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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: acetaminophen overdose major surgical or invasive procedure: none. history of present illness: 35yow with h/o depression and prior suicide attempts, transferred for hospital with tylenol od. patient reports taking "handfuls" of tylenol pm at 3:00am with intent to kill herself. she had not been planning suicide but was pushed to it by many "life stressors" including breaking up with her boyfriend. she has had a previous suicide attempt by cutting and overdose in the past. she denies current si/hi, and denies audio/visual hallucinations. . she was brought to hospital ed where initial vitals bp 129/82 hr 96 rr 18. she was treated with n-acetylcysteine, loaded with 150mg/kg and then received two maintenance doses . her lfts continued to rise, peak ast 2493, alt 3080, inr 3.2, prompting transfer to . tylenol level at 12hours was 178. on presentation now she complains of nausea, abdominal pain, and bloating past medical history: depression with prior suicide attempt by cutting, od s/p cholecystectomy h/o endometriosis social history: lives alone, works in retail at interior design store and in office, actress tob: none etoh: wine/week illicits: none family history: mother, aunt, grandmother with uterine cancer father with cad physical exam: t 97.8 hr 106 bp 114/60 rr 27 99%ra wt 59kg gen: lying in bed, moves with ease, nad heent: perrl, anicteric, mmm, op clear neck: supple, no lad cv: rrr, no mrg resp: ctab abd: +bs, soft, ttp epigastrum and ruq, no guarding/rebounding ext: no edema, 2+ dps neuro: a&ox3, cn ii-xii intact, strength 5/5 throughout, no asterixis skin: mild jaundice psych: speech l/s/gd. denies si/hi. denies ah/vh. affect normal. mood . pertinent results: ct at osh: small left ovarian cyst. o/w unremarkable . brief hospital course: ms. is a 35yo female with h/o depression who presented after a suicide attempt by tylenol overdose. . icu course: when the patient arrived she was alert and oriented times 3, and denied any active suicidal ideations. over the next 48 hours, her mental status gradually decreased. she was started on an n-acetylcysteine drip for fulminant hepatic failure. her lfts and coags were monitored every four hours, which improved during her hospital course. she was transiently on the transplant list because of her severe condition, but was taken off the list because of her improvement. she had two ct scans for gradual mental status decline, but never had any signs of cerebral edema and did not require mannitol. once she was alert and oriented with and inr <2, her nac drip was discontinued and she was transferred to the floor. she had acute renal failure on admission, likely secondary to atn from tylenol toxicity, which improved upon transfer to the floor. she remained with a one-to-one sitter throughout the hospital course, and did not have any acute events with regards to suicide attempts. she was followed by renal, liver transplant and neurosurgery during her stay. . tylenol od: **the patient arrived on the floor the morning after n-acetylcysteine was stopped. she reported that she was feeling well and denied any abdominal pain. she described some discomfort likely related to constipation which was relieved with pr bisacodyl. her liver enzymes were monitored and continued to trend down. her inr on the day of discharge was 1.6, improved from previous. the patient was started on ursodiol to help with bilirubin clearance as her bilirubin continued to rise. she was also maintained on a bowel regimen to help with constipation. she will follow up with dr. on and fax to him the results of labs drawn on monday, . . suicide attempt: **when ms. arrived on the floor, she denied suicidal ideation. she had been recently taken off a 1:1 sitter. she reported a strong support network. psychiatry continued to follow the patient and felt that she would be safe going home in the care of her parents. she will follow up with an outpatient hospital program in the berkshires for treatment of depression. she was given a prescription for potassium as she continued to need repletion while in the hospital. we discussed with her father the need for monitoring this medication with her as it has lethal potential when taken in large amounts. medications on admission: ortho evra - off x2weeks wellbutrin xl 350mg daily - off x6mos, restarted 1week ago discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. potassium chloride 10 meq tablet sustained release sig: four (4) tablet sustained release po once a day. disp:*120 tablet sustained release(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: acetaminophen overdose liver failure suicide attempt depression discharge condition: fair. the patient remains icteric, however she is eating well and denies pain. she denies suicidal ideation and reports feeling a close bond with her family. discharge instructions: please do not take any medications unless you speak to your md as many medications are processed by the liver and will be toxic to you. you have been started on actigall, which will help to decrease the bilirubin in your blood. please take this two times per day. you have also been placed on potassium supplementation and you should take 4 tablets once per day to help keep your potassium level within normal limits. please keep all outpatient appointments and follow up with psychiatry as indicated below. if you begin to have abdominal pain, become confused, or experience any other concerning symptoms, please call 911 or your md. if you begin to have any thoughts of hurting yourself or others please go to the nearest emergency room for assistance. followup instructions: please get labs drawn on monday in and fax the results to dr. office at . as you have discussed with huppuch, you will be expected at: , building, , , , ma on thursday, at 8am. you have an appointment with dr. on tuesday, at 9am. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Anemia, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Depressive disorder, not elsewhere classified Hepatic encephalopathy Hyperosmolality and/or hypernatremia Poisoning by aromatic analgesics, not elsewhere classified Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics

*allergies: nalfon (rash) ** please see admit note/fhp for admit info and hx neuro: a&ox3, follows commands, turns self in bed, assists w/ getting on bedpan. no c/o pain. cardiac: sb (normal for this pt) w/o ectopy, hr 39-48 w/ occassional low 30's when sleeping. sbp 126-146, hct stable, from 29.7 to 31.4. drank total of 5.6l go-lytely to get clear watery stool for colonoscopy to be done today for ? bleeding. bleeding scan yesterday was neg. k was 3.5, repleated w/ total of 40meq kcl, had labs @ 2300 so not drawing am labs until 0600, await results, repleat lytes as needed. filter placed sunday for dvt, hep gtt off yesterday. resp: o2sat 94-99 on ra, rr 14-22, ls clear throughout. has bipap machine in room that is his but states he usually does not use @ home. refused to use while here. gi/gu: npo for colonoscopy, may start clear liquid diet following the procedure. +bs, stool liquid/brown but clear enough, md stated it has to be "clear enough to read the newspaper through". no more go-lytely @ this time, but still stooling. attempted mushroom cath and now using fecal bag, ? if this works. urine out foley 60-100cc/hr, yellow/clear. fsbg 143, no coverage per riss, has standing dose in evening as well. id: afeb, no abx, no signs of infection at this time. iv sites wnl. psychosocial: very pleasant overall and patient w/ the stooling situation (on and off the bed pan at least a dozen times, drinking extra go-lytely,etc). he spoke w/ fam overnight on his room phone. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Closed [endoscopic] biopsy of large intestine Open and other sigmoidectomy Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Acidosis Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Gout, unspecified Percutaneous transluminal coronary angioplasty status Acute respiratory failure Cardiogenic shock Blood in stool Morbid obesity Acute diastolic heart failure Benign neoplasm of colon Other pulmonary embolism and infarction Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diverticulosis of colon (without mention of hemorrhage) Laparoscopic surgical procedure converted to open procedure Benign neoplasm of rectum and anal canal

*allergies: nalfon (rash) **please see admit note/fhp for admit info and hx neuro: a&ox3, sleeping on and off overnight, given prn ambien for assistance w/ sleep on bi-pap. moves self in bed, follows commands, makes needs known. no c/o pain. cardiac: nsr/sb w/o ectopy, hr 51-71, sbp 146-178. not yet on home bp meds but md's reluctant to restart at this time. given 10mg iv hydralazine x2 and 40mg iv lasix to control bp, was stabilized most of the evening following lasix. hct stable this am, up from 30.7 to 32.3. k 3.4 repleted md orders. resp: ls clear throughout, o2sat 93-96, rr 18-29 on ra. put on bi-pap for sleep, w/o o2, not needed. tolerated well most of the evening but pt removed after 4-5hrs. gi/gu: reg cardiac/heart healthy diet, tolerating well. +bs, sm melena stool x1, md aware. colonoscopy yesterday am showed diverticuli and polyp x1 (?malignancy though tumor marker lab was low). to have laparoscopic clipping of polyp ?monday. urine out foley yellow/lt yellow and clear, 45-1300cc/hr w/ larger amts following 40mg iv lasix. fsbg 219, covered per riss, has standing dose nph in evening. id: temp 96.2-96.9, wbc 5.7. no abx, no sign of infection @ this time. iv sites wnl, tlc dsg changed. psychosocial: daughter and friends visited early in shift, updated on condition and poc. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Closed [endoscopic] biopsy of large intestine Open and other sigmoidectomy Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Acidosis Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Gout, unspecified Percutaneous transluminal coronary angioplasty status Acute respiratory failure Cardiogenic shock Blood in stool Morbid obesity Acute diastolic heart failure Benign neoplasm of colon Other pulmonary embolism and infarction Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diverticulosis of colon (without mention of hemorrhage) Laparoscopic surgical procedure converted to open procedure Benign neoplasm of rectum and anal canal

allergies: naldol pt is full code pt is a 55 yo male admitted from ed, after seeing pcp; dev. dyspnea; arrived to ed hypotension, dyspnea, unresponsiveness; admit to micu for tx of pe, vented and started on heparin gtt; and developed gib secondary to heparin gtt; is currently extubated and . on hep gtt @ units/hr pmh/psh: cad, htn, chf, t2dm, morbid obesity, cardiac cath, gout neuro: pt is a+ox3, perl, pupils 3mm/brisk; follows commands; answers questions appropriately; no seizure activity; moves all extremities; facial symmetry intact cv: sbp 135-107; map 60; hr sinus brady no ectopy 40's-50's; +radial/pedal pulses bilaterally; +csm x4; no c/o cp/sob; dopamine continues off; no pedal edema; hct stable; ptt in target range; target ptt 60-100 resp: ls clear at bilat. apices, diminished at bases, sats> 94% on room air; +productive cough with blood tinged sputum; no sob; bilateral chest expansion noted; no wheeze, no rhonchi, no crackles; pt with cpap for sleep gi: +bsx4, stool mgt via mushroom cath draining loose brown stool, with leak around rectum; abd soft obese, reports non-tender; no nvd; started go-lytely prep @ 1400 today for colonoscopy ; otherwise npo for procedure, was on clear liqs and tolerating well gu: two way foley in place, not draining well, advanced foley further into bladder and reinflated balloon with 15 cc saline, immediately drained >500 cc clear yellow urine and large clot; now draining qs clear yellow skin: wnl with ancanthosis neck and eyes access: right sc triple lumen ports patent, dsg changed today; left ivhl patent endo: ss and standing dose; required increase of ss today, for rising bs, little response to previous humalog ss poc: c/o to floor; monitor hct q12hr, monitor ptt; continue prep for colonoscopy; npo for procedure, plan to change to diet post-procedure; . hep drip, plan to start coumadin soon Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Closed [endoscopic] biopsy of large intestine Open and other sigmoidectomy Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Acidosis Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Gout, unspecified Percutaneous transluminal coronary angioplasty status Acute respiratory failure Cardiogenic shock Blood in stool Morbid obesity Acute diastolic heart failure Benign neoplasm of colon Other pulmonary embolism and infarction Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diverticulosis of colon (without mention of hemorrhage) Laparoscopic surgical procedure converted to open procedure Benign neoplasm of rectum and anal canal

allergies: nalfon attending: chief complaint: dyspnea major surgical or invasive procedure: central line placement ivc filter placement history of present illness: 55yom with h/o hypertension, type ii diabetes mellitus, cad, and morbid obesity, presenting with massive pe. . the patient initially presented today to his pcp with /o dyspnea. he was recently treated for pneumonia but dyspnea persisted. he was referred to ed where he became acutely unresponsive and hypotensive. he was intubated for airway protection and given ctx, azithro. a heparin gtt was started given concern for pe, aspirin given, and he was started on dopamine gtt for bp support. . on arrival to ed vs t 98 hr 87 bp 208/175 rr 29 97%intubated . bedside echo revealed right heart strain and right heart failure raising further concern for pe. cta confirmed diagnosis of bilateral pa pes. he was heparinized and then received tpa 100mg. he also received 8l ns. ecg showed new twi in v1-v3 with elevated ck's. labs showed acute renal failure, lactic acidosis, and +ag metabolic acidosis. past medical history: hypertension morbid obesity type ii diabetes mellitus c/b nephropathy, baseline creat not known cad s/p cath showing 1v dz, s/p bare metal stent to rca chf - ef not known gout social history: divorced. lives with his son. disabled. remote tob use, quit at age 23. no etoh, illicits family history: mother and father d. complications of diabetes physical exam: t 101.5 hr 97 bp 174/74 rr 30 100% ac tv 600 rr 26 fio2 100% peep 10 gen: responding to commands, comfortable heent: perrl, anicteric, ett/ogt neck: jvp not appreciated, no lad cv: distant heart sounds, regular resp: coarse anteriorly with occasional crackle, clear posteriorly abd: obese, soft, nt, nd, +bs ext: venous stasis changes, decreased but palp dp l, radial, nonpalp dp r, no edema neuro: responds to command to squeeze hands, moves all extremities pertinent results: radiology: bleni: non-occlusive filling defect in right common femoral vein. no left lower extremity dvt. . cta: large bilateral pe's including withing the right and left main pulmonary arteries; perhaps slight right ventricular enlargement, but no pulmonary artery enlargement . cxr: linear areas of atelectasis and area of subsegemental atelectasis in the left lower lobe. a small, focal area of infiltrate cannot be excluded. endotracheal tube 8 cm superior to the carina. . ecg: 85bpm, nsr, rbbb, left axis deviation, twi v1-v3 . echo: the right atrium is dilated. the estimated right atrial pressure is >20 mmhg. there is symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). the right ventricular cavity is markedly dilated. there is severe global right ventricular free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no pericardial effusion. brief hospital course: 55yom with h/o htn, cad, tiidm p/w massive bilateral pe resulting in obstructive shock, nstemi, and right heart failure who underwent surgery for colonic mass found upon colonoscope for gi bleed. . # pe/shock: massive pe with resultant obstructive shock and right heart failure s/p lysis with tpa. patient was intubated at osh and was continued on mechanical ventilation for airway protection. he was transiently on dopamine for pressure support which was weaned with stable blood pressures. echo showed rv strain and rv dilation. bnp was >70,000 with troponin leak (tnt 1.0) c/w massive pe. he was doing well on ps and had an rsbi of 44 and extubated on without problems. was continued on an iv heparin gtt. a right sided permanent ivf filter was placed due to clot burden in the right right common femoral vein. patient was also started on stress dose steroids due to h/o of chronic prednisone use due to either gout vs. nephrotic syndrome. he was intially on hydrocortisone 100 mg q 8 hrs then tapered to 50 mg q 8 hrs. upon leaving the icu to the floor his hemodynamics were stable. patient will need a reapeat echo in aproximately 3 months to assess his rv. heparin was held starting due to findings on colonoscopy and ongoing melena despite stable hematocrit. patient likely needs to be anticoagulated in the long term given pe and permanent ivc filter. . # respiratory failure: patient was intubated for airway protection. initial gas showed inadequate compensation for metabolic acidosis which improved with increase in resp rate. he was weaned off the vent and extubated on without complications. . # gib. patient developed melena while on iv heparin. egd by gi showed mild gastritis. patient had ongoing melena with stable hct. c-scope showed at 6 cm polyp in the sigmoid colon. ?if this is causing melena given lesion is distal, ?small bowel lesion as well. plans for sigmoidoscopy by gi on monday for bx vs. excision. iv heparin on hold since given ongoing bleeding. # colonic mass: the patient underwent a colonoscopy which revealed a large mass in the distal sigmoid or upper rectum. plans were made for colonoscopic resection. the patient was taken to the endoscopy suite on and despite multiple attempts the polyp was seen to be quite large, friable and the base could not be visualized. the polyp was large and seemed to be prolapsing down into the rectum from the sigmoid colon. the base of the polyp was tattooed and surgery was recommended. the patient underwent laparoscopically assisted sigmoid colectomy, primary end to end stapled anastomosis on . . # leukocytosis with left shift and bandemia. thought to be a stress response in setting of acute pe. his wbc normalized rapidly. he was initially treated with vancomycin due to gpc in bottles at osh which eventually grew beta strep. vancomycin was discontinued. during perioperative period, the patient was started on levofloxacin and flagyl empirically. patient remained afebrile throughout the hospitalization. . # arf: h/o chronic kidney disease d/t diabetic/hypertensive nephropathy vs. h/o nephrotic syndrome. baseline creatinine not known. patient continued to make good urine. arf likely prerenal azotemia vs. atn. u/a showed granular casts, rare eos. cr continues to trend down. restarted on at lower dose to titrate up as tolerated. . # dm2. patient on nph and sliding scale. fs wnl here while npo then increased to 200's with fluids. consult placed and following. scale increased on . fs 124 at time of discharge. #adrenal status: patient was placed on stress dose steroids given home prednisone use. his hydrocortisone was tapered and the patient was discharged on his home regimen of 5mg prednisone. . # hypertension. patient hypotensive and in shock initially, started to become hypertensive off all meds on . given lasix and iv hydral with response. bp in 180s during the evening, restarted at lower dose, cr stable, on . also given prn iv hydral for elevated systolic pressures. patient was on beta blocker at home however has baseline hr in 40-50s therefore not restarted. the patient was restarted on his home anti-hypertensive therapy with return to bowel function. . # bradycardia. sinus brady to 40's while sleeping and during the day while awake. patient reports hr in the 40s at home and has never been symptomatic. held bb while here. normal rate at time of discharge. . restarted diet, tolerating well, likely needs to be npo for signoidoscopy planned for , repleting lytes prn. the patient's diet was advanced when bowel function returned following surgery and was tolerating regular diet at time of discharge. . # access: r subclavian placed by ir. . # ppx: pneumoboots, iv filter in place, protonix #physical: physical therapy consulted and recommended rolling walker at time of discharge. the patient used abdominal binders to support his girth following surgery while ambulating. # post operative course: the patient's course was uncomplicated. his diet was advanced upon return of bowel function/flatus. incision remained clean/dry and intact. . # communication: daughter (c) (h) son (h) (c) . # full code medications on admission: kcl, mvi, folic acid, mag oxide lasix 120 mg daily metoprolol 100 prednisone 5 mg daily colchicine 0.6 mg daily maalox nph insulin gemfibrozil diovan 160 mg daily allopurinol 400 mg daily oxycodone 5/325 asa discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 2. colace 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: 1) massive pulmonary embolism complicated by obstructive shock, hypotension, nstemi, right heart failure/strain 2) s/p tpa and ivc filter placement (permanent) 3) course complicated by gi bleed, gastritis on egd, colonic polyp, acute blood loss anemia 4) sinus bradycardia secondary: 1) hypertension 2) diabetes type ii - controlled with complications 3) cad s/p nstemi 4) morbid obesity 5) chf with history of diastolic dysfunction 6) obstructive sleep apnea 7) history of gout discharge condition: stable, oxygenating well room air, pain controlled, moving bowels discharge instructions: please call dr. if: notify md or return to the emergency department if you experience: *increased or persistent pain *fever > 101.5, chills *nausea, vomiting, diarrhea, or abdominal distention *inability to pass gas, stool, or urine *if incision develops redness or drainage *shortness of breath or chest pain *any other symptoms concerning to you you may shower and wash incision with soap and water no swimming or tub baths for 2 weeks please use your abdominal binders when out of bed and ambulating until your follow up with dr. . please use your walker as prescribed by physical therapy when ambulating. you will have your staples removed at your appointment at dr. office. continue all your home medications as prescribed. this is very important. lasix potassium metoprolol diavan nph insulin magnesium aspirin gemfibrozil allopurinol prenisone 5 mg daily colchicine for pain: may take percocet for extreme pain. take tylenol for pain. do not take percocet and tylenol together. please use stool softener (colace) twice daily to keep bowel movements soft. followup instructions: follow up with dr. in weeks for staple removal and postoperative check. follow up with your primary care provider on for potassium level, edema in legs (fluid balance) and your finger stick glucose. please use rolling walker as prescribed by physical therapy until cleared by your primary care provider. you may eat regular diet; recommend low fat, low cholesterol diet healthy for your diabetes. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Closed [endoscopic] biopsy of large intestine Open and other sigmoidectomy Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Acidosis Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Gout, unspecified Percutaneous transluminal coronary angioplasty status Acute respiratory failure Cardiogenic shock Blood in stool Morbid obesity Acute diastolic heart failure Benign neoplasm of colon Other pulmonary embolism and infarction Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diverticulosis of colon (without mention of hemorrhage) Laparoscopic surgical procedure converted to open procedure Benign neoplasm of rectum and anal canal

history of present illness: the patient is an 84 year old female with thoracic abdominal aneurysm, transferred from an outside hospital with acute abdominal pain. the patient presented to the hospital at 1:00 p.m. today with abdominal pain, which she describes as midabdominal, dull, constant, with no significant radiation. she notes that she has had episodes of emesis. she denies back pain, radiation in the groin, pain developed acutely and has slowly improved, but is still present. she denies shortness of breath, chest pain or chest pressure. she has had known aneurysm since . past medical history: hypothyroidism. asthma. hypertension. coronary artery disease. high cholesterol. echocardiogram in , showed mild mitral regurgitation and moderate aortic stenosis and normal ejection fraction. low back pain. past surgical history: cholecystectomy in . allergies: no known drug allergies. medications on admission: 1. albuterol. 2. atrovent. 3. hydrochlorothiazide. 4. aspirin. 5. levoxyl. 6. singulair. 7. lipitor. physical examination: the patient has a temperature of 97.1, heart rate 98, blood pressure 130/66, respiratory rate 18, oxygen saturation 96 percent. she is currently on a esmolol drip. she is alert in no acute distress. extraocular movements are intact. neck is supple. she has a regular rate and rhythm. she has a iii/vi systolic ejection murmur. she is clear to auscultation bilaterally. abdomen is nondistended. she has bowel sounds. it is soft. there is mild midabdominal tenderness. she does have a palpable abdominal aortic aneurysm with no noted tenderness. there are no bruits. she has a well healed laparoscopic cholecystectomy scar. she has no hernias. extremities are cool with good capillary refill. she has two plus carotids and no bruits, two plus brachial pulses, one plus femoral pulses, one plus popliteal pulses and monophasic dorsalis pedis and posterior tibial bilaterally. laboratory data: significant laboratories include a white blood cell count of 15.0, hematocrit 28.8, and inr of 1.6. electrocardiogram showed sinus bradycardia, right bundle branch block, no st elevations. hospital course: the patient was admitted to the vascular service on . she received a cardiac surgery consultation. while in the intensive care unit, the patient received invasive monitoring including a central line for central venous pressure monitoring and an arterial line for blood pressure monitoring. she received an esmolol drip for blood pressure control to keep her systolic below 120. her pain was controlled with a morphine drip. after extensive discussion between the attending surgeon, dr. , and senior vascular surgeons in house, it was decided that an operation would be extraordinarily risky for the patient and likely fatal. after discussion with the family, it was decided not to undergo surgery. the patient was made dnr/dni by the family. at approximately 7:00 p.m. on , the patient became acutely hypotensive and tachycardic. hematocrit was sent which showed a hematocrit of 24.6. it was assumed that the patient was then bleeding. the patient was declared dead at 8:10 p.m. on . , Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Aortic valve disorders Dissection of aorta, abdominal Thoracoabdominal aneurysm, without mention of rupture

allergies: atenolol / metoprolol attending: chief complaint: l bka stump with purulent drainage major surgical or invasive procedure: l brachial a - line r fa sheath echo intubation emergent cardiac cath - rca stent picc history of present illness: 72 y.o female with pvd had recent s/p l fem - peroneal bpg on . but ultimatly had l bka on .. pt presented from rehab c/o several day h/o increase bka stump pain with purulent discharge. pt denies fever. past medical history: hypertension hypothyroid rheumatoid arthritis atril fobrillation sinus brady cardia secondary to beta blockers glaucoma cretinine 0.6-1.0 echo: ef 60% s/p laminectomy with excision odf disc l4-5 s/p rt. fem-at 12/03 ( miamin fla. ) rt. tma rt. and lt. tkr rt. carpel tunnel social history: lives alone ambulates with walker essential distances. denies tobacco, has occasional brandy family history: unknown physical exam: afvss heent - ncat, perrl neg lesions nares, oral pharnyx, auditory supple, farom neg lymphandopathy lungs - cta b/l with sligtht crackles bases cardiac - rrr without murmers, palpable pmi abd - soft, pos bs, nttp, neg bruits, neg organomegaly, neg aaa nuero - a/o x3 nad ext - lle bka / palpable femoral pulse staples in place no purulent discharge noted no erythema noted rle - metarsal foot amputation good femoral / dp pulses at 2plus pertinent results: wbc rbc hgb hct mcv mch mchc rdw 4.0-11.0 4.2-5.4 12.0-16.0 36-48 82-98 27-32 31-35 10.5-15.5 k/ul m/ul g/dl % fl pg % % 7.5 3.16* 8.6* 27.7* 88 27.3 31.2 14.9 4:30a pt ptt plt ct inr(pt) 11.6-13.6 22.0-35.0 150-440 sec sec k/ul 321 4:37a 15.9* 31.4 1.6 4:37a 8.6 3.21* 8.8* 28.3* 88 27.5 31.2 14.9 4:37a --------------------basic coagulation (pt, ptt, plt, inr)-------------------- pt ptt plt ct inr(pt) 11.6-13.6 22.0-35.0 150-440 sec sec k/ul 329 4:30a 15.1* 36.1* 1.4 4:30a sinus rhythm. poor r wave progression. non-specific st-t wave changes. compared to the previous tracing no significant change. read by: , j. intervals axes rate pr---qrs-----qt/qtc p - qrs - t 63 132 84 -11 -16 glucose urean creat na k cl hco3 angap 70-105 .4-1.1 133-145 3.3-5.1 96-108 22-29 mg/dl mg/dl mg/dl meq/l meq/l meq/l meq/l meq/l 107* 9 0.7 141 3.7 104 33* 8 4:30a 111* 9 0.7 141 4.4 104 33* 8 4:37a calcium phos mg 8.4-10.2 2.7-4.5 1.6-2.6 mg/dl mg/dl mg/dl 9.6 3.1 1.8 4:30a 9.3 3.2 1.9 4:37a pecimen submitted: left bka revision. procedure date tissue received report date diagnosed by dr. /nwf previous biopsies: left bka. disc material/lb. diagnosis: bone and tissue, left below-knee amputation revision (a-e): acute and chronic osteomyelitis. changes consistent with prior surgical procedure. indications for catheterization: nstemi, chest pain final diagnosis: 1. three vessel coronary artery disease. 2. moderate systolic and diastolic left ventricular dysfunction. 3. successful pci of the rca with two drug-eluting stents. comments: 1. selective coronary angiography showed a right dominant system with thjree vessel disease. the lmca was angiographically without disease. the lad had a distal 70% stenosis. the lcx was small and had a subtotally occluded av branch. the rca was diffusely diseased and had a focal mid 95% stenosis. the distal rca had 70% stenosis prior to bifurcation. 2. limiting resting hemodynamics showed moderately elevated left sided filling pressures (lvedp 22 mmhg). there was no gradient across te aortic valve. left ventricolography showed no significanyt mitral regurgitation. there was inferobasal akinesis. the calculated contrast ejection fraction was 41%. 3. successful pci of the mid and distal rca with a 2.5 x 28 mm cypher des and a 2.5 x 8 mm cypher des (respectively). 4. unsuccessful attempt to cross into the lcx/om. , portable tte (complete) done at 4:39:44 pm final referring physician information , b. ,ste 5b , ma status: inpatient age (years): 72 f hgt (in): 65 bp (mm hg): 92/50 wgt (lb): 130 hr (bpm): 57 bsa (m2): 1.65 m2 indication: chest pain. left ventricular function. icd-9 codes: 786.51 test information date/time: at 16:39 interpret md: , md test type: portable tte (complete) son: bzymek, rdcs doppler: full doppler and color doppler test location: west sicu/ctic/vicu contrast: none tech quality: adequate tape #: 2005w111-1:09 machine: a-55-5 echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.1 cm <= 4.0 cm left ventricle - septal wall thickness: 0.8 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.7 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.9 cm <= 5.6 cm left ventricle - ejection fraction: 40% >= 55% aorta - valve level: 2.9 cm <= 3.6 cm aortic valve - peak velocity: 1.7 m/sec <= 2.0 m/sec mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 0.9 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 210 msec tr gradient (+ ra = pasp): *30 mm hg <= 25 mm hg findings left atrium: mild la enlargement. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra. left ventricle: normal lv wall thickness. mildly dilated lv cavity. moderate regional lv systolic dysfunction. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic root diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. trace ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild mitral annular calcification. mild thickening of mitral valve chordae. moderate (2+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. conclusions the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is moderate regional left ventricular systolic dysfunction with thinning and hypokinesis of the inferior and infero-lateral walls. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared to the prior study dated (tape reviewed), the regional wall motion abnormalites and significant mitral regurgitation are new. impression: regional lv systolic dysfunction c/w cad. moderate to severe mitral regurgitation. mild pulmonary hypertension. brief hospital course: complicated hospital stay. she was put on continuous antibiotics durng this hospital stay for he l bna infection. pt was admitted for l bka stump pain and drainage on , s/p l fem peroneal bpg on which ultimatley required a l bka . while being admitted through the er pt experienced chest pain, an ekg was done which showed ischemic changes. she was transfered to the vicu where she ultimately r/i for nstemi. pt then transfered to the sicu on . here, because of her mi, pt went into resp failure caused by chf. patient had to be intubated. during her stay at the sicu a cardiology consult was obtained. cardiology did a cardiac catherization, which resulted in a rca stent x 2.(see cardiac catherization report for full details). a l subclavian line was put in for cvp measuement. pt was successfully extubated om . during her stay in the sicu pt did develop a uti, she was tx successfully. pt transfered to the vicu on . here she was kept untill she was stable enough to undergo her l bka stump revision. cardiology cleared for her operation. on pt went to or for stump revision. the operation was successful, she left the or with a hickman drain. she was transfered back to the vicu in stable condition. on pt transferd to the floor. her hickman drain was dc'd after assessing for no drainage. consults were put in for pt / rehab screening. recommendation was for a full facility. medications on admission: levothyroxine lisinopril colace xalatan drops ou ecasa alamag feso4 dulcolax vicoden senokot mvi nuerontin keflex coumadin 3 mg po qhs discharge medications: 1. levothyroxine sodium 88 mcg tablet sig: one (1) tablet po daily (daily). 2. warfarin sodium 2 mg tablet sig: 1.5 tablets po hs (at bedtime). 3. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 6. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. polyvinyl alcohol 1.4 % drops sig: one (1) drop ophthalmic prn (as needed). 8. hydromorphone hcl 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 9. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 10. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 11. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 12. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). 13. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). 14. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 15. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 17. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 18. morphine sulfate 8 mg/ml syringe sig: one (1) injection q4h (every 4 hours) as needed for breakthrough. 19. vancomycin hcl 1,000 mg recon soln sig: one (1) intravenous once a day for 6 weeks: check vanco levels and adjust accordingly. 20. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. discharge disposition: extended care facility: senior healthcare discharge diagnosis: l bka wound infection (mrsa) after admission non st elevation myocardial infarction acute renal failure secondary to congestive heart failure with poor kidney perfusion resp failure secondary to chf / pul edema - required intubation chf echo ef 40 % / inf / inf-lat hk with wall thinning coronary artery disease recieved rca stent revision l below knee amputation left below knee amputation site infection on admission l femoral - peroneal byg l bka hypertension hypothyroidism ra atrial fibrillation- coumadin hx of sinus bradycardia sec to beta blockers glacoma echo ef 60% l4-l5 laminectomy s/p r fem at () s/p r tma s/p r ctr s/p b/l tkr bso discharge condition: stable discharge instructions: look for fever, chills, and other systemic signs of infection check wound for erythema, discharge, bleeding and swelling. if the above happens call dr. at the number provided monitor pt/inr goal is 2-2.5 followup instructions: please call dr phone number and schedule an appointment in week after discharge please call at to make an appointment with a cardiologist, first available. other appts. scheduled provider: , .d. where: phone: date/time: 11:20 provider: , m.d. where: center phone: date/time: 11:15 provider: , orthopedic private practice where: orthopedic private practice date/time: 11:00 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Transfusion of packed cells Transfusion of other serum Repair of entropion or ectropion with wedge resection Revision of amputation stump Other immobilization, pressure, and attention to wound Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Acute respiratory failure Infection (chronic) of amputation stump

history of present illness: the patient is a 70-year-old female with a several day history of fever, diaphoresis, and aches with a temperature up to 102 at home. the patient was getting out of her car at the emergency room when she fell loss of consciousness times two minutes. she then awoke and complained of headache, was alert and oriented times three. she then became lethargic and became unresponsive and dilated her left pupil. she was intubated. a ct scan was obtained, and this showed an acute left subdural hematoma and diffuse subarachnoid hemorrhage. she was taken emergently to the operating room and had an evacuation of the hematoma. past medical history: her past medical history includes chronic back pain with unsteady gait, hypertension, palpitations, and restless leg syndrome. medications on admission: her medications included lipitor 10 mg p.o. q.d., inderal 40 mg p.o. b.i.d., prilosec 20 mg p.o. q.d. she was started on nimodipine 60 mg q.4h. dilantin was also started at 100 mg p.o. t.i.d. laboratory on admission: white blood cell count 12.9, hematocrit 31.1, platelet count 280. sodium 134, potassium of 4.5, chloride 96, bicarbonate 23, bun 29, creatinine 1.2, glucose 149. pt was 13.2, ptt 23.6, inr 1.1. her amylase was 28. her fibrinogen was 862. she had a negative urine toxicity screen. radiology/imaging: head ct showed left frontal subdural hematoma with mass affect and shift to the right. subarachnoid hemorrhage. cervical spine was not cleared. the patient was placed in a hard collar. the patient had a postoperative ct scan which showed good evacuation of the subdural hematoma and ventricles now considerably larger than previously seen on scan. the patient also had vent drain placed immediately postoperatively. hospital course: on , the patient went for a ct angiogram to rule out aneurysm as a result of subarachnoid blood. neurologic examination revealed the patient localized to pain on the right. pupils were 4 down to 3 on the right and 2.5 to 2 on the left. toes were mute. head ct from showed slightly smaller ventricles with right intraventricular blood, and a question of clot around the ventricular catheter. on , the patient was evaluated by the general surgery service for increasing white blood cell count and distended abdomen. the patient had a distended abdomen, and a ct of the abdomen demonstrated a fair amount of free intraperitoneal air and free retroperitoneal air, particularly in the left retroperitoneum surrounding the left kidney down to the sigmoid area. no significant fluid or abscess, and a small 2-cm to 3-cm loculated collection at the top of the iliac vessels without contrast. her neurologic examination at that time revealed she was responsive, moving all extremities, and following commands. her abdomen was markedly distended and soft without rigidity or peritoneal signs; however, she localized with tenderness on the left side. on , the patient went to the operating room and had a takedown splenic flexure hartmann procedure performed by dr. . there were no intraoperative complications. the patient had an ileostomy done at that time. it was discovered intraoperatively that the patient had a diverticulum. on , the patient spiked to 102.9. her neurologic examination revealed she opened her eyes briskly to voice, squeezed to command on the right, moved spontaneously on the left, and withdrew to pain in the lower extremity. her neurologic state was stable, though with persistent fevers. the infectious disease service was consulted. the patient had a swab during the surgery that grew staphylococcus, so the patient was started on vancomycin on . on , she was started on flagyl and levaquin for the coagulase-negative staphylococcus that grew from the swab from the operating room. also, on , 1/2 blood culture bottles grew gram-negative rods from the blood culture that was sent on , and she was started on penicillin. her esr at that time was 92. chest x-ray on , showed left layering pleural effusion and retrocardiac dense opacity consistent with atelectasis. infectious disease recommended changing the patient from levaquin to ceftazidime 2 g iv q.8.h., continue flagyl and vancomycin, and start fluconazole 100 mg q.d. for surgical prophylaxis. on further evaluation, infectious disease felt that the 1/2 blood cultures from the which grew staphylococcus was most likely a contaminant since it took five days to grow. on , the patient spiked to 104.8. neurologically, she opened her eyes. she followed verbal commands. she localized to sternal rub with both upper extremities, bilateral lower extremities reactive to stimulation briskly withdrew. her incision was clean, dry and intact. final report from the blood culture, positive blood culture from , grew the anaerobe prevotella. further evidence to suggest the patient had an abscess brewing for a while before surgery with subsequent bacteremia. they recommended ct of the abdomen and pelvis. ct of the abdomen and pelvis on , showed small left pleural effusion, a tiny fluid collection in the left colonic gutter, and fluid in the left lower pelvis. abdominal ct showed no tappable fluid or abscess. on , the patient was unable to tolerate the ventilator settings on cpap. the patient was sedated due to difficulty ventilating. her temperature spiked to 103. she continued to move her upper extremities spontaneously, opening her eyes, and was attentive. she wiggled her toes and squeezed to command bilaterally. she was sent for a ct angiogram to rule out pulmonary embolism. the patient had a lumbar puncture done which was sent for gram stain and culture. ct angiogram was negative for pulmonary embolism. the patient continued to have a left small pleural effusion, bilateral atelectasis. chest x-ray showed a left lower lobe collapse with retrocardiac density, and ct of the head showed negative for abscess with small residual subdural hematoma. on , the patient had doppler studies which showed a deep venous thrombosis on the left side. the patient had filter placed. on , the patient's neurologic examination revealed pupils were 3.5 down to 2.5 bilaterally. she was attentive, opened her eyes, squeezed bilaterally to command, held up arms briefly, moved bilateral lower extremities, and wiggled her toes to command. infectious disease recommended stopping ceftazidime for a question of a beta lactonase drug allergy, so ceftazidime was discontinued and white count was followed. lumbar puncture results showed no growth on the cerebrospinal fluid for organisms. the patient was awake and attentive, continued to be intubated. pupils, right 4 down to 3.5 and left 3 to 2. not following commands. withdrew to lower extremity briskly to stimulation (and this was on ). on , the patient's temperature was done to 100.6. infectious disease fellow felt this was indicative of most likely the beta lactonase, ceftazidime, allergy. on , the patient's white blood cell count climbed to 29.6 after trending down to the low 20s to teens. infectious disease recommended drainage of the small fluid collection in the abdomen. she was extubated on , and continued on her intravenous flagyl, vancomycin, and levofloxacin with continued low-grade fevers. it was decided that because the patient's white blood cell count was coming down, and she was defervescing, that tapping the abdominal fluid collection would not be done unless she spiked a temperature and follow-up abdominal ct would be done in the next 10 to 14 days (and this was on ). on , the patient had increased respiratory difficulty after extubation. pulmonary was consulted, and the patient bronched, which bronch just showed atelectasis in the left lower lobe with signs of mucous plugging, and in upper airway showed copious amounts of upper airway secretions. on , the patient continued to have labored breathing. the patient was given aggressive chest physical therapy and physical therapy was consulted to assist with that. the patient was started on tube feeds in early and was tolerating that well, and nutrition continued to follow her as well as the enterostomal nurse changes of her colostomy. on , the patient's neurologic examination revealed the patient opened eyes to vigorous stimulation, squeezed to command on the right, and flexed in the lower extremities minimally to pain. laboratories revealed sodium was 133 on . the patient was started on salt tablets 2 g p.o. b.i.d. she continued to be followed by physical therapy and occupational therapy for aggressive pulmonary toilet. an mri of the brain on , showed subacute subdural hematoma with body occipital pole. on , the patient was transferred to the regular floor. she continued to be followed by physical therapy and occupational therapy. the patient's mri did show increased size of the ventricles. the patient will require vp shunt placement. on , the patient had a vp shunt placed. the patient was extubated in the operating room and sent to the recovery room, and the patient had respiratory distress in the recovery room requiring intubation. she was transferred to surgical intensive care unit for closer monitoring. she also had percutaneous endoscopic gastrostomy placed on . on , temperature spiked to 101.1. chest x-ray showed left infiltrate and collapse. on , neurologic status revealed the patient was awake and attentive but not following commands. on , the patient was extubated. her neurologic examination showed two fingers on the right and tense to the examiner. opened her eyes. vital signs were stable. she was afebrile. the patient was transferred to the floor on , in stable condition. on , the patient spiked a temperature to 101.8. infectious disease service was consulted. the patient was also fully cultured, and all cultures were negative to date. neurologically, on , the patient was awake and alert with a weak cough. continued to have copious secretions, whispering words, and following commands in upper and lower extremities. the patient had methicillin-resistant staphylococcus aureus in her sputum and methicillin-resistant staphylococcus aureus bacteremia. the patient continued with bilateral effusions, the right greater than left, and a urinary tract infection. the patient was on intravenous vancomycin and ciprofloxacin at this point. chest x-ray improved overall on . lateral decubitus failed to showed layering with no clear obvious effusions. oxygen saturations were improving, now to 96% to 99% on 100% face mask and 6 liters. the patient continued to be followed by physical therapy and occupational therapy and will require rehabilitation. medications on discharge: 1. diltiazem 60 mg per g-tube q.i.d. 2. reglan 10 mg per g-tube q.6h. 3. heparin 5000 units subcutaneous b.i.d. 4. 20 meq per g-tube q.d. 5. h20 200 cc per g-tube q.d. 6. hydrochlorothiazide 20 mg per g-tube q.d. 7. lopressor 150 mg per g-tube t.i.d. 8. vancomycin 1 g intravenously b.i.d. 9. tylenol 650 mg p.o. q.4h. p.r.n. 10. percocet one to two tablets p.o. q.4h. p.r.n. 11. ciprofloxacin 400 mg intravenously q.12h. 12. albuterol nebulizers q.6h. p.r.n. 13. atrovent nebulizers q.6h. p.r.n. condition at discharge: the patient's condition was stable at the time of discharge. discharge followup: the patient was to follow up with dr. in one month's time. , m.d. dictated by: medquist36 d: 12:06 t: 12:20 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Incision of cerebral meninges Insertion of endotracheal tube Open and other left hemicolectomy Temporary colostomy Interruption of the vena cava Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Diagnoses: Unspecified protein-calorie malnutrition Septicemia due to anaerobes Diverticulitis of colon (without mention of hemorrhage) Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Communicating hydrocephalus Accidental fall on or from sidewalk curb

history of present illness: the patient is a 71-year-old woman status post a fall in resulting in severe subdural hematoma with subarachnoid hemorrhage, eventually requiring a ventriculoperitoneal pleural shunt. the patient came back with recurrent pleural effusions requiring thoracentesis x2 and on the 19th underwent a revision of a ventricular pleural to a ventriculoperitoneal shunt secondary to progressive dyspnea secondary to recurrent pleural effusions. the patient tolerated the procedure well. there were no intraoperative complications. past medical history: 1. traumatic brain injury 2. chronic pulmonary embolus 3. myocardial infarction with stenting in 4. chronic right pleural effusion 5. hypertension she was admitted to the surgical intensive care unit postoperative and had a thoracentesis done to tap the right pleural effusion and that was done successfully without complication. the patient was successfully extubated and was weaned to room air and transferred to the regular floor post thoracentesis. she has remained neurologically stable, awake, alert and oriented x3, moving all extremities with good strength. her abdomen is soft, nontender, nondistended with good bowel sounds. her incisions are clean, dry and intact. she is seen by physical therapy and occupational therapy and found to require a short rehabilitation stay prior to discharge to home. discharge medications: 1. colace 100 mg po bid 2. protonix 40 mg po q 24 hours 3. insulin sliding scale 4. metoprolol 50 mg po bid 5. 10 mg po q day 6. lorazepam 0.5 mg po bid 7. trazodone 100 mg po q hs 8. quetiapine fumarate 100 mg po q hs the patient's condition was stable at the time of discharge. her incisions were clean, dry and intact. she will follow up with dr. in one month. , m.d. dictated by: medquist36 Procedure: Thoracentesis Replacement of ventricular shunt Gingivoplasty Diagnoses: Obstructive hydrocephalus Unspecified pleural effusion Percutaneous transluminal coronary angioplasty status Old myocardial infarction Mechanical complication of nervous system device, implant, and graft

allergies: penicillins / codeine / aspirin / epinephrine attending: chief complaint: diagnostic cath for reversible ischemia on stress major surgical or invasive procedure: aspirin desensitization history of present illness: 72 year old female with pmh of cabg social history: nc family history: nc physical exam: general: nad, comfortable heent: no lad, no jvd heart: rrr no m/r/g lungs: ctab ext: no e/c/c 2+ dp pulses neuro: cn ii -xii intact pertinent results: 12:34pm glucose-252* urea n-28* creat-1.5* sodium-141 potassium-4.6 chloride-102 total co2-25 anion gap-19 12:34pm calcium-10.2 phosphate-3.5 magnesium-2.0 12:34pm wbc-8.3 rbc-4.61 hgb-14.3 hct-41.2 mcv-90 mch-31.0 mchc-34.7 rdw-12.6 12:34pm plt count-247 12:34pm pt-12.2 ptt-19.7* inr(pt)-1.0 brief hospital course: the patient was admitted to the ccu for aspirin desensitization, which the patient tolerated well. she was transferred after several hours to the floor for her procedure. medications on admission: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 3. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. conjugated estrogens 0.3 mg tablet sig: five (5) tablet po 3x/week (mo,we,fr). 9. multivitamin capsule sig: one (1) cap po daily (daily). 10. benicar 40 mg tablet sig: one (1) tablet po qd (). discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 3. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. conjugated estrogens 0.3 mg tablet sig: five (5) tablet po 3x/week (mo,we,fr). 9. multivitamin capsule sig: one (1) cap po daily (daily). 10. benicar 40 mg tablet sig: one (1) tablet po qd (). 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: angina, cad discharge condition: stable discharge instructions: please note that your new medicine is aspirin which you should take every day. please continue to take all of your other medications as previously. if you have any chest pain or shortness of breath, or any other concerning symptoms, please call your doctor immediately. followup instructions: 1. please make an appointment to see your cardiologist, dr. within one month. Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other and unspecified hyperlipidemia Other complications due to other cardiac device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: the patient is a 42-year-old woman with a history of schizophrenia who was transferred from an outside hospital with a report of a right-sided intracranial lesion. the patient's mother reports the patient had complaints of a right-sided headache for three days. earlier, on the day of admission, she was found somewhat "out of it." she had reports of loss of consciousness at her day care center. upon arrival at the outside hospital, she had a second episode of loss of consciousness. the patient reportedly was hospital. she had a head computed tomography that has been interpreted as a right parietal/occipital lesion with a midline shift. she was given 10 mg of decadron and transferred to for further management. her cervical spine was cleared at the outside hospital. past medical history: (past medical history includes) 1. schizophrenia since the age of four. 2. seizure disorder. 3. diabetes mellitus. 4. hypertension. medications on admission: 1. lisinopril 10 mg p.o. q.d. 2. glucophage 2.5 mg p.o. q.d. 3. risperidol one p.o. b.i.d. 4. cogentin 0.25 mg p.o. q.h.s. 5. lipitor 10 mg p.o. q.d. allergies: the patient has an allergy to erythromycin. physical examination on presentation: on physical examination, temperature was 98, heart rate was 102, blood pressure was 117/94, respiratory rate was 18, oxygen saturation was 95% on room air. the patient was lying in bed with her eyes closed, in no acute distress. she opened her eyes to stimulation and attempts to examine her. she said her name was . she held her arms up in the air off the bed with no drift. she followed commands. pupils revealed left 5 mm down to 4 mm; right was 4.5 mm down to 3.5 mm. brisk withdrawal of lower extremities bilaterally. coma scale score was 10. radiology/imaging: a head computed tomography showed a 2-cm x 1.5-cm isodense area in the right parietal/occipital area with edema and extending anterolaterally for approximately 6.7 cm with 2 cm of midline shift. pertinent laboratory data on presentation: laboratories on admission revealed sodium was 131, potassium was 3.9, chloride was 92, bicarbonate was 25, blood urea nitrogen was 10, creatinine was 0.6, and blood glucose was 201. white blood cell count was 13.2, hematocrit was 37.1, and platelets were 313. hospital course: the patient was admitted to the neurosurgery service. she was seen by dr. in consultation . the patient underwent a magnetic resonance imaging scan to better differentiate the lesion and was taken to the operating room on for a right craniotomy for excision of tumor without intraoperative complications. she was monitored in the recovery room overnight where she remained neurologically stable; awake, alert and oriented times three. she moved all extremities with minimal right drift. her wound was clean, dry, and intact. she was transferred to the regular floor on postoperative day one. she was out of bed ambulating, and tolerating a regular diet, and voiding spontaneously. discharge disposition: she was cleared for discharge to home on . medications on discharge: 1. decadron taper down to 2 mg p.o. b.i.d. over three to five days. 2. protonix 40 mg p.o. q.d. 3. percocet one to two tablets p.o. q.4h. as needed. 4. lisinopril 10 mg p.o. q.d. 5. glucophage 2.5 mg p.o. q.d. 6. risperidol one p.o. b.i.d. 7. cogentin 0.25 mg p.o. q.h.s. 8. lipitor 10 mg p.o. q.d. condition at discharge: the patient was in stable condition. discharge instructions/followup: the patient was to follow up with dr. in the brain clinic on and for staple removal on , . , m.d. dictated by: medquist36 d: 09:11 t: 09:26 job#: Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other convulsions Unspecified schizophrenia, unspecified Malignant neoplasm of brain, unspecified

allergies: erythromycin base / penicillins / ampicillin attending: chief complaint: lethargy major surgical or invasive procedure: none history of present illness: ms. is a 44 y/o f with pmh significant for oligoastrocytoma s/p resection chemo and stereotactic radiosurgery for recurrence, seizure d/o, schizophrenia, dm and htn initially presenting with seizures to osh. per mom, pt was in her usual state of health when she fell asleep while sitting in a chair. pt woke up shortly after and was disoriented, but could recognize her mom. she than became unresponsive, walking aimlessly through the house, and again fell asleep. according to mom, she had no focal movements consistent with a seizure but had drinking a lot of fluids, consisting of 10cans of diet coke and 4-16oz bottles of water. pt usually drinks a great deal of fluids and had a similar episode of ms changes 6mos prior, when she was found to be hyponatremic. mom became concerned and brought pt to osh. en route to osh, she did have bladder incontinence. at osh had episode of emesis. ct of head showed no signs of bleed, but increased attenuation of frontal lobe c/w prominant sulci, encephalomalecia of right post temporal lobe. her fs at osh was 270 and na was 116, she was given ativan 2mg iv, hydrocortisone 100mg and zofran. she was to have started temodar her chemo last night. she was then transferred to ed. at , she was febrile to 102, with leukocytsosis, and elevated lactate with slightly improved na to 118. she was started on 1l of ns for hydration and 1l ns with iv mg 4gm. lp was attempted, but unsuccessful, she was started on ceftriaxone 2gm iv, vancomycin 1gm iv, flagyl 500mg iv and sent to for monitoring. course: empiric abx continued; pt given ns & placed on fluid restriction w/subsequent correction of sodium; lp successfully re-attempted by pain service; eeg done; mr scheduled; keppra restarted; risperdal restarted; glyburide & lisinopril held & pt placed on sliding scale. past medical history: 1. anaplastic oligoastrocytoma in r temporal lobe: s/p resection in ; s/p 12 cycles of temodar; s/p stereotactic radiosurgery on for recurrence 2. delayed developmentally as a child 3. autism 4. hypercholesterolemia 5. niddm??????10 yrs, last hba1c~6 6. htn 7. psychosis/schizophrenia?: diagnosed w/schizophrenia w/childhood schizophrenia by dr. ; seen by dr. for 20yrs; auditory hallucinations at baseline; last hospitalized in for suicide attempt 8. generalized tonic-clonic seizure??????1: per mom prior to tumor resection; remote seizure hx at 12 y/o social history: lives with mom, graduated from community college, no tob/etoh/drugs, patient was knew all her meds and doses and was self-administering them, doing her finances, and conducting adls until 1.5 weeks ago prior to admission. walks unaided. had been working prior to brain tumor. family history: dm, htn, breast cancer, prostate cancer and brother--schizophrenia physical exam: vs: tc 100.4ax/102.0 r in ed bp 127/80 p 125 sat 96%on 5lnc gen awakw, moving all extremities moaning about water heent perrl, dilated to 5mm bilaterally, clear op, mmm chest ctab, poor air mvmt bilaterally cv rrr, tachycardic, no murmrus abd soft, obese, nontender, +bs ext trace edema bilaterally, 2+dp pulses bilterally neuro: large neck, no neck stiffness, 2+reflexes bilterally, withdraws to babinskis', no clonus . pertinent results: labs: on admission: 09:50am wbc-17.8*# rbc-3.93*# hgb-11.8*# hct-30.7*# mcv-78*# mch-30.0 mchc-36.8* rdw-13.5 09:50am neuts-89.2* bands-0 lymphs-7.0* monos-3.5 eos-0.2 basos-0.1 09:50am plt smr-normal plt count-321 07:45am pt-13.7* ptt-19.1* inr(pt)-1.2 07:45am glucose-207* urea n-4* creat-0.6 sodium-116* potassium-4.4 chloride-79* total co2-21* anion gap-20 08:54am lactate-3.6* 09:50am alt(sgpt)-50* ast(sgot)-42* alk phos-90 amylase-47 tot bili-0.7 09:50am lipase-29 01:54pm osmolal-258* 01:54pm tsh-0.63 01:54pm cortisol-18.6 09:56pm type-art po2-108* pco2-31* ph-7.42 total co2-21 base xs--2 intubated-not intuba comments-qns for la . urine on admission 04:25am urine osmolal-556 04:25am urine hours-random creat-35 sodium-119 potassium-42 chloride-105 amylase-88 /creat-3. . labs on discharge: 06:05am blood wbc-10.9 rbc-4.21 hgb-12.3 hct-36.4 mcv-87 mch-29.3 mchc-33.8 rdw-14.0 plt ct-301 06:05am blood glucose-161* urean-10 creat-0.4 na-140 k-4.9 cl-98 hco3-29 angap-18 . spinal fluid: negative for malignant cells. lymphocytes, neutrophils and monocytes. . ekg: nsr at 96bpm, no st/twave changes, 1mm pr depressions in ii, iii . cxr: mild increase in opacity of the right lower lung medially could represent atelectasis. aspiration cannot be excluded. upper lungs clear. heart size normal. no pleural abnormality. . mri from : status post right temporal lobe brain tumor resection, with cystic csf space at the surgical site. enlarging mural nodule with enhancement, measuring 6 mm in diameter, which is worrisome for progression of previously diagnosed anaplastic astrocytoma. . mri from :impression: nodules of enhancement along the posterior margin of the surgical cavity in the right posterior lobe, slowly increasing in size most notably since the exam of . these findings are concerning for recurrence. eeg: findings: abnormality #1: there is a continuous mixed delta and theta frequency slowing over the left temporal region. background: is a low voltage 9 hz alpha frequency rhythm with normal anterior-posterior voltage gradient. hyperventilation: was not performed because of the patient's clinical condition. intermittent photic stimulation: was not performed because this was a portable study. sleep: normal transitions of the sleep architecture were not seen. cardiac monitor: sinus tachycardia with a rate of 102 bpm. impression: this is an abnormal portable eeg obtained in drowsiness due to the presence of continuous mixed delta and theta frequency slowing over the left temporal region. anatomical correlation is recommended. no epileptiform discharges were seen. a tachycardia was noted. . brief hospital course: course: in the , empiric antibiotics were continued. pt's hyponatermia was thought to be secondary to a combination of dehyration and polydipsia. the patient was given normal saline and placed on fluid restriction with subsequent correction of her sodium. pt's mental status was most likely secondary to hyponatremia; and it gradually improved with correction of serum sodium. an infectious work up was negative, with negative blood, urine, and csf fluid. csf fluid also revealed no malignant cells and no growth of bacteria. an eeg was performed which showed no seizure activity. pt was initially given a dilantin load; followed by reinitiation of keppra, overlapping with dilantin. risperdal was also restarted. glyburide and lisinopril were held and the patient was placed on an insulin sliding scale. she was transferred to the general medicine service for further care and treatment. . on the floor, infectious diseases was consulted and made the recommendation to stop the patient's empiric antibiotics as her csf profile was not suggestive of bacterial meningitis. a chest x-ray was repeated to investigate other sources of infection and found to be negative. her sodium remained within normal limits and a fluid restriction of 1500cc was imposed. her mental status continued to improve. pt was restarted on lisinopril and glyburide. a repeat mri showed nodules of enhancement along the posterior margin of the surgical cavity in the right posterior lobe, slowly increasing in size and concerning for recurrence (pt will have outpt f/u of this). the patient's dilantin level was below 10 so she was given an additional dose of dilantin 500mg po. pt was discharge home after return to baseline mental status, normalized sodium, on her home regimen of keppra, dilantin, and decadron with instructions to f/u with her pcp. medications on admission: 1. lisinopril 5 mg po qd 2. keppra 500 mg po bid 3. glyburide 5 mg po qd 4. lipitor 20 mg po qhs 5. risperdal 1 mg po bid 6. cogentin 1 mg qd discharge medications: 1. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 2. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for seizure d/o. 3. glyburide 5 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 5. risperidone 1 mg tablet sig: one (1) tablet po bid (2 times a day). 6. outpatient lab work dilantin level checked monday and called to dr. office 7. multivitamin capsule sig: one (1) cap po daily (daily). 8. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. dexamethasone 4 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 10. dilantin 30 mg capsule sig: one (1) capsule po at bedtime: take in addition to 100mg at bedtime. disp:*30 capsule(s)* refills:*2* 11. dilantin 100 mg capsule sig: one (1) capsule po three times a day. disp:*90 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. psychogenic polydipsia 2. seizure disorder 3. psychosis 4. worsening oligoastrocytoma 5. hyponatremia discharge condition: 1. hyponatremia resolved 2. seizure disorder stable 3. afebrile with stable vital signs 4. mental status at baseline discharge instructions: 1. please go to the emergency room if you become short of breath, dizzy, lightheaded, confused or have chest pain, seizure activity, fevers/chills, or mental status changes. 2. please make an appointment to follow up with your pcp, . in 1-2weeks. 3. please avoid drinking caffeine containing beverages or drinking more than 64 ounces of water a day. 4. you are not being sent home with any new medications. please continue taking all of your medications regularly. followup instructions: 1. please make an appointment to see your pcp, . (call ) within one to two weeks. provider: mri where: phone: date/time: 11:30 provider: , where: neurology phone: date/time: 1:30 md Procedure: Spinal tap Incision of lung Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Other convulsions Unspecified schizophrenia, unspecified Other and unspecified hyperlipidemia Other specified disease of white blood cells Personal history of malignant neoplasm of brain

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hematemesis major surgical or invasive procedure: 1. orotracheal intubation 2. esophagoscopy history of present illness: this is a 38-year-old female with a history of achalasia s/p dilation 2mm>10mm complicated by persistent complete obstruction hematoma vs edema resolved with supportive care. last dilation and since then pt did well until last night when she was having a chicken meal and possibly had chicken impaction. she vomited but was unable to clear it, had n/v multiple times with subsequent significant hematemesis. this morning she was still having problems with secretions, small amount of blood coming up, brought into ed for further evaluation. currently she has not vomited for approx 4 hours and has only mild stomach upset and light headedness. patient was able to stop tpn approx 6 weeks ago but since then has lost approx 4 lbs, notes worry over eating due to past problems with impaction. past medical history: 1. achalasia x 20y s/p 3 pneumatic dilations, botox inj, myotomy, neissen fundoplication 2. gerd 3. transaminitis 4. hepatomegaly social history: 1. married 2. occasionally smokes 3. denies drugs family history: nc physical exam: temp 99.2 bp 130/70 pulse 88 resp 18 o2 sat 96%ra weight 81.1 gen - alert, no acute distress heent - ncat, perrl, extraocular motions intact, anicteric, mucous membranes moist chest - clear to auscultation bilaterally cv - normal s1/s2, rrr, no murmurs, rubs, or gallops abd - soft, nontender, nondistended, with normoactive bowel sounds, no hsm extr - no clubbing, cyanosis, or edema. 2+ dp pulses bilaterally pertinent results: 04:50pm blood wbc-6.1 rbc-3.20* hgb-8.7* hct-25.9* mcv-81* mch-27.2 mchc-33.7 rdw-15.6* plt ct-246 04:55pm blood pt-13.5* ptt-26.2 inr(pt)-1.2 04:50pm blood glucose-117* urean-15 creat-0.6 na-138 k-4.1 cl-101 hco3-24 angap-17 brief hospital course: upper gi bleed: the patient had recurrent impaction with subsequent vomiting followed by hematemesis. likely recurrence of stricture with tear secondary to vomiting to clear impaction. the patient's hematocrit remained stable. she was treated with antiemetics, iv fluids and a proton-pump inhibitor. ## esophageal impaction: the patient was electively intubated in the icu and underwent esophagoscopy with removal of blood clots and chicken remains. she was successfully extubated after completion of the procedure. the patient was kept npo overnight amd started on clear fluids with problem the morning following the procedure. she was discharged in stable condition with appropriate follow up scheduled. discharge medications: 1. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. achalasia 2. retained food products 3. - tears discharge condition: good discharge instructions: you have been hospitalized for the evacuation of the food remains from your esophagus. you have been intubated and sedated and underwent esophagoscopy with subsequent removal of blood clots and food remains. you have been placed on medication to reduce the acidity in your stomach. please continue to take this medication as prescribed. please call dr. office to schedule a follow up visit in the near future (. please call your doctor or go to the er if your develop: * uncontrolled pain * bloody vomit * dizziness, lightheadedness * abdominal pain * any worrisome symptoms followup instructions: 1. dr. ( 2. provider: , md where: lm center phone: date/time: 9:15 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Other endoscopy of small intestine Insertion of endotracheal tube Removal of intraluminal foreign body from esophagus without incision Diagnoses: Esophageal reflux Gastroesophageal laceration-hemorrhage syndrome Stricture and stenosis of esophagus Foreign body accidentally entering other orifice Other chronic nonalcoholic liver disease Foreign body in esophagus Achalasia and cardiospasm

allergies: shellfish attending: chief complaint: chest pain major surgical or invasive procedure: patient underwent cardiac catherization with the placement of 4 stents and rotational atherectomy. history of present illness: 79 y/o female with h/o htn, t2dm, fh of hyperlipidemia, who presented to osh with sscp, nonradiating, associated with sob, diapharesis which started when she was trying to open a window at home. she felt weak and slipped off her chair. she then called 911. over the past 6 wks she has been having increasing frequency of exertional chest pain of similar quality. . at osh, her ekg showed 1 mm ste in v3, std in i, avl, v4-v6. ce were positive with a peak ck 300 mb 13 tn i 0.71. she was given plavix 300 mg x 1 at osh. osh cath revealed a prox lad 50-60%, rca with 99% mid portion. lv gram with normal function. she received 100 cc contrast. she also had increased bs to 300s at osh. she was then transferred here for cath. . cath showed lad 70% mid vessel, 50% diag, 50% om, rca with diffuse calcification with prox 60%, mid 90%, distal 70%. rotatone atherectomy of rca with 4 overlapping cypher stents placed from distal rca to ostium (~90 mm) with resulting normal flow. the patient was agitated at cath and touched groin site. total of 360 cc contrast with 69 minutes of fluro time. when the patient arrived to the ccu, she was cp free, no sob, and no complaints of pain. past medical history: 1. htn 2. t2dm 3. hyperlipidemia 4. hypothyroidism 5. osteoporosis 6. anxiety social history: tobacco use 1 ppd x 21 years, quit at age 42 no etoh lives at home with husband family history: mother with cad, age 58 father with cad, age 64 sister with esrd physical exam: vitals: 97.2 128/65 61 14 97% 4l nc heent: perrla, eomi. mm dry. nc/at. op clear. neck: jvp difficult to access due to patient positioning. no carotid bruits. cv: normal s1, s2 with no m/r/g. pulm: ctab, no wheezes or crackles abd: soft, nt/nd with normoactive bs. ext: no c/c/e. dp 2+ b/l. pertinent results: wbc-20.7* rbc-4.12* hgb-13.7 hct-36.4 mcv-88 mch-33.3* mchc-37.7* rdw-12.9 plt ct-240 glucose-297* urean-24* creat-0.9 na-132* k-3.5 cl-95* hco3-20* angap-21* ck-mb-8 ctropnt-0.07* calcium-8.4 phos-3.5 mg-2.5 cholest-147 triglyc-233* hdl-32 chol/hd-4.6 ldlcalc-68 tsh-1.5 . wbc-18.5* rbc-3.79* hgb-12.3 hct-34.2* mcv-90 mch-32.5* mchc-36.1* rdw-13.0 plt ct-204 glucose-220* urean-23* creat-0.8 na-132* k-3.9 cl-97 hco3-22 angap-17 . ekg nsr at 59, normal axis and interval, no st elevations or depressions . cardiac cath: lad to lcx, 70% mid vessel, 50% diag, 50% om rca diffuse calicified disease with prox 60%, mid 90%, and distal 70% rotatone atherection of rca, 4 overlapping cypher stents placed from distal rca to ostium . imaging studies: 1. cxr ap chest reviewed in the absence of prior chest radiographs: heart is normal size. lungs are clear. there is no pulmonary vascular congestion or pleural effusion. mediastinal and hilar contours are normal. no pneumothorax. . 2. echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no 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 a trivial/physiologic pericardial effusion. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild aortic valve sclerosis. . ucx negative brief hospital course: 79 y/o female with h/o htn, t2dm, hyperlipidemia, and hypothyroidism who presented with chest pain and was found to have an nstemi s/p rca stenting x 4. the following issues were addressed during this hospitalization. 1) nstemi: patient admitted () for chest pain 2nd to nstemi from . patient showed to have abnormal ekg and coronary artery disease.-cardiac catherization performed () and showed the following abnormalities: lad to lcx, 70% mid vessel, 50% diag, 50% om, rca diffuse calcified disease with prox 60%, mid 90%, and distal 70%.during cath, patient experience st changes. the following intervention was done: rotatone atherectomy of rca, 4 overlapping cypher stents placed from distal rca to ostium. patient, hemodynamically stable, then admitted to ccu for post-revascularization monitoring. post cath patient was started on plavix, integrilin for 18hrs, aspirin, and metoprolol. patient stable overnight except for one episode of nausea relieved by with no new ekg changes. patient discharged home with services and advised to follow up with pcp and cardiologist. echo results above. 2) t2dm: patient started on sliding scale insulin (novolog) with accuchecks qac. patient advised to follow up with primary care physician for glycemic control. she was re-started on home oral meds. the patient was not on home insulin prior to admission. 3) htn: patient placed on metoprolol 25mg tid and nitro gtt. on , nitro gtt was discontinued. patient then switched to atenolol 37.5mg qd. she was discharged on an acei. 4) hypothyroidism: patient started on home med dose of synthroid (100mcg). tsh was normal. 5) hyperlipidemia: patient started on lipitor 80mg. a fasting lipid panel was done on () showing triglyc: 233 hdl: 32 chol/hd: 4.6 ldlcalc: 68 patient to be discharged on lipitor 80mg. medications on admission: 1)aspirin 325mg qd. 2)clopidrogel (plavix) 300mg x 1 loading dose (pre-cath), then switched to 75mg qd post cath. 3)atorvastatin (lipitor) 80mg qd 4)metoprolol 25mg tid 5)eptifibatide (integrilin) 2mcg/kg/min iv x 18hrs. 6)levothyroxine (synthroid) 100mcg qd 7)insulin sc sliding scale discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 5. atenolol 25 mg tablet sig: 1.5 tablets po once a day. disp:*30 tablet(s)* refills:*2* 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. glyburide oral discharge disposition: home with service facility: , discharge diagnosis: 1) non-st elevation myocardial infarction s/p cardiac catherization with right coronary artery stent placement x 4. 2) diabetes mellitus type 2 3) hypertension 4) hyperlipidemia 5) hypothyroidism discharge condition: stable, ambulating. discharge instructions: patient advised to continue all home meds with the exceptions noted below. 1) please stop taking your hctz/atenolol. as a replacement, we have started you on atenolol 37.5mg to be taken once per day. 2) please stop taking your mevacor. as a replacement, we have started you on lipitor (atorvastatin) 80mg to be taken once a day. in addition, you have been started on the following medications. 1) plavix (clopidrogel) 75mg to be taken once per day. 2) lisinopril 5mg to be taken once per day. please follow up with your primary care physician (,) within the next 30 days. also, please see your cardiologist (dr. . we have scheduled an appointment with him on wedneday at 4:30pm. if you experience any chest pain, shortness of breath, dizziness, or sudden change in vision please contact your doctor immediately. followup instructions: please see your primary care physician and cardiologist and alert them about this hospital admission. you have an appointment with dr. (cardiology)on wednesday at 4:30pm. provider: , appointment should be within 30days. Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Insertion of four or more vascular stents Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Other and unspecified hyperlipidemia Osteoporosis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: le cellulitis/r hand weakness/l carotid stenosis major surgical or invasive procedure: none history of present illness: 85yo female with multiple medical problems presents to on with lle cellulitis and new-onset rue weakness. at osh, found to have >70% l carotid stenosis and transferred to for further management. past medical history: hyperchol, lung ca s/p r wedge resection, h/o cva w/visual deficit, gastritis, h/o endocarditis, s/p aortic aneurysm repair, bilateral cataracts, h/o gib social history: widowed, lives in prior 70 pack year smoking history, no etoh. family history: dm, cad physical exam: gen somnolent, minimally responsive cv rrr resp +bs bilaterally abd soft, ntnd ext 1+ le edema bilaterally pertinent results: 01:55am blood wbc-20.7*# rbc-3.19* hgb-10.0* hct-31.8* mcv-100* mch-31.4 mchc-31.5 rdw-18.3* plt ct-252 02:15am blood wbc-11.7*# rbc-3.24* hgb-10.1* hct-30.9* mcv-95 mch-31.0 mchc-32.6 rdw-18.1* plt ct-270 01:55am blood plt ct-252 01:55am blood pt-13.0 ptt-35.0 inr(pt)-1.1 02:15am blood plt ct-270 01:55am blood glucose-159* urean-98* creat-2.4* na-137 k-5.8* cl-97 hco3-33* angap-13 02:15am blood glucose-75 urean-86* creat-1.6* na-138 k-5.0 cl-97 hco3-38* angap-8 03:19am blood glucose-121* urean-65* creat-1.1 na-140 k-4.1 cl-97 hco3-40* angap-7* 02:15am blood ck(cpk)-14* 01:55am blood calcium-8.8 phos-10.7*# mg-2.3 02:15am blood calcium-9.5 phos-6.5* mg-2.3 03:19am blood calcium-9.7 phos-5.1* mg-2.1 02:19am blood type-art po2-33* pco2-145* ph-6.96* calhco3-35* base xs--5 03:07am blood type-art po2-158* pco2-85* ph-7.28* calhco3-42* base xs-9 brief hospital course: patient admitted for evaluation of new right sided weakness. neurology consulted for the possibility of a new cva. carotid duplex from osh demonstrated > 70% stenosis of patient's l carotid for which vascular surgery was consulted. during this time, patient noted to have guiac+ stool and a dropping hematocrit. a gi consult was obtained, and an egd was performed which demonstrated blood in the duodenum from a avm. the patient was maintained supportively despite continued bleeding and she was transfused with prbc's to maintain a hct >30. a repeat egd was performed on hd 6 which demonstrated actively bleeding again in the duodenum. a tagged rbc scan confirmed bleeding in the distal duodenum. patient continued to receive transfusions in order to maintain her hct. another egd was performed hd7 where a bicap probe was applied to the bleeding portion of the lesion with cessation of the bleeding. after this procedure, the pt's hct stabilized but did drift down slowly. over the next few days, patient stabilized and was tolerating a regular diet. she was transferred to the floor from the icu and rehab screening was begun. on hd10 patient noted to be more somnolent with +tarry stool. she was transferred to the icu and transfused and a stat egd was performed which demonstrated fresh blood in the duodenum. patient continued to deteriorate from a mental status standpoint with both psychiatry and neurology following. patient did develop hypercarbia and bipap was started as the patient was dnr/dni at this point in time. despite attempts at diuresis, patient's mental and respiratory status did deteriorate over the next few days. any opportunities for operative repair of her bleeding duodenal ulcer were put on hold secondary to these more urgent events. patient did improve briefly, was once again transferred to the floor. however, she continued to have respiratory difficulties and hypercarbia likely stemming from her previous transfusions. her mental status waxed and waned but she eventually did deteriorate on the floor necessitating transfer to the icu. over the next few days, her family at her bedside, the patient experienced episodes of hypotension, altered mental status and hypercarbia. her dnr/dni status was confirmed with her family. an infectious workup was initiated for potential sources of her hypotension and altered mental status and the pt was maintained on antibiotics and parenteral nutrition. the patient became more somnolent with increasing labored breathing and on hd25 she expired. medications on admission: albuterol, amio 200', advair 150'', lasix 80', lopressor 12.5'', prilosec 20' discharge medications: na discharge disposition: expired discharge diagnosis: gi bleed respiratory failure discharge condition: expired Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Non-invasive mechanical ventilation Endoscopic control of gastric or duodenal bleeding Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Acidosis Acute posthemorrhagic anemia Thoracic aneurysm without mention of rupture Atrial fibrillation Depressive disorder, not elsewhere classified Rheumatic heart failure (congestive) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other specified cardiac dysrhythmias Cellulitis and abscess of leg, except foot Personal history of other diseases of circulatory system Mitral valve insufficiency and aortic valve stenosis Pressure ulcer, lower back Iron deficiency anemia, unspecified Dehydration Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other specified hypotension Other alteration of consciousness Angiodysplasia of stomach and duodenum with hemorrhage Dieulafoy lesion (hemorrhagic) of stomach and duodenum Lesion of radial nerve

history of present illness: the patient is an 82-year-old male with a history of hypertension, remote tobacco abuse, chronic renal insufficiency, and a history of a tia who was in his usual state of health until five nights prior to admission when he awoke at midnight with severe epigastric pain radiating to both arms. he also had bilateral arm numbness. the symptoms were associated with diaphoresis and shortness of breath but no nausea or vomiting. after approximately one hour, he presented to the campus where he ruled in for a non-st elevation mi with a ck of 438 with a peak ck mb of 19.8 and troponin that peaked at 10.2. he was started on nitrates there as well as heparin and integrelin and remained pain-free. he denied any history of similar symptoms in the past and has had no prior history of angina or myocardial infarction. the patient was subsequently transferred to for cardiac catheterization. at the time of transfer, he was initially admitted to the cmi service after undergoing cardiac catheterization which revealed a long lad lesion that was angioplastied without stent placement, and a total occlusion of the rca with collaterals. he subsequently became hypotensive and bradycardiac in the catheterization laboratory which responded to iv fluids, dopamine, atropine, and he was then transferred to the ccu for further monitoring. he had a bedside transthoracic echocardiogram done in the cardiac catheterization laboratory without evidence of an effusion. a swan was also placed. there were no stents deployed at all throughout the catheterization. by the time he was admitted, he was off pressors and hemodynamically stable and pain-free. past medical history: tia in . copd with 2 liters dependence of home 02. bph. chronic renal insufficiency. gastritis. asthma. social history: he lis currently widowed. he lives in senior apartment housing in on the . he is very active. he uses a cane p.r.n. for walking. he denied any falls at home. his only family member is a niece in . he is currently retired. he has a remote tobacco history and reports occasional alcohol use. he denied any other drug use. family history: noncontributory. allergies: the patient has no known drug allergies. medications on admission: 1. aspirin 325 mg q.d. 2. metoprolol 50 mg b.i.d. 3. lipitor 10 mg q.d. 4. mdi p.r.n. 5. heparin drip on transfer. 6. integrelin drip on transfer. physical examination: vital signs: heart rate 91, regular, blood pressure 169/81 from a right groin a line, respirations 12, oxygen saturation of 97 percent on 2 liters nasal cannula. general: he was a well appearing male in no acute distress. heent: crusting around the right eyelid but the pupils were equal, round, and reactive to light. he was edentulous. neck: the neck was supple without lymphadenopathy or thyromegaly. cardiovascular: his heart was regular with a normal s1 and s2. he had no murmurs, rubs, or gallops. lungs: his lungs were clear to auscultation bilaterally anteriorly and laterally. abdomen: soft, obese, nontender, nondistended. he had normoactive bowel sounds. extremities: there was a right groin a line and a left groin venous sheath with a swan. he had no evident edema. he had 2+ dorsalis pedis and posterior tibial pulses bilaterally. neurologic: he was alert and oriented times three, moving all extremities. laboratory data: on admission, the cbc revealed a white count of 7.4, hematocrit 39.7, and platelets of 217,000. serum chemistries revealed a sodium of 135, potassium 4.0, chloride 102, bicarbonate 26, bun 29, creatinine 1.6, and glucose of 111. the initial ekg showed normal sinus rhythm at a rate of 71 with a normal axis and evidence of first-degree av block with prolonged pr interval of 238 milliseconds. he also had a widened qrs of 153 milliseconds, an old right bundle branch block, and no acute st or t wave changes. the ekg was prior to catheterization and the one post ptca was no different. he had a bedside echocardiogram done in the catheterization laboratory which showed normal lv wall thickness and normal lv cavity size. there was no evidence of effusion. it was difficult to assess free wall motion. cardiac catheterization revealed a totally occluded rca with collaterals, an 80 percent lad lesion extending distally which was angioplastied but no stent was placed. hemodynamics: the right heart catheterization revealed pulmonary capillary wedge pressure of 4, cardiac output of 8, and cardiac index of 3.8, he had an ra pressure of 10, rv pressure of 43/4, pa pressure of 37/10. assessment: this is an 82-year-old male with a history of prior tobacco use, hypertension, chronic renal insufficiency, copd, gastritis, and tia who initially presented to with a non-st elevation mi and guaiac positive stools, transferred to for cardiac catheterization with ptca to mid lad lesion complicated by hypotension and bradycardia requiring atropine, iv fluids and transient dopamine possibly secondary to vagal reaction, subsequently transferred to ccu for close monitoring, hemodynamically stable at the time of admission to the ccu. hospital course: 1. cardiovascular: as summarized above, the patient had a non-st elevation mi with evidence of an 80 percent mid lad lesion for which he underwent angioplasty without stent placement. he was initially continued on aspirin, plavix, beta blocker, statin, and ace inhibitor. at the time of discharge, his plavix was held due to guaiac positive stools and hematocrit drop throughout admission. he had a transthoracic echocardiogram the day after admission showing an ejection fraction of greater than 60 percent. no focal wall motion abnormalities. he had no recurrent chest pain or shortness of breath throughout admission. in regards to his rhythm, he has an underlying right bundle branch block and first-degree av block which were stable throughout this admission. he will be followed-up by his cardiologist after discharge. 1. pulmonary: he had a history of copd for which he is on baseline 2 liters of 02 by nasal cannula at home and albuterol and atrovent mdis p.r.n. at home. he is also on flovent mdi at home as well. he was continued on his mdi and was at his baseline 02 requirement throughout admission. 1. renal: he has a history of chronic renal insufficiency likely secondary to hypertension and was admitted with a creatinine of 1.6. his ace inhibitor post mi was initially held due to his creatinine. however, this responded to iv fluids and his ace inhibitor was restarted at the time of discharge. he will need close monitoring of his creatinine post discharge in the setting of reinstitution of his ace inhibitor. 1. gastrointestinal: his stools were noted to be guaiac positive at the outside hospital and there was still concern for possible gi bleed given continued guaiac positive stools during this admission and a slight drop in his hematocrit from 39 to 33. it was felt most appropriate for him to have an outpatient gi workup, and his pcp was and will arrange for outpatient colonoscopy. his plavix was held at the time of discharge due to a question of gi bleed and in the setting of not having a stent placed at the time of catheterization. he was continued on his aspirin, however. discharge diagnosis: coronary artery disease, status post non-st elevation myocardial infarction with 80 percent mid lad lesion, now status post angioplasty. hypertension. chronic renal insufficiency. chronic obstructive pulmonary disease. guaiac positive stools. anemia. discharge medications: 1. lipitor 10 mg q.d. 2. lisinopril 2.5 mg q.d. 3. flovent 110 micrograms aerosol two puffs b.i.d. 4. aspirin 325 mg q.d. 5. combivent mdi p.r.n. 6. toprol xl 100 mg q.d. disposition: at the time of discharge, the patient's vital signs were stable and he was without complaints. discharge status: he will be discharged to home and was cleared by physical therapy. follow up: he has been scheduled for follow-up with dr. on at 11:00 a.m. it was discussed with him the need to schedule follow-up for colonoscopy with his pcp as well. he will call the cardiology division at to schedule a follow-up with his cardiologist there within the next week. , md dictated by: medquist36 d: 17:03:53 t: 22:08:30 job#: Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified

history of present illness: this is a 65-year-old female with coronary artery disease and atrial fibrillation presented here with her second episode of significantly sharp abdominal pain. she describes having a prior episode for which she had necrotic bowel, which was operated upon. her pain began suddenly the day prior to admission prompting her visit to the emergency department at hospital, where she was noted to have a concerning physical exam as well as increased digoxin levels and increased inr level. she was reversed in terms of her anticoagulation and scheduled for the operating room, and then was transferred to the . physical examination on admission: temperature 97.0, heart rate 82, blood pressure 135/78, respiratory rate 26, and saturation 97 percent on room air. alert and oriented times three. appeared somewhat toxic and nasogastric tube in place. heart was regular rate and rhythm. lungs were clear to auscultation bilaterally. abdomen was tense and tender with rebound in the right lower and left lower quadrants, also revealing a well-healed scar from prior surgery. rectal exam was positive for melena and guaiac positive. distal pulses were 2 plus. extremities were warm and well perfused. hospital course: it was at this time the patient was admitted for further evaluation and treatment at . patient was preoperatively prepared. laboratories were drawn. hematocrit was 34.8. white count was 9.8. electrolytes were within normal limits. liver function tests were within normal limits. inr was 1.1. ekg was done that revealed the heart to be in normal sinus rhythm at a rate of 85 beats per minute. there was no pneumothorax on chest x-ray. cat scan showed dilated loops and contrast was making it to the right colon. patient was placed nothing by mouth and continued on the nasogastric tube. vancomycin, levofloxacin, and flagyl were started. an a-line has been placed as well as internal jugular venous central line. thus the patient was brought to the operating room for acute peritonitis, where extensive lysis of adhesions took place. there was noted to be volvulus and a loops of small bowel around an adhesion. patient tolerated the procedure well and blood loss was estimated to be 100 ml. patient was transferred to the trauma intensive care unit after this operation. patient was also seen by the vascular service for consideration of possible infarcted bowel. they agreed with the plan to explore the abdomen. in the operating room, there was noted to be no signs of any ischemic bowel and just the adhesions since bowel volvulus was described previously. the patient did have a troponin level of 0.057. patient was also seen by cardiology at this time due to st depressions seen on ekg on the day of admission. digoxin was held as the level was 3.3, and was noted to be well rate controlled in atrial fibrillation. it was decided that it would be best to re-anticoagulate her when safe from a surgical perspective and to followup with the primary cardiologist. they also stated that this was unlikely to be ischemic in origin. on hospital day number three, postoperative day number two, patient began to have increased pain issues. patient was given fentanyl and dilaudid, and received mild improvement. patient was febrile at this point to 100.3 and antibiotics were continued. pulses were followed. patient was extubated at this point. toradol was also added for further pain control. antibiotics were stopped at this time. there was no source of infection that can be noted. the patient was then transferred to the floor. as we awaited regaining bowel function, the patient was seen by physical therapy, who initially thought the patient would need likely stay in the rehabilitation facility and shortly thereafter cleared her for discharge her to home, and on , patient was stable. all vital signs were within normal limits. patient was tolerating a regular diet. was out of bed and increasing her activity participating in incentive spirometry. was urinating without difficulty and it was determined that the patient could be discharged to home with outpatient physical therapy and for her to resume her previous medications as she had been taking them, and to also resume her anticoagulation. discharge diagnoses: small bowel obstruction with volvulus. peritonitis. coronary artery disease. atrial fibrillation. congestive heart failure. hypercholesterolemia. hypertension. chronic obstructive pulmonary disease. osteoporosis. chronic back pain. recommended followup: the patient is to followup with dr. in weeks, call to schedule an appointment. discharge medications: 1. morphine sulfate 30 mg sustained release by mouth every 12 hours. 2. oxycodone 5 mg two tablets every four hours as needed for breakthrough pain. 3. docusate sodium 100 mg by mouth twice a day. 4. ibuprofen 600 mg by mouth every eight hours. 5. coumadin 1 mg by mouth every other day at night. 6. warfarin 2 mg by mouth every other day at night. 7. patient is to resume the remainder of her home medications. disposition: the patient is to be discharged to home with home physical therapy. , Procedure: Venous catheterization, not elsewhere classified Exploratory laparotomy Arterial catheterization Other lysis of peritoneal adhesions Application or administration of an adhesion barrier substance Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation 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 Other and unspecified hyperlipidemia Blood in stool Old myocardial infarction Long-term (current) use of anticoagulants Other chest pain Heart valve replaced by transplant Volvulus Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) Nonspecific abnormal toxicological findings Nonspecific abnormal electrocardiogram [ECG] [EKG]

allergies: pcn->rash, erythro-> tongue swelling, keflex, quinine-> thrombocytopenia. pmh: cad, cabg ', iddm, dx 9 yr old, +hx dka, +retinepathy, cri w/ cr ~2.0, pvd, nph dx '- vp shunt in place, +falls, memory difficulties. pt admitted to floor after fall at home. head ct (-), but cxr-> rul,rml and rll infiltrates. pt admitted to +hx fevers, rigors, non productive cough at home. tx w/ levo, flagyl continuing to have ^ o2 requirements and required 100% nrb w/ sats 95% and ^ wbc to 19. pt transferred to micu pt arrived to micu ~13:30 lethargic but in nad. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Other lavage of bronchus and trachea Other lavage of bronchus and trachea Pulmonary artery wedge monitoring Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Anemia, unspecified Obstructive hydrocephalus Congestive heart failure, unspecified Acute kidney failure, unspecified Acute respiratory failure Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Bronchopneumonia, organism unspecified

history of present illness: this 68-year-old with a history of insulin dependent diabetes mellitus and coronary artery disease presented to the emergency department on three to four days. the patient also reported some nausea with no vomiting. the patient had fallen at home twice in the preceding day and it was the falls that prompted the patient to seek medical care. the patient notes sick contact with several members of the family, including the patient's husband who was sick with similar symptoms for several days. in addition to the patient's fever, cough and falls, the difficult to control with blood sugars reaching upwards of 400 from a baseline of 1 to 200. history is negative for chest pain. past medical history: 1. insulin dependent diabetes mellitus since age 5 2. normal pressure hydrocephalus status post ventriculoperitoneal shunt in 3. coronary artery disease, status post coronary artery bypass graft in 4. degenerative joint disease 5. depression medications: 1. nph insulin 2. prevacid 3. lasix 4. neurontin 5. zoloft 6. premarin 7. lipitor allergies: the patient has allergies to penicillin which causes a rash, keflex which causes a rash, erythromycin which causes tongue swelling and quinine which causes thrombocytopenia by report. social history: the patient lives at home with her husband, is functional with a walker at home. denies drug or alcohol abuse. physical exam on admission: vital signs: the patient had a temperature of 100.2??????, heart rate 91, blood pressure 197/81, respiratory rate of 20, oxygen saturations were in the high 70s. general: the patient was ill appearing and rigoring. head, ears, eyes, nose and throat: the patient's pupils were equal and reactive with anicteric sclerae and dry mucous membranes. neck: supple without meningeal signs. there was no palpable lymphadenopathy, no jugular venous distention. respiratory: bilateral coarse rhonchi, right greater than left. cardiac: s1, s2, regular rhythm without murmur. abdomen: soft, nontender with positive bowel sounds. the patient had no costovertebral angle tenderness. extremities: there was no clubbing or cyanosis. there was bilateral trace edema. the skin was noted to have no rash. neurologic: the patient was alert and oriented x2, moving all extremities, nonfocal exam. admission labs: the patient's white blood cell count was 11. hematocrit was 33.3, platelets 184. sodium 136, potassium 4.2, chloride 90, bicarbonate 30, bun 50, creatinine 2.6. glucose was 227. imaging in the emergency department: a head ct scan was ordered and was negative for acute bleed, but did reveal hydrocephalus with a ventriculoperitoneal shunt. chest x-ray revealed right upper and right middle lobe infiltrates. hospital course: the patient was given a dose of levaquin in the emergency department and admitted to the medical floor for multilobar pneumonia. upon admission to the floor team, the patient was continued on levaquin as well as flagyl which was added for the concern of aspiration pneumonia. however, over her eight days on the floor the patient continued to require large amounts of oxygen and was becoming short of breath as well. additionally, the patient's white blood cell count which was 11 on admission had suddenly increased to 11.6 on the day of transfer. all micro data, including a csf blood, sputum and urine cultures were negative. legionella antigen was negative. the pulmonary service was consulted on the 13th and the patient underwent bronchoscopy which revealed watery bilateral secretions more consistent with pulmonary edema than an infectious process. bronchoalveolar lavage samples taken at the time were negative for microorganisms, however it did reveal highly atypical epithelial cells consistent either an infectious or possibly malignant process. the patient also underwent echocardiography on which revealed a congestive heart failure picture with left ventricular dysfunction, ejection fraction of approximately 30%. a chest ct performed on revealed consolidation in both lungs bilaterally, all lobes, with a moderate right effusion and a small left effusion. owing to the patient's increasing oxygen requirement and declining clinical course, the patient was transferred to the medical intensive care unit on for further care. medical intensive care unit course: on , the patient was admitted to the medical intensive care unit. the clinical impression of the medical intensive care unit team was that the patient likely had a mixed picture of both possibly infectious process as well as congestive heart failure. owing to her worsening respiratory distress. in addition to the patient's declining cardiopulmonary function, the patient also now had an acute on chronic renal failure as well as difficult to control blood sugars. the medical intensive care unit course by systems is outlined below. 1. respiratory: owing to the fact that the patient likely had a congestive heart failure component owing to her hypoxic respiratory failure, the patient was diuresed upon admission to the medical intensive care unit day 1 through day 3. on medical intensive care unit day 1, the patient diuresed approximately 1 liter and her respiratory status was noted to be improving. the patient also underwent aggressive chest pt and suctioning. she was noted to have excessive secretions. on at approximately 4 a.m., the patient was noted to be in increasing respiratory distress with increasing rancorous breath sounds. the patient was intubated emergently and then large amounts of secretion were suctioned from the patient's airway. following intubation, the patient continued to be aggressively diuresed and was placed on a lasix drip. the patient's respiratory status improved with diuresis and the patient was weaned to pressure support ventilation on the 18th where she remained for several days until the following day. however, the patient's respiratory status again declined and she was placed back on assist control ventilation. bronchoscopy was repeated on which again revealed diffuse edematous and hyperemic airways with a watery secretion noted. the patient was also noted to have mild dynamic collapse at the posterior wall of the trachea. it was still unclear from this whether the process was infectious or cardiac, but was felt likely to have components of both. bal samples were taken and again were negative for organism, but did reveal some atypical cells on cytological examination. chest x-ray at this time revealed diffuse bilateral fluffy infiltrates which could have been consistent with congestive heart failure or developing ards. the patient remained intubated until when after several days on pressure support the patient was extubated in the morning. however, the patient lasted approximately only 30 minutes before desaturating and apparently having difficulty clearing copious secretions. therefore, the patient was reintubated shortly thereafter on . the patient was extubated again on the 24th and this time the patient faired better and did not require reintubation. over the time from the 24th through the , the patient had gradually improving respiratory status, including decreasing oxygen requirement as the patient was weaned to 2 liters by nasal cannula. however, the patient's respiratory state was notable for frequent copious secretions that required suctioning by staff every one to two hours. for this reason, the patient was not transferred to the floor and it was felt that pulmonary rehabilitation would be a better disposition for the patient. 2. cardiovascular: the patient underwent echocardiography on which revealed poor left ventricular function with an ejection fraction of 30%. the patient was therefore diuresed throughout her medical intensive care unit course. in order to better determine the patient's hemodynamic and fluid status, a swan-ganz catheter was inserted on . the patient was noted to have increased pulmonary capillary wedge pressures in the high teens to low 20s as well as mildly elevated pulmonary arterial pressures ranging systolic high 50s to diastolic high 20s. this data further supported the use of diuresis for the patient. by the , the patient was placed on a lasix drip which continued through the . over the patient's course, the patient diuresed a total of over 8 liters of fluid and concurrent with this, the patient's respiratory status improved. additionally, the patient's peripheral edema also began to resolve. upon discontinuation of the patient's lasix drip, the patient was switched to 60 mg intravenous of lasix with which continuous improvement was noted. additionally, the patient was treated with captopril which was titrated up to 50 mg tid as the patient's blood pressure was tolerating this well. 3. infectious disease: the patient was initially treated with levaquin and flagyl upon admission. the patient continued to be treated with these agents through her floor hospital course. upon transfer to the medical intensive care unit, the patient was started on vancomycin offering triple antibiotic coverage. through the , the patient had no positive blood, sputum or urine cultures. however, on , a sputum sample was positive for methicillin resistant staphylococcus aureus. the patient's antibiotic regimen was changed to include only vancomycin 750 mg intravenous qd. the patient will continue on this vancomycin course through . 4. endocrine: the patient's blood sugars were difficulty to control throughout the beginning of her medical intensive care unit stay. as a result, the patient was placed on an insulin drip which was titrated to blood glucoses between 80 and 120. the medical intensive care unit drip was continued through the when the patient was switched back over to nph insulin. upon discharge, the patient is requiring between 30 and 35 units of nph insulin . 5. renal: the patient was noted to have elevated bun and creatinine upon admission. these levels gradually coursed down throughout the medical intensive care unit stay in spite of aggressive lasix diuresis. at the time, the patient's bun and creatinine have been stable for several days with bun in the 30s and creatinine ranging form 1.2 to 1.4 which are apparently improved from the patient's baseline. 6. gastrointestinal: following intubation, tube feeds were initiated through a nasogastric tube, however, the patient tolerated these poorly, likely secondary to her diabetic gastroparesis. the tube feeds were difficult to get in over the first medical intensive care unit week, however the patient gradually began tolerating more and more and was soon at her goal of ultracal via a nasogastric tube in order to ensure more reliable feeding and disposition to an acute rehabilitation facility. the patient underwent gj tube placement on without complications. the patient's current tube feeding regimen is ultracal with a goal of 70 cc an hour. for access, the patient had a right sided picc line placed for interventional radiology. at the time of discharge, both lumens are working appropriately. 7. neurology: the patient's mental status was slow to return to baseline following extubation likely secondary to multiple medications. however, at the time of discharge, the patient is alert and oriented x2 answering questions appropriately and appears to be at her baseline per family. at no times during the admission were there any neurosurgical issues or issues related to the patient's ventriculoperitoneal shunt. discharge diagnoses: 1. hypoxic respiratory failure 2. congestive heart failure 3. methicillin resistant staphylococcus aureus tracheobronchitis 4. insulin dependent diabetes mellitus 5. acute on chronic renal failure 6. diabetic gastroparesis discharge medications: 1. nph insulin 30 units subcutaneous 2. regular insulin sliding scale 3. captopril 50 mg po tid 4. reglan 10 mg po qd 5. colace 100 mg po bid 6. albuterol and atrovent metered dose inhalers inhaled q4h prn 7. kcl 20 milliequivalents po qd 8. lasix 60 mg intravenous 9. zoloft 100 mg po qd 10. aspirin 325 mg po qd 11. digoxin 0.25 mg po qd 12. nystatin swish and swallow 13. vancomycin 750 mg intravenous qd through additionally, the patient were requiring the following treatments at rehabilitation: pulmonary rehabilitation: the patient requires frequent suctioning and repositioning in addition to chest pt. the patient will also require speech and swallow evaluation and therapy directed at returning the patient to taking fluids and solids po. the patient will require physical therapy. diet ordered: the patient is presently npo following a speech and swallow evaluation that determined she was a high aspiration risk. nutritional supplementation is with ultracal tube feeds via gj tube with a goal feeding rate at 70 cc per hour. discharge condition: the patient is ready for discharge on in good condition. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Other lavage of bronchus and trachea Other lavage of bronchus and trachea Pulmonary artery wedge monitoring Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Anemia, unspecified Obstructive hydrocephalus Congestive heart failure, unspecified Acute kidney failure, unspecified Acute respiratory failure Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Bronchopneumonia, organism unspecified

history of present illness; this is a 70 year old man with a complaint of increased shortness of breath over the past several days prior to admission, positive cough with clear sputum, no hemoptysis, increased right lower extremity edema with erythema, pain. the patient was found to have a deep vein thrombosis in his right lower extremity in the emergency department by ultrasound. cta in the emergency department revealed a pulmonary embolus in the subsegmental branches of the pulmonary arterial vasculature. this was considered a small pulmonary embolus, however, the patient was substantially dyspneic and had a large oxygen requirement. the patient was reported to be on five liters of home oxygen for his diagnosis of chronic obstructive pulmonary disease, however, it was not clear whether the patient had been on his oxygen prior to admission. therefore, the patient was transferred directly from the emergency department to the intensive care unit for close monitoring of his respiratory status. the patient is a poor historian but does complain of chronic constant shortness of breath and occasional chest pain with occasional nausea, vomiting, diarrhea, occasional dysuria and no fevers, chills or sweats. the patient does report paroxysmal nocturnal dyspnea and orthopnea and always has to sleep on at least three pillows. the patient states that he has not taken his medications for several days because he "ran out". the patient's home situation is unclear. does not have his own home and lives with various different relatives. much of the history was ascertained by the patient's wife who is known schizophrenic and suffers from paranoid delusions. past medical history: 1. coronary artery disease, the patient's ejection fraction is 20%. 2. chronic obstructive pulmonary disease. the patient has no pulmonary function tests done at this hospital, however, he has been discharged in the past on five liters of home oxygen. 3. peripheral vascular disease, status post right femoral popliteal in , with chronic venous stasis. 4. insulin dependent diabetes mellitus. the patient has large insulin requirement. 5. gastroesophageal reflux disease. 6. history of transient ischemic attack. 7. history of methicillin resistant staphylococcus aureus. 8. history of nonsustained supraventricular tachycardia. allergies: penicillin with rash. medications on admission: 1. lasix 60 mg p.o. twice a day. 2. lisinopril 3 mg p.o. once daily. 3. lopressor 25 mg p.o. twice a day. 4. glipizide 5 mg p.o. four times a day. 5. combivent, salmeterol, flovent. 6. oxygen five liters. note: compliance with these medications is unknown, social history: the patient lives with various relatives at different times. he does not have his own apartment. he travels along with his wife who as mentioned before is schizophrenic and suffers from paranoid delusions, however, she is reporting that she is the health care proxy and the patient confirms this. however, they have no documentation of this. the patient denies alcohol or intravenous drug abuse. review of previous admission reveals numerous hospitalizations during which patient refused various recommended therapies and then left ama. physical examination: on admission, temperature is 97.6, blood pressure 133/55, heart rate 83, respiratory rate 20 with oxygen saturation 93% on six liters. generally, the patient was in mild distress. extraocular movements were intact. the patient had no scleral icterus. cardiovascular - distant heart sounds, regular rate and rhythm, no murmurs. pulmonary - he had diffuse breath sounds with occasional wheezes and sporadic crackles at the bases, symmetric expansion. the abdomen was soft, protuberant but nontender with active bowel sounds. the patient was guaiac negative in the emergency department. extremities - the patient had right lower extremity edema, greater than left, with erythema, calor, and charcot foot on the right. the patient had significant 4+ pitting edema on the right lower extremity where deep vein thrombosis had been noted on ultrasound. the patient also had chronic venous stasis changes on the left lower extremity with 2+ pitting edema. laboratory data: on admission, white blood cell count was 13.2, hematocrit 35.8, platelet count 404,000, 83% neutrophils, 0% bands, 10% lymphocytes. inr 1.4. sodium 135, potassium 5.5, chloride 101, bicarbonate 24, blood urea nitrogen 46, creatinine 1.3, glucose 354. arterial blood gases was 7.31, 54, 55. chest x-ray showed increased cardiac silhouette, no opacities, no effusions, no active infiltrate. ultrasound of right lower extremity showed deep vein thrombosis in the common femoral vein. cta showed likely left upper lobe subsegmental embolus and question right middle lobe tiny embolus, no large pulmonary emboli, right basilar atelectasis. electrocardiogram was sinus rhythm at 84 beats per minute, normal axis, intraventricular conduction delay, no acute st changes, poor r wave progression consistent with old electrocardiogram. hospital course: 1. pulmonary embolus, deep vein thrombosis - the patient was heparinized throughout his hospitalization. the patient and his wife refused coumadin treatment out of concern for bleeding. the patient refused to be transitioned on the coumadin because it required taking coumadin and heparin at the same time. the patient also refused discontinuing heparin and starting coumadin because of concerns of bleeding. it was also thought by the medical team that due to the patient's poor social condition and poor compliance in the past that going home with coumadin may be quite unsafe despite the very high risk of mortality without anticoagulation for deep vein thrombosis and pulmonary embolus in this setting. ultimately, however, despite medical team's advice and persistent attempts to convince the patient otherwise, the patient refused to take coumadin at home. however, the patient was heparinized throughout his hospitalization here. the patient also refused ivc filter placement which was offered as an alternative to coumadin therapy even though it was considered suboptimal to anticoagulation. the patient and his wife felt that he would be at high risk for complications of this procedure despite assurances to the contrary. the patient persistently refused medical interventions by the medical team and was evaluated by the psychiatry team and deemed to be competent to make his medical decisions and competent to refuse various medical interventions that were offered to him. therefore, the patient was discharged on aspirin as the only form of anticoagulation. again, it should be reiterated the patient refused coumadin therapy at home despite his full understanding that the one year mortality for untreated pulmonary embolism is in excess of 50%. 2. diabetic foot - the patient was seen by podiatry and the vascular surgery team who felt that the patient was suffering from acute cellulitis and diabetic foot. the patient had plain films that revealed no signs of chronic osteomyelitis. the patient was treated with intravenous vancomycin, levofloxacin and flagyl for the entirety of his hospitalization which was a two week course. the patient responded well clinically with significant improvement in edema, swelling, erythema and pain in the right lower extremity. the patient did have persistent right greater than left lower extremity edema that was thought to be a result of the known lower extremity deep vein thrombosis. the patient had one blood culture out of four bottles positive for methicillin resistant staphylococcus aureus at admission and therefore had been treated for two weeks with intravenous vancomycin for methicillin resistant staphylococcus aureus bacteremia that was thought to be related to his diabetic foot. it is also possible that this positive blood culture was a contaminant, however, he was treated with a two week course for bacteremia nevertheless. the patient was afebrile with a significant improvement in his white blood cell count and left shift at the time of discharge. the patient had no signs of active infection throughout his admission and had a normal sedimentation rate at the time of discharge. 3. diabetes mellitus - the patient was treated with large doses of nph and regular insulin throughout his admission. the patient and his wife continuously expressed concern that the patient was receiving too much insulin despite reassurance and despite fingerstick ranging from 90 to 150 throughout his hospitalization. the patient had good glycemic control on the insulin regimen of nph 30 units q.a.m. and 20 units q.p.m. and regular insulin 15 units q.breakfast and 10 units with dinner every day achieved good glycemic control for this patient. the patient had no evidence of diabetic ketoacidosis during his hospitalization. 4. chronic obstructive pulmonary disease - the patient has a known large oxygen requirement of over five liters per minute. this is probably the result of his long smoking history. the patient intermittently required more than five liters of oxygen at various times and this was thought to be related to his recent history of pulmonary embolus, however, the patient was essentially stable through the latter part of his hospitalization on five liters of oxygen. he did desaturate to the 70s when his oxygen fell off his face or was removed. therefore, the patient was discharged with his five liters of home oxygen which was the same regimen he was admitted with. there was some question of whether or not the patient had been getting proper oxygen therapy at home. the patient's refused vna services to insure that he was getting his oxygen, but was set up with home oxygen prior to discharge. the patient also was continued on combivent inhalers q6hours, salmeterol q12hours and p.r.n. albuterol. 5. acute renal failure - the patient after being called out to the floor after a 24 hour intensive care unit stay was bradycardic as a result of his lopressor dosing which is unclear if he had actually been taking at home. the patient had pressure in the 80s to 90s and an appropriately low heart rate of 50 to 60. the patient was closely monitored, given aggressive fluid resuscitation and nevertheless suffered oliguric acute renal failure. the patient's creatinine peaked at 3.3, however, as the beta blocker wore off, the patient's heart rate improved, blood pressure improved, renal perfusion improved, and urine output improved with recovery of his creatinine clearance and decrease in his creatinine to 1.2 which was actually better than reported baseline of 1.3 to 1.4. the patient had good urine output and was tolerating his lasix regimen at the time of discharge. the patient was diuresed aggressively after his renal failure improved due to the fluid overload state that occurred while he was oliguric. the patient did suffer from some degree of renal encephalopathy when his blood urea nitrogen approached 100, however, the mental status improved with improvement of his renal function. the patient was not discharged on a beta blocker due to this history of bradycardia. he was sinus bradycardic throughout the episode of bradycardia. no evidence of conduction disease. 6. congestive heart failure - the patient was discharged on his doses of lasix 40 mg once daily rather than the larger dose due to his recent renal failure and his stable status on 40 mg a day. it would be recommended that the patient be transitioned back onto his ace inhibitor in the future, however, his pressure remained in the low 100s and we avoided sending him home on ace inhibitor due to his renal failure. disposition: the patient refused rehabilitation placement because he felt that he did not need rehabilitation and that he was at his baseline. the patient was discharged to home which the patient and his wife reported was with relatives. the patient refused vna services because they were concerned that living with relatives they would not be able to have a nurse visit due to the preferences of the relatives. the patient repeatedly refused most of what this medical team tried to do, however, they also wanted to leave the hospital. it was thought to be more safe to discharge the patient with oxygen and with his various medications that he would agree to take rather than letting him leave against medical advice with none of the few things that the patient and his family would agree to, however, the patient was discharged with suboptimal medical regimen for his various medical problems. again, the patient had been seen by psychiatry. the patient's case had been discussed at length with both the legal counsel of the hospital and risk management division of the hospital and it was felt that the patient was competent to make his medical decisions, that he was competent to refuse various medical interventions and that as long as he was discharged with oxygen, he was not in immediate danger, that is within 24 hours of life threatening illness by leaving. the patient again was discharged with a suboptimal medical regimen due to his refusal for various interventions and medications. discharge diagnoses: 1. deep vein thrombosis. 2. pulmonary embolism. 3. chronic obstructive pulmonary disease exacerbation. 4. congestive heart failure exacerbation. 5. acute renal failure. 6. chronic renal insufficiency. 7. methicillin resistant staphylococcus aureus bacteremia. 8. methicillin resistant staphylococcus aureus sepsis. 9. beta blocker induced bradycardia with hypotension. 10. type 2 diabetes mellitus. 11. diabetic foot ulcer with methicillin resistant staphylococcus aureus. medications on discharge: 1. lasix 40 mg p.o. once daily which could be titrated up in the near future. 2. albuterol ipratropium inhaler one to two puffs q6hours. 3. nph insulin 30 units q.a.m. and 20 units q.p.m. 4. regular insulin 15 units q.breakfast and 10 units q.dinner. 5. protonix 40 mg p.o. once daily. 6. albuterol p.r.n. 7. multivitamin one tablet once daily. 8. flovent two puffs twice a day. 9. salmeterol two puffs twice a day. 10. aspirin 325 mg p.o. once daily. 11. coumadin was refused. the patient was sent home with a new wheelchair to facilitate his activities. , m.d. dictated by: medquist36 d: 12:44 t: 14:09 job#: please see discharge letter as per dr. for additional details. Procedure: Excisional debridement of wound, infection, or burn Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Obstructive chronic bronchitis with (acute) exacerbation Methicillin susceptible Staphylococcus aureus septicemia Pulmonary collapse Cellulitis and abscess of leg, except foot Other pulmonary embolism and infarction Ulcer of heel and midfoot

history of present illness: the patient is a 62-year-old gentleman with known coronary artery disease (status post myocardial infarction in and status post percutaneous transluminal coronary angioplasty with a stent in also to the distal right coronary artery and posterior left ventricular branch). the patient was admitted to an outside hospital on with chest pain over a 5-day period and ruled in for a myocardial infarction. his cardiac catheterization showed 3-vessel disease with an ejection fraction of 55% at the outside hospital, and he was transferred to for coronary bypass surgery. past medical history: 1. myocardial infarction. 2. hypercholesterolemia. 3. insulin-dependent diabetes mellitus. 4. status post laparoscopic cholecystectomy in . 5. hypertension. 6. question chronic renal insufficiency (with a baseline creatinine of 1.3). medications on admission: (medications at home on admission were as follows) 1. nph insulin 45 units subcutaneously twice per day. 2. lipitor 80 mg by mouth once per day. 3. aspirin. 4. norvasc. medications in hospital: 1. zocor. 2. lopressor 25 mg by mouth twice per day. 3. heparin. 4. intravenous integrilin. physical examination on presentation: on physical examination, the patient's heart rate was 72 (in sinus rhythm), his blood pressure was 139/65, his respiratory rate was 19, and his oxygen saturation was 98%. at the time of examination the patient was on an integrilin drip at 2, a nitroglycerin drip at 0.3 mcg/kg per minute, and heparin at 1200 units per hour. pertinent laboratory values on presentation: preoperative laboratories were as follows. the patient's white blood cell count was 11, his hematocrit was 43.4, and his platelet count was 303,000. sodium was 137, potassium was 4, chloride was 105, bicarbonate was 21, blood urea nitrogen was 13, creatinine was 0.8, and blood glucose was 156. in general, the patient was alert and oriented. he had excellent strength in all four extremities. he was a spanish-speaking gentleman. his lungs were clear bilaterally. cardiovascular examination revealed his heart was regular in rate and rhythm. no murmurs or rubs. he had several well-healed 2-cm surgical scars from his laparoscopic cholecystectomy. he had bowel sounds. his abdomen was soft with mild tenderness to deep palpation over the epigastric area. the abdomen was nondistended, and there was no hepatosplenomegaly. extremity examination revealed the extremities were warm with no varicosities. he had no cyanosis, clubbing, or edema. he had peripheral pulses present for femoral, popliteal, dorsalis pedis, posterior tibialis pulses, and radial arteries. he had no bruits in his carotid. concise summary of hospital course: the patient was seen by cardiothoracic surgery and referred to dr. . he was continued on his heparin, nitroglycerin, and integrilin drips. a bedside echocardiogram was done preoperatively by cardiology which showed a depressed left ventricular function and anteroapical septal hypokinesis, but no severe mitral regurgitation or effusion. please refer to the complete report. the patient remained in house prior to surgery on dr. service for the next few days prior to his operation. his sheaths were pulled. his creatinine was stable at 0.9. additional laboratories came back with an aspartate aminotransferase of 27, alanine-aminotransferase of 27, and a total bilirubin of 0.9. the patient remained in the cardiothoracic surgery recovery unit for monitoring on his heparin, nitroglycerin, and integrilin drips. on , his heparin was held for an elevated partial thromboplastin time. adjustments were made in his medication. he had a carotid study done which showed no significant stenoses on preoperatively. please refer to the radiology report. preoperatively, his prothrombin time was 13.4, his inr was 1.2, with a partial thromboplastin time of 75 on heparin. he continued to receive his beta blocker. on , the patient underwent coronary artery bypass grafting times four by dr. with a left internal mammary artery to the left anterior descending artery, a vein graft to the posterior descending artery, a vein graft to the obtuse marginal, and a vein graft to the diagonal. the patient was transferred to the cardiothoracic intensive care unit on a milrinone drip at 0.5 mcg/kg per minute and a levophed drip at 0.025 mcg/kg per minute in stable condition. on postoperative day one, the patient's levophed was weaned off. he remained on a milrinone drip and an insulin drip. temperature maximum was 99.5 degrees fahrenheit, his blood pressure was 140/62, in sinus rhythm at 91. his lungs were clear. his heart was regular in rate and rhythm. his dressings were clean, dry, and intact. chest tubes were discontinued. the patient was continued on his perioperative antibiotic. postoperatively, his white blood cell count was 9.6, his hematocrit was 30.1, and his platelet count was 205,000. his potassium was 4.5, blood urea nitrogen was 14, and creatinine was 0.9. the patient was screened by the clinical nutrition team. he was extubated early in the morning on postoperative day one after having been rested overnight on the ventilator. on postoperative day two, the patient had a temperature maximum of 100.8 degrees fahrenheit. he was hemodynamically stable and in sinus rhythm. he was awake and appropriate. he had decreased breath sounds at the left base, but otherwise his examination was unremarkable. his chest tubes were pulled. he was started on captopril and restarted on his lopressor. his hematocrit remained stable at 29.1. he was transferred out to two where he was evaluated by the physical therapy team. he started ambulating out on the floor. he was seen by the case manager. once during the day, on postoperative day two, the patient refused to walk with physical therapy complaining of fatigue. again, a spanish interpreter was present to help make clear the team's wishes for his ambulation. on postoperative day three, he had no specific complaints. his wires were discontinued. his foley catheter was pulled. he remained in a sinus rhythm. he was neurologically appropriate. his hematocrit rose slightly to 31.5 with a white blood cell count of 11.1. his creatinine was stable at 1. his blood sugars were slightly elevated. his nph was increased. he continued with physical therapy and ambulation. over the next day, he complained of a little bit of incisional pain but this was well controlled with percocet. he had no events overnight. he was saturating 92% on room air. his hematocrit was stable, but his creatinine rose from 1 to 1.2 on postoperative day four with plans to recheck his creatinine in the evening and stop his captopril if his creatinine rose precipitously. on postoperative day five, his electrocardiograms the night prior showed a bundle branch block in avf. cardiac enzymes were cycled. he had no chest pain overnight. his troponin was 0.21, with a creatine kinase of 164, and a mb fraction of 3. he was alert and oriented and comfortable in bed. he had decreased breath sounds at the left base with some crackles. his heart was regular in rate and rhythm. it was determined that his electrocardiogram changes were not due to enzymes elevation; not necessarily consistent with chest pain or unstable angina. a repeat electrocardiogram was ordered. he did have one run of ventricular tachycardia of about 150 per minute times nine beats with no previous ventricular ectopy. he was given magnesium 2 g times two doses, and he was encouraged to have aggressive chest physical therapy. and nebulizer treatments, as well as incentive spirometry work to help increase his pulmonary toilet with hopes of discharging him shortly. on postoperative day six, he had a slight left-sided chest rub. his sternal incision was okay. the wound had no erythema. heart was regular in rate and rhythm. he was in a sinus rhythm in the 80s. his temperature maximum was 99.4 degrees fahrenheit. his blood pressure was 140/92. he was saturating 96% on room air. his creatinine stabilized at 1. his potassium was 4.5. he had some slight erythema at his right knee wound from the saphenectomy site, but minimal edema otherwise in his extremities. discharge disposition: the patient was discharged to home on . medications on discharge: 1. metoprolol 20 mg by mouth twice per day. 2. lasix 20 mg by mouth twice per day (times seven days). 3. colace 100 mg by mouth twice per day. 4. aspirin 325 mg by mouth once per day. 5. percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed (for pain). 6. lipitor 80 mg by mouth once per day. 7. captopril 25 mg by mouth three times per day. discharge diagnoses: 1. status post coronary artery bypass graft times four. 2. status post myocardial infarction times two. 3. status post percutaneous transluminal coronary angioplasty with stent in . 4. hypercholesterolemia. 5. insulin-dependent diabetes mellitus. 6. hypertension. 7. question chronic renal insufficiency. discharge status: the patient was discharged to home. condition at discharge: condition on discharge was stable on . , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Old myocardial infarction Unspecified disorder of kidney and ureter

allergies: vicodin / penicillins attending: chief complaint: abdominal pain major surgical or invasive procedure: paracentesis transfusion of packed red blood cells and fresh frozen plasma upper endoscopy history of present illness: 57yom with h/o etoh cirrhosis, ugib, cll, a fib on coumadin p/w abdominal pain (mid abdominal) since this morning. at worst the abdominal pain was and was worse with bumps in car ride to ed. sharp in nature and perhaps transiently better after bm. he also notes increased lethargy over the past few days. he has had softer/loose brown stool; denies black stool or brbpr. reports chronic, intermittent diarrhea x many years, however noted 4 loose stools (more frequent than normal during these episodes). has noted perhaps slightly increased abdominal distention, but no significant increase in le edema from recent baseline. no fevers/chills. no dysuria/hematuria. denies n/v/hematemesis. has been taking po, but "not as much as usual" and he reports feeling dehydrated. . of note, he was hospitalized for chf and hct drop at which time egd was performed showing grade 2 varices which were banded. hct at time of discharge was 24.3 at time of discharge. . in the ed, initial vitals were 98.8 112 81/45 18 96%ra. ngl was negative for blood. he had guaiac positive brown stool. ct abd/pelvis was performed which showed moderate loculated ascitic fluid without other clear bowel pathology. he received levofloxacin 750mg iv, flagyl 500mg iv, and ceftriaxone 1g iv. he also received zofran 4mg iv x1 for nausea after ngl. additionally he was noted to have transient sbps to 70s (normally 90s); central line (right ij) was placed and he received 3l ns to which his bp improved to high 80s-90s systolic. . ros: no f/chills. no lightheadedness/dizziness. no ha/changes in vision. no sob/cough/pnd/orthopnea. no dysuria/hematuria. +chronic le edema which he denies being worse than baseline. no rashes. +jaundice. no joint pain. past medical history: # etoh cirrhosis -portal htn -varices with h/o ugib -ascites -no h/o sbp -no h/o hepatic encephalopathy # hypertension # diastolic chf # atrial fibrillation on coumadin # seasonal allergies # shingles # dental abscess # peptic ulcer disease # cll social history: significant for no tobacco usage, significant alcohol usage. he used to drink heavily in the past, with no history of any withdrawals or delirium tremens. he reports previously was drinking about glasses of wine 3-4 times a week, but reports has stopped currently. family history: diabetes, cancer and stroke. physical exam: vs: temp: 97.2 bp: 85/48 hr: 90 a.fib rr: 19 o2sat 99% ra gen: pleasant, comfortable, nad heent: left pupul 3->2.5mm, right pupil 2.5->2mm, eomi, + scleral icterus, mm dry, op without lesions neck: no supraclavicular or cervical lymphadenopathy appreciated, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: no increased wob, bibasilar rales l>r ( up on left), no rhonchi nor wheezes cv: irregularly irregular, s1 and s2 wnl, no m/r/g appreciated abd: +mild distention, +b/s, soft, mildly tender mid abdomen just superior to umbilicus, + hepatosplenomegaly, no rebound/guarding ext: + left lower extremity edema, 2+right lower extremity edema (reports asymmetry as chronic), warm, good pulses skin: no rashes, +jaundice neuro: aaox3. cn ii-xii grossly intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. no asterixis. . pertinent results: labs on admission: 11:22pm lactate-1.3 02:37pm lactate-3.1* 02:37pm hgb-9.1* calchct-27 02:25pm glucose-151* urea n-21* creat-1.3* sodium-135 potassium-4.1 chloride-101 total co2-28 anion gap-10 02:25pm estgfr-using this 02:25pm alt(sgpt)-21 ast(sgot)-41* alk phos-109 amylase-74 tot bili-5.5* 02:25pm lipase-28 02:25pm calcium-8.3* magnesium-2.0 02:25pm ammonia-57* 02:25pm digoxin-2.5* 02:25pm wbc-31.0* rbc-2.50* hgb-8.8* hct-25.7* mcv-103* mch-35.2* mchc-34.3 rdw-24.7* 02:25pm neuts-15* bands-2 lymphs-79* monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-0 02:25pm plt count-243 02:25pm pt-21.2* ptt-34.8 inr(pt)-2.1* . labs on discharge: 05:51am blood wbc-13.2* rbc-2.61* hgb-8.7* hct-25.1* mcv-96 mch-33.5* mchc-34.8 rdw-22.5* plt ct-121* 05:51am blood pt-20.0* ptt-50.8* inr(pt)-1.9* 05:51am blood glucose-83 urean-24* creat-1.0 na-140 k-3.9 cl-105 hco3-24 angap-15 05:51am blood calcium-8.9 phos-3.5 mg-2.1 . ekg: a. fib at rate 86. normal axis and intervals. biphasic tw in v2, twi v3-v6 (old), twi ii, iii, avf (both old) . microbiology: blood cx - negative urine cx - < 100k enterococcus blood cx - negative peritoneal fluid cx - gram stain 4+ pmns, no microorganisms, cx negative . imaging: . cxr: wet read: pleural plaques, bilateral haziness and cephalization c/w pulmonary edema vs. overlying pleural disease. . ct abd/pelvis: 1. increasing ascites within the abdomen, layering non-dependently with some areas of partial loculation and mild rim enhancement--these findings raise the possibility of peritonitis. 2. stigmata of portal hypertension including splenomegaly, paraesophageal varices, and a large recanalized umbilical vein. . abd u/s: impression: 1. poor visualization of the left hepatic lobe, left hepatic vein, and left portal vein. 2. patent main portal, right portal, and right and middle hepatic veins. 3. findings consistent with cirrhosis and portal hypertension. 4. moderate to large volume ascites. . ct abd/pelvis: impression: 1. markedly decreased amount of ascites. no evidence of hematoma or intraperitoneal hemorrhage. 2. stigmata of portal hypertension including splenomegaly, periesophageal varices, gastric varices, and large recanalized umbilical vein are unchanged. . egd: impression: varices at the lower third of the esophagus erythema in the gastroesophageal junction compatible with esophagitis otherwise normal egd to third part of the duodenum brief hospital course: 57 year old man with history of alcoholic cirrhosis and portal hypertension with grade 2 varices status post banding in , cll, diastolic chf presents with increase in loose bowel movements and abdominal pain. initially admitted to micu for transient hypotension, stable throughout admission. . hospital course by problem: . # abdominal pain/spontaneous bacterial peritonitis: due to spontaneous bacterial peritonitis given loculated ascites and peritoneal enhancement on ct, as well as diagnostic paracentesis demonstrating greater than 250 pmns. peritoneal culture with no growth. patient was treated with levofloxacin with resolution of abdominal pain. discharged with instructions to complete 7 day course of levofloxacin, then to start on ciprofloxacin for sbp prophylaxis. . # hypotension: normal sbps run in the 90s per patient, but bp on presentation was below this, off of normal anti-hypertensives. therefore felt to be relative hypotension. was initially admitted to the micu due to this, but bp stabilized with ivf. no more episodes of hypotension throughout hospital course. . # alcohollic cirrhosis: patient with known alcoholic cirrhosis, with esophageal varices. on furosemide, aldactone, nadolol as outpatient. these were initially held due to hypotension above, but then were added back (although furosemide and nadolol added at lower dose that on admission). otherwise, treatement of sbp as above, and treatment of anemia as below. the patient will follow up with hepatology as an outpatient. . # anemia: patient presented with hct of 25.7, trended to low of 18.5. etiology of patient's anemia felt to be likely multifactorial - due to history of cll, perhaps some low grade hemolysis (50% indirect bili, low haptoglobin, but normal ldh, and in setting of transfusions and cirrhosis, so difficult to interpret), as well as perhaps low grade bleed from esophageal varices. he is on coumadin for afib and aspirin as an outpatient, which were held on admission. patient received 6 units prbc, 7 units ffp, vitamin k po x 1 during hospital course. egd demonstrated non-bleeding varices, no intervention done. he was discharged with stable hct, off of his coumadin and aspirin, on protonix, with follow up with his pcp to check hematocrit as outpatient to ensure remains stable. re-starting anticoagulation will also be addressed by his pcp as outpatient. . # acute renal failure: creatinine 1.3 from previously normal baseline of 0.8-1.0. resolved with ivf, blood. . # rhythm: patient has a history of atrial fibrillation on coumadin. as above, coumadin held on admission due to decreased hct. digoxin also held on admission, and was held on discharge, to be addressed as an outpatient. otherwise remained rate controlled on nadolol during hospital course. . # pump: patient with known diastolic chf, preserved ef followed by dr. in outpatient setting. patient was given iv lasix with blood transfusions, and as above, was discharged on lower dose of lasix than presented on. appeared euvolemic during hospital course. will follow up as outpatient. . # cll: followed by dr. as outpatient. to be followed up as outpatient. medications on admission: 1. pravastatin 10 mg po daily 2. omeprazole 40 mg po daily 3. furosemide 80 mg po bid 4. digoxin 250 mcg po daily 5. nadolol 40 mg po daily 6. spironolactone 50 mg po daily 7. warfarin 6 mg alternating with 5 mg po (alternating dose qod) 8. lisinopril 2.5 mg po daily 9. aspirin 81 mg daily 10. testosterone patch (50mg/5gram td) discharge medications: 1. pravastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. 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* 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 5. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 7. levofloxacin 500 mg tablet sig: one (1) tablet po once a day for 4 days. disp:*4 tablet(s)* refills:*0* 8. ciprofloxacin 250 mg tablet sig: one (1) tablet po once a day: please start this after you have completed your course of levofloxacin. disp:*30 tablet(s)* refills:*2* 9. outpatient lab work please check cbc (including hematocrit), and inr (please bring this lab slip with you to your doctor's office on thursday, ) discharge disposition: home discharge diagnosis: primary: spontaneous bacterial peritonitis anemia secondary: cirrhosis hypertension diastolic congestive heart failure atrial fibrillation on coumadin cll peptic ulcer disease discharge condition: good. hematocrit stable, patient ambulatory. discharge instructions: you were admitted to the hospital with abdominal pain and found to have a spontaneous bacterial peritonitis (infection in the peritoneum of your abdomen). this was treated with antibiotics. you also had low blood counts requiring transfusions, and therefore underwent an endoscopy for further evaluation, which demonstrated non bleeding esophageal varices. you were discharged with instructions to follow up with your primary care physician, well as hepatology. . please take medications as directed. please note that medication changes include: - new medications include levofloxacin (antibiotics) to complete a 7 day course, and after this is completed, you will need to be on prophylactic ciprofloxaciin (a similar antibiotic) continually. - you had your dose of furosemide decreased from 80mg twice daily to 40mg daily. - you had your dose of nadolol decreased from 40mg daily to 20mg daily. - we have also discontinued your coumadin due to your bleeding for now - this will be re-addressed by your physician after discharge. - we have also discontinued your aspirin due to your bleeding for now - this will be re-addressed by your physician after discharge - we also have discontinued your digoxin due to your low blood pressure - this will be re-addressed by your physician after discharge as well. . please follow up with appointments as directed. . please contact physician if develop weakness/dizziness, blood in stool, black colored stools, abdominal pain, fevers, any other complaints. followup instructions: please make a follow up appointment with your primary care physician, . ( in the next 1 week. at this visit, you will need to have your blood counts checked. you will also have to re-address starting back on your coumadin. (please bring the printed lab slip with you so that your physician knows which labs need to be checked). if your doctor cannot see you in his office this week, please go in anyways on thursday to have your blood drawn (bring in the slip) and your primary care doctor will follow up on the results. . please follow up with hepatology, dr. at ( as directed. please call him to make a follow up appointment in the next 2-4 weeks. . the following appointments had already been scheduled, prior to your hospitalization: provider: , : date/time: 1:00 Procedure: Venous catheterization, not elsewhere classified Esophagogastroduodenoscopy [EGD] with closed biopsy Transfusion of packed cells Transfusion of other serum Diagnoses: Anemia, unspecified Congestive heart failure, unspecified Unspecified essential hypertension Alcoholic cirrhosis of liver Acute kidney failure, unspecified Portal hypertension Atrial fibrillation Long-term (current) use of anticoagulants Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Esophageal varices in diseases classified elsewhere, without mention of bleeding Chronic diastolic heart failure Chronic lymphoid leukemia, without mention of having achieved remission Spontaneous bacterial peritonitis

*allergies: pcn, vicodin *access: rij tlc (to be removed), 18g l hand piv ** please see admit note/fhp for admit info and hx. neuro: pt remains lethargic, in and out of sleep, easily arousable, a&ox3, was able to ambulate to chair and back to bed w/ x2 assist, tolerated good, has pt consult ordered, will see tomorrow. pt frequently removing o2sat, o2 (nc) and bp cuff, redirected. no c/o pain or discomfort, though noted to be groaning at times, states he is not uncomfortable. cardiac: a.fib w/o ectopy, hr 104-123, sbp 121-140. remains on lopressor, will start nadolol tonight. lytes wnl, hct stable @ 27.8. resp: remains on 2l nc, o2sat 95-99 (to 93% on ra), rr 19-25, ls clear upper/diminished lower, cough @ times. pt frequently removing o2 and sat monitor, continually reminding not to remove. gi/gu: now on soft diet, +bs, small orage stool x1 following biscody pr. abd w/ ascites, ? need of tap in a few days, aldactone started, last bladder pressure was 17 overnight. urine out foley /clear, 20-60cc/hr, no lasix since yesterday @ night, goal 500-1000cc neg @ mn, may require lasix for goal. t. bili 9.4. fsbg 115, no coverage required. id: temp 97.1-97.4 oral, wbc 20.0. aztreonam iv, will start bactrim eventually for cipro resistant e.coli from paracentesis fluid, bactrim sensitive. iv sites wnl. skin w/d/i. psychosocial: hcp visited today. pt mostly cooperative when directed but has been consistant w/ removing o2 and sat monitor stating he didn't know he still needed them. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Diagnoses: Anemia, unspecified Unspecified essential hypertension Alcoholic cirrhosis of liver Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Atrial flutter Acute respiratory failure Septic shock Paralytic ileus Other septicemia due to gram-negative organisms Other ascites Hepatic encephalopathy Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Pneumonia due to Klebsiella pneumoniae Spontaneous bacterial peritonitis Chronic lymphoid leukemia, in remission

*allergies: pcn, vicodin *access: rij tlc ** please see admit note/fhp for admit info and hx. neuro: pt remains lethargic and confused, a&ox2 (sometimes wrong year, sometimes wrong hospital). no c/o pain, mae, shifting in bed, attempting to reach for lines/tubes, bilat soft wrist restraints in place. cardiac: a.fib w/ occasional pvc and run beats of v-tach this am but not seen this afternoon. hr 110-117, sbp 117-137. bp meds switched to iv since not tolerating po's. lytes wnl, hct stable @ 29.2. resp: remains on 2l nc, o2sat 97-100, rr 19-25, ls clear upper/diminished lower, no c/o difficulty breathing, ? aspirtation w/ emesis this am but pt has strong cough and states he doesn't feel like any went into his lungs. frequent cough, productive @ times, pt able to swallow. cxr done this am for baseline comparison if resp status worsens (?aspiration). gi/gu: now npo w/ ngt in place and clamped. place following emesis this am, about 300cc emesis w/ ngt placement and then placed on lis and immediately got another 400cc, all fluid brown. residuals now undigested meds, 210cc@ noon but 90cc @ 1600 so pt bowels may now be moving better. +bs, stool x1, golden/loose/medium, lactulose prn but giving q8h, rifaximin and reglan now started as well, gave biscodyl pr. abd firm/ascites, kub done this am w/ cxr; belly tapped for 3.5l, fluid sent for specs/cx's. urine out foley icteric/clear, 20-100cc/hr. albumin 37.5g total being given following paracentesis. t.bili 9.4, stable. id: temp 96.4-97.2, wbc 24.9. repeat paracentesis fluid cx sent, remains on aztreonam for cipro resistant e.coli in last para cx. iv site wnl, skin w/d/i/jaundice. psychosocial: friend visited today, no other fam / friends heard from. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Diagnoses: Anemia, unspecified Unspecified essential hypertension Alcoholic cirrhosis of liver Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Atrial flutter Acute respiratory failure Septic shock Paralytic ileus Other septicemia due to gram-negative organisms Other ascites Hepatic encephalopathy Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Pneumonia due to Klebsiella pneumoniae Spontaneous bacterial peritonitis Chronic lymphoid leukemia, in remission

allergies: vicodin / penicillins attending: chief complaint: abdominal pain major surgical or invasive procedure: right internal jugular central line placement diagnostic paracentesis right arterial line history of present illness: 57 y/o man w/ etoh cirrhosis presenting with abdominal pain. pain began @ midnight last night and he came to the emergency department. . paracentesis performed in ed showed hemorrhagic ascites with rbc and sbp with 6500 wbc, 83% polys. he was treated with vanco/levo/clinda in the emergency department. ekg showed rapid atrial fibrillation vs. flutter but bp was low so he was bolused with 3l normal saline total. no rate controlling medications were given. . he reports that he took his morning medications including nadolol, digoxin, . once in the icu an arterial and central rij line were placed. he was volume resusitated with 1.5l bringing total to 4.5l. he also recevied 150grams of albumin. liver was consulted and will be by to see the patient. a dig level returned <.2 so he was dig loaded with .25 mg iv q6h x 24 hours. past medical history: 1. hypertension - not an issue since liver failure 2. atrial fibrillation on coumadin 3. seasonal allergies 4. shingles 5. dental abscess 6. peptic ulcer disease 7. cll: in remission social history: significant for no tobacco usage, significant alcohol usage. he used to drink heavily in the past, with no history of any withdrawals or delirium tremens. he drinks about 14 glasses of wine a week family history: diabetes, cancer and stroke. physical exam: vitals: 97.6 130-150, irregular 83/50-100/50 17 98%2lnc general: awake, alert, nad. heent: + jvd, no lad, moist oral mucose. pulmonary: lungs cta bilaterally cardiac: irregular rate and rhytm, holosystolic murmur abdomen: obese, soft, nt/nd, normoactive bowel sounds, liver ~ 2 cm below costal border; no asterixis. minimal tenderness to palpation back: no pain on palpation extremities: 2+ edema le neuro: slightly flat affect skin: mild scleral icterus, mild jaundice pertinent results: 05:00am pt-15.9* ptt-35.0 inr(pt)-1.4* 05:00am plt smr-normal plt count-200 05:00am hypochrom-1+ anisocyt-3+ poikilocy-1+ macrocyt-3+ microcyt-normal polychrom-1+ ovalocyt-1+ burr-1+ elliptocy-1+ 05:00am neuts-26* bands-1 lymphs-58* monos-3 eos-2 basos-0 atyps-10* metas-0 myelos-0 nuc rbcs-1* 05:00am wbc-23.8* rbc-2.95* hgb-10.2* hct-29.2* mcv-99* mch-34.6* mchc-34.9 rdw-25.2* 05:00am tot prot-4.2* albumin-3.3* globulin-0.9* calcium-8.9 phosphate-3.8 magnesium-2.2 05:00am ck-mb-notdone 05:00am ctropnt-<0.01 05:00am lipase-43 05:00am alt(sgpt)-22 ast(sgot)-64* ld(ldh)-484* ck(cpk)-40 alk phos-100 tot bili-8.8* dir bili-2.1* indir bil-6.7 05:00am estgfr-using this 05:00am glucose-112* urea n-23* creat-1.0 sodium-136 potassium-5.4* chloride-106 total co2-20* anion gap-15 05:09am lactate-2.7* 05:09am comments-green top 05:13am ammonia-110* 05:30am ascites wbc-6500* rbc-* polys-83* lymphs-11* monos-5* eos-1* 05:30am ascites tot prot-1.8 glucose-56 ld(ldh)-142 albumin-1.5 07:59am pt-17.7* ptt-43.6* inr(pt)-1.6* 07:59am plt smr-low plt count-151 07:59am hypochrom-normal anisocyt-2+ poikilocy-normal macrocyt-1+ microcyt-normal polychrom-2+ schistocy-occasional 07:59am neuts-37* bands-14* lymphs-48* monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 07:59am wbc-13.5* rbc-2.55* hgb-8.5* hct-25.6* mcv-100* mch-33.5* mchc-33.3 rdw-25.4* 07:59am digoxin-<0.2* 07:59am albumin-2.8* calcium-7.5* phosphate-3.4 magnesium-1.9 07:59am lipase-34 07:59am alt(sgpt)-19 ast(sgot)-32 ld(ldh)-190 alk phos-83 amylase-59 tot bili-7.2* 07:59am glucose-124* urea n-21* creat-0.8 sodium-138 potassium-4.2 chloride-110* total co2-21* anion gap-11 08:38am lactate-1.6 08:38am type-art 02:21pm hct-19.5* 02:21pm cortisol-27.3* 02:39pm type-art po2-126* pco2-32* ph-7.40 total co2-21 base xs--3 03:05pm cortisol-42.8* 03:26pm cortisol-45.4* 08:05pm hct-21.6* . microbiology (positive cxs): peritoneal fluid - e. coli sputum - klebsiella pneumoniae sputum - klebsiella pneumoniae sputum - klebsiella pneumoniae sputum - yeast bal - yeast sputum - yeast, klebsiella pneumoniae . cxr : compared to radiograph of seven hours prior. there is a new right ij catheter with its tip at the atriocaval junction. there is no pneumothorax. again seen are extensive calcified pleural plaques the sequela of prior asbestos exposure, emphysema, and a prominent basilar interstitial pattern which could relate to emphysema, asbestos related chronic lung disease, a component of volume overload, or a combination thereof. persisting small left pleural effusion. right cp angle excluded on this study. . ct abd/pelvis : 1. hepatic cirrhosis with stigmata of portal hypotension including numerous varices, a recanalized umbilical vein and worsening splenomegaly at 18 cm. 2. large amount of ascites overall similar in distribution and volume to ct. thickening of the peritoneum is stable. no evidence of hemoperitoneum. 3. small pericardial effusion incompletely evaluated on this abdominal ct. . echo : the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild prolapse of the anterior mitral leaflet. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is a small circumferential pericardial effusion. there are no echocardiographic signs of tamponade. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mitral valve prolapse with mild regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , pulmonary pressures are slightly lower (but still moderately elevated). the other findings are similar. . abd/pelvis ct: impression: 1. no focal abscess identified. 2. areas of consolidation in the dependent aspect of both lungs, likely representing a combination of atelectasis and infection. 3. cirrhosis, with portal hypertension, varices, splenomegaly, and moderate ascites. 4. enlarged right hilar, mediastinal lymph nodes, with pleural effusions, possibly reactive. given some more nodular componenets also seen within the lungs, followup chest ct is recommended after resolution of current acute symptoms. brief hospital course: mr. was initially admitted to the hospital with recurrent sbp, after having recently completed a hospital coure for sbp having been dicharged on ciprofloxacin. on re-admission, paracentesis demonstrated e coli that was resistant to ciprofloxacin, and he was therefore switched to aztreonam and completed a 14 day course. however, his hospital course was further complicated by transfer to micu due to hypercarbic hypoxic respiratory failure requiring intubation and hypotension with diagnosis of sepsis. numerous cultures were sent from his blood, urine, stool, and sputum during his prolonged micu course/infectious-sepsis work up, and positive culture data included sputum with growth of klebsiella pneumoniae and yeast. patient was on numerous different antibiotics empirically during his hospital and micu stay and eventually remained on meropenem and gentamicin for coverage of klebsiella, and vancomycin, caspofungin, and flagyl for empiric anti-microbial coverage. he also suffered from persisent hypotension causing his transfer to the micu and throughout his micu course for which he was on and off pressor support, including neosynephrine and vasopressin. mr. also had ongoing hematological difficulties during his hospital course in part felt to be due to his underlying diagnosis of cll along with his liver disease and his sepsis. these issues included persistent anemia requiring numerous blood transfusions to maintain his hematocrit, neutropenia for which he was treated with a 3 day course of ivig and maintained on g-csf, and thrombocytopenia requiring numerous platelet transfusions. his coagulopathy from his liver disease was also managed with numerous infusions of ffp to treat his elevated inrs. the patient also suffered from acute renal failure due presumably to sepsis which waxed and waned during his hospital course. he also developed severe anasarca with 32 liters positive during his micu course, although he remained intravascularly dry with pressor requirement and renal failure. his anasarca was minimally responsive to lasix boluses, followed by starting on lasix drip, which was not tolerated by his blood pressure. he also had a history of atrial fibrillation, for which he was maintained on digoxin with poor heart rate control. different measures were tried to control his heart rate, including nodal agents such as an esmolol gtt, but were not tolerated by his blood pressure. given his prolonged micu course, surgery was consulted for possible trach and peg placement, but felt that mr. peri-operative mortality risk was > 60%, and therefore was not a candidate for these procedures. given his overall poor prognostic picture based on the above, his continued fever spikes and pressor requirement despite prolonged broad spectrum antibiotics coverage, along with his prolonged intubation without option of tracheostomy, discussions were had with the patient's sister and best friend, who were the health care proxy, including goals of care. per discussion with the health care proxy's, they stated that the patient's goals would be quality, not quantity of life, and his goals of care were changed to comfort measures. the patient was extubated and pressor support discontinued and expired shortly after. medications on admission: coumadin 6 mg every other day; 5 mg other days lasix 80 (increaased 10 days ago from 40 ) lisinopril 2.5 daily digoxin 0.25 daily ppi nadolol 20 daily pravastatin 10 daily aldactone 50 mg daily discharge medications: na discharge disposition: expired discharge diagnosis: alcoholic cirrhosis spontaneous bacterial peritonitis sepsis klebsiella pneumonia respiratory failure pancytopenia chronic lymphocytic leukemia atrial fibrillation discharge condition: expired discharge instructions: na - patient expired followup instructions: na - patient expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Diagnoses: Anemia, unspecified Unspecified essential hypertension Alcoholic cirrhosis of liver Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Atrial flutter Acute respiratory failure Septic shock Paralytic ileus Other septicemia due to gram-negative organisms Other ascites Hepatic encephalopathy Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Pneumonia due to Klebsiella pneumoniae Spontaneous bacterial peritonitis Chronic lymphoid leukemia, in remission

discharge medications: discharge medications include, amiodarone 200 mg every day, coumadin 5 mg at bedtime, indomethacin 25 mg three times a day, with meals, neurontin 300 mg twice a day, albuterol metered dose inhaler 2 puffs every four to six hours as needed, lipitor 10 mg by mouth every day, aspirin 325 mg every day, multivitamin every day, hydrochlorothiazide 12.5 mg by mouth every day, atenolol 25 mg by mouth every day, univasc 15 mg by mouth every day. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Acute respiratory failure Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Streptococcal septicemia Rotator cuff (capsule) sprain

history of present illness: mr. is a 52-year-old male with past medical history of hypertension, obesity and occasional atrial fibrillation who was admitted on for pneumococcal pneumonia. he had experienced some fever, coughing and fatigue for several days prior to admission. on the day of admission, he became short of breath while sitting up and had an episode where he became unconscious for several hours. he was brought to the emergency department by emergency medical services with a blood pressure of 70/40 with a heart rate in the 110s. rhythm was atrial fibrillation. he was febrile to 103??????. respiratory rate was 32 and oxygen saturation was 76% on 6 liters by nasal cannula brought up to 100% on a non rebreathing mask. in the emergency department, he was noted to be alert, but pale, diaphoretic, tachycardic, with no edema of the lower extremities, but a tender right foot. his fingerstick showed a blood glucose of 180. he was treated with 7 liters of normal saline, but remained hypotensive with systolic blood pressures in the 70s. he was started on a peripheral dopamine drip at 5 mcg per kg per minute. blood cultures, sputum cultures and urine cultures were sent. he was treated with 2 gm of intravenous ceftriaxone and 500 mg of intravenous levofloxacin before being sent to the unit. past medical history: 1. hypertension 2. atrial fibrillation 3. seasonal allergies 4. shingles 5. dental abscess 6. peptic ulcer disease allergies: penicillin medications: 1. hydrochlorothiazide 12.5 mg po q day 2. atenolol 25 mg po q day 3. univasc 15 mg po q day 4. lipitor 10 mg po q day 5. aspirin q day 6. multivitamin q day social history: significant for no tobacco usage, significant alcohol usage. he used to drink heavily in the past, with no history of any withdrawals or delirium tremens. currently, he drinks wine, approximately three glasses a day with dinner. no intravenous drug use. homosexual orientation with a negative human immunodeficiency virus test in 10/. no history of any sexually transmitted diseases. family history: significant for diabetes, cancer and stroke. physical exam: general: mr. is an obese male in moderate respiratory distress, but was able to speak in full sentences. vital signs: temperature 103??????, heart rate 110 in atrial fibrillation, blood pressure 70 to 100 systolic/50 to 60 diastolic, respiratory rate 35, with oxygen saturation 95% on face mask. head, ears, eyes, nose and throat: pupils equal, round and reactive to light with dry mucous membranes. neck: no jugular venous distention, no meningeal signs and was supple. chest: bilateral rhonchi with occasional wheezing and decreased breath sounds at the bases with right greater than the left. heart: he was tachycardic with an irregular beat, s1 and s2 present with no murmurs, rubs or gallops. abdomen: positive bowel sounds. the patient was nontender and nondistended. extremities: no edema or erythema with 2+ dorsalis pedis pulses. laboratory values: significant for a white count of 11.6 with 28% neutrophils, 54% lymphocytes and 25% bands. hematocrit was 26.1 and platelets were 380. pt was 17.4 with an inr of 2.1 and ptt was 32.6. fibrinogen was 967 and urinalysis was positive for nitrites with trace protein, positive glucose, trace ketones and trace leukocytes. panel 7 was significant for bun of 109 and creatinine of 5.0. his anion gap was 28. alt was 80, ast was 122, total bilirubin 2.5. haptoglobin was 280, calcium 6.5, phosphate 7.8 and magnesium 2.3. toxicology screen was negative for aspirin, acetaminophen, ethanol, benzodiazepines, barbiturates, opiates, cocaine, amphetamines and methadone. his lactate level was 3.4. hospital course: the patient was intubated for respiratory failure. he remained in atrial fibrillation and was dc cardioverted after being loaded with amiodarone. blood cultures were positive for streptococcus pneumonia which was sensitive to penicillin. chest ct showed left upper lobe consolidation and bronchoscopy demonstrated mucous plugging. his broad spectrum antibiotics were converted to penicilli. his right ankle was tapped for joint fluid which came back negative for infection. the patient's renal failure resolved by . an eeg exam was performed on and showed moderate to severe encephalopathy with no focal or epileptiform features. right foot films on showed no evidence for osteomyelitis. ct exam of the thorax and abdomen on showed small bilateral pleural effusions. no intraabdominal fluid collection or abscess was noted. repeat chest x-rays throughout his stay in the medical intensive care unit showed persistent areas of consolidation in the left upper lobe with no pneumothorax. on , the patient became febrile again and had blood cultures and a lumbar puncture done. the lumbar puncture was negative for bacteria. there was no growth on the blood cultures. the patient continued to improve clinically and extubation was attempted on . he failed and had to be reintubated. on , he was transfused with 2 units of packed red blood cells for a downward drifting hematocrit. interval chest x-rays showed improvement and the patient was successfully extubated on . post extubation, the patient was awake and alert, able to tolerate po's when he was transferred to the floor. during transfer to the floor, his foley inadvertently pulled on and the patient developed hematuria. also, post extubation, mr. noted weakness in his right arm greater than his left. he was converted to po augmentin and finished his course on . the patient was begun on coumadin for continued paroxysmal atrial fibrillation. x-ray of the shoulder revealed no fracture or dislocation. mri of the right shoulder revealed a large full thickness tear of the supraspinatus portion of the rotator cuff. orthopedics was consulted and they recommended continued physical therapy with no surgery at the current time. he is to follow up with dr. in his office in two weeks. the patient's hematuria resolved within five days and his foley was discontinued. on , the patient developed a maculopapular rash across his upper torso and arms. after discontinuation of the augmentin, the rash resolved. it should be now noted that the patient has an allergic reaction to penicillin. the patient's right foot continued to improve with neurontin and indomethacin. etiology was unknown and rheumatology was consulted. recommendations are pending. note: this is a discharge summary occurring through . please see addendum for discharge condition and status with discharge medications. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Acute respiratory failure Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Streptococcal septicemia Rotator cuff (capsule) sprain

allergies: pcn, vicodin hcp , pt does not have telephonw contact info please see fhp/admission history; pt admitted after office visit, hct 17, with no recent history bloody/melanotic stools; to micu for further mgt, egd, echo in am, hct drop dt hemolysis vs. gib neuro: pt with flat affect, but alert and oriented x3, become very anxious at times with care, ie blood pressure cuff inflating or tying tourniquet; follows commands, moves all extremities; able to make needs known; perl, pupils 3mm and brisk bilaterally; denies pain; declining self care activities at this time cv: hr afib, no ectopy, 80's-100; sbp baseline 90's, since admission 87-110, map's 50-67; 3+ ptting edema in ble's; +pp difficult to plapate; no s+s bleeding, repeat hct after one unit transfused pending; tonight has rec'd 2units ffp for inr 3.5, and 1 unit prbc's, transfusing slowly d/t chf; am lytes pending resp: pt satting 100% 2lnc; right sided crackles at apex and dim at base, left cta; rr regular, 20's; slight sob on exertion, no wheezing gi/gu: +bs, no stools, but reports frequent loose golden stools ? d/t med side effects, pt took immodium prior o admission; guiac + stools in ed; no melena; abd soft non-tender, non-distended; npo for scope in am, can have ice chips; pt voiding small amts, 150-200cc clear urine, urine lytes sent id: afebrile, blood cultures x2 sent; started on cipro iv; wbc's at baseline 30's skin: intact but slightly jaundiced access: 18g piv x2 wnl Procedure: Transfusion of packed cells Transfusion of other serum Diagnoses: Congestive heart failure, unspecified Alcoholic cirrhosis of liver Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Portal hypertension Atrial fibrillation Blood in stool Diastolic heart failure, unspecified Other and unspecified alcohol dependence, continuous Chronic lymphoid leukemia, in remission

allergies: vicodin / penicillins attending: chief complaint: gib major surgical or invasive procedure: egd history of present illness: 57 year old male with chronic af on coumadin, diastolic dysfunction with lvef 55%, chf, past htn, cirrhosis with portal htn & cll in remission who was sent into cardiologist noted a hct drop to 18 from baseline in mid-30s during routine labs. inr 3.5 . 10 days pta, he was noted to have a 15 lb. weight gain with 3-4+ leg edema with more sob & fatigue while at heart failure clinic. lasix increased to 80mg at that time. his routine labs were drawn today and when hct drop, he was instructed by cardiologist to go to ed. . in ed, vitals were 97.9 86 102/40 18 100%2lnc. he was transfused 2uprbc, 2 units ffp, guaiac positive, but ng lavage negative. gi was notified. he has varices in the middle third of the esophagus and normal c-scope recently. given his history of cll, hemolysis was also assessed. . upon arrival in micu, he denies any pain, but does note fatigue. he reports increased lethargy, lhd, dizzyness over past 5 days. his weight is 14 pounds above his dry weight, but denies any dietary indiscretion, chest pain, changes in meds. past medical history: 1. hypertension 2. atrial fibrillation after coumadin 3. seasonal allergies 4. shingles 5. dental abscess 6. peptic ulcer disease 7. cll: in remission social history: significant for no tobacco usage, significant alcohol usage. he used to drink heavily in thepast, with no history of any withdrawals or delirium tremens. he drinks about glasses of wine 3-4 times a week family history: diabetes, cancer and stroke. physical exam: vitals: 98.3 94 103/46 17 100%3lnc general: awake, alert, nad. heent: + jvd, no lad, moist oral mucose. pulmonary: lungs cta bilaterally cardiac: irregular rate and rhytm, holosystolic murmur abdomen: obese, soft, nt/nd, normoactive bowel sounds, liver ~ 2 cm below costal border; no asterixis back: no pain on palpation extremities: 2+ edema le neuro: slightly flat affect skin: mild scleral icterus, mild jaundice pertinent results: ekg: afib, nl axis, nl intervals, twi i, ii, l, f,v3-6 (old); more pronounced st depression in ii, v4-6 compared to prior in . egd: 1 cords of grade ii varix was seen in the middle third of the esophagus.there was scarring from previous banding in the lower esophagus but no significant varices in lower esophagus. . c-scope: normal colon to cecum and terminal ileum. brief hospital course: hospital course by problem: # anemia: suspect gib as guaiac positive on exam and has hx of varices. egd performed showed no active bleeding but grade 2 varices banded just in case. received 2u ffp, 5u prbcs and hct from 17 - 24. ct abd showed no rp bleed. no clear evidence of hemolysis. his hematocrit remained stable stable until discharge. poor marrow response was noted and heme/onc was consulted. they felt his anemia was due to a combination of splenic sequestration, alcoholic bone marrow suppression and possibly a very small chronic gi bleed. after discharge from the micu, his hematocrit was monitored and remained stable. he was advised to stop drinking immediately. . # cll: followed by dr. , who had been aware of anemia and mentioned possiblity of hemolysis or marrow infiltration. previous hemolysis w/u has been negative and remained so now. per heme/onc, there was no indication for a bone marrow biopsy at this time as it would not change management. he will follow up with his pcp for further monitoring. . # diastolic dysfunction/chf: appeared volume overloaded on presentation with an increase in his weight and increased le edema. his chf meds were held initially in the setting of a gi bleed but then restarted after the normal egd with good response. a repeat echo showed mild lvh, preserved ef. he began diuresing appropriately on his home dose of lasix 80mg po bid and spironolactone to the point were he was able to ambulate normally without significant desaturation upon discharge. he will follow up with his cardiologist for further management. . # etoh cirrhosis: his etoh level was 29 on admission. he stated his last drink was earlier that pm. his spironolactone and nadolol were initially held out of concern for a gib but were restarted after the egd. he was told to quit drinking immediately, a plan to which he agrees. he will follow up with his hepatologist for further management. . # afib on coumadin: his coumadin was initially held and reversed with ffp prior to the egd but was then restarted after no bleeding was found. his inr was therapeutic prior to discharge. he was well rate controlled with his nadolol and digoxin. . # cad: his asa was initially held but then restarted after the egd. he will discuss with his primary care physician the utility of being on both asa and coumadin given his risk for gi bleed. he was continued on his pravastatin. . # arf: his creatinine was 1.9 on admission with a baseline of 0.9. likely due to prerenal azotemia, especially after it resolved after fluid resucitation with blood. full code medications on admission: asa 81 coumadin 6 mg every other day; 5 mg other days lasix 80 (increaased 10 days ago from 40 ) lisinopril 2.5 daily digoxin 0.25 daily ppi nadolol 20 daily pravastatin 10 daily aldactone 50 mg daily discharge medications: 1. pravastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a day). 6. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). 7. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 8. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 9. warfarin 5 mg tablet sig: one (1) tablet po daily (daily). 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: home discharge diagnosis: primary: anemia secondary: cirrhosis chronic lymphocytic leukemia hypertension atrial fibrillation discharge condition: hematocrit stable. all other vital signs stable. discharge instructions: you were admitted because your blood count was very low. this may have been due to a small amount of bleeding, your current alcohol use and your chronic lymphocytic leukemia. you received blood transfusions, and your blood count was stable therefater. in addition, you had an upper endoscopy and had some veins in your esophagus blocked off. we did not make any changes to your medications. you should stop drinking alcohol altogether. it is worsening your liver disease and affecting your ability to produce red blood cells. you should follow up with your primary care doctor, hepatologist and hematologist. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: followup instructions: please schedule appointments with your primary care doctor and your hematologist/oncologist as soon as possible. you should call to schedule an appointment with the clinic. dr. (hepatology) will contact you soon about setting up a follow up appointment soon. you should also have your inr checked early this week. provider: . phone: date/time: 3:00 md Procedure: Transfusion of packed cells Transfusion of other serum Diagnoses: Congestive heart failure, unspecified Alcoholic cirrhosis of liver Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Portal hypertension Atrial fibrillation Blood in stool Diastolic heart failure, unspecified Other and unspecified alcohol dependence, continuous Chronic lymphoid leukemia, in remission

history of present illness: the patient is an 85-year-old gentleman with a history of hypertension who had an episode of sharp substernal chest pain one hour prior to admission. it occurred at rest. no shortness of breath. no radiation. no nausea, vomiting, or diaphoresis. the patient had a similar episode for two hours one day prior to admission. at baseline, the patient does not have any exertional rest angina, orthopnea, or dyspnea on exertion. the patient was admitted to the hospital three years ago with similar chest pain and was cleared to go home. the patient was brought to hospital by emergency medical service today. an electrocardiogram showed 1-mm to 2-mm st elevations in leads ii, iii, v5, and v6. the patient was given aspirin, lopressor, nitroglycerin, and started on a heparin drip. the patient was given morphine, and the pain decreased to . he was med flighted to for cardiac catheterization. at that time, his blood pressure was 200/100. during catheterization, right atrial pressure was 7, pulmonary artery pressure was 30/15, and wedge pressure was 20. catheterization revealed a 100% totally occlusion of the first obtuse marginal, status post cypher stent placement. there was diffuse left anterior descending artery and right coronary artery disease. the patient was started on plavix and integrilin. no chest pain on arrival to the coronary care unit. electrocardiogram showed resolution of st elevations. the patient continued to be hypertensive; however, he had a good response to intravenous lopressor and nitroglycerin. past medical history: 1. hypertension. 2. hypercholesterolemia. medications at home: 1. lopressor 50 mg by mouth twice per day. 2. imdur 30 mg by mouth once per day. 3. aspirin. allergies: penicillin (unsure of the reaction). social history: the patient was a prior carpenter. he is widowed. he denies tobacco. he denies any drug use. he uses occasional alcohol. family history: no family history of coronary artery disease. physical examination on presentation: on examination, temperature current was 98.7 degrees fahrenheit, his heart rate was 60, his respiratory rate was 15, his blood pressure was 124/84, and his oxygen saturation was 100% on 2 liters. ins-and-outs positive one liter. the patient was comfortable and in no apparent distress. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light and accommodation. the extraocular movements were intact. the neck was supple. there was 8 cm of jugular venous pulsation. the lungs were clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm. there were no murmurs, rubs, or gallops. the abdomen was soft, nontender, and nondistended. there were normal active bowel sounds. extremities revealed the lower extremity was cool with 2+ dorsalis pedis pulses bilaterally. there was needed. neurologically, alert and oriented times three. there were no focal signs. groin status post catheterization revealed right venous and arterial sheath with no hematoma. pertinent radiology/imaging: an electrocardiogram prior to catheterization revealed a normal sinus rhythm at 60 beats per minute. there was a normal axis and normal intervals. there were st elevations in ii greater than iii and f/v6. no t wave inversions. there were 1-mm st depressions in v3. status post catheterization, resolution of st elevations. t wave flattening was present in ii, iii, and avf, and v4 through v6. cardiac catheterization on status post first obtuse marginal stent, left anterior descending artery 80% mid, first diagonal 70%, second diagonal 70% at the origin, left circumflex 100% at the first obtuse marginal, right coronary artery 70% at the origin and 90% mid. pertinent laboratory values on presentation: creatine kinase on admission to was 175. white blood cell count was 9.4, his hematocrit was 42.3, and his platelets were 218. chemistries revealed sodium was 138, potassium was 4.1, chloride was 102, bicarbonate was 27, blood urea nitrogen was 25, and his creatinine was 1.5. assessment: the patient is an 84-year-old gentleman with a history of chronic renal insufficiency, hypertension, and hypercholesterolemia who presented with an inferolateral distribution myocardial infarction involving the first obtuse marginal. the patient is status post cypher placement. summary of hospital course by issue/system: 1. coronary artery disease issues: the patient was continued on aspirin and was started on plavix. he was continued on statin, beta blocker, and ace inhibitor. the patient had an echocardiogram 24 hours after the event which showed mild left atrial dilation, mild regional left ventricular dysfunction, impaired left ventricular relaxation, an ejection fraction of 45% to 50%, and hypokinesis at the basal inferior wall and basal mid inferolateral walls. the patient was to have a follow-up echocardiogram in four to six weeks and was to follow up with dr. for further management. 2. chronic renal insufficiency issues: the patient's creatinine trended down during this admission and was at 1.3 at the time of discharge. the patient was to have his creatinine monitored as an outpatient. discharge status: to home. condition at discharge: stable. medications on discharge: 1. aspirin 325 mg by mouth once per day. 2. plavix 75 mg by mouth once per day. 3. lipitor 20 mg by mouth once per day. 4. protonix 40 mg by mouth once per day. 5. lisinopril 5 mg by mouth once per day. 6. atenolol 50 mg by mouth once per day. discharge instructions/followup: the patient was instructed to follow up with dr. and his primary care physician within two weeks of discharge. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Hematoma complicating a procedure Hematemesis Acute myocardial infarction of inferoposterior wall, initial episode of care

history of present illness: baby is a gram product of a 32 and 5/7 weeks gestation pregnancy with an edc of . mom did not have prenatal care so dates are uncertain. she is a 24-year-old g3 p2 mom with type o+, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative and gbs unknown. this infant was born by c-section for footling breech. he emerged breech with a nuchal cord x2. his apgar scores were 7 and 8. he was given blow-by oxygen in the delivery room because of persistent cyanosis. physical examination at discharge: weight on the day of discharge 2590 grams (25-50%). head circumference 33 cm (50%) and length 45.5 cm (25-50%). he is pink, comfortable in room air. afof, mmm, red reflex present bilaterally, no cleft palate. rrr, soft i/vi systolic ejection murmur left sternal border that radiates to axilla, warm and well-perfused, strong femoral pulses, lungs clear, no retractions, abdomen benign, hips stable without clicks, back straight, patent anus, circumcision healing well, testes descended, active and alert with good tone. summary of hospital course by systems: 1. respiratory: baby was intubated and received beractant x2. he was extubated within 24 hours but remained on nasal cannula oxygen for the first week of life. on day of life 3, caffeine was started for apnea. by day of life 8, he was transitioned to room air. he had a few episodes of apnea and remained on caffeine until day of life 15. he has had no episodes of apnea for more than 2 weeks prior to discharge. 2. cardiovascular: baby has remained cardiovascularly stable. he does have an intermittent soft systolic ejection murmur at the left sternal border which radiates to the left axilla. it sounds like a benign murmur most likely a peripheral pulmonic stenosis murmur. femoral pulses are strong. pressures have been stable. o2 saturations have been as high as 100% in ra. 3. fluids, electrolytes, nutrition: he was npo on admission. feeds were started within the first 48 hours of life. volume was gradually increased and calories were advanced to 24 calorie special care formula. two days prior to discharge, he was switched to similac 24 calories per ounce. he has been gaining good weight throughout hospitalization. 4. gi: he was started on phototherapy in the first 3 days of life and he had a peak total bilirubin of 8.8 on day of life 4. phototherapy was discontinued within the first week of life. bilirubins have been stable off phototherapy, the last one on of 5.7. total bilirubin. 5. hematology: hematocrit on admission was 45.9. he was never transfused. the last hematocrit was on of 40.7. 6. infectious disease: baby was started on ampicillin and gentamicin on admission and they were discontinued after 48 hours of negative cultures. on day of life 6, he developed temperature instability and feeding intolerance. culture and cbc were sent. he was started on vancomycin and gentamicin. the initial culture grew staph epi for which he was treated with vancomycin and gentamicin initially. gentamicin was subsequently discontinued and he remained on vancomycin for a total 7 day course. the repeat culture was negative. lumbar puncture was reassuring. 7. neurology: neurology exam has been appropriate throughout hospitalization. 8. sensory: hearing screen was performed with automated auditory brain stem responses. the baby passed in both ears prior to discharge. 9. ophthalmology: the patient did not meet criteria for an ophthalmology exam. there were no concerns during hospitalization. 10. psychosocial: social work was involved with the family. the contact social worker is and she may be reached at . condition at discharge: stable. discharge disposition: to home. primary disposition: dr. . her phone number is . her fax number is . care/recommendations: - feeds at discharge will be similac 24 calories per ounce, ad lib p.o. - the baby is on no medications. - iron and vitamin d supplementation: iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. all infants fed predominantly breast milk should receive vitamin d supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. - he passed the car seat position screening prior to discharge. - the state newborn screen was initially abnormal with an elevated 17 ohp. the level eventually normalized. there were no clinical concerns during hospitalization. the last newborn screen on was normal. - the baby received his hepatitis b vaccine on . - immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria: 1. born at less than 32 weeks; 2. born between 32-35 weeks with 2 of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; 3. chronic lung disease; 4. hemodynamically significant chd. 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 other home care givers. this infant has not received the rotavirus vaccine. the american academy of pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. follow up appointments scheduled/recommended: an appointment with the pediatrician, dr. , is recommended within 48 hours after discharge. vna is scheduled to visit the family within 48 hours of discharge. discharge diagnoses: 1. prematurity. 2. respiratory distress syndrome. 3. staphylococcus epi bacteremia. 4. status post hyperbilirubinemia. , Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Other phototherapy Prophylactic administration of vaccine against other diseases Circumcision Other oxygen enrichment Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,750-1,999 grams Routine or ritual circumcision 31-32 completed weeks of gestation Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Bacteremia of newborn

history of present illness: briefly, this is a 61 year old gentleman with no significant past medical history. he presented to an outside hospital with shortness of breath and substernal chest pain, times six days. he was transferred to for coronary artery bypass graft and also for respiratory failure. he had undergone a cardiac catheterization at the outside hospital, which showed 70% right coronary artery lesion, 100% left anterior descending lesion and 95% circumflex lesion. he was originally admitted to the ccu on the medical service and was started on an ivp as well as multiple pressors. he required intubation for respiratory difficulty. past medical history: only significant for a family history of coronary artery disease and history of tobacco. allergies: no known drug allergies. medications: he took no medications. he did, however, smoke one pack per day with occasional alcohol. physical examination: upon admission here, he was afebrile. his heart rate was 73. blood pressure was 88/50; respiratory rate of 11; saturating 97%. he was intubated and sedated. his cardiovascular is regular rate and rhythm with a 2/6 systolic murmur at the apex. he had bilateral diffuse crackles. his abdomen was soft, nontender, nondistended. extremities had no edema. dopplerable dorsalis pedis and posterior tibial pulses. he had a right and left groin sheath in. laboratory data: on admission, his white count was 9.2; hematocrit was 39.7; platelet count of 302. chemistries: 137; 4.5; 101; 27; bun of 11; creatinine of 0.9. blood sugar of 115. ck was 175. mb was 4.3. troponin of 1.8. the patient was admitted to the medical service on for evaluation and management. as stated previously, he underwent a repeat cardiac catheterization here at that reconfirmed the presence of three vessel disease and a repeat echo which again showed similar results. cardiothoracic surgery was consulted at that time for evaluation for emergent coronary artery bypass graft. the patient went to the operating room on where he underwent a coronary artery bypass graft times three and a mitral valve repair. please see the operative report for further details. the patient was transferred to the csiu postoperatively. his ejection fraction postoperatively was 45%. he was slowly weaned from his ventilator and ultimately able to be extubated. he required pressors postoperatively for blood pressure support. he was fully weaned from his levophed and he was also given amiodarone. he was taken off of his levophed and started on milrinone for blood pressure support. he was weaned off of his amiodarone drip. he was also given a course of levofloxacin for a positive urinary tract infection. he continued to improve and was extubated on postoperative day number one. he was kept in the csiu. physical therapy was consulted while he was in the csiu and they continued to follow him throughout his hospital course. he was ultimately deemed capable of going home and being improved from a physical therapy standpoint. he was weaned off of all pressors by postoperative day number three. he continued do well. his laboratory values were all within normal limits. he made excellent urine and was started on lasix for diuresis. he was started on captopril, lopressor, plavix and lasix for his cardiac medications. his wires and chest tubes were removed on postoperative day number four and the patient was transferred out to the floor on postoperative day number five. his foley catheter was also removed after arriving on the floor. he remained in sinus rhythm throughout his hospital stay and continued to do well. on , the patient was cleared by physical therapy, tolerating a regular diet and was discharged to home with vna services. discharge medications: 1. lopressor 50 mg p.o. twice a day. 2. lasix 20 mg p.o. twice a day. 3. colace 100 mg p.o. twice a day. 4. aspirin 325 mg p.o. q. day. 5. percocet one to two tablets p.o. every four hours prn for pain. 6. plavix 75 mg p.o. q. day. 7. lipitor 80 mg p.o. q. day. 8. potassium 20 meq p.o. twice a day. follow-up: the patient was instructed to follow-up with his primary care physician in one to two weeks. follow-up with cardiologist in three weeks. follow-up with the cardiothoracic service at in four weeks. disposition: he was discharged to home in stable condition. discharge diagnoses: 1. coronary artery disease. 2. status post myocardial infarction. 3. status post cardiac catheterization. 4. status post ibp. 5. now status post coronary artery bypass graft times three. 6. mitral valve regurgitation. 7. now status post mitral valve repair. secondary diagnoses: 1. urinary tract infection. 2. hypokalemia. 3. hypomagnesemia. the patient is discharged to home in stable condition. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Injection or infusion of platelet inhibitor Left heart cardiac catheterization Arterial catheterization Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Open heart valvuloplasty of mitral valve without replacement Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Hypopotassemia Acute respiratory failure Disorders of magnesium metabolism

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: doe x several months major surgical or invasive procedure: redo mvr history of present illness: this is a 61 yo female s/p cabg x 3 adn mvr on with nes complaints od dyspnea on exertion. finding of new murmur by pcp and echo finding 4+ mr. past medical history: mi cad/mr ischemia and valvular cardiomyopathy lv systolic dysfunction ^ lipids htn s/p cabg x 3 and mv repair in social history: lives alone in , ma. works in real estate. + 80 pk year tob hx -- quit 1.5 years ago. family history: no known cad physical exam: on presentation: vs hr 84 regular, bp 124/66. ht 5'8" wt 200# general: appears stated age in nad -- anxious. skin: warm, dry, + rash on left knee. neck: supple, no jvd, no lymphadenopathy. chest: cta bilat. cv: rrr. s1s2 with ii/vi murmur in apex. abd: nt. nd, + bs. extremities: no varicosities. neuro: cn ii-xii intact. a+o x 3. pertinent results: 11:05pm wbc-15.3*# rbc-3.51* hgb-10.0*# hct-30.2* mcv-86 mch-28.6 mchc-33.3 rdw-14.0 11:05pm plt count-299 11:05pm pt-14.1* ptt-32.4 inr(pt)-1.2 06:20pm urea n-15 creat-0.7 chloride-111* total co2-23 09:30am blood wbc-11.2* rbc-3.58* hgb-10.6* hct-31.9* mcv-89 mch-29.5 mchc-33.1 rdw-14.8 plt ct-676*# 09:30am blood plt ct-676*# 09:30am blood glucose-204* urean-13 creat-0.7 na-137 k-4.8 cl-100 hco3-28 angap-14 brief hospital course: mr was admitted on . he proceeded to the or and underwent a redo mvr with a 29mm mosiac porcine heart valve via right thoracotomy. total cardio-pulmonary bypass time was 85 minutes. there was no cross clamp time as this operation was done with a bleeding heart approach. he was tranferred to the icu in nsr rate 98, map 62, cvp 8, on neosynephrine, milrinone, insulin, and propofol drips. he was extubated on the evening of his operative day without any complications. his iv medications were weaned and both the milrinone and the neosynephrine being discontinued on the am of pod 2. he had some post-op tachycardia for which is lopressor dose was increased and ace inhibitor adjusted. he was also followed by the cradiology team and their recommendations were followed. his chest tubes remained in longer than is typical because of ongoing drainage. on pod 3 he was noted to have crepitus in his right check and upper chest. his chest tubes x 3 remained on suction with an air leak. on (pod 7) the chest tubes were put to water seal with a subsequent cxr showing a small pneumthorax and they were again put to suction. a persistent pneumothorax remined and on (pod 9) a thoracic consult was obtained with rcommendations for doxycycline sclerosis. the chest tube was eft to water seal with an ongoing leak but minimal drainage. the chest tube was clamped for a 24-hour period without any respiratory distress and was eventually discontinued on (pod 15) per the recommendations of the thoracic surgery team. mr. was followed by the physical therapy team throughout his hospital stay with initial evaluation on pod 2 and on pod 7 he was found to be for for home. on pod he was found to be safe for discharge home. medications on admission: lopressor 50 lipitor 80 daily aspirin 325 daily plavix 75 daily zestril 2.5 daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. atorvastatin calcium 40 mg tablet sig: two (2) tablet po qd (). disp:*60 tablet(s)* refills:*2* 4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po qd (). disp:*30 tablet(s)* refills:*2* 5. ibuprofen 600 mg tablet sig: one (1) tablet po every six (6) hours: take with food. disp:*120 tablet(s)* refills:*2* 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. lisinopril 5 mg tablet sig: 0.5 tablet po qd (). disp:*15 tablet(s)* refills:*2* 8. oxycodone hcl 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 10. plavix 75 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: s/p redo mvr (#29 mosaic porcine) vis right thoracotomy htn, ^ chol, cardiomyopathy, s/p mvr/cabg ' persistent right pneumothorax 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 wound followup instructions: dr in wks dr in wks dr in 4 wks Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Injection into thoracic cavity Continuous intra-arterial blood gas monitoring Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Aortocoronary bypass status Percutaneous transluminal coronary angioplasty status Mechanical complication due to heart valve prosthesis Iatrogenic pneumothorax

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral leg pain, paroxsymal atrial fibrillation major surgical or invasive procedure: full laminectomy l4, l5 and superior s1 with decompression of lateral recess and bilateral foramina, l4-5. history of present illness: the patient is a 75 year-old male who has presented with several months of increasing bilateral leg pain which is worse with standing and also walking. he has bilateral stocking in distribution sensory changes. he presented with classic neurogenic claudication. he was worked up including a mri scan which revealed severe stenosis at l4-5, secondary to degenerative joint disease and ligamentous hypertrophy. the patient was electively scheduled for surgery. he was originally scheduled for surgery on but on induction, developed arrhythmia and cardiovascular compromise. the patient was, therefore, readmitted today after placement of temporary pacemaker, to be in better control of his rate as well as preoperative beta blockers to allow for rate control. past medical history: pe w/ 6mos anticoag dvt, pe, ivc filter htn increased chol neuropathy cerv spondylosis colon polyps ed hemorrhoids social history: married, lives with wife, retired, quit smoking , 1 drink per day family history: non contributory physical exam: vital signs: 98.2 51 12 149/53 97%ra gen: alert, awake gentelman lying in bed, nad. heent:neck supple, no carotid bruits, sclera unicteric. cvs: rrr, s1/s2. chest: clear to auscultation. neuro: alert,awake, follow commands. motor:full les dtr: 1 +kj, 0 aj,toes down bilateral stocking in distribution sensory changes. pertinent results: 04:38pm freeca-1.21 04:38pm hgb-13.4* calchct-40 04:38pm glucose-95 lactate-2.3* na+-142 k+-4.4 cl--104 04:38pm type-art po2-269* pco2-38 ph-7.47* total co2-28 base xs-4 12:30pm blood ck-mb-2 ctropnt-<0.01 10:10am blood ck-mb-2 ctropnt-<0.01 05:00pm blood ck-mb-2 ctropnt-<0.01 06:15am blood wbc-6.0 rbc-3.31* hgb-10.1* hct-28.7* mcv-87 mch-30.5 mchc-35.2* rdw-13.3 plt ct-231 05:00pm blood wbc-7.3 rbc-3.38* hgb-10.6* hct-28.7* mcv-85 mch-31.3 mchc-36.8* rdw-13.0 plt ct-201 06:40am blood wbc-7.3 rbc-3.27* hgb-10.5* hct-28.2* mcv-86 mch-32.2* mchc-37.3* rdw-12.9 plt ct-288 06:15am blood wbc-6.0 rbc-3.31* hgb-10.1* hct-28.7* mcv-87 mch-30.5 mchc-35.2* rdw-13.3 plt ct-231 brief hospital course: is a 74 year old male who admitted electively for lumbar laminectomy on . he had his procedure under general anesthesia and transvenous temporary pacer wires placed for surgery without intraopetrative complications. patient remained in the pacu 6 hours then transferred to regular floor. his pain was well conrolled. electrophysiology(ep) service removed right temporary wires under flouroscopic guidance without any complications on postoperative day one. his foley catheter removed able to void without difficulty, tolerated his diet. on postiop day four(), patient had several episode of tachycardia; heart rate has been up to 160's. ep notified they felt that he rhtym was atrial tachycardia, recommmended to increase his beta-blockers. then later in the day he had several more episode of tachycardia rate upto 140's, then medicine thouight he might went into atrial fibrillation/flutter so he was tranferred to medicine for further evaluation of his cardiac status. cardiac: his beta blocker was switched to acebutolol hcl 200 mg po bid and he was kept on telemetry for three days. his rate remained well controlled with beta-blockers, and he didn't have any more tachycardia episodes, however his rate dropped to 40-50's on two occasions. patient remained asymptomatic with each event. prior to transfer to medicine his ecg showed some st elevation on leads v1-3. his cardiac enzimes were negative for any acute mycardial infarction. (trop all less than 0.01.) electrophysiology/cardiology was consulted and they monitored the patient over two days and felt he did not need a pace maker or ablation at this time and was safe to go to rehad on the acebutolol for rate control. it was also decided that he needs to be started and maintained on anti-coagulation and coumadin 5 mg was given. he will need to maintain a goal inr of and have follow-up as an outpatient for this. heme: pt. appears to have chronic normocytic anemia (hematocrits of 33-38) over last year. post-op his hct was lower (27-29), but stable. further work-up of his normocytic anemai should be done as an outpatient. goal inr as above on coumadin. medications on admission: ezetemibide 10 mg daily lisinopril 40 mg daily folic acid lipitor 10 mg daily discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. folic acid 1 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. duloxetine 20 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. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 * refills:*2* 7. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*20 tablet(s)* refills:*0* 8. hydrocortisone 1 % cream sig: one (1) appl topical tid (3 times a day) as needed. disp:*1 * refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*2* 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. disp:*20 tablet, delayed release (e.c.)(s)* refills:*0* 11. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*15 tablet(s)* refills:*0* 13. acebutolol 200 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 14. outpatient lab work please check inr on and . 15. warfarin 5 mg tablet sig: one(1) tablet po one a day for 4 days. discharge disposition: home with service facility: homecare discharge diagnosis: severe lumbar stenosis discharge condition: neurologically stable, well-rate controlled. discharge instructions: monitor for lumbar incision site for redness, swelling, or drainage. keep insicion dry and clean, do not wet. report any fever greater than 101.5, incresed lumbar ppain or leg pain, numbness, weakness, or any other neurologic concerns. if you feel dizzy or lightheaded please return to ed. please take all medications as prescribed, you have also been started on a blood-thinning medication that will require close follow-up with your primary care doctor. your goald inr is . followup instructions: follow up with dr 6 weeks. call the office for an appointment at . sture removal and wound check on in the dr office. call the above number for an appointment. follow up with dr , cardiologist, call to make an appointment. please follow-up with your primary care doctor of your inr (blood-thinning medications) with a goal inr of . Procedure: Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Transfusion of packed cells Diagnoses: Anemia, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Other specified cardiac dysrhythmias Spinal stenosis, lumbar region, without neurogenic claudication

allergies: ibuprofen attending: chief complaint: upper gastrointestinal bleeding major surgical or invasive procedure: intensive care unit, central line, total of 9 red blood cell transfusions. history of present illness: pt is a 75 yo male with mmp including h/o pe, htn, paf on coumadin, recent workup of anemia with hct in upper 20s who presents after went to pcp yesterday and found to have hct of 18. pt had a workup for anemia done. in , hct was 34, over time been in mid-upper 20s. iron studies in showed iron 221, tibc 221, ferritin 25. workup for anemia included bmbs in which showed no storage iron, small lymphoid aggregates, otherwise normal. pt was started on iron tid. . pt says that he has noticed that for the last week he has been sob when moving only and not at rest. whereas normally he can walk up and down the stairs, he has been having trouble walking a few feet before getting sob. no cp. no brbpr. +black stool since starting the iron many months ago. no diarrhea. +chronic constipation. no abdominal pain. no cough. +subjective fever over the past few days. +chills last night. no night sweats. no lightheadness. no n/v. . in the ed, vs on arrival were: t: 97.4; hr: 76; bp: 116/42. he received protonix 40 mg iv x 1, 2.5 mg vitamin k subcutaneous, and one unit ffp. ng lavage showed mucus blood with lavage and pt was guauaic positive . of note, colonoscopy in showed grade 2 internal hemorrhoids, otherwise normal colonoscopy to cecum . in micu, did egd which showed multiple erosions and a duodenal ulcer, but no active bleed. he had evidence of barrett's esophagus as well as findings c/w h. pylori infection. serologies were sent and came back positive for h. pylori. he has had serial hct which have remained stable. he has had no episodes of hematemesis or melena, but he does have guaiaic positive stools. he is taking pos w/o any difficulty. overnight ( -> ), he went into rapid afib and was given 5mg iv lopressor. his bp remained stable, but he became bradycardic w/ 5 sec pause. currently hr is 58. past medical history: pe w/ 6mos anticoag dvt, pe, ivc filter htn increased chol neuropathy cerv spondylosis colon polyps ed hemorrhoids social history: married, lives with wife, retired, quit smoking , 1 drink per day family history: non contributory physical exam: per admitting resident: vs: t: 98.1; bp: 123/54; hr: 71; rr: 14; o2: 98ra gen: slightly hard of hearing speaking in full sentences in nad heent: perrla; eomi; sclera anicteric; op clear. conjunctiva pale. neck: no lad. jvd hard to tell from carotid pulsations. cv: ii/vi holosystolic at lusb. +ii/vi apical murmurs. lungs: coarse rhonchorus sounds throughout. abd: nabs. soft, nt, nd. no hsm. back: no spinal, paraspinal tenderness ext: trace-1+ edema. dp 2+ neuro: cn ii-xii tested and intact. ms upper and lower. reflexes: biceps, brachio, patellar . pertinent results: 10:54pm hct-24.9*# 10:54pm pt-17.1* ptt-29.9 inr(pt)-1.6* 03:10pm ck(cpk)-89 03:10pm ck-mb-notdone ctropnt-<0.01 03:10pm hct-15.5* 03:10pm pt-20.3* ptt-31.3 inr(pt)-2.0* 02:20pm urine hours-random 02:20pm urine gr hold-hold 02:20pm urine color-yellow appear-clear sp -1.011 02:20pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 11:40am glucose-115* urea n-27* creat-1.2 sodium-141 potassium-4.4 chloride-106 total co2-28 anion gap-11 11:40am estgfr-using this 11:40am ck(cpk)-93 11:40am ck-mb-notdone ctropnt-<0.01 11:40am wbc-6.4 rbc-2.11*# hgb-6.2*# hct-18.5*# mcv-88 mch-29.3 mchc-33.4 rdw-14.3 11:40am neuts-62.5 bands-0 lymphs-24.2 monos-6.9 eos-6.0* basos-0.4 11:40am hypochrom-1+ anisocyt-2+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-1+ 11:40am plt smr-normal plt count-205 11:40am pt-29.0* ptt-30.7 inr(pt)-3.0* brief hospital course: 75 year old man with history of pulmonary embolisn, hypertension, paroxysmal atrial fibrillation on coumadin, presenting with drop in hematocrit. . 1) anemia- patient had upper gastrointestinal bleeding. he underwent upper endoscopy that showed multiple erosions and a duodenal ulcer, but no active bleed. he had evidence of barrett's esophagus as well as findings consistent with h. pylori infection. serologies were sent and came back positive for h. pylori. patient was on started on a 14 day course of protonix, amoxicillin and clarithromycin. he transfused a total of 9 red blood cell packs. his hematocrit was stable at discharge. needs to be rechecked in days. he needs to have follow-up upper and lower endoscopy in months. warfarin is held because of bleeding risk. . 2) atrial flutter (af): patient went into af night with rate of 140s. he was given 5mg iv lopressor with resultant bradycardia and a 5sec pause. he was asymptomatic with no drop in blood pressure. dr. recommended holding all beta-blockers, including any eye drops, and watching the patient on telemetry. the patient was seen by the cardiology service. it was decided that he needed ablation for his af, probably without a pacemaker. the patient once reported an episode of chills and a temperature of 100.3. workup for infection included negative urine and blood cultures and a negative chest xray. a mild left arm erythema (iv site) resolved quickly after the peripheral iv was pulled. nevertheless, cardilogy felt that there is no urgent indication for ablation. thus, the patient was discharged and in scheduled to follow-up as an outpatient in about 2 weeks. for now, coumadin has been held (bleeding risk) and metoprolol was not restarted. . 3) dyspnea: mild dyspnea at presentation, probably due to anemia. on exam, some crackles, but no congestion on chest xray. increased lasix to 20mg every day. symptoms improved rapidly. will need to monitor creatinine. medications on admission: cymbalta 20mg po qd tylenol prn coumadin 5/2.5mg iron 325 mg po qd pepcid 40mg po qd terazosin 2mg po qhs folic acid 2mg po qd lisinopril 20mg po qd lasix 20mg po qod (for leg edema) vytorin 10/20 mg po qd stool softener qd discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for prn back pain. 2. atorvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 3. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. folic acid 1 mg tablet sig: two (2) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours) for 8 days. disp:*16 tablet, delayed release (e.c.)(s)* refills:*0* 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day: start taking on . 9. amoxicillin 500 mg capsule sig: two (2) capsule po q12h (every 12 hours) for 8 days. disp:*32 capsule(s)* refills:*0* 10. clarithromycin 250 mg tablet sig: two (2) tablet po q12h (every 12 hours) for 8 days. disp:*32 tablet(s)* refills:*0* 11. furosemide 20 mg tablet sig: one (1) tablet po once a day. 12. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 13. duloxetine 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 15. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home with service facility: homecare discharge diagnosis: primary - gastrointestinal bleeding - h. pylori infection - atrial flutter secondary - paroxysmal atrial fibrillation on coumadin - tachy/brady syndrome - pe w/ 6mos anticoag - dvt, pe -> ivc filter - htn - hypercholesterolemia - neuropathy - cervical spondylosis - h/o colon polyps - hemorrhoids - s/p laminectomy l4, l5, superior s1 with decompression of lateral recess and bilateral foramina, l4-5 - failed back surgery syndrome - chronic leg pain discharge condition: good. discharge instructions: please take all your medications as prescribed. we changed your lasix to 20 mg daily. we started you on an antibiotic regimen for h. pylori infection. the course will end after 14 days (). please do not stop your amoxicillin, clarithromycin and protonix before that date. after this course, you will have to take omeprazole 20mg daily. we have stopped your coumadin because of bleeding risk. please discuss with dr. when to restart warfarin. . please go to your follow-up appointments. you will need to check your hematocrit and creatinine when seeing dr. on . . please call your doctor or go to the emergency department if you have nausea with bloody vomiting, black stools, fever >100.4 or any other concerning symptom. followup instructions: provider: 7 pain management center date/time: 10:40 . provider: , m.d. phone: date/time: 1:20 . provider: , .d. phone: date/time: 3:00 . dr. , tuesday 11:30 . dr. 1:00 pm . you will need to schedule a colonoscopy and upper endoscopy in 6 months. please ask dr. for a referral. Procedure: Other endoscopy of small intestine Transfusion of packed cells Transfusion of other serum Diagnoses: Pure hypercholesterolemia Iron deficiency anemia secondary to blood loss (chronic) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Atrial flutter Chronic kidney disease, unspecified Long-term (current) use of anticoagulants Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Barrett's esophagus Helicobacter pylori [H. pylori]

history of present illness: the patient is an 86 year-old portuguese speaking female who was transferred to out hospital from an outside hospital with complaints of chest pain, st elevations, status post thrombolytic therapy with continued pain. the patient was in her usual state of health and was found by her family about 12:00 a.m. on the 9th sitting on the floor vomiting. shortly after that she complained of chest pain that was substernal located in the center of her chest. she denied any shortness of breath. she did note some dizziness earlier in the day of admission. of note, the patient had an episode three months ago of vomiting as well treated with antibiotics. she notes that at that time it was associated with some chest discomfort that was thought to be secondary to the vomiting. at the outside hospital the patient had received tnk, however, she developed recurrence of her chest pain, st elevations and was sent here for a cardiac catheterization. the patient received lasix as well at the outside hospital. review of systems: plus minus lower extremity edema times two months. no fevers or chills, headaches, weight change, diarrhea, dysuria, paroxysmal nocturnal dyspnea or orthopnea. past medical history: 1. hypertension. 2. diabetes. medications: adalat, glucotrol. allergies: no known drug allergies. social history: the patient smoked years ago, lives with her daughter. etoh. the patient ambulates at baseline, but does not exercise routinely. family history: no myocardial infarctions in the patient's parents or siblings. physical examination on admission: blood pressure 124/68. heart rate 66. respiratory rate 18. o2 sat 100% on 4 liters. in general, the patient is sitting forward, vomiting and in discomfort, speaking portuguese only. heent pupils are equal, round and reactive to light and accommodation. extraocular movements intact. oropharynx clear. neck jvd of 8 cm. lungs bibasilar crackles one quarter of the way up bilaterally. cardiovascular regular rate and rhythm. normal s1 and s2. no murmurs, rubs or gallops. abdomen softly distended, positive bowel sounds, nontender, guaiac negative at outside hospital. extremities no clubbing, cyanosis or edema. 2+ peripheral pulses, healing laceration over the right medial ankle. neurological full strength in upper and lower extremities. cranial nerves intact, moving all extremities. laboratory studies on admission: white blood cell count 9.4, hematocrit 40.1, platelets 302, 85% neutrophils, 13% lymphocytes, pt 13.8, ptt 106, inr 1.3, sodium 144, potassium 3.6, chloride 108, bicarb 25, bun 22, creatinine 0.7 and glucose 264. initial ck at our hospital was . at the outside hospital two hours prior was 404 with an mb of 54, mbi of 13.5 and a troponin of 4.28. chest x-ray at the outside hospital was read as congestive heart failure. electrocardiogram initial electrocardiogram at the outside hospital showed st elevations of 4 mm in 2, 3 and avf, st depressions in 1, avl, v2, elevation of v6 and a q in 2, 3 and avf, normal sinus at 100. electrocardiogram here showed normal sinus at a rate of 70, left axis deviation, q in 2, 3, avf, elevation in 2, biphasic t waves in 2, 3, avf and poor r wave progression. hospital course: 1. cardiovascular: coronary artery disease, the patient admitted with imi. transferred from an outside hospital where she received tnk, however, continued to have chest pain and st elevations. on arrival here the patient was chest pain free. she was continued on a nitro and heparin drip and treated with aspirin and lopressor. ace inhibitor was also started. the patient remained chest pain free. she went for cardiac catheterization on at which time she was found to have a 90% lesion in her right coronary artery, which was a dominant vessel. a stent was placed to the right coronary artery. she had diffuse disease in her left anterior descending coronary artery with a 50% mid segment tubular lesion. the d1 had severe diffuse disease with serial 80% lesions, left circumflex was nondominant with a 50% obtuse marginal one mid segment lesion. the patient did well post catheterization. she was treated with plavix. nitro and heparin were weaned off. lopressor and captopril were titrated up to a dose of lopressor 37.5 t.i.d. and captopril 37.5 t.i.d. at the time of discharge. these should be continued to be titrated up for blood pressure less then 140 and then converted to q.d. dosing at rehab. the patient was also started on lipitor 10 and lipids should be followed up as well as liver function tests. her cholesterol was note to be 192 with an ldl of 130 and an hdl of 37. the patient's cks initially were 1016 with an mbi of 18.2 and troponin greater then asa. her second was her peak at 1450 with an mbi of 17 and then her cks trended downwards. the patient did not have any recurrent chest pain or congestive heart failure. of note in the emergency room the patient had a run of ventricular tachycardia that was self limiting and did not recur during her hospital stay. electrolytes were aggressively repleted. the patient was monitored on telemetry and had no further arrhythmias. the patient had an echocardiogram on that showed an ef of 50 to 55%, moderately dilated la, mild left ventricular depression, inferior hypokinesis, mildly thickened aortic valve and 1+ mr. 2. infectious disease: the patient had low grade temperatures during her hospital stay. her urinalysis showed coag negative staph as well as gardnerella vaginalis. she was started on levofloxacin 250 q.d. on the 11th and started on flagyl 500 b.i.d. on the 12th. these should each be continued for one week. her chest x-ray prior to discharge also showed bibasilar atelectasis versus pneumonia. she should continue levo, flagyl for treatment of possible pneumonia as well. 3. endocrine: the patient has diabetes mellitus. she was treated with finger sticks q.i.d. and regular insulin sliding scale while in house. she is on glucotrol at home and this should be resumed at rehab. 4. physical therapy: the patient was seen by physical therapy and recommended for short term rehab. the patient will be discharged to rehab and then to home. discharge diagnoses: 1. status post inferior myocardial infarction. 2. hypertension. 3. diabetes mellitus. discharge medications: plavix 75 mg po q.d. until , aspirin 325 po q.d., protonix 40 po q.d., lipitor 10 mg po q.d., levofloxacin 250 po q.d. until , flagyl 500 po b.i.d. until , lopressor 37.5 po t.i.d., captopril 37.5 po t.i.d. and glucotrol 5 mg po q.d. and insulin sliding scale. please note lopresor and captopril should be titrated up for a goal blood pressure less then 140, and heart rate in the 60s to 70s. this should then be converted to a q.d. dosing of beta blocker and ace inhibitor prior to discharge home. the patient will follow up with cardiologist as well as her primary care physician . . , m.d. dictated by: medquist36 d: 08:13 t: 08:24 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Paroxysmal ventricular tachycardia Acute myocardial infarction of other inferior wall, initial episode of care

allergies: augmentin attending: chief complaint: tachypnea major surgical or invasive procedure: - avr(21mm carpentie magna pericardial), asd closure. - tracheostomy - peg feeding tube placement history of present illness: this 75 year old lady with remarkable past medical history with stage iii lung cancer, treated about 7 years ago with chemo/radio therapy, managed to survive without recurrence of the cancer on recent extensive investigations when she presented with aortic stenosis. her investigation included angiogram and echo which basically showed severe aortic stenosis with calcified tricuspid aortic valve and significant disease in the right coronary artery and also a patent foramen ovale and mild mitral regurgitation. her past medical history as mentioned above includes the lung cancer, stage iii, with also subsequent right sided pleural effusion as well as pericardial effusion for which she had pericardiocentesis in the past. she thoroughly investigated with pet scan, etc to rule out possibility of any secondaries which were all negative. after full discussion, she wanted to go ahead with the surgery. she was electively admitted for aortic valve replacement, coronary artery bypass graft, and patent foramen ovale closure. past medical history: hypercholesterolemia pvd copd right iliac artery disease lung cancer malignant pericardial and pleural effusion pacer maker insitu left carotid endarterectomy hysterectomy pericardial window tonsillectomy mitral regurgitation aortic stenosis pfo cad social history: lives with husband. drinks 2 glasses of wine daily. quit smoking in after 30 pack years. family history: father with stroke. mother with mi. physical exam: hr 62 bp: (r) 169/81 (l) not done gen: nad, thin frail on oxygen skin: multiple spider veins.well healed incisions heent: perrl, eomi, anicteric sclera. op benign neck: no jvd. lungs: decreased breath sounds at base heart: rrr, 3/6 systolic murmur abd: benign ext: warm well perfused neuro: alert, nonfocal. cn iii-xii in tact pertinent results: 03:13am blood wbc-12.1* rbc-3.65* hgb-11.1* hct-33.8* mcv-93 mch-30.5 mchc-32.9 rdw-14.6 plt ct-272 03:13am blood glucose-104 urean-45* creat-1.1 na-146* k-4.5 cl-105 hco3-32 angap-14 03:37am blood alt-119* ast-155* ld(ldh)-368* alkphos-198* amylase-51 totbili-4.5* 03:13am blood calcium-8.7 phos-2.2* mg-2.3 01:20pm blood %hba1c-5.3 -done -done 06:43am blood tsh-7.5* 04:46pm blood cortsol-38.5* 11:48am blood type-art po2-141* pco2-41 ph-7.50* calhco3-33* base xs-8 cxr 1. findings consistent with cardiomegaly and interstitial pulmonary edema. 2. nodular densities within the right upper lobe and volume loss in the right upper lobe. although these findings could be due to prior granulomatous disease, further evaluation is necessary. recommend comparison with prior studies. if no prior studies are available, non-contrast ct of the chest is recommended. 3. two compression fractures of the thoracic vertebral bodies. the acuity of these fractures cannot be determined. clinical correlation recommended. cxr comparison with . in the interval, the dobhoff tube has been removed. there is a large amount of air underneath the diaphragms; a peg tube appears to be in place in the left upper quadrant. the appearance of the lungs is not significantly changed. a right-sided dual lead pacemaker, midline sternotomy wires, staples overlying the heart, a tracheostomy tube, a right internal jugular catheter, are all in place. surrounding osseous structures are unchanged. findings were discussed with at approximately 7:30 p.m., ekg a-v paced rhythm since previous tracing of , paced rhythm now present head ct 1. small areas of hypodensity within the left frontal lobe and right frontoparietal region, as well as within the subcortical white matter and corona radiata bilaterally. these findings are of uncertain significance. no evidence of -white differentiation to suggest a large minor or major vascular territorial infarct is identified, although mr is a more sensitive evaluation for evaluation for acute infarct. the abnormalities described may be further evaluated with mr. 2. mild fluid opacification of the mastoid air cells and mucosal thickening within the sinuses. 02:34am blood wbc-10.1 rbc-3.48* hgb-10.5* hct-31.1* mcv-89 mch-30.0 mchc-33.6 rdw-15.7* plt ct-243 02:34am blood plt ct-243 02:34am blood pt-18.9* ptt-32.9 inr(pt)-2.4 02:34am blood glucose-76 urean-29* creat-0.9 na-134 k-4.2 cl-101 hco3-26 angap-11 02:00am blood alt-71* ast-82* alkphos-206* amylase-92 totbili-1.6* 07:40pm blood ld(ldh)-330* totbili-1.6* dirbili-0.9* indbili-0.7 02:00am blood lipase-118* 02:34am blood calcium-8.6 phos-2.4* mg-1.8 ospital course: mrs. was admitted to the on and taken directly to the operating room where she underwent an aortic valve replacement and an atrial septal defect closure. postoperatively she was taken to the surgical intensive care unit for monitoring. she was noted to have severe facial and neck edema for which diuresis was initiated. her permenant pacemaker was interoggated by the electrophysiology service and reprogrammed. an underlying atrial fibrillation was noted. a heparin induced thrombocytopenia was sent for thrombocytopenia which was negative. on , mrs. was extubated however promptly developed respiratory distress requiring reintubation. the neurology service was consulted for anisocoria. a head ct scan was obtained which showed small areas of hypodensity within the left frontal lobe and right frontoparietal region, as well as within the subcortical white matter and corona radiata bilaterally. her anisocoria subsequently resolved. given her decreased level of consciouseness, the stroke service felt that she liklely experienced a cerebrovascular accident and coumadin should be started when it was safe. the thoracic surgery service was consulted for a tracheostomy. it was decided that she was indeed a candidate for a tracheostomy however given her history of radiation, an open procedure may be best. while changing a central line, mrs. became hypotensive which responded to resuscitation. the electrophysiology service was asked to evaluate her pacemaker which was found to be functioning within normal limits. slight changes were made to her sensing. rate control of her atrial fibrillation was recommended. the physical therapy worked with mrs. daily. on , the thoracic surgery service performed a tracheostomy without complication. a bronchoscopy was later performed which did not reveal significant secretions. the ventilator was slowly weaned to cpap. the speech and swallow service was consulted. as she had not tolerated a passe muir valve, a bedside swallowing evaluation was defferred and a peg feeding tube was recommended. a peg was placed on for long term nutrition needs. mrs. continued to experience episodes of hypotension which responded to pressors. most of her episodes seemed to be related to atrial fibrillation which was aggressively controlled with amiodarone. as she was subtherapeutic on coumadin, heparin was started as a bridge. her neurologic status improved and she was able to move all extremities to commmand. she began to tolerate her tube feeds and continued to improve over the next several days, using her trach collar. cvl was discontinued on and inr was therapeutic 98.0, 95/46, v paced at 81, rr 30 simv, 5 peep, 10 pressure support, 40%, alert, awake and comfortable. trach site c/d/i, rrr, no murmur, lungs cta bilat,sternal incision c/d/i, abdomen has minimal distention, nontender, no c/c/e of extremities, foley cath in place. mrs. continued to make steady progress and was discharged to rehabilitation on . she will follow-up with dr. , her cardiologist and her primary care physician as an outpatient. medications on admission: actonel 35 mg q week lipitor 20 mg daily zetia 10 mg daily toprol xl 50 mg daily digitek 0.25 mg daily ecasa 81 mg daily calcium 600 iu daily black cohosh daily (for night sweats) ntg patch 0.2mg 12 hours daily magnesium/mvi/kcl supplements daily discharge medications: 1. acetaminophen 160 mg/5 ml solution sig: one (1) solution po q4h (every 4 hours) as needed for temperature >38.0. 2. docusate sodium 150 mg/15 ml liquid sig: ten (10) ml po bid (2 times a day). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 5. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 6. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 7. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 10 days. 8. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 10 days. 9. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 weeks: then decrease to 1 tablet daily. 10. vancomycin 1,000 mg recon soln sig: one (1) gm intravenous q 24h (every 24 hours) for 2 weeks. 11. metoclopramide 5 mg/ml solution sig: five (5) mg injection q6h (every 6 hours) as needed for nausea/vomiting. 12. prevacid 30 mg susp,delayed release for recon sig: thirty (30) mg po once a day. 13. lipitor 20 mg po daily 14. zetia 10 mg po daily discharge disposition: extended care facility: & rehab center - discharge diagnosis: aortic stenosis pfo copd respiratory failure cva hyperlipidemia hypertension peripheral vascular disease permenant pacemaker insitu s/p rll stage iiib lung ca with xrt discharge condition: stable discharge instructions: 1) monitor wounds for signs of infection. these included redness, drainage and increased pain. 2) no lotions, creams or powders to wound until it has healed. 3) no lifting more then 10 pounds for 1 month. 4) no driving for 1 month. p instructions: dr. in 4 weeks dr. or dr. 2 weeks. (cardiologist) dr. in weeks. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Open and other replacement of aortic valve with tissue graft Closed [endoscopic] biopsy of bronchus Other and unspecified repair of atrial septal defect Transfusion of packed cells Continuous intra-arterial blood gas monitoring Diagnoses: Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Acute and chronic respiratory failure Hypotension, unspecified Ostium secundum type atrial septal defect Mitral valve insufficiency and aortic valve stenosis Cardiac pacemaker in situ Personal history of irradiation, presenting hazards to health Iatrogenic cerebrovascular infarction or hemorrhage

allergies: augmentin attending: addendum: it was decided that since the patient received 2 weeks of pseudomonas double coverage, that the antibiotics would be discontinued. discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 3. venlafaxine 75 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 5. glutamine 10 g packet sig: one (1) packet po bid (2 times a day). 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 8. epoetin alfa 3,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 9. spironolactone 25 mg tablet sig: two (2) tablet po bid (2 times a day). 10. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 11. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 12. digoxin 125 mcg tablet sig: 0.5 tablet po every other day (every other day): alternate 0.0625 with 0.125 every other day. 13. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 16. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours). 17. morphine 2 mg/ml syringe sig: injection q6h (every 6 hours) as needed. 19. furosemide 10 mg/ml solution sig: two (2) injection (2 times a day). 20. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed): sliding scale printed out. discharge disposition: extended care facility: md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Colonoscopy Reopening of recent laparotomy site Flexible sigmoidoscopy Transfusion of packed cells Transfusion of other serum Closure of gastrostomy Infusion of vasopressor agent Diagnoses: Other postoperative infection Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Iron deficiency anemia secondary to blood loss (chronic) Severe sepsis Chronic airway obstruction, not elsewhere classified Septic shock Pressure ulcer, buttock Heart valve replaced by transplant Pressure ulcer, heel Hyperosmolality and/or hypernatremia Other and unspecified coagulation defects Fitting and adjustment of cardiac pacemaker Other specified peritonitis Mechanical complication of gastrostomy Unspecified hemorrhoids with other complication Attention to tracheostomy

allergies: augmentin attending: chief complaint: abdominal sepsis major surgical or invasive procedure: right femoral cvl placement diagnostic paracentesis exploratory laparotomy right brachial arterial line placement history of present illness: 76f s/p tissue avr & pfo closure , c/b dvt on coumadin as well as respiratory failure requiring tracheostomy & peg placement, who presented from rehab on with fevers, abdominal pain, mental status changes & marked hypotension requiring pressor treatment in the ed. she was previously admitted on with mild abdominal pain, when she was noted to have free abdominal air. however, she was managed conservatively & was tolerating tube feeds prior to discharge on . past medical history: pvd hypertension copd stage iii lung ca, s/p chemo/xrt 7 yrs ago cad atrial fibrillation severe aortic stenosis patent foramen ovale 1+ mitral regurgitation hypercholesterolemia h/o l subclavian vein dvt (on coumadin) s/p tissue avr, pfo closure s/p open tracheostomy s/p peg placement s/p left cea s/p pacemaker insertion s/p thoracentesis & pericardial window for malignant effusions s/p total abdom hysterectomy h/o mrsa infection social history: quit cigs (30 pk yrs) drinks 2 glasses of wine daily lives with her husband family history: noncontributory physical exam: 98.8 81 (av paced) 90/59 (on dopamine gtt) 90% (on vent) alert, +trach rrr, no jvd cta bilat chest site cdi tense abdomen with guarding, no rebound peg site w/o surrounding cellulitis guaiac negative mottled extremities, nonpalpable femoral pulses with faint doppler signals diffuse ecchymotic patches l antecub port site cdi pertinent results: 07:57pm blood wbc-7.1 rbc-3.83* hgb-11.3* hct-34.0* mcv-89 mch-29.5 mchc-33.3 rdw-15.0 plt ct-382 07:57pm blood neuts-55 bands-26* lymphs-7* monos-7 eos-3 baso-0 atyps-0 metas-2* myelos-0 07:57pm blood pt-42.5* ptt-99.4* inr(pt)-11.9 07:57pm blood glucose-74 urean-48* creat-1.5* na-128* k-6.1* cl-94* hco3-23 angap-17 07:57pm blood alt-39 ast-58* alkphos-178* totbili-1.2 amylase-73 lipase-35 ck(cpk)-35, ctropnt-0.55* 08:06pm urine color-yellow appear-cloudy sp -1.015 08:06pm urine blood-lg nitrite-pos protein->300 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-5.5 leuks-mod 08:06pm urine rbc-* wbc-* bacteri-few yeast-none epi-0-2 09:34am ascites totpro-3.5 glucose-1 ld(ldh)-436 amylase-178 totbili-0.9 09:34am ascites wbc-6600* rbc-4000* polys-96* lymphs-0 monos-3* eos-1* 05:00pm blood cortsol-75.4* cultures 8:08 pm blood culture # 2. **final report ** aerobic bottle (final ): reported by phone to at 1620 .. enterococcus faecalis. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s levofloxacin---------- 1 s penicillin------------ 4 s vancomycin------------ <=1 s anaerobic bottle (final ): no growth. 1:31 am blood culture source: line-picc. **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): reported by phone to at 05:39am on . staphylococcus, coagulase negative. isolated from one set only sensitivities performed on request.. abdominal or swab gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): a swab is not the optimal specimen collection to evaluate body fluids. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). pseudomonas aeruginosa. sparse growth. of two colonial morphologies. gram negative rod #2. sparse growth. probable enterococcus. sparse growth. lactobacillus species. sparse growth. corynebacterium species (diphtheroids). rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 8 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s imipenem-------------- <=1 s meropenem------------- 1 s piperacillin---------- 32 s piperacillin/tazo----- 64 s tobramycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. echos tte: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. a bioprosthetic aortic valve prosthesis is present. the gradient was not assessed and the leaflets are not well seen. no aortic regurgitation is seen. the mitral valve leaflets and supporting structures are thickened. at least moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is no pericardial effusion. impression: symmetric left ventricular hypertrophy with low normal systolic function. at least moderate mitral regurgitation. pulmonary artery systolic hypertension. : repeated echo (unchanged, except for only mild mitral regurgitation) radiology ct abdomen: interval development of worsened pulmonary opacities, most pronounced in the right base. this appearance is concerning for aspiration, with note of reflux of oral contrast into the esophagus. interval development of a large amount of ascites throughout the abdomen with decrease in the previously seen free fluid. this may reflect underlying sepsis, chf or low albumin state, particularly given the associated anasarca and edematous changes in the bowel as noted above. us: successful paracentesis. approximately 400 cc of clear yellow fluid were recovered & sent for culture. ct abdomen: 1. no evidence of intra-abdominal abscess. 2. few tubular gas-filled structures within the left liver lobe. it is unclear whether these represent air within the portal venous or biliary system. there is no air within the mesenteric vessels, or loops of intra-abdominal large or small bowel. 3. slight interval increase in right lower lobe consolidation, concerning for worsening aspiration. 4. slight interval increase in bilateral pleural effusions, left greater than right. 5. significant interval decrease in the amount of intra-abdominal ascites. subcutaneous edema persists. brief hospital course: : presented to ed in septic shock. after cvl placed, negative echo & abdominal ct showing new ascites, she was admitted to the sicu for resuscitation and reversal of her supratherapeutic inr. : diagnostic paracentesis showed serous inflammatory ascitic fluid, and the patient was taken for ex lap & abdominal washout. a diffuse inflammatory process awas encountered, but no frank infectious collections were seen. the previously gastrostomy tube was removed & the gastrotomy site was oversewn. she remained in sicu postop, and was weaned off pressors & ventilatory support. her extended sicu course is summarized below according an organ systems. neuro: her pain was controlled with small doses of morphine & her agitation was controlled with ativan & seroquel. cv: echocardiograms showed good cardiac function, with mild mitral regurgitation. initially she required pressors to maintain her blood pressure, but she has been hemodynamically stable for some time. resp: she was maintained on assist control ventilation & at discharge was on with fio2 0.4 & peep . each day, she tolerated about 4 hours of cpap with psv towards the end of her admission. fen/gi: abdominal pain gradually improved after surgery. initial fluid avidity resolved after surgery & she was diuresed down to her baseline weight of 55kg. was fed with impact via nasogastric dobhoff tube. hypernatremia treated with free water boluses. patient had an gi bleed from a hemorrhoid which caused us to stop anticoagulation for l subclavian dvt. heme: inr was reversed with vitamin k & ffp prior to paracentesis. prior to discharge, she was re-anticoagulated with lovenox & coumadin for her l subclavian dvt. anticoagulation was stopped due to gi bleed. id: treated x 2 weeks with vanc/ceftaz/flagyl for her peritonitis. poor creatinine clearance required small dose of vanco (500qd). h/o mrsa infection. vre negative. c diff negative.prior to d/c patient was kept on gent/zosyn for pseudomonas in urine and blood. endo: blood glucose maintained less than 130 with riss. despite low bp, she had an appropriate cortisol response. patient has a r port-a-cath dispo: being discharged to vent rehab. hcp: medications on admission: flovent digoxin 125' lasix 20' kcl amiodarone 100' prevacid lipitor 20' ezetimibe 10' combivent asa 81 reglan vanco coumadin tylenol prn discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 3. venlafaxine 75 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 5. glutamine 10 g packet sig: one (1) packet po bid (2 times a day). 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 8. epoetin alfa 3,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 9. spironolactone 25 mg tablet sig: two (2) tablet po bid (2 times a day). 10. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 11. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 12. digoxin 125 mcg tablet sig: 0.5 tablet po every other day (every other day): alternate 0.0625 with 0.125 every other day. 13. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 15. piperacillin-tazobactam 2.25 g recon soln sig: one (1) recon soln intravenous q6h (every 6 hours). 16. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours). 17. morphine 2 mg/ml syringe sig: injection q6h (every 6 hours) as needed. 18. gentamicin in nacl (iso-osm) 120 mg/100 ml piggyback sig: one (1) intravenous q48h (every 48 hours). 19. furosemide 10 mg/ml solution sig: two (2) injection (2 times a day). 20. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed): sliding scale printed out. discharge disposition: extended care facility: discharge diagnosis: s/p exploratory laparotomy for abdominal washout for chemical peritonitis s/p aortic valve replacement/pfo repair tracheostomy pvd hypertension copd stage iii lung ca, s/p chemo/xrt 7 yrs ago cad atrial fibrillation severe aortic stenosis patent foramen ovale 1+ mitral regurgitation hypercholesterolemia h/o l subclavian vein dvt (on coumadin) s/p tissue avr, pfo closure s/p open tracheostomy s/p peg placement s/p left cea s/p pacemaker insertion s/p thoracentesis & pericardial window for malignant effusions s/p total abdom hysterectomy h/o mrsa infection discharge condition: stable followup instructions: f/u dr. 2 weeks Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Colonoscopy Reopening of recent laparotomy site Flexible sigmoidoscopy Transfusion of packed cells Transfusion of other serum Closure of gastrostomy Infusion of vasopressor agent Diagnoses: Other postoperative infection Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Iron deficiency anemia secondary to blood loss (chronic) Severe sepsis Chronic airway obstruction, not elsewhere classified Septic shock Pressure ulcer, buttock Heart valve replaced by transplant Pressure ulcer, heel Hyperosmolality and/or hypernatremia Other and unspecified coagulation defects Fitting and adjustment of cardiac pacemaker Other specified peritonitis Mechanical complication of gastrostomy Unspecified hemorrhoids with other complication Attention to tracheostomy

allergies: augmentin attending: addendum: pt. is on goal tf and tolerating it well. she has been on coumadin for afib and a clot in her l subclavian vein. her inr was 1.5 today and she was restarted on heparin. discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 2. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 4. amiodarone 200 mg tablet sig: 0.5 tablet po daily (daily). 5. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 6. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 7. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 7 days. 11. potassium chloride 20 meq/50 ml piggyback sig: one (1) intravenous prn (as needed) as needed for k < 4.0. 12. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 13. reglan 10 mg tablet sig: one (1) tablet po four times a day. 14. heparin (porcine) in ns 2 unit/ml parenteral solution sig: four hundred (400) units intravenous per hour: ptt goal 40-60. 15. coumadin 1 mg tablet sig: one (1) tablet po tonight: inr goal 2-2.5. discharge disposition: extended care facility: & rehab center - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Transfusion of packed cells Phlebography of other specified sites using contrast material Diagnoses: Anemia, unspecified Chronic airway obstruction, not elsewhere classified Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Personal history of other diseases of circulatory system Cardiac pacemaker in situ Heart valve replaced by transplant Malignant neoplasm of lower lobe, bronchus or lung Gastrostomy status Tracheostomy status Other specified disorders of peritoneum Nonspecific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum

history of present illness: this is a 76-year-old woman with past medical history significant for aortic stenosis and patent foramen ovale status post atrial septal defect repair and aortic valve replacement in , that presents to the emergency room with complaint of abdominal pain and report of free intraperitoneal air on x-ray at her rehabilitation facility, . briefly, this is a 76-year-old female who has multiple medical problems as described above, including hypercholesterolemia, peripheral vascular disease, chronic obstructive pulmonary disease, and known lung cancer, that was recently discharged 2 days prior to rehabilitation facility after a lengthy hospital course in which she underwent an aortic valve replacement and an atrial septal defect closure. she was taken after this point to the surgical intensive care unit for monitoring, however, had developed respiratory distress that required intubation. she required tracheostomy, as well, during this prior stay and was noted to be doing well at the rehabilitation facility in terms of her respiratory status up to this point. also of note, she also received before her prior discharge a percutaneous endoscopic gastrostomy tube placed by the general surgery service. this was done on , seven days before discharge to the rehabilitation facility. of note, the patient continued to have free intra-abdominal air during her stay in the intensive care unit before her discharge. however, her abdominal pain resolved, and she was able to resume her tube feeds per recommendation of the general surgery service. upon discharge she was sent to the rehabilitation facility, where she was noted to be progressing well until her 3rd day when she noted abdominal pain. at this time a kidney/ureter/bladder x-ray was performed that revealed significant right- and left-sided intraperitoneal free air. the patient was then sent back to the for further evaluation and treatment. past medical history: hypercholesterolemia, peripheral vascular disease, chronic obstructive pulmonary disease, right iliac artery disease, lung cancer, malignant pericardial and pleural effusions, pacemaker in situ, left carotid endarterectomy, hysterectomy, pericardial window, tonsillectomy, mitral regurgitation, aortic stenosis, patent foramen ovale, and coronary artery disease. medications: amiodarone, lipitor, warfarin, furosemide, lansoprazole, digoxin, aspirin, fluconazole, and vancomycin. vancomycin was for a methicillin-resistant staphylococcus aureus that was growing out of her sputum prior to her previous discharge. physical examination on admission: temperature 97.8 f, heart rate 81 in sinus rhythm, blood pressure 148/71, respiratory rate 18, 100 % on room air. she is generally comfortably appearing and is sitting up in bed at this time. her tracheostomy is noted to be in place without drainage or erythema around the site. her lungs are clear to auscultation bilaterally with some coarse breath sounds reported. her incision is noted to be well healed with steri-strips beginning to slough off. there is no drainage or erythema around the sternal wound. her heart is in regular rate and rhythm. without murmurs, rubs, or gallops at this time. her abdomen is noted to be slightly distended with slightly hypoactive bowel sounds. soft. minimally tender throughout. no signs of rebound or guarding at this time. her extremities are warm and well perfused. distal pulses are 2+ with no clubbing, cyanosis, or edema. hospital course: thus, at this time the patient was admitted to the for further evaluation and treatment. this 75-year-old female recently discharged with an aortic valve replacement and atrial septal defect repair was brought back into the hospital for further evaluation of persistent intraperitoneal free air status post percutaneous endoscopic gastrostomy tube placement on , nine days prior to this at readmission. the question at this point was whether there was an active leak from the percutaneous endoscopic gastrostomy tube. a cat scan was performed at this time that revealed no extravasation, though this did not satisfy our curiosity in regard to the possibility of anterior leak of the percutaneous endoscopic gastrostomy tube. the patient was noted to be stable, was afebrile, with a leukocyte count that was within normal limits and unchanged from 5 days previously. the plan at this time was to do a water-soluble contrast study through this peg tube and to assess the patient in the prone position for possible anterior leak. on hospital day #3 the patient began to feel better, with less abdominal pain and less distention at this time. patient continued to remain afebrile and to remain hemodynamically stable. there were no sudden rises in the leukocyte count, as well. the rest of her laboratories was within normal limits. we placed her peg tube to gravity at this time with the plan to have a prone study performed the following day, and to continue to hold tube feeds at this time. in addition, clostridium difficile toxin was sent off which came back negative. it was also notable that the patient was passing gas and having bowel movements at this time. on hospital day #4 the patient continued to progress well and was noted to be comfortable and did receive 1 unit of packed red blood cells at this time for a hematocrit of 25.6, noted to be down from 28 the previous day. the patient then had a follow up portable abdominal x-ray on tuesday, , hospital day #5, that continued to show persistent large amount of free intraperitoneal air. there was retained contrast present in the colon, but there was, again, no sign of any sort of leak at this time. thus, throughout the hospital course there was, at no point, that we could locate a definitive leak of contrast due to the percutaneous endoscopic gastrostomy tube. it was determined that the patient could have her tube feeds resumed. on hospital day #5 these tube feeds were resumed, indeed, and the patient tolerated them well and was slowly increased to her goal rate of 50 ml per hour of probalance with fiber. also at this time, the patient received a picc line on the right side that was placed under interventional radiology due to her presence of a permanent pacemaker on the left side. the patient also had a study of the venous system in the left upper extremity that revealed thrombosis of the left subclavian vein. this venous catheter was removed after the procedure and the port remained in place in the left antebrachial area. then, on hospital day #6, the patient was evaluated again and had been continued on her tube feeds at this time. she was noted to be tolerating these well and was noticeably less distended on examination. she was spending significant amounts of time in her chair and was tolerating a tracheostomy mask at this time with continued plan for her to rest at night on the ventilator. on hospital day #6, it was determined the patient was fit for discharge to rehabilitation facility on continued tube feeds. the patient was to receive 1 more week of vancomycin for positive blood culture and yeast in sputum. the patient was to continue on tracheostomy mask during the day as needed and to be placed on the ventilator as needed at night so that she could rest. fluconazole was not given necessary upon discharge. erving any increasing pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds, or if there are any questions or concerns or signs of any events there untoward. patient to continue on continuous positive airway pressure and pressure support for 12-14 hours a day goal and to receive assist control at night for rest. patient to have international normalized ratio checked daily with goal of 2.0-2.5. patient to receive tube feedings of probalance full strength at 50 ml per hour with checks every 4 hours for residuals, and tube feeds to be held for any residual greater than 100 ml. patient to have an appointment with dr. scheduled upon discharge from rehabilitation facility. discharge diagnoses: 1. intraperitoneal free air in abdomen. 2. status post aortic valve replacement. 3. status post atrial septal defect repair. 4. status post tracheostomy. 5. status post percutaneous endoscopic gastrostomy. 6. status post stage 3 lung cancer treatment. 7. methicillin-resistant staphylococcus aureus of the sputum. 8. aortic stenosis. 9. patent foramen ovale. 10. chronic obstructive pulmonary disease. 11. respiratory failure. 12. cerebrovascular accident. 13. hyperlipidemia. 14. hypertension. 15. peripheral vascular disease. 16. status post permanent pacemaker in situ. 17. status post left port placement . discharge medications: 1. fluticasone 110 mcg 2. actuation aerosol 2 puffs inhalation b.i.d. 3. digoxin 125 mcg tablets 1 tablet p.o. once daily 4. furosemide 20 mg p.o. once daily 5. amiodarone 200 mg 0.5 tablets p.o. once daily for a total of 100 mg per day. 6. lansoprazole 30 mg suspension delayed release 1 p.o. once daily. 7. atorvastatin calcium 20 mg p.o. once daily. 8. azintamide 10 mg p.o. once daily. 9. albuterol ipratropium. 10. actuation 103/18 mcg 6-8 puffs inhalation q.4 hours. 11. aspirin 81 mg chewable p.o. once daily. 12. vancomycin 1 g q.24 hours for 7 days intravenously. 13. potassium chloride 20 meq as needed for potassium less than 4.0. 14. acetaminophen 325 mg 1-2 tablets p.o. q.4-6 hours as needed for pain. disposition: stable and to be discharged to rehabilitation facility, , on . , m.d. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Transfusion of packed cells Phlebography of other specified sites using contrast material Diagnoses: Anemia, unspecified Chronic airway obstruction, not elsewhere classified Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Personal history of other diseases of circulatory system Cardiac pacemaker in situ Heart valve replaced by transplant Malignant neoplasm of lower lobe, bronchus or lung Gastrostomy status Tracheostomy status Other specified disorders of peritoneum Nonspecific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum

history of present illness: this is an 80-year-old male who presented to an outside hospital two days prior to admission complaining of substernal chest pain increasing over a 2-week period which was relieved by sublingual nitroglycerin. he ruled out for a myocardial infarction at the outside hospital and was transferred to for elective cardiac catheterization which showed a left main stenosis of 70 percent, a left circumflex stenosis of 90 to 99 percent, and a rca stenosis of 90 percent at that time and was referred for coronary artery bypass grafting by dr. . . past medical history: coronary artery disease, history of breast cancer, myelodysplasia, benign prostatic hypertrophy, right bundle branch block, hemorrhoids, left ankle dislocation, hypertension, osteoarthritis, hiatal hernia, and glaucoma. allergies: he has no known drug allergies. medications on admission: norvasc 5 mg once daily, atenolol 25 mg once daily, imdur 30 mg once daily, neurontin 900 mg once daily, allopurinol 300 mg once daily, lipitor 20 mg once daily, folic acid 1 mg once daily, doxazosin 4 mg once daily, alphagan eye drops 0.15 percent 1 drop right eye twice daily, timolol 0.5 percent 1 drop right eye in the morning, and aspirin 81 mg once daily. social history: the patient lives with his wife in . a positive history of tobacco (60-pack-year); quit 30 years prior and denies alcohol use or abuse. physical examination on presentation: the temperature was 97.5, the heart rate was 65, the blood pressure was 164/68, the respiratory rate was 20, and oxygen saturation was 96 percent on room air. neurologically, alert and oriented times three. in no acute distress. the neck was supple without bruits. cardiac examination revealed a regular rate and rhythm without murmurs, rubs, or gallops. no jugular venous distention noted. the lungs were clear to auscultation bilaterally. gastrointestinal examination revealed soft, positive bowel sounds, nontender, and nondistended. extremities revealed right groin catheterization site without hematoma. distal dorsalis pedis and posterior tibial pulses palpable. preoperative laboratory data: white blood cell count was 15.2, hematocrit was 44.8, and platelets were 143. sodium was 138, potassium was 3.7, chloride was 102, bicarbonate was 29, blood urea nitrogen was 13, creatinine was 0.9, and glucose was 111. negative urinalysis preoperatively. summary of hospital course: the patient was admitted on and found to have 3-vessel disease by cardiac catheterization. he was worked up for coronary artery bypass grafting. on he proceeded to the operating room with dr. . and underwent coronary artery bypass grafting times four with a lima to the lad, a saphenous vein graft to the ramus, a saphenous vein graft to the pl, and a saphenous vein graft to the pda. once the case was completed he was noted to have an increased amount of bleeding. he was reopened and re-explored in the operating room. he also received multiple blood products in the operating room. please see the operative note for complete details. he was transferred to the cardiac surgery recovery room on the evening of , a-paced at a rate of 70 on a neo-synephrine drip. on postoperative day one, he continued on a ventilator, unable to wean, with a chest x-ray showing a left-sided fluid collection. he already had mediastinal and left anterior chest tubes. therefore, a left posterior chest tube was placed with a fair amount of sanguineous drainage removed. on postoperative day two, his respiratory status improved but he still required ventilatory support and was not extubated. he was also noted to have a significantly elevated white blood cell count up to 60, and a hematology consultation was obtained. the hematology service had no big recommendations as to the source or treatment of the elevated white blood cell count, and by postoperative day three his white count had decreased to 24. on postoperative day three, mr. respiratory status improved; however, thick green sputum was suctioned from his endotracheal tube and sent for cultures. in the afternoon, he was weaned and successfully extubated. his chest tube drainage significantly decreased, and all of his chest tubes were also removed. on the evening between postoperative days three and four, mr. had some atrial fibrillation for which he was started on amiodarone and beta blockade; which he subsequently converted to a normal sinus rhythm. also on postoperative day four, he was found to be recovering well and safe for transfer to the inpatient floor for further recovery and rehabilitation. on postoperative day five, mr. had additional bursts of rapid atrial fibrillation; treated with intravenous lopressor as well as his oral amiodarone and lopressor doses. it was decided that he should be anticoagulated and was started on a heparin drip and oral coumadin. his cardiac pacing wires were also removed on postoperative day five. mr. continued to have coarse lungs with a productive cough; however, his sputum changed to yellow and no infection has been identified. on postoperative day six, he was noted to have some serous sternal drainage treated with betadine swabs and dry sterile dressing. on postoperative day seven, mr. was noted to have a continued scant amount of serous drainage from his sternal incision. he had an elevated white count up to 33, and he was therefore started on vancomycin intravenously, and a picc line was placed for potential long-term antibiotic administration. on postoperative day nine, mr. inr was elevated to 1.9; at which time his heparin drip was discontinued and he continued on his oral coumadin. his sternal drainage on postoperative days nine and ten was also noted to be significantly decreased. it was decided that he would continue on the vancomycin. mr. was followed by physical therapy throughout his hospital course, and it was decided that he was not safe for home and should continue with physical therapy and rehabilitation at a rehabilitation facility. he will be discharged to rehabilitation on . condition on discharge: stable. discharge status: to rehabilitation. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting. 3. benign prostatic hypertrophy. 4. atrial fibrillation. 5. sternal drainage. medications on admission: 1. allopurinol 300 mg once daily. 2. amiodarone 400 mg twice daily. 3. amlodipine 5 mg once daily. 4. aspirin 81 mg once daily. 5. lipitor 20 mg once daily. 6. colace 100 mg twice daily. 7. lasix 20 mg p.o. twice daily. 8. neurontin 600 mg twice daily. 9. metoprolol 25 mg p.o. twice daily. 10. potassium chloride 20 meq p.o. twice daily. 11. zantac 150 mg p.o. twice daily. 12. vancomycin 1 gram iv twice daily. 13. coumadin (to be dosed per inr). 14. levofloxacin 500 mg p.o. once daily. 15. percocet as needed (for pain). discharge follow-up plans: the patient should make an appointment with dr. . within four to six weeks. the patient should also make an appointment with dr. within one to two weeks as well as an appointment with his cardiologist within one to two weeks. , Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Reopening of recent thoracotomy site Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of breast Unspecified glaucoma Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hemorrhage complicating a procedure Right bundle branch block Osteoarthrosis, unspecified whether generalized or localized, site unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest discomfort, dizziness, blask stool major surgical or invasive procedure: egd history of present illness: 80 yo m with cad s/p cabg on coumadin for afib (post-surgical)presents with to ed from rehab with evidence of ugib. * pt was discharged from to rehab and was doing well. it appears that he was treated for ? of incisional infection with diclox. on the evening of , pt c/o diaphoresis, nausous and a chest discomfort that felt different than his anginal equivalent and transferred to for further eval. on arrival pt reports black stools for 2-3 days. he denied hematemsis, however in the ed witnessed coffee-ground emesis. ngt was place and hematemsis did not clear to 500cc ng lavage. * in ed vs 96.2, hr 84, bp 118/60. initial hct 24.1 and inr 2.7. two 16-ga ivs placed in right arm. given anzimet, protonix, 2uprbc, 3uffp, vitamin k 5mgsubq. after 2uprbc, hct remained 23.5, so pt admitted to micu for further ebvaluation. * of note during recent admission for cabg, his admission hct was 44.8 to 25 post-op on . was transfused 3 units on and hct went from 24 to 30.6 but then trended down to mid20s and was 27 on the day of discharge to rehab. past medical history: 1. cad: s/p cabgx 4 on . normal ef. 2. breast cancer s/p right mastectomy 3. afib on coumadin 4. oa 5. hiatal hernnia 6. glaucoma 7. hyperlipidemia 8. htn 9. myelodysplastic syndrome w/ leukocytosis recently social history: the patient lives with his wife in , but currently in rehab post cabg. a positive history of tobacco (60-pack-year); quit 30 years prior and denies alcohol use or abuse. family history: nc physical exam: vs: 96.2, 84, 118/60, 22 99%2l pe: gen-obese, pale man in nad heent-perrl, eomi, op wnl, dry mm neck-supple, no jvd cvs-rrr, nl s1/s2, no m/r/g chest-ctab; sternotomy wound c/d/i abd-soft, nt, nd, nabs, no hsm ext-1+ pedal edema neuro-a&o3, cns intact, strength 5/5 pertinent results: 02:00am blood wbc-14.9* rbc-2.53* hgb-7.3* hct-24.1* mcv-95 mch-29.0 mchc-30.4* rdw-17.8* plt ct-207 06:30pm blood wbc-21.8* rbc-2.57* hgb-7.5* hct-22.9* mcv-89 mch-29.4 mchc-32.9 rdw-19.8* plt ct-167 02:11am blood wbc-16.6* rbc-3.06* hgb-9.0* hct-26.6* mcv-87 mch-29.4 mchc-33.9 rdw-18.9* plt ct-155 06:17am blood hct-26.3* 12:45pm blood wbc-15.0* rbc-3.38* hgb-10.3* hct-31.0* mcv-92 mch-30.4 mchc-33.1 rdw-19.0* plt ct-129* 10:50am blood wbc-16.0* rbc-3.65* hgb-11.4* hct-33.0* mcv-90 mch-31.1 mchc-34.4 rdw-18.7* plt ct-119* 02:00am blood neuts-70 bands-0 lymphs-7* monos-14* eos-2 baso-2 atyps-1* metas-3* myelos-1* 11:40am blood neuts-70 bands-3 lymphs-8* monos-18* eos-0 baso-0 atyps-0 metas-0 myelos-1* 02:00am blood pt-20.5* ptt-30.5 inr(pt)-2.7 06:30pm blood pt-17.2* ptt-27.2 inr(pt)-1.9 10:50am blood pt-14.5* ptt-26.4 inr(pt)-1.3 02:00am blood glucose-132* urean-52* creat-1.0 na-139 k-4.6 cl-105 hco3-28 angap-11 12:45pm blood glucose-215* urean-23* creat-1.0 na-138 k-3.5 cl-107 hco3-25 angap-10 10:50am blood urean-17 creat-0.9 k-3.4 02:00am blood ck(cpk)-22* 11:40am blood ck(cpk)-23* 06:30pm blood ck(cpk)-27* 02:11am blood ck(cpk)-20* 02:00am blood ctropnt-<0.01 11:40am blood ctropnt-<0.01 06:30pm blood ck-mb-notdone ctropnt-<0.01 02:11am blood ck-mb-notdone ctropnt-<0.01 02:11am blood calcium-8.7 phos-3.4 mg-1.8 cxr: 1) stable cardiomegaly without evidence of congestive heart failure. 2) small right pleural effusion. left costophrenic angle excluded from the study. 3) no focal consolidations left base atelectasis without definite pneumonia. no chf. egd: 8mm bleeding ulcer in body of stomach. hemostasis achieved with epi and bicap brief hospital course: 80 yo m with cad s/p cabg (), af on coumadin, mds with recent leukocytosis p/w melena, ugib. 1) ugib: pt presents to ed with melena and hematesis in setting of coumadin use. in , pt given ivf along with 2 u prbcs. inr was reversed with 5mg vit k sq and ffp given since pt was actively bleeding. pt with minimal response to 3 total units of prbcs. gastroenterology service consulted who proceeded with egd that evening in the micu. a 8 mm bleeding ulcer in the body of the stomach was found. after application of epinephrine and bicap, hemostasis was acheived. pt remained hd stable throughout. pt recieved a total of 5 units of prbc in first 24 hours and hct stabilized. pt placed on bowel rest, protonix iv started and cardiac medications held. serial hct checked and on hd#2 pt stable for transfer from micu to general medicine floor. diet advanced slowly and diet advanced as tolerated. hct responded to previous transfusions and hct maintained above 28. upon discharge, egd bx returned being positive for h.pylori. pt to be discharged home on protonix, tetracycline and flagy (times 2 weeks); did not choose biaxin due to interactions with amiodarone. pt to follow up with dr on for repeat egd. 2) afib: pt with hisory of af post cabg for which he was placed on amio and coumadin with proper anticoagulation. on presentation, inr 2.5 and reversed with a total of 10mg vitk sq and at discharge was 1.2. pt to not continue taking coumadin upon discharge. pt as outpatient on amiodarone, and will continue after discharge. unsure as to plan for total length of treatment for post-cabg af with amio. pt to follow up with dr at which time, it should be addressed. 3) cad: pt with cad s/p cabg () who presents from rehab with ugib. as above asa and bb held. once pt stabilized lopressor was restarted and pt tolerated it well. pt to stop taking asa, until decision is made to restart post follow-up egd. because of chest discomfort pain, pt was ruled out for mi by cardiac enzymes. pt maintained on tele without event. pt to follow up with ct- dr on wed , to asses sternotomy wound and post cabg f/u. pt to be discharged home on atenolol 25 mg daily. pt should benefit from acei, and will be s/c home on low dose lisinopril. pt will need repeat chemistry checked as outpatient. 4) htn: pt with h/o htn for which he was on amlodopine. ccb held during stay because of ugib. pt remained relatively normotensive. decision made for pt to discontinue ccb until evaluated by pcp or cardiologist. pt to follow up with dr on tuesday . at which point, home medical regimen should be reviewed. 5) chf: no documented of chf by cath results (ef60%). however pt has not had an echo. pt maintened on home regimen of lasix 20 mg daily, for which he will be discharged on. pt without evidence of decompensated chf during stay. pt should benefit from acei, and will be s/c home on low dose lisinopril. 6) dipso: pt seen by pt while in hospital. they felt he was no longer in need for acute rehab. he is being discharged home with services, including pt and cardiac rehab. medications on admission: asa 81 coumadin 3 amio 400 amlodopine 5 lopressor 25 lasix 20 qd doxazosin 2 qd lipitor 29 colace percocet prn neurontin 600 allopurinol timolol discharge medications: 1. gabapentin 300 mg capsule sig: two (2) capsule po bid (2 times a day). :*120 capsule(s)* refills:*2* 2. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 3. amiodarone hcl 200 mg tablet sig: two (2) tablet po daily (daily). :*30 tablet(s)* refills:*0* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day: take until told otherwise by doctor. :*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 6. brimonidine tartrate 0.15 % drops sig: one (1) drop ophthalmic (2 times a day). 7. atenolol 25 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 8. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 9. doxazosin mesylate 2 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 10. colace 100 mg capsule sig: one (1) capsule po twice a day. :*60 capsule(s)* refills:*2* 11. lasix 20 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 12. lipitor 20 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 13. flagyl 250 mg tablet sig: one (1) tablet po four times a day for 2 weeks. :*56 tablet(s)* refills:*0* 14. tetracycline hcl 500 mg capsule sig: one (1) capsule po four times a day for 2 weeks. :*56 capsule(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: upper gi bleed peptic ulcer disease h. pylori coronary artery disease discharge condition: good discharge instructions: please take all medications as prescribed. you will no longer take aspirin, coumadin or amlodopine. you may restart taking aspirin after you've had a follow up egd to look at your ulcer and tald you may restart it. please attend all follow-up appointments, if unable rechedule as soon as possible. please call your pcp or go to ed if: fever >101.4, chest pain, shortness of breath, dizziness, persistent vomitting or diarrhea, black stool, vomit with "coffe grounds" (black particles), or blood in stool or vomit. followup instructions: 1) please follow up with your pcp, (), on tuesday at 11:00 am. 2) please follow up with your cardiothoracic surgeon, dr. . () wednesday at 1:30 at . . call with questions. 3) please follow up with dr to have a repeat egd to evaluate your stomach ulcer, on at 9:00 am. provider: west,room four gi rooms where: gi rooms date/time: 9:00 provider: , procedures endoscopy suites where: building (/ complex) endoscopy suite phone: date/time: 9:00 Procedure: Insertion of other (naso-)gastric tube Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of malignant neoplasm of breast Unspecified glaucoma Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Diaphragmatic hernia without mention of obstruction or gangrene Osteoarthrosis, unspecified whether generalized or localized, site unspecified Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Helicobacter pylori [H. pylori]

past medical history: history was notable for the following: 1. osteoarthritis. 2. left sided breast cancer. 3. diverticulitis. 4. gastrointestinal bleed. 5. fibromyalgia. medications on admission: 1. coumadin. 2. vistaril. 3. .................... 4. tamoxifen. 5. zoloft. 6. protonix. 7. ditropan. 8. . 9. lasix. allergies: the patient is allergic to sulfa and ibuprofen. social history: the patient has no history of alcohol, drugs, or smoking. physical examination: on presentation, the patient's physical examination revealed the following: temperature 100.3, heart rate 109, blood pressure 149/74, respiratory rate 18, oxygen saturation 97%. she was ill-appearing on presentation with a diffusely tender abdomen with positive rebound and no guarding. stool was guaiac negative. hospital course: the patient was then admitted medical service initially for management of her presumed c. difficile colitis. the patient was admitted to the medical service postoperatively and then was noted to have pleural effusion and then underwent a thoracocentesis of her effusion. on the 14th, the patient continued to have poor hospital course and on due to difficult medical management of the disease, surgical consultation was obtained and the patient underwent a subtotal colectomy with ileostomy. regarding the patient's operation, please referred to dr. operative note on . postoperatively, the patient was taken to the medical intensive care unit for further management of her disease. she underwent numerous transfusion of fresh-frozen plasma. the patient was continued to be intubated. the patient was managed in the medical intensive care unit with bilateral chest tubes placed while the patient was in the medical intensive care unit. the patient continued to have high fevers. sputum culture from demonstrated methicillin-resistant staphylococcus aureus and transthoracic cardiac echocardiogram demonstrated no pericardial effusion or no obvious vegetations, while the patient continued to have these fevers. the patient was continued on vancomycin and continued to be intubated for a long period of time until when the patient was extubated successfully. post extubation, the patient had difficulty with her voice and swallowing, and she was deemed an aspiration risk, so dobbhoff was placed. she was then transferred to the floor and she continued to do well. chest tubes were removed, and she stopped having fevers. physical therapy consultation was obtained and the patient began to improved dramatically while on the floor. she remained afebrile with stable vital signs with reasonable respiratory parameters, and she was continued on tube feeds or promote with fiber at a goal rate of 70 cc per hour. the patient will be discharged to a rehabilitation facility on the following regimen: 1. lopressor 50 mg po t.i.d. 2. ambien 10 mg po q.h.s. 3. vancomycin 1 gram q.d. 4. heparin 5000 units subcutaneously b.i.d. 5. regular insulin sliding scale. 6. protonix 40 mg iv q.d. 7. the patient will continue on her tube feeds, promote with fiber at 70 cc an hour. follow-up care: the patient will followup with dr. in one to two weeks. the patient will followup with her primary care physician at the time deemed appropriate by their office. of note: portions of this chart were not available during this dictation. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage 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 Thoracentesis Other and unspecified partial excision of large intestine Temporary ileostomy Pulmonary artery wedge monitoring Diagnoses: Acidosis Acute and subacute necrosis of liver Methicillin susceptible Staphylococcus aureus septicemia Hypopotassemia Other shock without mention of trauma Other emphysema Methicillin susceptible pneumonia due to Staphylococcus aureus Acute vascular insufficiency of intestine Knee joint replacement

technique: helically aquired contiguous axial images were obtained from lung bases to pubic symphysis after the administration of 150 cc of optiray contrast. optiray was used per history of allergies. no prior studies available for comparison. ct abdomen with iv contrast: a large right pleural effusion and a moderate left pleural effusion are present. there is associated collapse and consolidation of the posterior segment of the right lower lobe and minimal atelectasis of the left lower lobe. a round nonenhancing focus in the medial left hepatic lobe and anterior right hepatic lobe are consistent with simple hepatic cysts. no other hepatic abnormalities are identified. the gallbladder, spleen, pancreas, adrenal glands, kidneys, and upper ureters are normal in appearance. a small amount of fluid is noted to be tracking around the liver and spleen. the visualized loops of opacified small bowel are normal. the contrast opacified colon is noted to have thickened wall with adjacent fat stranding along its entire length. several diverticula are noted in the region of the splenic and hepatic flexures. several nonpathologically enlarged retroperitoneal lymph nodes are seen. there is no mesenteric lymphadenopathy. there is no free air in the abdomen. scattered calcifications are noted in the abdominal aorta but none are present at the takeoff of the celiac axis, sma, or . ct pelvis with iv contrast: again, all visualized loops of colon are noted to have a thickened wall. associated fat stranding is not as notable in the pelvis as it is in the upper abdomen. multiple diverticula are noted along the sigmoid colon. free fluid is noted around the cecum. the appendix is not visualized. multiple phleboliths are noted in the deep pelvis. the urinary bladder outline is within normal limits. no inguinal or deep pelvic lymphadenopathy. bone windows: no suspicious lytic or sclerotic osseous lesions are seen. mild degenerative changes are noted in the lumbar spine. (over) 1:48 am ct abdomen w/contrast; ct pelvis w/contrast clip # ct 150cc nonionic contrast; ct reconstruction reason: r/o toxic megacolon, mesenteric ischemia, colitis, abscess field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) coronal reformations confirm the above described findings. impression: 1) diffuse wall thickening of the entire colon with adjacent stranding most notable in the region of the splenic flexure and ascending colon. a small amount of ascites is also present. there is no evidence of abscess or megacolon. these findings are consistent with pancolitis and consistent with patient's known history of c difficile. given that there is no obstruction to flow into the sma or , this is unlikely to represent occlussive ischemic colitis. 2) large right pleural effusion with associated collapse and consolidation of the posterior right lower lobe. moderate left pleural effusion with associated atelectasis of the adjacent lung. 3) two simple hepatic cysts are noted. Procedure: Insertion of intercostal catheter for drainage 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 Thoracentesis Other and unspecified partial excision of large intestine Temporary ileostomy Pulmonary artery wedge monitoring Diagnoses: Acidosis Acute and subacute necrosis of liver Methicillin susceptible Staphylococcus aureus septicemia Hypopotassemia Other shock without mention of trauma Other emphysema Methicillin susceptible pneumonia due to Staphylococcus aureus Acute vascular insufficiency of intestine Knee joint replacement

allergies: bactrim / daypro attending: chief complaint: incidental finding of thoracic aortic anuerysm major surgical or invasive procedure: total aortic arch replacement, reimplantation of cephalic vessels history of present illness: incidental finding of ascending aortic aneurysm on ct scan obtained s/p fall. past medical history: familial thrombocytopenia hiatal hernia gerd htn osteoporosis r shoulder replacement colonic polyps removal cataract surgery social history: lives with husband. retired. denies tobacco use, rare etoh. family history: cousin died of anuerysm at age 65. mother with chf physical exam: 81yo in chair nad, hoarse neuro aa&ox3, nonfocal chest ctab resp unlab median sternotomy stable, c/d/i no d/c, rrr no m/r/g chest tubes and epicardial wires removed. abd s/nt/nd/bs+ ext warm with trace edema pertinent results: 06:10am blood wbc-9.8 rbc-4.55 hgb-13.2 hct-38.6 mcv-85 mch-29.0 mchc-34.2 rdw-14.9 plt ct-169 06:10am blood pt-23.4* ptt-24.8 inr(pt)-2.3* 07:00am blood glucose-93 urean-26* creat-0.7 na-143 k-3.9 cl-105 hco3-25 angap-17 radiology final report chest (portable ap) 10:31 am chest (portable ap) reason: assess for ptx or effusion medical condition: 81 year old woman with s/p replacement of asc aorta and arch and ct removal reason for this examination: assess for ptx or effusion portable chest comparison: . indication: chest tube removal. evaluate for pneumothorax. there has been interval slight decrease in size of a loculated left apical hydropneumothorax. small small-to-moderate left pleural effusion is probably unchanged allowing for positional differences. cardiac and mediastinal contours are stable. poorly defined right mid lung zone opacity and focal linear right basilar opacity are without change. there is a questionable small right pleural effusion. impression: slight decrease in size of loculated left apical hydropneumothorax. dr. approved: mon 2:17 pm cardiology report echo study date of patient/test information: indication: intra op tee for resection of ascending aortic aneurysm height: (in) 60 weight (lb): 130 bsa (m2): 1.56 m2 bp (mm hg): 167/56 hr (bpm): 57 status: inpatient date/time: at 11:31 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2006aw590-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: aorta - ascending: *5.3 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.2 m/sec (nl <= 2.0 m/sec) interpretation: findings: left atrium: normal la size. right atrium/interatrial septum: normal ra size. no asd by 2d or color doppler. left ventricle: normal lv wall thickness. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. mild regional lv systolic dysfunction. mildly depressed lvef. no resting lvot gradient. lv wall motion: regional lv wall motion abnormalities include: mid inferior - hypo; right ventricle: normal rv chamber size and free wall motion. aorta: mildly dilated aortic root. markedly dilated ascending aorta. moderately dilated descending aorta aortic valve: three aortic valve leaflets. mildly thickened aortic valve leaflets. no as. mild to moderate (+) ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: mild tr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the procedure. the patient appears to be in sinus rhythm. results were personally conclusions: pre bypass limited view of the heart from upper esophageal views. lv function assessed from transgastric views. the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is mild regional left ventricular systolic dysfunction. the inferior wall of the lv is mildly hypokinetic. overall left ventricular systolic function is mildly depressed. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. the ascending aorta is markedly dilated the descending thoracic aorta is moderately dilated. there is a thrombus seen in the descending aorta at the level of the left subclavian take off. the aorta at this level measures 4.3 cm. there is a well formed sinotubular junction and it measures 2.8 cm. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the views of the mitral valve was very limited because the aortic aneurysm was distorting the anatomy. there is no pericardial effusion. post bypass lv function much the same. however rv function is moderately depressed globally. somewhat better with a bolus of milrinone and epinephrine. graft seen in the ascending aorta, arch and descending aorta. 1+ aortic insuffciency present at the end of the procedure. electronically signed by , md on 15:35. physician: brief hospital course: mrs. was admitted to the on for further management of her ascending aortic anuerysm. she was taken to the catheterization lab where she was found to have moderate lad disease. given the severity of her disease, the cardiac surgical service was consulted for surgical repair of her aorta. she was worked-up in the usual preoperative manner including an echocardiogram which revealed trace aortic insufficiency, 1+ mitral regurgitation, 2+ aortic insufficincy. on , mrs. was taken to the operating room. she underwent a total arch replacement with reimplatation of cephalic vessels. postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. on postoperative day one, she awoke neurologically intact and was extubated. a bedside swallow evaluation was obtained for oral and pharyngeal dysphagia which was inconclusive. ent was consulted and determined that she had paresis of her left true vocal cord. beta blockade and aspirin were resumed. she was gently diuresed towards her preoperative weight. on pod 2 her pressors were weaned, chest tubes were removed. beta blockade and aspirin were resumed. she was gently diuresed towards her preoperative weight. on pod 3 the ep service was consulted regarding her remaining pacemaker dependent in heart block. the physical therapy service was consulted to assist with her postoperative strength and mobility. on pod 5 mrs. was reintubated with insertion of chest tubes for pleural effusions. on pod 6 she had a ppm implanted. she continued to have post operative atrial fibrillation for which anticoagulation was started. on pod her chest tubes were again removed, and a video swallow was performed that did show her left vocal cord paresis. her epicardial pacing wires were removed without incident. on pod 9 she had decreased urine output which was responsive to fluid boluses. on pod 13 her sternotomy incision was clean, dry, and intact without evidence of infection. she was discharged to an extended care facility on pod 13 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with her pcp and cardiologist in 2 weeks. she will follow up with dr. in two weeks. medications on admission: cozaar 50' hctz 25' atenolol 50' fosamax 70qweek 180 citracal mvi discharge medications: 1. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours). disp:*60 packet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*60 tablet(s)* refills:*0* 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. disp:*qs ml(s)* refills:*0* 6. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). disp:*qs qs* refills:*2* 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*qs qs* refills:*2* 8. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. furosemide 20 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 12. warfarin 1 mg tablet sig: 1-2 tablets po daily (daily): dosage will vary based on inr. disp:*60 tablet(s)* refills:*2* 13. alprazolam 0.25 mg tablet sig: 1-2 tablets po qhs (once a day (at bedtime)) as needed. disp:*60 tablet(s)* refills:*0* 14. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*90 tablet(s)* refills:*0* discharge disposition: extended care facility: nursing center - discharge diagnosis: ascending aortic anuerysm thrombocytonpenia-familial hiatal hernia gerd htn osteoporosis discharge condition: good discharge instructions: shower, wash incisions with mild soap and water and pat dry. no lotions, creams or powders to incisions. call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. no lifting more than 10 pounds for 10 weeks. no driving until follow up with surgeon. followup instructions: dr. in two weeks, dr. in one week, dr. , ent in two weeks, ep device clinic phone: date/time: 11:00 Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Resection of vessel with replacement, thoracic vessels Other repair of vessel Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified pleural effusion Unspecified essential hypertension Thoracic aneurysm without mention of rupture Cardiac complications, not elsewhere classified Diaphragmatic hernia without mention of obstruction or gangrene Atrioventricular block, complete Osteoporosis, unspecified Poisoning by tetracycline group Poisoning by chloral hydrate group

discharge status: the patient will be discharged to rehabilitation. discharge diagnosis: 1. chronic obstructive pulmonary disease exacerbation. 2. av fistula. 3. c-difficile infection. 4. gastrointestinal bleed. 5. recurrent deep venous thromboses and pulmonary emboli. 6. right upper lobe opacity. 7. paroxysmal atrial fibrillation. 8. thrombocytopenia. discharge medications: fluticasone 110 mcg 4 puffs inh b.i.d., combivent 1-2 puffs inh q.6 hours, albuterol 1-2 puffs q.2-4 hours p.r.n., tylenol 325 mg tab p.o. q.4-6 hours p.r.n., pantoprazole 40 mg p.o. b.i.d., cillium 58.6% 1 packet p.o. b.i.d., flagyl 500 mg p.o. t.i.d. x 14 days total, albuterol 1 neb q.4 hours plus q.2 hours p.r.n., prednisone 10 mg p.o. q.d. x 7 days, then 5 mg p.o. q.d. x 14 days, and this should not be stopped until reassessment by dr. , furosemide 20 mg p.o. q.d., ipratropium 1 neb inh q.4-6 hours plus q.2 hours p.r.n. follow-up: 1. the patient is to follow-up with dr. on :30 a.m. his new primary care physician. 2. the patient is to follow-up with dr. of vascular surgery on . 3. the patient is to have a right femoral ultrasound on , 11 a.m. to follow his av fistula. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of other therapeutic or prophylactic substance Colonoscopy Transfusion of packed cells Transfusion of other serum Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Acute posthemorrhagic anemia Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Hematoma complicating a procedure Intestinal infection due to Clostridium difficile Rupture of artery

history of present illness: mr. is an 82-year-old male admitted to the medical intensive care unit for gastrointestinal bleed, hypotension. this gentlemen was recently admitted one month ago for chronic obstructive pulmonary disease flare, deep vein thrombosis and pulmonary embolus and was discharged to where he was noted today on the day of admission to have 300 cc of bright red blood per rectum and hypotension systolic in the 80s. he had been started on lovenox in the hospital and on coumadin prior to being discharged for his venous thromboembolic disease. his last documented inr was 2.6 two days prior to admission. patient denied any fevers, abdominal pain, nausea or vomiting, chest pain, shortness of breath, dizziness or lightheadedness. he has never had gastrointestinal bleeds in the past. past medical history: 1. recent deep vein thrombosis/pe and discharged for same condition on . he also has a remote deep vein thrombosis several years ago. 2. chronic obstructive pulmonary disease on two liters of home 02 at night. never intubated, and not on chronic steroids, however, is frequently on steroid tapers. he is also status post blood resection. 3. hypertension. 4. prior cva with right-sided weakness. 5. benign prostatic hypertrophy. 6. osteoporosis. 7. a neuropathy. 8. status post appendectomy. 9. ventricular ectopy and nonsustained ventricular tachycardia and he did have an echocardiogram in showing an ejection fraction of 50%. 10. right upper lobe mass seen on ct on the most recent admission and also noticed on chest x-ray of this admission whose cause is unknown, but is most likely felt to be malignant in nature. medications: 1. prednisone 20 mg q.d. on taper. 2. lansoprazole. 3. aspirin. 4. zestril. 5. finasteride. 6. senna. 7. coumadin. 8. fosamax. 9. lasix. 10. albuterol. 11. atrovent mdis. 12. flovent. allergies: patient denies any medical allergies. social history: he lives with his wife of 40 years and he quit smoking 30 years ago after an extensive pack year history. he is a retired lawyer in the area. hospital course: in the emergency room, the patient was hypotensive in the 80s systolic range. a femoral groin line was placed and he was resuscitated with normal saline 4 units of fresh frozen plasma and four units of packed red blood cells. nasogastric lavage revealed small amount of coffee ground material and a small bright red clot which cleared with less than 500 cc normal saline. in the emergency department, he also received treatment for hypercalcemia in the setting of his ectopy seen on monitor. echocardiogram was obtained which showed st depressions in the lateral segments and a chest x-ray revealed no pulmonary edema, persistence of the right upper lobe mass and flattened diaphragm. chest x-ray was repeated after fluid resuscitation and remained unchanged. upon medical intensive care unit evaluation, physical examination showed a temperature of 97. heart rate of 120 with frequent premature ventricular contractions. blood pressure 170/87. respiratory rate of 24. oxygen saturation 100% on three liters per minute. generally, she was tachypneic with retractions and using accessory muscles with copious upper airway secretions. head, eyes, ears, nose and throat: significant for conjunctival pallor. pupils equal, round and reactive to light. extraocular movements intact. neck was supple without any lymphadenopathy and difficult to assess the jugular venous pressure due to the retractions. there was no thyromegaly. cardiovascular was tachycardic without murmurs, rubs or gallops. lungs were extraordinarily decreased breath sounds with expiratory wheezing, no crackles were noted. abdomen was soft, nontender, with hyperactive bowel sounds and no hepatosplenomegaly. the rectal exam was deferred secondary to the perfuse amounts of maroon stool seen in his exam. his extremities were without edema, warm and without palpable pulses in the feet. laboratory values: significant for a hematocrit of 41, which subsequently decreased to 21 after intravenous fluid resuscitation and a white blood cell count of 21.7. potassium is 6.4. coags were unable to be obtained secondary to a laboratory error on the sample of blood prior to fresh frozen plasma being administered. hospital course: an abdominal ct was performed revealing only a slightly dilated head of the pancreas consistent with ipmt. the remainder of his abdominal laboratories were normal. patient was taken to interventional radiology that night for angiography which revealed a small blush in the duodenum which was coiled at that time by interventional radiology. filter was also placed in the ivc by interventional radiology at the same time. >......<cells in the emergency department and he was admitted to the intensive care unit for observation and had a esophagogastroduodenoscopy the following morning which revealed only small superficial erosions and no frank ulcerations in the duodenum. his hematocrit remained stable and he was transferred to the floor. on the floor he had a left ij placed and his femoral line was removed. about the same time, he was noted to have approximately a liter of maroon stools and also an expanding groin hematoma at the site of the line removal. emergent ultrasound of the right groin revealed a heterogenous flow in the >.....<however, no direct fistula was seen. patient was found to have had a hematocrit drop of 10 points, so he was transferred back to the intensive care unit and received another three units of packed red blood cells. he had a repeat esophagogastroduodenoscopy which again showed only superficial mucosal erosions and no blood. he was kept npo and observed and colonoscopy was performed by gastrointestinal in the intensive care unit, which revealed diverticula, however, no evidence of bleeding. on hospital day seven, he has had clear rectal affluent from his golytely prep. his diet has been advanced to clears and his hematocrit has remained stable at 34 and he is called out to the floor. final diagnosis/problem list: 1. l bleed. unclear source given the positive angiographic findings and lack of findings on esophagogastroduodenoscopy times two and negative colonoscopy. his second visit to the intensive care unit regarding his decreased hematocrit may have been related to his groin hematoma as opposed to a new gastrointestinal bleed. if he re-bleeds again, he should have a bleeding scan obtained promptly and gastrointestinal should be re-consulted. otherwise, he will continue to be on protonix and his diet should be advanced soon to full as he has been without nutrition for seven days. 2. right thigh hematoma: a repeat ultrasound demonstrated a cfv at a cfa fistula. this will need to be followed over time. there was no discrete aneurysm or pseudoaneurysms seen and there was no flow seen in the hematoma indicating a stable lesion. it is likely that the triple lumen catheter passed through the artery and then was cannulated in the vein. vascular surgery is following this patient for this problem. 3. venous thromboembolic disease: filter was placed as the patient is not a candidate for anticoagulation at this point. 4. intermittent atrial fibrillation while in the intensive care unit: the patient has multiple premature ventricular contractions and ectopy and also has atrial fibrillation, however, again, we will not anticoagulate given his ongoing gastrointestinal bleeding issues. 5. chronic obstructive pulmonary disease: the patient has severe lung disease and he will continue using a steroid taper. he will continue to receive his inhaled steroids ipratropium and albuterol. 6. right upper lobe mass: most likely being malignancy given his extensive smoking history and the persistence of this mass over a one month time. his wife is aware of this as is his primary pulmonologist dr. . the wife and dr. have decided that it is not in the patient's best interest to discuss it with him at this time in the setting of this acute illness, however, it should be addressed with him at some point in the future. it is likely given his poor underlying pulmonary status, that he will die with this lesion as a result from it. 7. thrombocytopenia: prior to this admission, the patient had been noted to have platelets in the 250,000 range, however, on this admission, the patient had platelets in the 100,000s and drifting down to 80 and 70,000 range. all of his heparin was stopped including it in his flushes and a hit antibody was sent. the first hit antibody was negative, however, a repeat hit is pending. until this comes back, the patient should be off all heparin. 8. leukocytosis: most likely related to his prednisone and may also be related to his likely pulmonary malignancy. 9. prophylaxis: he is on pneumatic boots and proton pump inhibitors and no heparin should be used at this time. 10. access: he has a triple lumen catheter in his left ij. 11. code status: he is "do not resuscitate/do not intubate," however, but after long discussion with the patient and his wife, and with dr. , who will act as his primary care physician during this admission, he may be cardioverted once should he have an episode of vtvf, which is not an unreasonable condition given the frequency of the ectopy which he demonstrates on the cardiac monitor. , 11.575 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Other endoscopy of small intestine Interruption of the vena cava Injection or infusion of other therapeutic or prophylactic substance Colonoscopy Transfusion of packed cells Transfusion of other serum Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Acute posthemorrhagic anemia Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Hematoma complicating a procedure Intestinal infection due to Clostridium difficile Rupture of artery

history of present illness: the patient is a 79 year old lady with diabetes mellitus, coronary artery disease, dementia and colonic polyp which was removed during colonoscopy, who presented with bright red blood per rectum starting the day prior to presentation. the patient had similar episode in , and was found to have numerous colonic polyps. the day prior to presentation she started complaining about lower abdominal crampy pain after having massive bright red blood per rectum with clots. past medical history: 1. diabetes mellitus type 2. 2. coronary artery disease. 3. congestive heart failure. echocardiogram , showed an ejection fraction of 30%, 2+ mitral regurgitation, 3+ tricuspid regurgitation. 4. hypercholesterolemia. 5. chronic atrial fibrillation. 6. migraines. 7. nasal polyp. 8. venous stasis and chronic edema. 9. chronic renal insufficiency. 10. depression. 11. degenerative joint disease. 12. colonic polyps, status post gastrointestinal bleed in . 13. peripheral vascular disease, status post lower extremity bypass. past surgical history: 1. status post left lower extremity bypass. 2. status post appendectomy. 3. status post total abdominal hysterectomy and bilateral salpingo-oophorectomy from menorrhagia at age of 33. medications on admission: 1. cozaar 25 mg p.o. once daily. 2. celexa 20 mg once daily. 3. zaroxolyn 2.5 mg once daily. 4. calcitriol 6.25 once daily. 5. nph 30 units once daily. allergies: sulfa/rash. keflex/diarrhea. social history: the patient lives alone in assisted facility. the patient denies tobacco and alcohol use. physical examination: the patient is pleasant and cooperative in no acute distress. temperature is 98.7, pulse 84, blood pressure 124/64, heart rate 18, oxygen saturation 100% in room air. mucous membranes are moist. lungs are clear to auscultation bilaterally, decreased breath sounds inferiorly. heart irregular rhythm, regular rate, ii/vi systolic ejection murmur. the abdomen is obese, soft, nontender. extremities - 2+ edema, warm. laboratory data: white blood cell count was 8.6, hematocrit 31.2, platelet count 150,000. sodium 142, potassium 4.0, chloride 103, bicarbonate 25, blood urea nitrogen 100, creatinine 2.7, glucose 115. prothrombin time 14.9, partial thromboplastin time 33.6, inr 1.5. urinalysis negative. hospital course: the patient was admitted to medicine service and placed in the intensive care unit. surgery was consulted. nasogastric tube was placed. the patient was typed and crossed and transfused to keep her hematocrit above 30.0. red blood cell scan was performed. the patient's coagulopathy was reversed with vitamin k and fresh frozen plasma. on hospital day number two, the patient is afebrile and vital signs are stable. the patient continued to have some bright red blood per rectum, transfused to keep hematocrit above 30.0. bleeding scan localized bleeding into the area of the cecum. gastroenterology was also consulted who at that time recommended correcting coagulopathy and conservative management. the patient remained in the intensive care unit for observation. her bleeding has stopped by itself. she was transferred to the floor on . the patient again started bleeding with bright red blood per rectum and hematocrit dropped (anemia). the patient was again typed and crossed and transfused to keep hematocrit above 30.0. surgery was reconsulted. at that time, the patient's bleeding stopped by itself. surgery requested cardiology consultation. the patient had a swan-ganz catheter placed for cardiac monitoring. she was also started on lopressor for cardiac prophylaxis. however, overnight, the patient started bleeding again. she was then taken to the operating room on , for right hemicolectomy. please see operative note for details. the patient tolerated the procedure well and was transferred back to intensive care unit in stable condition. postoperative day number one, the patient is afebrile and vital signs are stable. she is diuresing well and unable to wean off ventilator due to edema. she was started on tpn for failure to thrive. she was also placed on vancomycin, levofloxacin and flagyl (vancomycin for staphylococcus aureus urinary tract infection). she also was started on lasix, however, she did not really respond well to it and it was stopped. the patient continued diuresis. the patient had a couple episodes of bradycardia down to high 30s, low 40s. her lopressor was stopped which improved her bradycardia (heart rate in high 50s and low 60s). the patient self extubated on postoperative day number three. nasogastric tube was removed. she was started on sips and advanced to clears which she was tolerating well. she continued on tpn. she started with physical therapy. she continued on vancomycin for urinary tract infection until second urine culture came back positive. on postoperative day number four, the patient is afebrile and vital signs are stable. she was started on p.o. medications. she was also restarted on cozaar for blood pressure control. second culture came back as mssa. the patient was switched to oxacillin. the patient was transferred to regular floor. her foley was removed. at renal service suggestion, she was started on epogen and zaroxolyn. her diet was advanced to regular diabetic diet which she was tolerating well. she was walking with physical therapy. on postoperative day five and six, the patient is afebrile and vital signs are stable. she is ambulating a few steps and moving from bed to chair with physical therapy. the wound is clean, dry and intact. she is confused at times, however, this is the patient's baseline. otherwise, she is stable with no concerns, no active issues at this time. condition on discharge: good. disposition: the patient is discharged to rehabilitation with physical therapy on diabetic diet. the patient should remain on epogen until she is followed up with primary care physician to determine length of treatment. medications on discharge: 1. tylenol one to two tablets p.o. q4-6hours p.r.n. pain. 2. celexa 20 mg p.o. once daily. 3. triamcinolone ointment applied to affected areas twice a day. 4. sarna lotion twice a day. 5. compazine 10 mg q6hours p.r.n. 6. benadryl 25 mg p.o. q.h.s. p.r.n. 7. calcium carbonate 500 mg p.o. three times a day with meals. 8. calcitriol 0.25 mcg once daily. 9. regular insulin sliding scale - please see sliding scale for details. 10. metolazone 2.5 mg once daily. 11. losartan 25 mg p.o. once daily. 12. epoetin 5000 units two tablets a week. 13. lasix 40 mg p.o. once daily. 14. protonix 40 mg p.o. once daily. discharge diagnoses: 1. lower gastrointestinal bleed, status post right hemicolectomy. 2. hypovolemia requiring blood and fluid rescucitation 3. urinary tract infection on this admission 4. diabetes mellitus. 5. coronary artery disease. 6. congestive heart failure. 7. hypercholesterolemia. 8. chronic atrial fibrillation. 9. migraines. 10. venous stasis and chronic edema. 11. chronic renal insufficiency. 12. depression. 13. degenerative joint disease. 14. peripheral vascular disease. 15. postoperative anemia. 16. failure to thrive. 17. episodic bradycardia. 18. malnutrition requiring parenteral nutrition , m.d. dictated by: medquist36 d: 14:18 t: 14:57 job#: Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Arterial catheterization Insertion of other (naso-)gastric tube Other lysis of peritoneal adhesions Arteriography of other intra-abdominal arteries Pulmonary artery wedge monitoring Open and other right hemicolectomy Closed [endoscopic] biopsy of large intestine Monitoring of cardiac output by other technique Endoscopic destruction of other lesion or tissue of large intestine Injection or infusion of nesiritide Diagnoses: Anemia, unspecified Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Atrial fibrillation Hemorrhage of gastrointestinal tract, unspecified Benign neoplasm of colon

history of present illness: the patient is a 79 year-old female with a history of chronic atrial fibrillation on coumadin, type 2 diabetes and peripheral vascular disease who presented with pain and bleeding from her rectum and inr 17. the patient reports that she has had intermittent bleeding oozing from her nose over the past several days as well as gum bleeding when she is brushing her teeth for the same period of time notes increased frequency of stools of loose consistency described as chocolate syrup mixed with blood clots. had routine pt/inr done today by the vna, which showed an elevated inr and directed to the emergency department by her primary care physician. denies syncope, lightheadedness, shortness of breath, chest pain, palpitations, no abdominal pain, nausea, vomiting or reflux symptoms. no history of peptic ulcer disease. reports having routine colonoscopy done several years ago in , which showed polyps. in the emergency department her vital signs were stable. hematocrit 22, inr 17, 4 and 4. also had increased ptt as well as bun and creatinine 213/3.2. she received 4 units of fresh frozen platelets, 5 mg of intravenous vitamin k and 2 units of packed red blood cells, admitted to medicine for correction of coagulopathy and gastrointestinal evaluation. past medical history: chronic atrial fibrillation, type 2 diabetes complicated by retinopathy, neuropathy and nephropathy. chronic renal failure, coronary artery disease. echocardiogram showed an ef of 45 to 50% with inferior posterior hypokinesis, hyperlipidemia, degenerative joint disease, peripheral vascular disease, status post left lower extremity bypass, chronic edema with stasis dermatitis. nasal polyps status post polypectomy, clonic polyps, depression, status post left knee replacement, status post tah/bso for menorrhagia at an age 33. allergies: sulfa, which causes a rash and keflex, which causes severe diarrhea. medications: lasix 40 mg po b.i.d., cozaar, coumadin 9.5, insulin 30 nph in the morning, celexa 10, calcitriol, darvocet and k-ciel. social history: recently returned to after seven year stay in with her son who is now deceased. no tobacco or alcohol. the patient lives alone. physical examination on admission: the patient is an elderly black female in no acute distress. she is alert and oriented times three. she is afebrile. the heart rate is 74. blood pressure 113/31. respirations 13. 99% on room air. her skin is anicteric. heent normocephalic, atraumatic. positive conjunctival pallor. no bleeding from her nares. positive bleeding gums. neck was supple. jvp 7 to 8 cm. lungs clear to auscultation anteriorly. heart s1 and s2, irregular irregular with no murmurs, rubs or gallops. abdomen obese, soft, nontender, no organomegaly. rectal positive external hemorrhoids nonbleeding. internal examination showed red blood on glove with scant brown stool. extremities massive lower extremity edema with chronic stasis dermatitis. neurological alert and oriented times three. appropriate. cranial nerves ii through xii intact. moves all extremities. laboratory: white blood cell count 8, hematocrit 22.5 this is mid 30s and 95, platelets 184, pt 51.3, inr 17.4, ptt 75.2. sodium 138, k 4.8, chloride 99, bicarb 25, bun 213, creatinine 3.2, which is 1.4 to 1.9 in 95 and a glucose of 141. hospital course: 1. coagulopathy: it was thought that the patient was having an increase in coumadin dose over the past several weeks due to expired tubes done by her vna and when her new tube was fine her inr was elevated at 17.4, she received several units of fresh frozen platelets and vitamin k and her coagulopathy was corrected. her coumadin was held as was her non-steroidal anti-inflammatory drugs. by the time of her admission her inr had been corrected and the decision was made to hold her coumadin since she would need a repeat colonoscopy. 2. gastrointestinal bleeding: the patient received 2 units initially of packed red blood cells with an appropriate hematocrit bump. she received a colonoscopy and esophagogastroduodenoscopy. colonoscopy was significant for numerous polyps throughout her colon and esophagogastroduodenoscopy was significant for gastric erosions. it was felt that the polyps were responsible for her recent bleed and that she would need outpatient repeat colonoscopy several weeks after. gastrointestinal was consulted during this admission. of note, the patient had an abdominal ct scan looking for possible cancer and metastatic disease from her polyps, which was significant for two lytic lesions on her ileum. she then received a bone scan, which was unrevealing for any further metastatic disease. of note, one of the polyps removed from her colonoscopy had high grade dysplasia contained within the adenoma. she had a serum protein electrophoresis, which showed no specific abnormalities. urine protein electrophoresis showed multiple protein bands with albumin predominated. it was felt that the rest of her oncology workup could be done by her primary care physician . . 3. renal failure: patient with an elevated creatinine. unclear what her recent baseline was. it was thought to be a combination of prerenal azotemia given her volume loss. it did correct with volume. 4. cardiovascular: patient with a history of chronic atrial fibrillation not requiring rate controlling agents. her lasix and coumadin were held while she was an inpatient and her coumadin would be continued to be held since she would need a repeat colonoscopy in several weeks. patient resuscitation in the micu was complicated by congestive heart failure. she had an echocardiogram that showed an ef of 30%, 2+ mitral regurgitation, 3+ tricuspid regurgitation and severe pulmonary hypertension. she diuresed well with lasix and her oxygen requirement was totally gone by the day of discharge. 5. diabetes: the patient was continued on her insulin with q.i.d. finger checks while in house. discharge diagnoses: 1. blood loss anemia. 2. colonic polyps. 3. lower gastrointestinal bleed. 4. congestive heart failure. 5. atrial fibrillation. 6. depression. 7. diabetes. 8. hypertension. 9. acute on chronic renal failure. 10. peripheral vascular disease. 11. hyperlipidemia. 12. chronic lower extremity edema. 13. coagulopathy. , m.d. dictated by: medquist36 Procedure: Other endoscopy of small intestine Endoscopic polypectomy of large intestine Endoscopic polypectomy of large intestine Diagnoses: Acute kidney failure, unspecified Atrial fibrillation Blood in stool Acute systolic heart failure Hyperosmolality and/or hypernatremia Benign neoplasm of colon Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Hemorrhage, unspecified Renal failure, unspecified

discharge status: home. discharge diagnoses: 1. pneumonia. 2. sepsis. 3. hypotension. condition on discharge: good. discharge medications: 1. levofloxacin 500 mg p.o. q. day times ten days. 2. tylenol p.r.n. 3. colace p.r.n. 4. lipitor 5 mg p.o. q. day. 5. dextromethorphan - guaifenesin p.r.n. 6. atrovent two puffs q. six to eight hours. 7. albuterol two puffs q. four to six hours. 8. atenolol 50 mg p.o. q. day. 9. hydrochlorothiazide 25 mg p.o. q. day. discharge instructions: 1. the patient was instructed to call her primary care physician or return if she experienced fever and chills or was unable to eat or drink. 2. she was also instructed to follow-up with her primary care physician in one week. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Unspecified septicemia Sepsis Anxiety state, unspecified

history of present illness: seventy-one year old female with recent history of upper respiratory infection symptoms, who presents to the emergency department with cough, fevers, and fatigue. the patient presented to her pcp on the complaining of two days of rhinorrhea, cough with yellow sputum, right sided pleuritic chest pain, and reported fever and chills. given her normal physical exam, she was treated for a bilateral upper respiratory infection with symptomatic treatment. however, the patient's symptoms persisted and she presented to the emergency department on the complaining of increased weakness, right sided lateral chest pain, persistent cough (nonproductive), rhinorrhea, and reported fevers and chills. review of systems: the patient denies headache, neck stiffness, sore throat, palpitations, chest pressure, abdominal pain, nausea, vomiting, diarrhea, bright red blood per rectum, dysuria, vaginal discharge, and lower extremity edema. in the emergency department, the patient was treated with levofloxacin and ceftriaxone, and received iv fluids. she was treated according to the sepsis protocol for presumed pneumonia/sepsis and central line was placed. past medical history: 1. hyperlipidemia. 2. anxiety disorder. 3. nephrolithiasis. 4. gastroesophageal reflux disease. 5. pyelonephritis . 6. hypertension. 7. copd. allergies: patient is allergic to codeine which causes chest pain, and to macrobid (nitrofurantoin/nitrofuran), which causes fever, chills, arthralgias, and arthritis. medications: 1. atenolol 50 q.d. 2. aspirin 325 q.d. 3. lipitor 5 q.d. 4. xanax prn. 5. aleve/naproxen prn. 6. the patient reports that her hydrochlorothiazide is being discontinued. social history: the patient denies tobacco and alcohol use. she lives by herself in an apartment above her children. family history: diabetes, coronary artery disease, cancer of the stomach and lungs. physical examination: vital signs: temperature 95.3, pulse 62, blood pressure 79/48, o2 saturation 95% on room air. in general, this is a well appearing, cooperative, elderly female. heent: perrl. anicteric sclerae. oropharynx: moderate pupils dry, but clear. neck is supple without lymphadenopathy. cardiovascular: s1, s2, regular, rate, and rhythm, no murmurs, rubs, or gallops. lungs: rhonchi and wheezing on the right side. abdomen: soft, nontender, nondistended with normoactive bowel sounds. back without cva tenderness. extremities without edema. pulses 1+, no rash. neurologic: alert and oriented times three. cranial nerves ii through xii intact. laboratories: white blood cell count 17.4, hematocrit 31.9, platelet count 198. sodium 137, potassium 3.7, chloride 99, bicarb 20, bun 22, creatinine 1.2, glucose 281. lactate was 6.7. chest x-ray showed right middle lobe consolidation consistent with pneumonia. hospitalization course: given her picture of sepsis, the patient was enrolled in the sepsis protocol and admitted to the medical icu for treatment of her pneumonia. 1. pneumonia: the patient was diagnosed with community acquired pneumonia and treated with levofloxacin and ceftriaxone. this led to a rapid improvement in her lung examination with resolution of the rhonchi and wheezing within 48 hours. the patient continued to complain of pleuritic type chest pain, for which she was treated very gently with tylenol and motrin unsuccessfully, and then successfully with darvocet (codeine was avoided because the patient is allergic). 2. hypertension/sepsis: most likely secondary to pneumonia. in addition to her antibiotic treatment, the patient was aggressively hydrated according to the sepsis protocol. this resulted in an improvement in her blood pressure. at the same time, her antihypertensive medications were held. 3. hyperglycemia: during hospitalization, the patient's glucose was found to be elevated. the patient reports no history of diabetes. obviously given her acute illness, the diagnosis of glucose intolerance cannot be made at this time. however, the patient was found to have a hemoglobin a1c of 6.3, indicating possibly glucose intolerance. it is recommended that the patient follows up with her pcp to evaluate this finding. medications on discharge: 1. levofloxacin 500 mg p.o. q.d. for 10 days. 2. cefpodoxime proxetil 200 mg b.i.d. for 10 days. 3. acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. prn. 4. docusate sodium 100 mg b.i.d. 5. lipitor 5 mg q.d. 6. dextromethorphan guaifenesin 10/100 mg/5 ml syrup take every six hours as needed. 7. atrovent inhalers and albuterol inhalers. 8. darvocet one tablet p.o. q.6h. for seven days. 9. atenolol 50 mg one tablet p.o. q.d. discharge status: home. discharge condition: good. discharge instructions: the patient was advised to followup with her pcp within one week (dr. , phone number . also she was advised to contact her pcp or come back to the emergency department if she continues to have fever, chills do not resolve or if she experiences any nausea and vomiting. discharge diagnoses: 1. pneumonia. 2. sepsis. 3. hypertension. 4. possible glucose intolerance. as of , the patient is still in the medical icu, but expected to be discharged on the following day to home. at this time, sputum cultures and blood cultures are pending. an addendum will follow. dr., 12-207 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Unspecified septicemia Sepsis Anxiety state, unspecified

history of present illness: baby girl delivered at 34 6/7 weeks gestation weighing 2720 gm and was admitted to the intensive care unit nursery from labor and delivery for management of respiratory distress and mother is a 37 year old gravida 5, para 2, now 3 woman with estimated date of delivery . the pregnancy was complicated by first trimester bleeding, treated with bedrest and elevated blood pressure a week prior to delivery. prenatal screens included rh negative, but type not documented, rubella immune, rpr nonreactive, hepatitis b the mother presented in preterm labor. no fever during labor. she received interpartum antibiotics one hour prior to delivery for prematurity and unknown group b streptococcus. delivery was by normal spontaneous vaginal delivery under epidural anesthesia. the infant emerged with a good cry, was dried, bulb suctioned and given blow-by oxygen to maintain pink color. unable to wean off of oxygen in the delivery room and thus the infant was admitted to the intensive care unit nursery. physical examination on admission: weight 2720 gm (50th to 75th percentile), length 46.5 cm (50th percentile), head circumference 31.5 cm (25th to 50th percentile). in general a nondysmorphic pink infant receiving free flow oxygen. skin without rashes. anterior fontanelle open and flat with molding. eyes, red reflex present bilaterally, no cleft. thorax, symmetric with subcostal retracting. lungs with diminished aeration. heart, regular rate and rhythm with normal s1 and s2, grade ii/vi systolic murmur, present femoral pulses. abdomen, soft, nondistended, no hepatosplenomegaly. genitalia, normal preterm female, patent anus, spine straight and intact. extremities, stable. no hip clicks. reflexes, appropriate for gestational age. hospital course: 1. respiratory - required supplemental oxygen delivered by nasal cannula until day of life #3, when weaned to room air. has remained in room air since with comfortable work of breathing, oxygen saturations in the high 90s to 100%, respiratory rates in the 40s. chest x-ray and clinical course consistent with transient tachypnea of the newborn. 2. cardiovascular - has been hemodynamically stable throughout hospitalization. the murmur heard on admission has resolved. recent blood pressure is 62/30 with a mean of 43. 3. fluids, electrolytes and nutrition - initially maintained of intravenous fluid of d10/w. started enteral feeds on day of life #1, the intravenous fluid was stopped on day of life #2, has been taking enfamil 20 with iron or breastfeeding when mom visits and then supplemented with enfamil 20 with iron as mother's milk not in yet. is feeding well. mother plans to breastfeed at home and supplement until her milk is in. discharge weight: 2580 grams. 4. gastrointestinal - the baby is jaundiced. a bilirubin checked on day of life #3 () was 10.3, direct .3, on day of discharge 12.4/0.3. 5. hematology - hematocrit on admission 45%. 6. infectious disease - received ampicillin and gentamicin for 48 hours following admission for rule out infection, complete blood count on admission revealed white count of 11.3 with 37 polys, 1 band, platelets 282,000. blood culture was negative. 7. neurology - examination, age appropriate. head ultrasound not indicated. 8. sensory - hearing screening was performed with automated auditory brain stem responses, infant passed both ears. condition on discharge: stable preterm infant, feeding well. discharge disposition: discharge home with parents. primary care pediatrician: , m.d., mulden . care and recommendations: 1. feeds - ad lib demand feeds, breastfeeding, supplement as needed and follow weight. 2. medications - none, recommend iron supplementation. 3. carseat position screening - pending. 4. state newborn screens - sent on day of life #3, pending. 5. immunizations received - received hepatitis b immunization on . 6. immunizations recommended - 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 plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or c. 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 appointments recommended: follow up appointment with pediatrician within three days of discharge, recommended sooner if the infant has increased jaundice. discharge diagnosis: 1. appropriate for gestational age preterm female 2. transient tachypnea of the newborn resolved 3. sepsis, ruled out 4. physiologic jaundice dr., 50-622 dictated by: medquist36 d: 16:48 t: 17:29 job#: Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 2,500 grams and over Other respiratory problems after birth 33-34 completed weeks of gestation

history of present illness: is the former 643 gram product of a 27 and 3/7th week gestation pregnancy born to a 31-year-old g1, p0 woman. prenatal screens: blood type b+, antibody negative, rubella immune, rpr nonreactive. hepatitis b surface antigen negative, group beta strep status was unknown. pregnancy was notable for intrauterine insemination, conception with resultant diamniotic dichorionic twins. there was a cerclage placed at 19 weeks due to cervical changes. discoordinate growth between the twins was noted at 23 and 6/7th weeks. the mother had a cytomegalovirus by igg titer which was positive with a igm result equivocal. she received a complete course of betamethasone. rupture of membranes of twin #1 occurred 12 hours prior to delivery and she was taken to cesarean section for known breech vertex presentation of the twins. this twin #1 emerged limp and apneic. she required bag mask ventilation and was intubated in the delivery room. apgars were 3 at 1 minute and 6 at 5 minutes and 6 at 10 minutes. she was admitted to the nicu for treatment of prematurity. physical examination: upon admission in the nicu, weight was 643 grams, length 30.5 cm, head circumference 23.5 cm, all less than 10th percentile for gestational age. in general, nondysmorphic preterm female, orally intubated in moderate respiratory distress. minimal aeration with breath sounds. no murmur. pulses are +2. no skeletal anomalies. genitalia consisted with female sex and gestational age. hospital course: 1. respiratory: was treated with 3 doses of surfactant. she was placed on the high frequency oscillatory ventilator upon admission to the nicu. her peak pressure was 14. she was treated with a high frequency ventilator through day of life #6 when she was changed to the conventional ventilator. on day of life #9, she was extubated with continuous positive airway pressure. due to apnea, she was again reintubated and maintained on the conventional ventilator through day of life 27. she was then intermittently on and off with continuous positive airway pressure interspersed with high flow nasal cannula. she came off cpap on and has remained on nasal cannula oxygen since that time. at the time of discharge, she continues on nasal cannula oxygen 100% with flow of 75 to 125 cc. chest x-ray is consistent with chronic lung disease. diuretic therapy with diuril was initiated on and she is being discharged home on diuril. also required treatment for apnea prematurity with caffeine citrate. the caffeine was discontinued on . her last episode of spontaneous bradycardia occurred on . will be followed by the pulmonary consult team at after discharge. attending is dr. and pulmonary fellow is dr. . phone # . the consult team would like to see the infant monthly for the next few months. additional recommendations included: - ideal sat range in mid-90s (94-97), if consistently lower needs increased flow, if consistently higher may try o2 wean - low saturation limit should be set to 89 - usual hygiene precautions - recommended restricted outdoor activity for over the next two months over the course of the winter - parents were instructed to bring a copy of the last chest x-ray, ap and lateral, to the pulmonary clinic 2. cardiovascular: required treatment for hypotension with volume expanders and dopamine. her maximum dopamine infusion was 20 mcg per kilo per minute. she received 3 doses of hydrocortisone on day of life #3 to #4 for her persistent hypotension. she was able to wean off the dopamine by day of life #6. no murmurs had been noted during admission. 3. fluids, electrolytes and nutrition: initially was maintained on intravenous fluids and total parenteral nutrition, enteral feeds were initiated on day of life #7 and gradually advanced to full volume. her maximum caloric intake was 32 calories per ounce with additional protein supplement. at the time of discharge, she is feeding expressed mother's milk fortified to 28 calories per ounce, four calories by neosure powder and four calories by corn oil. serum electrolytes were monitored closely during admission due to the administration of diuril. she is receiving potassium chloride supplements. her most recent set of electrolytes are from with a serum sodium of 139, serum potassium of 4.9, chloride of 121, total carbon dioxide content is 26. weight on the day of discharge is 2.215 kilogram with a head circumference of 31 cm and a length of 35.5 centimeters. 4. infectious disease: due to her severity of illness and her prematurity, was evaluated for sepsis at the time of birth. a blood culture was drawn prior to initiating antibiotic therapy. blood culture was no growth and the antibiotics were discontinued at 48 hours. has not had any other episodes of sepsis. she did have one repeat blood cultures sent on day of life #9 when she experienced temperature instability. a urine for cmv was sent and was negative. 5. hematological: is blood type b+, coombs negative. she has received four transfusions of packed red blood cells during her admission. most recent hematocrit was 34.1% on . a recent reticulocyte count was 12%. she is being discharged with iron supplementation. 6. gastrointestinal: required treatment for unconjugated hyperbilirubinemia with phototherapy. her peak serum bilirubin occurred on day of life #7 with a total of 6 mg/dl over a direct of 0.5 mg/dl. she received approximately 14 days of phototherapy and her rebound bilirubin level was a total of 1.8/0.7 direct. 7 neurological: has had three normal head ultrasounds during admission and there are no neurological concerns at the time of discharge. she is being referred to an early intervention program. 8 sensory: hearing screen was performed with automated auditory brain stem responses. passed in both ears. ophthalmology: has had a multiple ophthalmological exams, screening for retinopathy of prematurity. her first exam on showed immature retinas to zone 2. her repeat exam on showed development of stage i retinopathy of prematurity. most recent exam was on showing stage ii retinopathy in zone 2 in the right eye and stage ii in zone 3 in the left eye. recommended follow up in 2 weeks (). the consultation ophthalmologist is dr. at . 9 psychosocial: social work has been involved with the family. they can be contact at . condition on discharge: good. discharge disposition: home with the parents. primary pediatrician: , m.d., , , , phone number . care and recommendations at the time of discharge: 1. ad lib p.o. feeding mother's milk fortified to 28 calories per ounce, 4 calories by neosure powder which is recommended until the 6 to 9 month corrected age and corn oil 4 calories per ounce. medications: 1. fer-in- 25 mg per ml concentration, 0.3 cc p.o. q.d. 2. poly-vi- 1 cc p.o. q. day. 3. diuril 45 mg p.o. q. 12 hours. 4. potassium chloride supplements 3 meq p.o. b.i.d. third car seat position screening was performed and passed. state newborn screen has been sent on multiple occasion. most recent specimen was from , all results were within normal limits. a repeat specimen will be sent at the time of discharge. immunizations received: received hepatitis b vaccine, diphtheria, tetanus, acellular pertussis, hib, ipv, and pneumococcal conjugate vaccine on through . a second dose of hepatitis b vaccine was administered on . initial dose of synagis was administered on . immunizations recommended: 1. synagis rsv prophylaxis should be considered from through for the infant to meet any of the following 3 criteria: born at 2 weeks gestation, born between 32 and 35 weeks with plans for day care during rsv season with a smoker in the household or with preschool siblings. 2. influenzae immunization should be considered annually in the fall for preterm infants with chronic lung disease once the baby reaches 6 months of age to protect the infant. follow up appointments: 1. , m.d., , , appointment for approximately . 2. pulmonary medicine at , drs and , . 3. - early intervention program, . 4. caregroup vna, . discharge diagnosis: 1. prematurity at 27 3/7th weeks gestation. 2. twin #1 of twin gestation. 3. respiratory distress syndrome. 4. profound hypotension. 5. small for gestational age. 6. chronic lung disease. 7. anemia of prematurity. 8. apnea of prematurity. 9. unconjugated hyperbilirubinemia. 10. retinopathy of prematurity. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period 27-28 completed weeks of gestation Retrolental fibroplasia Extreme immaturity, 500-749 grams "Light-for-dates" without mention of fetal malnutrition, 500-749 grams

history of present illness: is a 7-year-old female with known coronary artery disease, status post percutaneous transluminal coronary angioplasty of a stent to the left anterior descending as recently as of this year who presented with four to five pounds of typical chest discomfort and low level exertion consistent with new onset and unstable angina. the patient has a past medical history significant for a retinopathy, hypertension, diabetes mellitus, has no history of transient ischemic attack,no history of stroke, gastrointestinal bleeding. she has hyperlipidemia and has known coronary artery disease as previously stated. no history of myocardial infarction is present. due to her progressive four bouts of typical chest pain, discomfort at low levels of exertion she presented to her pcp who ultimately admitted her to the for cardiac catheterization. electrocardiogram on admission showed no acute changes. her troponins were borderline and her cpks were ultimately negative. she had normal hemodynamic profile. in the catheterization laboratory she underwent a left heart coronary artery catheterization that revealed the following. left ventriculography showed a mitral regurgitation with left ventricular ejection fraction to be "normal." there was a right heart dominant circulation with left main coronary artery disease within normal however, there was 90% in-stent restenosis in the proximal left anterior descending. left circumflex is small but normal. right coronary artery was 80% distal right coronary artery. given the aggressive in-stent restenosis of the proximal left anterior descending in a diabetic female with a right coronary artery lesion the recommendation was to go forward with coronary artery bypass grafting. subsequently the patient was admitted to the hospital, placed on nitrates, no plavix, heparin, beta-blockade. the patient has no known drug history, no history of dye allergy. medications on admission: 1. plavix 75 mg q day. 2. lopressor 75 mg q am, 50 mg p.o. q pm. 3. zestril 40 mg q day. 4. aspirin 81 mg q day. 5. nph 20 units subcutaneously q am, 6 units subcutaneously q pm. 6. humilog sliding scale. 7. eyedrops, which she takes three separate brands, not otherwise specified. admission labs: crit of 9, bun and creatinine of 18 and .6. she was well nourished, well developed female, sinus with 160/70 blood pressure, lungs clear. heart was regular, no murmur. peripheral pulses were palpable. dorsalis pedis and posterior tibial bilaterally. ultimately on , the same day of admission the patient was taken electively to coronary artery bypass with dr. . she underwent coronary artery bypass graft times two including left internal mammary artery to left anterior descending and a right saphenous vein graft to the right coronary artery, posterior descending. she left the operating room with pericardium opened. she has a right radial a-line, central venous pressure, right atrial catheter, two ventricular wires, one atrial, one ground wire, one mediastinal, one right pleural and one left pleural tube was also present. upon transfer to the intensive care unit the patient was neurologically intact. neo-synephrine was being utilized for blood pressure support and was weaned off, started on lasix and lopressor. respiratory wise she was extubated. she was encouraged to use incentive spirometry with coughing, deep breathing and also to immobilize early. gastrointestinal: she was put on cardiac diet. bun and creatinine were 10.4, acceptable heme. she was started on aspirin and then subsequently transferred to the floor. while on the floor she was noted to have no real significant events. she was afebrile throughout her hospital course. lopressor was titrated to effect heart rate persistently at 90's and at present there are not any readings that are lower at this time. hospital course: unremarkable. she had hematocrit of 34, bun 23 and creatinine of .7 on day of discharge. blood pressure was however, hypertensive on postop day three she reached systolics of 200/palp which was able to precipitate chest discomfort, chest pressures, electrocardiogram done at this time shows sinus tachycardia with no st-t segment changes. additionally she has chest x-ray that showed bilateral apical pneumothoraces that were stable from previous x-ray seen after chest tube removal. discharge medications: 1. humilog sliding scale, please see page 1 for comprehensive details of sliding scale as well as nph 20 units subcutaneously q am, nph 6 units subcutaneously q pm. 2. percocet 5/325 mg one to two q 4 to 6 hours p.r.n. 3. lasix 20 mg p.o. q am times seven day. 4. k-dur 20 meq p.o. q day times seven days. 5. protonics 40 mg p.o. q day. 6. aspirin 325 mg p.o. q day. 7. lopressor 50 mg p.o. b.i.d. 8. zestril 10 mg additional medications include aforementioned colace, zestril, lopressor. condition on discharge: stable, afebrile. sternum is intact. 98.1 for temperature, 84 sinus, 130/70 blood pressure. crit and bun previously stated. cardiac was stable with no drainage. regular rate and rhythm. clear to auscultation. there were crackles at the basis. abdomen is benign. extremities: right saphenous vein graft patent. intact, well approximate, no evidence of erythema or exudate. discharge is to rehabilitation. follow-up: see dr. in four weeks. see pcp in three weeks. she can have wound check, blood pressure monitoring, physical rehabilitation at rehabilitation facility. diagnosis: 1. significant and aggressive in-stent restenosis, 80% distal or mid-right coronary artery lesion status post coronary artery bypass graft times two, left internal mammary artery to left anterior descending and right saphenous vein graft to posterior tibial artery. , m.d. dictated by: medquist36 Procedure: 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 (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Other complications due to other cardiac device, implant, and graft Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy

history of present illness: the patient is an 85 year old female with a past medical history of bilateral carotid stenosis, coronary artery disease, status post left anterior descending percutaneous intervention, hypertension, hypercholesterolemia, who was admitted to the ccu for monitoring following elective right internal carotid artery percutaneous intervention. the patient has initially been evaluated in , for word finding difficulty and a left facial droop and was found to have bilateral internal carotid artery stenosis. the patient has a history of significant coronary artery disease, multiple medical problems and her age. she was referred for elective stent intervention of her carotids as opposed to endarterectomy. she had a magnetic resonance scan - mra of head and neck on , which showed a two right hemispheric microhemorrhages and right subcortical small vessel ischemic disease. during the stent procedure, the patient required a neo-synephrine drip for decreased blood pressure and atropine times two for decreased heart rate. during the procedure, the patient was noted to have an right posterior carotid av fistula. past medical history: 1. peripheral vascular disease. 2. carotid stenosis bilaterally, ultrasound , bilateral internal carotid artery stenosis of 70 to 90%. 3. cerebrovascular accident with small vessel disease. known facial droop, right hemispheric microhemorrhages. 4. coronary artery disease, , catheterization with a left main 20% ostial stenosis, left anterior descending 80% midstenosis, status post stent, diagonal 90% stenosis status post stent, left circumflex 40% lesion at the om1. ejection fraction estimated to be 67% on a muga, ett mibi, that she had in . there was no nuclear defect, perfusion defects, during the test. 5. hypertension. 6. hypercholesterolemia. 7. osteoporosis. 8. status post cataract surgery. 9. status post zenker's diverticular repair. 10. questionable history of dementia. allergies: intravenous pyelogram dye causes her to have anaphylaxis. medications on admission: 1. lopressor 12.5 mg p.o. twice a day. 2. aspirin 81 mg once daily. 3. univasc 7.5 mg one once daily and 15 mg q.p.m. 4. dyazide 12.5 mg once daily. 5. lipitor 10 mg once daily. 6. plavix 75 mg once daily. 7. fosamax 70 mg q.week. 8. multivitamin one once daily. 9. lactulose. social history: she lives alone. no tobacco use and rare etoh use. physical examination: at the time of presentation, she was afebrile with a heart rate of 63, blood pressure 120/50 to 160/60, respiratory rate 16, oxygen saturation 99% on two liters. she is in no acute distress lying in bed. extraocular movements are intact. the pupils are equal, round, and reactive to light and accommodation. anicteric. no bruit or jugular venous distention appreciated. heart is regular rate and rhythm, s1 and s2, no murmurs, rubs or gallops. her lungs are clear to auscultation bilaterally posteriorly. abdomen with normoactive bowel sounds, soft, nontender, nondistended. extremities - no cyanosis, clubbing or edema. right leg immobilizer placed. her dorsalis pedis were . her neurologic examination revealed cranial nerves with the exception of her facial nerve were intact. she has flat nasolabial fold on the left side. normal upper and lower extremity strength. laboratory data: on the day of admission, white blood cell count 6.6, hematocrit 32.6, platelet count 291,000. total cholesterol was 173, hdl 45, ldl 109. assessment: this is an 81 year old female with a history of coronary artery disease, peripheral vascular disease, carotid artery stenosis, bilaterally, hypertension, hypercholesterolemia, admitted to the ccu status post right internal carotid artery stent. 1. neurology - the patient had stent, status post right internal carotid artery stent. she initially was on neo-synephrine to maintain a blood pressure goal between 110 and 150. she had q1hour neurological checks and then q2hour neurological checks. initially, her neo-synephrine was weaned off and the patient's blood pressure gradually rose to approximately 160 to 170. as a result, some very low dose nitroglycerin drip was started to try to keep her blood pressure between 150 and 110. the patient had hypotension with blood pressure down to 70. the nitroglycerin drip was stopped and neo-synephrine drip was started with blood pressure up to as high as 200s. when all drips were stopped, her blood pressure gradually came down to 120 to 130 systolic. this was fairly soon after the stent had been placed and the patient arriving in the ccu. overnight the first hospital night, the patient was placed on a low dose of neo-synephrine 0.1 to maintain her blood pressure between 110 to 120 with gradually being able to be weaned off the drip and on the second hospital day, the neo-synephrine drip was turned off. the patient did not require any atropine in the ccu, however, she did have a symptomatic bradycardia going down to mid 30s while she is sleeping, coming up to mid 40s to 50s when being awakened. on the neurologic examination, there was no focality or any change in her examination from her baseline which had the left nasolabial fold flattening. however, the patient did seem to be confused the evening status post the procedure and on day two on the , the patient had a ct of the head without contrast which showed no definite hemorrhage. the results were reviewed with the neurologist following along with the team, dr. . on the second day postprocedure, the patient was acting more oriented and less confused. her confusion seemed to coincide with the onset of night fall and possible disturbance of her sleep/wake cycle. the rest of her stay the patient had blood pressure near goal being consistently in the 120s to 130s. she was transferred to the floor and step-down unit on two for further monitoring. the patient was seen by physical therapy who felt the patient was a fall risk and recommended for both feet physical therapy and occupational therapy and a short term rehabilitation to optimize her functional capacity before returning to living alone at home. 2. hematology - the night after the procedure the patient had a right arterial and venous sheath in place for her arterial line that was monitoring her blood pressure. the patient, despite having a leg immobilizer and numerous discussions and explanations and exhortations to stay in bed, attempted to get out of bed on the first night of her admission, and was seen by house staff. house staff and nursing staff got the patient into bed. her groin examination was stable with no bruit or hematoma, however, on the next day, her hematocrit dropped to 26.3. the patient had two units of packed red blood cells transfused with her hematocrit being 34.9 on the day of discharge. her ct of her abdomen and pelvis showed no retroperitoneal hematoma. this examination was done on . 3. blood pressure control - the patient will be discharged on univasc 7.5 mg twice a day and will follow-up with dr. in four to six weeks to have her blood pressure medications adjusted possibly placing her back on her beta blocker as well. 4. coronary artery disease - the patient was continued on her aspirin and now will be on plavix for life long therapy. 5. infectious disease - the patient had a low grade temperature maximizing at 100.5 on the day prior to discharge. she had urine and blood cultures sent, all of which are no growth at the time of discharge. as well, her urinalysis was unremarkable. she had no localizing symptoms of temperature or fever. her temperature is 100 temperature maximum on the day of discharge. condition on discharge: good. discharge diagnoses: 1. bilateral carotid artery stenosis, status post right internal carotid artery stenting. 2. significant coronary artery disease, status post left anterior descending stenting. 3. hypertension. 4. hypercholesterolemia. 5. peripheral vascular disease. 6. mild dementia. 7. right facial droop seemingly due to an old stroke. procedure: right internal carotid artery stent. medications on discharge: 1. univasc 7.5 mg p.o. twice a day. 2. artificial tears one to two drops o.u. p.rn. 3. lactulose. 4. multivitamin. 5. lipitor 10 mg p.o. once daily. 6. plavix 75 mg p.o. once daily. 7. aspirin 325 mg p.o. once daily. 8. fosamax 70 mg q.week. follow-up: the patient is to see dr. in approximately four weeks in follow-up appointment for this procedure and at the same time to see her primary care physician. , m.d. dictated by: medquist36 d: 12:07 t: 13:27 job#: Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Arterial catheterization Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Osteoporosis, unspecified Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other late effects of cerebrovascular disease, facial weakness

history of present illness: this is a 78-year-old female with severe parkinson's disease found unconscious and unresponsive with agonal breathing. family reports the patient choked on some chicken. they proceeded to do cpr and the heimlich and retrieved some chicken with fingers. patient emergently was intubated at the scene, and afterwards her vitals were a pulse of 161, blood pressure 150/88. pulse came down to 100 and she was 98% on 100% o2. patient received a 500 cc bolus of normal saline. in the emergency department, patient's vitals were pulse 118, blood pressure 171/64, respiratory rate 17, and 100% o2. of note, the family thinks the patient was choking on chicken for about three minutes and was totally nonresponsive without palpable pulse for about two minutes. also of note, the patient is on her 6th day of treatment for urinary tract infection with cipro. family states that the patient was slightly more fatigued, but otherwise at her baseline with severe parkinson's disease, and not oriented. patient had good po intake, no other localizing signs. there is a question of a transient ischemic attack 2-3 weeks ago. in the micu, patient was found to have right lateral gaze and deviation, and was sent for head ct scan. past medical history: 1. parkinson's disease. 2. history of multiple falls, status post subarachnoid hemorrhage in , status post right pelvic fracture in . 3. dementia. 4. coronary artery disease, echocardiogram in showed an ejection fraction of 40% with anteroseptal hypokinesis. 5. history of deep venous thrombosis, pulmonary embolus, not currently on anticoagulation. 6. depression. 7. status post ivc filter placement in . 8. history of urinary tract infections with mental status changes. medications: 1. aspirin 325 mg po q day. 2. buspar 10 mg po qid. 3. lactulose. 4. multivitamin. 5. prilosec 20 mg po q hs. 6. remeron 30 mg po q hs. 7. seroquel 25 mg po prn. 8. sinemet 25/100 one tablet po tid. 9. trazodone 50 mg po tid. 10. tylenol prn. 11. cipro day six. 12. premarin. allergies: no known drug allergies. social history: patient lives with her daughter. there is no history of tobacco or alcohol use. family history: noncontributory. physical examination: vitals: pulse 124, blood pressure 147/64, respiratory rate 14, and o2 saturation 100%, vent set at simv respiratory rate of 12, tidal volume of 500, peep of 5, and fio2 of 100%. in general, the patient is awake, but intubated. lungs are clear to auscultation bilaterally anteriorly. cardiovascular: tachycardic, no murmurs, rubs, or gallops. abdomen is soft, nontender, nondistended, normoactive bowel sounds. extremities: 2+ pedal pulses, no clubbing, cyanosis, or edema. neurologic: right lateral gaze deviation, no movement past midline, pupils are equal, round, and reactive to light and accommodation. moves both upper extremities spontaneously, increased rigidity diffusely, babinski upgoing bilaterally. laboratories: white count 18.5, hematocrit 38.2, platelets 505. sodium 140, potassium 4.1, chloride 101, bicarb 21, bun 22, creatinine 1.0, glucose 149. arterial blood gas: 7.36, 41, 233. chest x-ray: rotated, ett in good position, no cardiopulmonary infiltrates. head ct scan: no hemorrhage. electrocardiogram: normal sinus rhythm at 118 beats per minute, left axis deviation, normal intervals, q waves in v1 through v2, no change from . echocardiogram from : ejection fraction of 40%, mild-to-moderate hypokinesis in the anteroseptal and apical walls, rv normal. egd from : hiatal hernia, grade ii esophagitis, barrett's. c-scope from shows grade i internal hemorrhoids. hospital course: in short, this is a 78-year-old female with a history of severe parkinson's, multiple falls, who presents status post choking. patient most likely had temporary-complete airway obstruction and possible pulseless electrical activity. the patient was emergently intubated and required no defibrillation. 1. pulmonary: the patient has no known lung disease. because of her episode and fear of any residual foreign objects, the patient was bronched. this revealed no evidence of upper airway obstruction. patient's vent was changed from simv to cpap with pressure support. she was taking good ventilations with very little sedation. the patient was noted to have very thigh secretions on suctioning. there was a question of aspiration pneumonia especially given elevated white count. discussion took place with the daughter, who is the proxy. decision was made to extubate the patient despite the large volume of secretions. the daughter was well aware of the risks, benefits. if the patient remained intubated, she would be much more likely to develop vent-acquired pneumonia. if she was extubated, there was a significant risk of drowning in secretions. the patient's daughter chose the latter choice, according to her what she thought her mother would want. there was no plan to reintubate once extubated. patient was extubated on . following extubation, the patient became tachypneic and uncomfortable. patient's comfort was maximized with morphine drip. because of the revised goals, the patient was transferred to the floor. the following day, she was transferred to hospice care. 2. heme: the patient was noted to have a hematocrit drop from 38.2 to 30.3. she was also having coffee-grounds suctioned. her hematocrit further decreased to 25. the patient was treated with 2 units of packed red blood cells. her hematocrit came up to 32. the patient had no further coffee-grounds, and he hematocrit stabilized. no nasogastric lavage was performed. hematocrit came up to 32 and remains stable. 3. infectious disease: the patient developed a fever, although her white count came down. fever was up to 101.3. blood cultures and urine cultures were negative. chest x-ray showed no sign of infiltrate. no antibiotics were initiated. 4. neurologic: patient has known severe parkinson's on sinemet. although despite the lateral gaze deviation, the patient's head ct scan was negative. condition on discharge: stable. discharge medications: 1. carbidopa/levodopa 25/100, one tablet po tid. 2. morphine prn. 3. lansoprazole. discharge instructions: the patient is discharged to hospice care. she is to followup with dr. as needed. patient's other medications can be restarted according to the wishes of the family and pcp. discharge diagnoses: 1. respiratory arrest status post foreign object removal. 2. possible pulseless electrical arrest secondary to complete airway obstruction. 3. upper gastrointestinal bleed, status post 2 units of packed red blood cells. 4. parkinson's. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Paralysis agitans Acute respiratory failure Hemorrhage of gastrointestinal tract, unspecified Vascular dementia, uncomplicated Foreign body in larynx Inhalation and ingestion of food causing obstruction of respiratory tract or suffocation

history of present illness: the patient was referred from an outside hospital with a chief complaint of increasing shortness of breath and tires easily with exertion. admitted to hospital in in congestive heart failure at that time. via echocardiogram, found to have aortic stenosis. referred to for cardiac catheterization to further evaluate her aortic stenosis. cardiac catheterization done on showed an aortic valve area of .38 cm.sq., with a mean gradient of 62, and a peak gradient of 85. moderate pulmonary hypertension, pa pressure 48/24, 1+ mitral regurgitation, severe aortic stenosis with an lvedp of 19 and an ejection fraction of 43%. she was then referred to cardiothoracic surgery for aortic valve replacement. past medical history: 1. aortic stenosis 2. diabetes mellitus type 2 3. right hip replacement 4. noninsulin dependent diabetes mellitus medications on admission: include glucovance 5/500 one tablet twice a day, univasc 7.5 mg once daily, lasix 20 mg every other day, and aspirin 325 mg once daily. allergies: no known drug allergies. family history: significant for her father, who died at 50 years from myocarditis. social history: she lives alone in with five stairs. she has a remote tobacco history, quit in , one pack per day for 50 years. no alcohol use. physical examination: vital signs: heart rate 108 and regular, blood pressure 145/76, respiratory rate 20, height 5'2", weight 141 pounds. general: healthy-appearing woman, in no acute distress. skin: no lesions or rashes. head, eyes, ears, nose and throat: pupils equal, round and reactive to light, extraocular movements intact, anicteric, not injected. oropharynx: mucous membranes moist. neck: supple, no lymphadenopathy, no jugular venous distention, no thyromegaly. chest: clear to auscultation bilaterally. heart: regular rate and rhythm, s1, s2, with iii/vi blowing murmur. abdomen: soft, nontender, nondistended, normal active bowel sounds, no hepatosplenomegaly. extremities: warm and well perfused, with no cyanosis, clubbing or edema, no varicosities. neurological: cranial nerves ii through xii grossly intact. moves all extremities. strength 5/5 in upper and lower extremities. sensation intact in all dermatomes. pulses: femoral 2+ bilaterally, dorsalis pedis 1+ bilaterally, posterior tibial 1+ bilaterally, and radial 2+ bilaterally. no carotid bruits were noted. laboratory data: white count 5.3, hematocrit 43, platelets 200. sodium 138, potassium 4.9, chloride 102, co2 25, bun 24, creatinine 0.9, glucose 309. electrocardiogram: rate of 91, first degree av block, intervals .22, .92, .36, with left ventricular hypertrophy. chest x-ray is pending at the time of physical. hospital course: the patient was a direct admission to the operating room on , at which time she underwent an aortic valve replacement. please see the operative report for full details. in summary, she had an aortic valve replacement with a #21 mosaic porcine valve. she tolerated the operation well, and was transferred from the operating room to the cardiothoracic intensive care unit. the patient did well in the immediate postoperative period, however, her blood pressure remained somewhat labile. therefore, she was continued on a neo-synephrine drip to maintain a systolic blood pressure greater than 110. in addition, she was slow to awaken after her anesthesia was reversed, and in several attempts to wean from the ventilator, she developed a respiratory acidosis. she therefore remained on the ventilator throughout the day of postoperative day one. on postoperative day two, the patient remained hemodynamically stable. her neo-synephrine drip was weaned to off. she was again weaned from the ventilator, and successfully extubated. her chest tubes were discontinued and, at the end of the day, she was transferred from the cardiothoracic intensive care unit to the floor for continuing postoperative care and cardiac rehabilitation. after being transferred to the floor, the patient did well. over the next several days, her activity level was increased with the assistance of physical therapy and the nursing staff. she remained hemodynamically stable. her respiratory condition remained stable and, on postoperative day four, she was deemed stable and ready to be transferred to rehabilitation for continuing postoperative care and physical therapy. at the time of transfer, the patient's physical examination is as follows: vital signs: temperature 98.4, heart rate 78 and sinus rhythm, blood pressure 106/50, respiratory rate 18, oxygen saturation 97% on room air. weight preoperatively was 67 kg, at discharge is 70.9 kg. laboratory data on : white count 4.1, hematocrit 23, platelets 144. sodium 141, potassium 4.3, chloride 108, co2 25, bun 24, creatinine 0.8, glucose 140. physical examination: alert and oriented x 3, moves all extremities, conversant. respiratory: scattered rhonchi with diminished breath sounds in the bases. cor: regular rate and rhythm, s1, s2, with soft systolic ejection murmur. sternum is stable. incision with staples, open to air, clean and dry. abdomen: soft, nontender, nondistended, normal active bowel sounds. extremities: warm and well perfused, with no cyanosis, clubbing or edema. discharge medications: ranitidine 150 mg twice a day, enteric-coated aspirin 325 mg once daily, glucovance 5/500 one tablet twice a day, metoprolol 25 mg twice a day, furosemide 20 mg once daily for 14 days, potassium chloride 20 meq once daily for 14 days, colace 100 mg twice a day, niferex 150 mg once daily, percocet 5/325 one to two tablets every four hours as needed, ibuprofen 400 mg every six hours as needed. discharge diagnosis: 1. aortic stenosis status post aortic valve replacement with a #21 mosaic porcine valve 2. diabetes mellitus type 2 3. right hip replacement condition on transfer: stable. discharge instructions: she is to have follow up with dr. in one month, and follow up in the clinic in two weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Acidosis Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Aortic valve disorders Personal history of tobacco use Hip joint replacement

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ftt major surgical or invasive procedure: none history of present illness: 81f w/ dm2, as s/p avr, cirrhosis ? nash, with 5d fatigue, decreased po intake, nausea. mild llq pain w/ no diarrhea per ed, though soft on repeat exam. denies sob, but says that she has had increased tachypnea over last 1.5 weeks. + weight loss, unsure of how much, but has noticed pants and shirts fitting differently. + cough over last few months, unproductive. + long smoking history. no fevers, night sweats, dysuria, cvat. of note, pt. continued to take all medications. per pt., last saw pcp 1 week ago . while in pt remained afebrile and hemodynamically stable on 2l nc with persistent tachypnea in 30s. she did have hypoglycemia to 44, first in transport to hospital, then in ed, which corrected with two amps d50 and start of d51/2 ns. cxr showed a left pleural effusion, and ua showed a uti which was initially treated with vanc/levo/flagyl to cover possible pneumonia and uti. electrolytes showed non-gap metabolic acidosis on vbg. past medical history: 1. aortic stenosis with porcine valve replacement; last ef in system 43% 2. diabetes mellitus type 2 3. right hip replacement 4. noninsulin dependent diabetes mellitus 5. nash social history: she lives alone with neighbor's help. she has a remote tobacco history, quit in , one pack per day for > 50 years, still smoking. no alcohol use. per her report, no cancer screening. family history: significant for her father, who died at 50 years from myocarditis. physical exam: on admission: vitals: t 99.1, bp 111/51, hr 120, rr 32 / 97% on 2l gen: sleepy, frail, cachetic chronically-ill appearing woman heent: perrl, eomi, mm dry, op clear neck: no cv: tachy, nl rhythm, loud murmur over entire precordium pulm: decreased bs l lower lung on lateral/anterior exa, r side clear abd: soft, non distended, nontender, +bs ext: lukewarm extremities, dp 2+ bilaterally neuro/psych: alert and oriented, nl tone, decreased bulk, weak thoroughout 4+/5 strength ue and les. pertinent results: 11:31pm type-mix po2-70* pco2-33* ph-7.22* total co2-14* base xs--13 comments-green top 11:31pm glucose-48* k+-5.4* 09:35pm urine color-yellow appear-cloudy sp -1.014 09:35pm urine blood-lg nitrite-pos protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-5.0 leuk-mod 09:35pm urine rbc-0-2 wbc->50 bacteria-many yeast-none epi-0 09:30pm urine hours-random creat-71 sodium-29 potassium-35 chloride-27 08:31pm glucose-70 lactate-1.3 08:00pm glucose-74 urea n-81* creat-2.0* sodium-134 potassium-5.8* chloride-110* total co2-10* anion gap-20 renal u.s. 2:47 pm renal u.s. reason: arf eval for hydronephrosis medical condition: 81 year old woman with arf, s/p tx for urosepsis, now w decreasing urine output. reason for this examination: eval for hydronephrosis indication: 81-year-old female with acute renal failure. comparison: . renal ultrasound: the right kidney measures 9.9 cm. the left kidney measures 11.6 cm. again seen is a 4.3 cm cyst in the upper pole of the left kidney. there are no stones or hydronephrosis bilaterally. there is a trace amount of ascites. impression: 1. left renal cyst. 2. no stones or hydronephrosis. chest (portable ap) 11:23 am chest (portable ap) reason: ? pulm edema medical condition: 81 year old woman with ascites. reason for this examination: ? pulm edema history: ascites with possible pulmonary edema. findings: in comparison with the study of , there is little change. again there is some enlargement of the cardiac silhouette with indistinct pulmonary vessels consistent with elevated pulmonary venous pressure. left pleural effusion persists. the possibility of pneumonia at the left base can certainly not be excluded in the absence of a lateral view. chest (portable ap) reason: evaluate for interval change medical condition: 81 year old woman with l pleural effusion, ? pna reason for this examination: evaluate for interval change history: left pleural effusion and possible pneumonia, to assess for change. findings: in comparison with the study of , there is again increased opacification at the left base consistent with some combination of effusion, atelectasis, and pneumonia. little overall change. abdomen u.s. (complete study) 2:36 pm abdomen u.s. (complete study) reason: evaluate for ascites, other intraabdominal pathology. pleas medical condition: 81 year old woman with ftt, ascites, history of cirrhosis ? nash. reason for this examination: evaluate for ascites, other intraabdominal pathology. please mark a spot for tapping (paracentesis). indication: 81-year-old female with history of cirrhosis and ascites. evaluate for intraabdominal pathology and mark a spot for tap. comparison: none. abdominal ultrasound: the liver is nodular and coarsened in echotexture consistent with underlying cirrhosis. within the right hepatic lobe, there is a 2.4 x 1.3 cm hypoechoic lesion with second questionable lobulated 4.2-cm lesion seen posteriorly. the gallbladder wall is thickened with a single mobile gallstone seen. a sign was not elicited. there is no intra- or extra-hepatic biliary dilatation. the right kidney measures 10.2 cm. the left kidney measures 11.5 cm. there is a 5.6-cm cyst in the lower pole of the left kidney. there are no stones or hydronephrosis. the spleen is enlarged measuring 16 cm. the visualized portions of the pancreas are unremarkable. there is a moderate amount of ascites within the right lower and left lower quadrants. a spot was marked for tap in the left lower quadrant. impression: 1. nodular and coarsened echotexture of the liver consistent with cirrhosis. 2. two hypoechoic lesions within the right hepatic lobe concerning for hepatocellular carcinoma for which further evaluation with mri is recommended. 3. cholelithiasis. 4. moderate amount of ascites. a spot was marked for tap in the left lower quadrant to be performed by the clinical team. these findings were discussed with dr. on at 5 p.m. chest (portable ap) 9:33 pm chest (portable ap) reason: please r/o acute process medical condition: 81 year old woman with htn, dm2, with fatigue, nausea reason for this examination: please r/o acute process indication: fatigue and nausea. upright ap chest: patient is status post median sternotomy and aortic valve repair. cardiomediastinal silhouette is unchanged. pulmonary vascularity is normal. patchy parenchymal opacity is present at the left base with a left- sided pleural effusion again noted. no pneumothorax, though evaluation of the left apex is limited by patient head positioning. degenerative changes of the left shoulder are partially imaged. impression: persistant left pleural effusion and associated consolidation, likely representing atelectasis though pneumonic consolidation cannot be completely excluded. brief hospital course: a/p: 81yo with ? nash cirrhosis, dm, htn, as s/p avr here w/ klebsiella bacteremia, cnna and arf, initially admitted to the icu and subsequently transferred to the floor. . # uti: patient initially found to have a positive ua with many bacteria, positive leukocuyte esterase and nitrite. she was initially started on levo which was subsequently changed to cipro and then to ceftriaxone to cover both the uti and peritonitis. urine cultures grew pansensitive e. coli and klebsiella sensitive to all but nitrofurantoin. patient will complete a course of ceftriaxone until . . #klebsiella bacteremia- patients blood culture grew out klebsiella. she was intially started on zosyn but after paracentesis done and she was found to have peritonitis, this was changed to ceftriaxone. patient had an episode fo hypotension thought to be secondary to sepsis. she was intially started on pressors in the icu which were quickly weaned. patients subsequent blood cultures had no growth and her blood pressure remained stable. . # spontaneous bacterial peritonitis: patient intially presentd with abdominal pain. patient had an abdominal ultrasound which showed nodular and coarsened echotexture of the liver consistent with cirrhosis and had a moderate amount of ascites. a paracentesis was done which showed 767 polys and the culture was negative. she was initially started on vancomycin and levofloxacin which was then changed to cipro and zosyn. she was then placed on ceftriaxone 1gm iv q24 hours. she was given oxycodone for pain control. she will complete a 2 week course of ceftriaxone for the peritonitis which will be done . . # pulmonary effusion: pt was initially tachynpnic likely attempt to compensate for metabolic acidosis. pulmonary effusion chronic after sternotomy. pt was intially started on vancomycin and flagyl but discontinued as there was no evidence of pneumonia. patients respiratory status improved and did not require further intervention. . # arf: patient intially had a creatinine of 2.1 on admission. she was becoming oliguric, initially thought to be hepatorenal. she was started on albumin, octreotide and midodrine for concern of hepatorenal syndrome. patients candesartan and lasix were held. renal was consulted and felt the acute renal failure was secondary to renal hypoperfusion in the setting of her bacteremia, not hepatorenal. a renal ultrasound was unremarkable. the midrodrine, octreotide and albumin were discontinued. patients creatinine slowly improved during her stay as her bacteremia resolved. her creatinine was 1.6 on discharge. no further intervention was felt necessary, however patient will need closer follow up of her creatinine before she has an mri. . # hyperglycemia-pts glyburide was intially held secondary to acute renal failure as well as pt not having po intake. when she began her po diet, her sugars were noted to be in the 400s. she was started on insulin (nph and regular). this was titrated up for better glucose control. she was sent home on 11u nph qam and 2units qhs. she will continue wiht a sliding scale. she will need outpatient follow up for her glucose control and management of oral agents. she was not sent home on her oral (glyburide) . # liver lesions: abd u/s showed two hypoechoic lesions within the right hepatic lobe concerning for hepatocellular carcinoma for which further evaluation with mri is recommended. lesions could be hcc vs. metastases. pt also reports significant weight loss. an afp was 2.7. an mri was not done because the patient had acute renal failure and her creatinine had not come down enough before discharge. she will need an mri with contrast once her creatinine improves. . # diarrhea: patient has history of diarrhea on lomotil at home. patient recently started on cephalosporin prior to admission. she did not have loose stool during her stay. c. diff cultures were negative x3. . #htn: the patients medications were changed from toprol xl to 25mg metoprolol given intial hypotensive episode in icu. . # anemia: patient has a microcytic anemia felt to be iron deficiency. she was started on iron supplements. . # nutrition-the patient was evaluted by speech adn swallow because it appeared that she had difficulty tolerating a regular diet without an aspiration risk. she was cleared for a soft solid diet with nectar thickened liquids. she also needs to take her pills with purees. . # access: a midline was placed on to continue her antibiotic course. . # code: dnr/dni medications on admission: glyburide5 b.i.d., lasix 40mg three days a week, toprol xl 100mg, aspirin 81mg, lovenox subcutaneous, vytoren 10/40mg, atacand 8mg, senna percocet prn dulcolax prn discharge medications: 1. ceftriaxone 1 gm iv q24h day 1 = . 2. insulin regular human 100 unit/ml cartridge sig: one (1) 11u qam, 2u qhs injection once a day: please get 11u insulin qam and 2u qhs. 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 7. vytorin 10-40 10-40 mg tablet sig: one (1) tablet po once a day. 8. insulin lispro 100 unit/ml cartridge sig: 1-10 units subcutaneous qachs as needed for sliding scale. 9. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 10. mri pt needs to follow up with dr and have him order an mri with gadolinium to evaluate liver lesions discharge disposition: extended care facility: - discharge diagnosis: urosepsis peritonitis acute renal failure discharge condition: improved discharge instructions: you were admitted to the hospital for a bacterial infection. you were found to have bacteria in your urine and your blood. you were also found to have an infection called peritonitis. you were treated with antibiotics. you will continue to receive the antibiotic ceftriaxone to complete a 2 week course () . you were also found to have some incidental lesions on your liver found on an abdominal ultrasound. we were unable to get an mri of your liver because one of your labs called creatinine was elevated which measures your kidney function. you will need to wait to get the mri until this creatinine improved to characterize these lesions. we have stopped your atacand and lasix. you were started on iron supplements. your toprol xl was changed to metoprolol 25mg twice daily. your glyburide was stopped. you were started on insulin. if you have any fever, chills, abdominal pain, nausea, vomiting, chest pain, shortness of breath, diarrhea, or any other symptom that concerns, please call your pcp or return to the er> please follow up with dr per your scheduled appointment in . followup instructions: please follow up with dr per your scheduled appointment on at 3:30pm pt will need an mri once creatinine improves to evaluate the lesions found on her liver on ultrasound. Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Acidosis Hyperpotassemia Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Bacteremia Iron deficiency anemia, unspecified Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Other ascites Diarrhea Spontaneous bacterial peritonitis

discharge status: home with his . primary pediatric care: will be provided by dr. of pediatrics. care recommendations: 1. feedings: the infant is feeding enfamil 20 on an ad lib schedule. 2. medications: the infant is discharged on no medications. 3. the infant passed a car seat oxygenation test on . 4. a state screen was sent on . 5. immunizations received: the infant received his hepatitis b vaccine on . discharge diagnosis: 1. term male 2. status post transitional respiratory distress 3. sepsis ruled out 4. status post apnea due to immature respiratory pattern , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation 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 Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 2,500 grams and over Routine or ritual circumcision

past medical history: 1. atrial fibrillation. 2. hypothyroidism. 3. hypertension. 4. sleep apnea, requiring bipap p.r.n. at night. 5. psoriasis. 6. benign prostatic hypertrophy. past surgical history: 1. right inguinal hernia repair. 2. transurethral resection of the prostate. 3. cryoablation by electrophysiology service. 4. right nephrolithiasis. 5. thyroid biopsy. medications on admission: 1. coumadin 5 mg alternating with 2.5 mg. 2. amiodarone. 3. lipitor. 4. levoxyl. 5. accupril. 6. norvasc. 7. multivitamins. 8. folate. 9. vitamin b6 and b12. 10. . 11. temazepam p.r.n. at night with bipap. allergies: no known drug allergies. social history: the patient is a psychologist. he currently lives alone. he has a son living nearby for support. history of smoking; quit in . prior alcohol was three drinks per night. the patient states that he quit three months ago to admission. family history: the patient's father is deceased at the age of 56 from a cva. mother deceased at 86 due to breast cancer. laboratory data: preoperative laboratory data: wbc 5.3, hematocrit 38.4, platelet count 255,000. sodium 138, potassium 4.8, chloride 102, co2 27, bun 21, creatinine 1.1, glucose 77, pt 16.4, inr 1.9, ptt 28.9. cardiac catheterization performed on . please see the cardiac catheterization report for full details. summary: left ventriculography revealed 4+ mr with normal wall motion and ef estimated between 50% to 60%. lvedp 2. the lmca had a mild plaque. the lad had a mid 40% lesion. the lcx had minimal luminal irregularities. the rca had minimal lumen irregularities. physical examination: examination revealed the following: the patient presented asymptomatically. vital signs were noted normal. heent: unremarkable. heart sounds were irregular with a noted systolic murmur. lungs: lungs were clear to auscultation. abdomen: abdomen revealed no masses, but soft and nontender. extremities: palpable pulses, no varicosities identified. the patient was evaluated in preadmission testing on of this year for preoperative evaluation of the mitral valve replacement scheduled on . the patient was admitted to on , where he was brought to the operating room. please see the operating room report for full details. in summary, the patient underwent an aortic valve replacement with - #25 and a mitral valve repair with #26. the patient tolerated the operation well, and the patient was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was on epinephrine 0.03 mcg per kilogram per minute; neo-synephrine 0.3 mcg per kilogram per minute; and propofol. the patient did well immediately postoperatively. he was weaned from his inotropes and pressor support. the anesthesia was reversed. he weaned from the ventilator and he was successfully extubated. the patient remained hemodynamically stable on postoperative day #1. he continued to be atrial paced. he was transferred to the floor on postoperative day #1. the patient was noted to return to the baseline of atrial fibrillation on postoperative day #2. the amiodarone bolus was administered and po amiodarone was initiated and coumadin for anticoagulation. over the next several days, the patient continued to make slow progress with the assistance of the nursing staff in the department of physical therapy. the patient did receive two units of blood while on the floor on and , where the hematocrit progressed from 22 to 24 and remained stable at 27.7 with anticoagulation. the patient's epicardial wires were discontinued on postoperative day #3. the patient continued to be hemodynamically stable with increased activity level and continued with pulmonary toilet. rehabilitation screen was performed on postoperative day #3. on postoperative day #4, the patient remained hemodynamically stable and the patient is ready to transfer to a rehabilitation facility to continue pulmonary care and increased activity levels and regain strength. anticipated discharge is tomorrow a.m. . physical examination presently revealed a temperature of 99.2, heart rate 80s to 90s in atrial fibrillation, lopressor was increased today from 12.5 to 25 b.i.d. blood pressure 130s to 140s/70. respiratory rate 20. the patient is on room air saturating between 93% to 95%. preoperative weight is 95 pounds. current weight as of today is 207.4 pounds. laboratory data: chemistries from revealed the following: sodium 138, potassium 4.7, chloride 104, co2 23, bun 20, creatinine 1.0, glucose 129. cbc from revealed the following: wbcs 10.2, hemoglobin 8.8, hematocrit 27.7, platelet count 145,000. goagulations on revealed pt of 13.8 with inr of 1.3. the patient is to have hematocrit and pt level re-evaluated in the morning and have coumadin dosed accordingly. physical examination: the patient neurologically is alert and oriented and moving all extremities. the patient follows commands. respiratory: the patient continues on room air. he has no dyspnea, no cough, no wheeze. respiratory rate is unlabored. he does have rales in the left base. cardiac: s1 and s2 irregular, no rub or murmur appreciated. gi: abdomen is distended. it is soft and nontender. he does have bowel sounds in four quadrants. he reports no nausea or vomiting. he is passing flatus, but he has not had a bowel movement. he continues on milk of magnesia and colace. extremities: there was no pedal edema appreciated. legs are warm and well perfused bilaterally. wound: sternal incision is open to air, dry, intact with steri strips. sternal incision has no drainage or no erythema. the patient does have approximately 1 cm subcutaneous emphysema area on the right clavicular area approximately 1 cm. discharge medications: 1. lipitor 10 mg po q.d. 2. levothyroxine sodium 125 mcg po q.d. 3. enteric coated aspirin 81 mg po q.d. 4. amiodarone 200 mg po b.i.d. 5. lopressor 25 mg po b.i.d. 6. lasix 20 mg po b.i.d. times two weeks. 7. 20 meq po b.i.d. times two weeks. 8. coumadin dose adjusted for goal inr of 2.0 to be checked daily. current coumadin doses given , 2 mg; , 5 mg; , 5 mg; , 5 mg for inr of 1.3. repeat pt/inr pending on am day of discharge. 9. milk of magnesia 30 cc po q.6h.p.r.n. constipation. 10. colace 100 mg po b.i.d. 11. oxycodone-acetaminophen one to two tablets po q.4h. p.r.n.pain. discharge diagnoses: 1. valvular disease status post aortic valve replacement -, #25, and mitral valve replacement with #26. 2. atrial fibrillation. 3. hypothyroidism. 4. hypertension. 5. sleep apnea with bipap p.r.n. at night. 6. psoriasis. die disposition: this patient is to be discharged to rehabilitation. he is to followup in the clinic in one week. he is to followup with dr. in four weeks post discharge. he is to followup with the primary care physician three weeks post discharge. he is to followup p.r.n. with the cardiologist at his primary physician's discretion. note: the patient is discharged to rehabilitation. the patient has a history of sleep apnea requiring bipap at home. the patient has not required the support of bipap during hospitalization. , m.d. dictated by: medquist36 d: 15:08 t: 15:24 job#: 1 1 1 dr Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Open heart valvuloplasty of mitral valve without replacement Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Mitral valve insufficiency and aortic valve insufficiency Long-term (current) use of anticoagulants Precipitous drop in hematocrit Insomnia with sleep apnea, unspecified

allergies: percocet / inderal la / lopressor / sotalol / ultram / opioid analgesics attending: chief complaint: dyspnea major surgical or invasive procedure: ablation right atrial foci history of present illness: mr. is an 80 year-old male with a history of avr/mvr who is being transferred from an osh for vtach. . over the last few months, has had increasing dyspnea on exertion. prior to , he could walk for a few hundred yards without doe. now he has difficulty walking more than 20 yards or one flight of stairs. since his aaa in , he has also noticed significant lower extremity edema. . on the day of transfer, was admitted to an osh on with severe respiratory distress. he complained of two days of sob, but he did not initially want to go to the hospital. overnight (-->) he experienced extreme sob at 4am (after waking to use the bathroom) and called ems. upon arrival to the osh ed, was in extreme respiratory distress, responsive, but unable to talk. vitals showed bp 192/110 hr 108 rr 20 temp 96.7 o2 sat 96% on ra. an ekg showed ivc which was suspicious for slow vtach so an amiodarone drip was started. a cxr showed heart failure and a nitro drip was started and 80mg iv lasix was given with >1 liter of urine output resulting. cpap was also used. . prior to transfer, had another episode of vtach at 1:45pm. . currently, the patient is feeling significantly improved. his sob is resolved and he states that his breathing is almost at it's baseline. he denies any chest pains, palpatations. he did have some mild nausea on arrival, which he atributes to a bumpy ambulance ride. he remains on a nitro gtt. past medical history: s/p aaa repair at hypertension hyperlipidemia valvular heart disease s/p bioprosthetic avr s/p mitral valve repair in atrial fibrillation/flutter bph anxiety hypothyroidism obstructive sleep apnea social history: the patient lives in his own home. one of his sons has been staying with him recently as he is between jobs. he has two sons. has a girlfriend. the patient continues to work at as a clinical psychologist. he reports smoking for 20 years but quit ~40 years ago. rare etoh. . adls/iadls: the patient is independent with his adls/iadls. he continues to drive and does not report any near misses. . advanced directives: the patient's son is his hcp. family history: nc physical exam: blood pressure was 134/69 mm hg while sitting in bed. pulse was 86 beats/min and regular, respiratory rate was 19 breaths/min with an oxygen saturation of >95% on 2 liters. generally the patient was well developed, well nourished and well groomed. the patient was oriented to person, place and time. the patient's mood and affect were not inappropriate. . there was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. the neck was supple with jvp 2-3cm above the neck at 45%. the carotid pulse was easily palpable. there was no thyromegaly. the chest wall showed pectus excavatum. the respirations were not labored and there were no use of accessory muscles. the lungs showed bibasilar crackles with good air movement. . palpation revealed no thrills, lifts or palpable s3 or s4. the heart sounds revealed a harsh midsystolic murmur at the aortic site. . there was no hepatosplenomegaly or tenderness. the abdomen was soft nontender and nondistended. the extremities had no pallor, cyanosis, clubbing. there was + bilateral edema. there were no abdominal, femoral or carotid bruits. inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: 05:23pm glucose-141* urea n-22* creat-1.3* sodium-137 potassium-4.0 chloride-101 total co2-29 anion gap-11 05:23pm estgfr-using this 05:23pm alt(sgpt)-42* ast(sgot)-35 ld(ldh)-312* ck(cpk)-82 alk phos-97 tot bili-0.7 05:23pm ck-mb-notdone ctropnt-0.02* 05:23pm calcium-8.3* phosphate-3.3 magnesium-2.4 05:23pm wbc-10.1# rbc-4.44*# hgb-11.8*# hct-35.6* mcv-80*# mch-26.6* mchc-33.2 rdw-17.5* 05:23pm plt count-208 05:23pm pt-35.0* ptt-32.9 inr(pt)-3.8* . ct head findings: comparison is made to and . . the tiny hyperdensity of the left centrum semiovale is again visualized which is not significantly changed. there is no surrounding vasogenic edema. this finding may represent a calcification. . no intracranial hemorrhages are identified. the /white matter differentiation is maintained. again seen are extensive periventricular hypodensities consistent with small vessel ischemic changes and small watershed infarcts of the right frontal and occipital lobes. the ventricles and extra-axial csf spaces are unchanged. . the visualized orbits are normal. the visualized paranasal sinuses and mastoid air cells are clear. no suspicious bony abnormalities are seen. . impression: no intracranial hemorrhages. no significant change in tiny hyperdensity of the left centrum semiovale which likely represents a calcification. . echo general comments: suboptimal image quality - poor echo windows. conclusions: the left atrium is markedly dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. a bioprosthetic aortic valve prosthesis is present. the transaortic gradient is at the upper limit of normal for this prosthesis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. a mitral valve annuloplasty ring is present. the mitral annular ring appears well seated and is not obstructing flow. no mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . impression: mild left ventricular hypertrophy with preserved regional/global biventricular systolic function. marked biatrial dilation. mild aortic regurgitation in the presence of a bioprosthetic avr. gradients across avr at at upper limits of normal. mitral valve annuloplasty ring appears well seated. gradients across ring also at upper limits of normal. mild pulmonary hypertension. mildly dilated thoracic aorta. brief hospital course: 80 year-old male with a history of cad, atrial fibrillation s/p avr/mvr who was transferred from from an osh for concern for ventricular tachycardia. on arrival his ekg's were as follows: ekg #1 (; osh): wide complex tachycardia with a rate of 110. ekg #2 (; ): nsr with a 1st degree av block. lad; possible . loss of r-waves in precordial leads (old). lvh electrophysiology consult was placed and it was felt that this was more likely a supraventricular tachycardia in the setting of a bundle branch block. plan was for evaluation and possible ablation in the electrophysiology lab however we had to wait several days as his inr was supratheraputic. once inr < 2 he went to ep lab and had ablation of atrial tachycardia focus. . 1. respiratory distress: the patient's examination and cxr were most consistent with pulmonary edema. he responded well to lasix and a nitro gtt. regarding possible causes for this, he was hypertensive on admission to the osh which may have been a precipitant, as well as his tachycardia. he has significant valvular disease and symptoms of both right and left heart failure. the patient diuresed appropriately on lasix and was weaned down to room air satting 96% for several days before discharge. he is discharged on lasix in addition to his usual medications. in addition, his ace dose was increased to 20 mg. an echo demonstrated preserved ejection fraction, mitral and aortic gradients at upper level of normal, and left ventricular hypertrophy, as noted above in the reports section. . 2. wide-complex tachycardia: the rhythm had a wide qrs with a rate in the 110-120 range, most likely ventricular tachycardia. the patient presented to the osh on amiodarone and was given a drip; by the time he arrived at , he was in nsr with a long pr-interval, and amiodarone was discontinued. enzymes were within normal limits. he did have a few episodes of this tachycardia on telemetry, during which he remained asymptomatic. his inr was elevated which delayed by a few days ep study. ep study demonstrated several right atrial foci, which were ablated on with no complications. his beta blocker was continued. . 3. hypertension: his ace inhibitor was uptitrated and he was continued on his beta blocker. 4. atrial fibrillation/flutter: the patient is s/p at least two attempts at ablation (', ') and a recent cardioversion. reports that he has been in sinus since the cardioversion. his initial inr was 3.8 so coumadin was held, and reintroduced just prior to discharge. given his amiodarone use, liver and thyroid tests were performed, which were essentially normal except for alt 42 and ldh 312. . 5. hyperlipidemia: - continued atorvastatin . 6. anxiety: - continued ativan . 7. hypothyroidism: - continued levothyroxine . 8. hematuria: the patient had his foley pulled out about one week prior to discharge, and he immediately passed bright red blood and then was unable to void for several hours. foley catheter was reinserted and he was started on continuous bladder irrigation as well as proscar to treat prostatic bleeding. the next day, flushes and irrigation were not easy to retrieve through the foley, and some clots were visible. the patient developed significant pain and chills. urology was consulted. blood and urine cultures grew pansensitive e coli, and the patient was put on ceftriaxone with rapid improvement in his symptoms. urology followed the patient and one day prior to discharge, his foley was pulled. the patient was able to void normally with no post void residual. his hematuria had resolved 2 days prior to discharge. he will need to follow up with urology as an outpatient. . 9. s/p fall - he was in the bathroom and tripped on edge of shower hitting his head on the hand rail. the fall was witnessed, no loss of conscious, however his inr was supratheraputic so he had a head ct which did not show any evidence of intracranial hemorrhage. he did well following this incident with no complications. . 10.contact- ***dr son - medications on admission: 1. aspirin 81 mg daily 2. carvedilol 12.5 mg 3. lisinopril 5 mg daily 4. amiodarone 300 mg daily --> increased to 400mg at osh. 5. atorvastatin 10 mg daily 6. warfarin 10 mg daily 7. levothyroxine 125 mcg daily 8. ativan 0.5 mg p.o. qhs p.r.n. daily. 9. ketaconazole cream topical . 10. testosterone injections every two weeks discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 5. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: wide complex tachycardia bacteremia urinary tract infection hematuria discharge condition: stable. ambulatory on room air. sinus rhythm. normal urination discharge instructions: admitted for an abnormal rhythm in your heart. the places in the heart that were causing the abnormal rhythm were ablated by the electrophysiology service. please keep your follow up appointments and take all your medications. new medications have been added to your regimen. you developed also hematuria (blood in your urine)and an infection in your bladder and bloodstream, which was treated with antibiotics. you need to follow up with urology. call your doctor or go to the ed if you feel any symptoms that concern you, for example chest pain, shortness of breath, further bleeding, or others. see your primary care doctor as soon as possible to resume your usual health care and inr checks. followup instructions: call your primary care doctor within one week of discharge call your urologist within two weeks. call your cardiologist within two weeks. also see: provider: , m.d. phone: date/time: 11:00 Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Cardiac mapping Diagnoses: Obstructive sleep apnea (adult)(pediatric) Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Atrial flutter Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Bacteremia Heart valve replaced by transplant Infection and inflammatory reaction due to indwelling urinary catheter

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever and ha major surgical or invasive procedure: ij catheter placement history of present illness: 42m with h/o hiv/aids, last cd4 312 and h/o bacterial and crytopcoccal meningitis presents to ed with complaint of fever to 101-102 and ha over the last seven days. ha is new, gradual in onset, steady and unremitting in intensity. he rates pain at worst between . states he had taken taken tylenol initially for relief but has since been ineffective. evaluated by pcp 3 days pta, no intervention at that time except recommendation to return to ed if ha persisted. pt endorses mild photophobia nad neck stiffness, no other symptoms. no chills, no n/v, no cp or sob, no urinary changes except "dark urine." in ed, ct negative, lp also essentially negative (protein and glucose normal, tube 4 with 2 wbc and no rbc, 88% lymphocytes). transient hypotension in ed, predominantly 90/50s, eventual response to fluid. received 2g ctx and 1g vanco in ed, as well as 6 liters ns. admitted to micu under must protocol, initial lactate 5.0. past medical history: 1. hiv/aids, last cd4 312, nadir 135 in 2. hepatitis b 3. hepatitis c 4. pancytopenia hiv, baseline hct 35 and baseline plt 80 5. distant h/o cryptococcal menigitis 6. distant h/o bacterial menigitis 7. distant h/o e.coli sepsis 8. h/o sti including chlamydia, molluscum, herpes 9. h/o psa 10. h/o oral candidiasis 11. s/p l herniorrhaphy social history: uses tobacco, approximately 1 pack weekly, denies alcohol or ivdu currently. pt is currently unemployed but was a former airline analyst. lives with roommate. family history: nc physical exam: t 101.5 in ed, 96.5 in micu bp 120/66 hr 92 rr 15 sats 100% ra gen: pt lethargic but appears ok, nad heent: ncat, perrla, eomi, conjunctiva non-injected, sclerae with mild icterus cv: rrr s mrg, flat neck veins lungs: ctab, good air movement abd: sntnd, +bs, no hsm appreciated. ext: 2+ ble pulses, no peripheral edema. 1-2 cm purplish blanching lesions on ble that are chronic, appear c/w chronic venous stasis change neuro: ao x 3, mae, neuro grossly intact pertinent results: 11:04pm lactate-2.7* 10:30pm cerebrospinal fluid (csf) protein-25 glucose-56 10:30pm cerebrospinal fluid (csf) wbc-2 rbc-0 polys-0 lymphs-88 monos-6 macrophag-6 10:10pm lactate-3.4* 09:30pm urine color-yellow appear-cloudy sp -1.013 09:30pm urine blood-lg nitrite-pos protein-500 glucose-neg ketone-neg bilirubin-sm urobilngn-1 ph-6.5 leuk-mod 09:30pm urine rbc->50 wbc->50 bacteria-many yeast-none epi-0 05:39pm lactate-5.0* 05:32pm glucose-125* urea n-50* creat-3.7*# sodium-120* potassium-5.0 chloride-85* total co2-22 anion gap-18 05:32pm albumin-2.5* calcium-8.3* phosphate-2.0* magnesium-1.6 brief hospital course: a/p 42m with h/o hiv/aids, hep b and c, distant h/o cryptococcal and bacterial meningitis with uti, septic shock, likely secondary to urinary source. also with resolving hyponatremia, arf, metabolic acidosis, anemia, concerning mental status changes, new abdominal distension. . 1. septic shock: patient with sirs plus suspected source of infection given ua, hypotension and evidence of inadequate end-organ perfusion. initial wbc in ed 24.0, lactate 5.0. blood/urine cx growing e.coli, pansensitive to antibiotics. lp in the ed was negative for infxn. pt was admitted to icu, administered aggressive ns ivf hydration, given vanco/ctx for empiric abx coverage until e.coli was isolated, and vanco was discontinued. pt was discharged on a course of cefpodoxime to complete a 14 day course for e.coli bacteremia. . 2. hyponatremia: due to infxn and hypovolemia, corrected with ivf hydration. . 3. mental status changes: initially seen in micu in setting of infection, long-term hiv and rapid sodium correction and liver disease. lp was negative for infxn. resolved with treatment of infection. . 3. arf: pre-renal in etiology given patient's hypovolemic and distributive picture, but differential includes hrs. fena 0.9%, which does not help in differenting prerenal vs. hrs. creatinine trended down during admission from 3.7 ---> 1.8 on discharge to be followed up as an outpatient. his previous baseline had been 0.9-1.2. . 4. anemia: hct stable 27.4 today (27.1 yest). slow to return to baseline 36-37. . 5. hiv: pt with h/o hiv, hepatitis. initially haart held due to metabolic acidosis in setting of arf and sepsis. haart was restarted prior to discharge once patient was stable and infection was under treatment. pt with elevated . 6. hepatitis pt with hx of hep b/c, during this admission found to have elevated afp, but patient declined further w/u at this time. pt to consider mri as outpatient to r/o hcc. no mass seen on abd u/s. . dispo - full code. pt to f/u with dr. as an outpatient. medications on admission: 1. abacavir sulfate 300mg 2. bactroban 2%--apply to open sore twice a day 3. efavirenz 600mg qhs 4. lamivudine 300mg q day 5. nadolol 30 mg daily 6. protonix 40 mg po bid 7. temazepam 15mg prn qhs 8. tenofovir 300mg po daily 9. tobradex 0.3-0.1%--two gtts each eye twice a day 10. zoloft 50 mg po daily discharge medications: 1. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 2. tobramycin sulfate 0.3 % drops sig: two (2) drop ophthalmic (2 times a day). disp:*1 bottle* refills:*0* 3. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. spironolactone 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. abacavir 300 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. efavirenz 600 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 8. lamivudine 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po every other day. disp:*15 tablet(s)* refills:*0* 10. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days. disp:*8 tablet(s)* refills:*0* 11. nadolol 20 mg tablet sig: 1.5 tablets po daily (daily). disp:*45 tablet(s)* refills:*2* 12. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. discharge disposition: home discharge diagnosis: primary: e.coli bacteremia/sepsis from urinary source secondary: hiv, hepatitis b, hepatitis c discharge condition: stable, afebrile >48 hours. ambulating without difficulty. discharge instructions: 1. please follow up with dr. in 1 week. please call ( to schedule a follow up. . 2. take the medications as directed below. . 3. if develop urinary pain or burning, fevers or chills, temperature >101, lightheadedness, or any symptoms, please call dr. or proceed to the nearest er. followup instructions: 1) primary care provider: , m.d. where: phone: date/time: 6:40 - your blood pressure has been high during your hospital course. this should be monitored closely as an outpatient. 2) renal please call to schedule an appointment with dr. at () to be seen within 2 weeks following discharge md Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Acidosis Thrombocytopenia, unspecified Urinary tract infection, site not specified Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Human immunodeficiency virus [HIV] disease Septic shock Septicemia due to escherichia coli [E. coli] Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: cardiac catheterization. avr (#25 ce pericardial), cabg x 4 (lima>lad, svg>diag>om, svg>pda) on history of present illness: 67 yom progressively doe on exertion for one week with associated chest pressure. the patient presented to podiatry, and was found to be in hf. referred to osh ed for evaluation which found hf and nstemi. transferred to for further cardiac evaluation. past medical history: dm ii pad htn dyslipidemia smoking history spinal stenosis djd peripheral neuropathy osa, not on cpap social history: quit smoking 25 years ago. prior 3ppdx 15-20 years. etoh /wk. no other drugs. family history: cad in father in mid 60s. no dm. no scd. physical exam: exam: 90% on nonrebreather jvp 10cm crackles 1/3 up bilaterally + 1 le edema discharge vitals 98.6 sr 71 105/53 22rr, ra sat 90-92% wt 84kg neuro a/ox3 non focal mae rleg 5/5 l leg pulm fine crackles bilat bases cardiac rrr no murmur/rub/gallop gi abd soft, nt, nd, +bs bm ext warm pulses palpable +1 edema incision sternal healing no erythema/drainage sternum stable, steris left leg - evh steris healin no erythema/drainage pertinent results: 05:55am blood wbc-11.3* rbc-3.36* hgb-9.9* hct-29.7* mcv-89 mch-29.5 mchc-33.3 rdw-14.0 plt ct-391 06:15pm blood wbc-10.2 rbc-3.49* hgb-10.8* hct-31.9* mcv-91 mch-30.8 mchc-33.8 rdw-13.5 plt ct-265 07:00am blood neuts-75.7* lymphs-15.4* monos-4.7 eos-3.6 baso-0.5 06:15am blood pt-20.8* inr(pt)-2.0* 05:55am blood plt ct-391 06:15pm blood pt-13.6* ptt-26.2 inr(pt)-1.2* 06:15pm blood plt ct-265 05:55am blood pt-18.6* ptt-29.9 inr(pt)-1.8* 10:15am blood pt-19.6* ptt-29.1 inr(pt)-1.9* 12:00pm blood plt ct-431 12:00pm blood pt-17.6* ptt-27.8 inr(pt)-1.6* 03:55am blood pt-15.8* ptt-26.6 inr(pt)-1.4* 06:15am blood creat-1.6* k-4.5 05:55am blood glucose-47* urean-28* creat-1.4* na-140 k-4.5 cl-104 hco3-29 angap-12 06:15pm blood glucose-131* urean-35* creat-1.3* na-140 k-4.0 cl-108 hco3-21* angap-15 12:00pm blood calcium-9.1 phos-3.8 mg-2.5 07:47am blood caltibc-238* vitb12-542 folate-greater th ferritn-421* trf-183* 06:15pm blood %hba1c-6.7* -done -done 07:47am blood triglyc-120 hdl-49 chol/hd-3.8 ldlcalc-112 ekg sinus rhythm right bundle branch block consider septal myocardial infarction, age indeterminate st-t wave abnormalities - cannot exclude in part ischemia - clinical correlation is suggested since previous tracing of , no significant change read by: , w. intervals axes rate pr qrs qt/qtc p qrs t 85 178 140 37 110 cxr chest (pa & lat) 9:13 am chest (pa & lat) reason: r/o inf, eff medical condition: 67 year old man with nstemi, chf, fever. reason for this examination: r/o inf, eff indication: chf, fever. rule out infiltrate or effusion. comparison: multiple x-rays from to . pa and lateral radiographs of the chest: there has been slight improvement to the bilateral perihilar airspace opacities. underlying cystic lucencies are becoming more prominent, which may be due to pre-existing emphysema or pneumatoceles from recent barotrauma. loculated left pleural effusion is unchanged. the patient is status post median sternotomy, cabg, and avr. impression: slight improvement in bilateral interstitial opacities which may represent asymmetrical edema, though with a new history of fever, infection is also a possibility. underlying cystic lucencies may represent pre-existing emphysema or pneumatoceles from recent barotrauma. the study and the report were reviewed by the staff radiologist. dr. dr. approved: mon 1:13 pm tee patient/test information: indication: coronary artery disease. h/o cardiac surgery. left ventricular function. valvular heart disease. height: (in) 69 weight (lb): 198 bsa (m2): 2.06 m2 bp (mm hg): 146/59 hr (bpm): 86 status: inpatient date/time: at 13:18 test: portable tte (complete) doppler: full doppler and color doppler contrast: none tape number: 2007w018-1:03 test location: west micu technical quality: adequate referring doctor: dr. measurements: left atrium - long axis dimension: *5.5 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.8 cm (nl <= 5.2 cm) right atrium - four chamber length: *6.0 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: *5.8 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 20% to 25% (nl >=55%) aorta - valve level: 2.7 cm (nl <= 3.6 cm) aortic valve - peak velocity: 1.9 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.1 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.38 mitral valve - e wave deceleration time: 213 msec interpretation: findings: this study was compared to the prior study of . left atrium: moderate la enlargement. left ventricle: mild symmetric lvh. mildly dilated lv cavity. severely depressed lvef. no resting lvot gradient. no vsd. right ventricle: moderate global rv free wall hypokinesis. aorta: normal aortic diameter at the sinus level. aortic valve: bioprosthetic aortic valve prosthesis (avr). avr well seated, normal leaflet/disc motion and transvalvular gradients. no ar. mitral valve: mildly thickened mitral valve leaflets. mild to moderate (+) mr. eccentric mr jet. tricuspid valve: mildly thickened tricuspid valve leaflets. pericardium: no pericardial effusion. conclusions: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. overall left ventricular systolic function is severely depressed with global hypokinesis. there is no ventricular septal defect. there is moderate global right ventricular free wall hypokinesis. a bioprosthetic aortic valve prosthesis is present (not well seen, but by op note, a magna tissue valve was placed on ). the aortic prosthesis appears well seated with normal transvalvular gradients. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. compared to the prior study dated , the lvef and rvef are now lower. by report (not well seen) an aortic valve bioprosthesis is now present. the degree of mitral regurgitation is similar. electronically signed by , md on 15:06. physician: , brief hospital course: cardiac catheterization here showed severe 3 vd. cardiac surgery was consulted and he underwent preoperative workup and awaited diuresis and plavix washout. he was also placed on levofloxacin for presumes pneumonia. on he was taken to the operating room where he underwent a cabgx4 and avr with tissue valve. he was transferred to the icu in critical but stable condition on milrinone and levophed. he was extubated and weaned from his vasoactive srips on pod #1. he was started on amiodarone on pod #2 for intermittent atrial fibrillation. he became bradycardic, and was seen by electrophysiology who recomended contining po amio and using lopressor instead. he should also follow up with dr. in 6 weeks for an icd evaluation given his ventricular ectopy. he was also started on coumadin for his a fib. he was transferred to the floor on pod #5. on pod #7 he was transferred back to the icu for hypotension after his ace inhibitor and beta blocker were increased aggreseively. his doses were decreased, his blood pressure improved and he was transferred back to the floor on pod #8. pulmonary was consulted and will follow up with him as an outpatient. he continued to progressed and was ready for discharge to rehab on pod 12 with of hearts monitor. medications on admission: labetalol 200 mg qd norvasc 10 mg qd actos 30 mg qd glipizide 10 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:*0* 2. atorvastatin 20 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 3. glipizide 10 mg tab,sust rel osmotic push 24hr sig: one (1) tab,sust rel osmotic push 24hr po daily (daily). disp:*30 tab,sust rel osmotic push 24hr(s)* refills:*0* 4. pioglitazone 15 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 9. amiodarone 400 mg tablet sig: one (1) tablet po twice a day: 400 x 1 week, then 200 mg daily for three weeks. 10. furosemide 40 mg tablet sig: one (1) tablet po twice a day. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. warfarin 2 mg tablet sig: one (1) tablet po once a day: please take and - check inr . 13. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. discharge disposition: extended care facility: rehab & nursing center - discharge diagnosis: as cad dm htn djd sleep apnea peripheral neuropathy discharge condition: good discharge instructions: of hearts monitor - twice a day readings to holter lab at shower, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: with dr. after discharge from rehab with dr. in 4 weeks dr. after discharge from rehab dr. (ep) please call to schedule ( please call to schedule all appointments of hearts monitor - holter lab ( - dr to follow provider: function lab phone: date/time: 2:30 provider: , intepretation billing date/time: 2:30 provider: . /dr. phone: date/time: 3:30 pt/inr as needed first draw goal inr 2.0-2.5 for atrial fibrillation sleep study to evaluate for sleep apnea after recovery from surgery Procedure: (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Chronic kidney disease, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction Rheumatic heart failure (congestive) Long-term (current) use of anticoagulants Mitral valve insufficiency and aortic valve stenosis Family history of ischemic heart disease Unspecified hereditary and idiopathic peripheral neuropathy

allergies: patient recorded as having no known allergies to drugs attending: addendum: pt retained until to make sure she remained afebrile. discharged to home as planned. discharge disposition: home md Procedure: Endoscopic sphincterotomy and papillotomy Cholecystectomy Endoscopic insertion of stent (tube) into bile duct Open and other right hemicolectomy Reopening of recent laparotomy site Transfusion of packed cells Incisional hernia repair Other percutaneous procedures on biliary tract Repair of other bile ducts Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Accidental puncture or laceration during a procedure, not elsewhere classified Hemorrhage complicating a procedure Incisional hernia without mention of obstruction or gangrene Diverticulitis of colon (without mention of hemorrhage) Acute and chronic cholecystitis Intussusception

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: crampy abdominal pain major surgical or invasive procedure: right colectomy with cholecystectomy () percutaneous drain placement () re-exploration () history of present illness: ms is a 58-year-old woman complaining of abdominal pain, a history of previous sigmoidectomy for diverticular disease. the patient complains of cramps and vomiting when n/g tube not to aspiration. physical exam: pertinent positives/negatives on admission, mildly obese, soft abdomen. no rebound/guarding. no rigidity. light diffuse tenderness. no hernia. pertinent results: 12:30pm wbc-10.9 rbc-4.74 hgb-14.7 hct-42.4 mcv-89 mch-31.1 mchc-34.7 rdw-13.5 12:30pm neuts-79.9* lymphs-14.9* monos-3.3 eos-1.7 basos-0.2 12:30pm plt count-395 12:30pm alt(sgpt)-32 ast(sgot)-18 alk phos-86 tot bili-0.6 12:30pm lipase-29 12:30pm glucose-126* urea n-9 creat-0.7 sodium-138 potassium-4.0 chloride-104 total co2-25 anion gap-13 02:15pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg brief hospital course: patient underwent ct scan, which was consistent with a mesenteric mass near the cecum. proceeded with exploratory laparotomy with planned wedge resection of mesenteric mass requiring right colectomy on . she underwent right colectomy for obstructing ascending colon from an isolated giant diverticula. the patient at operation noted to have a markedly inflamed gallbladder, pathology consistent with chronic cholecystitis and open cholecystectomy was performed at that time. postoperatively the patient was evaluated for tachycardia and underwent a cat scan which was suggestive of a right upper quadrant fluid collection. hida scan revealed a leak which was confirmed by ercp. endoscopic biliary stents were placed for better drainage of a duct of luschka leak from the hepatic fossa. it was recommended in consultation with dr. and dr. to proceed with a percutaneous drainage of fluid collection by interventional radiology on . postoperative hematocrit showed a change from 33 to 22. the patient was tachycardiac, transfused two units of blood and returned to the operating room for exploration on . patient was kept in the icu intubated. patient was extubated on . she was subsequently transferred out of the unit. patient was deemed stable and suitable for discharge on . jp x 2 were removed on discharge. medications on admission: singulair 10'; lipitor 40'; pulmicort; flonase; flovent; lisinopril; cardizem 240' discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 2. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 3. montelukast sodium 10 mg tablet sig: one (1) tablet po daily (daily). 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 5. budesonide 0.25 mg/2 ml nebu soln sig: one (1) ml inhalation (2 times a day). 6. diltiazem hcl 90 mg tablet sig: one (1) tablet po qid (4 times a day). discharge disposition: home discharge diagnosis: 1. mesenteric tumor, greater than 5 cm squared on the right ascending colon. 2. colonic obstruction, ascending colon. 3. incisional hernia. 4. cholecystitis, acute and chronic. hemorrhage status post percutaneous drain by radiology. luschka leak from hepatic fossa. htn asthma discharge condition: good. discharge instructions: go to an emergency room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 f), chills, or shortness of breath. proceed to the er/ew/ed if your wound becomes red, swollen, warm, or produces pus. you may remove your dressings 2 days after your surgery if they were not removed in the hospital. leave the steri strips on until they begin to peel, then you may remove them. staples and stitches will remain until your follow-up appointment. if you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. no heavy lifting or exertion for at least 6 weeks. no driving while taking pain medications. narcotics can cause constipation. please take an over the counter stool softener such as colace or a gentle laxative such as milk of magnesia if you experience constipation. you may resume your regular diet as tolerated. you may take showers (no baths) after your dressings have been removed from your wounds. continue taking your home medications unless otherwise contraindicated and follow up with pcp. followup instructions: f/u with . call for appt. Procedure: Endoscopic sphincterotomy and papillotomy Cholecystectomy Endoscopic insertion of stent (tube) into bile duct Open and other right hemicolectomy Reopening of recent laparotomy site Transfusion of packed cells Incisional hernia repair Other percutaneous procedures on biliary tract Repair of other bile ducts Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Accidental puncture or laceration during a procedure, not elsewhere classified Hemorrhage complicating a procedure Incisional hernia without mention of obstruction or gangrene Diverticulitis of colon (without mention of hemorrhage) Acute and chronic cholecystitis Intussusception

history of present illness: baby girl delivered at 35 and 6/7 weeks gestation with a birth weight of 2495 grams, and was admitted to the newborn intensive care unit for monitoring due to fetal exposure to multiple medications including barbiturates and benzodiazepines. mother is a 33-year-old gravida 5, para 2, now 3 woman. prenatal screens include a blood type o positive, antibody screen negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, and group b strep unknown. the maternal medical history is remarkable for a diagnosis of encephalitis manifested by hemiparesis and seizure disorder. she also has a latex allergy. maternal medications include primidone, lorazepam, gabapentin, carbamazepine, lamotrigine. she was admitted on the day prior to delivery with a non- reassuring fetal heart tracing. delivery was by cesarean section under spinal anesthesia. apgar scores were 8 and 9 at 1 and 5 minutes respectively. physical examination: weight 2495 grams (25th to 50th percentile), length 47 cm (50th percentile), head circumference 31 cm (10 to 25th percentile). examination remarkable for well-appearing preterm infant in no distress. color pink. anterior fontanel soft, flat. intact palate. no grunting, flaring or retracting. clear breath sounds. no murmurs. femoral pulses present. flat, soft, nondistended abdomen. no hepatosplenomegaly. normal perfusion. hips stable. normal tone and activity. summary of hospital course by systems: respiratory: she was admitted in room air without respiratory distress. no oxygen requirement during hospital stay. has had a history of bradycardia and desaturation mostly associated with feeding but occasionally with sleep. a pneumogram was done on that showed no central apnea, no acid reflux, no oxygen desaturations, 2 bradycardia to 70 beats per minute. the last desaturation bradycardia event recorded in the newborn intensive care unit was noted on . cardiovascular: she has been hemodynamically stable throughout her hospitalization. she developed a soft intermittent systolic murmur around 1 month of age that has not been evaluated. her heart rate ranges in the 130's to 160's. recent blood pressure is 75/35 with a mean of 45. fluids, electrolytes and nutrition: she was started on enteral feeds on the day of birth. initially she required gavage feedings due to poor oral feeding skills. she advanced to all oral feeds on day of life 20. initially she had frequent emesis and spitting with feeds thought due to maternal medication exposure. due to persistent emesis, she was tried on enfamil ar on day of life 21 without any significant effect. on day of life 28, she was changed to prosobee due to a history of formula intolerance in her siblings. at discharge she is taking prosobee 24 calories per ounce ad lib with small spits. discharge weight 3235 grams, length 51 cm, head circumference 33.5 cm. gastrointestinal: had mild physiologic jaundice with a peak bilirubin total of 5.5, direct 0.4 on day of life 4. she has also had some clinical symptoms of gastroesophageal reflux with a ph study done during a pneumogram that showed no significant acid reflux. hematology: recent hematocrit was 31 percent on . infectious disease: she was treated with erythromycin ophthalmic ointment from 9:26 to 9:30 for eye drainage. due to persistent eye drainage and the development of periorbital erythema, on cbc and blood culture was drawn and she was treated with vancomycin and gentamycin iv. the eye culture showed staph aureus, oxacillin sensitive. her cbc was normal and blood culture was negative. on , the periorbital erythema was no longer noted and the drainage had improved greatly and her treatment was changed to gentamycin ophthalmic ointment twice a day and oral cephalexin 4 times a day. neurology: has been very irritable and difficult to console. occupational therapy evaluation showed poor state and self regulation. she has periods of arching and increased tone and requires tight swaddling to help her sleep. also of note, a sacral dimple was noted on examination and an ultrasound of the spine was normal. sensory: audiology - hearing screening was performed automated auditory brain stem responses. she passed in both ears. ophthalmology examination was not indicated. psychosocial: there is a complicated social history secondary to the mother's degenerative neurological disease and she is not able to care for the infant. social work has been involved with the family. the contact social worker is and she can be reached at . dss has been involved with the family. a 51a was filed on , and again on due to concern regarding who would be available to care for the baby 24 hours a day, 7 days a week in the home. the 51a has been screened out. follow up will be provided by dss, the social worker. dss is delarda, and her telephone number of . dss also plans to make unannounced visits. the family has maternal grandmother, neighbors, and the father who will take care of the baby. condition on discharge: stable 51 day old infant at 43 weeks postmenstrual age. name of primary pediatrician: dr. . telephone no.: . fax no. . care recommendations: 1. feedings of prosobee 24 calories per ounce, ad lib, demand. 2. medications - gentamycin ophthalmic ointment, thin ribbon, to both eyes twice a day. cephalexin 40 mg orally 4 times a day until conjunctivitis resolves. 1. car seat position screening was done on , for 90 minutes and the infant passed. 2. state newborn screen has been done and is normal. 3. hepatitis b immunization was given on . 4. follow up appointments: 1. appointment with pediatrician on . 2. vna referral made to centrus premier home care. 3. eip referral made to criterion valley early intervention center. 4. referral made to the neonatal neurology program. discharge diagnoses: 1. aga preterm female. 2. apnea bradycardia of prematurity, resolved. 3. discoordinated feeding skills, resolved. 4. physiologic jaundice, resolved. 5. intermittent soft heart murmur, hemodynamically insignificant. 6. anemia. 7. conjunctivitis. , md Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Other nonoperative respiratory measurements Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Primary apnea of newborn Neonatal bradycardia Anemia of prematurity Other specified conditions originating in the perinatal period Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Undiagnosed cardiac murmurs Neonatal conjunctivitis and dacryocystitis Anticonvulsants affecting fetus or newborn via placenta or breast milk Microcephalus Other health problems within the family

infant born at 35 wks to 33yo g5 p2 o+, ab-, gbs?, hbsag-, rpr-nr woman. past medical history remarkable for dx of encephalitis manifested by hemiparesis and seizure disorder. medications include primidone, lorazepam, gabapentin, carbamazepine, lamotrigine. admitted yesterday for non-reassuring fetal tracing. decision made this morning to deliver to avoid potential airway issue in mother should stat c/s be indicated. spinal anesthesia. apgars 8, 9. mother with latex allergy. exam remarkable for well-appearing preterm infant in no distress with t 98.3 hr 156 rr 76 bp 78/42, 54 pink color, soft af, intact palate, no gfr, clear breath sounds, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl perfusion, stable hips, nl tone/activity. preterm infant with multiple pharmacologic exposures, including barbiturate and benzodiazepine. will admit to ensure transition, adequate feeding, and stable temperature control. parents aware of current status and immediate plan of care. primary pediatric care at pediatrics. Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Other nonoperative respiratory measurements Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Primary apnea of newborn Neonatal bradycardia Anemia of prematurity Other specified conditions originating in the perinatal period Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Undiagnosed cardiac murmurs Neonatal conjunctivitis and dacryocystitis Anticonvulsants affecting fetus or newborn via placenta or breast milk Microcephalus Other health problems within the family

allergies: tetracyclines / demerol / penicillins / cefepime / aspirin / darvocet a500 attending: chief complaint: shortness of breath major surgical or invasive procedure: endotracheal intubation bronchoscopy and bal history of present illness: 47 year old female s/p renal transplant with severe restrictive lung disease presents from home for sob. . she did not have pulmonary disease until the summer of when she was hospitalized for ureteral strictures. following cystoscopy, her hospital course was complicated by ards, trali and vap which led a 6 week hospital stay and a peg/trach. she spent the next few months at rehab where the peg/trach was pulled but has suffered from pulmonary disease ever since. she is on home o2, 3lnc at baseline and 5lnc with any exertion. she had been following dr. at clinic. she had pfts done in that showed severe restrictive disease. she has had a chronic problem with oxygenation and workup so far included ct scan done last week that showed progression of bilateral upper lobe ground glass opacities. dr. discussed the findings with the patient and it was decided that she get a repeat ct in 4 weeks and she may need to proceed to with bx to determine the cause of the ground glass opacities. the differential according to dr. for the ggo include alveolitis ( pcp or hp) or a superimposed viral syndrome since she complained of upper respiratory symptoms 4 days prior to that ct. . chronically, the patient seems to retain co2. according to serial abgs, her paco2 is chronically about 50. at baseline, she reports doing housework with includes walking up the stairs and doing laudry. over the past 3 days, she is unable to do much housework becuase of sob. she also reports a fever to 103, measure by her sister and with blood tinged sputum. she has been using her albuterol and advair with mild improvement. . in the ed, her initial vitals were: 98.4, 101, 172/77, 35, 66% on 4lnc. she was put on a nrb and abg was 7.18, 75, 206. she was treated for a presumed copd flare with 125mg iv solumedrol, ceftrixone, azithromycin and combivents. because of her initial poor oxygen saturation, she was treated for a pe emperically with heparin. cta was not done due to arf. repeat abg was 7.39, 75, 53 on a high flow face mask. because of her tenous respiratory status, she was sent to micu for futher care. past medical history: 1. esrd status post living related renal transplant in secondary to single left kidney and focal glomerulosclerosis. course complicated by ureteral stricture, status post ureteral stent that was last exchanged in . remains on cyclosporine and prednisone for immunosupression. 2. hypertension 3. depression 4. hyperlipidemia 5. endometriosis 6. severe gastroparesis in gastric emptying study. 7. prolonged micu admission () for trali/vap - mrsa pneumonia and acinetobacter/tracheostomy/peg. social history: significant for a 20 pack per year history of tobacco. reports having quit cigarettes two days ago. denies alcohol or ivdu. she lives with her husband. family history: noncontributory. physical exam: physical exam: vitals: 97.8, 111/40, 88, 88% fio280% 15l shovel mask gen: aox3, nad, lethargic but can answer questions appropriately, falls asleep in between questions, no sign of tiring out heent: dry mucous on lips neck: jvp 13 cm cv: rrr, no m/g/r pulm: diffuse crackles, no rhonchi or wheezes abd: soft, nt, nd, +bs ext: trace pedal edema pertinent results: 08:00pm blood wbc-9.7 rbc-3.83*# hgb-11.1*# hct-34.0*# mcv-89 mch-29.0 mchc-32.6 rdw-16.8* plt ct-351 01:27am blood wbc-9.7 rbc-3.51* hgb-10.3* hct-30.9* mcv-88 mch-29.3 mchc-33.2 rdw-17.0* plt ct-382 08:00pm blood pt-12.9 ptt-30.0 inr(pt)-1.1 10:04am blood ptt-66.8* 12:55am blood pt-12.6 ptt-27.2 inr(pt)-1.1 08:00pm blood glucose-150* urean-66* creat-4.0*# na-141 k-4.8 cl-101 hco3-26 angap-19 01:27am blood glucose-90 urean-59* creat-3.0* na-142 k-4.8 cl-107 hco3-24 angap-16 08:00pm blood totprot-7.1 calcium-8.9 phos-4.7* mg-2.4 01:27am blood calcium-8.5 phos-3.2# mg-2.2 11:41pm blood type-art po2-206* pco2-75* ph-7.18* caltco2-29 base xs--2 04:18am blood type-art po2-67* pco2-79* ph-7.18* caltco2-31* base xs-0 05:38pm blood type- temp-36.6 fio2-60 po2-42* pco2-60* ph-7.27* caltco2-29 base xs-0 06:01am blood type-art po2-90 pco2-43 ph-7.38 caltco2-26 base xs-0 08:31pm blood glucose-146* lactate-2.3* na-143 k-4.8 cl-105 calhco3-28 07:59am blood lactate-0.6 ekg: sinus 93 bpm, na, ni, no st/t wave changes compared to . studies: # pft : actual pred %pred fvc 1.11 3.39 33 fev1 0.88 2.59 34 mmf 0.81 2.98 27 fev1/fvc 79 76 104 . # diffusion : actual pred %pred dsb 7.08 20.40 35 va(sb) 2.15 5.11 42 hb 14.00 dsb(hb) 6.95 20.40 34 dl/va 3.24 3.99 81 . # cxr : no infiltrate. no pleural effusion. some cephalization. . # ct chest outpatient : 1. interim progression of diffuse upper lung ground glass, consistent with alveolitis. the differential diagnosis includes pneumocystis carinii, hypersensitivity, and drug reaction. 2. improved basilar consolidations, with plate-like atelectasis now seen at both bases. 3. moderate simple pericardial effusion, unchanged and without ct evidence of tamponade. 4. increased size of hilar lymph nodes, possibly related to alveolitis. 5. coronary artery calcifications, noteworthy in a patient of this age. 6. focal narrowing of the airway at the thoracic inlet, at the level of the clavicular heads, possibly stenosis complicated by malacia. . # echo : ef 60% the left atrium is normal in size. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate pericardial effusion. impression: normal lv and rv function. small pericardial effusion without evidence of tamponade. compared to the prior study dated , no significant change. . bronchial lavage: negative for malignant cells. numerous hemosiderin-laden macrophages and few bronchial cells. chest ct:1. worsening of the diffuse pulmonary process with increased ground-glass opacity and new peribronchial patchy ill-defined opacities in both lungs, more prominent in upper lobes, as well as increased consolidation in lingula and lower lobes with new bilateral small effusion. increased pericardial effusion with cardiomegaly and reactive lymphadenopathy. finding is most likely due to diffuse infectious process, such as virus, or bacteria, or other atypical infections, or alveolitis, or eosinophilic lung disease. correlation with bal result is recommended.given the fact that the upper lobe predominant disease has progressed steadily over a few months, an accelerated idiopathic/reactive alveolitis is strongly considered. if bac is non-contributory, a lung biopsy might also be considered. the lingular and basal disease might represent unrelated ventiltor associated disease. 2. dilated upper esophagus.(does the patient have any features of systemic sclerosis given the lung disease?) b/l le us: no evidence of dvt echo: the left atrium is mildly dilated. the estimated right atrial pressure is 11-15mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a small to moderate sized (1.4 cm) circumferential pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , estimated pulmonary artery pressures are higher. preseved regional/global biventricular systolic function. c.diff clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. (reference range-negative). 4:31 pm bronchoalveolar lavage gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. legionella culture (preliminary): no legionella isolated. potassium hydroxide preparation (final ): test cancelled by laboratory. patient credited. this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirvovecii (carinii). fungal culture (preliminary): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): viral culture (final ): test cancelled, patient credited. log in error. refer to () for results. viral culture: r/o cytomegalovirus (final ): test cancelled, patient credited. refer to () for results brief hospital course: assessment and plan: 47 year old woman s/p renal transplant with restrictive lung disease and subacute bilateral ground glass opacities presents with sob, admitted to micu for hypercarbic and hypoxemic respiratory distress, complicated by acute on chronic renal failure. # respiratory distress secondary to copd exacerbation: this is an acute on chronic lung disease which required intubation for management of hypercarbic and hypoxic respiratory failure. at baseline, she has poor lung function due to her restrictive physiology and chronic bilateral ground glass opacities of undertermined cause. her acute worsening is attributed to pna, with ct showing worsening of the diffuse pulmonary process with increased ground-glass opacity and new peribronchial patchy ill-defined opacities in both lungs, as well as increased consolidation in lingula and lower lobes with new bilateral small effusion. these findings are most consistent with an infectious process, most likely pna. lenis negative for dvt, and heparin was discontinued. no evidence of chf exacerbation on ct scan. patient was covered for pna initially with vancomycin and levofloxacin x 4 days, then patient continued on a 10 day course of levofloxacin. bal results (lavage of lingula)was negative for malignant cells. cultures were negative, no pcp. showed edematous and narrowed airways with no lesions. pulmonary team consulted and recommended outpatient work-up in weeks of repeat pfts and ct chest once current exacerbation has resolved. . # arf, s/p renal transplant : originally for focal glomerulosclerosis. complicated by ureteral strictures s/p stenting. baseline creatinine 2.5; on admission at 4. renal ultrasound with no new changes, similar to prior u/s. fena was 0.5, consistent with prenal etiology, likely from dehydration. renal function continued to improve throughout stay with hydration. cyclosporine was discontinued and cellcept began. epogen was continued. ua was positive for infection, as the patient was already broadly covered on antibiotics. recommend follow up ua as outpatient. # psychiatry: questionable history of depression. citalopram was begun. outpatient xanax and trazadone were held intially for hypersomnelence. tobacco dependence was treated with nicotine patch and lozenges although patient found with cigarettes and lighter on floor. # pericardial effusion: asymptomatic, found on ct scan. there was no clinical evidence of tamponade (normal blood pressures, no jvd). this should be monitored as an outpatient. # dilated esophagus: found incidentally on chest ct. outpatient barium swallow recommended for follow-up once patient has recovered from current exacerbation. the patient denied any gerd or regurgitation symptoms. # fen: patient with elevated potassium and started on low potassium diet which is to be continued on discharge. # ppx:patient recieved heparin sc for dvt prophylaxis and ppi. . # access: pivs. . # code: full code . # dispo: patient discharged to home with home oxygen. medications on admission: alprazolam 1mg q8hr prn prednisone 2.5mg daily cyclosporine daily advair diskus 250/50 spriva cp daily furosemide 40mg daily metoprolol 25mg daily tramadol 50mg lexapro 30 mg daily trazodone 100mg qhs prn naproxen 500mg q12h discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: four (4) puff inhalation q4h (every 4 hours). 2. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 3. escitalopram 10 mg tablet sig: three (3) tablet po daily (daily). 4. risperidone 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. epoetin alfa 4,000 unit/ml solution sig: one (1) injection injection once a week. 6. prednisone 2.5 mg tablet sig: one (1) tablet po daily (daily). 7. trazodone 50 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for insomnia. 8. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. disp:*2 tablet(s)* refills:*0* 9. alprazolam 1 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 10. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 11. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation q4h (every 4 hours) as needed. 13. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 14. advair diskus 500-50 mcg/dose disk with device sig: one (1) inhalation inhalation once a day. 15. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*0* 16. nicotine (polacrilex) 2 mg lozenge sig: one (1) lozenge mucous membrane q2h (every 2 hours) as needed for desire for cigarette. 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 18. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: chronic obstructive pulmonary disease exacerbation acute renal failure chronic kidney disease secondary: depression discharge condition: patient at baseline oxygen requirement, with oxygen saturations of 95% on 3l nc. discharge instructions: you have been treated for worsening shortness of breath and found to have a flare of your chronic pulmonary disease with respiratory failure requiring intubation with placement on a ventilator and acute worsening of you renal failure. you have been treated with steroids, antiobiotics, increased oxygen, and intravenous fluids. a change was made to your immunosuppression therapy. we discontinued your cyclosporin and resumed cellcept with the prednisone. please continue to take your medications as prescribed. it was also noted that your potassium level was increasing and it is recommended by the renal team that you eat a low potassium diet. you were evaluated by the pulmonology team and it is recommended that you see dr. in the next 2 weeks and then have repeat pulmonary function tests and a ct of your chest as scheduled. please call your physician or return to the emergency department if you experience any worsening of your shortness of breath or productive , fevers, chills, chest pain, or decreased urine output. followup instructions: please follow up as recommended: dr. office will call you to schedule a follow up appointment. provider: , md phone: date/time: 11:00 provider: scan phone: date/time: 3:00 please note your scheduled barium swallow and chest ct for have been cancelled due to your recent hospitalization. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Acute kidney failure, unspecified Obstructive chronic bronchitis with (acute) exacerbation Depressive disorder, not elsewhere classified Acute respiratory failure Complications of transplanted kidney

*allergies: tetracycline, demerol *access: r a-line, rij tlc neuro: pt remains on high doses of sedation; fent 500mcg, versed 12mg, propofol 40mcg and zyprexa 5mg tid. still pt arouses to voice, does not follow commands, mae, tries to grab tube if hands left free, perrl 3mm/. no signs of pain, does not follow command to nod head when asked questions, though has done so for me in the past. cardiac: nsr w/o ectopy, hr 69-83, sbp 105-125. hct 23.6 from 23.7. k 3.2 repleated. hydralazine has been held d/t sbp < 150. resp: pt remains on a/c 50%/350/26/12, last abg 7.38/43/67/26, md's tolerating pao2 > 60. to have trach placement today and open lung biopsy. ls clear throughout, yesterday's chest ct showed some improvement. rr 17-24, o2sat92-97%. gi/gu: tf off @ mn for trach and lung biopsy today. +bs, stool out fecal bag brown/loose, none in bag since bag change @ 2200. lactulose given. urine out foley 30-100cc/hr yellow/clear. lasix 120mg iv given yesterday, w/o good effect. bun / creat slowly trending down, now 106/3.2. fs wnl. id: temp 98.5-99.3, wbc 13.2. vanco dose given yesterday, give for level <20, given q48h, level prior to next dose. psychosocial: husband gave consent to anesthesia and surgery for procedures to be done today. witnessed over phone by nurse in previous shift. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Central venous pressure monitoring Transfusion of packed cells Diagnoses: Anemia in chronic kidney disease Acute kidney failure, unspecified Unspecified septicemia Candidiasis of other urogenital sites Infection with microorganisms resistant to penicillins Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Paralytic ileus Acute glomerulonephritis with other specified pathological lesion in kidney Dermatitis due to drugs and medicines taken internally Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified complications of medical care, not elsewhere classified Precipitous drop in hematocrit Complications of transplanted kidney Gastroparesis Acute edema of lung, unspecified Mixed acid-base balance disorder Cephalosporin group causing adverse effects in therapeutic use

*allergies: tetracycline, demerol *access: rij tlc, l wrist a-line neuro: pt remains on high level of fent/versed and now zyprexa 10mg tid. pt still moves in bed w/ stimuli, but more calm following zyprexa doses. perrl 3mm/, , follows commands but inconsistently, nods head for answers at times, indicated no pain w/ nods. restraints on both arms remain as she does reach for ett. cardiac: nsr/st, w/ rare pvc's, hr 70-103, sbp 106-146. ekg done yesterday to check qtc as she was possibly going to receive haldol as a standing order, zyprexa chose instead. hct stable @ 29.6. k has been low, repleated w/ 40meq in evening and 60meq iv in am. hydralazine held this shift since sbp < 150. resp: remains on a/c 65%/350/26/14, last abg yesterday 7.38/51/72/31. ls surprisingly clear considering her difficulty to wean. fam mtg scheduled for today to discuss possible lung biopsy and trach. resp issues thought to be caused by initial trali, then intubated, now vap and pulm edema. cont diuresis daily, though renal feels she is improving. gi/gu: yesterday changed to npo and ngt to lis for residual > 250, initially removed over 900cc. +bs, no stool this shift. enema, suppository, and disempactment done yesterday, another suppository this am. noted in hx that pt did have episode of severe gastroparesis in . d/t npo even meds, no bowel regimen this shift. urine out foley 50-140cc/hr yellow/clear. fs wnl. bun 120/creat 3.4. id: temp 97.8-97.9, wbc 20. cont nafcillin. pan cx yesterday for rapid increase in wbc, remains afebrile. inv wnl, skin intact. psychosocial: pt remains difficult to maintain in her bed, despite sedation levels being high. fam mtg for today, none called or visited overnight. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Central venous pressure monitoring Transfusion of packed cells Diagnoses: Anemia in chronic kidney disease Acute kidney failure, unspecified Unspecified septicemia Candidiasis of other urogenital sites Infection with microorganisms resistant to penicillins Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Paralytic ileus Acute glomerulonephritis with other specified pathological lesion in kidney Dermatitis due to drugs and medicines taken internally Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified complications of medical care, not elsewhere classified Precipitous drop in hematocrit Complications of transplanted kidney Gastroparesis Acute edema of lung, unspecified Mixed acid-base balance disorder Cephalosporin group causing adverse effects in therapeutic use

*allergies: tetracycline, demerol *access: rij tlc, r ant a-line; no change of tlc overnight neuro: pt remains on high levels of sedation: fentanyl 500mcg, versed 12mg, propofol 20mcg, and zyprexa 5mg q8h. comfortable most of the night, sleeping, startles to stimulus but then follows commands, nods for answers, mae, perrl 3mm/. no complaints of pain. cardiac: sb/st w/o ectopy, hr 58-138 but mostly in nsr, sbp 109-176, high bp and tachy resolved w/ addition of propofol. hct 21.1 from 24.6, gastric fluid guiac neg, md's notified, stated he will determine if she should be transfused. resp: a/c 40%/350/26/12, not breathing over vent, o2sat 95-100, am abg 7.34/41/82/23. lscta. sxn for sm amt bld tinged sputum. gi/gu: npo (even no meds), j-tube to gravity draining greenish bilious fluid 300cc @ 0400, fluid guiac neg. possibly resume tf this afternoon. +bs, no stool this shift, stool in metered bag is old. urine out foley yellow/clear, cont lg amts from 120mg iv lasix from previous shift, 60-480cc/hr. fs wnl, no coverage required. kub from yesterday showed no worsening of ileus. bun/creat still slowly improving 96/3.2 to now 89/3.0. id: temp 98.3-99.6, wbc from 23.4 to 15.2. was pan cx'd yesterday, results pnd. tlc line may be resited and tip cx, but was not done overnight. iv sites appear wnl. trach care done, site oozing scant amt serosanguinous fluid. j-tube site w/ dsd intact. psychosocial: son called late at night and was updated on condition and poc. son asked about open lung biopsy and this nurse told him that it was not done as the md's determined it was not necessary at this time. he seemed not to be satisfied with that answer, i told him he could call back in the am to speak w/ md. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Central venous pressure monitoring Transfusion of packed cells Diagnoses: Anemia in chronic kidney disease Acute kidney failure, unspecified Unspecified septicemia Candidiasis of other urogenital sites Infection with microorganisms resistant to penicillins Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Paralytic ileus Acute glomerulonephritis with other specified pathological lesion in kidney Dermatitis due to drugs and medicines taken internally Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified complications of medical care, not elsewhere classified Precipitous drop in hematocrit Complications of transplanted kidney Gastroparesis Acute edema of lung, unspecified Mixed acid-base balance disorder Cephalosporin group causing adverse effects in therapeutic use

*allergies: tetracycline, demerol neuro: remains on fent 500mcg, versed 12mg, propofol now 20mcg, and zyprexa 5mg q8h. arousable to voice, follows commands inconsistently, mae, has been comfortable most of the night, agitates w/ stimulation. plan to cont to decrease propofol now that procedure done (trach and j-tube). no pain per nodding and also trying to mouth words. cardiac: st/nsr w/o ectopy, hr 78-105, sbp 90-148, 250cc lr bolus for decreased sbp, and increased rate to 75cc/hr. a-line working well, tubing and dsg changed this am. hct stable @ 23.9. resp: new trach yesterday (#8, 7 inner cannula), remains on old vent settings a/c 50%/350/26/12peep, last abg @ 0500 this am was 7.34/41/105/23. ls clear throughout, sxn for sm amt bld tinged sputum. cxr overnight, results pnd. gi/gu: new j-tube currently to gravity draining greenish bile, ngt dc'd. npo and nothing through j-tube for 24h (until 1600). flush tube q6h w/ 10cc, output recorded this shift 100cc, bag emptied. +bs, no stool in new rectal bag, old stool in metered bag and tube. urine out foley yellow/clear, 18-140cchr. increase output following lr bolus. bun/creat slowly improving,now 96/3.2. fs q6h wnl. id: temp 99.7-100.3, wbc 23.8 from 13.2. vanco finished 8 day course yesterday. skin: new trach site, dsg changed, oozing sm amt serosanguinous fluid, wnl. j-tube site dsg intact. iv sites wnl. psychosocial: sister called for updated, husband to call/visit today. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Central venous pressure monitoring Transfusion of packed cells Diagnoses: Anemia in chronic kidney disease Acute kidney failure, unspecified Unspecified septicemia Candidiasis of other urogenital sites Infection with microorganisms resistant to penicillins Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Paralytic ileus Acute glomerulonephritis with other specified pathological lesion in kidney Dermatitis due to drugs and medicines taken internally Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified complications of medical care, not elsewhere classified Precipitous drop in hematocrit Complications of transplanted kidney Gastroparesis Acute edema of lung, unspecified Mixed acid-base balance disorder Cephalosporin group causing adverse effects in therapeutic use

allergies: tetracyclines / demerol / penicillins attending: chief complaint: rlq pain major surgical or invasive procedure: 1. renal biopsy - 2. endotracheal intubation 3. tracheostomy 4. peg 5. central venous line placement - removed 6. arterial line placement - removed 7. picc line placement history of present illness: mrs. is a 46f with pmh significant for fsgs s/p live donor renal transplant in , on csa and prednisone, with h/o ureteral stricture s/p multiple stentings by urology service, last in . she presents today with few days h/o rlq pain (over transplanted kidney site), chills, and dysuria, with nausea, but no vomiting. she did have some non-bloody loose stools 2 days ago, for which she took immodium x 1, and resolved. she was also noted to have worsening of her her renal function, with elevation of her bun/cr to 35/3.0, from baseline creatinine 2.2. her creatinine has been gradually worsening over the past year, from 1.8 in to 2.2 on , to 2.5 on . she last saw dr. in clinic in , at which point he asked her to decrease her csa dose from 100mg po bid to 100mg po qd alternating with 200mg po qd; however, per her report, she has continued to take 100mg po bid. last csa level 264 on . . in the ed, her initial vs were t 99.3f, bp 170/82, hr: 105, rr: 18, satting 94% on ra. she was found to have a slightly elevated wbc to 11.1 (68% pmn), and, as above, bun/cr of 35/3.0. a transplant renal u/s was done, which demonstrated no evidence of hydronephrosis, normal vascular flow and indices, and no fluid collections. lactate was 1.8. ua demonstrated small blood, small le, neg nitr, 3-5wbc with 0-2rbc, few bacteria, 0 epi. a repeat ua was sent, which was similar, except demonstrating 0-2 wbc. renal service saw her in the ed, and recommended levofloxacin 500mg po x 1, followed by 250mg po q48h, and 1l ns, which she received. pt deferred pelvic exam. also recommended were urine lytes (fena 1.95%), lfts/amylase/lipase, which were pending at time of admission, and transplant surgery consult, who were notified of her admission. she was admitted to the hepatorenal service for further inpatient management. past medical history: 1. esrd s/p living related renal transplant in single left kidney and focal glomerulosclerosis; c/b ureteral stricture, s/p ureteral stent placement, last exchanged 2. hypertension 3. depression 4. chronic pain 5. hyperlipidemia 6. endometriosis 7. severe gastroparesis on gastric emptying study social history: significant for a 20 pack per year history of tobacco. denied any alcohol or ivdu. she lives with her husband and son. family history: nc physical exam: vs: t: 98.4f bp: 196/90 hr: 84 rr: 18 sao2: 100% ra gen: lying comfortably in bed, mild abd distress heent: perrl, mmm cv: rrr, nl s1 and s2, no m/r/g chest: ctab, no w/r/r abd: soft, mildly ttp over transplant kidney site extr: no le edema, 1+ dps bilaterally neuro: a&ox3, no asterixis pertinent results: admission labs: . 02:05pm plt count-197 02:05pm neuts-68.1 lymphs-26.8 monos-3.4 eos-1.0 basos-0.7 02:05pm wbc-11.1* rbc-4.71 hgb-14.7 hct-41.4 mcv-88 mch-31.3 mchc-35.6* rdw-13.9 02:05pm urine gr hold-hold 02:05pm urine uhold-hold 02:05pm urine hours-random 02:05pm urine hours-random 02:05pm albumin-3.7 calcium-8.9 phosphate-3.6 magnesium-1.8 02:05pm lipase-47 02:05pm alt(sgpt)-9 ast(sgot)-15 alk phos-115 amylase-57 tot bili-0.5 02:05pm glucose-92 urea n-35* creat-3.0* sodium-139 potassium-4.5 chloride-104 total co2-24 anion gap-16 02:17pm k+-4.6 04:37pm lactate-1.8 04:37pm comments-green top 05:15pm urine rbc-0-2 wbc- bacteria-few yeast-none epi-0 05:15pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-sm 05:15pm urine color-yellow appear-clear sp -1.008 05:15pm urine uhold-hold 05:15pm urine hours-random 05:27pm cyclsprn-494* 06:19pm urine rbc-0-2 wbc-0-2 bacteria-occ yeast-none epi-0-2 06:19pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-sm 06:19pm urine color-yellow appear-clear sp -1.006 06:19pm urine uhold-hold 06:19pm urine hours-random creat-41 sodium-37 potassium-14 chloride-23 pertinent labs/studies: . wbc: 11.1 ->> 24.2 ->> 8.0 creat: 3.0 ->> 4.0 ->> 1.6 . 02:58pm blood caltibc-178* ferritn-606* trf-137* 03:30pm blood hiv ab-negative 07:58am blood anca-negative b . . . imaging studies: : renal us - no evidence of hydronephrosis. . : echo - impression: normal biventricular global and regional systolic function. small pericardial effusion without echocardiographic signs of tamponade. . : ct c/a/p - impression: 1) no perinephric fluid collections or hematoma surrounding the transplanted kidney. 2) air in the collecting system of the transplanted kidney and bladder as described above. 3) endotracheal tube position approximately 1cm from the carina. . : ct a/p - impression: 1. diffuse small bowel dilatation. contrast passes throughout the colon to the rectum at the time of imaging. findings are most consistent with an ileus. if there is concern for developing small bowel obstruction, serial abdominal radiographs are reccomended. 2. new small amount of ascites around the liver. 3. residual droplets of air in the transplant renal collecting system and bladder. nephroureteral stent in place. no hydronephrosis of the transplant. . : echo - 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 valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is a small circumferential pericardial effusion with no echocardiographic signs of tamponade. . : portable cxr - portable ap chest radiograph: compared to prior radiograph from . the area of consolidation in the right lower lobe has resolved and now remains residual atelectasis. the left retrocardiac opacity persists and likely represents consolidated portions of lung. no pleural effusions are seen. mild cardiomegaly is unchanged. no pulmonary vascular congestion or pulmonary edema is seen. mediastinal and hilar contours are normal. tracheostomy tube is seen in appropriate position. the tip of the left picc line overlies the expected region of the mid svc. . impression: resolution of right lower lobe consolidation, now with residual atelectasis. persistent left lower lobe/retrocardiac consolidation. . . pathology: : renal allograft biopsy - chronic allograft nephropathy. there is no evidence of acute cellular rejection in this sample. the differential diagnosis also includes "acute tubular necrosis", obstruction, and drug nephrotoxicity. cortical sample size is quite limited, and may not be representative of the organ. . . microbiology: . blood cultures: ; ; ; , , , , , : no growth : pending, no growth to date . urine cultures: , -> coag negative staph : no growth . bal - - 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive cocci. cx - 10k -100k coag + staph - no sensitivities performed (sputum revealed mssa) . sputum - : 4+ gpc, cx - sparse growth mssa - sparse growth coag + staph (presumed mssa) - cancelled due to op flora contamination - cancelled due to op flora contamination . : ebv - igm negative, igg positive ; - cmv viral load undetectable . stool: -> : c. diff negative x 10 samples . : rapid virus screen - negative discharge labs: . . 05:32am blood wbc-8.0 rbc-3.01* hgb-8.6* hct-26.6* mcv-89 mch-28.7 mchc-32.4 rdw-19.6* plt ct-484* 03:24am blood neuts-15* bands-9* lymphs-30 monos-13* eos-24* baso-1 atyps-4* metas-2* myelos-1* promyel-1* nrbc-17* 03:28am blood pt-12.8 ptt-26.0 inr(pt)-1.1 05:32am blood glucose-142* urean-54* creat-1.6* na-146* k-4.0 cl-109* hco3-29 angap-12 12:25pm blood alt-29 ast-23 alkphos-99 03:55am blood alt-26 ast-25 ld(ldh)-272* alkphos-89 amylase-88 totbili-0.2 03:55am blood lipase-118* 05:32am blood calcium-8.7 phos-2.9 mg-1.8 iron-pnd 05:32am blood ferritn-pnd trf-pnd brief hospital course: assessment: 46f with h/o fsgs s/p liver donor renal transplant c/b ureteral stricture s/p multiple stentings, presenting with few days of rlq pain, chills, and dysuria, and elevation in creatinine. . her initial course on the medical floor was notable for persistent acute renal failure. she was cultured and eventually underwent a renal biopsy that showed chronic allograft nephropathy. after the renal biopsy pt was noted to have decreased hct from 40-30, was given 2.5 liters of fluid through the day, then received 1u prbc finished at 12am, triggered at 4am for hypoxia, noted to desat to 60s, placed on nrb with increase of o2 sat to 80s, o/w vs were 98.8 112 144/90 rr 40, satting 80s on nrb. abg performed showed 7.26/47/74. pt given 40 lasix with increase uo of 140cc/hr then another 200 lasix. she was treated supportively for possible trali and placed on bipap with increases in her oxygenation to 95%. the remainder of her course will be by problem. . #. respiratory failure: felt to be initially be to trali (as happened around 48 hours after transfusion) did not improve with diuresis and cxr findings also suggestive. however, ultimate work up by blood bank was not consistent with this diagnosis. she was intubated within 12hours of the acute failure on and vent settings changed to ardsnet protocol for lung protective strategy. a discussion was taken with blood bank and it seems likely that this was trali initially based on initial clinical course, but the clinical picutre was confusing given prolonged course. this incidentally does not effect the ability to get future transfusions. her respiratory decompensated further while on the vent with fevers, elevated wbc and increase production sputum. mssa grew from sputum and bal, and she was treated initially on vanco and zosyn but swithced to nafcillin on when sputum returned with mssa. she was swithced back to vancomycin after a coag negative staph came back in her urine and completed a total of 8 days of vancomycin. she remained difficult to wean, felt mainly to be due to volume overload, agitation requiring heavy sedation (as below) and dense consolidations from the above mssa-ventilator associated pneumonia. as her respiratory failure persisted, a tracheostomy and j-tube placement was performed on . from there, a vent weaned continued, moving her at first to pressure support and slowly decreasing the support daily. the wean was delayed by a recurrent mssa ventilator-associated pneumonia, treated with an eight-day course of vancomycin (and briefly cefepime for the first few days; this was stopped after a few days, as below, as she was felt to be allergic to naficillin). at the time of discharge, she continued to require intermittent ventilatory support, but was doing well for hours at a time on trach mask. while on the ventilator, she appeared quite comfortable on pressure support of with 40%fio2, with rr's around 18 and tidal volumes easily in the 500's. the last few days the patient has been undergoing trach mask trials. on she tolerated 12 hours, 5 hours on , and only a few minutes on . on she was placed back on cpap/ps because of desat to low 80s. of note, the last few days prior to discharge patient has been having low grade temp to 100.5, although afebrile last 24 hours. repeat cxr on revealed resolution of previously identified right ll opacification but persistent left retrocardiac opacity. if the patient spikes a temperature again, consideration should be made towards repeat treatment of vap. . #. renal failure: the intial renal failure with which she was admitted was felt to probably be due to atn and resolved on its own back to a baseline cr of 1.7-2.0. she was continued on her mycophenolate 500mg po bid and prednisone 5mg daily. however, on in the setting of a drug rash, fever, and eosinophilia, as below, her cr worsened, eventually peaking at 3.1 on . this was felt to be due to acute interstitial nephritis; this responded well to high dose steroids (hydrocortisone 100mg tid x 1 day, then moved to , now 25mg ), with rapid improvement in cr back to 1.6 on the day of discharge. as requested by the renal transplant service, the patient will now be discharged on prednisone 5mg po bid and cellcept 500mg iv bid. it has been requested that the patient have follow up with dr. from transplant within one week at which time decisions towards appropriate immunsuppressive therapy will be made. the patient should have chem panel performed two to three times weekly to monitor renal function. if there are any abnormalities noted, dr. should be notified please at . . #. allergic reaction: on , mrs. was noted to have a truncal erythematous macular rash that became increasingly intense and confluent, spreading to her face and down her extremities. she also began spiking fevers and, as above, developed worsening renal function. dermatology saw the rash and felt that naficillin most likey caused this reaction and that it was worsening because of the cefepime, which was subsequently stopped. on high dose steroids (mainly started for probably ain) and topcial triamcinolone, her rash improved. she was not given any further beta-lactam based medications. . #. leukopenia: on , mrs. unexpectedly became leukopenic, dropping her wbc from 10 to 2. hematology was consulted and they felt that this was probably medication related. her leukopenia has since resolved. . #. agitation - during her period of ventilation, prior to wean attempts, the patient was noted to be very agitated, requiring large doses of fentanyl, versed as well as propofol. with addition of standing haldol, initially as much as 5mg iv q 6hours plus prn, the patient was slowly able to be weaned from sedation over a number of days. she most recently has been maintained on a fentanyl 72 hour patch 25mcg/hr, ativan .5mg + prn for ciwa > 10 (with little need for prns) and haldol has been decreased to 5mg . weaning attempts have been complicated by agitation with difficulty dissociating respiratory discomfort/distress from agitation. it is suspected that some of her agitation earlier was secondary to withdrawal from narcotics and benzos given the large amounts she was requiring previously for adequate sedation while vented. ongoing efforts should be made to decrease her ativan, and haldol as possible from standing to prns only to off. as mentioned above, additional consideration towards worsening respiratory status should be made given persistent left retrocardiac opacity (atelectasis vs. small effusion vs. pna) . #. ileus - the patient was intially noted to have some abdominal pain and distention. ct imaging revealed an ileus, likely secondary to large opiate requirements. with weaning of sedation and a trial of naloxone po to increase bowel motility, the patient's ileus resolved. she is now tolerating tube feeds at goal of 55/hr. (of note: after patient was discharged, dose of cellcept changed to 500mg iv bid per renal. this was communicated to the receiving rehab) medications on admission: cyclosporine 100mg po qod / 200mg po qod alternating prednisone 2.5mg po qd trazodone 100mg po qhs xanax 1mg po tid discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation. 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain, fever. 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 5. ipratropium bromide 17 mcg/actuation aerosol sig: eight (8) puff inhalation qid (4 times a day). 6. albuterol 90 mcg/actuation aerosol sig: 8-10 puffs inhalation q4h (every 4 hours). 7. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane qid (4 times a day). 8. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 9. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 10. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 11. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 12. metoclopramide 10 mg tablet sig: 0.5 tablet po qidachs (4 times a day (before meals and at bedtime)). 13. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day). 14. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 15. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 16. fentanyl 12 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 17. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 18. epoetin alfa 10,000 unit/ml solution sig: () units injection qm/w/f (): dose recommended by renal. 19. haloperidol lactate 5 mg/ml solution sig: five (5) mg injection qpm (once a day (in the evening)): please taper as possible. 20. prednisone 5 mg tablet sig: one (1) tablet po twice a day: patient needs to follow up with dr. () for for directions towards appropriate taper. 21. haloperidol lactate 5 mg/ml solution sig: 3-5 mg injection (2 times a day) as needed for agitation. 22. lorazepam 2 mg/ml syringe sig: one (1) injection q6h (every 6 hours) as needed: taper off ciwa as tolerated. can d/c if no prn needed > 48 hours. 23. mycophenolate mofetil 500 mg iv bid discharge disposition: extended care facility: medical center - discharge diagnosis: primary: 1. respiratory failure, hypoxic 2. acute on chronic renal failure 3. end stage renal disease s/p living related renal transplant in 4. ventilator associated pneumonia 5. s/p renal biopsy 6. s/p tracheostomy 7. s/p j-tube placement 8. leukopenia, resolved 9. drug rash, resolved 10.anemia secondary - hypertension - depression - chronic pain - hyperlipidemia - endometriosis - severe gastroparesis discharge condition: stable - ventilated (with tracheostomy), on tube feeds. . vent settings: pressure support ventilation, 10 (insp)/5 (exp), 40% fio2 with daily trials of trach mask discharge instructions: 1. please continue to take all medications as prescribed. 2. please keep all outpatient appointments 3. if you experience any worsening fever, cough, sputum production, or worsening in your vent settings, please seek medical attention. followup instructions: 1. please follow up with your pcp . within two weeks of discharge from the rehab facility. please call his office at to make an appointment. . 2. patient requires follow up with dr. . transplant has requested the patient be seen within one week. unfortunately, this appointment could not be made prior to discharge. please call at (nurse who can help arrange scheduling) to make this appointment. if any difficulty, please call to arrange an appointment. patient will require appropriate transportation. thank you . 3. provider: , m.d. date/time: 3:30. if you are unable to make this appointment, please call dr. office at ( to reschedule an appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Central venous pressure monitoring Transfusion of packed cells Diagnoses: Anemia in chronic kidney disease Acute kidney failure, unspecified Unspecified septicemia Candidiasis of other urogenital sites Infection with microorganisms resistant to penicillins Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Paralytic ileus Acute glomerulonephritis with other specified pathological lesion in kidney Dermatitis due to drugs and medicines taken internally Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified complications of medical care, not elsewhere classified Precipitous drop in hematocrit Complications of transplanted kidney Gastroparesis Acute edema of lung, unspecified Mixed acid-base balance disorder Cephalosporin group causing adverse effects in therapeutic use

allergies: tetracyclines / demerol / penicillins / cefepime attending: chief complaint: acute renal failure, fever, hypotension major surgical or invasive procedure: central venous catheter history of present illness: pt is a 46y/o wf w/ an extensive pmh including esrd s/p renal transplant who was recently hospitalized at from and presents now as a transfer from an osh where she went with fever, diarrhea, and hypotension. her last admission at was marked by arf found to be chronic allograft rejection. she developed trali after a transfusion and was intubated leading to a mssa vap. her icu course was further complicated by a staph epi uti and ain nafcillin treatment of her vap. she eventually failed extubation attempts and received a peg/trach prior to being transferred to rehab. at her rehab, she developed fever to 102 and hypotension to 92 systolic. . she was sent to the icu for these complaints and was found to have bcx + for coag - staph, gpc/gnr in her sputum, and a ucx c/w contamination. she received a ct torso showing, per report, bibasilar lung consolidation, questionable nephrolithiasis, and pancolitis. she was treated broadly with po vanco/flagyl (for ? cdiff; cx negative to date), levaquin (for ? uti; cx c/w contamination), and vancomycin (for gpc in blood/sputum; cx w/ staph epi). she was fluid repleted to a cvp of 12 but saw no change in her arf (1.6 on d/c -> 3.3 on readmission). she was transferred to for further managment of her multiple problems and unresolved arf. . on arrival, the patient was normotensive and afebrile. her trach was noted to have scant tan sputum. she denied any pain or sob. she was not vocal which limited the history available but did respond appropriately to questions by shaking her head y/n. she had access with a r ij triple lumen and 3 piv. past medical history: 1. esrd s/p living related renal transplant in single left kidney and focal glomerulosclerosis; c/b ureteral stricture, s/p ureteral stent placement, last exchanged . on csa and prednisone for immunosuppression. 2. htn 3. depression 4. hyperlipidemia 5. endometriosis 6. severe gastroparesis on gastric emptying study social history: significant for a 20 pack per year history of tobacco. denies alcohol or ivdu. she lives with her husband and son although most recently living at rehab. family history: nc physical exam: 98.0, 135/50, 67, 18, 97% vent: tc, ac 60% fio2, 600 tv, 18 rr, 5 peep, 21 plateau gen: obese wf lying in bed, not talking but nods head to questions and responds to commands, mild horizontal head tremor at rest heent: eomi, mmm, o/p w/ white exudate on hard and soft palate c/w thrush cv: rrr, no m/r/g lungs: cta anteriorly, posterior exam limited by positioning but mild bibasilar crackles appreciated abd: obese, soft, non-tender, peg site c/d/i ext: no c/c/e skin: no skin breakdown/rash, triple lumen and peripheral iv from osh w/out signs of erythema/exudate/tenderness neuro: fine tremor worsened by motion in both ue and le, able to move fingers and toes to command, patellar reflexes intact bilaterally, smile symmetrical, eomi, perrla pertinent results: 09:47pm urine uric acid-mod 09:47pm urine hyaline-1* 09:47pm urine rbc-* wbc-0-2 bacteria-few yeast-none epi-1 09:47pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 09:47pm urine color-yellow appear-clear sp -1.013 10:04pm pt-12.6 ptt-28.3 inr(pt)-1.1 10:04pm plt count-299 10:04pm hypochrom-1+ anisocyt-2+ poikilocy-2+ macrocyt-2+ microcyt-1+ polychrom-occasional ovalocyt-occasional burr-2+ teardrop-occasional 10:04pm neuts-89.1* bands-0 lymphs-7.8* monos-2.8 eos-0.2 basos-0.1 10:04pm wbc-14.9*# rbc-2.91* hgb-8.5* hct-26.1* mcv-90 mch-29.3 mchc-32.7 rdw-19.0* 10:04pm calcium-8.4 phosphate-5.8*# magnesium-1.9 10:04pm glucose-95 urea n-52* creat-2.9*# sodium-144 potassium-3.0* chloride-114* total co2-16* anion gap-17 ct head : there is a subtle area of low attenuation and asymmetry within the region of the superior right internal capsule which may represent chronic change. no intracranial hemorrhage or mass effect is seen. . cxr : this is improved. moderate cardiomegaly and vascular engorgement of the hila, lungs and mediastinum are unchanged. tracheostomy tube in standard placement. tip of the right picc line projects over the junction of the brachiocephalic veins, and that of the right subclavian line projects over the superior cavoatrial junction. no pneumothorax. . video swallow : an oral and pharyngeal swallowing video fluoroscopy study was performed in collaboration with the speech and swallow department. varying consistencies of barium were administered under constant fluoroscopic video guidance. without the speaking valve in place, patient was seen to aspirate nectar thin liquids. with the speaking valve, patient demonstrated penetration, but no definite evidence of aspiration. the patient demonstrated poor oral control throughout the study. . ct chest : 1) airway obstruction proximal to tracheostomy tube insertion site. fluid attenuation of airway lumen suggests retained secretions and edema as the primary factors, although underlying granulation tissue is not fully excluded. edematous changes extend proximally to the glottic region. 2) overdistended tracheostomy tube cuff. 3) collapse of right middle and both lower lobes with impaction of the airways probably due to areas of retained secretions. high attenuation material within right lower lobe segmental airways, likely due to aspiration of oral contrast media. 4) persistent pericardial and small pleural effusions. 5) multifocal infectious small airways disease process, slightly improved since . . cxr : since prior examination, no significant interval changes. persistent bibasilar opacity may represent aspiration pneumonia, less likely atelectasis. unchanged retrocardiac opacity represents atelectasis. stable right picc line with its tip projecting over the brachiocephalic vein junction. no evidence of pneumothorax. . : cbc: 9.5> 10.9/33.3< 370 : chem: x1.6* 144 4.1 108 30 20 1.6 brief hospital course: 46 y/o wf w/ a hx of esrd s/p xplant and recent admission for arf/trali/vap/uti/ain readmitted w/ arf, hypotension, and fever. managed at nsmc icu for several days prior to transfer and hd stable and afebrile on transfer. transferred to from icu on hd #30 for witnessed aspiration and pneumonia where she rapidly improved and was discharged directly from the unit. . 1. arf: pt w/ acute elevation of creatinine compared to her d/c level. unclear etiology but likely transplant rejection versus atn ( hypovolemia) versus ain ( rx). no evidence of obstruction on ct but non-obstructive renal stone seen. uric acid crystals on ua. cellcept was stopped and only high dose steroids where continued for immunosuppresssion. creatinine improved with hydration. baseline cr 1.9-2.0 since last admission. pt continued on prednisone, cellcept was restarted by renal after her creatinine began to trend down. pt once again had an episode of elevated cr while septic from aspiration pneumonia. her cr trended down back toward baseline while being treated with broad spectrum abx. abx were renally dosed. by time of discharge, cr had returned to baseline levels. . 2. fever: afebrile initially but multiple possible sources at osh for fever. treated with vancomycin for msse bacteremia (cx data from osh) for a course of 14 days (last day ). sputum cx here with acinetobacter baumanni, highly resistent. bal gram stain demonstrated gnr and gpc. initially treated with bactrim, but subsequent resistence development to bactrim, therefore changed to tobramycin on for a course of 14 days. re: diarrhea, c. diff a & b toxin was negative x3. stool o & p negative. aspiration event on hd #30 and patient returned to the micu with elevated temps. infection resolved on meropenem and vancomycin. cultures grew acinetobacter sensitive to unasyn/tobra; intermediate to meropenem. vanc d/c b/c no gram + organisms on culture. meropenem continued clinical improvement and she was discharged on day 7 of a 14 day course. . 3. respiratory distress: when first hospitalized, respiratory status improved with treatment for acinetobacter + msse pneumonia. on , pt transferred to micu after witnessed aspiration event and consequent desaturation to the 70%s. subsequent imaging and bronchoscopy ruled out tracheal stenosis, but demonstrated findings c/w aspiration pna. pt treated for aspiration pna with vancomycin and meropenum, mdi, ventilatory support with clinical improvement. pt on pressure support alternating w/ trach collar trials on d/c had been on trach collar for > 24 hours. . 4. tremor, dysphagia, weakness: after transfer from the micu to the floor, patient had dysphagia, diffuse weakness, and tremor. a head ct showed an abnormality in the internal capsule that was thought to be unrelated to current symptoms according to neuro. patient passed swallow evaluation and is eating well. weakness and tremor improving daily. per neurology, did not need an mri as an inpatient to further evaluate ic abnormality. she ws scheduled for an outpatient mri and has follow up with neurology following the mri. . 5. anemia: given pt's history of renal failure, hct was followed throughout hospitalization. pt was transfused at hct < 21. epo and fe therapy were continued during hospitalization. . 6. uti: pt during course of hospitalization had ua suggestive of uti. meropenum for treatment of aspiration pna provided cross-coverage for uti microbes. uti resolved as final surveillence cultures were (-). . 7. hypotension: reportedly hypotensive at osh. resolved on admission. . 8. fen: electrolytes repleted prn. renal tube feeds. speech and swallow evaluation. . 9. prophylaxis: heparin sc. ppi. pneumoboots. . 10. full code. medications on admission: 1. albuterol 2 puffs qid 2. atrovent 2 puffs qid 3. trazodone 50mg qhs 4. hydrocortisone 60mg q6h 5. vancomycin 250mg ng q6h 6. vitamin a/d 7. tylenol 650mg q4h 8. haldol 5mg qhs 9. hsq 10. calcium 500mg tid 11. reglan 500mg q6h 12. triamcinolone cream 13. prednisone 5mg 14. mycophenolate 250mg 15. metoprolol 25mg 16. nexium 20mg 17. celexa 20mg 18. amlodipine 5mg 19. dibucaine cream prn 20. balmex prn 21. epo 12k units qm/w/f 22. xanax 1mg tid 23. flagyl 500mg tid 24. levaquin 500mg (d3) discharge medications: 1. albuterol sulfate 0.083 % solution sig: neb inhalation q6h (every 6 hours) as needed. 2. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime). 3. acetaminophen 160 mg/5 ml solution sig: 325-650 mg po q4-6h (every 4 to 6 hours) as needed. 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 5. albuterol 90 mcg/actuation aerosol sig: 2-4 puffs inhalation q4-6h (every 4 to 6 hours) as needed. 6. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 7. epoetin alfa 10,000 unit/ml solution sig: () units injection qmowefr (monday -wednesday-friday). 8. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 9. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 10. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 12. ipratropium bromide 0.02 % solution sig: neb inhalation q6h (every 6 hours) as needed. 13. psyllium packet sig: one (1) packet po tid (3 times a day) as needed. 14. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 15. pantoprazole 40 mg iv q12h 16. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q8h (every 8 hours) for 10 days. 17. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 18. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 19. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 20. ranitidine hcl 150 mg capsule sig: one (1) capsule po twice a day. 21. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): give 2 units for bg 150-200. give 4 units for bg 201-250. give 6 units for bg 251-300. give 8 units for bg 301-350. give 10 units for bg 351-400. give 12 units for bg>400 and notify md. 22. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp<120, hr<60. tablet(s) 23. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed. 24. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 25. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: primary: 1. acute renal failure 2. pneumonia 3. urinary tract infection . secondary: 1. end stage renal disease 2. hypertension 3. depression 4. hyperlipidemia 5. transfusion related acute lung injury discharge condition: good discharge instructions: you were admitted to the hospital for respiratory distress and acute renal failure. . please continue to take all medications as prescribed. you will need to take 7 more days of meropenem antibiotic for a pneumonia. . you should follow up with your nephrologist dr. , the neurology department as below. . you should call your doctor or return to the er should you experience any of the following: fever > 101 severe difficulty breathing numbness/tingling/paralysis severe dizziness nausea/vomiting difficulty with urination severe chest pain/sob any other symptoms that worry you. followup instructions: please follow-up with your primary care on 2:45 pm. phone: . . please follow up with nephrology as below: provider: , m.d. date/time: 4:00 . please follow up with neurology as below: provider: / phone: date/time: 2:30 . you will need to have an mri obtained prior to your neurology appointment. xmr west 2 radiology phone: date/time: 6:30. basement of clinical center. . please continue medical care with treatment team at your rehabilitation facility. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Bronchoscopy through artificial stoma Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Acute respiratory failure Complications of transplanted kidney Acute pancreatitis Leukocytopenia, unspecified

history of present illness: 69-year-old male with past medical history of transient ischemic attacks, hyperlipidemia, lower gastrointestinal bleed from polypectomy (hyperplastic polyp plus adenoma) in negative for cancer admitted last week with history of anorexia and abdominal distention now returns with worsening abdominal pain and distention with dyspnea. workup during last admission found mesenteric peritoneal implants with evidence of peritoneal carcinomatosis on ct abdomen. ct chest found diffuse necrotic mediastinal lymphadenopathy with two right lobe nodules (one spiculated right upper lobe nodule at 1.1 cm in its greatest dimension and one non-calcified nodule in the right lower lobe with right paratracheal precarinal and a subcarinal mass). white blood count was elevated on discharge at 19.1, which was up from prior; however, no fevers or chills or lethargy. at prior admission patient presented after working out at gym with the complaint of feeling lethargic more than usual for four days. he then lost his appetite and noticed a three- pound weight gain over four days. patient denies melena, hematochezia, abdominal pain, chest pain, shortness of breath, nausea, vomiting, constipation. diarrhea times one. also states a 20-pound weight gain over the past year that was intentional. bronchoscopy of the subcarinal lymph nodes (subcarinal mass) was postponed secondary to plavix taken five days prior. at , 3300 cc of ascites fluid was drained via paracentesis. afterwards an outpatient scheduled visit with gi performed in-house which revealed no suspicious lesions. patient's current complaint of abdominal pain and distention with shortness of breath began acutely the day after discharge and progressively worsened in severity. his symptoms rapidly increased over saturday and sunday without notable exacerbating or alleviating factors. he attempted running on a treadmill sunday without incident. patient also mentions decreased urine output since last discharge despite continuous fluid intake. however, his food intake has decreased compared to baseline. patient has a complaint of night sweats. patient denies chest pain, shortness of breath, nausea, vomiting, fevers, constipation, diarrhea, dysuria, cough, hemoptysis, hematemesis, hematochezia, or melena. dr. from pathology only received 25 ml of the prior 2400 cc of ascites fluid drained last week. however, stains will be ready later this day. cytology has received the fluid from the paracentesis today done in the ed. past medical history: 1. hyperlipidemia. 2. osteoarthritis. 3. retinal hemorrhage. 4. small pfo. 5. status post colonoscopy with polypectomy in ; three sessile non-bleeding polyps (positive for adenoma) were removed, negative for cancer; diverticulosis noted throughout colon. 6. prostate needle biopsy in , negative for cancer. 7. status post asd repair with trace ai and mr in ; normal chamber size and function. 8. status post left inguinal herniorrhaphy; repair of left inguinal hernia with marlex mesh. outpatient medications: 1. plavix 75 mg. 2. lipitor 20 mg. 3. celebrex p.r.n. 4. zyrtec p.r.n. allergies: aspirin gives rash. family history: father died of questionable prostate cancer. one son and one daughter both healthy. mother: known medical problems. social history: tobacco: unknown number pack years. one alcoholic beverage per day. lives with wife in . traveled to south america and eastern europe 20 to 30 years ago. he has had no known exposure to asbestos in his lifetime. no known exposure to tb. physical examination: in general, in no acute distress. appears stated age. is concerned about prognosis. vital signs: t-max 96.7, t current 96.7, blood pressure 120/70, heart rate 76, respiratory rate 20, 97% on two liters oxygen via nasal cannula. head and neck: normocephalic, atraumatic. pupils equal, round, and reactive to light. extraocular movements intact. dry mucous membranes. oropharynx: clear, no lymphadenopathy. jugular venous distention flat. cardiac exam: s1 and s2 normal, regular rate and rhythm, i/vi holosystolic ejection murmur, no rubs or gallops. pulmonary exam: clear to auscultation bilaterally, no rales, no wheeze. abdomen exam: slightly distended, nontender, negative shifting dullness, negative fluid wave, negative peritoneal signs, no inguinal lymphadenopathy, normoactive bowel sounds, liver edge palpable on inspiration. extremities: distal pulses +2 bilaterally. no cyanosis, clubbing, or edema. neuro exam: alert and oriented times three, cranial nerves ii-xii intact, upper and lower extremity strength bilaterally. rectal exam: guaiac negative, no masses, prostate is enlarged, smooth, and without nodules. laboratory data: white count was 33.5, hematocrit 37.4, platelets 450, mcv 94. differential: neutrophils 68%, bands 8%, lymphs 2%, monos 5%, eos 17%, elevated, basos 0%. there is 1+ oncocytosis, 1+ poikilocytosis, and 1+ ovalocytosis. pt 14.0, ptt 29.7. chem-7 at 9 a.m. was 131, sodium and potassium 17.4, chloride 95, bicarbonate 23, bun of 43, creatinine 1.3, glucose 119 with an anion gap of 20. the elevated potassium was thought to be due to hemolysis ............. chem-7 was done at 10 a.m. sodium 134, potassium 5.8, chloride 97, bicarbonate 25, bun of 46, creatinine of 2.0, glucose 130, anion gap of 18. ua was done; yellow, clear, specific gravity of 1.015, trace protein, negative for urinary tract infection. ascites fluid from at 4:30 a.m. was drawn and demonstrated white blood cells at , red blood cells , polys at 6%, lymphs at 14%, monos at 64%, eos at 13%, basophils at 1%, and mesothelial cells at 2% not consistent with svp. total protein is 4.1, glucose was 113 mg/dl. ldh was 381 units per liter, amylase 20 units per liter, albumin 2.1 g/dl. cultures were negative for growth. chest x-ray was done in the emergency department and demonstrated bilateral filler lymphadenopathy but otherwise unremarkable. summary of hospital course: patient was admitted for malignant ascites and hyperkalemia of 5.8. hyperkalemia was corrected via 10 units of insulin plus 50% of 50 cc of glucose solution with a resulting potassium of 4.6 at 2 a.m. the following morning. ekg done in the ed and repeat ekg done on the floor demonstrated poor r-wave progression without prior for comparison. further analysis of the ascites drained on demonstrated gram stain with 2+ , no micro organisms. cultures were negative for growth, and cytokeratin stain was positive with negative staining with tif/1. a fena was performed and the patient was found to be pre-renal. patient was rehydrated with d5 normal saline at 100 cc per hour and reassessed clinically. on the patient's serum ldh was found to be elevated at 452. his albumin was found to be decreased at 2.2 on a full dermatological exam was performed and found to be negative for melanoma. a tsh was found to be elevated at 11. cea was normal at 1.2. serum ii ascites albumin gradient was found to be 0.1, indicating no portal hypertension. on interventional radiology was again consulted, and under ultrasound, found ascites accumulation for the third time for this admission. placement of - type abdominal drain was then ordered via interventional radiology. patient then developed severe constipation and was treated with dulcolax times one, senna times one, lactulose times two without effect. a bisacodyl suppository times one was then tried without effect. fleet p.o. was tried times one without effect. fleet enema was then tried times one with good effect. patient remained off plavix now for nine days. as of pathology indicates a preliminary diagnosis of adenocarcinoma likely of lung or pancreatic source. interventional radiology did place - style abdominal pain and peripherally inserted central catheter line without complication. hyperkalemia was noted to be corrected at 5.0. secondary to poor p.o. intake from abdominal distention, the renal failure began to present again with a bun of 48 and a creatinine of 2.1. intravenous fluids were then again ordered with d5 normal saline at 100 cc per hour times one liter. patient was then transferred to the oncology medicine service on the for initiation of chemotherapy for the diagnosis of adenocarcinoma with unknown primary source. discharge status: fair. disposition: to oncology medicine service on #50. discharge diagnoses: 1. malignant metastatic ascites. 2. adenocarcinoma of unknown origin. discharge medications to oncology medicine service at : 1. acetaminophen 325 to 650 mg p.o. q. four to six hours p.r.n. 2. zolpidem tartrate 5 mg p.o. h.s. 3. heparin 5000 units subq. q. 12 hours. 4. atorvastatin 10 mg p.o. q.d. 5. senna one tab p.o. b.i.d. p.r.n. 6. lactulose 30 ml p.o. q. eight hours p.r.n. 7. lorazepam 0.5 mg iv q. four hours p.r.n. dr., 12-766 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Percutaneous abdominal drainage Diagnoses: Acidosis Hyperpotassemia Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Ostium secundum type atrial septal defect Other malignant neoplasm without specification of site Secondary malignant neoplasm of retroperitoneum and peritoneum

history of present illness: this is a 69-year-old male with a past medical history significant for hyperlipidemia, osteoarthritis, retinal hemorrhage, small sbo status post a colonoscopy, who was admitted to the hospital on for further workup and possible treatment for a metastatic adenocarcinoma of unknown primary. briefly, the patient had been well until approximately two weeks ago when he became tired and lethargic at the gym on admission and workup at that time revealed the cancer in a metastatic stage. the patient was dr., 11-575 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Percutaneous abdominal drainage Diagnoses: Acidosis Hyperpotassemia Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Ostium secundum type atrial septal defect Other malignant neoplasm without specification of site Secondary malignant neoplasm of retroperitoneum and peritoneum

history of present illness: this is a 69-year-old male, who was readmitted on the day of admission with known metastatic adenocarcinoma of unknown primary. the patient had been well until approximately two weeks prior to this admission when he became lethargic and fatigued at the gym. hospital admission and workup revealed possible gi malignancy of unknown type. the patient presented with abdominal distention and ascites. patient was also found to have pulmonary nodules and diffuse mediastinal lymphadenopathy. after these findings, the patient was readmitted for further workup and possible treatment of his metastatic cancer. hospital course: on this admission, the patient was initially admitted to the floor and his condition declined, and was transferred into the intensive care unit. he underwent two large volume paracenteses, one on , which removed 3.5 liters of fluid and a peritoneal drain was placed. his condition further worsened as he went into increasing renal failure, became hypotensive, and there was substantial discomfort. the patient was thought to possibly be septic at this point, and the decision was made to make the patient comfort measures only. this decision was undertaken with full consultation of the patient's wife and family, who agreed with the decision. i spoke with the patient's wife about his condition when the patient was being transferred on from the intensive care unit back to the floor, and she was clear about her desire for comfort measures. the patient on the floor was placed on a morphine drip and ativan was used prn for comfort. respiratory rate and heart rate were monitored only as a way to assess pain. at approximately midnight between and , the house officer was called by the nurse to pronounce the patient. the patient's wife had told the nurse that she believed the patient had "passed." patient had no heart rate or respirations. patient is found to have fixed and dilated pupils. there were no respirations or heart sounds over the course of two minutes. the time of death was noted to be 11:51 p.m. on . the option of an autopsy was offered to the family, but they refused. the attending physician as well as the primary care physician were notified of this death. dr., 12-766 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Percutaneous abdominal drainage Diagnoses: Acidosis Hyperpotassemia Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Ostium secundum type atrial septal defect Other malignant neoplasm without specification of site Secondary malignant neoplasm of retroperitoneum and peritoneum

history of present illness: the patient is a 67 year old gentleman who presents with one day of frank rectal bleeding. the patient had a routine colonoscopy performed on , colon. he had done well until the day of admission. of note, he restarted his plavix, which he takes for prophylactic purposes after a history of amaurosis fugax. hospital course: on admission, the patient went for an emergent colonoscopy with diffuse blood seen throughout the colon except for the cecum, without a clear source of primary bleed. however, it was suspected that it was coming from the area of the proximal transverse or ascending colon in the region of his previous polypectomy. his blood pressure decreased transiently to 52/25 at one point during the procedure but came up rapidly with minimal administration of intravenous fluids. the patient's hematocrit was 41.0 at baseline and fell as far as 29.0 before it stabilized. the patient did not require transfusion. after discharge from the intensive care unit, his hematocrit was monitored and continued to be in the range of high 20s. his stool continued to be occult blood positive but was not overtly bloody. the patient was not symptomatic with shortness of breath, dizziness or light-headedness at the time of discharge. medications on discharge: 1. lipitor. 2. . 3. zantac. allergies: aspirin. social history: he smokes one to three packs cigarettes per day. he lives with his wife in . past medical history: 1. hyperplastic polyp with an adenoma. 2. hypercholesterolemia. 3. history of amaurosis fugax with small patent foramen ovale noted on transesophageal echocardiogram and unremarkable carotid ultrasonography. 4. diverticulosis in the sigmoid and descending colon. condition on discharge: stable. discharge status: to home. follow-up: the patient will see his primary care physician, . , on tuesday, , for follow-up and hematocrit check. the patient has been instructed should he have any recurrent episodes of overt rectal bleeding or symptoms of shortness of breath, dizziness or light-headedness, he should return to the emergency department immediately. discharge diagnosis: lower gastrointestinal bleed. , m.d. dictated by: medquist36 Procedure: Colonoscopy Diagnoses: Pure hypercholesterolemia Hemorrhage complicating a procedure Hemorrhage of gastrointestinal tract, unspecified Diverticulosis of colon (without mention of hemorrhage)

pmh/sh: hypercholesterolemia, mult emboli to os(amorausis figax), lt inguinal hernia repair. hx smoker 1-3pk/day x25yr allergies: asa->hives meds: plavix, vioxx, lipitor, zyrtec. Procedure: Colonoscopy Diagnoses: Pure hypercholesterolemia Hemorrhage complicating a procedure Hemorrhage of gastrointestinal tract, unspecified Diverticulosis of colon (without mention of hemorrhage)

allergies: lisinopril / morphine attending: chief complaint: chest pain, abdominal pain major surgical or invasive procedure: 1. left femoral line placement with swan ganz. 2. right midline placement by interventional radiology. 3. arterial line placement. history of present illness: 48 yo man with mmp including idiopathic dilated cm w/ end stage chf (ef 15-20%), s/p aicd on , chronic chest/abd pain, s/p recent admission to and d/c on w/ lingular pe and renal infarct who re-presents w/ c/o continued chest and abd pain. states that both are his chronic pain. describes chest pain as l sided, non-pleuritic, no radiation to arm or jaw, no associated diaphoresis, sob, n/v. states abd pain is diffuse across entire abd. pt states both of these are his chronic abd pain that he's had for 3 mos, and chronic cp he's had for 6 mos. comes to ed b/c pain is too much. pt initially presented to transferred to . . in , pt afebrile, sbp 90's-100's (baseline), hr 110's (baseline), labs wnl. ekg unchanged. bedside echo w/ no pericardial effusion or dilated aorta. d/w cardiology who do not want pt admitted to them as no further cardiac issues. plan to admit to medicine for likely placement. past medical history: 1. chf: idiopathic dilated cardiomyopathy. echo with lvef 15-20%, mild-mod mr. with global hypokinesis, moderate dilation, no perfusion defects and normal ekg. cath with no flow limiting coronary disease, elevated right and left sided filling pressures consistent with biventricular diastolic dysfunction (rvedp = 16 mmhg, lvedp = 31 mmhg), moderate pulmonary arterial hypertension, markedly reduced cardiac index, and markedly elevated svr and pvr. dry weight is 144lbs (65.5kg). 2. nsvt: pt with several episodes during hospitalization in and underwent aicd placement. 3. h/o stds: msm. +gonorrhea . hbv core ab+, sab+. hiv neg , hcv neg . 4. rue dvt - on coumadin 5. ? protein c and s deficient last admit social history: the patient immigrated from in . he currently lives alone in . he denies any use of alcohol, tobacco or illicit drugs. he is a man who has sex with men (see above). family history: cad - mother died of mi in her 50s. brothers and sisters also have "problems with their hearts." no known history of blood clots. physical exam: vs: t 97.4, hr 113, bp 101/87, rr 24, o2 99% on 3l nc gen: nad, comfortable, spanish-speaking gentleman, breathing comfortably. heent: perrl. mmm. op clear. no jvd. heart: tachycardic, regular rhythm, no m/r/g. defibrillator site c/d/i without erythema or swelling. lungs: cta b/l abd: soft, nondistended. hyperactive bs. diffuse ttp throughout abd, but no rebound/guarding. ext: no edema bilat. neuro: ao x 3. no focal deficits pertinent results: admission labs: 11:00pm pt-17.8* ptt-32.5 inr(pt)-1.7* 11:00pm plt count-423 11:00pm hypochrom-2+ anisocyt-1+ microcyt-1+ 11:00pm neuts-66.1 lymphs-24.6 monos-6.4 eos-2.2 basos-0.8 11:00pm wbc-6.4 rbc-4.43* hgb-11.9* hct-35.9* mcv-81* mch-26.8* mchc-33.1 rdw-16.6* 11:00pm digoxin-0.5* 11:00pm acetone-negative 11:00pm albumin-3.5 calcium-8.6 phosphate-2.5* magnesium-1.9 11:00pm ck-mb-notdone 11:00pm ctropnt-<0.01 11:00pm lipase-35 11:00pm alt(sgpt)-34 ast(sgot)-24 ck(cpk)-45 alk phos-147* amylase-43 tot bili-0.8 11:00pm glucose-135* urea n-13 creat-0.8 sodium-135 potassium-4.4 chloride-106 total co2-17* anion gap-16 11:17pm lactate-2.1*. . discharge labs: : wbc 6.8, hct 27.4, hgb 8.9, plt 486 : na 129, k 5.4, cl 102, co2 20, bun 19, cr 1, inr 2.1, pt 21.1, ptt 32.5 . imaging: chest x ray : impression: pa and lateral chest compared to : interstitial abnormality in the lungs has cleared substantially consistent with resolved edema. severe cardiomegaly persists. there is no pleural effusion or evidence of central adenopathy. transvenous right ventricular pacer defibrillator lead follows the expected course. . duplex abd/pelvis : impression: 1. patent hepatic vasculature. 2. moderate to large amount of sludge in the gallbladder, which is not distended. gallbladder wall edema, pericholecystic fluid and ascites fluid likely relate to third spacing in this patient. . cardiac cath : comments: 1. resting hemodynamics demonstrated normal pulmonary capillary wedge pressures (14mmhg mean pcwp) with moderate pulmonary hypertension (pulmonary artery pressures of 50/12 mmhg). cardiac output was above normal with cardiac index of 3.8 l/min/m2. 2. tailored therapy with dobutamine 20 mcg/kg/min and ultimately nitroprusside 1.5 mcg/kg/min improved cardiac index to 4.5 l/min/m2 with simultaneous reduction of pulmonary vascular resistance to 1.8 wood units, which demonstrated adequate reversibililty of pulmonary vascular resistance to remain a viable candidate for cardiac transplantation. 3. left femoral pulmonary artery catheter was left in place at 65 cm from the distal tip to the femoral sheath. final diagnosis: 1. moderate pulmonary hypertension. 2. above normal cardiac output and normal filling pressures at baseline on dobutamine 15 mcg/kg/min. 3. adequate reduction of pulmonary vascular resistance on trial of dobutamine and nitroprusside to confirm that pulmonary hypertension is reversible. . echo : conclusions: the left atrium is mildly dilated. the inferior vena cava is dilated (>2.5 cm). left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is severe global left ventricular hypokinesis. the right ventricular cavity is mildly dilated. there is moderate global right ventricular free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , right and left ventricular systolic function are slightly improved. the severity of mitral regurgitation is reduced. left ventricular cavity size is also slightly smaller. the heart rate has increased. pulmonary artery systolic hypertension is now present. brief hospital course: a/p: 48 yo m with h/o idiopathic dilated cardiomyopathy (ef 15-20%) s/p aicd and rue dvt who represents after d/c on with c/o chest pain, now transferred for decompensated chf. labs notable for hyperkalemia, and elevated inr and lfts, improved on inotrope therapy with milrinone, evaluated for possible cardiac transplant. . 1# cardiac: a. pump: pt w/ h/o idiopathic dilated cardiomyopathy, ef < 20%. s/p aicd placement. on transfer was found to be in cardiogenic (lft's acutely rose to high thousands and had arf, altered ms). treated with dobutamine and dopamine and clinically improved and began diuresing. we stopped spironolactone, valsartan, digoxin, lasix d/t rising cr. also stopped metoprolol given decompensated chf. a right heart cath with resting pcwp 14mmhg mean with moderate pulm htn, ci 3.8. tailored therapy with dobutamine 20 and nitroprusside 1.5 improved ci to >4.5 with decreased pulm vascular resistance to 1.8 wood units ->pt is suitable candidate for heart transplant. milrinone was added to dobutamine. the dobutamine was titrated down and stopped. on milrinone alone, his ci ranged from 2.23-3.07. his aldactone and valsartan were restarted at 25mg and 160mg, respectively. he tolerated this change well. his svr on this regimen was in the 800s. his swan was d/c'd on . the patient went for ir guided picc placement on , but a midline was placed instead secondary to rue clotting. he was transferred to the floor in good condition. we tried to increase his metoprolol from 12.5 to 25 without success due to hypotension (sbp 70's). his metoprolol was stopped entirely. he was on aldactone 25mg po qday, which was held on discharge due to hyperkalemia. he will be continued on a continuous milrinone infusion indefinitely, as well as his valsartan 160mg po qday. if his k normalizes, his aldactone can be re-started. . b. rhythm: the patient initially had ivcd and 1st degree block due to hyperkalemia. however, this resolved with his once his potassium was improved. he remained in sinus rhythm, but was tachycardic. his baseline hr is in the 110s. his metoprolol was stopped initially per chf given his decompensation. he also experienced occational episodes of nsvt per telemetry. on his icd discharged 5 times sinus tachycardia. ekg was unremarkable. ep evaluated the icd and increased his hr threshold from 160bpm to 180bpm, with pacing threshold at 200bpm. on ep reverted his icd to his old settings at 160bpm. he did experience nsvt for 18 beats on . ep did not make any changes. he remained asymptomatic. his metoprolol was stopped due to hypotension. he will need to be followed by ep with regards to his icd. . c. ischemia: pt c/o icd site chest pain, likely pt's chronic chest pain. icd site did not look inflamed or infected. no h/o cad. ruled out for mi on the floor. a repeat troponin on was <0.01. his ekgs showed no changes. his pain improved on oxycodone. . 2# elevated lfts: transaminases in the thousands, consistent with liver from poor perfusion. as his perfusion was improved, so did his lfts. they trended down on a daily basis. he continued to have vague abdominal discomfort. however, an abdominal u/s was negative for any thrombosis. . 3# elevated inr: thought likely due to liver failure as above. pt was anticoagulated as outpatient for dvt/pe. he was initially treated with vit k and ffp to lower inr since was very high when transfered to ccu. inr came down to 1.7. it stabilized at 1.4. he was also restarted on a heparin gtt due to his history of thromboses. they were still present on when he went for picc placement. a midline was placed instead. his coumadin was restarted on . his most recent inr was 2.1 on . his warfarin was 3mg po qhs. his inr will need to be watched. . 4# arf/hyperkalemia: thought due to poor forward flow as above with metabolic acidosis from uremia. initially was treated with calcium, insulin, d50 and responded well. received kayexalate as well. his hyperkalemia resolved, as did his arf with improved perfusion due to inotropes. his cr stabilized at his baseline at 0.9 on transfer to the floor. he was transiently hypotense once on the floor, causing his cr to increase to 1.9. with improved bp, his cr returned to baseline. his k remained high at 5-5.4. his ekg was unchanged. . 5# nausea and vomiting: patient had intermittent nausea and vomitting. he was given anzemet prn with good results. . 6# altered ms: initially had ms changes thought due to initial cardiogenic and poor perfusion. it resolved with increased perfusion and inotropy. he was also treated for a potential uti. his mental status remained stable for the duration of admission. . 7# uti: pt did complain of some dysuria in days preceding decompensation and initial ua showed 21-50 wbcs. he was initially treated with vancomycin and zosyn on given acute decompensation and concern for sepsis. however, he improved clinically with treating cardiogenic , vancomycin and zosyn were changed to cipro 500mg po q12h. he was given a total 7 day course without incident. a urine culture from was negative for growth. a repeat culture on grew resistant e coli in the setting of fever to 101; therefore he was started on cefazolin. it was stopped due to lack of symptoms and negative ua and negative repeat urine culture. he remained afebrile and did not complain of any further symptoms. . 8# anemia: on admission his hct was 35. it remained in the low 30s throughout admission. near the end of admission, his hct dropped to the high 20s. his labs did not fit with hemolysis. he was guiac negative throughout admission. he had no signs or symptoms of active bleeding and remained stable. his drop was not related to any procedures. his mcv did hover around 77-82. the patient was transferred before further work up could be performed for iron /b12/folate deficiency vs. anemia of chronic disease. he will need to have this work up prior to going home. . 9# chronic pain: pt w/ chronic abd/chest pain. ct on showed hepatomegaly and right renal wedge shaped infarct. liver enzymes were normal except alk phos which trended down. no etiology for pain found. was on tramadol, oxycodone, neurontin, lidocaine patch as outpt. had no insurance at that time. said that freecare pharmacy did not fill the lidocaine patch scrips as they do not cover topical anesthetics. hence he was back to the hospital. his lidocaine patch was changed to ointment. he was given oxycodone 15mg po qid/prn for pain. his tramadol was initially stopped given his arf. however, it was restarted on a prn basis once his arf had resolved. the chronic pain service that was initially following him signed off. his pain remained well controlled on his current regimen. . 10# fen: he was maintained on a heart healthy diet. he did have mild hyponatremia which remained stable. he did not experience any mental status changes with his levels. . 11# code status: he was full code during this admission . medications on admission: pantoprazole 40 mg po q24h digoxin 125 mcg po daily docusate sodium 100 mg po bid senna 8.6 mg po bid warfarin 3mg po hs spironolactone 25 mg po daily lovenox 60 mg/0.6 ml syringe sig sc bid (as bridge for therapeutic inr) valsartan 40 mg po qhs gabapentin 300 mg po tid tramadol 50 mg po q 4hr prn toprol xl 50mg qd spironolactone 25 mg po daily furosemide 80 mg po once a day. lidocaine 5 %(700 mg/patch) adhesive patch qd - apply for 12 hours, and remove for 12 hours. oxycodone 15 mg po q 6hr prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 3. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 4. lidocaine hcl 5 % ointment sig: one (1) appl topical daily (daily). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 7. oxycodone 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 8. valsartan 160 mg tablet sig: one (1) tablet po daily (daily): hold for sbp <80. 9. warfarin 2 mg tablet sig: 1.5 tablets po hs (at bedtime): please monitor inr accordingly. 10. hydrocortisone 2.5 % cream sig: one (1) appl rectal (2 times a day) as needed. 11. tramadol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 12. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed. 13. furosemide 20 mg tablet sig: one (1) tablet po daily (daily): hold for sbp <80. 14. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 15. dolasetron mesylate 12.5 mg iv q8h:prn 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 17. milrinone 0.38 mcg/kg/min iv infusion 18. heparin flush midline (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. discharge disposition: extended care facility: discharge diagnosis: primary: congestive heart failure . secondary: idopathic cardiomyopathy upper extremity deep vein thrombosis on right anemia renal infarct urinary tract infection hyperkalemia hyponatremia discharge condition: good. hemodynamically stable. afebrile. discharge instructions: please tall medications as prescribed. please keep all follow up appointments. please return to the hospital with any chest pain, shortness of breath, fevers/chills, or any other symptoms that concern you. followup instructions: provider: . phone: date/time: 11:00 . please follow up with dr. as above. Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Pulmonary artery wedge monitoring Right heart cardiac catheterization Transfusion of other serum Automatic implantable cardioverter/defibrillator (AICD) check Diagnoses: Other primary cardiomyopathies Hyperpotassemia Abdominal pain, unspecified site Anemia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Other chronic pulmonary heart diseases Nausea with vomiting Other specified cardiac dysrhythmias Hypotension, unspecified Cardiogenic shock Automatic implantable cardiac defibrillator in situ Personal history of venous thrombosis and embolism Diarrhea Acute systolic heart failure Hyperosmolality and/or hypernatremia Chest pain, unspecified First degree atrioventricular block

allergies: lisinopril / morphine attending: chief complaint: epigastric pain major surgical or invasive procedure: femoral central line placement history of present illness: mr. is a 48 year-old cuban gentleman with a history of idiopathic dilated cardiomyopathy (ef 15-20%) s/p aicd who presented to the emergency department with intermittant, epigastric pain that is similar to his presentation at his last admission on . also admits to bilious emesis. denies any f/chills. he reports pain worsened over the past 3 days with n/v as well as abdominal distension and firmness. he reports some increased dysuria intermittently for the past 2 days. . in the , pt temp was 97.7, hr 112, bp 110/69, 100%ra. he received 1l ns, d5w + bicarb and mucomyst prior to receiving iv contrast during his ct torso. past medical history: 1. chf: idiopathic dilated cardiomyopathy. echo with lvef 15-20%, mild-mod mr. with global hypokinesis, moderate dilation, no perfusion defects and normal ekg. cath with no flow limiting coronary disease, elevated right and left sided filling pressures consistent with biventricular diastolic dysfunction (rvedp = 16 mmhg, lvedp = 31 mmhg), moderate pulmonary arterial hypertension, markedly reduced cardiac index, and markedly elevated svr and pvr. dry weight is 144lbs (65.5kg). 2. nsvt: pt with several episodes during hospitalization in and underwent aicd placement. 3. h/o stds: msm. +gonorrhea . hbv core ab+, sab+. hiv neg , hcv neg . 4. rue dvt - on coumadin 5. ? protein c and s deficient last admit social history: the patient immigrated from in . he currently lives alone in . he denies any use of alcohol, tobacco or illicit drugs. he is a man who has sex with men (see above). family history: cad - mother died of mi in her 50s. brothers and sisters also have "problems with their hearts." no known history of blood clots. physical exam: admission pe: vs: t97.2 bp96/52 p116 r20 o2 95%ra gen: nad, comfortable, spanish-speaking gentleman, breathing comfortably. heent: perrl. mmm. op clear. no jvd. heart: rrr no m/r/g. defibrillator site c/d/i without erythema or swelling. lungs: cta b/l abd: soft, nondistended. hyperactive bs. diffuse ttp throughout abd, but no rebound/guarding. mild cvat on r, none on l. ext: no edema bilat. neuro: ao x 3. no focal deficits pertinent results: admission labs: . 08:20pm blood wbc-7.1 rbc-4.65 hgb-13.1* hct-38.5* mcv-83 mch-28.2 mchc-34.0 rdw-15.7* plt ct-351 08:20pm blood neuts-65.7 lymphs-27.6 monos-5.0 eos-1.2 baso-0.4 08:20pm blood hypochr-1+ microcy-1+ 08:20pm blood pt-36.2* ptt-30.3 inr(pt)-4.0* 08:20pm blood glucose-112* urean-20 creat-1.3* na-135 k-6.2* cl-100 hco3-21* angap-20 08:20pm blood alt-54* ast-77* ck(cpk)-140 alkphos-157* amylase-30 totbili-1.0 08:20pm blood lipase-30 08:20pm blood ck-mb-2 08:20pm blood calcium-8.8 phos-4.6* mg-2.2 . other labs: troponin <0.01, ck 140 homocystein level 10 aca igm 8.0 and aca igg 5.2 prothrombin mutation not detected factor v leiden mutation not detected . cxr (): 1. marked cardiomegaly, stable. 2. interval improvement in the degree of congestive heart failure with a tiny right pleural effusion. 3. stable appearance of the transvenous pacemaker and leads. . ct torso (): 1. likely small subsegmental nonocclusive lingular pulmonary embolus. 2. heterogeneous right nephrogram, new from , is pyelonephritis versus renal infarcts. 3. a moderate right pleural effusion. (enlarged from ), and small ascites (relatively unchanged). . echo : the left and right atrium are moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis. no masses or thrombi are seen in the left ventricle. the right ventricular cavity is moderately dilated with severe global 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. moderate to severe (3+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of ,the findings are similar. . echo : the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed. no definite thrombus identified (cannot definitively exclude). spontaneous echo contrast is noted in the left heart consistent with slow flow. the right ventricular cavity is dilated. there is moderate to severe global right ventricular free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . rle u/s : no dvt . discharge labs: . 06:40am blood wbc-6.1 rbc-4.68 hgb-12.7* hct-38.4* mcv-82 mch-27.0 mchc-33.0 rdw-16.4* plt ct-459* 06:40am blood plt ct-459* 06:40am blood pt-19.6* ptt-33.2 inr(pt)-1.9* 06:40am blood glucose-93 urean-23* creat-1.1 na-133 k-4.8 cl-98 hco3-24 angap-16 06:40am blood calcium-9.0 phos-4.0 mg-2.0 brief hospital course: 48 year-old m with nonischemic dilated cmp with ef<20%, multiple vte (dvt/pe) who presents with persistent epigastric pain initially admitted to medicine, transfered to the micu due to hypotension on the same day, then ccu the next day for further management of chf (tailored therapy). his hospital course for this admission is as follows: . 1 chf: severe systolic chf with ef <20% with moderate mr, hypotension likely secondary to poor cardiac output. we continued his digoxin at home dose. central line was placed, and he was started on dobutamine drip tailored therapy at 15/kg/min on which was gradually weaned to 12mcg/kg/min on , and weaned completely on and his central line was pulled on the same day. we monitored him closely for arrythmias on the tele while he was on the dobutamine drip. lasix, , and spironolactone was held initially given increased cr, while he was at the ccu, (valsartan 40''), lasix 40', aldactone 25' was restarted once his cr function was back to his baseline. he was held on most of his heart failure meds given bp parameter setting (sbp<95), but we adjusted the parameter to hold meds for sbp<85, and the decision was made not to take him for right heart cath at the time since he was able to tolerate his heart failure meds with changing parameters. he was discharged home with valsartan 40mg po qhs, lasix 80mg po qday, aldactone 25mg po qday, digoxin 0.125mg po qday. . 2 ischmia. no cp, no h/o cad. initial troponin and ck negative. . 3 rhythm. pt had sinus tach, likely to low cardiac output, anticipate improvement. . 4 abdominal pain. leading diagnosis is congestion from chf causing pain from liver capsule expansion. somewhat responsive to ppi. he continued to complained abdominal pain while in the hopsital, and seemed to improved with pain management. ct torso initially was unrevealing. we followed his daily lfts, which continued to be mildly elevated but stable c/w with liver congestion from his heart failure. . 5 dvt/pe. unclear etiology. rue vte developed at home, not in setting of line placement. patient now developed a small pe while supratherapeutic on coumadin. concerning for hypercoagulable state. hem/onc was consulted, but was difficult to send hypercoagulable stuides given patient already anticoagulated; we sent antiphospholipid ab which was wnl, pt didn't carry the more common factor mutation and prothrombin mutations, homocysteine levels was wnl; his initially inr was supratherapeutic 4.0->3.5, coumadin was held initially; coumadin was restarted at 3mg po qhs when inr came down to 2.5. given echo showed questionable lv thrombus and given ? hx of hypercoagulable state, he was also started on lovenox 60mg sc q12h when inr became undertherapeutic (inr<2.0) while on coumadin. he also finished a 7 day course for kefelx for superifical thrombophlebitis. . 6 r renal infarct. noted on ct torso, new finding which was concerning for thromboembolic disease, possibly lv thrombus give dilated cmp predisposing to intracardiac stasis. echo aslo suggestive of poor flow. no clots seen on echo however. no evidence of endocarditis given no fevers, bl cx negative to date from ed. we continued anticoagulation with coumadin and lovenox (when inr<2.0), and monitored renal function closely where cr trending down to baseline. . 7 cr elevation. baseline 1.0, initially slightly elevated secondary to poor cardiac output +/- renal infarct. anticipate improvement with improved cardiac output on pressors. we held lasix and initially given slightly elevated bun/cr; once cr back to his baseline, and lasix was restarted. . 8 pain syndrome. multifactorial, mainly around his icd site (no signs of infection and remained afebrile thorughout the hospital course) and abdomen (most likely related to congestive hepatopathy). chronic pain service was consulted, which recommended oxycodone 5-15mg po q4h prn, tradmadol 50mg po q4-6h prn, and gabapentin 600mg po tid, and lidocaine 5% patch 12 hours on and 12 hours off. patient's pain slightly improved on this regimen. . 9 congestive hepatopathy. lfts mildly elevated initally, we followed closely his daily lfts, which remained slightly elevated but stable. . 10 fen: cardiac diet, fluid restriction 1500ml/day, lyte repletion prn . 11 ppx: inr elevated initially, once therapeutic, started coumadin (and lovenox and inr<2.0), bowel reg prn, po diet, ppi . 12 full code medications on admission: medications at home: pantoprazole 40 mg q24h digoxin 125 mcg po daily spironolactone 25 mg po daily valsartan 40 mg po bid carvedilol 12.5 mg po bid tramadol 50 mg po q4-6h as needed furosemide 20 mg po qod warfarin 2mg qhs oxycodone 10mg q4, prn keflex 500 x2 more days . meds upon transfer to ccu: - digoxin 0.125 mg po daily - oxycodone (immediate release) 10 mg po q4h - oxycodone (immediate release) 5 mg po q6h:prn - pantoprazole 40 mg po q24h - tramadol 50 mg po q4-6h:prn - dolasetron mesylate 12.5 mg iv q8h:prn - cephalexin 500 mg po q6h duration: 2 days discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily): hold for sbp<85. disp:*15 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*0* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 5. warfarin 1 mg tablet sig: three (3) tablet po hs (at bedtime). disp:*45 tablet(s)* refills:*0* 6. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<85. disp:*15 tablet(s)* refills:*0* 7. lovenox 60 mg/0.6 ml syringe sig: one (1) subcutaneous twice a day for 3 days. disp:*6 syringes* refills:*0* 8. valsartan 40 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)): hold for bp<85. disp:*15 tablet(s)* refills:*0* 9. gabapentin 300 mg capsule sig: two (2) capsule po three times a day: hold for oversedation. disp:*90 capsule(s)* refills:*0* 10. tramadol 50 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. disp:*90 tablet(s)* refills:*0* 11. metoprolol succinate 25 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po daily (daily): hold for sbp<85. disp:*30 tablet sustained release 24hr(s)* refills:*0* 12. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*15 tablet(s)* refills:*0* 13. furosemide 80 mg tablet sig: one (1) tablet po once a day. disp:*15 tablet(s)* refills:*0* 14. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical once a day: apply for 12 hours, and remove for 12 hours. disp:*15 adhesive patch, medicated(s)* refills:*0* 15. oxycodone 5 mg tablet sig: three (3) tablet po every six (6) hours as needed: hold for oversedation and rr<12. disp:*180 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: idiopathic dilated cardiomyopathy chronic pain . secondary diagnosis: nsvt s/p aicd placement . h/o stds: msm. +gonorrhea . hbv core ab+, sab+. hiv neg , hcv neg . rue dvt/small subsegmental pe - on coumadin as outpatient chronic pain - aicd placement, dvt, superficial thrombophlebitis, abdominal pain discharge condition: patient is in stable condition, afebrile, no chest pain, shortness of breath, blood pressure stable, ambulating, o2 sat in the upper 90%. discharge instructions: if you experience any chest pain, sob, heart palpitations, fever, abdominal pain different than your baseline or any other serious medical conditions, please go to the emergency room immediately. . you heart is dilated and not pumping well. please restrict fluid intake to less than 1500ml per day. please weigh yourself everyday, if your weight increased by more than 5-10lbs, please contact your pcp or your cardiologist immediately. please make sure you take all your heart failure medications which may help your abodominal pain, including: digoxin 0.125mg po qday lasix 80mg po qday toprol xl 50mg po qday aldactone 25mg po qday valsatan 40mg po every night . you are on coumadin (indefinitely) and lovenox( for three days only), blood thinners. it is very important that you take coumadin everynight, please have your inr checked regularly by your pcp to keep it within the therapeutic range (goal inr ) to prevent clots development in your heart which can cause stroke and other serious problems. please make sure you get lovenox shot 60mg sc bid for three days in addition to take coumadin 3mg po every night indefinitely to allow inr be in the therapeutic range. . you have chronic pains, and we consulted chronic pain management team, they recommended you taking oxycodone 5-15mg po every hours as needed for pain control, tramodal 50mg po every hours as needed for pain control, lidocaine 5% patch 12 hours on and 12 hours off, and gabapentin 600mg by mouth three times a day for pain control. if you experience pain different than your baseline, please seek medical attention immediately. . please take your medication as prescribed. . please follow up with your appointments see below. followup instructions: please follow up with your pcp, . () on 9:50am and follow up with dr. on at 10:30am for inr check and appointments . provider: , md date/time: 9:50 provider: , : date/time: 10:30am Procedure: Arterial catheterization Diagnoses: Other primary cardiomyopathies Anemia, unspecified Congestive heart failure, unspecified Acute kidney failure, unspecified Chronic kidney disease, unspecified Automatic implantable cardiac defibrillator in situ Hypoxemia Primary hypercoagulable state Acute systolic heart failure Phlebitis and thrombophlebitis of superficial veins of upper extremities Other pulmonary embolism and infarction Abdominal pain, generalized Other specified hypotension Vascular disorders of kidney Acute venous embolism and thrombosis of deep vessels of distal lower extremity Other specified disorders of liver

discharge medications: 1. norvasc 2.5 mg by mouth once daily 2. ciprofloxacin 500 mg by mouth once daily for seven days 3. glipizide 10 mg by mouth once daily 4. plavix 75 mg by mouth once daily 5. aspirin 325 mg by mouth once daily 6. zantac 150 mg by mouth twice a day 7. colace 100 mg by mouth twice a day 8. lopressor 12.5 mg by mouth twice a day 9. tamsulosin 0.4 mg by mouth daily at bedtime 10. percocet one to two tablets by mouth every four to six hours as needed for pain , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Open and other replacement of aortic valve with tissue graft Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Aortic valve disorders Occlusion and stenosis of carotid artery without mention of cerebral infarction Unspecified disorder of kidney and ureter

history of present illness: the patient is an 83 year-old male transferred from with a past medical history of diabetes mellitus, cri, hypertension presenting with shortness of breath, chest pain and ruled in for a non q wave myocardial infarction with troponin highs of 14.5. the patient was found to be in congestive heart failure, was diuresed, creatinine increased from 2.1 to 2.6. echocardiogram showed severe aortic stenosis, 0.5 cm squared and an ejection fraction of 35%. the patient presented with mid sternal chest pain radiating to both arms, arm heaviness, and fatigue, question short of breath. relieved when he sat upright and worse when lying. the patient went to the emergency department and chest pain was relieved after one nitro and has been chest pain free since. he has had increased chest pain with exertion for the past one and a half years. also increased chest pain with eating, fifteen minutes after eating. no fevers or chills. the patient sleeps on one pillow. no paroxysmal nocturnal dyspnea, no cough, no lightheadedness, no syncope. history of five or six years of chronic lower extremity edema. no abdominal pain after meals. no melena. no hematochezia, polyuria. no transient ischemic attack symptoms. physical examination: the patient's vital signs are stable. neck no jvd. no lymphadenopathy. chest bibasilar rales. cardiovascular regular rate and rhythm. s1 and s2. 3 out of 6 systolic ejection murmur loudest at apex, radiates to carotids. abdomen nontender, nondistended. no organomegaly. rectal large prostate, guaiac negative stool. extremities no clubbing, cyanosis or edema. vascular bilateral femoral bruits, bilateral carotid bruit, question radiating from aortic stenosis. 2+ dorsalis pedis pulses. neurological cranial nerves ii through xii intact. strength 5 out of 5 upper extremities and lower extremities. left arm slight intention tremor. sensory grossly intact. patella reflexes equal bilaterally. babinski downward. laboratory: hematocrit 37.8, creatinine 2.6, calcium 8.5, inr 1.8. electrocardiogram normal sinus rhythm at 70, left axis deviation down sloping st depressions in 1 through avl, v4 through v6 versus left ventricular strain. hospital course: the patient is admitted to the service on for complaints of chest pain at which time the patient ruled in and was transferred to from . the patient was started on a heparin drip, nitro drip and sublingual nitroglycerin prn, beta blocker and aspirin. cardiac catheterization was also recommended. the patient's kidney function was also assessed as acute on chronic renal failure, which at that time was attributed to prerenal failure. subsequent cardiac catheterization showed left main coronary artery with no significant obstructive disease, left anterior descending coronary artery with 60% stenosis in the mid portion, left circumflex 70% proximal, 90% stenosis at the obtuse marginal one, 90% distal obstruction and right coronary artery with small nondominant 70% mid vessel stenosis. aortic valve gradient was 15 mmhg. at that time it was thought that because of the patient's three vessel disease that he should proceed to cardiothoracic surgery for coronary artery bypass graft. in addition, the patient was worked up for his carotid disease and the vascular laboratory reported carotid stenosis of 80 to 99% of the right coronary artery and no flow detected in the left internal carotid. a renal consult was obtained for the patient's acute on chronic renal failure at which time the following recommendations were made, to hold off on the patient's diuretics, review urinary sediment and to hold on the patient's ace inhibitor and to avoid nephrotoxins. it is believed that the patient's acute renal insufficiency was due to redo contrast nephrotoxicity. the chronic renal disease was secondary to diabetes. the patient had no evidence of atheroemboli. on hospital day five the patient was noted to have flash pulmonary edema. the stroke service was consulted in order to place a stent in the right internal carotid artery before the patient's aortic valve replacement and coronary artery bypass graft. the findings on duplex ultrasound were confirmed by mra. the patient was found to have severe right coronary artery stenosis. on the patient had a 30 mm carotid stent placed in the right ica. the patient was seen by cardiac surgery at which time possible risks and complications were explained to him and consent was signed. the patient was taken to the operating room on at which time coronary artery bypass graft times three was performed. the patient's left internal mammary coronary artery was taken to the left anterior descending coronary artery, saphenous vein graft to the posterior descending coronary artery, saphenous vein graft to the obtuse marginal. the patient was cross clamped for 115 minutes and cardiopulmonary bypass times 147 minutes. in addition, he an aortic valve replacement was performed. a #19 mm ce bovine pericardial valve was placed. postoperative day number one the patient did well on cpap and pressure support of 10 to 15. the patient's blood gases were normal at that time and on postoperative day number two the patient continue to resolve without neurological deficits. he was continued on his aspirin and plavix for patency of the carotid stent. on postoperative day number three the patient was felt to be stable and was subsequently transferred to the cardiac surgical floor. on the floor the patient's foley was discontinued, but had to be replaced secondary to a 12 hour lack of urination. post void residual was 700. the patient's creatinine continued to creep up to approximately 3.1. the patient's blood pressure also elevated and renal recommended norvasc 2.5 mg po q day. the patient also received 1 unit of packed red blood cells for a hematocrit of 26, which was on repeat hematocrit 30.7. on postop day seven the patient's av wires were taken out and the patient was found to be stable for rehab. urology had seen the patient and has recommended starting the patient on flomax .4 for the patient's urinary retention. the patient is to have voiding trial in one week and is leaving with a urinary leg bag. the patient is to follow up with nephrology and with the neurological stroke service. condition on discharge: good. discharge status: to rehab. discharge diagnoses: status post right internal carotid artery stent and status post coronary artery bypass graft with aortic valve replacement. discharge medications: norvasc 2.5 mg po q day, ciprofloxacin 500 mg po q 24 hours, glipizide 10 mg po q day, plavix 75 mg po q day, aspirin 325 mg po q day, zantac 150 mg po q day, colace 100 mg po b.i.d. and lopressor 25 mg po b.i.d. follow up plans: the patient is to follow up with the neurology stroke service in two weeks. the patient is to follow up with dr. in four weeks and should follow up with the nephrology service in two weeks as well. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Open and other replacement of aortic valve with tissue graft Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Open and other replacement of aortic valve with tissue graft Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Aortic valve disorders Occlusion and stenosis of carotid artery without mention of cerebral infarction Unspecified disorder of kidney and ureter

history of present illness: this is an 83 year old male transferred from hospital in with a past medical history of diabetes mellitus, chronic renal insufficiency with baseline of 2.1 creatinine and hypertension who presented with chest pain and shortness of breath and ruled in for non-q wave myocardial infarction with troponin of 14.5 at an outside hospital. there he was found to be in congestive heart failure and diuresed with a subsequent bump in his creatinine from 2.1 baseline to 2.6. at the outside hospital an echocardiogram showed severe aortic stenosis with valve area of 0.5 cm squared and an ejection fraction of 35%. the patient presented with mid sternal chest pain radiating to both arms, arm heaviness and overwhelming sense of fatigue and shortness of breath. it was relieved when he sat upright and worse when he was lying down. the patient went to the emergency department and his chest pain was relieved after one sublingual nitroglycerin. the patient has had increase in chest pressure with exertion over the past one and a half years. he has also had increased chest pressure, status post eating which occurs about 15 minutes after a meal. he has no fever and chills. he sleeps on one pillow with no increase, no paroxysmal nocturnal dyspnea, no coughing, no lightheaded and no syncope. he has a history of five to six years of chronic lower extremity edema. no abdominal pain after meals, no melena, no hematochezia, no dysuria, no transient ischemic attack symptoms. past medical history: no prior cardiac history. diabetes mellitus for 14 years. chronic renal insufficiency, baseline creatinine 2.1. stroke ten years ago with a question of a right facial droop, now on coumadin. echocardiogram at hospital, , showing ejection fraction of 35%, severe atrial fibrillation, hypertension, hypercholesterolemia, cataract surgery, tonsillectomy, appendectomy. medications on admission: (at outside hospital/admission here) aspirin 81 mg p.o. q.d.; glucotrol 20 mg p.o. q.d.; prevacid; lasix 40 mg intravenously b.i.d.; lopressor 12.5 mg b.i.d.; mucomyst 600 mg p.o. b.i.d.; heparin drip; nitroglycerin drip. the patient took coumadin at home 5 mg q.d. and nifedipine 60 mg q.d. at home. allergies: sulfa ? reaction; statins with myopathy. social history: lives with daughter in , quit tobacco in and smoked pack per day for 40 years, worked as a custodian, no alcohol, no drugs. family history: mother with diabetes in her 70s. physical examination: examination on admission revealed temperature 98.4, blood pressure 114/60, pulse 72, respirations 18, 140 lbs by patient report. general: alert and oriented in no acute distress. head, eyes, ears, nose and throat, extraocular movements intact, pupils equal, round and reactive to light, anicteric sclera, mucous membranes moist. neck, no jugulovenous distension, no lymphadenopathy. chest, bibasilar rales. cardiac, regular rate and rhythm, s1 and s2, harsh iii/vi systolic ejection murmur, loudest at apex, radiating to carotids and to femoral vessels. abdomen, nontender, nondistended, normoactive, no organomegaly. rectal, large prostate guaiac negative stool. extremities, no cyanosis, clubbing or edema. vascular, bilateral femoral bruits, likely radiated from heart. bilateral carotid bruits, questionably radiating from heart as well. 2+ dorsalis pedis pulses bilaterally. neurologic, cranial nerves ii through xii intact. strength, in upper and lower extremities. left arm with slight intention tremor. sensory grossly intact. patellar reflexes equal bilaterally. babinski downgoing bilaterally. laboratory data: laboratory studies at the outside hospital on admission on , white blood cell count 10, hematocrit 37.8, platelets 145, ldl in 200s. sodium 136, potassium 4.5, chloride 96, bicarbonate 30, bun 51, creatinine 2.6, platelets 202, calcium 8.5 and inr 1.8. electrocardiogram, normal sinus rhythm, 70, left axis deviation, positive left atrial abnormality, positive left ventricular hypertrophy, positive left ventricular strain pattern in v4 through v6 and one in avl. hospital course: this is an 83 year old male without significant past cardiac history with a history of hypercholesterolemia, diabetes mellitus, and hypertension who was transferred from an outside hospital after ruling in for non-q wave myocardial infarction, congestive heart failure and found to have critical aortic stenosis by echocardiogram. the patient was also found to have increase in his creatinine from 2.1 to 2.6 after diuresis of his congestive heart failure. on presentation he was asymptomatic with nitroglycerin drip and status post diuresis. 1. cardiac - a. coronary artery disease, the patient with increasing exertional chest pressure over the past few months with more recent increased angina when lying down flat, relieved when sitting upright. this is likely due to elements of congestive heart failure when lying flat. he ruled in for non-q wave myocardial infarction by positive troponins at outside hospital. he likely has both coronary artery disease and subendocardial ischemia with his critical aortic stenosis. on admission here he was continued on his heparin drip, weaned off of his nitroglycerin drip because of his critical aortic stenosis and continued on his beta blocker and aspirin. cardiac catheterization was done after his renal function showed some improvement. this showed: three vessel cardiac disease with calcified left anterior descending and moderate diffuse disease throughout with stenosis of 60% in the mid segment. the dominant circumflex had 50% proximal disease and 80% distal disease. an obtuse marginal had a proximal 90% stenosis. the nondominant right coronary artery also had a stenosis of 80% at its mid segment. because of his three vessel disease, this patient was thought to be a candidate for coronary artery bypass graft. the patient was awaiting coronary artery bypass graft and had multiple episodes of chest pain during this time. this chest pain was relieved on occasion by merely sitting the patient upright. other times it required one to two sublingual nitroglycerins administered judiciously to try to prevent too much preload reduction with his critical aortic stenosis. on occasion this chest pain was associated with flash pulmonary edema and desaturations to 85% which was relieved by sublingual nitroglycerin and lasix. b. pump, this is a patient with critical aortic stenosis seen by cardiac catheterization and echocardiogram with increasing angina, and dyspnea. he has no history of syncope. cardiac catheterization showed hemodynamics with normal right-sided filling pressures and mildly elevated left-sided filling pressures with a mean gradient of 35.5 mg of mercury across the aortic valve and a calculated valve area of 0.79 cm squared. the cardiac index was mildly reduced at 2.3. the patient had echocardiogram as well this admission which showed ejection fraction of 40%. the severe aortic stenosis was seen with symmetric left ventricular hypertrophy and regional dysfunction of his inferolateral and inferior walls with hypo and akinesis in this region consistent with coronary artery disease. he also had mild to moderate mitral regurgitation and moderate pulmonary artery hypertension by this study. the patient was continued on his metoprolol 25 mg p.o. b.i.d. and cautious use of nitroglycerin was used during his episodes of flash pulmonary edema. cep, the patient was in normal sinus rhythm throughout this hospitalization with evidence of left ventricular strain on his electrocardiogram with no significant event on telemetry. the patient has a history of hypertension and has blood pressure ranged from 120 to 160 systolic during this hospitalization. 2. carotid artery disease - the patient was thought to be a candidate for coronary artery bypass graft and aortic valve repair. prior to his surgery he did receive a carotid artery duplex evaluation which showed 80 to 99% stenosis of the right internal carotid artery and occlusion of the left side. he was then given an magnetic resonance imaging scan, magnetic resonance angiography of his head and neck which confirmed these ultrasound studies. it did show a patent circle of and flow in the vertebral arteries. the patient was thought to benefit most from right coronary artery stenting prior to his coronary artery bypass graft and aortic valve repair surgery. at the time of this dictation he will be undergoing this procedure today. he had no signs of acute stroke by his magnetic resonance imaging scan. 3. renal - the patient had acute and chronic renal failure, status post diuresis for his congestive heart failure on admission. the patient's creatinine fluctuated between 2.1 and 2.6 during this hospitalization with an increase 48 hours after cardiac catheterization and slight increases after his diuresis in the setting of his flash pulmonary edema. overall, however, it has ranged in the 2.4 to 2.5 range with good urine output. 4. hematology - the patient had been anticoagulated for his history of stroke. he was continued on his heparin ggt during this admission for his acute coronary syndrome as well as his cardiovascular disease. his coumadin was held. his platelets remained stable in the low 100s on heparin throughout this stay. 5. diabetes mellitus - his blood sugars ranged from 170 to 250 during his stay on the floor on a regular insulin sliding scale. he was kept on the sliding scale and his glucotrol was discontinued because of his multiple catheterizations and during this week. 6. hypercholesterolemia - the patient could not tolerate statins and develops myopathy with these. he was continued on a low cholesterol diet. disposition: the patient will have his carotid stent and go to the coronary care unit. he will then be transferred to the cardiothoracic surgery team for coronary artery bypass graft and aortic valve repair. this dictation encompasses the hospital stay from to . medications: 1. aspirin 81 mg p.o. q.d. 2. protonix 40 mg p.o. q.d. 3. metoprolol 25 mg p.o. b.i.d. 4. insulin sliding scale 5. nitroglycerin 0.3 mg sublingual times one prn , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Open and other replacement of aortic valve with tissue graft Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Aortic valve disorders Occlusion and stenosis of carotid artery without mention of cerebral infarction Unspecified disorder of kidney and ureter

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: anorexia, nausea/vomiting major surgical or invasive procedure: -r inguinal lymph node biopsy () exploratory lap/open ccy/liver biopsy/pancreatic biopsyx/peri-portal lymph node biopsy () exploratory-lap/washout/gj tube () history of present illness: 76ym diagnosed with a pancreatic head mass s/p stenting presents with 3 weeks of nausea, vomiting and anorexia. pt states that he has not been able to take anything by mouth for the past three weeks due to decreased appetite and more recently, nausea and vomiting. he reports a 50lb weight loss in the last 3 months. he also c/o vague diffuse bandlike abdominal pain. otherwise, no fevers, normal bowel movements. he presents for further evaluation of his pancreatic head mass and rehydration. past medical history: htn itp multiple orthopedic procedures pancreatic head mass s/p stenting x 2 social history: live with wife, retired engineer, 7 children, 13 grand children, hx of smoking, no etoh, no drugs, independent on all adl, iadls except financing (wife does that). family history: not contributory physical exam: gen elderly nad heent eomi, perrl, oropharynx without erythema/exudate neck supple cv rrr resp cta bilaterally abd soft ntnd ext bilateral groin with palpable lymph nodes, no le edema neuro aao x 4 pertinent results: sinus rhythm consider left atrial abnormality left axis deviation t wave changes are nonspecific since previous tracing of , no significant change read by: , a. intervals axes rate pr qrs qt/qtc p qrs t 61 178 104 -51 42 ct abd w&w/o c 11:40 am ct abd w&w/o c; ct pelvis w/contrast reason: please evaluate lympadenopathy field of view: 42 contrast: optiray medical condition: 75 year old man with panc head mass, lympadenopathy reason for this examination: please evaluate lympadenopathy contraindications for iv contrast: none. indication: 75-year-old male with pancreatic head mass and lymphadenopathy. evaluate lymphadenopathy. comparison: ct abdomen and pelvis. technique: mdct acquired axial images of the abdomen and pelvis were performed without iv contrast. multiphasic scans were then obtained of the abdomen and pelvis. ct abdomen without and with iv contrast: bibasilar dependent atelectasis. no pleural effusions. no focal liver lesions identified. pneumobilia is again seen and stable. hyperemic gallbladder wall with small amount of surrounding low-attenuation density likely representing fluid is also unchanged. a stent is seen extending from the distal common bile duct into the duodenum. the head, body, tail of the pancreas are unremarkable. spleen is within normal size limits and contains multiple punctate low-attenuation lesions too small to characterize. the right kidney contains multiple low attenuation lesions too small to characterize. the previously seen hypovascular left kidney lesion is decreased in size likely secondary to interval core biopsy. as previously described there is extensive lymphadenopathy seen surrounding the pancreatic head and extending retroperitoneal in the periaortic region extending to the bifurcation of the iliacs. a representative node is seen on series 4, image 48. it is left periaortic, measures 21 mm and is unchanged compared to previously measuring 20 mm. no free air or free fluid. multiple scattered, nonpathologically enlarged mesenteric nodes. small bowel and large bowel are unremarkable. ct pelvis with iv contrast: the urinary bladder, rectum are unremarkable. there are multiple pathologically enlarged nodes bilaterally within the inguinal region. a representative node seen on series 4, image 76 measures 17 mm and node is located lateral to the left external iliac artery. large prostate again noted, unchanged with periureteric edema/filling defect on the right upon insertion into the right hemitrigone. as mentioned previously these raise possibility of a possible bladder base lesion and recommend correlation with cystoscopy. unchanged bilateral fat containing inguinal hernias and extensive iliac nodal lymphadenopathy unchanged. bone windows: no suspicious lytic or sclerotic bony lesions. impression: 1. extensive lymphadenopathy unchanged compared to prior study from three weeks ago. findings consistent with systemic process such as lymphoma. less likely to represent diffuse metastatic disease. percutaneous biopsy can easily be achieved in various locations including retroperitoneum and external iliac chain specifically within the left external iliac region as marked on scan and indicated above. 2. left renal lesion significantly decreased in size, likely secondary to prior biopsy. lymphoma still a strong consideration within differential. 3. multiple low attenuation lesions within right kidney, too small to characterize. 3. right bladder base lesion. as previously described recommend cystoscopy for further evaluation. 4. multiple unchanged splenic lesions too small to characterize. 5. liver lesions too small to characterize on prior study, not definitely seen on todays scan. specimen submitted: lymph node for immunophenotyping. procedure date tissue received report date diagnosed by dr. /kg previous biopsies: lymph nodes, left inguinal. kidney needle bx. flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: kappa, lambda, and cd antigens 5, 19, and 45. results: due to paucicellular nature of the specimen, a limited panel is performed to determine b-cell clonality. b cells are scant but appear polyclonal and do not co-express cd5. interpretation non-specific lymphoid profile; no phenotypic evidence of lymphoma in specimen. correlation with clinical findings and morphology (see separate report) is recommended. flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. note: this test was performed using analyte specific reagents (asrs). these asrs have not been cleared or approved by the us food and drug administration (fda). however, the fda has determined that such clearance or approval is not necessary . this test was developed and its performance characteristics determined by the flow cytometry laboratory at , which is licensed by clia to perform high complexity tests. this test was used for clinical purposes; it should not be regarded as for research. clinical: rule out lymphoma. gross: lymph node for immunophenotyping. cta head w&w/o c & recons; ct 100cc non ionic contrast reason: r/o stroke. pls perform this if head ct w/o contrast is nega contrast: optiray medical condition: 76 year old man with lymphoma workup in progress with acute changes in mental status; r/o stroke. pls perform this if head ct w/o contrast is negative. reason for this examination: r/o stroke. pls perform this if head ct w/o contrast is negative. contraindications for iv contrast: none. indication: rule out stroke. technique: cta of the head with and without contrast and reconstructions. comparisons: subsequent mri of showing normal diffusion. findings: no intracranial hemorrhage, mass effect, shift of normally midline structures or ct evidence of acute ischemia seen. there are hypodensities in the region of the left internal capsule and subcortical region of the left insular region consistent with old ischemic infarctions. there are mild periventricular hypodensities consistent with chronic small vessel angiopathy. vascular calcifications are seen within the intracranial portions of the internal carotid arteries and both vertebral arteries. there is opacification of several ethmoid air cells on the left. the reminder of the visualized portions of the paranasal sinuses and mastoid air cells are well pneumatized. the bony structures and surrounding soft tissue structures appear unremarkable. ct angiogram: no areas of hemodynamically significant stenosis are seen. there is no evidence of aneurysms or dissections. a fenestrated basilar artery is seen. impression: 1. no ct evidence of acute ischemia. old lacunar infarcts in left internal capsule and insular subcortical regions. 2. unremarkable ct angiogram without areas of stenosis, aneurysm or dissection. incidental note is made of a fenestrated basilar artery. object: r/o seizure in a patient with confusion. referring doctor: dr. dr. findings: abnormality #1: focal hz mixed delta and theta frequency slowing was seen involving left temporal region broadly. abnormality #2: bursts of generalized hz delta frequency slowing were seen throughout the recording. background: in the most awake-appearing portions of this tracing, a well-formed 11-11.5 hz alpha frequency background was seen with low voltage beta frequency activity superimposed. hyperventilation: was contraindicated. intermittent photic stimulation: could not be performed as the test was requested as a portable study. cardiac monitor: revealed a generally regular rhythm with average rate of 72 bpm. impression: this is an abnormal eeg due to the presence of focal slowing seen involving the left temporal region suggesting a subcortical abnormality in this area; neuroimaging is recommended. additionally, the presence of bursts of generalized slowing is suggestive of a mild encephalopathy of toxic, metabolic, or anoxic etiology. no evidence of ongoing seizures is seen. interpreted by: , b. mr head w & w/o contrast 4:22 pm mr head w & w/o contrast; mra brain w/o contrast reason: please assess for dwi lesion and cns malignancy w/ mri/mra w contrast: magnevist medical condition: 76 year old man with lymphoma & stroke reason for this examination: please assess for dwi lesion and cns malignancy w/ mri/mra w/ gadolinium clinical information: lymphoma and stroke. mri of the brain with gadolinium. there are scattered t2 high-signal intensity foci in the periventricular white matter and centrum semiovale consistent with microvascular angiopathy. there is some increased signal on the flair sequence in the region of the calcarine cortex on the left raising the question of a meningeal lesion. there is no evidence of abnormal diffusion in this area. the tensor images do not extend all the way to the vertex. there is a focal area of abnormal signal on the susceptibility sequence in the left subcortical parietal white matter without mass effect or abnormal surrounding signal consistent with a cavernoma but possibly reflecting hemorrhage from other source. there is no evidence of a focal extra-axial lesion or fluid collection. ventricles and sulci are mildly prominent consistent with mild brain atrophy. there is increased signal in the ethmoid sinuses. there is no evidence of abnormal contrast enhancement. impression: abnormality of left calcarine cortex, possibly reflecting a meningeal process such as lymphomatous infiltration orperhaps earlier ischemia. the absence of contrast enhancement mitigates against tumor. a lesion in the left parietal lobe probably a cavernoma. see above discussion. ethmoid sinus disease. brain atrophy. mra of the circle of and its major tributaries there is no evidence of aneurysm or flow abnormality. impression: negative mra of the circle of . ct abdomen w/contrast 3:24 pm ct abdomen w/contrast; ct pelvis w/contrast reason: ?abscess ?fistula, please perform w/po and iv contrast thank field of view: 42 contrast: optiray medical condition: 75 year old man with panc head mass, lympadenopathy s/p ex lap w/takeback now w/draining wound reason for this examination: ?abscess ?fistula, please perform w/po and iv contrast thanks contraindications for iv contrast: none. indication: 75-year-old with a reported pancreatic head mass, post recent exploratory laparotomy on , now with draining anterior abdominal wound. assess for fistula. technique: mdct images of the abdomen after the administration of oral and 100 cc of iv contrast. coronal and sagittal reformatted images were obtained. comparison: and . ct of the abdomen after administration of oral and iv contrast: there are new bilateral pleural effusions with associated atelectasis. there is a new small pericardial effusion. new small amount of ascites is seen in the upper abdomen. the liver, spleen, pancreas, and adrenals are unremarkable. cysts are seen in both kidneys, unchanged from the prior study. cortical defect is seen in the mid portion of the left kidney at the site of a prior renal mass. previously noted tiny splenic hypodensities are not appreciated on this examination due to timing of contrast administration. a biliary stent is present. there has been interval placement of a percutaneous g-j tube terminating in the proximal jejunum. since the prior examination, the patient has undergone laparotomy with skin staples present. soft tissue stranding and small amount of fluid are seen anterior to the left lobe of the liver. posterior to the second staple in the upper abdomen, there appears to be a small fistula between the subcutaneous soft tissues in the anterior peritoneal cavity (series 2, image 25). another tubular-appearing area of inflammatory changes possibly representing a fistula is seen more inferiorly (series 2, image 45). a small fat-containing ventral hernia is seen near the inferior staple line (series 2, image 52). inflammatory changes and stranding are seen throughout the subcutaneous soft tissues of the anterior abdominal wall, posterior to the incisional line. no free air is seen in the abdomen, and there is no obvious a fistulous connection with the bowel. no evidence of oral contrast extravasation is seen. numerous small mesenteric lymph nodes are identified throughout the abdomen and larger paraaortic nodes, unchanged from the prior examinations. ct of the pelvis with oral and iv contrast: diverticula are seen throughout the sigmoid colon without evidence of diverticulitis. the rectum, bladder and visualized distal ureters are normal in appearance. the prostate is enlarged and contains several focal calcifications. no fluid is seen in the pelvis. deep pelvic and bilateral inguinal lymphadenopathy is unchanged from the prior study. osseous structures demonstrate mild degenerative changes in the thoracic and lumbar spine with vacuum phenomenon and osteophyte formation. multiplanar reformatted images confirm the above findings. impression: 1. interval exploratory laparotomy. there are inflammatory changes seen in the subcutaneous soft tissues extending the length of the incision. there appears to be a fistula between the soft tissues of the anterior abdominal wall and the anterior abdominal cavity posterior to the second staple. no enterocutaneous fistula is identified but ct is insensitive for excluding small fistulas. there may be a second small fistulous connection more inferiorly as described above. 2. stable appearance of mesenteric, retroperitoneal, pelvic, and bilateral inguinal lymphadenopathy. 3. no pancreatic head mass identified. 9:04 am swab site: abdomen source: abdominal incision. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive cocci. in pairs. 1+ (<1 per 1000x field): gram negative rod(s). wound culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). gram negative rod #1. moderate growth. gram negative rod #2. moderate growth. probable enterococcus. moderate growth. . ercp impression: 1. erythema of the mucosa was noted in the stomach body and fundus. these findings are compatible with gastritis. 2. a previously placed plastic stent at the ampulla and a gj tube were visualized. both the stent and the gj tube were confirmed to be in place fluoroscopically. 3. the previously placed plastic stent was removed using a snare. 4. cholangiogram revealed a 3 cm stricture at the distal common bile duct. there was mild post-obstructive dilation of the common hepatic duct. in addition, the left intrahepatic duct did not fill with contrast very well. however, no obvious stricture, filling defects, and masses were appreciated in the intrahepatic ducts. 5. a 6 cm by 10 fr cotton biliary stent was placed successfully across the common bile duct stricture. clear bile was seen draining into the duodenum subsequently. recommendations 1. repeat ercp in two months. consider placement of metal wallstent if patient's prognosis is poor as a result of progression of castleman's disease. brief hospital course: patient was admitted to the general surgery service and iv hydration was administered. he was restarted on his home medications and kept npo. he was found to have bilateral inguinal lymphadenopathy and on hd2 a r inguinal lymph node biopsy was performed. there were no complications and the patient returned to the floor from the recovery area. the patient was allowed to eat a regular diet as he wished, a picc line was placed for home tpn. on hd 3 the patient was transferred to the hematology/oncology service. . on , a code stroke was called for this patient. he was noted to have acute onset of a primarily motor aphasia, with anomia, inability to repeat, and only intermittently fluent speech. also has a mild r facial droop and perhaps some evidence of a field cut on the r. he was perseverative and inattentive. he had a ?left mca territory stroke without bleed. he was seen emergently by neurology and it was decided to give him tpa. patient was transferred to , then neuro-icu. repeat head ct done for worsening headache was negative. language and rest of deficits returned to . he began eating so tpn was stopped. patient was transferred to neurology floor on . he underwent carotid dopplers which were negative and had head mri, official read pending (prelim read negative for stroke). eeg showed left temporal slowing. he also had a lp which showed 2wbc, 1rbc, prot 32 gluc 73, cytology was also sent. patient thought to have ?embolic cva vs seizure d/o. transferred back to bmt service for further workup. . after transfer to bmt service patient waited while lymph node biopsy from inguinal node results were pending, these were inconclusive and he was transferred to surgery for ex-lap washout, ccy, gj tube, and more biopsies. a peri-portal lymph node biopsy showed atypical lymphadenopathy with findings consistent with multicentric castleman's disease, hhv8 negative. or cultures grew out hafnia alvei, serratia marcescens, and enterococcus sp. he was started on vancomycin and levofloxacin. his jp drain was pulled on pod 7. he continued to have fevers post-operatively which improved with antibiotic use. his abdominal incision was draining serosanginous fluid, frequently saturating his dressings. at this time his tube feedings were held and he was made npo due to nausea and vomiting. as bowel function improved, tube feedings were advanced to goal. an abdominal ct was performed to assess the wound drainage and it appeared to be a fistula between the soft tissues of the anterior abdominal wall and the anterior abdominal cavity posterior to the second staple. dressing changes continue and the drainage slowed gradually. he was transferred to the heme/onc service for steroid treatment of his castleman's disease. . on transfer to the bmt service, lft's were found elevated. gi service was reconsulted and ercp was performed. on a new stent was placed on the common bile duct obtaining drainage to the duodenum. patient should have a repeat ercp in 2 months. patient also had delirum in this setting, with + hallucinations and agitation. neurology was consulted who felt that it was not consistent with a seizure like activity, no focal findings, and felt that a metabolic etiology was more likely. all possible mental stauts changes medications were discontinued. treatment was also started with rituxan. on , patient's mental status cleared returning to his baseline. . for the treatment of his castleman's disease patient was given rituxan and steroids. he received his dose of retuxan on and also iv steroids. patient was given a second dose of rituxan on day of discharge. he will continue on high dose steroids for two weeks 50 mg prednisone until . patient will be seen in clinic on to decide further course. he tolerated this therapy well. . after physical therpay evaluation, it was decided that he was safe to be discharged home. medications on admission: metoprolol 50', enalapril 10', prozac discharge medications: 1. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 3. enalapril maleate 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. terazosin 1 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*2* 5. prednisone 50 mg tablet sig: one (1) tablet po daily (daily) for 9 days: last dose . disp:*9 tablet(s)* refills:*0* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* discharge disposition: home with service facility: vna - discharge diagnosis: -pancreatic head mass -bilateral inguinal lymphadenopathy -anorexia discharge condition: -stable discharge instructions: -please come to the emergency room if you have fever >101.4f, nausea or vomiting, shortness of breath, severe or persistent abdominal pain or bleeding or persistent redness around your surgical site -do not drive while taking pain medications -take a stool softener while taking pain medications -you may shower normally but keep your surgical site clean and dry followup instructions: -please follow up with dr. in weeks after discharge. call for an appointment. provider: , md phone: date/time: 4:00 ** please have your pcp send referral to dr. ** provider: suite gi rooms date/time: 10:00 provider: . phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Cholecystectomy Reopening of recent laparotomy site Division or crushing of other cranial and peripheral nerves Regional lymph node excision Percutaneous (endoscopic) jejunostomy [PEJ] Excision of inguinal lymph node Open biopsy of liver Endoscopic retrograde cholangiopancreatography [ERCP] Replacement of stent (tube) in biliary or pancreatic duct Injection or infusion of biological response modifier [BRM] as an antineoplastic agent Open biopsy of pancreas Diagnoses: Other postoperative infection Unspecified essential hypertension Long-term (current) use of steroids Other convulsions Cerebral embolism with cerebral infarction Dehydration Chronic pancreatitis Enlargement of lymph nodes Obstruction of bile duct Delirium due to conditions classified elsewhere Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Immune thrombocytopenic purpura Unspecified disease of pancreas Persistent postoperative fistula Other suppurative peritonitis Other specified disorders of gallbladder Anorexia Polyclonal hypergammaglobulinemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right flank pain major surgical or invasive procedure: right sided thoracocentesis (-2200 ml fluid) history of present illness: 55 yo female with metastatic adenocarcinoma with unknown primary on c2d1 gemcitabine/irinotecan and with malignant pleural effusions presented to ed with severe r flank pain, radiating to chest. patient reports pain was in severity. she was otherwise asymptomatic, denying shortness of breath or coughing at presentation. she experienced r flank pain previously for which she had applied a fentanyl patch with adequate pain control. of note, she has known lytic bone lesions to the r pelvis. she reports that she had not applied the fentanyl patch to the r flank recently as pain control had improved. . the patient's cancer initially presented as syncope and further work-up revealed pericardial/pleural effusion . the pleural fluid revealed metastatic adenocarcinoma and the pericardial fluid a well-differentiated mucinous adenocarcinoma. the patient has had 3 recent admissions: on for dyspnea and and for dizziness/syncope. on admission , the patient had pericardiocentesis and balloon pericardiotomy with removal of 520 cc of bloody fluid. on showed stable loculated pericardial effusion. (ef>55%) suggestive of pericardial constriction, although unchanged in size since prior admission. . during admission on , cardiology team saw the patient and recommended trial of low dose beta blocker for rate control; a pericardial window was not performed because the effusion was determined to be stable and symptoms thought to be related to dehydration and tachycardia. subsequent ct of the torso did not reveal a primary source but did reveal bony lytic lesions in the right ischium and bilateral ilia concerning for metastatic disease. she also underwent an upper and lower endoscopy without evidence of a primary lesion. considering pericardial and pleural fluid pathology, a subtle gastric or pancreatico/biliary tumor was suspected and the patient was started on gemcitabine/irinotecan. her last dose of chemotherapy was yesterday 8/2 per patient. chemotherapy was begun on . . pt. presented to ed with tachycardia above baseline in 130s to 140s. patient has h/o resting tachycardia 115-120. electrocardiogram in the ed showed sinus tachycardia unchanged from prior. radiography showed reaccumulation of pulmonary edema and ct of the chest showed no acute changes. a therapeutic thoracentesis was performed of 2200 ml of dark maroon right pleural fluid. in addition, after the procedure, the patient complained of increased shortness of breath increased from baseline, patient's o2 saturation was in the 90s. the patient was administered lasix (40 mg x1) in the ed with subsequent improvement of respiratory function. in ed patient was administered vancomycin 1 g, ondasetron 2 mg twice, and 4 doses of morphine sulfate 4 mg. patient was admitt-ed to icu for pain control and management of tachycardia in setting of pleural effusions. past medical history: - tuberculosis treated in with normal chest x-ray at in . - gyn: g2 p2. tubal ligation . stopped menstruating at age 50, normal pap's per patient - hypertension. - history of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral dvt - adenocarcinoma of unclear primary social history: she works as a nursing assistant. lives with her husband, who keeps very early hours, working at the food market. children are 18 and 19. family history: her father died of stomach cancer at age 72. mother died of colon cancer at age 63. she is the 10th of 13 children. she has lost 3 siblings to motor vehicle accidents. physical exam: gen: nad heent: sclera anicteric. perrl, eomi. no oral lesions neck: supple cv: tachycardic, regular, no m/r/g. chest: bilaterally decreased ll bs l>r to way up. r sided ronchi. abd: soft, nnd. no hsm or tenderness. soft subcutaneous firm mobile nodule in midepigastrium (at site of lovenox injection sites per patient). ext: no cyanosis or edema neuro: non-focal, cn ii-xii grossly intact, moves all extremities well skin: no rash or petechiae noted pertinent results: 11:40am gran ct-1260* 11:40am plt count-521* 11:40am wbc-2.7* rbc-4.04* hgb-13.2 hct-37.9 mcv-94 mch-32.5* mchc-34.7 rdw-17.4* 12:17pm lactate-1.7 12:22pm hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-1+ microcyt-normal polychrom-occasional 12:22pm alt(sgpt)-98* ast(sgot)-52* ck(cpk)-63 alk phos-148* amylase-30 tot bili-0.8 12:22pm lipase-74* 12:22pm glucose-119* urea n-5* creat-0.6 sodium-137 potassium-4.5 chloride-102 total co2-24 anion gap-16 . c.dif - negative blood and urine cx: no growth . cxr (): impression: increased size of now large right pleural effusion and minimally increased now moderate left pleural effusion. . chest ct () impression: 1. diffuse peribronchovascular opacity with air bronchograms involving the right middle and right lower lobes post thoracentesis. given the rapid evolution of this process, findings likely represent pulmonary edema. pulmonary hemorrhage or multifocal pneumonia is less likely. close interval radiographic follow up recommended. 2. large left pleural effusion with adjacent compressive atelectasis. 3. minimal pericardial fluid. 4. no pneumothorax or reaccumulation of the right pleural effusion. cxr (): impression: 1. unchanged moderate left-sided pleural effusion. 2. patchy opacities at the right lung base have cleared since the prior examination, likely representing pulmonary edema given its rapid improvement; mild persistent residual pulmonary edema. brief hospital course: the patient is a 55 y/o woman with metastatic adenocarcinoma of unknown primary (likely discrete gastric or pancreaticobiliary ca) admitted with tachycardia in the setting of malignant pericardial effusions and uncontrolled pain. . # malignant effusion - the patient presented for outpatient therapeutic thoracocentesis (done for worsening sob) with removal of 2200 ml r sided fluid, followed by excruciating pain at thoracotomy site. the dyspnea after her procedure was likely a result of reexpansion edema, which was reflected on her chest x-ray. she was initially treated in the intensive care unit with oxygen therapy as well as iv lasix and closely monitored. no infectious etiology was identified. it was decided that thoracentesis was not warranted as her pleural effusion was significantly smaller after the procedure. her respiratory distress rapidly improved with diuresis and she was soon back to baseline (requires home o2). . # mucinous adenocarcinoma of unknown primary: the patient began chemotherapy on with gemzar and cpt-11 for metastatic disease. she did not experience significant nausea during hospitalization, but continued to have diarrhea related to her chemotherapy which was treated with lomotil. . # dvt/pe - she is s/p ivc filter placement on s/p dvt of common femoral. she was continued on lovenox therapy. . # pain - patient had known lytic lesions, with high risk of pathologic fracture. bilateral hip xray on demonstrated no progression of known metastatic lesions. orthopedics were consulted on prior admisson and believe chemotherapy should proceed prior to any radiation therapy to the hip. also with pain at site of thoracentesis. she was treated with home fentanyl 25mcg patch for pain control, home lidocaine patch with morphine for breakthrough pain medications on admission: 1. enoxaparin 60 mg/0.6 ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours). 2. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 3. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po once (once) for 1 doses. 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po three times a day. 8. zofran 4 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 2. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 3. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every 6-8 hours as needed. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. enoxaparin 60 mg/0.6 ml syringe sig: sixty (60) mg subcutaneous q12h (every 12 hours). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po daily (daily) as needed for nausea. 7. megace oral 40 mg/ml suspension sig: ten (10) ml po once a day. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 10. lomotil 2.5-0.025 mg tablet sig: one (1) tablet po every hours as needed for diarrhea. 11. nebulizer for home use please provide one nebulizer and associated equipment. 12. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) nebulizer treatment inhalation every six (6) hours. disp:*120 ml* refills:*2* 13. ipratropium bromide 0.02 % solution sig: one (1) nebulizer treatment inhalation every six (6) hours. disp:*120 ml* refills:*2* discharge disposition: home with service facility: physician discharge diagnosis: 1.) malignant pleural effusion 2.) mucinous adenocarcinoma of unknown primary discharge condition: fair discharge instructions: you were in the hospital because of pain and difficulty breathing after your thoracocentesis (or pleural fluid drainage). you were given medications to help get fluid off of your lungs and pain medications. when you leave the hospital, continue to take all medications as prescribed and keep all health care appointments. if you feel worsening shortness of breath, chest pain, fever, chills, abdominal pain or if your condition worsens in any way, seek immediate medical attention. followup instructions: you have the following appointments with dr. office on . provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 9:30 provider: , rn phone: date/time: 10:00 Procedure: Thoracentesis Diagnoses: Unspecified essential hypertension Secondary malignant neoplasm of pleura Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Diarrhea Other malignant neoplasm without specification of site Secondary malignant neoplasm of bone and bone marrow

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: bilateral pleurex catheters were placed history of present illness: 55 yo female with metastatic adenocarcinoma with unknown primary on c2d1 gemcitabine/irinotecan and with history dvt/pe with ivc filter placement, history of malignant pleural and pericardial effusions who presents with 2 days worsening shortness of breath and orthopnea. she also reports right sided pleuritic chest pain. she endorses new lower extremity edema for past 2 days. also reports non-productive cough. denies any fevers, chills, nausea, vomitting, or urinary symptoms. + constipation. . of note, she has had had 3 recent admissions: on for dyspnea and and for dizziness/syncope. on admission , the patient had pericardiocentesis and balloon pericardiotomy with removal of 520 cc of bloody fluid. on showed stable loculated pericardial effusion. (ef>55%) suggestive of pericardial constriction, although unchanged in size since prior admission. . pt. presented to ed with above complaints, and also found to be tachycardic to 130s. patient has h/o resting tachycardia 115-120. electrocardiogram in the ed showed sinus tachycardia unchanged from prior. in the ed, patient was seen by cardiology given history of pericardial effusions and bedsided echocardiogram was performed, and showed moderate effusion but did not reveal any rv diastolic collapse or significant av respirophasic variation to suggest tamponade physiology. chest x-ray demonstrated re-accumulated large right-sided pleural effusion and moderate left-sided effusion. patient was admitted due to tachypnea, tachycardia, and difficult course with previous thoracentesis, which was complicated by post-procedure pulmonary oedema requiring diuresis. . she has is s/p b/l thoracentesis and is now being considered for pleurx catheter placement on monday. . currently, she is with mild sob, pain controlled, no other complaints past medical history: - tuberculosis treated in with normal chest x-ray at in . - gyn: g2 p2. tubal ligation . stopped menstruating at age 50, normal pap's per patient - hypertension. - history of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral dvt - adenocarcinoma of unclear primary social history: she works as a nursing assistant. lives with her husband, who keeps very early hours, working at the food market. children are 18 and 19. family history: her father died of stomach cancer at age 72. mother died of colon cancer at age 63. she is the 10th of 13 children. she has lost 3 siblings to motor vehicle accidents. physical exam: vitals: 98.3 119/82 118 94-95 2l 18 gen: comfortable, heent: sclera anicteric. perrl, eomi. no oral lesions neck: supple cv: tachycardic, regular, no m/r/g. chest: decrease b/s b/l r>l abd: soft, nt, nd, +bs. no hsm or tenderness. ext: 1+ edema b/l neuro: non-focal, cn ii-xii grossly intact, moves all extremities well skin: no rash or petechiae noted pertinent results: 09:45pm neuts-55.6 bands-0 lymphs-37.4 monos-3.5 eos-1.8 basos-1.7 09:45pm wbc-2.0*# rbc-3.57* hgb-11.9* hct-35.4* mcv-99* mch-33.3* mchc-33.5 rdw-19.4* 09:45pm ck(cpk)-59 09:55pm lactate-1.2 09:45pm glucose-104 urea n-5* creat-0.6 sodium-134 potassium-4.7 chloride-100 total co2-24 anion gap-15 brief hospital course: 55 y/o woman with metastatic adenocarcinoma of unknown primary with malignant pleural effusions and constrictive pericardial effusions s/p thoracocentesis with reaccumulation of effusions, admitted for pleurx catheter placement . 1. respiratory distress - secondary to r-sided malignant effusion. s/p therapeutic thoracentesis . sob was only transiently relieved by thoracentesis. pleurx catheter was felt to be a better plan than pleurodesis as sirs reaction could complicate pleurodesis. pt received her pelurx catheter placement on without complications. pt tolerated the procedure well and with symptomatic improvement of her dyspnea. . 2. constrictive pericardial effusions: showed chronic effusion but without tamponade physiology. pt was seen by cardiology with recommendations for potential procedure in the future, but no immediate intervention was thought to be warranted. pt was hemodynamically stable throughout admission. . 3. mucinous adenocarcinoma of unknown primary: the patient began chemotherapy on with gemzar and cpt-11 for metastatic disease of unknown primary. pt was discharged with follow up appointment with her primary oncologist for resumption of chemotherapy. . 4. uti: pt was found to have a uti on admission. she was discharged with a 10 day course of ciprofloxacin. medications on admission: 1. lidocaine 5 % daily 2. fentanyl 25 mcg/hr patch 72 hr 3. ondansetron 4 mg every 6-8 hours as needed. 4. docusate sodium 100 po bid 5. enoxaparin 60 mg/0.6 ml q12h 6. lorazepam 0.5 mg po daily prn nausea 7. megace oral 40 mg/ml po once a day. 8. senna 8.6 mg po bid as needed for constipation. 9. metoprolol tartrate 25 mg po tid 10. lomotil 2.5-0.025 mg tablet po every 4-6 hours as needed for diarrhea. 11. albuterol sulfate every six (6) hours. 12. ipratropium bromide every six (6) hours discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qdaily (). 2. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 3. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every 6-8 hours as needed for nausea. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. enoxaparin 60 mg/0.6 ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po daily (daily) as needed for prn nausea. 7. megestrol 40 mg/ml suspension sig: ten (10) ml po daily (daily). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 10. lomotil 2.5-0.025 mg tablet sig: one (1) tablet po every hours as needed for diarrhea. 11. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 4 days. disp:*7 tablet(s)* refills:*0* 12. ipratropium bromide 0.02 % solution sig: one (1) nebulizer treatment inhalation q6h (every 6 hours) as needed. 13. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) nebulizer treatment inhalation q6h (every 6 hours) as needed. discharge disposition: home with service facility: physicians home care discharge diagnosis: 1.) malignant pleural effusion 2.) metastatic adenocarcinoma 3.) urinary tract infection 4.) pericardial effusion discharge condition: stable, maintaining o2 sats discharge instructions: you were admitted because of shortness of breath. you were found to have a reaccumulation of fluid near your lung. you underwent a procedure called thoracentesis, or drainage of the pleural fluid. you also had catheters placed in your lungs to help drain the fluid. also while you were in the hospital you were found to have a urinary tract infection and treated with antibiotics. . please continue to take all medications as instructed and keep all health care appointments as scheduled. . if you have worsening shortness of breath, chest pain, lightheadedness, dizziness, fevers, chills, abdominal pain or vomiting, or if you feel worse in any way, seek immediate medical attention. followup instructions: provider: , rn phone: date/time: 10:00 provider: , md phone: date/time: 9:00 provider: , rn phone: date/time: 9:30 Procedure: Insertion of intercostal catheter for drainage Thoracentesis Thoracentesis Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Asthma, unspecified type, unspecified Secondary malignant neoplasm of pleura Personal history of venous thrombosis and embolism Other malignant neoplasm without specification of site Constrictive pericarditis Neutropenia, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: syncope major surgical or invasive procedure: endoscopy colonoscopy pericardiocentesis balloom pericardiotomy ivc filter placement history of present illness: 54 f wiht h/o htn, asthma, recent admission to ccu for pericardial/pleural effusion and tamponade presents from home after episode of syncope this morning. patient was walking to the bathroom and felt dizzy, then found on the floor by her husband. she does not know if she hit her head but reports right buttock pain from the fall. since her discharge she has been feeling "tired" and has had a poor appetite but denies any chest pain or shortness of breath. she has been getting around her apartment easily. she endorses "tightness" with deep inspiration. otherwise no fever, chills, gi, or gu complaints. . patient initially presented with doe and right flank pain and was evaluated by her pcp found to have cardiomegaly on cxr. subsequent showed a large pericardial effusion with tamponade physiology. she was admitted to the ccu from to s/p periocardiocentesis. patient also underwent right sided thoracentesis. both sources are showing evidence of a highly differentiated adenocarcinoma. patient was discharged with pcp follow up and ongoing workup. ct of the abd/pelvis did not reveal a source but did reveal some bony lytic lesions in the right ischium and bilateral ilia concerning for metastatic disease. of note, she also is known to have a large common femoral dvt. . in the ed, vs 97.5 113 86/68-->106/59 94% ra-->98% nrb. bedside showing large pericardial effusion. given 1l ns and taken to cath lab for urgent pericardiocentesis. past medical history: - tuberculosis treated in with normal chest x-ray at in . - gyn: g2 p2. tubal ligation . stopped menstruating at age 50, normal pap's per patient - hypertension. - history of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/. - recent pericardial effusion/tamponade - right pleural effusion - adenocarcinoma of unclear primary social history: she works as a nursing assistant. lives with her husband, who keeps very early hours, working at the food market. children are 18 and 19. family history: her father died of stomach cancer at age 72. mother died of colon cancer at age 63. she is the 10th of 13 children. she has lost 3 siblings to motor vehicle accidents. physical exam: vs: t:98.0 bp: 117/75 hr: 112 rr: 23 o2: 98%ra gen: nad, lying flat in bed heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, jvp to jaw lying flat cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. ?rub with one component, pericardial drain in place chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. cta anteriorly. abd: soft, ntnd. no hsm or tenderness. ext: no c/c/e. skin: dry, no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: ekg : sinus tachy at 118 bpm, nl axis, nl intervals, no st-t changes, normal voltage. unchanged compared to . admission labs: k:4.3 pt: 12.4 ptt: 23.9 inr: 1.1 135 104 8 -------------< 128 4.3 25 0.8 ck: 102 mb: 1 trop-t: <0.01 ldh 805 tprot: 6.9 . 14.1 7.4 >----< 278 43 n:74 band:0 l:20 m:5 e:1 bas:0 . pericardial fluid other body fluid chemistry: totprot: 5.9 glucose: 42 ld(ldh): 1566 amylase: 13 albumin: 3.1 . pericardial fluid other body fluid hematology: wbc: 2488 rbc: polys: 75 lymphs: 13 monos: 9 eos: 1 macro: 2 negative for malignant cells. . ap pelvis: no fracture or dislocation is identified within the single view. no pubic symphysis or si joint diastasis is detected. . cxr : single ap chest radiograph demonstrate hazy opacity within the right lung base likely representing atelectasis vs air space disease. small right pleural effusion is present. compared to prior radiograph from , there is moderate cardiac enlargement, concerning for pericardial effusion. impression: 1. opacity in right lung base concerning for atelectasis vs airspace disease. small right pleural effusion. 2. compared to prior radiograph from , there is moderate increase in cardiac size, concerning for pericardial effusion. . urgent : large pericardial effusion. effusion circumferential. stranding is visualized within the pericardial space c/w organization. rv diastolic collapse, c/w impaired fillling/tamponade physiology. general comments: emergency study performed by the cardiology fellow on call . post procedure : overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. . repeat :compared with the prior study (images reviewed) of , there is probably no signficant change. a loculated pericardial effusion with constriction should be considered. . endoscopy :gastro esophageal junction mucosal biopsy: gastric type mucosa with chronic active inflammation. very focal intestinal metaplasia consistent with barrett's esophagus in the appropriate clinical setting. no dysplasia. squamous mucosa with focal active inflammation . colonoscopy : no masses or polyps seen. external hemorrhoids. brief hospital course: pt is a 54 y/o woman here with recurrent malignant pericardial effusion. hospital course by problem: . # malignant effusion. s/p pericardiocentesis and balloon pericardiotomy with removal of 520 cc of bloody fluid. patient with known highly differentiated adenocarcinoma of unknown primary. fluid analysis suggested exudative fluid and cytology again pending. an on showed partial resolution of part of the pericardial effusion, but persistance of a loculated effusion. it was felt that the drain should be pulled and an repeated on showed no progression. on showed stable loculated pericardial effusion. . # mucinous adenoca unknown primary: the heme/onc team was consulted during admission and workup to determine source was undertaken. endoscopy and colonoscopy were performed without evidence of malignancy. . # dvt - large vte in common femoral artery extending to ivc found on ct scan. on discharge from recent hospitalization she was briefly anticoagulated. this was stopped however given concerns for recurrence of pericardial effusion. we reviewed recent ct scan and decided to place an ivc filter on day of admission to help prevent spread of dvt into the pulm vasculator. the risks/benefits of anticoagulation were considered and we opted to start heparin gtt with close monitoring of her hemodynamics and pericardial output. shortly after the ivc filter placement, she experience right sided pleuritic chest pain. this was thought to be a pe. her oxygen requirement did not increase but she remained mildly tachycardic. she was continued on heparin. the heparin was held for 24 hours after the drain was pulled. the patient was restarted on subq heparin and instructed on the use of levonox to continue on discharge. . # right buttock pain: patient with lytic lesions found on ct scan thought likely malignant. ap pelvis negative for fracture. . # syncope - likely due to large pericardial effusion and tamponade physiology . # cad: no known cad . # htn: held meds given tamponade, remained normotensive throughout admission. . # code: changed to dnr dni after discussion between patient and pcp shortly after admission. medications on admission: allergies: nkda . 1. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*10 tablet(s)* refills:*0* 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. albuterol 90 mcg/actuation aerosol sig: one (1) puff inhalation every six (6) hours as needed for shortness of breath or wheezing. discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 3. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for nasal dryness. disp:*1 spray* refills:*0* 4. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*60 syringe* refills:*2* 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for pain: please apply one patch to site of pain daily, leave on for 12 hours and then remove for 12hrs. disp:*30 adhesive patch, medicated(s)* refills:*1* discharge disposition: home discharge diagnosis: mucinous adenocarcinoma of unknown primary malignant pericardial effusion cardiac tamponade venous thromboembolism of common femoral artery and inferior vena cava discharge condition: stable, with normalized cardiac and respiratory function. discharge instructions: you have been treated for malignant pericardial effusion and tamponde with a pericardiocentesis and balloon pericadiotomy. the effusion was the result of an adenocarcinoma of unknown etiology. further studies were performed to evaluate for the source of malignancy. on evaluation it was found that you have a dvt and you were started on lovenox. . for you chest pain you were stared on a lidocaine patch. you may also take tylenol (up to 4g daily). we also prescribed you percocet as needed. please watch out for constipation when taking the percocet. . please do not take your blood pressure medication until otherwise instructed by your cardiologist. . please return to the hospital or see you primary care physician if you experience any fevers, chills, shortness of breath, lightheadedness or if you have any other concerns. followup instructions: the following appointments have been arranged for you: please follow-up with dr. on monday at 10am on the of the . please call 1- if you have any questions. you have follow up with dr. and dr. on at 10:30am. phone: . you also have the following appointments: provider: , m.d. phone: date/time: 1:00 provider: , .d. phone: date/time: 9:40 Procedure: Interruption of the vena cava Pericardiocentesis Esophagogastroduodenoscopy [EGD] with closed biopsy Pericardiotomy Diagnoses: Unspecified essential hypertension Asthma, unspecified type, unspecified Secondary malignant neoplasm of pleura Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Iatrogenic pulmonary embolism and infarction Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Other malignant neoplasm without specification of site Barrett's esophagus Secondary malignant neoplasm of bone and bone marrow Acute pericarditis, unspecified Other venous embolism and thrombosis of inferior vena cava

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: pericardial drainage. thoracentesis. history of present illness: 54 y/o female w/ pmh moderate hypertension, remote h/x of asthma presenting to ccu after pericardiocentesis. patient reports onset of right sided flank pain 6wx ago. last few weeks began noticing doe. trouble catching the bus and going up stairs. pcp sent her for cxr which showed cardiomegally and vascular congestion. today revealed cardiac tamponade. went to cath lab for pericardiocentesis and right heart catheterization. past medical history: tuberculosis treated in with normal chest x-ray at in . g2 p2. tubal ligation . hypertension. history of mild asthma, inhalers not used for several years. perimenopausal. social history: she works as a nursing assistant. lives with her husband, who keeps very early hours, working at the food market. children are 18 and 19. family history: her father died of stomach cancer at age 72. mother died of colon cancer at age 63. she is the 10th of 13 children. she has lost 3 siblings to motor vehicle accidents. physical exam: vs: t:98.2 bp:149/94 hr:103 rr: 20 o2: 98%ra gen: nad, looks stated age. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 5 cm. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. lung exam notable for decreased bs on rihgt and rll crackles. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: 12:18pm blood wbc-3.8* rbc-5.64* hgb-18.0* hct-53.1* mcv-94 mch-31.9 mchc-33.9 rdw-13.2 plt ct-283 06:45am blood wbc-5.4 rbc-5.49* hgb-17.5* hct-50.9* mcv-93 mch-31.8 mchc-34.3 rdw-13.4 plt ct-179 12:18pm blood pt-12.8 ptt-27.0 inr(pt)-1.1 06:45am blood pt-12.7 ptt-26.6 inr(pt)-1.1 12:18pm blood glucose-112* urean-10 creat-0.8 na-141 k-4.0 cl-103 hco3-25 angap-17 06:45am blood glucose-109* urean-10 creat-0.8 na-137 k-4.0 cl-103 hco3-23 angap-15 04:29am blood alt-20 ast-18 ld(ldh)-161 alkphos-132* amylase-28 totbili-1.0 04:29am blood albumin-4.0 calcium-9.5 phos-4.4 mg-2.2 06:45am blood calcium-9.2 phos-4.1 mg-2.3 05:20am blood tsh-6.1* 05:21am blood free t4-1.7 04:59am blood -positive titer-1:40 05:20am blood c3-147 c4-42* . pericardial fluid obtained : (note some of these samples are erroneously labeled as ascitic fluid in the omr. also please note that this sample was lost in the lab from to . processing began thereafter) 03:30pm other body fluid wbc-3400* rbc-7850* polys-1* lymphs-29* monos-13* mesothe-15* macro-42* totpro-8.9 glucose-0 ld(ldh)-1186 amylase-15 albumin-5.0 gram stain 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (pending): acid fast smear (pending): acid fast culture (pending): fungal culture (pending): anaerobic culture (pending): . pericardial fluid obtained after multiple saline flushes when the drain itself was being removed : (note some of these samples are erroneously labeled as ascitic fluid and though all obtained on some are mislabled as being obtained on in the omr) 07:17pm ascites wbc-875* rbc-8500* polys-73* lymphs-1* monos-26* gram stain 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): . pleural fluid obtained : wbc-1000* rbc-1875* polys-39* lymphs-38* monos-10* eos-2* meso-5* macro-4* other-2* totprot-5.6 glucose-106 ld(ldh)-305 gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (pending): anaerobic culture (pending): acid fast smear (pending): acid fast culture (pending): adenosine deaminase pending: . cxr:impression: interval cardiomegaly and fluid overload indicating mild cardiac failure. small right pleural effusion. followup examination is recommended after appropriate clinical interval. findings discussed with dr. by telephone at time of interpretation. . cardiac conclusions: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is a moderate to large sized pericardial effusion. there is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology; the right ventricle also appears compressed. there is significant, accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. . cardiac conclusions: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. there is a small (1-1.5cm; ?loculated pericardial effusion around the right atrium. no effusion is seen around the right ventricle or left ventricle. compared with the prior study (images reviewed) of , the ?loculated effusion around the right atrium is slightly larger, but hemodynamic compromise is not suggested. . lower extremity non-invasives.... brief hospital course: this is a 54 year old woman with a past medical history significant for treated tuberculosis as a child and mild hypertension who presented to her pcp with shortness of breath. a pa and lateral chest x-ray revealed cardiomegaly and an admission cardiac revealed a pericardial effusion with tamponade physiology. a pericardial drain was placed which relieved the patient's symptoms. the patient also had a large right sided pleural effusion which was drained. neither fluid contained any organisms on gram stain (including specific stains for tuberculosis). cultures had not grown anything at the time of discharge. was checked and felt to be non-specific at 1:40. a tsh was elevated at 6.1 but the free t4 was normal at 1.7. the patient was never febrile and she never developped an elevated white blood cell count. . again, the patient's dyspnea resolved with drainage of her pericardial fluid. she did have some pain at the pericardial drainage and thoracentesis sites for which she was treated with percocet. she was noted to have an elevated hematocrit, which was thought to be unrelated to her pericarditis. it was determined that she should follow up with her pcp regarding this issue. on the day of discharge the patient complained of pain in her calves bilaterally. she had spent a significant time in bed and there was some concern for venous thromboembolism, so she was sent for bilateral lower extremity ultrasound. the results of this demonstrated a distal dvt. as it was symptomatic, she was started on lovenox and coumadin as discussed with her pcp. to frequent urination and boarderline hyponatremia she was discontinued on hctz and began on amlodipine. she was discharged with a follow and follow up appointments with her pcp and the attending cardiologist. medications on admission: hctz 25mg po qday albuterol prn (used only recently, not for 1-2 years prior) discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*10 tablet(s)* refills:*0* 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. albuterol 90 mcg/actuation aerosol sig: one (1) puff inhalation every six (6) hours as needed for shortness of breath or wheezing. discharge disposition: home discharge diagnosis: idiopathic percarditis with cardiac tamponade. idiopathic pulmonary effusions. discharge condition: vital signs are stable. respiratory status improved. satting well on room air. discharge instructions: please take your medications as prescribed. please follow up with the appointments that we set up for you. please note that dr. does not want you to return to work until you have seen her on . . please come back to the hospital if you should develop chest pain or shortness of breath. you have just been admitted to the hospital with a serious condition. if you should develop any symptoms that are concerning to you followup instructions: provider: lab testing phone: date/time: 9:00 provider: , .d. phone: date/time: 11:30 provider: , m.d. phone: date/time: 1:00 Procedure: Coronary arteriography using a single catheter Pericardiocentesis Thoracentesis Right heart cardiac catheterization Diagnoses: Unspecified pleural effusion Unspecified essential hypertension Asthma, unspecified type, unspecified Dehydration Acute venous embolism and thrombosis of deep vessels of distal lower extremity Acute idiopathic pericarditis Personal history of tuberculosis

allergies: patient recorded as having no known allergies to drugs attending: addendum: she was not expired upon discharge from this admission. discharge disposition: extended care facility: - md Procedure: Percutaneous abdominal drainage Diagnoses: Pneumonia, organism unspecified Unspecified pleural effusion Unspecified essential hypertension Atrial fibrillation Unspecified disease of pericardium Cachexia Personal history of venous thrombosis and embolism Other ascites Encounter for palliative care Chronic obstructive asthma with (acute) exacerbation Secondary malignant neoplasm of lung Other malignant neoplasm without specification of site Tachycardia, unspecified Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Secondary malignant neoplasm of other digestive organs and spleen Secondary malignant neoplasm of retroperitoneum and peritoneum Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified Other urethritis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress and tachycardia major surgical or invasive procedure: paracentesis history of present illness: history of present illness: ms. is a 55 yo woman with metastatic adenocarcinoma of unknown primary, hypertension, h/o dvt s/p ivc filter and recently discharged after having acute shortness of breath thought atrial fibrillation with rapid ventricular response who presented to the ed today with acute-onset shortness of breath at about 6 p.m. on the day prior to admission. . she denies fever, chills, sweats, cough, increased sputum production. . of note, two days prior to admission, the pt had a ct scan of her torso that revealed progression of her disease throughout, including interval progression in abnormal pulmonary densities involving all lobes. they now have a more interstitial and consolidative appearance, greatest in the lower lobes. . in the ed, her initial vss were 132 100/70, 28-32, 97% with neb. she received continuous nebs, methylprednisolone 125 mg iv, furosemide 20 mg, levofloxacin and ceftriaxone. she was admitted to the for further management. past medical history: - tuberculosis treated in with normal chest x-ray at in . - gyn: g2 p2. tubal ligation . stopped menstruating at age 50, normal pap's per patient - hypertension. - history of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral dvt - adenocarcinoma of unclear primary social history: she worked as a nursing assistant. lives with her husband. 2 children. family history: her father died of stomach cancer at age 72. mother died of colon cancer at age 63. she is the 10th of 13 children. she has lost 3 siblings to motor vehicle accidents. physical exam: general: tachypneic, speaking in word sentences, pain well-controlled, lying in bed heent: dry mm, card: tachycardic resp: using accessory mucles abd: mildly distended and tympanic, nontender, decreased bowel sounds ext: warm, well-perfused, 2+ dp pulses bilaterally; no pedal edema. neuro: alert & appropriate pertinent results: 01:08am wbc-10.0 rbc-4.28 hgb-14.7 hct-43.9 mcv-103* mch-34.3* mchc-33.4 rdw-20.9* 01:08am neuts-89.7* lymphs-6.4* monos-3.6 eos-0.2 basos-0 01:08am plt count-194 01:08am pt-16.7* ptt-33.3 inr(pt)-1.5* 01:08am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 01:04am lactate-2.5* 01:08am glucose-193* urea n-12 creat-0.6 sodium-135 potassium-4.2 chloride-101 total co2-25 anion gap-13 01:08am probnp-338* 01:08am calcium-8.1* phosphate-3.3 magnesium-1.8 12:00am blood wbc-7.0# rbc-3.67* hgb-12.5 hct-38.8 mcv-106* mch-34.1* mchc-32.2 rdw-20.1* plt ct-147* 01:08am blood neuts-89.7* lymphs-6.4* monos-3.6 eos-0.2 baso-0 12:00am blood pt-14.9* ptt-23.9 inr(pt)-1.3* 12:00am blood plt ct-147* 11:31am blood glucose-119* urean-14 creat-0.5 na-131* k-4.5 cl-97 hco3-29 angap-10 03:21pm ascites wbc-11* rbc-* polys-15* lymphs-46* monos-0 macroph-37* other-2* 03:21pm ascites totpro-2.6 glucose-102 ld(ldh)-274 albumin-1.4 . reports: chest (portable ap) 11:49 pm single ap upright bedside chest radiograph: as seen on ct of the chest from one day prior, there are multiple large loculated pleural effusions, which appear roughly stable compared to one day prior. there are bibasilar fluffy opacities, right greater than left, consistent with pneumonia as seen on ct from one day prior. the pulmonary vasculature is engorged and there is perihilar haziness and increased interstitial markings, consistent with mild- to-moderate pulmonary edema. right subclavian catheter terminates at the svc- cavoatrial junction. cardiomediastinal silhouette is stable with prominence of the left hilum due to a component of loculated effusion. impression: 1. bibasilar opacities, consistent with pneumonia as seen on ct from one day prior. 2. mild-to-moderate interstitial edema. 3. persistent large loculated pleural effusions. . study date of 11:45:12 pm sinus tachycardia. peaked p waves with rightward p axis. low limb lead voltage. compared to the prior tracing of atrial ectopy is no longer precorded. the rate has increased. otherwise, no diagnostic interim change . study date of 8:40:58 pm baseline artifacat. sinus tachycardia. rightward axis. delayed r wave progression with late precordial qrs transition. non-specific t wave abnormalities. findings are non-specific but clinical correlation is suggested. since previous tracing of no significant change. . tte left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is a moderate sized (partially echo filled anterior to the right ventricle; echolucent anterior to the right atrium and inferior/lateral to the left ventricle) pericardial effusion. no definite right atrial or right ventricular diastolic collapse is seen. compared with the prior study (images reviewed) of , the findings are similar (heart rate is slower). brief hospital course: assessment and micu course: this is a 55 y.o. female with metastatic adenocarcinoma of unknown primary first diagnosed in from percardiocentesis fluid cytology, recent cycle of capcitabine/irinotecan, history of pe/dvt s/p ivc filter and enoxparin therapy, and svt secondary to malignancy, who was admitted from the ed to icu for recurrent respiratory distress and tachycardia. despite diuretic therapy, antibiotic therapy, nebulizer treatments, heart rate control, and corticosteroid therapy, she did not improve substantially. given this, along with progression of disease on ct imaging in spite of receiving chemotherapy, it was eventually determined by primary oncology team and patient's family to pursue comfort measures only. . #) dyspnea. secondary to disease progression, pleural & pericardial effusions. she was continued nebulizers and morphine elixir prn for comfort. avoid morphine iv unless necessary, per patient wishes. continue lorazepam for anxiety . # leaky foley, dysuria, and groin rash: she was briefly on cipro, but it was discontinued as her ucx was negative. she had a significantly irritated urethra, likey from a reaction to the original foley. she was switched to a silicon foley and given urojet, pyridium, and antibiotic ointment which resulted in mild symptomatic improvement. these measures should be continues. she was given ditropan with minimal improvement and the caliber of her foley was increased with no improvement. the next step may be removing the foley, but she has been resistent to this so far both because of the dysuria and because of reluctance to wear adult diapers. in addition, she has what looks like an incontinence rash in her groin, which should be treated with barrier cream (mupirocin ), sarna prn, and keeping her as dry as possible. she may need an antifungal if her rash begins to look fungal. . #) tachycardia. secondary to malignancy, was on diltiazem for heart rate control to help with dyspnea. managed as per her dyspnea as above. . #) adenocarcinoma. per dr. and patient and family, goals of care addressed and patient is comfort measures only. s/p paracentesis of 2l on . fluid bloody, fluid not indicative of sbp. pain control has been with fentanyl patch 25 mcg/hr, oral morphine 2.5-10mg po q2h prn. she has also benefited from scopolamine patch and saliva substitute. . #) thrush. given nystatin oral 5ml po qid prn. . #) f/e/n. regular diet. megace 400mg po daily for appetite. . #) prophylaxis. discontinued enoxaparin, continue bowel regimen for comfort - senna prn, po colace and pr colace prn. . #) communication. with patient and family. husband: . #) access. port. piv x 1. . #) code status. dnr/dni. cmo medications on admission: calcium carbonate 500 mg qid cholecalciferol (vitamin d3) 800 unit daily fentanyl 25 mcg/hr patch 72 hr lidocaine patch capecitabine 1500 mg loperamide 2 mg qid prn docusate sodium 100 mg senna 8.6 mg tablet megestrol 400 mg daily hexavitamin daily enoxaparin 60 mg/0.6 ml syringe levalbuterol hcl nebs prn ipratropium bromide nebs diltiazem hcl 120 mg daily discharge medications: 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. 3. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 6. lorazepam 0.5 mg tablet sig: 1-4 tablets po q4h (every 4 hours) as needed. 7. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q4h (every 4 hours) as needed. 8. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) nebulizer inhalation q4h (every 4 hours) as needed. 9. scopolamine base 1.5 mg patch 72 hr sig: one (1) patch 72 hr transdermal every seventy-two (72) hours as needed. 10. morphine 10 mg/5 ml solution sig: ml po q2h (every 2 hours) as needed. 11. heparin lock flush (porcine) 10 unit/ml solution sig: five (5) ml intravenous daily (daily) as needed: 10 ml ns followed by 5 ml of 10 units/ml heparin (50 units heparin) each lumen daily and prn. inspect site every shift. . 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal (2 times a day) as needed. 13. lidocaine hcl 5 % ointment sig: one (1) appl topical (2 times a day) as needed. 14. lidocaine hcl 2 % gel sig: one (1) appl mucous membrane prn (as needed). 15. oxybutynin chloride 5 mg tablet sig: one (1) tablet po tid (3 times a day). 16. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 17. megestrol 40 mg/ml suspension sig: ten (10) ml po daily (daily) as needed for appetite stimulation: for appetite stimulation. 18. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day). 19. artificial saliva 0.15-0.15 % solution sig: 1-3 mls mucous membrane qid (4 times a day) as needed. 20. sarna anti-itch 0.5-0.5 % lotion sig: one (1) application topical twice a day as needed for itching: please apply to groin rash prn. discharge disposition: expired facility: - discharge diagnosis: primary diagnosis: adenocarcinoma, metastatic, of unknown primary . secondary diagnosis: htn asthma dvt s/p ivc filter placement h/o pleural and pericardial effusions discharge condition: good. pain is under control. urethritis stable. discharge instructions: you were admitted with shortness of breath. you were in the icu originally and were treated empirically for pneumonia, volume overload and copd/asthma exacerbation as it was unclear what was causing your symptoms. your symptoms are most likely due to disease progression. after discussion with you and your family, given the poor prognosis of your disease, the decision was made to focus on comfort and you are being discharged to a hospice facility for further care. . you were noted to have urethritis and pain, likely partially due to your foley cathether. urology made recommendations about the type of foley catheter to use and this was implemented prior to discharge. . you had a paracentesis performed for comfort prior to discharge. there was no evidence of infection. . please call dr. or dr. if you have any further questions regarding your care. followup instructions: none Procedure: Percutaneous abdominal drainage Diagnoses: Pneumonia, organism unspecified Unspecified pleural effusion Unspecified essential hypertension Atrial fibrillation Unspecified disease of pericardium Cachexia Personal history of venous thrombosis and embolism Other ascites Encounter for palliative care Chronic obstructive asthma with (acute) exacerbation Secondary malignant neoplasm of lung Other malignant neoplasm without specification of site Tachycardia, unspecified Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Secondary malignant neoplasm of other digestive organs and spleen Secondary malignant neoplasm of retroperitoneum and peritoneum Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified Other urethritis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: emergent cabg x 3 () history of present illness: 57 y/o male w/no previous cardiac history, presented to hospital with sudden onset chest pain, ruled in for acute mi, placed on heparin/plavix/aggrastat, transferred emergently to cath lab. this revealed 90% lm with extensive thrombus, as well as 80% prox. lad disease. an iabp was placed, and he was takebn to the or emergently for cabg. past medical history: dm-2 htn s/p bilat hip replacements s/p gunshot injury to abdomen s/p spinal fusion gerd hx. exposure social history: works as substance abuse counsellor denies etoh denies tobacco married family history: non-contributory physical exam: pre-op: unremarkable today: neuro: grossly intact lungs ctab cor: rrr abd: benign ext: 1+ bilat edema sternal incison clean, dry, no erythema left leg evh sites c/d/i pertinent results: 06:45am blood wbc-7.5 rbc-3.46* hgb-10.2* hct-29.6* mcv-86 mch-29.4 mchc-34.4 rdw-13.3 plt ct-124* 03:42am blood pt-12.5 ptt-28.0 inr(pt)-1.0 06:45am blood glucose-44* urean-20 creat-0.9 na-138 k-3.7 cl-97 hco3-33* angap-12 03:42am blood glucose-70 urean-14 creat-0.8 na-134 k-4.1 cl-100 hco3-28 angap-10 03:00pm blood alt-22 ast-23 alkphos-122* amylase-19 totbili-0.4 brief hospital course: taken to or emergently from the cath lab due to significant lm disease w/extensive thrombus. underwent cabg x 3 (lima > lad, svg > distal lad, svg > ramus). intra-op tee revealed normal rv function (mild global & apical hypokinesis), trace mr, trace ai, ef 50%. post-op to csru, extubated day of surgery, hemodynamically stable, iabp d/c'd on pod #1, transferred to telemetry floor on pod # 2, chest tubes removed on pod # 3, he was cleared by physical therapy and discharged to home on pod#4 medications on admission: glyburide 2.5 mg ms contin 60mg po bid (am & hs) and 30mg qd (midday) lisinopril 5mg qd tenormin 25mg zantac 300 mg hs trazadone 100 mg hs asa 81 mg discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po twice a day for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. glyburide 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 7. morphine 15 mg tablet sustained release sig: four (4) tablet sustained release po every twelve (12) hours: 4 tablets q am & q hs, 2 tablets midday. disp:*70 tablet sustained release(s)* refills:*1* 8. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: south vna discharge diagnosis: cad mi dm htn discharge condition: good discharge instructions: no lifting > 10# or driving for 1 month may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions followup instructions: with dr. (cardiologist) at 3:20 pm ( with dr. (pcp) in weeks with dr. in 4 weeks 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 Left heart cardiac catheterization Implant of pulsation balloon Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

history of present illness: the patient is a year-old white male with a history of prostate cancer status post radiation therapy complicated by radiation proctitis who previously had a lower gi bleed in as well as recent hospitalization for lower gi bleed and rule out mi who now presents with episode bright red blood per rectum on date of admission. he also has lightheadedness. he denies any chest pain, shortness of breath, or fevers. he does have some right lower quadrant pain which he reports is chronic. he denies any melena or hematochezia. in the emergency department the patient was noted to have a hematocrit of 30.4 which is a slight decrease from 31.7 on the date of discharge two days of prior. he was hemodynamically stable. he had no episodes of bright red blood per rectum in the er. two large bore ivs were placed and a type and cross was sent. past medical history: 1. prostate cancer status post radiation therapy complicated by radiation proctitis. 2. admission for lower gi bleed in which he had coloscopy which showed diffuse diverticulosis with no sign of active bleeding but positive radiation proctitis. 3. he had an admission in in which he had decreased hematocrit down to 23 and guaiac positive stool and troponin of 2.1. however by cks he was ruled out for myocardial infarction. he was transfused with a hematocrit of 31. 4. he has a gait disturbance secondary to microvascular cerebral disease. 5. chronic renal insufficiency baseline of 1.5. 6. congestive heart failure ef 30 to 40%. medications: 1. prilosec 20 mg po q day. 2. casodex 50 mg po q day. 3. aspirin. allergies: no known drug allergies. social history: he lives with his wife and with her help able to handle own activities of daily living with his family's assistance. physical examination: blood pressure is 113/57, heart rate 72, respiratory rate is between 13 and 16 and saturation at 96%. general - he is alert, conversant, in no apparent distress. neck is supple with no jvd or lymphadenopathy. heent - moist mucous membranes. oropharynx is clear. cardiovascular - regular rate and rhythm with no murmurs, rubs, or gallops. respiratory - soft, bibasilar rales with decreased breath sounds in left upper lobe. abdomen with positive bowel sounds, mildly distended with right lower quadrant tenderness. extremities - 1 to 2+ dorsalis pedis and posterior tibialis arteries. laboratory data: white count 9.3, hematocrit 30.4, platelet count 56,000. inr 1.1, ptt 25.6, 75 neutrophils, 0 basophils, 0 bands. sodium 137, potassium 4.3, chloride 102, bicarb 27, bun 44, creatinine 1.7, glucose 89, ck 49, troponin 0.5. ekg showed normal sinus rhythm at 60 beats per minute with left axis deviation and early r wave transition. q waves in ii, iii, avf, v5 and v6 which are old with new t wave inversion in v4. transthoracic echo done on showed ef 30 to 40% with mild symmetric lvh. right ventricle noted to have normal systolic motion, thickened aortic valve with no stenosis, mitral valve with 1 to 1+ mr, delayed relaxation, 1+ tr. chest x-ray showed no acute pulmonary disease. no evidence of chf. hospital course: the patient is a year-old white male who was admitted for an episode of bright red blood per rectum. his was initially treated for his gi issues. 1. gastrointestinal - the patient came in with bright red blood per rectum. did not have any episodes during this admission. he was initially stabilized with twice daily hematocrit checks and was given large bore ivs. he was typed and crossed. the goal was to keep his hematocrit above 30. because of his low ejection fraction he was given a small amount of drinking fluids. a gastrointestinal consult was obtained in which it was recommended for him to go for a colonoscopy. if he had any active bleeding it was decided he would go for a tagged red blood cell scan or an angiogram. he went for a colonoscopy on the following day of his admission. during that procedure it was discovered that he had diverticulosis of the colon and angiectasias in the rectum. also discovered was a mass in the proximal ascending colon which was biopsied. he also had polyps in the ascending colon which were removed. on direct directions from gi after the colonoscopy was performed was to avoid aspirin and ansaid and to start iron replacement therapy. it was felt that the mass found in the proximal ascending colon was most likely to be adenocarcinoma. the patient continued to have bowel movements with blood clots in them. hematology / oncology was then also consulted and recommended he have surgery if the family wished for it or palliative care. the family was interested in considering surgery. consequently a surgical consult was placed. surgery felt that he was in danger of bleeding without intervention. consequently they recommended surgery. the family agreed and consented to perform surgery. he had the surgery on . during the procedure a right-sided hemicolectomy was performed. there were no complications during the actual procedure. on postoperative day one the patient complained of substernal chest pain and shortness of breath. after having catheterization done was transferred to the ccu. further gi issues - he had a prolonged course in which he did not eat. consequently tpn was started. tpn was continued for approximately one week starting on . after he was able to have bowel sounds and then had bowel movements. he had improved po intake on and the tpn was discontinued on . the staples were removed on . the wound site had some drainage of serous sanguinous fluid but was controlled with dressing. he had a right-sided flank ecchymosis which did not enlarge and he only required one transfusion after the operation. 2. cardiac - the patient developed substernal chest pain postoperative day one of his surgery. he had shortness of breath. the ekg was suggestive of an anterior septal injury. the pain was slowly responding to medical treatment; however, the st segments remained elevated after the onset. he had probably a previous myocardial infarction in the inferior part of his heart resulting in low ef. because of his surgery he was not given any iib or iiia antagonists. the eeg had shown st elevations in v2 were very prominent. prior ekg had not showed st elevations v1 through v4. he has also had acute inferior leads but that is from an old mi. it was felt that he had an anteroseptal mi and was brought to cardiac catheterization. during this episode he was given aspirin and sublingual nitro. at that time he was transfused two units of blood. initially some considerations were cardiac catheterization that day however he initially was treated medically with heparin and aspirin. it was felt that he was possibly overloaded and was given some lasix. his enzymes were cycled and he had cardiac catheterization on the following day. cardiac catheterization revealed left main coronary artery with ulcerated 90% thrombotic stenosis which included the ostium of the lad. the lad had an ostial 90% with moderate calcifications. the left circumflex as the dominant vessel. the right coronary artery was the nondominant vessel with moderate severe diffuse disease. during the catheterization he had an angioject thrombectomy on the left main and lad. a stent was placed in the left main and into the lad. the final result was 0% residual in the lad and 30% in the left main. the ostium in the left circumflex was uncompromised. after the procedure he was continued on heparin for 48 hours. he was given clopidogrel, which was to be continued for 30 days. during the catheterization he had an intra-aortic balloon pump placed. he was also intubated. the aortic balloon pump was placed because of hypotension after the first dye injection. he was intubated in the setting of hemodynamic instability. subsequently he was transferred to the ccu. he also had a type i dissection when the first diagonal was engaged. the stent placed from left main to the lad and left circumflex was rescued with open sail. in the cath lab he was started on pressors but was weaned prior to arriving on the ccu floor. his cks were increasing from 140 to 371. his troponin was greater than 50 and his ck- mb when his ck was 371 was 34. because of the low heart rate his beta blocker was held initially. he was given fluids for low blood pressure. in the ccu he was started on the aspirin, continued on the heparin and plavix. he did not require pressor support when he was in the ccu. beta blocker was started on the second day in the ccu. he was started initially on a low dose 12.5 mg po of metoprolol. his intra aortic balloon pump was weaned and removed on . he had an episode of atrial fibrillation which he was cardioverted twice; however, it had no effect and was given iv metoprolol. he became slightly hypertensive to the metoprolol but never had a hypertensive crisis. he spontaneously converted to sinus rhythm. he had periods of atrial fibrillation but would convert after given 10 mg of metoprolol. he was started on amiodarone in the setting of the initial atrial fibrillation when he did not convert with the cardioversion. he was also started on captopril. the captopril was increased as tolerated by blood pressure. it was started at 12.5 and gradually increased to 37.5 mg po tid. it was felt that he was in congestive heart failure and had persistent pleural effusions particularly on the left side. he was started on lasix and he did not initially respond to po lasix at 20 mg po q day. consequently he was started on 40 mg iv as needed and he responded with that with diuresis. he was then converted to 25 mg po bid and continued to diurese; however, his creatinine increased and his furosemide was then decreased to 20 mg po q day. he initially was continued on heparin for his atrial fibrillation; however, because he is not a good candidate for chronic anticoagulation, the heparin was discontinued and he was not started on coumadin. 3. pulmonary - he was initially intubated because of the hypotensive episode during the cardiac catheterization. however he was quickly extubated two days after intubation. however he had secretions and sputum cultures grew out gram negative rods which were never speciated because of mixed flora. he was started on ceftazidine which was renally dosed and then because he had a temperature spike through that he was started on levaquin. actually he became afebrile. the ceftazidine was discontinued and he was just maintained on a 14 day course of levofloxacin. he had a poor cough effort and was given chest pt which improved his secretions clearance. he also had some expiratory wheezes and was started on albuterol and atrovent nebulizers. he responded well to it and did not have any other further episodes of wheezing. the other issue was his congestive heart failure which caused pleural effusion. he was diuresed with furosemide. 4. infectious disease - he had a temperature spike and felt to have pneumonia secondary to his ventilator experience. he had a left lower lobe infiltrate; however, the blood culture and urine culture were negative and sputum culture did not identify any dominant pathogen. he was started on ceftazidine and levofloxacin. he was then just converted to levofloxacin after he became afebrile. his white count remained elevated between 13 and 16; however, no new source of infection was found. the levofloxacin will be continued for 14 days. 5. renal - the patient's creatinine had been between 1.2 and 2 through the course of admission. toward the end of his admission after the aggressive diuresis his creatinine increased to 2.0. this is most likely secondary to his over diuresis and a prerenal azotemia. his bun was 90 at that time. consequently the first night's dose was decreased to 20 mg qod and the creatinine will need to be followed to make sure that it will decrease. 6. he had decrease hematocrit initially from the lower gi bleed. however after the surgery his hematocrit remained fairly stable. he had one episode during the acute chest pain which he received two units of blood. he also required another unit of blood on when his hematocrit decreased to 27.3; however, after the one unit of blood his hematocrit remained stable. code status: the patient and his family have decided to change his code status from full code to dnr/dni. discharge instructions: the patient will need to follow up with cardiology and with surgery. he also will likely need to be followed up by oncology and gi services. his surgery follow up should occur within two weeks. his cardiology follow up should be in approximately two weeks. he will need to continue his plavix for 30 days total. he will need to be followed up for a relook catheterization in approximately three months. discharge medications: 1. aspirin 325 mg po q day. 2. clopidogrel 75 mg po q day for 30 days which should be stopped on . 3. metoprolol 25 mg po tid. 4. levofloxacin 250 mg q day stop on . 5. furosemide 20 mg po qod. 6. captopril 37.5 mg po tid to be held for systolic blood pressure less than 97. 7. colace 100 mg po bid. 8. heparin 5000 units subcutaneous . 9. protonix 40 mg po q day. 10. amiodarone 400 mg po q day. discharge condition: the patient is in fair condition. discharge status: the patient is dnr/dni. diagnosis: 1. acute myocardial infarction. 2. colon adenocarcinoma. discharge instructions: the patient is to be discharged to hospital. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Implant of pulsation balloon Open and other right hemicolectomy Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Acute myocardial infarction of other inferior wall, initial episode of care Hemorrhage of gastrointestinal tract, unspecified Diverticulosis of colon (without mention of hemorrhage) Malignant neoplasm of ascending colon

history of present illness: this is a 43 year-old man with a history of obesity and sleep apnea on cpap. he has had right sided facial pain since about eight years ago. it was in the v3 region typical stabbing-jabbing nature along the jaw line including the lower lip to the midline. no pain in the teeth, gums or tongue. he noticed triggering from eating and brushing his teeth. only on occasion was there triggering from touching the skin on his right lip. mr. was initially treated with carbamazepine up to a dose of 1200 mg. in dr. did a microvascular decompression where a vascular structure was found to compress the trigeminal root. decompression was performed interposing shredded teflon. postoperatively mr. did well. he had been well up until mid when he noticed some twinge of pain in the previously described v3 area. he was seen by dr. at the end of and found that talking could trigger his pain. at that time he was given tegretol gradually tapering up to 1200 mg a day without relief of the trigeminal neuralgia. he comes in today for craniectomy for right sided v3 rhitidotomy. the patient was admitted to the neurosurgery service. the procedure of v3 rhitidotomy was performed without any complications. for further details see operative note. post procedurally the patient was awake, alert and oriented. his hearing was intact. smile was symmetrical. tongue was midline. the face was symmetric. strength was normal, in his extremities. he was admitted to the intensive care unit postoperatively with q. one hour neurologic checks and the patient did well remaining stable. the next morning he was transferred out to the floor. he was awake, alert and oriented, had slightly decreased sensation to touch on the right side of v2. otherwise cranial nerve examination was intact. he did well on the floor and was discharged the next day. patient will continue on tegretol which will be weaned off. he is to follow up with dr. and to return for staple removal in ten days. discharge diagnosis: trigeminal neuralgia v3 region, right sided, status post rhitidotomy. discharge medications: percocet 5/325 for pain, tegretol 200 mg p.o. t.i.d. with a taper down to off in one week. discharge status: to home. , md dictated by: medquist36 Procedure: Division of trigeminal nerve Decompression of trigeminal nerve root Diagnoses: Unspecified sleep apnea Obesity, unspecified Trigeminal neuralgia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: food bolus impaction in esophagus major surgical or invasive procedure: upper endoscopy 2x elective tracheal intubation history of present illness: pt is a 48y/ w/ a pmh significant for htn who presents tonight w/ the acute onset of dysphagia and throat pain during a meal. the patient was in his usoh until dinner tonight when he noted the above symptoms directly after swallowing. he was unable to clear his throat at home and reports being unable to clear oral secretions. he reports a past history of 2 prior esophageal food boluses ~20yrs ago that have required egd disimpaction but denies any cp, sob, fever, abdominal pain, n/v, or diarrhea today. he denies any history of gerd symptoms and does not have any other significant gi history. he has not had any recent dyspagia or odynophagia. he denies any recent travel and has had no sick contacts. has not had any caustic ingestions. he denies a history of rheumatologic conditions or skin changes. his past egds have not shown any evidence of stricture or ring and he claims to have had an esophageal motility study in the past that showed a sluggish (though non-pathologic) esophagus. . in the ed, the patient was given glucagon x1 for presumed esophageal impaction w/out resolution of his symptoms and was admitted to the icu for egd managment of an impacted esophageal food bolus. past medical history: 1. htn 2. food bolus x2 social history: single gay male. works as a cpa. drinks socially but denies tobacco or drug use. lives in . family history: father w/ pancreatic cancer. grandparents w/ cad. physical exam: 100.1, 140/67, 109, 19, 97% 2l heent: eomi, mmm, o/p clear neck: mild tenderness to palpation at site of bolus cv: tachycardic, no murmurs lungs: cta bilaterally abd: s/nt/nd, +bs ext: no c/c/e neuro: appropriate in conversation, moving all extremities spontaneously skin: no obvious rashes pertinent results: 02:13am pt-12.6 ptt-22.9 inr(pt)-1.1 02:13am plt count-204 02:13am hypochrom-normal anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-normal spherocyt-1+ ovalocyt-1+ 02:13am neuts-90.8* bands-0 lymphs-5.2* monos-3.7 eos-0.2 basos-0.1 02:13am wbc-14.8* rbc-5.11 hgb-16.3 hct-45.0 mcv-88 mch-32.0 mchc-36.3* rdw-12.6 02:13am calcium-9.6 phosphate-2.6* magnesium-2.1 02:13am glucose-119* urea n-19 creat-1.1 sodium-140 potassium-4.0 chloride-103 total co2-27 anion gap-14 brief hospital course: 48y/ w/ a pmh of htn and gerd who presented with an esophageal impacted foreign body. . esophageal impaction: no relief with glucagon in the ed. egd was done and showed a tight impaction with food (pot roast) was found in the middle third of the esophagus at 30cm from the incisors. no ulceration were noted. the scope was removed and an overtube was passed to protect the airway while meat impaction was removed. the distal esophagus could not be seen despite multiple attempts to go around the bolus. the large biopsy forceps and net and colonoscopy snare were used to remove the meat. however after 90 mins, there was still a wedged piece of meat in the distal esophagus which could not be removed due to the patient becoming restless and concern about leaving the overtube in for a prolonged period of time. the pt was electively intubated for airway protection and sedation for a second attempt to remove the foreign body. during the second egd a food bolus was again seen in the middle third of the esophagus. it was pushed into the stomach with the endoscope, and the obstruction was completely removed. there were some erosions seen on the site of the bolus. in a patient with prior food impaction 20 yrs back, a motility disorder and/or a schatzki's ring was suspected. a mild schatzki's ring was found in the lower third of the esophagus, probably not accounting for the impaction. a small size hiatal hernia was seen. the pt was extubated and his pt's diet was subsequently advanced slowly. repeat egd in a few weeks to f/u on the ring and biopsy to r/o eosinophilic esophagitis was recommended. the pt was empricially treated with ceftriaxone for presumed aspiration for 2 days. a repeat cxr showed no evidence of aspiration and the patient was asymptomatic, there antibiotic coverage was stopped. . htn: atenolol on hold. pt normotensive. . ppx: protonix . code: full medications on admission: atenolol 50 discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. disp:*0 capsule, delayed release(e.c.)(s)* refills:*0* 2. atenolol 50mg qd discharge disposition: home discharge diagnosis: food impaction in the esophagus discharge condition: good discharge instructions: please come back to the hospital immediately if you experience any chest pain, fevers, problems swallowing or if you have any other concerns. . continue to take omeprazole 20mg . . please continue to take a soft diet for two more days, then advance to a regular diet. followup instructions: please follow up with your primary care doctor within the next week. . it is recommended that you have a repeat egd in four weeks to follow on the schatzki's ring and to have a biopsy to rule out eosinophilic esophagitis. please call the gi department on monday to arrange for an appointment (. Procedure: Other endoscopy of small intestine Other endoscopy of small intestine Removal of intraluminal foreign body from esophagus without incision Diagnoses: Unspecified essential hypertension Foreign body accidentally entering other orifice Foreign body in esophagus

allergies: penicillins / sulfonamides / atenolol attending: chief complaint: chest pain, shortness of breath. major surgical or invasive procedure: cardiac catheterization picc line placed and removed history of present illness: 69 year old female with cad s/p mi and cabg ' presents with intermittent chest pain x 1 week, worse in last 3 days with shortness of breath, lower extremity swelling. patient was recently seen by pcp and aldactazide was d/c'ed on and lasix was d/c'ed on (in setting of worsening renal function -lasix d/c'ed). in past couple weeks she notes increasing sob, 10-lb wt gain and increasing dyspnea on exertion. she also noted intermittent chest pain during this period but worse in past 3 days. she has slept sitting up for the past 8 months. she came to ed after becoming very short of breath on morning of admission. ekg q wave anterior ?st elevation in iii. she was started on heparin gtt and nitro gtt. she went to cath lab and found to have 90%lesion in om which was ballooned opened (couldn't stent). in the recovery area, patient sob lying flat (likely h/o osa although none diagnosed). she was on a non-rebreather satting 97%. . she was transferred to the ccu for further management. abg in the holding area on nrb was 7.29/57/148. on arrival to the ccu she was placed on bipap, ps 10 peep 5, fio2 50%. her abg on noninvasive ventilation was 7.36/53/146. after approximately hours, she was feeling sufficiently less short of breath to be weaned to nasal cannula, at which point her abg was 7.39/49/67. . initial vitals in the ed: 97.8, 98, 152/72, 20, 88% on ra. she was given asa, heparin gtt, lasix and sent to the cath lab. . on review of systems, + for non-productive cough x 3 weeks, and post-nasal drip. she has gained 10 pounds over the past 2 weeks. she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. all of the other review of systems were negative. past medical history: 1. coronary artery disease status post mi in and cabg in 2. diabetes mellitus type ii, requiring large amounts of insulin (last hga1c 7.9) 3. chf, last ef per echocardiogram 55% hypertension 4. hypercholesterolemia 5. history of metastatic left-sided infiltrating ductal breast cancer s/p chemo/xrt (post-cabg) dx'ed 6. hypothyroidism 7. utis (h/o recurrent ecoli uti in past) 8. copd 9. anxiety 10. postmenopausal bleeding status post d&c procedure on 11. obesity social history: +70 pack-year history but quit in , no etoh or other drug use. widowed 5 years ago. three grown children. lives in her own apt in her son's townhouse. her daughter has helped her with her adls over the past couple of days and does help her with her shopping. family history: no family history of premature coronary artery disease or sudden death. brother with both multiple myeloma and "thyroid problems." mother had ?oral cancer. physical exam: vs - 120/64, 86, 19, 100% on cpap 50% fio2 gen: obese, elderly female in nad. oriented x3. mood, affect appropriate. on cpap heent: ncat. sclera anicteric. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, unable to appreciate jvd obesity cv: unable to palpate pmi. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: midline surgical scar. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi anteriorly. radiation skin changes to l breast. abd: obese, soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: 2+ bilateral le edema to mid-shins. no femoral bruits. r femoral sheath with minimal ooze. skin: no ulcers, rash pulses: dopplerable dp/pt pulses pertinent results: labwork on admission: 09:40am wbc-14.3* rbc-4.00* hgb-10.6* hct-33.3* mcv-83 mch-26.4* mchc-31.8 rdw-16.7* 09:40am plt count-273 09:40am pt-13.2* ptt-23.9 inr(pt)-1.2* 09:40am neuts-83.7* lymphs-12.2* monos-3.1 eos-0.3 basos-0.7 09:40am glucose-277* urea n-41* creat-1.2* sodium-141 potassium-4.6 chloride-104 total co2-24 anion gap-18 09:40am ck(cpk)-159* 09:40am ctropnt-.48* 09:40am ck-mb-33* mb indx-20.8* probnp-6666* . pertininent labs: creatinine: baseline 1.1, peak 6.1, on discharge 2.0 hct: baseline 26-27, hct on discharge 24 (prior to receiving 1uprbcs) . imaging . chest (portable ap) this ap bedside radiograph is limited by patient's large size. the heart is probably enlarged with previous cabg. no vascular congestion. i doubt the presence of consolidations. i cannot exclude effusions particularly on the right. other than the equivocal pleural changes on current examination there is a little change from more satisfactory bedside exam . impression: suboptimal exam. no pneumonia and i doubt the presence of chf. . cardiac cath: report pending . echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is moderately-to-severely depressed (30 percent) secondary to global hypokinesis with regional variation (the inferior and posterior walls appear more hypokinetic). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction now appears reduced, but the technically suboptimal nature of both studies precludes certainty. brief hospital course: 69 year old female with cad s/p mi and cabg, dmii, obesity, chf p/w nstemi in setting of chf exacerbation. . #. congestive heart failure. ejection fraction on this admission 30% from 45% on last stress test . the patient was volume overload on admission and soon became oliguric as below despite escalating doses of lasix. the patient's oxygen saturations remained stable. the patient was followed by renal and may need dialysis if urine output does not improve. the patient's ace-inhibitor was held for renal failure. the patient has not tolerated a beta-blocker in the past and had one episode of junctional bradycardia during admission. the patient should have a repeat echocardiogram in two months for consideration of icd placement. . #. acute renal failure. the patient remained oliguric/anuric and volume overloaded but oxygen saturations remained stable. the renal failure is likely contrast nephropathy. her diovan and hctz were stopped given renal failure. the patient was followed by renal during admission, and creatinine gradually improved from 6.1 to 2.0 on day of discharge. she will need to follow-up with pcp one week after discharge to have kidney function evaluated and further address resuming and/or diuretics. . #. coronary artery disease. the patient is status post cabg in and admitted with nstemi on this admission now status post cardiac catheterization on with no obvious source for stemi. the patient received pcta to 90% stenosis of om2. the nstemi was likely demand ischemia from chf exacerbation in setting of discontinuation of diuretics. the patient was continued on asa, plavix, statin. the patient received integrilin and heparin gtt on admission. the patient's ace-inhibitor was held for renal failure. the patient has not tolerated a beta-blocker in the past and had one episode of junctional bradycardia during admission. . #. rhythm. sinus rhythm. the patient hd one episode of junctional bradycardia of unclear etiology but no subesequent episodes. electrophysiology followed the patient during admission. . #. hypoxemia, hypercarbic respiratory failure. now resolved. the patient has a 70 pack year smoking history with copd and likely restrictive defect secondary to obesity. the patient had an additional element of pulmonary edema in the setting of anxiety post-cath/lying flat/copious fluids peri-cath. the patient was continued on albuterol/atrovent nebs. . #. anemia. stable. iron studies consistent with iron-deficiency. the patient also has a history of acd and mild b12 deficiency. the patient was started on iron supplementation, and prior to discharge, she was transfused 1u prbc for hct 24 given her extensive cardiac history. after discharge, she was monitored for several hours for sob, worsening doe. she was able to ambulate and dress herself with baseline shortness of breath, oxygenation remained 97%. . #. diabetes mellitus, type 2. not well-controlled based on last hga1c. the patient was continued on lantus and hiss. . # urinary tract infection. the patient was given a dose of levaquin in the ed, but this was changed to ceftriaxone and then cefpodoxime as the patient had a history of quinonlone-resistant uti in the past. urine culture on this admission showed sensitivity to quinolones and cephalosporins. . # hypothyroidism. tsh 3.1 during this admission. the patient was continued on her outpatient levothyroxine. . #. fen : cardiac/ diet . #. access: r picc was placed for blood draws and d/c'd on discharge . #. ppx: - heparin sc . #. code: full (confirmed with patient but would not want prolonged intubation) . post discharge follow-up by pcp : 1) repeat creatinine, hct one week post discharge 2) address whether to restart diovan 160, hctz 25, and/or other diuretics 3) repeat echo in 2 months to reassess ef and need for icd placement medications on admission: diovan 160mg po qday aspirin 325 simvastatin 80 mg qday lantus 100 u/ml--155 units sq every morning levothyroxine 150 mcg--one every day hctz 25mg qday levothyroxine 150mcg qday metformin 1000mg po bid lantus 155u sc qam hiss sliding scale flonase 50 mcg/actuation--2 sprays each nostril once a day lasix 40mg qod (on hold on ) spironolactone 25mg po qday (d/c'ed on ) cranberry tablets (uti prevention) discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) spray nasal daily (daily). 4. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. cyanocobalamin 100 mcg tablet sig: 0.25 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 7. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. insulin please continue your outpatient insulin (lantus) regimen as before discharge disposition: home with service facility: homecare discharge diagnosis: primary: coronary artery disease non st segment elevation myocardial infarction congestive heart failure acute renal insufficiency urinary tract infection . secondary: diabetes mellitus obesity hypothyroidism iron deficiency anemia discharge condition: stable, saturating at baseline on room air discharge instructions: you had a heart attack as well as congestive heart failure. during cardiac catheterization, you had an occlusion in one of your coronary arteries which was subsequently opened. after this, you also had renal failure, which is now improving significantly. you will need to have your kidney function checked regularly until it returns to baseline. please continue to take all of your medications as prescribed. please weight yourself every day, maintain a low salt diet and call your doctor if you have a greater than 3 pound weight gain in days, worsening swelling in your feet, or shortness of breath. please call 911 or go to the emergency room if you have chest pain, chest pressure, shortness of breath, fever, chills, nausea/vomiting, or any other concerning symptoms. followup instructions: please call , , and schedule an appointment with your primary care physician or nurse practioner, to have your kidney function (creatinine) rechecked early next week. you already have to following appointments scheduled: provider: , md phone: date/time: 2:30 provider: , md phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of autologous vein bypass graft Personal history of malignant neoplasm of breast Chronic kidney disease, unspecified Acute respiratory failure Long-term (current) use of insulin Old myocardial infarction Obesity, unspecified Acute diastolic heart failure Personal history of irradiation, presenting hazards to health Other drugs and medicinal substances causing adverse effects in therapeutic use

history of present illness: baby girl , twin number one, was born at 31 and 6/7 weeks gestation, weighing 2060 grams. she was born to a 29 year-old, gravida vii, para iii now v mother, with prenatal screens as follows: blood type 0 positive, antibody negative, hbsag negative, rubella non reactive, rubella non immune, gbs unknown. the mother has 2 older siblings that live with their father and she has a 4 year old that lives with her. the father of this baby is reportedly not involved and he is also the father of the 4 year old. mother was transferred from on the day prior to delivery for pregnancy induced hypertension. she was treated with magnesium sulfate, ampicillin and erythromycin. she received one dose of betamethasone 18 hours prior to delivery. rupture of membranes occurred prior to delivery. preterm labor developed. contractions progressed to full cervical dilatation with some cervical dilatation. this infant delivered by cesarean section due to vertex and breech presentation of the twins. this infant emerged with a vigorous cry, was given blow-by oxygen and had apgars of 7 and 8 at 1 and 5 minutes. physical examination: on admission, birth weight was 2060 which is 90th percentile. length was 46 cm which is 75th to 90th percentile. head circumference 30.5 cm which is 75th percentile. infant had mild to moderate respiratory distress, was pink and well perfused in oxygen. soft anterior fontanel, normal facies, intact palate, mild to moderate retractions, fair air entry. no murmur. femoral pulses were present. flat and soft nontender abdomen without hepatosplenomegaly. she had normal external genitalia, stable hips and fair tone and active. hospital course by systems: respiratory: the infant had mild to moderate respiratory distress on admission to the nicu. she was placed on c-pap and 21% fi02. while on c-pap, initial gases were stable. she weaned from c-pap to room air on day of life one, within the first 24 hours. she has remained on room air since that time. she has not received any methylxanthine therapy, although she does have approximately 1 to 2 spells per day which are mild and usually self-resolved. her respiratory rates at present are 30s to 50s with stable oxygen saturations greater than or equal to 95% on room air. cardiovascular: she has remained hemodynamically stable. she has had no murmurs audible. normal heart rate, blood pressure and perfusion. no cardiovascular issues at this time. fluids, electrolytes and nutrition: iv fluids were initiated on admission to the nicu. she remained n.p.o. until day of life one when enteral feedings were started and she began a slow advance in feeds and achieved full feeding by day of life 5 which is . her calories were concentrated to a maximum caloric density of 26 calories per ounce of either breast milk, using hmf 4 calories per ounce and 2 calories per ounce of mct oil or special care 24 with an additional 2 calories per ounce of mct oil, at 150 ml/kg/day pg q. 4 hours. her most recent set of electrolytes was on with a sodium of 141, potassium of 5.7 which was hemolyzed, chloride of 112 and a c02 of 18. her most recent weight is 2180g. gastrointestinal: she presented with a peak bilirubin level of 9.7 over 0.3 on day of life 3, . phototherapy was initiated at that time. she received a total of 2 days of phototherapy and had a most recent bilirubin level of 4.7 over 0.2 on which was declining from a rebound bilirubin level. hematology: hematocrit on admission was 45; platelet count of 273. those were the only hematocrit and platelets measured. she has had no issues requiring blood product transfusion and is pink and well perfused. blood typing has not been done on this infant. infectious disease: cbc and blood culture were screened on admission due to the preterm labor. the cbc was benign. she received 48 hours of ampicillin and gentamicin which was subsequently discontinued when the blood pressure remained negative at 48 hours. she has had no further issues with sepsis. neurology: head ultrasound was screened on which is day of life 5 which showed normal cranial ultrasound. she has maintained a normal neurologic exam throughout her stay in the nicu. sensory: audiology: hearing screens were not done so far but will need to be done prior to discharge home. ophthalmology: no eye exams have been performed thus far. the patient will be due for the first eye examination in approximately 2 weeks. psychosocial: a social worker has been involved with this family. the contact social worker is . she can be reached at if there are any concerns. condition on discharge: fair. discharge disposition: transfer to nursery, level ii. name of primary pediatrician: , telephone number . care recommendations: feeds of 26 calorie breast milk or special care at 150 ml/kg/day pg. medications: none. car seat screening should be done prior to discharge from the hospital. will require repeat state screen on . immunizations received: none thus far. 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 weeks 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; (3) chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. state newborn screen was sent on day of life 3. results are pending. this should be repeat on . discharge diagnoses: 1. respiratory distress resolved. 2. sepsis ruled out. 3. hyperbilirubinemia resolving. 4. apnea of prematurity ongoing. Procedure: Other phototherapy Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 2,000-2,499 grams Other respiratory problems after birth 31-32 completed weeks of gestation

discharge medications: reglan 10 mg/g tube qid, meropenem 1 gram iv q8 hours until , vancomycin 1 gram iv q12 hours until , fentanyl patch 125 mcg q3 hours, heparin 5,000 units subq , prevacid 30 cc/g tube q day, ambien 10 mg/g tube prn at hs, and tylenol 650 mg/g tube q4-6 hours prn. her tube feeds are peptamen with a goal of 75 cc/hour. the patient is referred to rehab for rehabilitation of her respiratory status as well as for physical therapy. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Diagnoses: Methicillin susceptible pneumonia due to Staphylococcus aureus Streptococcal septicemia Herpes simplex without mention of complication Chronic or unspecified parametritis and pelvic cellulitis

history of present illness: the patient is a 36-year-old female with past medical history significant for chronic back pain and neck pain requiring chronic pain medication was admitted to outside hospital on for three days of increasing abdominal pain that was initially sudden on onset. the patient also had 8 weeks of green yellowish vaginal discharge. the patient was febrile with temperature of 104 in the emergency room at an outside hospital and tachycardiac and decreased blood pressure with systolic in the 60's. the patient was found to have peritoneal signs and subsequently taken to the operating room. there on open laparotomy the patient was found to have "pus in her abdomen and pelvis, rapid strep test was performed and was positive for group b strep. the patient had initially been treated with broad spectrum antibiotics which was changed to penicillin and clindamycin. on the patient was changed to vancomycin and flagyl to also cover a blood culture positive for coagulase negative staph infection. there was no clear source of infection and abdomen and pelvis on laparotomy. the patient remained intubate with increasing o2 requirement that worsened consistent with adult respiratory distress syndrome. the patient was previously on levophed times 36 hours, now stress dose steroids were subsequently discontinued. the patient had a colonoscopy on , evaluated for c. diff colitis which was negative. past medical history: 1. endometriosis. 2. history of status post appendectomy. 3. history of oophorectomy on the left side. 4. chronic back pain and neck pain. 5. lower extremity reflex sympathetic dystrophy. 6. radiculopathy with epidural fibrosis on chronic narcotics. 7. migraines. allergies: codeine and morphine and sulfa. medications: 1. meperidine upon transfer 50 mg p.o. mg b.i.d. 2. lasix 20 mg intravenous time two. 3. vancomycin 1.5 grams q 12 hours. 4. albuterol mdi. 5. propofol ggt 6. flagyl 250 mg q 6 hours. 7. insulin sliding scale. social history: the patient has one child via invetro fertilization, quit tobacco eight years ago. rare tobacco usage. physical examination: upon presentation temperature 101, heart rate 94, blood pressure 127/54 sating at 97% respiratory rate 34 on vent settings. an assist control 400, tidal volume respiratory rate 24, fio2 100%, peep 12. in general sedated but tachypneic, not responding to commands. head, eyes, ears, nose and throat examination is normocephalic, atraumatic. pupils are equal, round, and reactive to light and accommodation. extraocular movements intact. oropharynx was clear. neck: left ij line in place, no lymphadenopathy appreciated. lungs: clear bilateral crackles. heart: regular rate and rhythm. normal s1 and s2. no murmurs, rubs or gallops. abdominal examination: midline incision with staples at the laparotomy site. no drainage. hypoactive bowel sounds, nontender to palpation, warm and erythematous over abdomen and flanks. extremities: 2+ nonpitting ankle edema, 2+ nonpitting edema of the hands. dp/pt pulses 2+ bilaterally. neurologic exam: sedated, not following commands. labs: upon presentation white count 15,700, hematocrit 26.4, hemoglobin 8.6, platelets 535,000. prothrombin time of 12.8, ptt 30.4. inr 1.1. sodium 141, potassium 3.8, chloride 109, bicarbonate 24, bun 13, creatinine 0.4. glucose of 104. calcium 7.9, magnesium 1.5. chest x-ray: slight increase worsening of her adult respiratory distress syndrome, bilateral infiltrates. assessment/plan: 36-year-old female who has sepsis status post abdominal surgery on possible pelvic source who now with persistent o2 requirement and bilateral infiltrates and fevers suggestive of adult respiratory distress syndrome. hospital course by systems: 1. pulmonary. the patient was admitted to the intensive care unit originally tried on assist control ventilation. however, the patient had persistently high pulmonary pressures in the 50's, a transesophageal balloon was placed which confirmed the patient's pressures. the patient had episodes of acute hypoxemia and hypercarbia. during hospital course initially was difficult to ventilate and oxygenate. the patient was subsequently tried with increased paralytics however, the patient despite large doses of paralytics was not paralyzed. the patient was also placed on increasing doses of sedation requiring fentanyl of 1300 mg per hour and ativan at 20 mg per hour. despite these, the patient was very light on sedation. ultimately the patient was proned with improvement in her oxygenation and ventilation. the patient was subsequently left on pressure control ventilation for prolonged period of time with permissive hypercapnia, ph allowed to fall to 7.2. the patient ultimately was changed over to pressure support. ventilation was adequate ventilation, oxygenation and sedation was subsequently weaned. the patient was ultimately trached on . the patient will require prolonged weaning course for her adult respiratory distress syndrome. 2. cardiology. tachycardia, the patient was always tachycardiac during hospital course secondary to anxiety. the patient had several episodes of hypotension requiring intravenous fluid boluses and transient chemical pressors which the patient subsequently was able to wean off. recorded stem test which was performed upon admission for her hypertension and subsequently was normal. the patient is currently hemodynamically stable however, remains tachycardiac. electrocardiogram reveals sinus tachycardia. 3. renal. the patient had normal bun and creatinine throughout hospital course and has good urine output. the patient's in's and out's have been relatively even. all her intravenous fluids in were diuresed through her urine. 4. infectious disease. during hospital course upon presentation the patient was febrile. unclear of source. outside blood cultures grew out group a strep. the patient was continued on clindamycin, vancomycin, cefepime and was covered broadly during initially. gynecology was consulted with regards to patient possible vaginal source. vaginal cultures were negative. chlamydia and gc were also negative. vaginal ultrasound was performed upon presentation which originally was questionable hydropyelosalpinx however, ct scan of her abdomen did not confirm this. a ct scan of abdomen did reveal large amounts of pelvic fluid of which intervention radiology was consulted for sampling of the fluid. ultrasound guided sampling of the fluid did not reveal any organisms and cultures have thus been negative thus far. the patient persistently spiked temperatures during hospital course and blood cultures have not grown any organism to date. only one set of cultures have been positive, 1/2 bottles drawn through an arterial line and the arterial line grew out coagulase staph, arterial line subsequently discontinued and the catheter tip grew out coagulase negative staph as well. infectious disease ultimately recommended peeling back on antibiotics after she completed her course of clindamycin for group a strep. cefepime was subsequently discontinued. the patient subsequently defervesced after peeling back of antibiotics. the patient was started on acyclovir intravenously for cutaneous hsv which was positive on tsa staining. the patient was covered empirically for hsv encephalitis as lumbar puncture was attempted to rule out hsv encephalitis however, was unsuccessful given the patient's history of lower back surgery and multiple injections. the patient was covered empirically for c. diff colitis as well with metronidazole given the patient's prolonged course of clindamycin, cefepime. the patient had not had any stool or bowel movements. the patient received a seven day course of flagyl. ultimately vancomycin was restarted on for methicillin resistant staphylococcus aureus in her sputum as for increased secretions. 5. genitourinary: given the fact that the patient had pus in her pelvis and abdomen upon presentation to the hospital gynecology service was consulted "for questionable group a strep", pelvic inflammatory disease. the patient was covered broadly with clindamycin, vancomycin and cefepime originally. vaginal cultures were negative and as mentioned infectious disease the patient's transvaginal ultrasound revealed hydropyelosalpinx however, on ct scan was not confirmed. the patient was treated for a course of group a strep, bacteremia and subsequently antibiotics were peeled back. 6. gastrointestinal. the patient was placed on total parenteral nutrition upon presentation and subsequently tube feeds were started and ultimately a percutaneous endoscopic gastrostomy tube was placed for further nutritional needs. with regards to the patient's adult respiratory distress syndrome infectious disease addendum to this discharge summary will be made at a later date with discharge medications. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Diagnoses: Methicillin susceptible pneumonia due to Staphylococcus aureus Streptococcal septicemia Herpes simplex without mention of complication Chronic or unspecified parametritis and pelvic cellulitis