to return to on the day of admission to have coronary artery bypass graft. past medical history: 1. diabetes mellitus type ii 2. hypertension 3. hypercholesterolemia 4. glaucoma past surgical history: 1. right mastectomy in admission medications: 1. glucophage 850 mg po tid 2. avandia 4 mg po bid 3. glucotrol xl 10 mg po bid 4. zestril 10 mg po qd 5. lipitor 40 mg po qd 6. xalatan eyedrops 7. resqula eyedrops 8. patanol eyedrops 9. cosopt eyedrops 10. 60 mg po bid 11. sucralfate 1 gm q day allergies: codeine physical exam: general: the patient is an obese white female in no acute distress. vital signs: her pulse is 98, blood pressure 181/64, temperature 99.6??????. head, ears, eyes, nose and throat: she is alert and oriented x3. she has no jugular venous distention, no carotid bruits. lungs: clear to auscultation bilaterally. heart: regular rate and rhythm with no murmurs. abdomen: obese, soft and nontender. extremities: she has a left lower leg ulcer with doppler signals in the distal pulses. imaging: electrocardiogram shows normal sinus rhythm with a rate of 69, no evidence of ischemia and a left shift. admission labs: white count of 6.6, hematocrit of 33.1, platelets 250. pt 12.2, ptt 26.6, inr 1.1. her sodium is 143, potassium is 3.7, chloride of 106, bicarbonate of 29, bun of 10, creatinine of 0.6, glucose of 111. calcium was 8.9, magnesium 1.5, phosphorous 3.1. hospital course: the patient on the day of admission went to the operating room where she underwent a coronary artery bypass graft x2. the grafts were left internal mammary artery to the diagonal, saphenous vein graft to the right pda. she tolerated this procedure well. she was transferred to the cardiac intensive care unit on a drip of propofol at 20 mcg per kg per minute and neo at 0.3 mcg per kg per minute. in the first postoperative day, the patient was weaned to be extubated. her drips were weaned. she remained hemodynamically stable through the first postoperative night. on postoperative day #1, she was transferred to the floor in stable condition. on the floor, she remained hemodynamically stable. she was started on her lopressor which was appropriately adjusted for a heart rate around 80. her chest tubes were discontinued on postoperative day #2. her pacer wires were discontinued on postoperative day #3. physical therapy evaluated the patient and deemed her appropriate for a short stay in rehabilitation. she is tolerating a regular diet. she is placed on her preoperative hypoglycemic agents. her blood sugars have remained in good control. she is stable and ready to be discharged. discharge diagnoses: 1. coronary artery disease, status post coronary artery bypass graft x2 2. diabetes mellitus 3. hypertension 4. hypercholesterolemia 5. glaucoma discharge medications: 1. lasix 20 mg po bid x7 days 2. potassium chloride 20 milliequivalents po bid x7 days 3. colace 100 mg po bid 4. zantac 150 mg po bid 5. asac 325 mg po qd 6. mvi po qd 7. zinc 240 po qd 8. vitamin c 500 mg po bid 9. santyl ointment on the left leg per application 10. glucophage 850 mg po tid 11. lipitor 40 mg po qd 12. glucotrol xl 10 mg po bid 13. avandia 4 mg po bid 14. patanol eyedrops 15. cosopt eyedrops 16. resqula eyedrops 17. lopressor 50 mg po bid 18. xalatan eyedrops q hs 19. dilaudid 2 to 4 mg po q4h prn 20. insulin sliding scale discharge condition: stable follow up: she will follow up with dr. in four weeks. she will follow up with dr. in two to three weeks. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Obesity, unspecified Atherosclerosis of native arteries of the extremities with ulceration Heart disease, unspecified Unspecified disorder of iris and ciliary body

maternal history: mom is a 33 year old, gravida i, para 0, 1 woman, with past medical history notable for asthma, on albuterol and cystic fibrosis carrier status. father of the baby is negative for cf. prenatal screens: a positive, coombs negative, rpr nonreactive, rubella immune; gbs unknown. antepartum history: edc for estimated gestational age of 28 and 3/7 weeks by dates, with confirmatory first trimester ultrasound. 18 week ultrasound normal and consistent with dates. pregnancy complicated by preterm labor at 27 weeks, at which time she was hospitalized and received a full course of betamethasone prior to discharge home. she presented on day of delivery with evidence of hellp syndrome and proceeded to cesarean section under general anesthesia. no labor. no antepartum fever or other clinical evidence of chorioamnionitis. rupture of membranes at delivery yielding clear amniotic fluid. delivery room course: infant hypoxic, apneic with heart rate less than 100 at delivery. orally and nasally bulb suctioned. dry bag mask ventilation began, pressures of 30 to 35 mm of mercury, required for chest movement, with improvement in color and heart rate by one to two minutes of age. baby was intubated with a 2.5 endotracheal tube but could not confirm position by auscultation. extubated and reintubated again without incident. adequate breath sounds bilaterally. heart rate well maintained. apgars 3 at one minute and 7 at five minutes. physical examination: birth weight 890 grams; 10th to 25th percentile; head circumference 24 cm, 10th percentile; length 35.5 cm, 25th percentile. heart rate 130. respiratory rate 30. blood pressure 47/19 with a mean of 28. saturations 90 percent on 50 percent oxygen on the conventional ventilator. head, eyes, ears, nose and throat: anterior fontanel soft and flat, non dysmorphic. palate intact. neck and mouth normal. oral endotracheal tube in place. normal cephalic. chest: moderate intercostal retractions. fair breath sounds. bilateral coarse crackles throughout both lung fields. cv: well perfused, regular rate and rhythm. femoral pulses normal. s1 and s2 normal. no murmur. abdomen is soft, nondistended, no organomegaly, no masses. bowel sounds active. patent anus. three vessel umbilical cord. genitourinary: normal male premature genitalia. central nervous system: minimal spontaneous movement to tactile stimulation. tone: decreased in generalized distribution, appropriate for gestational age. no suck or root or gag. integumentary: normal. musculoskeletal normal spine, limbs, hips and clavicles. current examination: corrected gestational age of 37 and 2/7 weeks. baby is and active in room air, with bilateral breath sounds; clear and equal. occasionally some upper nasal secretions audible. cardiovascular: baseline heart rate 160's to 190's, stable blood pressures. no murmur. abdomen soft, full, nontender. no hepatosplenomegaly. normal phallus, testicles palpable in scrotum bilaterally. right soft inguinal hernia, easily reducible; probable left side hernia, intermittently palpable. voiding and stooling. moving all extremities. neurologic: upper and lower slight clonus, 2 plus. anterior fontanel soft and flat. hospital course: respiratory: infant received two doses of surfactant. he was electively extubated to c-pap and then required reintubation for increased work of breathing. remained on the conventional ventilator with escalation of his settings, showing a metabolic acidosis, presumed to be related to a patent ductus arteriosus. he ultimately transitioned to the high frequency ventilator and completed his first course of indomethacin. he then weaned again on ventilatory settings and did again show metabolic acidosis. he received an occasional dose of sodium bicarbonate for presumed patent ductus arteriosus. he did receive a second course of indomethacin on . he then transitioned back to the conventional ventilator. he had his patent ductus arteriosus ligated on and returned postoperative on the conventional ventilator for several days and then again required high frequency ventilator and had a concern for pie on his chest x-ray. on day of life 14, he again transitioned back to the conventional ventilator which he remained on until day of life 34. he then transitioned to continuous positive airway pressure of 7 cm. he did require some dexamethasone nasal drops for nasal irritation. he transitioned to nasal cannula by day of life 44, high flow 400 ml, ultimately weaning on , day of life 51, to room air, after being started on diuril. he currently is on 30 mg/kg per day, divided in two, being given every 12 hours, which is 28 mg p.o./p.g. every 12 hours. this is currently on hold for the operating room. he also is receiving potassium supplements, 1 meq three times a day which equals 1.5 meq/kg per day, also on hold for the operating room. his electrolytes on were 128, 4.8, 92, 23. at that time, his kcl supplements had been increased. electrolytes of are pending at the time of this dictation. baby did receive caffeine citrate from day of life 15 to day of life 20. this was discontinued secondary to a heart rate up to 210 with some supraventricular tachycardia which was resolved once it was discontinued. he has not received any further methylxanthine treatment. infant is currently in room air with baseline respiratory rate of 50 to 60. cardiovascular: initially, the baby was cardiovascularly stable. he did not require any boluses or pressors. as noted above, he did show symptoms of a patent ductus arteriosus which ultimately was treated with two course of indomethacin and ligation at the . after returning to recover postoperatively from his ligation, he had a follow-up echo on which was within normal limits. he currently has no murmur. baseline heart rate is 150 to 190 with blood pressure systolics in the 60's, diastolics in the 30's to 40's and means in the 40's to 50's. fluids, electrolytes and nutrition: baby initially had an umbilical arterial catheter and a double lumen uvc. he was started on parenteral nutrition. postoperatively, after recovering from his posterior descending artery ligation, he had enteral feedings introduced on day of life 12. he advanced to full feedings by day of life 20 without any significant events. his calories were increased slowly to breast milk 32 with promod which he is currently feeding at 150 ml/kg per day. his mother is bringing in primarily hind milk as his weight gain has been concerning, requiring the 32 calories per ounce per feeding. he is requiring some p.g. feedings. he has been going to breast and receiving supplemental p.g. feedings after breast feeding and occasionally taking a bottle. his transfer weight is grams. he has been falling just below the 10th percentile for weight. his last length was 42 cm, at the 10th percentile. his head circumference has been growing also along the 10th percentile. his additives to achieve 32 calories per ounce have been hmf 4 calories per ounce per feeding, mct oil 4 calories per ounce per feeding, polycose 4 calories per ounce per feeding, similac powder 2 calories per ounce per feeding. he has also been receiving promod one- quarter teaspoon in every 50 cc of breast milk. he has been on supplemental ferrous sulfate 0.15 ml/pg once a day of 25 mg/ml, which equals 2 mg/kg per day, vitamin e 5 units pg daily, diuril and kcl as stated above. preparation for the operating room: baby was made n.p.o. on after his midnight feeding. he was receiving peripheral intravenous fluid of d-10-w with 2 meq of sodium chloride and 2 meq of potassium chloride per 100 ml of solution. this was running at 130 cc per kg per day. all of his supplements and additives have been on hold as of midnight on . last nutrition laboratory studies: on , phosphorus was 5.4; alkaline phosphorus 358; calcium 10.9; electrolytes as stated above. gastrointestinal: the infant initially did exhibit physiologic jaundice. he had a peak bilirubin of 7.7, 0.3. he responded to triple phototherapy. his final rebound bilirubin on day of life 15 was 2.6, 0.5. hematology: the baby's blood type is b positive. he is coombs negative. his admission hematocrit was 49.9. he received a total of 4 blood transfusions during this hospitalization, the last one being on for a hematocrit of 24.8. his last hematocrit was on of 43 with a reticulocyte count of 0.9 percent. infectious disease: on admission because of his respiratory distress and prematurity, the baby had a blood culture and cbc sent. his white count was 1.7 with 25 polys, 0 bands, 61 lymphocytes, platelet count of 174,000. at that time, he was started on ampicillin and gentamycin. cnc was 425. at 24 hours, he had a repeat cbc which showed a white count of 7, 67 polys, 1 band, 22 lymphs, platelets of 249,000 and hematocrit of 52. again, on day of life two, he had a repeat white count of 5.8 with platelet count of 210,000; hematocrit of 48.7. at 48 hours of age, the baby was thought to be stable from an infectious disease standpoint and antibiotics were discontinued. his cultures remained negative. on day of life seven, he had an increase in his respiratory support which, in retrospect was thought to be related to his cardiovascular patent ductus. however, he had another cbc sent and blood culture and was started on vancomycin and gentamycin. he received one week of therapy for presumed sepsis. his cultures did show this. he also had a lumbar puncture during that course of treatment, which was benign. on day of life 24, he had a left ankle laceration secondary to a piece of tape. he had a blood culture and a cbc sent at that time an again received 7 days of vancomycin and gentamycin. he did not have a lumbar puncture at that time or a urine culture sent. his blood culture remained negative. the lesion healed nicely and he had no further issues with infection. of note, on general neonatal intensive care unit skin surveillance, he was noted to have colonization of methicillin resistant staphylococcus aureus on his skin. neurology: infant has had serial head ultrasounds, the last one being on , day of life 42. corrected gestational age of 34 and 3/7 weeks. all of his head ultrasounds have been within normal limits with no evidence of intraventricular hemorrhage or periventricular leukomalacia. the baby clinically is appropriate for gestational age. he has some slight clonus noted on his extremities. on examination, he is and active and responsive to his surroundings. he calms nicely and responds to comfort measures. sensory: audiology screening has not been performed at the time of transfer. ophthalmology: baby has had serial eye examinations, the last one being on , which showed immature retina zone three, with a plan to follow-up in three weeks, which will be the week of . psychosocial: parents have been visiting frequently. mom is a nurse midwife and she and his dad have been appropriately responding to clinical issues. they enjoy holding him and are pleased with his progress. they are coping as best they can with the neonatal intensive care unit environment and look forward to his ultimate transfer closer to home at hospital where mother practices and ultimately home with his family. condition on discharge: stable. discharge disposition: to operating room for repair of inguinal hernias by dr. , telephone number . care recommendations: continue n.p.o. with intravenous fluids as stated above. medications on hold at the time of transfer. car seat position screening not appropriate at the time of transfer. state newborn screen: serial screens have been done, the last one being on which was within normal range. immunizations: none done at the time of transfer, will be due on day of life 60. immunizations recommended: 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: not planned at the time of transfer, to be determined at the time of discharge. discharge diagnoses: former 28 and week premature male, now corrected gestational age of 37 and 2/7 weeks. status post respiratory distress syndrome with chronic lung disease. status post presumed sepsis. status post posterior descending artery ligation. status post hyperbilirubinemia. status post apnea and bradycardia of prematurity. immature retinas. inguinal hernias. , 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 Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Other phototherapy Transfusion of packed cells Umbilical vein catheterization Other surgical occlusion of vessels, thoracic vessels Bilateral repair of inguinal hernia, not otherwise specified Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period 27-28 completed weeks of gestation Primary apnea of newborn Neonatal bradycardia Patent ductus arteriosus Septicemia [sepsis] of newborn Late metabolic acidosis of newborn Inguinal hernia, without mention of obstruction or gangrene, bilateral (not specified as recurrent)

history of present illness: infant born at 33-4/7 weeks to a 29-year-old gravida 3, para 2 mother with the following negative, hepatitis b surface antigen negative, rapid plasma reagin nonreactive, group b strep unknown. antepartum history: remarkable for intrauterine insemination triplet pregnancy. triplets were dichorionic-diamniotic and monochorionic-dichorionic (#s 2 and 3 are identical). followed closely for triplets and short cervix. admitted briefly at 25 weeks and received betamethasone. readmitted at 27 weeks for preterm labor and cervical shortening. treated with magnesium sulfate, then monitored as an inpatient until delivery. past obstetrical history: obstetric history remarkable for normal term deliveries in and . peripartum: decision to deliver based on maternal discomfort. cesarean section under spinal anesthesia. apgar scores of 7 and 8 for this triplet. physical examination on presentation: weight was 2150 g (50th percentile), length was 45.5 cm (50th percentile), head circumference was 32.5 cm (75th percentile). examination was remarkable for a pink, well-appearing, preterm infant in no acute distress. head, eyes, ears, nose, and throat revealed anterior fontanel open and flat, normal faces, intact palate. chest revealed normal clavicles. no grunting or retractions. clear breath sounds bilaterally. a 1/6 systolic murmur at the left lower sternal border. no gallop was present. femoral pulses were present. abdomen was flat, soft, nontender, without hepatosplenomegaly. a 3-vessel cord. genitourinary revealed normal phallus, testes, scrotum, and stable hips. extremities revealed normal perfusion, full range of motion times four. neurologic examination revealed normal tone and activity for chronologic and gestational age. hospital course by systems: 1. respiratory: the patient has been on room air since admission with no apnea of prematurity. 2. cardiovascular: the patient has been hemodynamically entirely stable. murmur no longer audible by time of discharge. 3. fluids/electrolytes/nutrition: the patient initially started on intravenous fluids and was quickly transitioned to full enteral feeds. currently feeding enfamil 24 calories per ounce. discharge weight 2050 grams, head circumference 32 cm, length 47 cm. 4. hematology: initial hematocrit was 35.7 with a platelet count of 290,000. normal wbc differential. 5. infectious disease: no sepsis risk; therefore, no antibiotics were started. blood cultures were negative. has been receiving empiric ilotycin ophthalmic ointment for persistent eye drainage. 6. audiology: the patient passed hearing screen in both ears. 7. car seat test: the patient passed his car seat test. 8. newborn screens/immunizations: newborn screen has been sent. hepatitis b vaccination was given . 9. gastrointestinal: the patient had mild hyperbilirubinemia. no phototherapy was necessary. the patient has been bottle fed and stooling well. 10. thermoregulation: the patient had difficulty maintaining euthermia in open crib alone over the week prior to discharge necessitating a few returns to the incubator. he maintained temperatures greater than or equal to 97.7 f alone in an open crib the day prior to discharge, but did not feed or gain weight as well as he had been. reinstitution of cobedding with his brothers resolved this issue, as one of them is being discharged with him. discharge status: discharged to home along with triplet #2. primary pediatrician: primary care pediatrician is dr. in . appointment has been made for friday at 2:45pm. care recommendations: enfamil 24 p.o. ad lib. discharge diagnoses: 1. triplet #1 2. prematurity 33-4/7 weeks. 3. hyperbilirubinemia, resolved. 4. temperature dysregulation, resolved. 5. status post sepsis evaluation. 6. status post circumcision. 7. conjunctivitis vs. dacryostenosis. m.d . 50-563 dictated by: medquist36 Procedure: Prophylactic administration of vaccine against other diseases Circumcision Audiological evaluation Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Neonatal jaundice associated with preterm delivery Other preterm infants, 1,750-1,999 grams Routine or ritual circumcision Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section Neonatal conjunctivitis and dacryocystitis Other hypothermia of newborn

allergies: codeine attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp history of present illness: 79y female who presented to with 5 days of abdominal and mid-back pain that worsened severely on the morning of admission. she had mulitple episodes of dry heaving and vomited a small amount of blood. she was quickly transported to for acute pancreatitis. ultrasound revealed gallstones and peripancreatic fluid. she was admitted to the icu for futher management. past medical history: diverticulosis hypertension osteoarthritis coronary artery disease chronic back pain gastroesophageal reflux disease past surgical history: cholecystectomy left knee surgery social history: remote smoking history. no alcohol. married, lives with husband, has three children. family history: father died of myocardial infarction at age . mother died of leukemia. physical exam: vitals: 100.1, hr 96, bp 147/72, rr 21, 98% ra alert and oriented perrla, eomi rrr, no murmur lungs clear to auscultation bilaterally, with decreased sounds at the bases bilaterally abdomen: soft, obese, tender to palpation in epigastrum; involuntary guarding, no rebound ext: no clubbing, cyanosis or edema pertinent results: 12:03am blood wbc-11.2* rbc-4.26 hgb-13.4 hct-40.4 mcv-95 mch-31.4 mchc-33.1 rdw-13.0 plt ct-154 12:03am blood pt-12.5 ptt-22.7 inr(pt)-1.0 12:03am blood glucose-153* urean-21* creat-0.9 na-143 k-4.5 cl-110* hco3-20* angap-18 12:03am blood alt-840* ast-663* alkphos-165* amylase-1376* totbili-4.7* 12:03am blood lipase-2886* 12:03am blood albumin-4.0 calcium-8.7 phos-2.7 mg-1.8 06:37am blood wbc-11.8* rbc-3.57* hgb-10.9* hct-32.9* mcv-92 mch-30.6 mchc-33.2 rdw-13.3 plt ct-274 05:58am blood glucose-155* urean-27* creat-0.7 na-135 k-4.2 cl-100 hco3-26 angap-13 06:37am blood amylase-404* 06:37am blood lipase-818* cholangiogram : dilated common bile duct that is not well filled with contrast brief hospital course: ms. was admitted to the icu for aggressive fluid resusciation. she underwent emergent ercp. this revealed severe pancreatitis with bulging of the major papilla suggestive of an impacted stone. a sphincterotomy was done, and stone fragments removed from the bile duct using a balloon catheter. she tolerated the procedure well. on hospital day three, she was transferred to the floor and started on a clear diet. she was treated with levofloxacin and flagyl. she did not tolerate an oral diet, and therefore was made npo and started on tpn. sips were then slowly reintroduced. her amylase and lipase levels decreased throughout her stay. physical therapy worked with her during her hospital course. her tpn was tapered, and by hospital day 12, it was discontinued. she tolerated a regular diet. the decision was made to discharge her to home. medications on admission: toprol xl 25mg daily protonix 40mg daily hctz 25mg daily discharge medications: 1. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation: while taking pain medications. disp:*60 capsule(s)* refills:*2* 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. hydromorphone hcl 2 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: gallstone pancreatitis hypertension coronary artery disease hypvolemia discharge condition: good discharge instructions: md or go to er for temp >101, persistent nausea, vomiting or pain, or any other questions. you may resume a regular diet and your regular home medications. followup instructions: provider: , . follow-up appointment should be in 2 weeks Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Arterial catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Osteoarthrosis, unspecified whether generalized or localized, site unspecified Lumbago Diverticulosis of colon (without mention of hemorrhage) Acute pancreatitis Calculus of bile duct without mention of cholecystitis, with obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: known cad referred for cabg major surgical or invasive procedure: cabg history of present illness: known cad w stable angina which progressed to exertional symptoms. +ett followed by cath which revealed lm and 2vd preserved ef past medical history: cad, htn, niddm, ^chol, oa, bph, hernia repair, r le vein stripping, colonic surgery, appy,turp,hemorroidectomy social history: retired, lives alone remote tob (quit 25 yrs ago) +etoh/2-3 beers/day family history: mother/cad physical exam: gen: nad chest: cta cardiac: rrr no murmur abdm: soft nt/nd/nabs ext: warm well perfused, bilat edema, left thigh varicosities neuro: nonfocal brief hospital course: direct admit to or for cabg, see or report for details, pt had cabg x3(lima->lad, svg->om, svg->pda). tolerated operation well. 1 day stay in icu then transferred to flooor for increased activity tolerance. postop afib on pod 2, rate controlled w/bblockers started on amiodarone and warfarin. developed sternal drainage on pod4(nl wbc) started on vancomycin drainage resolved over next several days.. activity level slow to improve, pt screened for rehab, and cleared for d/c to rehab on pod8. medications on admission: amaryl 4mg qd, norvasc 5mg qd, zestril 20mg qd, amitriptyline 10mg qd, lipitor 10mg qd, toprol xl 25 mg , 81 mg qd discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. amitriptyline 10 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 5. furosemide 20 mg tablet sig: two (2) tablet po bid (2 times a day) for 2 weeks. 6. glimepiride 4 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. amiodarone 200 mg tablet sig: two (2) tablet po once a day: 400mg qd x1wk then 200mg qd. disp:*60 tablet(s)* refills:*0* 9. warfarin 1 mg tablet sig: one (1) tablet po once a day: adjust dose to target inr 2-2.5. discharge disposition: extended care facility: nursing home - discharge diagnosis: s/p cabgx3(lima-lad,svg->om,svg->pda) pmh:cad,htn,dm2,^chol,diverticulitis, diverticulum,bph,oa,neuropathy,gibld,ventral hernia discharge condition: good discharge instructions: keep wounds clean and dry, ok to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds p instructions: wound clinic in 2 weeks dr in 4 weeks dr in weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atherosclerosis of aorta Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Other and unspecified angina pectoris Unspecified hearing loss Diverticulitis of colon (without mention of hemorrhage) Osteoarthrosis, unspecified whether generalized or localized, other specified sites

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motorcycle accident major surgical or invasive procedure: 1. open reduction/internal fixation of left anterior column fracture with an intramedullary screw. 2. open reduction/internal fixation of the pelvic ring injury with symphyseal plating. 3. closed reduction and retrograde im nail fixation of left femur fracture 4. exam under anesthesia with closed treatment of left ankle history of present illness: this is a 28 year-old man who was transferred from an outside hospital for a pelvic fracture and left femur midshaft fracture. he was involved in a motorcycle crash at approx 35mph; he was wearing a helmet and denied loc. at the osh he was hemodynamically stable. past medical history: s/p colectomy h/o lower gi bleeding social history: no tobacco/drugs occassional etoh family history: noncontributory physical exam: vs t100.4 p96 bp148/78 r18 96% on room air gen: no acute distress, aox3, would like to go home chest: clear to auscultation bilaterally cv: regular rate and rhythm with no murmurs ab: soft, nontender, minimal tenderness near incision but no erythema or pus ext: splint clean, dry, intact. good toe perfusion. pertinent results: 08:54pm ph-7.39 import 08:54pm freeca-1.09* import 08:46pm urea n-20 creat-1.2 potassium-4.0 import 08:46pm magnesium-1.8 import 08:46pm wbc-7.7 rbc-2.45* hgb-7.3* hct-20.9* mcv-85 mch-29.8 mchc-35.0 rdw-13.9 import 08:46pm plt count-153 import 02:55pm glucose-154* urea n-20 creat-1.3* sodium-140 potassium-4.6 chloride-107 total co2-26 anion gap-12 import 02:55pm alt(sgpt)-77* ast(sgot)-203* alk phos-38* amylase-93 tot bili-0.6 import 02:55pm lipase-97* import 02:55pm albumin-3.2* calcium-6.8* phosphate-4.3 magnesium-1.3* import 02:55pm wbc-9.4 rbc-2.88* hgb-8.4* hct-24.7* mcv-86 mch-29.3 mchc-34.2 rdw-14.1 import 02:55pm plt count-176 import 02:55pm pt-13.0 ptt-24.8 inr(pt)-1.1 import 11:57am wbc-14.5* rbc-3.01* hgb-8.9* hct-26.3* mcv-88 mch-29.8 mchc-34.0 rdw-13.8 import 11:57am plt count-181 import 11:57am pt-13.9* ptt-27.3 inr(pt)-1.3 import 08:20am pt-14.1* ptt-27.1 inr(pt)-1.3 import 08:20am fibrinoge-134* import 07:32am type-art po2-123* pco2-40 ph-7.27* total co2-19* base xs--7 intubated-not intuba import 07:20am glucose-138* urea n-22* creat-1.3* sodium-137 potassium-4.2 chloride-107 total co2-15* anion gap-19 import 07:20am wbc-22.9* rbc-3.51* hgb-10.1* hct-30.9* mcv-88 mch-28.8 mchc-32.7 rdw-13.8 import 07:20am plt count-238 import 05:24am type- ph-7.26* import 05:24am glucose-165* lactate-6.2* na+-140 k+-3.9 cl--107 tco2-18* import 05:24am hgb-11.9* calchct-36 import 05:24am freeca-1.05* import 05:00am urea n-23* creat-1.5* import 05:00am amylase-105* import 05:00am asa-neg ethanol-121* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg import 05:00am wbc-34.4* rbc-3.83* hgb-11.2* hct-34.0* mcv-89 mch-29.1 mchc-32.9 rdw-13.3 import 05:00am plt count-374 import 05:00am pt-17.9* ptt-30.2 inr(pt)-2.1 import 05:00am fibrinoge-105* brief hospital course: on arrival the patient was tachycardic but otherwise hemodynamically stable. his evaluation revealed the following significant injuries: left femur diaphysis fracture left pubic fracture along iliopectinate line left acetabular fracture left ankle fracture pubic symphysis diastesis large pelvic hematoma with 2 bleeding branches of pudendal artery left kidney laceration with extravasation of urine small splenic laceration the pudendal artery bleeding was stopped with ir coils and the patient was seen by urology and orthopedic surgery. he receieved blood transfusions for a low hematocrit and was monitored in the icu until hd2. a repeat ct scan showed a decrease in the size of the pelvic hematoma and resolution of the small perirenal fluid collection. the patient was taken to the or by orthopedic surgery on the day of admission for repair of the femur and ankle and on hd5 for repair of the pelvis. he was discharged on hd 7 in good condition with follow-up by urology, orthopedic surgery and trauma surgery. medications on admission: none discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*60 tablet(s)* refills:*0* 6. enoxaparin sodium 40 mg/0.4ml syringe sig: forty (40) mg subcutaneous daily (daily) for 1 months. disp:*qs * refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: left femur fracture left ankle fracture pelvic fracture left hip fracture pelvic hematoma bleeding from pudendal artery left kidney laceration small splenic laceration discharge condition: good discharge instructions: you should call a physician or come to er if you have worsening pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds, or if you have any questions or concerns. you should not drive or operate heavy machinery while on any narcotic pain medication such as percocet as it can be sedating. you may take colace to soften the stool as needed for constipation, which can be cause by narcotic pain medication. you should keep your dressing intact and dry until seen at follow-up visit. you should follow the instructions provided by the physical therapists. you may bear weight on your right leg for short distances only. you may not bear weight on your left leg. otherwise you should remain on bedrest until seen by urology at your follow-up visit. followup instructions: call for a follow-up appointment with urology in 2 weeks (). you will need a repeat ct scan at that time. an appointment will be scheduled for you at the orthopedic surgery clinic for . call to confirm the time. you will need repeat x-rays before this visit; the clinic will arrange these films. call the trauma surgery clinic for an appointment in weeks (). Procedure: Injection or infusion of other therapeutic or prophylactic substance Aortography Arteriography of other intra-abdominal arteries Transfusion of packed cells Open reduction of fracture with internal fixation, other specified bone Arteriography of renal arteries Closed reduction of fracture without internal fixation, tibia and fibula Closed reduction of fracture with internal fixation, femur Retrograde cystourethrogram Diagnoses: Closed fracture of shaft of femur Hemorrhage, unspecified Closed fracture of acetabulum Injury to kidney without mention of open wound into cavity, laceration Closed fracture of other specified part of pelvis Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma Motor vehicle traffic accident of unspecified nature injuring motorcyclist Fracture of lateral malleolus, closed

history of present illness: the patient is a 36-year-old male with human immunodeficiency virus who developed fever and nausea several days prior to admission. he denied any cough, abdominal pain, or diarrhea. he reports bouts of nausea and vomiting. per the patient's partner, the patient will approximately four day prior to admission. he felt better the following, but then two days two days prior to admission had chills and "seemed off." he did not see mr. until the morning of admission when mr. seemed confused and was "talking gibberish." he was complaining of dizziness as well. of note, two weeks prior to admission the patient was seen in the emergency room for rectal trauma related to anal intercourse and placed on ciprofloxacin. in the emergency department, the patient was given 2 g of ceftriaxone to cover for meningitis and a lumbar puncture was performed. past medical history: 1. human immunodeficiency virus; with most recent cd4 count of 577 and undetectable viral load. 2. hepatitis b with hepatitis b surface antigen positive. 3. history of syphilis; treated with penicillin in the past. 4. irritable bowel syndrome. 5. history of perirectal abscess. medications on admission: (medications on admission included) 1. trizivir 300/150 mg one tablet by mouth twice a day. 2. ciprofloxacin 500 mg one tablet by mouth twice a day. allergies: the patient has no known drug allergies. social history: the patient lives at home with his male roommate. he occasionally smokes cigarettes. he denies any intravenous drugs or other drug use. physical examination on presentation: temperature was 100.9 to 101.7, heart rate was 90 to 100s, blood pressure was 130s to 150s/70s, saturating 95% on room air. in general, the patient was alert, pleasant, confused with word switching. head, eyes, ears, nose, and throat showed sclerae were anicteric. the fundi was without palpal edema, exudate, or hemorrhage. the oropharynx was clear. the neck was supple. kernig sign was negative. the lungs were clear to auscultation bilaterally. the heart had a regular rate and rhythm. normal first heart sound and second heart sound. no murmurs. the abdomen was soft, nontender, and nondistended, with normal active bowel sounds. extremities were without edema. neurologically, the patient was alert. his speech showed multiple word-finding difficulties and switching words. sounds like "gibberish" at times. he had normal muscle bulk. strength was in both the upper and lower extremities. finger-to-nose was slow but normal. the toes were downgoing bilaterally. cranial nerves ii through xii were intact. pertinent laboratory data on presentation: sodium was 139, potassium was 4, chloride was 105, bicarbonate was 23, blood urea nitrogen was 15, creatinine was 1.1, blood glucose was 129. alt was 11, ast was 15, alkaline phosphatase was 77, total bilirubin was 0.7, albumin was 4.4. white blood cell count was 4.5 (with 57% neutrophils, 28% lymphocytes, 7% monocytes, and 8% atypical cells), hematocrit was 42.1, with a mean cell volume of 104, platelets were 159. lumbar puncture results showed the white count in tube #1 to be 81 with 24 red blood cells. in tube #4 the white count was 141 with 6 red blood cells, protein was 153, glucose was 69, and the gram stain was pending. radiology/imaging: a head ct showed no bleed and no midline shift. a kub showed no free air. there was gas and stool throughout the colon. a chest x-ray showed a heart size within normal limits. there was no pneumonia, infiltrates, or effusions. assessment and plan: in summary, the patient is a 36-year-old male with human immunodeficiency virus presenting with fever and altered mental status. at the time of admission, the working differential diagnosis included meningitis, central nervous system inflammatory state, and vasculitis. hospital course: the patient was admitted to the medicine service for further workup. the lumbar puncture results obtained at the time of admission eventually came back showing a gram stain which showed no polys and no organisms. it was felt the findings were most consistent with viral meningitis; although, the patient was initially covered with vancomycin, ceftriaxone, and acyclovir pending culture results. over the first 24 hours the patient had improvement of his mental status until early on , in the morning, when he had a seizure. his seizure was broken with haldol and ativan. per neurology recommendations, the patient was loaded on dilantin and transferred to the medical intensive care unit for close observation. in the intensive care unit, the patient was intubated for airway protection while a magnetic resonance imaging was performed. the magnetic resonance imaging was negative for any masses, hemorrhage, or meningeal enhancement. there was subtle increased t2 signal in the left semiovale felt to be consistent with his human immunodeficiency virus status. the magnetic resonance angiography was also negative. the patient was continued on acyclovir for a question of herpes simplex virus and doxycycline pending ehrlichiosis titers. an electroencephalogram was performed which was consistent with widespread encephalopathy. the patient stabilized and was quickly extubated. the dilantin was then held in absence of any seizure focus on the electroencephalogram or recurrent seizures. ceftriaxone, doxycycline, acyclovir were continued. highly active antiretroviral therapy was held, per infectious disease recommendation. the patient was recatheterized in order to allow a cerebrospinal fluid to be sent off for all appropriate viral cultures, as the initial amount of cerebrospinal fluid was not sufficient. on , the patient was complaining of left shoulder pain and was found to have a left dislocated shoulder with fracture of the proximal humerus, felt to be secondary to the seizure episode. it was reduced by the orthopaedic service on . the patient was transferred out from the intensive care unit to the general medicine service on . note: the rest of this discharge summary will be continued in system format. 1. infectious disease: the patient was closely followed by the infectious disease service during this hospitalization given his human immunodeficiency virus disease. he was felt to have a viral meningitis; although, cultures never elucidated the exact cause of his meningitis. on , ceftriaxone was stopped as there was a very low likelihood of bacterial meningitis. the patient was continued on acyclovir, despite the fact that his herpes simplex virus pcr eventually came back negative, as it was felt that there was not a sufficient sample to be sure that it was true result. in addition, a repeat fluid sent four days after treatment had begun was also felt not to be able to be trusted given that the patient was already on antiviral therapy. the patient continued to improve from an infectious disease standpoint after being transferred out to the general medical floor and remained afebrile with a normal mental status. a peripherally inserted central catheter line was placed on in order to continue with intravenous antibiotics at home. the patient's antiretrovirals were discontinued on ; per the recommendations of the infectious disease team. the patient was to follow up the day following discharge to discuss with his primary infectious disease doctor (dr. about restarting his antiretroviral therapy. 2. neurology: the patient had no further seizures following the one prior to admission to the medical intensive care unit. antiepileptic drugs were discontinued when he was transferred out the general medical floor, and the patient had no further seizure events. 3. musculoskeletal: as previously stated, the patient suffered a left shoulder fracture/dislocation which was successfully reduced by the orthopaedic team. the patient's arm was placed in a sling, and the patient was to follow up with orthopaedics in 7 to 10 days until further followup. discharge diagnoses: 1. human immunodeficiency virus. 2. viral meningeal encephalitis. 3. left shoulder fracture/dislocation. 4. thrush. medications on discharge: 1. acyclovir 700 mg intravenously q.8h. (times 14 days). 2. doxycycline 100 mg p.o. b.i.d. (times 7 days). 3. tylenol 650 mg p.o. q.6-8h. as needed. 4. dulcolax one tablet p.o. b.i.d. as needed. 5. nystatin swish-and-swallow 5 cc p.o. q.i.d. 6. colace 100 mg p.o. b.i.d. 7. percocet one to two tablets p.o. q.4-6h. as needed. 8. trizivir one tablet p.o. b.i.d. (to begin after the patient follows up with dr. . discharge followup: 1. the patient was to see dr. in one to two weeks. 2. the patient was also to follow up in the clinic in 7 to 10 days. 3. he was to speak with dr. the day following discharge in order to determine when to restart his trizivir. dictated by: Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Spinal tap Incision of lung Insertion of endotracheal tube Closed reduction of dislocation of shoulder Diagnoses: Other convulsions Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Asymptomatic human immunodeficiency virus [HIV] infection status Closed dislocation of shoulder, unspecified Herpetic meningoencephalitis Unspecified viral meningitis Rickettsiosis, unspecified Closed fracture of unspecified part of upper end of humerus

past medical history: not significant. medications: the patient was taking no medications prior to admission. allergies: the patient has no known drug allergies. physical examination: physical examination revealed the following: temperature 35.9 degree celsius. blood pressure was 135/66. heart rate 77. respiratory rate 22. oxygen saturation 99%, four liters nasal cannula. examination revealed the patient to be awake, alert, and in mild distress. heent: normocephalic, atraumatic. tms clear bilaterally. no facial abnormalities. c-collar on patient, no tracheal deviation. lungs: lungs were clear to auscultation bilaterally. there was no subcutaneous emphysema, no crepitus, no wheezes, rales, rhonchi. heart: regular rate and rhythm. s1 and s2 normal. no murmurs, rubs, or gallops. abdomen: soft, nontender, nondistended. pelvic: examination revealed right hip tenderness, otherwise, stable. extremities: right femur deformity. distal pulses were palpable bilaterally on the radial, ulnar, dorsalis pedis, popliteal, posterior tibial pulses. the patient had intact distal and sensory function to light touch, soft, pinprick, two-point discrimination. rectal: examination revealed normal tone, guaiac negative. the wound showed a left shoulder superficial abrasion. laboratory data: laboratory data revealed the following: white blood count 12.4, hg 12.6, hematocrit 35.3, platelet count 224,000. pt 13.4, ptt 20.6, inr 1.3, fibrinogen 289, sodium 140, potassium 3.5, chloride 103, bun 16, creatinine 1.0, glucose 167, amylase 40, urinalysis negative, lactate was 3.8, serum toxicology negative, urine toxicology negative. abg: po 257, pco 32, ph 7.43, total co2 22, base deficit -1. of note: sample was venous sample. free calcium of 1.2. calculated hematocrit 41. radiographic studies: left shoulder x-ray showed a left clavicular fracture. right hip x-ray negative. right femur x-ray shows a right femur fracture, angular and displaced. c-spine x-ray shows c1 to c2 subluxation, question of atlantoaxial subluxation, no fractures. pelvis x-ray: no fractures or dislocations. tl spine series: no fractures or dislocations. chest x-ray shows a widened mediastinum. ctg of the chest showed a sternal fracture, right rib fractures, right fourth rib fracture. no pneumothorax. no hemothorax, no aortic dissection. ct of the abdomen shows a low attenuation in the left lower lobe of the liver, consistent with either contusion or hemangioma. ct of the head was negative. ct of the c-spine shows a c1-c2 atlantooccipital subluxation, no fractures. the patient was consulted with orthopedic surgery on the 25th. the patient had a left posterior hip dislocation reduced by the department of orthopedics. on the same day, the patient also had a right femoral im rod placed successfully for left clavicular fracture. no further work was necessary per orthopedic department. the patient only to be maintained in sling. regarding sternal fractures and right 4th rib fracture, no further work to be done per orthopedic surgery. the patient was made npo on the evening of the 25th to have a four vessel angiogram to be performed by dr. . given the c1-c2 subluxation, question of carotid vessel compromise. in the meantime, the patient was put on neck traction to reduce the c1-c2. four-vessel angiograms results were negative for any extravasation, bleed, or vessel deformity. after approximately 24 hours, dr. with orthopedic surgery spinal consultation recommendation a ct scan of c1-c2 with maximal leftward rotation and maximal rightward rotation with thin-cuts to be performed on the patient to reassess the patient's c1-c2 instability. films were reviewed by dr. . in the meantime, c-collar was maintained on the patient. traction was taken off on the 26th. results of the c spine shows a fixed c1-c2 subluxation upon rotational views. dr. noted that the patient could be cleared from the cervical spine on the . therefore, the patient's hard collar could be discontinued and taken off. the day, prior to discharge, the patient was switched to po pain medications, pca pump. the patient was maintained on lovenox subcutaneously. the department of orthopedics recommended that the patient be weightbearing as tolerated on the right lower extremity. the patient was tolerating pos well up to the day of discharge. the patient had no other further complications prior to discharge. the patient is to be discharged to facility today on . the patient is to continue pt therapy, outpatient full weightbearing as tolerated on the right lower extremity, maintain the left shoulder sling. the patient is cleared c-spine clinically, therefore, the patient does not need a cervical collar. the patient is follow up with the orthopedic clinic with dr. , approximately 7 days to 10 days after discharge. telephone #: . discharge status: good. the patient will be discharged to facility. final diagnosis: status post right femur fracture with open reduction and internal fixation, right femoral rod; right fourth rib fracture, sternal fracture, left clavicular fracture, c1-c2 subluxation. medications on discharge: 1. colace 100 mg po b.i.d. 2. percocet 5/325 one tablet to two tablets po q.4h. to 6h.p.r.n. pain. the patient is to need physical therapy services, full weightbearing as tolerated on right lower extremity. the patient is to use crutches if needed. the patient was instructed to follow up with dr. in the orthopedic spine clinic within 7 days to 10 days after discharge. phone: . the rehabilitation facility is advised to schedule the appointment on the patient's behalf. , m.d. dictated by: medquist36 d: 13:21 t: 14:16 job#: Procedure: Open reduction of fracture with internal fixation, femur Diagnoses: Closed fracture of sternum Closed fracture of one rib Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of unspecified part of neck of femur Closed fracture of clavicle, unspecified part Closed dislocation, first cervical vertebra Closed posterior dislocation of hip

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sepsis. major surgical or invasive procedure: none. history of present illness: 78m with parkinson's disease, cad s/p cabg and multiple pci's with stents, chf with ef 30%, osteoporosis, and history of multiple falls who is being admitted to micu for sepsis from presumed urinary source. patient with multiple falls in past, the last 2 days prior to this admission felt to be mechanical (tripped on shoe) with head laceration treated with staples. pt unsure if he loss consciousness during this but knows that he hit his head. denied lh, dizziness, cp, palps, sob, tongue biting, incontinence surrounding event. head ct nml and c-spine with t3 compression fracture, old. patient was cleared in ed and sent home. this a.m. he was getting oj out of refrigerator and lost balance, falling backwards. no vertigo, loc, cp, sob, palps, lh, dizziness preceding event ('unsteady on feet'). he called for help and was brought to the ed this a.m. in ed had temp to 102.8, hr 118, bp 138/42. bp dropped transiently to 92/60 but he was repositioned and bp increased to 115/73. recieved 3l ns in ed, was pancultured, and was given levofloxacin 500, vancomycin 1g, and flagyl 500 (for abd pain and h/o diarrhea x 4 months), asa, ticlid. ce's cycled and monitored on telemetry. patient and family do not want central line placed. also had inferolat st depressions on ekg while tachycardic, and cardiology was curbsided and felt they were rate related. upon arrival to the floor he states that he is comfortable and without pain. this a.m. patient noted dysuria and frequency, no urgency. on ros mouth is dry, he is fatigued, and he has been having diarrhea x 4 months (w/u as outpt unrevealing - improved after stopping ppi). denies fevers, chills, night sweats, weight loss, ha, vision changes, uri sxs, chest pain, sob, palpatations, abdominal pain, melena, hematochezia, nausea, hematemesis. no focal motor or sensory deficits. past medical history: 1. cad s/p cabg and nstemis (: lima-lad, svg->diag, om1, om2, svg->pda); s/p pci of proximal svg-d1-om 1-om2 with des in and pci of svg-om/d with des in . 2. chf: ef 30% 3. parkinson's disease 4. hypercholesterolemia 5. htn 6. h/o tia 7. bladder ca 8. osteoporosis 9. s/p right hip fracture, orif in social history: former prof at . the patient lives in . he lives with his wife on the same street as his daughter. has another daughter who lives in . he smoked until , smoking one pack a day for fifteen years. family history: positive for father, who died of a stroke, mother who had a stroke in her 90s and one brother had disease. physical exam: vitals: 97.6, 102, 137/86, 23, 99%2l gen: diaphoretic well nourished male lying flat in nad, pleasant, communicative. heent: perrl, eomi, anicteric sclera, mm dry, op clear but difficult to visualize d/t inability to open mouth fully with c-collar in place. dysarthric speech with accent. neck: cervical collar in place cardiac: tachycardic, regular rhythm, nl s1 and s2, no mrgs lungs: ctab ant, no wheezes, rhonchi, crackles abd: soft, ntnd, nabs, no hsm, no rebound or guarding ext: warm, 2+ dp pulses, no c/c/e neuro: cn: unable to gaze laterally to left with left eye (may not be cooperating with exam), cn iv,x,vi intact. easy to open eyes bilaterally when closed tight. cn ix, x, xii intact. unable to assess d/t c-collar. motor throughout, sensory intact. + rigidity in ue, l>r. toes upgoing bilaterally. no clonus. no tremor noted. pertinent results: lab data: cbc: 06:40am blood wbc-13.2* rbc-4.17* hgb-11.8* hct-35.3* mcv-85 mch-28.3 mchc-33.4 rdw-16.7* plt ct-279 coags: 09:20am blood pt-13.6* ptt-26.7 inr(pt)-1.2* chemistries: 06:40am blood glucose-100 urean-15 creat-0.8 na-131* k-4.3 cl-99 hco3-22 angap-14 cardiac enzymes: 09:20am blood ctropnt-0.07* 08:04pm blood ck-mb-76* mb indx-15.3* ctropnt-1.01* 03:04am blood ck-mb-55* mb indx-13.8* ctropnt-1.60* 12:19pm blood ck-mb-34* mb indx-11.6* ctropnt-1.44* 04:54am blood ck-mb-11* mb indx-8.1* ctropnt-0.88* anemia labs: 04:54am blood caltibc-222* vitb12-602 folate-14.5 hapto-279* ferritn-30 trf-171* 04:54am blood ret aut-2.0 misc: 09:30am blood lactate-4.0* ct of c-spine (): there is a anterior wedge compression fracture of the t3 vertebral body. the presence of adjacent osteophytes raises the possibility that the fracture is chronic, but this observation requires clinical correlation. ct head (): no intracranial hemorrhage, no fracture. 7mm rounded lymph node in the right submental region. ct head (): 1. no definite acute intracranial abnormality. 2. mild atrophy and left more than right basal ganglia chronic lacunes, with some volume loss. 3. chronic-appearing ethmoid inflammatory disease with extensive opacification of bilateral ethmoid air cells, right more than left. cxr (): interstitial pulmonary edema. renal us (): no renal stones or hydronephrosis on either side. echo (): the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is regional left ventricular systolic dysfunction with akinesis of the basal 2/3rds of the inferior and inferolateral walls. the remaining segments are mildly hypokinetic. no masses or thrombi are seen in the left ventricle. right ventricular chamber size is normal with mild free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. severe (3+) mitral regurgitation is seen. tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: 1. sepsis: patient with sirs based on tachycardia and fever with evidence of end organ damage with lactate of 4.0, qualifying for sepsis. was not hypotensive. cxr without evidence of infiltrate. ct scan did show sinusitis. overall, the source was presumed to be urinary as had wbc on ua - urine culture did not grow any organisms. in the unit, the patient was treated with ivf. hr and urine output were followed. broad spectrum antibiotics were used initially levofloxacin and vancomycin for urinary and nasal pathogens. flagyl was started initially with d/c as there was no evidence of aspiration or bowel pathogen. the patient did well in the unit and was called out to the floor. treatment was a planned 10 days of levaquin. on the day of discharge, the patient had an episode of diapheresis. oral temperature was 97 with a rectal temperature of 100. his finger stick was ~170 and an ekg showed no changes. given that his wbc had increased slightly from the prior day (12.3->14.8), blood and urine cultures were drawn. at the time of discharge, the patient felt well. 2. cad: in the setting of sepsis, the patient had an ekg with inferolateral st depressions with and a troponin that peaked at 1.6. cardiology saw the patient and felt this was demand as opposed to an acs. as such, they did not feel that an acute cath was needed. the patient was placed on heparin and integrillin on the 17th - the heparin was stopped two days later and the integrillin was stopped the next day. the patient was followed by cardiology - cardiac cath was considered, but not pursued. plan was for outpatient stress test once the patient was improved s/p sepsis. an echo was repeated showing an ef of 30% (unchaged from ) with mod/severe mr tr. regarding cardiac meds, the patient was treated with asa, ticlopidine (per home regimen), beta-blocker (metoprolol 75mg ), lisinopril 10mg daily, statin (came in on simvastatin; atorvastatin used while in-house with plan for resumption of simvastatin). in addition to the above, he was transfused 2 units of prbcs on for hct <30. thereafter, his hct remained >30. 3. chf: initially, cxr with pulmonary edema; did not require oxygen and was breathing easily with no le edema. lasix was held at the onset, given sepsis. as his bp remained stable, he was gently diuresed. thereafter, he was continued on acei and lasix. 4. fall: combination of loss of balance and neurologic d/o (parkinson's). no loc, did not sycopize. head ct negative for bleed. c-spine film showed no evidence of cervical spine fracture and a stable wedge deformity of t3 dating back to . b12 and folate were normal with a negative rpr. scalp staples from admission were still in place with plan for removal at rehab. 5. diarrhea: a chronic issue for the patient. while an inpatient, c.diff was checked and negative x2. 6. parkinson's: stable while an inpatient; continued home regimen of sinemet and comtan. 7. htn: antihypertensives held initially given sepsis. slowly added back. metoprolol and lisinopril were continued. 8. hyponatremia: patient has a long history of hyponatremia. sinemet may be contributor. acutely, hypovolemic hyponatremia may have been playing a role. at the time of discharge, serum sodium was 133. 9. osteoporosis: continue calcium and vitamin d. outpatient aldendronate was to be resumed upon discharge. 10. hyperlipidemia: as above, simvastatin at home with atorvastatin while in-house. cholesterol panel from showed tc 167, tg 233, hdl 62 and ldl 58. plan was for resumption of simvastatin upon discharge. dni/dni. medications on admission: 1. carbidopa-levodopa 25-100 mg tablet 8 times a day 2. comtan 200mg 5 five times a day 3. aspirin 325 mg tablet 4. metoprolol tartrate 50 mg 5. ticlopidine 250 mg tablet 6. lisinipril 10mg daily 7. furosemide 20 mg po daily 8. zocor 40 mg tablet 9. calcium plus vitamin d 10. alendronate 70mg qweek on sunday 11. multivitamin discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. ticlopidine 250 mg tablet sig: one (1) tablet po bid (2 times a day). 3. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 4. furosemide 40 mg tablet sig: one (1) tablet po once a day. 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 6. hexavitamin tablet sig: one (1) cap po daily (daily). 7. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for with meals. 8. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 9. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po 8x/d (). 10. entacapone 200 mg tablet sig: one (1) tablet po 5x/day (). 11. simvastatin 40 mg tablet sig: one (1) tablet po once a day. 12. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 13. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 14. cholestyramine-sucrose 4 g packet sig: one (1) packet po daily (daily). 15. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 16. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days. 17. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 18. alendronate 70 mg tablet sig: one (1) tablet po once a week: each sunday. discharge disposition: extended care facility: - discharge diagnosis: primary: 1. sepsis / uti 2. coronary artery disease. secondary: 1. parkinson's disease 2. hyperlipidemia 3. hypertension discharge condition: good; improved. discharge instructions: you were admitted after a fall and found to have an infection. you will be sent home with antibiotics which you should take, as directed, for the full course. given your history of heart failure, you should be sure to weigh yourself every morning and call your pcp if your weight > 3 lbs. there were no changes made to any of your current medications. followup instructions: you have the following appointments scheduled: , m.d. phone: date/time: 2:40 , md phone: date/time: 9:30 in addition to the above, you should call your pcp to be seen within 1-2 weeks. Procedure: Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified septicemia Hyposmolality and/or hyponatremia Aortocoronary bypass status Percutaneous transluminal coronary angioplasty status Sepsis Paralysis agitans Osteoporosis, unspecified Personal history of malignant neoplasm of bladder Hypovolemia Diseases of tricuspid valve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: summary dicatated major surgical or invasive procedure: - cabg x5 on iabp. (lima-lad, svg->diag, om1, om2, svg->pda) - cardiac catheterization - right hip open reduction internal fixation brief hospital course: his white count improved on and he was ready for discharge to rehab. discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po once a day. 6. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily) for 1 months. 7. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 9. multivitamin capsule sig: one (1) cap po daily (daily). 10. alendronate 70 mg tablet sig: one (1) tablet po qfri (every friday). 11. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q12h (every 12 hours): 30 mg . 12. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 13. lasix 40 mg tablet sig: one (1) tablet po twice a day for 1 weeks. 14. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po twice a day for 1 weeks. tab sust.rel. particle/crystal(s) discharge disposition: extended care facility: - discharge diagnosis: s/p cabg x 5 discharge condition: good. discharge instructions: 1) keep wounds clean and dry. ok to shower, no bathing or swimming. 2) no lotions, creams or powders to incision until it has healed. 3) take all medications as prescribed. 4) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 5) report any fever greater then 100.5 6) report any signs of wound infection. these include redness, drainage or increased pain. 7) no driving for 1 month 8) no lifting greater then 10 pounds for 10 weeks. 9) take lasix with potassium for 2 weeks and then stop. 10) call with any questions or concerns. followup instructions: dr in 4 weeks, please call ct office to schedule appoointment. follow-up with cardiologist in weeks. call for appointment. follow-up with orthopedist dr in 2 weeks, please call orthopedic surgery office to schedule appointment. follow-up with your primary care physician 2 weeks. please call all providers for appointments. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of four or more coronary arteries Implant of pulsation balloon Open reduction of fracture with internal fixation, femur Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other chronic pulmonary heart diseases Paralysis agitans Osteoporosis, unspecified Personal history of malignant neoplasm of bladder Hyperosmolality and/or hypernatremia Home accidents Closed fracture of intertrochanteric section of neck of femur Accidental fall from chair

history of present illness: 77 year old man with a history of hypertension, tias, parkinson's, and osteoporosis who felt at home and sustained a right hip fracture, fell following getting up from a chair while he was working at the computer. no trauma to the head or neck. past medical history: significant for hypertension, tias, parkinson's, and osteoporosis. medications: meds at home include 1. sinemet 25/250 q. d. 2. lotrel q. d. 3. triamterene 37.5/25 q. d. 4. fosamax 70 q. d. 5. aspirin 81 q. d. 6. zinc 220 q. d. 7. multivitamin 1 q. d. allergies: no known drug allergies. family history: noncontributory. social history: remote smoking. no etoh use. married and lives with wife. review of systems: noncontributory. physical examination: temperature 97.4, heart rate 89, blood pressure 192/94, respiratory rate 16, o2 100% on room air. neurologic, alert and oriented x3. heent: normal head and oropharynx. neck is supple with no jvd and no bruits. lungs clear to auscultation. cardiac: regular rate and rhythm. abdomen is soft, nontender, with normoactive bowel sounds and no hepatosplenomegaly. extremities with no edema and 1+ peripheral pulses. laboratory data: white count 17, hematocrit 38, platelets 267. sodium 125, potassium 3.8, chloride 90, co2 25, bun 19, creatinine 0.8, glucose 126. ck 163 with a troponin of less than .01. hip film with a right femur fracture, avulsion of the lesser trochanter, fracture of the greater trochanter. chest x-ray with a question of opacity at the left lung base. ekg: sinus rhythm with normal axis, t wave inversion in lead iii, nonspecific t wave changes in q and lead iii. hospital course: patient was admitted to medicine and was scheduled to undergo surgery for hip repair, however, was found to have additional ekg changes prior to his surgical time. at that point, his surgery was delayed and a cardiology consult was obtained. it was felt the patient was having an nste mi by enzymes and he was scheduled for cardiac catheterization which he underwent on . please see the cath report for full details. in summary, he was found to have left main 70% stenosis, lad 70% stenosis, left circumflex with an 80% stenosis and an rca that was a total occlusion proximally with left to right collaterals. a ventriculogram was not obtained at that time. an intra- aortic balloon pump was placed and cardiac surgery was emergently consulted. following the cath, the patient went emergently to the operating room where he underwent coronary artery bypass grafting. please see the or report for full details. in summary, the patient had coronary artery bypass grafting x5 with the lima to the lad, saphenous vein graft to the diagonal and sequentially to om1 and 2 as well as a saphenous vein graft to the pda. his bypass time was 110 minutes with a crossclamp time of 86 minutes. he tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient had levofed, propofol and insulin drips infusing. his mean arterial pressure was 68 with a cvp at 20. he additionally had an intra-aortic balloon pump at 1:1. the patient did well in the immediate postoperative period. he remained hemodynamically stable on the day of the surgery. on the morning following surgery, the intra-aortic balloon pump was removed. the patient was weaned from sedation following which he was weaned from the ventilator and successfully extubated. gentle diuresis was begun at that time. additionally, the patient was weaned from all vaso active medications on postoperative day 1. on postoperative day 2, the patient continued to progress. he was begun on low dose beta blockade. his diuresis was increased and his chest tubes were removed and he was transferred from the cardiothoracic intensive care unit to 5- 2 for continuing postoperative care. additionally, the patient was followed by orthopedic surgery service during his postoperative recovery. by postoperative day 3, the patient had transitioned to all oral medications. he remained on complete bedrest given his fractured right hip. his temporary pacing wires were removed on postoperative day 4 and on postoperative day 5, he was scheduled to go to the operating room for orif of his right hip. however, on that day, he inadvertently had breakfast and his surgery had to be delayed for 1 day. therefore, on , the patient was brought to the operating room at which time he underwent a repair of his fractured right hip by dr. . please see or report for full details. in summary, the patient had an orif of his fractured right hip. he remained hemodynamically stable throughout the procedure, was transferred from the operating room to the post- anesthesia recovery unit. following recovery from anesthesia, the patient was again transferred to for continuing postoperative care and rehabilitation. over the next 2 days, the patient had an uneventful postoperative course. his activity level was increased with the assistance of the nursing staff as well as the physical therapy staff and on postoperative days 7 and 1, he was cleared for transfer to rehabilitation for ongoing postoperative care. at the time of this dictation, the patient's physical examination was as follows: vital signs: temperature 99, heart rate 67 sinus rhythm, blood pressure 116/62, respiratory rate 18, o2 saturation 98% on 2 liters nasal prongs. lab data: white count 17, hematocrit 34, platelets 428, potassium 4.4, bun 27, creatinine 0.7, calcium 8.1. physical examination: alert and oriented, moves all extremities, follows commands. pulmonary clear to auscultation bilaterally. cardiac: regular rate and rhythm. sternum is stable. incision with steri-strips, clean and dry, no drainage or erythema. abdomen is soft, nontender, nondistended with normoactive bowel sounds, however, no flatus or bm at this time. extremities are warm with no edema. left leg incision with steri-strips from his endoscopic harvest site is clean and dry. condition: patient's condition at time of discharge is good. discharge diagnoses: 1. coronary artery disease status post coronary artery bypass grafting x5 with a lima to the lad, saphenous vein graft to diagonal, om1 and om2 sequentially, and saphenous vein to pda. 2. status post open reduction/internal fixation. 3. parkinson disease. 4. hypertension. 5. hypercholesterolemia. 6. osteoarthritis. 7. bladder ca status post excision x3. disposition: the patient is to be discharged to rehabilitation. he is to have follow up with dr. in 4 weeks, follow up with dr. in 4 weeks and follow up with his primary care provider 3 to 4 weeks. patient is to call to schedule appointments with dr. and dr. . discharge medications: the patient's medications at the time of discharge include: 1. lasix 40 mg q. d. x2 weeks. 2. potassium chloride 20 meq q. d. x2 weeks. 3. colace 100 mg b.i.d. 4. zantac 150 mg q. d. 5. aspirin 81 mg q. d. 6. tylenol 325 to 650 q. 4 hours p.r.n. 7. atorvastatin 10 mg q. d. 8. carbodopa/levodopa 25/100 1 q. d. 9. heparin 5,000 units subcutaneously t.i.d. 10. digoxin .25 q. d. 11. metoprolol 37.5 mg b.i.d. 12. percocet 5/325 1 to 2 tabs q. 4 to 6 hours p.r.n. 13. multivitamin 1 q. d. 14. fosamax 70 mg q. friday. 15. lisinopril 2.5 mg q. d. , m.d. dictated by: medquist36 d: 16:49:44 t: 17:49:51 job#: Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of four or more coronary arteries Implant of pulsation balloon Open reduction of fracture with internal fixation, femur Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other chronic pulmonary heart diseases Paralysis agitans Osteoporosis, unspecified Personal history of malignant neoplasm of bladder Hyperosmolality and/or hypernatremia Home accidents Closed fracture of intertrochanteric section of neck of femur Accidental fall from chair

allergies: zosyn / vancomycin / heparin agents attending: chief complaint: weakness major surgical or invasive procedure: ng tube placement history of present illness: 78m with h/o parkinson's disease, cad s/p cabg, h/o tia, s/p recent hospitalization for pna () now with worsening weakness. per pt's wife since he got sick with the pneumonia his parkinson's has been acting up and he has been having increasing trouble swallowing. she states he has been more weak and she has been having trouble having him transfer and walking him to the bathroom (his legs have been buckling under him). wife states he has had a worsening cough and has been feeling a little sob. denies fevers, chills, nausea, vomiting, diarrhea. . in the ed, initial vs were t: 99.8f bp: 171/109 hr: 102 rr: 18 sao2: 98% on 2l nc. initial labs were notable for leukocytosis to 17 (89% n). cxr demonstrated resolving rml and rll pna. pt was given tylenol 650mg po, aspirin 325mg po, vancomycin 1g iv, zosyn 4.5g iv, ticlid 250mg, carbidopa 25/levodopa 100, comtan 200mg. was also given metoprolol 75mg po and subsequently bp dropped to systolics in the 80's. he was then given boluses of 1l ns x 3 and bp improved to 120's and he was transferred to the micu. past medical history: 1. cad s/p cabg and nstemis (: lima-lad, svg->diag, om1, om2, svg->pda); s/p pci of proximal svg-d1-om 1-om2 with des in and pci of svg-om/d with des in . 2. chf: ef 30% 3. parkinson's disease 4. hypercholesterolemia 5. htn 6. h/o tia 7. bladder ca 8. osteoporosis 9. s/p right hip fracture, orif in social history: former prof at . the patient lives in . he lives with his wife on the same street as his daughter. has another daughter who lives in . he smoked until , smoking one pack a day for fifteen years. family history: positive for father, who died of a stroke, mother who had a stroke in her 90s and one brother had disease. physical exam: vs: t: 97.7 bp: 138/72 hr: 73 rr: 24 sao2: 100% on 2l nc. gen: pt very somnolent, awakens to voice but then falls asleep again. heent: perrl, eomi, op slightly dry. neck: no carotid bruit, + elevated jvp. heart: unable to ausculatate heart sounds due to loud respiratory noises. lungs: very noisy upper airway noises, slightly decreased bs's at r base. abdomen: soft, nt/nd, nabs, no masses or bruits. extremities: le's with trace edema. dps 1+. cns: not answering questions. + cogwheel rigidity. skin: +rash on knees pertinent results: cxr : two views of the chest demonstrate stable cardiomegaly, mediastinal contours, and sternal sutures. there has been significant improvement in airspace opacity of the right middle and lower lobes seen on . a small amount of residual opacity remains in these locales. the left lung is clear. there is no pleural effusion or pneumothorax. there has been no change from in multiple thoracic vertebral wedge deformities and associated kyphosis. impression: improving right middle and right lower lobe pneumonia. . ecg: nsr at 97. nl axis, borderline qt interval. q's in iii (old). st depressions in i, ii, avl, v3-6 (old), j point elevation in v1-2 (old). no sig changes from prior. . cxr: impression: 1. ng tube in proximal stomach. 2. progressive multifocal pneumonia. . head ct: findings: there is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. irregular low attenuation foci in bilateral lentiform nuclei, left greater than right with associated volume loss are consistent with chronic lacunar infarction. scattered focal low attenuation lesions in the periventricular and subcortical white matter are consistent with chronic microvascular ischemia. the -white matter differentiation is preserved. the surrounding soft tissue and osseous structures are unremarkable. the visualized paranasal sinuses and mastoid air cells are clear. impression: no intracranial hemorrhage or mass effect. no change since . . cxr : impression: improved pulmonary edema. worsening left lower lobe pneumonia . right upper quadrant ultrasound: the liver is normal in echotexture with no focal masses. a nonshadowing gallstone or sludge ball is seen within the gallbladder measuring 8 x 7 x 5 mm. the common bile duct measures 4 mm. there is no biliary dilatation. the portal vein is patent with antegrade flow. there is no ascites. the right kidney measures 11.2 cm, and there is no hydronephrosis. impression: normal right upper quadrant ultrasound. brief hospital course: 78 yo m with parkinson's, cad, s/p recent admission for pna now with likely aspiration pna increased secretions . micu course involved, the patient had hypotension and was given ivf and zosyn/vanc (concern for pna/sepsis). the patient had angioedema and was switched to levo/flagyl. given his hypotension his lasix was held as were other bp meds. he failed his speech and swallow and had an ngt placed. he was normotensive and transferred to the floor. . floor course: # hypotension: the patient's hypotension resolved since receiving ivf. the cause was likely multifactorial including poor intake likely due to parkinsons's disease, increased diarrhea and finally possibly some sepsis as with white count and pneumonia. during the majority of the patient's course he was npo so ivf were continued and he was treated for his pneumonia. his blood pressure was normal on the floor and his blood pressure medications were reintroduced as tolerated. . # pneumonia: the patient had presumed aspiration pneumonia as the patient had increased secretions. in the micu he was on zosyn and vancomycin but had angioedema and due to this allergic reaction, he was switched to levofloxacin and flagyl. he continued to fail speech and swallow evaluations given his increased secretions. during his course he developed an increased white count, an increased work of breathing and tachypnea. his cxr showed worsening and he was presumed to have worsened aspiration pneumonia, especially given his ongoing risk of aspiration. he was put on daptomycin, flagyl and aztreonam and he improved, initially though he continued to aspirate and his continued aspiration made his pneumonia worse to the point where his prognosis was poor. the patient had an episode of hypoxia and tachycardia, which was attributed to his increasing secretions. he was aggressively suctioned and a scopalamine patch was placed, but given this and his poor prognosis the family decided to make the patient cmo. antibiotics were discontinued and the patient was given morphine and scopalamine for comfort. . # parkinson's: the family fears the patient's parkinson's is worsening, though the patient's recent decline in functioning and mentation could also be related to his infection. he was continued on his home doses of carbidopa/levodopa and entacapone, and he appeared less lethargic and bradykinetic as his infection improved. the patient's outpatient neurologist, dr. , was contact and he recommended keeping his medications at the same dose and having an inpatient neurologist see him. the inpatient team did not have any medication changes to add, though they recommended movement disorders consult as his dysphagia may have been related to progressive supranuclear palsy. during the patient's course he lost his ng tube and he had difficulty with oral intake to the point where he could not receive his parkinson's medications. the pharmacy did not carry the oral disintegrating sinemet, and neurology said they could not recommend alternative iv medications to treat his parkinson's. unfortunately without his medications the patient became more bradykinetic and as his pulmonary status worsened a g tube was declined and the patient was without medications. . # nutrition: the patient failed his speech and swallow in the micu and had an ng tube placed. he was kept on iv fluids and npo, while awaiting a second speech and swallow evaluation. once he failed this tube feeds were started. initially he received tube feeds, and when another speech and swallow was failed it was decided that since the patient was at risk with tube feeds and eating, he would try eating. he pulled out his ng tube, and at that point the family decided the patient would continue a modified diet, but would likely continue to have pneumonia based on his high risk of continued aspiration. palliative care was called in, and during a family meeting, the family with the help of the team decided to have a g-tube placed. the patient was found to have elevated inr, and the gi team felt his risk of bleeding was very high and despite reversal of his inr gi decided he was a poor candidate for a gtube given his worsening clinical status. the family decided against the g tube given the risks and the patient was made cmo. . # transaminitis: the patient developed a transaminitis that may have been related to his medications as with medication adjustment, his lft's improved. he had a hepatitis panel sent and ruq us sent, but the work-up was not completed as the patient was made cmo, and the patient's lft's were improving. . # elevated inr: the patient was noted to have elevated inr through his course this was likely multifactorial including from abx, poor nutrition and liver disease. he improved with sc vitamin k, though gi felt given this, his lft's and his pulmonary status the g tube should not be placed. the family was in agreement with this plan. . # melena: the patient was noted to have melena, and also blood in his ngt, given his repeated failed attempts at ng tube placement this was attributed to trauma, and his hematcrit was followed closely and remained stable. the patient never required blood products. . # thrombocytopenia: the patient developed a significant drop in his platelets during his course and the concern was for hit versus his antibiotics. hit antibodies were sent and all heparin products were held. his hit antibody was positive and with the holding of heparin products the patient's thrombocytopenia improved. . # altered mental status: the patient was very lethargic during his course, and this was attributed to his pneumonia as he improved when his infection improved. towards the end of his course as his aspiration worsened and he was not able to get his parkinson's medications the patient became somnolent and lethargic. he remained in this state, though was then made cmo and was comfortable. . # chf: on admission the patient had an elevated bnp and a recent ef of 30%. given his initial hypotension and then diarrhea, his lasix was held and his ins/outs and daily weights were followed. through the majority of the patient's course he was dry to euvolemic. once his diarrhea resolved, he became more overloaded and fluids were stopped and he was diuresed. diuresis and fluids were stopped though once the patient was made cmo. . # diarrhea: the patient had profuse diarrhea and this was concerning for c. difficile given antibiotic use. his cdifficile was negative and he was supported with iv fluids. . # history of cad s/p cabg: the patient had no active issues during his course. he was continued on asa, statin, beta-blocker, and his ace was added in once his pressure was stable. . # history of tia: the patient had no issues during his course and was continued on ticlid. . # dnr/dni: it was decided to make the patient dnr/dni. . # cmo: on the patient had hypoxia and tachycardia. his respiratory status was worse and he was having increased secretions. he was suctioned, and with many talks with family, family understood poor prognosis and cmo was initiated. palliative care was very involved and per their recommendations the patient was made comfortable with scopalamine and morphine. medications on admission: cholestyramine 4gm packet asa 325mg po qday ticlopidine 250mg po bid metoprolol 75mgpo lasix 60mg po qday lisinopril 10mgpo qday mvi qday ca with vit d zocor 40mg po qhs fosamax 70mg po qweek carbidopa/levodopa q3h entacapone with carbidopa/levodopa discharge medications: none discharge disposition: expired discharge diagnosis: 1. aspiration pneumonia 2. thrombocytopenia 3. chf 4. parkinson's disease 5. melena 6. hypotension discharge condition: deceased discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Abnormal coagulation profile Congestive heart failure, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Paralysis agitans Hypotension, unspecified Pneumonitis due to inhalation of food or vomitus Osteoporosis, unspecified Blood in stool Personal history of malignant neoplasm of bladder Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Hypoxemia Anticoagulants causing adverse effects in therapeutic use Dehydration Hyperosmolality and/or hypernatremia Accidents occurring in residential institution

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sepsis secondary to infected stone, complicated by respiratory failure major surgical or invasive procedure: endotracheal intubation percutaneous nephrostomy tubes history of present illness: mrs. is a 48 yo female with no significant past medical history who presents from osh to ed with fever, intubated for respiratory failure, and likely with infected kidney stone. five days ago, pt started to have nausea and vomiting. she was unable to take in sufficient intake, only being able to take sips of fluids. per pcp note from speaking with her on telephone, pt refused to go to the ed or pcp office for evaluation. compazine rectal suppositories were called in and advised to go to ed if could not keep fluids down in eight hours. pt initially presented to with abdominal pain, back pain, tenderness, and vomiting as above. abdominal ct showed moderate right hydronephrosis with a 1 cm x 5 mm distal right ureter stone. pt was started on dopamine gtt at osh and in ambulance en route to , bp dropped to 60s systolic. in the ed on presentation, pt was initially verbal, vs: t: 101.2 (103.4 initially); hr: 120; bp: 64/23; rr:22; o2: 93% ra. she arrived on a dopamine gtt drip peripherally. per ed intern, pt was tachycardic on the dopamine which was d/cd as levofed was started. pt was intubated for question of ards and worry of tiring out as rr was in the 40s. when anesthesia saw pt, bp was in the 60s systolic. a right femoral line was placed emergently as well as an a-line. phenylephrine was started for bps in the 60s-80s systolic despite neosynephrine. pt received 3 l ns in ed (total 7 l including osh), was pancultures, and received broad spectrum antibiotics including: unasyn (3 grams), levofloxacin (500 mg iv), metronidazole (500 mg), vancomycin (1 gram), and ceftriaxone (1 gram). pt received 3 units ffp and one unit of cryoprecipitate in the ed as was noted to develop petechiae. she was then taken to ir and a right nephrostomy tube was placed. pt was transferred to the micu on neosynephrine gtt. cx's + for pan-s e. coli and abx were switched from amp/gent to levo. pt was successfully weaned from the vent and was transfered to floor for further management. past medical history: osteopenia s/p c-section x 3 h/o uretal reflux no h/o stones s/p removal of breast cyst social history: pt is a preschool teacher. married and has three children ages 17, 13, and 11. she lives in . no smoking, alcohol, or drug use. family history: m: breast cancer. physical exam: vs: t: 97.3; bp: 111/68; p: 108; o2: 97 on ac 500/12/.80/5 gen: intubated, sedated. unresponsive. looks comfortable. heent: ett in place. neck: increased neck girth. unable to appreciate jvd. cv: tachycardic. s1s2. no murmurs. lungs: anteriorly: slightly decreased breath sounds without wheezes, rales, rhonchi. abd: distended. +bs slightly decreased. soft, nt. no hepatomegaly appreciated. flank: right flank with nephrostomy tube in place with sanginous drainage. ext: trace edema b/l. dp 2+. neuro: sedated. patellar, achilles . skin: no petechiae seen. slight flank rash, non-blanchable. pertinent results: labs: wound tip cx - negative urine cx - negative; - pan-s e. coli blood cx , - ngtd u/s: 1. uncomplicated ultrasound and fluoroscopically guided right nephrostomy tube placement. 2. marked right-sided hydronephrosis. ekg: sinus tachycardia ~120s. normal axis. normal intervals. good r wave progression. no st changes (slight st depression <1mm in v5-v6) radiology: ap cxr - clear diaphragms with hilar engorgement b/l and upper/mid zone cephalization. ruq u/s: multiple small stones and severe gallbladder wall edema. however, there is no positive sign. this could be secondary to the patient's fluid status and low albumin. clinical correlation is necessary. if indicated, hida scan could be performed. discharge labs: 06:15am blood wbc-31.0* rbc-3.75* hgb-11.7* hct-32.4* mcv-86 mch-31.1 mchc-36.1* rdw-13.8 plt ct-328 06:15am blood glucose-101 urean-30* creat-1.1 na-140 k-4.5 cl-104 hco3-23 angap-18 06:15am blood alt-52* ast-24 ld(ldh)-247 alkphos-187* totbili-0.6 brief hospital course: pt is a 48 yo female who presented with urosepsis in the setting of an impacted right stone. now s/p right nephrostomy tube. 1. pt with urosepsis secondary to infected stone. she is s/p right nephrostomy tube. she received ~7 liters of fluid prior to micu and was weaned down to neosynephrine as sole pressor. she was given more fluid and was able to be weaned off of pressors by day 2 in the micu with the goal map of greater than 65. because pt had a femoral line, the cvp was watched to monitor fluid status, but the absolute number was not accurate. cortisol stimulation test was done and was adequate (42-->44). pt was on an insulin drip initially for tight glycemic control in the setting of sepsis and this was able to be weaned off. in terms of antibiotics, pt received multiple ones in the ed. given that it was a gu source, and likely a gnr or enterococcus, pt was switched to gentamycin and ampicillin upon admission. she then became afebrile and did not spike after that. urine cultures from here and osh eventually grew e. coli which was pan-sensitive. antibiotics were changed to levaquin po which was renally dosed initially. blood cultures remained negative here and at osh. nephrostomy tube drainage initially was noted to be "pussy." however, it then was sanginous and then drained serous fluid. urology was consulting and felt that the nephrostomy tube should be left in place for a month and then break up the impacted stone. 2. pt with leukocytosis which continued even when pt was afebrile, seemingly doing much better and stable. differential diagnosis included infection, drug effect. in terms of infection: repeat abdominal/pelvis ct scan was done to look for pocket of infection in the kidney. the scan was normal and showed no evidence of other infection, though limited by being a non-contrast study. c. diff was thought of as pt received an enormous amout of antibiotics initially, but c.diff were negative. continuing antibiotics, eventually her wbc trended downward. 3. respiratory failure/fluid status. - pt with a metabolic and respiratory acidosis initially. she was intubated in setting of impending respiratory failure likely secondary to overwhelming metabolic acidosis. she was vented on an ards net protocol, with a goal tidal volume of 5-7cc/kg. she self extubated and did well off of the ventilator on day two. pt then had a large oxygen requirement up to 6l nc. this was secondary to gorss pulmonary edema. she was initially on a lasix drip tenous blood pressures but started to autodiurese up to 5 l per day. o2 was successfully weaned off. 4. acute renal failure- creatinine baseline 0.7-1.0, 2.7 upon admission. it was likely pre-renal in the setting of both a hypoperfusion state given hypotension, made worse by sepsis and obstruction. creatinine peaked at 2.8 and steadily decreased to normal. 5. hematologic issues a. anemia- hct down to 26 from 38 baseline. could be in setting of volume resuscitation, though seemed a drastic drop. stool was gauaic negative and hemolysis labs were negative. a likely plausible explanation of anemia was that nephrostomy tube drainage was initially pure blood and thus a large hct drop was possible. hct remained stable and was slowly trending up. b. thrombocytopenia- plateletes were in 80s increased to low 100s. likely in setting of sepsis. remained stable. c. coagulopathy- inr/ptt initially elevated, likely because of shock liver and hypoperfusional state (lfts were all slightly high). coags trended to normal. 5. access- right femoral central line, right a femoral () placed in ed. we correlated a line and bp in arm and d/cd the a line (5 points lower in arm but changes correlate). we d/cd the central line and all lines were sent for cultures. pt had two pivs after that. 6. f/e/n- initially were giving fluid prn with aggressive electrolyte repletion. pt was extubated and advanced to regular diet. 7. contact: (; ) 8. prophylaxis- initially on pneumoboots changed to subcutaneous heparin when platelets stable. on ppi while intubated. 9. code status: full code discharge medications: 1. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*14 tablet(s)* refills:*0* 2. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. capsule(s) 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. ambien 5 mg tablet sig: 1-2 tablets po at bedtime as needed for insomnia. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: nephrolithiasis urosepsis disseminated intravascular coagulation secondary to urosepsis respiratory failure discharge condition: good. discharge instructions: please seek medical attention or return to the emergency department for fevers >101.4 or for anything else concerning to you. please take your medications as directed. followup instructions: follow up with dr. urology in weeks (. they will call you with an appointment. please call them if you do not hear from them before the end of the day on wednesday. follow up with dr. in one week. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Percutaneous nephrostomy without fragmentation Arterial catheterization Transfusion of other serum Transfusion of coagulation factors Infusion of vasopressor agent Diagnoses: Thrombocytopenia, unspecified Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Urinary tract infection, site not specified Acute and subacute necrosis of liver Severe sepsis Acute respiratory failure Defibrination syndrome Septic shock Dehydration Septicemia due to escherichia coli [E. coli] Hydronephrosis Calculus of ureter Disorder of bone and cartilage, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: word finding difficulties major surgical or invasive procedure: g-tube placed history of present illness: a yom with multiple stroke risk factors admitted for after a minute period of word-finding difficulty, ruled out for stroke and now transferred from neurology service to medicine for management of uncontrolled hypertension. pt. was on bb and nitrate for bp control prior to admission, and currently remains with sbp>190 on iv ace-i and bb with iv hydralazine prn. past medical history: h/o strokes in , cad/mi, s/p cabg in hypercholesterolemia s/p r cea in htn social history: lives alone in ecf, ambulates with walker, frequent falls recently, no etoh. family history: nc physical exam: vs: 96.8 | 195/87 | 77 | 22 | 97% on ra gen: nad, breathing sounds and looks distressed (pt. appears to be gasping and has a lot of secretions) but says he is breathing fine. heent: op clear, dry mmm, no lad, perrl and eom intact. cv: rrr, nl s1s2, no murmurs. chest: cta b/l, no crackles or wheezes. abd: soft, nt/nd, +bs, no organomegaly. extr: no edema, no cyanosis, + distal pulses. neuro: right-handed, awake, alert, garbled speech, when comprehensible pt. answers appropriately, but usually difficult to understand. nl. muscle tone. pertinent results: head ct: impression: no acute intracranial hemorrhage, mass effect, or change since . for the diagnosis of acute infarction, mr - weighting is the test of choice. . mra brain: impression: no evidence of acute infarction. no change in the appearance of the brain since . . cxr: impression: no evidence of chf or pneumonia. . carotid series: impression: mild plaque is present in the carotid arteries bilaterally with stenosis evaluated as less than 40% on each side. . echo: conclusions: 1.the left atrium is normal in size. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is hard to assess given the limited views but is probably mildly decreased (lvef 45-50%). there is hypokinesis of the basal and mid portion of the inferolateral wall. 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. no aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. 7.moderate tricuspid regurgitation is seen. 8.there is no pericardial effusion. compared with the findings of the prior report (images unavailable for review)of , there is no significant change in the overall ef. however, the inferior hypokinesis is not well seen given the limited views. impression: no cardiac source of embolus seen. . cxr portable: impression: no acute cardiopulmonary disease. . ecg: sinus rhythm. right bundle-branch block. borderline left axis deviation. possible left anterior fascicular block - cannot exclude prior infero-posterior myocardial infarction. compared to the previous tracing of multiple abnormalities as noted persist without major change. tracing #1 . ecg: sinus rhythm. right bundle-branch block. borderline left axis deviation. possible left anterior fascicular block. cannot exclude prior inferior wall myocardial infarction. borderline prolonged q-t interval. compared to the previous tracing of multiple abnormalities persist without major change. the q-t interval is now prolonged. . labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 12:18pm 10.8 3.96* 12.5* 35.9* 91 31.6 34.8 14.2 210 05:10am 12.0* 4.54* 14.2 41.1 90 31.4 34.7 14.2 260 05:20am 12.5* 4.15* 13.0* 37.7* 91 31.3 34.4 14.3 239 06:35am 13.7* 3.98* 12.4* 36.9* 93 31.1 33.6 14.0 226 05:07am 10.9 4.34* 13.2* 39.5* 91 30.4 33.4 14.2 257 05:40am 13.7* 4.99 15.3 44.3 89 30.7 34.6 13.8 249 05:10am 15.5*# 4.85 14.9 43.0 89 30.6 34.6 13.8 259 03:27am 8.0 4.33* 13.6* 38.2* 88 31.5 35.7* 13.5 226 02:45pm 8.7 3.84* 12.5* 35.6* 93 32.5* 35.1* 13.6 228 . glucose urean creat na k cl hco3 angap 12:18pm 141* 30* 0.9 145 3.1* 109* 241 15 09:10pm 122* 24* 0.9 145 3.3 108 231 17 05:10am 112* 27* 0.9 147* 3.4 112* 241 14 05:20am 108* 35* 1.0 150* 3.81 115* 21*2 18 06:35am 137* 37* 1.0 147* 4.41 115* 17*2 19 05:07am 88 37* 1.1 144 4.01 110* 16*2 22* 05:40am 95 26* 1.0 140 3.5 106 19*1 19 08:05pm 111* 23* 1.0 138 3.9 106 20*1 16 05:10am 126* 23* 1.1 140 3.8 103 21*1 20 03:27am 91 24* 1.0 140 4.0 105 271 12 11:00pm 102 28* 1.0 137 3.9 102 251 14 02:45pm 124* 31* 1.2 138 4.71 103 302 10 . ck-mb mb indx ctropnt 08:05pm 12* 4.1 0.04* 03:27am notdone1 <0.01 11:00pm notdone1 <0.01 02:45pm notdone1 <0.01 . cholest triglyc hdl chol/hd ldlcalc 03:27am 157 581 55 2.9 90 brief hospital course: a/p: yom with h/o strokes and multiple stroke risk factors now with uncontrolled htn. . a yom with multiple stroke risk factors, admitted s/p min. period of word finding difficulty, with some feeling of unsteadiness, and complete recovery prior to ems arrival, c/w tia. physical exam most notable for brisk reflexes and increased tone on l along with l facial droop, likely related to prior strokes. symptoms were resolved upon arrival to ed. mri was negative for stroke. asa was changed to aggrenox (started 1cap qd w/baby asa, then incr to 1cap and asa d/c'd). statin was increased for elev ldl (goal <70). pt. received haldol for agitation in the icu, and zyprexa x1 on . pt was transferred to the medicine after he was r/o'd for a stroke. his aggrenox was continued. pt's mental status was very labile, it waxed & waned but he never completely recovered his speech. he was confused throughout his admission, oriented to self at times. he had to be restrained on a few occassions for agitation and to prevent pulling piv, which he did several times. . htn: pt. had c/o chest pain which resolved; ruled out for mi on admission (ces negative x3); he remained cp free s/p labetalol gtt on . however again became hypertensive to 200s on . on alternating metoprolol, enalaprilat. had short asymptomatic run of v-tach , rpt ecg showed no changes, lytes, cardiac enzymes negative for ischemic chanes. echo showed ef 45-50%, hypokinesis of inferolateral wall, mod mr, mod tr, no significant change in ef comp to . carotid u/s <40% stenosis bilaterally. htn remained difficult to control(sbp 190s). initially holding parameters to keep sbp 140 in setting of potential stroke made it difficult to up titrate bb and hydral iv without decreasing his bp too much. in setting of holding his meds his bp would increase to sbp 180s-190s. he received a nitropatch x2 with minimal control. his bb was increased to metoprolol 25mg iv q4 hours and hydral increased to 30mg iv q6 hours. in this setting he also required nitropaste 1 inch thick for sbp 180. throughout his admission he did not regain the ability to swallow, which therefore all his meds were given iv. several attempts were made to pass an ngt for access to meds and nutrition unsuccessfully. nifedipine crushed under the tongue was also used on 2 occassions with moderate response. on his last day of admission, his bp was better controlled w/25mgivbb, 30mgiv hydral, nitropatch. iv ace-i d/c'd on ; continue bb, start nitro patch; eventually transition back to po meds and restart ace-i for d/c (pt. should be on ace-i due to h/o cabg). . fen/gi: did not pass swallow eval . unable to pass ngt after multiple attempts. currently receiving meds iv. his medications were continued iv for no bp control in the absence of the pt's inability to swallow and no other means to provide meds. because pt had pulled several piv, the team was relunctant to place a central line for iv access for fluids, meds and tpn. the medicine team tried again unsuccessfully to place an ngt as well as a doboff tube. on pt again self d/c'd piv. he received a double lumen picc on with the intention of starting tpn if gi could not place the g-tube. per gi pt received a g-tube on without complications. pt was sent back to the floor. tf order was placed in anticipation of pt receiving tf the following day post 12 hours after procedure. . id: on cipro for uti (positive u/a, cx contaminated). wbc incr. to 15 on , currently 15.5, afebrile. no evidence of infiltrate on cxr. ?pharyngitis (c/o sore throat, +erythema), rapid strep/cx pending. changed abx to levofloxacin. rpt urine cx with no growth after levo was started. he had completed 6 days of levo, no wbc and remained afebrile. . endo: qid d-sticks, insulin sliding scale prn. hba1c=6.2. . ppx: pneumoboots, heparin, h2 blocker, olanzapine prn agitation. . code: dnr/dni . dispo: case manager aware of pt's need for rehab. pt was to be screened by when g-tube placed to establish nutrition and better access for meds. . **pt expired at 1550 post pea. he was dnr/dni. dr. and the son, were notified. . medications on admission: meds (home): pravachol 40qd, toprol xl 100qd, ismo 60qd, asa ec 81qd. discharge disposition: expired discharge diagnosis: expired discharge condition: deceased Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Pure hypercholesterolemia Mitral valve disorders Urinary tract infection, site not specified Unspecified essential hypertension Aortocoronary bypass status Peripheral vascular disease, unspecified Paroxysmal ventricular tachycardia Old myocardial infarction Dehydration Hyperosmolality and/or hypernatremia Unspecified transient cerebral ischemia Diseases of tricuspid valve Acute pharyngitis

history of present illness: is a former 980 gram product of a 27 and week gestation pregnancy, born to a 36 year old, gravida iv, para iii to iv woman. prenatal screens: blood type a negative, antibody negative. rpr nonreactive. hepatitis b surface antigen negative. group beta strep status unknown. pregnancy was complicated by premature rupture of membranes for six days prior to delivery and preterm labor. the mother was treated with ampicillin and erythromycin. she was betamethasone complete. the infant was born by spontaneous vaginal delivery. she required chest compressions and positive pressure ventilation. at delivery, apgars were three at one minute, seven at five minutes. she was admitted to the neonatal intensive care unit for treatment of prematurity. of note, the mother had a previous delivery at 33 weeks in . she also has a history of depression and was treated with paxil. physical examination: upon admission to the neonatal intensive care unit, weight was 980 grams; length was 34.5 cms; head circumference 25 cms; all about the 40th to the 50th percentile. general: premature, vigorous female, orally intubated. head, ears, eyes, nose and throat: anterior fontanel soft flat, non dysmorphic features. palate intact. chest: breath sounds equal with diffuse crackles. cardiovascular: regular rate and rhythm without murmur, normal pulses. abdomen soft, three vessel cord, no hepatosplenomegaly. genitourinary: normal female genitalia. patent anus. musculoskeletal: no hip click, no sacral dimple. neurologic: normal tone for age, moving all extremities. hospital course: by systems, including pertinent laboratory data: system #1: respiratory: was intubated in the delivery room. she received two doses of exogenous surfactant. her maximum ventilator settings were a peak inspiratory pressure over 27, over a positive end expiratory pressure of five; intermittent mandatory ventilatory rate of 25. she weaned rapidly to low vent settings and was extubated to nasopharyngeal c-pap on day of life #3. she remained on the continuous positive airway pressure through day of life 23 and she remained in room air until discharge. also required treatment for apnea of prematurity with caffeine citrate. the caffeine was discontinued on . her last episode of spontaneous bradycardia was on . #2: cardiovascular: has maintained normal heart rates and blood pressure. a soft murmur was heard intermittently from three weeks of age on. an electrocardiogram was performed on and was within normal limits. chest x-ray showed normal heart size and silhouette. four extremity blood pressures were within normal limits. the murmur is thought to be consistent with peripheral pulmonic stenosis. #3: fluids, electrolytes and nutrition: was initially n.p.o. and maintained on intravenous fluids. enteral feeds were started on day of life #5 and gradually advanced to full volume. her maximum caloric intake was 30 calories per ounce, with additional pro-mod protein supplement. at the time of discharge, she is taking neosure four to five, 25 calories per ounce, a minimum of 130 cc/kg per day. she takes in 150 to 175 cc/kg per day. her discharge weight is 2.765 kg with a length of 48 cms and a head circumference of 34 cms. serum electrolytes were within normal limits. #4: infectious disease: was evaluated for sepsis shortly after admission to the neonatal intensive care unit. a white blood cell count was 44,800 with a differential of 59% polys, 1% bands. a blood culture was obtained prior to starting intravenous ampicillin and gentamycin. due to the concern with the prolonged rupture of membranes, a lumbar puncture was performed with results within normal limits. she received a seven day course of ampicillin and gentamycin. there were no other infectious disease issues during admission. #5: hematology: hematocrit at birth was 44.9%. did not receive any transfusions of blood products. her low hematocrit occurred on at 27%. her most recent hematocrit was on , 31% with a reticulocyte count of 3.1%. she is being discharged home on supplemental iron. #6: gastrointestinal: required treatment for unconjugated hyperbilirubinemia with phototherapy. her peak serum bilirubin occurred on day of life #2, with a total of 4.8 mg/dl over 0.3% mg/dl. she received approximately 72 hours of phototherapy. a rebound bilirubin on day of life seven was 3.4, total over 0.2 direct. #7: neurologic: initial head ultrasound on showed a left intraventricular hemorrhage. a head ultrasound performed at approximately one month of age, on , showed left sided periventricular leukomalacia with the evolving left germinal matrix hemorrhage and slight increase size of the left ventricle. her most recent head ultrasound was performed on which showed a more defined area of cystic encephalomalacia in the left frontal periventricular region. the overall effected area was not much change from the prior examination. there was also some surrounding echogenicity. the previously noted left germinal matrix hemorrhage had resolved. there was very mild dilatation of the frontal horns of the left ventricle. will be referred to the neonatal neurologic clinic at . #8: sensory: audiology, hearing screening was performed with automated, auditory brain stem responses. passed in both ears. ophthalmology: serial ophthalmologic examination screening for retinopathy of prematurity have been performed. her initial examination on showed immature retina to zone three. a repeat examination on showed stage i zone three, three clock hours on the left, immature to zone three on the right. another follow-up examination on showed immature to zone two bilaterally, almost to zone three. an additional examination was performed on . condition on discharge: good. discharge disposition: to home with parents. primary pediatrician: dr. , , , , , . phone number . care and recommendations: feedings: neosure fortified to 24 calories per ounce. recommended until six to nine months of corrected age. medications: ferrous sulfate 25 mg per mls dilution, 0.2 cc p.o. q. day. car seat position screening was performed. maintained normal heart rates and oxygen saturations for 90 minutes. state newborn screens were sent on and -- all results within normal limits. immunizations: initial hepatitis b vaccine, diphtheria, acellular pertussis, hemophilus influenzae b, injectable polio vaccine and pneumococcal conjugant vaccine were all administered on to . 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 plans for day care during the rsv season, with a smoker in the household or with preschool siblings. 3.) with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. follow-up: appointment with dr. , primary pediatrician, within three days of discharge. follow-up with the neonatal neurologic clinic at , phone number . discharge diagnoses: prematurity at 27 and 2/7 weeks gestation. respiratory distress syndrome. suspicion for sepsis, ruled out. left germinal matrix hemorrhage. left periventricular leukomalacia. apnea of prematurity. anemia of prematurity. unconjugated hyperbilirubinemia. cardiac murmur. dr., 50-aad dictated by: medquist36 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 Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Other phototherapy Prophylactic administration of vaccine against other diseases Umbilical vein catheterization Diagnoses: Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery 27-28 completed weeks of gestation Primary apnea of newborn Intraventricular hemorrhage, grade I Stenosis of pulmonary valve, congenital Other preterm infants, 750-999 grams

past medical history: is remarkable for diabetes, osteoporosis, hypertension, rheumatoid arthritis. past surgical history: is remarkable for mastectomy and bilateral knee arthroscopies. medications on admission: were norvasc, gemfibrozil, clarinex, zoloft, ambien, flonase and bextra. she has no known drug allergies. she is not a smoker. physical examination: her height was 5 feet 3 inches. weight is 138 pounds. vital signs at the time of admission were stable. on examination she did have a spastic gait. motor examination in the upper extremities on the left were 3 plus and the deltoid, biceps, triceps, brachial radialis, wrist flexors, wrist extensors and intrinsics. the lower extremities were bilaterally. deep tendon reflexes were 3 plus bilaterally at brachial radialis, biceps, triceps, 3 plus at the right knee, absent at the left knee, 2 plus at the ankles. she had no and clonus bilaterally. she did have an mri done on that did show a peri-odontoid c2 pannus with significant compression of the cervical medullary junction with an increased t2 cord signal. x-rays with flexion and extension did show a c1-2 instability with hypermobility of c1 on c2. hospital course: she was admitted and brought to the operating room on where she underwent a transoral odontoidectomy and posterior occipital cervical fusion. she also had placement of a delta feeding tube placed intraoperatively. postoperatively she was transferred to the post anesthesia care unit where she remained intubated and sedated. she was kept there overnight for close observation. when she was lightened off the propofol she was moving all four extremities briskly. she was also on decadron 6 mg every six hours. on , the first postoperative day her vital signs were stable. she was afebrile. she could open her eyes to voice and continued to move all four extremities spontaneously as well as on command. she was kept intubated. she was also followed by medicine as they saw her preoperatively as well. she was transferred to the intensive care unit for close neurosurgical neurological monitoring. she continued extubated and once the swelling in her airway was decreased she was able to be extubated which did occur on . her posterior incision was clean, dry and intact. she received aggressive chest physical therapy. she was started on kefzol. she was stable enough to be transferred to the floor on . she was started on physical therapy and occupational therapy. she was on total parenteral nutrition for nutrition but then on she did start on clear fluids which was quickly advanced. she tolerated this well. she had received intravenous lasix on several occasions for diuresis. she also received blood products while in the intensive care unit and was treated for fluid volume overload with intravenous lasix. she was also started on total parenteral nutrition for malnutrition while she was n.p.o. her decadron was weaned to 2 b.i.d she did have some mild erythema at the inferior aspect of the posterior cervical wound and started on keflex 500 mg 4 times a day for ten days. she will be discharged to home on with home physical therapy to assist with her ambulation. she is scheduled to follow up with dr. in six weeks and dr. for staple removal on next wednesday, for staple removal. , Procedure: Parenteral infusion of concentrated nutritional substances Other exploration and decompression of spinal canal Transfusion of packed cells Other cervical fusion of the posterior column, posterior technique Atlas-axis spinal fusion Fusion or refusion of 2-3 vertebrae Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Personal history of malignant neoplasm of breast Osteoporosis, unspecified Rheumatoid arthritis Cervical spondylosis with myelopathy Panniculitis specified as affecting neck

allergies: novocain / fentanyl attending: chief complaint: thoracic mass major surgical or invasive procedure: thoracic spinal mass resection history of present illness: 83y/o male with hx of recal cell carcinoma presented with abdominal pain over the past one month. the pain located at the left side of umbilicus, almost as band like distribution. the pain was also sensed as dull, uncomfortable feeling. besides this pain, he did not have any other symptoms such as weakness, numbness, difficulty in ambulation, urination, stooling. last weekend, he felt the symptom did not imporved and visited osh ed. there he was obtained ct scan and eventually follow up mri, and found to have t9 mass lesion. he was referred to for further evaluation. ros: no headache, fever, trauma hx, urinary/bowel incontinence. past medical history: renal cell carcinoma: s/p l nephrectomy in . pathology was renal cell ca, clear cell type, grade iii, size 8.5 cm, invasion into renal vein was present. has had surveillance ct scans yearly at osh - all negative. atrial fibrillation - has been in sinus, anti-coagulated turp for bph hyperlipidemia social history: married, 6 children. retired from the air force, was a fighter pilot. drinks 3-4 drinks/week. tobacco - smoked 40 yrs, ~1 pack/wk - quit in . no illicits. family history: father - mi, mother - ad, brother - colon ca at age 73. physical exam: vitals: 97.8 hr 64, reg bp 105/64 rr 16 so2 100% r/a gen:nad. heent:mmm. sclera clear. op clear. extra ear canals, ear drums clear. neck: no carotid bruits cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: tenderness at the left side of umbilicus. no defenese, rebound. ext: no arthralgia, no cyanosis/edema neurologic examination: mental status: awake and alert, cooperative with exam, normal affect orientation: oriented to person, place, and date language: fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors no apraxia, no neglect cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2mm bilaterally. visual fields are full to finger movement. fundi normal bilaterally. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to tuning fork bilaterally. no tinnitus. no nystagmus. ix, x: palatal elevation symmetrical : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations, intact movements motor: normal bulk and tone bilaterally no tremor, no asterixis full strength throughout mmt tri wext wflx io ip quad hs ta gc toeext toeflx r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 slightly unstable one foot standing at the left. no pronator drift sensation: hyperestesia at the left t9-t10 both anterior/posterior trunk. intact to light touch, pinprick, temperature (cold), vibration, and propioception throughout all extremities. position sense slightly decreased at the left toe. reflexes: b t br pa ankle right 2 2 2 2 2 left 2 2 2 2 2 toes were downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements normal, ffm normal. gait: stance is narrow based, with stable gait. stable tandem gait meningeal sign: negative brudzinski sign. no nucal rigidity. pertinent results: 6.1>13.4/37.7<202 sed-rate: 17 pt: 37.5 ptt: 37.7 inr: 4.2 139 107 29 99 agap=14 ------------------ 4.3 22 1.6 ca: 9.4 mg: 2.4 p: 3.1 t-spine ct (): 1. large mass involving the posterior elements at the level of t9 on the left which is invading the central canal and causing thecal sac compression. 2. multiple masses in the lung consistent with metastases. findings were discussed with you the day of the study. l-spine ct (): 1. congenitally narrowed central spinal canal as described above. mild degenerative changes at l4-5 with a diffuse broad-based disc bulge. there is no evidence for neural foraminal narrowing. 2. no bony lesions are identified to indicate metastatic isease in the lumbar spine. please see thoracic spine report of the same date for significant findings regarding likely metastatic disease. chest ct (): 1. numerous bilateral soft tissue density pulmonary nodules consistentwith pulmonary metastases. given the history of prior nephrectomy, metastatic renal cell carcinoma is likely. 2. destructive osseous lesion in the t9 vertebral body with encroachment upon the spinal canal. urgent neurosurgery consult and further characterization with dedicated mri is required. 3. coronary artery calcifications. brief hospital course: patient was admitted to medicine service for initial work up. ct guided biospy was performed on , pathology result was renal cell carcinoma and the t9 lesion was considered metastasis. right after receiving this result, patient was scheduled for (1) tumor embolization by interventional radiology and (2)t7-11 laminectomies/mass resection and fusion on by dr. . post operatively he was moving all extremities with full strength he had a drain placed interoperatively. on pod#2 his hematocrit was 22.8 he received 2 units of prbcs, follow up crit was: physical therapy was consulted and cleared patient for discharge to home. medications on admission: coumadin tricor zocor discharge medications: 1. fenofibrate micronized 145 mg tablet sig: one (1) tablet po daily (). 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4h (every 4 hours) as needed for pain. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). discharge disposition: home with service facility: nursing services discharge diagnosis: metastic renal cell carcinoma discharge condition: neurologically stable. discharge instructions: discharge instructions for spine cases ?????? do not smoke ?????? keep wound(s) clean and dry / no tub baths or pools for two weeks from your date of surgery ?????? if you have steri-strips in place ?????? keep dry x 72 hours. do not pull them off. they will fall off on their own or be taken off in the office ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? if you are required to wear one, wear cervical collar or back brace as instructed ?????? you may shower briefly without the collar / back brace unless instructed otherwise ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, ibuprofen etc. unless directed by your doctor ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits restart coumadin in a month followup instructions: have staples removed in 10 days. follow up in 6 weeks with dr. , clinic, . follow up with renal oncology clnic at 4pm on with dr. /dr. , . Procedure: Imageless computer assisted surgery Excision or destruction of lesion of spinal cord or spinal meninges Transfusion of packed cells Dorsal and dorsolumbar fusion of the posterior column, posterior technique Biopsy of bone, other bones Transfusion of platelets Insertion of interbody spinal fusion device Fusion or refusion of 4-8 vertebrae Computer assisted surgery with fluoroscopy Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Personal history of tobacco use Other and unspecified hyperlipidemia Secondary malignant neoplasm of lung Personal history of malignant neoplasm of kidney Acquired absence of kidney Secondary malignant neoplasm of bone and bone marrow Myelopathy in other diseases classified elsewhere Other drugs and medicinal substances causing adverse effects in therapeutic use Anomaly of spine, unspecified Family history of malignant neoplasm of gastrointestinal tract

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypothermia/ slurred speech, ? right sided weakness major surgical or invasive procedure: none history of present illness: pt is a 78 yo female with dm2, htn, who presents from osh (and nursing home) with hypothermia, slurred speech, aphasia, and right sided weakness. 2-3 months ago, pt was noted to have le weakness and slowly became wheelchair bound. mri showed l4-l5 stenosis. she underwent laminectomy . at rehab, pt was noted to have elevated bps and was admitted to from for htn and management and titration of medications. . this am at rehab, pt was found sitting in her wheelchair and confused. she had a right sided headache and slurred speech. at osh ed t: 92 and bp 172/ 69. she was started on nitropaste and transferred to for workup of possible stroke. . in the ed, vs on arrival were: t: 92 (rectally); hr: 47; bp: 177/69; o2: 100 ra. a bear hugger was placed on pt she was given 10 mg dexamethasone, 400 mg iv ciprofloxacin, and 2 mg lorazepam. she was also given 1 unit of prbc and two l of ns. past medical history: dm2 htn h/o utis s/p l4-l5 diskectomy in s/p right foot debridement right arm weakness 2/2 fall neuropathy hypothyroidism echo - mild concentric lvh with preserved systolic performance and associated diastolic filling abnormality. mild mr. tr social history: no tobacco. occasional wine. married, now in rehab, though prior was at home family history: non contributory physical exam: vs: t: 97.2; hr: 53; bp: 153/68; rr: 4; o2: 100 4l gen: laying in bed, apneic at times. she is arousable by deep sternal rub and falls right back to sleep. heent: pupils pinpoint but slowly reactive. could not follow command for eom as falls asleep. op view limited though clear. periorbital above eyelid edema neck: no lad cv: bradycardic s1s2. lungs: anteriorly: cta but poor movement abd: nabs, soft, nt, nd. +echhymosis back: unable to assess ext: 2+ pitting edema to thighs b/l. arms also swollen neuro: unable to assess fully as pt arousable to sternal rub and then falls asleep. opens eyes to commands. biceps, brachio, patellar . toes downgoing. pertinent results: admission labs 04:45pm glucose-134* urea n-31* creat-1.1 sodium-116* potassium-4.3 chloride-83* total co2-20* anion gap-17 . 03:20pm sodium-123* 09:10am glucose-86 urea n-23* creat-1.1 sodium-121* potassium-4.0 chloride-95* total co2-18* anion gap-12 calcium-8.6 phosphate-3.1 magnesium-2.2 . 09:10am urine hours-random creat-17 sodium-60 osmolal-245 color-yellow appear-clear sp -1.020 blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-8.0 leuk-sm rbc-0 wbc-0 bacteria-occ yeast-none epi-0 . urine culture : enterococcus sp.. >100,000 organisms/ml ampicillin------------ =>16 r nitrofurantoin-------- 128 r tetracycline---------- <=1 s vancomycin------------ <=1 s . 09:10am wbc-6.1 rbc-3.28* hgb-10.1* hct-28.3* mcv-86 mch-30.6 mchc-35.5* rdw-15.4 plt count-178 . 06:07am type-art temp-36.2 po2-206* pco2-29* ph-7.44 total co2-20* base xs--2 intubated-not intuba . cardiac enzymes: 04:45pm ck(cpk)-223* ck-mb-14* mb indx-6.3* ctropnt-0.05* 11:20pm ck(cpk)-198* ck-mb-12* mb indx-6.1* ctropnt-0.05* 04:20am ck(cpk)-174* ck-mb-11* mb indx-6.3* ctropnt-0.05* . 04:45pm tsh-5.0* 04:45pm t4-8.3 . am cortisol 9 stim 14.0 to 31.6 with cosyntropin . vanc trough level 11.3 . cxr : history: hyponatremia, unresponsive. one portable view. comparison with the previous study done . there is minimal streaky density at the lung bases consistent with subsegmental atelectasis. lung volumes are slightly lower than before and bronchovascular markings are more prominent. pulmonary vasculature is less distinct than on the earlier study. the aorta is tortuous and calcified as before. the cardiac silhouette is somewhat prominent, but the cardiac size may be exaggerated by ap technique. mediastinal structures are otherwise unremarkable. the bony thorax is grossly intact. impression: subsegmental atelectasis. increased lung markings which may reflect mild pulmonary vascular congestion. . echo : conclusions: the left atrium is elongated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. tissue velocity imaging demonstrates an e/e' <8 suggesting a normal left ventricular filling pressure (pcwp<12mmhg). 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 mildly thickened. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: preserved global and regional biventricular systolic function. impaired lv relaxation. no pathologic valvular disease. no obvious source of embolism identified. . eeg : impression: this is an abnormal eeg in the waking and drowsy states due to the independent, right greater than left, temporal theta slowing with drowsiness. this likely represents bilateral, right greater than left, temporal subcortical dysfuction. in this age group, the most common cause is subcortical ischemia. . carotid u/s impression: 1. there is less than 40% stenosis within the right internal carotid. 2. there is 60% to 69% stenosis within the left internal carotid artery. . right humerus films: findings: there is no significant change in appearance of a markedly comminuted fracture of the proximal right humerus involving the surgical neck. there are innumerable comminuted bony fragments. there is no overt change in the degree of displacement of the humeral shaft anteriorly in relation to the humeral head. the irregularity of glenoid mentioned previously cannot be definitely appreciated on this view. impression: no overt change in appearance of displaced fracture of the right proximal humerus with innumerable comminuted bony fragments as described above. . head mris technique: multiplanar t1- and t2-weighted sequences were obtained through the brain with diffusion-weighted imaging. findings: the study is severely limited due to patient motion artifact. however, there is no slow diffusion to indicate an acute infarct. there is no midline shift or large amount of mass effect. there are periventricular white matter hyperintensities on the flair sequence likely due to chronic microvascular ischemic change. there is mild mucosal thickening through all the visualized paranasal sinuses. no areas of abnormal magnetic susceptibility are noted. again the study was severely limited. impression: severely limited study with no gross abnormalities. no evidence of an acute infarct. mra of the circle of . technique: 3d time-of-flight mra of the circle of . findings: the major vessels of the circle of including the internal carotid arteries, the proximal middle anterior and posterior cerebral arteries as well as the basilar artery are patent. this study is severely limited due to patient motion artifact and should not be considered diagnostic. impression: portions of the visualized circle of are patent. the remainder of the circle of cannot be assessed due to severe patient motion artifact. neck mra. technique: 2d time-of-flight and post-gadolinium mras of the neck with axial t1 fat sat images for dissection. findings: the study is severely limited due to patient motion artifact. however, the vertebral arteries as well as the common and internal carotid arteries are all patent. the axial t1 fat-sat images are nondiagnostic. there is probably some narrowing near the carotid bulb on the left. impression: patent carotid and vertebral arteries. the basilar artery is also patent. limited exam due to patient motion. brief hospital course: # stroke - neuro was consulted. initially thought to be a tia because the mri/a was negative, but focal deficit of aphasia/language was persistant and eeg consistent with ischemia, so neuro made the diagnosis of stroke. she was started on asa 325 mg qd and atorvastatin 80mg qd. her lipid profile was excellent, but should be checked regularly. she had an echo that was negative for causes of embolism. . # nstemi - patient came in with elevated cardiac enzymes but normal ekg. cks were trending down. most likely represents a resolving nstemi. patient was monitored on telemetry for 72 hours without events. patient should have cardiology follow-up. . # hyponatremia - likely initially from medication induced (hctz) sodium losses and intravascular depletion leading to free water retention. she responded to 3l fluids in the ed. pt was fluid restricted and hctz was held. sodium improved to 124 while in the icu. on the floor patients sodium improved to 130. urine osms were inappropriately high at 250-350, indicating likely siadh. cxr was clear. patient should have strict free water restriction (not fluid, just free water). . # urinary tract infection - urine cultures were sent and were shown to be postive for entercocci sensitive to vancomycin, resistant to ampicillin. pt was started on vancomycin on admission. she needs to complete a 14 day course. . # right humerus fracture - old injury on right side, previously imaged at the hospital. it was re-imaged with no change. ortho was consulted and recommended no surgery and to continue with pt. . # hypothermia - patient had hypothermia on admission and then again on the floor. it was not associated with any change in vital signs. not thought to be due to central process, thryroid dysfunction or adrenal insufficiency. thought to be due to inactivity and old age. patient had normal temperature at discharge. . # dm2- glargine 10u qhs and riss. . # hypertension - controlled on metoprolol, amlodipine and captopril. hydralazine was discontinued and captopril up titrated. . # hypothyroid - tsh slightly elevated (5.0) but in the setting of sickness. she is on levothyroxine. repeat in hospital was 3.1. will continue at current dose, recheck tsh as outpatient. . # f/e/n- diet cardiac and diabetic. free water restrict. . # contact: . # prophylaxis: subcutaneous heparin while not walking, bowel regimen . # code status: full code though would not want prolonged intubation. discussed with her husband, the hcp, and pt's son. medications on admission: asa 325 mg qday levothyroxine 125 mcg qday lipitor 80 mg qday niacin 500 mg qday cozaar 100 mg qday metoprolol 50 mg hctz 50 mg qday norvasc 10 mg qday hydralazine 20 mg tid glipizide 10 mg qday insulin sliding scale discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 5. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 6. captopril 12.5 mg tablet sig: two (2) tablet po tid (3 times a day): hold for sbp < 100. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 8. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 8 doses: last day is the . 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 12. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day) for until ambulating doses. 13. insulin glargine 100 unit/ml cartridge sig: ten (10) units subcutaneous at bedtime. 14. insulin regular human 300 unit/3 ml insulin pen sig: per sliding scale subcutaneous qhacs: 61-150 0u, 151-200 2u, 201-250 4u, 251-300 6u, 301-350 8u, 351-400 10u, >400 12u. . 15. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: hospital of and the islands discharge diagnosis: stroke urinary tract infection-enterococcus hyponatremia nstemi hypertension diabetes hypothyroidism discharge condition: stable discharge instructions: please take all medications as directed. we have changed several of your medications. . please seek medical attention if you experience any difficulty moving, changes in sensation, difficulty talking, incontinence, chest pain, nausea, vomiting or any other symptoms that are concerning to you. followup instructions: please follow up with you pcp 2-3 weeks. please have them give you a referral to cardiologist for cardiac rehab. . you may see ortho as you need them. Procedure: Venous catheterization, not elsewhere classified Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Other disorders of neurohypophysis Cerebral artery occlusion, unspecified with cerebral infarction Volume depletion, unspecified

history of present illness: patient is a 59-year-old man who developed neck and chest pain at about 1 o'clock on the day of admission, with shortness of breath, pain, then changed to be more pleuritic in nature. it was not associated with any abdominal pain. he also noted weakness of his upper extremities for a few moments at the time of acute neck and chest pain. past medical history: 1. hypertension. 2. hyperlipidemia. 3. kidney stones. medications prior admission: 1. atenolol. 2. aspirin. allergies: he has no known allergies. laboratory data at time of admission: white count 10, hematocrit 44, platelets 187, pt 13, ptt 27, inr 1.2. sodium 139, potassium 4.1, chloride 101, co2 25, bun 21, creatinine 1.4, glucose 84. electrocardiogram: showed elevations in v1 through ii. physical examination: temperature 95.6, heart rate 69, sinus rhythm, blood pressure 157/66, respiratory rate 18, and o2 saturation is 98% on room air. neurologic: alert, awake, oriented. respiratory: no rales, rhonchi, or wheezes. cardiovascular: regular, rate, and rhythm. abdomen is soft, nontender, nondistended, no rebound, no guarding. extremities are warm. pulses: femoral equal at 2+ dorsalis pedis and posterior tibial are also equal bilaterally at 2+. ct scan of the abdomen and pelvis shows a type a aortic dissection from the root of the aorta including the brachiocephalic left carotid and left subclavian descending aorta down to the left iliac, question occlusion of the left renal. cardiothoracic surgery as well as vascular surgery are called for consultation. the patient is seen and brought to the operating room for repair of his aortic dissection. at that time the patient had a hemi.................... repair with 22 mm of gel weave. his coronary bypass time was 189 minutes with cross clamp of 94 and the circ arrest time of 19 minutes. the patient tolerated the surgery well, and was transferred from the operating room to the cardiac intensive care unit. on the morning of postoperative day one, the patient remained sedated and intubated. all cardiac iv medications were weaned to off. the patient's sedation was discontinued, and he was eventually extubated late in the afternoon of postoperative day one to assess his neurological status. neurologically, the patient was noted to move all extremities, and follow commands, however, his right appeared slightly smaller than the left pupil. on postoperative day two, it was noted that the patient's cardiac enzymes had increased. the patient was intubated and transesophageal echocardiogram was done at that time. transesophageal echocardiogram showed low to normal ejection fraction with anterior hypokinesis and apical hypokinesis with no effusions. the patient was then seen by the cardiology service, and brought to the cardiac catheterization laboratory. please see catheterization report for full details. in summary, the catheterization showed a left anterior descending artery occlusion which was angioplastied. circumflex was small, but no lesions, and the right coronary artery was large with a 60% pda lesion. following ptca of the left anterior descending artery with no stent displaced, the patient had timi-3 flow throughout the entire left anterior descending artery. on postoperative day three, it was noted that the patient's creatinine had increased from his baseline of 1.4 to 2.8. nephrology was consulted at that time. the patient remained sedated, intubated, and hemodynamically stable throughout this period. over the next two days, the patient was weaned from the ventilator on postoperative day five. he was successfully extubated. his cardiovascular status remained stable with a cardiac index of 2.3 on minimal nitroglycerin to control his blood pressure. as stated previously, his respiratory status continued to improve slowly, and he was eventually extubated on postoperative day five. his renal status plateaued, and his creatinine on postoperative day five, had finally begun to come down. over the next several days, the patient remained in the intensive care unit to monitor his cardiac, respiratory, and renal status. on postoperative day nine, it was deemed that he was stable and ready to be transferred to the floor for continuing postoperative care and the beginning of cardiac rehabilitation. once on the floor, the patient continued to do well. his activity level was increased with the assistance of physical therapy, and the nursing staff. his renal failure continued to slowly resolve. hemodynamically he remained stable. on postoperative day 12, it was decided that the patient was stable and ready for discharge to home. at that time, the patient's physical exam is as follows: vital signs: temperature 97.0, heart rate 82, sinus rhythm, blood pressure 108/64, respiratory rate 18, and o2 saturation is 92% on room air. weight preoperatively is 91 kg, at discharge it is 92.9 kg. laboratory data on the day of discharge: white count 13.5, hematocrit 34.1, platelet count 418. sodium 134, potassium 4.8, chloride 98, co2 24, bun 40, creatinine 1.8, and glucose 81. neurologic: alert and oriented times three. moves all extremities and follows commands. respiratory: clear to auscultation bilaterally. heart sounds regular, rate, and rhythm, s1, s2, no murmur. incision with staples open to air, clean and dry. sternum stable. abdomen is soft, nontender, nondistended with normoactive bowel sounds. extremities are warm and well perfused with no edema. discharge medications: 1. enteric coated aspirin 325 q day. 2. lasix 20 mg . 3. labetalol 100 mg . 4. amiodarone 400 mg q day x2 weeks, then 200 mg q day. 5. albuterol inhaler two puffs q6h prn. 6. percocet 5/325 1-2 tablets po q4h prn. condition on discharge: stable. disposition: he is to be discharged to home. follow-up instructions: he is to have followup with dr. in weeks at which time he will need a chem-7 to check his renal function and follow up with dr. also in weeks. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnostic ultrasound of heart Insertion of endotracheal tube Open and other replacement of aortic valve Resection of vessel with replacement, thoracic vessels Angiocardiography of right heart structures Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Cardiac complications, not elsewhere classified Atrial fibrillation Other and unspecified hyperlipidemia Dissection of aorta, thoracic

history of present illness: this is a 64 year old female transferred from hospital to intensive care unit at on . the patient was originally admitted to the outside hospital on , after the acute onset of abdominal pain. the patient was in her usual state of health until this day around 5:00 p.m. when the patient developed the acute onset of epigastric pain and violent nonbloody emesis after eating a meal of macaroni and cheese. the patient states that the pain was ten out of ten, did not radiate to her back, but did radiate to her bilateral flanks. it was associated with increased shortness of breath, no chest pain, light-headedness or syncope. the patient's husband called 911. when she was taken to the outside hospital, her amylase was 3861, white blood cell count 23.0, hematocrit 45.0, normal liver function tests. the patient had temperature of 98.2, blood pressure 135/72, respiratory rate 18, oxygen saturation 98% ? in room air. the patient had an abdominal ct which showed mild acute pancreatitis with no gallstones or other pancreatic complications. the right upper quadrant ultrasound was done that revealed no evidence of gallstones (suboptimal study). the patient then had a repeat abdominal ct on , which showed necrosis of the pancreatic head with peripancreatic inflammatory changes. the amylase had trended down to the 80s over four days and the patient also had significant decrease in her abdominal pain. the patient was transferred to on , for question of endoscopic retrograde cholangiopancreatography as well as for failing respiratory status at the outside hospital. the patient had a chest x-ray that showed bilateral pleural effusions, status post aggressive intravenous fluids. the patient was noted to have increased wheezing on physical examination. she was given 20 mg intravenous lasix with good effect. the patient was also given stress dose steroids of solu-medrol, however, she had hallucinations from this. her pao2 was 61 mmhg. physical examination: temperature is 98.6, pulse 112, blood pressure 134/81, respiratory rate 31, oxygen saturation 88 to 90% on four liters of oxygen via nasal cannula. weight 84.5 kilograms. in general, she is a pleasant female in no apparent distress, speaking full sentences, despite tachypnea. head, eyes, ears, nose and throat examination - mucous membranes are dry. the oropharynx is clear. the pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. anicteric sclera. neck - no jugular venous distention, no bruits, no thyromegaly. pulmonary - diffuse severe end expiratory wheezes with fair air movement, mild bibasilar crackles, increased inspiratory and expiratory ratio. abdomen is soft, positive bowel sounds, nontender, question mildly distended, no rebound or guarding. extremities - no cyanosis, clubbing or edema, 1+ dorsalis pedis pulses. neurologic - the patient is alert and oriented times three. mini mental status examination - 28/30. cranial nerves ii through xii are intact. motor is , right upper extremity. sensation intact. past medical history: 1. chronic obstructive pulmonary disease, ? 2. coronary artery disease, status post non q wave myocardial infarction in , with left bundle branch block. 3. congestive heart failure with a reported ejection fraction of 40% in . peak ck 213 with mb of 18. 4. cardiac catheterization , showed apical hypokinesis, no significant coronary artery disease. 5. left thalamic cerebrovascular accident , with mild right upper extremity greater than right lower extremity weakness. 6. no history of hyperlipidemia, gallstones or alcohol use. medications at home: norvasc 10 mg p.o. once daily. medications here: 1. hydralazine 20 mg intravenous q6hours. 2. enalapril 0.625 mg intravenous q6hours. 3. clonidine 0.1 mg patch. 4. norvasc 10 mg p.o. once daily which has been held. 5. nitroglycerin drip. 6. haldol and ativan p.r.n. 7. morphine intravenous. 8. imipenem 500 mg intravenous q6hours. 9. famotidine 20 mg intravenous q12hours. 10. heparin subcutaneous 5000 units three times a day. 11. the patient had been on gentamicin and zosyn from , to . on , the patient's antibiotics were changed to imipenem. 12. albuterol and atrovent nebulizers q2hours p.r.n. 13. serevent two puffs twice a day. 14. flovent two puffs twice a day. 15. ocean spray nasal solution p.r.n. 16. dulcolax p.r.n. allergies: no known drug allergies. however, solu-medrol has caused hallucinations. social history: the patient is married with three children and lives in and runs a restaurant with her husband. she is a two pack per day smoker for her whole life. no alcohol use or intravenous drug use. family history: questionable history of pancreatic fibrosis in two or three sisters at an early age leading to early deaths. mother with lung cancer. father with hypertension, cerebral hemorrhage. laboratory data: at the outside hospital, white blood cell count 18.0 prior to transfer. arterial blood gases 7.42, 35, 61 and went to 7.41, 43, 68, went to 7.39, 41, 66. blood culture showed no growth to date. on , amylase was 3861, trended down to 94. lipase 862 and trended down to 153. ck 168, mb 2.7, troponin 0.02 but then increased her troponin to 0.18. ck 198, mb 9.5. electrocardiogram - left bundle branch block, pulse 112. laboratory data at included white blood cell count 23.0, hematocrit 40.2, platelet count 258,000, mcv 88. prothrombin time 13.8, inr 1.3, partial thromboplastin time 23.8. sodium 142, potassium 3.3, chloride 106, bicarbonate 28, blood urea nitrogen 14, creatinine 0.6, glucose 135. amylase 68, lipase 27. differential on white blood cell count revealed neutrophils 91%, no bands, 6% lymphocytes, 3% monocytes, 0.1% eosinophils. calcium 8.9, magnesium 2.0, phosphorus 2.5, albumin 3.1. alt and ast 24, total bilirubin 0.4, alkaline phosphatase 126, ldh 496. cholesterol 174, ldl 107, hdl 42. arterial blood gases revealed on five liters nasal cannula 7.46/41/55 with a bicarbonate of 30. lactate 1.3. potassium 3.3, free calcium 1.26. at 7:53 p.m. on 70% face mask, the patient had arterial blood gases of 7.47/38/80, bicarbonate of 28. urinalysis revealed specific gravity 1.005, large blood, negative leukocyte esterase and nitrites, 5 white blood cells, trace ketone, 423 red blood cells, no epithelial cells. chest x-ray - mild cardiomegaly, interstitial markings with congestive heart failure. hospital course: 1. pancreatitis - the patient with history of necrotizing pancreatitis of unclear etiology. normal liver function tests, amylase and lipase and hematocrit of 40.2. unclear family history of childhood pancreatic fibrosis but at the time of presentation, the patient is 64 years old and this may be unrelated acute event. the patient may have passed a gallstone given her age, gender, clinical history with acute onset of severe pain after a fatty meal. the patient was continued on imipenem for necrotizing pancreatitis which was discontinued on . the patient was kept npo except for most medications and ice chips. she did not require placement of nasogastric tube. the patient initially was able to tolerate gradually increasing diet including sips which was then advanced to full clears and soft solids. however, on , the patient noted epigastric tenderness to light palpation after eating and the patient was again made npo. the patient continued to do well after she was made npo with a goal of restarting clears on . the patient was continued on tpn throughout her hospital course with the long term plan being that the patient will likely need tpn for at least seven to ten days postdischarge in order to meet her full nutritional needs assuming that she will be able to tolerate gradually increasing p.o. the patient continued to have amylase and lipase that were within normal limits. however, her ldh and alkaline phosphatase did remain elevated at 465 and 173, respectively. the patient's hematocrit was 38.5 on . long term plans for gastrointestinal follow-up would include touch base with the gastroenterology service to assess length of tpn as well as question of endoscopic retrograde cholangiopancreatography at some later date as an outpatient once acute episode of pancreatitis has resolved. 2. pulmonary - the patient initially had bilateral pleural effusions likely secondary to congestive heart failure and volume overload as well as potential third spacing of fluid from her pancreatitis. the patient never required intubation and was maintained on mask ventilation and eventually titrated down to nasal cannula and currently saturating 94% in room air with no subjective shortness of breath. 3. congestive heart failure - the patient had an echocardiogram which showed an ejection fraction of 55% with 1+ mitral regurgitation, no evidence of pericardial effusion. 4. hypertension - the patient continued to have labile hypertension throughout her hospital course. the patient was started on a regimen of metoprolol and norvasc which were gradually titrated. however, while the patient was npo, the patient's norvasc was held and metoprolol was continued and is currently at a dose of metoprolol 100 mg p.o. three times a day. however, once the patient is able to tolerate p.o. she should be restarted on her norvasc 10 mg p.o. once daily. both of these medications can be titrated down to maintain a good blood pressure. 5. ileus - the patient has an ileus, however, she gradually had an improving abdominal examination, positive flatus and then began to pass stool with ability to tolerate her p.o. medications. 6. infectious disease - the patient had an increased white blood cell count that was persistently elevated in the 20s and remained relatively stable, however, gradually started to increase to 26 and 25. the patient had a clostridium difficile toxin sent as she had been experiencing significant loose stools and it was positive for evidence of clostridium difficile. the patient was then started on flagyl 500 mg p.o. three times a day. this was started on . the patient will need a full fourteen day course for this infection. the patient had complete resolution of her diarrhea after the start of flagyl. she remained afebrile. 7. psychiatry - the patient had intensive care unit delirium and required p.r.n. haldol while she was in the intensive care unit. she did not require any restraints and was not receiving any narcotics at the time. after transfer to the medicine floor, the patient did quite well and had no further episodes of delirium. 8. access - the patient had a right ij that was placed on , at the outside hospital. this was discontinued on . the patient had a picc line placement for long term tpn. 9. disposition - the patient is full code. her family is quite involved including her husband and her children. family can be reached at . in addition, her primary care physician, . , is also very available and involved in her care. the patient was seen by physical therapy who deemed that she would need rehabilitation. the patient is in the process of being screened and referred to various facilities. the patient will require tpn at the time of discharge for at least one week most likely. condition on discharge: stable. the patient is not at her functional baseline, however, with resolution of her acute medical condition, it is likely that she will improve to her baseline functional status. medications on discharge: 1. sodium chloride 0.65% nasal spray for dryness. 2. flomax 110 mcg two puffs twice a day. 3. tylenol rectal suppository p.r.n. fever or pain. 4. dulcolax 10 mg rectal suppository q.h.s p.r.n. constipation. 5. nicotine 14 mg a day patch. 6. miconazole powder 2% to groin once daily. 7. norvasc 10 mg p.o. once daily if the patient on p.o. 8. metoprolol 100 mg p.o. three times a day. 9. benadryl 25 mg p.o. q6hours p.r.n. rash. please discontinue this medication if the patient is not still experiencing rash. 10. flagyl 500 mg p.o. once daily for a full course of two weeks. this was started on and it should be completed on . discharge diagnoses: 1. necrotizing pancreatitis. 2. labile hypertension. 3. respiratory distress secondary to congestive heart failure and bilateral pleural effusions from volume overload. , 12.adf dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Thoracentesis Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis Acute respiratory failure Paralytic ileus Diastolic heart failure, unspecified Acute pancreatitis

medications on discharge: (her final discharge medications included) 1. sodium chloride nasal spray as needed (for nasal dryness). 2. flovent 110-mcg 2 puffs inhaled b.i.d. 3. dulcolax as needed. 4. nicotine patch. 5. miconazole powder. 6. norvasc 10 mg p.o. q.d. 7. metoprolol 100 mg p.o. t.i.d. 8. flagyl 500 mg p.o. t.i.d. (this will be completed on ). 9. levofloxacin 500 mg p.o. q.d. (for another 12 days). 10. ipratropium bromide meter-dosed inhaler 1 puff inhaled q.6h. as needed. 11. lovenox 80 mg b.i.d. (second dose on and ). 12. benadryl as needed (for rash). 13. coumadin 5 mg p.o. q.d. (times two days). 14. coumadin 3 mg p.o. q.d. (starting on ; dose adjusted based on inr with a goal of 2 to 3). note: also send the patient's primary care physician (dr. a copy of the original discharge summary as well as this addendum. , m.d. dictated by: medquist36 d: 18:16 t: 19:24 job#: Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Thoracentesis Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis Acute respiratory failure Paralytic ileus Diastolic heart failure, unspecified Acute pancreatitis

allergies: flagyl / codeine attending: chief complaint: code stroke for l-sided weakness major surgical or invasive procedure: none history of present illness: 44yo rh f h/o itp s/p splenectomy, htn, migraines with aura who was mopping on saturday and was last seen well at 5:30pm. she suddenly saw flashing lights as she does prior to a migraine and walked into her brother's room to mop there and complained of feeling very hot and dizzy, by which she means that she felt like she was going to have a seizure, by which she means that her left fingers "wanted to clench" and she was fighting it. she denies light-headedness or feeling like the room was spinning. she then slumped to the left and felt her arm/leg were weak and had some very slight shaking of that side. she did not lose consciousness or continence at any time. her boyfriend observed her face to be twisted (it is unclear if this means that there was a droop) and saw her foaming slightly at the mouth. she seemed confused to her sister, looking around to both sides, "as if she did not know what was going on". she complained of feeling hot and short of breath. she did not have any slurred speech or difficulty speaking. upon ems arrival, they tried to get her to stand but her left leg was dragging. she presented here as a code stroke and received tpa for an nihss of 5 (for left nlf flattening, a mild left hemiparesis with left drift, a dense left hemianopia, possibly some additional inattention to the left and extinction to double simulataneous stimulation) at 7:40pm. she was admitted to the neuro-icu and suffered no complications of tpa. she is now transferred to the neurology floor for further treatment and evaluation. past medical history: pmh: htn itp s/p splenectomy in (rec'd pneumovax) migraines with visual aura - daily for the past two years. consist of throbbing headaches preceeded by a visual of flashing lights. a/w nausea, p/p, worsened with cough/sneeze, made better with motrin/sleep. occasionally a/w l-sided numbness h/o anxiety/panic attacks (no hospitalizations) social history: sh: lives with boyfriend. smoked for 20yrs, cigs/day, quit 1yr ago. no etoh/drugs family history: fh: +migraines in mgm, mother. father and brother with . no h/o stroke or autoimmune disease physical exam: normal neurologic exam brief hospital course: the patient was seen in the ed and presented as a code stroke. she was given iv tpa and admitted to the neurologic icu for 24-hour observation and treatment of her acute stroke. she had no complications of iv tpa treatment. cta/ctp showed "no hemorrhage, mass, hydrocephalus, shift of normally midline structures is detected. low density region is seen within the left caudate nucleus, anterior limb of left internal capsule, and medial aspect of the left lentiform nucleus consistent with an area of chronic infarction, as there is also ex-vacuo dilatation of the left frontal of the lateral ventricle. the - white matter differentiation is preserved. the contrast enhanced ct scan demonstrates areas of prolonged mean transit time and reduced blood flow in the right frontal region, linear in distribution, and a larger, wedge- shaped area in the right posterior temporal region." cta showed no stenoses that would account for the above. her exam and imaging were consistent with acute right middle cerebral artery infarction. mri/a showed "multiple foci of acute infarcts in the right hemisphere, possibly embolic etiology. no hemodynamically significant stenosis or filling defect noted in the intracranial vasculature." her exam improved completely, to normal, by the time she was transferred to the neurology floor and upon discharge. she had already recanalized her vasculature by the time she received tpa and most likely her improvement is due to endogenous thrombolyis rather than tpa. the mechanism of her infarction is thought to be a clot that broke up. tte and tee failed to reveal a cardioembolic source. possible risk factors include her migraine headaches. given her age, a hypercoagulable workup is pending. lipids were elevated and she was started on a statin. she was also started on verapamil for migraine prophylaxis. she was also found to be hypertensive and had a renal u/s, which showed no renal artery stenosis; she was therefore started on an acei for blood pressure control. renal ultrasound incidentally showed fatty liver; hepatitis panel was pending at discharge. she will follow-up with neurology in stroke clinic. her hospital course was significant for a leukocytosis. she remained afebrile with a normal differential, however, and the leukocytosis is overall decreasing. cxr and ua were negative and the clinical suspicion for infection is low. most likely, it represents a leukamoid reaction after the acute stroke. it should be followed as an outpatient by her pcp. she also had an episode of vaginal spotting and green discharge, from a 2cm, round lesion on her labia that burst. she reported a foul odor. her exam is normal. we spoke with ob/gyn, who recommended follow-up as an outpatient and scheduled you her for an appointment. she will be seen as an outpatient in stroke clinic. medications on admission: motrin daily no asa atenolol 50 discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. verapamil 120 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). disp:*30 tablet sustained release(s)* refills:*2* 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: right middle cerebral artery infarction migraine discharge condition: normal neurologic exam discharge instructions: you were admitted to the neurology service after having a stroke. your deficits have resolved, but you will need to be treated to prevent future strokes. this includes treatment for high cholesterol and high blood pressure, diet and exercise. please continue to take all medications as prescribed and keep all appointments. followup instructions: provider: , .d. phone: date/time: 8:30 provider: , md phone: date/time: 1:00 provider: , .d. phone: date/time: 10:30 md, Procedure: Injection or infusion of thrombolytic agent Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Cerebral embolism with cerebral infarction Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus

history of present illness: the patient is a 44 year old gentleman who has had roughly three weeks of chest pain on exertion. he is being referred to dr. for coronary artery bypass grafting. the patient had had no knowledge of coronary artery disease prior to three weeks ago. when the patient noticed chest pain, he went to his primary care physician, initiated workup for coronary artery disease. his workup included a cardiac catheterization which revealed a left ventricular ejection fraction of 35%. the left anterior descending artery had diffuse disease, was small caliber and had 90% mid-stenosis. the right coronary artery had 40% mid-stenosis and 50% distal stenosis, 90% ostial stenosis. there was 90% mid-posterior descending artery stenosis. the second diagonal had 70% proximal stenosis. the left circumflex had 80% proximal stenosis. the obtuse marginal had 90% stenosis, obtuse marginal two 90% stenosis, and obtuse marginal 80% to 90% stenosis. past medical history: 1. diabetes mellitus, onset ten years ago, now insulin dependent. 2. hypertension times one to two years, no on captopril. past surgical history: status post laser surgery on eyes several years prior to admission. medications on admission: captopril 25 mg p.o.t.i.d., insulin nph 30 units q.a.m., regular insulin 6 units q.a.m., regular insulin 6 units with dinner, aspirin 325 mg p.o.q.d. times the past two weeks. allergies: the patient has no known drug allergies. family history: the patient's father is status post coronary artery bypass grafting times three at age 60. his brother is status post myocardial infarction at age 46, and status post percutaneous transluminal coronary angioplasty and stenting. social history: the patient is a bookkeeper for a trucking firm which his brother owns. the patient lives with his brother. the patient denies any use or abuse of tobacco and admits to occasional alcohol use. physical examination: on physical examination on admission, the patient had a pulse of 89, blood pressure on left 155/90, height 5'7", weight 150 pounds. general: well appearing, consistent with staged age of 44. skin: intact without rash. head, eyes, ears, nose and throat: no lymphadenopathy, oropharynx without lesion, anicteric sclerae. neck: supple, no masses, trachea midline. pulmonary: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm without murmur. abdomen: soft, nontender, nondistended, positive bowel sounds. extremities: warm, no cyanosis, clubbing or edema, no evidence of varicosities. neurologic examination: alert and oriented times three, cranial nerves ii through xii intact, motor proximal and distal muscles of upper and lower extremities and symmetric, sensation intact to light touch over all extremities. pulses: femoral 2+ bilaterally, dorsalis pedis 2+ bilaterally, posterior tibialis 2+ bilaterally, and radial 2+ bilaterally. laboratory data: cardiac catheterization as above. hospital course: the patient was admitted to on . on the day of admission, he underwent coronary artery bypass grafting times three. the surgeon was dr. . the anastomoses were left internal mammary artery to the left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. the patient tolerated the procedure well and was transferred from the operating room to the cardiac surgery recovery unit. upon leaving the operating room, the patient was intubated, was on an insulin drip, was on a lidocaine drip, a propofol drip and a neo-synephrine drip. please see the previously dictated operative note for more details. the hospital course was complicated only by difficult to control blood sugar. the patient required a rather aggressive insulin drip while in the intensive care unit. in fact, his insulin needs necessitated a second day in intensive care unit. on postoperative day number one, all vasoactive drips were weaned off and patient was only on the insulin drip. the patient was extubated on postoperative day number one. by postoperative day number two, the patient's blood glucose was controlled and his insulin drip was weaned off. at this point, the clinic was consulted to assist in the management of the patient's blood sugar. on postoperative day number three, the patient was transferred from the intensive care unit to the patient care floor. his active to this point had been out of bed to chair and he had no complaints. by the time he had arrived on the floor, his chest tube was removed. on the day of arrival on the floor, his foley catheter was removed as were his transcutaneous pacing wires. physical therapy worked with the patient for the duration of the hospital stay and, by postoperative day number five, the patient was able to ambulate at level v, was comfortable, his pain was well controlled with oral pain medication and he was able to tolerate oral intake and void on his own. the patient was discharged to home. physical examination on discharge: temperature 100.8, pulse 76, blood pressure 134/76, respiratory rate 20 and oxygen saturation 97% in room air. fingerstick blood sugars for the past 24 hours have ranged from 120 to 190. general: comfortable. lungs: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm, no murmurs, sternum stable, no evidence of drainage. abdomen: soft, nontender, nondistended. extremities: trace edema, saphenectomy sites clean, dry and intact with no evidence of erythema, exudate or infection. disposition: to home. condition on discharge: stable. discharge medications: metoprolol 25 mg p.o.b.i.d. colace 100 mg p.o.b.i.d. while on percocet. percocet one to two tablets p.o.q.4-6h.p.r.n. pain. ibuprofen 400 to 600 mg p.o.q.4-6h.p.r.n. enteric coated aspirin 325 mg p.o.q.d. humalog insulin sliding scale: the patient will be on two different humalog sliding scales as per the clinic; one scale correlates before breakfast and supper and one scale correlates before lunch and bedtime. nph insulin 36 units s.c.q.a.m. and 8 units s.c.q.h.s. iron sulfate 325 mg p.o.t.i.d. follow-up: the patient will see his primary care physician, . , in three weeks, dr. in three to four weeks and will call the clinic for an appointment if he wishes to follow up with them for control of his blood sugar. discharge diagnosis: 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 (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Polyneuropathy in diabetes Background diabetic retinopathy Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled

allergies: nkda meds pta: asa, lopressor, insulin ros: cv: hr 100's st, no vea; bp 140-150's/80-90; 1st cpk 553/41/7.4% mb at 2pm, r groin site w/sm ooze initially, 6:30pm pt turned on side w/ r knee bent, lg ooze - pressure held/mod pressure dsg applied/ sm hematoma noted, pulses dp palpable, unable to obtain pt's, act due at 8 pm resp: lungs clear w/rales at l base only, o2 3l n/c w/sats 100% gi: abdomen soft, non-tender, + bs, 1/2ns at 125/hr x 2 liters, tolerating sips clear lix, no stool gu: condom cath in place, unable to void, bladder distended, foley placed w/o incidence 1125cc clear yellow urine social: lives w/brother, , works in an office, has been back to work since cabg, family in to visit a: ruling in mi, s/p ptca/stents - pain-free p: monitor r groin site/pulses/ follow hct, act at 8 pm - awaiting sheath pull, cycle cpk's, continue supportive care. 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: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Acute kidney failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Acute myocardial infarction of other inferior wall, initial episode of care Urinary complications, not elsewhere classified Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other drugs and medicinal substances causing adverse effects in therapeutic use

history of present illness: mr. is a 44-year-old man with a history of type 1 diabetes times 33 years, coronary artery disease, hypertension, status post coronary artery bypass grafting in who presented initially to following 24 hours of epigastric pain and nausea, which he described as intermittent and relieved with antacids. there was associated vomiting on the morning of admission. there was no chest pain or shortness of breath. the patient stated that he was febrile at home to a temperature of 100.5. he describes the abdominal discomfort as different from his usual anginal pain. at the outside hospital, patient was noted to have elevations in leads iii and avf and elevations in leads ii and v4 through v6. ck was elevated at 658 with an mb fraction of 48.3 and a troponin i of 1.18. he remained free of chest pain. he was given aspirin, heparin drip, lopressor, nitropasted, sublingual nitroglycerin and transferred to for emergency cardiac catheterization. in the catheterization laboratory, patient was found to have diffuse three vessel disease with a saphenous vein graft to posterior descending artery graft with a 100% proximal occlusion, a saphenous vein graft to om2 vein 99% occlusion, left internal mammary artery to left anterior descending graft which was patent. he received percutaneous transluminal coronary angioplasty of the right coronary artery with stenting as well as a stent of the saphenous vein graft to om2. he was started on integrilin and admitted to the coronary care unit. at the time of admission he was without complaint. review of systems: positive for intermittent diarrhea times two weeks. past medical history: 1. coronary artery disease, status post coronary artery bypass graft times three vessels: left internal mammary artery to left anterior descending; saphenous vein graft to om1; saphenous vein graft to posterior descending artery. 2. insulin dependent diabetes mellitus, with q.i.d. fingersticks and dosing. 3. hypertension. 4. status post laser surgery to his eyes. 5. hypercholesterolemia. allergies: patient states no known drug allergies. medications on admission: humulin n 36 units q.a.m., 12 units q.p.m., humalog sliding scale, lopressor 25 mg po b.i.d., iron sulfate 325 mg po t.i.d., enteric coated aspirin 325 mg po q.d. family history: the patient is status post coronary artery bypass grafting at the age of 60. his brother is status post myocardial infarction at the age of 46. social history: the patient is a bookkeeper for a truck firm. he denies tobacco and occasionally uses alcohol. he denies street drugs. physical examination: patient's temperature was 99. heart rate 95. respiratory rate 22. blood pressure 148/70. in general, he was alert, lying flat following catheterization in no acute distress. head, eyes, ears, nose and throat exam: indicated normocephalic, atraumatic. extraocular muscles were intact. pupils equal, round and reactive to light. sclera were anicteric. oral mucosa were moist. the neck was supple without jugular venous distention. the chest was clear to auscultation bilaterally. cardiovascular exam indicated a regular rhythm, normal s1, s2, no murmurs, rubs or gallops. the abdomen was soft, nontender, nondistended with normal bowel sounds. extremity exam: the patient had 2+ peripheral pulses with no cyanosis, clubbing or edema. his right groin was without hematoma or bruit. laboratory studies: initially indicated a white blood cell count of 14.2, hematocrit of 37.7, platelets 386,000. coagulation studies were within normal limits. chem-7 was normal with the exception of a creatinine of 1.3, which is the patient's baseline. electrocardiogram from the outside hospital indicated normal sinus rhythm at a rate of 92, normal axis, depression in lead ii and avf and elevations in lead iii with depressions in lead avl. poor r wave progression and t wave inversions in lead v6. cardiac catheterization results indicated a cardiac output of 4.4. cardiac index of 2.53, wedge pressure of 13. pulmonary artery pressure of 29/15. catheterization results are as follows: left main normal, left anterior descending 60%, mid at 90% distal stenosis, left circumflex artery 80% proximal and 80% mid stenosis, right coronary artery 30% proximal and mid stenosis with a 99% posterior descending artery stenosis and a 90% stenosis of the distal segment beyond the posterior descending artery. saphenous vein graft to om2 indicated 99% stenosis. saphenous vein graft to posterior descending artery indicated 100% proximal stenosis. left internal mammary artery to left anterior descending was patent. hospital course: the patient was admitted to the coronary intensive care unit for follow-up of cardiac catheterization and hemodynamic monitoring on telemetry. the following is the hospital course by system: 1. cardiovascular: patient remained hemodynamically stable. his enzymes peaked at a ck of 767, mb of 43 and a troponin of greater than 50. he remained free of chest pain during his hospital course with no further electrocardiogram changes. lipid panel indicated total cholesterol of 143, hdl of 29, ldl of 97 and triglycerides of 83. echocardiogram indicated a 60-65% ejection fraction with mild left ventricular hypertrophy and mildly dilated aortic root and 1+ mitral regurgitation. the patient was started on metoprolol and titrated up. he was also started on lipitor 40 mg po q.h.s., plavix, aspirin and folic acid, as well as an ace inhibitor. as patient remained stable for the four days following cardiac catheterization, and was cleared for discharge home by physical therapy, he was sent home on hospital day number four with cardiology follow-up with dr. at 4:45 p.m. on . he was to have a repeat catheterization with possible brachytherapy in two to three months. 2. infectious disease: on hospital day number two, the patient spiked a temperature overnight. cultures were drawn which were negative. the patient had no symptoms. his nausea, vomiting and diarrhea resolved during his hospital course and was thought to be secondary to a possible viral gastroenteritis. 3. endocrine: the patient was restarted on his outpatient regimen of humulin and humalog sliding scale in order to achieve maximal glycemic control during this post myocardial infarction period. on hospital day number three, sugars began to be elevated in a 200-300 range. this was corrected by increasing the insulin dose. at the time of discharge, the patient had been setup with a follow-up appointment in the clinic. he was to see dr. on at 9:30 a.m. 4. neurologic: the patient was noted to have a bilateral peripheral neuropathy involving loss of sensation in his thumb, second and third digits bilaterally. this was thought to be possibly secondary to his coronary artery bypass graft surgery. patient would be followed in the clinic by dr. on at 10:30 a.m. medications on discharge: 1. atenolol 100 mg po q.d. 2. lisinopril 2.5 mg po q.d. 3. enteric coated aspirin 325 mg po q.d. 4. plavix 75 mg po q.d. times 30 days. 5. folic acid 1 mg po q.d. 6. lipitor 40 mg po q.h.s. 7. humulin n 36 units q.a.m., 12 units q.p.m. 8. humalog sliding scale. discharge diagnoses: 1. acute inferolateral myocardial infarction. 2. coronary artery disease. 3. insulin dependent diabetes mellitus. 4. hypertension. 5. hypercholesterolemia. discharge disposition: the patient was discharged to home in good condition. , m.d. dictated by: medquist36 d: 18:06 t: 18:06 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Acute kidney failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Acute myocardial infarction of other inferior wall, initial episode of care Urinary complications, not elsewhere classified Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other drugs and medicinal substances causing adverse effects in therapeutic use

history of present illness: mr. is a 45 year-old man with known three vessel coronary disease, type 1 diabetes, peripheral vascular disease, and celiac sprue who presents to the emergency department following an episode of nausea and diaphoresis. several months prior he had a stress test for symptoms of dyspnea on exertion that showed inferoposterior hypokinesis and a subsequent catheterization revealed a three vessel disease. at that time it was decided to give him a trial of medical therapy including nitrates, beta blocker and ace inhibitor given the presumed difficulty of intervening on his right coronary artery lesion and the likelihood of restenosis. in the meantime the patient notes that he has been doing very well. his dyspnea on exertion and shortness of breath has been very stable. he denies having any other chest pain, orthopnea or paroxysmal nocturnal dyspnea or pedal edema. on the morning of admission he states he was doing some yard work when he had the sudden onset of diaphoresis and nausea, but frankly denies having any chest pain, shortness of breath or vomiting. he initially believed that this was due to hypoglycemia, but checked his blood sugar and found that it was 105. he then took one sublingual nitroglycerin and his symptoms resolved within the hour. his symptoms of nausea returned in the emergency department at the outside hospital he presented to, but resolved again following nitroglycerin. however, this did leave him with a systolic pressure in the 80s with a heart rate of 45 that was then treated with a 1 mg of atropine. he was transferred to for further care. past medical history: 1. coronary artery disease, catheterization in shows an ejection fraction of 55%, posterior hypokinesis and three vessel disease. 2. type 1 diabetes mellitus for thirty years with complaints of neuropathy and retinopathy. 3. peripheral vascular disease status post multiple vascular procedures most recently a left femoral to anterior tibial artery bypass graft. 4. celiac sprue diagnosed by colonoscopy performed secondary to anemia. 5. status post head injury 25 years ago. 6. depression. 7. anemia. past surgical history: 1. status post repair of malfunctioning penile prosthesis . 2. status post right inguinal hernia . 3. status post left femoral thromboendarterectomy and profundoplasty with stem to above the knee bypass graft using nonreverse saphenous vein with immediate revision with vein patch angioplasty in . 4. status post left external iliac to deep femoral artery bypass with 8 mm gortex graft and left femoral to above the knee popliteal bypass graft with 8 mm gortex for failed previous bypass graft. medications on admission: 1. lopresor 25 mg po b.i.d. 2. wellbutrin 200 mg po b.i.d. 3. pepcid 20 mg po b.i.d. 4. zestril 20 mg po q day. 5. imdur 30 mg po q day. 6. plavix 75 mg po q day. 7. aspirin 81 mg po q day. 8. lantus 25 units subq q.h.s. 9. sliding scale humalog. 10. percocet one tablet q six hours prn. 11. neurontin 600 mg po t.i.d. 12. clindamycin 300 mg po t.i.d., which he has been taking for a recent dental abscess. social history: he is a former heavy smoker with a thirty pack year history. he has quit for two years, but recently restarted. he drinks occasional alcohol. family history: notable for a father with a history of myocardial infarction in his sixties and mother with a history of a myocardial infarction in her fifties. physical examination: his temperature is 97.8. heart rate 54. respiratory rate 18. blood pressure 128/65. o2 sats 99% on room air. in general, he is comfortable and in no acute distress. he has chronic slightly slurred speech. head, eyes, ears, nose and throat his pupils are equal, round and reactive to light. extraocular movements intact. oropharynx is unremarkable. there is no observed soft tissue swelling. neck is supple without jvd or lymphadenopathy. heart has a regular rate and rhythm without murmurs, rubs or gallops with a normal s1 and s2. lungs are clear to auscultation bilaterally. abdomen is soft, nontender, nondistended with normoactive bowel sounds and no hepatosplenomegaly. extremities without clubbing, cyanosis or edema. there is 1+ palpable dorsalis pedis pulses bilaterally. neurologically he is awake and oriented times three. his cranial nerves ii through xii are intact. laboratory studies on admission: his white blood cell count 8.2, hematocrit 33.6, platelets 242, pt 12.4, ptt 37.1, inr 1.1, sodium 139, potassium 4.9, chloride 105, bicarb 24, bun 10, creatinine 0.8, glucose 253. his cks at the outside hospital were 71 and 58. his troponin is less then 0.3. hospital course: the patient was admitted to the medicine service for a suspicion of myocardial ischemia. the cardiology team was involved and they recommended that the patient receive a treadmill stress echocardiogram. they also discovered that the patient had complaints of some poorly characterized episodes of blood tinged sputum over the past without months without hemoptysis. for that reason a pulmonary consultation was obtained. they performed a ct scan on his chest that was essentially normal. they believed that the combination of aspirin, plavix and a questionable history of vioxx use may be leading to some minor mucosal irritation and bleeding, possibly due to smoking. the patient had an exercise stress echocardiogram that was stopped prematurely for a drop in his systolic blood pressure. he had no symptoms or electrocardiogram changes. given his history of three vessel coronary disease and diabetes mellitus it was believed that he would strongly benefit from a cardiac bypass. on the patient was taken to the operating room where he had a coronary artery bypass graft times three. he had a left internal mammary coronary artery to left anterior descending coronary artery, left radial artery to distal right coronary and saphenous vein graft to obtuse marginal. his cardiopulmonary bypass time was 69 minutes, his cross clamp time was 58 minutes. postoperatively, he s taken to the cardiac surgery intensive care unit. he was extubated on the evening of his operation and the following day was transferred to the floor. he still had his chest tubes in place when he was transferred. these were subsequently discontinued on the third postoperative day. in addition, his sternal wires were discontinued in a normal fashion. the team was involved given his long history of diabetes and problems with hyperglycemia. he did have blood sugars as high as 430 during this admission. we had to make adjustments to both his lantus and his humalog sliding scale. by the fourth postoperative day we believed the patient was almost ready for discharge, however, he was sitting up and upon coughing had a notable amount of serous drainage expressed from his sternum while coughing. he was started on intravenous vancomycin. his sternum was painted with betadine and was covered with a dry sterile dressing. he was kept in the hospital for further observation and by the following day he had only scant drainage. it was felt he was safe to be discharged home with a week of keflex. in addition, his blood sugar was under better control. on the patient was discharged home in stable condition. he was instructed to keep his follow up appointment in approximately one week. at that time he could come back here and have a wound check to check the status of his sternum. in addition, he is instructed to follow up with his primary care physician . in approximately two weeks and dr. in four weeks. discharge medications: 1. lantus insulin 30 units subq q.h.s. 2. sliding scale humalog q.i.d. 3. lopresor 25 mg po b.i.d. 4. wellbutrin 200 mg b.i.d. 5. pepcid 20 mg po b.i.d. 6. niferex 150 mg po q day. 7. plavix 75 mg po q day. 8. aspirin 325 mg po q day. 9. neurontin 600 mg t.i.d. 10. colace 100 mg po b.i.d. 11. percocet one to two po q 4 to 6 hours prn. 12. lasix 20 mg b.i.d. times seven days. 13. potassium chloride 20 mg po b.i.d. times seven days. 14. keflex 500 mg q.i.d. times seven days. discharge diagnoses: 1. coronary three vessel disease now status post three vessel coronary artery bypass graft. 2. insulin dependent diabetes mellitus times thirty years with neuropathy and retinopathy. 3. peripheral vascular disease treated with antiplatelet therapy. 4. status post head injury. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Other esophagoscopy Other bronchoscopy Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Tobacco use disorder Polyneuropathy in diabetes Celiac disease Background diabetic retinopathy Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia (transfer from outside hospital) major surgical or invasive procedure: none. history of present illness: hpi: 74 y/o male with hx of cad, htn, s/p pm for sick sinus syndrome, cri s/p nephrectomy who was recently discharged from now returns from osh after being intubated for chf, initially hypotensive after lasix given then became hypertensive and also found to have + blood from ngt. . during previous admission patient admitted for abdominal pain underwent egd and c-scope and found to have multiple diverticulae and gastritis. shortly after egd patient had respiratory failure was intubated thought to be chf, extubated the next day. patient also thought to have nstemi which was medically managed and patient eventually discharged . . patient presented to osh with presumed chf after being hypertensive and was intubated. per daughter patient missed his blood pressure medications the day of admission. patient denies any fever,chills, coughs or gradual sob prior to event. he recieved lasix at home and then en route however still sob in ed so was put on bipap and then intubated. during his admission at osh his bp has been labile with hypertension sbp 190s. patient started on nitro gtt for bp control and got lopressor 5mg x3. at osh cxr showed initially diffuse infiltrates c/w pulmonary edema vs pna; repeat cxr the following day showed improved infiltrates. patient's peak tropi was 1.8 and ck 68 at osh. ekg done at osh showed pattern c/w lvh and more pronounced st depression in lateral leads. repeat ekg done on arrival to was similar to old ekgs. upon arrival to patient on minimal vent support with well controlled bp on nitro gtt. past medical history: cad; nstemi and anemia cri (baseline cre 3.1) s/p nephrectomy gastritis diverticulosis hiatal hernia aortic stenosis sss s/p pacemaker social history: lives with daughter since recent d/c from hospital + tobacco 1 cig per day; formerly 1ppd no etoh use family history: reported family hisotry of cad physical exam: t 98.6 bp 118/62 p 60 ac rr 16 tv 500 fio2 0.4 100% gen: nad, intubated, awake heent: perrl, eomi, og tube in place neck: no obvious jvd, rij in place lungs: clear ant/lat cardiac: rrr s1/s2 grade iii/vi sem at rusb abd: soft non-tender ext: no edema, dp and pt +1 pertinent results: 12:56pm wbc-7.9 rbc-3.17* hgb-9.7* hct-29.5* mcv-93 mch-30.6 mchc-32.9 rdw-14.3 12:56pm glucose-94 urea n-46* creat-3.0* sodium-141 potassium-4.0 chloride-111* total co2-25 anion gap-9 12:56pm ck-mb-notdone ctropnt-0.42* probnp-* . p-mibi (): no anginal symptoms with an uninterpretable ecg for ischemia. there is a mild fixed perfusion defect involving the inferior and inferolateral walls. the left ventricle is moderately dilated at stress and rest and there is global hypokinesis with a calculated lvef of 35%. . tte (): the left atrium is mildly 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 mildly depressed (lvef 50%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (area 0.8-1.19cm2). moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) eccentric mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. . renal ultrasound (with dopplers) : 2.0 cm cyst of the right renal lower pole. otherwise, normal appearance of the right kidney with patent vasculature and no son evidence of renal artery stenosis. surgically absent left kidney. brief hospital course: mr. was transferred to the ccu intubated. upon arrival, he had a favorable abg and wsa quickly extubated without difficulty. his bp was intially controlled with a nitroglycerin drip which was slowly weaned off over the first night of his hospitalization. on the morning of hospital day #2, he became acutely short of breath with acute development of pulmonary edema at the same time that his blood pressure suddenly rose to 220-240/100-120. he was given iv lasix and metoprolol and his nitroglycerin drip was quickly titrated back up. he was put on bipap with improvement in his oxygenation. over the course of the day, he was weaned easily off bipap. the focus at this point became controlling his hypertension which was done with a high dose of toprol xl, increasing his dose of imdur, and starting him on amlodipine. he was temporarily controlled on po hydralazine but this was titrated off due to his history of poor medication compliance. his history of a nephrectomy precluded the use of an acei or . as far as working up the etiology of his refractory hypertension, a renal ultrasound showed no evidence of renal artery stenosis and a random cortisol level was within normal limits; a 24-hour urine collecion had normal levels of vma and metanephrines. for his presumed coronary artery disease, he underwent a pharmacologic stress test which showed only a mild fixed defect in the inferior/inferolateral walls along with an lvef of 35%. he was discharged home to stay with his daughter with plans to follow up with dr. of cardiology. medications on admission: meds at home: lipitor 80mg qhs mirtazapine 15mg qhs buspirone 5mg trazadone 25mg sucralfate 1g qid asa 325mg protonix 80mg atrovent imdur 60mg toprol xl 300mg . meds on transfer: nitro gtt sq heparin asa 325mg carafate lopressor 25mg q6 lasix 70mg iv plavix 75mg humulog sliding scale discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*qs disk with device(s)* refills:*2* 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 5. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 6. buspirone 5 mg tablet sig: one (1) tablet po bid (2 times a day). tablet(s) 7. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*120 tablet, delayed release (e.c.)(s)* refills:*2* 9. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 10. isosorbide mononitrate 60 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily): total dose 180mg. disp:*90 tablet sustained release 24hr(s)* refills:*2* 11. furosemide 20 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 12. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 13. toprol xl 100 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po at bedtime: total dose 300mg. disp:*90 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis: hypertensive crisis with pulmonary edema . secondary diagnoses: aortic stenosis, hypertension, diastolic dysfunction, chronic kidney disease discharge condition: stable. discharge instructions: please take all medications as prescribed. please keep all follow-up appointments. please notify your primary care doctor, dr. ( or return to the emergency department if you experience shortness of breath, chest pain or pressure, dizziness, abdominal pain, nausea or vomitting or any symptoms that concern you. followup instructions: please follow-up with your primary care physician . within 1-2 weeks of discharge (. . you will be seeing dr. from the department of cardiology for follow up. his office will get in contact with you within the next 1-2 days to tell you when and where to attend the appointment. if you have not heard anything within the next 2 days, you should call his office at . Procedure: Diagnostic ultrasound of heart Non-invasive mechanical ventilation Diagnoses: End stage renal disease Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Aortic valve disorders Other chronic pulmonary heart diseases Diaphragmatic hernia without mention of obstruction or gangrene Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Cardiac pacemaker in situ Hypoxemia Diastolic heart failure, unspecified Diverticulosis of colon (without mention of hemorrhage) Cyst of kidney, acquired Acute myocardial infarction of other specified sites, subsequent episode of care

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain and diarrhea major surgical or invasive procedure: endotracheal intubation upper endoscopy colonoscopy history of present illness: this 74 year old gentleman has been experiencing abdominal discomfort, weight loss, and diarrhea since around the time when he was diagnosed with a myocardial infarction. he was admitted to medical center for his mi and was elected for medical management in view of cri. pt was seen in by gi for his complaint of diarrhea, decreased food intake and weight loss. at that time he denied hematemesis, melena, hematochezia. he reports having been evaluated by dr. at medical center, where a ct scan of the abdomen revealed diverticular disease of the colon, there was no evidence of inflammatory changes in the wall of the colon, extensive vascular calcification was seen, the liver was not enlarged, the patient is status post nephrectomy for kidney stones and a small cyst was found in the remaining right kidney. upper endoscopy was done, mild gastritis was seen as well as a hiatal hernia, because of the fact that he is on aspirin and plavix no biopsies were done at that time. the patient was being followed by dr. but became somewhat frustrated for the lack of clinical improvement and came to for a second opinion. pt had barium study around the same time which revealed a transient lower esophageal spasm, no hiatal hernia was found, a small bowel x-ray was not done at that time. he is known to have an elevated creatinine which is 3.1 at baseline. he was also known to have mild anemia with a hematocrit of 31.6 and a hemoglobin of 10.9. . mr. presented to the emergency room with essentially the same complaint of diffuse abdominal pain and diarrhea. he could not provided a good description of the abdominal pain. he does state however that it was diffuse without radiation to the back and was not related to meal. he continues to have diarrhoea and has lost 30 pounds in the past 3 months. recently he has noticed some melaena and brbpr. in er stool was brown in colour but guiac positive. pt also complains of sour brash without actual heart burn. he states he was placed on ppi with mild relief. he was also given empirical treatment of flagyl and mesalamine with mild relief and has now stopped taking them. in er he was noted to have a hct of 27 but was hemodynamically stable without postural bp drop. he was admitted for further evaluation of his symptoms. past medical history: pmh: 1. recent mi in managed medically. 2. cri status post nephrectomy for renal stone. baseline cr 3.1 3. iron def anaemia. 4. htn. 5. gastritis. 6. ppm inserted for presumed sick sinus syndrome. social history: he is a smoker, no alcohol intake at this time family history: positive for coronary artery disease, negative for inflammatory bowel disease or colon cancer. physical exam: per dr. on admission vital: temp 98.6, hr 80/min, rr 16/min, bp 140/60 general: appears comfortable at rest. neck: supple, no jvd, no lymphadenopathy. cvs: rrr, nl s1+s2, 3/6 sem rsb radiating to carotids chest: ctab, nl effort. , diffuse discomfort, no rebound/guarding/regidity, nl bs. extreme: no o/c/c. neuro: alert and oriented x 3, nl mood and affect. pertinent results: admission cbc: 03:18pm blood wbc-8.4 rbc-3.29* hgb-9.9* hct-30.3* mcv-92 mch-30.0 mchc-32.6 rdw-14.0 plt ct-245 . cbc trends: hct 30.3 - 26.5 - 23.4 - 27.0 . admission chem panel 05:10pm blood glucose-108* urean-30* creat-3.1* na-137 k-3.9 cl-106 hco3-20* angap-15 . cardiac enzymes: 09:15am blood ck-mb-2 ctropnt-0.08* 11:19pm blood ck-mb-5 ctropnt-0.19* 05:09am blood ck-mb-9 ctropnt-0.46* 01:02pm blood ck-mb-7 ctropnt-0.42* 09:15am blood ck(cpk)-25* 11:19pm blood ck(cpk)-110 05:09am blood ck(cpk)-155 01:02pm blood ck(cpk)-136 . imaging: echo: conclusions: 1. the left atrium is mildly dilated. the left atrium is elongated. 2.there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed with apical and mid lateral and inferolateral akinesis with basal hypokinesis. 3. right ventricular chamber size is normal. 4.the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. 5.there is moderate aortic valve stenosis (area 0.8-1.19cm2) moderate(2+)aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 7.there is moderate pulmonary artery systolic hypertension. 8.there is no pericardial effusion. . ruq us: impression: no dilated intrahepatic ducts. normal hepatic texture ct : limited by lack of iv contrast, no evidence of obstruction or mass. . cxr: 1. evidence of early pulmonary vascular congestion and interstitial edema. 2. probable scarring at the medial aspect of the right lung base, with no definite consolidation. . chest (portable ap) 5:36 am single frontal radiograph of the chest again demonstrates a dual- lead cardiac pacer, unchanged. the heart is enlarged, unchanged. there is no evidence of pneumothorax or pleural effusion. the pulmonary vasculature appears less indistinct and there is decreased cephalization since the prior examination consistent with improving pulmonary edema. there is improving airspace opacity at the right lung base. unchanged retrocardiac airspace disease is seen. there is atherosclerotic calcification of the aortic arch and the aorta is tortuous. impression: 1. enlarged cardiac silhouette and improving pulmonary edema. improving right base airspace disease and persistent unchanged left lower lobe airspace disease. . echo measurements: left ventricle - septal wall thickness: *1.7 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: *1.7 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.5 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 50% (nl >=55%) aortic valve - peak velocity: *3.4 m/sec (nl <= 2.0 m/sec) aortic valve - peak gradient: 47 mm hg aortic valve - mean gradient: 25 mm hg aortic valve - pressure half time: 698 ms tr gradient (+ ra = pasp): *50 mm hg (nl <= 25 mm hg) this study was compared to the prior study of . left atrium: normal la size. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra. left ventricle: moderate symmetric lvh. normal lv cavity size. mild regional lv systolic dysfunction. mildly depressed lvef. lv wall motion: regional lv wall motion abnormalities include: basal inferolateral - hypo; mid inferolateral - hypo; right ventricle: normal rv chamber size and free wall motion. aortic valve: moderately thickened aortic valve leaflets. moderate as (aova 0.8-1.19cm2). mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. moderate pa systolic hypertension. . pulmonic valve/pulmonary artery: pulmonic valve not well seen. . pericardium: no pericardial effusion. conclusions: the left atrium is normal in size. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with inferolateral hypokinesis. overall left ventricular systolic function is mildly depressed. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is probably moderate aortic valve stenosis (area 0.8-1.19cm2) ; aortic valve area was not fully assessed. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , left ventricular systolic function appears similar. brief hospital course: 74 you m with pmh of mi, cri, htn, pacemaker sick sinus syndrome initially presented for w/u of 3mo. of abd. complaints. hospital course by problem: . # gi: the patient was made npo and was treated with ivf, antiemetics and pain meds. gi recommended a small bowel capsue endoscopy and colonoscopy. egd showed nodularity and atrophy of the mucosa with contact bleeding noted throughout the duodenum. cold forceps biopsies were performed for histology. colonoscopy showed multiple diverticula with medium openings were seen in the whole colon. diverticulosis appeared to be of moderate severity. ischemic bowel disease as well as a partial sbo diagnoses were entertained given prior ct scans with mesenteric calcificaion. - per gi recommendations the patient was placed on protonix 80mg and sucralfate. - the patient required 2 units of prbc's during his micu stay with stable hematocrit thereafter. the source of the hematocrit drop was thought secondary to upper gi bleeding given the egd findings. - an abdominal mri/mra was considered but not obtained per gi given the lack of recurrent symptoms. - patient had guaiac negative stool x2 prior to discharge. - he did not experience any further abdominal discomfort for three days prior to discharge. - he will follow up with dr. at clinic for further evaluation should abdominal pain return. . # respiratory failure/pulm edema: shortly after the egd and colonoscopy, a code blue was called when the patient was found unresponsive with shallow respirations. he was intubated for airway protection and transferred to the micu-east. cxr showed evidence of pulmonary edema and he was treated iwth lasix and nebs. he was extubated the following day, on . - transferred to cardiology-medicine service on where he was stable for 72 hours without any oxygen requirement. he did not require further diuresis. . # cards vascular: during the episode of pulmonary edema, the patient had an ekg with st depressions in v3-v6. he has a known history of an nstemi in that was medically managed at medical center related to his severe renal insufficiency. his cardiac enzymes were cycled and he had a troponin elevation to 0.46 without ck elevation. his ekg changes resolved when his heart rate normalized. we treated his nstemi medically with aspirin, plavix, lopressor, as well as a nitro gtt. we transitioned him to hydral and imdur which he tolerated well post-extubation. - the cardiology service was formally consulted upon transfer back to the medical floor with recommendations for medical management at this time. consider stress imaging in a period of 6 weeks. this decision was discussed with mr. primary cardiologist at med ctr. . # anemia: the patient had iron studies which showed a mixed picture of both iron deficiency and anemia of chronic inflammation. post-mi, we treated with 2u prbcs to maintain his hct at or near 30. hematocrit was uptrending at time of discharge to 35.3 . # id: spiked temp to 101 overnight on . blood and urine cultures sent. no evidence of infection prior to spike, wbc has been trending downwards. we did not treat with antibiotics. he was afebrile for the remainder of the admission. . # renal: patient is s/p nephrectomy with baseline cr 2.8-3.1. his renal function was stable at time of discharge. . # htn: he was weaned from his nitroglyerin gtt, we increased his metoprolol (as he is paced) and continued with hydral and imdur. hydralazine was stopped on the cardiology medicine floor. - discharged with toprol xl 300mg daily (pt is paced), with good bp control. - on outpatient follow-up the patient can be switched to carvedilol if he is feeling significant side affects from the metoprolol. he tolerated the regimen well for a period of 3 days on the inpatient service. . the patient was discharged to his home where he lives with his daughter. medications on admission: plavix 75 qd nexium 40 qd lipitor 80 qd atrovent 1 puff qid flovent 1 puff lexapro 20 qd imdur 60mg qd atenolol 100mg qd mirtazipine 15mg qhs colace 100mg docusate 2 tab lasix 40mg qd asa 325mg qd buspirone 5mg alfuzosin 10mg qhs discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). 2. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 3. buspirone 5 mg tablet sig: one (1) tablet po bid (2 times a day). 4. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 5. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*120 tablet, delayed release (e.c.)(s)* refills:*2* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. disp:*1 * refills:*3* 11. isosorbide mononitrate 60 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 12. metoprolol succinate 100 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily). disp:*90 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home discharge diagnosis: diverticulosis coronary artery disease nstemi hypertension hiatal hernia discharge condition: stable discharge instructions: you were admitted for evaluation of your abdominal pain. you developed trouble breathing after colonoscopy and suffered a heart attack. you were evaluated by cardiologists here at who also consulted with your cardiolgist at . we maximized your medical therapy for heart disease. please take all of your medications as prescribed . call dr. or 911 if you experience any chest pain, shortness of breath, worsening abdominal pain, uncontrolled bleeding, fevers, nausea, vomiting or any other concerning symptoms. followup instructions: please see dr. in the next two weeks . please follow up with dr. (gastroenterology) in the next week for further evaluation. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Esophagogastroduodenoscopy [EGD] with closed biopsy Closed [endoscopic] biopsy of large intestine Transfusion of packed cells Diagnoses: Acidosis Anemia in chronic kidney disease Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortic valve disorders Chronic kidney disease, unspecified Acute respiratory failure Old myocardial infarction Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Cardiac pacemaker in situ Sinoatrial node dysfunction Diverticulosis of colon (without mention of hemorrhage)

history of present illness: , twin ii was born at 31 1/7 weeks gestation to a 36 year old gravida 2, para 0, now 2 woman. the prenatal screens are blood type 0 positive, antibody negative, rubella immune, rpr nonreactive, hepatitis surface antigen negative and group b streptococcus unknown. this pregnancy was complicated by preterm labor. the mother received a complete course of betamethasone prior to delivery. on the day of delivery the mother presented with a second episode of preterm labor, premature rupture of membranes and then prolapsed cord. so, the infant was delivered by emergency cesarean section. the apgars were 6 at one minute and 8 at five minutes. the infant's birthweight was 2,290 gm, birth length was 39.5 cm, and the birth head circumference was 27 cm. admission physical examination: the admission physical examination reveals a preterm infant in mild respiratory distress. anterior fontanelle open and flat. eyes with narrow palpebral fissures, mild subcostal retractions, good air entry once intubated, lungs clear. heart was regular rate and rhythm, no murmur, three vessel umbilical cord. abdomen was soft, nontender and nondistended. no hepatosplenomegaly. genitalia was consistent with immaturity. testes were descended bilaterally. patent anus, spine intact. stable hip examination and age-appropriate neurological examination. hospital course: (by systems) respiratory status - the infant was intubated in the delivery room. he received one dose of surfactant. on day of life #1 he transitioned to nasopharyngeal continuous positive airway pressure. he then weaned to nasal cannula oxygen on day of life #4 and then weaned successfully to room air on day of life #5 where he remained for the rest of his neonatal intensive care unit stay. was treated with caffeine citrate for apnea of prematurity from day of life #3 until day of life #25. his last episode of bradycardia was on . cardiovascular status - the infant has remained normotensive throughout his neonatal intensive care unit stay. he has had an intermittent, grade i to ii/vi systolic ejection murmur, first presenting on day of life #32. his electrocardiogram is within normal limits. his lower extremity blood pressures are within normal limits. his chest x-ray showed a normal cardiothalamic silhouette and normal pulmonary markings. he passed the hyperoxia test with a po2 greater than 300 and his murmur is found to be consistent with peripheral pulmonic stenosis. fluids, electrolytes and nutrition status - on the day of discharge his weight is 2,825 gm, his length is 48 cm and his head circumference is 33.5 cm. enteral feeds were begun on day of life #2. he reached full volume feedings on day of life #14 and then was increased from to a maximum calorie enhanced formula of 26 cal/oz. at the time of discharge he is eating standard formula of 24 cal/oz on an ad lib schedule with consistent weight gain. gastrointestinal status - was treated with phototherapy for hyperbilirubinemia of prematurity from day of life #2 until day of life #11. his peak bilirubin occurred on day of life #3 and was total of 9.4 and direct of 0.3. he has had intermittent guaiac positive stools and has an anal fissure. he was circumcised on , and the area has healed nicely. he also has a left hydrocele. hematology - his last hematocrit on was 44.0. he is receiving supplemental iron of 2 mg/kg/day. he has received no blood product transfusions during his neonatal intensive care unit stay. infectious disease status - was started on ampicillin and gentamicin at the time of admission for sepsis risk factor. the antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures negative. on day of life #20, he completed a five day course of erythromycin ophthalmic ointment for conjunctivitis. there were no other infectious disease issues, except that the infant was colonized on routine surveillance surface cultures with methicillin-resistant staphylococcus aureus. neurological status - head ultrasounds done on day of life #7 and at one month of age were entirely within normal limits. sensory - 1. audiology: hearing screening was performed with automated auditory brain stem responses and the infant passed with both ears. 2. ophthalmology: the eyes were examined most recently on , revealing mature retinal vessels. a follow up examination is recommended in six months. psychosocial - the social worker has been involved with the family. condition on discharge: the infant is discharged home in good condition. discharge disposition: the patient is discharged home with his mother. primary pediatrician: primary pediatric care will be provided by dr. of pediatric associates, , , , telephone #. recommendations after discharge: 1. feedings - 24 cal/oz formula on an ad lib schedule. 2. medications - iron sulfate (25 mg/ml 0.2 cc p.o. q. day. 3. state newborn screen - last state newborn screen was sent on . 4. immunizations - the infant has received his first hepatitis b vaccine on and his first snyagis on . 5. recommended immunizations - i. synagis respiratory syncytial virus 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 three of the following - daycare during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings; or c. with chronic lung disease. ii. influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. discharge diagnosis: 1. status post prematurity at 31 1/7 weeks. 2. twin ii. 3. sepsis ruled out. 4. status post respiratory distress syndrome. 5. status post hyperbilirubinemia of prematurity. 6. status post apnea of prematurity. 7. status post conjunctivitis. 8. left hydrocele. 9. status post circumcision on . 10. heart murmur consistent with peripheral pulmonic stenosis. , m.d. dictated by: medquist36 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 Other phototherapy Prophylactic administration of vaccine against other diseases Circumcision 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 Routine or ritual circumcision Other preterm infants, 1,250-1,499 grams 31-32 completed weeks of gestation Other anomalies of intestine

history of present illness: this is an interim summary covering the dates between and . this is a 21 day old male infant, with a corrected gestational age of 34 weeks. he was born at 30 weeks gestation to a 36 year old, gravida ii, para 0 to 2 woman. the pregnancy was complicated by preterm labor and the mother received a course of betamethasone earlier in the pregnancy. she presented with a second episode of preterm labor and was noted to have a prolapsed cord. this infant was delivered via stat cesarean section. birth weight was 1,290 grams. rupture of membranes was unknown and clear fluid was noted at the time of delivery. the infant emerged vigorous with good spontaneous respiratory effort; however, he required bagged mask ventilation for poor air entry and respiratory distress. he was intubated in the delivery room. apgars were 6 and 8. he was brought to the neonatal intensive care unit for prematurity and respiratory distress. physical examination: general: pink, active infant in mild respiratory distress. head, eyes, ears, nose and throat: narrow palpebral fissures. palate examination deferred. orally intubated. cardiovascular: normal, regular rate and rhythm, normal s1 and s2, no murmurs. normal pulses in the upper and lower extremities. lungs: good air entry; breath sounds coarse bilaterally. mild retractions. abdomen: soft, nontender, nondistended, three vessel cord. genitourinary: normal male external genitalia with testes palpable in canals bilaterally. neurologic: tone appropriate for gestational age; moving all extremities bilaterally. immature reflexes. hospital course: 1.) respiratory: the infant received one dose of surfactant replacement therapy and was extubated shortly afterwards. he remained on c-pap for one additional day and since then, has been on room air. he did have apnea of prematurity which was noted on day of life two. he has been on caffeine since day of life five with minimal ongoing apnea of prematurity. 2.) cardiovascular: the infant has been hemodynamically stable. he has no murmur. 3.) fluids, electrolytes and nutrition: the infant was advanced slowly on enteral feedings. during that time, he did receive parenteral nutrition given his low birth weight. he is currently on full enteral feedings, of which he is able to take by mouth. he is receiving premature enfamil 26 calories per ounce with promod. he has been growing well. 4. gastrointestinal: peak bilirubin was 7.2 on day of life the infant was treated with single phototherapy until day of life 11. he has no clinical jaundice. 6. hematologic: the infant has not received any transfusion. most recent hematocrit was 44 on . he has no signs or symptoms of anemia. 7. infectious disease: the infant was initially started on ampicillin and gentamycin, given his prematurity and respiratory distress. his blood culture remained negative and antibiotics were discontinued at 48 hours. he has no current active infectious issues. 8. neurologic: head ultrasound on day of life 7 was negative. 9. sensory: the patient will require both audiologic screening and ophthalmic examination prior to discharge. 10. psychosocial: the social worker has been involved with the family. condition: stable. name of primary pediatrician: dr. . immunizations received: none. discharge diagnoses: 1. prematurity. 2. respiratory distress syndrome. 3. rule out sepsis. 4. hyperbilirubinemia. 5. breathing immaturity. , m.d. dictated by: medquist36 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 Other phototherapy Prophylactic administration of vaccine against other diseases Circumcision 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 Routine or ritual circumcision Other preterm infants, 1,250-1,499 grams 31-32 completed weeks of gestation Other anomalies of intestine

discharge status: discharge status was to rehabilitation. medications on discharge: (discharge medications included) 1. folic acid 3 mg once per day. 2. metoclopramide 10-mg tablets take one tablet three times per day. 3. pantoprazole 40 mg once per day. 4. ursodiol 300 mg three times per day. 5. prednisone acetate 1% drops one drop four times per day in the left eye only. 6. oxycodone 5-mg tablets one to two tablets by mouth q.4h. as needed (for pain). 7. metoprolol 25 mg by mouth twice per day. 8. paroxetine 10 mg once per day. 9. atropine sulfate 1% ophthalmic drops one drop twice per day in the left eye only. 10. flurbiprofen sodium 0.03% ophthalmic drops one drop four times per day to the left eye only. 11. loperamide 2 mg twice per day (hold for constipation). 12. finasteride 5 mg once per day. 13. caspofungin 35 mg intravenously once per day. 14. ondansetron 2 mg/ml 4 intravenously q.4-6h. as needed (for nausea). 15. spironolactone 25 mg twice per day. 16. epogen 40,000 units one times per week (on sunday). 17. multivitamin one time per week. 18. magnesium oxide 400-mg tablets one tablet three times per day. 19. tylenol 325 mg q.4-6h. as needed (for pain or fever). 20. subcutaneous heparin 5000 units q.12h. 21. erythromycin 5 mg/g ophthalmic ointment one twice per day to the right eye only. 22. regular insulin sliding-scale. page 1 referral information: 1. the patient is to have fingerstick checks four times per day and follow the regular insulin sliding-scale. 2. the patient is to have erythromycin ointment placed in his right eye twice per day. 3. the patient is to have vital signs checked and strict ins-and-outs documented, as the liver service may want to tweak his diuretic regimen. 4. the patient is on tube feeds. the patient is to follow the directions under diet information listed below with his tube feeds. 5. the patient's electrolytes should be checked three times per week; on sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, calcium, magnesium, and phosphate as the patient often needs phosphate and magnesium repletion. 6. the patient's hematocrit is to be checked at least once per week. the patient has anemia and has a history of guaiac-positive stools. 7. intravenous caspofungin is to be administer until otherwise notified by dr. of ophthalmology based on the progression or regression of disease in his eye. 8. the patient is also to receive physical therapy while in the rehabilitation facility. , m.d. dictated by: medquist36 d: 14:02 t: 14:16 job#: Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Insertion of other (naso-)gastric tube Ureteral catheterization Transfusion of packed cells Other cholangiogram Other percutaneous procedures on biliary tract Transfusion of platelets Injection of other anti-infective Injection or infusion of oxazolidinone class of antibiotics Other mechanical vitrectomy Removal of ocular contents with synchronous implant into scleral shell Diagnoses: Subendocardial infarction, initial episode of care Hepatorenal syndrome Iron deficiency anemia secondary to blood loss (chronic) Other specified septicemias Disseminated candidiasis Calculus of ureter Adult failure to thrive Biliary cirrhosis

history of present illness: in brief, this is a 62 year old male with a complex medical history significant for cirrhosis, portal hypertension and ascites secondary to a secondary biliary cirrhosis who initially presented with insidious blood loss and here for inadequate p.o. intake. hospital course: 1. fever - the patient continues to have intermittent fevers to 101 degrees, approximately q.o.d. blood cultures have been negative to date and are negative upon discharge, however, the patient has had pseudomonas and history of vancomycin-resistant enterococcus on his bowel. the patient also has a urine culture positive for stenotrophomonas, additionally with negative blood cultures. the patient also had a history of fungemia secondary . the patient will be discharged on fluconazole 250 mg p.o. q.d. for approximately four weeks and will receive a treatment of bactrim for stenotrophomonas for approximately two weeks following discharge. 2. fungemia - the patient had a history of fungemia and initially was treated with caspofungin intravenously for approximately one week and was switched to fluconazole 250 mg p.o. q.d. and at discharge blood cultures were negative for fungus. 3. persistent nausea, vomiting with decreased p.o. intake - the patient continues as on his admission and has difficulty tolerating p.o. food and p.o. intake. the cause of this has been determined. the patient at the time of discharge has a dobbhoff tube in place receiving nephro and plus promod at approximately 40 cc/hr for tube feeds in addition to his p.o. intake. the patient will continue to have tube feeds at his outside facility until he is able to maintain an adequate p.o. diet. the patient will use antiemetics, reglan and zofran as needed for nausea and vomiting. 4. cirrhosis/ascites/secondary biliary cirrhosis - during the hospital stay he had multiple diagnostic and therapeutic taps and paracentesis. all taps were negative for any evidence of spontaneous retroperitonitis and were followed by aggressive volume and albumin repletion to prevent any associated renal impairment. the underlying causes of the disease still remains unknown and he is being closely followed by hepatology and the transplant service. please see the transplant surgery notes for details regarding his hospital stay procedures. the patient will be followed by dr. and dr. as an outpatient and will have close follow up. 5. retinitis - the patient was diagnosed with retinitis, believed to be secondary to disseminated fungemia. he initially presented with severe pain, photophobia and change of vision that has improved dramatically over the course of admission and treatment for his fungal infection. all cytomegalovirus cultures have been negative to date and he was not started on antivirals. he will be followed by ophthalmology and continued on cyclogyl 1% b.i.d. right eye and prednisone forte 1% q.i.d. he will follow up with clinic and dr. the week following discharge. 6. renal failure - the patient had an acute and chronic renal failure with a baseline creatinine of 1.5 to 2.0 range. initially this was thought to be secondary to either a superimposed acute tubular necrosis or interstitial nephritis. he was followed by renal in-house. additionally it was felt that given his complex volume state given his ascites and limited ability to maintain p.o. intake and thus there may be a volume component on top of his renal dysfunction. on discharge his creatinine was stable, however, may be at a new baseline, an approximate 2.3 to 2.7 range. 7. hydronephrosis - the patient had a ureteral stone and right kidney hydronephrosis during his stay and he was treated with an interurethral stent and limited cystoscopy per urology. the stent relieved the obstruction and hydronephrosis resolved. post procedure the patient will be followed by urology and dr. on discharge. 8. hyponatremia - the patient has been hyponatremic, reportedly secondary to his cirrhosis and ascites. he has been stable in the high 120s to 130s range. he was treated with fluid restriction diet of less than 1.5 liters per day. condition on discharge: the patient's condition on discharge is much improved compared to his admission. he is ambulating with assistance, maintaining his oxygenation well and on room air. he does have a feeding tube in place but he is able to intake p.o. as tolerated. discharge instructions: the patient is to make an appointment with dr. , liver center, phone # for an appointment in two to four weeks for follow up of his evolving liver disease. 2. the patient is to call dr. at for an appointment in one to two weeks with dr. and dr. on the same day. 3. the patient has an ophthalmology appointment at the eye center with dr. on monday , at 1:15, telephone #, please call if any changes are needed. 4. the patient has an appointment with dr. , surgical center on , phone # for evaluation of interurethral stent. discharge diagnosis: 1. failure to thrive 2. insidious blood loss 3. anemia 4. nausea and vomiting 5. fever 6. cirrhosis 7. ascites 8. portal hypertension 9. fungemia 10. retinitis 11. hydronephrosis and renal calculi 11. urinary tract infection discharge medications: 1. folic acid 1 mg tablets, please take three tablets p.o. q.d. 2. metoclopramide 10 mg tablet 3. polyvinyl alcohol 1.4% drops one to two drops prn as needed for dry eyes 4. pantoprazole 40 mg tablets p.o. q.d. 5. ursodiol 300 mg tablets, one tablet p.o. b.i.d. 6. lactulose 15 to 30 ml q. 8 hours as needed for constipation and prevention of encephalopathy, please titrate to 3 to 5 loose bowel movements per day. 7. cyclopentolate 1% drops one drop ophthalmologic b.i.d. 8. prednisolone acetate 1% drops one drop four times a day 9. oxycodone 5 mg tablets, one to two tablets q. 4 hours as needed for pain 10. fluconazole 200 mg tablets, one tablet p.o. q. 24 hours for 30 days 11. bactrim 800-160 mg tablets one tablet p.o. by mouth for ten days from the time of discharge 12. zofran 4 mg/5 ml solution, 48 mg/10 ml p.o. q. 4-6 hours prn as needed for nausea 13. clotrimazole cream one application tp b.i.d., apply to head of penis for one to two weeks for discomfort , m.d. dictated by: medquist36 d: 14:09 t: 14:49 job#: this is update to when patient transg=ferred back to micu with myocardial ischemia and sepsis post-cholangiogram. Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Insertion of other (naso-)gastric tube Ureteral catheterization Transfusion of packed cells Other cholangiogram Other percutaneous procedures on biliary tract Transfusion of platelets Injection of other anti-infective Injection or infusion of oxazolidinone class of antibiotics Other mechanical vitrectomy Removal of ocular contents with synchronous implant into scleral shell Diagnoses: Subendocardial infarction, initial episode of care Hepatorenal syndrome Iron deficiency anemia secondary to blood loss (chronic) Other specified septicemias Disseminated candidiasis Calculus of ureter Adult failure to thrive Biliary cirrhosis

history of present illness: the patient is a 62 year old man presenting with nausea, vomiting and failure to thrive. one year prior to admission, the patient presented with obstructive jaundice concerning for cholangiocarcinoma and mirizzi syndrome with obstruction of the hepatic duct by gallbladder bile duct mass. the patient had an exploratory laparotomy with pathology which was negative for malignancy, however, pathology of the liver was consistent with stage iii-iv fibrosis. the patient also has portal hypertension. his hepatitis panel as of , was negative, negative /ama. he had presumed diagnosis of secondary biliary cirrhosis, status post roux-en-y hepatojejunostomy in , was admitted with a massive variceal bleed requiring ventilatory support and more than 40 units of packed red blood cells, status post tips, was complicated by vre and methicillin resistant staphylococcus aureus in the bowel. the patient did well and was discharged to home but had insidious progressive anemia, status post recent admission in , for workup and did not receive a colonoscopy secondary to inability to tolerate golytely and prep. he underwent an esophagogastroduodenoscopy that was positive for gastritis. the patient is now readmitted with the same, status post five liter paracentesis, with a sag of 0.9, and , cholangiogram with changing of the biliary drain. past medical history: 1. upper gastrointestinal bleed, intubated in , with more than 40 units of packed red blood cells with esophageal varices, status post tips for portal hypertension. 2. coronary artery disease, status post percutaneous transluminal coronary angioplasty and stent. 3. diabetes mellitus type 2. 4. chronic renal insufficiency. 5. hypertension. 6. t12 compression fracture. 7. hemorrhagic cerebrovascular accident. 8. methicillin resistant staphylococcus aureus and vre in bowel in . 9. status post coiling of the brachial artery pseudoaneurysm. 10. hepatic encephalopathy. 11. peptic ulcer disease. 12. mirizzi syndrome. 13. status post common bile duct excision with hepatic jejunostomy. 14. tpn. 15. stage iii-iv fibrosis. 16. ejection fraction 40 to 45%. allergies: penicillin. physical examination: on admission, temperature was 96.9, pulse 86, blood pressure 106/58, respiratory rate 29, oxygen saturation 99% in room air. he is a comfortable man, older than stated age, in no acute distress, anicteric. the oropharynx is clear. dry mucous membranes. neck without lymphadenopathy. the heart is regular rate and rhythm. lungs are clear to auscultation bilaterally. the abdomen is soft, obese, positive ascites, nontender, drain site times two, dry and intact. extremities positive tenting, no edema. rectum - brown stool, normal tone, no masses, guaiac positive. laboratory data: on admission, white blood cell count was 3.8, hematocrit 28.1, platelet count 28,000. sodium 135, potassium 4.7, chloride 103, bicarbonate 20, blood urea nitrogen 36, creatinine 2.4, inr 1.2. electrocardiogram is consistent with old inferior wall myocardial infarction, normal sinus rhythm. hospital course: 1. ophthalmology - the patient complained of blurry vision and was evaluated by ophthalmology. changes were found to be consistent with cmv retinitis. the patient had cmv serologies that came back all negative. the patient was subsequently found to grow out out of his blood. he was started on ambisome. 2. acute renal failure - the patient had acute on chronic renal failure, partially prerenal secondary to his third spacing and ascites. the patient also had a urinary stone of proximal right ureter dilatation and right renal pelvis dilatation. the patient was seen by urology for stone removal. in addition, the patient may also have had some hepatorenal syndrome contributing to his renal failure. he had received vancomycin which may have contributed. the patient had been empirically treated for spontaneous bacterial peritonitis given his worsening state, however, was to be retapped. 3. hematology - the patient had low hematocrit, anemia likely secondary to multiple causes including anemia of chronic disease, blood loss anemia. the patient was continued guaiac positive stool as well as bone marrow suppression given the lower reticulocyte count. the patient's thrombocytopenia is likely multifactorial. likely contributing factors include splenomegaly, as well as component of bone marrow suppression. the patient had a decreased white blood cell count, was hiv negative, likely due to bone marrow suppression. 4. fen - the patient had not been able to tolerate his tube feeds due to nausea and vomiting. subsequently, he improved with treatment of the fungemia. the patient was treated for fungemia with caspofungin. the course of the patient after , will be dictated in a discharge summary addendum. , m.d.,ph.d. 02-366 dictated by: medquist36 Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Insertion of other (naso-)gastric tube Ureteral catheterization Transfusion of packed cells Other cholangiogram Other percutaneous procedures on biliary tract Transfusion of platelets Injection of other anti-infective Injection or infusion of oxazolidinone class of antibiotics Other mechanical vitrectomy Removal of ocular contents with synchronous implant into scleral shell Diagnoses: Subendocardial infarction, initial episode of care Hepatorenal syndrome Iron deficiency anemia secondary to blood loss (chronic) Other specified septicemias Disseminated candidiasis Calculus of ureter Adult failure to thrive Biliary cirrhosis

please note discharge medications and time and place of follow-up will be added as an addendum when the patient is formally discharged from the hospital, expected to be this week. , m.d. dictated by: medquist36 Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Insertion of other (naso-)gastric tube Ureteral catheterization Transfusion of packed cells Other cholangiogram Other percutaneous procedures on biliary tract Transfusion of platelets Injection of other anti-infective Injection or infusion of oxazolidinone class of antibiotics Other mechanical vitrectomy Removal of ocular contents with synchronous implant into scleral shell Diagnoses: Subendocardial infarction, initial episode of care Hepatorenal syndrome Iron deficiency anemia secondary to blood loss (chronic) Other specified septicemias Disseminated candidiasis Calculus of ureter Adult failure to thrive Biliary cirrhosis

history of present illness: the patient is well known to the hepatobiliary surgery service of dr. . he recently underwent a roux-en-y hepaticojejunostomy for mirizzi syndrome and bile duct stricture. he subsequently was discharged to home. at home prior to this admission, he had passed some tarry stool, had some bloody vomitus and syncope. this developed into a very severe upper gi bleed, requiring admission with aggressive volume resuscitation, aggressive administration of blood products, including more than 40 u of packed red blood cells, along with multiple units of fresh frozen plasma, cryoprecipitate and platelets. he was scoped by the gastroenterologist on for the first time during this hospitalization in which they noted an ulcer on the gastric side of the ge junction with some bleeding but was minimal. on the following day as he was watched in the intensive care unit, this blossomed to ongoing hemorrhage, and on , they noted possibly some esophageal varices; however, with such a significant amount of blood, they could not really make a very good study out of it, and they placed tube for all of the active bleeding. three days later, he had another endoscopy which did not show any active bleeding but showed blood in the fundus. at the same time, as the ongoing volume resuscitation and blood product resuscitation continued, he was noted to have a significant amount of portal hypertension and tips on . in addition on the same day, an interventional radiology angiogram was performed, and coiling of a right hepatic artery, posterior branch, pseudoaneurysm, as well as coiling of the left gastric artery, which was done on . the patient had very complicated intensive care unit and hospital stay. neurologic: the patient was intubated, and upon being awakened from the vent after a significant amount of time, he was noted to be not following commands had a change in mental status. as a neurology consult was obtained, ct of his head was obtained, and there was no organic intracranial reason to have these symptoms which were attributed just to the trauma and insult that he had been through, as well as the hepatic encephalopathy. he was treated with lactulose through an ng tube in an effort to clear off the encephalopathy which was successful, and he was gradually weaned off. pulmonary: the patient had a required ventilatory dependence; however, he was successfully weaned and extubated from the ventilator. he has no sequelae from this long-term ventilation. cardiovascular: the patient was in hemodynamic hemorrhagic shock with significant blood loss anemia. once resuscitation was completed, he was resumed on beta-blockers. on , the patient had a cardiac echocardiogram which had an ejection fraction estimated at 40-45%, moderate dilation of the left atrium, with trivial mitral regurgitation. the left ventricular cavity was also mildly dilated and somewhat depressed in its systolic function, and they noted posterior and akinesis and distal septal hypokinesis. gastrointestinal: in addition to the already discussed above facts regarding his history of roux-en-y hepaticojejunostomy and various interventional radiology procedures, after the coilings of the right hepatic artery pseudoaneurysm and the left gastri artery, there was no further note of new onset gi bleeding. his hematocrit stabilized, and gradually the patient was started on tube feedings, and he was continued on tpn. the tube feedings were done via a nasojejunal tube which was placed at endoscopy on . this was the only way he could maintain his calories, given his changes in mental status around this event and obviously the prolonged resuscitation and ventilation in the intensive care unit. the patient had percutaneous transhepatic cholangial tubes, both in the left and right sides. these were eventually capped. he had hyperbilirubinemia, which did eventually trend downward. he had hypoalbuminemia which continues, and at the very least is trending in the proper direction. on , the patient had an ultrasound which showed patency of the tips and no further hematemesis. he did have some guaiac positive stools but gradually developed guaiac negative stools. at one point, his nasoduodenal tube was pulled out, and he was able to achieve his goal calories and protein with a lot of encouragement and education, and currently is being sustained solely on his own p.o. intake. gu: during the process of the hypovolemic shock, the patient went into acute renal failure. this gradually returned to baseline function with an excellent urine output on his own. in trying to get all of the volume off him, he was being diuresed with lasix and spironolactone; however, after he was returning very close to his normal baseline body weight, these were discontinued. in the process of numerous volume shifts that the patient experienced, he experienced some hyponatremia, and this improved with minimizing the amount of free-water ingested, educating him, as well as adjusting tpn when he was being given tpn. infectious disease: the patient had multiple intravenous lines which carried him through the resuscitation in the intensive care unit. his positive cultures were that of mrsa in sputum, and he was diagnosed with a mrsa pneumonia and had an adequate treatment with vancomycin. he also had cultures from bile, some of which grew out bacteria, including mrsa, vre, vse, those last two being vancomycin resistant enterococcus and vancomycin sensitive enterococcus. after the patient was finished with antibiotics and was transferred to the floor finally, he was doing well and then developed high fever, and of his lines were removed at that time, and he was started on vancomycin. however, given that he had previous problems with vancomycin resistant enterococcus, he was started on intravenous linezolid and transitioned to p.o. linezolid. he has currently been afebrile for quite some time. hematologic: he remains anemia but without a lot of changes in his hematocrit. he is being treated with folate and a healthy diet to try to improve his bone marrow stores of vitamins and favor hematopoiesis. he has accumulated or formulated a significant amount of antibodies from the multiple blood transfusions, and our pathology and blood bank has made it quite clear that he is very difficult to cross-match for blood transfusions. endocrine: he has had some insulin requirements during the hospitalization. he is not on his oral hypoglycemics. he has been having his blood sugars checked regularly. at this point, he will go home and need to contact his primary care physician to decide on his outpatient regimen. he is not requiring insulin regularly on the regular diet. he had been requiring insulin when he was on tpn, but since then, this is just an intermittent blood sugar requirement, in association with frequent blood sugar checks. he knows, as on his discharge summary, to document three times a day his fingersticks and to give them to his primary care physician upon their visit. he is not going home on insulin, and he is not going home on oral agents. musculoskeletal: he has suffered a severe amount of diffuse atrophy of his muscles and has required aggressive physical therapy and assistance with adls, with which he is gradually improving on and doing significantly better; however, he will require physical therapy as an outpatient. disposition: home with vna services for tube checks, cardiopulmonary checks and wound checks. home physical therapy. past medical history: coronary artery disease status post coronary artery stents. diabetes mellitus type ii. hypertension. common bile duct strictures. chronic renal failure. roux-en-y hepaticojejunostomy as explained above. t12 compression fracture. ascites. discharge medications: linezolid 600 mg p.o. b.i.d. x 2 weeks, protonix 40 mg p.o. b.i.d., lopressor 25 mg p.o. b.i.d., folate 3 mg p.o. q.d., silver sulfadiazine 1% creme to be applied to his ears for the pressure ulcerations twice a day discharge instructions: call or return for problems with nausea, vomiting, high fevers, any signs of bleeding from the gastrointestinal tract, any type of syncope. check fingersticks regularly and record them. see his primary care physician. dr. in follow-up. call with problems with oral intake, weight loss. the patient should be seen within one week or within ten days of discharge. he is aware that he needs to call to schedule an appointment. discharge diagnosis: 1. long complicated intensive care unit stay. 2. methicillin resistant staphylococcus aureus pneumonia. 3. enterococcus and methicillin resistant staphylococcus aureus in bile, including both vancomycin resistant enterococcus and vse strains. 4. long-term antibiotic treatment. 5. total parenteral nutrition and tube feeds for nutrition, eventually discontinued. 6. prolonged ventilatory dependence. 7. hemodynamic instability. 8. hypovolemic shock secondary to ongoing severe upper gastrointestinal bleed. 9. status post right hepatic posterior branch pseudoaneurysm coiling. 10. coiling of the left gastric artery. 11. encephalopathy, now resolved. 12. tube placement for upper gastrointestinal bleeding. 13. multiple cholangiograms. 14. gastric ulcer, question of mild esophageal varices. 15. ptc tube times two. 16. tipf. 17. t12 compression fracture. 18. ascites. 19. chronic renal failure. 20. hypertension. 21. hypoalbuminemia. 22. hyperbilirubinemia. 23. status post liver biopsies. 24. type 2 diabetes. 25. bile duct strictures status post surgical repair. 26. blood loss anemia necessitating aggressive transfusions. 27. echocardiogram showing ejection fraction of 40-45% with some wall motion abnormalities. 28. coronary artery disease status post coronary stents. 29. history of 15 pack-year smoking, quitting several years ago. 30. severe deconditioning requiring aggressive physical therapy and rehabilitation. 31. ....................orthopedically for his t12 compression fracture for at least six weeks, which will need to be evaluated at some point in the future, and he can arrange to be seen as an outpatient. 32. history of portal hypertension. 33. history of multiple endoscopies, cholangiograms, including requirement of tube for severe hemorrhage. 34. blood requirements for greater than 49 u of packed cells, 33 u ffp, 23 platelets, 5 cryoprecipitate, now with multiple antibodies to blood products. 34. status post multiple piccs and central lines, all of which are removed. 35. baseline creatinine between 1.6-2.0; currently he is at 1.5. hematocrit on discharge 32. discharge diet: regular diet without added salt. disposition: to home with vna and physical therapy services. percutaneous drains are capped currently. , m.d.,ph.d. 02-366 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Endoscopic control of gastric or duodenal bleeding Arteriography of other intra-abdominal arteries Other cholangiogram Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Insertion of Sengstaken tube Replacement of stent (tube) in biliary or pancreatic duct Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acute gastric ulcer with hemorrhage, without mention of obstruction Acute posthemorrhagic anemia Portal hypertension Other shock without mention of trauma Methicillin susceptible pneumonia due to Staphylococcus aureus Other and unspecified coagulation defects

history of present illness: the patient is a 62 year old gentleman who initially presented with common bile duct stricture with question of cholangiocarcinoma, who underwent exploratory laparotomy and cholecystectomy with negative biopsies now thought to have represented a mirizzi syndrome and resolution of his symptoms. however, he developed a recurrent strictureafter that required ptc and percutaneous balloon dilatation. he had an initial response but recurred after the ptc catheter was removed. a repeat ptc demonstrated a stricture of the chd at the bifurcation and distal rhd.prior to the operation, the patient denied any fever, chills, nausea, vomiting. past medical history: 1. coronary artery disease, status post stent. 2. diabetes mellitus type 2. 3. hypertension. 4. mirizzi syndrome. 5. common bile duct stricture. 6. chronic renal failure. past surgical history: 1. status post coronary artery bypass graft. 2. status post exploratory laparotomy and cholecystectomy. medications on admission: 1. lopressor 25 mg twice a day. 2. glyburide 2 mg once daily. 3. lisinopril 20 mg p.o. once daily. 4. pioglitazone 4 mg once daily. 5. atorvastatin 20 mg p.o. once daily. hospital course: the patient was taken to the operating room on , where common bile duct resection, roux-en-y, hepatojejunostomy was performed (please see operative note for details). the patient was transfused four units of red blood cells intraoperatively. the patient tolerated the procedure well and was transferred to post anesthesia care unit in stable condition. postoperative day one, the patient had a low grade fever, hypotensive in 90/40. his epidural dose was decreased and then eventually turned off. he received fluid boluses which would intermittently improve his blood pressure. his propofol was turned off. he also had two blood cultures to rule out infection. he was also started on albumin infusion. on postoperative day number two, the patient is afebrile, still hypotensive. he was started on neo for pressors and transfused two units of fresh frozen plasma to keep platelet count above 100,000. antibiotics of levofloxacin and flagyl were changed to zosyn. on postoperative day number three, the patient is afebrile. his blood pressure improved and he was continued on albumin. he was weaned off pressors. he was successfully extubated. his epidural was restarted without hypotensive episodes. his - is putting out large volumes (up to two free liters of serous fluid). his - and bowel cultures grew pansensitive enterococcus. on postoperative day number four, the patient is afebrile and vital signs are stable. good urine output, still high - output. his nasogastric tube was removed. the patient is doing well, starting to ambulate. on postoperative day number five, the patient is afebrile, vital signs are stabile. he is ambulating with help. his epidural was capped, unable to remove it because of coagulopathy (inr 1.7). the patient was started on subcutaneous vitamin k for total of two doses. he is started on clears which he is tolerating well. the patient's creatinine which raised after his surgery to a level of 3.0 continues to be elevated. on postoperative day number six, the patient is afebrile and vital signs are stable. he is ambulating and tolerating clears. renal consultation was obtained who felt that the patient's acute on chronic renal insufficiency (baseline creatinine 1.8) is probably due to a combination of medications and dye. the patient also underwent a t tube study which showed that the right sided transhepatic tube was open with free flow and the left side seemed to be either kinked or plugged distally. after the study, the left tube was capped. the patient's epidural was removed. on postoperative day number seven, the patient is afebrile, and vital signs are stable. he is tolerating advance to regular diet, tolerating well, left tube capped, tolerating well. bilirubin decreased from 3.2 to 2.8. he is having bowel movements and ambulating with help. - is still putting large amount of clear serous exudate. he was started on ******************* which resulted in a significant improvement in the patient's peripheral edema. the patient was also switched from zosyn to ciprofloxacin p.o. on postoperative day number eight, the patient is afebrile and vital signs are stable. he is tolerating regular diet, somewhat decreased amount of - output, however, it is still high. the right sided t tube is open to gravity and draining well. lisinopril was discontinued. the wound is clean, dry and intact. he is ambulating with help, and normal bowel movements. an ultrasound for further kidney workup will be done later today. condition on discharge: good. disposition: the patient is discharged home with vna. the patient should ambulate as much as possible, may take shower, no baths, no swimming. - to bulb suction. t tube to gravity. change dressings once daily. check wound once daily. diet is diabetic diet. medications on discharge: 1. tylenol one to two tablets p.o. q4-6hours p.r.n. pain. 2. albuterol inhaler one to two puffs q6hours p.r.n. 3. ipratropium one to two puffs q6hours p.r.n. 4. lopressor 25 mg p.o. twice a day. 5. percocet one to two tablets p.o. q4-6hours p.r.n. pain. 6. colace 100 mg p.o. twice a day. 7. ciprofloxacin 500 mg p.o. twice a day. 8. spironolactone 100 mg p.o. once daily. 9. lasix 40 mg p.o. once daily. 10. protonix 40 mg p.o. twice a day. discharge diagnoses: 1. common bile duct stricture, status post roux-en-y hepatojejunostomy. 2. hypertension. 3. diabetes mellitus type 2. 4. chronic renal failure. 5. acute renal failure. 6. postoperative coagulopathy. 7. postoperative anemia. , m.d.,ph.d. 02-366 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other lysis of peritoneal adhesions Other cholangiogram Anastomosis of hepatic duct to gastrointestinal tract Excision of other bile duct Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Acquired coagulation factor deficiency Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Obstruction of bile duct

allergies: penicillins attending: chief complaint: low back pain major surgical or invasive procedure: picc line placement post pyloric feeding tube placement fistulogram with dilation of proximal lue veins paracentesis history of present illness: 64m with h/o dm ii, cad s/p cabg, esrd on hd via av fistula, who was transferred from hospital after being admitted for his low back pain and underwent kyphoplasty for t 10 and t12 compression fracture, and was then readmitted from rehab for worsening lbp and low grade fevers. on readmission, he was noted to have a new t11 compression deformity as well as a suggestion of cord compression at t10. blood cultures from and cultures from a ct guided drainage around the lower thoracic vertebrae grew , and he was started on caspofungin. his surveillance cultures have been negative, but his pain has not improved. his fever resolved after the caspo was started, and his esr and crp have fallen. a repeat mri was done on and revealed a heterogenous paraspinal mass and associated epidural mass. he was transferred over to for further management as a direct admission. past medical history: - upper gastrointestinal bleed status post tips for varices. - peptic ulcer disease. - coronary artery disease status post percutaneous myocardial infarction in .transluminal coronary angioplasty / stent / inferior. - diabetes mellitus type 2. - chronic insufficiency, now esrd, has been on hd for ~6 weeks at this point via a left arm fistula. - hypertension. - history of hemorrhagic cerebrovascular accident. - methicillin resistant staphylococcus aureus and vancomycin resistant enterococcus in . - cirrhosis secondary to biliary strictures. - mirizzi's syndrome (bile duct compression) complicated by encephalopathy, variceal bleeding requiring 40 units of packed red blood cells. - ejection fraction of 30 to 35% per echo. no h/o chf. - cmv retinitis and fungemia ( ) c/b fungal eye infection s/p r eye removal. - biliary sepsis with pseudomonas and enterococcus. - anemia, thrombocytopenia - benign prostatic hypertrophy. - nephrolithiasis. social history: manager of freight shipping company to and from . married. family history: nc physical exam: t 97.8 bp 98/50 hr 84 rr 18 o2sat 94% 4l - 95% ra gen: nad, chronically ill appearing heent: false r eye with crusted matter (patient says this is usual), left eye rrl, +ngt neck: supple, no lad cv: rrr, 2/6 sem at lusb lungs: decreased bs at all but apicies, and limited patient being too weak to sit up abd: soft, mildly distended, +bs, non tender back: non tender with palpation of spine and back ext: warm, left ue fistula +thrill, lue swelling, lle with 5/5 strength, rle with 3/5 quad strenght, patellar reflexes 2+ bilaterally neuro: alert and oriented x3, tired. pertinent results: cbc 04:00am blood wbc-12.9* rbc-3.06* hgb-10.9* hct-35.3* mcv-115* mch-35.5* mchc-30.8* rdw-20.6* plt ct-108* 04:00am blood neuts-83.9* lymphs-7.4* monos-5.8 eos-2.9 baso-0.1 04:00am blood plt ct-108* coags 04:00am blood pt-16.1* ptt-32.0 inr(pt)-1.6 chemistries 04:00am blood glucose-111* urean-25* creat-2.6*# na-140 k-3.6 cl-103 hco3-35* angap-6* 04:00am blood albumin-2.3* calcium-8.2* phos-2.3*# mg-1.9 lfts 04:00am blood alt-23 ast-36 ld(ldh)-131 alkphos-418* totbili-1.0 04:00am blood ggt-199* pth 10:43am blood pth-19 cxr ap portable supine view of the chest: a presumed tips shunt is again demonstrated with an apparent vascular stent in the left upper quadrant. there is high-density material that projects over the spine in the mid abdomen that may represent previous vertebroplasty procedure. there are low lung volumes. there is left-sided pleural effusion and left lower lobe collapse/consolidation. the right lung appears to be grossly clear. the low lung volumes produce crowding of the pulmonary vasculature. no evidence of pneumothorax on the supine view. the ng tube terminates below the diaphragm within the stomach. mr impression: 1) no evidence of spinal stenosis in the lumbar spine. 2) please review the report of the mri of the thoracic spine for details on the destructive lesions in the lower thoracic vertebrae. mr impression: destruction of vertebral bodies and intervertebral disc spaces with collapse of the above mentioned vertebral bodies causing kyphosis of the thoracic spine at this level. there is also abnormal enhancing soft tissue in the epidural space around the spinal cord causing mild cord compression. there is possible slight increase in t2 signal in the cord. these findings were discussed with dr. at the time of the interpretation. the patient has a history of documented fungal discitis diagnosed with aspiration of this area in hospital. the findings are consistent with an infectious process. abd u/s impression: 1. cirrhosis and large amount of ascites. 2. occluded tips with forward, hepatopetal flow in the portal veins. 3. echogenic and relatively small kidneys, consistent with parenchymal disease. no hydronephrosis. abd/pel ct brief hospital course: 64m with dm ii, cad s/p cabg, cirrhosis biliary stenosis s/p tipss procedure, esrd on hd, h/o candidemia, osteoporosis s/p lower thoracic compression fractures s/p kyphoplasty c/ osteomyelitis and diskitis with new epidural mass/collection transferred from hospital for further management. osteomyeltis/diskitis/epidural collection the patient initially presented to hospital (cch) on with complaint of low back pain and was found to have t10 and t12 compression fractures. the etiology was likely secondary hyperparathyroidism leading to osteoporosis. he underwent a kyphoplasty on at at both t10 and t12, and was discharged to rehab on , but was readmitted to cch on with a new t11 compression fracture and during that hospitalization was found to have fungemia and osteomyelitis (from ct guided aspiration of t11). he was started on caspofungin at that time. on his admission to cch () he was noted to have some cord edema at the t11 level by mr, but was asymptomatic. a repeat t-spine mri on revealed the above mentioned abnormalities, but additionally an epidural/paraspinal mass extending from t9-t12. on transfer to , the patient was stable with good rectal tone and a non-focal neurologic exam. blood and urine cultures were resent, as well as fungal cultures. an mri of the lumbar and thoracic spine was done and showed destruction of vertebral bodies and disc spaces, with an abnormally enhancing epidural space impinging on the spinal cord. ortho spine was consulted and felt that the patient was a poor surgical candidate for an anterior procedure, but that a posterior debridement and stabilization could be considered. the patient was continued on caspofungin, hepatically dosed, initially. id was consulted and suggested stopping the caspofungin and starting a 6 week course of ambisome, given that ambisome has good bone penetration and the patient's infection had progressed despite the caspo. they also suggested an abdominal/pelvic ct which showed no obvious sources of infection. additionally, the patient has had multiple previous blood and urine infections with the same organism ( ) s/p long antifungal courses. the fact that he was again infected with the same organism suggested that he may be harboring the infection, possibly within a seeded foreign body. the patient has a tipss shunt in place, and initially it was thought that he ureteral stent in place from 6/. given his multiple urinary infections with , urology was consulted regarding possible removal of the stent, if no longer needed. however, a kub showed that the stent in fact had been removed prior to this hospitalization. there was a small stone seen on ct that urology did not feel was worth the risk of lithotripsy. esrd on hd the service was consulted on admission. his usual dialysis days are mwf via his left arm fistula. a ultrasound was done and showed no hydronephrosis. his pth was normal so calcitriol was stopped. on , the patient was scheduled for hd, but there was no bruit or thrill over his fistula. he underwent a fistulogram with dilation of proximal lue vessels. he was able to reinitiate hd on . cirrhosis s/p tipss the hepatology team was consulted on the patient's admission. the patient was started on lactulose for mild asterixis, and titrated as needed. he had a liver u/s with doppler which showed an occluded tipss. the patient underwent a diagnostic and therapeutic paracentesis on , given a low grade fever, which showed a transudative fluid with only 5 wbcs. cultures showed ... uti the patient does not make a great deal of urine. a foley was placed on admission that drained pus, and a u/a was pyuric. he was initially started on levofloxacin but given that the urine culture was negative, and that his ascites fluid was not consistent with sbp, this was discontinued. c. diff. the patient was positive for clostridium difficile on at hospital. treatment was initiated with flagyl at that time, and was continued here. right false eye discharge the patient had a right eye prosthesis after having cmv retinitis and ophthalmitis on a previous admission last year. there was some prurulent material surrounding the prosthesis that was sent for culture on admission. the patient did not have tenderness around this area, and said that he normally has some crusting around the eye, and there was no surrounding erythema. cultures grew coag positive staph, and was likely mrsa colonization. fen the patient had an ngt placed at the outside hospital, that was placed for poor po intake and anorexia. a cxr was done on admission that showed the tube to be in good position. tube feeds had been initiated and were continued here. the liver team suggested a post-pyloric feeding tube, and this was placed on . nutrition was consulted regaring tube feeding recommendations. access the patient had a left arm fistula, and a right sided picc line was placed on . he had a fistulogram on as above. precautions the patient was on mrsa, vre, and c diff precautions. code status was discussed with the patient and wife during this admission, and he was full code initially but on , his code status was changed to dnr/dni per his wishes. on the patient was transferred to the medical service after pressors had been discontinued and his code status was "comofort measures only". initially antibiotics were continued per the patient's wife's wishes, being that she felt they made him more comfortable, but ultimately they were discontinued because of the large amount of fluid they required. on at 11:30pm the patient expired. family and attending were notified. medications on admission: 1. albuterol nebs q2h 2. tylenol 650 mg tid 3. ambisome 250 mg iv daily 4. docusate 100 mg 5. gapapentin 200 mg qhs 6. sc heparin tid 7. riss 8. ipratropium neb q2h 9. levofloxacin 250 mg iv q48h- started today. 10. metoclopramide 5 mg iv q6h 11. meropenem 500 mg iv q12h- started today. 12. metronidazole 500 mg iv q8h- started today. 13. senna 1 tab discharge disposition: expired discharge diagnosis: primary diagnoses fungemia osteomyelitis t11 epidural collection impinging on spinal cord (t9-t12) t9-t12 compression fractures esrd on hd s/p dilation of proximal lue veins cirrhosis biliary strictures s/p tipss (not currently patent) mild encephalopathy severe back pain discharge condition: expired Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Hemodialysis Angioplasty of other non-coronary vessel(s) Percutaneous abdominal drainage Arteriography of other specified sites Infusion of vasopressor agent Diagnoses: Urinary tract infection, site not specified Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Septic shock Intestinal infection due to Clostridium difficile Mechanical complication due to other implant and internal device, not elsewhere classified Disseminated candidiasis Secondary hyperparathyroidism (of renal origin) Acute osteomyelitis, other specified sites Other complications due to renal dialysis device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft Biliary cirrhosis Intervertebral disc disorder with myelopathy, thoracic region Pathologic fracture of vertebrae Other osteoporosis Kyphosis associated with other conditions

history of present illness: the patient is a 62 year old male status post hepaticojejunostomy for mirizzi syndrome recently discharged from on . upon discharge from patient was doing well. he followed in clinic with dr. . on the night prior to admission patient noticed blood tinged bile and clot in his bile bag. patient had an urge to defecate and passed a large amount of liquidy tarry stool and fainted with loss of consciousness briefly. patient presented to hospital where he was found to be hypotensive with guaiac positive stool. at that time there was no bright red blood per rectum and no melena. patient was transferred to . past medical history: significant for cad status post stent, status post cabg. type 2 diabetes. hypertension. chronic renal insufficiency. physical examination: on presentation to the e.r., the patient was afebrile at 97.8, pulse 98, blood pressure 99/58, respiratory rate 25, 98% saturation in room air. at that time patient had already received 2 liters of crystalloid at hospital, 800 cc of crystalloid and two units of prbc at . patient was ill appearing and pale, but alert and oriented times three. sclerae were anicteric. no jvd. cardiovascular exam was not significant. lung exam was not significant. abdominal exam showed right ptc bag filled with bile and blood clots. left ptc was capped at that time. patient's surgical wound was intact and had no evidence of infection. rectal exam showed guaiac positive stool. extremities were warm. there was no pedal edema. hospital course: the patient was immediately admitted to the icu. laboratory values on admission were white count of 14.7, hematocrit 26.7, platelets 335. differential on the white count was 81.5% neutrophils, 1% bands, 9% lymphocytes. chemistry at that time was sodium 130, potassium 5.8, chloride 103, co2 18, bun 56, creatinine 2.6, glucose 71. ast 27, alt 12, alka phos 98, t-bili 0.2, amylase 171, lipase 251, total protein 7.4, albumin 2.8. pt 14.4, ptt 27.2, inr 1.4. in the icu patient received two additional units of prbc and a total of 5 liters of crystalloid resuscitation and made adequate urine of 1000 cc over 24 hours and maintained a normotensive blood pressure. the patient underwent emergent tube cholangiogram to study his biliary system to try to identify a potential source of bleeding. the tube cholangiogram study showed no evidence of active bleeding at that time. it also showed dilatation of the biliary system consistent with previous studies. by hospital day two patient was adequately resuscitated and was able to be transferred to the floor. he remained under close observation and supervision on the floor without complications, without evidence of any bleeding. the patient remained afebrile throughout his stay. he was discharged on hospital day four. condition on discharge: stable. discharge status: discharged to home. discharge diagnoses: 1. gastrointestinal bleeding. 2. mirizzi syndrome status post hepaticojejunostomy. 3. hypertension. 4. type 2 diabetes. 5. coronary artery disease status post coronary artery bypass graft, status post stent. 6. chronic renal insufficiency. discharge medications: 1. levofloxacin 500 mg one tablet p.o. q.24. 2. calcium carbonate 1 gm q.12 for one week and then 500 mg p.o. b.i.d. 3. bicitra 30 cc p.o. q.d. 4. lopressor 25 mg p.o. b.i.d. 5. protonix 40 mg p.o. b.i.d. followup: the patient is to follow up with dr. or dr. in the office in one week. patient also needs renal followup and patient prefers to follow up with a nephrologist referral from his pcp. also has the phone number of the nephrologist, dr. , and is able to make an appointment if needed. , m.d. dictated by: medquist36 Procedure: Other cholangiogram Diagnoses: Hyperpotassemia Anemia, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypotension, unspecified Unspecified disorder of kidney and ureter Hemorrhage of gastrointestinal tract, unspecified Obstruction of bile duct

allergies: cefuroxime / ketorolac / olanzapine / cephalosporins / zyprexa / toradol / ceftin attending: chief complaint: right upper quadrant pain major surgical or invasive procedure: ercp history of present illness: 49y/o m with h/o dm2 s/p ercp being transferred to after received 60 units insulin instead of 6 units insulin for glucose 250. . pt presented to with ruq pain, which he describbes as sharp, does not radiate. no records from at this time - pt states that ercp was performed there, but could not get through ampulla. pt was then transferred here for ercp. per ercp fellow, mrcp had showed question of stones and a dilated cbd. ercp performed here , sphincterotomy done for ampullary stenosis, sludge removed. pt was going to be sent back to osh from where he came, but was given 60 units regular insulin for glucose 250, rather than 6 units. . pt's pain now about "," no change in quality. no other complaints, no cp or sob. has h/o schizophrenia - denies suicidal ideation, auditory/visual hallucinations. . on arrival to , pt's glucose was 185 20 minutes prior. previous readings, done every half hour since the 60 units were given, were 289, 244, 269, 283, 239, and 185. pt arrived on d10 drip at 15cc/hour. past medical history: 1. coronary artery disease s/p lcx stent 2. diabetes mellitus type 2 - diagnosed , was on glyburide for short period of time but stopped taking it for unclear reasons, was getting insulin at osh but has not injected insulin himself 3. schizophrenia 4. psoriasis 5. h/o pancreatitis 6. pernicious anemia - b12 injections monthly 7. arthritis - on oxycontin x few years social history: lives with wife and mother-in-law. on disability since , mainly due to schizophrenia. used to work as church sexton and at . + tobacco 1 ppd x 35years. no etoh or ivdu. family history: grandmother - pernicious anemia. no dm in the family. no mi; mgm with cva 72y/o. physical exam: vs: t nr 123/66 90 22 100% ra gen: nad, breathing comfortably, not diaphoretic heent: r eye deviation, perrl, op clear, mm dry neck: no jvd, no lad cv: rrr, nl s1/s2, no m/r/g pulm: ctab abd: soft, tender in ruq, no rebound or guarding, nondistended, +bs ext: 1+ pitting edema skin: patches of psoriasis particularly on r shin and posterior aspect of l arm pertinent results: 08:41pm blood wbc-6.6 rbc-4.66 hgb-11.9* hct-36.1* mcv-77* mch-25.4* mchc-32.9 rdw-14.6 plt ct-141* 08:41pm blood pt-12.3 ptt-25.1 inr(pt)-1.1 08:41pm blood glucose-434* urean-6 creat-1.2 na-134 k-4.4 cl-96 hco3-27 angap-15 08:41pm blood alt-43* ast-36 ld(ldh)-242 alkphos-182* amylase-58 totbili-0.6 08:41pm blood lipase-52 08:41pm blood calcium-8.5 phos-2.0* mg-1.5* cbd brushings - benign epithelial cells brief hospital course: mr. was closely monitored on d10ns infusion. finger sticks were checked every 30 minutes for the first seven hours of his admission. as his glucose levels were trending down, the rate of the infusion was increased from 75cc/hour to 125cc/hour, and he was given a total of 3 amps d50. his nadir bs was 93. he experienced no signs or symptoms of hypoglycemia. since he never became truly hypoglycemic, electrolytes were not monitored overnight. his home hypoglycemic was held. his bb was held overnight, and restarted the next morning. mr. continued to have mild abdominal pain overnight, unchanged from the symptoms that brought him to . the next morning, gi cleared the pt for a po diet, which he tolerated well, without worsening pain. he was treated with iv morphine and oxycodone prn for his chronic pain issues, and was given a nicotine patch while in-house. he expressed no desire to quit smoking. he was continued on his home antipsychotic regimen, and had no evidence of si, ah, or vh while in-house. he was covered prophylactically with sc heparin and a ppi. the next morning, spoke with , who agreed that he had no active issues requiring inpatient management. he was d/c'ed home, by way of transport to to retrieve his belongings, and was told to f/u with his pcp in the next week. medications on admission: seroquel 100mg tid bupropion sr 200mg prilosec 20mg asa 325mg daily b12 injections monthly lasix 40mg (for chronic le edema) potassium 40meq daily soma 700mg (muscle relaxant) paroxicam 20mg oxycontin 80mg metoprolol 100mg qam, 50mg qpm lipitor 40mg daily discharge disposition: home discharge diagnosis: hypoglycemia discharge condition: stable discharge instructions: if you experience increased pain, shortness of breath or other concerning symptoms please call your pcp please take your medications as directed followup instructions: please follow up with your pcp in one week provider: , . call to schedule appointment md Procedure: Endoscopic sphincterotomy and papillotomy Endoscopic dilation of ampulla and biliary duct Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi Diagnoses: Coronary atherosclerosis of unspecified type of vessel, native or graft Unspecified schizophrenia, unspecified Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Obstruction of bile duct

allergies: codeine / penicillins attending: chief complaint: left arm pain major surgical or invasive procedure: bone biopsy--left humerus history of present illness: 82m with h/o prostate ca who p/w increasing pain of left arm. sveral months pta, pt hit his arm. he went to local er and was told he had a mild fracture, treated with sling and pain control. however, the pain worsened over the last few months. pt came in to for further evaluation. in , pt noted to have displaced left humerus fracture, likely pathologic. ros of notable for increased le edema. past medical history: prostate ca s/p resection, unknown status cad s/p cabg x 4 in with no further caths per family vfib arrest, s/p icd placement with 2 subsequent firings chf, unknown ef%, followed by dr. at hospital (cards) afib s/p pacemaker hypercholesterolemia glaucoma social history: lives at home with son and daughter heavily involved in care. tob: 1 ppd x many years, quit 6y ago etoh: none illicits: none family history: non contributory physical exam: t=99.0, bp=100/70, hr=82 irreg, rr=20, o2=98% 3lnc, 88% ra elderly man lying in bed, in nad perrl <eomi, mmm, op clear jvp 10cm, no lad irreg irreg, no m/r/g lungs rales lower b/l abd benign ext: lue with limited rom, 2+ radial pulses b/l pertinent results: 07:00pm wbc-9.8 rbc-3.98* hgb-13.7* hct-40.7 mcv-102* mch-34.4* mchc-33.6 rdw-13.4 07:00pm neuts-79.8* lymphs-11.7* monos-6.3 eos-0.1 basos-2.1* 07:00pm plt count-240 07:00pm pt-19.3* ptt-29.5 inr(pt)-1.8* 07:00pm calcium-9.6 phosphate-3.4 magnesium-2.1 07:00pm crp-191.6* psa-<0.1 left arm film: pathologic fracture of the proximal humerus as described above. a large lytic lesion is present involving the humeral head and proximal humerus. this is concerning for metastatic disease. taking into account the recent chest x-ray that did not demonstrate evidence of malignancy, this is concerning for metastasis from a renal cell carcinoma and abdominal ct is recommended for further evaluation. chest ct: 1. 2.6 x 2.4 cm left lower lobe lesion, likely lung carcinoma. this lesion would be amenable to a ct-guided biopsy if clinically desired. 2. extensive pleural thickening and calcification likely from asbestos exposure. 3. rounded pulmonary nodule in the right upper lobe, suspicious for metastasis. 4. bony destruction of t9 and t10 vertebrae with tumor extension into the bony spinal canal. there is a high risk for compression fracture in the future given the extent of these lesions. 5. two suspicious enhancing areas within the right lobe of the liver raise the question of metastases, though the appearance is not typical. 6. likely bilateral renal cysts, incompletely characterized. 7. mild aneurysmal dilatation of the distal aspect of the abdominal aorta. left common iliac artery aneurysm. roughly 50% stenosis of the right superficial femoral artery. bilateral atrial enlargement. brief hospital course: 1) resp: initially, pt admitted to floor for workup of malignancy. however, on day#1, he developed increasing agitation. he was not clearing secretions and was intubated for airway protection. he was then transferred to . pt was in icu for about 6 days. as his agitation and myoclonuse improved, he was extubated, and then transferred back to floor. . 2) humerus fracture: as this represented likely pathologic fracture, a needle biopsy was done. pt also had malignancy w/u with torso ct. this showed lung masses and abdominal mets. the pathology from humerus revealed likely metastatic lung carcinoma. pt was seen by ortho onc but was not a surgical candidate. . 3) onc: pt was seen by onc, rad onc, neurosurg, and ortho onc regarding likely lung ca with mets to bone including spine. however, based on discussions with family, pt was made cmo given very poor prognosis. a few days after this change, on , the pt was found unresponsive and pronounced dead at 7:15am. the family was called and declined autopsy. . 4) cv: his cad, chf, afib were not active issues during this hospitalization. ep service was consulted to turn off icd given pt made cmo, however, this was not completed as there was concern that the family did not want to tell pt this was to be done. medications on admission: coumadin 1.25mg per day, 6d/week; 2.5mg per day, 1d/week colace 100mg toprol xl 25mg per day lasix 120mg po qday (recent increase from 80mg per day) lescol xl (statin) 80mg qd losartan 25mg qd xalatan 1 drop ou qhs tylenol 1000mg tid prn morphine elixir 10mg/5ml, teaspoon q3h prn:pain in lue discharge medications: none discharge disposition: expired discharge diagnosis: metastatic lung cancer pathologic left humurous fracture discharge condition: expired discharge instructions: none. followup instructions: none. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other radiotherapeutic procedure Infusion of vasopressor agent Biopsy of bone, humerus Diagnoses: Anemia, unspecified Pure hypercholesterolemia Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of prostate Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of tobacco use Unspecified glaucoma Other opiates and related narcotics causing adverse effects in therapeutic use Acute respiratory failure Hypotension, unspecified Automatic implantable cardiac defibrillator in situ Encounter for palliative care Hyperosmolality and/or hypernatremia Drug-induced delirium Malignant neoplasm of lower lobe, bronchus or lung Secondary malignant neoplasm of bone and bone marrow Pleurisy without mention of effusion or current tuberculosis Myoclonus Neoplasm related pain (acute) (chronic) Accidental poisoning by other specified solid or liquid substances Personal history of contact with and (suspected) exposure to asbestos Pathologic fracture of humerus

history of present illness: this is an 84-year-old female with cad, hypertension, chf, atrial fibrillation, mitral regurgitation, pulmonary hypertension, status post avr here from rehab complaining of nausea and vomiting and found to have new acute renal failure and transaminitis. patient was thought to be more confused and weaker with decreased appetite, nausea with retching. she was found to have a potassium of 6.0 in the ed and treated with kayexalate. recently her amiodarone dose had been increased. past medical history: 1. atrial fibrillation status post cardioversion in . 2. coronary artery disease status post mi and cabg. 3. status post avr. 4. status post pacer in for atrial fibrillation. 5. status post bilateral breast cancer. 6. status post right lumpectomy with xrt and left mastectomy. 7. chf with known ef of 55% in with 3+ mr, 4+ tr, rv dysfunction and pa hypertension. 8. status post tia. 9. hypertension. 10. status post tah/bso. 11. anemia. medications on admission: 1. amiodarone 400 mg a day. 2. ec-asa 325 mg a day. 3. calcium carbonate. 4. captopril 6.25 mg t.i.d. 5. digoxin 0.125 mg q.d. 6. colace 100 mg p.o. b.i.d. 7. lansoprazole 30 mg a day. 8. metoprolol 50 mg b.i.d. 9. vitamin d. 10. coumadin 0.5 mg a day. 11. boost. 12. tylenol prn. allergies: 1. sulfa. 2. verapamil. 3. procainamide. social history: patient comes from rehab. nephew, is healthcare proxy. is widowed. denies tobacco, alcohol use, or ivdu. physical exam on admission: temperature 97.6, pulse 70, blood pressure 107/44, respirations 18, and oxygen saturation is 93% on room air. in general, elderly, thin, flat affect, poor historian, alert, nad. heent: pale conjunctivae. perrla. no scleral icterus. dry mucous membranes. neck: jugular venous pressure 10 cm. chest: status post left mastectomy. lungs: decreased breath sounds at right base with few rales, otherwise clear to auscultation bilaterally. cardiovascular: normal s1, s2, regular rate and rhythm, holosystolic murmur and 2/6 systolic ejection murmur. abdomen: normoactive bowel sounds, soft, nontender, and nondistended, no hepatosplenomegaly. extremities: + pitting edema bilaterally, warm, and nonpalpable pedal pulses. neurologic: alert and oriented. able to answer questions. laboratory data on admission: white count 8.2 with 78% neutrophils, 15% lymphocytes, 5% monocytes, hematocrit 33.8, platelets 160, mcv 112. chemistries remarkable for a k of 4.9, chloride 95, bicarbonate of 28, bun 49, creatinine 3.4, baseline 1.3 increasing to 2.1 recently, glucose of 86. alt 202, ast 263, amylase 182, lipase 29. digoxin level was 3.8. studies: ecg: v-paced at 70 beats per minute. no changes in left bundle branch pattern. right upper quadrant ultrasound: noted for ascites and gallstones. hospital course: 1. respiratory status: patient developed progressive respiratory distress on the floor and of unclear reasons developed respiratory arrest necessitating intubation and transfer to the micu. the etiology of this was unclear, but thought to be due to aspiration pneumonia. she had a negative head ct and no seizure activity was noted at the time. she also was ruled out with cardiac enzymes. she had a chest x-ray suggestive of worsening left upper lobe opacities and was started on levo and flagyl with sputum cultures, which only grew out oral flora. part of her respiratory decline while intubated was thought also to be due to progressive chf, though diuresis did not improve her respirations. patient had difficulty weaning from the vent, and after much discussion with the patient and healthcare proxy, it was decided finally after several weeks to extubate her with comfort measures. the patient eventually expired. this was thought to be more humane way of treating the patient given her comorbidities and likely decline if she were to have a trach and peg. this was not in keeping with her former values to be independent and not have invasive measures performed. 2. cardiovascular: patient had known chf with known very advanced valvular regurgitation. after transfer to the micu and intubation, she was found to be in with low blood pressures requiring pressors. as all her cultures were negative, etiology was not sepsis and thought to be cardiogenic versus hypovolemic. she was aggressively volume resuscitated resulting in higher blood pressures, but total body volume overload with her being nearly 15 liters positive by the end of her admission. although we attempted to diurese her, she appeared to be quite preload dependent and did not respond well to diuretics. she was pressor dependent until the very end when discussions were made to have her be . she was also noted to be continually in atrial fibrillation, which also decreased her cardiac output. her cardiologist and the cardiology team were consulted/curbsided and given her grave medical condition, there was no benefit to cardioverting her. 3. elevated lfts: patient had negative hepatitis serologies and acetaminophen level was normal. leading thought was toxicity secondary to digoxin or amiodarone as transaminitis decreased since these medications were stopped. however, patient's cardiologist believed that this may have been due to poor cardiac output alone. 4. acute renal failure: creatinine decreased after aggressive volume resuscitation and maintaining pressors to maintain blood pressure. this was thought to be a prerenal, though patient has progressively poor urine output. 5. fen: the patient was continued on tube feeds until extubation. 6. glycemic control: patient continued on sliding scale insulin. 7. code status: patient was initially full code, but after extensive family discussions involving the entire staff, pcp, social work as well as dr. , patient, and nephew agreed that status would be most keeping with her values. patient was thus extubated, and pressors were weaned off and patient was transferred to the floor. she was maintained on oxygen and morphine drip, and eventually expired on . discharge condition: expired. , 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 Arterial catheterization Transfusion of packed cells Transfusion of other serum Injection or infusion of nesiritide Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Atrial fibrillation Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Cardiogenic shock Septic shock

discharge status: to . discharge diagnoses: 1. atrial fibrillation, status post cardioversion. 2. anemia. 3. congestive heart failure. 4. hypotension. 5. acute renal failure. medications on discharge: 1. colace 100 mg one capsule twice a day. 2. senna 8.6 mg one tablet twice a day p.r.n. constipation. 3. simvastatin 10 mg two tablets q.h.s. 4. acetaminophen 325 mg one to two tablets q6hours p.r.n. 5. warfarin 2.5 mg one tablet q.h.s. 6. amiodarone 200 mg two tablets once daily. 7. aspirin 325 mg one tablet once daily. 8. magnesium hydroxide 30ml p.o. q6hours p.r.n. 9. pantoprazole 40 mg one tablet q24hours. 10. bisacodyl 5 mg two tablets once daily p.r.n. as needed for constipation. 11. acetaminophen 325 mg one to two tablets p.o. q6hours p.r.n. 12. metoprolol 50 mg 0.25 tablet p.o. twice a day. 13. digoxin 0.125 mg tablet one half tablet p.o. once daily. 14. heparin flush once daily. follow-up: the patient is to follow-up with dr. for sternal wire revision. the patient is to stop taking coumadin one week before her appointment for sternal wire revision. the patient is to follow-up with dr. in one to two weeks. the patient is to follow-up with dr. in one to two weeks. discharge instructions: the patient's inr should be maintained at a goal of 2.0 to 3.0. the patient may need gentle diuresis with lasix 20 mg p.o. once daily for increasing volume overload and may need gentle hydration with normal saline for decreased blood pressure. , m.d. dictated by: medquist36 d: 17:23 t: 20:34 job#: Procedure: Atrial cardioversion Diagnoses: Other iatrogenic hypotension Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Acute on chronic diastolic heart failure Alkalosis Old myocardial infarction

history of the present illness: mrs. is an 84-year-old female with a past medical history significant for coronary artery disease, status post one vessel cabg in , status post mi in , status post aortic valve replacement, with atrial fibrillation, status post cardioversion times three, chf with ejection fraction of 55%, who presented to the for elective cardioversion. the patient had a recent admission in for chf and atrial fibrillation. at that time, she was started on anticoagulation with coumadin and amiodarone. the patient presented to for admission in for left facial droop and slurred speech with evaluation significant for a negative head ct and carotid dopplers. the patient was discharged to and returns today for elective cardioversion. on arrival to the , she was noted to be hypotensive with systolic blood pressure in the 80s and a heart rate in the 70s, in atrial fibrillation. she was asymptomatic at the time. she received 150 cc of normal saline with an increase in her systolic blood pressure to the 90s. oxygen saturation was 80% on room air and 100% on 2 liters nasal cannula. her dc cardioversion was uneventful and she returned to sinus rhythm. currently, the patient denied any lightheadedness, chest pain, shortness of breath, nausea, vomiting, palpitations, diaphoresis, or radiating pain. she has no recent fevers, chills, or night sweats. no abdominal pain, no cough. she does note pain at the site of her sternotomy which has been ongoing for three or more years. there is an erythematous area that she notes is improving in the last three to four months. ct surgery evaluated the patient in the holding area of the catheterization laboratory and recommended sternal wire revision. the patient was admitted to the cardiology floor for monitoring due to her postprocedure hypotension and for heparinization while her inr came down so that she could have sternal wire revision procedure on monday with a normal inr. past medical history: 1. atrial fibrillation, status post cardioversion times three. 2. coronary artery disease, status post mi, status post one vessel cabg in . 3. status post aortic valve replacement. 4. status post pacemaker in . 5. status post bilateral breast cancer, status post right lumpectomy and xrt in and radical left mastectomy in . 6. congestive heart failure with an ejection fraction of 55% on an echocardiogram in . 7. hypertension. 8. tia. 9. status post tah/bso. allergies: the patient has no known drug allergies. admission medications: 1. coumadin 2.5 mg q.d. 2. amiodarone 200 mg q.d. 3. aspirin 325 mg q.d. 4. lasix 60 mg q.d. 5. atenolol 50 mg q.d. social history: the patient is widowed and lives at the alzheimer's home. she denied any alcohol use and states that she quit smoking at the age of 50. family history: positive for ovarian cancer. physical examination on admission: vital signs: afebrile with a pulse of 68, blood pressure 96/40, respirations 18, oxygen saturation 100% on 2 liters. general: she was a frail-appearing female in no acute distress responding to all questions appropriately. the examination was significant for a dry oropharynx, jvp at 8-9 cm with prominent ej pulsations, rales in the lungs present a third of the way up the left lung field posteriorly with decreased breath sounds in the right lung field a third of the way up posteriorly. no dullness to percussion. moderate air movement. heart: regular with a i/vi systolic ejection murmur heard at the left upper sternal border. abdomen: benign. extremities: warm with 2+ pitting edema bilaterally from the feet to the knees. skin: notable for prominent sternotomy wires and an area of erythema and warmth over the third sternal wire and extreme tenderness to touch over all sternotomy wires. laboratory/radiologic data: significant for a hematocrit of 42, platelets 172,000 and an inr of 1.9. ekg showed atrial pacer spikes and a rate of 69 beats per minute with left bundle branch block. hospital course: the patient was admitted to the cardiology service. 1. sternotomy site inflammation: the ct surgery service was consulted and felt that the sternotomy site inflammation was not due to infection but was due to erosion of the skin over the wire. they were not able to see the patient on monday and, therefore, suggested arranging an outpatient appointment for her at a further date. it was, therefore, decided that the patient would go home on her coumadin and remain on coumadin for three weeks in order to prevent increased stroke risk during the three weeks after cardioversion and will follow-up with ct surgery for sternotomy wire revision at a later time once she is no longer in the window of increased stroke risk after cardioversion. the patient was, therefore, discontinued from her heparin and restarted on her coumadin doses. 2. atrial fibrillation: the patient remained in sinus rhythm with rates between 68 and 100 beats per minute with no events other than one run of three minutes of ventricular tachycardia which was asymptomatic. other than that, telemetry was uneventful. the patient was continued on her coumadin with a goal inr of .5. 3. hypoxia: after diuresis with lasix and diuril, the patient's oxygen saturation improved. she was continued on diuresis. 4. coronary artery disease: the patient was continued on her aspirin, beta blocker, and statin. 5. blood pressure: the patient was hypotensive postprocedure with blood pressures as low as 70 systolic. she received 1 liter of fluids and still appeared dry with low blood pressures in the 80s to 90s systolic. she was, therefore, transfused with packed red blood cells in order to increase her intravascular volume and minimize the fluid to her periphery as it was deemed that she was intravascularly depleted but total volume overloaded. 6. left lower extremity edema: the patient was given pressure stockings which decreased the edema in her feet; however, there was still 2+ edema in her legs. she was continued on her lasix and zaroxolyn. 7. hematology: the patient's hematocrit decreased to 29 on the second day of admission. therefore, she was transfused 2 units of packed red blood cells with lasix in between. disposition: the patient was discharged to center. she will return to see dr. as an outpatient in four weeks for sternal wire revision. condition on discharge: fair. discharge status: to center. discharge diagnosis: 1. atrial fibrillation. 2. hypotension. 3. anemia. discharge medications: 1. metoprolol 25 mg p.o. b.i.d. 2. aspirin 325 mg p.o. q.d. 3. colace 100 mg p.o. b.i.d. 4. simvastatin 20 mg p.o. q.h.s. 5. warfarin 2.5 mg p.o. q.h.s. 6. metolazone 2.5 mg p.o. b.i.d. 7. amiodarone 200 mg p.o. q.d. 8. furosemide 40 mg p.o. b.i.d. follow-up: the patient is to follow-up with dr. in four weeks for sternal wire revision. call for an appointment. the patient is to stop taking her coumadin one week before her appointment for sternal wire revision. the patient is to have her inr checked daily and the results sent to dr. . the patient is to follow-up with dr. in one to two weeks. , m.d. dictated by: medquist36 d: 06:50 t: 19:21 job#: Procedure: Atrial cardioversion Diagnoses: Other iatrogenic hypotension Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Acute on chronic diastolic heart failure Alkalosis Old myocardial infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: doe major surgical or invasive procedure: upper and lower gi endoscopy mitral valve replacement(29mm mosaic porcine valve) and three vessel coronary artery bypass grafting(left internal mammary to left anterior descending, vein grafts to obtuse marginal and posterior descending artery) history of present illness: 77 yo male with history of cad and imi. elective cath done in preparation for planned mvr. cath revealed lm 50%, lad 80%, cx 50%, rca 100%, mild ai, ef 50%, moderate mr.echo also showed 4+ mr and 2+ ai. referred to dr. for mvr/cabg/possible avr. past medical history: cad/imi niddm elev. chol. htn chf djd very hoh pacer for bradycardia ( sigma 300 dr) social history: retired, lives with wife no etoh quit smoking 5 years ago, 55pack-yrs no recr. drugs family history: non-contrib. physical exam: hr 72 rr 16 right 124/60 left 120/58 5'8" 158# wdwn in nad skin unremarkable perrl, eomi, nc/at, op benign neck full rom, no jvd or bruits ctab rrr 3/6 murmur soft, nt, nd, + bs warm, well-perfused, no edema, no varicosities alert and oriented x 3, mae, non-focal 2+ fem/dp/pt/radials pertinent results: 07:25am blood wbc-8.4 rbc-3.68* hgb-8.9* hct-28.1* mcv-77* mch-24.2* mchc-31.7 rdw-21.9* plt ct-315# 07:25am blood plt ct-315# 07:25am blood pt-25.9* ptt-35.4* inr(pt)-2.6* 07:25am blood glucose-85 urean-24* creat-1.4* na-140 k-4.4 cl-99 hco3-32 angap-13 brief hospital course: admitted for surgery on and taken to the or. hematocrit drawn prior to incision was 20.5. this represented a significant drop from his last pat hct which was 27.5. surgery cancelled in the or for anemia work-up to rule out a source of active bleeding.patient taken to csru in stable condition and extubated there later in the day. seen by general surgery team and gi consult. abd/pelvic ct scanning also done with no source of bleeding or hematomas found. egd and colonoscopy done on with were negative. capsule endoscopy on showed angioextasia in the distal small bowel. angiography showed no active bleeding. hematology consult recommended iron supplementation. general surgery deferred push enteroscopy via laparotomy. he as taken to the operating room on where he underwent a cabg x 3 and mvr (porcine). please see op note for details. he was extubated on pod #1. he was seen by electrophysiology who reprogrammed his ppm to a backup rate of 80 from 70, and turned off the sleep mode to help wean from his epinephrine. the pacer was returned to its original settings on . he was anticoagulated for underlying atrial fibrilation. medications on admission: amiodarone 200 mg daily lopressor 25 mg omeprazole 20 mg daily asa 325 mg daily glyburide 2.5 mg daily combivent lasix 40 mg vytorin 10/40 mg daily kcl amoxicillin prn dental discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. glyburide 2.5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. vytorin 10/40 10-40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. potassium chloride 20 meq packet sig: one (1) po twice a day. disp:*60 * refills:*2* discharge disposition: home with service facility: discharge diagnosis: anemia cad imi niddm chf djd very hoh pacemaker (bradycardia) sigma 300 dr discharge condition: good discharge instructions: follow up appts. as below followup instructions: see dr. in weeks schedule follow up appt. with dr. in 3 weeks ( after hematology work-up is complete). please call him this coming thursday for update. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Other endoscopy of small intestine Diagnostic ultrasound of heart Colonoscopy Arteriography of other intra-abdominal arteries Open and other replacement of mitral valve with tissue graft Transfusion of packed cells Transfusion of other serum Artificial pacemaker rate check Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Iron deficiency anemia secondary to blood loss (chronic) Cardiac complications, not elsewhere classified Atherosclerosis of aorta Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Old myocardial infarction Urinary complications, not elsewhere classified Stricture of artery Surgical or other procedure not carried out because of contraindication Fitting and adjustment of cardiac pacemaker Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication Oliguria and anuria Angiodysplasia of stomach and duodenum with hemorrhage

allergies: nifedipine / zithromax / hydrochlorothiazide / augmentin attending: chief complaint: 1 wk inability to swallow w/ hx tracheal-esophogeal fistula major surgical or invasive procedure: 1. rigid bronchoscopy. 2. flexible bronchoscopy. 3. endobronchial biopsy of the trachea, as well as the anterior carina. 4. stent placement in the trachea. history of present illness: 57 y/o female developed cough . chest ct showed mediastinal mass, biopsy - neg for malignancy. - respiratory infection w/ bronch that showed compression of r mainstem bronchus and diagnosed w/ fibrosing mediatinitis. pt on imuran and tamoxifen in . - esophogoscopy > esophogeal stricture and tracheal-esophogeal fistula, narrow trachea. tracheal stent placed ,path considered probable lymphoma- no firm diagnosis then pt developed pna, + phlem over past 2 months. - bronch showed stent to be broken along posterior aspect. had difficulty swallowing liquids and solids, unable to eat anything. pt presented to general ed- - in pt x2days. past medical history: pneumonia, diabetes mellitus, hytertension, tracheo-esophageal fistula, fibrosing mediastinitis social history: non- smoker, no etoh. lives w/ husband in , ny in 2 story house. retired lawyer, now has business w/ husband. (- family history: father -died prostate ca age 50 mother- alive age 89, s/p cabg, htn physical exam: general- obese older middle age female. neuro- alert and oriented, nad heent- perrla, no lymphadenopathy resp-ronchi,course, clear upper, productive cough cor-rrr abd- + bs, nt, nd ext-warm, trace edema. pertinent results: , pathology examination name birthdate age sex pathology # , 57 female report to: dr. gross description by: dr. , dr. /dif specimen submitted: 1. biopsy distal trachea, 2. esophageal biopsies, 3. esophageal biopsy for lymphoma study procedure date tissue received report date diagnosed by dr. /stu previous biopsies: egd. esophageal biopsy for immunophenotyping tracheal mass f/s,tracheal mass. diagnosis: 1. distal trachea, biopsy (a): involvement by classical hodgkin's lymphoma, not otherwise specified, see note. note: sections show tracheal mucosa, cartilage, and fibrous tissue with an extensive lymphoid infiltrate composed of small lymphocytes, plasma cells, neutrophils, histiocytes and scattered large atypical lymphoid cells. these large atypical lymphoid cells have multiple nuclei, with large eosinophilic nucleoli, and abundant pale to eosinophilic cytoplasm and correspond to classic or diagnostic -sternberg cells. by immunohistochemistry, the large atypical lymphoid cells are positive for cd30, but negative for cd20, leukocyte common antigen (lca) and latent membrane protein (lmp). cd3 and cd5 highlight background small lymphocytes. cd10 and cd15 highlight background stromal cells and neutrophils, respectively. cytokeratin cocktail (ae1/ae3/cam5.2) does not stain the large atypical lymphoid cells. mib-1 fraction among rs cells is high (80%). overall, the morphologic and immunophenotypic characteristics are in keeping with classic hodgkin lymphoma (who classification). since the biopsy is represented by small fragments of tissue subtype classification is not advisable. 2. esophagus, biopsy (b): involvement by classical hodgkin's lymphoma, not otherwise specified, see note. note: sections show squamous epithelium and fibrous tissue with an extensive subepithelial inflammatory infiltrate composed of small lymphocytes, neutrophils, plasma cells, histiocytes and scattered to focally clustered large atypical lymphoid cells, with abundant cytoplasm, irregular nuclear contours, consistent with -sternberg cells, some of the classic type. by immunohistochemistry, the large atypical lymphoid cells ae positive for cd30, and negative for cd20, cd45 and alk-1. overall, the morphologic and immunophenotypic findings are in keeping with classic hodgkin lymphoma (who classification). 3. esophagus, biopsy (c): a. fragments of squamous epithelium with extensive infiltration by neutrophils, consistent with an ulcer base. b. none invasive yeast forms identified, see note. note: special stains for microorganisms could not be performed due to exhaustion of the tissue block. morphologic features of hodgkin lymphoma are not seen. clinical: tracheo-esophageal fistula. possible lymphoma. gross: the specimen is received in three parts, all labeled with ", ". part 1 is received in formalin and additionally labeled "biopsy distal trachea" and consists of four fragments of soft tan tissue measuring 0.6 x 0.3 x 0.2 cm in aggregate, entirely submitted in a. part 2 is received in formalin and additionally labeled "esophageal biopsy" and consists of a 1.6 x 1.3 x 0.2 cm aggregate of tan soft tissue fragments, entirely submitted in b. part 3 is received fresh additionally labeled "esophageal biopsy for lymphoma study" and consists of multiple tan tissue fragments measuring 0.8 x 0.8 x 0.3 cm in aggregate. touch preparations are made and a portion is submitted for flow cytometry and frozen storage, (four possible molecular studies). a representative fragment is additionally submitted for routine histology in c. by his/her signature above, the senior physician certifies that he/she personally conducted a gross and/or microscopic examination of the described specimens(s) and rendered or confirmed the diagnosis(es) related thereto. immunohistochemistry test(s), if applicable, were developed and their performance characteristics were determined by the department of pathology at , , ma. they have not been cleared or approved by the u.s. food and drug administration. the fda has determined that such clearance or approval is not necessary. these tests are used for clinical purposes. they should not be regarded as investigational or for research. this laboratory is certified under the clinical laboratory improvement amendments of (clia - 88) as qualified to perform high complexity clinical laboratory testing. complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 04:44am 3.6* 3.74* 9.5* 30.6* 82 25.3* 30.9* 13.6 214 differential neuts bands lymphs monos eos baso atyps metas 10:35pm 88.8* 6.1* 4.8 0.2 0 red cell morphology hypochr 10:35pm 1+ basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 04:44am 214 basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrino 06:54am 325 chemistry renal & glucose glucose urean creat na k cl hco3 angap 04:44am 186* 21* 0.5 142 3.9 103 31* 12 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 06:54am 8 14 131 71 50 0.3 lipemic specimen interferences minimized other enzymes & bilirubins lipase 06:54am 96* lipemic specimen interferences minimized chemistry totprot albumin globuln calcium phos mg uricacd iron 04:44am 8.4 2.8 2.0 blood gas blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph calhco3 base xs 04:56pm art 93 38 7.44 27 1 hemogloblin fractions ( cooximetry) o2 sat 04:56pm 97 radiology final report ct trachea w/c & w/recons 12:58 pm ct trachea w/c & w/recons; ct 100cc non ionic contrast reason: for change in mediastinal mass, stent position, fistula contrast: medical condition: 57 year old woman with trachea-esophageal fistula and ? lymphoma vs carcinoma, s/p trach stent now fx. contraindications for iv contrast: none. indication: history of mediastinal mass, status post tracheal stent placement with fracture, evaluate stent position, fistula. technique: multidetector high-resolution ct scanning of the trachea was performed following administration of 100 cc of intravenous optiray contrast. findings: assessment of the airways demonstrates interval placement of a tracheal stent which terminates at the level of the carina. there is collapse at the distal portion of the stent. posterior dependent intraluminal opacity is demonstrated most consistent with secretions and a possible element of granulation tissue. note is made that the amount of intraluminal material changes from series 3 becoming less pronounced on repeat scanning on series 7. a small linear lucency is seen extending from the right lateral margin of the distal trachea extending into the esophagus consistent with a tracheoesophageal fistula. this occurs approximately 1.5 cm above the carina, best appreciated on series 7, image 29. distal to the stent there is persistent severe proximal narrowing of the right main stem bronchus. note is again made of slight asymmetry in the region of the right vocal cord, as discussed previously. evaluation of the soft tissues again, demonstrates diffuse abnormalities with extensive bulky lymphadenopathy extending from the right supraclavicular region into the superior mediastinum and into the right hilar and subcarinal regions. allowing for differences in technique with contrast on the current study this appears not significantly changed. the previously described involvement of the trachea and esophagus with lack of a discrete fat plane between the posterior wall of the trachea and esophagus is also redemonstrated. there are no new lesions identified. the heart and great vessels are otherwise unremarkable. assessment of the lung parenchyma demonstrates no focal areas of consolidation or effusion. scattered heterogeneous areas of lung attenuation could be due to air trapping during relative expiratory phase of scanning. the limited visualized portions of the upper abdomen are unremarkable. the osseous structures demonstrate no suspicious lytic or sclerotic lesions. impression: 1. interval placement of tracheal stent with distal narrowing. 2. findings consistent with interval development of tracheoesophageal fistula at the distal right lateral margin of the trachea. 3. no significant interval change in extensive conglomerate nodal masses and soft tissue abnormalities as described previously. 4. persistent severe narrowing of the proximal right main stem bronchus. the study and the report were reviewed by the staff radiologist. dr. dr. approved: 6:28 pm radiology final report chest (portable ap) 5:42 medical condition: 57 year old woman with te fistula s/p bronch and egd comparison: . indication: status post bronchoscopy and egd procedure. a stent remains in place within the trachea extending to the carinal region. the right main stem bronchus is not visualized. there has been interval placement of a left picc line, which terminates in the superior vena cava. a feeding tube is coiled in the stomach. an endotracheal tube has been removed. there remains widening of the right mediastinal and hilar contours, although this appears improved compared to the earlier study of and slightly improved compared to the more recent study of . there are patchy areas of consolidation within both lower lobes and there is also a layering right pleural effusion, which has increased in the interval. a small left pleural effusion is considered unchanged. previously noted septal lines and perihilar haziness on the left have improved. impression: improvement in pulmonary edema with resolution of septal lines and decreased left perihilar haziness. residual asymmetrical right perihilar haziness and patchy bibasilar consolidations may reflect residual dependent pulmonary edema or superimposed process such as atelectasis or aspiration. slight increase in right pleural effusion and stable left pleural effusion. radiology final report bilat up ext veins us port 8:10 am reason: lue for left basilic dvt seen in ir (limited medical condition: 57 year old woman with multiple resp issues,tracheal esoph fistula, tracheal stent plcmnt, s/p bronch w/ new tracheal stent placement. picc line placed by ir> ir saw left ue- left basilic dvt. reason for this examination: lue for left basilic dvt seen in ir (limited non-doppler) history: status post picc line placement on in intervention radiology. thrombus in the left basilic vein was suspected on limited son evaluation without doppler. comparison: no previous studies. findings: grayscale and doppler son of the right and left internal jugular, subclavian, axillary, and brachial veins were performed. the right basilic vein was also evaluated. the left basilic vein and bilateral cephalic veins could not be identified, which may be related to technical limitations secondary to the patient's body habitus. on the left, there is an occlusive thrombus in one of the two brachial veins and in the axillary vein. normal compressibility, color flow and waveforms are present in the second brachial vein. normal color flow and waveforms are present in the internal jugular and subclavian veins. on the right, there is an occlusive thrombus in the internal jugular vein, which expands the vein. no intraluminal thrombus is identified in the subclavian, axillary, brachial, or basilic veins, which demonstrate normal color flow and waveforms. normal compressibility is present in the axillary, brachial, and basilic veins. findings were discussed with dr. . impression: 1. occlusive thrombus in one of the left brachial veins and in the left axillary vein. 2. occlusive thrombus in the right internal jugular vein. the study and the report were reviewed by the staff radiologist. dr. . dr. approved: sat 9:52 am brief hospital course: pt presented to ed @ after being inpt at x2 days for inablity to swallow. pt by ed staff, consult w/ interventional pulmonology, w/ admission to md, thoracic surgery. admitted to 2. ip w/ plan for ct airway, bronchcoscopy, esophogoscopy for of fistula, stent, and biopsies, and nutritional intake. pt started on ivf for hydration, npo-regular rx administed iv route,inc'd bstx w/ riss, moderated anxiety prior to ct scan, by np, rx for ativan prn. ct airway done. - or for rigid bronch and egd- tracheal stent in distal trachea, fractured along posterior along whole ength, severe distal malacia, 16x40 metal stent placed over present stent, bx from ant carina and right esophogeal mucosa. stable post-op, intubated, sedated and tranfer to csru(icu). pod#1()vssno events, afebrile. bronch done-ett in good position, metal stent in good position, rt mainstem bronchus w/ plugs> therapeutic aspiration, left patent lul, lll> bal done. nutrition consult done- to start promote w/ fiber via doboff tube. access- picc line placed l brachial under fleuroscopy. in the process, pt found to have clot in left basilic veing wh did not compress, limited non-doppler. formal doppler studies done.impression:1. occlusive thrombus in one of the left brachial veins and in the left axillary vein.2. occlusive thrombus in the right internal jugular vein. tx'e w/ pneumo boots, sq heparin. anticoagulation risk of airway bleeding outwieghs risk pe. pod#2- bronch done- w/ ett and metal stent in good position, rt and lt airways patent, moderate secretions lul- w/ therapeutic aspiration. pt weaned and extubated post - bronch pod#3 ()- pt diruesed for pul edema on cxry, vss, fentanyl prn, lopressor for ^ hr, tf, iv hep locked, solumedrol iv. pod#4- pt transferred to floor- 2, aao, extremity edema- lasix, o2, lungs clear, strong productive cough, +bs-+bm, plan- physical and pulmonary rehab, awaiting final results, and await esophogeal stent placement by gi . - pt stable, awaiting path results, npo- tf via doboff, pul/physical rehab cont. -dr. informed pt of final pathology diagnosis of lymphoma requiring treatment as soon as possible. esophogeal stent placement in gi suite done. - barium swallow done- normal, no communication between trachea and esophogas w/ stents in place. small aspiration of barium during procedure w/ cough episode. instructed to chew and swallow with caution w/ chin tuck. diet- full liquids advancing to soft solids w/ mutiple chews instructed. dvt therapy for rij and left brachial vein- lovenox ordered, pt refused administration and education offered by rn, prescription given to patient on discharge. blood sugar has been elevated throughout hospital course considering prednisone therapy, stress of hospitalization. pt cont on avandia 8mgqd, w/ regular insulin sliding scale prn. fingerstick 165-180 when getting nutrition via tube feeding, 110-118 w/ minimal intake post esophogeal stent placement . pt refused administration and education of insulin sq by rn. prescription given. both to be addressed at appoinment w/ patient's pcp md @3:15pm. plan for discharge to home w/ husband. pt instructed to f/u w/: primary care provider , md thursday as acheduled per patient; oncologist (which pt has contact pta) for treatment lymphoma; pulmonologist- , md, , ny, ; and gastroenterologist- , md, pittsford, ny, medications on admission: prednisone 25', protonix 40", avapro 150', avandia 8', advair 500/50", singular 10', lasix 40', k-dur 20" discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. disp:*1 1* refills:*0* 3. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. disp:*250 ml(s)* refills:*0* 6. lorazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*60 tablet(s)* refills:*0* 7. rosiglitazone maleate 8 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 9. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed. disp:*100 ml(s)* refills:*0* 10. sodium chloride 0.9 % parenteral solution sig: ten (10) ml intravenous daily (daily) as needed: to picc line. disp:*200 ml(s)* refills:*0* 11. insulin regular human 100 unit/ml solution sig: sliding scale sliding scale injection asdir (as directed). disp:*1 1000* refills:*2* 12. potassium chloride 20 meq packet sig: one (1) packet po bid (2 times a day). disp:*60 packet(s)* refills:*2* 13. enoxaparin sodium 80 mg/0.8 ml syringe sig: one (1) suringe subcutaneous q12h (every 12 hours). disp:*60 suringe* refills:*2* 14. prednisone 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 15. prednisone 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 16. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* discharge disposition: home discharge diagnosis: tracheal esophogeal fistula,. tracheal stent placement pneumonia, dm, htn, tracheo-esophageal fistula, fibrosing mediastinitis 1. rigid bronchoscopy. 2. flexible bronchoscopy. 3. endobronchial biopsy of the trachea, as well as the anterior carina. 4. stent placement in the trachea discharge condition: good discharge instructions: call primary provider md health, 2561 lac , , ny for: fever greater than 101, chest pain, shortness of breath, increased pain, swelling, reddness of left arm/shoulder. contact primary provider, , md, , ny, , and gastroenterologist , md, 1900 , pittsford, - as per recommendations. contact oncologist per primary provider or as you have previously arranged/contact for treatment of lymphoma. followup instructions: contact primary provider- md health, 2561 lac , , ny, for follow-up therapy and monitoring of: diabetes- insulin administration education done for blood sugar greater than 120; and deep vein thombosis therapy w/ lovenox injections(low molecular weight heparin). appointment scheduled by patient for - afternoon. pulmonologist- , mdrochester, ny, . call for appointment as he determines. gastroenterologist , md, 1900 , pittsford, - . call for appointment as he determines. contact oncologist per primary provider or as you have previously arranged/contact for treatment of lymphoma. Procedure: Venous catheterization, not elsewhere classified Other intubation of respiratory tract Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Esophagogastroduodenoscopy [EGD] with closed biopsy Closed [endoscopic] biopsy of trachea Closed [endoscopic] biopsy of esophagus Closed [endoscopic] biopsy of esophagus Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites Mediastinitis Tracheoesophageal fistula

allergies: penicillins / sulfonamides attending: addendum: please addend discharge summary as follows (see below) - corrected brief hospital course: summary paragraph: this is a 63 year old right-handed woman with history subarachnoid hemorrhage associated with acomm aneurysm in s/p vp shunt, associated infarcts (right frontal and left parietal) likely related to vasospasm at the time, hyponatremia, hypothyroidism, hypertension, high cholesterol and obstructive sleep apnea who had presented following an episode of unresponsiveness with stiffening, incontinence and tongue-biting thought likely related to seizure. she also has a history of hemifacial spasm, an episode of which occurred shortly before the seizure, raising the possibility that the facial movement in fact represented focal motor seizure activity. in the hospital, mri demonstrated an area of infarct in the right frontal lobe, which had grown in size since the last scan, as well as severe occlusion of the branches of the right internal carotid artery and middle cerebral artery. evolution of the right hemispheric infarct was thought in part to be responsible for her abulia, and also responsible for her new seizures. abnormalities of the hypothalamic-pituitary axis were also present, including impaired thirst response, and thermoregulation. finally, temporal artery biopsy was considered, for her elevated esr and crp, as well as possible tenderness on the left of the temporal artery. she was discharged on a low dose of keppra for seizure protection. discharge disposition: home with service facility: homecare discharge diagnosis: 1) severe occlusive disease of the right intracranial ica and mca 2) right cerebral infarction related to the progressive occlusive disease 3) seizures secondary to the new cerebral infarction 4_ status post sah with clipping of an anterior communicating artery aneurysm 5) abulia and severe cognitive and behavioral abnormalities secondary to 2 and 4. 6) hypothalamic dysfunction discharge condition: improved - back to baseline. discharge instructions: please md or return to ed if you experience new seizures or change in mental status followup instructions: 'add-on' for temporal artery biopsy on monday with dr. (vascular surgeon). this is a procedure that is performed under local anesthesia. please be available at home, and the vascular surgery office will call you to schedule and do not eat after midnight on sunday night. if you have any questions about the procedure, call the vascular surgery office at . please f/u with neurology/dr. ( ) - appointment at 3:30. ( please call dr. office for further follow-up instructions. please f/u with pcp: call her office on monday to schedule appointment. endocrine appointment: provider: . phone: date/time: 4:30 md Procedure: Spinal tap Incision of lung Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other convulsions Unspecified sleep apnea Other late effects of cerebrovascular disease Hyperosmolality and/or hypernatremia Unspecified disorder of the pituitary gland and its hypothalamic control Presence of cerebrospinal fluid drainage device

allergies: penicillins / sulfonamides attending: chief complaint: seizure major surgical or invasive procedure: none history of present illness: the patient is a 63 yo r-handed woman with a sah in , s/p clipping of acomm aneurysm, vp-shunt placed 2 weeks later, history of siadh, hypothyroidism, hemifacial spasm for many years, htn and hypercholesterolemia who presents to the ed after seizure at home. she was in her usoh and sleeping, when her husband noted around 2.30am that she was smacking with her mouth. he asked her whether she was ok, and she was able to respond. then shortly thereafter she became acutely unresponsive with stiffening up of her body; there was no shaking observed. she did become incontinent and she may have bitten her tongue. the episode lasted minutes. in the ambulance she was able to open her eyes, and in the ed she was able to say a few words. she remained rather somnolent. she did not receive ativan. her husband tells us that he has noticed that she has r-facial twitching and l-hand twitching since a few months. according to a family friend, this activity has actually been present for at least 7-8 years. she was evaluated years ago by dr. , who found this activity to be consistent with hemifacial spasm. she has been drooling from the right side of the mouth. she has also noted to have a decreased in energy level and stamina over the past six months. she does not seem to engage in activities that she once enjoyed (exercise/physical activity). in , the patient had a subarachnoid bleed related to an acomm aneurysm rupture; several weeks later, a shunt was placed for management of hydrocephalus. she had several strokes apparent on imaging at the time that were likely related to vasospasm. since the strokes, she has had significant cognitive and memory problems. left side (both arm and leg) are not as strong as the right side, but she is able to walk unassisted. she can cook and can ambulate by herself according to her husband, but cannot manage certain other activities that require more extensive processing (ie, paying bills, shopping). she has also been noted to be progressively abulic since then. she has been seen in clinic by dr. and . their last visit was more than a year ago. she has never had seizures in the past. she was recently seen at mnt , for "change in mental status" that her husband says was possibly similar to this episode. she had imaging that was unchanged from prior imaging, and an lp significant for rbcs (thought traumatic), but an otherwise benign workup, though right facial twitching was noted. she has had both high and low sodiums in the past few years, mostly low sodium levels recently, including a sodium in the low 120's several days before this admission, on bloodwork ordered by her pcp. ros: per husband: denies any fever, chills, weight loss, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. has been flushy a few days back. past medical history: sah, aneurysm s/p clips, strokes and shunt per hpi hyponatremia, thought to be related to siadh history of hypernatremia hemifacial spasm per hpi hypothermia (chronic) high cholesterol hypothyroidism htn osa information obtained later in the hospitalization from pcp details recent elevated esr to 80s. she has had an elevated esr in the past few years (60 in , and 80 in ). memory loss, cognitive decline social history: she is married and has 3 children. she lives with her husband. she formerly provided child care; she does not work at present. she does not smoke or drink alcohol. family history: her brother died of kidney disease. physical exam: exam vitals: t33.7 hr83 bp135/102 rr14 so2 98% gen: in bed, lethargic, but able to respond heent: mmm, no iceterus neck: no lad; no carotid bruits; neck supple lungs: clear to auscultation bilaterally heart: regular rate and rhythm, normal s1 and s2, no murmurs, gallops and rubs. abdomen: normal bowel sounds, soft, nontender, nondistended extremities: no clubbing, cyanosis, ecchymosis, or edema mental status: opens eyes to voice, inattentive. initially only oriented to name; later oriented to place, month, not year. recognizes husband. attention: not able to do dowbw or fw. memory: registration: 0/3 items; recall 0/3 at 5 min. language: able to repeat "cats dogs". naming intact for body parts. comprehension intact (can point to ceiling); slight dysarthria, some paraphasic errors. writing and not able to test. apraxia: able to wave goodbye, not able to do more difficult tasks. cranial nerves: ii: blinks to threat; pupils equally round 1.5-->1mm. not able to visualize discs iii, iv, vi: horizontal eye movements intact, couldn't get her to look up and down (poor cooperation). v: facial sensation intact to tickle vii: facial movement symmetrical; no facial droop, but drooling from r-mouth viii: responds to voice xii: tongue protrudes in midline motor system: normal bulk. tone in her legs slightly increased, r>l. would twitch around her r-eye and mouth (few secs at the time), mainly when woken up. moves all 4 extremities. good strength in rue, less so in lue (may be baseline). no asymmetry in her le, but rle is exorotated. no formal exam possible. sensory system: responds to tickle and noxious throughout with withdrawal. reflexes: b t br pa pl right 2 2 2 2 1 left 2 2 2 2 1 all rather brisk. grasp reflex present bilaterally toes: downgoing bilaterally. coordination: could not be assessed. gait: could not be assessed. pertinent results: 06:15am cerebrospinal fluid (csf) wbc-0 rbc-5100* polys-90 lymphs-7 monos-3 06:15am cerebrospinal fluid (csf) wbc-0 rbc-3075* polys-100 lymphs-0 monos-0 03:20am tsh-2.8 03:20am free t4-1.8* 03:20am wbc-9.8 rbc-3.71* hgb-11.0* hct-33.9* mcv-91 mch-29.8 mchc-32.6 rdw-16.5* 03:20am neuts-60.1 lymphs-34.0 monos-4.6 eos-1.0 basos-0.2 03:20am anisocyt-1+ macrocyt-1+ 03:20am pt-11.1 ptt-26.4 inr(pt)-0.9 03:20am plt count-417 03:20am urine color-straw appear-clear sp -1.009 03:20am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 03:20am urine rbc-0 wbc-0-2 bacteria-none yeast-none epi-0-2 03:45am glucose-85 lactate-7.8* na+-128* k+-3.9 cl--92* tco2-23 04:28am lactate-3.1* 03:30pm lactate-1.2 na+-129* 03:30pm type-art po2-135* pco2-33* ph-7.35 total co2-19* base xs--6 03:45am ph-7.29* comments-green top 03:20am glucose-82 urea n-11 creat-0.9 sodium-127* potassium-4.2 chloride-90* total co2-18* anion gap-23* 03:20am ck(cpk)-241* f/u on : 448* with negative index 03:20am ck-mb-9 ctropnt-<0.01 ekg: sinus rhythm normal ecg since previous tracing of , sinus bradycardia absent hdl: 101 chol/hd: 2.2 ldlmeas: 124 hba1c: 5.8 recent vit-b12:1567 folate:>20 (). am cortisol: 22.1; random cortisol: 10 other urine chemistry: na:124 osmolal:573 osms:304 other blood chemistry: fsh: 53 lh: 23 prolact: 35 initial ct: non-contrast head ct. findings: the patient is status post bilateral craniotomies. a catheter is seen with its tip located within the third ventricle exiting the skull and continuing inferiorly along the left skull and out of view. numerous surgical clips are seen within the middle cranial fossa causing moderate streak artifact, which limits assessment of this area. allowing for this factor, there is no acute intracranial hemorrhage, shift of normally midline structures or mass effect. a focal area of low density within the right frontal lobe with dilatation of the adjacent ventricle likely reflects encephalomalacia from prior surgery. a similar area of hypodensity is also seen within the left frontoparietal lobe. given the lack of mass effect and preserved cortices, it most likely reflects an old infarct. the sulci and basal cisterns are grossly unremarkable. bilateral periventricular white matter hypodensity is consistent with chronic microvascular ischemia. bone windows demonstrate bilateral craniotomy defects. the visualized paranasal sinuses and mastoid air cells are well aerated. impression: limited evaluation of the middle cranial fossa secondary to artifact from surgical clips. no definite acute intracranial hemorrhage or mass effect. the patient is status post bilateral craniotomy with a left ventriculoperitoneal shunt in place. no evidence of hydrocephalus. these findings were relayed to the ed dashboard at 4:30 a.m. on the date of dictation. repeated head ct: findings: motion artifact limits assessment. again seen is a left-sided ventricular catheter with its tip terminating in the region of the third ventricle. artifacts from multiple aneurysm clips cause significant streak artifact. again seen are encephalomalacic changes in the left frontoparietal and right frontal regions, unchanged. no gross intracranial hemorrhage is identified, although as mentioned, motion and metallic streak artifact prevent full evaluation. the ventricular size is stable. right craniotomy defects are again seen. the incompletely visualized paranasal sinuses demonstrate extensive mucosal thickening within the ethmoid air cells. impression: limited study does not demonstrate any gross intracranial hemorrhage or mass effect. initial cxr to eval shunt patency: pa and lateral upright chest radiograph was compared to the previous film from . the patient is status post vp shunt placement. the heart size is slightly enlarged, unchanged. mediastinum is wider than it was on the previous ct most probably due to the ap and pa projections. the lungs are clear. no pleural effusion or pneumothorax is seen. impression: 1. no evidence of acute cardiopulmonary process. 2. status post vp shunt placement. initial eeg: findings: abnormality #1: throughout the recording the background rhythm was slow and disorganized, typically reaching a hz frequency in any given area. there were frequent bursts of sharp activity in the right frontal area and right hemisphere, appearing to indicate movement or muscle artifact. this correlated with right facial twitching on the video. abnormality #2: there was some additional right frontal intermittent hz slowing. hypervententilation: could not be performed. intermittent photic stimulation: produced no activation of the record. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular rhythm. impression: abnormal eeg due to the slow and disorganized background and due to the intermittent right frontal slowing. the first abnormality signifies a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. the right frontal slowing is concern for a focal subcortical abnormality in the right hemisphere though its nature cannot be specified by the recording. there were no clearly epileptiformfeatures seen in association with the facial jerking or at other times. cta head/neck to eval for vasc anomaly/aneurysm: findings: study is of limited diagnostic utility secondary to technical difficulties and pooling of contrast material within the left venous system including the left subclavian vein and spinal epidural plexus. this finding raises concern for possible occlusion within the distal left subclavian vein/brachiocephalic trunk. there is resultant very faint opacification of the carotid arteries and vertebrobasilar circulation. the circle of is poorly visualized. images of the brain again demonstrate a left-sided ventricular catheter with its tip terminating in the region of the third ventricle. artifacts from multiple aneurysmal clips cause significant streak artifact. the ventricular size is stable. areas of encephalomalacic change within the left frontoparietal and right frontal regions are unchanged. right craniotomy defect is again seen. there is extensive mucosal thickening within the visualized ethmoid air cells. large bilateral pleural effusions are identified at the lung apices. impression: 1. limited evaluation of the vascular system secondary to clip artifacts and pooling of contrast within the left subclavian vein and spinal epidural venous plexus. given these findings, there is concern for possible occlusion/stenosis within the distal left subclavian/brachiocephalic vein. was this the site of prior central line placement? clinical correlation recommended. 2. no definite acute intracranial hemorrhage or mass effect. these findings were discussed with dr. at 3 p.m. on . mri/a brain: technique: multiplanar t1- and t2-weighted imaging of the brain. comparison is made with a recent head ct from and a brain mr . findings: there is a t2 signal hyperintensity in the right frontal and left parietal lobes consistent with postoperative encephalomalacia. there is a left frontal ventriculostomy shunt catheter which terminates in the third ventricle. compared to the previous exam from , there is no new mass effect. there is considerable metallic artifact emanating from the suprasellar cistern and right middle cerebral artery region. allowing for the limitation due to the artifact, the diffusion-weighted imaging is normal. impression: somewhat limited exam due to metallic artifact. no significant interval changes compared to a previous head ct from . no evidence of an acute infarct. mra of the brain technique: 3d time of flight of the circle of is performed. findings: there is limitation of the exam due to extensive metallic artifact emanating from the aneurysm clips. there is flow within the carotid arteries and vertebrobasilar circulation. the circle of is not directly visualized. impression: limited exam. no evidence of major vascular occlusion. telemetry to look for sz, eval hemifacial spasm vs sz: day #1 impression: this 24-hour eeg telemetry without video demonstrates a background pattern most consistent with moderate to severe encephalopathy. there are two brief periods of what appear to be very sharp and slow wave 2 hz activity which seem more focussed over the left temporal region as well as right frontal region more briefly. this could represent motion artifact from the patient's known clinical condition and hemifacial spasm or truly epileptiform in nature. it is difficult to discern this without video correlation at this time. we will continue to monitor to observe for further electrographic changes. both events were self-limited lasting seconds and without generalization to suggest seizure. no ongoing or prolonged rhythmic activity was seen. day #2 impression: this 24-hour eeg telemetry captured no clear electrographic seizures. a moderate encephalopathy is evident based on this recording. there are some sharp and slow wave morphologies seen over the left temporal as well as both frontal regions which could represent muscle artifact or potential epileptiform activity; however, no clear evolution of the event to seizure occurs. no clear waking and sleep cycles were seen during this recording. day #3 impression: this 24-hour eeg/telemetry captured multiple pushbutton events. electrographic and clinically no clear evidence for seizure was seen. the background rhythms remained slow and disorganized for the recording. no clear cycling through normal stages of sleep was seen. brief hospital course: 63 yo right-handed woman with history subarachnoid hemorrhage associated with acomm aneurysm in s/p vp shunt, associated infarcts (right frontal and left parietal), hyponatremia, hypothyroidism, hypertension, high cholesterol and obstructive sleep apnea who presented following an episode of unresponsiveness with stiffening, incontinence and tongue-biting thought likely related to seizure. she also has a history of hemifacial spasm, an episode of which occurred shortly before the seizure, raising the possibility that the facial movement in fact represented focal motor seizure activity. neurology: she was admitted to the neurology service on the floor for further workup. on the first day of hospitalization, she was found to be markedly hyponatremic (na 127); history later obtained from daughter and husband suggested that she had been given two liters of water to drink after the sodium had been drawn, and that perhaps it was even lower. on lp, csf was significant for rbcs 5000-> 3000, suspicious for traumatic tap. initial head ct showed a patent shunt system (confirmed with cxr), and no new signs of bleeding. she was loaded with dilantin in the er prior to transfer to the neurology floor. on the first hospital day, following the dilantin load, she became unresponsive again, with hypotension and hypothermia. as her lactate had been elevated as well, she was transferred to the neurology icu for further workup and suspicion of sepsis. she was monitored overnight, and had improved blood pressure but persistent hypothermia. further history obtained suggested that she has had chronic problems with hypothermia in the past. once she stabilized (overnight), she was transferred back to the floor, though she continued to be markedly somnolent (difficult to arouse) on exam, with small, minimally reactive pupils, not following commands, but mumbling few words in her native language. for the possibility that dilantin had further suppressed her mental status, and possibly even caused the hypotensive episode, the dilantin was discontinued and keppra was started for seizure prophylaxis. she continued to have facial twitching on the floor. eeg did not show any seizure activity, with no epileptiform correlate to her facial twitching, suggesting that the diagnosis of hemifacial spasm had been accurate. to confirm further that this was not associated with seizure, and to rule out subclinical seizures once her dilantin had begun to be weaned, she was monitored on ltm for several days. there was no evidence of seizure activity. she was continued on a low dose of keppra (500 mg ) for seizure prophylaxis, despite negative eegs, as she had presented with clinical diagnosis of first time seizure, and had imaging suggestive of seizure focus. a discussion was held with her family about whether to continue the seizure medication, as it was considered by the team to be safe to discontinue it; for peace of mind, and with the protection it might afford the patient from having a similar episode in the future, and considering the abnormalities on her head imaging, the keppra was continued. this could be continued for several months, at which point, if she has no further seizure episodes, it could be discontinued. this discussion will be held between her family and dr. , her epileptologist, as an outpatient. mri/a was performed to evaluate her past infarcts, and for a possible new structural lesion to explain the seizure. mri showed evolution of her right frontal and left parietal infarcts. it was difficult to visualize the circle of due to artifact from the clip, though poor filling of the right aca and mca was noted. compared to prior studies, she seemed to have progressive occlusion of the ica, mca and aca on the right, perhaps responsible for evolving right sided infarct, which had increased in size since prior exams. the aca territory infarct (mesial frontal on the right) was thought to potentially be responsible for some of the symptoms of apathy, and signs of abulia on exam. this was also considered to a potential focus for seizure activity. to optimize further stroke prevention, fasting lipid panel was checked and demonstrated elevated hdl of 101, ldl 124. hba1c was within goal. no further intervention was made. cta was also performed to better visualize the vasculature, but the study (read one week after it was performed) was technically limited due to pooling of the blood in the epidural venous plexus and therefore no available imaging of the arterial system. ct of the head confirmed no new bleed. her exam improved significantly, and by hospital day five, she had returned to baseline. she was feeling well, with some persistent cognitive difficulties as well as disorientation (particularly to place). she was ambulating and talking without difficulty. neuroendocrine: as she had known hypothyroidism, once sepsis was ruled out, hypothermia was initially thought possibly related to this disorder; however, thyroid studies confirmed that she was on the appropriate dose of medications (tsh was normal and free t4 was slightly elevated, if anything). random cortisol was checked, as was morning cortisol levels - both were normal. endocrinology was consulted regarding possible dysfunction of the pituitary-hypothalamic axis. since her subarachnoid hemorrhage in , the patient has had intermittent episodes of hypothermia that are not related to ambient temperature. she has also had intermittent low blood pressures. her urine culture was negative and blood cultures are pending (although this is unlikely due to infection). this was thought by both neurology and endocrine potentially related to hypothalamic dysfunction secondary to her sah in . unfortunately, her aneurysm clips produce artifact on ct and mr that make imaging of the hypothalamus difficult. upon recommendation, fsh, lh, igf-1, prl were checked. fsh was appropriately elevated for a post-menopausal woman. her lh was normal. her prolactin level was elevated at 35 ng/ml (normal ng/ml). the patient is scheduled for an outpatient appointment with endocrinology on . fluids/electrolytes: initially, the patient's sodium was low; this was followed over the course of several days it normalized. towards the end of her hospital stay, she actually became hypernatremic, with sodium as high as 152. her free water deficit was replaced via iv fluids. urine lytes were sent and revealed excretion of sodium in the urine, but also high osmolality. on the day of discharge, her serum sodium was 146; endocrine recommended stopping iv fluids and pushing for po intake instead. vascular: on hospital day six, the primary care physician the team about labs that were drawn prior to her hospital stay, significant for an elevated esr in the 80s; she suggested initiating workup for temporal arteritis. the patient's esr and crp were repeated and esr was elevated at 97; crp was elevated at 12.1. on exam, her left temporal artery is tender to palpation, slightly enlarged in comparison with the right temporal artery. though she did not endorse any symptoms of temporal arteritis (temporal headaches, visual changes, jaw claudication), her family and the neurology team felt that she might not volunteer these symptoms. she was seen by vascular surgery for evaluation for a temporal artery biopsy. as this could not be done immediately, this procedure will be done on , as an outpatient. pathology results should be made available to dr. as well as her primary care physician. gi: initially, her abdomen was distended. kub revealed stool and gas, and after stool softeners and increased mobility, abdominal exam improved. dispo: she was seen by physical therapy, who recommended discharge to a skilled nursing facility. however, the patient has not done well in rehab centers in the past. she has excellent support at home. thus, he was discharged home with services. exam at discharge was improved greatly over admission, with the patient awake, smiling, and able to converse in english. on entering the room the patient was noted to be walking back to her bed from the bathroom without assistance. left temporal artery remained enlarged and tender compared with the right. otherwise, general exam was unremarkable. the patient did not remember where she was initially, but when asked later, could recall it was . speech was fluent with no errors, and there remained chronic mild weakness of the left arm. medications on admission: -norvasc 5mg daily -levothyroxine 50mcg daily -lipitor 10mg daily discharge medications: 1. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. norvasc 10 mg tablet sig: one (1) tablet po once a day: or as prior. discharge disposition: home with service facility: homecare discharge diagnosis: seizure hypothalamic dysfunction impaired thirst response, with alternating hypo- and hypernatremia based on fluid intake discharge condition: improved - back to baseline. discharge instructions: please md or return to ed if you experience new seizures or change in mental status followup instructions: 'add-on' for temporal artery biopsy on with dr. (vascular surgeon). this is a procedure that is performed under local anesthesia. please be available at home, and the vascular surgery office will call you to schedule and do not eat after midnight on sunday night. if you have any questions about the procedure, call the vascular surgery office at . please f/u with neurology/dr. ( ) - appointment at 3:30. ( please call dr. office for further follow-up instructions. please f/u with pcp: call her office on to schedule appointment. endocrine appointment: provider: . phone: date/time: 4:30 Procedure: Spinal tap Incision of lung Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other convulsions Unspecified sleep apnea Other late effects of cerebrovascular disease Hyperosmolality and/or hypernatremia Unspecified disorder of the pituitary gland and its hypothalamic control Presence of cerebrospinal fluid drainage device

history of present illness: baby girl #2 is the 1870-g product of a 34-2/7 week gestation, born to a 19-year-old gravida 3, para 0 (now 2), therapeutic abortion times 2, hispanic female. prenatal screens: o negative, ab negative (received rhogam), rubella immune, rapid plasma reagin nonreactive, hepatitis b surface antigen negative, group b strep positive, chlamydia negative, gc negative. pregnancy with spontaneous twins. this pregnancy was further complicated by carbon monoxide poisoning (worked in a meat factory) in . treated with oxygen and a 1-week course of prednisone. mother also experienced premature contractions at 32-6/7 weeks gestational. she was treated with terbutaline. there was no change in her examination and was discharged home with medications. infant also complicated with discordant growth of estimated fetal weights of 1490 g and 1755 g on . mother presented with spontaneous rupture of membranes on in preterm labor. she received penicillin, and a cesarean section was performed secondary to breech/vertex positioning. this infant was breech. she received blow by oxygen and suctioning, and apgar scores were assigned at 7 and 8 and 1 and 5 minutes, respectively. physical examination on presentation: weight was 1870 g (approximately 50th percentile), length was 43 cm (50th percentile), and head circumference was 38.5 cm (50th percentile). anterior fontanel was soft and flat, nondysmorphic intact palate. normal red reflex bilaterally. clear breath sounds. no murmurs. soft abdomen. no hepatosplenomegaly. a 3-vessel cord. normal female genitalia. patent anus. no hip click. no sacral dimple. active. normal tone. hospital course by system: 1. respiratory: has remained on room air throughout hospital course. had one episode of apnea and desaturation within the first 48 hours of life and has had no further issues. 2. cardiovascular: has had no issues. 3. fluids/electrolytes/nutrition: birth weight was 1870 g. she was initially started on 80 cc/kg per day of d-10-w. enteral feedings were initiated on day of life one, and she achieved full enteral feedings by day of life four. she is currently ad lib feeding breast milk 24-calorie concentrated with enfamil powder or enfamil 24-calorie. her discharge weight was 2070 g. 4. gastrointestinal: her peak bilirubin was on day of life four at 7/0.3, and she has not required any treatment for her hyperbilirubinemia. 5. hematology: hematocrit on admission was 55.8. the infant has not required any blood transfusions during her hospital stay. 6. infectious disease: a complete blood count and blood culture were obtained on admission. complete blood count was benign. blood culture remained negative at 48 hours. with 48-hour negative blood culture, ampicillin and gentamicin were discontinued. the infant has had no further issues with sepsis during this hospital course. 7. sensory: audiology; an automated auditory brain stem response was performed, and the infant passed both ears. 8. psychosocial: a social worker was involved with the family and can be contact at . condition at discharge: condition on discharge was stable. discharge disposition: to home. pediatrician: name of primary pediatrician is dr. at . the telephone number there is , fax - . care recommendations: 1. feeds at discharge: continue ad lib enteral feeding of breast milk 24-calorie, concentrated with enfamil powder or enfamil 24-calorie to support nutritional needs and growth. 2. medications: continue fer-in- supplementation of 2 mg/kg per day to support anemia of prematurity. 3. car seat position screening was performed, and the infant passed. 4. state newborn screens have been sent per protocol and have been within normal limits. immunizations received: the infant received hepatitis b vaccine on . discharge diagnoses: 1. preterm twin #2 born at 34-2/7 weeks gestation; now 36-1/7 weeks corrected. 2. status post rule out sepsis. , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Audiological evaluation Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 1,750-1,999 grams

history of present illness: baby boy was born at 41 and 4/7 weeks gestation and admitted to the nicu for monitoring following neonatal cardiorespiratory depression. maternal history: mom is a 25-year-old g1, p0, now 1 woman with prenatal screens: blood type o positive, dat negative, hbsag negative, rpr nonreactive, rubella nonimmune, gbs positive. antenatal history: was for an estimated gestational age of 41 and 4/7 weeks at delivery. this pregnancy was uncomplicated. it was spontaneous vaginal delivery under epidural anesthesia. rupture of membranes occurred 15 hours prior to delivery and yielded clear amniotic fluid. there was no interpartum fever or other clinical evidence of chorioamnionitis. interpartum antibacterial prophylaxis was administered beginning 19 hours prior to delivery. the neonatal course: the nicu team was not requested prior to delivery. the infant emerged apneic and hypotonic. he received tactile stimulation and bag mask manual ventilation. heart rate was initially less than 100 by report but responded to ventilation. the nicu team arrived at approximately 4 to 5 minutes of age. the infant had onset of spontaneous respirations at 5 minutes of age followed by gradual resolution of hypotonia. apgar scores were 3 at 1 minute, 5 at 5 minutes and 7 at 10 minutes. the infant was noted to have moderate subcostal retractions at 10 minutes and was transferred to the nicu for monitoring of neonatal transition. physical examination: birth weight of 4210 grams which is greater than 90th percentile; length 53.5 cm which is greater than 90th percentile; head circumference 37 cm which is greater than 90th percentile. heent: anterior fontanel soft and flat, nondysmorphic, occipital caput. red reflex was deferred. no nasal flaring. chest: mild to moderate intercostal retractions, resolving over the first 30 minutes of age. good bilateral breath sounds. no adventitious sounds. cardiovascular: well perfused. normal rate and rhythm. femoral pulses normal. normal s1 and s2. no murmurs. abdomen: soft, nondistended. no organomegaly. no masses. bowel sounds active. anus appears patent. three-vessel umbilical cord. genitourinary: normal penis. testes descended bilaterally. cns: active, alert, responds to stimuli. tone was normal to low, and symmetric. moves all extremities well. suck, root, gag were intact. no facial asymmetry. skin: normal. musculoskeletal: normal spine, limbs, hips and clavicles. summary of hospital course by systems: respiratory: the infant required nasal cannula oxygen initially in the nicu at 100 cc flow of 100% nasal cannula. the infant weaned to room air on day 2 of life and has remained stable on room air since 6 p.m. on . he has had no spells and required no methylxanthine therapy.occasionally he had mild desaturation of feeding but did not require intervention. cardiovascular: the infant had a hemodynamically stable status throughout the hospitalization in the nicu with no murmurs and stable blood pressures and heart rate. fluids, electrolytes and nutrition: the infant never required iv fluids, ad lib po feedings were initiated on the newborn day. the infant has been ad lib po feeding and really has started taking off with feeds on . he is po feeding very well at this time voiding and stooling normally. he has had no electrolytes measured. gastrointestinal: there had been no gi issues. bilirubin was sent on day 3 of life and the result is 1.2 hematology: no blood typing has been done on this infant. initial cbc was done on admission and hematocrit was 47.4 with a platelet count of 356. there had been no further blood sampling done. infectious disease: due to the delayed transition and depression at birth, cbc and blood culture were done on admission to the nicu. the blood culture remained negative. cbc was benign and not left shifted. antibiotics were never given. neurologic: the infant has maintained a normal neurologic examination for gestational age. sensory: audiology - hearing screen was performed automated auditory brain stem responses and the results are ..... psychosocial: social worker has been involved with the family. there are no active ongoing psychosocial issues at this time. if the social worker needs to be reached, she can be reached at . condition on discharge: good. discharge disposition: home to the parents. parents are spanish speaking only. name of primary pediatrician: dr. from . telephone no.: . care recommendations: 1. feedings: ad lib po feedings of breast feeding or similac 20 with iron. 2. medications: none. 3. no car seat position screening was done on this infant. 4. state newborn screen was done on day of life 3 and results are pending. 5. immunizations received: 6. immunizations recommended: 7. 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 gestation. 2. born between 32 and 35 weeks gestation with two of the following: 8. daycare during the rsv season. 9. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 10. with chronic lung disease. 1. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. follow up appointment is recommended with the pediatrician within 48 hours of discharge from the nicu. discharge diagnoses: 1. delayed transition to extrauterine life. 2. sepsis ruled out. , Procedure: Prophylactic administration of vaccine against other diseases Circumcision Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other respiratory problems after birth Routine or ritual circumcision Post-term infant

history of present illness: the patient is a 58-year-old male with no known history of coronary artery disease, reported having left shoulder pain and heartburn about 2-3 times per week over the past 2 months, which appeared at rest and with exertion. the patient, when presenting at his pcp during his last routine examination had an ekg, which showed st-elevations in v1, v2 and lead , -depressions in leads ii, iii and avf. he was admitted to an outside hospital with elevated troponin and then was transferred to today on and underwent a cardiac catheterization, which showed 3-vessel disease. the patient currently reports minimal chest discomfort and minimal shortness of breath. past medical history: the patient's only problem is that he had a left arm birth defect or birth injury. otherwise, his past medical history is unremarkable. past surgical history: none. allergies: no known drug allergies. medications at home: 1. multivitamin once a day. 2. aspirin 81 mg every other day. social history: he lives alone in . he works fulltime with computers. he is very independent. he has a positive tobacco history, less than 25-year-pack history. his last cigarette was last week. he drinks 2-3 alcohol beverages per week. family history: he has a positive family history. his dad died of a myocardial infarction at the age of 80. review of systems: general: weight stable, appetite good. he sleeps well. skin: he says he gets heat rash back during summer. he wears glasses. no history of glaucoma, cataracts or epistaxis or migraines. respiratory: he is very short of breath. history of bronchitis 2 years ago, otherwise, unremarkable. cv: positive angina without palpitations. no claudication. gi: possible questionable heartburn in the last couple of weeks. gu: denies any bph or dysuria or frequency. neurologic: denies cva, tia or seizure history. musculoskeletal: denies any history of fractures or arthritis. hematologic: denies any bleeding disorders or anemia. psychiatric: denies any depression or anxiety. physical examination: the patient is 5 feet 10 inches and his weight is 148 lbs. vital signs: temperature 97.1, blood pressure 120/66, normal sinus rhythm 58, respiratory rate of 20, and 99 percent oxygen saturation on room air. the patient appeared, lying flat in bed, in no acute distress. neurologically, he was alert and oriented x 3 and appropriately following commands and questions. neurologically, he was also grossly intact. respiratory: clear to auscultation. his heart was regular rate and rhythm, no clicks, rubs, murmurs or gallops. his abdomen was soft, nontender, nondistended, positive bowel sounds and it was flat. his extremities were warm and well perfused. no clubbing, cyanosis or edema. no varicosities besides some small superficial veins, which appeared on the right leg more than the left leg. his right groin catheterization site had a dressing on it and appeared intact without any hematoma forming. his pulses were as follows: his radial pulses were 2 plus on the right side, 1 plus on the left side, dp 2 plus bilaterally, pt 2 plus bilaterally and femoral pulses 1 plus bilaterally. preoperative laboratory data: his white blood count was 6.3, hematocrit 39.4, platelets 27, pt 12.6, ptt 31.9 and inr 1. sodium 133, potassium 3.9, chloride 101, bicarbonate 23, bun 11, creatinine 0.8, glucose 88, alt 58, ast 84, alkaline phosphatase 74, total bilirubin 0.5, and albumin 3.5. his chest x-ray on showed an elevation of the left hemidiaphragm. there is increased possible prominence of the interstitial markings, which raise the possibility of background emphysema. his cardiac catheterization report is as follows: his ejection fraction is 40 percent, his lmca showed no significant stenosis, his lad is subtotal mid-stenosis, his origin om1 serial 70 percent mid-lcx, rca is mid 80 percent before acute marginal that supplies to pda and lad and totally occluded mid-rca. his ekg showed a rate of 64 in sinus rhythm, nonspecific right ventricular conduction delay, or incomplete right bundle branch block pattern, modest nonspecific t-wave changes and rightward axis. his ua was negative. hospital course: he was prepped for surgery. the patient was brought to the operating room on , which is his second day of hospital admission. he underwent a coronary artery bypass graft x 4. his grafts were as follows: lima to lad, saphenous vein graft to pda, saphenous vein graft to om1 and saphenous vein graft to om2. procedure was performed by attending surgeon dr. . cardiopulmonary bypass time was 91 minutes, cross-clamp time was 73 minutes. the patient tolerated the procedure well. he had a heart rate of 81 in normal sinus rhythm, mean arterial pressure of 66, cvp of 9, pa diastolic of 11, pa mean of 18. he was transferred to csru with epinephrine drip of 0.015 mcg/kg/minute, a neo-synephrine drip of 0.5 mcg/kg/minute, and a propofol drip of 30 mcg/kg/minute. on postoperative day 1, the patient was extubated successfully. he was hemodynamically stable. blood pressure of 101/52, 89 normal sinus rhythm and 99.4 with a t-max of 100.4, cardiac index of 2.3, pa pressures 33/10. he was currently on a neo-synephrine drip of 1.5. the plan was to wean his neo-synephrine, discontinue his swan and discontinue his chest tubes. his physical examination was unremarkable. on postoperative day 2, the patient had a rhythm of sinus tachycardia in 140 range beats per minute with exertion. otherwise, he appeared doing well and he was hemodynamically stable. the plan was to give him a dose of lopressor now and to continue monitoring his heart rate with an ekg and to get the patient out of bed and ambulate as much as possible considering his increasing heart rate when he does so and continue pt and ir. on postoperative day 3, the patient's heart rate was 98. on physical examination, he appeared doing well. his lungs were clear. his heart was at regular rate and rhythm. his epicardial pacing wires were removed. the patient's hematocrit was decreased from 24.9 on to 21 today, which is . the plan was to give the patient 2 units of packed red blood cells, also increase his lopressor to 37.5 and the patient was also scheduled to receive lasix. on , which is, postoperative day 4, the patient's hematocrit was rechecked. it was now 28.9 following 2 units he received yesterday of packed red blood cells. the patient stated that he was feeling fine and he was planned for discharge. discharge status: the patient was discharged to home with services in good condition. discharge diagnoses: coronary artery disease. status post coronary artery bypass graft x 4. follow up: the patient was recommended to follow up with the following doctors: dr. in weeks, dr. in weeks and dr. in 4 weeks. medications: 1. colace 100 mg p.o. b.i.d. 2. aspirin 325 mg p.o. q.d. 3. percocet 5-325 mg 1-2 tablets p.o. q.4-6h. p.r.n. 4. lopressor 50 mg p.o. b.i.d. 5. captopril 12.5 mg; patient told to take tablet p.o. t.i.d. 6. lasix 20 mg p.o. b.i.d. 7. potassium chloride 10 meq take 2 capsules p.o. b.i.d. , m.d. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome

allergies: iodine attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 48 yom with pmh of hypertension, hyperlipidemia presents with chest pain radiating across left chest to back, arm, shoulder, with diaphoresis, shortness of breath and pain on inspiration, lightheadedness, and palpitations. pain began at 1200 yesterday when patient was 15 minutes in to his usual walk. describes pain as starting substernally. the patient stopped to rest and the pain subsided but did not end completely. he took maalox with no relief. he returned home on bus and tried to eat dinner later that night but had no appetite. at roughly 2300 he described new onset of the pain more intensly while at rest. pain continued as he was lying down, along with sweating, muscle spasms, palpitations, shortness of breath. pain was in intensity and radiated to the left shoulder, arm, and back. patient went to hospital next to where he lives and had an ekg, which demonstrated st changes, and was immediately transferred to for cardiac catheterization with aspirin. his pain improved with nitroglycerin but was not fully relieved. the patient states that he underwent a work-up for chest pain at the va roughly 2 years ago and was told that it was gi-related. he had exercise stress test at that time, but does not know result. he has not had chest pain since then. at baseline, his main activity is walking, being limited by history of back injury at previous job. he is unable to climb stairs or run. past medical history: htn hyperlipidemia seasonal allergies back surgeries: discectomy x 2 social history: lives at soldiers home, retirement community for disabled vets not married. works as writer. minimal etoh, nonsmoking, no illicit drugs. family history: htn, cabg in father at age of 70 physical exam: vitals: t 98.7 bp 129/78 hr 62 r 18 sat 99% ra pe: g: nad, conversant heent: clear op, mmm neck: supple, no lad, jvd not measured as patient post cath lungs: clear bilaterally, no w/r/c cardiac: rr, nl rate. nl s1s2. no murmurs abd: soft, nd. nl bs. no hsm. mild tenderness at ruq. ext: no edema. 2+ dp pulses bl. neuro: a&ox3. appropriate. cn 2-12 grossly intact. pertinent results: 02:45am wbc-9.9 rbc-4.84 hgb-14.1 hct-39.9* mcv-82 mch-29.1 mchc-35.3* rdw-13.2 02:45am calcium-9.9 magnesium-2.1 02:45am glucose-138* urea n-23* creat-1.7* sodium-136 potassium-4.2 chloride-96 total co2-26 anion gap-18 02:45am ctropnt-2.84* 02:45am ck(cpk)-1215* 02:45am ck-mb-44* mb indx-3.6 06:43am ck-mb-35* mb indx-3.5 01:35pm ck-mb-24* mb indx-3.2 01:35pm ck(cpk)-740* 07:56pm ck-mb-15* mb indx-2.9 ctropnt-1.71* 07:56pm ck(cpk)-514* 02:45am blood ck-mb-44* mb indx-3.6 02:45am blood ctropnt-2.84* 06:43am blood ck-mb-35* mb indx-3.5 01:35pm blood ck-mb-24* mb indx-3.2 07:56pm blood ck-mb-15* mb indx-2.9 ctropnt-1.71* 05:42am blood ck-mb-10 mb indx-2.9 05:42am blood pt-12.5 ptt-51.8* inr(pt)-1.1 05:25pm blood ptt-57.3* 06:40am blood pt-12.6 ptt-68.5* inr(pt)-1.1 10:25am blood pt-12.5 ptt-53.6* inr(pt)-1.1 * cardiac catheterization : comments: 1. selective coronary angiography of this right dominant system demonstrated a fresh thrombus in the distal portion of the left main coronary artery extending into the ostium of the lad. in addition to the 90-95% proximal occlusion, the distal portion of the lad demostrated embolized clot extending out to the apex. the rca was a large dominant vessel with no flow limiting lesions. the lcx was a large nondominant vessel without any angiographic evidence of any significant coronary artery disease. 2. lv ventriculography was deferred. 3. limited resting hemodynamics demonstrated a cardiac output/index via the fick method of 4.5 / 2.0 respectively. the left heart filling pressures were mildly elevated with a mean pcwp of 16 mmhg. 4. successful thrombus extraction from the proximal lad using the guide with complete clearence of it. the final angiogram showed timi iii flow with no dissection and no embolization. final diagnosis: 1. one vessel coronary artery disease. 2. anterior st elevation myocardial infarction 3. successful thrombus extraction from the proximal lad * echo : conclusions: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with akinesis of the distal of the left ventricle and the true apex. the rest of the walls exhibit compensatory hyperkinesis. no definite thrombus is seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic root, ascending aorta and aortic arch are mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. impression: symmetric left ventricular hypertrophy with mild regional systolic dysfunction. mildly dilated thoracic aorta. * ekg pre intervention sinus rhythm anterolateral myocardial infarct with st-t wave configuration consistent with acute/recent/in evolution process. consider also inferior myocardial infarction, age indeterminate no previous tracing available for comparison * femoral vascular ultrasound : findings: in the right groin superficial to the artery and vein, note is made of an area of low echogenicity with higher echogenic material within it. this is a well-circumscribed area and measures 1 x 1 x 1.36 cm. there is no connection with the artery or the vein. there is no flow within this lesion. it is located away from both vessels. it most likely represents a small lymph node. no evidence of any pseudoaneurysm. conclusion: small lymph node identified. no definite pseudoaneurysm. brief hospital course: chest pain: the patient presented with classic coronary chest pain, elevated enzymes, and st segment elevations in leads i, ii, avl, v2-v6. he reported an allergy to iodine and so on presentation was pretreated with methylprednisone 100mg, benadryl 50 mg and famotidine 40 mg in preparation for cath. he also began heparin gtt, 600 mg, and morphine 2 mg iv. during cath procedure he received integrillin and heparin boluses. as noted in the cath report enclosed, the patient had a large clot removed from his lad, and the proximal end of the clot overlapped partially with the take-off point of the left circumflex artery. no stenting was required given the good result after clot extraction. notably there was distal clot in the lad seen at the apex, which was bolused directly with integrillin but could not be further treated. following the procedure the patient developed a small hematoma at the groin catheter site which was non-expanding. his hematocrit was stable on discharge and he had a doppler study that showed no pseudoaneurysm. * coronary artery disease: the patient was discharged on aspirin 325 mg qd, statin 80 mg qd. although the patient had been on a beta blocker prior to admission, his pulse was in the 50s-low 60s throughout his post cath period. a beta blocker was not started for this reason. an ace inhibitor, lisinopril at 5 mg, was started. it is noted that the patient was on a much higher dose of ace inhibitor as an outpatient, but in general his systolic blood pressure has ranged from 110s to 130s while in the hospital. his dose of lisinopril or an equivalent drug could be titrated upward in the future as the blood pressure allows. all of the patient's other hypertension medications were discontinued: atenolol, famlodipine, hctz, fosinopril. it is noted that these medications may become necessary in the future. the patient was also educated on the importance of low salt diet in controlling his hypertension. * cardiac pump: on the day following his cardiac catheterization the patient had an echocardiogram to assess his left heart function. his ejection fraction was found to be 45% and he had akinesis of the apex of his heart. no left ventricular thrombus was seen, but in order to prevent a clot forming, the patient was started on coumadin and heparin gtt. he was discharged on lovenox 100 mg sq every 12 hours and his physicians at the soldiers' home were informed about the need to help with administering these shots and measuring his inr. he was discharged on 5 mg coumadin, but his inr was not therapeutic at discharge. his therapeutic goal inr is 2.0 to 2.5. * also, the patient should have a repeat echo in six weeks or more to see if he has regained some of his heart function. * medications on admission: atenolol 100 famlodipine 10 fosinopril 40 loratidine hctz 25 statin 10 mg percocet 2 tabs every 4 hours for back pain discharge medications: 1. clopidogrel 75 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. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: two (2) tablet po q800, q1200, q1600, q2000 () as needed for pain. 7. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*10 syringes* refills:*2* 8. outpatient work pt and inr laboratory check. 9. outpatient work pt and inr check 10. outpatient work pt and inr check discharge disposition: extended care facility: soldiers home in - discharge diagnosis: 1. myocardial infarction 2. left ventricular akinesis 3. hypertension discharge condition: stable, ambulating, tolerating po. small stable hematoma in right groin. discharge instructions: you had a cardiac catheterization that revealed a blockage to one of your coronary arteries, which was treated. you should not lift anything greater than 10 pounds for the next two weeks to allow complete healing of the catheter site in your groin. if you continue to feel pain at this site several days after going home, or if you feel numbness, tingling or pain in your right leg that is different from any pain you had before, you should contact your physician. should walk frequently and remain active but avoid strenuous activity. * in order to prevent a clot forming in your heart, you have been placed on blood thinners. you should take coumadin (also called warfarin) for the next six months. you have already been started on coumadin, but it will take a few days to reach a therapeutic level. in order to make sure it is therapeutic, you should have your "inr" level checked in two days after you go home (saturday - if this can't be done, have it checked friday, then monday). this is performed by a blood draw at a or health clinic. you should have your inr checked every other day thereafter until you are on the correct standard dose. for the time that you are taking coumadin, you should not eat green leafy vegetables such as broccoli, spinach and collard greens, because this will interfere with the medication. * while you are taking coumadin, you will be more prone to bruising. * in order to prevent against blood clots in the short term, you must use lovenox shots. you must use these shots until your inr level and coumadin level are adequate (inr 2-2.5). you will administer the shots to yourself twice a day. you may get assistance in these shots from the health clinic at the . for the first day, a nurse from the should assist you performing the shots. * your primary care physician, . , has been contact and has been faxed the report from your hospital stay. he has requested that you schedule an appointment with him in weeks time. between now and then, it is very important that you follow up with the health care clinic at . * you should have an echocardiogram of your heart performed in six weeks time to assess your heart function. * you have had a change in your medication regimen. in addition to starting coumadin and lovenox, you should also take: 1) lisinopril 5 mg once a day. 2) your other blood pressure medications should be stopped until you meet with your primary care physician. will make the decision on whether to restart them. the medications that you should stop until further notice are fosinopril, famlodipine, hydrochlorothiazide, and atenolol. 3) you may continue to take loratidine for allergies and percocet for pain. 4) your statin dose has been increased. you have a prescription for atorvastatin 80 mg every day. 5) you should take an aspirin 81 mg every day. 6) you have been started on a new medication, named 75 mg, to be taken once a day. * it is very likely that a high-salt diet has been part of the reason for your high blood pressure. salt is contained in high amounts in many restaurant foods (including chinese food) and in pre-prepared foods. you have been provided with a list of foods that are high in salt and should be avoided, such as canned meats, soups, ketchup and many other foods. * please come to the nearest emergency department if you develop chest pain, shortness of breath or any other complaints. followup instructions: you should go to the 'treatment room' at the as soon as you arrive home from the hospital. they will help you with your lovenox shot. * on saturday (or friday if the is closed saturday), you should have your inr level checked at the and continue checking it every other day. your target inr is 2.0-2.5. you have been given prescriptions to get this test. * you should visit with the doctors at the clinic on a regular basis to discuss your case and continue your care. * you should call your primary care physician, . , tomorrow at to discuss your recent hospitalization. you have an appointment with dr. scheduled for . dr. should help you to schedule an appointment with a cardiologist. * you should have an echocardiogram performed at the va in six weeks time from now. this is important to monitor your heart function. dr. will help you to schedule this echocardiogram. * Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Angiocardiography of right heart structures Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Other and unspecified hyperlipidemia

allergies: sulfa (sulfonamides) / shellfish attending: chief complaint: purpura, fever, "flu-like" symptoms major surgical or invasive procedure: oral intubation central line placement : placement of 8.0 portex tracheostomy tube, placement of #19 french ponsky percutaneous endoscopic gastrostomy tube, flexible bronchoscopy. : picc line placement : right foot incision and drainage. : bilateral incision and drainage with debridement of both feet. history of present illness: the patient is a 21 year old african-american male with no significant past medical history who presented to the ed on after being transferred from hospital. the patient had presented to via his family on at 5:30 pm with the chief complaint of generalized body aches. he complained of left knee pain after recently suffered an injury to his left knee (scraped) while playing basketball for which he was evaluated for at an osh. he also complained of nausea, vomiting, diarrhea, and headache. . at , the patient was noted to have a temperature of 103, p 122, bp 128/69. he was sat'ing 99% on ra. the patient was found to have a left swollen knee and purpura fulminans. he was given ceftriaxone 2 gm iv (split dose), doxycycline 100 mg po, vancomycin 1 gm iv. he also received an estimated 3.5 liters. . the patient's abg at at 12:40 am was as follows: . 7.33/27/103/13.6 . his chem7 at was notable for a k of 3.2, gap of 15, cr 2.4. . at , the left knee was tapped. he was then transferred to for further evaluation. . on arrival, the cxr concerning for ards with: . diffuse faint opacity bilaterally with increased interstitial markings, worrisome for atypical diffuse infection such as virus or pcp. . his abg at was as follows: . 7.11/47/116/16 with a lactate of 9.6 at 5:15 am on . . he was subsequently intubated. his sbp dropped to the 80s and he was thus started on levophed now at 0.458. solumedrol and later decadron were given. central line with continuous svo2 monitor placed. . ros: as per hpi, unable to get further info as pt int/sed past medical history: pmh: asthma . past surgical history: none social history: the patient works at . he is married but separated and currently sexually active (unprotected) with a female partner. the patient had travelled to three weeks ago. no animal/rodent contact. physical exam: on admission to the ed: tc=97.7 p=97->136 bp=102/49 rr=23 92% on ra . on arrival to micu . tc= p=136 bp=115/63 rr=28 gen - int/sed heent - perrla heart - tachy, nl s1s2, no mrg lungs - clear abdomen - soft nt nd nabs ext - wwp skin - diffuse purpura over arms/legs, including soles and palms neuro - mae, sedated on meds pertinent results: 03:00am fibrinoge-142* d-dimer->* 03:00am pt-27.7* ptt-80.6* inr(pt)-2.9* 03:00am plt smr-low plt count-81* 03:00am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal burr-1+ 03:00am neuts-73* bands-10* lymphs-4* monos-1* eos-1 basos-0 atyps-1* metas-10* myelos-0 03:00am wbc-11.0 rbc-5.19 hgb-14.4 hct-44.4 mcv-86 mch-27.8 mchc-32.5 rdw-13.6 03:00am cortisol-42.0* 03:00am tot prot-4.8* calcium-6.9* phosphate-3.8 magnesium-1.1* 03:00am ck-mb-9 03:00am alt(sgpt)-14 ast(sgot)-36 ck(cpk)-1401* alk phos-108 amylase-92 tot bili-0.6 03:00am glucose-86 urea n-20 creat-3.1* sodium-141 potassium-4.0 chloride-108 total co2-11* anion gap-26* 03:01am lactate-9.6* 04:45am urine rbc-* wbc-* bacteria-many yeast-none epi-0 04:45am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-15 bilirubin-sm urobilngn-1 ph-5.0 leuk-neg 04:45am urine color-amber appear-hazy sp -1.023 05:15am po2-116* pco2-47* ph-7.11* total co2-16* base xs--14 06:30am joint fluid number-none 06:30am joint fluid number-none 06:30am joint fluid wbc-4100* hct-14.0* polys-89* lymphs-9 monos-2 . cxr - the heart is normal in size. the mediastinal contours are within normal limits. note is made of increased interstitial markings bilaterally, worrisome for atypical infection such as virus or pcp. arch is somewhat prominent. . ct head - no evidence of hemorrhage, shift of normally midline structures, or hydrocephalus. -white differentiation appears grossly preserved. air- fluid levels are noted within the frontal, maxillary and sphenoid sinuses. there is also opacification of the ethmoid airspaces. . mri head/cspine ()- no evidence of intracranial enhancement, mass effect, or hydrocephalus. no focal signal abnormalities or acute infarcts. extensive soft tissue changes in the mastoid air cells and the paranasal sinuses could be related to intubation. no evidence of epidural abscess or hematoma. no spinal cord compression seen. clinical correlation recommended. . ct torso () - ct of the chest without iv contrast: the endotracheal tube is above the level of the carina. the ng tube is in satisfactory position. there are multiple sub 5-mm pulmonary nodules diffusely throughout the lung fields. there are small bilateral pleural effusions as well as bibasilar atelectasis. there is diffuse anasarca. there is evidence of pulmonary edema. there are no visualized lymph nodes meeting ct criteria for pathology on this unenhanced scan. the pleural effusions measures simple fluid in hounsfield units. . ct of the abdomen without iv contrast: on this unenhanced scan, the liver, adrenal glands, gallbladder, spleen, pancreas, kidneys, and ureters are normal. the small bowel is normal. the large bowel is distended and fluid- filled, and featureless. again there is diffuse anasarca. there is no visualized lymphadenopathy or free fluid, given the limitations of this unenhanced scan. the aorta is of normal caliber. there is no evidence of retroperitoneal hematoma. . ct of the pelvis without iv contrast: the rectum is fluid-filled and distended. the bladder contains a foley catheter. there is diffuse anasarca. no free fluid. no inguinal lymphadenopathy. . portable chest of tracheostomy tube and right picc line remain in standard position. cardiac silhouette appears prominent but stable in size. pulmonary vascularity is within normal limits. previously reported basilar areas of consolidation are no longer evident. there are no new areas of consolidation, but the extreme periphery of the right lung base laterally has been excluded, precluding assessment of this region. . echocardiogram : the left atrium is dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 70%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. there is a trivial/physiologic pericardial effusion. . tee (under general anesthesia): no thrombus/mass is seen in the body of the left or right atrium. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). a chiari network is present in the right atrium (normal finding). the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. no mitral regurgitation is seen. no masses or vegetations are seen on the aortic, mitral, tricuspid or pulmonic valves. there is a trivial pericardial effusion or pericardial fat present. . cxr : portable chest radiograph reviewed. the picc tip is unchanged in position overlying the mid svc. the heart and mediastinal contours are stable. the lungs are suboptimally evaluated given exposure, but appear clear. the pleura appear clear. pulmonary vasculature appear normal. impression: no evidence for picc migration. . culture data: : blood cx x 2. no growth. : urine. no growth. : synovial fluid from left knee. 1+ polymorphonuclear leukocytes. no microorganisms seen. : stool. no growth. : bal. 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. : sputum culture. rare oropharyngeal flora. no microorganisms seen. : blood cx x 2. no growth. : blood cx x 2. no growth. : urine. no growth. : blood cx x 2. no growth. no fungus, no mycobacteria. : stool. c. diff negative. : urine x 2. no growth. : sputum. pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth oropharyngeal flora. yeast. : sputum. no growth. : blood x 2. no growth. : urine. no growth. : bal. no growth. no legionella. no pcp. pmn's. : urine. no growth. : blood x 2. no growth. : sputum. no growth. no pmn's. : blood x 2. no growth. : stool. negative for c. diff. : blood. no growth. : urine. no growth. : stool. negative for c. diff. : blood. no growth. no fungus, no mycobacteria. : catheter tip. no significant growth. : stool. negative for c. diff. : blood x 2. no growth. : urine. no growth. : sputum. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. oropharyngeal flora absent. yeast. moderate growth. yeast. sparse growth. 2nd morphology : sputum. 2+ (1-5 per 1000x field): budding yeast. respiratory culture (final ): oropharyngeal flora absent. yeast. moderate growth. yeast. sparse growth. 2nd morphology. : blood x 2. no growth. : urine. no growth. : blood x 2. no growth. : urine. no growth. : sputum. no growth. : blood x 2. no growth. : urine. no growth. : sputum. oropharyngeal flora absent. yeast. sparse growth. : blood x 2. no growth. : urine. no growth. : sputum. no growth. : blood x 2. no growth. : urine. no growth. : right foot wound culture. 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no bacterial growth. : left foot wound culture. 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no bacterial growth. : blood culture (1 set). no growth. **: blood culture (1 set). coag negative staph, oxacillin resistant. : catheter tip. no significant growth. : blood culture x 3. no growth. : blood culture x 2. no growth. : blood culture. no growth. **: stool. feces positive for c. difficile toxin by eia. : blood culture. no growth. **: wound, right foot. staphylococcus, coagulase negative. rare growth. yeast. rare growth. : blood culture. no growth. **: wound, right foot. pseudomonas aeruginosa. sparse growth. staphylococcus, coagulase negative. sparse growth. yeast. sparse growth. **: wound, right foot. pseudomonas aeruginosa. sparse growth. yeast. rare growth. staphylococcus, coagulase negative. rare growth. **: wound, left foot. staphylococcus, coagulase negative. rare growth. **: wound, left foot. sparse growth mixed bacterial flora ( >=3 colony types) consistent with skin flora. staphylococcus, coagulase negative. sparse growth. of three colonial morphologies. : urine. no growth. : blood. still pending. : sputum. oropharyngeal flora absent. non-fermenter, not pseudomonas aeruginosa. sparse growth. brief hospital course: admission in intensive care unit: 21 year old male with no known significant pmh p/w menongococcemia, purpura fulminans, ards and dic. his hospital course, by problem list is as follows. . 1) septic shock/purpura fulminans: blood culture bottles at hospital were positive for n. meningitidis, although near-daily cultures of blood, sputum, and urine throughout the patient's icu stay remained negative. on admission to the icu, the patient recieved a 4 day course of xigris and a 7 day course of empiric stress dose steroids (hydrocortisone/fludricortisone). to treat his infection, he had an 8d course of cephalosporin (for meningococcemia; recieved ceftriaxone x 6d then cefepime), vancomycin, and flagyl. he persistently spiked nightly fevers to 103, and he had a profound leukocytosis up to 98.6k, with l shift. culture data remained negative, and his only source was a questionable lll pneumonia on cxr. bedside flexible bronchoscopy and a bal were pristine, so antibiotics were discontinued on hospital day 9. he briefly defervesced after changing of his central venous catheter, but then continued to have nightly fevers. he recieved another 10d course of vancomycin, cefepime, and flagyl empirically. when these antibiotics were discontinued, his white count had normalized, although he continued to have low grade fevers. infectious disease was consulted upon admission, and followed the patient throughout his hospital stay. . the patient also was noted to have progressive acral necrosis of his fingers and toes. this was followed daily by the icu team, and plastic/hand surgery and podiatry were consulted. there was no evidence of wet gangrene/progressive infection, and the necrosis was allowed to demarcate. by discharge from the icu, this had been stable for one week, and the patient's necrosis remained limited to the distal 1.5 phalanxes of bilateral hands (largely sparing the thumbs), as well as the distal phalanx of bilateral feet. occupational therapy was consulted to help the patient with this, and the patient will be followed as an outpatient or at rehab by ot. he also will follow up weekly with hand surgery and podiatry to assess need for amputation (versus allowing auto-amputation). . the patient also had diffuse lower extremity bullae and purpura, which were cared for supportively with bacitracin as well as xeroform dressings. . #) persistent fevers: intravenous access was difficult to obtain, and access was maintain via l subclavian central venous catheter. this was removed in the setting of persistent fevers and ir placed a picc line. blood cultures revealed methicillin resistant staph epidermidis and pt was started on vancomycin for 14 day course. c. diff toxin assay were also positive and the patient was started on metronidazole. pt. was sent to or for surgical wound debridement with podiatry of the r foot, wound cultures revealed pseudomonas and ceftazidime was started for full gram negative coverage. . 2) acute renal failure: upon admission, the patient was noted to have a cr 3.1, bun 20 from presumed normal baseline. this trended up to a maximum cr of 7.3 on hd#6. the renal team was following the patient throughout his stay, and thought the renal failure was likely acute tubular necrosis from his sepsis. dialysis was considered, but the patient never met acute indications for dialysis. he was treated prn with high dose diuretics (lasix 200mg iv and diuril 500mg iv up to ) for decreased urine output in the context of anasarca. however, predominately, he was treated supportively, and from hd#7, his creatine began to trend down and he autodiuresed significantly. by discharge from the icu, his creatinine had normalized to 0.8. . 3) respiratory failure: the patient was intubated on arrival due to respiratory distress/fatigue with profound metabolic acidosis. initial chest xrays were consisted with ards, and the patient was maintained on lung protective ventilation. as mentioned above, daily chest xrays showed questionable pneumonia versus pulmonary edema. the patient was on vancomycin, cefepime and flagyl; and was also diuresed. his chest xrays continued to show significant edema, however, his vent settings were able to be weaned over his stay. he was not able to pass a spontaneous breathing trial, and extubation was also deferred because the patient had significant oral lesions and glossal edema, raising the concern for difficulty in reintubation. the patient therefore recieved a tracheostomy tube and peg tube with thoracic surgery. he tolerated the procedure well, and postoperatively was quickly able to be transitioned to a trach mask, then a passamuir valve over the course of 2 days. his respiratory status remained stable throughout the remainder of his icu stay. . 4) cardiovascular system - the patient had several different cardiovascular issues during his stay. on hd#1 an echo showed severely depressed lv function, with estimated ef < 15%. repeat echo on hd#4 showed improved, but still severly depressed lv function, ef 30%. this was not repeated during his icu stay. he also had one episode of non-sustained (~30 beats) ventricular tachycardia. his hemodynamics were stable and his electrolytes were normal at this time, however, and he had no further episodes of similar tachycardias. he was maintained on telemetry throughout this stay. he did have elevation of his cardiac biomarkers, which peaked on hospital day #7 with a troponin t of 4.21. his cks had been elevated (thought due to his acral necrosis), and his ekgs were unchanged. the troponinemia was ascribed to his renal failure and systolic heart failure (as opposed to an nstemi), and indeed, the rise and fall improved with resolution of his renal function. he should have a repeat echo as an outpatient, in weeks after hospital discharge. . additionally, after resolution of his initial sepsis, the patient was persistently tachycardic (hr usually 120s-130s, up to 150s, always sinus rhythm), and hypertensive (sbps up to 180s-190s). the etiology was thought to be due to a combination of pain, anxiety, and fevers, and a generalized state of sympathetic excess. the patient was started on amlodipine, hydralizine, and metoprolol. . 5) neurologic - as the patient's sedation was weaned in advance of possible extubation, he was noted to have questionable neurologic deficits. specifically, he was not moving his upper extremities spontaneously, and while he was able to follow commands by eye blinking, he did not appear to demonstrate any tracking movements with his eyes. as he had been on xigris, and also had significant microvascular pathology in other organ systems, an mri head/cspine was obtained to rule out intracerebral or spinal hematoma, bleeds, or infection. this examination was normal. an ophthamologic consult was also obtained to perform a dilated pupil retinal exam. this showed diffuse bilateral retinal hemorrhages, and outpatient follow up was reccomended. his tracking gaze, and upper extremity movement continued to improve as sedation was weaned. . 6) fluids/nutrition - the patient was maintained on tube feeds throughout his admission. initially, he had high residuals, and therefore, was supplemented with parenteral nutrition. nutrition service provided useful reccomendations. by discharge, the patient had passed a speech and swallow examination, and was tolerating po intake with his pm valve in place. from a fluids standpoint, the patient required initial aggressive fluid rescuscitation for his sepsis and insensible volume losses, and was significantly volume overloaded throughout his stay, although this improved dramatically with forced- and auto-diuresis, and improvement of his renal function. . . . . . . . . . . . . . . . . . ................................................................ transfer to floor. the patient's renal failure normalized; his creatinine returned to normal. the patient was breathing room air through a tracheostomy tube; the trach tube was removed on . soon afterward, he was tolerating po food; the g-tube was removed on . the patient spiked low-grade temperatures until , when his temperature remained below 100.4f. cultures were positive for the following: - mrse in blood and wound culture ( in blood, in wound) - + c. diff () - + yeast in wound cultures ( in wound culture) - pseudomonas in wound cultures ( in wound culture) for these organisms, the patient was continued on vancomycin (started ), cefepime to ciprofloxacin (started ), and metronidazole (started ). he will continue to get a full six week course of these antibiotics. . his foot wounds were dressed daily by podiatry, using duoderm gel on dry sterile dressings and xenoform on leg wounds, bacitracin on leg bullae. his fingers were dressed with dry sterile dressing between the fingers to minimize maceration. . the patient is discharged to a rehab facility in stable condition for continued physical therapy, daily dressing changes, and iv antibiotic treatment (vancomycin). he requires substantial pain control especially for his dressing changes, and he has developed a tolerance to morphine; his pain is controlled with 2-4mg morphine every morning before dressing changes, and he has tolerated a sliding scale of morphine (1-8mg) for physical therapy and any additional dressing changes or examinations of the wounds. he is discharged in stable condition, tolerating po fluids/regular diet, breathing room air, and afebrile. medications on admission: albuterol inhaler discharge medications: 1. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 2. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 3. fentanyl 75 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 4. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 30 days. 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 30 days. 6. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 30 days. 7. vancomycin 500 mg recon soln sig: 1750 (1750) mg intravenous q 12h (every 12 hours) for 30 days. 8. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 9. oxycodone 5 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed for break through pain: please hold for sedation or rr<8. 10. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 11. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed. 12. morphine 10 mg/ml solution sig: 1-8 mg intravenous every twelve (12) hours as needed for pain: please give prior to dressing changes. 13. metoprolol tartrate 100 mg tablet sig: one y (150) mg po daily (daily). 14. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 15. oxycodone 5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain: for breakthrough pain. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: meningococcemia respiratory failure disseminated intravascular coagulation acute respirator distress syndrome clostridium difficile infection mrse bacteremia wound infections discharge condition: stable, afebrile, tolerating po, oxygenating 100% on room air, tracheostomy tube and g-tube removed. discharge instructions: you were admitted for meningococcemia; your hospital course was complicated by disseminated intravascular coagulation (dic), acute respiratory distress syndrome (ards), and hypotension. you also have been diagnosed with mrse bacteremia (bacteria in the blood), for which you are taking vancomycin; c. difficile colitis (a diarrheal illness), for which you are taking flagyl; and several different bacteria and yeast that have infected the wounds, for which you are taking ciprofloxacin and fluconazole. these antibiotics will continue for four and a half more weeks. please take all of your medications as directed. if you develop a fever, shortness of breath, new pain, or other concerning symptoms, please seek medical advice immediately. followup instructions: provider: . (infectious disease), phone: date/time: 10:00am provider: . (internal medicine), phone: provider: , surgery (nhb) date/time: 10:30 provider: surgery clinic phone: date/time: 9:30 provider: , dpm (podiatry) phone: date/time: 1:30 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Other incision with drainage of skin and subcutaneous tissue Other incision with drainage of skin and subcutaneous tissue Arthrocentesis Nonexcisional debridement of wound, infection or burn Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Excision of lesion of other soft tissue Infusion of drotrecogin alfa (activated) Infusion of vasopressor agent Diagnoses: Acidosis Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Severe sepsis Asthma, unspecified type, unspecified Defibrination syndrome Other specified cardiac dysrhythmias Septic shock Intestinal infection due to Clostridium difficile Acute systolic heart failure Other specified disease of white blood cells Rhabdomyolysis Gangrene Other and unspecified diseases of the oral soft tissues Cellulitis and abscess of foot, except toes Pseudomonas infection in conditions classified elsewhere and of unspecified site Critical illness myopathy Meningococcemia Meningococcal meningitis Acute osteomyelitis, ankle and foot Retinal hemorrhage Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified Candidiasis of skin and nails

allergies: angiotensin receptor antagonist / ace inhibitors attending: chief complaint: dyspnea, ivig-mediated atn major surgical or invasive procedure: none history of present illness: pt is a 77 year-old r handed male with pmhx significant for cad s/p mi x3 w/ stent, htn, afib admitted for ivig therapy related to recently diagnosed motor neuropathy. . - following history adapted from neuromuscular fellow note of - . pt states that for a couple of years, he has had some difficulty reaching things on high shelves. he began to have to use both his hands to lift anything as heavy as a plate from a high shelf. he did not notice any other problems at that time. in , he was diagnosed with atrial fibrillation. in of this year, he began to notice some dyspnea on exertion while lifting his paraplegic wife. at the end of he noticed he could no longer breathe while lying flat. he went to in and shortly afterward developed severe shortness of breath and lower extremity edema. he was hospitalized in and given a diagnosis of a left lower lobe infiltrate and started on diuretics and antibiotics. . after discharge his symptoms did not improve. he returned to and was admitted to with worsening orthopnea, pitting edema and shortness of breath. he was given a diagnosis of diastolic heart failure with an elevated bnp. there was no evidence of mi. he was cardioverted during admission and aggressively diuresed in the ccu. amiodarone was added. he continued to be hypoxic and require supplemental oxygen. tte showed ef 50%. . he was discharged to rehabilitation. since then, he has continued to need supplemental oxygen. he has continued orthopnea and dyspnea on exertion and always sleeps in a chair. he walks with a walker now to carry his oxygen tank and provide a chair if he needs to rest. he can walk around his house without the walker, and admits he often dosen't use the nasal cannula at home. he has been unable to get a chest ct due to the inability to lay flat. . in addition to the breathing problems, a couple of months ago he also developed paresthesias and numbness in the fourth and fifth digits of his left hand. this included the palm and the dorsal surface of the fourth and fifth digits. he also notes weakness of the left hand, particulary his grip. his fourth and fifth fingers "feel big," and when touched feel as though something is between his fingers and the stimulus. he denies neck, wrist and elbow pain. . he denies weakness in the lower extremities. he also denies numbness and paresthesias in the lower extremities. he has not noticed any rippling muscles or twitching. he has had chronic lower extremity cramps at night for years, but this is unchanged. he denies trouble speaking or swallowing, and denies double vision or increased weakness at the end of the day. . a few weeks ago, he had pfts, which showed an fvc 29% predicted, fev1 32% predicted. the fev1/fvc ratio was 111% predicted, which is elevated. the test was consistent with a restrictive lung process. he also had a moderately reduced dlco. . there is no history of fevers, chills, chest pain, rashes abdominal pain, nausea, vomiting, incoordination, change in vision, change in speech and swallowing. past medical history: cad, s/p stenting of rca in tte at osh: ef=60% as above atrial fibrillation, diagnosed s/p cardioversion, on coumadin htn hypercholesterolemia gout s/p spinal fusion benign tumor of left breatst 6 yrs ago left knee replacement benign tumor of spine appendectomy osa carpal tunnel release bilaterally, rib removal for ? thoracic outlet syndrome bilaterally car accident with head trauma social history: he has a ninth grade education. he was in the military, then he worked in a machine shop. in the shop, he says the air was constantly thick with smoke from the materials they were using. he lives with his wife. she was paralyzed from the waist down by a spinal cord infacrtion about 15 years ago. he is her primary caretaker. family history: his father died at age 72 from heart disease. his mother died at age from heart disease. he has a living brother and a living sister. his other sister died from breast cancer at age 45. there is no history of neurological problems in the family. physical exam: gen: sitting in chair, nad heent: nc/at, mmm, o/p clear, neck supple, no carotid bruits, cv:rrr s1/s2 no m/r/g resp:cta b/l abd: soft nt nd + bs ext: no c/c/e . neuro exam: oriented to person, place and time, patient repeating intact, naming intact, language fluent with normal comprehension. able to spell world backwards. inact. registration. recall after 3 minutes, with prompting. . cn: perrl, eomi, face symmetric, normal sensation, no hearing on left ear, sternocleidomastoid intact, palate symmetric, tongue midline. . motor: he has full strength of neck flexion and extension. there is no pronator drift. tone is normal. right deltoid , left deltoid 4+/5. right biceps strength is ; left biceps strength is 4+/5. right triceps , left triceps 4+/5. wrist extension strength is 4+/5 bilaterally. wrist flexion is full strength bilaterally. right finger flexion . left 1st, 2nd, and rd digit finger flexion . left 4th and 5th digit flexion 4-/5. there is mild 4+/5 weakness of the iliopsoas muscles bilaterally. dorsiflexion and plantar flexion are also full strength bilaterally. there was mild weakness of toe extension bilaterally. . sensation: decreased sensation to cold temperature from hands to elbows bilaterally. decreased vibration on toes bilaterally. . dtr: absent throughout. toes dowgoing bilaterally. . coordination: finger nose finger without dysmetria, normal . gait: normal stride and arm swing pertinent results: - electrophysiologic findigs most c/w multifocal motor neuropathy w/ conduction block, affecting bilateral median nerves and ulnar nerve. brief hospital course: this is a 77 yo man with multifocal motor neuropathy, cad, htn, osa, s/p pci, hyperlipidemia, restrictive lung disease (diagnosed with fvc of 34% predicted)who initially presented with slowly progressive dyspnea and orthopnea over six months. the patient also reported weakness of his left hand over the last year. on exam the patient was found to have proximal muscle weakness in his upper and lower extremities. he was also noted to have a numbness from his elbows to his finger tips bilaterally with weakness of his left 4th and 5th digits. he also had largely absent reflexes. the patient's study from suggested his defecits are from a multifocal motor neuropathy with conduction block. he also seems to have an ulnar neuropathy. the pt was admitted for an elective 5 day course of ivig for this motor neuropathy. after administration of the ivig, the pts creatinine increased from 0.9 on to 1.4 on , to 5.4 on , and to a peak of 7.4 on . the pt was transferred to the micu on for this worsening renal function thought to be secondary to ivig-mediated atn, oliguria, and increasing sob with a mild increase in o2 requirement. in the micu, the pt was followed by renal. his bumex was d/c'd, aspirin and indomethecin were also d/c'd. renal us and cxr were obtained. renal us showed no obstruction. cxr show no pulmonary congestion. prior to transfer to the floor, the pt was given lasix 120 mg iv x1 and chlorothiazide 500 mg iv x1. the pt diuresed 2l in response to these doses, and then he further autodiuresed 3-4 l each day subsequently. it was felt the pt had entered into the diuresis phase of atn prior to discharge. the pt frequently required potassium repletion (k often 3.1-3.4) likely secondary to tubulopathy and inability for k reabsorption during the recovery phase of atn. indomethacin was held as was his allopurinol, but prior to discharge his allopurinol was restarted at a lower dose of 100 mg qod. the pts coumadin for his paf was initially held given the possible need for hemodialysis, but this was restarted at 2.5 mg qhs and titrated up to 5 mg qhs with an inr prior to discharge of 1.6. the pt developed a hyponatremia of 128 on which improved to 137 prior to discharge after he had been placed on fluid restriction and diuresed. prior to and after discharge, po intake was encouraged as the pt was in the regeneration phase of his tubules and at risk of dehydration secondary to loss of tubular concentrating capacity. . the pts shortness of breath improved over his stay. the etiology was likely multifactorial including arf in the setting of diastolic dysfunction and baseline chf as well as restrictive lung disease. the pt continued on his home bipap machine at night. as the pt is on amiodarone ipf is also possible, but the pt is unable to lie flat for a ct. . prior to discharge the pt began to c/o intense l hand swelling, throbbing, and numbnbess. this was more than at his usual ulnar neuropathy baseline. venous us on ruled out venous thrombus. the pt was started on a 6 day outpatient prednisone taper as he has a history of gout and his recent arf/diuresis was a likely trigger (and his allopurinol had initially been held). medications on admission: lopressor 12.5 mg bumex 2 mg aspirin 81 mg daily kcl 10 meq daily indomethacin 50 mg allopurinol 300 mg daily warfarin 2.5 mg daily amiodarone 200 mg daily mevacor 40 mg qhs butalbital prn stool softener combivent bipap at night supplemental oxygen discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 2. atorvastatin calcium 80 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 3. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). :*90 tablet(s)* refills:*2* 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). :*30 tablet(s)* refills:*2* 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). :*30 tablet, chewable(s)* refills:*2* 6. warfarin sodium 5 mg tablet sig: one (1) tablet po hs (at bedtime). :*30 tablet(s)* refills:*2* 7. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). :*15 tablet(s)* refills:*2* 8. potassium chloride 20 meq packet sig: two (2) packets po once a day for 5 days: take till potassium checked clinic on -then take more potassium if indicated by your primary care physician. :*10 packets* refills:*0* 9. prednisone 20 mg tablet sig: three (3) tablet po once a day for 2 days: start with this dose. :*6 tablet(s)* refills:*0* 10. prednisone 20 mg tablet sig: two (2) tablet po once a day for 2 days: take after done with 60mg dose . :*4 tablet(s)* refills:*0* 11. prednisone 20 mg tablet sig: one (1) tablet po once a day for 2 days: start after done with 40mg dose. :*2 tablet(s)* refills:*0* 12. prednisone 20 mg tablet sig: one (1) tablet po use as directed for 6 days: take 3 tablets for 2 days, take 2 tablets for 2 days, and take 1 tablet for 2 days. :*12 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: ulnar neuropathy multifocal motor neuropathy w/ conduction block acute renal failure obstructive sleep apnea atrial fibrillation discharge condition: stable discharge instructions: please call your neurologist or return to the ed if you experience increased shortness of breath, weakness, numbness, decreased urine output. please do not take cholchicine till further notice. please continue to maintain adequate fluid intake. please keep all follow up appointments. followup instructions: provider: /, md where: neurology phone: date/time: 11:00 . provider: cc2 pulmonary lab-cc2 where: pulmonary function lab phone: date/time: 8:30 . provider: laboratory where: clinical ctr--neurology dept date/time: 10:00 dr. / -pcp-- at 1:20pm-please have your k, cr and chem panel checked. your cr. at time of discharge had decreased from 7.4 to 3.2 clinic- clinic will call you by with a follow up appointment. if you do not hear from the clinic by -please call them immeditaly to schedule a follow up appointment. md, Procedure: Injection or infusion of immunoglobulin Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Gout, unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Old myocardial infarction Long-term (current) use of anticoagulants Chronic diastolic heart failure Lesion of ulnar nerve

allergies: angiotensin receptor antagonist / ace inhibitors attending: chief complaint: shortness of breath major surgical or invasive procedure: electric cardioversion. history of present illness: mr is a 76 year old gentleman with a history of cad s/p stenting of rca in , hypertension, hypercholesterolemia, and new-onset atrial fibrillation, presenting with progressive shortness of breath. his problems started a few months ago. he started to feel more short of breath, especially with exertion/walking, and he would experience left-sided sharp chest pain (non pleuritic, no radiation or associated symptoms) with severe episodes. of note, he was diagnosed with new atrial fibrillation in , and was started on coumadin at this time (and was on beta blocker already). he went to floriday in , and while on the plane, he had increased shortness of breath with the associated chest pain. he also noted the onset of new bilateral le swelling. when he got off the plane, he went to a hospital in where he was admitted for 2 days, a cxr showed lll infiltrate, and he was started on antibiotics (completed a 7-day course of a fluoroquinolone). a bnp was normal at 50, he was given 40 mg iv lasix, and discharged on po lasix. his symptoms did not improve and in fact, worsened. he denied any fever/chills/abdominal pain/bowel or urinary symptoms, but said he was experiencing pnd/orthopnea (states he hardly sleeps at night, can only sleep at 60-90 degree angle) which had been getting progressively worse. he denied palpitations, light headedness, or dizziness, but he stated that he had had episodes in the past few months where he would just pass out/thought he suddenly fell asleep. he denied any prodromal symptoms before these episodes and denied any tongue biting, loss of bowel or bladder function. he does not think he lost consciousness with these episodes. he was hospitalized this second time from , and at this time, he was treated with rocephin/azithro, v/q was low prob, bilateral leni's were negative, bnp was 126. to work up these ?syncopal episodes, neuro was consulted, and ct of the head was negative, bilateral carotid us showed only 30% stenosis, eeg was negative, and tte showed ef=60% with trival pr, borderline concentric lvh. he was discharged and returned to on the day of admission. he came right to the hospital, stating that he had no improvement in his symptoms of shortness of breath. in the ed, he was afebrile, 92% on room air, found to have bnp of 1386. he was given 40 mg iv lasix with good diuresis. cta could not be performed, for he couldn't lie flat due to his sob. he was admitted for further workup of this shortness of breath. past medical history: 1. cad, s/p stenting of rca in tte at osh: ef=60% as above 2. atrial fibrillation, diagnosed , on coumadin 3. htn 4. hypercholesterolemia 5. gout 6. s/p spinal fusion 7. benign tumor of left breatst 6 yrs ago 8. left knee tkr 9. benign tumor of spine 10. appendectomy social history: lives with wife who is paraplegic, retired machine store owner. quit smoking 50-60 yrs ago (smoked 1 pack/wk x 1yr), drinks 1-2 drinks/d family history: non-contributory. physical exam: pe: vs: 96.3 78 153/50 20 97% 2l gen: very pleasant gentleman, speaking in short sentences, using accessory muscles to breath, working hard to breath heent: perrl, op clear neck: no lad, jvd to ear at 90 degrees cv: irreg irreg s1/s2, no m/r/g appreciated lungs: crackles 1/3 up lungs bilaterally but distant breath sounds, no wheezes/rhonchi abd: protuberant, soft, nt/nd, nabs extr: + pitting edema to mid calf bilaterally, dp 1+ bilaterally pertinent results: echo/tte (): the left atrium is normal in size. the left ventricular cavity size is normal. views are technically suboptimal for assessment of ventricular systolic function. left ventricular function is probably mildly impaired with inferior/inferolateral hypokinesis. estimated ejection fraction ?50%. right ventricular chamber size is normal. right ventricular systolic function is probably normal. the aortic root is moderately dilated. the ascending aorta is moderately dilated. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. there is at least mild pulmonary artery systolic hypertension. echo/tte (): the left atrium is normal in size. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be estimated. there is no pericardial effusion. compared with the report of the prior study (tape unavailable for review) of , the findings are similar (trace aortic regurgitation is now seen - may be due to technical differences). cxr pa/lat (): the heart is of normal size for technique. the pulmonary vascularity is difficult to evaluate due to very low lung volumes. there are bibasilar atelectases. there is a left retrocardiac opacity that most likely represents atelectasis. there are no obvious pleural effusions. there are degenerative changes of the thoracic spine. the patient is status post posterior spinal fusion of the lumbar spine. there is no pneumothorax. cxr pa/lat (): impression: persistent patchy bibasilar opacities, most likely due to atelectasis. underlying infection in the left lower lobe cannot be fully excluded. 05:13pm blood freeca-1.26 05:13pm blood o2 sat-97 05:22pm blood o2 sat-60 01:16pm blood lactate-1.2 05:13pm blood lactate-0.9 01:16pm blood type-art po2-44* pco2-81* ph-7.31* calhco3-43* base xs-10 05:13pm blood type-art po2-92 pco2-81* ph-7.31* calhco3-43* base xs-10 intubat-not intuba 08:00pm blood type- po2-44* pco2-80* ph-7.31* calhco3-42* base xs-9 05:22pm blood type-art po2-34* pco2-71* ph-7.33* calhco3-39* base xs-7 comment-qns to 05:06am blood cortsol-29.8* 05:00am blood tsh-2.0 05:00am blood vitb12-> folate-10.2 05:00am blood caltibc-252* ferritn-1088* trf-194* 03:00pm blood calcium-9.2 phos-3.4 mg-1.9 04:00am blood calcium-9.5 phos-4.0 mg-1.9 03:00pm blood ck-mb-4 probnp-1386* 03:00pm blood ctropnt-<0.01 09:50pm blood ck-mb-notdone 09:50pm blood ctropnt-<0.01 04:00am blood ck-mb-notdone 04:00am blood ctropnt-<0.01 06:10am blood probnp-1365* 03:00pm blood lipase-23 03:00pm blood ck(cpk)-132 09:50pm blood ck(cpk)-87 04:00am blood ck(cpk)-92 06:10am blood alt-20 ast-32 ld(ldh)-267* alkphos-87 totbili-0.8 03:00pm blood glucose-98 urean-28* creat-1.1 na-132* k-5.4* cl-91* hco3-36* angap-10 04:00am blood glucose-99 urean-22* creat-1.0 na-137 k-4.1 cl-91* hco3-40* angap-10 05:00am blood glucose-122* urean-30* creat-0.8 na-133 k-4.3 cl-86* hco3-42* angap-9 05:10am blood glucose-117* urean-35* creat-1.0 na-133 k-4.6 cl-87* hco3-41* angap-10 03:00pm blood pt-19.6* ptt-32.2 inr(pt)-2.4 03:00pm blood plt ct-225 05:00am blood pt-19.7* inr(pt)-2.4 05:00am blood plt ct-303 05:10am blood pt-17.1* inr(pt)-1.9 05:10am blood plt ct-274 03:00pm blood neuts-70.6* lymphs-20.8 monos-6.6 eos-1.7 baso-0.3 05:00am blood neuts-87.2* lymphs-5.7* monos-6.8 eos-0.3 baso-0.1 03:00pm blood wbc-4.9 rbc-3.81* hgb-13.2* hct-38.9* mcv-102* mch-34.6* mchc-33.8 rdw-13.3 plt ct-225 04:00am blood wbc-5.4 rbc-3.90* hgb-13.5* hct-40.4 mcv-104* mch-34.6* mchc-33.5 rdw-13.5 plt ct-220 05:00am blood wbc-12.8* rbc-3.62* hgb-12.1* hct-37.1* mcv-103* mch-33.5* mchc-32.6 rdw-12.7 plt ct-303 05:10am blood wbc-9.6 rbc-3.56* hgb-12.1* hct-36.9* mcv-104* mch-34.0* mchc-32.8 rdw-13.1 plt ct-274 brief hospital course: mr is a pleasant man with a history of known cad, osa and new-onset af who was first admitted to hospital with subacute on chronic (2-3 months) dyspnea. he was treated for pneumonia and then was treated for chf. he was then admitted to medicine for a further evaluation of his breathing difficulty. the cause of his symptoms was likely a diastolic heart failure (dchf), given his chest-xray findings, normal lvef on echo, elevated bnp and clinical findings and history. an etiology of his dchf was not found, but was possibly ischemic. early in his course, he underwent successful electric cardioversion of his atrial fibrillation. this occurred in the ccu given his progressively falling systolic blood pressures, in the setting of heart failure and initiation. fluid removal, via nesiritide and lasix was continued for a brief time in the ccu. he remained in sinus rhythm for most of the remainder of his course, with paroxysms of atrial fibrillation. his symptoms slowly improved and success was achieved in lowering his weight and oxygen requirement. nevertheless, on discharge he still required low-level nasal cannula supplemental oxygen and was somewhat breathless on exam. 1. dyspnea: as mentioned, the likely etiology of his symptoms was dchf, but an alternate etiology possible. his initial cxr and bnp, along with his increasing weight, lower extremity edema, orthopnea, and pnd all pointed towards chf. he improved somewhat with diuresis (via lasix and nesiritide), beta-blockade (metoprolol 25 mg po bid) and then cardioversion from af to sinus rhythm. of note, a work-up for pulmonary embolism via cta at the hospital was negative. a persistent atelectasis versus infiltrate of his left lower lobe in the lung was observed. he was treated for pneumonia at the outside hospital and also received a five-day course of levofloxacin at (for a uti). 2. chf: the admission echo showed an ef of 50%. again, the cause of his dysfunction was not known, but was likely diastolic, but the exact etiology was unknown. he was ruled out for acute myocardial infarction on admission. he had an isolated elevation of his ferritin level, but had no other signs of systemic hemochromatosis. futher, systemic amyloid was not apparent on exam, but was certainly a possible cause for his diastolic dysfunction. follow-up ischemic and cardiac imaging (ie. mibi, catheterization, or mri) was deferred to his new outpatient cardiologists. as mentioned, he improved somewhat with beta-blockade, a one liter fluid restriction, nacl restriction, and fluid removal via lasix and nesiritide. he was to follow up with dr. from ep cardiology. 3. paf: he presented with recent onset of atrial fibrialltion. he underwent electric cardioversion in the ccu given low spbs, as mentioned. he was started on amiodarone hcl 400 mg po tid, which was decreased to daily given a new-onset tremor. he then remained in sinus rhythm with rare, brief episodes of paf. coumadin was initially held because of a supratherapeutic inr. it was later reinitiated at 2 mg po qhs for an inr goal of . he was to follow up with dr. from ep cardiology. 4. uti: he had an initial leukocytosis, peaking at 15.6. he had no fever or systemic symptoms, but a urinalysis minimal cystitis (wbc 11) with few bacteria. he was started empirically on levfloxacin for 5 day course for uti. 5. hypotension: the patient had low sbps over his course, mainly ranging from the 90s-110s. however, upon initittion of ace-i or (one dose of losartan 50 mg and then 25 mg on two separate occasions) he had a relatively acute drop of his sbps to the 70s-80s. he was asymptomatic and his mentation remained intact. his sbps normalized to his to his new (low) baseline after cardioversion and discontinuation of the /ace-i. 6. cad: he was continued on asa, bb, and statin. his nitrates were held given low sbps. he ruled out for mi as above. 7. rue/rle pain: the patient had intermitted pain of his right elbow, hand, and knee along with associated decreased range of motion, tenderness and warmth. there were no effusions or erythema. the etiology was unclear, but was possibly pseudogout (given his x-ray findings) or gout. his clinical picture was consistent with crystalline diseases in the setting of diuresis. he was seen by rheumatology and was continued on allopurinol qod given his known gout history. it was noted that increasing or decreasing his allopurinol in the setting of a possible acute exacerbation may have worsened his symptoms. conditions associated with pseudogout were sought: he had an elevated ferritin, and a normal calcium, phosphate and tsh. he was discharged with rheumatology follow-up. his pain was controlled with percocet, as nsaids were avoided given his renal dysfunction. 8. arf/ckd: the patient had marked renal sensitivity to both nsaids and /ace-i. his creatinine throughout most of his course was less than 1, but climbed to the low 2.0's upon administration of these agents. medications on admission: isordil 20 mg tenormin 50 mg daily mucinex ceftin vasotec 2.5 mg daily coumadin 7.5/5 mg detrol 2 mg qhs mevacor 20 mg daily allopurinol 300 mg daily asa/plavix held at osh nkda discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). tablet(s) 2. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 5. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 6. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 7. amiodarone hcl 200 mg tablet sig: two (2) tablet po daily (daily). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 days. 10. warfarin sodium 3 mg tablet sig: one (1) tablet po hs (at bedtime): please check inr daily and adjust dosing for goal of inr of . 11. lasix 40 mg tablet sig: one (1) tablet po twice a day: please follow i/o's and weights, along with creatinine and adjust prn. 12. bipap ipap 9 cm h20. epap 6 cm h20. o2 at 2l/min. discharge disposition: extended care facility: hospital - discharge diagnosis: primary diagnosis: 1) diastolic heart failure. 2) atrial fibrillation. 3) hypotension. secondary diagnosis: 4) urinary tract infection. 5) coronary heart disease. 6) likely crystalline joint disease exacerbation. discharge condition: fair/stable. discharge instructions: 1) please contact your doctor or return to the er if you have increased shortness of breath, fatigue, fevers, chills, or any other concerning symptoms. 2) use your bipap every night. 3) take your medications as instructed. followup instructions: 1) please contact your new heart failure doctor, dr. () a appointment: provider , md where: cardiac services phone: date/time: 9:00 2) please see your new ep (electrophysiology) heart doctor, dr. () for the following appointment. your amiodarone dosing will be adjusted. dr. will check your of hearts monitoring: provider , m.d. where: cardiac services phone: date/time: 12:30 3) please contact the rheumatologists at for a new appointment in regards to your joint pain. they will discuss treatment options with you. repeat uric acid and ferritin levels will be checked at that time. 4) please see your primary doctor (, m. ) in the next 4-6 weeks. contact your doctor (ie. the day you leave the rehab facility) to arrange correct dosing of your coumadin. your inr levels need to be checked frequently while you are on your new medication regimen. 5) speak to your cardiologists and primary care doctor g your plavix. 6) follow-up with your own pulmonologist or make an appointment with the pulmonologists at the sleep clinic at ( in regards to your cpap use for your osa. md, Procedure: Other electric countershock of heart Non-invasive mechanical ventilation Injection or infusion of nesiritide Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Hypotension, unspecified Unspecified sleep apnea Acute diastolic heart failure Knee joint replacement

contrast: 100 cc optiray iv due to fast bolus and allergies. findings: there is no pulmonary embolism. there is bibasilar consolidation. there is a small left pleural effusion. there is no pericardial effusion. the tracheal bronchial tree is patent. there are no pathologically enlarged, hilar, mediastinal or axillary lymph nodes. there is diffuse regions of ground glass opacity involving both lungs. there are small regions of geographic sparring, predominantly in the periphery of the lungs. no pulmonary nodules or masses are identified. incidental note is made of a nasogastric tube and endotracheal tubes. impression: 1. there is no pulmonary embolism. 2. bibasilar dense consolidation. diffuse ground glass opacity involving the lungs as described above. the differential diagnosis would include edema and infectious/ inflammatory etiologies. 3. there is no pericardial effusions and there is no large pleural effusion. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute respiratory failure Unspecified sleep apnea Paroxysmal supraventricular tachycardia Cushing's syndrome

history of present illness: the patient is a 50-year-old female who presents with an acute episode of shortness of breath to the . she has a past medical history significant for hypertension, diabetes mellitus, obstructive sleep apnea and question restrictive lung disease. she was in her usual state of health until the day of admission when, while walking at , she became acutely short of breath. over the next 30 minutes, the dyspnea became worse and she became diaphoretic. she did not have any chest pain. she was transferred by ems to where she was found to be in pulmonary edema, had small st elevations in v1 and also became hypotense. she was intubated, given nitroglycerin, started on a dobutamine drip and then brought to the for further management. past medical history: 1. hypertension 2. question restrictive lung disease 3. sleep apnea 4. type ii diabetes mellitus medications before admission: 1. metformin 850 mg tid 2. nph insulin 85 in the morning, 35 in the evening 3. aspirin 325 mg qd 4. lisinopril 5 mg qd 5. atenolol 100 mg qd 6. lasix 40 mg qd 7. theophylline 300 mg 8. beclomethasone inhaler 9. dexamethasone 1 mg qd allergies: seafood - she had a severe reaction requiring hospitalization. family history/social history: both parents died when she was very young. she is an ex-smoker, ex-alcoholic. does not work. she is on disability. hospital course by system: 1. cardiac: she had three issues - rhythm, pump and coronary artery disease. in terms of her rhythm, the patient was shocked twice in the emergency department because of concern for a flutter versus sinus tachycardia. there was no response. she was transferred to the ccu where she was taken off the dopamine drip, but she remained tachycardic. she was eventually felt to be in sinus tachycardia secondary to pneumonia. pulmonary embolus was ruled out by ct angiogram. lopressor was started and her rate became under control and lopressor was eventually increased to 75 tid. in terms of her pump, a chest x-ray initially revealed bilateral infiltrates consistent with pulmonary edema. a bedside echocardiogram showed no lv dysfunction. she was felt to have diastolic dysfunction, which in the context of her sinus tachycardia put her into failure. while in the ccu, she was aggressively diuresed. diltiazem was started, but then it was discontinued because it had no effect on her rate. in term of her coronary artery disease, she has no past medical history significant for coronary artery disease, but risk factors are present. an ace inhibitor was started, but it was also discontinued in the ccu secondary to hypotension. 2. pulmonary: pneumonia: on admission, she had a white blood count of 28. on hospital day 2, she was found to have sputum and blood cultures that were growing gram positive cocci in pairs. she was started on ceftriaxone and levaquin and the ceftriaxone was eventually discontinued. ventilation: she was intubate in the emergency department and when admitted to the ccu, was on 100% inspired oxygen ventilator settings. she was aggressively diuresed given albuterol nebulizers and intravenous steroids and on hospital day 4, was transferred to the medical intensive care unit because of failure to wean from the vent. on hospital day 7, she was extubated and saturating 93% on 5 liters nasal cannula. she is on 3 liters nasal cannula at baseline at home. restrictive lung disease: this was believed to have been a contributing factor to her dyspnea. the history, though, is unclear. 3. infectious disease: as mentioned previously, the pneumonia on hospital day 2, the sputum culture grew strep. she was started on levofloxacin and ceftriaxone. the ceftriaxone was discontinued. over time, her white blood count gradually decreased from 28 to 11.9 and she became afebrile. blood cultures from grew alpha streptococci and gamma hemolytic strep. these were felt to be a contaminant. on , blood cultures were drawn and these were shown to be negative. urinary tract infection: a urine culture from was negative. 4. endocrine: diabetes: she was placed on a regular insulin sliding scale and once she started taking po's, was put on standing nph insulin orders. hypercalcemia: calcium was noted to be persistently greater than 10 towards the end of her hospital stay. pth level was drawn and her hypercalcemia will be worked up as an outpatient. 5. gastrointestinal/fen: she went from npo to tube feeds to eating solid foods on . she did develop diarrhea while in the intensive care unit. clostridium difficile antigen was negative. the diarrhea eventually improved. when she was transferred from the intensive care unit to the medicine service on which was hospital day 9, vital signs were the following: temperature 98.6??????, blood pressure 128/80, pulse 96, respirations 20 and saturating 96% on 3 liters. she was sitting comfortably. pupils were equal, round and reactive to light. mucous membranes were moist. the lungs were clear to auscultation. on cardiac examination, regular rate and rhythm, s1, s2, no murmurs, rubs or gallops. the abdomen was soft and there was trace edema in the extremities. the patient had a stress test in . it was a persantine mibi. there were no anginal type symptoms with no ischemic electrocardiogram changes. there was also no evidence of myocardial perfusion defects. the ejection fraction was approximately 55%. there were no wall motion abnormalities and a prominent right ventricle was noted. on , the day after her stress, the patient was deemed fit to return home. she had had a physical therapy evaluation that felt that she would be fine to go home on this day. the patient had a pth done which is still pending to work up her hypercalcemia. the patient also had a urine cortisol done because of concern for a slightly cushingoid appearance. the patient is to follow up with these results with her primary care physician. patient was discharged home in good condition. discharge diagnoses: 1. pulmonary edema likely secondary to diastolic dysfunction in the setting of a sinus tachycardia secondary to pneumonia 2. hypertension 3. sleep apnea 4. diabetes 5. restrictive lung disease on discharge, the patient was to continue her previous medications from before her hospital admission. she was also given a prescription for combivent, for albuterol and she was also given a prescription for levofloxacin 500 mg qd to finish a 10 day course of treatment for her pneumonia. she was admitted on and discharged on . , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute respiratory failure Unspecified sleep apnea Paroxysmal supraventricular tachycardia Cushing's syndrome

history of present illness: the patient was referred to dr. for laparoscopic excision of a known adrenal adenoma contributing to the patient's labile hypertensive state. hospital course: the patient was taken to the operating room for a planned laparoscopic adrenalectomy. surgery was referred as an mri on demonstrated a right adrenal mass with fatty elements with recommendation from radiology for biopsy. please see dr. operative note for details of the operation. following the surgery, the patient's extubation was complicated by respiratory distress requiring re-intubation and admission to the medical intensive care unit on the . the patient was intubated times 36 hours in the medical intensive care unit. he was extubated without complications. he remained stable for the remainder of his visit during the intensive care unit. at the time of discharge, he had been afebrile times 24 hours. the patient did, however, demonstrate some areas of blanching erythema on his port sites, on postoperative day three. this was felt to be consistent with cellulitis. the patient was put on iv kefzol. the patient tolerated both, initially, a liquid diet and, ultimately tolerated a general house diet without nausea, vomiting or abdominal distention. he was passing gas at the time of discharge. discharge medications: 1. lopressor, 50 mg po b.i.d.. 2. percocet, one to two tablets po q 4-6 hours p.r.n. pain. 3. keflex, 500 mg po q.i.d. times seven days. 4. patient was advised to not take any of his previous hypertension medications besides the newly described lopressor due to the risk of severe hypotension. he was, however, advised to continue taking his previous medications which included lansoprazole, thiamin, folate. condition on discharge: stable. discharge status: to home. diagnosis: 1. status post right laparoscopic adrenalectomy for probable benign adrenal adenoma. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Unilateral adrenalectomy Diagnoses: Other primary cardiomyopathies Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Benign neoplasm of adrenal gland

history of present illness: the patient was referred to dr. for laparoscopic excision of a known adrenal adenoma contributing to the patient's labile hypertensive state. hospital course: the patient was taken to the operating room for a planned laparoscopic adrenalectomy. surgery was referred as an mri on demonstrated a right adrenal mass with fatty elements with recommendation from radiology for biopsy. please see dr. operative note for details of the operation. following the surgery, the patient's extubation was complicated by respiratory distress requiring re-intubation and admission to the medical intensive care unit on the . the patient was intubated times 36 hours in the medical intensive care unit. he was extubated without complications. he remained stable for the remainder of his visit during the intensive care unit. at the time of discharge, he had been afebrile times 24 hours. the patient did, however, demonstrate some areas of blanching erythema on his port sites, on postoperative day three. this was felt to be consistent with cellulitis. the patient was put on iv kefzol. the patient tolerated both, initially, a liquid diet and, ultimately tolerated a general house diet without nausea, vomiting or abdominal distention. he was passing gas at the time of discharge. discharge medications: 1. lopressor, 50 mg po b.i.d.. 2. percocet, one to two tablets po q 4-6 hours p.r.n. pain. 3. keflex, 500 mg po q.i.d. times seven days. 4. patient was advised to not take any of his previous hypertension medications besides the newly described lopressor due to the risk of severe hypotension. he was, however, advised to continue taking his previous medications which included lansoprazole, thiamin, folate. condition on discharge: stable. discharge status: to home. diagnosis: 1. status post right laparoscopic adrenalectomy for probable benign adrenal adenoma. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Unilateral adrenalectomy Diagnoses: Other primary cardiomyopathies Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Benign neoplasm of adrenal gland

history of present illness: the patient is a 57-year-old female with a history of high-grade dysplasia within her esophagus consistent with barrett's esophagus. she has a long history of esophageal problems, history of vigorous achalasia, and esophageal spasms status post long myotomy which she did well for a period of time. she then developed achalasia and dr. performed a laparoscopic myotomy after which she has done well. at this time she has had some biopsies which showed adenomatous mucosa without any evidence of dysplasia. since her myotomy, she has actually done quite well and has been quite happy, and eating, and had no regurgitation, or other problems. she had a recent biopsy of her distal esophagus which showed high-grade dysplasia. hence, the decision was made to do a ivor- esophagogastrectomy. past medical history: good general health. she denies heart disease, lung disease, or diabetes. she has had an open cholecystectomy, a bilateral tah/bso, as well as a laparoscopic myotomy. she is status post knee replacement one year ago and walks with a cane. medications: 1. amitriptyline 300 mg po q day. 2. prilosec 20 mg po q day. 3. trazodone 100 mg po q day. physical examination: on physical exam by dr. , she was a well-developed overweight woman who walks with a cane. she had a normal head and neck examination. neck was supple without mass, nodes, or thyromegaly. chest was clear to auscultation and percussion. she has well-healed scar on the left. her abdomen is soft without hernias or masses. extremities were well perfused. hospital course: she is admitted on as mentioned previously, an ivor- esophagogastrectomy. postoperatively, she went to the surgical intensive care unit. she had some issues with low blood pressure which was in the 80s/40s and requiring very small amount of levophed. she was extubated on postoperative day one, and her vital signs remained stable. she did well and her pain was controlled with her epidural. she remained in the unit on postoperative day two, however, was transferred to the floor on postoperative day two in stable condition. however, over the course of the evening of postoperative day two, she developed some confusion and pulled out her chest tube and her foley. decision was made to remove dilaudid from her epidural, and the patient did better. the chest tube was completely removed given that the chest x-ray confirmed it was improperly positioned and out of the pleural cavity. given that there was drainage into her pleural cavity and noted that the chest tube was no longer in place to drain the fluid, the patient did have some difficulty with her oxygen saturation. however, she maintained her o2 sats in the mid 90s on 50% facemask. on the evening of postoperative day three, the patient had been doing well all day. on the evening of postoperative day three, the patient became confused again despite the dilaudid no longer being in her epidural, and she pulled out her nasogastric tube as well as her foley once again. decision was made to put her in soft restraints, and to replace the nasogastric tube under fluoroscopic guidance on the following day, which was done on postoperative day number four. on the evening of postoperative day number four, the patient had shortness of breath and her o2 saturation decreased to the low 90s and she is having labored breathing, and was slightly tachycardic. a chest x-ray was done which showed a right pleural effusion which is consistent with fluid left from her surgery. decision was made to try to fluoroscopically place a chest tube as well as fluoroscopically replace her nasogastric tube. on the following day, postoperative day number five, her vital signs continued to remain stable. it was felt that there was no enough fluid in her lungs to warrant putting a chest tube in, however, a nasogastric tube was placed fluoroscopically and the patient did well. at this point the patient continued to improve clinically. her tube feeds were increased. she was tolerating them well with aggressive pulmonary toilet. patient's o2 sats continued to improve. her nasogastric tube was kept in place and continued to drain fluid. assumptions was made that the patient had a partial delay of gastric emptying. on postoperative day number eight, the patient's nasogastric tubes were clamped and residuals were minimal. hence, on postoperative day number nine, the decision was made to start the patient on sips. patient remained afebrile. vital signs remained stable, and the patient was discharged home on tube feeds in stable condition. discharge diagnosis: status post ivor- esophagogastrectomy. discharge medications: 1. amitriptyline 300 mg po q day. 2. trazodone 100 mg po q day. 3. nexium 40 mg tid. 4. levaquin 100 mg po q day x2 days. 5. albuterol inhaler two puffs qid prn. 6. tylenol elixir 650 mg po q six prn. 7. isocal tube feeds 70 cc/hour through the j tube. discharge instructions: the patient will follow up with dr. . the patient will get vna services for help with her j tube and wound care. condition on discharge: is discharged home in stable condition. , m.d. dictated by: medquist36 Procedure: Other enterostomy Enteral infusion of concentrated nutritional substances Other lysis of peritoneal adhesions Partial esophagectomy Partial gastrectomy with anastomosis to esophagus Intrathoracic esophagogastrostomy Diagnoses: Unspecified pleural effusion 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 Esophagitis, unspecified Other specified disorders of stomach and duodenum Other specified disorders of esophagus Other esophagitis Atrophic gastritis, without mention of hemorrhage Pelvic peritoneal adhesions, female (postoperative) (postinfection)

allergies: codeine pmh: htn, elevated chol, chronic afib. cad->s/p angioplaty 3 weeks ago, tah/bso 30 years ago. neuro: lethargic but arousable to voice. intermittantly oriented to self. inconsistently moves extremities. able to squeeze right hand w/ mod strength but doesn't lift off bed nor withdraw to pain. right leg the same but will withdraw to pain. can lift lue and lll off bed. pupils 3-4 mm, equal, right pupil intermittantly slightly sluggish. often times repeats word/statements. doesn't always understand what is being asked of her-will frequently start taking deep breaths in and out when asked to move extremities. calling out to god, , and mother occasionally during night. when asked if she sees anyone she states no. hob raised 15 degrees md order for resp status. cv: hr 70-80's a fib, no ectopy. neo gtt titrated to maintain sbp 140-150's. currently at 2 mcg/kg/min. received 1u prbc's for hct 23.5->am hct pnd. dopplerable dp/pt bilat. feet slightly cool, balls of feet slightly mottled. vvi in place. coumadin dose given evening before transfer from 6. resp: regular. mouth breathing. o2 sats stable on 4l np. initially w/ resp acidosis, then metabolic acidosis. 1 amp bicarb for 7.26, hco3 21. ph up to 7.31/pco2 50-no change md. repeat abg with decrease in pco2. bs with rales approx 1/3 up bilat. received 20 mg iv lasix w/ good result. gi/gu: abd soft, + bs. large u/o w/ lasix. k+ down to 2.9-40 meq iv kcl given. treated ca++ of 0.8 also. no bm. remains npo d/t report of coughing with pm meds given on 6. id: afebrile. wbc wnl. endo: glucose stable. skin: no breakdown noted. right leg incision site eccymotic. sternal incision ota. comfort: denies pain. turned frequently. social: family into see patient before they went home last night. questions answered. called last evening to get update. a: neo gtt for bp support. lethargic, disoriented, unable to follow commands consistently. rales bilat. 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 Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Atrial fibrillation Occlusion and stenosis of carotid artery without mention of cerebral infarction 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 Cerebral embolism with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage

history of present illness: the patient is an 81 year old woman with a history of atrial fibrillation, coronary artery disease status post angioplasty, status post total abdominal hysterectomy, who presents with a several week history of chest pain worsening in frequency and duration over the last several days. the patient describes this pain as drowning and suffocating with shortness of breath lasting five to 30 minutes. the symptoms typically like her old angina. no radiation, no nausea or vomiting; non-pleuritic chest pain. prior to current episode, last angina was many years ago. no tearing or ripping sensation. no diaphoresis, no orthopnea or paroxysmal nocturnal dyspnea. the patient presented to on , and had pain which was relieved with sublingual nitroglycerin. the patient was started on a heparin drip and nitropaste in the intensive care unit. an ekg showed no acute st or t changes, with atrial fibrillation at 80. past medical history: 1. atrial fibrillation. 2. angioplasty. 3. hernia repair. 4. total abdominal hysterectomy, oophorectomy 35 years ago. allergies: codeine, which causes nausea. social history: no tobacco, no alcohol. lives with her husband. family history: mother died at 66 with an myocardial infarction. brother, at 77, had a bypass graft. medications: 1. aspirin 81 mg p.o. q. day. 2. lopressor 25 mg p.o. q. day. 3. norvasc 5 mg p.o. q. day. 4. nitropatch 0.04 mg times 12 hours. 5. coumadin 2 mg times five days and 4 mg times two days. physical examination: temperature 97.6 f.; 130/82; pulse is 92; respiratory rate 18; 91% on room air and 93% on two liters. the patient is in no acute distress. crackles bilaterally at the bases; scattered wheezes. cardiac: irregularly irregular rate; no murmurs. no carotid bruit. belly is soft, nontender, guaiac negative. lower extremities with mild edema bilaterally and two plus dorsalis pedis and posterior tibial pulses. laboratory: ekg showed atrial fibrillation at 66; no acute st or t changes. chest x-ray showed cardiomegaly without evidence of failure. white blood cell count of 5.5, hematocrit of 38.2, platelets 222. chem-7 142, 4.1, 103, 30, 14, 0.8 and 95. hospital course: the patient was admitted to the service and was continued on a heparin drip, lopressor, aspirin and norvasc. the patient was kept on heparin and cardiac catheterization was performed when the patient's inr was less than 2.0. cardiac catheterization was performed on , which showed three-vessel disease. at that time, it was decided that the patient should undergo minimally invasive non-bypass coronary artery bypass graft. on , the patient underwent coronary artery bypass graft times three vessels with left internal mammary artery to the left anterior descending, saphenous vein graft to the diagonal and then sequentially to obtuse marginal 1. on postoperative day number one, the patient did well and had her swan-ganz catheter removed. the patient was transferred to the floor on postoperative day number one. on postoperative day number two, it was noted that the patient had right arm weakness and confusion. a neurology consultation was called and a stroke was diagnosed which was most likely related to the patient's atrial fibrillation. the patient was transferred back to the unit on postoperative day number two after this event. ct scan which was obtained after this embolic event showed a left thalamic hypodensity likely representing a subacute chronic infarction. on postoperative day number three, the patient's chest tubes were removed and the patient was sent for a swallow evaluation. the swallow study was clinically suspicious for aspiration, so the patient was made strictly npo. the patient also underwent a carotid artery study which showed significant plaque through the left internal carotid artery with no focal stenosis and severe narrowing throughout the left ica. the right ica suggests 80 to 99% stenosis. on , a vascular surgery consultation was called and their recommendation was for an mra. on , the patient was started on tube feeds with fiber at 10 cc an hour towards a goal of 55 cc an hour. on postoperative day number six, it was noted that the patient's neurologic examinations were improving. on postoperative day number seven, the patient underwent an mra of her carotids which demonstrated a left ica with total occlusion and a right ica with 80 to 99% stenosis. vascular surgery made the recommendation for intervention at six weeks postoperatively. the patient underwent a video swallow on , which she failed and she was to remain npo with tube feeds through her ng tube. on , a family discussion was initiated regarding plans for a peg, however, the family wished to wait to see whether or not her swallowing would improve before placing a peg. for this reason, the patient was started back on her coumadin on . on , a dobbhoff tube was placed for the comfort of the patient instead of an ng tube for tube feeds. on postoperative day number ten, rehabilitation screens were called as it was felt that the patient was stable for rehabilitation. discharge instructions: 1. the patient was to return for follow-up with swallow studies in a week to ten days after discharge. at that time, evaluation would be made as to whether or not she could resume p.o. diet. 2. the patient was to follow-up with dr. in vascular surgery in four weeks with regard to carotid artery surgery. 3. the patient was to follow-up with dr. in four weeks for a postoperative visit. disposition: the patient was discharged to rehabilitation on , on the following medications. discharge medications: 1. colace 100 mg per ng tube twice a day. 2. aspirin 81 mg per ng tube q. day. 3. dulcolax one p.r. p.r.n. 4. plavix 75 mg per ng tube q. day. 5. heparin drip 700 units an hour until therapeutic on coumadin with an inr of 2.0 to 2.5. 6. albuterol, atrovent nebulizers q. four hours p.r.n. 7. tylenol 650 mg p.o. q. four hours p.r.n. 8. lasix 20 mg per ng tube twice a day times seven days. 9. 20 meq per ng tube twice a day times seven days. 10. lopressor 25 mg p.o. twice a day. 11. coumadin 2 mg p.o. q. day times five days; 4 mg p.o. times two days. discharge diagnoses: 1. status post coronary artery bypass graft times three. condition at discharge: good. , 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 Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Atrial fibrillation Occlusion and stenosis of carotid artery without mention of cerebral infarction 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 Cerebral embolism with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage

the patient was discharged to rehabilitation on in good condition on the same discharge medications as was previously stated in the discharge summary. , 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 Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Atrial fibrillation Occlusion and stenosis of carotid artery without mention of cerebral infarction 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 Cerebral embolism with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: admission to the ccu following complication after cardiac catherization: ventricular tacchycardia/ ventricular fibrillation (>10 defibrillations) major surgical or invasive procedure: stent placement of rca which was found to be 90% occluded. history of present illness: this is a 62 y/o male with h/o pvd, transferred from the cath lab to the ccu for ventricular taccycardia and ventricular fibrillation, s/p cypher stents to the rca (90%). in the cath lab the patient was found to have a r dominant system, following placement of the cypher stent he had multiple episodes of vt/vf. this terminated with >10 defibrillations, amiodarone loading dose of 450, 3mg of atropine and dopamine gtt. patient's sbps dropped to the 30s. he was intubated in the cath lab. prior to transfer to the ccu from the cath lab, the dopamine drip was stopped. the patient was found to be in afib. on arrival to the ccu, repeat ekg was in normal sinus. . the patient had been in his usual state of health until about 2 months ago when he began experiencing leg tightness in both calves after walking a mile. his pcp referred him for peripheral intervention. on abi/pvrs with exercise showed: right lower extremity was triphasic at the femorals only and monphasic below. abi was 0.88 on the right which decreased to 0.46 after exercise. on the left, the wave forms were triphasic up to the femorals only and monophasic below. abi's were 0.79 which decreased to 0.31 with exercise. pvrs were 3mm on the right and 6 mm on the left. . in terms of his cardiac status, the patient denied any specific cardiac symptom. he had a stress in which was negative for ischemia. ef by echo in was 40%. he was referred to the for peripheral and coronary angiography. past medical history: htn pvd elevated psa gout social history: smokes ciggarettes, attempting to quit, smoke ciggs/ week family history: no fam h/o cad physical exam: vitals afeb, hr 83, bp 131/92, r22, o2 sat 100% gen: intubated and sedated heart nl rate, soft s1,s2, no gmr lungs: intubated abd: benign ext: 1+dp b/l, 1+pt b/l, no femoral bruits, no edema pertinent results: labs 07:10am blood wbc-9.9 rbc-4.58* hgb-12.7* hct-37.7* mcv-82 mch-27.6 mchc-33.6 rdw-14.9 plt ct-176 07:10am blood glucose-91 urean-33* creat-1.6* na-139 k-3.8 cl-105 hco3-24 angap-14 07:10am blood ck(cpk)-* 01:00pm blood ck(cpk)-* 05:54pm blood ck(cpk)-939* 07:10am blood ck-mb-21* mb indx-0.1 . cath report for . coronary angiography of the right dominant system showed 1 vessel coronary artery disease. the dominant right coronary artery showed modest disease throughout the vessel including the pda and the plb with a 90% mid segment stenosis. the left main was normal with modest calcifications. the lad showed mild disease without a critical lesion. the lcx also demonstrated no angiographic evidence of flow limiting lesions. 2. resting hemodynamics revealed normal right and left filling pressures (mean ra pressure 11 mm hg, mean pcwp 13). the cardiac index was normal 2.74. 3. left ventriculography not performed. 4. successful ptca and stenting of the rca with overlapping 3.5 x 23 mm, 3.5 x 8 mm, and 3.5 x 33 mm cypher des. the procedure was comlicated by abrupt vessel closure resulting in cardiac arrest. this was treated successfully and final angigoraphy revealed no residual stenosis, no apparent dissection, and normal flow (see ptca comments). final diagnosis: 1. one vessel coronary artery disease. 2. successful placement of three drug-eluting stents in the rca. brief hospital course: this is a 62 y/o male s/p stent to the rca, stemi in the cath lab, vt/ vf, multiple shocks who was tranferred to the ccu following cardiac arrest in the cath lab. . 1. ischemia :the patient was maintained on integrillin x 18 hours. he was successfully stented went into cardiac arrest (vt/vf) and was shocked multiple times. from the cath lab the patient was transferred to the ccu. the patient was monitored in the ccu and later transferred to the floors with no complications in his course. he was maintained on aspirin, plavix and lipitor. a ace-i was not initially started because of the patient's period of hypotension in the cath lab. sbps fell to the 30s. 2. pump: patient's ef was estimated to be 40% in . 3. rhythm: in the cath lab, the patient was went into vt/vf, was then shocked multiple times and later found to be in afib. an amiodarone gtt was started. a dopamine gtt had been started but d/c prior to the patient leaving the cath lab.once in the ccu the patient was found to be in nsr. amiodarone drip was later d/c. the patient remained in nsr for the remainder of his hospital course. 4. respiratory function: the patient was intubated during the cardiac arrest but was succesfully extubated the following day. 5. renal function: patient had elevated bun/cr 32/1.6 and decreased uop which responded to ivf. at the time of discharge the patient was instructed to drink a liter of fluids x 3 days. at the time of followup in the cath lab in two weeks, dr. would decide whether or not to start an ace-i. 6. dispo: the patient was instructed that the cath lab would be contacting him in 2 weeks about an appointment. he was also given an appt for f/u with dr. in 2 months. the patient was instructed to followup with his pcp 1 week of medications on admission: nifedipine 60 daily plavix 75 daily colchicine 0.6 daily lipitor 20 daily aspirin 81daily mvi discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 30 days. disp:*30 tablet(s)* refills:*2* 3. atorvastatin calcium 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol succinate 100 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: ventricular fibrillation and ventricular tachycardia following rca stent placement with stemi discharge condition: good. discharge instructions: you must contact medical services immediately if you should experience any chest pain, shortness of breath, numbeness, or tingling. you can resume normal activity but you can not resume any activity that involves lifting or any type of exertion. for the next 3 days you must consume 1 liter of fluid per day. followup instructions: you must follow up with dr. in 2 months. his office is located on the in the building, . your appointment is scheduled for , at 9:30am. please feel free to call the office if you have any questions about your appointment tel:. you will be contact by cardiac cath lab to followup with dr. in 2 weeks for your peripheral disease. at that point dr. will look at your renal function lab values and decide whether or not to start you on an another medication, ace-inhibitor. you will need to make an appointment in 1 week to see your pcp . . provider: study where: cc clinical center radiology phone: date/time: 9:00 provider: , m.d. where: cardiac services phone: date/time: 1:00 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of endotracheal tube Right heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Peripheral vascular disease, unspecified Ventricular fibrillation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: : exploratory laparotomy, lysis of adhesions, ascites, drainage and open appendectomy. , , , : egd (endoscopy of upper gastrointestinal tract) : emg (to evaluate foot drop) : sigmoidoscopy : colonoscopy history of present illness: mr. is a 66yo man with a history of cad (s/p rca des ), chf (ef 40%-->60%), htn, and pud complaining of several months of abdominal pain. he describes the pain as generalized (worst in lower quadrants), constant, severe, exacerbated by eating, alleviated with burping, and notes associated significant weight loss (unable to quantify). he denies fever, chills, nausea, vomiting, diarrhea, melena, hematochezia, and never had similar pain prior to several months ago. . he was admitted / for this abdominal pain and underwent a workup including abdominal ct, mri, mra, mrcp, egd, and eus with fna of a pancreatic lesion in the body. the etiology of his abdominal pain was unclear; the differential at this time included pud, pancreatic malignancy, or mesenteric ischemia. at a followup appointment with his pcp , he developed severe pain and was brought to the ed by ambulance. physical exam was concerning for llq tenderness without rebound or guarding and labs were notable for wbc count of 14.1. ct abdomen revealed mildly distended loops of bowel without transition point so surgery was consulted concerning possible sbo, which was refractory to conservative management. on he underwent exploratory laparotomy with loa, appendectomy, drainage of hemorrhagic ascites. appendix pathology is notable for chronic arteritis, and so rheumatology was consulted and patient was transferred to the medicine service. . on the floor at time of transfer to medicine, the patient reports mild lower abdominal discomfort (+prior episodes) unlike the pain that brought him to the hospital (which resolved after surgery). . in the ed, initial vs: 10 97 88 172/97 18 100. he appeared very uncomfortable, and was very tender to palpation at llq, but no guarding or rebound. guiac was positive per rectal. he appeared dry. he received levo, flagyl, morphine, and zofran. . currently, patient reports his pain is about . he denies nausea/vomiting. he has no chest pain or shortness of breath. no fever, chills, no cough. . ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: - hypertension - hyperlipidemia, last ldl 55 and hdl 52 (). - coronary artery disease, status post right coronary artery drug-eluting stent in , complicated by vf. - left ventricular systolic dysfunction, ef 40%. - peripheral vascular disease status post bilateral lower extremity revascularizations s/p pta of b/l sfa in , atherectomy of peroneal artery and pta on the r in . - ectatic infrarenal aorta, 2.8 cm greatest diameter - renal insufficiency - peptic ulcer disease (noted on scoping in ) - tobacco abuse, ongoing. - pancreatic lesion as above - history of prostate cancer treated with cyberknife radiation therapy. - history of gout social history: patient is divorced. lives alone. has 5 children but one of the kids live in . daughter lives in . quit smoking since the last admission a week ago. denies etoh (last drink a year ago) or illicit drug use. used to work as a welder. family history: no family history of gi malignancy or gi disease. physical exam: vitals: t: 97.7 p: 73 bp: 187/95 r: 22 o2: 99%ra i/o (24hr): 1310/1350 general: awake, watching television, nad heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp 8cm, no lad lungs: good air entry throughout, bibasilar crackles, no wheezes/rhonchi cv: regular rate and rhythm, s1, s2, +s4 at apex, 2/6 systolic ejection murmur at base, no s3 or rub abdomen: well healing midline incision with surrounding ecchymosis, no erythema or drainage, soft, appropriately tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly or masses ext: warm, well perfused, no clubbing, cyanosis or edema neuro: alert and oriented x3. strength 5/5 in upper extremities, hip flexion, knee extension bilaterally; 0/5 dorsiflexion, plantar flexion on right; plantar and dorsi-flexion on left; 2+ patellar reflexes, absent ankle reflexes; sensation to light touch grossly intact in lower extremities, (sensory defect to temp/pinprick on lateral aspect of right foot/leg per neurology). . at discharge: avss/afebrile gen: thin male in nad. heent: sclerae anicteric. o-p clear. poor dentition. neck: supple. lungs: cta(b) cor: rrr; s1, s2, +s4, no m/r abd: well healed midline incision. nondistended, soft, mildly tender to palpation in luq, rlq. extrem: wwp; no c/c, mild pedal edema neuro: a+ox3. motor - normal tone except low in distal rle. strength 5/5 bilat in ip, quad. hamstring r, 5/5 l. ant tib r, 5/5 l. gastroc r, 5/5 l. foot inversion and eversion 0/5 r and 5/5 l. te r, 5/5 l. tf r, 5/5 l. dtrs 2+ bilat knees and absent bilat ankles. sensory - decreased sensation to cold and pinprick on dorsal and plantar surfaces of r foot, lateral worse than medial. also decreased over lateral lower leg up to mid lower leg. no proprioception of toes on right foot, proprioception of right ankle intact. decreased vibratory sensation on toes of right foot, normal over medial malleolus. sensation on left foot normal throughout. pertinent results: admission lab: 12:15pm blood wbc-14.1*# rbc-3.92* hgb-10.9* hct-33.4* mcv-85 mch-27.9 mchc-32.7 rdw-15.7* plt ct-141* 12:15pm blood neuts-90.9* lymphs-5.1* monos-3.2 eos-0.3 baso-0.6 12:15pm blood plt ct-141* 12:15pm blood pt-13.0 ptt-32.2 inr(pt)-1.1 12:15pm blood glucose-109* urean-24* creat-1.1 na-137 k-4.3 cl-95* hco3-27 angap-19 12:15pm blood alt-15 ast-19 alkphos-83 amylase-56 totbili-0.5 12:15pm blood calcium-9.2 phos-4.5# mg-1.9 01:22pm blood lactate-2.6* 09:18pm blood lactate-0.7 ------------------- discharge labs: wbc 4.5, hb 8.8, hct 27.2, plt 83 na 137, k 4.8, cl 107, hco3 25, bun 38, cr 0.9, glc 110 ------------------- studies: mri/mrcp (): 1. 0.8 x 1.5 cm lesion in the distal body of the pancreas with relative enhancement, might correspond to the pancreatic neoplasm. short term follow up in 3 months or eus study is recommended for further evaluation. 2. small amount of ascites. . egd (): - erythema, friability, granularity and congestion in the pylorus (biopsy) - a few scattered polypoid lesions were noted in the second part of duodenum. (biopsy) otherwise normal egd to third part of the duodenum - bx: a. antrum "hilar": chronic inactive gastritis; focal intestinal metaplasia; stains for h. pylori will be sent as an addendum.. b. duodenum, polyp: duodenal mucosa, no diagnostic abnormalities recognized; multiple levels have been examined. . eus (): - submucosal mass with overlying hemorrhagic mucosa was noted in the second part of the duodenum - unclear clinical significance. - eus: a 1.5 cm poorly-localized abnormal area was noted in the pancreas body - this showed features of focal chronic pancreatitis, however, a neoplasm could not be ruled out - fna was performed. otherwise normal appearing pancreas. - cytology : pancreatic fna: atypical. many isolated and small groups of columnar mucinous-type benign-appearing epithelial cells; these may represent low-grade panin (mucinous metaplasia) in association with chronic pancreatitis or a mucinous cystic neoplasm. degenerated and reactive glandular cells. benign-appearing squamous cells consistent with esophageal contamination. . mra abd (): 1. stable fusiform aneurysm of the abdominal aorta. widely patent sma and celiac arteries. the inferior mesenteric artery shows narrowing at its orgin, however remains patent. 2. stable t1 hypointense lesion in the body of the pancreas which remains indeterminate. . ct abd/pelvis (): - a few mildly distended loops of small bowel with no definite transition point. a paralytic ileus is favored; however, partial small-bowel obstruction cannot be entirely excluded. - cachexia. - severe atherosclerotic calcifications of the aorta and iliac arteries and sma and celiac arteries with stable fusiform aneurysmal dilatation of the aorta and focal aneurysmal dilatation of the iliac arteries as compared to ct from . . mr enterography (): 1. partial bowel obstruction likely explained by adhesions which could be due to prior prostate radiotherapy. 2. bilateral renal cysts. 3. atherosclerosis with 3.5 cm infrarenal aortic aneurysm. . mr l spine w/o contrast (): 1. multilevel degenerative changes of the lumbar spine as described above, most pronounced at l4-5, without evidence of high-grade spinal canal narrowing at any level. additional multifactorial multilevel neural foraminal narrowing as described above. 2. no evidence of metastatic disease to the lumbar spine on this noncontrast mri examination. . mr lumbar spine (with contrast ): multilevel degenerative changes of the lumbar spine, most pronounced at l4-5, without evidence of high-grade spinal canal narrowing at any level. no evidence of metastatic disease to the lumbar spine. . egd (): abnormal mucosa in the stomach and duodenum. polyp in the second part of the duodenum. abnormal mucosa in the duodenum (biopsy showed mildly active duodenitis). duodenal ulcer. . emg (): complex, abnormal study. there is electrophysiologic evidence for a severe, subacute and ongoing right sciatic neuropathy with axonal features. peroneal- innervated muscles are affected more than tibial-innervated muscles, and no axonal continuity was observed to tibialis anterior or extensor hallucis longus. the abnormal nerve conduction studies in the left lower extremity may reflect a concurrent, length-dependent polyneuropathy with axonal features, or, less likely, a polyradiculopathy. incidental note is made of a moderate median neuropathy at the right wrist. the myopathic units noted in short head of biceps femoris were not seen in any other muscle, and are a finding of uncertain clinical significance. the weakness noted in the right upper extremity does not appear to be due to an acute neurogenic process. . egd (): impression: -abnormal mucosa in the stomach - abnormal mucosa in the duodenum - polyp in the second part of the duodenum - abnormal mucosa in the duodenum (biopsy) - duodenal ulcer . tte (): mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , the findings are similar. . persantine-mibi (): no evidence of ischemia, continued mild global hypokinesis and lv dilation. . ecg (): normal sinus rhythm. st-t wave abnormalities that are most marked with t wave inversions in leads ii, iii, avf and v3-v6. . cta abd/pelvis (): 1. no evidence of bowel ischemia. 2. stable infrarenal aaa and bilateral iliac aneurysms. . egd (): - friability, granularity and nodularity in the whole stomach compatible with gastritis - the pyloric channel was edematous and friable. - friability and nodularity in the whole examined duodenum compatible with duodenitis or ? vasculitis - there was no active bleeding. there was no blood or coffee-ground liquid. - erythema and congestion in the antrum compatible with gastritis - otherwise normal egd to third part of the duodenum . sigmoidoscopy (): - angioectasias in the rectum - there was dark red blood coating along the mucosa of colon, which precluded us from examining the mucosa of colon. a large amount of dark red blood was also seen beyond the splenic flexure. however, we did not see bright red blood. - otherwise normal sigmoidoscopy to splenic flexure . colonoscopy (): - the terminal ileum was easily entered and appeared normal. - polyp in the descending colon - ulcers in the rectum (biopsy) - ulcers in the sigmoid colon, descending colon and distal transverse colon (endoclip, biopsy) - there was old blood throughout the colon. - otherwise normal colonoscopy to cecum and terminal ileum . gi bleeding study (): report pending . le dopplers (): 1. no evidence of dvt in either lower extremities. 2. left cyst. . cxr : 1. right lower lobe pneumonia. 2. kinking of proximal aspect of right internal jugular approach central venous catheter, recommend clinical correlation for function. . cxr: 1. worsening right lower lobe pneumonia. 2. kink at the proximal aspect of right internal jugular approach central venous catheter, recommend clinical correlation for function. . portable abdomen: 1. worsening right lower lobe pneumonia. 2. kink at the proximal aspect of right internal jugular approach central venous catheter, recommend clinical correlation for function. . cxr: as compared to the previous radiograph, there is no relevant change. the subtle right lower lobe opacity has not increased in extent or severity. unchanged course and position of the monitoring and support devices. . cxr: status post extubation with otherwise no significant change. . cxr: as compared to the previous radiograph, the pre-existing right basal parenchymal opacity is unchanged in extent and appearance. no newly appeared focal parenchymal opacity. unchanged size of the cardiac silhouette. minimal tortuosity of the thoracic aorta. . unchanged course and position of the left-sided picc line. the right venous introduction sheath has been removed in the interval. . microbiology: stool clostridium difficile toxin a & b test: negative. blood culture, routine (final ): corynebacterium species all other blood/urine cxs negative . pathology: pathology: appendix: arteritis, predominantly chronic (transmural inflammation) with organizing thrombi, but focally acute and necrotizing. duodenum: mildly active duodenitis descending colon and rectum biopsies: colonic mucosa with focal ischemic colitis and extensive ulceration. brief hospital course: assessment: 66yo man with a history of cad (s/p rca des ), pvd, aaa, htn, hyperlipidemia, and pud admitted with acute worsening of chronic abdominal pain, right foot drop, and small bowel obstruction diagnosed with polyarteritis nodosa. course was complicated by acute gi bleeding and ecg changes. . course reviewed by problem: . #. polyarteritis nodosa. after presenting with abdominal pain and small bowel obstruction that did not respond to conservative management, the patient was taken to the or on . appendectomy revealed arteritis. rheumatology was consulted, and given the findings of gi symptoms and weight loss, pathologic arteritis, and sciatic neuropathy (see below), polyarteritis nodosa was diagnosed. pertinent labs included negative anca, negative viral hepatitis serologies (b&c), crp of 25.4 that came down to 3.1, esr of 102 that came down to 19, negative cryoglobulin, urine protein/creatinine of 0.2. starting , he was treated with iv steroids for three days, followed by po prednisone 50 mg po daily, and cyclophosphamide 75 mg po was started and titrated up to 100mg po daily, then dc'd due to decreasing white count, restarted on at 75 mg daily given stable cbc recs. the cyclophosphomide whould be taken with 1-2l of fluids; he should receive iv fluids if unable to tolerate po. usual course is 6 months but may be adjusted based on ability to tolerate. he was switched to iv steroids while having gi bleeding, which was tapered to methylprednisolone 16 mg iv q 12h on discharge; could consider change to prednisone 40mg if unable to give iv steroids. he will continue on this dose of steroids and cyclophosphamide on discharge, with weekly monitoring of cbc for evidence of toxicity and further gi blood losses. weekly cbc should be faxed to rheumatologist dr. at for review and recommendation regarding course of cyclophosphamide and steroids. he will follow up with rhematology on at 9am. while on steroids, he required an insulin sliding scale and was also started on atovaquone for pcp prophylaxis, both of which were continued on discharge. he was also started on calcium and vitamin d and will need a dexa scan and consideration of bisphosphonate as an outpatient. . #. acute gastrointestinal bleeding. on , the patient had two episodes of melena overnight and a hematocrit drop from 27.5 to 22.9 over 24 hours; he was transfused 2 units with appropriate response in hematocrit to 30.7. he never became hypotensive. egd revealed diffuse gastritis and duodenitis and a nonbleeding duodenal ulcer, but nothing to explain the acute drop in hematocrit. he continued to have bloody stools/melena and his hematocrit trended down, requiring the transfusion of one more unit prbcs. the patient was transferred to the icu on for hypotension in the setting of gib. he was electively intubated for procedures. he had a colonoscopy, which showed multiple ulcerations in the left colon and rectum. biopsy revealed focal ischemic colitis. no source of overt bleeding was noted, however the patient continued to ooze slowly and required units of prbcs per day, nearly 40 units total during the stay. he also required several platelet transfusions. hct was stable in the high 20s (27.2 on discharge) and plts in the 80s (83 on discharge) in the days prior to discharge and he was having no evidence of active bleeding. he will require further monitoring of his crit and prn transfusions for hct <25 and plt <50 at rehab; would recommend hct for several days until stable, then decrease to daily hct for several days, then frequency further decreased if also stable. he will continue pantoprazole po. . #. nutrition. the patient has had significant weight loss over the last six months, largely due to decreased intake and food fear secondary to postprandial pain. this pain has improved during the admission, but patient continues to require tpn to meet nutritional recommendations, especially as he has been npo in the setting of gib. his diet was advanced and pt was able to tolerate some pos prior to discharge. . #. leukocytosis: wbc 14.1 on admission. patient was afebrile, without localizing symptoms or signs of infection, negative chest radiograph, negative ua, urine culture, and blood cultures were negative. he received levo and flagyl in the ed, and was continued with iv cipro/flagyl for 10 days given concern of mesenteric ischemia. he remained afebrile throughout the hospitalization and wbc count trended down. in the icu, the patient had e/o rll infiltrate while intubated - he was initially started on vanc/zosyn/cipro for possible vap. however, as the pt improved quickly and it was more likely to be aspiration pneumonitis, the abx were discontinued on the 4th day. . #. hypertension: blood pressure was well controled on metoprolol iv when npo. pt maintained on metoprolol and captopril while in the icu - bp 130s-180s. on transfer to the floor, metoprolol was held to prevent blunting of hr response to gi bleed, and pt was switched to lisinopril and amlodipine for bp control. . #. hyperlipidemia: home dose simvastatin was restarted when able to tolerate oral intake. . #. coronary artery disease: patient is s/p right coronary artery drug-eluting stent in . home dose metoprolol and aspirin were restarted when tolerating pos, however then held in the setting of gi bleed. would recommend restarting as an outpt when stable. . #. left ventricular systolic dysfunction: ef 40% in , 45% in and >55% on . patient had no heart failure symptoms during this hospital stay. . #. right foot drop: experienced tingle of right foot two days after suregery with subsequent worsening right lower extremity weakness and numbness. neurology consulted. found severe sensory/motor deficits in (r) l5 and moderate deficits in s1 territories on examination. l-spine mri demonstrated multilevel degenerative changes of the lumbar spine, most pronounced at l4-5, without evidence of high-grade spinal canal narrowing at any level. additional multifactorial multilevel neural foraminal narrowing. no evidence of metastatic disease to the lumbar spine on this noncontrast mri examination. as recommended, a specific lumbo-sacral plexus mri following the sciatic nerve with and without contrast was performed, which was unchanged from the mri perfomed the day before. a review of the studies by neurology and radiology attendings determined that the spine imaging was unremarkable. his presentation was felt to likely represents compressive neuropathy in distal sciatic or proximal pernoneal. it was recommended to continue agressive pt, and, if not improved in weeks, to perform emg/nc. he was scheduled for neurology follow-up after discharge. physical and occupational therapy were consulted. the patient was fitted with a orthotic splint boot which should be used on discharge. neurology follow up should be scheduled on dc. . #. post-operative course: on , the patient underwent exploratory laparotomy, lysis of adhesions, ascites, drainage and open appendectomy, which went well without complication (reader referred to the operative note for details). the etiology of the small bowel obstruction was found to be due to pelvic adhesions. after a brief, uneventful stay in the pacu, the patient arrived on the floor npo with an ng tube, on iv fluids and antibiotics, with a foley catheter in place, and a dilaudid pca for pain control. he was continued on tpn. the patient was hemodynamically stable. . post-operative pain was initially well controlled with the pca, which was converted to oral pain medication when tolerating clear liquids. after a clamping trial, the ng tube was discontinued on pod#4, and the patient was started on sips of clears on pod#5. diet was progressively advanced as tolerated to a regular diet with ensure plus by pod#7. he was restarted on his home medications on pod#6. he was weaned off tpn on pod#8. the foley catheter was discontinued at midnight of pod#2. the patient subsequently voided without problem. the midline incision with staples experienced sigificant serosanginous drainage for the first two post-operative days, which was scant by pod#2. the patient's hematocrit remained stable. the incison otherwise remained clean and intact. . # deconditioning: pt experienced difficulty ambulating due to weakness and abd pain. after working with pt for several days on the general medicine floor, pt able to ambulate to the door. morphine was used for pain control prn. he will require further pt in rehab for maximum recovery medications on admission: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 4. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 5. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 6. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for bloating. 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 8. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 12. aspirin 81 mg tablet sig: one (1) tablet po once a day. discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation: over-the-counter. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for fever or pain. 3. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 4. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 5. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools. 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 9. cyclophosphamide 50 mg tablet sig: 1.5 tablets po qam: pt should drink 1-2 l of fluid with dose. if unable to tolerate this volume of fluid, please give ivf. please continue taking until your rheumatologist tells you to stop. . 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 12. atovaquone 750 mg/5 ml suspension sig: one (1) po daily (daily). 13. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 14. humalog 100 unit/ml solution sig: one (1) unit subcutaneous four times a day: please take according to inpatient sliding scale while on steroids. 15. morphine 2-4 mg iv q 6 hrs prn pain 16. methylprednisolone sodium succ 500 mg recon soln sig: sixteen (16) mg intravenous twice a day: please continue taking until your rheumatologist tells you to stop. 17. outpatient lab work please check cbc x 3 days. can decrease frequency to daily once stable. 18. outpatient lab work please check cbc once weekly (monday) and forward to rheumatologist dr. (fax ). discharge disposition: extended care facility: - discharge diagnosis: primary: polyarteritis nodosa . secondary: 1. small-bowel obstruction secondary to pelvic adhesions. 2. hypertension 3. coronary artery disease 4. right foot drop due to sciatic neuropathy 5. malnutrition 6. acute gastrointestinal bleed discharge condition: the patient is hemodynamically stable, without respiratory distress or uncontrolled pain. hematocrit stable for several days with no evidence of active bleed. mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to to evaluate your abdominal pain. you were found to have a small bowel obstruction and were taken to surgery to lyse these adhesions and take out your appendix. the pathology from the appendix showed that you have arteritis (inflammation of blood vessels). you also developed right foot drop, also thought to be from the arteritis. we are treating you with prednisone and cyclophosphamide for the arteritis. while you were in the hospital you were bleeding from your gastrointestinal tract, which is why you had endoscopy. the source of the bleeding was likely due to the arteritis in your small bowel. you received blood transfusions to keep your blood counts within normal limits while you were bleeding. your blood counts were stable for several days prior to discharge and you tolerated an oral diet. . please take all medications as prescribed and follow up with the doctors listed below. the following changes have been made to your medications: -stop taking metoprolol given your recent gi bleed. this should be slowly restarted as an outpatient given that you have coronary artery disease -increase your lisinopril to 40 mg daily -stop taking terazosin -stop taking ferrous sulfate as it may make it difficult to detect if you are having a gi bleed. you can restart this when you are stable -stop taking aspirin in the setting of your gi bleeding -stop taking simethicone -your nicotine patch was held while you were in the hospital as you didn??????t seem to need it. you may restart it as needed -start taking methylprednisone 16 mg iv q 12 hrs until rheumatology tells you to stop -start taking cyclophosphamide 75 q am for planned 6 month course if tolerated or until rheumatologist tells you to stop -start taking vitamin d and calcium -start taking insulin and atovaquone while you are on steroids -start taking amlodipine 5 mg for blood pressure -start taking morphine as needed for pain . please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. . incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. followup instructions: please schedule the following follow-up appointments prior to discharge from rehab: - with your primary care physician, , md, mph () - , md () in general surgery - , md () in gastroenterology . please go to the following follow up appointments: . department: rheumatology when: monday at 9:00 am with: , md building: lm bldg () campus: west best parking: garage . department: neurology when: thursday at 10:00 am with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Parenteral infusion of concentrated nutritional substances Exploratory laparotomy Esophagogastroduodenoscopy [EGD] with closed biopsy Other lysis of peritoneal adhesions Arteriography of other intra-abdominal arteries Closed [endoscopic] biopsy of large intestine Flexible sigmoidoscopy Other appendectomy Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified protein-calorie malnutrition Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Chronic systolic heart failure Other ascites Hemorrhage of gastrointestinal tract, unspecified Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) Long-term (current) use of aspirin Polyarteritis nodosa Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Other acquired deformities of ankle and foot

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transferred from with with tracheal stenosis following previous admission with intubation for unclear dka and coma. major surgical or invasive procedure: rigid bronchoscopy for tracheal dilation history of present illness: 69 year old woman with type ii dm was admitted to hospital for dka and coma c/b respiratory failure. she was intubated x8 days, deintubated, and reintubated x3 days. post intubation experienced dysphonia and dysphagia. transferred to rehab to . at home she started to experience increased bowel sounds and le edema. she also experienced cough and stridor. these symptoms ultimately resulted in an admission to hospital () and transfer to (). there she had flexible bronchoscopy and ct scan, revealing significant stricture to 50% about 3-4 cm distal to vocal cords. she was finally transferred to () for further evaluation and management. past medical history: 1) type ii dm 2) anemia 3) claustrophobia and anxiety 4) pneumonitis 5) ovarian cyst 6) appendectomy in the remote past social history: patient lived alone in . she suffers an unclear "short-term memory loss." since her admission to hospital and discharge from rehab, she has lived with her son in . he has taken responsibility for her medical management but has had to miss work to do so. he is now feeling the strain of this responsibility and understands that his mother may need nursing care. history is unclear for use of alcohol, tobacco, and illicits. family history: unclear. physical exam: on admission to tsicu heent: perrla. oral dry/pink. neck no jvd or bruits. thyroid enlargement noted. stridor noted. cv: rrr. s1 s2. tachy. pulm: audible wheezing without stethoscope. decreased breath sounds with expiratory wheezes. gi: positive bs. abd soft, nontender. gu: cloudy urine via foley. extrem: no edema or clubbing. paplable pulses. neuro: oriented to year, season, and month. looks at calendar to determine day. knows herself, her son, her bd, is poor historian. not sure which hospital she is in but does know she is in hospital. moves all limbs purposefully and to command. articulates needs and wishes. wants all shades and doors open due to claustrophobia. pertinent results: lab data: cbc: blood wbc-17.2* rbc-3.51* hgb-9.4* hct-29.4* mcv-84 mch- 26.9* mchc-32.1 rdw-18.2* plt ct-549* coags pt-12.4 ptt-21.6* inr(pt)-1.1 plt ct-549* hemolytic ret aut-1.6 chemistry glucose-212* urean-12 creat-0.5 na-145 k-3.8 cl-105 hco3- 28 angap-16 calcium-9.0 phos-3.6 mg-1.8 urine blood-neg nitrate-neg protein-neg glucose-1000 ketone- neg bilirubin-neg urobiln-neg ph-6.5 leuk-neg other tsh 3.7 rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. ekg normal sinus rhythm. left atrial abnormality. rsr' pattern in leads v1-v2 with t wave inversions in leads v1-v2 suggest possible anteroseptal ischemia. clinical correlation is suggested. no previous tracing available for comparison ct trachea 1. high-grade (more than 90%), focal proximal tracheal stenosis, 4 cm below the vocal cords, extending less than 1 cm in cranicaudad length. these findings are most consistent with post-intubation benign tracheal stenosis given history of prior intubation. 2. mucous plugging involving the right bronchus intermedius and right lower lobe bronchus. 3. small noncalcified lung nodule in the right middle lobe measuring 6 mm. followup ct in 3 months is recommended to assure stability. 4. evidence of prior granulomatous disease. cxr single ap view of the chest is obtained and is compared with the prior radiograph performed . no pneumothorax is visualized. left basilar subsegmental atelectasis. small small granuloma in the left upper lobe. otherwise no change since the prior examination. brief hospital course: 1. hyperglycemia. patient was admitted taking metformin/glipizide and getting lantus (30 units) qhs. at she was on an insulin drip for blood glucose levels in the 300s, which subsequently fell to the 50s. in the tsicu glucose levels ranged 100-270 on insulin drip. consult note assessed insulin resistance and recommended discharge on patient's regimen of metformin and amaryl. but due to refractory glucose levels (raning 166-343) on the floor, she was started on an hiss 70/30 with daily titration for serum glucose. note suggested this was a reasonable starting point for improving glycemic control. she was maintained on a diabetic diet. at time of discharge, the patient was taking 70/30 insulin ; plan was for administration by her son or self-admnistration under the direct supervision of her son. 2. tracheal stenosis. patient underwent bronchoscopy . report found post intubation tracheal stenosis, status post electrocautery knife and balloon dilatation and mitomycin c application with final internal diameter of 15 mm. following the procedure sa02 was 95% on 5l nc. thoracic surgery progress note indicated lungs ctab. sa02 was 96% ra and remained normal through the rest of her hospital course. plan was for follow-up with interventional pulmonology in weeks. 3. anemia. patient had microcytic anemia with low iron and normal tibc. hct on adsmission was 29.4. this is suggestive of iron deficiency anemia but warrants outpatient follow-up with colonoscopy. medications on admission: (as per discharge summary). 1) lipitor which she says she has not been taking recently, 2) ? of glucophage 3) ? of metoprolol 4) ? of vitamin e 5) aspirin 6) lasix discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. ct chest small noncalcified lung nodule in the right middle lobe measuring 6 mm. followup ct in 3 months is recommended to assure stability 3. diltiazem hcl 120 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily). disp:*30 capsule, sust. release 24hr(s)* refills:*2* 4. atorvastatin 10 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 5. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. hexavitamin tablet sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 8. cyanocobalamin 1,000 mcg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. insulin nph-regular human rec 100 unit/ml (70-30) suspension sig: fifty five (55) units subcutaneous once a day: just before eating breakfast. disp:*qs units* refills:*2* 10. insulin nph-regular human rec 100 unit/ml (70-30) suspension sig: fifty (50) units subcutaneous once a day: just before eating dinner. disp:*qs units* refills:*2* 11. lancets misc sig: one (1) miscell. three times a day. disp:*1 box* refills:*2* 12. glucometer dex test sensors strip sig: one (1) miscell. three times a day. disp:*1 box* refills:*2* 13. syringe syringe sig: one (1) miscell. twice a day. disp:*1 box* refills:*2* discharge disposition: home discharge diagnosis: diabetes mellitus type 2 anxiety pneumonitis ovarian cyst appendectomy tracheal stricture discharge condition: good; improved discharge instructions: call interventional pulmonary for: fever, shortness of breath, chest pain, coughing up blood. take insulin twice per day under supervision of family member. please be sure to eat immediately after taking insulin, as your blood sugar can get too low. it will be very important that you take all your medications as prescribed - this is including your insulin. in addition, please be sure to call and make an appointment to see your pcp 1-2 weeks. you need to be worked-up for your anemia deficiency anemia. please be sure you have a colonoscopy done through your pcp. followup instructions: 1. call interventional pulmonary for an appointment in 4 weeks for bronchoscopy procedure and re-evaluation consultation. 2. call to make a follow-up appointment with your pcp 1 week. 3. small noncalcified lung nodule in the right middle lobe measuring 6 mm. followup ct in 3 months is recommended to assure stability. 4. you are anemic with possible iron deficiency. you should speak with your primary doctor about an evaluation for this, including a colonoscopy if this has not been done to ensure you do not have an early colon cancer. 5. your diabetes is difficult to manage. you can consider making a follow-up appointment at the diabetes center to help control your diabetes over the long-term. you may call them at and schedule an appointment. Procedure: Other operations on trachea Local excision or destruction of lesion or tissue of trachea Diagnoses: Chronic airway obstruction, not elsewhere classified Iron deficiency anemia, unspecified Other diseases of lung, not elsewhere classified Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Other diseases of trachea and bronchus

history of present illness: patient is an 86-year-old female, who is admitted to on to the medical intensive care unit stay after pea arrest complicated by bowel resection. the patient was noted to have urosepsis. was placed on meropenem and linezolid with declining renal function. at this time, the patient's family declined hemodialysis or peritoneal dialysis. was medically managed with intent to transfer to rehabilitation. past medical history: 1. acute renal failure, status post pea arrest. 2. septic shock. 3. acute renal failure. 4. acute respiratory failure. 5. anoxic brain injury. 6. anemia. 7. dic. 8. heparin-induced thrombocytopenia. medications: 1. miconazole powder qid as needed. 2. levothyroxine 75 mcg po q day. 3. metoprolol 50 mg po tid. 4. lansoprazole 30 mg po q day. 5. dilantin 100 mg po tid. 6. hydralazine 25 mg po qid. 7. isosorbide dinitrate 20 mg tid. 8. amlodipine 5 mg po q day. 9. lidocaine jelly 2% apply to mucous membranes . 10. metamucil one packet . 11. acyclovir ointment topically qid. 12. linezolid 600 mg q12 for 10 days. 13. meropenem 500 mg q day for 10 days. 14. morphine 2 mg q2 prn pain. hospital course: patient is status post pea arrest and urosepsis with septic shock noted, aggressive fluid resuscitation with appropriate blood pressure maintenance. patient continued on iv antibiotic therapy in lieu of aggressive therapy. the patient developed acute on chronic renal failure. family was not amenable to dialysis at that time. patient's respiratory status improved, although primary problem of renal failure did not resume. picc line was placed on for continuous iv antibiotics. the patient was noted to have thrombocytopenia secondary to heparin induced thrombocytopenia. tube feeds were advanced to 35 ml an hour with continual residual checks, and discharged from micu directly to for continual rehabilitation. discharge medications: 1. miconizol powder qid as needed. 2. levothyroxine 75 mcg po q day. 3. metoprolol 50 mg po tid. 4. lansoprazole 30 mg po q day. 5. dilantin 100 mg po tid. 6. hydralazine 25 mg po qid. 7. isosorbide dinitrate 20 mg tid. 8. amlodipine 5 mg po q day. 9. lidocaine jelly 2% apply to mucous membranes . 10. metamucil one packet . 11. acyclovir ointment topically qid. 12. linezolid 600 mg q12 for 10 days. 13. meropenem 500 mg q day for 10 days. 14. morphine 2 mg q2 prn pain. followup: dr. at center. of note, the patient returned following day with coffee-ground emesis with change to comfort care measures and expired on as a result: 1. urosepsis. 2. acute renal failure. 3. status post pea arrest. 4. bowel resection. 5. coffee-ground emesis. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Cardiopulmonary resuscitation, not otherwise specified Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Thrombocytopenia, unspecified Subendocardial infarction, initial episode of care Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified septicemia Acute respiratory failure Cardiac arrest Other shock without mention of trauma Pneumonia due to Klebsiella pneumoniae

history of present illness: st elevation myocardial infarction. was a 61-year-old man transferred acutely from hospital after experiencing chest pain and noting to have st elevation in the lateral precordial leads. the patient had a background history of coronary artery disease, status post coronary artery bypass graft in , stent in and . he also had a history of diabetes, hypertension, and hypercholesterolemia. the patient was urgently transferred to the cath lab, arriving at approximately 1:45 in the morning, at which point he was awake, alert with a blood pressure of 80 to 90 systolic and complaining of chest pain. his cardiac exam revealed normal heart sounds and bibasilar rales. abdominal exam, neurological exam, musculoskeletal exam were all within normal limits. pertinent lab, x-ray, ekg, and other tests: ecg revealed st elevation in v5, v6, i, and avl. it was felt the patient needed urgent catheterization, plus or minus stenting for acute st elevation myocardial infarction. the patient underwent coronary angiography revealing occlusion of his 3 vein grafts and also acute thrombosis of the distal end of his left internal mammary artery graft to his left anterior descending artery. the native blood vessels were chronically occluded proximally. the procedure was complicated by difficulty in accessing the vein grafts and establishing which of his blood vessels was the culprit lesion. the patient had a stent placed to his distal left internal mammary artery as this anastomosed with the lad. this procedure went relatively easily, and there were no acute complications. however, while the patient was being brought back to the coronary care unit he vomited on the way to the elevator and then suffered a cardiac arrest. the initial rhythm was ventricular tachycardia. precordial thump failed to restore a sinus rhythm, so the patient was shocked once. his rhythm converted to sinus bradycardia, so 1 mg of atropine was given. the patient was resuscitated using 1 further mg of atropine, 1 mg of epinephrine, 300 mg of iv amiodarone. his rhythm returned to his previous atrial fibrillation, and he was placed back on the cath lab table. an intraaortic balloon pump was inserted and a stat bedside echo done. the echo did not reveal any acute mechanical complication of his myocardial infarction. temporary ventricular pacing and a dopamine infusion were started. repeat catheterization showed that the stent to his lima was patent. because of concern that the anterior descending artery disease may have caused the cardiac arrest, the multiple stenoses were attempted to be dilated. however, this proved to be extremely difficult due to heavy calcification in the blood vessels. despite attempting dilatation and giving increased doses of pressors, atropine, and bicarbonate the patient was unable to recover a perfusing rhythm and he died at 06:57 a.m. the family were informed of his death, and his course in the hospital was explained to them in detail. cause of death: cardiogenic shock from myocardial infarction. medications on discharge: none obviously. discharge followup: none obviously. , Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Implant of pulsation balloon Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Acute myocardial infarction of other anterior wall, initial episode of care Cardiac complications, not elsewhere classified Cardiac arrest Cardiogenic shock Ventricular fibrillation Coronary atherosclerosis of artery bypass graft

80 year-old man brought from after being found lying by a radiator in his house, where he had apparently been for at least a couple of days.(the neighbor had not seen him for that long). he had been intubated, given amps of nahco3 and fluid boluses. antibiotics started for presumed aspiration pneumonia. ct scan neg. for ich. nkda. past medical history not known. neuro: non-responsive on first arrival. he did start to move his right hand and does make some facial movements. pupils are 2mm; right pupil sluggish; left pupil brisk. he had received 2 doses of mso4 at , ivp, and received 2 mg mso4 ivp on arrival to micu. cv: junctional rhythm, rate in 60s. 12-lead done on arrival. a-line right radius with good tracing. bp somewhat labile--low hundreds to 160 systolic over 40s to 60s. patient has no pedal pulses. popliteal by doppler. good radial pulses. both feet are blue and necrotic. left hand is dusky, nails are bright blue. small finger of right hand is necrotic. please see serial cks. pt. has rhabdomyolysis. cks 6000 to 5000. resp: imv, ps of 10. fio2 .40. rate of 8; patient breathing 8 to9. please see abgs. patient has a metabolic alkalosis, ph 7.5, essentially unchanged during the night. tidal volumes 400 to 600s. lung sounds are clear. patient has no secretions, although suctioned via ett, and lavaged with ns x1. gi/gu: foley draining copious amounts of clear yellow urine. hypoactive bowel sounds. abdomen cachectic, soft. no stool. ngt checked for placement and is patent for gastric meds. skin: patient has several burn areas with mild sero-sanguinous drainage, and crusted and blackened surface. coccyx area, right scapula, and upper back are burned. upper back has duoderm which is intact. order written to change q 3days and prn. silvadene ordered for other areas. right ear also is burned on upper outer rim and received silvadene. areas are covered with telfa dressings. id: afebrile, vanco x 1, rocephin ordered q day. plan: nephew in was by md. re: dnr status. patient is currently full code. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Acute kidney failure, unspecified Defibrination syndrome Pneumonitis due to inhalation of food or vomitus Gangrene Coma Blisters, epidermal loss [second degree] of back [any part] Accident caused by other hot substance or object Other disorders of muscle, ligament, and fascia

history of present illness: the patient is a 80 year-old male who is brought to by ems after a neighbor had not seen the patient for two to three weeks. ems found the patient slumped over the radiator unresponsive with a faint tachycardic pulse. he was intubated and supported on imv. at the time his vital signs were reportedly temperature 93.3, heart rate 148, blood pressure 124/86, respiratory rate 16. the emergency room nurse noted a blood pressure of 50/palp and a respiratory rate 20. ct scan at the time was negative for intracranial hemorrhage. fluid boluses were negative with amps of sodium bicarb. no arterial blood gases was performed prior to this treatment. the patient was started on broad spectrum antibiotics at for presumed aspiration pneumonia. the patient's skin was noted to be necrotic in different areas including his toes, feet, fingers and the tip of his penis. in addition the patient had an eschar over the sacrum reportedly over the skin that was intact with the radiator and an abrasion over the left scapular. these areas were treated with silver sulfadiazine duoderm dressings. he was transferred here for further treatment of his ischemic extremities and management of his ventilatory status. past medical history: none known. he has reportedly not seen a doctor in more then 20 years. allergies: no known drug allergies. medications on transfer: digoxin .125 mg intravenous q.d., ceftriaxone 1 gram intravenous q.d., ciprofloxacin 400 mg intravenous q.d., metronidazole 250 mg intravenous q 6 hours, ________________ 20 mg intravenous b.i.d., morphine sulfate 1 to 10 mg intravenous q one hour prn. the patient received two doses on the . social history: unable to obtain. the patient lives alone. family history: not obtainable. physical examination on admission: vital signs temperature 96.8. heart rate 65 and regular. blood pressure 140/45. vent settings simv 700 by 8, pressure support 10, peep of 5, fio2 .5, getting an o2 sat of 100%. he has a right subclavian and right art line in place. in general he is intubated and noted sedative drip is hanging. heent pupils are pin point bilaterally, mildly reactive, positive corneal reflex. sclera are anicteric. lungs decreased breath sounds at bases bilaterally. no wheezes, rhonchi or crackles. heart regular rate and rhythm with s1 and s2. no s3 or s4. abdomen positive abdominal bruit in abdomen, pulsatile aorta. skin over the left scapula, there is an excoriation measuring 17 by 7 cm with black eschar covered with duoderm. on the coccyx there is a stripped sheet eschar 15 by 7 cm with surrounding skin breakdown. toes and fingers are cold and cyanotic. there are open superficial sores on the tibia bilaterally. there is warm erythema proximal to the areas of necrosis. ankles have blisters bilaterally. neurologically, there is no response to sternal rub. he has positive corneal reflex. no gag. toes are equivocal. vascular, femoral pulses are palpable 2+ bilaterally. popliteal pulses dopplerable bilaterally. biphasic dorsalis pedis pulse and posterior tibial pulse are not dopplerable or palpable. radials are 2+ bilaterally. laboratories from : white blood cell count 12.5, hematocrit 37, platelets 88. differential is 56 neutrophils, 36 bands, 1 lymph. electrolytes are 145, potassium 4.8, chloride 104, bicarb 30, bun 188, creatinine 5.4, glucose 249, ck 6040, calcium 7.5. on the his laboratories at white count 13.2, hematocrit 34, platelets 74. differential 84 neutrophils, 13 bands, 1 lymphocytes, sodium 144, potassium 3.9, chloride 100, bicarb 35, bun 140, creatinine 3.9, troponin is .37 and ck is 6767. on admission to white count 14.8, hematocrit 33.8, platelets 95, inr 1.5, ptt 26.5, sodium 148, potassium 3.9, chloride 105, bicarb 36, creatinine 3, glucose 103, calcium 8.1, magnesium 2.3, phosphate 4.9, albumin 1.8. ck 6322. arterial blood gas is 7.50, 41 and 142. microdata, sputum from 4+ staph aureus. chest x-ray here showed an ett/ogt in place, subclavian on the right was advanced into the right atrium. this was subsequently pulled back. right lower lobe infiltrate without effusions. no cephalization. no pneumothorax. electrocardiogram from the 20th, atrial fibrillation with ventricular rate of 132, qrs duration of 149, qtc 536, left bundle branch block. on admission he was in sinus at 64, pr 162, qrs 120, qtc 473, normal axis, left bundle branch morphology, poor r wave progression, t wave inversions inferiorly. no prior comparison is made with an electrocardiogram before the . hospital course: the patient was admitted to the medical intensive care unit. 1. ventilatory management: the patient was continued on simv for the first several days of his hospital admission. on the he had an arterial blood gas of 7.49, 42 and 146. on the 27th it was 7.45, 41 and 162. he had a good rapid shallow breathing index of 35. his compliance was 60. the decision was made to extubate the patient on the . he was extubated successfully and placed on 4 liters nasal canula and has been maintaining good oxygen saturation. he has not required reintubation. 2. rhabdomyolysis: the patient's cks were noted to be elevated greater then 6000 on admission. these trended down, but are not normal as of this dictation. the patient's renal failure was suspected to be secondary to this rhabdomyolysis. urine sediment was examined on the night of admission and demonstrated muddy brown cast. the patient was hydrated first with normal saline and then with half normal saline and d5w. the patient's creatinine fell and at the time of this dictation it was .8. his bun is 27. 3. ischemic extremities: a vascular surgery consult was requested on the second hospital day. they did not see a need for acute intervention and felt that the ischemic areas would become gangrenous. possibly requiring amputation. after consultation with the family amputation was determined to be inconsistent with the patient's premorbid wishes and the vascular surgery service signed off. 4. disseminated intravascular coagulopathy: the patient's platelets rose gradually reaching a level above 150 by hospital day five. his inr and ptt were also normal. dic is not an active issue at present. 5. infectious disease: the patient was initially started on vancomycin and ceftriaxone for coverage of sputum with staph aureus. upon speciation of his sputum it was determined that it was sensitive to oxacillin. he was changed to oxacillin on hospital day number three and this was subsequently discontinued when the patient was made comfort measures only. the patient's family saw him on the and were concerned about his prognosis. as the patient's mental status did not seem appropriate an electroencephalogram was ordered and this demonstrated encephalopathic changes. the patient's family made the decision to withdraw care and make the patient comfort measures only on . his medications were changed at that time to a fentanyl drip and an ativan drip both titrated for his comfort and intravenous fluids to keep his vein open and prn tylenol. the patient is currently comfort measures only. disposition: to be determined. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Acute kidney failure, unspecified Defibrination syndrome Pneumonitis due to inhalation of food or vomitus Gangrene Coma Blisters, epidermal loss [second degree] of back [any part] Accident caused by other hot substance or object Other disorders of muscle, ligament, and fascia

allergies: penicillins / zantac / codeine attending: chief complaint: headache w/ spontaneous subarachnoid hemorrhage, fevers major surgical or invasive procedure: diagnostic angiogram history of present illness: 47yo male with history of diffuse large b cell lymphoma, type 1 diabetes mellitus, and gastroparesis was transferred to medicine from neurosurgery for evaluation of fevers in the setting of spontaneous subarachnoid hemorrhage. . patient initially presented on with the sudden onset of headache, diplopia, and neck stiffness while watching television. he presented to the ed where he was found to have a subarachnoid hemorrhage with no evidence of aneurysm. he was initially admitted to the trauma icu and was then transferred to the neurosurgery floor. surprisingly, his bleed was thought to be spontaneous with no clear precipitant. his course has been complicated by blood sugar abnormalities for which is following, nausea and vomiting for which he has been left npo, and fevers. his nausea and vomiting has markedly improved today on the day of transfer due to his being allowed to eat. . regarding his fevers, he initially developed fevers to 101 on and has had near daily fevers since then. his tmax during his hospitalization was 103.1 on . his wbc was initially elevated to 24 and has remained between during his hospitalization. he has not received any antibiotics during this hospitalization. he has felt malaise and occasional chills with fevers. . he reports otherwise feeling generally feeling well, particularly since starting eating today. his nausea, vomiting, and diarrhea has now markedly improved since starting his diet. regarding recent antibiotic use, he took a 5 day course of clindamycin after surgery on for trigger finger. his antibiotic course was complicated by diarrhea which improved with yogurt and probiotics. on review of systems specifically, he denies neck stiffness, vision change, photophobia, chest pain, shortness of breath, abdominal pain, diarrhea, dysuria, joint pains. past medical history: 1. type 1 diabetes mellitus on insulin pump at home 2. hypertension 3. goiter 4. diabetic retinopathy 5. gastroparesis 6. hypercholesterolemia 7. h/o ptb, smear positive, in - had pneumomediastinum, treated with isoniazid and rifampin for 9 1/2 months. stopped early b/c of pancreatitis. 8. diffuse large b cell lymphoma - diagnosed in and followed with watchful waiting 9. psoriasis social history: home: lives with partner ; previously employed as an investigator for the supreme court occupation: disabled; volunteers; previously ran a soup kitchen etoh: occasional drugs: none tobacco: none family history: - father - yo - hypertension - mother - died at age 51 - breast cancer - sister - age 53 - ttp physical exam: physical exam (on admission): o: t: 98.2 bp: 117/ 66 hr: 53 r 16 o2sats 99 ra gen: wd/wn, comfortable, nad. heent: mmm and intact neck: stiff lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. . cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: left 6th n palsy, but otherwise intact v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. . motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift . sensation: intact to light touch, propioception, pinprick and vibration bilaterally. . reflexes: b t br pa ac right 2 2 2 2 2 left 2 2 2 2 2 . toes downgoing bilaterally. coordination: normal on finger-nose-finger. . physical exam (on transfer): t 98.6 / bp 111/70 / hr 77 / rr 16 / pulse ox 97% ra / fs 256 gen: nad, resting comfortably in bed heent: clear op, mmm neck: supple, no lad, no jvd cv: rr, nl rate. nl s1, s2. 2/6 systolic murmur heard best at lusb lungs: cta, bs bl, no w/r/c abd: soft, nt, nd. nl bs. no hsm. insulin pump sites clean, dry, and intact ext: no edema. 2+ dp pulses bl skin: no rashes neuro: a&ox3. appropriate. cn 2-12 intact. preserved sensation throughout. 5/5 strength throughout. normal coordination. gait assessment normal psych: listens and responds to questions appropriately, pleasant . upon dishcarge: pt was neurologically intact without any deficits. l 6th nerve palsy now resolved. pertinent results: labs: 07:20am blood wbc-17.3* rbc-3.86* hgb-12.6* hct-35.3* mcv-91 mch-32.6* mchc-35.6* rdw-14.6 plt ct-337 06:05am blood wbc-13.0* rbc-3.48* hgb-11.1* hct-32.0* mcv-92 mch-31.9 mchc-34.7 rdw-14.7 plt ct-353 07:20am blood neuts-34* bands-0 lymphs-48* monos-13* eos-1 baso-0 atyps-4* metas-0 myelos-0 06:05am blood neuts-40.6* lymphs-50.9* monos-7.1 eos-1.0 baso-0.4 07:20am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-2+ target-1+ schisto-1+ burr-1+ 07:45am blood pt-14.3* ptt-28.9 inr(pt)-1.2* 07:20am blood pt-14.5* ptt-27.6 inr(pt)-1.3* 07:20am blood glucose-145* urean-6 creat-0.8 na-138 k-3.5 cl-100 hco3-26 angap-16 06:05am blood glucose-198* urean-10 creat-0.8 na-135 k-3.8 cl-98 hco3-27 angap-14 01:30am blood alt-67* ast-42* alkphos-72 totbili-0.4 01:47am blood alt-54* ast-40 ld(ldh)-212 alkphos-90 totbili-0.6 07:20am blood ld(ldh)-272* 06:05am blood ld(ldh)-215 01:30am blood lipase-16 07:45am blood calcium-8.1* phos-3.2 mg-1.9 07:20am blood calcium-8.9 phos-3.3 mg-2.1 . microbiology: - - mrsa screen - negative - - urine cx - negative - - mrsa screen - negative - - blood cx x 2 - negative - - blood cx x 1 - negative - - urine cx - negative - - blood cx x 1 - negative - - blood cx x 2 - no growth to date - - cdiff - negative - - urine cx - coag negative staph - - stool c diff - negative - - ebv serologies -- igg positive and igm negative - - cmv viral load - pending - - toxoplasmosis serologies - negative - - hiv ab - pending - - cdiff negative - - stool o+p - pending . studies: - - noncontrast head ct - subarachnoid hemorrhage centered in the suprasellar cistern with extension along the tentorium on the right. subacute/chronic subdural also seen along falx. cta is recommended to evaluate for aneurysm. - - cta head - subarachnoid hemorrhage centered in the suprasellar cistern with extension along the tentorium on the right. subacute/chronic subdural also seen along falx. cta is recommended to evaluate for aneurysm. - - ct brain perfusion - 1. expected evolution of subarachnoid and subdural hemorrhage, without evidence of interim rebleeding. 2. mild stenosis at the origin of the left vertebral artery. 3. no evidence of an intracranial aneurysm or vascular malformation. 4. unremarkable ct perfusion study in the middle cerebral arterial territories. - - cxr portable - the lungs are clear without infiltrate or effusion. the cardiac and mediastinal silhouettes are normal. there is no focal infiltrate. no significant change compared to prior - - carotid / cerebral study - pending - - lenis - no lower extremity dvt bilaterally. - - kub portable - no evidence for ileus or obstruction. unchanged vas deferens calcifications. - - portable cxr - no evidence of pneumonia. - - ct head - marked improvement in subarachnoid and subdural hemorrhage since , without evidence of interim bleeding or hydrocephalus. - - cardiac echo - the left atrium and right atrium are normal in cavity size. 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). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: trace aortic regurgitation with normal valve morphology.normal biventricular cavity sizes with preserved global and regional biventricular systolic function. brief hospital course: 1. fevers - had episodic fevers from 101 - 103 deg f with no localizing signs/symptoms. id was consulted for evaluation and infectious workup was pursued. multiple sets of blood cultures were negative or no growth to date. urine culture showed coag-negative staph, likely a contaminant. had no signs of csf infection, and cxr was negative for pneumonia. echo was obtained due to question of new murmur on exam, which showed trace ar, normal valves, and otherwise normal heart structure/function. given his initial diarrhea and recent exposure to clindamycin, stool for c. diff was sent, and was negative. hiv, toxo, ebv, and cmv serologies were also sent. hiv serologies were pending at time of discharge. he was monitored for signs of lymphoma, but no lymphadenopathy was appreciated, wbc count/diff appeared to be within his baseline, and ldh was normal. drug effect was thought to be the most likely possibility, and he was transitioned from dilantin to keppra on . fever secondary to his recent bleed were thought to also be contributing. . 2. subdural and subarachnoid hemorrhage - initially found to have spontaneous hemorrhages, with no source by cta and diagnostic angiogram, but which were stable on repeat imaging. presented as headache pain, n/v, and diplopia. his associated headache pain was controlled with iv pain medication initially, and he was then transitioned to a po pain regimen, which was well-tolerated prior to discharge. in addition, he was started on keppra for seizure prophylaxis and nimodipine for vasospasm protection. nimodipine was discontinued prior to discharge. he remained neurologically intact and stable through hospitalization, with resolution of a 6th cranial nerve palsy thought due to his hemorrhages. . 3. hypertension - blood pressure was stable and wnl during hospitalization, and he was transitioned from nimodipine to his home antihypertensive, lisinopril, prior to discharge. . 4. type 1 diabetes mellitus - self-managed by patient via his insulin pump. was followed by diabetes team, where he receives his diabetic care, and his blood sugars were wnl with his self-management. . 5. gastroparesis - had several days of nausea, vomiting, diarrhea, which resolved fully when patient resumed a normal diet. after resolution of symptoms, he was restarted on his home anti-emetic regimen of zofran, reglan, and ativan. his lomotil was held during hospitalization and he was instructed to resume use at home, as needed. stool was c. diff negative x1 with second set pending. . 7. hyperlipidemia - stable, was continued on home pravastatin. . 8. gerd - stable, was continued on his home ppi. medications on admission: 1. centrum 1 tab daily 2. lisinopril 5mg daily 3. lomotil 2.5mg po prn 4. ativan 1mg po qhs prn 5. pravastatin 20mg po daily 6. pantoprazole 40mg po daily 7. reglan 10mg po qid 8. zofran 4mg po bid 9. insulin pump 10. vitamin d 400 units daily 11. magnesium 350mg daily discharge medications: 1. hydromorphone 2 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for headache for 2 weeks: this medication may make you drowsy or sedated. do not drive or use heavy machinery until you know how this affects you. disp:*60 tablet(s)* refills:*0* 2. vicodin 5-500 mg tablet sig: 1-2 tablets po every 6-8 hours for 2 weeks: this medication may make you drowsy or sedated. do not drive or use heavy machinery until you know this affects you. . disp:*30 tablet(s)* refills:*0* 3. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 4. pravastatin 20 mg tablet sig: one (1) tablet po once a day. 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 6. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 7. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. keppra 1,000 mg tablet sig: one (1) tablet po twice a day for 30 days: please take twice daily for 1 month. disp:*60 tablet(s)* refills:*0* 9. multivitamin tablet sig: one (1) tablet po daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 12. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po bid (2 times a day). 13. ativan 1 mg tablet sig: one (1) tablet po at bedtime as needed. 14. lomotil 2.5-0.025 mg tablet sig: one (1) tablet po once a day as needed. 15. magnesium 300 mg capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: atraumatic subarachnoid hemorrhage discharge condition: stable with normal vs, able to ambulate unassisted. discharge instructions: you were admitted to the neurosurgery service for a spontaneous bleed in your head, with no surgical intervention warranted. you were given medication to control your headache pain, which improved by the time of discharge. your fevers were evaluated by the medical and infectious disease services, and no signs of an infection in your blood, urine, heart, or lungs were found. you are asked to record your temperature daily and when you feel feverish, and use tylenol when needed. you were felt safe to go home, with close outpatient follow-up. . you were started on keppra, a medication to prevent seizures. please continue taking keppra for 1 month and discuss with your neurosurgeon when you see him. you were also given a prescription for pain medication, which you should take if your headache returns. lastly, you may begin taking lomotil again at home, as you need it. . you are asked to follow-up with your primary care doctor, dr. , for lab results that are pending. please schedule an appointment with her in the next two weeks. . please seek medical attention immediately if you develop a new headache which does not respond to pain medication, increased sensitivity to light, double vision, fever > 101.4 deg f, chills, sweats, weight loss, chest pain, trouble breathing, abdominal pain, or any other concerning symptoms. followup instructions: please follow-up with dr. with a ct angiogram in 1 month. if you have any questions please call . you have the following appointments scheduled: provider: , otr phone: date/time: 1:00 provider: gates, rnc msn phone: date/time: 11:30 provider: scan phone: date/time: 10:15 md Procedure: Arteriography of cerebral arteries Arteriography of cerebral arteries Diagnoses: Pure hypercholesterolemia Polyneuropathy in diabetes Subarachnoid hemorrhage Sixth or abducens nerve palsy Other malignant lymphomas, unspecified site, extranodal and solid organ sites Long-term (current) use of insulin Fever, unspecified Subdural hemorrhage Background diabetic retinopathy Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled Goiter, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: percutaneous transluminal coronary angioplasty with stenting history of present illness: 56 y/o male with history of hypercholesterolemia and cva presents with chest pain radiating to the neck. he was found to have 3-4 mm ste in 2,3,avf, v5-v6. he was started on a heparin gtt in the ed and received 600 mg po plavix and 325 mg po asa. he was transferred to the cath lab for emergent cardiac catheterization. past medical history: hypercholesterolemia cerebral vascular accident social history: former smoker. family history: non contributory. physical exam: vitals: t hr bp rr sat pain /10 general: well developed male in nad head: nc/at eyes: eomi, anicteric, perrl neck: no lad, palpable carotid pulses, no bruits, no jvd chest: lungs clear to asculation, no wheezes/rhonchi/crackles heart: normal pmi, rrr, no murmurs/gallops/rubs abdomen: mildly obese, nabs, soft, no organomegaly, no masses. ext: no clubbing/cyanosis/edema. good pulses. pertinent results: admission labs: 09:41pm wbc-16.8* rbc-5.65 hgb-12.4* hct-38.0* mcv-67* mch-22.0* mchc-32.7 rdw-14.6 09:41pm plt count-246 09:41pm neuts-82.8* lymphs-14.6* monos-1.8* eos-0.4 basos-0.3 09:41pm pt-14.4* ptt-64.3* inr(pt)-1.4 09:41pm glucose-130* urea n-19 creat-0.3* sodium-144 potassium-3.8 chloride-109* total co2-21* anion gap-18 09:41pm magnesium-1.0* cholest-119 09:41pm %hba1c-5.7 -done -done 09:41pm triglycer-71 hdl chol-40 chol/hdl-3.0 ldl(calc)-65 . cardiac cath (): 1. selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. the lmca had no angiographically apparent flow limiting stenosis. the lad was a large vessel with mild diffuse luminal irregularities and gave rise to a large d1. the lcx had no angiographically apparent flow limiting lesions and gave rise to a large om which had a 60 % proximal stenosis. the rca was a dominant vessel and was totally occluded distally. 2. resting hemodynamics revealed elevated left and right sided filling pressures with pcwp 35. 3. left ventriculography was deferred. 4. successful pci of the distal rca with two overlapping cypher des (3.0 x 18 mm, 3.0 x 13 mm). the proximal stent was post-dilated with a 3.25 mm balloon. 5. successful closure of the rfa arteriotomy site with a 6 french angioseal device. . final diagnosis: 1. angiographic evidence of two vessel coronary artery disease. 2. elevated left and right sided filling pressures. 3. acute inferior myocardial infarction, managed by acute pci of the right coronary artery. . echo (): the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferior and inferolateral walls.the remaining left ventricular segments contract normally. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. . impression: mild symmetric left ventricular hypertrophy with regional dysfunction c/w cad. dilated ascending aorta. brief hospital course: 56 y/o male admitted for inferior stemi. had catheterization with stenting of the distal rca with two overlapping cypher drug eluting stents. he tolerated the procedure well and was discharged three days later on titirated doses of metoprolol and lisinopril as well as simvaststin, plavix, and aspirin. his stay was uncomplicated. discharged on simvistatin 20 mg qd b/c of history of failed attempt to increase dose to 40mg qd by pcp, due to increased lft's. medications on admission: simvastatin 20 mg qd aspirin 81 mg qd vitamins discharge disposition: home discharge diagnosis: coronary artery disease acute st segment elevation myocardial infarction discharge condition: stable, without chest pain. discharge instructions: please call your doctor or go to the emergency room if you experience chest pressure/pain or any symptomes concerning for a heart attack. please make an appointment with your primary care doctor in the next week. please follow up with the cardiologist, dr. , here at . please be sure to take the aspirin and plavix every day. this is very important. followup instructions: please make an appointment with your primary care doctor in the next week. please follow up with a cardiologist. we have made an appointment for you. provider: , md where: cardiac services phone: date/time: 2:00 pm Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia

allergies: prednisone / azithromycin / trilisate / sulfa (sulfonamides) attending: chief complaint: palpitations major surgical or invasive procedure: cardioversion history of present illness: 78 yo f w/ pmh afib on coumadin who presents with a "racing heart". patient states that she exeprienced palpitatins one day ago, however was unsure if she was in a. fib. she had an appt with pcp for neck pain when ecg done showed a. fib with rvr so she was sent to ed. she denies any chest pain, sob, palpitations. denies doe. denies recent fevers or chills, caugh/n/v. . in the ed, 96.9 hr 130 bp 122/76 and 98%ra. she received 325 mg aspirin and lopressor 5 mg iv x 3 with slowing of her heart rate to 110s. . on transfer to the floor pt c/o neck pain which she states has been bothering her for several months. she has tried tylenol with minimal relief. some relief with local heat and bengay. denies any recent trauma. . on review of symptoms, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle, syncope or presyncope. past medical history: 1. parkinson's disease 2. congestive heart failure with an ejection fraction of 50-55% on tee in 3. atrial fibrillation 4. hypertension 5. constipation 6. dizziness 7. colonic polyps 8. irritable bowel syndrome 9. gastritis 10. hyponatremia 11. back pain 12. hearing loss 13. insomnia 14. basal cell carcinoma 15. left bundle-branch block social history: social history is significant for the absence of current tobacco use. there is no history of alcohol abuse. pt cares for her husband at home, has on wheels, cleaning woman every other week; husband has aide 4x/week. family history: her parents died when they were in their 60s, her mother of renal disease, her father of heart disease. physical exam: vitals: t 97.6 hr 65 bp 158/78 rr: 20 100% 2l gen: awake, alert, sitting in chair breathing comfortably heent: clear op, mmm neck: supple, no lad, jvp 8-10 cv: rr, nl rate. nl s1, s2. soft sys murmur llsb lungs: crackles bilaterally way up. abd: soft, nt, nd. nl bs. no hsm ext: trace edema. 2+ dp pulses bl pertinent results: reports: . chest (portable ap) 1:11 pm impression: 1. unchanged cardiomegaly, without evidence of pulmonary edema. 2. probable small bilateral pleural effusions with bilateral basilar atelectasis. . chest (portable ap) 9:34 am cardiac silhouette is enlarged, and there has been development of congestive heart failure with perihilar and basilar edema. bilateral moderate pleural effusions have increased in size with adjacent atelectasis. . tte: : conclusions: the left atrium is elongated. no left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). the right atrium is markedly dilated. the estimated right atrial pressure is 11-15mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with severe hypokinesis of the inferior and inferoseptal walls. the remaining segments contract well. the right ventricular cavity is mildly dilated. right ventricular systolic function is normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is a small pericardial effusion without hemodynamic evidence of compromise/tamponade physiology. . compared with the prior study (images reviewed) of , the inferior/inferoseptal wall motion abnormality is new, overall lvef is more depressed, and the severity of mitral regurgitation has increased. the severity of pulmonary artery systolic hypertension is also markedly increased. . . admission labs: 12:55pm glucose-102 urea n-34* creat-1.3* sodium-138 potassium-4.1 chloride-95* total co2-29 anion gap-18 12:55pm estgfr-using this 12:55pm ck(cpk)-61 12:55pm ctropnt-<0.01 12:55pm ck-mb-notdone 12:55pm wbc-7.7 rbc-3.60* hgb-11.5* hct-34.4* mcv-96 mch-32.0 mchc-33.5 rdw-15.0 12:55pm neuts-66.8 lymphs-26.2 monos-4.7 eos-0.6 basos-1.7 12:55pm macrocyt-1+ 12:55pm plt count-454* 12:55pm pt-25.5* ptt-33.4 inr(pt)-2.6* 06:20am blood wbc-8.1 rbc-3.43* hgb-11.1* hct-32.5* mcv-95 mch-32.5* mchc-34.3 rdw-15.2 plt ct-395 06:06am blood neuts-62.7 lymphs-27.8 monos-7.1 eos-2.0 baso-0.4 06:20am blood plt ct-395 06:20am blood pt-23.1* ptt-150 inr(pt)-2.3* 01:00pm blood pt-18.8* ptt-24.9 inr(pt)-1.8* 06:06am blood pt-24.2* ptt-30.4 inr(pt)-2.4* 06:20am blood glucose-89 urean-26* creat-0.9 na-141 k-3.7 cl-97 hco3-34* angap-14 05:09am blood ck(cpk)-94 04:35pm blood alt-9 ast-35 ld(ldh)-193 ck(cpk)-136 alkphos-109 amylase-83 totbili-0.8 05:09am blood ck-mb-3 ctropnt-<0.01 04:35pm blood ck-mb-3 ctropnt-<0.01 11:05am blood ck-mb-3 ctropnt-<0.01 05:09am blood caltibc-339 vitb12-912* folate-19.0 ferritn-33 trf-261 11:28am blood type-art po2-91 pco2-58* ph-7.28* caltco2-28 base xs-0 11:28am blood lactate-2.2* brief hospital course: 78 yo f with chf (ef 50%) and a history of afib who presented with palpitations due to recurrent afib. . #. rhythm: the patient presented in afib w/rvr. there were no signs of infection or any complaint of chest pain suggesting ischemia as etiology for afib recurrance. had rates 120's-130's on admission, with stable blood pressure. initially rate control was attempted by increasing metoprolol to 75mg , however pt still had hr's in 110's. pt was then dc cardioverted, and remained in nsr. she did not need a tee prior to cardioversion, as pcp records were and inr had largely been therapeutic in past month. metoprolol dose was then decreased to home dose as pt had rate in 70's. --pt's inr became supratherapeutic, so coumadin was held for several days, and then re-started once inr was in acceptable range. --started sotalol for rhythm control, however pt had prolonging qtc. sotalol dose was then decreased from 80mg to 40mg . qtc was monitored while on sotalol. . #. pump - ef 40% -- given renal insufficiency on admission and dry mucous membranes, lasix and lisinopril were held, however lasix and lisinopril were later restarted -- approximately 24 hours after cardioversion, pt c/o sob and had hypoxic respiratory failure, which was thought secondary to post-cardioversion chf. she required a 100% nrb, nitro gtt, and was transferred to the ccu for bipap. she underwent aggressive diuresis along with bipap, and sob and o2 requirement greatly improved. pt now satting well on 2l nc and returned to the floor once breathing was stable. she ruled out for mi during this episode. . #. cad: no documented history of cad, though inferior hk on echo --she was contined on bb, asa --she was not previously on statin ldl 102 , previously 114. simvastatin was started during the admission. #. htn: the lasix, metoprolol, and lisinopril were held on admission, then restarted to her home doses. . #. : pt had elevated bun and creatinine up to 1.3 on admission, came down to 1.0. acei and lasix were held on admission, now both have been re-started . #. nausea + abdominal distension: pt complained of this during her episode of sob. now resolved. kub negative for obstruction. likely due to constipation. lfts wnl. . #. parkinson's disease - continued sinemet . # neck pain: pt has had chronic neck pain for several months, thought arthritis. has tried ultram and physical therapy in the past without relief. pain consult was called, however would need c-spine mri prior to any injections, so will continue conservative management for now and hold off on inpatient consult. we re-scheduled her outpatient pain appointment (had appt scheduled for prior to admission). . #. fen - low-sodium/cardiac diet, replete lytes prn . #. access: piv #. ppx: therapeutic inr, bowel regimen, ppi #. code: full medications on admission: coumadin 5 mg po daily lasix 20 mg po daily lisinopril 10 mg daily toprol xl 50 mg qhs sinemet 25-100mg-- 1.5 tablets tid coenzyme q10 400 mg tid fosamax 70 mg q weekly calcium citrate with d discharge medications: 1. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po tid (3 times a day). 4. coenzyme q10 10 mg capsule sig: one (1) capsule po tid (). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 9. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 11. alendronate 70 mg tablet sig: one (1) tablet po qsun (every sunday). 12. sotalol 80 mg tablet sig: 0.5 tablet po bid (2 times a day). 13. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 14. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 15. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 16. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: center discharge diagnosis: primary diagnoses: afib w/rvr hypoxic respiratory failure pulmonary edema s/p cardioversion secondary diagnoses: parkinson's disease chf htn discharge condition: stable. in sinus rhythm. discharge instructions: please seek medical attention immediately if you experiences chest pain, shortness of breath, palpitations, nausea, vomiting, sweating, or any other concerning symptoms. please take all medications as prescribed. you have been started on sotalol. followup instructions: you have the following appointments scheduled: provider: , md date/time: 10:40 provider: , md phone: date/time: 11:30 provider: , md phone: date/time: 1:40 clinic appointment at 2:30pm ( Procedure: Other electric countershock of heart Diagnoses: Mitral valve disorders Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Constipation, unspecified Paralysis agitans Acute respiratory failure Unspecified disorder of kidney and ureter Other left bundle branch block Long-term (current) use of anticoagulants Diseases of tricuspid valve Irritable bowel syndrome Cervical spondylosis without myelopathy

allergies: prednisone / azithromycin / trilisate / sulfa (sulfonamides) attending: chief complaint: shortness of breath major surgical or invasive procedure: cardioversion history of present illness: 79 y/o woman with a history of afib, on coumadin, s/p silent inferior mi at some point in early with ef 40-45%, parkinson's disease and autonomic dysfunction, transfered to the ccu for managment of acute pulmonary edema resulting in hypoxic and hypercarbic respiratory arrest. . she was admitted originally to the floor after presenting to the ed with shortness of breath, in afib with rates to the 130s and an infiltrate on chest xray. she was treated with levofloxacin and metoprolol . cardiology was consulted for her afib and on the afternoon of she was dccv succesfully to sinus rhythym. her inr had been therapeutic > 3 weeks per ep documentation so no tee was performed. . at 3am on the morning of transfer to the ccu she was noted to be hypertensive and dyspnic. she had o2 sats in the low 90s on a nrb and an x-ray with acute pulmonary edema. she received 2 mg of morphine, 20 mg lasix, inch of nitro paste. telemetry revealed a wide complex av dissociated rhythym at a rate of approx 100, felt likely to be monomorphic vt. this was not captured on a 12 lead ekg. a blood gas on the floor was 7.24/56/104. . upon arrival to the ccu, she was started on bipap noninvasive ventilation, received an additional 40 mg of lasix, 2 mg of morphine, and a nitro drip was initiated. after 10-15 minutes on bipap, a repeat blood gas revealed worsening acidosis: 7.13/78/83. she was then intubated. she experienced transient post-intubation hypotension responsive to 200mcg, then 100mcg neosynephrine. she was breifly on dopamine. . ros: not obtained in full from patient due to extremis. of note, she was seen by her cardiologist on the day of admission (dr. with generalized aches and pains and increased fatigue. at that time she was in atrial fibrillation and while most of her symptoms were felt to be attributable to her pd, her rate control was submoptimal with a pulse in the 100s. she was increased to 37.5 toprol xl and her aldactone was decreased from 25 to 12.5mg and lisinpril decreased to 5mg from 20mg because of concern for orthostatic hypothesnion given her known autonomic dysfunction. she presented later that day to the ed. past medical history: 1. parkinson's disease - seen by neurology 2. congestive heart failure with an ejection fraction of 40% on tee in 3. atrial fibrillation - seen by 4. hypertension 5. left bundle-branch block 6. dizziness 7. irritable bowel syndrome 8. gastritis - egd ; negative pathology 9. colonic polyps - last colonoscopy and need repeat 10. intermittent hyponatremia 11. back pain 12. hearing loss 13. insomnia 14. basal cell carcinoma 15. osteoarthritis - neck and back pain - tylenol does not help, so she does not take it social history: patient lives at home alone in , ma. her husband died last month at . she is not living with her daughter, because of too many stairs and feeling unsafe getting in and out of her house. patient has 2 children that are close by and help them with some of the shopping and adl's. they have a cleaning woman 2x per week. she has hired a caregiver to come 8:30am-12:30pm - gives her sponge bath, helps put on shoes and helps with morning activities due to severe osteoarthritis pain and stiffness. patient receives on wheels as well as does shopping via peapod. she uses a walker when she feels "unsteady" as she has felt for the past week. family history: her parents died when they were in their 60s, her mother of renal disease, her father of heart disease. physical exam: physical exam on admission: vitals (9 am): t 96.7, bp 110/doppler, hr 100, rr 20, sat 98% on ra gen: frail eldery female, anxious, and not sleeping well heent: perrla, op - clear, no lad, jvd appreciated cv: irreg, irreg, nl s1, s2 resp: bibasilar crackles r>l abd: + bs, soft, nt ext: trace lower ext edema bilat, with 1+ dp bilaterally neuro: aao x 3 pertinent results: admission laboratories 06:40pm ret aut-1.2 06:40pm pt-23.5* ptt-35.5* inr(pt)-2.3* 06:40pm plt count-257 06:40pm neuts-65.1 lymphs-27.6 monos-5.9 eos-1.1 basos-0.4 06:40pm wbc-6.0 rbc-3.35* hgb-10.1* hct-30.1* mcv-90 mch-30.3 mchc-33.7 rdw-15.4 06:40pm tsh-2.6 06:40pm caltibc-404 vit b12-658 folate-13.6 ferritin-30 trf-311 06:40pm calcium-8.9 magnesium-3.0* iron-26* 06:40pm glucose-107* urea n-36* creat-1.3* sodium-130* potassium-4.7 chloride-94* total co2-28 anion gap-13 06:56pm k+-4.6 . discharge laboratories 07:20am blood wbc-4.8 rbc-3.16* hgb-9.6* hct-28.7* mcv-91 mch-30.3 mchc-33.2 rdw-15.8* plt ct-340 07:20am blood plt ct-340 07:20am blood pt-21.8* ptt-28.7 inr(pt)-2.1* 07:20am blood glucose-87 urean-17 creat-0.9 na-137 k-4.5 cl-97 hco3-35* angap-10 . chest (portable ap) 7:25 am findings: ett and ngt have been removed. there is much better aeration with diminution of the size of upper lobe pulmonary vessels. pleural effusions persist but are less extensive. cardiomegaly is unchanged. there are no new consolidations. impression: improved fluid but residual features of chf evident. . ekg sinus rhythm. there is arm lead reversal. left bundle-branch block. compared to the previous tracing of arm lead reversal is new. rate pr qrs qt/qtc p qrs t 61 194 130 478/ 112 brief hospital course: # cardioversion for atrial fibrillation the patient was initially admitted to the hospital on with a diagnosis of pneumonia. she was treated for several days with levofloxacin, but continued to be short of breath. she was in atrial fibrialltion with a rate of approx 100, and it was thought that cardioversion to normal sinus rhythym might help her symptoms. she was succesfully cardioverted to sinus rhythym on . later that evening, however, she developed acute pulmonary edema and required transfer to the ccu, intubation, and mechanical ventialtion. during this period of stress, she was noted to be in an accelerated idioventricular rhythm. she was hemodynmaically stable and this rhythm resolved to normal sinus rhythm without specific treatment. she was extubated the next day and transfered to the floor. she remained in normal sinus rhythm after cardioversion until discharge. # hypertension and diastolic heart failure her blood pressure and heart failure medications were titrated to the doses on which she is being discharged. her hospital course was complicated by one episode of hypotension thought to be due to hydralazine 10 mg po, which was administered for hypertension (sbp 175). her episode of hypotension resolved with intravenous fluids and her blood pressure remained stable to slighlty elevated prior to discharge. to better control her blood pressure and for pedal edema, an additional medication was added (lasix 10 mg). it is anticipated that she will require this medication for the short term, approximately one week. also, of note, the timing of the patients medications, lisinopril at night and spironolactone, lasix, metoprolol in the am is important to adhere to as per her home regimen (with the exception of lasix which is new). dr. office was contact prior to discharge for followup within one week of discharge from rehabilitation to monitor her outpatient blood pressure and adjust medications as needed (currently schedule for ). # parkinson's disease she has parkinson's disease and labile blood pressure. the patient is very knowledgable about her medications. at rehab, the patient's parkinson's medications (all dosages for the day) should be provided to the patient for self-administration with monitoring. the patient has increased anxiety if she does not receive her parkinson medication (carbidopa/levodopa) on time and also reports symptomatic return if medications are not given promptly at 8:30 am, 12:30 pm, 4:30 pm, and 8:30 pm. of note, she will require teaching and education regarding any medication changes. dr. , her outpatient neurologist was contact prior to discharge and did not recommend increasing her carbidopa/levodopa until he had seen her as an outpatient. his administrative assistant with contact her regarding scheduling an outpatient appointment within 3 weeks. #disposition: she was seen by physical therpay who recommended rehab. medications on admission: maalox/diphenhydramine/lidocaine 15-30 ml po tid:prn acetaminophen 1000 mg po q6h:prn metoprolol succinate xl 25 mg po daily albuterol 0.083% neb soln 1 neb ih q6h:prn sob mirtazapine 15 mg po hs aspirin 81 mg po daily milk of magnesia 30 ml po q6h:prn bisacodyl 10 mg po/pr daily:prn morphine sulfate 2-4 mg iv q2h:prn calcium carbonate 500 mg po qid:prn carbidopa-levodopa (25-100) 1.5 tab po qid nitroglycerin sl 0.3 mg sl prn docusate sodium 100 mg po bid constipation senna 1 tab po bid:prn constipation ferrous sulfate 325 mg po daily simvastatin 40 mg po daily ipratropium bromide neb 1 neb ih q6h:prn sob warfarin 4 mg po 3x/week (mo,we,fr) 3x/week(mo,we,fr) levofloxacin 750 mg po q48h warfarin 5 mg po 4x/week (,tu,th,sa) 4x/week(,tu,th,sa) discharge medications: 1. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 2. magnesium hydroxide 400 mg/5 ml suspension : thirty (30) ml po q6h (every 6 hours) as needed for constipation. 3. simvastatin 40 mg tablet : one (1) tablet po daily (daily). 4. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po qid (4 times a day) as needed. 5. albuterol sulfate 2.5 mg/3 ml solution for nebulization : one (1) inhalation q6h (every 6 hours) as needed for sob. 6. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours) as needed for sob. 7. senna 8.6 mg tablet : 1-2 tablets po bid (2 times a day) as needed for constipation. 8. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day) as needed for constipation. 9. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily) as needed for iron deficiency anemia. 10. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed. 11. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 13. mirtazapine 15 mg tablet : one (1) tablet po qhs (once a day (at bedtime)) as needed. 14. carbidopa-levodopa 25-100 mg tablet : 1.5 tablets po qid (4 times a day): patient requests ability to self administer, very important to her. . 15. lisinopril 10 mg tablet : one (1) tablet po daily (daily): to be given in the evening only if sbp > 110. 16. spironolactone 25 mg tablet : 0.5 tablet po daily (daily): to be taken in am. 17. metoprolol succinate 25 mg tablet sustained release 24 hr : one (1) tablet sustained release 24 hr po daily (daily): to be taken in am. 18. furosemide 20 mg tablet : 0.5 tablet po daily (daily): this is a new medication for heart failure. 19. warfarin 2 mg tablet : two (2) tablet po 3x/week (mo,we,fr). 20. warfarin 5 mg tablet : one (1) tablet po 4x/week (,tu,th,sa). 21. outpatient lab work please check inr twice while in rehab discharge disposition: extended care facility: & rehab center - discharge diagnosis: pneumonia atrial fibrialltion post-cardioversion pulmonary edema discharge condition: ambulating with assist, tolerating pos, needs blood pressure medication titration and physical therapy discharge instructions: you were admitted to the hospital with shortness of breath. you were found to have a pneumonia. you were treated for this. you were also in atrial fibrillation. you underwent a cardioversion. you developed post-cardioversion pulmonary edema and required care the ccu briefly. you required mechanical ventialtion briefly. please take all medications as prescribed and please attend all follow up appointments. you have some heart failure, which means that your heart does not pump as much as it should. it is important to weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet you were also started on a new medication for heart failure, this is called lasix or furosemide. you had this while you were in the hospital. it may affect your blood pressure so you medications may be adjusted while you are in rehab. followup instructions: provider: , md phone: date/time: 1:40 provider: , md phone: date/time: 12:50 provider: , md phone: date/time: 12:00 ***dr. , your outpatient neurologist, will contact you regarding scheduling a followup appointment for assessment of your parkinsons' symptoms. md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other electric countershock of heart Diagnoses: Pneumonia, organism unspecified Acidosis Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Acute on chronic diastolic heart failure Paroxysmal ventricular tachycardia Paralysis agitans Acute respiratory failure Old myocardial infarction Long-term (current) use of anticoagulants

#5- mom called this a.m. to check on discharge status. mom when plans changed, then came in with dad. spoke with nurse practitioner and dr. regards to baby not being dc'd due to brady today. mom disappointed. mom and dad stayed with infant, held him and fed him. a: involved family. p: continue to support, keep involved and informed. #9- o: infant experienced one brady to 55 today while awake and crying. infant became cyanotic and required mild stimulation. during feeds hr does drift to the 80's and self resolves independently or with removal of bottle. a: infant experienced one brady today while awake and crying. p: continue to monitor and support as needed. Procedure: Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy 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 Other preterm infants, 2,500 grams and over Routine or ritual circumcision Neonatal Candida infection

history of present illness: this 49-year-old female is status post st. mitral valve replacement 14 years ago and presented to an outside hospital two weeks prior to admission complaining of shortness of breath. she was worked up for congestive heart failure exacerbation during that admission and she has had what feels like are flu-like symptoms that have increased during the past several weeks. she had a cardiac catheterization two weeks ago which demonstrated one leaflet of the st. jude valve was nonfunctioning. she was transferred to for elective mitral valve replacement by dr. . past medical history: significant for: 1. congestive heart failure. 2. history of atrial fibrillation. 3. history of rheumatic heart disease. 4. status post cerebrovascular accident at age 30. 5. status post mitral valve replacement st. 14 years ago. allergies: biaxin, doxycycline, amoxicillin, augmentin, cardizem and sulfa. medications on admission: 1. prevacid 30 mg p.o. q. day. 2. lasix 20 mg p.o. b.i.d. 3. metoprolol 50 mg p.o. b.i.d. 4. coumadin 5 alternating with 2.5. 5. digoxin 0.25 mg p.o. q. day. 6. kcl 20 meq p.o. p.r.n. review of systems: significant for chronic dyspnea on exertion. social history: she smokes three cigarettes a day, does not drink alcohol. physical examination: she is a thin asian woman in no apparent distress. vital signs stable, afebrile. heent examination: normocephalic, atraumatic. extraocular movements intact. oropharynx benign. neck is supple, full range of motion. no lymphadenopathy or thyromegaly. carotids 2+ and equal bilaterally without bruits. lungs had mildly decreased breath sounds at the bases. cardiovascular examination: a regular rate and rhythm with no rubs or gallops. abdomen was soft and non-tender with positive bowel sounds. no masses or hepatosplenomegaly. extremities without clubbing, cyanosis or edema. pulses were 2+ and equal bilaterally throughout. neuro examination was nonfocal. hospital course: she was admitted to be converted from coumadin to heparin so she could have surgery and her pt was 15.3 on admission with an inr of 1.6. on she underwent a re-do mitral valve replacement with a #. mechanical valve. the crossclamp time was 87 minutes, total bypass time 66 minutes. she was transferred to the cisu in stable condition on neo and propofol. she was extubated the postoperative night. she had her chest tubes discontinued on postoperative day two. she did have an electrophysiology consult as she had complete heart block and was pacer dependent. she continued to progress and was transferred to the floor on postoperative day three and was still pacer dependent. she also had a high white count postoperatively, as high as 33,000 and was cultured several times without ever having an etiology. she was being evaluated by electrophysiology but they felt that they would want her white count to decrease before they would put a pacemaker in. she did have a heart rate in the 40's and tolerated this well but her heart rate did not increase with activity and on she underwent permanent pacemaker placement with a kappa sr pacemaker in the right side. she tolerated the procedure well and continued to progress but required anticoagulation and on her inr was 1.7 and she was discharged to home in stable condition to have her coumadin followed up by dr. . laboratory on discharge: white count 18,100, hematocrit 25.4, platelet count 467,000. sodium 140, potassium 4.5, chloride 104, co2 25, bun 13, creatinine 0.9, blood sugar 103. pt 16, inr 1.7, ptt 77.8. discharge medications: 1. lasix 20 mg p.o. b.i.d. 2. colace 100 mg p.o. b.i.d. 3. kcl 20 meq p.o. q. day. 4. prevacid 30 mg p.o. q. day. 5. aspirin 81 mg p.o. q. day. 6. vicodin one to two p.o. q. 4-6h. p.r.n. pain. 7. coumadin 7.5 mg tonight, 7.5 mg tomorrow night and then probably 5 mg alternating with 2.5 depending what dr. prescribes as he will be following her pt which will be drawn in two days. follow up: dr. in one to two weeks and dr. in four weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of mitral valve Initial insertion of single-chamber device, rate responsive Initial insertion of transvenous lead [electrode] into ventricle Diagnoses: Tobacco use disorder Cardiac complications, not elsewhere classified Atrial fibrillation Other complications due to heart valve prosthesis Rheumatic heart failure (congestive) Atrioventricular block, complete Personal history of other diseases of circulatory system Diseases of tricuspid valve

allergies: amoxicillin / morphine attending: chief complaint: respiratory distress major surgical or invasive procedure: none history of present illness: 85 y/o f w/osteoporosis, restrictive lung disease on home o2 (felt scoliosis), who presented to the ed on c/o leg pain. she got up from the sofa and twisted her knee, and after this developed leg pain. she did not fall at that time, did not have syncope. in the ed, she had a plain film concerning for fracture, so she had a ct scan of her lower extremity showing a tibial plateau fracture. ortho saw her and recommended pain control and a knee immobilizer. she was admitted to medicine. . last night, she developed worsening hypoxia. at her baseline per office notes she is in the mid-80s when off oxygen. (she wears 2 liters o2 at home). initially she was 93% on 2l but dropped to 86% last night, so was turned up to 4-5 l with response to 96%. she refused to wear her bipap secondary to back pain. at her routine vitals check at 7 this morning, she was noted to have a pulse 152, bp 104/60, rr 36, and o2 sat 84% on 4l which improved to 96% on a nrb. ecg showed rapid afib. she was given metoprolol 5 mg iv x3 without response. abg was 7.42/60/161 on a nrb. she then was given diltiazem 15 mg iv with response in her pulse down to the 90s, which improved her shortness of breath somewhat. she was transferred to the micu for further monitoring. currently, she states that she is having some chest pressure. she reports she has been having worsening shortness of breath with eating that has been going on for weeks (mentioned in dr. note ), and does think that her breathing got worse this morning. past medical history: # congenital rickets # osteoporosis with numerous fractures # spinal fusions for her scoliosis # history of cataracts # htn # pulm htn # restrictive lung disease: most recent pfts : fvc 0.58 (38%pred), fev1 0.44 (48%pred), fev1/fvc 76 (128%pred). felt to be related to her scoliosis # tonsillectomy and adenoidectomy # benign breast cysts # l-femoral trochanteric fracture ' (s/p repair at ) social history: she used to smoke intermittently in the past but quit 40 years ago. she was never a heavy smoker. she denies alcohol use and recreational drug use. she does not have any children. lives with her husband, who has recently been ill. family history: remarkable for her mother who had a cva. a sister had coronary artery disease and mitral valve disease. her father died in an advanced old age of an unknown cause. physical exam: pe: t: 97.2 bp: 117/59 p: 105 r: 28 94% on nrb i/o over last 24 hours: 1140/1200 (?unclear how well recorded this is) gen: elderly woman, tachypneic, using accessory muscles, speaking in word sentences, using abd muscles significantly during exhalation heent: clear op, mmm neck: supple, jvd 7-8 cm at 60 degrees cv: tachycardic, irregularly irreg, no murmur lungs: diffuse inspiratory crackles, poor air movement with some end-exp wheezing abd: soft, nt, nd. nl bs. ext: 1+ lle edema. 2+ dp pulses bl. in knee immobilizer skin: no lesions pertinent results: 04:30am blood wbc-6.7 rbc-3.65* hgb-11.1* hct-33.1* mcv-91 mch-30.5 mchc-33.6 rdw-14.5 plt ct-290 12:00pm blood ptt-102.1* 09:06am blood fibrino-990* 04:30am blood glucose-190* urean-56* creat-0.9 na-137 k-4.9 cl-93* hco3-33* angap-16 03:01am blood probnp-* 04:35am blood pth-157* 04:35am blood tsh-0.48 12:18pm blood type-art temp-37.6 rates-/14 po2-134* pco2-101* ph-7.25* caltco2-46* base xs-12 intubat-not intuba . cxr : ap supine chest: there is moderate cardiomegaly. a large hiatus hernia is redemonstrated. significant distortion is appreciated at the thoracic cavity secondary to marked scoliotic change. patchy air space opacities are present in the left upper and right mid lung concerning for aspiration or multifocal pneumonia. asymmetric edema is also a consideration. there is no pleural effusion or pneumothorax. no fractures are identified. impression: study limited by distortion from severe s-shaped thoracic scoliosis. cardiomegaly with alveolar opacity in the right mid and left upper lung concerning for aspiration or multifocal pneumonia. evolving asymmetric edema cannot entirely excluded and follow up radiographs are recommended. . repeat cxr : cardiac silhouette remains enlarged. there is vascular engorgement and worsening bilateral perihilar haziness. additional more confluent area of opacification in the right middle and retrocardiac portion of the right lower lobe are noted. left retrocardiac area is difficult to assess to large hiatal hernia. impression: 1. worsening perihilar edema. 2. worsening right middle and lower lobe opacity which may be due to asymmetrical edema or superimposed aspiration or pneumonia. . ecg this morning: rapid afib at 137, normal axis, st dep in i, avl, ii, iii, and v2-v6 all of which are new compared to both old ecg in and compared to admission . echo : the left atrium is elongated. a left-to-right shunt across the interatrial septum is seen at rest consistent with the presence of small secundum type atrial septal defect. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . cxr : compared with 3/11, there has been considerable clearing and re-aeration of the right lung. there appears to be mild edema. the left lung base also appears better aerated, but there is some persistent infrahilar atelectasis. . cxr : moderate chf, increased compared to one day prior. 2. large hiatal hernia. brief hospital course: a/p: 85 y/o f w/osteoporosis, restrictive lung disease on home o2 (felt scoliosis) transferred to micu for hypoxia. . # respiratory distress: pt. required constant bipap while in the micu to maintain a decent respiratory status. she failed multiple attempts off bipap and would become tachypneic, hypoxic, and with markedly increased work of breathing. the last day of admission, she became progressively dyspneic and somnolent this taken off of bipap, it was unclear why she required so much bipap. pulomary edema to rapid afib/chf vs. pneumonia vs. copd exacerbation was initially thought to be the cause but the patient's respiratory status did not improve with rate control (with metoprolol and diltiazem), frequent attempts at aggressive diuresis, iv steroids, antibiotics, or frequent nebulizers (albuterol, atrovent). her blood gases continued to deteriorate, with pco2 rising, even on bipap, and she became progressively acidotic. patient's family was contact and goals of care were discussed, as patient did not seem to be improving. it was decided to make patient comfort measures only . she started receiving hydromorphone iv as needed. continue with nebulizers, furosemide for comfort. antibiotics discontinued . ms. quietly passed away at 0728 with her two neices at her bedside. medications on admission: meds at home: combivent inhaler two puffs four times a day lasix 20 mg twice a day toprol 75 mg daily diltiazem 120 mg once a day potassium chloride 20 meq per day calcium two tablets per day aspirin 81 mg per day 60 mg daily fosamax 70 mg once a week. vitamin e daily oscal + d salmeterol 50mcg . meds on transfer: metoprolol 5 mg iv x3 diltiazem 15 mg iv x1 lasix 40 mg iv x1 albuterol/atrovent alendronate 70 mg q thursday lasix 20 mg po daily (did not receive this am) salmeterol vitamin e vitamin d colace calcium carbonate diltiazem 120 mg po daily (did not receive this am) toprol 50 mg daily (did not receive this am) atrovent nebs q6h levofloxacin 500 mg q24h (begun ) flagyl 500 mg iv q8h (begun ) discharge medications: none discharge disposition: expired discharge diagnosis: respiratry failure discharge condition: patient died at 0728 discharge instructions: none followup instructions: none Procedure: Non-invasive mechanical ventilation Arterial catheterization Diagnoses: Acidosis Unspecified essential hypertension Atrial fibrillation Diaphragmatic hernia without mention of obstruction or gangrene Acute respiratory failure Osteoporosis, unspecified Other diseases of lung, not elsewhere classified Hypoxemia Encounter for palliative care Closed fracture of upper end of tibia alone Scoliosis associated with other conditions Arthrodesis status

allergies: morphine, amoxicillin. Procedure: Non-invasive mechanical ventilation Arterial catheterization Diagnoses: Acidosis Unspecified essential hypertension Atrial fibrillation Diaphragmatic hernia without mention of obstruction or gangrene Acute respiratory failure Osteoporosis, unspecified Other diseases of lung, not elsewhere classified Hypoxemia Encounter for palliative care Closed fracture of upper end of tibia alone Scoliosis associated with other conditions Arthrodesis status

code: dni, per dr. pt unsure whether she wants to be dnr, will discuss with hcp in am. allergies: morphine, amoxicillin events: weaned off dilt drip, iv lasix given, maintaining acceptable sat on nrb mask. neuro: pt a&o x 3, pleasant, follows commands, able to make needs known. complaining of pain to left foot, received prn percocet with good effect, pt did complain of brief period of nausea. pt slept most of night. cv: hr a-fib 78-103 with occasional pac/pvc, successfully weaned of dilt gtt. received additional po dilt dose at 0500 for hr increasing into 110's. abp 98-124/45-63. please see carevue for am labs. pt afebrile, tmax 98.3 ax. piv x 2, left radial a-line. resp: pt remains on nrb mask @ 10lmp, rr 17-29, sats >90%, per dr. goal sat >90% is acceptable. pt noted to desat to 88% when mask removed. desatted to mid 80's x 1, improved to >90% with mdis. lung sounds coarse to diminished throughout with occasional crackles. weak non-productive cough. gi: bs x 4, no stool this shift. able to take meds with water. remains npo in case of bipap/cpap. gu: foley patent, draining clear amounts of light yellow urine. pt given 80mg lasix ivp with minimal effect, dr. aware. am k 4.0 after 40meq po potassium at mn. skin: left leg in knee immobilizer, otherwise skin intact. plan: monitor hr, uo clarify dnr status pain management goal sats >90% routine icu care and monitoring Procedure: Non-invasive mechanical ventilation Arterial catheterization Diagnoses: Acidosis Unspecified essential hypertension Atrial fibrillation Diaphragmatic hernia without mention of obstruction or gangrene Acute respiratory failure Osteoporosis, unspecified Other diseases of lung, not elsewhere classified Hypoxemia Encounter for palliative care Closed fracture of upper end of tibia alone Scoliosis associated with other conditions Arthrodesis status

code: dnr/dni allergies: morphine, amoxicillin pt is 85 year old woman who was transferred from 7 where she was admitted for a tibial plateau fracture. brought to micu for hypoxia, tachypnea, tachycardia, new afib. events: pt restarted on dilt gtt, able to maintain good sat on nrb. please see carevue for labs. neuro: pt a&o x 3, pleasant, cooperative with care. full rom to upper extremities, able to move right toes, left leg in knee immobilizer for fracture. pt getting much better pain control with fentanyl patch, received prn tylenol x 1 for pain to left leg () after turning. cv: hr 86-111 a-fib with occasional pac/pvc, abp 103-128/58-71. pt restarted on dilt gtt (10mg/hr) for rate control after receiving lopressor x 1 with no response. heparin gtt started for new a-fib, most recent ptt 150, gtt stopped for one hour and restarted at 550 units/hour. next ptt due at 0900. mild edema noted to bilateral lower extremities. peripheral pulses palpable. resp: received pt on bipap, able to be switched to nrb around midnight. pt able to maintain sats >90%, pt noted to desat when mask removed. per team goal sat >90%. rr 91-30 with sats >91% on nrb 13lpm at 70%. pt has weak cough. lung sounds clear in apices, diminished in bases. cxr shos rll pna. gi: bs x 4, no stool this shift. ordered for heart healthy diet. gu: foley patent and draining clear, yellow urine. received lasix last evening with good response, however uo now diminishing. id: tmax 98.0 po. receiving abx therapy, levofloxacin and vanco, for rll pna. skin: intact, prefers to be on left side for comfort. social: pt's two are , (works in ) and (lives in ). called last night, updated on pt's condition and plan of care, she asked that she be called with any issues that come up for now as other has virus. plan: transition dilt gtt to po dilt wean oxygen requirements as tolerated by pt pain management next ptt due at 0900, titrate heparin according to protocol monitor uo continue abx therapy Procedure: Non-invasive mechanical ventilation Arterial catheterization Diagnoses: Acidosis Unspecified essential hypertension Atrial fibrillation Diaphragmatic hernia without mention of obstruction or gangrene Acute respiratory failure Osteoporosis, unspecified Other diseases of lung, not elsewhere classified Hypoxemia Encounter for palliative care Closed fracture of upper end of tibia alone Scoliosis associated with other conditions Arthrodesis status

history of present illness: the patient is a 40-year-old female with a history of depression, hypertension, asthma, and question of prior suicide attempts who presented after being witnessed taking an intentional overdose. emergency medical service found her with four bottles, including norvasc, doxepin, clonidine, and prozac; only the clonidine bottle was empty (by report). the patient was a apparently awake and alert on arrival to the emergency department. however, she was found in respiratory distress (by report), tachypneic, also tachycardic with blood pressures as high as 229/141, and a heart rate in the 108 range to 132 range. by report, the patient became unresponsive and was intubated for airway protection. due to significant agitation, the patient was given multiple doses of versed and four separate doses of pancuronium. a head ct was negative for intracranial bleed. she was given hydralazine 20 mg intravenously with a decrease in her blood pressure to the 170s. for her ingestion, she received 70 g of charcoal in the emergency department. on arrival to the intensive care unit, the patient was intubated and paralyzed status post dose of paralytic just prior to leaving the emergency room. past medical history: 1. depression, with recent discharge from for cocaine overdose and depression. 2. asthma. 3. hypertension. 4. ovarian venous thrombosis, for which the patient was started on coumadin; however, never followed up for further workup and was noncompliant with the medication. allergies: nonsteroidal antiinflammatory drugs causing rash. medications on admission: per primary care physician, . (telephone number ) the patient is supposed to be taking doxepin 50 mg p.o. q.h.s., norvasc 2.5 mg p.o. q.d., prozac 20 mg p.o. q.h.s., prilosec 20 mg p.o., ventolin 2 puffs q.i.d., azmacort 2 puffs t.i.d., hydrochlorothiazide 25 mg p.o. q.d., neurontin, accolate. social history: unable to obtain social history on arrival; per old record and primary care physician, patient is married and lives with her husband and two children. she is under a significant number of stressors at home. she actively uses cocaine. one of her family members is a drug dealer, given the patient free access to the cocaine. physical examination on presentation: physical examination on admission revealed temperature of 98.4, blood pressure of 172/90, pulse of 116, respiratory rate of 12, oxygen saturation of 100%, paralyzed, on the ventilator, setting at ac 700 x 12, fio2 of 100%, and a positive end-expiratory pressure of 5. head, eyes, ears, nose, and throat revealed mucous membranes were moist. pupils were 5 mm and reactive to light. perforated nasal septum. lungs were clear to auscultation. heart was tachycardic but regular. no murmurs, rubs or gallops. abdomen was soft, obese, nontender and nondistended, good bowel sounds. extremities revealed no cyanosis, clubbing or edema. scattered round papular scar-type lesions on the legs and arms. multiple ecchymoses, especially on the right hand, and question right temple of the face. pertinent laboratory data on presentation: laboratory findings on admission revealed a white blood cell count of 13.8 (with a differential of 81 neutrophils, 13 lymphocytes, 4 monocytes, 0.5 eosinophils, 0.7 basophils), hematocrit of 38.5, platelet count of 483. chem-7 revealed sodium of 135, potassium of 3.5, chloride of 98, bicarbonate of 22, blood urea nitrogen of 17, creatinine of 0.9, blood sugar of 158. creatine kinase was 120, with a mb of 3. urinalysis showed yellow/clear urine, with a specific gravity of 1.02, 30 protein, 15 ketones, ph of 9, 325 white blood cells, occasional bacteria, 3 to 5 epithelial cells. urine culture was pending. serum drug screen was positive for benzodiazepines. urine drug screen was positive for benzodiazepines and cocaine. radiology/imaging: electrocardiogram showed tachycardic, sinus rhythm, normal axis, normal intervals. there was right atrial enlargement and poor r wave progression. there were no changes when compared with prior. chest x-ray showed no pneumonia, ett tube at 2.9 cm above groin with nasogastric tube well positioned in stomach. head ct showed no intracranial hemorrhage. there was slight thickening of the sinuses. hospital course: the patient was admitted to the medical intensive care unit for further management after intubation in the emergency department. 1. airways: the patient's sedation as well as paralysis was allowed to wear off with plan for extubation. however, the patient was extubated within one hour of arriving to the medical intensive care unit. she was able to maintain her airway, oxygenate, and ventilate well; and the decision was made not to reintubate. 2. overdose: it was unclear which medications the patient ingested. once extubated, with the help of a spanish interpreter, the patient was interviewed and insisted that she wanted to take some medication just to sleep. her electrocardiogram was followed for qt prolongation in case one of the medications she ingested was a tricyclic antidepressant. she was placed on a ciwa scale in case part of her agitation was due to alcohol withdrawal. the ativan was stopped once further information became available, and the patient was confirmed not to have significant alcohol history. 3. cardiovascular: upon presentation the patient was tachycardic and hypertensive with a blood pressure of up to 230/140. she initially received hydralazine with improvement in her blood pressure to 170/90. intravenous hydralazine was continued during her medical intensive care unit stay. due to positive cocaine screen, lopressor and labetalol were avoided. the patient was ruled out for myocardial infarction with serial troponins, since she received intramuscular injections. due to nonsteroidal antiinflammatory drugs allergy, aspirin was held. 4. agitation: following self-extubation, the patient became increasingly more agitated and combative. per spanish interpreter, the patient was aware of herself, her location, and time, and date. she was noted to induce emesis by placing her fingers in her mouth. due to the progressive increase in agitation and , emergent psychiatry evaluation was obtained. the patient was judged to be a danger to self as well as others, and restraints were indicated. neither soft nor leather restraints were able to restrain the patient, and chemical restraint was recommended by psychiatry. the patient received a cocktail of haldol, ativan and cogentin leading to a decrease in her agitation. the next day, the patient woke up much more cooperative and not agitated. 5. prophylaxis: for prophylaxis, the patient was maintained on subcutaneous heparin and prevacid through the nasogastric tube. discharge status: the patient was to be discharged to for psychiatric hospitalization. medications on discharge: (her medications on discharge included) 1. norvasc 2.5 mg p.o. q.d. 2. azmacort inhaler 2 puffs b.i.d. 3. hydrochlorothiazide 25 mg p.o. q.d. 4. singulair 10 mg p.o. q.d. 5. albuterol meter-dosed inhaler 2 puffs q.4h. p.r.n. 6. thiamine 100 mg p.o. q.d. 7. multivitamin one tablet p.o. q.d. 8. folate 1 mg p.o. q.d. 9. compazine 5 mg p.o./p.r. p.r.n. for nausea. condition at discharge: medically stable. , m.d. dictated by: medquist36 Procedure: Insertion of endotracheal tube Continuous invasive mechanical ventilation of unspecified duration Diagnoses: Other pulmonary insufficiency, not elsewhere classified Asthma, unspecified type, unspecified Cocaine abuse, unspecified Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents Poisoning by other specified drugs and medicinal substances Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior Vomiting alone

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: intrascapular back pain at osh major surgical or invasive procedure: none history of present illness: 81 yo w/ htn, hypercholesterolemia, hypothyroidism, h/o cva (), dm, and transferred to from an osh for evaluation and further management of a possible dissection of her descending thoracic aorta (type b) versus an intramural ulcer seen on ct. pt initially presented to the osh with intrascapular back pain. in the ed at her pain had resolved but she was found to be hypertensive to the 180's and was started on a nipride drip and given lopressor 2.5 mg iv x1. she received iv vitamin k to reverse an inr of 3.3. she denied chest pain, shortness of breath. past medical history: 1. hypercholesterolemia. 2. htn 3. hypothyroidism 4, h/o cva () 5. dm by labs 6. cri (baseline cr 1.8-2.0) social history: lives alone. has a idential twin sister. children involved in her health care. denies tob, etoh, or drug use. family history: nc physical exam: done in ed: hr 60, bp l arm 114/58, r arm 122/61 on nipride 1.7 mcg/kg, rr 14, o2 98% nrb gen: awake in nad, a&ox3 heent: perrla, eomi, mmm, clear oropharynx, upper/lower dentures neck: supple, from lungs: ctab cv: rrr, no m/r/g, b/l radial, femoral, dp, pt pulses skin: warm, dry, no bruises or rashes pertinent results: 09:15pm type-art po2-163* pco2-32* ph-7.50* total co2-26 base xs-2 09:15pm glucose-228* lactate-4.6* na+-137 k+-2.9* cl--103 09:15pm freeca-1.07* 08:43pm glucose-237* urea n-34* creat-1.9* sodium-138 potassium-3.4 chloride-97 total co2-24 anion gap-20 08:43pm ck-mb-1 ctropnt-<0.01 08:43pm calcium-9.0 phosphate-2.6* magnesium-1.8 08:43pm wbc-9.6 rbc-3.26* hgb-10.4* hct-28.5* mcv-87 mch-31.8 mchc-36.4* rdw-13.2 08:43pm plt count-138* 08:43pm pt-16.4* ptt-32.2 inr(pt)-1.8 04:30pm urea n-33* creat-1.7* potassium-3.6 04:30pm phosphate-3.7 magnesium-2.0 04:30pm pt-16.1* ptt-32.6 inr(pt)-1.7 09:01am glucose-198* urea n-33* creat-1.8* sodium-140 potassium-3.4 chloride-100 total co2-27 anion gap-16 09:01am ck(cpk)-53 09:01am ck-mb-notdone ctropnt-0.01 09:01am wbc-12.0* rbc-3.83* hgb-11.9* hct-35.5* mcv-93 mch-30.9 mchc-33.4 rdw-12.7 09:01am neuts-86.4* bands-0 lymphs-9.8* monos-3.1 eos-0.4 basos-0.2 09:01am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 09:01am plt smr-normal plt count-194 09:01am pt-22.2* ptt-33.6 inr(pt)-3.3 brief hospital course: 81 yo w/ dm, htn, hypercholesterolemia, h/o cva (), trasferrred from osh c/o interscapular back pain. there found to have sbp's in 200's, and a cta revealing a dissection of her descending thoracic aorta (type b) vs an intramural ulcer, subsequently transferred to vascular surgery service at for evaluation/further management. in our ed started on nipride drip, given lopressor and vitamin k to reverse inr of 3.3. bp down to 130's/60's, hr 55. course complicated by arf, chf, nstemi (peak ck 520/mbi 11.3, w/ ecg on showing sinus @70bpm, normal axis, twi in v2-6, i, ii, iii, avf) and delerium. made dnr/dni on at family meeting. studies: 1. carotid u/s: mild non significant plaque, luminal narrowing <40%. 2. ct head (): chronic small vessel ischemic disease with multiple bilateral small lacunar infarcts. 3. ct of chest (done at hospital ): type b dissection involving a small segment of the descending thoracic aorta, more distal to the dissection is an aneurysm measuring 5.6x 3.9cm. 4. mri (): there is no evidence of dissection involved within the aorta. multifocal penetration ulcers are identified throughout the aorta. there is no evidence however of focal intramural hematoma. the right common carotid artery is significantly tortuous. there is a 4.3-cm aneurysm of the descending thoracic aorta with areas of thickened atherosclerosis. this reaches its maximum dimension above the level of the diaphragmatic hiatus. bilateral pleural effusions are present. problems: 1. question of aortic dissection: transferred to vascular service here after cta at outside hospital concerning for aortic dissection. pt's blood pressure was aggressively controlled with iv labetalol drip. however, a mri/a done here did not show evidence of aortic dissection but rather multifocal penetration ulcers along her aorta. no intervention was needed and pt's bp was able to be adequately controlled on po b- and ace-i. 2. a on crf: etiology likely multifactorial. our initial differential included decompensated diastolic chf(fe urea found to be 34%), medications (eosinophils found in her urine), vs a progression of her dissection into her renal arteries, however this was ruled out by repeat mri. she was also found to have b/l renal artery stenosis clinically significant on the right. she refused a diagnostic catheterization with possible stenting. her cr returned to 1.6 on the day of discharge. she will need follow up with her pcp to evaluate for diabetic/hypertensive nephropathy. pt is to have outpt cr and k checked. results to be sent to dr. . 3. dm. pt was started on a regular insulin sliding scale with good effect. she will need evaluation of her blood glucose by her pcp and possible initiation of oral hypoglycemic medications. 4. diastolic chf. pt became clinically overloaded and was transiently on natrecor for diuresis as well as prn lasix. pt required o2 via nrb and nc but was successfully weaned off prior to discharge. an echocardiogram done on showed an ef of ~60%, e/a ratio 0.91, no wall motion abnorm, and 1+ ar. pt subsequently suffered a nstemi shortly after the echo, therefore a repeat echo was performed on which showed an ef of 50-55%, +ar, and 1+mr (no significant change since prior echo). she was d/c'ed on an acei for afterload reduction and given a prescription for lasix to be started if clinically indicated after she sees dr. . 5. hypothyroidism. pt continued on her outpt dose of synthroid. no active issues. 6. nstemi. pt started on a beta , , and lipitor, which she tolerated well. enzymes peaked at 520. persantine-mibi stress test on showed moderate reversible defect in the inferior wall. however, the pt refused cardiac cath at this time and she was discharged on medical management as above. she will follow up in the cardiology clinic. 8. resp acidosis--resolved on its own. thought to be secondary to episodes of hypoventilation secondary to pain vs. medications (benzo's, barbituates, narcotics). 9. delirium--resolved. etiology thought to be multifactorial. differential included metabolic (increased bun/uremia?) vs. infection vs. nstemi vs. medication in the setting of arf. lft's, tsh, amylase/lipase all were within normal limits. benzo's, bendadryl and narcotics were discontinued. pt was administered prn zyprexa and haldol at night for increased confusion with good result. 10. uti diagnosed by ua. pt was treated with levofloxacin. medications on admission: levoxyl, lasix, atenolol, lipitor, coumadin discharge medications: 1. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 2. levothyroxine sodium 100 mcg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po qd (once a day). disp:*30 tablet, chewable(s)* refills:*2* 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. zestril 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 1 days: please take . disp:*1 tablet(s)* refills:*0* 7. outpatient lab work crea/k please send to , e. 8. lasix 40 mg tablet sig: one (1) tablet po q: m,w,f: please do not take unitl you see dr , e. . disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: perforated ulcers of descending aorta non st segment elevation myocardial infarction delirium uti acute on chronic renal failure discharge condition: good discharge instructions: please call your primary care physician or return to the hospital if you have symptoms of shortness of breath, chest pain, or any other promblems arise. , e. followup instructions: 1. pcp: . . office to call to make appointment early this week (tues/wed) 2. please follow-up with cardiologist. , m.d. center cardiac services phone: date/time: 11:30 md Procedure: Venous catheterization, not elsewhere classified Injection or infusion of nesiritide Diagnoses: Acidosis Subendocardial infarction, initial episode of care Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Diastolic heart failure, unspecified Other alteration of consciousness Rupture of artery