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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: metastatic duodenal cancer major surgical or invasive procedure: operative procedure: 1. pylorus-preserving pancreaticoduodenectomy. 2. open cholecystectomy. 3. right hepatic lobectomy history of present illness: dr. is a 57-year-old patient with a known adenocarcinoma in the duodenum causing recurrent gastrointestinal bleeding and recurrent anemia. she has had exhaustive preoperative evaluation which has demonstrated also the presence of a single metastasis in the liver. for palliation, if not curative ntent, i recommended that she undergo a combined whipple procedure to try to get the primary tumor out to eliminate the bleeding and impending obstruction of the duodenum. i also convened with dr. of our hepatobiliary surgery team to consider resection of the metastatic disease in the liver, as there is no other evidence of systemic metastases. past medical history: past medical history: significant only for known cyst in the breast. brief hospital course: patient went to the operating room on . please see the omr note for operative details. there were no unanticipated intra-operative complications, and the patient lost approximately one liter of blood and received three units prbcs during the procedure. 2 19-french drains were placed to liver bed and pancreatic biliary anastomoses locations. post-operatively she went to the surgical icu. her pain was controlled with epidural and pca. on pod1 inr was 2.0 and the patient received 2 units of ffp. pod1 liver us also demonstrated normal spectral analysis and color doppler evaluation of the vasculature of the residual left hepatic lobe. on pod2 she received another 2 units ffp for inr 1.9, and since transaminases remained elevated another liver ultrasound. ultrasound was normal-"again, seen are widely patent main and left portal veins with appropriate direction of flow. the left hepatic vein and hepatic artery are also patent and patency and appropriate direction of flow. again, the left hepatic artery demonstrates a resistive index of 0.60. there is no biliary ductal dilatation. here is no free fluid. the inferior vena cava is widely patent." pod3 the g-tube was clamped and half-strength j-tube feedings were begun. patient was also transferred out of the unit to the floor on pod3. tf were slowly advanced and on pod4 she was advanced to sips as well as transitioned to oral pain medications. foley catheter was removed from the bladder on pod5 and tube feeds were cycled at night. lasix was given on pod5 and the patient began to mobilize significant fluid accumulation, especially in the lower extremities. by pod5 she was also tolerating full liquids and was doing well ambulating around the floor and working with physical therapy. her central line was removed on pod6 and she was transitioned to all oral medications per the "whipple protocol". her electrolytes were aggressively repleted and intermittent doses of lasix were helpful in gaining euvolemia. she continued to have some trouble with nausea that was controlled with antiemetics but was troublesome nonetheless. jp drains were removed before discharge, and the patient was begun on a 7 day course of cefazolin for a superficial cellulitis. she was discharged to home with services on pod10. she was afebrile, tolerating a full diet and ambulating without difficulty. her wounds were healing nicely and she was instructed on proper g and j tube care. she has follow-up as outlined below. 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. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*100 tablet(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* 4. potassium chloride 10 meq capsule, sustained release sig: four (4) capsule, sustained release po once a day. disp:*120 capsule, sustained release(s)* refills:*2* 5. furosemide 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 6. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*60 tablet(s)* refills:*0* 7. cephalexin 500 mg tablet sig: one (1) tablet po four times a day for 7 days. disp:*28 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: metastatic duodenal cancer discharge condition: stable discharge instructions: please call the office or the emergency room if you develop fever greater than 101.5, your wounds become red, swollen or begin draining pus or you develop severe nausea or vomiting. please take the full 7 day course of antibiotics, as well as all other medications prescribed. do not drive while taking narcotic pain medications, and use a stool softener such as colace while you are taking the pain medication. you may shower when you get home but avoid tub bathing for 3 weeks. no heavy lifting or activity for at least 6 weeks. followup instructions: please follow-up with dr. in the office in weeks. please call ahead of time to make an appointment. (. Procedure: Radical pancreaticoduodenectomy Cholecystectomy Transfusion of packed cells Transfusion of other serum Lobectomy of liver Diagnoses: Malignant neoplasm of liver, secondary Mitral valve disorders Acute posthemorrhagic anemia Malignant neoplasm of duodenum Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: lumbar puncture (x 2) history of present illness: 41yo m with history of drug abuse who presents with altered mental status. history is obtained from mother. . according to his mother, patient was arrested last tuesday for possession of drug. she was however not aware of the kind of drug that he possessed. he was in jail and was released on probation on wednesday. he admits to taking 2 tablets of saboxone on saturday prior to seeing his daughter on saturday as he does not want to appear sick while seeing his daughter. then returned to his mothers home on night feeling unwell and stayed with his mother overnight. on morning of admission, he woke up feeling unwell. his mother noticed that he became more disoriented as the day goes by. his gait became unsteady and he had slurred speech. there was no alcohol in his breath and his mother was pretty sure that he has been sober. he was intermittently agitated but not violent. he took 3 tablets of soboxone to "prevent sickness". of note, he has been having diarrhea and muscle ache for 1 day. his mother reported that he was diaphoretic on the way to the addiction clinic. he however denies n a u s e a / v o m i t i n g / l a crimation/rhinorrhea/headache/photophobia/halucination/flushing. his mother brought him to the addiction center and then he was sent straight to the ed because of altered mental status. past medical history: drug dependency social history: drug abuse lives in by himself. he has a 6 year old daughter who is under the care of her grandparents. he is unemployed most of the time, did some odd job from time to time and financially supports himself. family history: nc physical exam: t 101.2 p122 bp122/87 r18 100% on ra gen- intubated, sedated, in c collar heent- pupils 2mm bilaterally, reactive to light, anicteric, oropharynx moist, neck in c collar cv- rrr, no r/m/g resp- ctab from anterior abdomen- active bs, obese abdomen extremities- in 4 point restraint, no edema pertinent results: 10:28pm cerebrospinal fluid (csf) protein-98* glucose-89 10:28pm cerebrospinal fluid (csf) wbc-13 rbc-* polys-70 lymphs-30 monos-0 10:28pm cerebrospinal fluid (csf) wbc-25 rbc-* polys-68 lymphs-32 monos-0 09:14pm po2-274* pco2-39 ph-7.43 total co2-27 base xs-2 08:56pm lactate-1.1 07:40pm urine hours-random 07:40pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg cultures of csf and blood w/o growth 07:20pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-negative barbitrt-negative tricyclic-pos 07:20pm albumin-4.2 calcium-9.3 phosphate-3.7 magnesium-2.1 brief hospital course: 41yo m with drug abuse, history of opioid withdrawal admitted for altered mental status . 1) mental status changes pt had lp x2 and was extubated with no resiudual mental status changes - lp results were negative including cx - fever, altered mental status, diarrhea, diaphoresis, muscle aches c/w opiod withdrawal, especially given history of oxycontin use and urine tox positive for opiates, recent use of suboxone, and history of prior withdrawal symptoms. continued methadone. - addiction consult ordered, pt was unwilling to start rehab . 2) respiratory distress - intubated for airway protection. pt extubated without complications. respirtory status stable on discharge. medications on admission: none discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 4. ativan 1 mg tablet sig: 1-2 tablets po every four (4) hours as needed for agitation for 3 days: take 1-2 tablets every 4 hours as needed for agitation for the first day. take 1 tablet every 4 hours as needed on the second day. take tablet every 4 hours as needed on the third day. disp:*25 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: altered mental status with respiratory distress secondary: drug abuse discharge condition: stable, alert, oriented, respiratory status stable with no supplemental o2 requirement. discharge instructions: please call your doctor or return to the hospital if you have any changes in your mental status or feel confused, have any trouble breathing, chest pain, fever and chills, severe headache, or any other health concern. please taper your ativan as directed. please follow up with dr. (or another physician) in clinic at clinic. followup instructions: please call clinic at hospital at for an appointment with dr. (or any available physician) within the next 7-10 days to follow up on your health and final laboratory results. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Drug detoxification Diagnoses: Accidental poisoning by heroin Accidental poisoning by central nervous system stimulants Drug withdrawal Home accidents Poisoning by heroin Combinations of opioid type drug with any other drug dependence, continuous Poisoning by opiate antagonists

history of present illness: patient is a 66-year-old spanish speaking male with a past medical history significant for type 2 diabetes mellitus, congestive obstructive pulmonary disease, and coronary artery disease status post three vessel coronary artery bypass graft in , ptca and stenting of the right coronary artery in , ptca of the left anterior descending artery in , and inferior wall myocardial infarction with right ventricular infarction in with subsequent ptca and stenting of the proximal right coronary artery, who presents with an episode of acute onset substernal chest pain. the patient reports acute onset of substernal chest pain with radiation down both arms. the pain began approximately one hour prior to presentation. pain was associated with nausea, syncope, diaphoresis, shortness of breath, and chills. the patient was transported to the emergency department by ems and on route, was found to have a blood pressure of 60/palpation and complete heart block with a ventricular rate of 36. in the emergency department, the patient complained of persistent chest pain and was found to have a blood pressure of 92/50, heart rate 37, and oxygen saturation of 100% on a 100% nonrebreather. the patient's initial electrocardiogram demonstrated complete heart block with a sinus rate of 60 and junctional rate of 38, with st elevations in the inferior leads and reciprocal st depressions laterally. the patient also demonstrated elevation in right sided lead v4 consistent with right ventricular infarct. the patient was started on integrilin and heparin and sent for emergent cardiac catheterization. past medical history: 1. coronary artery disease with three-vessel disease status post coronary artery bypass graft surgery in with lima to the left anterior descending artery, saphenous vein graft to the om, and saphenous vein graft to the posterior descending artery. also status post right coronary artery stenting x2 in , status post left anterior descending artery ptca in (80% stenosis distal to the lima touchdown), status post inferior wall myocardial infarction in with ptca and stenting of a proximal right coronary artery total occlusion; the inferior wall myocardial infarction was just complicated by a right ventricular infarction with hypotension requiring intraaortic balloon pump and pressors. 2. type 2 diabetes. 3. gastroesophageal reflux disease. 4. congestive obstructive pulmonary disease. 5. hypertension. 6. hypercholesterolemia. allergies: ace inhibitor with a reaction of cough. medications on admission: 1. aspirin 325 mg po q day. 2. lipitor 10 mg po q day. 3. lopressor 50 mg po bid. 4. insulin 75-25 66 units q am, 30 units q pm. social history: the patient is married and lives with his wife. the patient reports prior tobacco use, quit five years ago. family history: noncontributory. exam on admission: vital signs: temperature 98.8, heart rate 79, blood pressure 123/80, respiratory rate 16 with an oxygen saturation of 95% on room air. in general, the patient is an obese male lying at 30 degrees in no acute distress. heent: normocephalic, atraumatic. anicteric sclerae. pupils are equal, round, and reactive to light and accommodation. clear oropharynx, dry mucous membranes. neck examination: notable for elevated jugular venous distention with no lymphadenopathy, supple. pulmonary examination notable for expiratory wheezes predominantly on the right, otherwise clear to auscultation. cardiovascular examination: regular, rate, and rhythm with normal s1, s2, s4 with no murmurs or rubs. abdominal examination: obese, soft, nontender, nondistended. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of autologous vein bypass graft Atrioventricular block, complete Acute myocardial infarction of other inferior wall, initial episode of care

history of present illness: this is a 65-year-old male with a history of diabetes and coronary artery disease (status post coronary artery bypass graft times three in , status post right coronary artery stent times two in , and status post percutaneous transluminal coronary angioplasty of the left anterior descending artery in ) who presented with 10/10 chest pain (persistent pressure similar to his past acute myocardial infarction) starting around 8 o'clock in the morning on the day of admission. he was seen in his primary care physician's office and was sent to the emergency room directly. in the emergency room, his temperature was 98.3, blood pressure was 183/65, pulse was 94, respiratory rate was 12, and oxygen saturation was 97% on room air. his initial electrocardiogram was unremarkable. he was given sublingual nitroglycerin for his chest pain. however, in the emergency room, his systolic blood pressure dropped to the 50s and heart rate went down to the 40s. his repeat electrocardiogram showed high-grade atrioventricular block with acute inferior myocardial infarction. he was given atropine and dopamine for bradycardia and hypotension in the emergency room, and he went into supraventricular tachycardia. he was brought to the catheterization laboratory directly for percutaneous transluminal coronary angioplasty. during the catheterization, an intra-aortic balloon was placed for blood pressure support, and he was intubated for airway protection. he also required pressors including neo-synephrine and dopamine during the catheterization. a transvenous temporary pacing wire was also placed during the catheterization. his proximal right coronary artery (which was totally occluded with thrombus) was successfully stented with normal flow. at the end of the catheterization, his heart rate remained stable off pacer, and blood pressure remained stable off pressors. he was transferred to the coronary care unit for monitoring. past medical history: 1. coronary artery disease; status post 3-vessel coronary artery bypass graft in ; status post right coronary artery stent in ; and status post percutaneous transluminal coronary angioplasty of left anterior descending artery in . 2. diabetes. 3. hypercholesterolemia. 4. chronic obstructive pulmonary disease. 6. gastroesophageal reflux disease. 7. hypertension. medications on admission: insulin 75/25 50 units q.a.m. and 30 units q.p.m., imdur 10 mg p.o. t.i.d., cozaar 25 mg p.o. q.d., lopressor 100 mg p.o. b.i.d., zantac 150 mg p.o. b.i.d., lipitor 20 mg p.o. q.d., aspirin. allergies: ace inhibitor (cough). social history: he stopped smoking five years ago. family history: denies coronary artery disease. physical examination on presentation: physical examination on admission to catheterization laboratory revealed temperature was 96.9, blood pressure was 136/71, heart rate was 133. in general, intubated and sedated, responsive to painful stimuli. cardiovascular examination revealed normal first heart sound and second heart sound, tachycardic. lungs revealed breath sounds were equal bilaterally. the abdomen was soft, nontender, and nondistended. extremities revealed distal pulses bilaterally by doppler. left groin arterial and venous sheaths with intra-aortic balloon pump and swan-ganz catheter. pertinent laboratory data on presentation: laboratories revealed white blood cell count was 9.6, hematocrit was 48.4, platelets were 179. pt was 13.5, ptt was 25.5, inr was 1.3. sodium was 136, potassium was 4.5, chloride was 95, bicarbonate was 31, blood urea nitrogen was 9, creatinine was 0.7, and blood glucose was 414. calcium was 8.7, magnesium was 1.5, phosphate was 4.2. albumin was 3.9, total bilirubin was 0.7, alt was 20, ast was 14, alkaline phosphatase was 85, lipase was 13, amylase was 24, ld was 196, creatine kinase was 45 (which later peaked at 1081). arterial blood gas revealed 7.31/47/358 on ventilator with fio2 of 0.8. radiology/imaging: electrocardiogram revealed st elevations in ii, iii, and avf; st elevations in i and avl; right-sided electrocardiogram showed st elevations in leads v2 through v6. catheterization in revealed 3-vessel coronary artery disease, patent left internal mammary artery to left anterior descending artery, and saphenous vein graft to obtuse marginal. total occlusion of saphenous vein graft to right coronary artery. normal ejection fraction of about 60%. successful percutaneous transluminal coronary angioplasty and stenting of the distal right coronary artery and direct stenting of the mid right coronary artery. catheterization in revealed 2-vessel coronary artery disease, patent left internal mammary artery to left anterior descending artery and saphenous vein graft to obtuse marginal. severe diastolic dysfunction. successful percutaneous transluminal coronary angioplasty of 80% left anterior descending artery stenosis just distal to the anastomosis. ejection fraction was about 70%. catheterization on admission revealed left main coronary artery was normal, left anterior descending artery with severe proximal disease, left circumflex was nondominant with total occlusion of the first obtuse marginal. right coronary artery was dominant vessel with proximal total occlusion with thrombus. the proximal right coronary artery was successfully stented. right heart catheterization showed right atrial mean pressure of 19, pulmonary artery pressure of 57/40, with a mean pressure of 49, wedge of 28. hospital course: he was weaned off pressors and intra-aortic balloon pump quickly in the coronary care unit. metoprolol and cozaar were added as his blood pressure tolerated. the 18-hour course of post catheterization integrilin had to be stopped prematurely due to epistaxis. he also developed severe laryngeal edema secondary to traumatic intubation on admission. he was evaluated by ear/nose/throat and treated with a dose of intravenous solu-medrol with significant improvement. he was extubated on hospital day five without any difficulty. he was also treated with a 7-day course of levaquin for possible aspiration pneumonia given the prolonged course of intubation and a low-grade temperature. his cardiac enzymes trended downward throughout the hospital stay with a peak creatine kinase of 1081 and ck/mb of 125. repeat echocardiogram showed inferoseptal hypokinesis with an ejection fraction of 55%. no evidence of ventricular septal defect. on the day of discharge, he was evaluated by physical therapy and deemed stable to go home. condition at discharge: condition on discharge was stable. discharge status: discharge status was to home. discharge diagnoses: 1. status post acute inferior myocardial infarction with right ventricular infarct; status post proximal right coronary artery stent. 2. diabetes. 3. chronic obstructive pulmonary disease. 4. hypercholesterolemia. medications on discharge: 1. insulin 70/30 50 units q.a.m. and 30 units q.p.m. 2. aspirin 325 mg p.o. q.d. 3. plavix 75 mg p.o. q.d. (for 30 days). 4. lipitor 10 mg p.o. q.d. 5. metoprolol 50 mg p.o. b.i.d. 6. levofloxacin 500 mg p.o. q.d. (for three more days). discharge followup: follow-up appointment with primary care physician, . (telephone number ) on at 1:20 p.m. dr. will arrange for the patient to see his outpatient cardiologist, and outpatient cardiac rehabilitation will be arranged. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of endotracheal tube Insertion of temporary transvenous pacemaker system Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of autologous vein bypass graft Hematoma complicating a procedure Atrioventricular block, complete Cardiogenic shock Acute myocardial infarction of other inferior wall, initial episode of care Other complications due to other cardiac device, implant, and graft

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ruq pain and fevers x 1 day major surgical or invasive procedure: ercp s/p cbd stent history of present illness: 51 yo male with hep b and c s/p liver trx from 1 year ago and now new dx of likely hcc now with fevers to 105, right upper quadrant abdominal pain. denies nausea, vomiting, or diarrhea. he had similar presentation in /0707 and underwent ercp and was found to have a stricture in the cbd exchange of stent. ros no night sweats or recent weight loss or gain. denied headache, sinus tenderness, rhinorrhea or congestion. reported cough x 1 day. denies shortness of breath. denied chest pain or tightness, palpitations. has been having 2 bm/ day no change. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias past medical history: 1. hepatocellular carcinoma diagnosed in with multiple tumors; patient was not a candidate for transplant in us so had an orthotopic transplant in - f/u by dr. the liver center. 2. hepatitis b, diagnosed in - last viral load: undetectable 3. hepatitis c, diagnosed in - viral load undetectable in his hepatitis b surface antibody was positive in the range of 1:450 on . his last alpha-fetoprotein level was 53.2 with an l3 fraction of 44.1 on . his last hbv viral load was nondetectable in . 4. subcapsular liver fluid collection status post biopsy on 5. recent ct imaging in demonstrates multiple lung nodules in lungs concerning for recurrence with afp rising to >60 in . 6. recurrent c diff and social history: he was a bus driver until the diagnosis of his hepatocellular carcinoma. he has been in the us since and is originally from . he smoked half a pack a day for 35 years, but quit about 8 months ago. he denies any alcohol use or any iv drug abuse. he has 4 children who are all healthy. he lives at home with his wife and family. family history: no family history of liver disease, diabetes, or cardiovascular disease. physical exam: vs t 102 upon arrival to micu and tm = 105 in ed p = 117, bp = 146/70 rr o2sat = 100% 3l general: diaphoretic but not in acute distress. heent: nc/at, perrl, eomi without nystagmus, no scleral icterus noted, mmm, no lesions noted in op neck: supple, no jvd or carotid bruits appreciated pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, 2/6 sem at lusb noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp and pt pulses b/l. lymphatics: no cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact pertinent results: 01:30pm blood wbc-5.4# rbc-4.08* hgb-12.7* hct-37.0* mcv-91 mch-31.0 mchc-34.1 rdw-14.1 plt ct-144* 05:16am blood wbc-6.7 rbc-3.81* hgb-12.1* hct-33.7* mcv-89 mch-31.8 mchc-35.9* rdw-14.3 plt ct-118* 01:22am blood wbc-3.2*# rbc-2.82*# hgb-9.1* hct-24.9*# mcv-89 mch-32.3* mchc-36.5* rdw-14.3 plt ct-74* 09:08am blood wbc-2.5* rbc-3.27* hgb-10.4* hct-30.1* mcv-92 mch-31.8 mchc-34.5 rdw-13.9 plt ct-70* 04:11am blood wbc-2.3* rbc-3.15* hgb-10.0* hct-28.2* mcv-90 mch-31.8 mchc-35.5* rdw-14.2 plt ct-79* 05:07am blood wbc-3.0* rbc-3.41* hgb-10.7* hct-30.1* mcv-88 mch-31.3 mchc-35.4* rdw-14.3 plt ct-105* 01:30pm blood glucose-109* urean-11 creat-1.0 na-135 k-4.7 cl-100 hco3-23 angap-17 09:30pm blood glucose-132* na-135 k-3.7 cl-103 hco3-21* angap-15 05:16am blood glucose-112* urean-10 creat-1.1 na-136 k-3.6 cl-105 hco3-21* angap-14 01:22am blood glucose-121* urean-10 creat-0.9 na-138 k-3.4 cl-111* hco3-18* angap-12 09:08am blood glucose-116* urean-9 creat-0.8 na-140 k-3.6 cl-113* hco3-18* angap-13 04:11am blood glucose-97 urean-6 creat-0.7 na-139 k-3.7 cl-111* hco3-20* angap-12 05:07am blood glucose-119* urean-6 creat-0.8 na-141 k-3.6 cl-112* hco3-22 angap-11 01:30pm blood alt-40 ast-73* amylase-73 totbili-0.6 09:30pm blood alt-36 ast-53* ld(ldh)-274* alkphos-72 totbili-0.9 05:16am blood alt-35 ast-48* ld(ldh)-273* alkphos-68 totbili-1.1 01:22am blood alt-32 ast-44* alkphos-56 amylase-70 totbili-0.7 09:08am blood alt-31 ast-42* alkphos-54 amylase-71 totbili-0.5 04:11am blood alt-28 ast-35 alkphos-55 amylase-67 totbili-0.4 05:07am blood alt-26 ast-35 alkphos-65 totbili-0.4 ercp: 1.the major papilla was located in the second part of the duodenum with an existing plastic stent within. 2.this was removed and the papilla was cannulated to access the cbd. 3.previous sphincterotomy was noted. 4.there was pus draining from the duct on removal of the stent. 5.the cbd was moderately dilated with an anastomotic stricture as noted previously in the mid cbd. 5.the intrahepatic /chd above the stricture were only mildly dilated as previously. 6.the anastomotic stricture was dilated to 6mm using a hurricane balloon. 7.two cotton biliary stents (10fr x 10cm and 10 f x 12 cm) were placed successfully across the stricture in the cbd. 8.there was good drainage of bile into the duodenum. ct abd/pelvis: 1. no definite cause for abdominal pain or fever identified. 2. biliary stent spans the length of the common duct. no biliary ductal dilatation. 3. tiny amount of residual subcapsular fluid around the hepatic dome is significantly improved. 4. fatty infiltration of the liver with areas of sparing. 5. no change in 4-mm nodules at the base of the right lower lobe and lingula. 6. long appendix with top normal caliber of 6mm appears similar to . no periappendiceal inflammation or fluid. ruq u/s: 1. no abnormalities identified to explain the patient's symptoms. 2. redemonstration of 1.3-cm left hepatic lesion. followup mri in four to six months from the prior mri is recommended. cxr: heart size is normal, and there is no mediastinal or hilar abnormality. the lungs are clear, and there is no pleural effusion or pneumothorax. cxr: brief hospital course: 51 yo man with hep b/c cirrhosis and hcc s/p liver tx in presents with ascending cholangitis. now post-ercp with changing of biliary stent. ## ascending cholangitis: pt s/p ercp with changing of biliary stent. had frank pus draining after stent was pulled. now on levo, metronidazole. changed to po and discharged on 14-day course. pt remained afebrile and clinically stable afterward. ## cirrhosis s/p liver tx: has multiple pulmonary nodules concerning for recurrent hcc. his mmf was held out of concern for malignancy. his sirolimus was decreased to 2 qd, and his prednisone was continued. he was scheduled for a pet-ct and f/u with drs. and . ## hep b: continued entecavir ## pulmonary nodules: ? hcc mets. scheduled for outpt pet-ct and f/u appointments with drs. and . his mmf was discontinued. ## panctyopenia: ? immunosuppressives, bactrim was discontinued medications on admission: entecavir 0.5 mg qam - rapamycin 3 mg qd - cellcept mg b.i.d. d/c'ed yesterday to minimized the amount of immunusuppression given recurrence of his cancer - bactrim single strength 1 tablet 3 times per week, m/w/f - hepatitis b immunoglobulin with last shot on , and s/p hep b igg on - prilosec - oxycodone 5 prn discharge medications: 1. entecavir 0.5 mg tablet sig: one (1) tablet po daily (daily). 2. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 11 days. disp:*33 tablet(s)* refills:*0* 3. sirolimus 1 mg tablet sig: two (2) tablet po daily (daily). 4. prilosec 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 11 days. disp:*11 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: ascending cholangitis secondary: cirrhosis s/p orthotopic liver transplant in chronic hepatitis c chronic hepatitis b hepatocellular carcinoma discharge condition: afebrile, ambulatory, stable discharge instructions: you were admitted with fevers and abdominal pain. this was likely from an infection in your transplant kidney that has been treated with antibiotics. please take all of your medications as prescribed. we have stopped your bactrim and your cellcept. you should not take these medications unless told to do so specifically by dr. . please keep all of your follow-up appointments. please call your doctor or return to the hospital if you experience fevers, abdominal pain, bleeding, chest pain, shortness of breath or anything else concerning. followup instructions: provider: , md, phd: date/time: 9:30 provider: , hematology/oncology-cc9 date/time: 9:30 provider: mri phone: date/time: 12:00 provider: , hepatology date/time: 8:00 md Procedure: Endoscopic dilation of ampulla and biliary duct Endoscopic insertion of stent (tube) into bile duct Removal of T-tube, other bile duct tube, or liver tube Diagnoses: Cirrhosis of liver without mention of alcohol Unspecified septicemia Personal history of other infectious and parasitic diseases Personal history of tobacco use Sepsis Other specified cardiac dysrhythmias Long-term (current) use of other medications Malignant neoplasm of liver, primary Secondary malignant neoplasm of lung Dehydration Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cholangitis Obstruction of bile duct Accidents occurring in unspecified place Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Other chronic nonalcoholic liver disease

past medical history: 1. hypertension. 2. hypercholesterolemia. 3. gout. 4. copd. 5. smoking history. medications at home: 1. digoxin. 2. coumadin. 3. toprol. 4. colchicine. 5. lipitor. 6. moexipril. past surgical history: no past prior surgical history. hospital course: patient was admitted on , and underwent an endovascular abdominal aortic aneurysm repair. postoperatively, patient had some respiratory distress, and remained intubated in the pacu on postoperative day #1, and patient appeared to go into chf intraoperatively, and lasix was given. the patient's pulmonary status improved after the diuresis, and patient subsequently underwent a bronch, which showed no plugging, no secretions, and no signs of chf, and patient was subsequently extubated in the recovery room. post extubation, the patient did well, and patient was transferred to the floor. on chest x-ray, the patient appeared to have a left lower lobe consolidation, question pneumonia. patient was started on levaquin, and patient was deemed ready for discharge on postoperative day #2. prior to discharge, patient was afebrile and vital signs are stable. patient was tolerating p.o. and was voiding without a foley catheter. patient's pulse exam: he has bilateral palpable dps and good palpable femoral pulses. patient's incision was clean, dry, and intact. follow-up instructions: patient will be discharged to home with instructions to followup with dr. in weeks, and he will have a follow-up ct angiogram here in about one month. the patient is to be discharged on all his preoperative home medications. also including levaquin for 10 days. discharge medications: 1. atorvastatin 20 mg p.o. q.d. 2. colchicine 0.6 mg p.o. q.d. 3. digoxin 0.25 mg p.o. q.d. 4. lasix 120 mg p.o. q.d. 5. lopressor xl 150 mg p.o. q.d. 6. moexipril 7.5 mg p.o. q.d. 7. percocet 1-2 tablets p.o. q.4-6h. prn. 8. coumadin 5 mg p.o. q.h.s. 9. levaquin 500 mg p.o. q.d. for 10 days. discharge diagnoses: 1. hypertension. 2. congestive heart failure. 3. atrial fibrillation. 4. gout. 5. status post endovascular abdominal aortic aneurysm repair. , m.d. dictated by: medquist36 d: 08:52 t: 09:02 job#: Procedure: Insertion of endotracheal tube Other bronchoscopy Arteriography of other intra-abdominal arteries Endovascular implantation of other graft in abdominal aorta Diagnoses: Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Gout, unspecified Pulmonary collapse Abdominal aneurysm without mention of rupture

allergies: patient recorded as having no known allergies to drugs attending: addendum: - pt had episodes of bradycardia into the 20 at night. pt asymtomatic from episodes of bradycardia. cardiology was consulted. they thought that the pt had dig toxicity. pt digoxin was dc'd. he remains on lopressor. the pt's dig level was drawn, he level was wnl. it was diagnosed by ekg. on discharge pt is stable. discharge disposition: extended care facility: for the aged - acute rehab md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Endarterectomy, other vessels of head and neck Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Gout, unspecified Peripheral vascular disease, unspecified Pulmonary collapse Other specified forms of chronic ischemic heart disease Other specified cardiac dysrhythmias Pneumonitis due to inhalation of food or vomitus Cardiac arrest Other specified complications of procedures not elsewhere classified Cerebral embolism with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: addendum: pt inr was 6.1 on .. pt hospital stay was prolong because of the inr. in the interim of this hospital stay from - pt worked with the patient. they stated that the pt could go home instead of rehab. also the pt antibiotic course of meropenem 1000 mg iv q8h was finished on . because of this his picc line was dc'd. with the above the pt is allowed to go home without vna services. vascular surgery talked to dr. , his cardiologist. dr office will be in contact with patient today in reference to monitering his inr. to note pt is on plavix and asa. discharge disposition: extended care facility: for the aged - acute rehab md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Endarterectomy, other vessels of head and neck Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Gout, unspecified Peripheral vascular disease, unspecified Pulmonary collapse Other specified forms of chronic ischemic heart disease Other specified cardiac dysrhythmias Pneumonitis due to inhalation of food or vomitus Cardiac arrest Other specified complications of procedures not elsewhere classified Cerebral embolism with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: addendum: pt to go home with vna. (change) discharge disposition: extended care facility: for the aged - acute rehab md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Endarterectomy, other vessels of head and neck Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Gout, unspecified Peripheral vascular disease, unspecified Pulmonary collapse Other specified forms of chronic ischemic heart disease Other specified cardiac dysrhythmias Pneumonitis due to inhalation of food or vomitus Cardiac arrest Other specified complications of procedures not elsewhere classified Cerebral embolism with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use

history of present illness: this patient is well known to dr. . he underwent abdominal aortic aneurysm repair endovascular repair for a 5.7-cm abdominal aortic aneurysm. his postoperative course was complicated by congestive heart failure and a right groin infection. he denies any claudication since his repair. he is seen in followup because of his carotid disease. he has known asymptomatic carotid disease, 60-69% on the left and 40-59% on the right. patient now is admitted for elective carotid endarterectomy. allergies: no known drug allergies. medications on admission: included coumadin 7.5 alternating with 5 mg; last dose was , lasix 80 mg q.a.m. and 40 q.p.m., toprol 200 mg daily, digoxin 0.5 daily, moexipril 7.5 mg daily, colchicine 0.6 mg daily. social history: is significant for smoking. he denies alcohol use. illnesses: include congestive heart failure with ejection fraction of 55%, chronic atrial fibrillation, history of hypertension, history of copd, history of hypercholesterolemia, history of gout. past surgical history: endovascular aaa repair and a type-ii endovascular leak repair. hospital course: patient was admitted to the preoperative holding area. he underwent a left carotid endarterectomy on . he tolerated the procedure well. he was transferred to the pacu in stable condition. extubated and neurologically intact. the patient developed at 4:15 p.m. respiratory distress. attempted intubation was unsuccessful. patient went into pea arrest. acls protocol was followed. patient was successfully intubated and transferred to the sicu for continued monitoring and care. it was noted on transfer to the sicu, the patient had unequal pupils, and a neurology consult was placed. a mri was obtained along with a carotid ultrasound. ct of the head was obtained with contrast. the preliminary report was no acute hemorrhage. neurology felt the patient would require a mri of the head with multiple areas of restricted diffusion in the anterior cerebral artery and middle cerebral artery on study. that was most consistent with embolic phenomena. source for embolization needed to be followed up. iv heparinization could not be given because of patient's history of gi bleeding. patient continued to be followed by the stroke service. recommendations were that we should obtain a mra of the neck to assess for evidence of reocclusion. patient remained in the sicu intubated. pulmonary consult was placed. patient failed to wean, and they felt this was first of all copd with acute respiratory failure, questionable left lower lobe aspiration pneumonia and a new cva. recommended to continue pressure support. hold off on aggressive weaning until patient has improved clinically both from sputum and chest x- ray and physical exam. continued on levofloxacin and flagyl for presumed aspiration pneumonia. start bronchodilators, atrovent and albuterol nebulizers q.4-6h., solu-medrol 40 mg iv q.12h. for a few days, then can be converted to inhaling flovent. continue diuresis and continue to monitor. patient was placed on triple antibiotics of vancomycin and levofloxacin. he developed a t-max of 103 on postoperative day 3. they felt this was related to his pneumonia. on postoperative day 4, a post-pyloric tube was placed for enteral feeding. he has been on a regular insulin-sliding scale. ultrasound of the chest was obtained for a left pleural effusion. this was not loculated. vancomycin and levofloxacin were continued. the patient had significant amount of secretions, which inhibited extubation and weaning. patient underwent bronchoscopy on secondary to failure to wean from ventilator. airways were without lesions or bleeding. there were copious thick, mucoid secretions right bronchotracheal tree greater than left. patient remained intubated. by postoperative day 4, the patient continued still to have a temperature of 101.9 to 101.3. his tube feeds were at goal, and he remained on the vent. by postoperative day 6, the patient's temperature curve had improved to 99.8. his clinical exam was improved. his white count was improved. on postoperative day 7, the patient's levofloxacin was discontinued and was begun on zosyn. his vancomycin was continued. still remained intubated with a t-max of 101.2. patient was successfully weaned and extubated on postoperative day 9, that was . mental status was much improved. tube feeds were continued. pos were held. ambulation to chair was begun. postoperative day 10, it was noted the patient had some inflammatory response of the left 5th finger, which was consistent with gout. colchicine was reinstituted along with indocin with improvement in his inflammatory response. initial evaluation by physical therapy was on postoperative day 10, . patient would require rehab prior to discharge to home. antibiotics were discontinued. tube feeds were continued and gentle diuresis was continued for a 0.5 liter to a liter of fluid. white count was 18.3, hematocrit 27.7. fluconazole was added to the patient's antibiotic regimen of vancomycin and zosyn on for persistent sputums with yeast. patient was seen by speech and swallow. the initial evaluation could not be done because the patient was not awake enough to follow commands. they did feel the patient might be aspirating and aspiration precautions were required. patient continued to be seen by physical therapy, and they continued with aggressive pulmonary therapy. the patient was re-evaluated on by speech and swallow, who felt that the patient had questionable signs and symptoms of aspiration. was list at the bedside. a video swallow was recommended. the patient should remain npo with his tube feeds, to continue until the swallow was completed. infectious disease was requested to see the patient, and again the recommendations regarding current antibiotic treatment and length of therapy. recommendations were that the right basilar effusions should be evaluated by ct with drainage if indicated and fluid sent for culture. continue meropenem until chest ct is obtained. patient also recommended stop vancomycin and fluconazole. recommendations of a right thoracentesis and culture of the fluid was discussed with dr. service, that they did not want to do any further invasive procedure on the patient and will diurese the patient and follow the pleural effusion. patient's temperature curve continued to show improvement with improvement in his white count. blood cultures, which were obtained showed no growth. patient was begun on meropenum on . the zosyn was discontinued. the fluconazole was continued. this was added to his antibiotic regimen secondary to a new right lower lobe opacity on chest x-ray. patient underwent an oropharyngeal video fluoroscopic swallowing evaluation on . there was no aspiration or component of aspiration noted. recommendations to advance the diet to thin liquids, and purees, and medicines in thin liquids. as the patient's mental status improves and overall strength increases, the team may wish to advance his diet further. patient required transfusion on for hematocrit of 26. patient was transferred to the vicu on . his white count continued to show improvement, and he continued to be diuresed. at this point, recommendations were to continue the meropenum for a total of 7 more days, that was on . picc line was requested on for continued antibiotics. patient continued to show improvement in his respiratory status. patient was discharged to rehab in stable condition. discharge medications: acetaminophen liquid 325-650 mg q.4- 6h. p.r.n., moexipril 7.5 mg daily, fluticasone propionate 110 mcg puffs 2 b.i.d., insulin-sliding scale, albuterol 0.083% nebulizers q.6h., ipratropium bromide nebulizers q.6h. p.r.n., colchicine 0.6 mg daily, protonix 40 mg q.12h., plavix 75 mg daily, aspirin 325 mg daily, warfarin 5 mg daily, digoxin 0.5 mg daily, metoprolol 50 mg q.a.m., metoprolol 25 mg q.p.m., meropenum 1 gram q.8h. for total of 7 days from . discharge diagnoses: 1. carotid stenoses bilaterally status post left carotid endarterectomy on . 2. respiratory failure. 3. pulseless electrical activity arrest secondary to failed intubated. 4. left anterior cerebral and middle cerebral artery infarct by mri. 5. postoperative fever with left lower lobe collapse and pleural effusion, pneumonia treated. 6. aspiration pneumonia treated. 7. gout exacerbation treated. 8. status post bronchoscopy on . secondary diagnoses: 1. chronic atrial fibrillation. 2. coronary artery disease. 3. history of congestive failure, compensated. 4. history of hypertension controlled. 5. chronic obstructive pulmonary disease. 6. blood loss anemia corrected. patient should follow up with dr. as directed. he should follow up with neurological service as directed. , Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Endarterectomy, other vessels of head and neck Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Gout, unspecified Peripheral vascular disease, unspecified Pulmonary collapse Other specified forms of chronic ischemic heart disease Other specified cardiac dysrhythmias Pneumonitis due to inhalation of food or vomitus Cardiac arrest Other specified complications of procedures not elsewhere classified Cerebral embolism with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use

allergies: heparin agents attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization s/p bare metal stent in rca history of present illness: 65 yo f with tobacco history presented to osh with sudden onset chest pain. the patient reports that the pain began at 11:30pm while at home. the pain was described as sudden, constant, substernal, unrelieved by rest or position. she also reports radiation of the pain to the left arm, jaw, and neck. she also experienced nausea and vomitting x 1, diaphoresis, mild lh. she denied any sob, syncope, palpitations. . in the ed at the osh, the patient had an ekg which showed st elevations in ii, iii, avf, as well as in v3-v6, with depressions in v1-v2, i, avl. cpk 54, mb 4.2, trop i 0.16. she was given nitro and morphine with mild relief of her chest pain. she also received asa, lopressor, integrillin bolus, and was transferred to for urgent cath. . on cath lab noted to have totally occluded rca, otherwise normal. bare metal stent was placed. after reprofusion she had bradycardia and required atropine. on right heart cath went into vfib and was shocked once returning to sinus rhythm. currently chest pain free. . ros: prior to event she was feeling well except for recent back injury. however this had improved by yesterday. denied any recent fevers, chills, nausea, vomting. no sob, orthopnea, pnd, le edema. no diarrhea, constipation, melena, abd pain. past medical history: uterine ca s/p xrt rt fem- lt bypass social history: tobacco use 1ppd for 40 yrs. occasional etoh use. no illicit drug use. lives with mother, brother. widowed, 2 children. family history: mother alive at 93, questionable history of cad in 40-50's. father died at age 83 from complications of hip surgery. physical exam: vital signs: t 97.1 bp 118/67 hr 87 rr 16 o2sats 100% 3lnc general: comfortable, lying flat in bed, nad heent: perrl, eomi, dry mm, anicteric neck: no jvd lung: ctab anteriorly heart: distant hs, rrr, no m/r/g abdomen: soft, nt, nd, + bs ext: right groin with sheath in place. 1+ dp bilaterally neuro: a&o times 3 pertinent results: cardiac cath: final diagnosis: 1. inferior st elevation mi due to mid rca occlusion. 2. cardiac arrest during right heart catheterization. 3. successful pci of a totally occluded rca with a bare metal stent. . ekg: nsr, ste in ii,iii,avf,v3-v6, std in v1-v2,i,avl . echo la is normal in size. ivc is dilated (>2.0 cm). lv wall thicknesses and cavity size are normal. ef 35-40%, moderate regional lvsystolic dysfunction with focal severe hypokinesis of the inferior septum, inferior, and inferolateral walls. the remaining segments contract well. rv chamber size is normal. av leaflets (3) are mildly thickened but aortic stenosis is not present. mv leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mr, mild 1+ tr. mild pa systolic hypertension. there is an anterior space which most likely represents a fat pad. . 06:57pm type-art po2-87 pco2-31* ph-7.42 total co2-21 base xs--2 intubated-not intuba 06:57pm glucose-106* lactate-1.4 na+-133* k+-3.9 cl--105 06:57pm hgb-10.2* calchct-31 06:57pm freeca-1.16 04:12pm glucose-92 urea n-10 creat-0.6 sodium-132* potassium-8.1* chloride-104 total co2-21* anion gap-15 04:12pm calcium-8.5 phosphate-3.6 magnesium-2.2 04:12pm pt-15.8* ptt-25.5 inr(pt)-1.4* 02:31pm potassium-4.6 02:31pm ck(cpk)-4297* 02:31pm ck-mb->500 02:31pm magnesium-2.0 12:32pm potassium-6.4* 12:32pm ck(cpk)-5090* brief hospital course: mrs. is a 65 year old female presenting with acute substernal chest pain, nausea, vomiting, and ekg with ste in ii, iii, avf admitted for stemi, now s/p rca bare metal stent. . cardiac: ischemia: ms. presented with sudden onset chest pain found to have inferior stemi. unfortunately the patient waited several hours and developed q-waves inferiorly. on admission to the patient underwent cardiac catheterization which showed a total occluded rca otherwise patent vessels. a bare metal stent was placed in the rca. after reperfusion she had bradycardia and required atropine. on right heart catheterization the patient went into vf and was shocked once returning to sinus rhythm. a bare metal stent was used secondary to the patient's need for chronic coumadin therapy, in an attempt to avoid long term use of aspirin, plavix and coumadin. the patient was started on plavix 600mg load, followed by 75mg qday which she will continue for 1 month, asa 325mg qday. she was originally started on a beta blocker and an ace inhibitor however as her blood pressure could not tolerate both (sbps in the 80s), metoprolol was d/c'd based on her heart rate in the 60s. a trial of captopril 6.25mg tid alone was attempted the evening prior to her discharge, however, again her blood pressure remained in the 80s (low of sbp of 69) despite fluids. based on this inability to tolerate both the ace inhibitor and metoprolol, both medications were d/c'd. she was also placed on lipitor 80mg qday for an elevated ldl and low hdl. her hga1c was checked and was 5.4%. she was monitored on telemetry. an echo showed lvef 35-40% with moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior septum, inferior, and inferolateral walls. in addition, smoking cessation was discussed with the patient and she expressed understanding of the importance of this. by report the patient had a questionable reaction to heparin at the outside hospital. . pump: the patient had no signs of failure on exam. echo results are as above. . rhythm: the patient maintained sinus rhythm with pvc's after mi. she was briefly put on metoprolol but this was d/c'd due to low sbps. she remained in sinus rhythm. . valve: no known valve disease. . pvd: ms. is s/p bilateral fem- bypass which she required as a result of raditation. after catheterization she was restarted on coumadin. her inr was followed and she will continue to follow up with this as an outpatient. . back pain: the patient reported lower back pain after an injury sustained a week prior to admission. she says the pain had been improving prior to admission, however she continued to report lbp and paraspinal tenderness. she was given valium and heat packs which reportedly relieved her pain. fen: she was maintained on a cardiac diet . code: full medications on admission: warfarin 2/3mg qhs(alternate) discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily) as needed for pci. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) as needed for pci. disp:*30 tablet(s)* refills:*0* 4. warfarin 1 mg tablet sig: three (3) tablet po every other day (every other day). disp:*15 tablet(s)* refills:*2* 5. warfarin 2 mg tablet sig: one (1) tablet po every other day (every other day). disp:*15 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: stemi s/p stent of rca vf secondary: fem- bypass bilaterally discharge condition: stable. the patient is ambulating around the unit. discharge instructions: you were admitted for a heart attack. you are now on medications which help patients after a heart attack including plavix and aspirin. please take all medications as prescribed. if you begin to experience chest pain, shortness of breath, lightheadedness, or any other concerning symptoms please call followup instructions: cardiology provider: , .d. phone: date/time: 9:00 internal medicine pcp : , md phone: date/time: 1:30 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Paroxysmal ventricular tachycardia Other specified cardiac dysrhythmias Acute myocardial infarction of other inferior wall, initial episode of care Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Accidents occurring in other specified places

history of present illness: is the number one first born triplet of a 34 and week gestation pregnancy born to a 36 year-old g4 p2 woman. estimated date of confinement was . prenatal screens blood type b negative, antibody positive, anti-d treated with rhogam, hepatitis c surface antigen negative, rpr nonreactive, rubella immune, group beta strep status unknown. pregnancy was complicated by pregnancy induced hypertension. this was a spontaneous triplet conception. this infant was born by cesarean section. apgars were 9 at one minute and 9 at five minutes. he was admitted to the neonatal intensive care unit for treatment of prematurity and respiratory distress. physical examination: weight 2.090 kilograms, length 43.5 cm, head circumference 32 cm. general, age appropriate with obvious respiratory distress. head, eyes, ears, nose and throat normocephalic, atraumatic. scalp palate intact. red reflex present bilaterally. neck supple with no masses. chest lungs with poor air entry, active grunting, intercostal retractions and nasal flaring. cardiovascular regular rate and rhythm. no murmur. abdomen soft with active bowel sounds. femoral pulses 2+. hips stable by midline. anus patent. genitourinary male with testes present bilaterally in canal. neurological tone and reflexes consistent with gestational age. hospital course/pertinent laboratory data: 1. respiratory: required intubation and received one dose of surfactant. he was extubated on room air on day of life number one and remained in room air through the rest of his neonatal intensive care unit admission. he has had no episodes of spontaneous apnea or bradycardia. 2. cardiovascular: has maintained normal heart rates and blood pressures, a soft murmur was heard on day of life 12. has been intermittent since then. it is felt to be benign in nature. 3. fluids, electrolytes and nutrition: was initially npo and maintained on intravenous fluids. enteral feeds were started on day of life number one and gradually advanced to full volume. he has been all po since day of life number 10 . at the time of discharge he is taking enfamil 24 calories per ounce minimum of 130 cc per kilogram per day. discharge weight is 2.37 kilograms with a length of 47 cm and a head circumference of 33 cm. 4. infectious disease: due to the unknown etiology of his respiratory distress was evaluated for sepsis and treated presumptively. a white blood cell count was 14,300 with a differential of 30% polys, 0% bands. the blood culture was obtained prior to starting antibiotics. the blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. gastrointestinal: peak serum bilirubin occurred on day of life number three a total of 5.6/0.3 mg per deciliter direct. he did not require treatment. 6. neurological: has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge. 7. sensory: audiology, hearing screen was performed with automated auditory brain stem responses. passed in both ears. 8. hematological: is blood type a positive, coombs negative. birth hematocrit was 43.5%. condition on discharge: good. primary pediatrician: dr. general medical associates , , . phone number . fax number is . care and recommendations at the time of discharge: 1. feeding: enfamil 24 calories per ounce ad lib. 2. no medications. 3. car seat position screening was performed. was observed in his car seat for 90 minutes without any episodes of desaturation or bradycardia. 4. state new born screen: initial was sent on with a repeat on the day of discharge . no notification of abnormal results to date. 5. immunizations received: hepatitis b vaccine was administered on . 6. immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criterias, first born at less then 32 weeks; second born between 32 and 35 weeks with two of three of the following; day care during rsv season, smoker on the household, neuromuscular disease, airway abnormalities, or school age siblings; or thirdly 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 age. before this age the family and other care givers should be considered for immunization against influenza to protect the infant. 7. follow up appointments: recommended with dr. within three days of discharge. discharge diagnoses: 1. prematurity at 34 and week gestation. 2. triplet number one of triplet gestation. 3. respiratory distress syndrome. 4. suspicion for sepsis ruled out. 5. intermittent heart murmur likely benign , m.d. dictated by: medquist36 d: 06:37 t: 06:27 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube 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 Respiratory distress syndrome in newborn Other preterm infants, 2,000-2,499 grams 33-34 completed weeks of gestation Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section Undescended testis

history of present illness: the patient is a 76-year-old woman with a history of right upper extremity tremor. she had an mri scan which showed a 7 mm right posterior communicating artery fetal pca aneurysm. she was seen by dr. and admitted for angio and possible coil embolization of this aneurysm. she was admitted status post arteriogram which showed evidence of this right pca aneurysm which was not amenable to coiling; therefore, the patient was scheduled for clipping of this aneurysm. she remained in the hospital, was seen by cardiology and cleared for surgery. past medical history: 1) migraines, 2) palpitations, 3) hepatitis a. allergies: 1) codeine, 2) sulfa, 3) penicillin. past surgical history: tonsillectomy and adenoidectomy as a child. hospital course: she was taken to the or on for clipping of this right fetal pca aneurysm without intraop complication. postop, the patient was in the intensive care unit. she was extubated on postop day #1. she was awake, alert, oriented, following commands, moving all extremities with no drift. she was weaned to 2 liters nasal cannula. she was ruled out for an mi per protocol per cardiology, which she did rule out for. her vital signs remained stable. she was afebrile, and she was transferred to the floor on postop day #2. she remained neurologically awake, alert, oriented x 3 with a slight left drift on postop day #3. repeat head ct showed no new evidence of hemorrhaging or stroke. she had an upper extremity doppler due to some left upper extremity weakness and swelling which was also negative. she was seen by physical therapy and occupational therapy and found to require rehab. her left upper extremity weakness did improve greatly before discharge. her vital signs remained stable. her incision was clean, dry and intact. discharge medications: 1) hydrocodone 1-2 tabs po q 4 h prn, 2) aspirin 81 mg po qd, 3) famotidine 20 mg po bid, 4) albuterol inhaler 1 puff q 6 h prn, 5) dilantin 100 mg po tid, 6) heparin 5,000 units subcu q 12 h, 7) fexofenadine 60 mg po bid, 8) metoprolol 100 mg po bid, 9) alprazolam 0.25 mg po bid prn, 10) albuterol 1-2 puffs q 6 h prn. discharge condition: stable at the time of discharge. follow-up: she will follow-up with dr. in one month. staples should be removed on postop day #10. , m.d. dictated by: medquist36 Procedure: Clipping of aneurysm Arteriography of cerebral arteries Diagnoses: Acidosis Urinary tract infection, site not specified Unspecified essential hypertension Cerebral aneurysm, nonruptured

allergies: opioid analgesics attending: chief complaint: left flank pain major surgical or invasive procedure: s/p catheterization and tpa thrombolysis history of present illness: 76 yo man with pmh significant for afib and recent subtherapuetic inr, who presented to pcp's office on with left flank pain. the pain started suddenly on , was described as sharp "like a knife", and was located in left flank region without radiation. mr. also had significant nausea, concommitant with the flank pain, which he attempted and failed to relieve through self-induced vomiting. he had no hematuria, fever, or diarrhea. no recent trauma. the pain persisted, constant in intensity at 10/10, and he saw his pcp where he was found to have microscopic hematuria by ua and was referred to the hospital ed. ct there showed a left renal artery obstruction c/w thrombosis vs. thromboembolism. he was transferred to . past medical history: coronary artery disease status post angioplasty ~ 15 yrs ago atrial fibrillation prostate condition - unspecified hypertension hypercholesterolemia asthma - pt unaware of pfts in past social history: 60 pack yr smoking hx, quit 30 yrs ago alcohol occasionally no drug use lives with wife retired, former worker family history: father with unknown type cancer mother with mi physical exam: vs: t 98.6 hr 99 bp 161/94 rr 15 o2sat 96%ra genl: nad heent: perrla, eomi neck: no carotid bruits, no lad, no jvd cv: irregularly irregular, nl s1s2, no mrg pulm: lungs clear abdomen: soft, tender at left flank, nondistended, normoactive bowel sounds, no abdominal bruit, no pulsating mass to suggest aaa back: left cva tenderness, no ecchymosis ext: le without edema, 1+dp pulses/ 1+ pulses, no cyanosis pertinent results: admission labs: cbc: wbc-9.4 rbc-5.07 hgb-12.5* hct-37.8* plt ct-164 diff: neuts-85.0* bands-0 lymphs-10.8* monos-3.8 eos-0.1 baso-0.3 coags: pt-14.0* inr(pt)-1.3 chem10: glucose-118* urean-20 creat-1.5* na-137 k-4.8 cl-96 hco3-28 calcium-8.7 phos-2.8 mg-1.8 fe studies: iron-21* caltibc-365 ferritn-54 trf-281 anemia studies: vitb12-496 folate-15.8 ret aut-1.3 fibrino-667* discharge labs: chem10: glucose-157* urean-13 creat-1.3* na-140 k-4.6 cl-106 hco3-23 calcium-8.8 phos-3.3 mg-2.2 cbc: wbc-4.8 rbc-4.03* hgb-10.2* hct-30.7* plt ct-232 coags: pt-18.8* ptt-115.7* inr(pt)-2.5 micro: blood cx x 2 - negative urine cx - negative studies: . ua at osh with 0-2 rbc, 0-2 wbc, creat 1.3 stool guaiac negative . ct abd/pelvis at osh with essentially complete absence of flow to the left kidney other than min flow to some portions of ant mid pole and lower pole, contrast in prox left renal aa with lack beyong that point suggests in situ thrombus or embolism; cysts in both kidneys, aorta diffusely calcified but nl in caliber, no aortic dissection, prostate enlarged, no lad, diverticuli, enlarged heart; otherwise nl . ekg at with afib, normal axis, no lvh, q in iii, no st/t wave abnormalities. echo (): left atrium - long axis dimension: *5.0 cm (nl <= 4.0 cm) left atrium - four chamber length: *7.5 cm (nl <= 5.2 cm) left ventricle - septal wall thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 0.8 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.2 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 45% (nl >=55%) aorta - valve level: 2.9 cm (nl <= 3.6 cm) aorta - ascending: *4.1 cm (nl <= 3.4 cm) aorta - arch: *3.1 cm (nl <= 3.0 cm) aortic valve - peak velocity: 1.2 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.1 m/sec mitral valve - e wave deceleration time: 181 msec tr gradient (+ ra = pasp): *22 to 30 mm hg (nl <= 25 mm hg) interpretation: findings: left atrium: moderate la enlargement. right atrium/interatrial septum: moderately dilated ra. left ventricle: normal lv cavity size. mildly depressed lvef. right ventricle: mildly dilated rv cavity. rv function depressed. aorta: normal aortic root diameter. aortic valve: mildly thickened aortic valve leaflets (3). mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild tr. pericardium: no pericardial effusion. conclusions: 1. the left atrium is moderately dilated. the right atrium is moderately dilated. 2. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. inferior hypokinesis is present. 3. the right ventricular cavity is mildly dilated. right ventricular systolic function appears depressed. 4. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. 5. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. cath : selective renal angiography demonstrated a large blood clot present within the left main renal artery extending into the peripheral branches. perfusion of the left renal parenchyma was significantly reduced. catheter-directed intrathrombus pulse spray infusion of 10 mg of tpa was performed via a multisidehole infusion catheter. the multisidehole infusion catheter positioned within the thrombosed was connected to a continuous drip of tpa at 1 mg per hour during the first hours of the infusion and 0.5 mg per hour continuous infusion of tpa thereafter. followup angiogram was planned to be performed in approximately 15 hours. cath : followup left renal angiography demonstrated significantly reduced amount of thrombus within the left renal artery. perfusion to the left renal parenchyma has significantly improved. areas of the left renal parenchyma in its lower lateral pole demonstrated persistent hypoperfusion. pulse spray catheter-directed infusion of 6 mg of tpa into the left renal artery was performed. the catheter was connected to the continuous infusion of tpa at 1 mg per hour for 4 hours. a followup left renal angiography will be then performed. follow-up 10/28: marked improvement of the left renal artery thrombus with only small residual filling defects, predominantly in the lower renal artery branch. overall, improved parenchymal perfusion compared with the prior study with still some areas of hypoperfusion in the interpolar region and lower pole. arterial duplex, right lower extremity, : no evidence of right inguinal pseudoaneurysm or av fistula. brief hospital course: 76yo man with afib, cad, htn, bph, w/ left renal artery occlusion, renal failure, s/p catheter guided tpa lysis to restore flow. . history is detailed below by problem: . 1) left renal artery occlusion: the patient was found to have a left renal artery thrombus cms distal to origin of aorta with occlusion of the tributaries extending into renal pelvis. renal arteriography was performed with injection of tpa x 3. adequate flow was restored and patient received heparin bridging to coumadin over 5 days. on the night following his tpa therapy, he had bleeding from a hematoma at the right groin catheter site. bleeding was stopped with pressure and the hematoma was monitored closely; it resolved throughout his hospital course. 2) renal insufficiency: mr. creatinine was 1.5 on admission, up from baseline of 1.0, believed secondary to renal artery occlusion. with restoration of arterial perfusion, his creatinine trended down to 1.3 at discharge. per the interventional radiology service, this would be analagous to slow recovery from atn and would expect for it to continue to fall. 3) anemia: pt has fe deficiency anemia. his hematocrit dropped from 37 on admission to 29 to a low of 27.1 on . guaiac exams were negative, and no active sources of bleeding were idenitified. his hematocrit stabilized in the low 30s prior to discharge. 4) hypertension: he was normotensive throughout his course, received lasix home med dose of 40 mg po qd and continued on verapamil sr 240 mg po q24h. was held given the ace inhibitor component. medications on admission: 180 mg po qd furosemide 40 mg po qd zocor 40 mg po qd coumadin 5 mg po qd discharge medications: 1. zocor 40 mg tablet sig: one (1) tablet po once a day. 2. verapamil 240 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). disp:*30 tablet sustained release(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 5. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 6. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*10 tablet(s)* refills:*0* 7. atrovent 18 mcg/actuation aerosol sig: one (1) inh inhalation twice a day. discharge disposition: home discharge diagnosis: renal artery embolus and renal infarct s/p thrombolysis discharge condition: good discharge instructions: please call your primary care doctor if you have fevers > 101.5, severe chest pain, shortness of breath, worsening back pain, blood in your urine or if your symptoms worsen. take your coumadin as prescribed and have your inr checked by your primary care doctor at clinic. followup instructions: follow up appointment w/ pcp on , , at 215pm provider: , md phone: date/time: 10:00 provider: scan phone: date/time: 2:00 Procedure: Injection or infusion of thrombolytic agent Injection or infusion of thrombolytic agent Aortography Arteriography of renal arteries Arteriography of renal arteries Arteriography of renal arteries Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Asthma, unspecified type, unspecified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status Long-term (current) use of anticoagulants Backache, unspecified Calculus of kidney Vascular disorders of kidney

allergies: patient recorded as having no known allergies to drugs attending: addendum: prior to her planned discharge, she had emesis on the evening of . we decided to keep her in-house due to the emesis. early the next morning, she had more emesis and melena and was found slumped over on the toilet, but still conscious. a trigger was called. she was hypotensive and tachycardic. she was transferred to the icu. her hct was 20. she received 4 units of prbc for her active bleed. her hct stablilize at 26. she had an acute upper gi bleed with a firm upper abdomen sugestive of a pseudocyst hemorrhage. a ct scan on revealed of large hematoma within previously seen large pancreatic pseudocyst, with extension of hematoma into the stomach. possible erosion via thinned lesser curvature wall. the next day on , celiac trunk angiogram demonstrates irregularity in the splenic artery , but no areas of active extravasation of contrast. she had successful embolization of the splenic artery with multiple coils until stasis was achieved. she toleraed this well and had no drop in hct. her diet was advanced slowly and she was able to tolerate regular food by . her abdomen was soft and nontender. vaccines: she received vaccines x 3 after her splenic embolization. she was transferred out to the floor after successful embolization. she then had an episode of hypotension and tachycardia and was again transferred to the sicu for closer monitoring. no new bleeding was identified and her hct was stable. a follow-up ct on showed: 1. interval splenic artery embolization. 2. no significant interval change in the pancreatic pseudocyst and the hematoma. the hematoma and the pseudocyst continues to protrude and impress on the posterior aspect of the stomach. 3. large amount of free fluid in the abdomen and pelvis with increase in the fluid collection in the left subphrenic space. a small amount of high attenuation dependent material is seen in the left flank and in the pelvis that could represent proteinaceous material versus small amount of blood. no large new hematoma is identified. she was transferred out to the floor after being treated with lopressor and fluid. her hct was again stable. she was started on cipro/flagyl and will continue on cipro for a uti. she will be discharged and have a repeat ct in 2 weeks. pertinent results: 05:46am blood wbc-15.2* rbc-2.58* hgb-6.3* hct-20.0* mcv-78* mch-24.4* mchc-31.4 rdw-16.4* plt ct-393 09:14am blood hct-28.4*# discharge disposition: home md Procedure: Other endoscopy of small intestine Percutaneous abdominal drainage Endoscopic sphincterotomy and papillotomy Endoscopic insertion of stent (tube) into bile duct Other endovascular procedures on other vessels Diagnoses: Esophageal reflux Unspecified essential hypertension Personal history of tobacco use Unspecified disorder of kidney and ureter Chronic pancreatitis Diverticulosis of colon (without mention of hemorrhage) Cyst and pseudocyst of pancreas Hemoperitoneum (nontraumatic) Hemorrhage, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp eus history of present illness: this is a 67 year old female, well known to the hpb service with a history of necrotizing gallstone pancreatits c/b pancreatic necrosis/pseudocyst. she also had arf/ards and a prolonged icu stay. she ultimately went to the or on for pseudocyst drainage, but this was not done because the pseudocyst was smaller in size. she had an ex lap., ioc, ccy, and gastrotmy. she recovered from this and has been followed by alphoso brown. she presents with 5 days of mid-epgastric pain, n/v x 1 day. she has intermittent loose stools and no report of fever/chills. past medical history: 1. htn 2. diverticulitis 3. etoh abuse 4. gerd 5. renal insufficiency 6. severe necrotizing gallstone pancreatitis 7. respiratory failure s/p tracheosotomy psh: open ccy, ioc, gastrotomy () social history: used to drink alcohol heavily until . smoked cigs/day, quit years ago. lives in with her daughter and son-in-law. does not work. came here from ~ . family history: nc physical exam: vs: 99.2, 98.4, 75, 160/82, 98% ra heent: mild scleral icterus, mm dry, no jvd, no bruits cv: reg s1, s2, no murmur pulm: decreased bs, r>l, clear abd: soft, minimally tender ext: no c/c/e, +2 bilat., warm rectal: pertinent results: ct peritineal drain excluding appendiceal 2:59 pm impression: successful ct-guided aspiration of a large subhepatic fluid collection revealing 400 ml of greeenish-brownish nonpurulent fluid. it was sent for various lab tests, which are currently pending. findings discussed with dr. by dr. at completion of the examination. . ercp biliary&pancreas by gi unit 8:51 am cholangiogram demonstrates a dilated biliary tree. narrowing is seen in the distal third of the cbd. the pancreatic duct is normal in course and caliber. final images demonstrate placement of a biliary stent. impression: dilated biliary tree with narrowing in the lower third of the common bile duct. . eus: a 5 cm x 8 cm cyst was noted in the region of the head of the pancreas. the cyst walls were thin and well-defined. the distance between the gastric wall and the cyst was 3 mm. moderate amount of debris was noted within the cyst. no intrinsic mass or septations were noted within the cyst. a 4 cm x 8 cm cyst was noted in the region of the pancreas body / tail . the cyst walls were thin and well-defined. the distance between the gastric wall and the cyst was 3 mm. moderate amount of debris was noted within the cyst. no intrinsic mass or septations were noted within the cyst. small amout of pancreatic parenchyma was noted in the pancreas body. the pancreatic duct was tortuous and measured 3 mm in diameter. impression: two large peri-pancreatic fluid collections with well-defined wall and moderate amount of debis were noted. . cta abd w&w/o c & recons 1:15 pm impression: 1. decreased size of large pancreatic pseudocyst replacing the neck, body, and medial tail of the pancreas. pancreatic parenchyma within the head and uncinate process abnormally enhances but there is normal enhancing pancreas within the tail. 2. persistent splenic vein occlusion with collateral formation. portal vein is narrowed at the portal venous confluence to only a few mm, but remains patent. the smv, imv, ivc, and renal veins are patent. 3. no pseudoaneurysm evident. normal arterial vasculature within the abdomen and pelvis. 4. decreased size slightly of subhepatic fluid collection. 5. decreased size of intrahepatic bile ducts with appropriate position of extrahepatic bile duct stent. . 09:30am blood wbc-12.7*# rbc-3.38* hgb-8.4* hct-26.1* mcv-77* mch-24.9* mchc-32.3 rdw-15.9* plt ct-406 09:30am blood glucose-151* urean-7 creat-1.0 na-136 k-3.4 cl-99 hco3-29 angap-11 09:55am blood alt-75* ast-19 alkphos-292* amylase-99 totbili-1.2 06:20am blood alt-346* ast-206* alkphos-639* amylase-125* totbili-8.0* 09:55am blood lipase-27 12:55am blood lipase-673* 09:30am blood calcium-8.5 phos-3.6 mg-1.7 brief hospital course: she was admitted on . she was npo and started on ivf. a ct was obtained on showed: 1. intrahepatic bile duct dilatation and common bile duct dilatation. 2. subhepatic collection, measuring almost 10 cm in diameter. 3. pancreatic pseudocyst, measuring 10.3 cm x 7.1 cm. 4. bilateral inguinal hernias. 5. free fluid in the pelvis. 6. significant inflammation in the peripancreatic area, consistent with the patient's history of necrotizing pancreatitis with low attenuation areas in pancreas which may represent necrosis. : ct aspiration: 400cc drawn off. studies/cytology sent/p. her abdomen softened and her pain improved somewhat. : ercp: stent placed (no drainage of pseudocyst)-no spincterotomy. her tbili began to fall from a high of 8.0 to 1.4 on . on , she was having crampy pain, loose stools, foul odor. she was started back on her creon, and the diarrhea resolved. : eus: two large peri-pancreatic fluid collections with well-defined wall and moderate amount of debis were noted. she had a baseline ct on and this showed decreased size of large pancreatic pseudocyst replacing the neck, body, and medial tail of the pancreas. pancreatic parenchyma within the head and uncinate process abnormally enhances but there is normal enhancing pancreas within the tail. persistent splenic vein occlusion with collateral formation. portal vein is narrowed at the portal venous confluence to only a few mm, but remains patent. the smv, imv, ivc, and renal veins are patent. no pseudoaneurysm evident. normal arterial vasculature within the abdomen and pelvis. decreased size slightly of subhepatic fluid collection. decreased size of intrahepatic bile ducts with appropriate position of extrahepatic bile duct stent. . she complained of luq pain on hd 8 and this seemed to resolve. overall, she felt better and her lft's, pancreatic enzymes decreased. she was tolerating a regular diet and her abdomen was softer and mildly tender. she was taking creon with meals. she will return to the or next week for drainage of the cyst. medications on admission: enalapril, atenolol, protonix, feso4, creon-20, ca/vitd, mvi discharge medications: 1. enalapril maleate 10 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. amylase-lipase-protease 33,200-10,000- 37,500 unit capsule, delayed release(e.c.) sig: eight (8) cap po tid w/meals (3 times a day with meals). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for 2 weeks. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: abdominal pain pancreatic pseudocysts discharge condition: good tolerating diet abdomen soft, nondistended. discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomitting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomitting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your skin, or the whites of your eyes become yellow. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. = = = = = ================================================================ please resume all regular home medications. . continue to ambulate several times per day. . contninue to eat and drink plenty of fluids. followup instructions: please follow-up with dr. on thursday, . call ( to schedule an appointment. you should have nothing to eat or drink 6 hours before surgery. provider: , md phone: date/time: 10:00 Procedure: Other endoscopy of small intestine Percutaneous abdominal drainage Endoscopic sphincterotomy and papillotomy Endoscopic insertion of stent (tube) into bile duct Other endovascular procedures on other vessels Diagnoses: Esophageal reflux Unspecified essential hypertension Personal history of tobacco use Unspecified disorder of kidney and ureter Chronic pancreatitis Diverticulosis of colon (without mention of hemorrhage) Cyst and pseudocyst of pancreas Hemoperitoneum (nontraumatic) Hemorrhage, unspecified

allergies: patient recorded as having no known allergies to drugs attending: addendum: she stayed in the hospital a few more days due to lack of bed availability. the only significant change was that she got another interval ct scan on of the abdomen and pelvis which was unchanged from her previous ct scan on . also on she pulled out her picc line and since then she has not recieved tpn. she is taking food by mouth but on we were going to do a calorie count to make sure that she was taking enough food by mouth. instead she is getting discharged today and will have to do the calorie count. she will also follow up with dr. in 3 weeks to discuss cholecystectomy. chief complaint: severe pancreatitis major surgical or invasive procedure: percutaneous tracheostomy picc line placement. history of present illness: this is a 66 year old female who woke up the morning of with severe periumbilical abdominal pain, nausea and vomitting. she vomitted 7 times, and reports no blood. her pain became epigastric in nature but did not radiate, stayed in midline of her abdomen. she reports normal bowel movements, no diarrhea and no ruq pain. she had been in her usoh before this time and denies any other concerns. she presented to that day, and her vitals there were significant for low-grade temp (100.4), blood pressure was stable in the 120s-140s, and persistently tachycardic in the 120s. her alt was 380, ast 514, t bili 1.1, alk phos 242, amylase 2960, lipase 3990, and she was admitted to icu with a presumed diagnosis of gallstone pancreatitis. while there, she initial received not enough ivf per their notes, and her creatinine increased from 1.6 on admit to 2.9 this am. she received 2l ns bolus and her uop remained low (15-30 cc/hr). her lfts decreased, amylase decreased, calcium was very low at 6.0. her creatinine increased to 2.6 this afternoon. her imaging studies demonstrated diffusely enlarged pancreas c/w pancreatitis, cholelithiasis, ascites. mrcp showed pancreatitis, normal bile and pancreatic ducts, diffusely swollen and edematous pancreas, peripancreatic soft tissue stranding, no pseudocyst or abscess. her gallbladder was distended. past medical history: 1. htn 2. diverticulitis 3. etoh abuse social history: used to drink alcohol heavily until . smoked cigs/day, quit years ago. lives in with her daughter and son-in-law. does not work. came here from 5 years ago. family history: nc physical exam: 100.5 141/80 127 31 95% 2l gen: awake, alert, oriented, interactive, nad heent: anicteric, mm very dry neck: supple lungs: decreased breath sounds with scattered bibasilar crackles cv: tachycardic, reg, no m/r/g abd: distended, tympanic, no bowel sounds, ttp over epigastrium without rebound ext: no edema, 2+ distal pulses, feet warm pertinent results: tte : conclusions: the left atrium is normal in size. ivc appears collapsed and underfilled. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). 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. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . ct abd : impression: 1. dilated small bowel to 3.1 cm consistent with ileus, although early small bowel obstruction cannot be excluded. 2. heterogeneous-appearing pancreas with significant amount of stranding consistent with severe pancreatitis. comment on necrosis cannot be made without iv contrast, but the appearance is highly supicious. 3. ascites. 4. subcutaneous soft tissue nodule in the posterior tissues of uncertain clinical significance. . ct abd with iv contrast : impression: severe pancreatitis with marked inflammatory change about the pancreas and into the mesentery. this follow-up ct with contrast confirms the prior impression that most of the pancreas is replaced by a necrotic fluid collection. other than increased ascites, the appearance is likely little changed. . ct abd: impression: interval stable appearance of severe pancreatitis with replacement of the neck and body of the pancreas with an inflammatory phlegmon. no residual enhancement of normal pancreas tissue is identified in these regions. pancreatic and head tissue do enhance. persistent ileus. chest (portable ap) 7:07 pm chest (portable ap) reason: et tube medical condition: 66 year old woman on vent, oxygern desat, r mainstem intubation s/p pulling tube out et tube reason for this examination: et tube indication: 66-year-old female on ventilator with o2 desaturation and right mainstem intubation, status post pulling et tube back. comparison: . ap semi-upright chest radiograph: after withdrawal of the endotracheal tube, the tube tip now appears 2 cm above the carina with the neck in flexed position. persistent small effusions versus atelectasis bilaterally. ct abdomen w/contrast 2:50 pm ct chest w/contrast; ct abdomen w/contrast reason: eval interval change in pancreas, r/o free air in pancreas, field of view: 48 contrast: optiray medical condition: 66 year old woman with necrotizing pancreatitis w/ persistant fever. pt. also w/ recent ileus. reason for this examination: eval interval change in pancreas, r/o free air in pancreas, eval ileus/obstruction contraindications for iv contrast: none. ct torso technique: multidetector ct through the chest, abdomen, and pelvis with oral and iv contrast. history: 66-year-old woman with necrotizing pancreatitis with persistent fever. evaluate interval change in pancreas and ileus, rule out sbo. comparison is made with prior study dated . chest ct: the aorta, pulmonary artery, and great vessels are unremarkable. there is mild cardiomegaly. there are no mediastinal or axillary lymph nodes. there is an endotracheal tube in place. there are bilateral subclavian iv lines with tips in the proximal ivc and left brachiocephalic vein. unchanged bibasilar segmental atelectasis and bilateral pleural effusions. abdomen ct: the liver, spleen, adrenal glands, and right kidney are unremarkable. there is an unchanged simple cyst in the left kidney. there is no hydronephrosis. the gallbladder is mildly dilated. there is no biliary duct dilatation. there is a feeding tube with distal tip within the fourth portion of the duodenum. there is an unchanged mild amount of ascites. unchanged multiple splenules adjacent to the spleen. there is an unchanged lack of-enhancement of the neck and body of the pancreas, which are replaced by a phlegmon/ fluid. redemonstration of enhancement within the head and tail of the pancreas. there is no evidence of gas or air within the pancreatic phlegmon. the mesenteric vessels are patent without evidence of pseudoaneurisms stable extensive peripancreatic stranding. the bowel loops are unremarkable. the aorta is normal in caliber. pelvic ct: the bladder is not distended with foley catheter in its interior. the uterus is unremarkable. multiple diverticula are seen in the sigmoid colon. there is free fluid within the pelvis. bone windows: there are no concerning bone lesions. impression: 1. interval resolution of the small dilatation. 2. stable appearance of severe pancreatitis with inflammatory phlegmon/fluid within the neck and body of the pancreas with retained enhancement of head and tail of pancreas and no new gas collections.chest (portable ap) 3:28 am chest (portable ap) reason: eval pleural effusions/ pneumonia medical condition: 66 year old woman w/ pancreatitis, eval for pleural effusions/ pneumonia reason for this examination: eval pleural effusions/ pneumonia ap chest, 3:49 a.m., history: pancreatitis, evaluate for effusions and pneumonia. impression: ap chest compared to through 28. moderate-sized bilateral pleural effusions layer posteriorly a function of supine positioning but have probably increased as well. moderate enlargement of the cardiac silhouette is stable. left lower lobe consolidation present since is probably atelectasis. lungs are free of consolidation elsewhere but mild interstitial edema is probably present. tip of the endotracheal tube is at the sternal notch, right subclavian line tip projects over the junction with the jugular vein while a left subclavian line ends at the origin of the svc. no pneumothorax. chest (portable ap) 10:28 am chest (portable ap) reason: dobhoff placemtn medical condition: 66 year old woman w/ pancreatitis, intubated, w/ fever, s/p r subcl cvl change, and pull-back of line now reason for this examination: dobhoff placemtn study: ap chest. history: 66-year-old woman with pancreatitis. the patient is intubated and has fevers. evaluate for placement of dobhoff tube. findings: there is a dobbhoff tube whose distal tip is not seen. however, there is at least one loop seen within the fundus of the stomach. there is a tracheostomy and a right-sided central venous catheter, which are unchanged in position. there is cardiomegaly. there is persistent left retrocardiac opacity and likely bilateral effusions. the effusion on the left side is improved. -intestinal tube placement (w/fluoro) 12:58 pm -intestinal tube placement reason: needs post-pyloric feeding tube medical condition: 66 year old woman with severe pancreatitis, needs post-pyloric feeding tube reason for this examination: needs post-pyloric feeding tube indication: patient with pancreatitis and need for post pyloric feeding tube. nasointestinal tube placement under fluoroscopy: a feeding tube was advanced via the right nostril under fluoroscopic visualization to the fourth portion of the duodenum with approximately 5 cc of water soluble contrast administered via the tube to confirm placement. no immediate complications were seen. impression: successful placement of 8 french feeding tube into fourth portion of the duodenum. ct abd w&w/o c 1:11 pm ct abd w&w/o c; ct pelvis w/contrast reason: please eval for pseudocyst, abscess, intrabdominal process. field of view: 36 contrast: optiray medical condition: 66 yo female with necrotizing pancreatitis. reason for this examination: please eval for pseudocyst, abscess, intrabdominal process. contraindications for iv contrast: none. indication: necrotizing pancreatitis. technique: after administration of oral contrast, mdct was used to obtain contiguous axial images through the abdomen, followed by iv contrast-enhanced images through the abdomen and pelvis. this study is compared to . ct abdomen before and after iv contrast: there is dependent atelectasis at both lung bases. small pleural effusions are seen. there is a nasogastric tube coursing below the diaphragm. the liver, gallbladder, spleen, adrenals, and right kidney are within normal limits. the left kidney has a 22 x 25 mm fluid density round lesion in its anterior aspect, representing a cyst. the nasogastric tube can be seen coursing into the fourth portion of the duodenal. the bowel loops appear normal, without evidence of obstruction or perforation. there is no free air. a 13 mm and a 7-mm round soft tissue densities near the anterior-inferior aspect of the spleen are identified, representing splenules. the pancreatic head, body, and tail are mostly replaced by a large hypoattenuating lesion, consisting of fluid density and some soft tissue, 42 mm in greatest ap diameter. there is residual enhancement of the pancreatic head and tail. the fluid collection extends into the mesentery, where there is extensive nodularity indicating likely fat necrosis. fluid is seen tracking along the anterior pararenal spaces into the right and left pericolic gutters; some surrounds the liver and the spleen and tracks along into the pelvis. celiac axis and sma are both well identified. however, the smv and splenic vein confluence are very attenuated, and the splenic vein is not well identified. some collateral vessels have appeared in the interim including short gastrics. the portal vein and hepatic veins appear patent. no saccular outpouchings to suggest pseudoaneurysms are seen, although this is not a cta study targeted to the abdominal vessels. there is no free air in the abdomen. ct pelvis with iv contrast: as described above, a small amount of free fluid is seen tracking along the pericolic gutters and into the pelvis. a foley is seen in the collapsed bladder and a rectal tube is seen. the uterus is small. bowel loops are normal, without evidence of an obstruction or perforation. no lymphadenopathy is identified. bone windows show no suspicious sclerotic or lytic lesions. impression: 1. essentailly unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. no new gas collections to suggest abscess are seen. there is extensive fat necrosis of the mesentery. 2. splenic vein thrombosis and interval development of left-sided varices. ct abdomen w/contrast 5:53 pm ct abdomen w/contrast; ct pelvis w/contrast reason: compare to ct abdomen on to make sure that there are no field of view: 36 contrast: optiray medical condition: 66 yo female with necrotizing pancreatitis. reason for this examination: compare to ct abdomen on to make sure that there are no new processes and that she is clear to go home. contraindications for iv contrast: none. 66-year-old female with necrotizing pancreatitis. comparison: . technique: mdct continuously acquired axial images of the abdomen were obtained without iv contrast followed by images of the abdomen and pelvis after 150 ml optiray iv contrast. ct of the abdomen without and with iv contrast: the visualized lung bases are clear. the liver, gallbladder, spleen, adrenal glands, and right kidney are unremarkable. again demonstrated is a 2 cm cyst of the left kidney. the stomach, duodenum, and intra-abdominal loops of large and small bowel are unremarkable without evidence of obstruction or perforation. there is no free intra-abdominal air. again demonstrated is replacement of most of the pancreatic head, body, and a portion of the tail with a large fluid density lesion, which has decreased in size compared to now with greatest ap diameter of 3 cm. there has also been improvement in adjacent mesenteric fat necrosis. there has been interval resolution of ascites previously seen to track along the pericolic gutters and pararenal spaces. no new fluid collection or abscess is identified. the splenic vein appears less compressed on today's study and opacifies with contrast without definite evidence of thrombosis. no saccular outpouchings to suggest pseudoaneurysms of the adjacent arteries are identified. please note this is not a ct angiogram study targeted for the abdominal vessels. the celiac trunk, sma, and opacify well. ct of the pelvis with iv contrast: the rectum, urinary bladder, uterus, adnexa, and pelvic loops of bowel are unremarkable. there is free passage of oral contrast through to the rectum. there is no free pelvic fluid or lymphadenopathy. bone windows: no suspicious lytic or sclerotic osseous lesions are identified. impression: interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. no new fluid collections or abscesses are identified. mesenteric fat necrosis also appears mildly improved. 09:12pm complete blood count white blood cells 10.7 k/ul 4.0 - 11.0 performed at west stat lab red blood cells 3.19* m/ul 4.2 - 5.4 performed at west stat lab hemoglobin 8.2* g/dl 12.0 - 16.0 performed at west stat lab hematocrit 25.3* % 36 - 48 performed at west stat lab mcv 79* fl 82 - 98 performed at west stat lab mch 25.8* pg 27 - 32 performed at west stat lab mchc 32.6 % 31 - 35 performed at west stat lab rdw 18.8* % 10.5 - 15.5 differential neutrophils 55.8 % 50 - 70 performed at west stat lab lymphocytes 31.6 % 18 - 42 performed at west stat lab monocytes 6.0 % 2 - 11 performed at west stat lab eosinophils 4.1* % 0 - 4 performed at west stat lab basophils 2.6* % 0 - 2 performed at west stat lab red cell morphology hypochromia 1+ anisocytosis 2+ microcytes 2+ basic coagulation (pt, ptt, plt, inr) platelet count 427 k/ul 150 - 440 performed at west stat lab 05:50am report comment: line: picc renal & glucose glucose 112* mg/dl 70 - 105 performed at west stat lab urea nitrogen 29* mg/dl 6 - 20 performed at west stat lab creatinine 0.8 mg/dl 0.4 - 1.1 performed at west stat lab sodium 138 meq/l 133 - 145 performed at west stat lab potassium 4.2 meq/l 3.3 - 5.1 performed at west stat lab chloride 106 meq/l 96 - 108 performed at west stat lab bicarbonate 24 meq/l 22 - 32 performed at west stat lab anion gap 12 meq/l 8 - 20 chemistry calcium, total 9.5 mg/dl 8.4 - 10.2 performed at west stat lab phosphate 3.7 mg/dl 2.7 - 4.5 performed at west stat lab magnesium 2.1 mg/dl 1.6 - 2.6 performed at west stat lab 07:08am chemistry albumin 3.5 g/dl 3.4 - 4.8 performed at west stat lab iron 68 ug/dl 30 - 160 hematologic iron binding capacity, total 218* ug/dl 260 - 470 ferritin 549* ng/ml 13 - 150 transferrin 168* mg/dl 200 - 360 ct abd w&w/o c 3:46 pm ct abd w&w/o c; ct pelvis w/contrast reason: please assess for progression/resolution of pancreatitis. as contrast: optiray medical condition: 66 yo female with necrotizing pancreatitis. reason for this examination: please assess for progression/resolution of pancreatitis. assess for fluid collections. please give po and iv contrast. contraindications for iv contrast: none. indication: 66-year-old woman with necrotizing pancreatitis. technique: contiguous axial ct images of the abdomen and pelvis were obtained with and without the administration of intravenous contrast , 145 cc of optiray. comparison: comparison is made with the prior ct studies, including the most recent prior ct study dated . findings: again note is made of a large intrapancreatic fluid collection located at the center of the pancreas, measuring 3.5 x 8.4 cm, not significantly changed compared to the prior study. surrounding pancreatic parenchyma is homogeneously enhanced. again note is made of mild fat stranding around the pancreas, in this patient with known pancreatitis. major branches of sma and smv are patent, however, part of the fluid collection abuts smv. the liver is unremarkable without evidence of focal liver lesion. gallbladder, pancreas, adrenal glands, and the visualized portion of large and small intestine are within normal limits. note is made of diverticulosis of the hepatic flexure. again note is made of left renal cyst, unchanged compared to the prior study. no hydronephrosis. no ascites. no significant lymphadenopathy. normal appendix is noted. pelvis: the visualized portion of large and small intestine are within normal limits. no ascites. no significant lymphadenopathy. the visualized portion of lung bases are clear with atelectasis. there is no suspicious lytic or blastic lesion in skeletal structures. impression: 1. persistent intrapancreatic fluid collection versus pseudocyst, not significantly changed compared to the prior study. homogeneous enhancement in surrounding pancreatic tissue, with mild fat stranding in peripancreatic fat. 2. left renal cyst. test name value units reference range 05:39am complete blood count white blood cells 8.7 k/ul 4.0 - 11.0 performed at west stat lab red blood cells 3.02* m/ul 4.2 - 5.4 performed at west stat lab hemoglobin 7.6* g/dl 12.0 - 16.0 performed at west stat lab hematocrit 24.3* % 36 - 48 performed at west stat lab mcv 81* fl 82 - 98 performed at west stat lab mch 25.0* pg 27 - 32 performed at west stat lab mchc 31.1 % 31 - 35 performed at west stat lab rdw 19.1* % 10.5 - 15.5 basic coagulation (pt, ptt, plt, inr) platelet count 340 k/ul 150 - 440 performed at west stat lab 05:30am renal & glucose glucose 132* mg/dl 70 - 105 performed at west stat lab urea nitrogen 37* mg/dl 6 - 20 performed at west stat lab creatinine 0.9 mg/dl 0.4 - 1.1 performed at west stat lab sodium 137 meq/l 133 - 145 performed at west stat lab potassium 4.3 meq/l 3.3 - 5.1 performed at west stat lab chloride 106 meq/l 96 - 108 performed at west stat lab bicarbonate 21* meq/l 22 - 32 performed at west stat lab anion gap 14 meq/l 8 - 20 chemistry albumin 3.6 g/dl 3.4 - 4.8 performed at west stat lab calcium, total 10.2 mg/dl 8.4 - 10.2 performed at west stat lab phosphate 5.3* mg/dl 2.7 - 4.5 performed at west stat lab magnesium 2.3 mg/dl 1.6 - 2.6 performed at west stat lab iron 75 ug/dl 30 - 160 hematologic iron binding capacity, total 221* ug/dl 260 - 470 ferritin 546* ng/ml 13 - 150 transferrin 170* mg/dl 200 - 360 brief hospital course: a/p: 66 year old female with htn, who presents with severe acute pancreatitis and admitted on . 1. pancreatitis: the patient initially presented as a transfer from with severe pancreatitis. the etiology was unclear thought likely secondary to alcohol, although the patient denies, rather than obstructing gallstone. there was no evidence of biliary ductal dilatation from ct scan at . the patient was hydrated aggressively with ivf on her first day after transfer. she was found to have high fevers and was tachycardic, she was started on empiric antibiotics for pancreatitis. a ct abdomen shows pancreatic necrosis. lft's were elevated with alt 380, ast 514, tbili 1.1, ap 242, amylase 2960, lipase 3990. an abdominal ct on showed stable appearance of severe pancreatitis with inflammatory phlegmon within the neck and body of the pancreas. per surgery, it is unlikely infected, at present, fevers may be due to cytokine release. a operation was deferred at present and can be readdressed later if persistent fevers occur without a source. a repeat ct on showed essentially unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. on a ct showed interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. no new fluid collections or abscesses are identified. 0n a ct of abdomen and pelvis is unchanged from . she will follow up with dr. in 3 weeks to discuss cholecystectomy and another ct scan to see any interval changes before her follow up with dr. . 2. abdominal distension/ileus: the patient had good stool output, and her abdominal exam was stable. on she was noted to have abundant bilious output from ng tube. there was concern for ileus vs obstruction on ct abdomen. a surgery consult was obtained and it was thought to be an ileus. the ngt was left in place and tpn started. next, a dobbhoff was placed and trophic tube feedings were started and she was tolerating them fine. a rectal tube was placed for liquid stool. there was an increased amount of fecal leakage around the tube. a new tube was inserted. she had no skin breakdown. after several days, the stool became more formed. she continued to have incontinence. she was seen by speech and swallow after her tracheostomy was downsized and passed a speech and swallow evaluation. , a picc was placed and tpn started after her dobbhoff was self d/c'd. she was started on a soft diet and calorie counts revealed that she was not taking in enough calories by mouth. she pulled out her picc line and the tpn has been stopped since then. we are going to see how she does with out tpn and see if she will take enough calories by mouth. we would recommend a calorie count. 3. fever/leukocytosis: upon admission, she was febrile to 101.3 with an increasing white count. she was on vanco and zosyn for pna. also must consider possible pancreatic infected pseudocyst. a cxr on showed bilateral pleural effusions, left lower lobe consolidation. 4. arf: creatinine improving from osh, likely volume depletion. her bun 38 and cr 2.3 on admission improved with adequate hydration. 5. tachycardia: likely related to volume depletion so would discontinue beta-blocker. other possibility is alcohol withdrawal as she would now be about 48 hours from last possible drink. tte shows hyperdynamic ef, impaired relaxation, tr grad 48. a echo showed an ef>75%. she was on metoprolol and enalapril for hr and bp control. 6. hypoxia/wheezing: 91% on ra with decreased breath sounds at bases and now audible expiratory wheezes. develop pulmonary edema as a result of her fluid resuscitation and require intubation. the patient had respiratory failure on and was intubated. likely multifactorial, pna and chf. chf in setting of aggressive volume repletion, interstitial infiltrates on cxr, bnp 1305. she was sedated for 22 days while intubated. the sedation was stopped. a tracheostomy was placed on . she had a prolonged intubation and was weaned off the ventilator on hd 30. she requires frequent suctioning for thick, white secretions. passy-muir valve was attempted with this patient, but she was unable to tolerate it. on , her tracheostomy was downsized from a 8 to 6 for a pmv trial. she was able to tolerate the passy-muir. a trigger was called for a drop in o2 saturation secondary to a mucus plug. she was suctioned and her inner cannula was removed. after suctioning, humidification, and nebulizers, her o2 sats came back up to 98%. she continued to do well with the trach and passy-muir and able to vocalize. 7. occupational therapy initially, the patient did not follow simple commands in creole or english. she was able to squeeze hand once when asked, but otherwise was not answering questions appropriately. she attempted verbalization x 3, but it was unintelligible secondary to trach. after the passy-muir, she was able to communicate with the staff and family members. she was highly motivated to return to her baseline. 8. physical therapy after the passy-muir was placed and tolerable, she seemed highly motivated to ambulate and increase daily activity. she improved from basic transfers to the chair, to being able to ambulate the halls short distances. she will continue to need physical therapy to improve functional activity, comm: with patient and son-in-law, . daughter, , home , son-in-law ce: medications on admission: vicodin prn atenolol 50 mg daily lisinopril 10 mg daily * medications on transfer: colace prn morphine 2 mg iv prn, last dose today at 9:45 pm metoprolol 5 mg iv q6htylenol 650 mg pr q6h, last at 5 pm today hydralazine 20 mg iv q4h prn last dose at 1:30 this am protonix 40 mg iv daily unasyn 3 gm q6h (day 1 = ) ns, 2l since 3 pm today discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 5. amylase-lipase-protease 468 mg tablet sig: two (2) tablet po tid (3 times a day). 6. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 7. enalapril maleate 10 mg tablet sig: one (1) tablet po daily (daily). 8. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). ml(s) 10. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 12. iron 325 (65) mg tablet sig: one (1) tablet po once a day. disp:*90 tablet(s)* refills:*2* 13. outpatient physical therapy physical therapy should see her every day to continue her rehabilition and ambulation. 14. respiratory therapy need to see her for trach care. 15. calorie count would recommend doing a calorie count to make sure that she is taking in enough calories by mouth. discharge disposition: extended care facility: - discharge diagnosis: severe pancreatitis with rising lfts discharge condition: good discharge instructions: you should contact your md if you experience: * increasing pain * fever (>101.5 f) or vomiting * inability to pass gas or stool * other symptoms concerning to you please take all your medications as ordered continue trach care - suction prn, humidification at all times, change trach sponge and ties prn, change inner cannula daily followup instructions: 1. cat scan on at 11:00am. it is in the sharpio building on the fourth floor. do not eat solid food three hours before your appointment. the office number is . 2. follow up appointment with dr. on at 8:30am. office phone number is . md Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Central venous pressure monitoring Transfusion of packed cells Diagnoses: Acidosis Anemia, unspecified Pneumonia due to other gram-negative bacteria Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Acute respiratory failure Other specified cardiac dysrhythmias Paralytic ileus Dehydration Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Acute pancreatitis Cyst and pseudocyst of pancreas Calculus of gallbladder without mention of cholecystitis, with obstruction Personal history of alcoholism Person awaiting admission to adequate facility elsewhere Unspecified intestinal malabsorption

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: severe pancreatitis major surgical or invasive procedure: picc placement percutaneous tracheostomy history of present illness: this is a 66 year old female who woke up the morning of with severe periumbilical abdominal pain, nausea and vomitting. she vomitted 7 times, and reports no blood. her pain became epigastric in nature but did not radiate, stayed in midline of her abdomen. she reports normal bowel movements, no diarrhea and no ruq pain. she had been in her usoh before this time and denies any other concerns. she presented to that day, and her vitals there were significant for low-grade temp (100.4), blood pressure was stable in the 120s-140s, and persistently tachycardic in the 120s. her alt was 380, ast 514, t bili 1.1, alk phos 242, amylase 2960, lipase 3990, and she was admitted to icu with a presumed diagnosis of gallstone pancreatitis. while there, she initial received not enough ivf per their notes, and her creatinine increased from 1.6 on admit to 2.9 this am. she received 2l ns bolus and her uop remained low (15-30 cc/hr). her lfts decreased, amylase decreased, calcium was very low at 6.0. her creatinine increased to 2.6 this afternoon. her imaging studies demonstrated diffusely enlarged pancreas c/w pancreatitis, cholelithiasis, ascites. mrcp showed pancreatitis, normal bile and pancreatic ducts, diffusely swollen and edematous pancreas, peripancreatic soft tissue stranding, no pseudocyst or abscess. her gallbladder was distended. past medical history: 1. htn 2. diverticulitis 3. etoh abuse social history: used to drink alcohol heavily until . smoked cigs/day, quit years ago. lives in with her daughter and son-in-law. does not work. came here from 5 years ago. family history: nc physical exam: 100.5 141/80 127 31 95% 2l gen: awake, alert, oriented, interactive, nad heent: anicteric, mm very dry neck: supple lungs: decreased breath sounds with scattered bibasilar crackles cv: tachycardic, reg, no m/r/g abd: distended, tympanic, no bowel sounds, ttp over epigastrium without rebound ext: no edema, 2+ distal pulses, feet warm pertinent results: tte : conclusions: the left atrium is normal in size. ivc appears collapsed and underfilled. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). 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. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . ct abd : impression: 1. dilated small bowel to 3.1 cm consistent with ileus, although early small bowel obstruction cannot be excluded. 2. heterogeneous-appearing pancreas with significant amount of stranding consistent with severe pancreatitis. comment on necrosis cannot be made without iv contrast, but the appearance is highly supicious. 3. ascites. 4. subcutaneous soft tissue nodule in the posterior tissues of uncertain clinical significance. . ct abd with iv contrast : impression: severe pancreatitis with marked inflammatory change about the pancreas and into the mesentery. this follow-up ct with contrast confirms the prior impression that most of the pancreas is replaced by a necrotic fluid collection. other than increased ascites, the appearance is likely little changed. . ct abd: impression: interval stable appearance of severe pancreatitis with replacement of the neck and body of the pancreas with an inflammatory phlegmon. no residual enhancement of normal pancreas tissue is identified in these regions. pancreatic and head tissue do enhance. persistent ileus. chest (portable ap) 7:07 pm chest (portable ap) reason: et tube medical condition: 66 year old woman on vent, oxygern desat, r mainstem intubation s/p pulling tube out et tube reason for this examination: et tube indication: 66-year-old female on ventilator with o2 desaturation and right mainstem intubation, status post pulling et tube back. comparison: . ap semi-upright chest radiograph: after withdrawal of the endotracheal tube, the tube tip now appears 2 cm above the carina with the neck in flexed position. persistent small effusions versus atelectasis bilaterally. ct abdomen w/contrast 2:50 pm ct chest w/contrast; ct abdomen w/contrast reason: eval interval change in pancreas, r/o free air in pancreas, field of view: 48 contrast: optiray medical condition: 66 year old woman with necrotizing pancreatitis w/ persistant fever. pt. also w/ recent ileus. reason for this examination: eval interval change in pancreas, r/o free air in pancreas, eval ileus/obstruction contraindications for iv contrast: none. ct torso technique: multidetector ct through the chest, abdomen, and pelvis with oral and iv contrast. history: 66-year-old woman with necrotizing pancreatitis with persistent fever. evaluate interval change in pancreas and ileus, rule out sbo. comparison is made with prior study dated . chest ct: the aorta, pulmonary artery, and great vessels are unremarkable. there is mild cardiomegaly. there are no mediastinal or axillary lymph nodes. there is an endotracheal tube in place. there are bilateral subclavian iv lines with tips in the proximal ivc and left brachiocephalic vein. unchanged bibasilar segmental atelectasis and bilateral pleural effusions. abdomen ct: the liver, spleen, adrenal glands, and right kidney are unremarkable. there is an unchanged simple cyst in the left kidney. there is no hydronephrosis. the gallbladder is mildly dilated. there is no biliary duct dilatation. there is a feeding tube with distal tip within the fourth portion of the duodenum. there is an unchanged mild amount of ascites. unchanged multiple splenules adjacent to the spleen. there is an unchanged lack of-enhancement of the neck and body of the pancreas, which are replaced by a phlegmon/ fluid. redemonstration of enhancement within the head and tail of the pancreas. there is no evidence of gas or air within the pancreatic phlegmon. the mesenteric vessels are patent without evidence of pseudoaneurisms stable extensive peripancreatic stranding. the bowel loops are unremarkable. the aorta is normal in caliber. pelvic ct: the bladder is not distended with foley catheter in its interior. the uterus is unremarkable. multiple diverticula are seen in the sigmoid colon. there is free fluid within the pelvis. bone windows: there are no concerning bone lesions. impression: 1. interval resolution of the small dilatation. 2. stable appearance of severe pancreatitis with inflammatory phlegmon/fluid within the neck and body of the pancreas with retained enhancement of head and tail of pancreas and no new gas collections.chest (portable ap) 3:28 am chest (portable ap) reason: eval pleural effusions/ pneumonia medical condition: 66 year old woman w/ pancreatitis, eval for pleural effusions/ pneumonia reason for this examination: eval pleural effusions/ pneumonia ap chest, 3:49 a.m., history: pancreatitis, evaluate for effusions and pneumonia. impression: ap chest compared to through 28. moderate-sized bilateral pleural effusions layer posteriorly a function of supine positioning but have probably increased as well. moderate enlargement of the cardiac silhouette is stable. left lower lobe consolidation present since is probably atelectasis. lungs are free of consolidation elsewhere but mild interstitial edema is probably present. tip of the endotracheal tube is at the sternal notch, right subclavian line tip projects over the junction with the jugular vein while a left subclavian line ends at the origin of the svc. no pneumothorax. chest (portable ap) 10:28 am chest (portable ap) reason: dobhoff placemtn medical condition: 66 year old woman w/ pancreatitis, intubated, w/ fever, s/p r subcl cvl change, and pull-back of line now reason for this examination: dobhoff placemtn study: ap chest. history: 66-year-old woman with pancreatitis. the patient is intubated and has fevers. evaluate for placement of dobhoff tube. findings: there is a dobbhoff tube whose distal tip is not seen. however, there is at least one loop seen within the fundus of the stomach. there is a tracheostomy and a right-sided central venous catheter, which are unchanged in position. there is cardiomegaly. there is persistent left retrocardiac opacity and likely bilateral effusions. the effusion on the left side is improved. -intestinal tube placement (w/fluoro) 12:58 pm -intestinal tube placement reason: needs post-pyloric feeding tube medical condition: 66 year old woman with severe pancreatitis, needs post-pyloric feeding tube reason for this examination: needs post-pyloric feeding tube indication: patient with pancreatitis and need for post pyloric feeding tube. nasointestinal tube placement under fluoroscopy: a feeding tube was advanced via the right nostril under fluoroscopic visualization to the fourth portion of the duodenum with approximately 5 cc of water soluble contrast administered via the tube to confirm placement. no immediate complications were seen. impression: successful placement of 8 french feeding tube into fourth portion of the duodenum. ct abd w&w/o c 1:11 pm ct abd w&w/o c; ct pelvis w/contrast reason: please eval for pseudocyst, abscess, intrabdominal process. field of view: 36 contrast: optiray medical condition: 66 yo female with necrotizing pancreatitis. reason for this examination: please eval for pseudocyst, abscess, intrabdominal process. contraindications for iv contrast: none. indication: necrotizing pancreatitis. technique: after administration of oral contrast, mdct was used to obtain contiguous axial images through the abdomen, followed by iv contrast-enhanced images through the abdomen and pelvis. this study is compared to . ct abdomen before and after iv contrast: there is dependent atelectasis at both lung bases. small pleural effusions are seen. there is a nasogastric tube coursing below the diaphragm. the liver, gallbladder, spleen, adrenals, and right kidney are within normal limits. the left kidney has a 22 x 25 mm fluid density round lesion in its anterior aspect, representing a cyst. the nasogastric tube can be seen coursing into the fourth portion of the duodenal. the bowel loops appear normal, without evidence of obstruction or perforation. there is no free air. a 13 mm and a 7-mm round soft tissue densities near the anterior-inferior aspect of the spleen are identified, representing splenules. the pancreatic head, body, and tail are mostly replaced by a large hypoattenuating lesion, consisting of fluid density and some soft tissue, 42 mm in greatest ap diameter. there is residual enhancement of the pancreatic head and tail. the fluid collection extends into the mesentery, where there is extensive nodularity indicating likely fat necrosis. fluid is seen tracking along the anterior pararenal spaces into the right and left pericolic gutters; some surrounds the liver and the spleen and tracks along into the pelvis. celiac axis and sma are both well identified. however, the smv and splenic vein confluence are very attenuated, and the splenic vein is not well identified. some collateral vessels have appeared in the interim including short gastrics. the portal vein and hepatic veins appear patent. no saccular outpouchings to suggest pseudoaneurysms are seen, although this is not a cta study targeted to the abdominal vessels. there is no free air in the abdomen. ct pelvis with iv contrast: as described above, a small amount of free fluid is seen tracking along the pericolic gutters and into the pelvis. a foley is seen in the collapsed bladder and a rectal tube is seen. the uterus is small. bowel loops are normal, without evidence of an obstruction or perforation. no lymphadenopathy is identified. bone windows show no suspicious sclerotic or lytic lesions. impression: 1. essentailly unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. no new gas collections to suggest abscess are seen. there is extensive fat necrosis of the mesentery. 2. splenic vein thrombosis and interval development of left-sided varices. ct abdomen w/contrast 5:53 pm ct abdomen w/contrast; ct pelvis w/contrast reason: compare to ct abdomen on to make sure that there are no field of view: 36 contrast: optiray medical condition: 66 yo female with necrotizing pancreatitis. reason for this examination: compare to ct abdomen on to make sure that there are no new processes and that she is clear to go home. contraindications for iv contrast: none. 66-year-old female with necrotizing pancreatitis. comparison: . technique: mdct continuously acquired axial images of the abdomen were obtained without iv contrast followed by images of the abdomen and pelvis after 150 ml optiray iv contrast. ct of the abdomen without and with iv contrast: the visualized lung bases are clear. the liver, gallbladder, spleen, adrenal glands, and right kidney are unremarkable. again demonstrated is a 2 cm cyst of the left kidney. the stomach, duodenum, and intra-abdominal loops of large and small bowel are unremarkable without evidence of obstruction or perforation. there is no free intra-abdominal air. again demonstrated is replacement of most of the pancreatic head, body, and a portion of the tail with a large fluid density lesion, which has decreased in size compared to now with greatest ap diameter of 3 cm. there has also been improvement in adjacent mesenteric fat necrosis. there has been interval resolution of ascites previously seen to track along the pericolic gutters and pararenal spaces. no new fluid collection or abscess is identified. the splenic vein appears less compressed on today's study and opacifies with contrast without definite evidence of thrombosis. no saccular outpouchings to suggest pseudoaneurysms of the adjacent arteries are identified. please note this is not a ct angiogram study targeted for the abdominal vessels. the celiac trunk, sma, and opacify well. ct of the pelvis with iv contrast: the rectum, urinary bladder, uterus, adnexa, and pelvic loops of bowel are unremarkable. there is free passage of oral contrast through to the rectum. there is no free pelvic fluid or lymphadenopathy. bone windows: no suspicious lytic or sclerotic osseous lesions are identified. impression: interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. no new fluid collections or abscesses are identified. mesenteric fat necrosis also appears mildly improved. 09:12pm complete blood count white blood cells 10.7 k/ul 4.0 - 11.0 performed at west stat lab red blood cells 3.19* m/ul 4.2 - 5.4 performed at west stat lab hemoglobin 8.2* g/dl 12.0 - 16.0 performed at west stat lab hematocrit 25.3* % 36 - 48 performed at west stat lab mcv 79* fl 82 - 98 performed at west stat lab mch 25.8* pg 27 - 32 performed at west stat lab mchc 32.6 % 31 - 35 performed at west stat lab rdw 18.8* % 10.5 - 15.5 differential neutrophils 55.8 % 50 - 70 performed at west stat lab lymphocytes 31.6 % 18 - 42 performed at west stat lab monocytes 6.0 % 2 - 11 performed at west stat lab eosinophils 4.1* % 0 - 4 performed at west stat lab basophils 2.6* % 0 - 2 performed at west stat lab red cell morphology hypochromia 1+ anisocytosis 2+ microcytes 2+ basic coagulation (pt, ptt, plt, inr) platelet count 427 k/ul 150 - 440 performed at west stat lab 05:50am report comment: line: picc renal & glucose glucose 112* mg/dl 70 - 105 performed at west stat lab urea nitrogen 29* mg/dl 6 - 20 performed at west stat lab creatinine 0.8 mg/dl 0.4 - 1.1 performed at west stat lab sodium 138 meq/l 133 - 145 performed at west stat lab potassium 4.2 meq/l 3.3 - 5.1 performed at west stat lab chloride 106 meq/l 96 - 108 performed at west stat lab bicarbonate 24 meq/l 22 - 32 performed at west stat lab anion gap 12 meq/l 8 - 20 chemistry calcium, total 9.5 mg/dl 8.4 - 10.2 performed at west stat lab phosphate 3.7 mg/dl 2.7 - 4.5 performed at west stat lab magnesium 2.1 mg/dl 1.6 - 2.6 performed at west stat lab 07:08am chemistry albumin 3.5 g/dl 3.4 - 4.8 performed at west stat lab iron 68 ug/dl 30 - 160 hematologic iron binding capacity, total 218* ug/dl 260 - 470 ferritin 549* ng/ml 13 - 150 transferrin 168* mg/dl 200 - 360 brief hospital course: a/p: 66 year old female with htn, who presents with severe acute pancreatitis and admitted on . 1. pancreatitis: the patient initially presented as a transfer from with severe pancreatitis. the etiology was unclear thought likely secondary to alcohol, although the patient denies, rather than obstructing gallstone. there was no evidence of biliary ductal dilatation from ct scan at . the patient was hydrated aggressively with ivf on her first day after transfer. she was found to have high fevers and was tachycardic, she was started on empiric antibiotics for pancreatitis. a ct abdomen shows pancreatic necrosis. lft's were elevated with alt 380, ast 514, tbili 1.1, ap 242, amylase 2960, lipase 3990. an abdominal ct on showed stable appearance of severe pancreatitis with inflammatory phlegmon within the neck and body of the pancreas. per surgery, it is unlikely infected, at present, fevers may be due to cytokine release. a operation was deferred at present and can be readdressed later if persistent fevers occur without a source. a repeat ct on showed essentially unchanged appearance of severe pancreatitis with large phlegmonous/fluid collection within the neck and body of the pancreas. on a ct showed interval improvement in pancreatitis with decrease in size of large phlegmonous/fluid collection of the neck and body of the pancreas. no new fluid collections or abscesses are identified. 2. abdominal distension/ileus: the patient had good stool output, and her abdominal exam was stable. on she was noted to have abundant bilious output from ng tube. there was concern for ileus vs obstruction on ct abdomen. a surgery consult was obtained and it was thought to be an ileus. the ngt was left in place and tpn started. next, a dobbhoff was placed and trophic tube feedings were started and she was tolerating them fine. a rectal tube was placed for liquid stool. there was an increased amount of fecal leakage around the tube. a new tube was inserted. she had no skin breakdown. after several days, the stool became more formed. she continued to have incontinence. she was seen by speech and swallow after her tracheostomy was downsized and passed a speech and swallow evaluation. , a picc was placed and tpn started after her dobbhoff was self d/c'd. she was started on a soft diet and calorie counts revealed that she was not taking in enough calories by mouth. tpn continues at this time. 3. fever/leukocytosis: upon admission, she was febrile to 101.3 with an increasing white count. she was on vanco and zosyn for pna. also must consider possible pancreatic infected pseudocyst. a cxr on showed bilateral pleural effusions, left lower lobe consolidation. 4. arf: creatinine improving from osh, likely volume depletion. her bun 38 and cr 2.3 on admission improved with adequate hydration. 5. tachycardia: likely related to volume depletion so would discontinue beta-blocker. other possibility is alcohol withdrawal as she would now be about 48 hours from last possible drink. tte shows hyperdynamic ef, impaired relaxation, tr grad 48. a echo showed an ef>75%. she was on metoprolol and enalapril for hr and bp control. 6. hypoxia/wheezing: 91% on ra with decreased breath sounds at bases and now audible expiratory wheezes. develop pulmonary edema as a result of her fluid resuscitation and require intubation. the patient had respiratory failure on and was intubated. likely multifactorial, pna and chf. chf in setting of aggressive volume repletion, interstitial infiltrates on cxr, bnp 1305. she was sedated for 22 days while intubated. the sedation was stopped. a tracheostomy was placed on . she had a prolonged intubation and was weaned off the ventilator on hd 30. she requires frequent suctioning for thick, white secretions. passy-muir valve was attempted with this patient, but she was unable to tolerate it. on , her tracheostomy was downsized from a 8 to 6 for a pmv trial. she was able to tolerate the passy-muir. a trigger was called for a drop in o2 saturation secondary to a mucus plug. she was suctioned and her inner cannula was removed. after suctioning, humidification, and nebulizers, her o2 sats came back up to 98%. she continued to do well with the trach and passy-muir and able to vocalize. 7. occupational therapy initially, the patient did not follow simple commands in creole or english. she was able to squeeze hand once when asked, but otherwise was not answering questions appropriately. she attempted verbalization x 3, but it was unintelligible secondary to trach. after the passy-muir, she was able to communicate with the staff and family members. she was highly motivated to return to her baseline. 8. physical therapy after the passy-muir was placed and tolerable, she seemed highly motivated to ambulate and increase daily activity. she improved from basic transfers to the chair, to being able to ambulate the halls short distances. she will continue to need physical therapy to improve functional activity, comm: with patient and son-in-law, . daughter, , home , son-in-law ce: medications on admission: medications at home: vicodin prn atenolol 50 mg daily lisinopril 10 mg daily * medications on transfer: colace prn morphine 2 mg iv prn, last dose today at 9:45 pm metoprolol 5 mg iv q6htylenol 650 mg pr q6h, last at 5 pm today hydralazine 20 mg iv q4h prn last dose at 1:30 this am protonix 40 mg iv daily unasyn 3 gm q6h (day 1 = ) ns, 2l since 3 pm today discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 5. amylase-lipase-protease 468 mg tablet sig: two (2) tablet po tid (3 times a day). 6. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 7. enalapril maleate 10 mg tablet sig: one (1) tablet po daily (daily). 8. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). ml(s) 10. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 12. iron 325 (65) mg tablet sig: one (1) tablet po once a day. disp:*90 tablet(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: epigastric pain pancreatitis with rising lft's discharge condition: good discharge instructions: * increasing pain * fever (>101.5 f) or vomiting * inability to pass gas or stool * other symptoms concerning to you please take all your medications as ordered continue trach care - suction prn, humidification at all times, change trach sponge and ties prn, change inner cannula daily followup instructions: please follow-up with dr. in 2 weeks. call ( for an appointment. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Central venous pressure monitoring Transfusion of packed cells Diagnoses: Acidosis Anemia, unspecified Pneumonia due to other gram-negative bacteria Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Acute respiratory failure Other specified cardiac dysrhythmias Paralytic ileus Dehydration Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Acute pancreatitis Cyst and pseudocyst of pancreas Calculus of gallbladder without mention of cholecystitis, with obstruction Personal history of alcoholism Person awaiting admission to adequate facility elsewhere Unspecified intestinal malabsorption

briefly, this is a 66 yr old creole speaking female admitted from an osh c pancreatitis for care. the pt presented on c c/o epigastric pain, n/v and was found to have markedly elevated amylase & lipase, elevated lft's and rising cr values despite five liter hydration. us found enlarged gall bladder c stones but no dialated ducts of wall thickening. the pt reports no allergies @ bs and is a full code. ros: ms: pt initially cooperative and polite c son in law and grand dtr @ bs. unfortunately the pt gradually became beligerant over the coarse of the shift c pt disbelieving that she was at the hosp and did not feel that the hospital care delivered was important or necessary. in the coarse of the shift the pt has d/c'ed an ngt, nasal cannulae on several occasions, piv, nbp cuff, venodyne boots and was openly hostile to care givers (, rn's, co-workers). the pt was med c 0.5mg then another 1.5mg iv ativan which has now calmed the pt and hence is allowing the aggressive deliverly of medically necessary fluids and electrolyte repletion. the pts son in law was contact and is expected to visit soon to assist c the pts normal cognitive/coping fxn. soft wrist restraints in place to protect pt/iv's. bed alarm activated and bs sitter also @ bs for pt safety. pt c sketchy report on etoh intake and the possibility of dt's has not been ruled out. pt freq re-oriented to person/time/place/rationale of care to assist nl cognition. 2mg iv haldol also provided while pt was openly beligerant c no discernable affect. of note, the pt received 2mg iv morphine so4 @ 00:30 for epigastric pain c resolution of pain all shift. as noted above, the pt primary language is creole though she does speak broken english and can understand spoken english. the pts family reports that the pt is hoh. cv: hemodynamically stable, tachycardic (120-150) and afebrile. tachycardia attributed to dehydration, pain and anxiety. pan labs drawn/sent for analysis @ 02:30 c a serum calcium value of 5.1, magnesium value of 1.5, now repleting c 4gm calcium gluconate & 4gm magnesium sulfate respectively. the pt was also bolused c one liter lr and will start a sodium bicarb gtt shortly per team request and probable pre-renal arf (am bun/cr values of 38/2.3 respectively). pt c poor peripheral access, currently has a 20# piv in l wrist and an 18# piv in rue ac. pt making approx 20-30ml urine per hour. as noted above, the pt removed her venodyne boots which were providing dvt prophylaxis. resp: pt c nl sats on 4lnco2, rr in the 20-30 range and mild sob when aggitated/un-cooperative/removing nc. ls are fairly clear c no overt rhonchi or wheezing appreciated. gi: the pt is npo. npo status explained to pt. pt reports feelings of thirst. no bm thus far overnight. soc: pt arrived from osh c son-in-law and grand-dtr both of whom were pleasant and cooperative. family and pt both kept up to date c poc/pt status. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Central venous pressure monitoring Transfusion of packed cells Diagnoses: Acidosis Anemia, unspecified Pneumonia due to other gram-negative bacteria Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Acute respiratory failure Other specified cardiac dysrhythmias Paralytic ileus Dehydration Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Acute pancreatitis Cyst and pseudocyst of pancreas Calculus of gallbladder without mention of cholecystitis, with obstruction Personal history of alcoholism Person awaiting admission to adequate facility elsewhere Unspecified intestinal malabsorption

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gallstone pancreatitis abdominal pain major surgical or invasive procedure: exploratory laparotomy, cholecystectomy, gastrostomy history of present illness: this 67-year-old woman admitted for who has known gallstone pancreatitis. she had ards and had a significant necrotizing pancreatitis at her last admission. we were able to ride her through her pancreatic problem, without the need for an operation at that point in time, and we were able to ultimately get her out of the hospital after she recovered from her pulmonary failure problem. she was markedly debilitated and went to a rehab facility for many weeks. in the meantime, i have seen her, and i followed her course from the clinic. she has had generally strong progression, but has been unable to gain weight, and does not eat more than soft solids, with limited amounts. she claims of abdominal pain when she eats, as well as regurgitation. she, in general, has a failure to thrive and general unwellness. we also knew that we would have to address her gallbladder and its stone disease at some point in time. past medical history: 1. htn 2. diverticulitis 3. etoh abuse 4. gerd 5. renal insufficiency 6. necrotizing pancreatitis 7. respiratory failure s/p tracheosotomy social history: used to drink alcohol heavily until . smoked cigs/day, quit years ago. lives in with her daughter and son-in-law. does not work. came here from 5 years ago. family history: nc physical exam: post-op pe vs: 98.4, 82, 146/76, rr 15, 100% o2-intubated. heent: intubated, l and r ij lines inplace cv: rrr, normal s1, s2, no m/r/g lungs: cta bilat. abd: soft, mildly distended, no tympany, diffuse tenderness wound: dressing with serosanguinous drainage ext: dp 2+ bilat., no edema neuro: awake, alert and oriented pertinent results: us intr-op 60 mins 10:20 am us intr-op 60 mins reason: pseudocyst indication: patient with complicated pancreatitis and pseudocyst formation. for possible surgical cystgastrostomy. technique: the patient has already had a laparotomy and a gastrostomy performed. using sterile technique, intraoperative son was performed using transgastric approach and also from an intragastric position. report: findings. a small amount of anterior fluid measuring about 10 ml was seen. corresponding to the pancreas' position, there is an ill-defined, enlarged isoechogenic material likely representing a phlegmon. no discrete fluid collection is seen elsewhere. using son visualization, the small anterior cyst was aspirated. further passes were obtained from the phlegmon also under ultrasound guidance. conclusion: no evidence of large pseudocyst corresponding to recent ct images cholangiogram,in or w films 9:54 am cholangiogram,in or w films reason: cholangiogram indication: intraoperative cholangiogram. findings: eight spot films were provided from intraoperative fluoroscopic guidance for cholangiogram. images demonstrate filling of normal appearing biliary tree without filling defects or stricture and free passage of ontrast into the duodenum with some reflux into distal pancreatic duct. sponge markers overly the right upper abdomen. pathology examination name birthdate age sex pathology # , 67 female report to: dr. gross description by: dr. /dif specimen submitted: gallbladder (1). procedure date tissue received report date diagnosed by dr. /tk?????? diagnosis: gallbladder: cholesterolosis. no inflammation. cardiology report ecg study date of 9:51:38 pm sinus tachycardia with ventricular premature beats. possible anterior myocardial infarction - age undetermined. lateral st-t changes are non-specific. compared to the previous tracing of ventricular arrhythmia is seen and st-t wave abnormalities are more marked. read by: , a. intervals axes rate pr qrs qt/qtc p qrs t 106 146 86 328/390 38 -14 99 06:05am blood wbc-10.9 rbc-3.31* hgb-8.8* hct-26.8* mcv-81* mch-26.7* mchc-32.9 rdw-16.6* plt ct-194 02:20pm blood glucose-121* urean-5* creat-0.8 na-138 k-3.8 cl-102 hco3-29 angap-11 02:20pm blood calcium-8.1* phos-1.8* mg-1.5* brief hospital course: she was admitted on for a planned pseudocyst gastrectomy, but there was no evidence of a cyst intraoperatively. she underwent a ccy and went to the sicu intubated. pain: she had an epidural that was providing good pain relief. she was changed to po tylenol with codeine once her diet was advanced. gi: she was npo, with and ngt and iv fluids. the ngt remained for 3 days. she had return of bowel function and her diet was advanced. resp: she was successfully extubated later the evening of her surgery. she did not have any respiratory issues. cv: regular rate and rhythm. she was getting metoporol iv and then switched to po atenolol and lisinopril once tolerating po meds. renal: her bun and creatinine were monitored closely. she received a fluid bolus for low urine output the night of her surgery. her bun and creatinine were stable and wnl. wound: she had an abdominal incision with staples. the incision was clean, dry, and intact and there was no drainage. the staples will be removed at her follow-up appointment. medications on admission: lisinopril, atenolol, protonix, feso4, pancrease discharge medications: 1. atenolol 25 mg tablet sig: three (3) 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:*qs tablet, delayed release (e.c.)(s)* refills:*2* 3. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for 1 months. disp:*35 tablet(s)* refills:*0* 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 5. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*qs tablet(s)* refills:*2* 6. pancrease 20,000-4,500- 25,000 unit capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po three times a day: with meals. disp:*90 capsule, delayed release(e.c.)(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: gallstone pancreatitis pancreatic pseudocyst discharge condition: stable discharge instructions: return to er if: * fevers/chills * nausea/vomiting * inability to take medication * increased abdominal pain * decreased urine output * any bleeding * redness/swelling/drainage from wound you may shower and wash incision with soap and water. pat dry. no heavy lifting >10 lbs for 4 weeks. continue to walk several times per day. followup instructions: please follow-up with dr. in weeks. call ( to schedule an appointment. Procedure: Drainage of pancreatic cyst by catheter Insertion of other (naso-)gastric tube Cholecystectomy Control of hemorrhage, not otherwise specified Intraoperative cholangiogram Other open umbilical herniorrhaphy Transfusion of packed cells Gastrotomy Diagnoses: Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Other specified cardiac dysrhythmias Alkalosis Hemangioma of other sites Dehydration Chronic pancreatitis Cyst and pseudocyst of pancreas Adult failure to thrive Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction Umbilical hernia without mention of obstruction or gangrene

allergies: bactrim, promethazine meds: ativan, protonix, premarin, prozac. n: pt awake/alert ox3. neurologically intact with perrl 3mm/brisk and equal strengths x4. ventriculostomy drain placed at bedside and opening icp 18. has ranged from 0-18. csf bld tinged. leveled at 20cm above tragus. following angio, neuro status unchanged. c/o pain in throat from ett. otherwise stable. loaded with dilantin. decadron q6 cv: initially bp labile requiring 1-3mcg/kg snp which was changed to labetolol and now pt off antihypertensives and requiring fld bolus x2 d/t bp 90's/50s. warm extremities with palp pp. rt fem sheath site intact without hematoma. mgso4 repleted. hct 26/pt-inr 13/1.1 need to maintain sbp>100 and <130 per dr . r: lungs clear throughout. intubated in angio and remains intubated awaiting or. abg stable. sxn'd for no sec. settings changed to cpap. gi: npo. ngt placed for meds. abd soft/bs+. gu; brisk clear yellow u/o. id: afebrile. endo: glucose elevated 193/riss. soc: pt's daughter last evening and will plan on coming in this morning. pt concerned about her cat being fed in her apt. Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Clipping of aneurysm Arteriography of cerebral arteries Arteriography of cerebral arteries Transfusion of packed cells Ventricular shunt to extracranial site NEC Diagnoses: Esophageal reflux Unspecified essential hypertension Subarachnoid hemorrhage Personal history of venous thrombosis and embolism Other alteration of consciousness Other nonspecific abnormal serum enzyme levels

history of present illness: the patient is a 60-year-old female, who was in her usual state of health, who developed severe headache in the afternoon, laid down on the couch, awoke, stood up and got a severe occipital headache and became suddenly nauseated. she has a history of migraines being treated through the emergency room with a protocol of demerol and phenergan. she received this once or twice a month in the emergency room. she states this headache was much worse than usual migraine. she took an aspirin, and she called ems. past medical history: migraines x 40 years, cervicalgia, myofascial pain syndrome, hypertension, gerd, history of a pe and dvt, status post cholecystectomy, hysterectomy, vein stripping of the right leg, pilonidal cyst, laminectomy. the patient was admitted through the emergency room. cta of the head showed suprasellar cistern subarachnoid hemorrhage which extends into the sulci bilaterally with no shift of normally midline structures. cta shows a right aca aneurysm. allergies: bactrim. medications on admission: 1. prozac 10 once daily. 2. premarin 0.9 once daily. 3. ativan 1 . 4. protonix 40 once daily. physical exam: temp 97.9, heart rate 102, bp 153/71, respiratory rate 16, sats 97 percent. heent: pupils equal, round and reactive to light, 2 down to 1.5. eoms full. neck: pain with movement. pulmonary: lungs clear bilaterally. cardiovascular: regular rate and rhythm. abdomen: soft, nontender, positive bowel sounds. extremities: no edema. neurologically: awake, alert and oriented x 3. prefers eyes closed. complaining of photophobia. pupils equal, round and reactive to light. eoms full. visual fields intact. strength is in all muscle groups. her reflexes are 2 plus throughout. her toes are mute. hospital course: the patient is admitted to the neurosurgical service to the icu for close neurologic observation. on , diagnostic angio showed a right a1, a2 bifurcation aneurysm which could not be coiled. the patient was taken to the icu post procedure and remained neurologically stable, was intubated prior to the procedure, awakened easily, following commands, wiggling toes. femoral a-line was in place. positive pedal pulses. blood pressure was kept at 110-130 range. the patient was on close neurologic observation in the icu. she was taken to the or on for craniotomy for clipping of a right acom aneurysm. there were no intraop complications. postop, the patient was intubated with minimal sedation, nodding yes and no appropriately to questions, following commands. pupils equal, round and reactive to light. eoms full. grasps were . the patient was able to wiggle her toes. the patient had a vent drain placed in the or which was leveled at the tragus. her vital signs were stable. the patient had lower extremity dopplers done on that showed no evidence of dvt. her iv fluids decreased to 50 cc/h. her cvp was kept . she was neurologically stable, following commands, awake, alert and attentive on postop day 1. the patient was taken back to angio on . angio showed no vasospasm, and no residual aneurysm. kub was done. the patient was transfused with 1 unit of packed red blood cells for a crit of 26.6, and repeat post-transfusion 30.4. the patient had a jp drain in place which was removed. the vent drain continued to drain csf and was leveled at 10 cm above the tragus. on , the patient was alert, attentive, opening eyes, moderately confused, following commands, no drift. goal cvp again . iv fluids kept at 120/h. drain was leveled at 12 cm above the tragus. she had a repeat head ct that showed a right head of the caudate infarct without any other changes. the patient's neurologic status remained stable. on , she spiked to 101.5. she was pancultured. csf showed 21 red cells and 7,250 white cells. on , the patient had a cta which was negative for vasospasm. the patient was out-of-bed to the chair. decadron was weaning. she was awake, alert and oriented x 3. pupils equal, round and reactive to light. eoms full. no nystagmus. she had no drift. her grasps were full. ips were full. on , the vent drain was removed, and the patient had a lumbar drain placed without complication. patient awake and alert, but only oriented to herself, which has been her baseline since admission. following commands x 4 with good strength, no drift, face symmetric. her dressing was clean, dry and intact. her lumbar drainage was down to 5 cc q 2 h. the patient was seen by physical therapy, occupational therapy and felt to require short rehab stay. on , the patient complained of a headache. she had no drift. repetition intact. face was symmetric. moving all four extremities. ips were full. eoms full. the patient had an lp. opening pressure was 15, closing pressure 6. csf was tea-colored. the patient was seen by gi service for a rising amylase and lipase which were asymptomatic. they recommended following daily lfts, an mrcp to evaluate biliary tree, as well as to reevaluate cystic pancreatic lesion. she was transferred to step down unit on . the patient had repeat lower extremity dopplers done on which were negative for dvt. the patient's neurologic status remained stable, although the patient continued to be confused. she was awake, alert and oriented x , moving all extremities with good strength, following commands. medications on discharge: 1. dilantin 100 mg po tid. 2. lansoprazole 30 po once daily. 3. miconazole powder to groin topically . 4. heparin 5,000 units subcu tid. 5. colace 100 mg po bid. 6. estrogen conjugated 0.9 mg po once daily. 7. fluoxetine 10 mg po once daily. 8. ibuprofen 400 mg po q 8 prn. condition on discharge: stable. follow up: she will follow-up with dr. in 2 weeks. , Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Clipping of aneurysm Arteriography of cerebral arteries Arteriography of cerebral arteries Transfusion of packed cells Ventricular shunt to extracranial site NEC Diagnoses: Esophageal reflux Unspecified essential hypertension Subarachnoid hemorrhage Personal history of venous thrombosis and embolism Other alteration of consciousness Other nonspecific abnormal serum enzyme levels

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoglycemia, change in mental status major surgical or invasive procedure: none history of present illness: 73 y.o. female found unresponsive in her home by her daughter who lives below patient and states that she heard a "thud" and went up to find mother unresponsive. ems called and reports that pt had fs of 41 and was posturing on route to osh. pt intubated and taken to osh where she was given lorazepam and loaded with dilantin. head ct showed no evidence of acute bleed. cxr negative. pt then transfered to for further work up. per daughter, pt has been compliant with insulin. in , pt paralysed and comatose. turned off propofol for neuro eval. pt started on insulin gtt. lp was negative past medical history: dm type 2, prior admits for dka. hx of hypoglycemis sz's. benign positional vertigo htm hypothyroid social history: no etoh no drugs quit tob 22 yrs ago lives on floor above daughter family history: dm2 breast ca physical exam: t 96, bp 145/60, p 64, r 14, ac 600/14/60% sat100% gen: elderly african american female, obese, obtunded, intubated heent: pupils sluggishly reactive to light, equal, mmm cv: nl s1/s2, rrr, no m/r/g pulmo: ctab abd: bs+, nt, nd ext: no c/c/e, warm pertinent results: 01:27am vit b12-262 01:27am calcium-8.9 phosphate-2.9 magnesium-1.7 01:27am lipase-24 01:27am alt(sgpt)-14 ast(sgot)-25 alk phos-97 tot bili-0.3 01:27am glucose-157* urea n-27* creat-1.2* sodium-139 potassium-4.1 chloride-106 total co2-18* anion gap-19 06:15am pt-12.7 ptt-29.2 inr(pt)-1.0 06:15am plt count-269 06:15am neuts-86* bands-1 lymphs-10* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 06:15am wbc-9.9# rbc-3.75* hgb-10.1* hct-31.6* mcv-84 mch-27.0 mchc-32.0 rdw-13.7 06:15am phenytoin-11.0 06:15am glucose-344* urea n-22* creat-1.1 sodium-135 potassium-4.8 chloride-103 total co2-17* anion gap-20 07:34am type-art rates-/20 o2-100 po2-452* pco2-34* ph-7.38 total co2-21 base xs--3 aado2-242 req o2-47 intubated-intubated 01:20pm glucose-306* urea n-22* creat-1.1 sodium-135 potassium-4.5 chloride-104 total co2-17* anion gap-19 02:16pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-14 lymphs-86 monos-0 02:16pm cerebrospinal fluid (csf) wbc-1 rbc-21* polys-17 lymphs-83 monos-0 02:16pm cerebrospinal fluid (csf) protein-42 glucose-150 04:42pm lactate-2.5* 04:42pm type-art po2-286* pco2-30* ph-7.45 total co2-21 base xs--1 csf-spinal fluid: gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. urine culture (final ): mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination. mri head : 1) small focus of restricted diffusion in the right hippocampus, not seen previously, which suggests either a small acute infarct or possibly an artifact. 2) unchanged evidence of chronic small vessel ischemic infarcts in the white matter bilaterally. 3) unremarkable mr angiogram of the circle of . the preliminary report had stated: no significant interval change. no evidence of diffusion abnormality. again seen are regions of increased t2 signal consistent with chronic small vessel ischemic infarcts. cxr : there is no overt chf, pneumonia, or pneumothorax cxr : no pneumonia or chf. cardiomegaly brief hospital course: pt ruled-out for meningitis w/ negative lp, acute cva w/ mri, mi w/ 3 trop < 0.01, b12 wnl, tox screen negative, tsh=5.3 and fasting cortisol=17.9, ruling these out as endocrine etiological possibilities. loaded w/ dilantin and benzos as presentation of seizure-like activity. given mild dka, pt was started on insulin gtt, ivf, q4hr lytes, q1hr fs, and kept npo. on the second day of hospitalization the pt becamse more alert and was able to follow commands, the ag acidosis resolved. by the thrid day of hospitalization her mental status had markedly improved, she was extubated and transitioned back to her home meds. was consulted to tailor an insulin regimen that would maintain euglycemia. pt was moved to the medicine floor where she continued to be monitored and managed for glycemic control while feeding po. pt had some episodes of aggitation/confusion, mostly at night, requiring the use of haldol. psychiatry was consulted and the pt was put on haldol 5 mg subsequent to which her episodes of aggitation and confusion resolved. her blood glucose continued to be difficult to control using lantus, however, she remained euglycemic for the twenty four hour period prior to discharge on nph 15 units in am and 5 units in pm (fs = 80-129), and was sent-out on this regimen. she was continued on dilantin 100 mg tid with a serum dilantin level of 13.6 at discharge. her blood pressure was maintained using metoprolol 25 , lisinopril 10 qd, and her hypothyroid was treated with synthroid 88 mcg qd. asa 325 qd and citalopram 10 qd were continued as well. medications on admission: asa 325 synthroid 75mcg qd lisinopril 10 qd nph 20 qam, 20qpm regular insulin 8 unints qam metoprolol celexa discharge medications: 1. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po qd (once a day). disp:*15 tablet(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 3. levothyroxine sodium 75 mcg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 4. lisinopril 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 7. insulin nph human recomb 100 unit/ml suspension sig: as directed units subcutaneous as directed: 12 units in the morning and 5 units at night. disp:*1 one month supply* refills:*2* discharge disposition: extended care facility: health care - discharge diagnosis: hypoglycemia, mental status changes discharge condition: controlled serum glucose, baseline mental status discharge instructions: seek immediate medical attention if you experience any change in mental status, lightheadedness, shortness of breath, chest pain, palpitaitons, severe nausea, vomiting or diarrhea. followup instructions: dr. (pcp) Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Arteriography of cerebral arteries Magnetic resonance imaging of brain and brain stem Diagnoses: Acidosis Urinary tract infection, site not specified Unspecified acquired hypothyroidism Other convulsions Other persistent mental disorders due to conditions classified elsewhere Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled Other generalized ischemic cerebrovascular disease Other alteration of consciousness Benign paroxysmal positional vertigo

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: thrombocytopenia, vaginal bleeding, pancreatitis, diabetes major surgical or invasive procedure: none history of present illness: this is a 58 year-old woman with a history of hypertension transferred to from with pancreatitis for further management. patient was admitted to on with one week of polydipsia and one day of increased lethargy, confusion. on questioning now patient gives 2 week history of decreased appetite, early satiety, intermittent ruq abdominal "discomfort" with eating. no history of gallstones. significant polyuria, polydipsia of 1 week duration, no constant abdominal pain. no fevers, chills, wieght change or nightsweats. rare alcohol. also reports poor po intake--small meals. on admission to she was found to have a blood glucose of 1590, ketones in urine without gap, amylase of 491 and lipase of 7561. vital signs at that time were stable and in the normal range--bp's 150's and hr 90's, afebrile. she was admitted to the icu, vigoroisly hydrated, started on insulin drip. ct demonstrated acute pancreatitis, possible gallstones and a 19 x 17cm soft tissue density in the pelvis felt likely to be a fibroid, although patient is s/p hysterectomy. creatinine on admission was 2 and increased to 5.3 with oliguria. baseline creatinine of 0.8. amylase and lipase peaked on at 1,027 and and on trended down to 813 and 6228 respectively. platelets on admission were 338,000 and fell to 55,000 on . with normalization of blood glucose on , serum sodiu to 157. hydrated with d5water. mrcp done on but no results reported. .. at this time patient also noticed vaginal bleeding--has not menstruated for two years. past medical history: past medical history:hypertension s/p hysterectomy by records but patient denies had 3 normal vaginal deliveries. social history: social history: no smoking, rare alcohol, no drug use. lives with her children. family history: family history: mother died from breast cancer in 70's, father died of mi at 46. physical exam: physical exam on admission: vs: temp: 98 bp: 137 /47 hr:90 rr:20 99%rm airo2sat general: pleasant, comfortable, nad, obese, oriented x3 (although does not know --"in teens" heent: perlla, eomi, anicteric, no sinus tenderness, mmdry, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules, lungs: cta b/l with good air movement throughout heart: rr, s1 and s2 wnl, no murmurs, rubs or gallops appreciated abdomen: distended, +b/s, diffuse tenderness especially in area of large abdominal mass from umbilicus to left upper quadrant to epigastrum, no grey- or cullens extremities: no edema, non-tender, cold feet but warm lower exremities neuro: aaox3. cn ii-xii intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. no pass-pointing on finger to nose. 2+dtr's-patellar and biceps skin: patient has blistering over both shoulder regions, mottling on lower extremities below knee bilaterally, no jaundice, splinters .. pertinent results: admission labs wbc-17.6* rbc-3.86* hgb-12.5 hct-37.5 mcv-97 mch-32.5* mchc-33.4 rdw-13.7 plt ct-46 diff: neuts-83.7* lymphs-11.2* monos-4.1 eos-0.9 baso-0.1 coags: pt-14.7* ptt-24.9 inr(pt)-1.5 dic labs: fibrinogen-363 d-dimer->* chemistries: glucose-247* urean-71* creat-3.5* na-147* k-4.0 cl-107 hco3-25, albumin-3.3* calcium-7.8* phos-1.7* mg-1.5* liver functions: alt-31 ast-56* ld(ldh)-661* alkphos-80 amylase-132* totbili-0.7, lipase-157* cardiac enzymes: ck-mb-4 ctropnt-<0.01 cholesterol: 123, tg-191-->119, hdl-25, ldl-74 others: haptoglobin-379* tsh-0.40 urine electrolyte:creat-102 sodium-less than uric acid-a, osmolal-420 au/a: sp -1.016, blood-lg nitrite-neg protein-30 glucose-1000 ketone-15 bilirubin-neg urobilngn-neg ph-5.0 leuk-neg, rbc-0 wbc-0-2 bacteria-few yeast-none epi-0-2, uric acid-occ pelvic ultrasound: an enlarged fibroid uterus measuring 19 x 12.1 x 15.4 cm is present. multiple large fibroids are seen, 1 located at the fundus on the right measuring 6.3 x 6.4 x 7.6 cm. another located towards the left measures 5.7 x 5.8 x 5.9 cm. other fibroids are also present. fibroids distort the endometrium, and the endometrium cannot be assessed. neither ovary is visible. there are no adnexal masses. ekg:rate about 90, nsr, nl axis, borderline lvh and left atrial abnormality, borderline prolonged qt of 472. u waves. skin biopsy: brief hospital course: pancreatitis: diff dx: gallstones, alcohol, triglycerides, hypercalcemia, infection, meds, vascular. triglycerides were elevated at osh. triglycerides and calcium within normal limits at . no medication changes since . possible gallstones seen at outside hospital ct. gives no gallstone history but possible biliary colic in 2 weeks preceding admission. never had elevation of bili or alk phos, only very minimal transaminitis. also, ? abd mass causing compression leading to pancreatitis-- this is a very curious picture as amylase and lipase extremely elevated at osh but here relatively modestly elevated--last lipase there of 6228 and here 157. she was treated with ivfs and made npo. initially she was treated with levofloxacin and flagyl, but these were discontinued after a couple of days. gastroenterology was consulted and they felt that it was likely triglyceridemia that caused her pancreatitis. patient improved with aggressive hydration although noted to be in dic and to have severe pancreatitis by criteria. patient stabilized by and planned transfer to floor. abdominal/pelvic mass: gynecology consulted. she had a pelvic ultrasound that revealed fibroids. plan was for outpatient follow-up. endocrine: dka vs. honk at outside hospital with serum glucose 1500 and ketones but no anion gap. she was treated with an insulin drip and then tarnsitioned to long-acting insulin. was consulted. stable by . oliguric renal failure: likely pre-renal due to improvement with ivfs. hypernatremia: likely from extreme dehydration. treated with ivfs. thrombocytopenia/platelet drop: hit antibody negative. likely from dic. hematology consulted. improving. mouth and vaginal bleeding: due to dic/thrombocytopenia. improving by . skin papules: possible xanthomas. dermatology consulted and lesion biopsed. the patient's pancreatitis was improving and her diabetes was under control by hospital day #4. plan was to transfer out of the intensive care unit but early on the morning of the patient had a pea arrest. the patient got up out of bed to go to the bathroom with assistance of nursing and nusrsing saw the patient gasp and then syncopize. upon arrival the patient was unconscious and pea. patient underwent attempts at rescucitation for approximately 35 minutes which was unsuccessful. patient declared dead at 5:37am. autopsy scheduled. no obvious cause of pea arrest. thrombolysis attempted approximately 20 minutes into code given possibility of pe. medications on admission: medications outpatient:hydrochlorothiazide 25 mg daily, lisinopril 10mg daily, atenolol 25 mg daily, norvasc 2.5 mg daily, indapamide 2.5 mg daily, aspirin 81 mg daily medications on admit: iss, metoprolol 2.5 mg iv q6h, morphine, nystatin, protonix, levo 250 mg daily, flagyl 500 q8h allergies: nkda discharge medications: n/a discharge disposition: expired discharge diagnosis: pancreatitis dic hyperglycemia dka discharge condition: deceased discharge instructions: n/a followup instructions: n/a Procedure: Insertion of endotracheal tube Injection or infusion of thrombolytic agent Transfusion of platelets Diagnoses: Thrombocytopenia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Cardiac arrest Morbid obesity Acute pancreatitis Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled Other specified noninflammatory disorders of vagina

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: aspiration, seizure major surgical or invasive procedure: none history of present illness: patient is an 87 yo spanish speaking woman with dementia (requiring nursing care), diabetes ii, chf, atrial fibrillation who presented to the ed yesterday with seizure like activity in the setting of recent failure to thrive. her family noted a gradual decline over the last few weeks with lethargy/increased confusion, decreased po intake, diarrhea last week, no vomiting or fevers. she was also more confused than normal (baseline does not know where she is, doesn't hold a coherent conversation), no headaches, no vomiting, no dyspnea, chest pains. she last spoke around 1430 and then was being fed dinner and doing poorly when she dropped the fork from her left hand and began shaking the left arm. ems was called, upon arrival ems noted the patient to have l-sided posturing (and enroute l arm shaking for a few seconds/posturing to left side, eyes rolled back) and she was vomiting. past medical history: ftt, iddm, chf, dementia, htn, djd, gerd, anemia, afib, uti. os s/p btka, h/o s/p right thyroidetomy social history: lives at rehab x 7 months, family decided to move her there as she was unable to walk and she was becoming more combative/aggressive, no h/o smoking but did use chewing tobacco 'her whole life' until 2 years ago, no etoh or illicit drugs, from , moved to area in family history: 1 daughter, 2 sons w/dm physical exam: admission: t afebrile bp 120/64 hr 67 rr 16 sao2 100% cvp 2-5 general: elderly woman, intubated/sedated, moves all extremities to stimulation heent: ncat, perrl, eomi cv: irregular rate, no m/r/g appreciable pulm: roncerous. no crackles. abd: soft, non-distended, non-tender, no organomegaly ext: no c/e/c. fingers cold b, b feet warm and well-perfused with 2+ dp pulses neuro: perrl. eomi. sensation intact v1-v3. facial movement symmetric. motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor no pronator drift reflexes: +2 and symmetric throughout. toes downgoing bilaterally . discharge: t 96.3 bp 121/58 hr 76 rr 20 sao2 89-93% ra, sao2 99% 2l general: elderly woman, alert, speaking spanish but not truley communicating heent: ncat, perrl, eomi, mildly elevated jvp cv: irregular rate, no m/r/g appreciable pulm: ctab, no labored breathing, occ fine crackles in bases bilaterally abd: soft, non-distended, non-tender, no organomegaly ext: no c/e/c. neuro: alert, speaking but not communicative, pneumoboots in place skin; no rashes, pertinent results: admission labs 04:55pm blood wbc-10.7 rbc-4.90 hgb-14.3 hct-46.1 mcv-94 mch-29.2 mchc-31.0 rdw-13.6 plt ct-341 04:55pm blood neuts-67.1 lymphs-24.9 monos-6.2 eos-1.4 baso-0.4 04:55pm blood glucose-198* urean-19 creat-0.7 na-141 k-5.3* cl-99 hco3-18* angap-29* 04:55pm blood alt-16 ast-36 ck(cpk)-52 alkphos-77 totbili-0.7 04:55pm blood ctropnt-<0.01 01:45am blood ck-mb-notdone ctropnt-<0.01 04:55pm blood albumin-4.3 calcium-9.5 phos-4.5 mg-1.7 04:55pm blood tsh-5.9* 01:45am blood free t4-1.2 02:44am blood phenyto-13.2 05:09pm blood glucose-175* lactate-10.0* na-143 k-3.9 cl-100 calhco3-19* 05:09pm blood hgb-14.9 calchct-45 05:09pm blood freeca-1.12 imaging ct pelvis/abdomen-5/5-1. no definite evidence of intra-abdominal acute process. 2. moderate right basilar atelectasis. please note, aspiration or early pneumonia is difficult to exclude given this appearance. 3. cardiomegaly and coronary artery calcification. 4. small hiatal hernia. . ct head -no intracranial hemorrhage or evidence of major vascular territorial infarct. chronic microvascular disease. . mri head - 1. no evidence of acute infarction. multiple flair hyperintense foci in the cerebral white matter, pons, on both sides, most likely representing sequela of chronic small vessel occlusive disease, givent he aptient's age and risk factors. 2. prominent ventricles and extra-axial csf spaces most likely due to age- appropriate parenchymal volume loss. however, superimposed alzheimer's dementia cannot be excluded, given the mild dilation of the temporal horns and small hippocampi. 3. small linear focus of enhancement in the left occipital lobe, seen only on the mprage sequences, could represent a small developmental venous anomaly. however, dedicated mr angiogram was not performed on the present study. this can be considered based on clinical discretion. . eeg -abnormal portable eeg due to the slow and disorganized background and bursts of generalized slowing. these findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. there were no areas of prominent focal slowing, and there were no epileptiform features . echo--possible small mitral valve vegetation. normal global and regional biventricular systolic function. moderate aortic regurgitation. moderate mitral regurgitation. moderate tricuspid regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , severity of valvular regurgitation has increased slightly. pulmonary pressures are higher. the other findings are similar. a transesophageal study may better be able to assess the mitral valve morphology. . cxr's :the endotracheal tube terminates approximately 3 cm from the carina. patient rotation somewhat limits interpretation. lung volumes are low, but pulmonary vasculature does not appear engorged. there is no evidence of pleural effusion. no focal parenchymal opacities are seen in the lungs. the cardiac size, mediastinum and hila cannot be fully evaluated due to patient rotation. :ap single view with patient in semi-erect sitting position demonstrates patient in semi-oblique position towards the right. the dobbhoff line is seen and apparently has not passed the hiatus. otherwise, there is no evidence of any new abnormality, but as before, pulmonary vascular congestion is present and the lateral pleural sinuses are blunted. impression: unsuccessful advancement of dobbhoff line finding resistance in hiatal area. : as compared to the previous radiograph, there is considerable patient rotation. the endotracheal tube, nasogastric tube and central venous access line right have been removed. the lung volumes are slightly smaller than before, there is unchanged mild-to-moderate bilateral pleural effusions and signs suggesting mild volume overload. retrocardiac atelectasis is unchanged. there is no evidence of newly appeared parenchymal opacities. . microbiology data -bcx-staph coag negative 2/3 bottles bcx- negative bxc pending -urine culture negative -csf-cryptococcal ag negative, hsv neg, prot 113, glucose 85, wbc 4 -sputum cx-1+gnr brief hospital course: 89 yo woman with dementia, dm, atrial fibrillation, chf who presented with lethargy/altered mental status, witnessed to have a possible seizure, and admitted to the icu after intubation. . # altered mental status/seizure: eeg showed widespread encephalopathy, ct was negative for acute pathology. per pt's family, pt has a history of seizure in setting of urosepsis. a full infections work up was performed. she was initially on ceftriaxone/ampicillin and acyclovir for concern for meningitis. ceftriaxone/ ampicillin/acyclovir were discontinued. an lp was not suggestive of bacterial or viral infection, hsv negative. blood cultures were negative, only coag nesg staph (positive from the same set) that was likely contaminant. prior to speciation, she was on vancomycin for possible gram positive bacteremia. she also received a tte which did not show any over vegetations - see below. ua and ucx were negative. given her vomiting, it was thought that she may have an aspiration pna. although she had no leukocytosis, no fever and no infiltrate on cxr, she did grow 2+ gnr in her sputum. for this she was on unasyn and vancomycin for possible aspiration pna. an ekg showed no new arrythmia and cardiac enzymes were negative making a primary cardiac event with hypoxia unlikely. a metabolic cause was also thought to be unlikely as electrolytes were normal. head ct was negative for bleeding. mri showed no new pathology. she was followed by neurology. per their discussion, her seizure may have been a manifestation of underly neurodegenerative disease. she was intially given dilantin and then switched to keppra. she was on keppra 500 at discharge. she should be titrated up to keppra 1,000mg on . she had no further seizures but was maintanted on seizure precautions. . # intubation: pt was intubated for airway protection and is required minimal ventilator support. she was easily extubated. . # possible bacteremia: pt was reported to have bcxs with gpcs, prompting concern for endocarditis with septic emboli to brain (neg on mri). an echo showed no overt vegetations but a questionable hyper-echo area on the aortic valve where vegetation could not be ruled out. however, upon clarification with the lab, pt has only bcxs positive with coag neg staph which was likely contaminant. given that further blood cultures were negative and that the coag neg staph was likely a contaminant, no further endocardidtis work up was pursued. she did receive 7 days of vancomycin. her tte was discussed with cardiology who noted that the patient has aortic and mitral valve abnormalities and that if the clinical suspicion for endocarditis is low that these possible vegetations may just be fibrin strands. please draw routine blood cultures on monday and with any fever. if blood cultures are positive, please readmit patient to . . # possible aspiration pna: given the witnessed aspiration event, there was a concern of aspriation pna. she did not have a fever, leukocytosis or infiltrated but did have 2+ gnr on sputum. she was treated with unasyn and vancomycin for 7 days, day 1 was . she received a speech and swallow evaluation which she passed w/o evidence of impaired swallowing. it was ultimately decided that she did not have an aspiration pna w/o fever, leukocytosis or infiltrated and her abx was stopped at 7 days rather than the planned 14 day course. . # acute on chronic systolic congestive heart failure: the patient has a known ef of 40% but was not admitted on any heart failure regimen. she received 6+l in the ed and on day 1 in the micu. she had subsequent volume overload and was diuresed. several days later, she was found to have hypoxia 86% ra, crackles and elevated jvp. a cxr showed pulmonary edema. she was once again diuresed with lasix 10 iv for two days - put out 1.5-2l daily. she was started on low dose lisinopril and every other day lasix without adverse effect, stable creatinine. she did have slightly low k with diuresis which required repletion. she will need chem 7 every other day to monitor sodium, potassium and creatinine. . # hypotension/bradycardia: pt had a brief episode in ed with the rest of vs being stable. this may have been drug effect after intubation or a vagal episode. this has not recurred. . # atrial fibrillation: currently rate-controlled but has had some episodes of rvr. she was maintained on metoprolol and asa 325mg. . # diabetes: her home metformin was held and she was on a humalog sliding scale. metformin was restarted at discharge. medications on admission: metformin 500 vicodin prn flovent 110 albuterol prn tylenol prn robitussin prn prozac 20 daily asa 325 daily seroquel 50mg qam lopressor 25 discharge medications: 1. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 4 days. 4. keppra 1,000 mg tablet sig: one (1) tablet po twice a day: start after 4 days of keppra 500mg . 5. metformin 500 mg tablet sig: one (1) tablet po twice a day. 6. flovent hfa 110 mcg/actuation aerosol sig: one (1) puff inhalation twice a day. 7. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: nebs inhalation q6h (every 6 hours) as needed for wheezing. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 9. lopressor 50 mg tablet sig: tablet po twice a day. 10. seroquel 50 mg tablet sig: one (1) tablet po once a day. 11. vicodin 5-500 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 12. lasix 20 mg tablet sig: tablet po qod. 13. lisinopril 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: healthcare- discharge diagnosis: seizure acute on chronic systolic congestive heart failure discharge condition: improved discharge instructions: you were admitted for a seizure. you did not have a brain infection or head bleeding. you seizure was most likely due to underlying dementia. you were started on anti-seizure medications. you were started on a low dose and your medications will need to be titrated up. . you were found to have an aspiration pneumonia due to vomiting and received antibiotics. . if you have another seizure, fevers, chill or respiratory distress, you should return to the emergency room. followup instructions: please call your primary care provider to arrange for an appointment in the next two weeks. . this patient has been started on lisinopril and lasix for heart failure. she will need every day chem 7 to monitor her sodium, potassium and creatinine. . please draw routine surveillance blood cultures on monday . md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Acidosis Esophageal reflux Congestive heart failure, unspecified Atrial fibrillation Other convulsions Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Encephalopathy, unspecified Acute on chronic systolic heart failure Below knee amputation status Senile dementia with delirium

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dizzineness, status post fall major surgical or invasive procedure: 1. femoral temporary venous pacer 2. a line 3. ppm (ddd) placement history of present illness: 84 y/o f with severe as (0.8), chronic lymphoma, dvt on coumadin, asthma who p/w falls x 1 month. also had one episode of "fainting" one week ago. came to ed for fall. admitted to medicine floor. noted to have 8 sec run of non-conducted p's (assymptomatic). baseline ecg reveals bifasicular block with prolonged pr. came to ccu for chb. recieved 3u ffp. attempt at rij for temp wire unsuccessful. pt became hypotensive requiring max dose dopa and neo gtt's. intubated for airway protection. r fem temp wire placed successfully under flouro. pacing at 80 bpm's with threshold 0.4mamp set at 10. coming down on pressors. due to ventricular ectopy, weaning dopa first. past medical history: 1) aortic stenosis: last echo with ef > 55%, severe as (worse than prior echo) 2) rheumatoid arthritis (followed by dr. in rheum, on methotrexate) 3) asthma 4) htn 5) lle dvt 6) pneumonia 7) anemia of chronic disease 8) cad 9)h/o thrombocytopenia of unknown etiology (negative hit, and sra) 10) areflexive bladder (requiring chronic foley) social history: lives with daughter. etoh/tob/ivdu family history: non-contributory physical exam: vs: afebrile, 110/64, 86, 20, 100% 4l. gen: elderly female intubated with temporary pacer wire in place sedated with propofol drip. heent: perrl, mmm, jvp elevated ~11cm, firm hematom r neck. chest: cta anteriorly and laterally. cvr: rrr, iii/vi cresendo decresendo murmor at rusb radiating to carotids. s2 clearly heard. abdomen: soft, nt, obese with ?large area of distention. ext: 1+ edema. neuro: pt intubated, spontaneous movements even on sedation. pertinent results: 7.8/ 26.2/ 137 previous cbc: 6.7/29.2/137 140/4.1/104/26/22/1.1/139 ca: 8.5 mg: 1.9 p: 3.3 inr 2.5 . head ct no ich or mass . ct abdomen w/o contrast 10:49 am conclusion 1. moderate size hematoma in the subcutaneous tissues of the right groin. no pelvic or intra-abdominal hematoma. 2. large hernia containing two separate segments of colon. 3. mild circumferential thickening along part of the ascending colon partly located within the abdomen and within the right inferolateral abdominal wall hernia with mild adjacent stranding compared to previous ct. no sign of mechanical obstruction. possibilities would include an area of focal segmental congestion or even colitis depending on clinical correlation. 4. infrarenal abdominal aortic aneurysm measuring up to 3.9 cm transverse unchanged. 5. moderate right basal pleural effusion and minor associated right posterobasal atelectasis. 6. cholelithiasis. echo there is mild symmetric left ventricular hypertrophy. left ventricular chamber size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is probably borderline normal (ef~50-55%) but views are technically suboptimal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (estimated ~0.6 cm2 but lvot velocity estimation is technically limited) . there is no aortic regurgitation. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: a/p: this is a 84 year old female with severe as (0.8), chronic lymphoma, dvt on coumadin, asthma who p/w s/p fall and complete heart block. now s/p ddd pacer. . #cardiovascular - #ischemia - no previous history of ischemia. continued on asa 325. # pump - recieved 3u ffp. attempt at rij for temp wire unsuccessful. pt became hypotensive during attempt at rij temp wire requiring max dose dopamine and neosynephrine gtt's. hypotension was thought to be secondary to increased vagal tone with pressure and manipulation at the rij. patient was intubated for airway protection in setting of right neck hematoma. patient was subsequently weaned off pressors. repeat echo showed preserved ef 50-55%, tight as valve area 0.6 cm2. patient became hypotensive and required fluid boluses and resumed on dopamine ggt temporarily after removal of right femoral sheath and right groin hematoma was seen on ct. patient was resumed on diltiazem and was diuresed with iv lasix with goal of -500cc/day. # rhythm - noted to have 8 sec run of non-conducted p's (assymptomatic). baseline ecg reveals bifasicular block with prolonged pr. admitted to ccu for chb. received temp wire in r groin under fluoro. patient had ppm (ddd) placed on . . ##respiratory - s/p intubation for airway protection given hematoma in neck. initially propofol used for sedation, however was changed to fentanyl and versed with better effect. patient was extubated sat'ing well on room air. continued advair, ipratropium and albuterol neb prn. . ##hematomas - patient developed multiple hematomas at access sites including rij, left forearm, right groin and left chest (pacer site). bleeds stopped with pressure bandages, ffp and vit k. abdominal ct showed right groin bleed and no rp/intrapelvic bleed. anticoagulation was held and patient was transfused as needed. . ## as: severe with area of 0.8, mean gradient 50's. ct surgery was consulted and spoke with patient who said that she does not wish to go to surgery at this time. . ## uti: enterococcus 100k, providencia rettgeri 10-100k on ucx. was on vanco 1g for 48 hours perioperatively. completed 1 week of ampicillin for entercoccus uti and levoquin 4 days,for gn coverage. . ## anemia: labs consistent with iron def anemia. started po iron repletion. in an elderly with iron def. anemia concerning for gi origin and should have outpt workup. patient received blood after decreased hct after rij attempt, r femoral groin cordis removal and left chest hematoma at pacer site. hct now stable and patient off coumadin. . ## - pt with h/o dvt (dx' ) and anticogulated with coumadin on admission, inr was 2.5. coumadin was held and patient was put on heparin gtt. patient received ffp prior to central line placement and after right groin bleed. patient also received vit k prior to ppm placement and s/p right groin bleed and heparin ggt was held. initially patient was started on coumadin with heparin bridge however had pacer bleed and so coumadin and heparin were held given bleeding risks. . ## falls: likely chb. head scan negative. pt consult, will need to go to rehab. . ## ppx: colace/senna prn . ## code: full code medications on admission: diltiazem 120 mg er methotrexate sodium 2.5 mg--8 tablet(s) by mouth q week on thursday warfarin 7.5 mg-10 mg po daily folate albuterol flovent servevent discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 5. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed: not to exceed 4g/day. 7. albuterol sulfate 0.083 % solution sig: one (1) inhalation q2h (every 2 hours) as needed for shortness of breath or wheezing. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 10. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po tid (3 times a day). 12. furosemide 80 mg tablet sig: one (1) tablet po once a day. 13. methotrexate 2.5 mg tablet sig: eight (8) tablet po qthursday. discharge disposition: extended care facility: center - discharge diagnosis: primary diagnosis: high-degree heart block secondary diagnosis: chronic lymphoma aortic stenosis hx of dvt lymphoma rheumatoid arthritis iron deficiency anemia discharge condition: good discharge instructions: please take medications as prescribed. we have started you on lasix 80mg po qd. since you have aortic stenosis, please have your primary care physician adjust your lasix does accordingly. we did not resume you coumadin because you developed multiple hematomas while on it. please get your labs drawn on and have the your primary care physician the results. check daily weights. you have iron deficiency anemia and have been started on iron repletion. you have have a gi outpatient follow-up to exclude other causes of your anemia. you have a permanent pacemaker which you need to follow-up at device clinic regularly for maintenance. if you have any chest pain, fevers/chills, loss of consciousness or any worrying symptoms please call your primary care physician or come to the emergency room. followup instructions: provider: clinic phone: date/time: 11:00 provider: ,md phone: date/time: 12:30 please follow-up with you primary care physician weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Arterial catheterization Transfusion of packed cells Transfusion of other serum Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Hematoma complicating a procedure Asthma, unspecified type, unspecified Aortic valve disorders Other malignant lymphomas, unspecified site, extranodal and solid organ sites Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Atrioventricular block, complete Long-term (current) use of anticoagulants Iron deficiency anemia, unspecified Rheumatoid arthritis Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pea arrest major surgical or invasive procedure: l subclavian central line sterilly placed endotracheal tube placement og tube placement history of present illness: 85 year old f w/mmp including complete heart block s/p pacer, severe as, aaa, asthma, hx dvt, cad tranferred urgently to for apnea and cardiac arrest. she had just been admitted from ed to floor for 1 week of productive cough, dyspnea, confusion including visual hallucinations, and an 02sat of 88% ra. at that time vs were noted to be stable: bp 102/47, hr 73, t 96.9 rr 18 96% on 4l. . approximately 30min after her admission, she was found to be unresponsive, pulseless and apneic. code blue was called, cpr initiated. she had some electrical activity on the monitor, and had no pulse. compressions continued; the pt was intubated. after epi x2, atropine x1, and cardiac compressions, pt regained pulse with a bp 105/50. abg prior to intubation 7.20/ pco2 92/ po2 29 /hco3 38. she was then transferred to icu for further management. past medical history: 1) aortic stenosis: last echo with ef > 55%, severe as (worse than prior echo) 2) rheumatoid arthritis (followed by dr. in rheum, on methotrexate) 3) asthma 4) htn 5) lle dvt 6) pneumonia 7) anemia of chronic disease 8) cad 9)h/o thrombocytopenia of unknown etiology (negative hit, and sra) 10) areflexive bladder (requiring chronic foley) social history: lives with daughter. etoh/tob/ivdu family history: non-contributory physical exam: 105/60 74, paced ac 450x20 98% on 40% fio2 gen: chronically ill appearing elderly female, intubated heent: anicteric, mmm, pupils fixed and dilated 1 day post arrest, then became responsive neck: supple, shotty lad, jvp not appreciated, but prominent ej cv: paced. no s3 or s4. iii/vi sem best at usb though heard throughout precordium; difficult to appreciate an s2. lungs: wheezes bilaterally, decreased bs abd: soft, nt, protuberant hernia. nl bs. no hsm or pulsatile mass. ext: 2+ tense edema, equal. skin: flaking skin on legs neuro: intubated, not responsive, moving all extremities. triple flexion response to plantar reflex. pupils 4-->3, equal (were unresponsive immediately after code). pertinent results: 10 pm cxr: impression: interval placement of endotracheal tube with distal tip in appropriate position. the previously noted patchy opacity in the lateral left lung base is not included on the current radiograph secondary to positioning. . pa and lat cxr: impression: small left pleural effusion and left retrocardiac opacity representing atelectasis versus pneumonia. mild interstitial pulmonary edema. . ct: wet read - head negative for acute process; cta chest negative for pe or dissection. ? low lung volumes in left chest and left ventricular mass that could be lvh. abdominal scan notable for hernia; no acute change in aaa; no ascites. . ecg: a-sensed, v-paced at 74 bpm, wide qrs. brief hospital course: micu course: the etiology of the patient's pea arrest was not obvious. she was rescuscitated, and transferred to icu when stabilized. in the icu, a r subclavian was ultimately placed - the patient had very difficult access. a cxr ruled out a pneumonthorax. the ecg showed normal voltage, though paced, making tamponade less likely. the cta was without evidence of pe. the cardiac enzymes were not suggestive of an acute mi. cardiology was consulted. interrogation of the pacer revealed that at approximately the time of the incident, she had a 13 minute episode of atrial tachycardia suggestive of afib; however, there was no way to know for certain what rhythm she was in. it was felt that, perhaps, afib coupled with underlying severe as may have resulted in hypoxia leading to pea arrest. once resucitated, she was able to maintain a bp without pressors, and remained intubated. however, she did not regain her mental status over the subsequent days despite being on minimal sedation (0.5 versed) or at times completely without sedation. at most, she would open her eyes and move, but no reproducible purposeful movements or ability to follow commands was seen. a discussion was had with the family regarding withdrawal of aggressive measures and providing comfort measures only. the family concurred with this course of action and the patient was extubated on . all medications save for nebulizers and morphine were stopped. the patient was transferred from the unit to the floor on . on the morning of at 9:26 am the patient passed away on a morphine gtt. her daughter, , her hcp, was notified and declined an autopsy. medications on admission: asa 325 qd diltiazem xr 120 qd fluticasone 110 2puff serevent 1 puff lasix 80 qd folate ferrous sulfate k-dur 10 meq qd calcium 500 tid vit d 800u qd methotrexate 17.5 mg qthursday discharge medications: deceased discharge disposition: expired discharge diagnosis: pneumonia pea arrest deceased discharge condition: deceased discharge instructions: deceased followup instructions: deceased Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Pneumonia, organism unspecified Anemia of other chronic disease Congestive heart failure, unspecified Atrial fibrillation Asthma, unspecified type, unspecified Aortic valve disorders Acute respiratory failure Cardiac pacemaker in situ Rheumatoid arthritis Abdominal aneurysm without mention of rupture Chronic lymphoid leukemia, without mention of having achieved remission

past medical history: 1. coronary artery disease status post coronary artery bypass graft times four. 2. hypertension. 3. hypercholesterolemia. 4. insulin dependent diabetes mellitus. 5. osteoarthritis. 6. status post retinal surgery. 7. status post tna. 8. status post percutaneous transluminal coronary angioplasty times two. 9. morbidly obese. preoperative medications: 1. aspirin 325 mg po q.d. 2. plavix 75 mg po q.d. 3. glucophage 1000 mg po b.i.d. 4. glyburide 10 mg po b.i.d. 5. k-dur 10 mg po q day. 6. lasix 20 mg po q.d. 7. lipitor 80 mg po q.d. 8. univasc 15 mg po q.d. 9. zetia 10 mg po q day. 10. prilosec 20 mg po q.d. 11. paxil 10 mg po q.d. 12. lopresor 50 mg po b.i.d. 13. humalog 75/25 25 units q.a.m. 39 units q.p.m. 14. humulin insulin 15 units q.a.m., humulin sliding scale q.p.m. allergies: penicillin, which gives him hives. social history: the patient has a remote history of a 45 pack year smoking history. quit many years ago. the patient is an accountant. the patient was originally scheduled for surgery on , but when the patient was seen in the preoperative holding area the patient was found to have a significant upper respiratory infection. the patient was given a one week course of antibiotics and surgery was rescheduled for . ho course: the patient was admitted on and taken to the operating room with dr. for a redo sternotomy and an aortic valve replacement with a 25 mm pericardial valve. the patient was transferred to the intensive care unit in stable condition on an epinephrine amiodarone drip. the patient was weaned and extubated from mechanical ventilation on postoperative day number one. the patient had adequate cardiac index on epinephrine. epinephrine was weaned to off. the patient was started on lopressor for control of hypertension and tachycardia. the patient became agitated on the evening of postoperative day number one and started on low dose haldol. postoperative day number two the patient began working with physical therapy. the patient was started on lasix postoperative day number two with adequate diuresis. the patient required a nitroglycerin drip to control his blood pressure. postoperatively, the patient had a continued leukocytosis of unknown origin. the patient was afebrile. on postoperative day number four the patient was able to walk 300 feet with physical therapy. postoperative day number four the patient was noted to have a moderate amount of serosanguinous drainage fro the distal portion of his sternal incision. the patient continued to have drainage. it was decided that the wound would be covered with dermabond. the wound was cleaned and prepped in a sterile fashion. dermabond was applied to the distal portion of the sternal incision. however, the incision continued to drain serosanguinous fluid and required repeat dermabond applications over the next several days. the patient continued to work with physical therapy and was able to achieve a level five. the patient's pacing wires were removed without difficulty. the patient remained hemodynamically stable. the patient had been on antibiotics for prophylaxis of a sternal wound vancomycin and levofloxacin. on postoperative day number seven the vancomycin was stopped. on postoperative day number seven the patient required placement of a picc line as the patient had no further intravenous access. the patient tolerated this procedure well. the patient continued to have drainage from the sternal incision and had difficulty understanding and following the repeat instructions for maintaining strict sternal precautions and not using his arms. however, on postoperative day nine the patient had no drainage from his sternum and was deemed stable for discharge to home. condition on discharge: temperature max 99.3, pulse 85 in sinus rhythm. blood pressure 150/80. respiratory rate 16. room air oxygen saturation 92%. weight on is 156.2 kilograms. preoperatively the patient weighed 153.7 kilograms. white blood cell count 13.1, hematocrit 26.5, platelet count 481, potassium 4.3, bun 16, creatinine 0.8. the patient is awake, alert and oriented times three, pleasant gentleman. heart is regular rate and rhythm. no murmurs, rubs or gallops. respiratory breath sounds with scattered wheezes bilaterally. gastrointestinal, abdomen is obese, positive bowel sounds, soft, nontender, tolerating a regular diet. sternal incision upper part steri-strips are intact. the lower part of dermabond is intact. there is no erythema. there is no drainage. the sternum is stable. discharge medications: 1. lasix 40 mg po b.i.d. times ten days. 2. potassium chloride 20 milliequivalents po b.i.d. times ten days. 3. lipitor 80 mg po q day. 4. plavix 75 mg po q.d. 5. protonix 40 mg po q.d. 6. enteric coated aspirin 325 mg po q.d. 7. colace 100 mg po b.i.d. 8. glucophage 1000 mg po b.i.d. 9. glyburide 10 mg po b.i.d. 10. paxil 5 mg po q day. 11. moexipril 7.5 mg po q.d. 12. levofloxacin 500 mg po q day. 13. lopressor 100 mg po b.i.d. 14. percocet 5/325 one to two tabs po q 4 hours prn. 15. insulin per patient's home regimen, which is 75/25 25 units q.a.m. and 39 units q.p.m. and a humulin insulin sliding scale. th is to return to far two for a wound check. the patient is to follow up with his primary care physician . in two weeks. the patient is to follow up with dr. in one month. discharge diagnoses: 1. status post redo sternotomy with aortic valve replacement with a 25 mm pericardial valve. 2. insulin dependent diabetes. 3. hypertension. 4. postoperative sternal drainage now resolved. the patient is discharged to home in stable condition. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Closure of skin and subcutaneous tissue of other sites Hypothermia (systemic) incidental to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension Aortocoronary bypass status Primary pulmonary hypertension Morbid obesity Osteoarthrosis, unspecified whether generalized or localized, site unspecified Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled

service: history of present illness: the patient is a 46-year-old woman with complaints of facial tingling, right greater than left and left eye drooping which prompted a scan that showed a 6 mm left internal carotid aneurysm. she has also been complainaing of headache in recent months and underwent a diagnostic angiogram which confirmed the aneurysm and also showed a small daughter aneurysm component. after extensive discussions with the patient a decision was made to pursue a trial of initial endovascular embolization. past medical history: herniated ruptured disk; heartburn with reflux; partial hysterectomy and infertility surgeries. physical examination: her vital signs were stable, her blood pressure was 127/69, pulse 46, in no acute distress. her pupils were equal, round and reactive to light. her neck was supple with no lymphadenopathy. her chest was clear to auscultation. cardiac examination was regular rate and rhythm with no murmurs, gallops, or rubs. abdomen was flat, nondistended, with no masses, positive bowel sounds. extremities showed no cyanosis, clubbing or edema. hospital course: the patient was admitted status post a left internal carotid artery coil embolization without intraprocedure complications. postoperatively the patient was awake, alert and oriented. pupils were 3 down to 2 mm and brisk. extraocular movements were full. the face was symmetric, moving all extremities with good strength, no drift. finger-to-nose was intact. she was monitored in the surgical intensive care unit and transferred to the floor on . on she was awake, alert, complaining of moderate bifrontal headache and nausea. she was out of bed ambulating, increasing her diet and was felt to be safe for discharge to home on . she was in neurologically stable condition on the day of discharge. discharge medications: percocet 1-2 tablets p.o. q. 4 hours p.r.n. for pain. follow up: the patient will follow up with dr. in one month. condition on discharge: her groin site was clean, dry and intact with good pulses and no hematoma. she was out of bed ambulating, tolerating a regular diet. she was in stable condition at the time of discharge. , m.d. dictated by: medquist36 Procedure: Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Esophageal reflux Cerebral aneurysm, nonruptured

discharge status: the patient's discharge status was to home. condition at discharge: the patient's condition on discharge was good. medications on discharge: 1. lasix 20 mg by mouth once per day (for 10 days). 2. potassium chloride 20 meq by mouth once per day (for 10 days). 3. aspirin 325 mg by mouth once per day. 4. percocet one to two tablets by mouth q.4h. as needed (for pain). 5. levofloxacin 500 mg by mouth q.24h. (for seven days). 6. lopressor 100 mg by mouth three times per day. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Cardiac complications, not elsewhere classified Aortic valve disorders

history of present illness: an 80-year-old female, with a history of aortic stenosis, had recently had increase in dyspnea on exertion. the patient had a cath today which revealed severe as with 0.59, 1+ ar and a left ventricular ejection fraction of 65%, with normal coronaries. the patient was referred to the cardiac surgery service for avr. the patient had an echo in that showed as, of 0.4, 2+ tr, 1+ mr, av gradual peak at 93. past medical history: 1. hospitalized in with ?pneumonia versus chf, and the patient was intubated at that time. the patient had a question of a history of afib at that time, and the patient was on coumadin for a brief period of time. 2. status post tonsillectomy. social history: no smoking history. the patient denies drinking alcohol. the patient is married and lives with husband. medications: 1. atenolol 25 qd. 2. multivitamins 1 tablet qd. labs on admission: white count 5.9, hematocrit 35.2, platelets 181, inr 1.1, sodium 137, potassium 3.3, chloride 104, bicarb 23, bun 28, creatinine 0.6, glucose 132. ua was negative. lfts were normal. review of systems: the patient denied tias, cva, seizures, no pnd, no palpitations, no cough, no wheezes. the patient states that she has occasional heartburn relieved with tums. the patient has a rare history of diarrhea, some hemorrhoids. the patient denies claudication. denies diabetes, thyroid disease, or heme issues. physical exam: the patient is a healthy appearing 80-year-old female. neurologically, the patient was grossly intact without carotid bruits. examination of the lungs revealed clear to auscultation bilaterally. examination of the heart revealed a iv/vi systolic ejection murmur with s1 and s2. abdomen was soft, nontender, nontender. examination of the extremities revealed warm with positive peripheral pulses without any edema. hospital course: the patient was admitted to the cardiac surgery service and underwent aortic valve replacement with a #19 tissue valve. the patient was extubated and transferred to the csru. the patient was on perioperative kefzol, remained afebrile with pulse at 100, and blood pressure 133/56, otherwise doing well. the patient's white count was 21.9, hematocrit 36.9. the patient was put on low dose lopressor 12.5 , and the patient's swan was switched to a cvl. on postop day #2, the patient was started on lasix for low urine output. the patient remained afebrile with pulse around 90, blood pressure 130s/40s, otherwise doing well. the patient still had the chest tube, wires and foley. the chest tubes were removed. lopressor was increased to 25 mg . on postop day #3, the patient continued to remain afebrile. pulse was running around 88, normal sinus, blood pressure 120s/40s, otherwise doing well. taking in good pos and making good urine. white count was down to 13. the patient was transferred to the floor in stable condition. on postop day #4, the patient had no complaints. the patient's lopressor was at 50 . the patient had a low-grade fever of 100.3, otherwise remained stable, pulse around 87, and blood pressure 110s/60s. she was taking good pos and making good urine. white count at 13. the patient's wire was removed and had worked with physical therapist. on postop day #5, the patient remained afebrile with stable vital signs. pulse still running around 90. the patient worked with physical therapist and passed level 5, and it was safe for the patient to return home. on postop day #6, the patient had no complaints. the patient was on lopressor 100 for systemic ventricular tachycardia. the patient's t-max was 100.1, pulse remained at 99, and blood pressure 116/51. the patient was taking good pos and making good urine. the patient was switched to lopressor 75 mg tid, and the patient was doing well. pressure and heart rate were better controlled. the patient was discharged home in good condition. condition on discharge: good. disposition: home with services. final diagnoses: 1. status post aortic valve replacement. 2. severe aortic stenosis. 3. pneumonia. 4. status post tonsillectomy. fop plans: 1. please follow-up with dr. in 4 weeks; please call his office for follow-up appointment. 2. please follow-up with dr. , the pcp, weeks; please call for a follow-up appointment. discharge medications: 1. lasix 20 mg po bid for 7 days. 2. potassium 20 meq po q 12 h for 7 days. 3. colace 100 mg po bid. 4. metoprolol 75 mg po tid. 5. aspirin 325 mg po qd. 6. percocet 1-2 tabs po q 4 h prn pain. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Cardiac complications, not elsewhere classified Aortic valve disorders

service: history of present illness: the patient is a 51-year-old african american female with severe morbid obesity, obstructive sleep apnea on bipap and bilateral pedal edema who presents to the emergency department on the day of admission for further evaluation of left breast tenderness she initially presented to the surgical service for evaluation in . at that time, the patient had an ultrasound done which was negative for abscess. she was started on intravenous nafcillin with significant improvement. she was noted at that time to have significant bilateral pedal edema which was felt to be dependent because of intravenous fluids and sodium in the antibiotics. she was augmentin, also started on atenolol. the patient came to the emergency department day of admission because she noted increasing puckering of her left breast erythema and foul smell covering the breast over the past two weeks. she has had a discharge from a wound in her back, but none from her breast. she has noted increased bilateral lower extremity edema to the thighs over the last two weeks. she has occasional shortness of breath and has been having increasing orthopnea. she chronically uses two to three pillows and denies increased paroxysmal nocturnal dyspnea. she has obstructive sleep apnea and has been on bipap for the last two years. according to her daughter, the bipap machine has not been functioning well over the last several weeks and she feels that the patient has been somewhat more lethargic because of that. she has not had a cardiac echocardiogram recently. the patient denies any fevers, chills or cough. denies chest pain or palpitations. she denies any previous history of deep venous thrombosis or pulmonary embolus and denies history of lung disease. in the emergency department, she was slightly tachycardic to 103 to 112 initially. blood pressure was stable at 90 to 110 over 66 to 73. she was breathing at 24. on admission to the emergency department, she was noted to be hypoxic at 73% on room air which increased to 90% on 60% face mask. arterial blood gas was checked on 40% venti mask and was 7.27, 90 and 60. she was given nebulizers and started on bipap. chest x-ray showed a question of cardiac enlargement and congestive heart failure. the patient was given 20 of lasix intravenous, diuresed 1200 cc in the emergency department. also started on heparin empirically for question of pulmonary embolism. ............. showed on the left lower extremity suboptimal study without evidence of deep venous thrombosis. heparin was discontinued, also given ancef for cellulitis in the emergency department. mental status and o2 saturations improved on bipap in the emergency department. room air still saturating at 84%. she was admitted to the intensive care unit for close observation for hypoxia and hypercapnia. past medical history: 1. morbid obesity 2. status post incision and drainage of back wound in 3. history of left breast cellulitis previously treated at 4. obstructive sleep apnea on bipap at night 5. osteoarthritis of knee past surgical history: 1. status post cesarean section medication: 1. aspirin 325 mg po qd allergies: novocaine, reaction is not clear social history: tobacco one pack per day x35 years, no alcohol. the patient is unemployed, lives in with her children. family history: mother with hypertension and question of heart disease. no family history of cancer or diabetes. physical exam: general: she is a morbidly obese african american female who is alert and oriented x3 in no apparent distress. vital signs: temperature 98.6??????, heart rate 84 to 90, blood pressure 119/70, respiratory rate 23, o2 saturation 91% on 3 liters. head, ears, eyes, nose and throat: pupils equal, round and reactive to light. extraocular muscles are intact. oral mucosa dry. tongue coated, no oral lesions, positive macrognathia was noted. neck: short, supple, no lymphadenopathy appreciable, jugular venous distention. chest: poor inspiratory effort transmitted, upper respiratory sound, no crackles, rales, rhonchi or wheezing. heart: regular rate and rhythm, normal s1 and s2, no murmurs, rubs or gallops, no appreciated right sided s3. breasts: large area of firm peau d'orange extending to back with slight erythema and increased warmth. no drainage, no nipple discharge. abdomen: severely obese, soft, nontender, nondistended, positive bowel sounds. indurated pannus was noted across left side. extremities: bilateral 2+ lower edema to the sides bilaterally and no palpable pulses bilaterally. no cyanosis, clubbing or lesions appreciated. neurologic: nonfocal neurologic exam. admission laboratories: white blood cell count 4.5, hematocrit 50.9, hemoglobin 14.7, platelets 192. sodium 140, potassium 3.6, chloride 96, bicarbonate 32, bun 6, creatinine 0.5, glucose 106. urinalysis: specific gravity 1.031. urine was , positive nitrites, no glucose. trace ketones, moderate bilirubin, 30 red blood cells, 14 white blood cells, occasional bacteria. urine culture was negative. arterial blood gases on the on 40% face mask 7.27, 90 and 60. also, later that day, 7.29, 81 and 60. on , first arterial blood gas 7.24, 102 and 96. second arterial blood gas 7.30, 83, 37 on room air. there was a question of this arterial blood gas being a venous blood gas. imaging: chest x-ray on the 21st showed congestive heart failure, ill defined density of the left base which may represent early pneumonia. portable on following lasix showed a limited radiograph due to position and body habitus with apparent elevation of the left hemidiaphragm, the left upper extremity ultrasound limited bilateral lower extremity duplex venous exam without evidence of deep venous thrombosis. electrocardiogram showed tachycardia at 103, normal intervals, r-axis deviation, diffuse low voltage, s in 1, q in 3, no t-wave inversion in 3, q in avf, q-wave flattening in avl. there was a question of precordial lead reversal of v2 and v3 with v4 and v5. no acute ischemic st-t wave changes were noted. no right atrial enlargement, no evidence of right ventricular hypertrophy. hospital course: the patient was transferred from the emergency department to the micu because of hypoxia and hypercapnia. while in the micu, she was maintained on oxygen during the day, either nasal cannula or face mask. she was placed on bipap overnight. on , she refused bipap. her oxygen saturations were in the high 80s to low 90s while in the micu. this likely represents her baseline. blood gases were stable with pco2s ranging in the 70s to 100s. the patient tolerated this well and denied symptoms of shortness of breath or chest pain. vq scan was done to address the question of pulmonary embolus. it was also suboptimal. it showed no evidence of perfusion defects. the patient was treated for three days with ciprofloxacin for urinary tract infection in addition to her ancef for the breast cellulitis. left breast ultrasound demonstrated soft tissue edema along the left lateral chest wall, fluid tracking along the fascial planes. several small fluid pockets, the largest of which was 2.8 x 1.2 x 0.8 cm. echocardiogram showed a dilated right ventricle, hypokinetic right ventricular free wall, left ventricular wall thickness cavity and abnormal septal wall motion position consistent with right ventricular pressure volume overload, tricuspid and mitral regurgitation which could not be quantitated. pulmonary artery pressure could not be determined. the patient remained stable while in the intensive care unit. her blood gases continued to remain with pco2s in the 70s to 100s. her o2 saturations were high 80s to low 90s. her cardiovascular function was not an active issue during this admission. the patient remained afebrile on ancef and was switched to keflex on . the patient was transferred to the regular medical floor 12 on . she continued to refuse bipap. no repeat blood gases were performed. the patient remained stable from a pulmonary point of view. the patient had a mammogram while on the regular medical floor. it was technically inadequate secondary to the patient's body habitus and motion artifact and the patient's inability to stand straight. there were no lesions suspicious for neoplasm noted, however. a repeat mammogram should probably be scheduled in the future for this patient. this patient was seen by the nutrition consult who recommended and 1800 kilocalorie diabetic diet, even though the patient is not diabetic. she would definitely benefit from weight loss which would improve her functional status and her pulmonary status. the patient was seen by physical therapy who recommended continued rehabilitation. the patient is being discharged to for continued rehabilitation on . discharge medications: 1. colace 100 mg po tid 2. saline nasal spray 0.4 1 to 3 sprays each nostril qid prn 3. lactulose 30 cc po bid 4. debrox otic 6.5% 10 drops left ear 5. keflex 500 mg po qid until for treatment of left breast cellulitis 6. milk of magnesia 30 cc po qid 7. motrin 800 mg po q6h prn 8. lasix 20 mg po qd 9. heparin 5000 units subcutaneous 10. aspirin 325 mg po qd discharge diagnoses: 1. obstructive sleep apnea 2. obesity hypoventilation syndrome 3. left breast cellulitis 4. right heart failure discharge instructions: the patient has been instructed to follow up with dr. at community health center, telephone (/pager . if the patient is unable to reach this physician, will follow up with dr. at , telephone (. the patient should follow up within one week to 10 days of discharge for evaluation for left breast cellulitis.the patient was informed that she needs a f/u ultrasound of her left breast after her course of antibiotics. dr. was called and a message was left on her voicemail and with her staff informing her of the necessity of this f/u examination of the patient's breast. dr. phone number and pager number were also left with dr. and she was asked to call if she had any questions. , m.d. dictated by: medquist36 d: 13:43 t: 13:47 job#: Procedure: Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Acidosis Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified sleep apnea Morbid obesity Diseases of tricuspid valve Inflammatory disease of breast Osteoarthrosis, unspecified whether generalized or localized, lower leg

allergies: nitroglycerin attending: chief complaint: right arm and leg weakness major surgical or invasive procedure: mri brain, mra head and neck ct head ct c-spine carotid us history of present illness: patient was admitted to neurology after presenting with acute onset of r arm and leg weakness with significant resolution of deficits. according to patient, he had full strength at discharge. during that admission, mri revealed a small acute stroke in the l anterior centrum semiovale and a large old l frontal stroke. carotid us showed 70-79% stenosis. echo showed no thrombus. he was taking aspirin at time of stroke and plavix was added. however, abnormal signal of the clivus on mri prompted a a bone scan which revealed multiple foci of abnormal uptake in long bones. this led to a torso ct which showed b/l infiltrating renal masses. his antiplatelets were stopped in anticipation of a biopsy which was performed , results of which are pending. he has remained off any aspirin or plavix since. he went to sleep at 1am this morning with normal strength. he woke at 730am and fell when trying to get out of bed, with r arm and leg weakness. after about 30 minutes, he was able to get up, eat breakfast, and then drive his cab. his details are somewhat unclear based on his account, but he called 911 at some point when his weakness was not improving. he arrived at at 11am code stroke page went out at 1116am. i arrived at 1120am and he was in ct scanner. when ct scan completed, he complained of r arm and leg weakness and numbness but denied visual changes, facial weakness, dysarthria, dysphagia, l sided symptoms, fever, sob, cp, palpitations, headache or neck pain. past medical history: 1) l centrum semiovale stroke 2) l frontal stroke on mri 3) htn 4) hypercholesterolemia 5) s/p cabg 6) gout 7) dm 8) b/l 70-79% ica stenosis 9) b/l renal masses social history: cab driver lives alone occassional etoh (drinks scotch every few months) hx of 50 pack year smoking, quit several years ago physical exam: vitals 97.8 bp 119/56 p 67 r 19 o2 sat 99% general: well nourished, in no acute distress heent: ncat neck: supple, no carotid bruits lungs: clear to auscultation cv: regular rate and rhythm. no m/g/r back: pinpoint scab at l renal biopsy site. no hematoma. neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, month, day, and date attention: can say days of week backward with 1 self corrected omission. language: fluent, no dysarthria, no paraphasic errors, reptition and comprehension intact, names items on stroke card (not hammock or feather). intact. unable to write due to weakness. cranial nerves: visual fields are full to confrontation. pupils equally round and reactive to light, 3 to 2 mm bilaterally. extraocular movements intact, no nystagmus. facial sensation and facial movement normal bilaterally. hearing decreased to finger rub bilaterally. midline, no fasciculations. sternocleidomastoid and trapezius normal bilaterally. motor: increased tone in legs bilaterally. no tremor. d t b wf we fif hf he kf ke af ae tf te right 5- 5- 5 4 3 4 0 5- 5 5 5 5 5 5 5 left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 right pronator drift sensation was intact to light touch. stocking glove loss to pin prick and temperature. absent vibration in toes. reflexes: b t br pa pl right 2 2 2 1 tr left 1 1 1 1 tr toes were downgoing l, mute r coordination is normal on finger-nose-finger on l gait was not assessed pertinent results: 04:00am blood wbc-10.3 rbc-3.64* hgb-8.8* hct-28.7* mcv-79* mch-24.3* mchc-30.7* rdw-22.0* plt ct-292 04:00am blood plt ct-292 04:00am blood pt-12.9 ptt-26.6 inr(pt)-1.1 04:00am blood glucose-90 urean-50* creat-1.2 na-141 k-5.3* cl-114* hco3-19* angap-13 06:46pm blood ck-mb-notdone ctropnt-<0.01 04:00am blood ck-mb-notdone ctropnt-<0.01 04:00am blood calcium-8.7 phos-3.6 mg-1.6 cholest-88 04:00am blood %hba1c-5.9 -done -done 11:10am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:00am blood triglyc-190* hdl-18 chol/hd-4.9 ldlcalc-32 ct: small areas of low attenuation visualized in the left centrum semiovale. there is white matter area just anterior to the left lateral ventricle and a small area in the left caudate nucleus. these areas were not clearly visualized on the prior study. however, they do not appear to be of acute nature. an old infarct is also visualized in the left frontal cortex, unchanged in appearance since the prior study. there is no evidence of hydrocephalus, shift of normally midline structures or new acute major territorial infarction. the surrounding soft tissue and osseous structures appear unremarkable. mri increased diffusion-weighted imaging sequence signal located in the left parietal lobe, head of the putamen on the left side and basal ganglia on the right side. these are consistent with acute infarction. an area of increased flair/t2 signal is visualized in the left parietal lobe consistent with an old infarction, unchanged in appearance since the prior study. an area of increased dwi signal is also visualized in the left centrum semiovale, unchanged since the prior study. mra severe stenosis at the origin of the right internal carotid artery and a moderate stenosis at the left ica origin. this appearance has not changed since the previous study. there is a stenosis of the a1 segment of the right anterior cerebral artery. there are no other hemodynamically significant stenoses of the visualized vasculature. carotid us: rt: 70-79% lt: 60-69% tee: small secundum atrial septal defect. simple atheroma in the descending aorta and aortic arch. basal inferior left ventricular aneurysm/dyskinesis. brief hospital course: 75yo man recently admitted to stroke for acute r arm and leg weakness found to have small l cso stroke and made a full recovery. workup at that time showed b/l 70-90% carotid stenoses, b/l renal masses of unclear etiology. asa, plavix held for renal biopsy, done . presented with r arm and leg weakness and fall. had fluctuating deficits ranging from rue weakness (4+/5) to plegia. mri showed several small strokes bilaterally (left>right). mra showed carotid stenoses but adequate distal flow. there was intitial concern for hypoperfusion in setting of carotid stenosis, although symptoms not clearly bp dependent. he was admitted to icu for q1hr checks. unable to achieve goal sbp of 130-150 with ivf. he was started on neosynephrine briefly for waxing and deficits. no significant change. he was started on anticoagulation with iv heparin as the most likely etiology of his strokes was felt to be cardioembolic +/- hypercoagulable state from unknown malignancy. he was transferred to the neurology step down unit for close neuro observation. throught the remainder of his admission, his exam was stable. he had a repeat carotid us which showed: rt ica 60-79% lt ica 60-69% (no change from previous). he had a tee which showed an asd with asa and mild right to left shunt with valsalva. he was transitioned to lovenox and coumadin. he should have his inr checked in several days and dose should be adjusted for goal inr 2.0-3.0. he ruled out for mi with negative cardiac enzymes x3. tee was done (results noted above). cholesterol level was normal, hdl was low. antihypertensives were held in setting of acute stroke. he was continued on lipitor. he had a renal biopsy prior to admission () to evaluate for possible lymphoma given multiple renal masses found on previous admission. prelim path results suggest a reactive process/ inflammation (cells were polyclonal) his blood sugars have been fairly well controlled on insulin sliding scale; his hba1c was 5.9. he was restarted on outpaient dose of metformin prior to discharge medications on admission: 1) iron 150mg qd 2) allopurinol 150mg qd 3) simvastatin 40mg qd 4) atenolol 25mg qd 5) lisinopril 10mg qd 6) lasix 20mg qd 7) metformin 850mg 8) insulin (70/30) 28 units am and 20 units pm discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. warfarin sodium 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 3. enoxaparin sodium 80 mg/0.8 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours). disp:*20 syringe* refills:*2* 4. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 5. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. metformin 850 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: left-sided cerebral infarction discharge condition: strength in right arm improved discharge instructions: discharge to acute rehab followup instructions: 1. primary care: patient is to call insurance and change pcp at 2pm (dr. , preceptor ...this is new pcp) building south suite. 2. provider: , .d. where: neurology phone: date/time: 1:30 Procedure: Monitoring of cardiac output by other technique Diagnoses: Anemia, unspecified Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Ostium secundum type atrial septal defect Personal history of other diseases of circulatory system Long-term (current) use of insulin Unspecified disorder of kidney and ureter Cerebral embolism with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction

allergies: nitroglycerin attending: chief complaint: iscemic leg major surgical or invasive procedure: 1. abdominopelvic arteriogram. 2. procedure: a. bilateral groin explorations. b. left superficial femoral artery and profunda thrombectomy. c. thrombectomy of femoral-femoral graft. d. patch angioplasty of left common femoral artery. history of present illness: the patient is a 76 year-old male with past medical history of peripheral disease as well as multiple strokes, hypercholesterolemia, status post carotid endarterectomy who presented with acute left lower extremity ischemia. past medical history: 1. dmii, last hga1c 5.9% 2. cad s/p cabg x3+x2 last 3. h/o embolic cva, source not identified 4. mild , 50-55% in 5. htn 6. copd 7. hypercholesteroemia 8. gout 9. amarousis fugax. 10. pvd s/p l cea in , now with r carotid stenosis 80% 11. 3 prior cva thought d/t l carotid stenosis 12. h/o gib social history: cab driver lives alone occassional etoh (drinks scotch every few months) hx of 50 pack year smoking, quit several years ago family history: no strokes or seizures. multiple family members with mi. physical exam: pe: afvss neuro: perrl / eomi mae equally answers simple commands neg pronator drift sensation intact to st 2 plus dtr neg babinski heent: ncat neg lesions nares, oral pharnyx, auditory supple / farom neg lyphandopathy, supra clavicular nodes lungs: cta b/l cardiac: rrr without murmers abdomen: soft, nttp, nd, pos bs, neg cva tenderness ext: pulses: l palp pt, dop dp. r dop pt/dp. groin c/d/i pertinent results: wbc-8.0 rbc-3.47* hgb-10.1* hct-30.7* mcv-88 mch-29.0 mchc-32.7 rdw-16.6* plt ct-316 plt ct-316 glucose-130* urean-24* creat-1.0 na-137 k-4.2 cl-107 hco3-22 angap-12 ck(cpk)-53 calcium-7.7* phos-3.4 mg-1.6 glucose-122* lactate-1.4 na-138 k-4.6 cl-110 hgb-9.3* calchct-28 cardiology report ecg sinus bradycardia with first degree a-v block. left atrial abnormality. intraventricular conduction defect. inferior myocardial infarction, age undetermined. lateral st-t wave changes may be due to myocardial ischemia. low qrs voltages in the precordial leads. since the previous tracing the rate is slower. intervals axes rate pr qrs qt/qtc p qrs t 55 6 101 cardiology report echo study date of measurements: left atrium - long axis dimension: *4.3 cm (nl <= 4.0 cm) left atrium - four chamber length: *6.1 cm (nl <= 5.2 cm) right atrium - four chamber length: *5.4 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.5 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 35% to 40% (nl >=55%) aorta - valve level: 3.4 cm (nl <= 3.6 cm) aortic valve - peak velocity: 1.5 m/sec (nl <= 2.0 m/sec) aortic valve - pressure half time: 704 ms mitral valve - e wave: 1.3 m/sec mitral valve - a wave: 1.0 m/sec mitral valve - e/a ratio: 1.30 mitral valve - e wave deceleration time: 189 msec tr gradient (+ ra = pasp): *35 mm hg (nl <= 25 mm hg) left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv cavity size. moderately depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic root diameter. aortic valve: mildly thickened aortic valve leaflets (3). trace ar. mitral valve: mildly thickened mitral valve leaflets. moderate thickening of mitral valve chordae. calcified tips of papillary muscles. moderate to severe (3+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild pa systolic hypertension. pericardium: no pericardial effusion. conclusions: 1. the left atrium is mildly dilated. 2. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed. posterior and apical akinesis with lateral hypokinesis is present. 3. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. 4. the mitral valve leaflets are mildly thickened. there is moderate thickening of the mitral valve chordae. moderate to severe (3+) mitral regurgitation is seen. 5. there is mild pulmonary artery systolic hypertension. 6. compared with the report of the prior study (images unavailable for review) of , lv function has deteriorated. 8:31 pm chest (pre-op pa & lat) comparison: . pa and lateral chest radiographs: cardiomediastinal and hilar contours appear unchanged. again noted is calcification within the aorta. again seen are median sternotomy wires. pulmonary vascularity appears within normal limits. no focal consolidations are seen within the lungs. there is no evidence of pleural effusions. impression: no evidence of acute cardiopulmonary disease. brief hospital course: the patient as placed on heparin drip and underwent angiogram which showed occlusion of his common femoral artery on the left. a proposed fem-fem bypass was recommended. the patient, however, has had previous surgery with bilateral groin explorations and it was unclear whether he has had a previous fem-fem bypass or peripheral distal bypass. therefore, groin exploration and possible fem- fem bypass is recommended. the patient agreed to proceed to surgery. risks and benefits were explained and he consented. the patient agreed to the below procedure: procedure: 1. bilateral groin explorations. 2. left superficial femoral artery and profunda thrombectomy. 3. thrombectomy of femoral-femoral graft. 4. patch angioplasty of left common femoral artery. pt tolerated the procedure well, there were no complications. pt extubated in the or. transfered to the pacu in stable condition. once recovered from anesthesia. pt transfered to the vicu in stable condition. pt had normal post operative recovery. on dc, pt is stable. taking po / ambulating / urinating / pos bm medications on admission: protonix, metformin 850", 70/30 28 u qam, 20 u qpm, lasix 40', lisinopril 10', feso4, lipitor 20', asa 81', allopurinol 300', atenolol 50' . discharge medications: 1. atorvastatin 20 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). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 5. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 6. hydrocodone-acetaminophen 5-500 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. metformin 850 mg tablet sig: one (1) tablet po bid (2 times a day). 9. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 10. insulin fingerstick qachs insulin sc fixed dose orders breakfast dinner 70 / 30 14 units 70 / 30 10 units insulin sc sliding scale breakfast lunch dinner bedtime regular glucose insulin dose 0-75 4 oz oj 76-110 mg/dl 0 units 0 units 0 units 0 units 111-160 mg/dl 2 units 2 units 2 units 2 units 161-200 mg/dl 4 units 4 units 4 units 4 units 201-240 mg/dl 6 units 6 units 6 units 6 units 241-280 mg/dl 8 units 8 units 8 units 8 units > 280 mg/dl notify m.d. 11. 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: left leg ischemia. discharge condition: stable discharge instructions: discharge instructions following leg bypass surgery this information is designed as a guideline to assist you in a speedy recovery from your surgery. please follow these guidelines unless your physician has specifically instructed you otherwise. please call our office nurse if you have any questions. dial 911 if you have any medical emergency. activity: there are no specific restrictions on activity. you should be as active as is comfortable. some fatigue is expected for the first several weeks. leg swelling is typical following this type of surgery and can be controlled by elevating your leg above the level of your heart when you are not walking. please call us immediately for any of the following problems: redness in or drainage from your leg wound(s). new pain, numbness or discoloration of your foot or toes. watch for signs and symptoms of infection. these are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. if you experience any of these or bleeding at the incision site, call the doctor. exercise: limit strenuous activity for 4 weeks. no heavy lifting greater than 20 pounds for the next 7 days. no driving. bathing/showering: you shower immediately upon coming home. no bathing. a clear dressing may cover your leg incision and this should be left in place for three (3) days. remove it after this time and wash your incision(s) gently with soap and water. dissolving sutures, which do not have to be removed, were probably used. if you have staples these will be removed on your follow-up appointment. wound care: sutures / staples may be removed before discharge. if they are not, an appointment will be made for you to return for removal. when the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. these will stay on about a week and you may shower with them on. if these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. medications: unless told otherwise you should resume taking all of the medications you were taking before surgery. you will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (check with your physician if you have fluid restrictions.) if you feel that you are constipated, do not strain at the toilet. you may use over the counter metamucil or milk of magnesia. appetite suppression may occur; this will improve with time. eat small balanced meals throughout the day. cautions: no smoking! we know you've heard this before, but it really is an important step to your recovery. smoking causes narrowing of your blood vessels which in turn decreases circulation. if you smoke you will need to stop as soon as possible. ask your nurse or doctor for information on smoking cessation. avoid bending for 4-6 weeks. no strenuous activity for 4-6 weeks after surgery. diet : there are no special restrictions on your diet postoperatively. poor appetite is expected for several weeks and small, frequent meals may be preferred. for people with problems we would recommend a cholesterol lowering diet: follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and ldl (low density lipoprotein-the bad cholesterol). exercise will increase your hdl (high density lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. you may be self-referred or get a referral from your doctor. if you are overweight, you need to think about starting a weight management program. your health and its improvement depend on it. we know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. if interested you can may be self-referred or can get a referral from your doctor. if you have diabetes and would like additional guidance, you may request a referral from your doctor. follow-up appointment: be sure to keep your medical appointments. the key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. don't let them go untreated! please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. this should be scheduled on the calendar for seven to fourteen days after discharge. normal office hours are 8:30-5:00 monday through friday. please feel free to call the office with any other concerns or questions that might arise. followup instructions: call dr at . schedule an appointment for 2 weeks. provider: (nhb) date/time: 1:30 provider: , surgery (nhb) date/time: 2:00 Procedure: Other revision of vascular procedure Arteriography of femoral and other lower extremity arteries Incision of vessel, lower limb arteries Arteriography of other intra-abdominal arteries Arteriography of renal arteries Resection of vessel with replacement, lower limb arteries Diagnoses: Anemia, unspecified Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atherosclerosis of native arteries of the extremities with intermittent claudication Gout, unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of other diseases of circulatory system Old myocardial infarction Embolism and thrombosis of iliac artery Atherosclerosis of unspecified bypass graft of the extremities

allergies: ativan / tetracycline attending: chief complaint: infected catheter major surgical or invasive procedure: tunneled dialysis catheter placement on history of present illness: 61 yo man with esrd on hd, dm1, cad p/w fevers, chills, night sweats x 1 day. of note, had r subclavian tunnel cath placed weeks ago and patient c/o some discomfort at line site. he denies sob, chest pain, abdominal pain, dysuria. does have diarrhea but is being treated for c. diff colitis (flagyl day ). in ed, pus noted to be coming out of tunnel cath site, fever 100.5, lactate 4.3, leukocytosis. code sepsis called when patient became tachycardic. tunnel cath pulled and l ij sepsis line placed. in pt. received vanco and gent and 100 ml ivf. past medical history: - esrd on hd mwf - dm 1 or 2 c/b pvd, cad, esrd - bilateral bkas - cad s/p cabg - clot in l arm av graft - no longer functioning - r sc tunnel cath placed - s/p mssa bacteremia - htn - h/o vre, mrsa social history: lives in with his mother. a retired pharmacist. never smoked, rare etoh use. family history: mother and father with dm, father with pvd. no h/o cad. physical exam: tm 100.5, hr 90, bp 95/57, 95% on 2l nc at rate 20 gen - nad, a&ox3 heent - perrl neck - no jvd, no lad heart - distant, rrr, nl s1s2, no m/r/g lungs - ctab abd - obese, soft, nt, nabs ext - b/l bka, no ulcers, no edema, digital ulcer r finger pertinent results: 01:30pm wbc-13.1*# rbc-3.22* hgb-11.2* hct-33.3* mcv-103* mch-34.8* mchc-33.6 rdw-16.1* 01:30pm neuts-95.6* bands-0 lymphs-2.4* monos-1.5* eos-0.3 basos-0.1 01:30pm pt-14.2* ptt-24.9 inr(pt)-1.3 01:30pm plt smr-normal plt count-165 01:30pm glucose-128* urea n-66* creat-7.6*# sodium-138 potassium-5.1 chloride-91* total co2-30* anion gap-22* 01:30pm calcium-10.0 phosphate-3.0# magnesium-2.0 01:48pm glucose-142* lactate-4.3* 04:33pm urine blood-mod nitrite-neg protein-100 glucose-250 ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 04:33pm urine color-straw appear-clear sp -1.014 04:33pm urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0-2 06:17pm ld(ldh)-212 06:21pm lactate-1.8. . cxr no acute cardiopulmonary abnormality. cardiomegaly. . tte 1. the left atrium is moderately dilated. the left atrium is elongated. 2.the right atrium is moderately dilated. 3.there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is probably normal (lvef>55%) but given the limited views, difficult to be sure. 4.right ventricular chamber size is normal. right ventricular systolic function is normal. 5.the aortic root is moderately dilated. 6.the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. 7.the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. no masses or vegetations are seen on the aortic valve. 8.there is mild pulmonary artery systolic hypertension. 9.there is no pericardial effusion. . tee 1. the left atrium is moderately dilated. 2. there is mild global left ventricular hypokinesis. 3. right ventricular function is depressed. 4. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 5. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. 6. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. 7. there is no pericardial effusion. . mri of upper ext and veins findings: thoracic aorta is normal in appearance, without evidence of aneurysm or dissection. at the level of the pulmonary artery bifurcation, in the axial plane, the ascending thoracic aorta measures 2.7 cm in diameter, and the descending thoracic aorta measures 2.4 cm. incidental note is made of bovine arch anatomy. no evidence of stenosis or occlusion of the arch vessels. both common carotid arteries are likewise widely patent. there is thrombus within the right internal jugular vein, extending into the superior vena cava. an approximately 7 cm length of right internal jugular vein and superior vena cava is involved. right subclavian vein is patent, as well as the right external jugular vein. tubular filling defects are seen within the left subclavian vein and left internal jugular vein, corresponding to central lines, as previously shown on chest x-ray dated . minimal areas of irregularity within the left brachiocephalic vein may represent clot surrounding one of the central lines. additionally, there is suggestion of expansion of an approximately 1 cm long segment of the distal left internal jugular vein surrounding the catheter, which may represent a small focus of thrombus surrounding a central line. left subclavian vein is patent, though appears somewhat attenuated within the level of the expected area of the basilic vein. no mediastinal adenopathy. no gross pleural effusion. multiplanar reconstructions confirm the above findings, and were essential for diagnosis. impression: 1.non occlusive thrombus within the right internal jugular vein, extending into the superior vena cava. 2. left subclavian and left internal jugular venous central lines in place, with likely areas of clot within the left internal jugular vein as described, and possibly a small focus of thrombus surrounding one of the central lines, within the left brachiocephalic vein. brief hospital course: 61 yo man with esrd on hd, dm 2, cad presents with line sepsis. . 1) line sepsis - patient presenting with signs of symptoms of line infection. blood cultures and cath tip returned with mrsa. a temp groin cath was placed at ir for hd. patient was started on vanc and was still febrile for 3 days. his cultures cleared on and remained negfative for the rest of the admission. patient was ruled out for endocarditis with a negative tte and negative tee . he required central access for meds. on he had a tunneled cath placed for hd access. . 2) bilateral ij clot - in the work up to receive his tunneled cath patient was found on mra to have clot inn both of his ij's. he was started on heparin gtt and coumadin. the patient was sent out on coumadin and heparin was stopped once therapeutic. . 3) dm 2 - continued on glipizide and iss . 4) cad s/p cabg - no symptoms of ischemia. continued on asa, zocor, and lopressor. . full code medications on admission: - flagyl completed 10 days - asa 325 mg po qd - lopressor 25 mg po bid - zocor 40 - zestril 5 - insulin - glipizide 7.5 mg qam and 5 mg po qpm - nephrocaps 1 po qd - phoslo 667 mg po tid discharge medications: 1. warfarin sodium 1 mg tablet sig: six (6) tablet po at bedtime: ask doctor to adjust dose based on your blood tests (inr). disp:*180 tablet(s)* refills:*2* 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. insulin regular human 100 unit/ml solution sig: one (1) unit injection asdir (as directed): continue home regimen. 4. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 7. glipizide 5 mg tablet sig: 1.5 tablets po q am (). disp:*45 tablet(s)* refills:*2* 8. glipizide 5 mg tablet sig: one (1) tablet po q pm (). disp:*30 tablet(s)* refills:*2* 9. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 10. sevelamer hcl 800 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: -bacteremia from dialysis catheter line infection with methicillin resistant staph aureus -diabetes mellitus type 1 -end-stage renal disease on hemodialysis -hypertension -coronary artery disease discharge condition: stable discharge instructions: please take all medciations and make all appointments as listed in the discharge paperwork. if you have any fevers, chills, or pain/redness around your line site, please call dr. or come to the hospital. followup instructions: -follow-up with primary care physician 1-2 weeks -have blood work sent to check your blood thinner level (inr) -provider: , md where: lm center phone: date/time: 1:00 -provider: , md where: lm center phone: date/time: 10:30 -provider: , m.d. where: cardiac services phone: date/time: 10:30 Procedure: Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Removal of other device from thorax Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Coronary atherosclerosis of native coronary artery Infection with microorganisms resistant to penicillins Aortocoronary bypass status Methicillin susceptible Staphylococcus aureus septicemia Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Infection and inflammatory reaction due to other vascular device, implant, and graft Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Hypercalcemia Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Other atherosclerosis of native arteries of the extremities

allergies: ativan / tetracycline attending: chief complaint: fever major surgical or invasive procedure: 1. tunnelled catheter placement 2. history of present illness: 61yo end stage renal disease on hemodialysis, cad s/p cabg, pvd s/p bilateral bkas, recents mrsa line sepsis who presents from hd with fever and suspected recurrent line sepsis. . patient reports on wednesday having stomach discomfort. he states he felt like he did with previous line infections. patiends tunneled line was placed on . he checked his temperature which was 101.3. on thursday he had partial session (2hours) but was ended early due to his fever/lightheadedness/nausea. his temperature was noted to be 103. in hemodialysis he recieved vancomycin was given at hd and he then transfered to ed. . in , pt recieved 2 liters iv fluids and was started on gentamycin. his sbp went to 60's so periheral dopa was started with improvement of pressures. multiple attempts at central access were made but without success. renal consultation was done with no indication for emergent hd. renal approved use of hd catheter for temporary access. . in micu, patient had aggressive fluid, continued on vanco and gent, renal consulted. heparin started past medical history: - esrd on hd mwf - dm 1 or 2 c/b pvd, cad, esrd - bilateral bkas - cad s/p cabg - clot in l arm av graft - no longer functioning - r sc tunnel cath placed - s/p mssa bacteremia - htn - h/o vre, mrsa social history: lives in with his mother. a retired pharmacist. never smoked, rare etoh use. family history: mother and father with dm, father with pvd. no h/o cad. physical exam: pe: temp 98.2 bp 118/62 84 gen: nad, obese man, flushed face lungs: cta no w/r/r chest: right subclavian line without evidence of infection heart: rrr no m/r/g abd; soft nontender ext: s/p bilat bka neuro: cn ii-xii intact, cerbellar function intact pertinent results: 10:30pm urine color-straw appear-hazy sp -1.014 10:30pm urine blood-sm nitrite-neg protein-100 glucose-100 ketone-tr bilirubin-neg urobilngn-neg ph-8.0 leuk-mod 10:30pm urine sperm-mod 10:00pm type-art po2-187* pco2-41 ph-7.48* total co2-31* base xs-7 intubated-not intuba comments-green top 09:50pm glucose-249* urea n-48* creat-7.2*# sodium-137 potassium-5.8* chloride-95* total co2-26 anion gap-22* 09:50pm alt(sgpt)-11 ast(sgot)-15 ld(ldh)-198 ck(cpk)-164 alk phos-70 tot bili-0.8 09:50pm ck-mb-2 ctropnt-0.10* 09:50pm calcium-8.6 phosphate-4.6* magnesium-1.6 09:50pm wbc-14.5*# rbc-3.93* hgb-13.1* hct-36.3* mcv-92 mch-33.2* mchc-36.0* rdw-14.6 09:50pm neuts-93* bands-3 lymphs-1* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 09:50pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 09:50pm plt smr-normal plt count-125* 09:50pm pt-22.8* ptt-31.1 inr(pt)-3.4 06:25pm lactate-4.9* k+-6.8* brief hospital course: 61yo male with esrd on hd, bilateral ij clots on coumadin, cad s/p cabg, mrsa sepsis who presents with sepsis. transferred from micu to floor on . 1) sepsis- sirs (initial lactate of 4.9), in micu pt give iv fluids. recieved depo in ed. switched to levofed in micu. off pressors as of . line resited to right subclavian w/ central access available . gent was d/c on . mrsa + in blood cx , now on vanc and gent for synergy. dosed gent after hd. hd catheter re-sited on r side. spiked and has gpc's from also, most likely transient bacteremia during line change. tee done showed no evidence of endocarditi. ct abodmen showed hypo attenuating lesion in the head of pancreas with possible dilatation of the pancreatic duct. this can be further evaluated with mrcp as it could represent ipmt or a cyst. mrcp was ordered, however patient refused study. he will be scheduled for outpatient mrcp with ourpatient gi follow up. patient will continue vanco (level dosed) per id rec for 6 wks, 2) renal - renal consulted in ed. pt got new tempory r sc line . recieved uf on (). perma cath placed monday . patient continued sevelamer, ca carbonate, nephrocaps. in future plan for transplant surgery to evaluate pt for possible kidney transplant . 3)fen- metabolic alkalosis on admission, recieved over 7l in micu. patient was continued cardiac diabetic diet . 4)cad-enzymes negative.continue aspirin, statin. patient restarted on metroprolol and lisinopril with holding parameters systolic <90 . 6)gi- patient continued anti-emetics for nausea. patient also recieved ppi. . 7)hem -thrombocytopenia-may be due to sepsis. daily cbc were checked to monitor platlets. . 9) bilateral ij clots- hep gtt. patient continued on heparin. he started coumadin on . he remained hospitalized until his coumadin became theurpetic (inr 2.0-3.0) . 10) respiratory- in icu patient has desaturated less than 90 on room air. on floor patient longer required oxygen . 11) dm ii- patient restarted glipizide on the floor with sliding scale . 12) access: line resited to r subclav and replaced over wire , cxr on to check placement of subclavian. subclavian line to be replaced ir . patient also has peripherial line. . medications on admission: 1. warfarin sodium 1 mg qd 2. simvastatin 40 mg qd 3. insulin regular human 100 unit/ml . 4. b complex-vitamin c-folic acid 1 mg qd 5. metoprolol tartrate 25 mg 6. lisinopril 5 mg qd 7. glipizide 5 mg 8. calcium acetate 667 mg tid with meals 9. sevelamer hcl 800 mg po tid discharge medications: 1. warfarin sodium 5 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 2. glipizide 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 3. glipizide 5 mg tablet sig: 1.5 tablets po qam (once a day (in the morning)). 4. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). 8. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. vancomycin 1,000 mg recon soln sig: one (1) gram intravenous at hemodialysis for 6 weeks: have vancomycin level checked and if level <15 give 1g vancomycin. disp:*qs * refills:*0* 11. outpatient lab work have pt, ptt levels checked. your doctors be adjusting your coumadin based on this. 12. outpatient lab work have vancomycin level drawn at hd sessions and if level <15 administer 1 gram vanco. discharge disposition: home discharge diagnosis: 1. line infection 2. tunnelled catheter placement discharge condition: stable discharge instructions: continue taking all medications as prescribed. return to the hospitals if you have any further fevers, nausea, vomiting, shortness of breath or other concerning symptoms. have your vanco level checked and dosed at hemodialysis. have your inr checked each week and called to dr. to adjust your coumadin dosage. followup instructions: provider: , md where: building ( complex) phone: date/time: 10:00 provider: west,room two gi rooms where: gi rooms date/time: 10:00 provider: , md where: phone: date/time: 9:00 Procedure: Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Diagnoses: Thrombocytopenia, unspecified Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Abnormal coagulation profile Severe sepsis Infection with microorganisms resistant to penicillins Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Methicillin susceptible Staphylococcus aureus septicemia Pulmonary collapse Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Alkalosis Septic shock Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Home accidents Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy

allergies: ativan / tetracycline attending: chief complaint: fever and hypotension major surgical or invasive procedure: hemodialysis placement and removal of several temporary hd catheters placement of permanent hd line tee history of present illness: hpi: 62 yo m w/ h/o esrd on hd, cad s/p cabg, pvd s/p bilateral bka, and h/o mrsa () / mssa () / and fungal () line sepsis a/w f x 1 day. patient reports onset of fevers this am. bs have been well controlled on his po meds. he called his doctor and was told to go to the er given his h/o line infections. patient's most recent bacteremia was in . patient was tx w/ ambisome x 2 weeks via a picc. his line was changed just 6 weeks ago. of note, patient has difficult access and has bilateral ij clots. of note, patient has been having hypotn at and has thus been on reduced doses of his bp meds x 2 weeks. he denies cough, sob, n, v, d, abd pain, dysuria, catheter tenderness, or rash. no pain/erythema surrounding old clotted graft site. in ed, patient spiked t 102.3, dropped his bp to 97/60 despite ivfs, and desat'd to 88% on ra. vanc, levo, and flagyl were administered and he has received a total of 4 l ns. initial lactate 3.9 but trended down to 2.0 w/ ivfs. despite ivf, he required very low dose levophed to maintain map > 65. . all: ativan, tetracycline -> lip swelling past medical history: pcp: ## esrd on hd (south suburban, , mwf) - considering tx in future thus no current plan for fistula/graft to replace lines despite recurrent line infxns; makes good urine ( pint - pint qd) ## cad s/p cabg ## pvd s/p bilateral bka ## h/o mrsa line sepsis and - tunneled line replaced , tee : neg for veg, tx w/ 6 weeks vanc ## t1dm ## h/o l arm av graft, clotted ## h/o mssa bacteremia ## htn ## bilateral ij clots, on coumadin ## pancreatic cysts w/ plan for outpatient ct and op f/u ## chf: echo - ef 55%, 1+ mr #h/o fungal line sepsis: (), tx w/ ambisome x 2 weeks via picc, repeat cx and negative, line changed 6 weeks ago ## s/p flu vacc social history: lives in with his mother. a retired pharmacist. smokes occ cigar (1-2 per week), no etoh. family history: mother and father with dm, father with pvd. no h/o cad. physical exam: t 100.1 (tm 102.3) bp 126/60 (min 97/60) hr 103 rr 18 o2 100% on 100% nrb (after desat to 88% on ra)->96% ra fs 112 genrl: in nad, lying on right side due to c/o back pain neck: no jvd cv: rrr, no m/r/g, soft s1/s2 pulm: left tunneled line w/ some surrounding erythema and overlying clot, very minimal bibasilar crackles, no wheeze/ronchi/rhales abd: nabs, soft, nt/nd, no masses/hsm extr: s/p bilateral bka, left upper arm w/ residual graft material but not erythmematous/tender, left femoral line neuro: a, ox3, maew pertinent results: reports: . tee: no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is low normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. . cxr: impression: no pneumonia. interval removal of catheter. . admission labs: . 11:30am urine rbc-0-2 wbc- bacteria-occ yeast-none epi-0-2 11:30am urine blood-tr nitrite-neg protein-30 glucose-250 ketone-neg bilirubin-neg urobilngn-neg ph-9.0* leuk-neg 11:30am urine color-straw appear-clear sp -1.011 11:30am pt-17.7* ptt-28.4 inr(pt)-2.2 11:30am plt count-127*# 11:30am hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-1+ 11:30am neuts-81* bands-8* lymphs-6* monos-4 eos-0 basos-0 atyps-1* metas-0 myelos-0 11:30am wbc-7.8 rbc-3.86*# hgb-12.9*# hct-36.4*# mcv-95 mch-33.5* mchc-35.5* rdw-15.9* 11:30am cortisol-27.1* 11:30am albumin-3.8 calcium-9.4 phosphate-3.4# magnesium-1.8 11:30am ck-mb-2 ctropnt-0.07* 11:30am lipase-27 ggt-16 11:30am alt(sgpt)-13 ast(sgot)-15 ld(ldh)-176 alk phos-84 tot bili-0.6 11:30am ck(cpk)-59 11:30am glucose-131* urea n-55* creat-6.9*# sodium-140 potassium-5.2* chloride-94* total co2-28 anion gap-23* 11:47am lactate-3.9* 05:57pm lactate-2.0 k+-5.7* 07:45pm plt count-111* 07:45pm wbc-6.6 rbc-3.17* hgb-10.5* hct-31.2* mcv-99* mch-33.2* mchc-33.7 rdw-15.9* 07:45pm glucose-62* urea n-53* creat-7.0* sodium-139 potassium-5.1 chloride-99 total co2-26 anion gap-19 . ekg: sinus tachy 103 bpm, 1st degree avb, wide qrs, twi v23 . additional labs: 06:30am blood wbc-6.0 rbc-3.27* hgb-10.8* hct-31.3* mcv-96 mch-32.9* mchc-34.4 rdw-16.0* plt ct-212 06:00am blood wbc-8.4# rbc-3.33* hgb-10.9* hct-33.1* mcv-99* mch-32.8* mchc-33.1 rdw-16.5* plt ct-238 06:23am blood wbc-5.1 rbc-3.04* hgb-10.4* hct-30.6* mcv-101* mch-34.4* mchc-34.2 rdw-15.9* plt ct-206 04:28am blood wbc-4.5 rbc-2.97* hgb-10.0* hct-29.7* mcv-100* mch-33.6* mchc-33.5 rdw-15.6* plt ct-154 03:18am blood wbc-7.9 rbc-3.22* hgb-10.4* hct-31.2* mcv-97 mch-32.5* mchc-33.5 rdw-16.0* plt ct-105* 11:30am blood wbc-7.8 rbc-3.86*# hgb-12.9*# hct-36.4*# mcv-95 mch-33.5* mchc-35.5* rdw-15.9* plt ct-127*# 08:30am blood neuts-77.4* lymphs-16.6* monos-3.7 eos-2.0 baso-0.3 06:00am blood neuts-73* bands-5 lymphs-12* monos-8 eos-1 baso-0 atyps-0 metas-1* myelos-0 06:12am blood pt-13.4* ptt-29.4 inr(pt)-1.2 06:00am blood plt ct-238 05:51am blood plt ct-223 06:27am blood pt-13.7* ptt-28.5 inr(pt)-1.3 06:00am blood plt smr-low plt ct-131* 06:30am blood glucose-204* urean-63* creat-7.7*# na-139 k-4.6 cl-101 hco3-23 angap-20 09:20am blood glucose-269* urean-48* creat-6.6* na-136 k-4.5 cl-98 hco3-23 angap-20 06:50am blood glucose-188* urean-48* creat-6.4*# na-140 k-4.9 cl-103 hco3-22 angap-20 08:30am blood glucose-229* urean-61* creat-7.9*# na-139 k-5.1 cl-101 hco3-21* angap-22* 06:12am blood glucose-164* urean-48* creat-6.8*# na-140 k-4.7 cl-102 hco3-22 angap-21* 08:11am blood glucose-134* urean-60* creat-8.0* na-139 k-5.3* cl-99 hco3-22 angap-23* 06:00am blood glucose-161* urean-52* creat-7.0*# na-139 k-4.9 cl-100 hco3-25 angap-19 05:51am blood glucose-197* urean-88* creat-9.7* na-136 k-5.0 cl-96 hco3-23 angap-22* 02:10am blood glucose-114* urean-53* creat-7.1* na-137 k-5.0 cl-97 hco3-21* angap-24* 06:12am blood alt-4 ast-8 ld(ldh)-128 alkphos-83 totbili-0.3 03:27pm blood ck(cpk)-86 11:30am blood ck(cpk)-59 11:30am blood alt-13 ast-15 ld(ldh)-176 alkphos-84 totbili-0.6 11:30am blood lipase-27 ggt-16 03:27pm blood ck-mb-notdone ctropnt-0.11* 02:10am blood ck-mb-2 ctropnt-0.09* 11:30am blood ck-mb-2 ctropnt-0.07* 06:30am blood calcium-9.4 phos-4.3 mg-1.9 08:30am blood calcium-8.9 phos-5.6* mg-2.1 05:51am blood calcium-9.4 phos-5.6* mg-2.3 04:55am blood calcium-8.3* phos-3.2 mg-2.1 03:27pm blood calcium-8.8 phos-2.5* mg-1.6 11:30am blood cortsol-27.1* 06:12am blood vanco-8.9* 08:11am blood vanco-9.9* 06:00am blood vanco-11.8* 05:51am blood genta-3.4* vanco-16.1* 06:23am blood genta-3.6* vanco-18.1* 04:28am blood genta-3.2* vanco-17.4* 03:18am blood genta-5.4 10:54pm blood type-art po2-75* pco2-45 ph-7.35 calhco3-26 base xs-0 10:35pm blood type-art po2-36* pco2-50* ph-7.32* calhco3-27 base xs-0 08:39pm blood type-art temp-39.7 po2-78* pco2-36 ph-7.43 calhco3-25 base xs-0 intubat-not intuba 01:45am blood type-art temp-38.7 rates-/22 o2 flow-2 po2-84* pco2-37 ph-7.42 calhco3-25 base xs-0 intubat-not intuba comment-nasal 08:39pm blood lactate-2.2* 01:45am blood lactate-2.0 k-4.9 05:57pm blood lactate-2.0 k-5.7* 11:47am blood lactate-3.9* 10:35pm blood o2 sat-63 01:45am blood o2 sat-95 . micro: blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-pending; anaerobic bottle-pending blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final {enterococcus faecalis} sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s chloramphenicol------- =>64 r levofloxacin---------- =>8 r linezolid------------- 2 s penicillin------------ 8 s vancomycin------------ =>32 r blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative blood culture aerobic bottle-final; anaerobic bottle-final negative catheter tip-iv wound culture-final {staphylococcus, coagulase negative} staphylococcus, coagulase negative | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ =>16 r levofloxacin---------- 4 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ 2 s blood culture aerobic bottle-final; anaerobic bottle-final negative catheter tip-iv wound culture-final {staph aureus coag +} staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- 4 r oxacillin------------- 0.5 s penicillin------------ =>0.5 r sputum gram stain-final; respiratory culture-final cancelled blood culture ( myco/f lytic bottle) blood/fungal culture-pending; blood/afb culture-pending blood culture aerobic bottle-final {staph aureus coag +}; anaerobic bottle-final {staph aureus coag +} blood culture aerobic bottle-final {staph aureus coag +}; anaerobic bottle-final {staph aureus coag +} blood culture aerobic bottle-final {staph aureus coag +}; anaerobic bottle-final {staph aureus coag +} staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- 4 r oxacillin------------- 0.5 s penicillin------------ =>0.5 r urine urine culture-final negative brief hospital course: 62 yo male w/ h/o dm, esrd on hd, cad s/p cabg, pvd s/p bilateral bka, and h/o mrsa () / mssa () / and fungal () line sepsis admitted with fever and hypotension. . #. sepsis: pt was transferred to the micu hypotension and decreased o2 sats (secondary to fluid overload and likely line sepsis). pt was treated with low dose levophed for hypotension unresponsive to ivf. he subsequently was taken off pressors and was transferred back to the floor. he satted well on ra during the remainder of the admission. patient had blood cultures from which grew staph aureus (mssa) from dilaysis catheter. cath tip (l femoral line) from grew coag neg staph (oxacillin resistant). blood cx from grew bottles with vre (linezolid resistant). pt had been on vanco (dosed by level) for most of his hospital stay to treat his mssa line sepsis, however this was switched to linezolid once pt grew vre from his blood. the linezolid was subsequently d/c'd, as the vre was found to be linezolid resistant. pt was then put on unasyn, to be given daily for vre coverage. the sensitivites were then changed, as the vre was found to be sensitive to linezolid. finally, for discharge the patient was transitioned to linezoid 600mg po for 14 days, and cefazolin 1gm iv after each hd for 14 days. . #) pancreatic mass: pt had prior mrcp, which was consistent with a pancreatic duct tumor. this will need to be addressed as an outpatient, as this has not been a focus of this admission, given pt's other acute problems. has been instructed to follow up with dr. . . # constipation: pt had almost 2 week bout of constipation, which resolved s/p manually disimpaction x 4 plus numerous enemas. . #. conduction delay: over past 2 months, pt has had increasing pr interval. originally concerning for possible abscess or vegetation, however pt had negative tte and tee. . #. bilateral ij clots: mr was originally on coumadin, although this was held during most of this admission, given the need for multiple line placements. this continued to be held on discharge as the patient had to return in 2 days for a repeat graft attempt. . #. cad s/p cabg: continued asa, statin we held mr bb and ace given hx of hypotension; these were not restarted at time of discharge as he was continuing to e normotensive (to slightly hypotensive during hd). . #. chf: low normal ef by last echo. after an episode of desaturation prior to micu transfer, pt has had good respiratory status and has been satting in 90's on ra. . #. esrd: continued hd per renal. - renal following. pt usually dialyzed mwf. - pt's temporary r femoral catheter was removed prior to discharge - needs permanent tunneled cath for ; transplant attempted on graft, which was unsuccessful. a second graft will be attempted . pt is also n schedule with ir for placement of another temporary line should the graft be non-functional again. . #. chronic anemia: stable. on epogen. . #. t1dm: held glipizide. riss while in house. restarted glipizide on discharge as pt eating normally. . #. fen: we monitored k closely and any other indications for acute hemodialysis. pt was on a renal diet. . #. ppx: ppi, hep sc, mrsa/vre precautions, oob to chair. . #. access: pt had a r femoral temporary catheter, needs permanent access. one graft failed, as described above, and he will return for a second attempt friday . also on schedule for ir that afternoon in case graft fails and he needs another temporary line. . #. full code . #. communication: (mother) . #. dispo: pt had lived at home with mother prior to admission. cleared by pt for discharge back to home. medications on admission: coumadin 4 mg po daily glipizide 7.5 mg po qam, 5 mg po qpm calcium acetate 1334 mg po tid lisinopril 2.5 mg po daily (reintro , normally 10 qd) metoprolol 12.5 mg po bid (reintroduced , normally 25 ) sevelamer 800 mg po tid simvastatin 40 mg po daily b complex-vitamin c-folic acid 1 mg capsule daily asa 81 mg po qd discharge medications: 1. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. medication glipizide 7.5mg po qam and 5mg po qpm 7. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 8. linezolid 600 mg tablet sig: one (1) tablet po twice a day for 14 days. disp:*28 tablet(s)* refills:*0* 9. cefazolin 1 g piggyback sig: one (1) gram intravenous after each hemodialysis for 14 days. discharge disposition: home discharge diagnosis: line sepsis esrd discharge condition: stable. discharge instructions: please seek medical attention immediately if you experience chest pain, shortness of breath, nausea, vomiting, diarrhea, or fevers/chills. please take all medications as prescribed. please attend all follow-up appointments. please return friday as instructed by transplant surgery for repeat graft surgery. followup instructions: provider: , md phone: date/time: 9:20 provider: , md phone: date/time: 2:20 provider: , md phone: date/time: 10:20 please call dr. for an appointment in the next 2-3 weeks at Procedure: Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Arteriovenostomy for renal dialysis Transfusion of other serum Diagnoses: Anemia in chronic kidney disease End stage renal disease Mitral valve disorders Congestive heart failure, unspecified Aortocoronary bypass status Methicillin susceptible Staphylococcus aureus septicemia Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Constipation, unspecified Long-term (current) use of anticoagulants Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Below knee amputation status Other specified diseases of pancreas

allergies: ativan / tetracycline attending: chief complaint: back pain/ positive blood cultures major surgical or invasive procedure: central venous line, attepmted ir guided cathether x 2 (second successful), intubation history of present illness: 63 year old male with esrd on hd, dm, history of multiple line infections had blood cultures drawn from line on growing 2/4 bottles gram positive cocci. his blood cultures were drawn as a result of back pain he had been having for 3 weeks as a concern for possible epidural abscess. he states that 3 weeks ago, he was taken by ambulance to osh for low blood sugar and felt he "wrenched his back." he states that the discomfort is bilateral low back without radiation down the backs of his legs. it is worse with lying flat and better sitting up in his wheelchair. it has improved in the past week, although he was recently prescribed tramadol. he is able to ambulate some with prosthetics (b/l bkas). he denies fevers, chills, nausea, vomiting, diarrhea. he has had some constipation but takes stool softeners. he makes little urine. he denies bowel incontinence. he denies headaches, changes in vision, numbness, weakness, tingling. no chest pain, shortness of breath or cough. he received vancomycin at hd prior to being sent to ed. . ed: rectal exam with normal rectal tone. his bp in ed was 80's systolic but improved after 1 l ns. mri ordered, but patient declined at that time. past medical history: - several previous line infections, last one tx with 27 d of vanco iv renally dosed - esrd on hd mwf for 5 yrs - placement of new hemodialysis catheter r subclavian (l arm av --> l subclavian --> r arm av --> r subclavian - dm 1 or 2 c/b pvd, cad, esrd - dm for 20 yrs since age 44 - bilateral bkas - cad s/p cabg - s/p mssa bacteremia - h/o vre, mrsa 5 yrs ago in wound infection in l stump and uti - htn - afib on coumadin - bilateral contractures on hands - cataracts bilaterally family history: significant for both of his grandmothers, his mother, and father with diabetes. father with peripheral vascular disease. mother is still alive. father died at 90. no hx of cancer or heart disease. physical exam: v: 100.3f hr 80 bp 80/dop 20 94 ra gen: awake, alert and oriented, pleasant, talkative, nad heent: perrl, eomi, anicteric sclera, op clear without lesions, mm slightly dry neck: obese cv: rrr, s1, s2. right subclavian line dressed, intact and non-tender pulm: faint crackles right base abd: normoactive bowel sounds, soft, obese, nontender ext: bilateral bkas. neuro: cn ii-xii intact. in prox/distal upper extremities and prox lower extremities bilaterally. sensation intact to light touch bilaterally. back: mild ttp left paraspinal muscles in lumbar region. no spinal ttp. pertinent results: 06:50pm blood wbc-6.8 rbc-3.02* hgb-11.1* hct-33.4* mcv-111*# mch-36.8* mchc-33.2 rdw-17.0* plt ct-154 03:07am blood wbc-7.9 rbc-2.54* hgb-9.5* hct-27.4* mcv-108* mch-37.3* mchc-34.6 rdw-18.2* plt ct-230 06:50pm blood neuts-78.2* lymphs-14.3* monos-6.0 eos-1.2 baso-0.3 06:50pm blood pt-31.3* ptt-39.6* inr(pt)-3.3* 03:07am blood glucose-127* urean-80* creat-7.0* na-138 k-5.2* cl-98 hco3-23 angap-22* 06:50pm blood glucose-132* urean-17 creat-3.1*# na-144 k-4.4 cl-100 hco3-35* angap-13 06:35am blood alt-14 ast-24 ld(ldh)-238 alkphos-128* amylase-105* totbili-0.5 07:58pm blood alt-107* ast-181* ld(ldh)-532* ck(cpk)-312* alkphos-131* amylase-60 totbili-0.7 03:16am blood alt-140* ast-209* ld(ldh)-338* alkphos-118* totbili-0.8 03:07am blood alt-86* ast-65* alkphos-98 amylase-83 totbili-0.7 07:58pm blood ck-mb-6 ctropnt-0.08* 06:35am blood albumin-3.7 calcium-9.0 phos-3.6# mg-2.2 07:58pm blood albumin-4.0 calcium-13.2* phos-6.1*# mg-3.2* vbg at time of code: 08:15pm blood type-art po2-87 pco2-96* ph-7.04* caltco2-28 base xs--7 comment-green top 09:17pm blood type-art fio2-100 po2-316* pco2-53* ph-7.23* caltco2-23 base xs--5 aado2-343 req o2-62 -assist/con intubat-intubated 11:57pm blood type-art rates-/28 tidal v-500 peep-5 fio2-50 po2-72* pco2-37 ph-7.40 caltco2-24 base xs-0 -assist/con intubat-intubated . ir procedures: femoral line hd: radiologists: the procedure was performed by drs. and . dr. , the attending radiologist, was present and supervising throughout the procedure. procedure and findings: after informed consent was obtained from the patient explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table, and the right groin was prepped and draped in the standard sterile fashion. using ultrasonographic guidance and local anesthesia with 1% lidocaine, a 21-gauge needle was advanced into the right common femoral vein and a 0.018 guide wire was advanced through the needle up to the distal part of the ivc under fluoroscopic guidance. hard copy ultrasound images were obtained before and after venous access was obtained documenting vessel patency. the needle was then exchanged for a 4.5 french micropuncture sheath. the wire was exchanged for a 0.035 wire that was placed with the tip in the ivc. the groin incision was progressively dilated with 12 and 14 french dilators. a double lumen 14.5 french hemodialysis catheter was placed over the wire, and the wire and the inner dilator were removed. the patient's final fluoroscopic image of the line demonstrates the tip in the ivc. the patient tolerated the procedure well, and there were no immediate complications. impression: successful placement of temporary hemodialysis line via the right common femoral vein. the line is ready for use. . mr head w/o contrast; mra brain w/o contrast reason: eval for cerebral edema or stroke medical condition: 63 year old man admitted with fevers, now s/p pea arrest and unresponsive, although patient was responsive briefly after arrest reason for this examination: eval for cerebral edema or stroke mri scan of the brain with mr angiography. history: admitted with fevers, status post pulmonary embolism with arrest. unresponsive. assess for cerebral edema or stroke. technique: multiplanar t1- and t2-weighted brain imaging was obtained. comparison studies: none. findings: there is mildly restricted diffusion within the thalami bilaterally, as well as increased flair signal in this locale. a similar pattern of restricted diffusion and elevated flair signal is also seen in a ribbon-like distribution involving both parietal lobe cortices. the symmetric distribution of the findings is in with the suspected anoxic episodes sustained by the patient. there is no evidence for abnormal blood products intracranially. there is no hydrocephalus or shift of normally midline structures. the principal vascular flow patterns are identified. there are extensive air-fluid levels distributed throughout the paranasal sinuses as well as probable secretions within the - and oropharynx. these findings presumably represent the effects of intubation. there is low t1 signal within the odontoid process. the etiology of this finding is uncertain. if there is concern for malignancy elsewhere that could spread to bone, a correlative radionuclide bone scan would be of assistance in comprehensively evaluating the skeleton, when the patient's clinical state would permit such an investigation to be conducted. it is possible, however, that this finding may merely be a somewhat unusual expression of degenerative disease. conclusion: findings of concern for anoxic brain damage as noted above. mr angiography of the circle of and its tributaries. technique: three-dimensional time-of-flight imaging with multiplanar reconstructions. findings: the major vascular tributaries of the circle of are patent, without sign for the presence of hemodynamically significant stenosis. within the limits of this study technique, no definite sign of an aneurysm is apparent, either. there may be very slight irregularity of caliber of the occipital branch of the left posterior cerebral artery, which if real, could represent a minimal degree of atherosclerotic change. echo: conclusions: no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. no atrial septal defect is seen by 2d or color doppler. lv systolic function appears depressed. right ventricular systolic function is normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valvular vegetations identified. chest x-ray: single ap portable view of the chest reason for exam: followup pulmonary edema comparison is made with prior study performed a day earlier. et-tube is in standard position. left ij line tip is in the artery level of the cavoatrial junction. ng tube tip is out of view below the diaphragm. mild-to-moderate right pleural effusion has mildly increased in amount. mild- to-moderate pulmonary edema got worse. right lower lobe opacity is increasing consistent with atelectasis. eeg: impression: this is a markedly abnormal brain death protocol eeg. the majority of the tracing demonstrates a flat and non-reactive background even at high sensitivity gains. this is consistent with a severe encephalopathy with dysfunction of the deep midline structures. lack of reacitivity suggests a poor prognosis. the tracing cannot meet the criteria for brain death however given that several brief bursts of sharp and wave discharges were captured from the bifrontal regions. while it is possible that these discharges were purely artifactual we cannot say this definitively. note that clinical correlation of brain death is required by hospital protocol. brief hospital course: hospital course prior to code: patient is a 63 yo m with esrd on hd, with diabetes and multiple line infections admitted initially for bacteremia and back pain found to have osteomyelitis secondary to a line infection. since admission, the patient has been treated with vancomycin but had persistent bacteremia thought due to persistent infected line. line was removed on and this was the last time of . events prior to code: diagnosed with osteomyelitis/discitis. events: hypoxia after 12 mg morphine +tramadol hd line removal hypotensive prior to tee ?16mg morphine (tee without signs of endocarditis) ir procedure done- prolonged and unsuccessful placement of hd line (100 mg fentanyl, versed). day of code blue: per team today patient was doing well but had prolonged ir procedure without hd catheter placement due to difficulty cannulating vessels (left ij was placed). per team, the patient returned to the floor and was initially stable. he was more somnolent than usual, but given his recent sedation, this was thought to be expected. at approximately 8pm, the patient was found to be unresponsive. patient was found to be pulseless and cpr was initiated. code blue was called. the patient was intubated and given epinephrine 1mg. found to be in bradycardia and given atropine. labs were sent. calcium and bicarb were given. rhythm changed to vt and patient was shocked. 1 amp bicarb given and again shcoked. compressions resumed. blood sugar was 111 and insulin+d50 were given in the icu patient was then stabilized on the ventilator without significant acid base disturbances. though the patient initially had mild signs of neuro function, it did not persist and with complete withdrawal of sedation, the patient was still without recovery. per neurology: minimal activity on eeg and no response to sternal rub. neuro exam is significant for sluggishly reactive pupils otherwise no other obtainable reflexes or response to noxious stimulation indicating gross dysfunction of bilateral hemispheres and brainstem. prognosis is poor based on initial exam but will need to be followed serially. care was withdrawn after extensive discussions with his hcp (brother). the patient quickly expired after this. by problem list prior to expiration: 1) pea arrest/neuro status: patient had arrest likely secondary to respiratory depression given that the patient was found to have shallow breathing and decreased rr prior to code and found to have profound acidosis during the arrest. other potential causes including hypercalemia were ruled out. given patient's previous history of hypotension, somnolence to versed and fentanyl, it seems likely that the patient arrested as a result of respiratory acidosis. after transfer to the icu and correction of acidosis, patient was monitored after this and was found to have no residual neurologic function. per neurology consult minimal activity on eeg and no reaction to noxious stimuli (see eeg report). insult likely secondary to hypoxic brain injury as a result of hypotension in the setting of pea arrest. these findings were communicated to the healthcare proxy (brother) who felt that given the poor overall prognosis, his brother's wishes would be to withdraw care. 2) id: patient was initially admitted with line infection/bacteremia later found to have osteomyelitis: line was removed with, ij replaced. no signs endocarditis on tee. surveillance cultures were negative. also treated with vancomycin. was given one dose of gentamycin for synergy. - osteomyelitis: t7-8, not able to get sample, but presuming infected secondary to persistent bacteremia, treated with vancomycin iv - sacral decubitus ulcers: chronic and stage 2 3) esrd: patient with need and difficulty placing access and had failed ir attempts to place catheter, was not dialyzed for several days. able to obtain access eventually on , right common femoral venous line was placed, but patient was not dialyzed after this given overall decline in clinical status. # transaminitis: occurred in the setting of the code/ hypotension likely due to hypoperfusion. # atrial fibrillation: rate controlled and supratherapeutic inr while in the icu. holding anticoagulation for now. # diabetes: sliding scale # contractures: appear to be chronic # sternum- concerning for sternal fracture in the setting of aggressive cpr. medications on admission: glipizide 5mg po bid lisinopril 2.5 mg daily asprin 81mg daily lopressor 12.5mg daily sl ntg prn coumadin 4 mg qday zocor 40 mg qhs nephrocaps 1 mg daily phoslo 667 mg--take 3 tabs po tid renagel 800 mg - tid w/ each meal colace - discharge disposition: expired discharge diagnosis: esrd hypoxic brain injury osteomyelitis atrial fibrillation discharge condition: deceased md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Insertion of endotracheal tube Hemodialysis Other electric countershock of heart Venous catheterization for renal dialysis Diagnoses: Other iatrogenic hypotension End stage renal disease Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation Aortocoronary bypass status Unspecified osteomyelitis, other specified sites Systolic heart failure, unspecified Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Anoxic brain damage Bacteremia Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of anticoagulants Pressure ulcer, lower back Infection and inflammatory reaction due to other vascular device, implant, and graft Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Below knee amputation status Other and unspecified disc disorder, thoracic region

history of present illness: the patient is a 58-year-old gentleman with coronary artery disease, status post myocardial infarction, diabetes mellitus, chronic renal insufficiency, and left below-knee amputation who presented to the vascular service with a nonhealing ulcer on his left foot for one month. the patient was seen at an outside clinic where it was noted he had an increase in cellulitis in the past one to two weeks. the patient was admitted to for evaluation and treatment. past medical history: 1. diabetes mellitus; with nephropathy and neuropathy. 2. hypertension. 3. renal insufficiency (creatinine was 4.6 in ). 4. coronary artery disease; status post myocardial infarction. 5. obesity. past surgical history: 1. left below-knee amputation in . 2. right fifth toe amputation approximately nine years ago. 3. bypass graft to foot ? medications on admission: 1. colace 100 mg p.o. b.i.d. 2. atenolol 100 mg p.o. q.d. 3. multivitamin p.o. q.d. 4. glyburide 5 mg p.o. q.d. 5. enteric-coated aspirin 325 mg p.o. q.d. allergies: ativan and tetracycline. physical examination on presentation: physical examination on admission revealed the patient was afebrile, vital signs were stable. cardiovascular revealed a regular rate and rhythm. lungs were clear to auscultation bilaterally. the abdomen was soft, nontender, and nondistended. extremities revealed left below-knee amputation site was clean. right femoral pulse was 1+, dopplerable popliteal, dopplerable posterior tibialis and dorsalis pedis. he had 2-cm x 2-cm ulcer on his right foot; questionable bone involvement, a minimal amount of bleeding, scant necrotic material. pertinent laboratory data on presentation: laboratories on admission revealed a white blood cell count of 15, hematocrit was 36.1, platelets were 182. sodium was 136, potassium was 4, chloride was 105, bicarbonate was 18, blood urea nitrogen was 93, creatinine was 6, blood glucose was 234. calcium was 8.7, magnesium was 2, phosphorous was 5.5. inr was 1.1. hospital course: the patient was admitted to the vascular service and was started on levofloxacin and flagyl for his ulcer. on hospital day two, the patient's ulcer cultures grew methicillin-resistant staphylococcus aureus, and he was started on vancomycin in addition to his previous antibiotics. a podiatry consultation was obtained who recommended dressing changes and close monitoring for bone involvement. ankle-brachial index was obtained for right leg which showed low ankle-brachial index for the patient's right lower extremity. due to the patient's significant coronary history, a cardiology consultation was obtained which found the patient to have no symptoms of ischemia on electrocardiogram, but they recommended a stress test as well as an echocardiogram. a stress test sestamibi was obtained on hospital day three, which showed severe nonreversible inferior defect, moderate reversible defect at the apex, and septal defect, moderate left ventricular enlargement, with an ejection fraction of 34%, and generalized diffuse hypokinesis. the recommendation was made to hold off of the patient's distal bypass surgery until his cardiac issues were resolved. due to the patient's high blood urea nitrogen and creatinine, the renal service was consulted. they initially said that the patient did not need dialysis now; however, he would most likely be dialysis dependent within the next year. as a part of the patient's cardiology workup, a cardiac catheterization was obtained. the patient was appropriately medicated and hydrated prior to the procedure. a cardiac catheterization was performed on which showed a right-dominant minimal mitral regurgitation, the left main coronary artery was okay, the left anterior descending artery revealed total meddle left anterior descending artery occlusion was bridging collaterals, the left circumflex with minor irregularities, right coronary artery was occluded filled by left anterior descending artery and posterior descending artery. cardiothoracic surgery was consulted and recommended that the patient undergo a few sessions of dialysis before his coronary artery bypass graft procedure. during the patient's preparation for surgery, he was transferred to the medicine service. the patient remained afebrile and stable. his right foot dressing changes were done twice per day. he had his first session of hemodialysis on . the patient remained asymptomatic and underwent hemodialysis on . also as preparation for his coronary artery bypass graft, a noninvasive carotid study was performed which showed no significant lesions bilaterally. after his session of dialysis on , the patient was taken to the operating room on for a coronary artery bypass graft times three (left internal mammary artery to left anterior descending artery, saphenous vein graft to right coronary artery percutaneous transluminal coronary angioplasty) was performed with ventricular and atrial wires as well as mediastinal left pleural tubes placed in the operating room. the operation went without complications, and the patient was transferred to the postanesthesia care unit in stable condition. overnight, on postoperative days zero to one, the patient could not be weaned off the ventilator due to acidosis and respiratory distress. however, on postoperative day one, the patient was successfully extubated and placed on oxygen by nasal cannula. cardiovascularly, the patient remained stable. his swan-ganz catheter was removed. he started transfer from bed to chair. on postoperative day two, the patient's chest tube was removed. he was started on a beta blocker. he had another session of hemodialysis on , and he was transferred to the floor in stable condition. on postoperative day three, the patient remained afebrile with stable vital signs. he continued transfer from bed to chair. his glyburide was held because of the patient's low blood sugars in the evening. on postoperative day four, the patient was stable. the patient did not ambulate yet because his left stump site vein graft was still swollen and did not fit into his prosthesis. the patient was transfused one unit of packed red blood cells and dialysis for a fall in hematocrit. his quinton catheter was removed and cultured. it did not grow out anything to date. on postoperative day five, due to access the patient could not be dialyzed as scheduled; however, the renal service thought that the patient was stable enough to postpone the procedure until proper access was obtained. transplant surgery was consulted for access. the patient went into the operating room on where a right internal jugular perm-a-cath was placed and a the left brachiocephalic fistula was done. on postoperative day six, the patient remained afebrile, and vital signs were stable. he had some erythema and a little bit of induration at the bottom of his chest excision, no discharge. the patient was started on vancomycin to be given during his hemodialysis. on postoperative day seven and one, the patient remained stable and afebrile. his wound did not change. on postoperative days eight and two, the patient was afebrile. vital signs were stable. no active issues at this point. condition at discharge: condition on discharge was good. discharge status: the patient was to be discharged to a rehabilitation facility. discharge instructions: the patient cannot bend or lift weight with his left arm for six weeks because of his new fistula. the patient can transfer from bed to chair. the patient can weightbear on the left arm. the patient was to remain on hemodialysis at this time. the patient should remain on levofloxacin and flagyl for his ulcer and vancomycin at hemodialysis for his questionable wound infection. he will be reassessed at a later date. discharge followup: the patient should come to follow up with dr. in six weeks for his postoperative check. the patient's follow-up appointment with vascular surgery will be made at a later date. medications on discharge: 1. lopressor 25 mg p.o. b.i.d. 2. aspirin 325 mg p.o. q.d. 3. docusate 100 mg p.o. b.i.d. 4. tylenol 650 mg p.o. q.4-6h. as needed. 5. percocet one to two tablets p.o. q.4-6h. as needed. 6. milk of magnesia 30 cc q.h.s. as needed. 7. oxazepam 15 mg to 30 mg p.o. q.h.s. as needed. 8. levofloxacin 250 mg p.o. q.48h. 9. flagyl 500 mg p.o. b.i.d. 10. calcium acetate two tablets p.o. t.i.d. with meals. 11. multivitamin p.o. q.d. 12. glyburide 5 mg p.o. b.i.d. 13. vancomycin 1000 mg at hemodialysis. 14. bisacodyl 10 mg p.o./p.r. q.d. as needed. discharge diagnoses: 1. coronary artery disease; status post myocardial infarction. 2. status post coronary artery bypass graft times three. 3. status post catheterization. 4. status post carotid ultrasound. 5. diabetes mellitus. 6. on hemodialysis. 7. hypertension. 8. chronic renal failure. 9. status post left below-knee amputation. 10. left foot nonhealing ulcer. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Hemodialysis Venous catheterization for renal dialysis Other incision with drainage of skin and subcutaneous tissue Arteriovenostomy for renal dialysis Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Coronary atherosclerosis of native coronary artery Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with ulceration Cellulitis and abscess of foot, except toes Ulcer of heel and midfoot

chief complaint/history of present illness: the patient is a 59 year old male with a history of ischemic cardiomyopathy who presented to an outside hospital with a history of dyspnea on exertion times one week and bilateral lower extremity edema. the patient initially attributed these symptoms to his asthma, however, when the symptoms continued to worsen and he was short of breath at rest, he presented to the hospital. at that time he denied chest pain, palpitations, sharp pain or any extremity pain. chest x-ray at that time showed congestive heart failure. he was given lasix with no change in his shortness of breath but a marked decrease in his lower extremity edema. arterial blood gases at that time was 7.45, 40, 56, with an aa gradient of 24. an echocardiogram and stress test were ordered at that time. echocardiogram showed an ejection fraction of 19%. stress test showed reversible inferior wall defect. the patient was then transferred to for cardiac catheterization and further evaluation. past medical history: significant for ischemic cardiomyopathy, mitral regurgitation, mild to moderate aortic stenosis, diabetes mellitus, and asthma. allergies: he states an allergy to sulfa. medications on admission: glucophage 500 mg t.i.d., slo- no dose given, ventolin nebulizer, aspirin 81 mg a day, lasix intravenously at an outside hospital. coreg 3.125 mg and lisinopril 5 mg q.d. social history: married, smokes times 40 years, recently quit. works as a sales executive. hospital course: after admission to the patient was brought to the cardiac catheterization laboratory. please see the catheterization results for full details. in summary the catheterization showed a cardiac output of 4.45 with an index of 2.2 and wedge of 13. pa is 38/21. coronaries showed left main with a 70% lesion, left anterior descending with mild disease, circumflex with no critical lesions and right coronary artery with mid segment total occlusion with distal flow from the left anterior descending. physical examination on admission - general, white man in no acute distress, alert and oriented times three. pupils equal, round and reactive to light. chest clear to auscultation anteriorly. cardiovascular, distant heartsounds, s1 and s2, abdomen soft with positive bowel sounds. extremities, no edema, cyanosis or clubbing. laboratory data at the outside hospital showed the hemoglobin a1c of 10.6, arterial blood gases 7.45, pco2 39, po2 55, white count 5.8, hematocrit 42.9, platelets 387, sodium 137, potassium 4.3, chloride 101, carbon dioxide 24, bun 16, creatinine 0.8, glucose 310. liver function tests were normal. creatinine kinase and troponin were negative times three. cholesterol 215. hdl 82. ldl 122. the patient had a persantine myoview which showed an estimated ejection fraction of 19%, grossly dilated left ventricular with multiple perfusion defects, septal and inferior lateral walls with reversibility in the inferior and lateral wall. echocardiogram done showed an ejection fraction of 20 to 25% with a dilated left ventricle and mitral regurgitation. given these results along with the patient's cardiac catheterization, intra-aortic balloon pump was placed and following catheterization the cardiothoracic surgery service was consulted. the patient was seen and accepted for coronary artery bypass grafting +/- mitral valve replacement. on , the patient was brought to the operating room where he underwent coronary artery bypass graft times three with mitral valve annuloplasty. please see operative report for full details. in summary, the patient had a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, saphenous vein graft to the posterior descending artery, saphenous vein graft to the diagonal and mitral valve annuloplasty with a #28 band. he tolerated the procedure well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient had an intra-aortic balloon pump at 1:1, propofol, milrinone and levophed infusing. the patient did well in the immediate postoperative period. the patient was kept sedated on the night of his surgery. on the morning of postoperative day #1 sedation was discontinued. the patient was weaned from the ventilator and successfully extubated. he remained hemodynamically stable with the assistance of the intra-aortic balloon pump as well as neo-synephrine and levophed drips. the patient was also started on amiodarone for frequent premature atrial contractions. on postoperative day #2, the patient continued to remain hemodynamically stable. his intra-aortic balloon pump was weaned and successfully removed. over the next several days, the patient remained hemodynamically stable. his pressors were weaned to off with the exception of his milrinone which continued to be weaned very slowly and on postoperative day #5, was ultimately discontinued. during this time, gentle diuresis was begun. following the discontinuation of milrinone, the patient began to be more vigorously diuresed and his ace inhibitor was begun. on postoperative day #5 the patient doing well and it was decided that he was stable and ready for transfer to the floor for continued postoperative care in cardiac rehabilitation. at that time the heart failure service was asked to consult on the patient to add in the care of mr. . over the next several days with the assistance of the nursing staff and physical therapy the patient's activity level was increased. he continued to be diuresed. his medications were adjusted and he remained hemodynamically stable, and on postoperative day #10 it was decided that the patient was stable and ready to be discharged to home the following morning. condition on discharge: at the time of discharge the patient's condition was stable. his physical examination revealed vital signs with temperature 97.6, heartrate 90, sinus rhythm, blood pressure 110/70, respiratory rate 18 and oxygen saturation 94% on room air. weight preoperatively was 78 kg, at discharge 78.1 kg. laboratory data revealed white count 9.7, hematocrit 32.9, platelets 741, sodium 135, potassium 4.2, chloride 98, carbon dioxide 28, bun 11, creatinine 0.7, glucose 183. neurological, alert and oriented times three. he moves all extremities and follows commands. breathsounds are diminished in the left base but otherwise clear to auscultation. heartsounds, regular rate and rhythm, s1 and s2, sternum stable. incision with steri-strips, open to air, clean and dry. abdomen soft, nontender, nondistended, normoactive bowel sounds. extremities, warm and well perfused. the right leg incision with steri-strips, open to air, clean and dry. discharge diagnosis: 1. coronary artery disease, status post coronary artery bypass grafting times three with left internal mammary artery to the left anterior descending, saphenous vein graft to the posterior descending artery, saphenous vein graft to the diagonal. 2. mitral regurgitation status post mitral valve repair with a #28 annuloplasty band. 3. diabetes mellitus. 4. asthma. 5. cardiomyopathy. discharge medications: 1. furosemide 40 mg b.i.d. 2. potassium chloride 20 meq b.i.d. 3. aspirin 325 mg q.d. 4. metformin 500 mg t.i.d. 5. flovent 2 puffs b.i.d. 6. albuterol 2 puffs q. 4 hours and prn 7. captopril 25 mg t.i.d. 8. percocet 5/325 one to two tablets q. 4 hours prn follow up: the patient is to have follow up in the clinic in two weeks, follow up with dr. in four weeks and follow up with heart failure service on , at 10 am with dr. . , 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 Thoracentesis Implant of pulsation balloon Annuloplasty Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Mitral valve disorders Unspecified pleural effusion Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Other specified forms of chronic ischemic heart disease Left heart failure Acute on chronic systolic heart failure

discharge medications: aspirin 325 mg po q day, percocet, metformin 500 mg three times a day, flovent two puffs b.i.d., albuterol two puffs q 4 hours prn, zestril 5 mg po q.h.s., toprol xl 12.5 mg po q.a.m., colace 100 mg po b.i.d. prn and lasix 40 mg po q day. fop: the patient is to follow up with dr. in one to two weeks and dr. in three to four weeks. , 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 Thoracentesis Implant of pulsation balloon Annuloplasty Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Mitral valve disorders Unspecified pleural effusion Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Other specified forms of chronic ischemic heart disease Left heart failure Acute on chronic systolic heart failure

history of present illness: the patient is a 59 year-old gentleman with end stage heart disease on the transplant list who presents status post fall six weeks ago. the patient stated that he felt lightheaded while walking to the bathroom and fell backwards on the edge of the tub landing on the upper back. the patient felt mild to moderate pain in the neck and shoulder after the fall, but continued with his every day activities. three to four days later he noted a band like electric pain across his upper back from shoulder to shoulder as well as neck. he complained of pain to his primary care physician, was overlooked during visit due to patient's heart disease as well as patient's evaluation for a rash. the patient went to hospital this morning where a ct of his neck showed a c4 lamina and spinous process fracture and anterior subluxation of c3 on c4 and he was therefore transferred to for further management. past medical history: cardiomyopathy with congestive heart failure, atrial fibrillation with an ef of less then 10%. leg edema. he is a cardiac transplant candidate. he has a pacemaker, which is placed on , biventricular. chronic renal insufficiency. medications on admission: coreg 3.125 mg po q.a.m., mirapex .25 mg one po b.i.d., percocet one to two po q 4 hours prn, zaroxolyn 5 mg two tabs po b.i.d., iron one tab po q day, dulcolax one po q day, coumadin 5 mg two tablets b.i.d., cardura 2 mg po q.h.s., lasix 20 mg three tablets in the morning and three tablets at night. allergies: baclofen. social history: previous alcohol. sober since . positive tobacco history. physical examination: he was immobilized on a stretcher. he was awake, alert and oriented times three. cooperative. temperature 97.6. blood pressure 110/68. heart rate 76. respiratory rate 18. sats 95% on room air. heent pupils are equal, round and reactive to light. extraocular movements intact. cranial nerves ii through xii intact. neck immobilized. chest clear to auscultation bilaterally. cardiovascular rhythm irregular. rate normal. no murmurs, rubs or gallops. abdomen positive, distended, positive bowel sounds. extremities gross edema bilaterally in the lower extremities. neurological decreased pin prick sensation in the right upper extremities. sensation intact to light touch. strength is 5 out of 5. deep tendon reflexes are 2+ throughout. laboratory: sodium 139, k 2.8, chloride 95, co2 31, bun 63, creatinine 1.6, glucose 105, pt 20.6, ptt 35.8, inr 3.0, ast 47, ck 141, alkaline phosphatase 179, white count was 5.0, hematocrit 30.8, platelets 147. ct of the c spine shows a grade two anterior lysis of c3 and c4 bilateral lamina c4 fractures and narrowing of the spinal canal with no bone fragment, no hematoma and body height was preserved. hospital course: the patient was admitted initially to the medical service and seen by neurosurgery and found to be require cervical fusion to stabilize neck injury. the patient on underwent a c3 to c5 arthrodesis and lateral mass screw and rod fixation. c4 to c5 spinous process, tension band wiring without intraoperative complications. the patient was monitored in the surgical intensive care unit postoperative where he remained hemodynamically stable, awake, alert, following commands and moving all extremities. the patient remained stable and was transferred to the floor on in stable condition. he was seen by physical therapy and occupational therapy and found to be safe for discharge to home. medications on discharge: lasix 60 po b.i.d., zaroxolyn 2.5 mg b.i.d., k-ciel 80 milliequivalents per day, coreg 3.125 po q day, mirapex .25 mg po b.i.d., percocet one to two tabs po q 4 hours prn, iron 325 mg po q day, dulcolax 10 mg po q day, cardura 2 mg po q.h.s. the patient's coumadin will be started on one week. he will follow up at for a psychiatric evaluation for his heart transplant on . follow up with dr. on for staple removal and follow up with dr. in two weeks to restart his coumadin. he is in stable condition at the time of discharge. , m.d. dictated by: medquist36 Procedure: Other cervical fusion of the posterior column, posterior technique Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Atrial fibrillation Hypopotassemia Heart valve replaced by other means Unspecified disorder of kidney and ureter Automatic implantable cardiac defibrillator in situ Fall from other slipping, tripping, or stumbling Closed fracture of fourth cervical vertebra

allergies: pt reports no allergies. one mention of allergy to baclofen preadm meds: pericolace, lasix, allopurinol, corexz, mirapex, poxazosin, sarolyline, coumadin, klour and percocet. soc-> h/o etoh, none since . 70 ppy tobacco. pt admitted to tsicu at 9pm. hypotension tx with neo gtt to max, then added dopa gtt. goal sbp>110 for cord perfusion. pt baseline bp 90/40. pap placed iwth icu attending, pulled back to cvp d/t increased ventricular ectopy. hep gtt resumed. abgs improved to basline on cpap. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Other spinal traction Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Unspecified pleural effusion Congestive heart failure, unspecified Acute respiratory failure Cardiac pacemaker in situ Hemorrhage of gastrointestinal tract, unspecified Quadriplegia, unspecified

history of present illness: the patient is a 58 year-old gentleman with a history of cardiomyopathy, congestive heart failure with an ef less then 10%, coronary artery disease, atrial fibrillation, chronic renal insufficiency on a cardiac transplant list admitted to the neurosurgery service on preop revision for a c3-c5 arthrodesis and a lateral mass and rod fixation. the patient underwent a c3-c5 arthrodesis on the lateral mass screw fixation on without intraoperative complications. the patient was discharged to home in stable condition and returns now for a failed left sided c3 lateral mass screw. the patient is preop for revision of that fusion. the patient was complaining of some bilateral numbness in the upper extremities. he was admitted for intravenous heparin, discontinued off his coumadin and placed in cervical traction. at the onset of cervical traction the patient began complaining of increased numbness in the upper extremities bilaterally. he subsequently complained of decreased grip on the left side. on examination he had mild left intrinsic weakness relative to the right and mild difficulty with left hip flexion. he was taken out of the traction and placed back in a hard collar. at 7:45 the patient developed acute onset of significant quadriparesis and labored respiratory rate despite being taken out of traction. the patient remained hemodynamically stable, but was emergently fiberoptically intubated and transferred to the intensive care unit for close monitoring and was started on high dose solu-medrol drip. on the patient was awake, following commands and opening his eyes, mouthing words and internally rotating his legs to stimulation. not moving his feet. spontaneous shoulder movements bilaterally. no hand movements. he did spike a temperature to 103.2 and was fully cultured. his sputum had 1+ gram positive cocci in pairs. on his condition had deteriorated. he developed new pleural effusion with respiratory compromise and requiring increased ventilatory support. neurologically he had no compelling improvement in his motor examination. no upper extremity motor function, 1 out of 5 strength to noxious stimulations, able to internal rotate bilateral lower extremities weakly 2 out of 5. on he continues to open his eyes to voice moving both legs to command, 2 out of 5 with no antigravity strength. his arms were flaccid. he was internally rotating his left arm to stimulation, but not the right arm. his cardiomyopathy continued to worsen. he was requiring full ventilatory support with bilateral pleural effusions and worsening congestive heart failure. on dr. had a meeting with the family to discuss the grave prognosis of the patient's condition. the family decided to withdraw support and the patient was taken off ventilatory support. the time of death is on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Other spinal traction Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Unspecified pleural effusion Congestive heart failure, unspecified Acute respiratory failure Cardiac pacemaker in situ Hemorrhage of gastrointestinal tract, unspecified Quadriplegia, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cough major surgical or invasive procedure: picc line placement history of present illness: mr. is 64-year-old man with liver cirrhosis nash, dm, htn, chf ef 40%, cad, sizure disorder who p/w cough. per report from his nursing home, he has had cough, low grade fever x 3 days. today, he had an episode of likely aspiration while using mouth wash, had a coughing fit and during this episode desat'ed to 80's. his family reports that he has been on small amounts of oxygen at the nursing home, which he has been on chronically since rehab for unclear reasons. they state that he has had a ratteling cough for several days but has not appeared unwell. they also note that he has normally waxing and mental status, that he is not "chatty" normally and that his mental status appears to be at baseline. per the patient, he feels relatively well and denies sob. he was biba from his nh, enroute ems had a difficult time obtaining a good pleth/sats and reported variable o2 sats in high 80's. . in the ed: the patient was thought to be ill appearing and "dry". his vital signs were temp 100.0, hr 107, bp 120/80's, rr 22-26, sa 96% 2lnc. ekg unchanged, trop 0.06.cxr was noted to have hazy rll and lll. he received vanc and ctx. past medical history: 1. seizure disorder with history of status epilepticus with recent admission for recurrent seizures & 2 prior admission in & for status requiring intubation. he has been on multiple antiepileptic drugs 2. nash, cirrhosis, hepatocellular carcinoma, recently removed from list chronic illness 3. diabetes. 4. hypothyroidism. 5. hypertension. 6. chf with ejection fraction of 40% on an echo in . 7. coronary artery disease status post cardiac catheterization in w/o stenting. 8. history of upper gi bleed status post tips in . 9. stage iv sacral decubitus ulcer. social history: prior to his illness, he was living with wife; remote tobacco, no etoh or drug use. he now resides at nursing home. family history: non-contributory. physical exam: general: awake, alert, nad. heent: nc/at, perrl, eomi without nystagmus, no scleral icterus noted, mmm, no lesions noted in op neck: supple, no jvd or carotid bruits appreciated pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp and pt pulses b/l. lymphatics: no cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. skin: sacral ulcer, heel ulcers neurologic: -mental status: waxing and between, persistently alert but oriented to person only at times and occasionally a&ox3. -contractures in hands and arms. pertinent results: labwork on admission: 09:45am blood wbc-5.2 rbc-3.63* hgb-12.5* hct-37.6* mcv-104*# mch-34.4* mchc-33.2 rdw-15.1 plt ct-65* 09:45am blood neuts-81.1* lymphs-12.2* monos-5.2 eos-1.4 baso-0.2 09:45am blood glucose-178* urean-50* creat-1.1 na-150* k-4.1 cl-110* hco3-34* angap-10 09:45am blood alt-27 ast-23 ck(cpk)-53 alkphos-124* totbili-0.3 10:35am blood ammonia-73* 09:45am blood tsh-0.77 09:45am blood free t4-1.9* . labwork on discharge: 07:45am blood wbc-2.2* rbc-2.95* hgb-9.9* hct-30.7* mcv-104* mch-33.7* mchc-32.4 rdw-14.6 plt ct-59* 07:45am blood glucose-72 urean-22* creat-0.8 na-146* k-3.9 cl-109* hco3-34* angap-7* . chest (portable ap) study date of formal report pending, but right upper and lower lobe consolidations present. . chest port. line placement study date of preliminary report !! pfi !! tip of picc catheter 8 cm from svc will need to be withdrawn. brief hospital course: 64 year-old man with cirrhosis, type 2 diabetes, coronary artery disease, hypertension, congestive heart failure with ef 40%, and seizure disorder presenting with cough, fevers, and consolidations on chest x-ray consistent with pneumonia. . 1. pneumonia: chest x-ray from admission showed right middle and lower lobe consolidations. his oxygen saturations remained above 92% on room air. he was monitored in the intensive care unit overnight and transferred to a general medical floor the morning after admission. he was started on vancomycin and ampicillin-sulbactam to complete a two-week course for hospital-acquired versus aspiration pneumonia. a picc line was placed for intravenous access to complete the course of antibiotics, ending . . 2. hypernatremia: asymptomatic and due to free water depletion. his free water flushes were increased to 400 cc q4h with improvement in sodium. his sodium should be monitored intermittently and his free water flushes should be adjusted accordingly for hypernatremia. . 3. question urinary tract infection from nursing home: the patient was on nitrofurantoin on admission, and it is unclear whether this was for treatment or prophylaxis of urinary tract infection. this was discontinued when the above antibiotics were started for pneumonia. he can restart nitrofurantoin if this was being given for prophylaxis when the course of vancomycin and unasyn is complete. . 4. mental status: it was believed that the patient was delirious on admission, however, after discussion with the patient's wife and the nursing home his mental status was thought to be at baseline. he was treated for pneumonia as above. he was frequently redirected. . 5. history of nonacloholic steatohepatitis/cirrhosis: the patient is status post tips. he is not candidate currently due to his multiple comorbiditis. his meld score was 5 on admission. he was continued on rifamixin and lactulose. . 6. chronic systolic congestive heart failure: ef is 40%. his metoprolol was continued during admission. the patient was hypovolemic on admission and lasix was held. lasix was restarted prior to discharge. . 7. seizure disorder: no active issues. the patient was continued on keppra, topomax and zonisamide. there was initial confusion regarding his dose of keppra, and the patient was initially given 2250 mg on admission, however, this was subsequently changed to his home dose of 500 mg twice daily. . 8. type 2 diabetes: no active issues. the patient was continued on glargine 100 units twice daily as per his outpatient regimen. he received humalog sliding scale insulin as needed. . 9. coronary artery disease: no active issues. the patient was continued on metoprolol. he is not on aspirin or statin at baseline, likely due to his liver disease, and this can be readdressed as an outpatient. 10. hypothyroidism: the patient was continued on his outpatietn dose of levothyroxine 400 mcg daily. during admission, his t4 was elevated to 1.9 with normal tsh. his laboratories should be checked after resolution of this acute illness and his dose of levothyroxine adjusted accordingly. . 11. sacral decubitus ulcer: the patient was followed by the care nurse. . 12. pancytopenia: his blood counts were at baseline during admission. his pancytopenia is believed secondary to liver disease. this should be monitored intermittently. medications on admission: topiramate 100 mg po bid metoprolol 25 mg po bid levetiracetam po bid zonisamide 500 mg daily levothyroxine po daily fluocinolone 0.025 % cream lactulose 10 gram/15 ml syrup rifaximin po tid lorazepam 0.5 mg po daily furosemide 40 mg po daily heparin (porcine) 5,000 unit/ml multivitamin po daily folic acid 1 mg po daily lansoprazole 30 mg thiamine hcl 100 mg po daily polyvinyl alcohol 1.4 % drops discharge medications: 1. topiramate 100 mg tablet : one (1) tablet po bid (2 times a day). 2. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 3. levetiracetam 500 mg tablet : one (1) tablet po bid (2 times a day). 4. zonisamide 100 mg capsule : five (5) capsule po daily (daily). 5. levothyroxine 100 mcg tablet : four (4) tablet po daily (daily). 6. lactulose 10 gram/15 ml syrup : thirty (30) ml po tid (3 times a day). 7. rifaximin 200 mg tablet : two (2) tablet po bid (2 times a day). 8. lorazepam 0.5 mg tablet : one (1) tablet po once a day. 9. furosemide 40 mg tablet : one (1) tablet po once a day. 10. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 11. multivitamin tablet : one (1) tablet po daily (daily). 12. folic acid 1 mg tablet : one (1) tablet po daily (daily). 13. omeprazole 40 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 14. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 15. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic q6h (every 6 hours). 16. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily). 17. insulin glargine 300 unit/3 ml insulin pen : one hundred (100) units subcutaneous twice a day: plus novolin sliding scale. 18. tramadol 50 mg tablet : one (1) tablet po three times a day: hold for oversedation and confusion. 19. scopolamine base 1.5 mg patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours). 20. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day). 21. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q4h (every 4 hours). 22. ipratropium bromide 0.02 % solution : one (1) inhalation q4h (every 4 hours). 23. nystatin 100,000 unit/ml suspension : five (5) ml po tid (3 times a day). 24. heparin, porcine (pf) 10 unit/ml syringe : one (1) ml intravenous prn (as needed) as needed for line flush. 25. ampicillin-sulbactam 3 gram recon soln : one (1) recon soln injection q6h (every 6 hours): continue until . 26. vancomycin in dextrose 1 gram/200 ml piggyback : one (1) intravenous q 12h (every 12 hours): continue until . discharge disposition: extended care facility: discharge diagnosis: primary diagnoses: pneumonia (hospital acquired versus. aspiration) hypernatremia delirium secondary diagnoses: 1. seizure disorder with history of status epilepticus with recent admission for recurrent seizures & two prior admission in & for status requiring intubation. he has been on multiple antiepileptic drugs 2. nonalcholic steatohepatitis, cirrhosis, hepatocellular carcinoma, recently removed from list due chronic illness 3. diabetes - insulin dependent 4. hypothyroidism 5. hypertension 6. congestive heart failure with ejection fraction of 40% on an echo in 7. coronary artery disease status post cardiac catheterization in w/o stenting 8. history of upper gi bleed status post tips in 9. stage iv sacral decubitus ulcer discharge condition: afebrile, vital signs stable discharge instructions: dear mr. , you were transferred to the hospital with fevers and a cough. you were found to have a pneumonia and picc line was placed in your arm so that you can complete a two week course of antibiotics (12 more days). you were also noted to have high levels of sodium in your blood, and this is probably because you were not getting enough water in your diet. you are being given more water with your tube feeds. we did not change any of your medications (except adding those two antibiotics for two weeks). your thyroid levels were high, and they should be re-checked and the dose of your thyroid medicine may need to be adjusted. if you develop increased difficulty breathing or any other symptoms which seriously concerns you, please return to the hospital. followup instructions: previously scheduled appointments: provider: laboratory phone: date/time: 10:00 provider: lab phone: date/time: 1:00 provider: clinic phone: date/time: 10:20 . you should try to see your primary care provider 2 weeks. pcp: , . Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Pneumonitis due to inhalation of food or vomitus Grand mal status Chronic systolic heart failure Pressure ulcer, lower back Malignant neoplasm of liver, primary Hyperosmolality and/or hypernatremia Gastrostomy status Pressure ulcer, stage IV Other chronic nonalcoholic liver disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: 64 year old male with hx of cirrhosis nash, dm, htn, chf with ef 40%, cad, seizure disorder, stage iv decubitus ulcer p/w low grade fever and lethargy. pt was found to have a temp of 99.6 at nursing home on day of admission. the family also thought that the pt was lethargic and may be w/ ams. he recd tylenol at nh and his temp came down to 98.6. he was brought to the er . in the er vs 98.9 81 116/63 16 96/2l. he had a neg head ct. cxr showed new lll opacity. he recd 1 dose each of vanc and cefepime. . ros: ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. . past medical history: 1. seizure disorder with hx of status epilepticus. recent admission for recurrent seizures & 2 prior admissions in & for status requiring intubation. has been on multiple antiepileptic drugs. 2. nash, cirrhosis, hepatocellular carcinoma, recently removed from transplant list chronic illness 3. diabetes mellitus type ii 4. hypothyroidism 5. hypertension 6. chf with ef 40% on echo in 7. coronary artery disease status post cardiac catheterization in w/o stenting 8. history of upper gi bleed s/p tips in 9. stage iv sacral decubitus ulcer social history: remote tobacco history. no alcohol or illicit drug use. currently resides at nursing home. family history: non-contributory physical exam: physical examination: vs: 98.2 150/75 87 22 93/3l gen: nad, awake, alert heent: eomi, perrl, sclera anicteric, conjunctivae clear, op moist and without lesion neck: supple, no jvd cv: reg rate, normal s1, s2. no m/r/g. chest: b/l wheezes and rhonchi. abd: soft, nt, nd, no hsm ext: no c/c/e skin: maculopapular rash on back pertinent results: cxr: impression: study limited due to low inspiration. bibasilar likely atelectasis although underlying aspiration or pneumonia cannot be excluded. there may be a small left pleural effusion. head ct: impression: no evidence of hemorrhage seen. appearance of the brain is unchanged from . opacification of visualized right maxillary sinus unchanged. abdominal u/s: grayscale imaging: the liver demonstrates a heterogeneous echotexture without focal mass lesion detected on this limited evaluation of the hepatic parenchyma. no intra- or extra-hepatic biliary ductal dilatation with the common duct measuring 3 mm. the gallbladder appears unremarkable, without wall thickening or pericholecystic fluid/intraluminal stone. there is splenomegaly with the spleen measuring 17.6 cm. no intra-abdominal ascites. doppler examination: color and pulsed pulse-wave doppler images were obtained. the main portal vein is patent with normal hepatopetal flow with a velocity of 22 cm/sec. the tips shunt is patent with wall-to-wall flow. velocities of 27, 90 and 94 cm/sec. the splenic vein and smv are patent. ivc demonstrates patency with triphasic waveforms. impression: normal tips evaluation with wall-to-wall flow. no ascites identified. l/si spine plain films and pelvic plain films: brief hospital course: # respiratory failure: the patient developed respiratory failure during seziure activity and recent hcap. he was intubated for airway protection and sent to the micu. he was able to be extubated days later without difficulty. the patient was treated with lasix for diuresis. sputum cultures were positive for klebsiella, proteus, sensitive to meropenem, zosyn and tobra however most likely contaminent not infection, and the patient was not started on antibiotics as the patient had received vanc/ceftriaxone/flagyl eariler in his hospital course. he was evaluated by pulmonary who felt his tachypnea was likely due to fluid overload. he was diuresed and his respiratory status later stabilized. no further bronchoscopy was recommended as it was unlikely that he laryngeal/tracheal stenosis given his clinical improvement with diuresis. . #seizure disorder: the patient has a known seizure disorder and hx of ncse. he again had continuous seizure activity documented by continous eeg monitoring. his home regimen of keppra, zonegran and topamax was increased and ativan, dilantin were added to the regimen. he required dilantin loading on two occassions. his seizures were eventually well controlled and the ativan was weaned off without seizure recurrence under eeg monitoring. his mental status started to improve signficantly and at discharge, he was answering questions briskly, able to state the place but did not know the date, and was eager to leave the hospital. . # cirrhosis: secondary to nash. during his hospital stay his lfts/bili and coags remained stable. he underwent an abdominal u/s of liver w/ normal tips evaluation with wall-to-wall flow. no ascites identified. he was continued on lactulose and rifaxamin. . #. stage iv sacral decub: no evidence of osteomyelitis per x-ray. wound care consulted and recommended daily packing. . #dm: the patient was temporarily taken off home lantus as had episodes of hypoglycemia. he was restarted on his home dose of lantus without problem. . #hypothyroidism: continued home levothyroxine . # hypernatremia: the patient became transiently hypernatremic during his micu course. free water boluses were increased through his tube feeds. the hypernatremia resolved. . # cad: stress mibi in w/ fixed, medium sized, severe perfusion defect involving the pda territory. increased left ventricular cavity size. inferior hypokinesis with preserved systolic function. no recent h/o chest pain. most recent echo with improved ef. . # pancytopenia: chronic issue, likely bm suppression or secondary to seizure medications. trended, remained stable. . #fen: tube feeds, repleted electrolytes prn, free h20 boluses through tube feeds. #ppx: ppi, lactulose, pneumoboots (no heparin sq given low platelets), aspiration precautions, contact #: full code #communication: with wife (-home) and -cell) medications on admission: -topiramate 100 mg tablet -metoprolol tartrate 25 mg -levetiracetam 500 mg tablet -zonisamide 500 mg capsule qd -levothyroxine 400 mcg tablet -lactulose 10 gram/15 ml prn -rifaximin 200 mg tid -lorazepam 0.5 mg hs -furosemide 40 mg qd -heparin 5,000 unit/ml tid -multivitamin qd -folic acid 1 mg qd -lansoprazole 30 mg tablet,qd -thiamine hcl 100 mg qd -insulin glargine 100 unit/ml solution : one (1) 60 units subcutaneous twice a day: give 60 units at breakfast, 60 units at dinner. -ascorbic acid 500 mg -ipratropium bromide 0.02 % solution q6h -albuterol sulfate 2.5 mg /3 ml (0.083 %) qid -silver sulfadiazine 1 % cream -cephalexin 500 mg capsule q6h -zinc sulfate 220 mg capsule : one (1) capsule po daily (daily). -nystatin 100,000 unit/ml three times a day. -polyvinyl alcohol-povidone 1.4-0.6 % dropperette ophthalmic prn -aspirin 325 mg qd -lidocaine hcl 2 % gel : one (1) appl mucous membrane prn -oxycodone 5 mg tablet : 0.5 tablet po q4h (every 4 hours) -clotrimazole 1 % cream : one (1) application topical twice a day as needed for facial rash for 3 weeks. discharge medications: 1. levothyroxine 100 mcg tablet : four (4) tablet po daily (daily). 2. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 3. therapeutic multivitamin liquid : one (1) tablet po daily (daily). 4. folic acid 1 mg tablet : one (1) tablet po daily (daily). 5. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 6. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day). 7. zinc sulfate 220 mg capsule : one (1) capsule po daily (daily). 8. aspirin 325 mg tablet : one (1) tablet po daily (daily). 9. oxycodone 5 mg tablet : 0.5 tablet po q6h (every 6 hours) as needed: before sacral ulcer dressing. 10. nystatin 100,000 unit/ml suspension : five (5) ml po tid (3 times a day). 11. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 12. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed for tinea cruris. 13. levetiracetam 1,000 mg tablet : two (2) tablet po bid (2 times a day). 14. keppra 250 mg tablet : one (1) tablet po twice a day. 15. zonisamide 100 mg capsule : six (6) capsule po daily (daily). 16. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q4h (every 4 hours) as needed for wheeze. 17. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for wheeze. 18. erythromycin 5 mg/g ointment : one (1) application ophthalmic qid (4 times a day). 19. lactulose 10 gram/15 ml syrup : fifteen (15) ml po tid (3 times a day): titrate to bm per day. 20. phenytoin 50 mg tablet, chewable : four (4) tablet, chewable po daily (daily): give in am. 21. phenytoin 50 mg tablet, chewable : six (6) tablet, chewable po daily (daily): give 8 pm. 22. topiramate 100 mg tablet : three (3) tablet po bid (2 times a day). 23. povidone-iodine 10 % solution : one (1) appl topical daily (daily): apply to peg tube insertion site. 24. insulin glargine 100 unit/ml cartridge : thirty eight (38) units subcutaneous at bedtime. 25. insulin regular human 300 unit/3 ml insulin pen : 11-32 units subcutaneous three times a day: per sliding scale: fs 71-100, 11 units fs 101-150, 17 units fs 151-200, 20 units fs 201-250, 24 units fs 251-300, 28 units fs 301-350, 32 units. discharge disposition: extended care facility: village discharge diagnosis: increased seizure frequency in the context of pna secondary dx: nash dm refractory seizures recurrent hepatic encephalopathy discharge condition: stable; baseline ms difficulty with some memory and attention deficits. distal extremity contractures, and asteryxis. discharge instructions: you were admitted with worsening seizures and mental status in the context of acquiring a pneumonia. you required temporary intubation and were treated with antibiotics. your seizures were controlled with a combination of anti-epileptic medicines, which you should continue. please return to the er if you experiece any worsening of your seizure frequency, develop new types of seizures, develop changes in mental status, weakness, changes in sensation, vision, or language, and severe headaches, vertigo, or anything else that concerns you seriously. followup instructions: follow up with neurologist dr. ; call ( for appt Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Acute respiratory failure Hypotension, unspecified Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Grand mal status Chronic systolic heart failure Pressure ulcer, lower back Iron deficiency anemia, unspecified Other ascites Malignant neoplasm of liver, primary Hepatic encephalopathy Hyperosmolality and/or hypernatremia Gastrostomy status Pressure ulcer, stage IV Other chronic nonalcoholic liver disease Oliguria and anuria

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever, hypotension major surgical or invasive procedure: egd peg placement picc placement history of present illness: hpi: 63 male with a history of end-stage liver disease secondary to non-alcoholic steatohepatitis, seizure disorder, type 2 diabetes, hypothyroidism presents with fevers and hypotension and profound dehydration from . per their records, he had been having fevers for several days. it was considered that he could have a nasal source from chronic dobhoff. ceftaz was started, and then was changed to meropenem several days prior to admission. he has continued to spike through that and motrin. . he has poor baseline functional status, and is not able to relate any complaints. comparing records, his mental status appears to be better on admission than it had been since his discharge. he had some green diarrhea on the day prior to presentation and his blood sugars had been very high for the past several days (300's). . of note, patient was recently discharged from on after prolonged admission since , originally admitted for convulsive status epilepticus. he was treated for his seizures, which were felt secondary to his elevated ammonia level. he also developed sepsis and was started on cvvh. his blood cultures at that time had coag negative staph and vanco-sensitive enterococcus. he also had an episode of vt and an echo at the time revealed a decreased ef of approximately 40%. . ed course: he was hypotensive to 60s on arrival. he was given aggressive fluid resuscitation. he was in in acute renal failure. a subclavian line was placed. past medical history: pmhx: - nash cirrhosis, on transplant list - hcc - diabetes mellitus hypertension - seizure disorder - hypothyroidism - gerd - chf, tte in demonstrated lvef 40% with regional lv wall motion abnormalities, which was new as compared to (ef at that time was >55%. - cad, s/p cardiac cath in for planned ptca of rca which failed secondary to occlusion and dissection; followed by - hyperlipidemia - ugib s/p tips social history: remote smoking history, married. currently lives at . family history: nc physical exam: physical exam on admission: physical examination: vs tm 101.2 tc 97.4 98/52 78 28 100% on 35% trach mask general: elderly, ill appearing male, lying in bed, nad heent: mmdry, white film on tongue, poor dentition, perrl neck: supple, no lad, trach in place, jvp flat lungs: coarse bs bilaterally cardiac: regular, ii/vi hsm at apex, no s3 or s4 abdomen: obese, sl distended, nt, pos bs gu: no scrotal edema extr: trace le swelling. upper extremities with 2+ pitting edema in the forearms. skin: stage 2 coccyx ulcer. neuro: arousable, followed simple commands like open mouth or eyes. can barely move hands, and is not able to move toes. pertinent results: ekg: nsr 78 bpm, nl axis, nl intervals, deep q in ii, iii, avf. good rwp. consistent with prior from . . imaging: . cxr: persistent atelectasis within the right perihilar region and left lung base. tip of right subclavian central venous catheter overlie the proximal right atrium. recommend partially withdrawing. . abd u/s findings: there is no ascites identified in the abdomen. no new liver masses are identified, and there is no biliary dilatation identified. doppler examination of the tips shunt demonstrate flow within the shunt which is wall- to-wall, however, the distal portion of the shunt shows some narrowing. velocities within the tips shunt are 30, 96, and 282 in the proximal, mid and distal portions respectively. elevated velocities within the distal portion are concerning for a distal stenosis. flow in the main portal vein is hepatopetal and is 44 cm/sec. some flow away from the tips shunt is identified within the anterior right portal vein. flow within the left portal vein is still demonstrated towards the tips shunt on this exam. brief hospital course: a/p : 63m h/o esld nash, hcc, seizure disorder, dm2, hypothyroidism, poor baseline mental status (unable to speak, unable to move extremities at baseline per wife), admitted from rehab via with fevers, hypotension, profound dehydration, and electrolyte derangements, now with improved mental status after rehydration. . # fevers/hypotension: his initial presentation was felt to be concerning for sepsis in light of fevers prior to admission. patient was determined to be severely hypovolemic in the ed, and was given 7 liters of normal saline. his bp improved and has since remained stable. the possible sources of infection were felt to include decubitus ulcer, gi/diarrhea, uti, pulmonary. he was initially covered with linezolid with history of vre, which was switched to daptomycin, piperacillin/tazobactam, and metronidazole for broad coverage. his chest x-ray showed no pneumonia. he had no recurrent fevers and blood and urine cultures and stool c. diff were negative. his antibiotics were subsequently removed and his vitals remained stable. given this clinical picture, hypovolemia from dehydration rather than sepsis was considered the most likely cause of hypotension. . # seizures: patient had a recent prolonged admission with refractory seizures, necessitating pentobarbital coma at one point. seizures during his prior admission were primarily absence in nature, as he would stare off and become non-responsive, but no rhythmic motions were noted. the epilepsy service was consulted to assist with management of his several anti-epileptics. given his low albumin, corrected phenytoin levels (goal 20-30) and free phenytoin levels (goal 2-2.5) were followed. his phenytoin dose was slightly decreased. continuous eeg monitoring x 2 days demonstrated slow background but no rhythmic epileptiform activities, ruling out subclinical seizures. he was continued on his prior regimen of phenytoin (at a lower dose), zonismaide, levetiracetam, and topiramate. he was also placed on lorazepam 0.75 mg tid for seizure prophylaxis in the setting of lowered seizure threshold. his phenytoin dose was further decreased to 150mg per peg tid after his free phenytoin level returned elevated at 2.9. he should have a free phenytoin level checked on and again on , and the results should be communicated to dr. at . she will determine any further dose adjustments. he should also continue on his current dose of lorazepam until , when it should be decreased to 0.5mg iv q8h. he was discharged on these medications with follow up with dr. . please contact her at the above number for any questions regarding his antiepileptic medication regimen. . # ams: although patient is minimally responsive to commands, this current mental status and functional status (rigidity and limited ability to move extremities) is his new baseline. wife stated patient is the "best" he has been since . he had periods of increased lucidity with orientation to person and place. his ammonia was followed and was found to be higher than previous levels. he was maintained on lactulose and his rifaximin was increased. antiepileptic management as above. he remained at his baseline mental status for the remainder of his stay. . # ugib: on , patient had coffee-ground emesis. his dobhoff was removed and tube feedings were held. noticed some brown mucous at trach site. ng lavage showed coffee grounds but no bright red blood. his hct was stable from prior days at 24.9. he received 3 u prbcs with an increase in his hct to 30.9. his aspirin and sc heparin were held, and he was placed on a ppi . egd on showed small hiatal hernia and grade b esophagitis with contact bleeding in the lower third of the esophagus. peg tube was placed on and he has been tolerating tube feeds. his hematocrit has remained stable at 29. his sc heparin was restarted. consider holding aspirin for 2 weeks (to restart on ) to allow mucosa to heal, in light of risk of recurrent life-threatening gi bleeding. he was maintained on a ppi. . # hypernatremia: hypernatremia to 166 on admission was considered most likley due to hypovolemia given his clinical exam and improvement with replacement of his 8l free water deficit. he also received free water boluses via peg tube. his sodium level remained stable. . # cad: patient has history of cad, and had elevated troponin on admission, but was unable to give a history of chest pain. acute renal failure was considered a possible contributor to elevated troponin levels, and his ck trended downwards. his beta blocker and ace-inhibitor were initially held in the setting of hypotension. his aspirin was held in the setting of an upper gi bleed as above. his home beta blocker and ace-inhibitor were restarted after he remained stable after gi bleed. his blood pressure has remained stable. . # decubitus ulcer / heel blisters: pt was admitted with stage 2 ulcer on coccyx and pressure blisters on heels. wound care and plastic surgery consults were obtained and recommendations followed. a rectal tube was placed for hygiene and he may need fecal diversion in the future. patient will need follow up with plastic surgery post-discharge. . # esld/cirrhosis: he has a history of hcc and nash cirrhosis, and is s/p tips after a gi bleed. he was previously considered for liver transplant but has been delisted due to his baseline mental status. a ruq us was performed on admission with some concern for tips stenosis. ir assessed the tips under fluoroscopy and found mild narrowing but no hemodynamically significant stenosis. his ammonia level was found to be elevated from baseline as above, although his mental status remained at baseline. he was maintained on lactulose and his rifaximin was increased. . # pancytopenia: patient was found to be pancytopenic (but not neutropenic) on admission, with low platelets and leukopenia thought likely secondary to chronic liver disease/sequestration, and low hematocrit thought likely secondary to anemia of chronic disease. his wbc and platelet counts remained stable. his hematocrit was stable after resuscitation from gi bleed as above. further workup was deferred to the outpatient setting. . # arf: creatinine was 1.9 on admission (greatly increased from baseline of 0.5), considered likely prerenal given hypovolemia. it improved greatly with fluid resuscitation and has remained stable at 0.4-0.5. . # dm2 uncontrolled with complications: prior to admission, fingersticks had been trending upwards at rehab. nph and riss titrated to maintain fs <150. on ace-inhibitor as above. . # hypothyroidism: continued home regimen of levothyroxine 200mcg daily. . # respiratory failure s/p tracheostomy: no respiratory difficulties during this admission with stable oxygen saturation on baseline 35% trach mask. speech and swallow service was consulted, and patient was fitted for passy-muir valve. . # fen: patient has tolerated tube feeds via peg tube at goal rate. hypovolemia on admission was corrected with aggressive fluid resuscitation. patient subsequently developed anasarca due to low albumin state, although respiratory status was not compromised. he was given occasional doses of iv furosemide for gentle diuresis. hypernatremia as above. . # ppx: pneumoboots for dvt prophylaxis was maintained. sc heparin was also administered, with temporary hold in setting of gi bleed. on ppi. . # communication: wife . # access: picc placed. . # full code . # dispo: patient was determined medically stable and was discharged to rehab. . medications on admission: - meropenem - dilantin 300 tid - keppra 2250 - topiramate 200 - zonisamide 700 qd - asa - metoprolol 12.5 - lisinopril 2.5 qd - lactulose - rifaxamin - aldactone 100 qd - lasix 140 qd - insulin nph 20 - synthroid 200 qd - fragmin discharge medications: 1. levetiracetam 500 mg tablet : 4.5 tablets po bid (2 times a day). 2. topiramate 100 mg tablet : two (2) tablet po bid (2 times a day). 3. zonisamide 100 mg capsule : seven (7) capsule po daily (daily). 4. levothyroxine 100 mcg tablet : two (2) tablet po daily (daily). 5. lactulose 10 gram/15 ml syrup : thirty (30) ml po tid (3 times a day). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 8. lisinopril 5 mg tablet : 0.5 tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 10. lorazepam 2 mg/ml syringe : 0.75 mg injection q 8h (every 8 hours). 11. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 12. nystatin 100,000 unit/g cream : one (1) appl topical (2 times a day). 13. heparin lock flush (porcine) 100 unit/ml syringe : two (2) mg intravenous daily (daily) as needed. 14. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) nebulizer inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 15. ipratropium bromide 0.02 % solution : one (1) nebulizer inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 16. insulin nph human recomb 100 unit/ml suspension : as directed units subcutaneous twice a day: administer 28 units every morning and 32 units every evening. 17. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day) for 3 days. 18. zinc sulfate 220 (50) mg capsule : one (1) capsule po daily (daily) for 3 days. 19. phenytoin 100 mg/4 ml suspension : one y (150) mg po tid (3 times a day). 20. outpatient lab work please check free phenytoin level (goal 2.0-2.5) on and . please communicate results to dr. . 21. insulin lispro 100 unit/ml solution : as directed units subcutaneous four times a day: please see sliding scale. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: hypernatremia hypovolemia upper gi bleed sacral decubitus ulcer secondary: epilepsy cad chf discharge condition: stable, mental status at baseline, bp stable, electrolytes within normal limits discharge instructions: you were admitted to the hospital with fever, low blood pressure, and a very high sodium level. you were initially treated with antibiotics. no source of infection was discovered despite extensive testing and your fever never recurred, so you were taken off antibiotics. your blood pressure improved with iv fluids. your sodium level also improved with fluids. you were followed by the neurology-epilepsy service during your stay, and they recommended adjustments to your anti-seizure medications. you had continuous eeg monitoring that did not show any evidence of seizure activity. you had some bleeding from your stomach which was thought to be secondary to irritation of the stomach lining. your aspirin was held and you were starting on an anti-acid medication. you were also followed by the wound care service for your sacral decubitus ulcer. you were given a few doses of iv furosemide for edema in your arms and legs. a picc line was placed. a feeding tube was placed in your stomach. your respiratory status was stable. . please take all of your medications as prescribed. please attend all of your follow up appointments. . if you experience low blood pressure, fever, blood in vomit or stool, seizure activity, change in mental status from your baseline, or other concerning symptoms, please call your doctor or go to the er. followup instructions: 1) epilepsy: , md phone: date/time: 9:00am 2) plastic surgery: please follow-up in clinic for yoursacral decubitus ulcer. call ( to make an appointment. 3) please call your primary care doctor, dr. , to schedule a follow up appointment. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Phlebography of the portal venous system using contrast material Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other shock without mention of trauma Pressure ulcer, lower back Diarrhea Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Esophagitis, unspecified Hypovolemia Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Generalized nonconvulsive epilepsy, with intractable epilepsy Chronic respiratory failure Esophageal hemorrhage Tracheostomy status

allergies:nkda events:63 yo old man recently discharged to rehab after stay in micu w/,intubated vented and s/p trache .a case of esld,seizures,htn,dm,s/ ,presented to ed with low bp,temp 101.8,initial lab na 126,treated with 8lit n/saline,bp improved .admitted to micu for further management . neuro:on admission he was not responding to call or pain,pupils 2mm and brisk.not moving any extremities.by early am noted more aware,like responding to some questions. resp:,on trache mask 35%,sats 95-100%.suctioned scanty white secretions.having good coughing reflex.trache care given,tie changed. cvs:hr 80-90's nsr.initially bp remained stable,his baseline bp 90 sys.on arrivan drawn,na 165,k 2.6.fluid bolus 2lit d5w given for low bp with good effect.k repleted with 80meq total .calcium 6.6,2gm calcium gluconate given.am pending.na down to 156.ivf d5w 125 cc/hr continued.ekg done. gu/gi:abdomen soft,bs hypo,pedi tube on lt nare.clamped.at present npo.had large loose stool on arrival.mushroom cath inserted.draining loose stool.on foley cath,urine output 30-50cc/hr,yellow clear. integu:stage 2 decub on coccyx,looks like abrasion.duoderm applied. bath given and positioned.afebrile.vre. social:visited by wife and son and updated.full code,may change later. iv access:2 lumen picc on rt ac ,site looks clean ,dressing intact,patent.rt scv ,patent.dressing changed.18g piv on lla. endo:riss and covered.on nph dose also. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Phlebography of the portal venous system using contrast material Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other shock without mention of trauma Pressure ulcer, lower back Diarrhea Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Esophagitis, unspecified Hypovolemia Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Generalized nonconvulsive epilepsy, with intractable epilepsy Chronic respiratory failure Esophageal hemorrhage Tracheostomy status

code: full allergies: nkda Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Phlebography of the portal venous system using contrast material Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other shock without mention of trauma Pressure ulcer, lower back Diarrhea Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Esophagitis, unspecified Hypovolemia Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Generalized nonconvulsive epilepsy, with intractable epilepsy Chronic respiratory failure Esophageal hemorrhage Tracheostomy status

code: full allergies: nkda events: pt's ngt vomited out overnight, replaced this am, upon insertion ng draining large amounts of coffee ground emesis ~800cc, team notified. dr. at bedside attempting to lavage gastirc contents till clear, however unable. residual decreasing through shift. transfused with 2 units prbc, ordered for additional unit. neuro: pt alert, inconsistently following commands, minimal spontaneous movement noted to extremities, pupils equal and reactive, able to answer simple yes/no questions by nodding. pt denies pain. no seizure activity noted this shift, am phenytoin level 35, goal 20-30, 1400 dose held. due to be rechecked with am . continuous eeg leads in place, 48 hour observation finishes . cv: hr 80-90s nsr with rare pvc, nbp 110-130/50-60, peripheral pulses weak, but palpable. hct down to 23 from 24 after one unit, md aware, ordered additional 2 units - first of two infusing. next hct due to be checked 3-4 hours after 2nd unit of prbc transfused. access includes right brachial picc (blue port hard to flush), and piv x 1. resp: pt with #8 portex, on humidified trach mask at 35%, rr mostly in 20s with sats at 100%. lung sounds clear in apices, at times diminished in bases. suctioned x 4 for small amounts of thick, white sputum. single episode of bloody secretions this am, team aware. gi: bs x 4, mushroom catheter intact draining liquid brown stool. ngt dropped this am, confirmed with cxr, kept to low intermittent suction (except for after meds) for large amounts coffee ground residuals. tf on hold for now, if hct continues to be unstable team considering starting tpn tomorrow. gu: foley patent and draining adequate amounts of clear, yellow urine. uo 50-80cc q2h. endo: nph held this am per dr. request, fbs covered with sliding scale. sking: small abrasion to left lower leg, covered with adaptic gauze and dsd. stage 1 to coccyx area. see wound care req for dressing specifics. social: wife and sons in to visit today, updated by rn and md on pt's condition and plan of care. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Phlebography of the portal venous system using contrast material Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other shock without mention of trauma Pressure ulcer, lower back Diarrhea Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Esophagitis, unspecified Hypovolemia Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Generalized nonconvulsive epilepsy, with intractable epilepsy Chronic respiratory failure Esophageal hemorrhage Tracheostomy status

code: full allergies: nkda events: tpa used to clear occluded picc ports, am sent, pt scoped at bedside and peg inserted, eeg leads removed. neuro: pt dozing intermittently throughout shift, to stimuli, able to answer simple questions by nodding, following commands inconsistently. pupils equal and reactive. continues on anti-seizure meds, no seizure activity noted, eeg wires removed this afternoon, final results pending. pt denies pain, however grimaces with turns. cv: hr 80-90 nsr with no ectopy noted, sbp 100-120, am hct 30.9, goal >27, repeat sent at 1600, results pending. peripheral pulses palpable. access includes picc to right ac and piv x 1, all ports patent, sites wnl. resp: with #8 portex, additional inner cannulas at bedside. continues on humidified trach mask at 35%. rr teens to 20s with sats >98%. lung sounds clear to coarse, improves with suctioning. suctioned multiple times for yellow to blood tinged secretions. gi: bs x 4, mushroom catheter intact and draining liquid black stool. peg placed this afternoon at bedside with no complications. pt remains npo except for meds, team plans to resume tf in am. gu: foley patent and draining clear, yellow urine. uo 40-80cc/hour. uo beginning to taper, team aware. skin: dressing to coccyx and low leg changed. wound to coccyx pink with patches of purple and black, appears to be healing. endo: nph held this am due to pt's npo status, fbs <200, covered with sliding scale. social: wife and son in to visit this evening, updated by rn on pt's condition and plan of care. plan: continue to follow hct monitor urine output resume tf tomorrow morning? pulmonary toileting routine icu care and monitoring support to pt and family Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Phlebography of the portal venous system using contrast material Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other shock without mention of trauma Pressure ulcer, lower back Diarrhea Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Esophagitis, unspecified Hypovolemia Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Generalized nonconvulsive epilepsy, with intractable epilepsy Chronic respiratory failure Esophageal hemorrhage Tracheostomy status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: status epilepticus in setting of severe metabolic derangement in setting of liver failure due to nash and hcc, with prolonged multifactorial encephalopathy (post-ictal, non-convulsive status, metabolic derangements) and a protracted hospital course in light of the above, as well as several complications as outlined extensively under "brief hospital course". major surgical or invasive procedure: continuous venous venous hemodialysis. intubation x 1. continuous eeg monitoring. history of present illness: 63yo man with cirrhosis, dm, htn, and seizures diagnosed in presents with seizures as a transfer from an osh. history is per his wife, as he is currently seizing. she reports he was in his usoh until this evening, when returning from dinner he had a seizure with left head deviation and left arm shaking. ems brought him to hospital at 8pm. at , a "focal seizure" was noted, with extremities lifted and gaze deviation to the left; he was resonding to verbal commands at that time. he was given ativan 2mg iv x 1, after which he was reportedly "confused", following commands incorrectly. at 2105, he was still noted to be confused, with "gaze to right". at 2200, he was noted to have occasional right gaze deviation. he had labs, which were notable for nh3 of 139, and had a negative head ct. he was given lactulose at 0040 and transferred to . he arrived around 2am, reportedly "awake, confused, looking to right, grip weak on right." when seen by the resident just before 4am, she saw him raise his right arm, then have right head and eye deviation, lasting one minute and spontaneously resolving. during the next five minutes, he had intermittent gaze deviation to the right, 2-3x, each approximately 30 seconds. his wife told her this was different from the prior events in that it was the right, not left, and that he had no shaking. neurology consult was called. ros per his wife is negative for fevers, chills, cough, abdominal pain, nausea, vomiting, other complaints. he was noted to have his first seizure while in the icu in . he was admitted for tips procedure and had ammonia level in the 200s at the time. on , he was found to have slight left head deviation with jerking movements of the shoulders and head. he was treated with dilantin (goal 20-25) and then a versed gtt. he was noted to have subclinical seizures on bedside eeg. he was eventually seizure free and was changed to keppra. he has had seizures since only in the context of aed vacation, and was thus restarted on the medications. of note, mri had shown bilateral cortical dwi abnormalities thought to be due to hepatic disease vs seizure; these had resolved on repeat mri one week later. past medical history: dm htn nash cirrhosis, on transplant list seizures as above hypothyroidism gerd social history: lives with wife, remote smoking history, no etoh or drug use family history: nc physical exam: vs: t 97.9, hr 84, bp 152/74, rr 14, sao2 98%/ra, fs 187 genl: lying on side, moving purposefully, appears to be seizing (see below) cv: rrr, nl s1, s2, no m/r/g chest: cta bilaterally anteriorly abd: soft, nt, bs+ ext: warm and dry neurologic examination: pt is lying on side, with head and eyes deviated far to the right, and right beating nystagmus. he has rhythmic jerking of his eyebrows, but not his arms or legs. ms: nonverbal, not following commands, responds to noxious cn: pupils equal and reactive, unable to assess eom as head tonically deviated to right, but eyes are to the right with right beating nystagmus. ?left facial flattening vs drawing over of face to the right. motor: hypertonic throughout, no jerking of limbs, moves all extremities antigravity to noxious sensory: responds to noxious throughout pertinent results: studies: ct - head - impression: 1. there is no evidence of intracranial hemorrhage, mass effect, or large vascular territory infarct. there is no evidence of fracture. 2. there is increase in opacification of the ethmoid air cells. again seen is opacification of the right maxillary sinus with central hyperintensity. this is likely due to chronic sinusitis changes, however, would recommend work up to rule out fungal infection if clinically warranted. there is no change to the appearance of this sinus compared to prior studies. a left maxillary sinus also has mucosal thickening posteriorly, and there is fluid or mucosal thickening in the left frontal sinus as well. eeg - impression: this is an abnormal portable eeg due to the presence of frequent sharp and sharp and slow wave discharges arising from the left posterior quadrant with maximal frequency of about 1 per hz in the setting of brief episodes of theta frequency slowing seen in the same region. the findings suggest an area of cortical and subcortical dysfunction along with cortical irritability which may serve as a focus for potential seizure activity. no clear electrographic seizures were noted. eeg - impression: this telemetry captured five pushbutton activations. in addition to the pushbutton activations, routine sampling and spike and seizure detection programs captured multiple episodes of rhythmic, sustained, and prolonged generalized spike and slow wave discharges occurring at a maximal frequency of about 8 hz, at times associated with eye blinking or left upper extremity jerking and, at other times, without a clear clinical correlate. the majority of these electrographic seizures were captured at the beginning of the recording on the evening of . these events are consistent with non-convulsive status epilepticus. as the electrographic tracing continued, the tracing evolved into a pattern of burst suppression, albeit with continued intermittent sharp and sharp and wave discharges arising from the left posterior quadrant. this pattern continued overnight until the following morning where there were several episodes of rhythmic monomorphic sharp wave discharges seen in a generalized distribution. while these electrographic findings may be artifactual in nature, we cannot rule out recurrent electrographic seizure activity. eeg - impression: this telemetry captured one pushbutton activation. routine sampling and spike and seizure detection programs demonstrated several episodes of rhythmic 8 hz monomorphic blunted sharp wave discharges occurring in a generalized distribution. there is no clear source of artifact associated with these events raising the possibility of persistent electrographic seizure activity. at other times, the recording showed bursts of low amplitude activity admixed with sharply contoured waves arising from the left posterior quadrant and, at times, evolving over the left hemisphere intermixed with periods of background voltage suppression consistent with a burst suppression pattern. ct-torso - impression: 1. limited evaluation secondary to lack of intravenous contrast administration. new right and left lower lobe collapse compared to . new small right pleural effusion. patchy appearance of left lung base raises the suspicion for component of aspiration. overall findings suspicious for pneumonia. clinical correlation is recommended. endotracheal tube and nasogastric tube remain in good position. 2. small amount of perihepatic fluid. tips shunt. no significant amount of abdominal ascites. no evidence of acute abdominal or pelvic pathology within the limitations described.\ ct torso - " chest: the patient is status post tracheostomy tube placement, with the tip terminating at the level of thoracic inlet. there are small mediastinal lymph nodes; however, there is no significant lymphadenopathy. coronary arteries are calcified. there is no pericardial effusion. small pericardial nodes are noted; however, measure less than 5 mm. there is trace pleural effusion bilaterally. in the lung window, again note is made of patchy opacities in the dependent portion of lower lobes, decreased since prior study, likely representing residual atelectasis. somewhat confluent area in the left lower lobe is noted, likely due to a part of resolving atelectasis; however, the attention should be paid to this location at the time of next follow up. there is no endobronchial lesion. abdomen: the patient is status post rf ablation of two lesions in the right lobe of the liver, which demonstrate hypoattenuation relative to liver parenchyma on all the phases. the patient is status post tips placement. the visualized portion of portal vein is patent. there is no new focal arterial enhancement. again, note is made of splenomegaly. gallbladder is unremarkable without evidence of calcification. pancreas is somewhat atrophic, without ductal dilatation or focal solid lesion. there is fat replacement of the pancreatic head. there is unchanged fat stranding surrounding the celiac trunk with small nodes. there are enlarged peripancreatic and porta hepatis nodes measuring up to 1.4 cm in short axis, unchanged since prior study. there is no significant ascites. the adrenal glands are within normal limits. the visualized portion of large and small intestines are within normal limits. bilateral kidneys have surrounding fat stranding with unchanged small hypoattenuating lesion, likely representing cyst, unchanged since prior studies. there is no hydronephrosis. the evaluation of the posterior portion of the abdomen is somewhat limited due to artifact from the arms. pelvis: there is colonic diverticulosis without evidence of diverticulitis. note is made of residual fluid in the somewhat dilated rectum. foley catheter is noted in the urinary bladder. the visualized portions of small intestines are within normal limits, without ascites or lymphadenopathy. there are degenerative changes of thoracolumbar spine; however, there is no suspicious lytic or blastic lesion in skeletal structures. atherosclerotic changes of the vascular structures are again noted. impression: 1. decreased parenchymal opacities in both lower lobes with residual atelectasis and effusion. somewhat confluent area near the left lower lobe, likely a part of resolving atelectasis. attention should be paid to this location at the time of next followup. 2. post rf ablation of two liver lesions without new arterial enhancement, with severe cirrhosis and splenomegaly. 3. enlarged porta hepatis and peripancreatic nodes, unchanged. 4. diverticulosis. " ct-head - impression: limited evaluation secondary to artifact from overlying metallic devices. no gross acute intracranial hemorrhage. unchanged multifocal sinus disease as described on . note on attending review: the study is markedly limited for the evaluation of brain parencyma due to streak artifacts from the several external metallic objects. there is gross midline shift. other than this, it is extremely difficult to assess the intracranial structures for abnormality. there is new moderate opacification of the sphenoid sinus and the left side of frontal sinus and the marked opacification of ethmoid air cells is worsened. the nasopharynx is opaciifed with a tube, likely nasogastric tube within. this appearance is new. eeg - impression: this telemetry captured no pushbutton activations. routine sampling and spike and seizure detection programs showed bursts of sharply contoured waveforms occurring in a generalized distribution but also with a leftsided predominance lasting up to one to two seconds in duration and admixed with other periods of voltage suppressed background lasting, at times, up to 10-20 seconds. these findings are consistent with a burst suppression pattern. superimposed on this pattern, later in the tracing, there is also rhythmic high amplitude low frequency slow wave morphology discharges that are related to artifact from the dialysis machine. there were no prolonged or repetitive discharges. no clinical seizures were noted. echo mild regional left ventricular systolic dysfunction, c/w cad. mild mitral regurgitation. compared with the prior study (images reviewed) of , regional lv wall motion abnormalities are new, and consequently, lv systolic function is now depressed. head mri with and without contrast. conclusion: negligible interval change in the appearance of the brain compared to the prior study. particularly in view of the history of status epilepticus, it is of some interest that the present diffusion scan is normal, whereas as a diffusion imaging study from , showed very extensive areas of signal abnormality. the reason for this discrepancy is not clear. addendum: multiple paranasal sinuses exhibit mucosal thickening, and likely fluid as well within the mastoid sinuses. presumably, these findings relate to the intubated status of the patient. head mri with and without contrast. 1. no acute intracranial process. 2. multiple paranasal sinuses exhibit mucosal thickening and some demonstrate air-fluid levels. this may represent sinusitis or post intubation changes most recent labs - see attached printout. brief hospital course: the patient was admitted to the icu for convulsive status epilepticus on . routine portable eeg showed frequent and at times periodic lateralized discharges from the left posterior quadrant. on the patient was taken out of the unit to the step down unit on 5. at that time his exam revealed staring spells with confusion most of the time - excluding an episode of lucidity. he was also not using his r(dominant) hand as much as usual. he was breathing well and did not require intubation. on the evening of he had a seizure and then three more on the morning of . later in the day a nurse noted that he was breathing and was turning "dusky". a code was called. o2 sat was initially 89% (was breathing at this point) and hr regular, 72. the patient again had difficulty breathing and was intubated and started on propofol gtt. he was transferred to the icu and soon after got 20mg/kg of dilantin. continuous eeg was set up and revealed non-convulsive status epilepticus. this yielded to burst suppression due to the propofol. at this point his anti-seizure regimen inlcuded keppra, neurontin, dilantin, and propofol. elevated ammonia/hepatic encephalopathy was thought to be the trigger of the patient's seizures. he was titrated to three bowel movements a day with lactulose and rifaximin. the liver service was consulted. . eeg on continued to demonstrate isolated occipitally predominant and leftsided predominant spike and wave discharges despite this heavy dose of antiseizure medication. in the afternoon of the same day the patient was noted to have increasing acidosis, elevated lactate and rising cks which were both attributed to his propofol. propofol was stopped and the patient was put into a pentobarbital coma. . on mr became hypotensive requiring two pressors. pentobarbital was stopped but he remaind on keppra, dilantin and tapering neurontin. he was empirically started on vancomycin and zosyn for concern of sepsis. a ct of the abdomen failed reveal a nidus of infection, though the study was limited due to the lack of contrast. the renal service was consulted regarding his acidosis. he was started on cvvh. . blood cultures from grew coag negative staph and vancomycin sensitive enterococcus. the infectious diseases service was consulted. xigris was started to treat the systemic inflammatory response syndrome. . an eeg on was read by the covering resident as suggestive of insufficient burst suppression and the patient was given a 400mg iv dilantin bolus. . renal function/acidosis improved on the cvvh and by it was discontinued. that evening his heart rhythm was noted to go into vtach. cardiology was emergently consulted. a stat echo showed hypokinesis of the anterior septum, akinesis of the inferior septum, and severe hypokinesis of the inferior wall. he was started on amiodarone. . by pressors were weened off and zosyn was stopped. vancomycin was continued for a two week course. of note a definite source of the infection was never identified. . on the patient was started on a versed gtt and dilantin was started. . over the next four weeks the patient's renal status would normalize and his fever and infectious issues would resolve confirmed by sterile blood cultures. over the same period he was maintained on phenobarbital, keppra, dilantin, and transitioned from the versed gtt to an ativan taper. an mri failed to detect any significant abnormality or change from prior. physical examination of the patient during this period revealed an unresponsive edematous male with reactive pupils, intact corneal reflexes, intact ocrs, and response to nail bed pressure intermittently in the lue and lle. as the ativan was tapered the patient's eeg showed an increased quantity of 1hz global paroxysmal epileptiform discharges. as such on zonisamide was added to the above regimen. also during this time, the a tracheostomy was performed. plans for a peg tube were thwarted by the patient's overwhelming edema, which was a result of the fluid boluses he recived while hypotensive/septic. lasix and aldactone were used to diurese approximately 15 liters off the patient. . since then, he has been gradually weaned off phenobarb with no significant changes in his eeg. ativan was also slightly tapered and zonegran was slightly increased. mr. was noted to have intermittent hematuria, therefore urology was consulted. it was suggested that this was due to trauma from his foley, and a repeat u/a and ucx were stable. his bag was taped to his leg to stabilize it and he will need op follow-up for cystoscopy. he also had intermittent episodes of hypotension, therefore his metoprolol was decreased from qid to and this resolved. lisinopril was added for renal protection given his dm. . he was transfered to the step down on for further management. . hospital summary from - neuro: pt had his phenobarbital weaned down with improvement in his alertness - opening eyes much more. however, his eeg began to demonstrate more discharges. as a result, his medical regimen was increased with stabilization of his eeg. after several days, his phenobarbital again was weaned to 100 mg po bid. his ativan was also weaned and his zonegran dose was increased. he was also started on topamax with less frequent discharges on above aed therapy. topamax increased to 125 by . over the course of the next two weeks, pb was tapered alltogether, as well as his ativan, both in small decrements. topamax was increased to 200 mg and zonegran to 600 mg daily. his keppra was maintained at 2250 mg , and his dilantin at 300 mg tid, the latter with corrected (for low albumin) levels around 30. . of note, a repeat mri of the brain on showed no ischemic changes. . despite this slow taper, the patient remained deeply encephalopathic, despite the absence of epileptiform abnormalities on eeg, which continued to show an encephalopathic pattern with very low voltage slow background and occasional parasagittal sharp wave discharges, but these were not frequent or rapid enough to suggest ongoing seizures. on exam, he would have his eyes open, but he would not regard, localize sound or regard his examiner, nor blink to threat. he would not grimace nor move his extremities to noxious stimulation, but he would grimace to flexion of his arms, suggesting that perhaps he had distal sensory deficits as well as marked weakness and muscle bulk loss, suggestive of a critical illness polyneuromyopathy. his reflexes were absent, supporting this finding. . note that 1 week prior to discharge hid improved neurologically on a daily basis: he made eye-contact, would fix and follow a face (non consistently), and would occasionally following midline commands such as sticking out his tongue, and mouthing words like "good-morning". prior to this, he was basically considered to be in a persistent vegetative state, but thankfully he disproved this prior to discharge to rehab. . neurologically, our advise is an extreme slow taper of his ativan, perhaps as slow as -.25 mg per 2 weeks. he should have interval eegs to assess for continued epileptiform activity. as this patient is complex, in case of questions please do not hesitate to contact the epilepsy fellow regarding his eeg findings, for proper electro-clinical correlation. . cv: low bps initially during stay in step down. metoprolol dose was halved with improvement in his bps with stable bps on metoprolol 12.5 and lisinopril. later, the metoprolol was further decreased due to continued low bloodpressures. . resp/id: requiring prolonged stay in the stepdown unit due to the intensive nursing care needs, the patient kept having marked sputum production. staph aureus was cultured, and for concern of pna he was started on vancomycin, but continued on regimen with continued staph in his sputum. his vre (rectal swab) showed sparse growth on . his vancomycin was discontinued, and he remained afebrile. he continued to produce sputum occasionally blood-tinged, and i refer to the respiratory care sign-out regarding his pulmonary status. a chest ct done just prior to discharge showed "decreased parenchymal opacities in both lower lobes with residual atelectasis and effusion. somewhat confluent area near the left lower lobe, likely a part of resolving atelectasis. attention should be paid to this location at the time of next followup". . gi: the patient had stable ltfs and ammonia levels, as long as having daily bms. he was treated with 60 ml of lactulose qid, titrated to 3 bowel movements per day. he was also on rifaximin for selective decontamination. hepatology followed the patient during hospital stay, with advise regarding management of his liver failure, adjusting lactulose and others, metabolic management. towards the end of his stay, an u/s of his abdomen, a bone-scan and ct torso were obtained - see below. . fen: stable electrolytes with only occasional replacement necessary. he had a dobhoff in place fo several weeks, and an assessment of the amount of ascitis by u/s on showed no intra-abdominal ascites, making peg placement possible. his dobhoff tip was found to be intragastric, and when pushed down further it only resulted in curlingup in the back of his mouth. after withdrawing again, a repeat cxr on showed the tip to be in the stomach still. follow-up was recommended. . to assess overall prognosis (re: peg placement) a bone-scan and ct torso (post-rfa protocol) were obtained on , which showed extensive degenerative joint disease but no progression of his hcc (see details in results-section). hepatology was then scheduling his peg placement, but due to logistical issues this could not be done promptly. this should be considered on a day-care basis, unless the patient's level of consciousness allows him a safe swallow, and the enteral feedings prove to be only temporary. . endo: the continued to have low thyroid function, likely absorption impaired continuous feeds, so he was changed to iv thyroxine with improvement after gradual upward titration of the dosis. tsh and t4's were checked regularly. . heme: all lineages decreasing on , hematology was consulted, iron and vitamin studies were normal. their advise was to d/c dilantin if clinically possible, but we were not able to do so at this stage. guiac's were checked regularly as well, all negative. in summary, the pancytopenia was considered secondary to chronic illness with polypharmacy, and a bone marrow biopsy was not performed. cbc's are to be followed. . musculoskeletal: as outlined under the neurological section, he had marked muscle wasting and areflexia, as well as decreased response to peripheral noxious stimuli, making a critical illness polyneuro-myopathy likely. of note however, his pain seemed to be exacerbated when his joints were passively moved, ranging from smaller joints in the hand to larger joints as elbow. his bone scan, done to assess for bony metastasis of his hcc, showed diffusely symmetric increased uptake of tracer in all joints, indicating degenerative disease. in the setting of his polyneuro-myopathy, prolonged immobilization despite pt, it is not a suprising finding. however, if the patient is further mobilized, and this continues to be a problem, pain medication should be adapted and a further workup is warranted. . social: his wife was updated frequently and on a regular basis, during later stages of the admission twice per week on set days of the week. she continued to be understanding, and slowly appeared to accept the persistent vegetative state her husband was in, with no improvement of his neurological exam during the 2nd to last month of his stay. fortunately, he did improve during the last week of his stay he did suddenly improve, with eye-contact and occasionally following midline commands, and mouthing words like "good-morning". his wife was pleased. medications on admission: lactulose 30mg 5x/day rifaximin 400mg tid protonix 40mg propranolol 10mg tid levothyroxine 175mg daily lantus 64units qhs keprra 1500mg mycelex 10mg 5x/day "zepia" 10mg daily(?) discharge medications: 1. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 2. artificial tear with lanolin 0.1-0.1 % ointment : one (1) appl ophthalmic prn (as needed). 3. metoclopramide 5 mg/ml solution : one (1) injection q6h (every 6 hours). 4. levothyroxine 200 mcg recon soln : one (1) recon soln injection daily (daily). 5. lorazepam 2 mg/ml syringe : 0.75 mg injection q6h (every 6 hours). 6. heparin (porcine) 5,000 unit/ml solution : one (1) injection (2 times a day). 7. fluocinolone 0.025 % cream : one (1) appl topical (2 times a day). 8. famotidine 20 mg tablet : one (1) tablet po q24h (every 24 hours). 9. spironolactone 100 mg tablet : one (1) tablet po daily (daily). 10. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic prn (as needed). 11. ibuprofen 100 mg/5 ml suspension : one (1) po q4-6h () as needed for temp>100.4. 12. furosemide 40 mg tablet : 3.5 tablets po daily (daily). 13. lisinopril 5 mg tablet : 0.5 tablet po daily (daily). 14. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 15. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day). 16. phenytoin 100 mg/4 ml suspension : three (3) po tid (3 times a day): 300 mg tid. 17. levetiracetam 1,000 mg tablet : 2250 mg tablets po twice a day as needed for seizure. 18. lactulose 10 gram/15 ml syrup : sixty (60) ml po qid (4 times a day): to 3 - 3 bowel movements per day. 19. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day) as needed for thrush. 20. topiramate 100 mg tablet : two (2) tablet po bid (2 times a day). 21. metoprolol tartrate 25 mg tablet : 0.5 tablet po daily (daily). 22. zonisamide 100 mg capsule : seven (7) capsule po daily (daily). 23. insulin standing order and sliding scale as presribed in nursing signout discharge disposition: extended care facility: & rehab center - discharge diagnosis: status epilepticus in setting of severe metabolic derangement in setting of liver failure due to non alcoholic steatotic hepatitis and hepato cellular carcinoma, with prolonged multifactorial encephalopathy (post-ictal, non-convulsive status, metabolic derangements) and a protracted hospital course in light of the above, as well as several complications as outlined extensively under "brief hospital course". discharge condition: stable, neurologically slowly improving, labs unchanged, afebrile. discharge instructions: please follow up with dr as planned, unless you are still at at that time. take all your medications as presribed. followup instructions: epilepsy: , md phone: date/time: 9:00 you will be contact by hepatology regarding follow-up and possible peg placement, for details see hospital course'. 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 Hemodialysis Venous catheterization for renal dialysis Temporary tracheostomy Infusion of drotrecogin alfa (activated) Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension 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 Severe sepsis Unspecified acquired hypothyroidism Paroxysmal ventricular tachycardia Acute respiratory failure Pneumonia due to Staphylococcus, unspecified Septic shock Grand mal status Malignant neoplasm of liver, primary Hepatic encephalopathy Other and unspecified complications of medical care, not elsewhere classified Rhabdomyolysis Staphylococcal septicemia, unspecified Chronic maxillary sinusitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: found down at home major surgical or invasive procedure: egd x 3 tips tube intubation history of present illness: 62 yo m w/ h/o "liver dz", and history of ulcer, who called ems due to feeling like he was going to "pass out". has been feeling lh for the past day. due to pre-syncopal symtptoms called ems. ems found the patient to be hypotensive, sbp 60s, and in transit vomited approx 500cc brb. . patient reports that he had been in his usoh until approx 3 wks ago when he noted the onset of post-prandial diffuse abdominal pain. desrcibed as mild and crampy. also noted with taking pills. some relief when accompanied by milk. no n/v/d. no prior hematemesis. no melana. no history of variceal bleeding. . in the ed, hypotensive 86/48, vomited 800cc brb. ngl performed, returned 500cc brb and did not clear. 2 14g piv, placed rec'd 4u prbc, 2l ns, octreotide, protonix. past medical history: "ulcer dz" "liver dz" chf social history: no etoh. +remote smoking history. stopped 30 yrs ago. family history: nc physical exam: t 96.2, bp 112/68, hr 68, rr14, 98% 2l nc elderly, well appearing male, alert and oriented, w/ ngt in place draining brb. perrl op w/ dried blood. jvp could not be appreciated regular s1,s2. no m/r/g lca b/l distended, protuberant abdomen. +bs. soft. nt. no fluid wave. trace le edema. no c/c no asterixis, palmar erythema, gynecomastia, spider angiomata. pertinent results: admission labs: 06:40am wbc-4.8 rbc-2.57* hgb-8.4* hct-25.0* mcv-97 mch-32.6* mchc-33.5 rdw-14.1 06:40am plt count-98* 06:40am pt-14.4* ptt-25.2 inr(pt)-1.3* 06:40am fibrinoge-228 06:40am urea n-37* creat-1.0 06:40am amylase-47 06:40am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 07:03am po2-122* pco2-40 ph-7.32* total co2-22 base xs--5 comments-green top 07:31am urine mucous-few 07:31am urine granular-0-2 hyaline-* 07:31am urine rbc-0 wbc-0-2 bacteria-none yeast-none epi-0 07:31am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-6.0 leuk-neg 07:31am urine color-yellow appear-clear sp -1.023 07:57am plt count-66* 07:57am wbc-6.0 rbc-2.95* hgb-9.9* hct-28.1* mcv-95 mch-33.6* mchc-35.3* rdw-14.3 09:19am fibrinoge-246 09:19am pt-14.1* ptt-22.9 inr(pt)-1.3* 09:19am albumin-3.1* calcium-7.4* phosphate-2.9 magnesium-1.6 09:19am lipase-35 09:19am alt(sgpt)-27 ast(sgot)-28 ld(ldh)-147 alk phos-88 amylase-47 tot bili-0.6 09:19am glucose-72 urea n-36* creat-0.9 sodium-142 potassium-4.9 chloride-113* total co2-19* anion gap-15 09:32am freeca-1.06* 09:32am lactate-2.1* na+-140 k+-4.9 cl--114* tco2-21 09:32am type- temp-35.7 ph-7.33* 10:20am hct-31.4* 12:34pm pt-15.3* ptt-48.1* inr(pt)-1.4* 12:34pm plt count-134*# 12:34pm wbc-11.1*# rbc-4.23*# hgb-13.4*# hct-39.2* mcv-93 mch-31.6 mchc-34.1 rdw-14.6 12:34pm calcium-6.5* 12:34pm glucose-104 urea n-34* creat-0.9 sodium-140 potassium-5.7* chloride-114* total co2-16* anion gap-16 02:31pm plt count-158 02:31pm wbc-10.8 rbc-4.28* hgb-13.3* hct-39.2* mcv-92 mch-31.1 mchc-33.9 rdw-14.8 02:32pm fibrinoge-205 02:32pm pt-14.0* ptt-27.3 inr(pt)-1.2* 02:32pm caltibc-280 ferritin-33 trf-215 02:32pm calcium-7.0* phosphate-3.2 magnesium-1.5* iron-196* 02:32pm glucose-136* urea n-34* creat-0.9 sodium-139 potassium-5.6* chloride-114* total co2-16* anion gap-15 02:43pm type-art temp-36.7 rates-14/ tidal vol-700 peep-5 o2-50 po2-146* pco2-31* ph-7.35 total co2-18* base xs--7 -assist/con intubated-intubated 05:00pm fibrinoge-208 05:00pm pt-13.7* ptt-29.0 inr(pt)-1.2* 05:00pm plt count-182 05:00pm wbc-13.1* rbc-4.27* hgb-13.6* hct-39.1* mcv-91 mch-31.8 mchc-34.8 rdw-14.8 05:00pm hcv ab-negative 05:00pm hbsag-negative hbs ab-positive hbc ab-negative hav ab-positive 05:00pm calcium-7.8* phosphate-3.4 magnesium-1.6 05:00pm glucose-140* urea n-34* creat-0.9 sodium-141 potassium-4.5 chloride-114* total co2-17* anion gap-15 05:17pm type-art rates-14/ tidal vol-600 peep-5 o2-40 po2-108* pco2-30* ph-7.35 total co2-17* base xs--7 -assist/con intubated-intubated 07:54pm hct-37.1* 09:49pm fibrinoge-224 09:49pm pt-13.2* ptt-28.1 inr(pt)-1.1 09:49pm plt count-111* 09:49pm wbc-10.5 rbc-3.91* hgb-13.0* hct-35.4* mcv-90 mch-33.2* mchc-36.7* rdw-15.2 09:49pm calcium-7.9* phosphate-3.5 magnesium-2.3 09:49pm glucose-156* urea n-32* creat-1.0 sodium-140 potassium-4.2 chloride-114* total co2-17* anion gap-13 brief hospital course: 62 yo m w cirrhosis and varices admitted for an upper gi bleed x 2. the following issues were investigated during this hospitalization: . 1) gib: shortly after admission to the icu the pt. having massive hemoptysis with resultant hypotension. he was scoped emergently after intubation and found to have stage 3 variceal bleeding which was unable to be stopped with banding. he was started on protonix and octreotide drips with ciprofloxacin prophylaxis. esophageal balloon was placed with stabilization of bleeding. he required 12u prbcs and 7u ffp on hd1. a tips was successfully placed on , but followed by continued bleeding. he was transfused once more on . a ruq u/s on an confirmed patency of tips. his hematocrit remained stable after the transfusion on and he was transferred to the general medicine floor for continued management. . 2) liver disease: etiology is unclear but has been described as nash and cryptogenic in nature. there is no report of a liver biopsy. during this hospitalization, initial work-up revealed negative hepatology serologies and no evidence of hemochromotosis. an abdominal ct showed a 1.5 cm lesion in the right lobe of the liver and afp is elevated to 13.7. additional work-up was deferred given his acute medical problems necessitating icu hospitalization. he should pursue further work-up of this lesion as an outpatient. an appointment has been scheduled for him in the liver clinic here at . . 3) altered mental status - etiology unclear, but initially concerning for anoxic brain injury in the setting of hypotension upon presention, but repeat imaging showed resolution of initial changes, which was more suggestive of resolving metabolic condition (i.e. hepatic encephalopathy). infectious work-up in the micu was negative. on the general floor, the patient was maintained on lactulose and rifaximin for ammonia control. his mental status gradually and significantly improved and he was noted to be awake, alert and oriented x 3, often communicative. he was discharged on rifaximin and lactulose, which he should continue given his tips. . 4) seizure activity: patient was observed to be have brief episodes of tonic-clonic seizure activity on , and subsequently found to have frequent, intermittent seizure activity on eeg in the following 24 hours essentially c/w status epilepticus. he was seen by the neurology consult service and started on dilantin. his hospital course was thereafter significant for no seizure activity. the patient was discharged on dilantin with instructions to have dilantin levels checked, with goal of 15-20 (corrected for albumin). . 5) dm: the patient's outpatient metformin was held given the extent of his liver disease. his blood sugar was monitored and treated with an insulin sliding scale and glargine qhs. . 6) ventilator-acquired pneumonia: pt. was intubated in the icu to protect his airway. during this time, he developed a pneumonia with coag + staph aureus growing in his sputum. he was started on vancomycin, which was later switched to nafcillin once sensitivies came back showing mssa. he was treated for a total of 8 days. . 7) f/e/n: the patient was started on tube feeds in the icu, which were continued on arrival to the general medicine floor. during his hospitalization on the floor, he self d/c'd the dobhoff tube twice, the last of which was done the evening before his discharge from the hospital. prior to this last self d/c, the patient had just been started on pureed diet and nectar-thickened liquids after a speech and swallow evaluation which showed thin aspiration. because of this self d/c, there was not enough time for accurate calorie counts. thus, it is important that his nutrition be closely followed on discharge and tube feeds should be reconsidered if the patient's appetite or food intake should decline. medications on admission: lisinopril 10mg qd protonix 40 nadalol 40mg tid aspirin 81 mg qday insulin 70qam 65qpm metformin 1000 cyanocobalmin discharge medications: 1. artificial tear with lanolin 0.1-0.1 % ointment : one (1) appl ophthalmic prn (as needed). 2. sodium chloride 0.65 % aerosol, spray : sprays nasal tid (3 times a day) as needed. 3. levetiracetam 500 mg tablet : three (3) tablet po bid (2 times a day). 4. phenytoin 100 mg/4 ml suspension : two hundred (200) mg po q 8h (every 8 hours). 5. propranolol 10 mg tablet : one (1) tablet po tid (3 times a day). 6. lactulose 10 g/15 ml syrup : thirty (30) ml po tid (3 times a day): give for goal 3 bms/day. 7. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 8. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 9. ipratropium bromide 0.02 % solution : one (1) nebulizer treatment inhalation q6h (every 6 hours) as needed. 10. albuterol sulfate 0.083 % solution : one (1) nebulizer treatment inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. lantus 100 unit/ml cartridge : fifty five (55) units subcutaneous at bedtime. 12. insulin regular human 300 unit/3 ml insulin pen : one (1) unit subcutaneous qachs: give per attached sliding scale. discharge disposition: extended care facility: & rehab center - discharge diagnosis: cryptogenic cirrhosis esophageal varices hepatic encephalopathy seizure activity diabetes mellitus, type 2 ventilator-acquired pneumonia liver mass discharge condition: stable, tolerating po with pureed diet, alert and oriented x3 discharge instructions: you were admitted to the hospital for bleeding from your stomach, which is a complication of your liver disease. you were also found to have seizures. call your doctor or return to the er for fevers, chills, nausea, vomiting, abdominal pain, confusion, lethargy, tarry stool, or blood in your stool. it is very important that you take all of your medications as prescribed. your doctors your lactulose to make sure you are having at least 3 bowel movements per day. your doctors at the nursing home need to check your dilantin levels every other day, and correct this for your albumin. the equation is: corrected dilantin level = measured dilantin level divided by . your goal corrected dilantin level is between 15 and 20. if your level is persistently low or high, your doctors should your neurologist, dr. , at . followup instructions: provider: . / phone: date/time: 4:30 (neurology) . provider: , md phone: date/time: 2:30 (hepatology) md Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Other endoscopy of small intestine Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Endoscopic excision or destruction of lesion or tissue of esophagus Transfusion of packed cells Other irrigation of (naso-)gastric tube Transfusion of other serum Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Insertion of Sengstaken tube Diagnoses: Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acquired coagulation factor deficiency Portal hypertension Acute respiratory failure Long-term (current) use of insulin Grand mal status Methicillin susceptible pneumonia due to Staphylococcus aureus Esophageal varices in diseases classified elsewhere, with bleeding Hepatic encephalopathy Other abnormal tumor markers Unspecified disorder of liver

code: full allergies: nkda neuro: pt arousable to voice, does speak at times, but mostly one word responses. follows commands , , perrl. impaired gag. no seizure activity noted. most recent dilantin level 11.5. bilateral soft wrist restraints remain on for pt safety. pt denies pain. cv: hr in 70's with no ectopy noted, bp 120's systolic, does increase to 150-160's with nursing care. pt on propranolol. peripheral pulses palpable. am crit 29.2, being checked q8h, next due at 4pm. goal crit >25. resp: rr 20's with sats >90% on ra. lung sounds clear in apices, diminished in bases. nonproductive dry cough. gi: bowel sounds x 4, abdomen soft. flexiseal rectal tube in place for large amount dark, liquid stool. tube feeds (replete with fiber) running at goal of 70cc/hr with minimal residuals. ng tube patent, checked. pt receiving prn lactulose q2h for increased ammonia level. most recent 107 (138) gu: foley patent and draining clear, yellow urine. uo 50-100cc/hr. id: pt afebrile. wbc 6.6 skin: warm and dry, abrasions to neck and leg from tape. endo: pt's am glargine dose increased to 50 units, pt also on sliding scale, no coverage needed this shift. social: family called, updated on pt's condition and plan of care. plan: monitor neuro status, continue with lactulose continue q8h crits with goal >25 pt called out to floor Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Other endoscopy of small intestine Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Endoscopic excision or destruction of lesion or tissue of esophagus Transfusion of packed cells Other irrigation of (naso-)gastric tube Transfusion of other serum Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Insertion of Sengstaken tube Diagnoses: Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acquired coagulation factor deficiency Portal hypertension Acute respiratory failure Long-term (current) use of insulin Grand mal status Methicillin susceptible pneumonia due to Staphylococcus aureus Esophageal varices in diseases classified elsewhere, with bleeding Hepatic encephalopathy Other abnormal tumor markers Unspecified disorder of liver

service: ccu-6 history of present illness: the patient is a 48-year-old man with a history of a question of coronary artery disease, status post myocardial infarction in , hypertension, borderline diabetes mellitus who was in his usual state of health until 11 p.m. last night when, while midsternal pressure like chest pain with radiation to back, positive shortness of breath, positive diaphoresis, positive nausea, no vomiting, no lightheadedness. he called ems. the patient had had similar episode of chest pain and to a hospital in called southwest in where he was told he had "blocked artery" and that he had had a myocardial infarction. the patient was started on exertion when he walks upstairs, positive dyspnea on exertion, but denies orthopnea, paroxysmal nocturnal dyspnea or edema. he has had anginal chest pain which is similar to his presenting complaint, but without radiations to his back. at outside hospital, electrocardiogram showed split ts in the inferior and lateral leads with progression to st elevations in v1 through v5. he was given nitroglycerin, lasix and morphine and his chest pain resolved. he had a troponin 1 of 1.75, cpk of 304 and he was transferred to for emergent cardiac catheterization. cath lab hemodynamics showed ra 5, rv 31/4, pa 31/15, pcwp 16; angiography showed lm without significant disease, lad 90% proximal 99% mid stenosis; left circumflex mid total occlusion before large om, rca total occlusion distal with bridging and left to right collaterals. he had successful angioplasty and stent of lad and cx. physical exam: vital signs: blood pressure 105/73, pulse 84, respiratory 21, o2 saturation 92% on 2 liters. general: he is a middle aged vietnamese man in no acute distress. head, ears, eyes, nose and throat: pupils equal, round and reactive to light and accommodation. mucous membranes moist. oropharynx clear. neck: no jugular venous distention, no carotid bruits. cardiovascular: regular rate, s1, s2, artificial s1 gallop and balloon pump, no murmurs or rubs. lungs: bibasilar rales, left greater than right. abdomen: normoactive bowel sounds, nontender, nondistended. extremities: no cyanosis, clubbing or edema. neurologic: alert and oriented x3. labs at outside hospital: cpk was 304, troponin 1.75. electrocardiogram at 1:23 a.m. was normal sinus rhythm at 101, normal axis deviation, 2 to elevation v1 to v5, q v3, avf. labs at at 8 a.m.: cbc - white blood cells 11.2, hemoglobin 13.0, hematocrit 36.7, platelets 232. chem-7 - 139, 4.2, 107, 22, 15, 0.9, 254 with a magnesium of 1.9. his cpk was 594. his mb was 46. the index was 7.7. hospital course: in summary, the patient is a 48-year-old man with coronary artery disease, past myocardial infarction, hypertension, diabetes mellitus who presented with acute myocardial infarction and went for catheter. lad and l-circumflex were stented successfully. iabp was placed. 1. cardiovascular: coronary artery disease: three vessel disease with successful intervention on lad and left circumflex, but rca not done secondary to good collateral. the patient was continued on aspirin 325 qd. plavix was started with 300 mg bolus and continued at 75 mg, will continue for 30 days. metoprolol was titrated up. the patient was discontinued on atenolol 25 mg po qd. captopril was initially started and the patient was changed to lisinopril 2.5 qd. he tolerated this regimen well. intra-aortic balloon pump was discontinued without complication. atorvastatin was started at 10 mg po qd. see dr. in one week, 5 mg po q hs for two days and patient was discontinued with follow up in clinic. rhythm: the patient was monitored on telemetry. rate and rhythm remained normal. 2. pulmonary: lungs clear. his o2 saturations were good. 3. renal: creatinine remained stable. electrolytes were checked and repleted prn 4. infectious disease: white blood cells increased to 13.5, but then decreased back down to 11.0, leukocytosis likely secondary to acute myocardial infarction. the patient remained afebrile. 5. fluids, electrolytes and nutrition: the patient was started on a cardiac diet. electrolytes were checked and repleted as needed. code: full disposition: the patient was discharged home with follow up to clinic and clinic in four weeks and appointment in one month with cardiology; this and prescriptions were explained with a vietnamese interpreter to ensure understanding. discharge condition: good discharge status: discharge home discharge diagnosis: acute myocardial infarction , m.d. dictated by: medquist36 d: 15:23 t: 15:29 job#: cc: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Right heart cardiac catheterization Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other chronic pulmonary heart diseases Old myocardial infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: presented s/p near drowning episode major surgical or invasive procedure: none history of present illness: 76 rh yo woman with h/o old stroke (no residual weakness), htn, who was swimming in , ma with her daughter and husband this am. a bystander noticed her face down in the ocean, swam out to retrieve her, and started cpr (x 5-10 min). she was likely face down for 2-3 minutes. found to be unresponsive, pulseless, with spontaneous breathing. taken to osh -> intubated and sedated, ct head showed deep right hemisphere bleed without mass effect or bleed, transferred to for further management. seen by nsurg in ed -> no intervention. given versed 2mg, fentanyl 100 mcg, 10mg of labetolol iv in ed. additional history - no weakness or numbness preceeding event. pt walks one mile each day without fail. no fever/chills, or complaints of pain per family. past medical history: htn stroke , had right sideded weakness that resolved after several months of phys therapy. osteoarthritis macular degeneration no h/o dm, mi, cad. social history: pcp no tob/etoh/drugs. lives with husband and daughter. daughter is hcp , (home). dnr, not dni. retired ice cream scooper, quit 15 yrs ago. family history: sister had a stroke, etiology unknown to family physical exam: vitals: t 97.8 rectal, 172/79 (after 10mg iv labetolol), hr 74, o2 sat 100% on mechanical ventilation. gen: intubated and sedated skin: no rash, blood around nasopharynx/oropharynx heent: dry tongue, ett in place neck: hard cervical collar in place chest: cta bilat anteriorly cv: regular rate and rhythm without murmurs abd: +bs, nontender, softly distended extrem: no edema neuro: mental status: intubated and sedated with versed and fentanyl cranial nerves: i: deferred ii: fundoscopic exam: unable to visualize discs. pupils: 2.5-> 2.0 bilat, consensual constriction to light. iii, iv, vi: unable to perform doll's head 2o2 c-collar v: corneal reflex present bilaterally. vii: unable to appreciate, no wincing to pain viii; unable to assess ix, x: unable to assess, ett in place : unable to assess xii: unable to assess sensory: withdrawls both legs to pain, not arms. motor: normal bulk, tone. no fasciculations. no adventitious movements. moves right leg spontaneously to a flexed-knee position. reflexes: brisk rue>lue. crossed adductors bilaterally, 3+ patellar and 2+ ankles. toes equivocal bilaterally. coordination: unable to assess gait: unable to assess pertinent results: wbc 11.5, hct 33.5, plt 227, mcv 93 chem: bun/cr 20/0.9, na 146, k 2.8, cl 118, gluc 268, lactate 2.2, amylase 120 serum tox screen negative coags wnl ct without contrast of head: approx 25cc intracranial bleed, deep in the right putamen area. no shift. ekg: 100 bpm, lad, nsr? may have ectopic p wave as p wave invertd in i, v2. nl intervals. brief hospital course: the patient was admitted to our nicu service for close monitoring. she was intubated and treated with iv labetolol to control her blood pressures (keep it below 140 systolic). over the course of the next several days, she became more alert as the sedation was weaned and eventually was extubated without incident. a chest xray showed an infiltrate worrisome for a pneumonia so she was begun on levofloxacin (this course will end on ). she was titrated off of the iv anti-hypertensives and titrated up on captopril, then ultimately switched to lisinopril for once a day dosing. her neurologic exam now on the day of discharge is significant for left sided weakness and a left hemi-neglect (both of these have been improving). she is now stable and ready for discharge for to rehab for further physical therapy. medications on admission: prinovil actonel asa 325 anemia "mild" supplements: calcium, mag, lutein, likopeic?, vit e, vit c, iron, glucosamine chondroitin. discharge medications: lisinopril 40 qd docusate prn iron 325 qd protonix 40 qd levofloxacin 500 qd discharge disposition: extended care facility: hospital of & islands - discharge diagnosis: 1. stroke 2. hypertension 3. reflux disease discharge condition: stable, talking and alert. discharge instructions: please restart asa in one week. followup instructions: please follow-up with your primary care physician 4 weeks or as needed. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hypocalcemia Unspecified essential hypertension Intracerebral hemorrhage Paroxysmal ventricular tachycardia Iron deficiency anemia, unspecified Hemiplegia, unspecified, affecting unspecified side Accidental drowning and submersion while engaged in other sport or recreational activity without diving equipment

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: r ij central line placement history of present illness: briefly, this is 53 yo m s/p ddrt in who was in his usal state of health until 2 days prior to presentation when he develped non-bloody diarrhea and non bloody, non-bilious emesis. no sick contract, no travel, no abnormal food exposure and no recent antibiotic exposure. he reports lightheadedness and dizziness and 2 syncopal episodes. . in the emergency department he was found to be hypotensive with bp 70/40 (baseline sbp = 90-110) with hr = 60s-80s with a leukocytosis of 16k and acute on chronic renal failure with cr = 4.0 up from his baseline of 1.9-2.3. code sepsis was initiated and he received ivf, stress dose steroids and vancomycin 1 gm, zosyn 2.25 gm. . in the icu, he was hemodynamically stable and his bp normalized to sbp 110s without additional ivf nor need for pressors. . on the floor the pt feels comfortable, he denies any further lh or dizziness lying in bed and with ambulation. he denies abdominal pain, fevers, chills and states that he would like to go home in the morning. past medical history: esrd ? htn s/p deceased donor renal transplant in gout htn impaired glucose tolerance hyperlipidemia social history: born in , moved to us in at about age 23. he had worked in electronics but is now on disability. no tobacco, alcohol or ivdu. . family history: father who died at 78 of kidney disease, mother who is in her 80s and well. there is no history of diabetes or cancer in the family. he has one brother and two sisters who are well. he also has two children, ages 23(a daughter) and 17 (a son) who are well. physical exam: t 98.6 bp 106/77 p 94, o2 sat 97% ra heent: nc/at, perrl, no scleral icterus noted, mmm, neck: supple, no jvd or carotid bruits appreciated pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. ext: no c/c/e bilaterally, 2+ dp b/l skin: no rashes or lesions noted. pertinent results: 05:20am wbc-16.1*# rbc-4.89 hgb-15.2 hct-44.9 mcv-92 mch-31.1 mchc-33.9 rdw-14.5 05:20am neuts-78.4* lymphs-14.3* monos-6.7 eos-0.4 basos-0.2 05:20am plt count-217 05:58am lactate-1.4 07:30am albumin-3.1* calcium-6.7* phosphate-3.0 magnesium-1.9 01:37pm freeca-1.19 03:36pm type-mix po2-41* pco2-30* ph-7.27* total co2-14* base xs--11 comments-central ve 01:37pm type- ph-7.24* . admission cxr: no acute process. right ij line with tip in the svc/ra junction. . ct abd/pelvis: 1. mild fascial thickening posterior to the transplant kidney. no evidence of hydronephrosis or perinephric fluid collection. 2. incompletely visualized coronary artery calcifications. 3. cholelithiasis without evidence of cholecystitis. . renal transplant u/s: a transplant kidney is seen in the right lower quadrant and measures 13.2 cm. there is no hydronephrosis or perinephric fluid collection. resistive indices in the upper, mid, and lower poles are 0.64, 0.72, and 0.69 espectively. the main renal artery and main renal vein are patent with normal waveforms. a foley catheter is in the decompressed bladder. impression: normal renal transplant ultrasound. . ct head: no intracranial hemorrhage or mass effect. . cardiac evaluation: ett - 8.5 mets. no anginal symptoms nor ekg changes. . admission ekg: nsr, lad, poor r wave progression and first degree av block. no acute st changes. brief hospital course: 53 y.o. m with h/o esrd s/p deceased donor kidney transplant in on chronic immunosuppression presents with emesis, diarrhea, hypotension and acute on chronic renal failure. . 1. hypotension: was likely due to volume loss from diarrhea and vomiting. elevated wbc with left shift. etiology most likely viral given lack of fever, abdominal pain. he was continued on ivf with bicarbonate. he received hydrocortisone 50mg q8h for one day, then was placed back on his outpatient dose of oral prednisone. pt initially received antibiotics in the ed, none were necessary anymore after that since his bp remained stable and he also remained afebrile. he was discharged with stable bp but off his antihypertensives. he should schedule a followup appointment with dr. within one week after discharge. at this time, it can be decided if he should continue any of his antihypertensives. . 2. diarrhea: probably infectious, most likely viral, however atypical bacterial presentation was initially considered. also in this immunosuppressed pt need to consider crytpo/micropsiridia and cmv. cmv was negative in the past. no recent antibiotic exposure and presentation not suggestive of c diff. extensive stool studies were sent but pending upon discharge. his diet was advanced and his diarrhea resolved slowly after admission. . 3. non anion gap metabolic acidosis: probably secondary to diarrhea, possible component of rta in the context of worsening rf, however, the patient has had normal bicarbonate in the past. he received ivf with hco3 and his hco3 came back up to normal levels. . 4. syncopal episodes: unlikely to be cardiac/seizure/stroke, probably due to orthostatic hypotension secondary to hypovolemia. ct head was negative. patient was without focal neurological signs. he was monitored on telemetry for 24 h. hypocalcemia was repleted with iv calcium gluconate as needed. . 5. esrd s/p ddrt 10 years ago on neoral and imuran and prednisone. renal us was wnl w/o signs of rejection. he was continued on neoral, imuran and prednisone (except for one day while being on stress dose steroids instead of his po prednisone). . 6. acute on chronic renal insufficiency: likely secondary to hypovolemia, quickly improved with ivf. back to baseline (around 2.0) on . . 7. hypocalcemia: no qt prolongation. probably secondary to diarrhea. repleted with iv calcium gluconate. . 8. hypertension: initially hypotensive. resolved after ivf. then remained normotensive. all antihypertensives were held given hypotension. they should be restarted as an outpatient. . 9. prophylaxis: tolerating pos, pantoprazole while on steroids, issc while on steroids, sq heparin . 10. access: rij was placed on , then pulled the next day. piv. . 11. code: full medications on admission: colchicine 0.6mg po qd prn gout hydralazine hcl 50mg po bid imuran 50mg po q day lopressor 100mg po qday neoral 50mg prednisone 5mg po qday probenecid 500mg--one by mouth twice a day for gout vasotec 10mg--one by mouth every day ranitidine 150mg po bid discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. cyclosporine modified 25 mg capsule sig: two (2) capsule po q12h (every 12 hours). 3. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 4. probenecid 500 mg tablet sig: one (1) tablet po twice a day. 5. ranitidine hcl 150 mg capsule sig: one (1) capsule po twice a day. discharge disposition: home discharge diagnosis: primary diagnosis: 1. gastroenteritis with hypotension, self-limited, likely viral 2. esrd s/p deceased donor renal transplant 3. hypertension secondary diagnosis: 1. gout 2. hyperlipidemia discharge condition: afebrile. hemodynamically stable. ambulating. tolerating po. discharge instructions: you have suffered from a gastroenteritis which was likely caused by a virus. your blood pressure was low and you received intravenous fluids and briefly antibiotics. . please call your primary doctor or return to the ed with fever, chills, chest pain, shortness of breath, nausea/vomiting, worsening diarrhea, spontaneous bleeding or any other concerning symptoms. . please take all your medications as directed. you should hold your blood pressure medications (lopressor, hydralazine and vasotec) until your next outpatient visit when it will be decided if you should be restarted on them or not. . please keep you follow up appointments as below. followup instructions: we have called to schedule you an appointment with , md phone:. the office will call you with your appointment time. you should have your blood checked (cbc, calcium) and follow up with her on your blood pressure medications and kidney function. . in addition, please keep the following scheduled appointments: . provider: , md phone: date/time: 9:30 . provider: , m.d. date/time: 4:10 md Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Hypocalcemia End stage renal disease Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Hypovolemia Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted kidney Intestinal infection due to other organism, not elsewhere classified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right leg pain and swelling major surgical or invasive procedure: temporary ivc filter placement esophagogastroduodenoscopy colonoscopy history of present illness: 54 y.o. male with pmhx of esrd (thought to be htn) s/p deceased donor kidney transplant in , htn and gout who presented to the er with right leg swelling and pain x 3 days. he denies any recent injury or prolonged travel and has not had problems with leg swelling in the past. he additionally denies sob or cp. in the ed, patient was evaluated and noted to have a tender, erythematous right le with a right calf measuring 43cm compared to 38 cm of the left calf. bilateral le dopplers were performed and showed a dvt in the right common femoral to the calf veins. given his kidney disease, renal transplant was consulted in the ed and felt there were no active transplant issues. patient was noted to be guaiac positive and does have a history of a colonic polyp, found in . a heparin gtt was started and the patient was admitted for further management. past medical history: esrd ? htn s/p deceased donor renal transplant in gout htn impaired glucose tolerance hyperlipidemia social history: born in , moved to us in at about age 23. he had worked in electronics but is now on disability. no tobacco, alcohol or ivdu. . family history: father who died at 78 of kidney disease, mother who is in her 80s and well. there is no history of diabetes or cancer in the family. he has one brother and two sisters who are well. he also has two children, ages 23(a daughter) and 17 (a son) who are well. physical exam: vitals: t - 97.5, bp - 120/64, hr - 82, rr - 18, o2 - 96% ra gen: awake, alert, nad heent: nc/at; perrla, eomi, op clear, nonerythematous, mmm neck: supple, no lad, jvp flat sitting upright chest: ctab cardiac: s1, s2, no m/r/g appreciated abd: soft, nt, nd, +bs rectal: brown stool, guaiac positive. no hemmorhoids seen. ext: le asymmetry, r>l with erythema and 1+ pitting edema in rle. palpable pulses () dorsalis pedis, bilaterally. neuro: aaox3, moves all 4, 5/5 strength, sensation intact to light touch pertinent results: imaging: . bilateral lower extremity doppler ultrasound: scale, color, doppler son of the right and left common femoral, superficial femoral and popliteal veins were performed. there is deep vein thrombosis extending from the right common femoral vein to the calf veins. there is no deep vein thrombosis within the left lower extremity. respiratory phasicity is preserved in the left common femoral vein. . renal transplant ultrasound: a transplant kidney is seen in the right lower quadrant, measuring 12.4 cm. there is no hydronephrosis or renal calculi. the main renal artery and main renal vein are patent with normal waveforms. resistive indices in the upper, mid, and lower poles are 0.66, 0.67, and 0.71, respectively. the bladder is well distended without abnormality. impression: normal renal transplant ultrasound. patent vasculature with normal ris. . : ivc filter placement impression: successful placement of retrievable gunther tulip ivc filter via left common femoral vein approach. if indicated, this filter can be removed within two weeks of placement. . : lung v/q scan: impression: normal lung scan. no evidence of pe . brief hospital course: patient is a 54 year old male s/p renal transplant for esrd () without any identified risk factors for deep venous thrombosis. he presented to the hospital with right lower extremity swelling and tenderness for 3 days. a duplex ultrasound was performed in the ed and he was found to have a right femoral vein dvt that extended to his popliteal vein. . dvt: patient had no clear risk factors for dvt and no prior history of dvts. patient was started on a weight-based heparin drip at admission. he was treated, with good effect, with oxycodone and acetominophen for pain. because of the size of the thrombus and the clinically significant threat of pulmonary embolus, an ivc filter was placed by interventional radiology on . no contast was used for placement because of patient's renal insufficiency and it was placed via ultrasound guidance. anticoagulation with heparin was held for procedures: filter placement and also endoscopy (see below). the heparin goal was a ptt 60-80. patient was continued on heparin until when he passed a grossly bloody stool in the morning. at that time he was tachycardic to 130's but continued to maintain his blood pressure around 130 systolic. his hct on was 29.7 on the morning of as 26.6. with this hct drop, hemodynamic change, gross blood in his stool, and a single access point for fluids, it was decided that patient would be better served in a monitored setting so he was transferred to the intensive care unit. . hypercoaguable workup so far has showed increased b2 microglobulin which is nonspecific and frequently elevated in patient's with chronic renal insufficiency. also increased thrombin time which is expected given heparin anticoagulation. patient should follow up as an outpatient with the coagulation clinic. futher work-up was sent off and pending at time of discharge. his protein c level was elevated while protein s was within the normal range. he was negative. beta-2-glycoprotein 1 antibodies (iga, igm, igg) and factor v leiden were pending at time of discharge. . extensive discussion took place between the primary medical team, primary care physician, team, and interventional radiology team regarding removal of the patient's ivc filter, as it was initially placed as a temporary filter. the patient was brought down to ir to have the filter removed on , however at that time it was found that the filter had thrombosed. he was then transferred to the to receive 24 hours of local tpa via a central line that was placed in ir. because of the risks involved in removal of the ivc including possible showering of emboli and difficulty removing due to fibrosis, the decision was made to leave the ivc filter in place, and as a result it will become a permanent ivc filter. . the patient was started on coumadin on and his levels were carefully monitored given the potential interaction with his transplantation medications. he was discharged when his inr was therapeutic. he was not a candidate for lovenox given his renal insufficency. he was encouraged to elevated his leg when possible and wore stocking to help with the edema. he was instructed to follow up with his primary care physician's office for weekly inr checks. . 2. guaiac positive stool: patient was noted to have guaiac positive stool in the emergency room. a colonoscopy completed in showed a nonbleeding polyp/adenoma. his hematocrit was noted to be down from 40 in , but had been as low as 31 prior. upper and lower endoscopy on demonstrated an eg juntion ulcer which was biopsied, as well as three non-bleeding polyps in colon that were removed. these are a possible source of the initial guaiac positive result. patient passed a grossly bloody stool on and became hemodynamically unstable at that time. he was transferred to the intensive care unit at that time for further management, where he received two units of packed red blood cells, and an additional 1 unit two days later. a repeat colonoscopy was completed on which demonstrated no sources of bleeding. he had no further episodes of bleeding and his hct remained stable. it was felt the bleeding was from the biospy/polyp removal sites which resolved with time. . he was maintained on a twice daily proton pump inhibitor, which he should continue to take. . the biopsy obtained was positive for h. pylori, for which treatment was initiated. due to interactions with his cyclosporine, patient was started on with a regimen of flagyl and tetracycline also with peptobismul to complete 14 day course. . 3 esrd s/p transplant: patient was continued on his immunosuppression regime and maintained a stable creatinine throughout his hospitalization, at this baseline of 1.7-2.0. an us study of the graft showed good flow, normal functioning kidney. patient was followed by the transplant renal team. he was continue cyclosporine, imuran and prednisone. his medications were renally dosed, and he received intravenous fluids with bicarbonate prior dye received while attempt was made to remove his ivc filter. . 4 htn - patient's lopressor and enalapril home medications were discontinued initially at time of admission. after his stay, his beta blocker was slowly re-introduced and tolerated well. if indicated, his hydralazine and vasotec should be re-introduced as an outpatient.. . 5 gout: patient carries diagnosis of gout, but could not recall any joint tap in the past that would have provided a crystaline diagnosis. he had what was considered to be a flare of his gout on . the pain was similar to previous flare. with co-ordination with the renal time, colchicine was started. additionally, in consultation with the renal transplant team, the patient was started on a predisone taper. this was started at 40 mg and decreased 5 mg qday. . if not previously completed, the patient may benefit from a dianostic tap of a joint in the event of future gout flares to avoid higher doses of prednisone if his joint pain is not in fact gout. at time of discharge, he was on tylenol 1000mg tid for left foot pain felt to be secondary to bumping his foot into his iv pole; the pain responded well to tylenol. . 6. tachycardia: patient initially had significat tachycardia to the 140s while ambulating or exerting himself once he came out of the intensive care unit. the trend improved with intravenous fluid repletion. it was felt that his tachycardia was secondary to a volume depleted state as he had been npo; it was also likely that he had significantly decreased venous return with the large right dvt. to ensure that he did not have a pulmonary embolus that was contributing to the tachycardia, a v/q scan was completed which was normal. his tachycardia resolved during his stay prior to discharge. . 7. glucose intolerance: patient's blood glucose finger sticks trended back down to the normal range after his prednisone taper was completed. his hb a1c was checked and found to be 6.7. he was maintained on a diabetic diet. . 8. fen/propylaxis/access: patient's electrolytes were monitored carefully and treated as needed. he was kept on a proton pump inhibitor, as well as a bowel regimen. he was ambulating regularly without difficulty at time of discharge. he had a mid-line placed during his stay due to access difficulties. . 9. discharge: patient was ambulating without difficulty or pain and his inr was therapeutic at time of discharge. he was instructed to follow up with his primary care physician for both an appointment as well as an inr check, to which he expressed good understanding. medications on admission: colchicine 0.6 mg qd hydralazine 50 mg imuran 50 mg qd lopressor 100 mg qd cyclosporine 50 mg prednisone 5 mg qd probenecid 500 mg vasotec 10 mg qd ranitidine 150 mg discharge medications: 1. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily) as needed for pain. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 4. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 6. cyclosporine modified 25 mg capsule sig: two (2) capsule po q12h (every 12 hours). 7. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 9. metronidazole 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 8 days. disp:*16 tablet(s)* refills:*0* 10. bismuth subsalicylate 262 mg tablet, chewable sig: two (2) tablet po qid (4 times a day) for 8 days. disp:*64 tablet(s)* refills:*0* 11. tetracycline 250 mg capsule sig: two (2) capsule po q12h (every 12 hours) for 8 days. disp:*32 capsule(s)* refills:*0* 12. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 14. warfarin 1 mg tablet sig: one (1) tablet po daily16 (once daily at 16). disp:*30 tablet(s)* refills:*2* 15. outpatient lab work - please have your inr/ptt (coumadin level) checked within 1 week of discharge. - please have a cbc (blood counts) and chemistry 7 (to check your creatinine) drawn within one week of discharge. have results sent to your primary care physician . . 16. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home discharge diagnosis: primary diagnosis: right leg deep vein thrombosis lower gi bleeding . secondary diagnoses: - esophogeal ulcer - colonic polyps (removed) - esrd s/p deceased donor renal transplant in - gout - htn - impaired glucose tolerance - hyperlipidemia discharge condition: stable, ambulating without difficulty. vital signs stable. discharge instructions: you were admitted for treatment of a deep vein thrombosis. you were treated with a filter in your inferior vena cava and also heparin to thin your blood. these interventions were done so that the thrombosis would not move to your lung. you were transitioned to an oral medication called coumadin to thin your blood. the levels of coumadin will need to be followed closely. you also underwent a colonoscopy and experienced some bleeding which resolved. your hydralazine and enalapril were held while you were hospitalized due to bleeding. please see your primary care physician before restarting this medication. . if you experience fever, chills, nausea, vomiting, chest pain, shortness of breath, leg swelling, bleeding, lightheadedness, or any other concerning symptoms, please call your primary care physician immediately or go to the nearest emergency room. followup instructions: you will need to follow up with your primary care physician, . , within a week of discharge, please call him monday morning at ( to make an appointment. . you will also need to have your coumadin level followed very closely to ensure your blood levels are correct. please arrange to have your level checked during week of discharge through dr. prescription for this will be given to you at time of discharge. . please also follow up with your renal (kidney) doctor within weeks of discharge. . you have the following previously arranged appointment as noted below: provider: , m.d. date/time: 11:10 md Procedure: Venous catheterization, not elsewhere classified Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Endoscopic polypectomy of large intestine Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Other specified cardiac dysrhythmias Other complications due to other vascular device, implant, and graft Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Benign neoplasm of colon Leukocytosis, unspecified Helicobacter pylori [H. pylori] Kidney replaced by transplant Other abnormal glucose

code: full allergies: nkda neuro: pt a&o x 3, following commands consistently, moves independently in bed, oob to chair with supervision. pt complaining of pain to right knee, received prn pain med with good effect. cv: hemodynamically stable, hr 70-90 nsr with no ectopy noted, nbp 110-130/60-90, right leg noticably larger than left, known dvt however due to recent gib heparin gtt off. pedal pulses palpable. most recent hct 30.1 (1600), next due to be checked with am labs. piv x 1. resp: rr teens with sats >95% on ra. lungs cta. cough/gag intact. gi: bs x 4, ordered for clear liquid diet, tolerating well, will be advanced if no events overnight. gu: pt voiding adequate amounts clear, yellow urine to urinal. skin: intact. Procedure: Venous catheterization, not elsewhere classified Interruption of the vena cava Injection or infusion of thrombolytic agent Colonoscopy Endoscopic polypectomy of large intestine Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Other specified cardiac dysrhythmias Other complications due to other vascular device, implant, and graft Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Benign neoplasm of colon Leukocytosis, unspecified Helicobacter pylori [H. pylori] Kidney replaced by transplant Other abnormal glucose

history of present illness: the patient is an 85 year old woman with a history of hypertension, atrial fibrillation, status post a fall a month ago, admitted for one week and then discharged to rehabilitation. she was referred to the emergency room by her primary care physician for an episode of left facial weakness and decreased comprehension and speech. the patient's daughter also describes an increase in lethargy with persistent nausea and episodes of vomiting. a head ct scan in the emergency department shows an increased size of the right subdural hematoma with no acute component. on arrival the patient was awake and alert, oriented times three, complaining of nausea and vomiting. past medical history: 1. hypertension. 2. subdural hematoma a month ago. 3. heart murmur. 4. atrial fibrillation. physical examination: on physical examination, the patient was awake and alert, oriented times three, conversing appropriately. extraocular muscles are full. pupils equally round and reactive to light with right down 4 to 3 and the left 3 to 2. strength was five out of five throughout and reflexes were intact. head ct scan shows a right 2 cm subdural hematoma with no acute component but increase in size compared to head ct scan from a month prior. the patient was neurologically stable. hospital course: the patient had twist drill drainage of the subdural hematoma at the bedside without complication. the patient had just slight left facial asymmetry with no pronator drift, moving all extremities strongly. the patient also developed symptoms of transient ischemic attacks prior to admission. she had a carotid ultrasound of her neck which was clear and a transesophageal echocardiogram which revealed a left atrial appendage thrombus near the aortic arch, gradient of 2, and four plus tricuspid regurgitation. she was seen by cardiology who recommended a rate control for her atrial fibrillation. she was started on digoxin and lopressor as well as diltiazem. she will be followed up as an outpatient for treatment of the atrial thrombus as an outpatient. she will require anti-coagulation but she will not be able to receive anti-coagulation for one month. neurologically, she is awake, alert and oriented times three. no drift. face is symmetric. strength was five out of five in all muscle groups. a repeat head ct scan showed good evacuation of the subdural hematoma and the drain was removed on . she was transferred to the regular floor. carotid ultrasound of her neck did show less than 40% stenosis of the right internal carotid and 40 to 59% of the left internal carotid stenosis. the patient was seen by physical therapy and occupational therapy and found to require rehabilitation prior to discharge to home. she was discharged to rehabilitation in stable condition with follow-up with dr. in one month and also with cardiology for treatment of a left atrial thrombus. her vital signs were stable at the time of discharge. discharge medications: 1. diltiazem 180 mg p.o. q. day. 2. digoxin 0.125 mg p.o. q. day. the patient should have a level drawn and checked on . 3. metoprolol 25 mg p.o. twice a day. 4. dilantin 100 mg p.o. three times a day. 5. levobetaxolol hydrochloride 0.5%, one drop o.u. q. day. 6. sodium chloride 1 gram p.o. four times a day. 7. protonix 40 mg p.o. q. 24 hours. condition at discharge: the patient's condition was stable at the time of discharge. discharge instructions: 1. she will follow-up with dr. in one month with a repeat head ct scan. 2. she will follow-up with cardiology in one month for treatment of her left atrial thrombus. , m.d. dictated by: medquist36 Procedure: Incision of cerebral meninges Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Fall from other slipping, tripping, or stumbling

history of present illness: the patient is a 71-year-old male with a history of chronic obstructive pulmonary disease and a remote history of minor hemoptysis who presented to the for further management of massive hemoptysis from hospital. for about one week prior to admission, he noted increased upper respiratory secretions and a cough which was secondary to seasonal allergies. on , the day prior to admission, he coughed up some gross red blood and went to the local hospital. he was intubated there for airway protection and had a flexible bronchoscopy at hospital which showed large clots diffusely in the airways. overnight, on at hospital, his hematocrit dropped from 40% to 30%, and on the following morning, he had a repeat bronchoscopy. at that time, the bronchoscopy revealed blood throughout the airways, with a possible source in the left upper lobe apical/posterior segment. he was transferred to the for further management. past medical history: 1. chronic obstructive pulmonary disease. 2. severe low back pain. 3. abdominal aortic aneurysm which is 4 cm in diameter. 4. history of lacunar cerebellar infarction. 5. history of hemoptysis one year ago - reported negative evaluation. medications on admission: 1. combivent. 2. oxycontin 80 mg p.o. twice per day. 3. percocet five tablets p.o. every day. allergies: the patient has no known drug allergies. social history: his social history includes one pack of cigarettes per day for over 30 years. no known alcohol use. family history: family history was noncontributory. physical examination on presentation: on physical examination, temperature was 100.5, heart rate was 82, blood pressure was 119/51, respiratory rate was 12, and oxygen saturation was 100% on 50%. the patient was ventilated on assist-control. he was sedated initially on paralytic agents to prevent cough. his lung sounds were coarse throughout, particularly on the right, with inspiratory wheezes. his cardiovascular examination was significant for distant heart sounds. a regular rate and rhythm. a holosystolic murmur loudest at the apex. abdominal examination revealed bowel sounds were present. the abdomen was soft, nontender, and nondistended. extremity examination revealed cool extremities. pulses were 1+. pertinent laboratory values on presentation: his laboratory data was notable for a hematocrit of 30.6 and platelets were 199. partial thromboplastin time was 27. inr was 1. his electrolytes included a sodium which was 136, potassium was 3.8, chloride was 101, bicarbonate was 28, blood urea nitrogen was 12, creatinine was 0.6, and blood glucose was 92. pertinent radiology/imaging: the patient had a chest x-ray that was unremarkable. a chest ct showed a 1.5cm nodule in the left upper lobe (? bac). hospital course by issue/system: 1. respiratory issues: the patient was had a flexible bronchoscopy which revealed old blood diffusely, with a large clot in the left mainstem. there were no other endobronchial lesions. as to not disturb the clot, a rigid bronchoscopy was schedueld. on hospital day two, he had a rigid bronchoscopy that showed dry blood in the left mainstem, which was removed. the uptake to the left lower lobe was erythematous and abnormal in appearance and brushings, washings and transbronchial needle aspirates were obtained. postoperatively, the patient was noted to be hypertensive, so he was started on a nitroglycerin drip but otherwise had an uneventful recovery. the day after the rigid bronchoscopy the patient was extubated and had adequate oxygenation for the duration of his intensive care unit course. however, on the day following extubation the patient was noted to have an opacity/infiltrate in the left lower lobe that was consistent with a ventilator-acquired pneumonia. therefore, the patient was started on vancomycin and ceftazidime. the diagnosis of pneumonia was consistent with his low-grade temperatures from 100 to 100.9 in the days following his extubation. the patient's oxygen requirements gradually decreased over the course of his intensive care unit admission; weaning down to two liters by nasal cannula on the day of transfer to the floor. the pathology results from his bronchoscopy came back negative for malignant cells. these included two samples of washings of the bronchial tree as well as a transbronchial needle aspiration. 2. cardiovascular system: the patient was noted throughout the duration of his intensive care unit stay to be hypertensive with a blood pressure ranging from the 140s to over 200 that coincided with his degree of pain medications. it was noted after his rigid bronchoscopy for his blood pressure to stay consistently over 200. due to concerns about the effects on his cerebral vasculature, he was started on a nitroglycerin drip which adequately reduced his blood pressure into the 150s. the nitroglycerin drip was turned off the following day, and he was started on captopril for afterload reduction, and this was maintained throughout the remainder of his intensive care unit course; initially starting at 6.25 mg three times per day and titrating up to 25 mg three times per day. 3. infectious disease issues: the patient was noted following extubation to have a new left lower lobe infiltrate that was consistent with ventilator-associated pneumonia; as noted above. he was started on ceftazidime and vancomycin for this infection which necessitated outpatient intravenous therapy. 4. pain issues: the patient came in with a history of severe low back pain with a home regimen of 80 mg of oxycontin twice per day with up to five percocet tablets per day. he was initially started on a morphine drip for pain that was titrated to his blood pressure and heart rate. following extubation, these requirements as he was able to take oral intake. his narcotic regimen was gradually increased to his baseline regimen; including 80 mg of oxycontin and five percocet tablets. 5. rehabilitation issues: on the day following his extubation, the patient was seen in consultation by physical therapy who allowed him to walk around the unit and increase his capacity which had likely been reduced during his time on the respirator. 6. gastrointestinal issues: the patient had a computed tomography scan of his chest in the middle of his intensive care unit stay that was notable for a thickened esophagus. this finding was not inconsistent with an esophageal malignancy and should be followed up on as an outpatient, and this was relayed to the floor team. discharge disposition: the patient to be discharged to the medicine service at the . discharge diagnoses: 1. hemoptysis. 2. ventilator-associated pneumonia. 3. chronic obstructive pulmonary disease. 4. severe low back pain. 5. history of lacunar infarction. 6. abdominal aortic aneurysm. the patient will follow-up with his referring pulmonologist for a follow-up chest ct to evalute the nodule seen in the left upper lobe (? bac). , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed endoscopic biopsy of lung Diagnoses: Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Pneumonitis due to inhalation of food or vomitus Abdominal aneurysm without mention of rupture

history of present illness: the patient is a 59 year old male with a past medical history significant for hypertension, who was found to have a complex mass at the head of his pancreas on workup for jaundice. the patient was seen by anesthesiology for preoperative evaluation of his whipple when an electrocardiogram was shown to have nonspecific st changes laterally. the patient denied any symptoms of chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea. the patient was referred for a stress on . at peak exercise, he developed 3. depressions laterally and inferiorly with a fall in his systolic blood pressure. mibi imaging demonstrated moderate to severe inferior and apical ischemia, global hypokinesis and an ejection fraction of 42%. the patient was taken to the cardiac catheterization laboratory for emergent catheterization. the catheterization revealed three vessel disease with an ejection fraction of approximately 50%. the left main seemed to be diffusely diseased with 88 to 90% stenosis as was the left anterior descending and left circumflex. the patient was admitted and underwent a preoperative workup and was taken to the operating room on , for a three vessel coronary artery bypass graft. past medical history: 1. hypertension. 2. bladder cancer. 3. ruptured achilles. 4. pancreatic mass. past surgical history: none. medications on admission: 1. zestril 5 mg p.o. once daily. 2. celexa. 3. ativan. 4. aspirin. allergies: sulfa. social history: the patient quit tobacco thirty years ago, no alcohol use, no recreational drug use. physical examination: on physical examination prior to surgery, the patient's heart rate was 65, sinus rhythm, blood pressure 160/76, respiratory rate 16. he was alert and oriented and the pupils are equal, round, and reactive to light and accommodation. the neck was supple without jugular venous distention or bruits. his lungs were clear bilaterally. the heart was regular. the belly was soft, nontender, nondistended. extremities were warm and well perfused, no varicosities. he had 2+ radial pulses as well as 2+ dorsalis pedis and posterior tibial palpable bilaterally. laboratory data: the patient's blood urea nitrogen and creatinine were 15 and 0.8. preoperatively, his hematocrit was 45.6. electrocardiogram revealed normal sinus rhythm at a rate of 58. hospital course: the patient was taken to the operating room on , for a three vessel coronary artery bypass graft. the patient tolerated the procedure well. there were no complications his postoperative course was essentially uneventful. he was weaned from the ventilator. he was give beta blocker and diuresed postoperatively while in the intensive care unit which he tolerated well. on , postoperative day number two, the patient was transferred to the floor in stable condition. his lopressor was adjusted for appropriate beta blockade. he was started on plavix 75 mg p.o. once daily considering his coronary artery disease and his aspirin was decreased to 81 mg p.o. once daily. his postoperative course on the floor was uneventful. he was ambulating with physical therapy. his diuresis was continued. on , the patient was discharged to home in stable condition. medications on discharge: 1. plavix 75 mg p.o. once daily. 2. aspirin 81 mg p.o. once daily. 3. percocet one to two tablets p.o. q4-6hours p.r.n. 4. colace 100 mg p.o. twice a day. 5. lopressor 37.5 mg p.o. twice a day. 6. lasix 20 mg p.o. twice a day times three days. 7. potassium chloride 20 meq p.o. once daily times three days with the lasix. fop: the patient was told to follow-up with dr. in the office in approximately four weeks and to follow-up with his cardiologist in one week as well as to follow-up with his primary care physician regarding his blood sugar which was slightly elevated while the patient was in the hospital. condition on discharge: stable. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Personal history of malignant neoplasm of bladder

allergies: erythromycin base / benadryl / doxycycline hcl / robaxin / nalfon attending: chief complaint: abdominal wall cellulitis, r/o necrotizing fasciitis major surgical or invasive procedure: bedside debridement history of present illness: 59f with mmp who presented from for a concern of necrotizing fasciitis. she has had a chronic subcutaneous infection of her pannus, which was debrided multiple times at . over the last days prior to admission, she appeared to be septic, with fevers, leukocytosis, mental status changes, increasing fluid requirements & a rising creatinine. past medical history: morbid obesity dm2 cad s/p mi s/p stent paf cri/arf asthma arthritis s/p cholecystectomy htn neuropathy social history: hospital administrator no toxic habits family history: noncontributory physical exam: afeb, p 69 (1 avb), bp 102/48 17 100% ao x3, nontoxic dry membranes rrr, no jvd bilat wheezing soft, obese, 18 cm open incision in rlq with surrounding cellulitis, large subcutaneous cavity with intact fascia, +fat necrosis, +sweet/foul smelling discharge 1+ bilat le edema pertinent results: labs ---- 01:08pm blood wbc-8.9# rbc-3.30* hgb-9.5* hct-28.6* mcv-87 mch-28.6 mchc-33.0 rdw-16.4* plt ct-210# 01:08pm blood glucose-123* urean-56* creat-3.3*# na-128* k-4.1 cl-96 hco3-18* angap-18 10:45am blood cortsol-22.7* 01:30pm blood tsh-0.45 01:30pm blood vanco-6.0* 07:02am blood wbc-7.0 rbc-3.30* hgb-9.3* hct-28.7* mcv-87 mch-28.3 mchc-32.5 rdw-16.3* plt ct-238 07:02am blood glucose-146* urean-39* creat-1.3* na-140 k-3.8 cl-108 hco3-23 angap-13 micro ----- 1:09 pm urine **final report ** urine culture (final ): pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. 2nd isolate. <10,000 organisms/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- 2 s meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s 5:21 pm swab source: rectal swab. **final report ** r/o vancomycin resistant enterococcus (final ): enterococcus sp.. moderate growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r chloramphenicol------- <=4 s levofloxacin---------- =>8 r linezolid------------- 2 s penicillin------------ =>64 r vancomycin------------ =>32 r 11:19 am swab source: wound. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative rod(s). wound culture (preliminary): pseudomonas aeruginosa. heavy growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | anaerobic culture (pending): rads ---- renal ultrasound: the right and left kidneys measure 11.9 and 11.5 cm respectively without evidence of stones, masses or hydronephrosis. v/q scan: low probability of pe. mild to moderate airway disease brief hospital course: admitted to sicu, labs & cultures sent (her admission ua showed evidence of a uti). given that no evidence of necrotizing fasciitis, the patient was managed conservatively for her sepsis with antibiotics & iv hydration. renal, cardiac & plastics consults were obtained. with hydration, ms. arf improved & was noted to have improved mental status. she was transferred to the floor in better condition & pt/ot consults were obtained. on hd2&3, she underwent bedside debridement of the inferior aspect of her wound. cultures were sent, which eventually grew out pseudomonas. on hd4, she complained of dyspnea & had low o2 sats. a ct chest was considered but because of her renal issues, a v/q scan was obtained, which effectively ruled out a pe. she improved with incentive spiromtery & chest pt. on the night of hd4, she complained of frustration & threatened to injure herself if she could not return closer to home. psych liasion service felt patient did not have true suicidal ideation. on hd6, she was accepted back at hospital and was transferred back under the care of her pcp, . medications on admission: lopressor mavik lipitor tylenol 3 maxzide avandia neurontin quinine ultram synthroid priolosec flexeril alieve asa b12 albuterol ketocon discharge medications: 1. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 weeks. disp:*7 tablet(s)* refills:*0* 2. oxacillin sodium 10 g recon soln sig: two (2) gm injection q6h (every 6 hours) for 1 weeks. disp:*56 gm* refills:*0* 3. hydromorphone 2 mg/ml syringe sig: 0.5-1 mg injection prn dressing changes (). disp:*15 mg* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp<100, hr<60. disp:*60 tablet(s)* refills:*2* 7. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*60 disk with device(s)* refills:*2* 8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation every four (4) hours. disp:*2 inhalers* refills:*2* 9. albuterol sulfate 0.083 % solution sig: one (1) treatment inhalation q2 as needed for shortness of breath or wheezing. disp:*5 treatment* refills:*2* 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). disp:*90 ml* refills:*2* 11. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous three times a day as needed: flush cvl qshift & prn. disp:*30 ml(s)* refills:*3* 12. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed: groin. disp:*qs applications* refills:*0* 13. insulin sliding scale fingersticks qid. administer regular insulin as follows: bs<70, amp d50; 121-160, 3 units; 161-200, 7 units; 201-240, 10 units; 241-280, 13 units; 281-320, 17 units; 321+, 20 units & contact md. 14. 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stools. disp:*60 capsule(s)* refills:*2* 15. seroquel 25 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. discharge disposition: extended care facility: hospital discharge diagnosis: abdominal wall cellulitis (s/p operative i&d) bedside wound debridement cad s/p mi s/p stent atrial fibrillation 1st degree av block depression type 2 diabetes asthma neuropathy chronic renal insufficiency acute renal failure urinary tract infection vre+ wound infection hypovolemia hypokalemia hypomagnesemia delirium, resolved discharge condition: improved discharge instructions: diabetic diet as tolerated. continue your wet to dry dressing changes and your antibiotic courses. can switch to vac dressings. feel free to contact us with any additional questions or concerns. followup instructions: see pcp . . md, Procedure: Venous catheterization, not elsewhere classified Other incision with drainage of skin and subcutaneous tissue Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Diagnoses: Cellulitis and abscess of trunk Unspecified pleural effusion Urinary tract infection, site not specified Acute kidney failure, unspecified Atrial fibrillation Asthma, unspecified type, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Depressive disorder, not elsewhere classified Morbid obesity Hypovolemia Insomnia, unspecified Pseudomonas infection in conditions classified elsewhere and of unspecified site First degree atrioventricular block Herpes zoster with other specified complications

allergies: penicillins / aspirin attending: chief complaint: sob, cp, nausea major surgical or invasive procedure: none history of present illness: year old man with h/o copd, recent nstemi who presents from facility c/o sob and chest pain and nausea for most of tuesday. he denies vomiting and abdominal pain. in the ed, he was found to have a temperature to 101.3, retrocardiac opacity on cxr, negative abdominal and pelvis ct. he was given levofloxacin, flagyl, and 1800 cc of ns with systolic pressures staying in the 90's. in the ed, he began ruling in for a non-st elevation mi; cardiology initially recommended only antiplatelet therapy, but later recommended a heparin drip. while in the ed, after receiving ivf and approximately one unit packed red blood cells, the patient was noted to be in mild respiratory distress with oxygen saturations of 89% despite 4l nc. he was otherwise tachycardic to the 130s, but sbp stable in the 120s. a repeat cxr showed congestive heart failure. he was treated with lasix 40mg iv x 2 with good results. when patient came to the icu, he denied cp and his breathing had improved. past medical history: coronary artery disease, s/p non-st elevation myocardial infarction, no prior catheterization performed as his son did not feel he would want interventional measures; last echo () - ef 35% to 45% gastroesophageal reflux disease chronic obstructive pulmonary disease s/p cholecystectomy for gangrenous gallbladder in dementia iron deficiency anemia anxiety history of deep venous thrombosis social history: used to smoke 1 ppd for many years, quit several years ago. occasional etoh on special occasions. lives in , according to his son, he needs assistance for everything other than feeding. per his son, he has dementia at baseline with poor short term memory but is able to remember people and is usually oriented. family history: noncontributory physical exam: tm 101.3 tc 99.2 bp 94/30 hr 98 rr 38 o2sat 93% 2l nc gen: patient lying comfaortable in bed, able to communicate heent: eomi, sclera anicteric, mmm, poor dentition lungs: diffuse ins/exp wheezes cardiac: rrr s1/s2 grade ii/vi holosystolic murmur at apex abdomen: distended, soft, +bs, nt no rebound or gaurding; giuac neg in ed ext: no edema, dp 1+, trace pt neuro: aaox3 pertinent results: cxr: there appears to have been interval development of interstitial opacities bilaterally consistent with pulmonary edema. again seen is a poorly defined retrocardiac opacity/consolidation consistent with left lower lobe pneumonia. ct abdomen: no ct findings to explain the patient's abdominal pain/distention. no bowel abnormalities. sigmoid diverticulosis without evidence of diverticulitis. left base consolidation, suspicious for pneumonia. multiple simple hepatic cysts. stable tiny hypodensity in the left kidney, not well evaluated on this study. status post cholecystectomy with stable mild prominence of the extrahepatic biliary system. stable mild dilatation of the infrarenal aorta. short left common iliac dissection, chronicity indeterminite. brief hospital course: assessment: yo man with copd, recent nstemi admitted with dyspnea, chest pain, and nausea; found to have a lll pneumonia by cxr and cardiac enzyme elevations suggestive of nstemi. . 1. respiratory distress - his dyspnea and hypoxia were most likely secondary to the left lower lobe pneumonia in the setting of severe lung disease. in addition, he most likely had a component of congestive heart failure, especially given ivf and prbc administration in the first few days of his admission. his pneumonia was treated with levofloxacin and vancomycin initially given his allergy to penicillin. there was no need to cover for anaerobes as he did not aspirate. blood cultures were negative, and he tested negative for influenza and legionella. he was treated with supplemental oxygen, albuterol inhaler and nebulizer treatments, atrovent nebulizer treatments, fluticasone-salmeterol, and steroids. he remained afebrile, hemodynamically stable w/o any respiratory distress, and he will complete a 14 day total course of antibiotics. . 2. chest pain - he was found to have cardiac enzyme elevations, with cks in the 300s. he was treated with a nitroglycerin drip in the to become chest pain free, and a heparin drip for 48 hours. he was also treated with aspirin, plavix, and metoprolol. his imdur was restarted when the nitro drip was stopped. he had one additional episode of chest pain in the setting of exertion (transferring); this resolved within five minutes. his chest pain was frequently accompanied by nausea - this is likely to be an anginal equivalent for him. pt had troponin rise from 0.36 to 0.64 over the weekend. pt was asymptomatic - denied cp, nausea, vomiting. considered other causes of enzyme leak such as pe, chf, renal failure or demand ischemia. given his baseline renal insufficiency and chf, this troponin increase could be due in part to those causes. he was started on lovenox 70mg q12 and continued on this for 3 days. also, given that his cks were flat, he is not an ideal candidate for cardiac cath, and he is already on appropriate medical management, the team felt that there were no further interventions for this patient. would continue to manage symptomatically and continue current cardiac regimen. . 3. chf - on last echo, his lvef was 35-45%. he went into pulmonary edema after receiving iv fluids and prbcs. he was monitored clinically for signs of overload and treated as needed. . 4. htn - he was continued on a beta-blocker, to keep his sbp<110. . 5. gerd - he was treated with a proton pump inhibitor. . 6. cri - at baseline, his creatinine is 1.3-1.6; it was stable throughout his hospital stay. . 7. anemia - the patient has chronic iron deficiency anemia and was transfused approximately one unit of packed red blood cells in the emergency room. his hematocrit remained stable throughout the hospitalization. . communication - son , (home), (office), (cell) code status - dnr/dni, no central lines w/o discussion w/ son, no invasive procedures including tee. . medications on admission: 1. docusate sodium 100 mg po bid 2. aspirin 81 mg 3. clopidogrel 75 mg daily 4. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puff inhalation 5. combivent 103-18 mcg/actuation aerosol sig: one (1) puff inhalation every 6-8 hours as needed for shortness of breath or wheezing. 6. digoxin 125 mcg daily 7. isosorbide mononitrate 30 mg tablet sustained release 24hr daily. 8. pantoprazole 40 mg po q12h. 9. risperidone 0.5 mg po hs 10. toprol xl 25 mg tablet sustained release once a day. 11. senna 8.6 mg po bid 12. lactulose as needed. 13. promethazine 12.5 mg tid prn 14. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual q 5min as needed for chest pain. discharge medications: 1. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days. 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 12. risperidone 0.5 mg tablet sig: one (1) tablet po hs (at bedtime). 13. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 14. ipratropium bromide 0.02 % solution sig: one (1) inhalation q4h (every 4 hours). 15. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours). 16. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for back pain. 17. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 18. insulin lispro (human) 100 unit/ml solution sig: follow sliding scale subcutaneous asdir (as directed): may d/c when steroid taper complete. 19. phenergan 12.5 mg tablet sig: one (1) tablet po every hours as needed for nausea. 20. prednisone 20 mg tablet sig: two (2) tablet po qd () for 3 doses. 21. prednisone 10 mg tablet sig: three (3) tablet po qd () for 4 doses. 22. prednisone 20 mg tablet sig: one (1) tablet po qd () for 4 doses. 23. prednisone 10 mg tablet sig: one (1) tablet po qd () for 4 doses. 24. prednisone 5 mg tablet sig: one (1) tablet po qd () for 4 doses. 25. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual prn (as needed) as needed for chest pain: take 1 every 5 minutes up to 3 times. discharge disposition: extended care facility: nursing home - discharge diagnosis: primary: nstemi lll pneumonia copd dementia . secondary: gerd iron deficiency anemia anxiety h/o dvt discharge condition: fair discharge instructions: please return for further care if you have chest pain, shortness of breath, worsening nausea or vomiting, cough, fever, chills, change in mental status or any other symptoms that are concerning to you. . please take all your medications as directed. you should continue your antibiotics for 8 more days. . follow up with your physician at the appointment listed below. followup instructions: provider: , md phone: date/time: 3:30 Procedure: Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Acidosis Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Other pulmonary insufficiency, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Anxiety state, unspecified Iron deficiency anemia, unspecified Personal history of venous thrombosis and embolism Subendocardial infarction, subsequent episode of care Other specified hypotension Volume depletion, unspecified Obstructive chronic bronchitis without exacerbation

allergies: codeine / erythromycin base / ampicillin / gabapentin / aspirin / clindamycin / actonel / fosamax attending: chief complaint: as/ai; severe shortness of breath major surgical or invasive procedure: sp avr w/ tissue valve history of present illness: 75 yo f complaing of severe shortness of breath at all times. echo ef 60%, mild to mod ai, severe as with wv 0.4, mod mr. past medical history: aortic stenosis aortic insufficency lactose intolerance peripheal neuropathy mild anemia hypercholesterolemia osteoporosis sp appy sp tah w/ bladder suspension sp t & a social history: quit tobacco x 40 yr. denies etoh. retired. lives with husband. family history: mother died @ 74; mi/dm father dies @ 76; esophageal cancer physical exam: hr 76 bp 156/86 nad rrr, iii sem ctab soft, nt no e/c/c pertinent results: 06:45am blood wbc-7.4 rbc-3.27* hgb-10.1* hct-30.2* mcv-93 mch-30.8 mchc-33.3 rdw-13.1 plt ct-201 01:38pm blood wbc-10.6# rbc-3.77* hgb-11.7* hct-33.4* mcv-89 mch-31.0 mchc-34.9 rdw-13.6 plt ct-124*# 07:15am blood k-4.2 01:00am blood glucose-73 urean-9 creat-0.5 na-138 k-3.8 cl-97 hco3-32* angap-13 02:57am blood glucose-82 urean-9 creat-0.5 na-135 k-4.2 cl-105 hco3-23 angap-11 brief hospital course: pt under went an unremarkable hospital course. pt was tolerating a regular diet with good pain control on po pain medications. pt was ambulating on her own and working with physical therapy. on , pt's cxr showed r pleural effusion. pt's o2 saturation were 95% on ra. on discharge, the pt was 6 kg over her pre operative weight and was dc'd on 1 week on lasix 40mg for continued diuresis. cxr pending. an addendum will be added regarding results. medications on admission: amitryptilline 10 mg po qday calcium qday vit e qday iron 3 times per weekb 6 vit injection qo month 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. amitriptyline hcl 10 mg tablet sig: one (1) tablet po hs (at bedtime). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. hydromorphone hcl 2 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*75 tablet(s)* refills:*0* 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 8. potassium chloride 20 meq packet sig: one (1) po q12h (every 12 hours) for 7 days. disp:*7 tabs* refills:*0* 9. tramadol hcl 50 mg tablet sig: 0.5-1 tablet po q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: healthcare center discharge diagnosis: aortic stenosis/aortic insufficency colitis gastritis oa peripheal neuropathy anemia lactose intolerance hypercholesterolemia discharge condition: stable discharge instructions: please call physician if experiencing fevers/chills, nausea/vomiting, increasing redness/drainage from the incision. please do not drive while taking narcotics. please do not lift greater than 10 lbs x 6 weeks. please follow up with your pcp regarding new medications (lopressor, baby asa, , lasix/potassium x 1 weeks). followup instructions: please call the office () for an appointment with dr. in 4 weeks. please follow up with your pcp/cardiologists within 2-3 weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Transfusion of platelets Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Anemia, unspecified Pure hypercholesterolemia Aortic valve disorders Osteoporosis, unspecified Unspecified hereditary and idiopathic peripheral neuropathy Intestinal disaccharidase deficiencies and disaccharide malabsorption

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p mvc with injuries major surgical or invasive procedure: : traction pin to lle : 1.im nail right femur, 2.closed reduction right pilon fracture, 3.application multiplanar external fixator, 4.operative treatment of left subtrochanteric femur fracture with intramedullary nail, 5.washout and debridement, left open femur fracture wound, 6.treatment of left femoral shaft fracture with im implant. : ivc filter placement, i&d left open femur fx : orif right pilon fx history of present illness: mr. is a 33 year old man who was invoved in a high speed rollover motor vehicle crash on . he was trapped under his car for 30 minutes with a gcs of 3 he was taken by to for further care and treatment. past medical history: denies social history: works as a forklift operator lives with wife family history: n/a physical exam: upon admission intubated cardiac: regular rate rhythm chest: no crepitus, equal but decreased breath sounds abdomen: soft nontender nondistended extremities: in cervical collar left arm, large laeration over dorsum of left hand bilateral le: thighs grossly swollen, l lateral thigh with open laceration around 2 cm in lenght, right lower extremity externall rotated to 90 degrees, right ankle grossly unstable, rle pappable dp, doppler pt weak, lle no dp doppler pt pertinent results: 10:35am wbc-8.3 rbc-3.25* hgb-9.6* hct-28.3* mcv-87 mch-29.6 mchc-33.9 rdw-14.2 plt ct-666* 10:31am wbc-12.1* rbc-3.37* hgb-10.1* hct-29.4* mcv-87 mch-30.0 mchc-34.4 rdw-14.5 plt ct-677* 06:07am wbc-12.4*# rbc-3.14* hgb-9.8* hct-27.4* mcv-87 mch-31.2 mchc-35.7* rdw-15.0 plt ct-610*# 06:37am wbc-7.6 rbc-3.03*# hgb-9.0*# hct-26.7*# mcv-88 mch-29.8 mchc-33.8 rdw-14.4 plt ct-206 06:50am wbc-7.9 rbc-2.26* hgb-7.1* hct-19.5* mcv-86 mch-31.4 mchc-36.4* rdw-14.2 plt ct-149* 05:45pm hct-21.2* 01:30pm hct-20.8* 07:57am wbc-8.9 rbc-2.63* hgb-8.0* hct-22.6* mcv-86 mch-30.5 mchc-35.6* rdw-13.9 plt ct-134* 05:00am wbc-9.3 rbc-2.32* hgb-7.2* hct-20.0* mcv-86 mch-30.9 mchc-36.0* rdw-14.2 plt ct-135* 01:15pm wbc-9.0 rbc-2.35* hgb-7.5* hct-20.5* mcv-87 mch-31.9 mchc-36.7* rdw-13.4 plt ct-143* 03:13am wbc-8.4 rbc-2.61* hgb-8.1* hct-22.9* mcv-88 mch-31.2 mchc-35.5* rdw-13.5 plt ct-154 02:28pm wbc-9.1 rbc-3.38* hgb-10.5* hct-29.4* mcv-87 mch-31.0 mchc-35.6* rdw-13.5 plt ct-213 04:54am wbc-8.0 rbc-3.96* hgb-12.0* hct-34.8* mcv-88 mch-30.4 mchc-34.6 rdw-13.5 plt ct-214 01:11am wbc-11.6* rbc-3.93* hgb-12.1* hct-34.3* mcv-87 mch-30.9 mchc-35.4* rdw-13.5 plt ct-216 07:57am neuts-75.7* lymphs-13.4* monos-5.9 eos-4.9* baso-0.2 10:31am glucose-133* urean-7 creat-0.7 na-130* k-4.2 cl-94* hco3-25 angap-15 06:07am glucose-102 urean-12 creat-0.7 na-133 k-4.4 cl-97 hco3-26 angap-14 06:50am glucose-104 urean-8 creat-0.7 na-138 k-3.5 cl-103 hco3-28 angap-11 05:00am glucose-109* urean-8 creat-0.8 na-136 k-3.7 cl-102 hco3-29 angap-9 01:15pm glucose-138* urean-12 creat-0.9 na-129* k-4.2 cl-99 hco3-26 angap-8 03:13am glucose-148* urean-13 creat-0.8 na-134 k-4.2 cl-103 hco3-26 angap-9 02:28pm glucose-150* urean-9 creat-0.7 na-139 k-4.3 cl-108 hco3-23 angap-12 04:54am glucose-113* urean-10 creat-0.8 na-143 k-3.5 cl-108 hco3-21* angap-18 brief hospital course: mr. presented to via on after a motor vehicle crash in which he was ejected and pinned under the car. he was intubated at the scene. he was seen by the trauma surgery service and was consulted on by orthopaedics and plastic surgery. injuries:1. left open femur fx, 2. right femur fx, 3. avulsion of left hand with extension tendon exposure. 4. right pilon fx. he was admitted to the trauma intensive care unit for further monitoring. on a traction pin was placed on his lle which resulted in return of dp/pt doppler pulses. later that day he was consented and prepped for surgery, he was taken to the operating room for a im nail right femur, closed reduction right pilon fracture, application multiplanar external fixator, operative treatment of left subtrochanteric femur, fracture with intramedullary nail, washout and debridement, left open femur fracture wound, treatment of left femoral shaft fracture with im implant. he tolerated the procedure well and was taken back to the trauma intensive care unit for recovery. he was later extubated without difficulty. he remained hemodynamically stable and was able to be transferred out of the trauma intensive care unit to the floor on . he returned to the operating room on for a washout and debridement of the left open femur fracture. during that procedure an ivc filter was placed by dr. of trauma surgery. he tolerated the procedure well without difficulty. he was also transfused with 2 units of packed red cells for post-operative anemia. on mr. pressure was noted consistently high, with his pain controlled and was started on 12.5mg daily of lopressor, with noted effect. on he was taken to the operating room for removal of the right leg ex-fix with orif of ther fibula and tibia. he remained hemodynamically stable and tolerated the procedure well. he continued to work with physical therapy to improve his strenght and mobility. throughout his stay his pain was controled and his vital signs remained within normal limits. he was discharged in stable condition with instructions for follow up care. medications on admission: denies 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. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 6. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po daily (daily): hold for sbp less than 120. 7. oxycodone 5 mg tablet sig: 1-4 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 8. enoxaparin 30 mg/0.3 ml syringe sig: one (1) 30mg syringe subcutaneous q12h (every 12 hours) for 4 weeks. 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). discharge disposition: extended care facility: - discharge diagnosis: multi-trauma post operative anemia discharge condition: stable discharge instructions: if you develop any swelling, redness, or drainage from your incision, or if you have a temperature greater than 101.5 or if you become short of breath please call the office or come to the emergency department. continue to be nonweight bearing on your right leg and weight bearings as tolerated on your left leg. continue your lovenox injestions as directed physical therapy: activity: activity as tolerated right lower extremity: non weight bearing treatment frequency: you may apply a dry sterile dressing to draining right ex-fix areas. your staples on your right pilon fx can be removed in 4 days (14 days after surgery) followup instructions: please follow up with dr. in clinic in 2 weeks, please call to schedule that appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Open reduction of fracture with internal fixation, tibia and fibula Debridement of open fracture site, femur Debridement of open fracture site, femur Closed reduction of fracture without internal fixation, tibia and fibula Closed reduction of fracture with internal fixation, femur Closed reduction of fracture with internal fixation, femur Application of external fixator device, femur Removal of implanted devices from bone, femur Diagnoses: Anemia, unspecified Other specified complications of procedures not elsewhere classified Closed fracture of subtrochanteric section of neck of femur Open fracture of shaft of femur Closed fracture of unspecified part of fibula with tibia Motor vehicle traffic accident of unspecified nature injuring driver of motor vehicle other than motorcycle

history of present illness: 1. closed head injury consisting of a left frontal subarachnoid hemorrhage which was stable. 2. left elbow fracture. 3. left scapula fracture. 4. left distal radioulnar joint separation. 5. altered mental status secondary to #1. physical examination: examination on discharge includes in general the patient is wearing a cervical collar and appears alert and oriented x 1 and is in no acute distress. heent shows the pupils to be equal, round, and reactive to light, extraocular motion is intact. neck examination shows the trachea is midline, no jugular venous distension is noted. cardiovascularly he has regular rate and rhythm. pulmonary showed that the lungs are clear to auscultation bilaterally, no wheezes are heard. abdomen is soft, nondistended and nontender. bowel sounds are normal and active. extremities show no cyanosis, clubbing or edema, 2+ pulses are felt throughout. genitourinary examination shows a foley catheter in place, otherwise normal. skin is warm and dry. neurologic examination shows that the patient is able to follow all commands, moving all extremities normally. sensation appears intact in all extremities. there are no cerebellar signs. laboratory data: during his hospital stay laboratory and x-ray findings include a ct scan of his abdomen which was negative for any traumatic injury. a chest x-ray was negative for any traumatic injury. a ct scan of his chest showed a left scapular fracture. pertinent laboratory findings on admission included a white count of 16.4, an hematocrit of 40, platelet count of 306, a urine toxicology which was positive for benzodiazepines, a lactate was 2.2. pt was 12.8, ptt 21, inr 1.1, fibrinogen 328. electrolytes on admission included sodium of 146, potassium 4.4, chloride 103, bicarbonate 29, bun 13, creatinine 0.9, glucose 122. a pelvic x-ray showed no fracture upon admission. a ct of his head on the day of admission showed a left frontoparietal subarachnoid hemorrhage. a ct of his cervical spine showed a preliminary result negative for any fractures. flexion-extension view x-rays of the cervical spine upon flexion and upon extension were negative for any signs of injury to the cervical spine. hospital course: upon admission the patient was awake, somnolent and uncooperative. his vital signs included a temperature of 98.4, heart rate of 107, blood pressure 140/palpable, respiratory rate of 18, breathing 97% on room air. his physical examination on admission included an examination of the extremities showing 2+ pulses throughout, sensation being intact. his left arm was tender and there was deformity of the left arm which was splinted. his back showed no stepoffs but some mild thoracic tenderness therefore the patient was placed on cervical spine precautions and log roll precautions. his pelvis was stable and nontender. his rectal examination had normal tone without any gross blood. his abdomen was soft, nondistended and nontender with normal bowel sounds. his chest was stable and nontender without any abrasions, bruises or ecchymoses. his lungs were clear to auscultation bilaterally. the patient was admitted to the trauma surgery intensive care unit for neurological checks. a neurosurgery consultation was obtained and a head scan was repeated the following morning. this patient had brought films with him. ct scan of his cervical spine from an outside hospital was reported to be negative for fracture. an orthopedic consultation was obtained due to his left arm pain. the x-rays of his left arm showed a left radial head fracture and this arm was splinted by orthopedics. during the patient's stay in the trauma intensive care unit, he remained on cervical spine and log roll precautions but made progress and remained hemodynamically stable. he did not require intubation. a repeat scan of his head after a reported witnessed fall was negative for any change from the previous study. his right frontoparietal subarachnoid hemorrhage appeared to be stable. the patient's blood pressure remained under control per neurosurgery orders. the patient's scapular fracture was determined to be nonoperative. the patient's radial head fracture was kept in a posterior splint for five to seven days, that is, the splint will be removed today upon discharge and gentle range of motion elbow exercises will ensue. the patient remained stable and was transferred to the floor, that is the unit cc6a, where his mental status remained altered likely secondary to his closed head injury. the patient's vital signs remained stable. he did not spike any fevers and his blood pressure and heart rate remained within normal limits throughout his stay on the floor. medications while in house included ativan p.r.n., hydralazine and metoprolol to control blood pressure, morphine for pain control, lovenox for dvt prophylaxis, ranitidine for gastric ulcer prophylaxis, a nicotine patch, and the patient's diet was advanced to a full house diet. his iv was heparin locked. dr. was contact as a consultation for this patient's neurological rehabilitation and advised inpatient neurological rehabilitation for mr. . the patient's cervical collar will remain. upon clinical examination the patient had tenderness in the posterior neck region and was put back in his cervical collar. his collar will remain for six weeks after the admission date of . condition on discharge: stable. discharge status: to an inpatient neurological rehabilitation facility. discharge medications: 1. acetaminophen 325 mg 1-2 tablets p.o. q. 4-6 hours p.r.n. headache pain. 2. hydralazine 25 mg tablet one tablet orally every six hours. 3. enoxaparin sodium 30 mg subcutaneous injection every 12 hours. 4. lorazepam 1 mg p.o. t.i.d. 5. ranitidine one tablet p.o. b.i.d. 6. oxycodone/acetaminophen combination 325 mg, 1-2 tablets p.o. q. 4-6 hours p.r.n. 7. docusate sodium 100 mg capsule one p.o. b.i.d. 8. nicotine patch 21 mg, 24-hour transdermal patch q.d. 9. morphine sulfate 2-4 mg iv q. 4 hours p.r.n. pain. follow-up plans: 1. follow up with dr. for neurological rehabilitation progress. dr. is aware of the patient. 2. clinic follow up in one to two weeks with dr. for recheck on the patient's left arm fracture. , m.d. dictated by: medquist36 d: 13:48 t: 14:08 job#: Procedure: Arterial catheterization Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Alcohol abuse, unspecified Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Street and highway accidents Closed fracture of scapula, unspecified part Closed fracture of head of radius Multiple and unspecified open wound of upper limb, without mention of complication Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest discomfort major surgical or invasive procedure: aortic valve replacement utilizing a 29mm ce perimount magna pericardial valve. replacement of ascending aorta utilizing a 26mm gelweave graft. history of present illness: mr. is a 34 year old male who first presented with chest discomfort and tingling sensation in his left shoulder in . then in , after playing tennis, developed vague chest discomfort associated with dyspepsia and nausea. echocardiogram revealed a bicuspid aortic valve with moderate to severe aortic insufficiency. his ascending aorta was dilated, measuring 4.5 centimeters. his aortic root measured 2.9 centimeters. lvef estimated at 55-60%. subsequent cardiac catheterization confirmed moderate aortic insufficiency and dilated ascending aorta. his coronary arteries were normal and his lvef was measured at 65%. based on the above results, he was referred for cardiac surgical intervention. past medical history: biscupid aortic valve, aortic insufficiency, dilated ascending aorta, history of seizure disorder as an infant, ? syndrome as a child social history: denies tobacco. admits to only occasional etoh. he is married and works as a software engineer. family history: father underwent cabg at age 61 physical exam: vitals: bp 130/80, hr 84, rr 12 general: well developed male in no acute distress heent: oropharynx benign, neck: supple, no jvd, heart: regular rate, normal s1s2, diastolic murmur lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, no varicosities pulses: 2+ distally neuro: alert and oriented, nonfocal pertinent results: 04:55am blood wbc-5.7 rbc-2.61* hgb-8.2* hct-22.9* mcv-88 mch-31.4 mchc-35.7* rdw-13.9 plt ct-159 04:55am blood glucose-112* urean-11 creat-0.8 na-140 k-4.1 cl-100 hco3-32 angap-12 radiology final report chest (pre-op pa & lat) 4:01 pm chest (pre-op pa & lat) reason: aortic insufficiency\bental procedure /sda medical condition: 34 year old man s/p cabgx3/asd reason for this examination: ?pneumonia chest, two views, pa and lateral history of cabg and avr. status post median sternotomy and avr. there is slight cardiomegaly. no evidence for chf. there is a small left pleural effusion with minimal atelectasis at the left lung base. mediastinal emphysema is present anteriorly in the substernal region, presumed post-surgical. no pneumothorax. dr. cardiology report echo study date of patient/test information: indication: intraoperative tee for avr, asc. aorta repair, height: (in) 75 weight (lb): 180 bsa (m2): 2.10 m2 status: inpatient date/time: at 10:27 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2006aw03-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: left ventricle - septal wall thickness: *1.2 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.0 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 50% to 55% (nl >=55%) aorta - valve level: 3.0 cm (nl <= 3.6 cm) aorta - ascending: *4.4 cm (nl <= 3.4 cm) aorta - descending thoracic: 1.9 cm (nl <= 2.5 cm) interpretation: findings: left atrium: normal la size. right atrium/interatrial septum: normal ra size. normal interatrial septum. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. mild symmetric lvh. normal lv cavity size. normal regional lv systolic function. low normal lvef. lv wall motion: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; right ventricle: normal rv chamber size and free wall motion. aorta: moderately dilated aortic root. moderately dilated ascending aorta. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: bicuspid aortic valve. mildly thickened aortic valve leaflets. systolic doming of aortic valve leaflets. no as. moderate (2+) ar. eccentric ar jet directed toward the anterior mitral leaflet. mitral valve: normal mitral valve leaflets. no ms. trivial mr. tricuspid valve: physiologic tr. pulmonic valve/pulmonary artery: physiologic (normal) pr. pericardium: trivial/physiologic pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the procedure. the patient appears to be in sinus rhythm. results were personally conclusions: pre-bypass: the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler, but can not completely rule out a very small pfo. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. the ascending aorta is moderately dilated. there are simple atheroma in the descending thoracic aorta. the aortic valve is bicuspid. the aortic valve leaflets are mildly thickened. there is systolic doming of the aortic valve leaflets. there is no aortic valve stenosis. moderate (2+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. the mitral valve leaflets are structurally normal. trivial mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. post-bypass normal rv systolic function. low normal lv systolic function. ef 50-55%. a bioprosthesis is located in the aortic position. it is well seated and displays normal leaflet function. there is no aortic stenosis. there are two jets of trace aortic regurgitation. the first is clearly valvular. there is a second jet that emanates from the region of the native right coronary cusp that is directed perpendicularly to the lvot. the nature of this jet suggests a likely perivalvular source but this can not be confirmed on 2d imaging. this jet decreased somewhat in intensity after protamine administration. graft material is seen in the ascending aorta. the thoracic aorta is intact post-cpb. electronically signed by , md on 14:31. brief hospital course: mr. was admitted and underwent replacement of his aortic valve and ascending aorta by dr. . the operation was uneventful and he transferred to the csru for invasive monitoring. for further surgical details, please see seperate dictated operative note. he initially experienced postoperative coagulopathy which required fresh frozen plasma and platelets. with blood products, his bleeding quickly improved and no further intervention was required. within 24 hours, he awoke neurologically intact and was extubated. beta blockade was initiated on postoperative day one. his csru course was otherwise uncomplicated and he transferred to the sdu on postoperative day two. over several days, beta blockade was advanced as tolerated. he remained in a normal sinus rhythm. he continued to make clinical improvments with diuresis and made steady progress with physical therapy. given his pericardial tissue valve, he will need to remain on aspirin therapy. he was medically cleared for discharge to home on postoperative day 5.prior to discharge, his chest x-ray showed only a small pleural effusions and no evidence of heart failure. medications on admission: lisinopril pepcid discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*50 tablet(s)* refills:*0* 3. hydromorphone 2 mg tablet sig: one (1) tablet po q2h (every 2 hours) as needed. disp:*50 tablet(s)* refills:*0* 4. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). disp:*180 tablet(s)* refills:*2* 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. 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* 9. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. disp:*10 tablet(s)* refills:*0* 10. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 5 days. disp:*20 capsule, sustained release(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: dilated ascending aorta, bicuspid aortic valve, aortic insufficiency - s/p aortic valve replacement and replacement of ascending aorta, postoperative coagulopathy, history of seizures discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon, dr. in weeks - call for appt. local pcp, . in weeks - call for appt. local cardiologist, dr. in weeks - call for appt. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Transfusion of other serum Transfusion of platelets Diagnoses: Thoracic aneurysm without mention of rupture Aortic valve disorders Hemorrhage complicating a procedure Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

history of present illness: baby girl was born at 34 4/7 weeks gestation and admitted to the nicu for prematurity. maternal history: mother is a 32-year-old g3, p0 now 1 woman with a past ob history notable for an sab x 2. medical history was notable for chronic hypertension treated with nifedipine and type 2 diabetes mellitus, on insulin. prenatal screens were as follows: blood type b positive, dat negative, hbsag negative, rpr nonreactive, rubella immune, gbs unknown. antenatal history: the edc was . pregnancy was complicated by maternal hypertension and diabetes mellitus as above mentioned and hyperemesis gravidarum requiring iv therapy. induction of labor for neuropathy then proceeded to cesarean section after fetal decelerations were noted on intrapartum monitoring. there was no fever or other clinical evidence for chorioamnionitis. artificial rupture of membranes occurred 2 hours prior to delivery and yielded clear amniotic fluid. intrapartum antibacterial prophylaxis was administered beginning 6 hours prior to delivery. a full course of betamethasone was completed prior to delivery. in the delivery room the infant was vigorous, was orally and nasally bulb suctioned, dried, and subsequently pinked on her own and was in no distress on room air. the apgar scores were 8 and 8 at 1 and 5 minutes. physical examination: the physical examination on admission showed a well-appearing preterm infant consistent with gestational age of 34 weeks gestation, birth weight 1,760 grams which is the 25th percentile. head circumference 30.25 cm which is 25th-50th percentile, length 43 cm which is 25th percentile. heent: anterior fontanelle soft and flat. nondysmorphic facies. intact palate. no nasal flaring. chest shows no retractions, good breath sounds bilaterally. no adventitious sounds. cv: well perfused. normal rate and rhythm. femoral pulses were normal. normal s1, s2. no murmur. abdomen: soft, nondistended. no organomegaly. no masses. bowel sounds active. patent anus. three-vessel umbilical cord. gu normal genitalia. cns active, alert, responds to stimuli. tone was appropriate for gestational age and symmetric. moves all extremities well. root, suck, and gag reflexes were intact. skin normal. musculoskeletal normal spine, limbs, hips, and clavicles. hospital course: 1. respiratory: the infant has remained on room air since birth. she has had no issues with apnea of prematurity and has required no methylxanthine. 2. cardiovascular: she has been free of murmur since birth, has had a normal heart rate and rhythm, normal blood pressure. no issues. 3. fluids, electrolytes, and nutrition: iv fluids were administered on admission to the nicu due to concern for hypoglycemia. the d stick never dropped lower than 47. she was started on d10w and on the newborn day was also started on feedings p.o./pg. she weaned off iv fluids by day #1 of life and started to take all p.o. feeds up until day #4 of life at which time she started to tire, requiring some pg feeds. she has required pg feeds occasionally all the way up until , at which time she became all p.o. feeds. she has exhibited good weight gain. she is above birth weight at this time with her most recent weight being grams on . she is presently on 24 calorie per ounce feeds of breast milk with neosure powder or neosure 24 calorie per ounce and she is taking approximately 150 ml per kilogram per day. elemental iron was started on . she continues to take an additional 2 mg per kilogram per day of elemental iron. 4. gi: her peak bilirubin level was 5.2/0.4 on day of life #1. she has required no phototherapy. she had heme- positive stool on , at which time a tiny rectal fissure was noted. she has since had negative heme stools. she is voiding and stooling normally. 5. hematology: no blood typing has been done on this infant. her crit at birth was 48.7, platelet count 291. she has had no further crit measured. 6. infectious disease: a cbc and blood culture were screened on admission to rule out sepsis. antibiotics were not indicated at that time. the blood culture remained negative. the cbc was benign with a white blood cell count of 9.7, 36 polys, 5 bands, 46 lymphs. 7. neurology: she maintained a normal neurologic exam for gestational age. 8. sensory/audiology: a hearing screen was performed with automated auditory brainstem responses in which she passed in both ears. 9. psychosocial: a social worker has been involved with the family. there are no active ongoing psychosocial issues at this time but if there are any concerns the social worker can be reached at . condition at discharge: good. discharge disposition: discharged home with the family, both parents. primary pediatrician: dr. , telephone number . care recommendations: ad lib p.o. feeding of breast milk with 4 calories per ounce of neosure powder added or neosure 24 with iron and some breast feeding per day with supplementation. medications: elemental iron. car seat screening: performed and the infant passed. state newborn screen status: the infant had a state screen sent on day of life #3. the results are still pending. immunizations received: hepatitis b vaccine was given on . immunizations recommended: 1. synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria. 1) born less than 32 weeks gestation. 2) born between 32 and 35 weeks gestation with 2 of the following, either daycare during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings or 3) with chronic lung disease. 2. influenzae 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 influenzae is recommended for household contacts and out of home caregivers. follow-up appointments: with the pediatrician on . visiting nurse for . discharge diagnosis: 1. prematurity, born at 34 4/7 weeks gestation. 2. sepsis, ruled out. 3. infant of a diabetic mother. , Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Observation for suspected genetic or metabolic condition Other preterm infants, 1,750-1,999 grams 33-34 completed weeks of gestation Other anomalies of intestine

history of present illness: the patient is a 72-year-old female with a history of diverticulosis and recent gi bleed. she presented to the emergency room on with history of bright red bleeding per rectum. during that night, she has had three similar episodes, which resolved on their own. the patient is known to have diverticular disease as verified by angiography and red blood cell scan previously done at this hospital. physical examination: physical exam on admission reveals a temperature of 97.9 degrees, pulse of 85, blood pressure 139/98, respirations 16, and saturation is 99 percent on room air. heart sounds are regular rate and rhythm. lungs are clear to auscultation bilaterally. the abdomen is soft, nontender, and nondistended. however, bright red blood is noted on rectal exam. hospital course: the patient was deemed hemodynamically stable by the surgery team, and it was felt that an emergent segmental colectomy was the optimal treatment. the patient was taken to the operating room to undergo a segmental colectomy removing the left transverse segment, splenic flexure, and left colon. please refer to the operative note of dr. for more details on that procedure. the patient tolerated the procedure well and was discharged to the pacu in stable condition. due to the significance of her bleeds, the patient was admitted to the icu postoperatively. hematocrit had been noted to change from 35 to 22 over the course of 10 a.m. to 6 p.m., although some of this is expected postoperative bleeding loss. this level of bleeding merited an admission to the icu. for prophylaxis, the patient was placed on kefzol and flagyl. while in the icu, an arterial blood gas was noted to have a pco2 of 55 and a ph of 7.24. no interventions were undertaken at that time; however, it was decided that bipap support would be administered if the acidosis persisted. the patient remained in the icu for postoperative days two and three. however, on postoperative day three, as her condition was increasingly stable, she was transferred to the floor where she continued to do well. on postoperative day five, the patient experienced significant return of bowel function with positive flatus and was tolerating a regular diet well and the decision was made to discharge her home in good condition. the patient was instructed to follow up with dr. in two weeks. discharge diagnoses: diverticulosis. anemia. diabetes. hypertension. discharge medications: 1. protonix 40 mg q.d. 2. moexipril 15 mg q.d. 3. iron sulfate q.d. 4. prazosin 1 mg q.d. 5. hydrochlorothiazide 50 mg q.d. 6. percocet 5/325 1 to 2 tablets q. h. p.r.n. pain. 7. glyburide 5 mg. , Procedure: Venous catheterization, not elsewhere classified Other and unspecified partial excision of large intestine Arteriography of other intra-abdominal arteries Transfusion of packed cells Diagnoses: Acidosis Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypotension, unspecified Embolism and thrombosis of iliac artery Diverticulitis of colon with hemorrhage

history of present illness: the patient is a 72-year-old female with recent discharge after diverticular bleed presents with repeated bright red blood per rectum. during the last admission, the patient had colonoscopy on showing fresh blood in the left colon up to 50 cm with extensive diverticulosis. she had packed red blood cells again on showing active bleeding at the distal transverse colon proximal to the splenic flexure and then in angio, which was unable to visualize active bleeding. on the morning of admission, the patient had 3 episodes of passing clots (greater than size of a quarter). she denies dizziness, lightheadedness, nausea, vomiting, diarrhea, fevers, chills, chest pain, or shortness of breath. she does report hearing a rapid heartbeat. in the ed, vital signs stable and hematocrit noted to be 24 down from 28 on discharge. she was given 2 units of packed red cells. past medical history: diverticulosis, status post recent gi bleed. diabetes type ii. hypertension. medications: 1. protonix 40 mg by mouth every day. 2. minipress 1 mg by mouth every day. 3. moexipril 15 mg by mouth every day. 4. hydrochlorothiazide 50 mg by mouth every day. 5. glyburide 5 mg by mouth every day. 6. iron supplements 3 times a day. 7. potassium 20 meq by mouth every day. allergies: penicillin. social history: husband in hospital in status post stroke, 6 children. physical examination: temperature 97 degrees, blood pressure 122/72, pulse 75, respirations 14, and o2 saturation 100 percent on 2 liters. in general, a well-appearing female in no acute distress. heent: perrl, anicteric. moist mucous membranes. throat without erythema. cardiovascular: regular rate and rhythm. normal s1 and s2. chest: clear to auscultation bilaterally. abdomen: normoactive bowel sounds, soft, nontender, and nondistended. extremities: pitting edema plus bilaterally, 2 plus dps. rectal: bright red blood seen at anus. laboratory data: laboratory data on admission is significant for white count 4.6 with 76 percent neutrophils, 19 percent lymphocytes, 3 percent monocytes, hematocrit 24.7, and platelets 269. chemistry is notable for potassium of 3.7, bun 17, creatinine 0.8, glucose 119, ck 389, mb of 7, and troponin less than 0.01. radiographic studies: ekg, no st- or t-wave changes. sinus tachycardia at 96 beats per minute. hospital course: bright red blood per rectum. the patient was prepped for repeat colonoscopy, which showed multiple diverticula with large openings in the sigmoid and descending colon, but no blood seen anywhere, as well as a single sessile 6 mm non-bleeding polyp of benign appearance in the descending colon, which was excised. no intervention was performed at that time and the patient did not have any further bleeding. her hematocrit remained stable at 32 on discharge. again, she was recommended to eat a very high- fiber diet and take colace. a left hemicolectomy was discussed with her in case of re-bleed and the patient is aware that she may have to have this done in the future as it is very likely that she will re-bleed. hypertension. her blood pressure medications were held, and she was advised to not take them until she follows up with her primary care doctor in the next week. type ii diabetes. oral hypoglycemics were held while n.p.o., but she will resume her normal medications on discharge. diet. repleted electrolytes and the patient was tolerating solids by discharge. discharge condition: stable. discharge status: to home. discharge diagnoses: lower gastrointestinal bleed likely secondary to diverticulosis. diabetes. hypertension. blood loss anemia. discharge medications: as per admission medications with the addition of colace 100 mg by mouth 2 times a day. follow-up plans: the patient was advised to call pcp for in the next week to monitor hematocrit and blood pressure. , Procedure: Colonoscopy Endoscopic polypectomy of large intestine Transfusion of packed cells Transfusion of packed cells Diagnoses: Acidosis Hypocalcemia Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other specified cardiac dysrhythmias Benign neoplasm of colon Diverticulosis of colon with hemorrhage Other specified hypotension Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication

history of present illness: this is a 72-year-old female with history of hypertension, diabetes type 2, and diverticulosis by colonoscopy in , who presents with large volume of brbpr x2 this a.m. the patient was unclear about amount of bleeding, but quantifies it as cupfuls. she had 2 more episodes in the ed with 1 episode about 200 cc rn. in the ed, her hematocrit was noted to be 37.2 (baseline 36 to 37) and hemodynamically stable with blood pressure 129/88 and pulse 95. unfortunately, she failed ng lavage. she has never had prior gi bleeding and denied chest pain, shortness of breath, lightheadedness, abdominal pain, nausea/vomiting, palpitations, recent fevers and chills, recent nsaid use, gerd, anticoagulation, etoh. she received 1.5 liters of normal saline following resuscitation in ed and was transferred to the floor. past medical history: hypertension. niddm. diverticulosis with no history of gi bleed (colonoscopy, , showing diverticula of sigmoid and descending colon and grade 1 internal hemorrhoids, otherwise normal to cecum). seborrheic keratosis. medications: on admission, 1. hydrochlorothiazide 50 mg p.o. q.d. 2. kcl 20 meq p.o. q.d. 3. glyburide 5 mg p.o. q.d. 4. prazosin 1 mg p.o. b.i.d. 5. moexipril 15 mg p.o. q.d. 6. mdi. 7. calcium carbonate. allergies: penicillin with unclear reaction. social history: the patient lives in with husband (who is currently hospitalized in rehab center with cva), no tobacco or etoh. physical examination: on admission, vital signs, blood pressure 124/79, pulse 74, respirations 18, 97 percent on room air with blood pressure and pulse changing to 99/58 with pulse of 81 during course of examination. general: nad, resting on the stretcher, alert and oriented x3. heent: perrla, eomi, mmm, clear oropharynx, anicteric sclerae. neck: supple, no jvd, no lymphadenopathy. cardiovascular: regular rate and rhythm, normal s1 and s2; no murmurs, rubs, or gallop. lungs: clear to auscultation bilaterally. abdomen: normoactive bowel sounds, soft, nontender, nondistended. no hepatosplenomegaly. extremities: no clubbing, cyanosis, or edema, 2 plus pt pulses. rectal: skin tag at anus with bright red blood noted, good sphincter tone. laboratory data: on admission, significant for white count of 4.3 with 16 neutrophils, 33 lymphocytes, 4 monocytes, 4 eosinophils. hematocrit 37.2, platelets 311. chemistry is notable for bun 26, creatinine 0.9. on , ecg, normal sinus rhythm at 79 beats per minute, normal axis and intervals, left atrial enlargement, frequent pacs, no st-t wave changes from prior ecg. hospital course: bright red blood per rectum. patient was typed and crossed for several units of packed red cells and was ensured adequate peripheral iv access and given normal saline for volume resuscitation. over the course of the evening, she had several more episodes of hematochezia while attempting to prep for colonoscopy for the following day. her hematocrit dropped to 24 over the next several hours and the patient was sent for packed red blood cell scan given the active bleeding. this localized the area of bleeding to the distal transverse colon just proximal to the splenic flexure. she was then immediately sent to angiography, which unfortunately was unable to localize the bleed. she was monitored in the micu for the next several days and transfused several units of packed red cells for continually decreasing hematocrit. she had a colonoscopy on showing extensive diverticulosis in the entire colon, though more concentrated in the left colon, and fresh blood in the rectosigmoid colon to about 50 cm from the anal verge, but most concentrated from about 40 to 50 cm and no bleeding proximally. while fresh blood was continually seen, no specific bleeding diverticulum was identified. she stabilized over the next few days and continued on iv protonix, though the most likely source of bleeding was from the sigmoid or descending colon, secondary to diverticulosis. after her hematocrit stabilized with no further episodes of hematochezia, the patient was transferred to the floor and prepared for discharge. surgery had evaluated the patient earlier, but did not wish to operate at this time. however, we discussed with the patient that these episodes were likely to recur and should they recur surgery may be indicated in the future. anemia. the patient was transfused a total of 8 units of packed red blood cells during this admission. she was started on iron supplements on discharge. niddm. she was on sliding scale insulin, but will restart her p.o. hypoglycemics on discharge. prophylaxis. the patient will not need to continue ppi at home as unlikely to have upper gi lesions. discharge condition: stable. discharge status: to home. discharge diagnoses: diverticulosis. lower gastrointestinal bleed. hypertension. diabetes, non-insulin dependent. internal hemorrhoids. discharge medications: 1. hydrochlorothiazide 50 mg p.o. q.d. 2. kcl 20 meq p.o. q.d. 3. glyburide 5 mg p.o. q.d. 4. prazosin 1 mg p.o. b.i.d. 5. moexipril 15 mg p.o. q.d. 6. mdi. 7. calcium carbonate. 8. iron 325 mg 1 tablet p.o. t.i.d. 9. colace 100 mg p.o. b.i.d. follow-up plans: the patient was advised to follow up with her primary care doctor, dr. , in the next few days. she was advised from the gi team to eat a high-fiber diet, but that these episodes may recur. she was instructed to return to the emergency department immediately should she experience any further bright red blood per rectum. , dictated by: medquist36 d: 11:00:25 t: 12:47:56 job#: Procedure: Colonoscopy Endoscopic polypectomy of large intestine Transfusion of packed cells Transfusion of packed cells Diagnoses: Acidosis Hypocalcemia Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other specified cardiac dysrhythmias Benign neoplasm of colon Diverticulosis of colon with hemorrhage Other specified hypotension Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication

admitting diagnosis; encephalitis, resp. failure, acidotic allergies; nkda contact precautions for herpes zoster pmh; chf, advanced copd (on home 02), htn, obesity, pneumonia, seizure disorder. pt is a 67 y/o woman admitted from pacu @ 1300 after being transferred there from cc7 @ 0830 am today. the pt was found unresponsive; arousable to tactile stilumi and acidotic (ph 7.25) on cc7 this am. she has been hospitalized since . this is her second time in the micu since her admission. current review of systems pt is responsive to questions, follows commands consistently and shakes her head yes or no to questions. perrla, bsk. mae, weak on r side primarily in lower extremities. recieving dilantin for seizure d/o- level sent today and in therapeutic range. cv- hr 90's, nsr, no ectopy noted. bp 100-140's/60's. maps 80's. last k+: 4.4 resp- ac 500x16x40%x5 peep, awaiting abg results. pt had one episode where she started to plug off; sats dropped to 70's, she responded well to bag and lavage suctioniing- sats returned to high 90's. she had copius amts of tan, secretions- sputum culture sent. please follow up on all results w/ team. ls coarse in upper lobes diminished in bases. gi- abd soft, +bs, no bm today. currently npo, plan to remain o/n. gu-pt has 1/2 ns infusing @ 100 cc/hr. received a 600 cc bolus in the pacu. adequate u/o; clr, yellow. access- new a-line placed today in pacu, r radial- wnl. mult lumen r ij also in place; wnl. pt has several zoster lesions accross her trunk and down her back t o her coccyx. pt bathed and dsgs changed on arrival-skin care consult needed for breakdown. pt has a necrotic area around coccyx. mitroconazole powder ordered for yeast like areas in skin folds. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Arterial catheterization Diagnoses: Acidosis Urinary tract infection, site not specified Congestive heart failure, unspecified Obstructive chronic bronchitis with (acute) exacerbation Other convulsions Acute respiratory failure Other alteration of consciousness Unspecified infectious and parasitic diseases

history of present illness: on presentation, , the following history was obtained by the intensive care unit resident. patient is a 69-year-old female with a history of congestive heart failure, chronic obstructive pulmonary disease, status post recent admission to hospital for pneumonia complicated by chronic obstructive pulmonary disease exacerbation on a prednisone taper. she was discharged back to the nursing home four days prior to admission where she was recovering well until the night prior to admission. she was witnessed to have three generalized tonic-clonic seizures lasting approximately 20 minutes. ems was called and patient was intubated in the field for status. arrived at hospital with continued seizures, treated with ativan 4 mg, valium 5 mg and loaded with 5 phenytoin. head ct revealed diffuse white matter disease with evidence of edema, but no bleed. lumbar puncture was slightly bloody, although decreased white count from tubes one through four. she was transferred to for further management. she was given ceftriaxone 2 grams at hospital. patient had been treated for a urinary tract infection with bactrim and was noted to have a zoster rash on her back, which was noted at hospital. she was started on acyclovir at the time. according to the patient's family, she was more lethargic during the day, , although, the family was told that her vitals were okay. on arrival to , the patient was sedated and intubated. ct scan was reviewed with radiology and felt not to be consistent with subarachnoid hemorrhage. medical intensive care unit team was called and admitted the patient. she was not able to give any history of her own at that time. past medical history: 1. possible multifocal atrial tachycardia. 2. chronic obstructive pulmonary disease. 3. cardiomegaly. 4. congestive heart failure. 5. hypertension. 6. obesity. medications on admission: digoxin .25 mg po q.d., lasix 40 mg po q.d., potassium chloride 10 mg po q.d., diazepam 2 mg po t.i.d., azmacort 2 mg po q.i.d., famotidine 20 mg po q.h.s., multivitamin 1 tablet po q.d., vitamin c 500 mg po b.i.d., bactrim double strength b.i.d., theophylline 200 mg po b.i.d., fluticasone salmeterol 1 puff po b.i.d., acyclovir 800 mg po q.i.d., tylenol prn. allergies: patient has no known drug allergies. social history: she lives at a nursing home, former tobacco user with 60+ pack year history of smoking, quit six years prior to admission. patient was full code on admission. physical examination on admission: temperature was 97.3. heart rate 86-96. blood pressure 105-117/55-63, breathing at 12-13, 02 saturation 98%. arterial blood gas was 7.43, 44, 86 on simv with pressures 700 x 12, fio2 of .5, peep of 5, pressure support was 5. she has anicteric pupils, equal, round and reactive to light. no doll's eyes. oropharynx showed ett in place. she had a supple neck. lungs were clear to auscultation bilaterally. her heart was irregularly irregular with no murmurs, rubs or gallops. her abdomen is soft, nontender, nondistended, positive bowel sounds times four. she had 1+ edema. patient was sedated and unresponsive to voice, withdrawing toes, spontaneously opens eyes. laboratories from hospital: white blood cell count 15.3, hematocrit 56.2 with a differential of 90 neutrophils, 4 lymphocytes, 4 monocytes, platelets 136,000, inr 1.4, ptt is 25, sodium 140, potassium 4.5, chloride 99, bicarbonate 33, bun 44, creatinine 1.3, glucose 125, albumin 3.7, calcium 9, magnesium 2.1, tsh was 5.3, t4 7, t3 uptake 41, theophylline was 6.4, which is subtherapeutic. therapeutic range is . digoxin 1.4. ammonia was 36. alt 31, ast 25, alkaline phosphatase 112, t bilirubin .8, total protein 6.9. electrocardiogram shows sinus arrhythmia with st elevations in v1 and v2 and nonspecific st-t wave changes. cerebrospinal fluid tube one shows 2 white cells, 150 red cells, glucose of 75, protein 225. head ct demonstrated white matter disease, left cerebral edema with compression of the lateral ventricle, no gross shift, question of air bubbles. hospital course: hospital course can best be summarized day to day as her main problems were her neurologic problems and pulmonary problems and these were overlapping issues. the patient's work-up at included an mri of her head which showed diffuse cerebral edema. mra and mrv were normal and electroencephalogram showed frontal spike on the left with a diffusely slow background. treatment included reloading the patient with phenytoin steroids and acyclovir for presumed hsv encephalitis. follow-up mris did not demonstrate progression and in fact showed resolution of her cerebral edema. the culture results from hospital revealed hsv2 positive pcrs. it is felt to be positive for her aseptic meningitis or asymptomatic shedding from a sacral nerve root. the infectious disease service was not convinced that her clinical picture was consistent with hsv2, they felt it was more likely to be consistent with hhv6. the patient completed her acyclovir however, and this is not a further issue. the patient was noted to be more responsive and was finally extubated in the intensive care unit on . she was transferred to the medical service for further management. her neurologic exam at that time showed that her eyes were open at baseline. she was able to follow examiner with her eyes. her speech was slow, dysarthric with simple sentence production and soft voice. she was moving all four extremities, left greater than right, was capable of following one and two step commands with variable re-productability, cannot print by correct date or location but knew her name. cranial nerves respond to visual threat. full elevation and depression of eyes, right lateral gaze was intact, capable of moving eyes to the left, but incomplete motion. eyes were in mid position at baseline. facial sensation was difficult to assess, motion was noted to be decreased in her lower face on the right side. her hearing was grossly intact. palate was up bilaterally. head turning and shoulder shrug were difficult to assess. the patient had full tongue motion. her strength and normal bulk increased tone on right side, left side was stronger than right, but capable of moving all four extremities. patient was hyperreflexic in the right upper extremity, diffusely decreased lower extremity reflexes, toes are downgoing bilaterally. sensory examination showed that the patient was capable of localizing painful stimuli. she had no tremors. cerebellar signs were difficult to elicit. patient's course on the medical floor: on , the patient was noted to be more responsive. repeat mri showed some regression of the t2 hyperintensity white matter changes, especially in the centrum semiovale and a possible increase in cerebral blood flow. the patient continued to feel better. on , she was suctioned aggressively for several episodes of desaturation. on , the patient had no significant shortness of breath. a rash was noted for the first time. it is felt to be consistent with dilantin infatabs rash. the infatabs were changed back to the regular formulation and the rash slowly, but incompletely resolved. on , the patient was noted to have several desaturations which responded to aggressive suctioning. on , the patient was once again suctioned with improvement in her respiratory status. on , the patient was examined during morning pre rounds and found to have an arterial blood gas of ph 7.25, pco2 of 95, po2 of 56. she was intubated and taken back to the medical intensive care unit. the patient self extubated on and returned to the regular medical floor on . the patient was started on cpap while on the regular medical floor. she tolerated this treatment the first night. the patient on the morning of was noted to have decreased oxygen saturations. she was found to have an 02 saturation of 57%. an arterial blood gas was done at that time ph 7.38, po2 was 32, pco2 was 69. her bipap was adjusted and she was administered a nebulizer. follow-up arterial blood gas was ph 7.39, pco2 72, po was 79. patient was maintaining at her previous baseline. she was left in no apparent distress at that time on oxygen by shovel mask. the patient developed decreased oxygen saturations at 5:30 a.m. on . she was reintubated and taken back to the intensive care unit. after a long and protracted course in the intensive care unit, the decision was made by the patient's family to make the patient "do not resuscitate, do not intubate." she was extubated as she was tolerating spontaneous breathing trials. the patient's respiratory status did not improve. the decision was made to make her comfort measures only. the patient was called out to the regular medical floor on . on the morning of , she was found on pre rounds. her pupils were unreactive. she had no heart sounds, no breath sounds, no spontaneous movements, no response to pain, no radial or femoral pulses. the patient was pronounced dead on at 8 a.m. discharge condition: dead. discharge diagnoses: identical to her admission diagnoses with the addition of: 1. encephalitis. 2. cerebral edema. 3. seizure disorder. patient did not have any seizures during this hospitalization. dr., 12-761 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Arterial catheterization Diagnoses: Acidosis Urinary tract infection, site not specified Congestive heart failure, unspecified Obstructive chronic bronchitis with (acute) exacerbation Other convulsions Acute respiratory failure Other alteration of consciousness Unspecified infectious and parasitic diseases

history of present illness: this is a 71-year-old gentleman who experienced a presyncopal episode and was admitted to the hospital emergency department. there, the patient had an exercise tolerance test which was positive and was then transferred to for cardiac catheterization. cardiac catheterization revealed an ejection fraction of 33%, left ventricular end-diastolic pressure of 25, and severe 3-vessel coronary artery disease; including left main with mild disease, the left anterior descending artery with 70% to 80% proximal to mid stenosis, the left circumflex with 95% proximal, 70% at the second obtuse marginal, and the right coronary artery which was nondominant with a 99% stenosis. the patient was then referred for coronary artery bypass grafting. past medical history: (the patient's past medical history includes) 1. non-insulin-dependent diabetes mellitus. 2. hypertension. 3. hypercholesterolemia. 4. former heavy smoker. 5. he drinks alcohol; he has had more to drink recently. 6. history of alzheimer's disease/dementia. 7. status post appendectomy. 8. status post motor vehicle accident as a child. allergies: the patient has no known drug allergies. medications on admission: (his medications on admission included) 1. glyburide 5 mg by mouth twice per day. 2. aricept 10 mg by mouth at hour of sleep. 3. lipitor 10 mg by mouth once per day. 4. zestril. 5. effexor 75 mg by mouth once per day. 6. lopressor 25 mg by mouth twice per day. 7. aspirin by mouth every day. 8. plavix 75 mg by mouth once per day. social history: the patient is married and lives with his wife. and alcohol as above. review of systems: the patient's review of systems was noncontributory. physical examination on presentation: physical examination on admission revealed the patient was an alert and oriented pleasant gentleman. he was in no apparent distress. his neurologic examination revealed the patient to be grossly intact. he did have a right carotid bruit, but no left carotid bruit was noted. the patient's lungs were clear to auscultation bilaterally. his heart was regular in rate and rhythm. no murmur was noted. his abdomen was benign. the abdomen was nontender and nondistended. extremity examination revealed his extremities were warm and well perfused with no varicosities. pertinent laboratory values on presentation: his laboratory values revealed his white blood cell count was 7.8, his hematocrit was 37.8%, and his platelet count was 167,000. his inr was 1.2. his sodium was 138, potassium was 3.9, chloride was 105, bicarbonate was 25, blood urea nitrogen was 15, creatinine was 0.8, and blood glucose was 128. his liver function tests were within normal limits. pertinent radiology/imaging: his electrocardiogram showed a normal sinus rhythm with no acute ischemia. his echocardiogram showed mild mitral regurgitation, trace tricuspid regurgitation, no aortic regurgitation, and global hypokinesis. concise summary of hospital course: the patient underwent a carotid ultrasound which showed moderate plaque in the right and left internal carotid artery with narrowing of the right internal carotid artery to 60% to 69% and the left 40% to 59%. his vertebrals were noted to be normal. the patient had no events while awaiting surgery. on the patient underwent coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending artery, a saphenous vein graft to the second obtuse marginal, and a saphenous vein graft to the third obtuse marginal. the surgery was performed by dr. with dr. and dr. assistants. the surgery was performed under general endotracheal anesthesia. there was a cardiopulmonary bypass time of 82 minutes and a cross-clamp time of 72 minutes. the patient tolerated the procedure well and was transferred to the coronary care unit in a normal sinus rhythm. the patient was on epinephrine, nitroglycerin, insulin, and propofol drips. the patient had two atrial and two ventricular pacing wires and two mediastinal and one left pleural chest tube. initially, on the first operative night, the patient was noted to have a low cardiac index and a low ejection fraction on epinephrine. this was eventually weaned off, and he did have some ventricular ectopy. he was also given 500 cc of crystalloid for a low cardiac index. therefore, the patient was not extubated on his first operative night. the patient was eventually a-paced to help with his cardiac index. in the morning on postoperative day one, the patient was extubated without difficulty. over postoperative day one, the patient was weaned off all of his drips. by late in the day, he was transferred to the surgical floor. on postoperative day two, he had his chest tubes discontinued without incident. he was started on lopressor twice per day and encouraged to ambulate. on postoperative day three, his cardiac pacing wires were discontinued without incident. during that day, he had his foley catheter discontinued, but he did fail to void. therefore, his foley catheter was replaced that night. his foley catheter was removed the following day, and he was able to void without difficulty. on postoperative day four, the patient was complaining of having multiple loose stools. flagyl was started empirically, and clostridium difficile cultures were sent. subsequently, the clostridium difficile cultures sent were all negative. the flagyl was discontinued. his loose stools did resolve on their own. throughout the remainder of his hospital course, he continued to work with physical therapy to increase his strength and ambulation. by postoperative day eight, it was felt that he would be ready for discharge to home with a visiting nurse and physical therapy services on postoperative day nine. physical examination on discharge: the patient's physical examination revealed the patient to be alert and oriented times three. in no apparent distress. the lungs were clear to auscultation bilaterally. his heart was regular in rate and rhythm. no murmurs, rubs, or gallops. his wounds were clean, dry, and intact. his sternum was stable. his abdomen was soft, nontender, and nondistended. his extremities revealed no signs of edema. pertinent laboratory values on discharge: his discharge laboratories will be dictated in an addendum. his discharge chest x-ray showed small bilateral effusions, but no sign of infiltrate or pneumothorax. condition at discharge: the patient's condition on discharge was good. primary discharge diagnosis: status post coronary artery bypass grafting times three on . secondary discharge diagnoses: 1. diabetes mellitus. 2. alzheimer's disease/dementia. 3. hypertension. 4. hypercholesterolemia. medications on discharge: (discharge medications included) 1. enteric-coated aspirin 325 mg by mouth every day. 2. glyburide 5 mg by mouth twice per day. 3. effexor-xr 75 mg by mouth once per day. 4. lipitor 10 mg by mouth once per day. 5. aricept 10 mg by mouth at hour of sleep. 6. lopressor 50 mg by mouth twice per day. 7. percocet one to two tablets by mouth q.4h. as needed. 8. lasix 20 mg by mouth twice per day (times seven days). 9. potassium chloride 20 meq by mouth twice per day (times seven days). 10. multivitamin one tablet by mouth once per day. 11. iron sulfate 325 mg by mouth once per day. discharge instructions/followup: 1. the patient was instructed to follow up with his primary care physician (dr. in one to two weeks. 2. the patient was instructed to follow up with his cardiologist (dr. in two to three weeks. 3. the patient was instructed to follow up with dr. in four weeks. 4. the patient was instructed to continue an 1800-calorie american diabetes association diabetic diet with low sodium and low cholesterol. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Diarrhea Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Syncope and collapse

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: increasing angina at rest and with exertion major surgical or invasive procedure: s/p cabgx4(lima->lad, svg->om, diag, pda) history of present illness: 56 yo f referred for cardiac catheterization which showed three vessel disease. past medical history: cad htn hyperlipidemia gerd dm c/b neuropathy interstitial nephritis glaucoma hiatal hernia endometriosis thyroid cyst right cataract surgery bladder biopsy c/b hemorrhage csection x 2 carpal tunnel surgery x 3 right hand trigger finger s/p release right salpingo-oopherectomy breat bx x 2 social history: - tob - etoh works as secretary family history: brother deceased from mi at age 49 sister with mi at 41 father deceased from mi at age 70 physical exam: nad skin unremarkable heent r eye 3 mm & reactive, l eye 2 mm and nonreactive. neck no lad, lungs ctab heart rrr, no m/r/g abdomen benign extrem warm, no edema 1+ le pulses, 2+ radial pulses bilat no carotid bruits pertinent results: 06:50am blood wbc-7.7 hct-25.6* plt ct-513* 04:25am blood wbc-9.6 rbc-2.98* hgb-9.1* hct-25.8* mcv-87 mch-30.4 mchc-35.1* rdw-13.1 plt ct-364 06:50am blood plt ct-513* 06:15am blood glucose-196* urean-9 creat-0.7 na-135 k-4.7 cl-100 hco3-26 angap-14 09:40am blood alt-17 ast-17 alkphos-73 amylase-31 totbili-0.3 06:15am blood glucose-196* urean-9 creat-0.7 na-135 k-4.7 cl-100 hco3-26 angap-14 brief hospital course: cardiac catheterization on showed no mr, lvef 68%, three vessel disease. on he underwent a cabg x 4, he was transferred to the sicu in critical but stable condition. she awoke neurologically intact and was extubated that same day. she had a brief episode of post op afib which converted with amiodarone. she was transferred to the floor on pod #1. she continued to do well postoperatively. she was seen in consultation by who changed her insulin regimen. she remained in the hospital for further blood sugar management. medications on admission: lisinopril, nexium, ditropan, nph, lactaid, hctz, cartia, nitro, asa, chromium, tums, restasis, systane discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. 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* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po daily (daily) for 7 days. disp:*7 capsule, sustained release(s)* refills:*0* 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 9. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. disp:*60 capsule, delayed release(e.c.)(s)* refills:*0* 10. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 7 days. disp:*24 capsule(s)* refills:*0* 11. oxybutynin chloride 5 mg tablet sig: 0.5 tablet po qid (4 times a day). disp:*60 tablet(s)* refills:*0* 12. insulin glargine 100 unit/ml solution sig: thirty (30) units subcutaneous q am. disp:*qs 1 month* refills:*0* 13. humalog 100 unit/ml solution sig: one (1) unit subcutaneous every six (6) hours: please see printer sliding scale. disp:*qs 1 month* refills:*0* discharge disposition: home with service facility: vna assoc. of discharge diagnosis: cad htn lipids dm neuropathy interstitial nephritis right cataract glaucoma c-section x 2 carpal tunnel surgery x 3 right trigger finger surgery endometriosis r oopherectomy/salpingectomy hital hernia gerd discharge condition: good. discharge instructions: follow medications on discharge instructions. do not drive for 4 weeks. do not lift more than 10 lbs. for 2 months. shower daily, let water flow over wounds, pat dry with a towel. do not use powders, lotions, or creams on wounds. call our office for temp>101.5, sternal drainage. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 2-3 weeks. make an appointment with dr. for 4 weeks. see dr. from the clinic on at 11 am. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Polyneuropathy in diabetes Other and unspecified hyperlipidemia Unspecified procedure as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney Unspecified cataract

allergies: aspirin / biaxin / codeine / bactrim attending: chief complaint: initially admitted for 7 days shortness of breath, transferred to ccu for hypotension major surgical or invasive procedure: bi ventricular pacemaker placement history of present illness: this is a 80 yo f cad s/p cabg, known chf with ef of 20% presenting with 7 days shortness of breath and weight gain. patient has had gradual worsening of these symptoms over the week pta. at baseline she is able to walk the 3 blocks to her church. on day of admission she was unable to walk 5 feet without being short of breath. she weighs herself daily. her baseline weight is 133lbs and she was at 141 on the day of admission. she has noticed some symmetric mild swelling of her legs similar to other episodes of decompensated chf. she reports orthopnea. she reports a non-productive cough and sore throat for the last 2 days. she also complained of a few episodes of her typical anginal pain (left back/shoulder pain) that resolved with sublingual nitro and tylenol. . of note she had a somewhat recent medication () change from bumex (thought to have caused a rash which resolved with steroid treatment) and was changed onto her old regimen of lasix (160 qam, 80qpm-although at her last cardiology appt here she was stable at 160qam, 160qpm). . she went to see her pcp , who found her to be hypoxic to 88% and then sent her to the ed. in the ed cxr showed chf, bnp was elevated from 4000 to , pe/dissection were ruled out. in addition, she was given 80mg iv lasix, and only put out 350cc (uo) over 8 hours at the ed. she was admitted to the service overnight for further management. past medical history: coronary artery disease: s/p anterioseptal mi in cabg /- lima - lad and svg - rca -status post coronary artery bypass graft and aneurysmectomy s/p pcta in with stent placed proximal circumflex artery hypertension hypothyroidism diabetes type ii x 40 years chronic sinusitis cataract in l eye, scheduled for surgery . social history: tobacco: denies alcohol: denies living situation: primarily italian-speaking woman who lives by herself on the of a building (no elevator). her son and his family live below and one of her grandkids sleeps in her apt everynight. she also has a med alert call bracelet. patient has 2 sons and one daughter; all who live in relatively close vicinity of her. family history: family history: brother and dad with coronary artery disease. father had diabetes and cancer (skin?). physical exam: vitals: t: 97.1 p: 67 bp: 80/50 r: 24 sao2: 99% on 2l general: awake, alert, nad. heent: nc/at, perrl, eomi without nystagmus, no scleral icterus noted, mmm, op erythematous without exudate neck: supple, no lad, no carotid bruits appreciated, + jvd to earlobe sitting at 30 degree pulmonary: left basilar crackles cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: minimal bilateral edema, 2+ radial, dp and pt pulses b/l. skin: no rashes or lesions noted. neurologic: alert, oriented x 3. speaks italian primarily. grossly non-focal. . pertinent results: admission labs: wbc-19.5 hgb-10.6 hct-31.6 plt 356 digoxin-1.2 tsh-0.89 albumin-3.6 calcium-7.8 phosphate-3.7 magnesium-2.1 ctropnt-0.05* ast-273 ld-414 ck-33 alk phos-97 tot bili-0.3 glucose-96 urea n-52 creat-1.0 sodium-135 potassium-3.5 chloride- 103 total co2-18 anion gap-18 urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg pt-19.4 ptt-28.9 inr(pt)-1.8 cortsol-29.3 wbc-23.3 hgb-11.8 hct-35.2 plt ct-410 wbc-18.4 hgb-10.5 hct-30.8 plt ct-301 glucose-45* urean-64* creat-1.5* na-135 k-4.2 cl-101 hco3-23 angap-15 alt-353 ast-122 ld(ldh)-292 alkphos-93 totbili-0.2 bnp- glucose-111 urean-49 creat-1.1 na-137 k-4.4 cl-103 hco3-23 wbc-16.3 hgb-10.8 hct-33.1 plt ct-307 hbsab-negative hbcab-negative igm hbc-negative igm hav-negative . discharge labs: : wbc 11.8, hct 36.5, na 138, k 4.1, cl 93, hco2 33, bun 27, cr 0.9, mg 2.2 . micro: urine culture (final ): no growth. urine culture (final ): no growth . cxr () impression: mild pulmonary edema. cxr () impression: interval resolution of the probable interstitial edema seen on prior exam. no pneumonia. . cta () impression: 1. no pulmonary embolism or aortic dissection. 2. moderate congestive heart failure. redemonstration of marked cardiomegaly, mitral and coronary artery calcifications. . ekg () sinus rhythm. intraventricular conduction disturbance. multiform ventricular premature beats. compared to the previous tracing of st segments are currently elevated in leads vi and v3-v5. possible nanterior injury. . tte : 1. the left atrium is markedly dilated. the right atrium is markedly dilated. 2. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis with some preservation of basal lateral and basal inferior wall motion. overall left ventricular systolic function is severely depressed. 3. the right ventricular cavity is moderately dilated. there is severe global right ventricular free wall hypokinesis. 4. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. 5. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification. moderate (2+) mitral regurgitation is seen. 6. there is severe pulmonary artery systolic hypertension. . ekg () sinus rhythm. intraventricular conduction delay. left axis deviation. probable atypical left bundle-branch block. possible anterior myocardial infarction, age indeterminate. clinical correlation is suggested. since the previous tracing of no significant change. . echo : conclusions: the left atrium is moderately dilated. the right atrium is markedly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. overall left ventricular systolic function is severely depressed. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. tissue synchronization imaging demonstrates significant left ventricular dyssynchrony with the septal wall contracting 280 ms later than the lateral wall. these findings are c/w significant lv dysnchrony for which the patient may benefit from crt therapy. the right ventricular cavity is dilated. there is severe global right ventricular free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the findings of the prior study (images reviewed) of , the mitral regurgitation is increased, and the left ventricular ejection fraction is somewhat higher. . cxr : impression: 1. biventricular pacing leads in standard position on this portable projection, but dedicated pa and lateral view would be helpful to confirm appropriate location. no pneumothorax. 2. chf with interstitial pulmonary edema. . brief hospital course: 80f with h/o dm, cad s/p cath, who presents with sob and weight gain x7days. admitted to ccu for hypotension not relieved with fluids. . 1) hypotension: on second hospital day, she got all her daily bp medications in the am with additional lasix. she was found to be hypotensive with bp running 70-80/40-50s on and triggered on the service. she had normal mentation, denied feeling sob or dizzy. she was given 250cc ns bolus x 3, and her sbp went up to 85 (baseline sbp 90-100). decision was made to transfer her to ccu service for further management of her hypotension overnight. in the ccu, patient was given an additional 500cc bolus of ns with only minimal improvement in blood pressure. all blood pressure meds were held. patient continued to be without sob, dizziness, and mentating well. echo was ordered for that showed moderate dilation of the right ventricular cavity with severe global right ventricular free wall hypokinesis (a change from prior). tte continued to show severely depressed systolic function with ef<20% but no other significant change. given this new, biventricular failure, her was restarted at a loser dose. bb and other heart failure medications were also restarted. she was re-admitted to the ccu for hypotension and decreased urine output. she was given a medication holiday and responded. her bp increased and she began to diurese on her own, and become respnsive to lasix. hypotension was likely a result of biventricular failure and anit-hypertensive medications, as well as intravascular volume depletion. . 2) sob/chf: her shortness of breath likely due to chf exacerbation. pt was afebrile and no focal consolidation on imaging or exam to suggest pna. she had a non-productive cough. pt had poor output to 80mg of iv lasix on , but repeat dosing on had good effect of 350/3 hours. echo was performed, and digoxin was held initially. after being transferred out of the ccu, she initially responded well to diuresis. however, her urine output progressively decreased despite being put on a lasix drip. she was again transferred to the ccu. while there, her lasix drip was stopped, as well as her chf medications (metoprolol/valsartan). a repeat echo showed an ef of 20%. her bp improved off of her medications, she was given compression stalkings and she proceeded to mobilize her own fluids. after that, she responded very well to lasix boluses (80mg iv) tid. near the time of discharge, the patient was switched to lasix 160mg po bid, responding well. her d/c wt was 59kg, with an estimated dry weight of 58kg. she was length of stay negative 19-20l. . also, ep was consulted given her degree of chf. she also experienced asymptomatic nsvt during her stay. ep thought she would benefit from pcm +\- icd. a biv pacemaker was placed by ep on successfully without complications. her bp responded favorably and post placement check was normal. . 3)leukocytosis: upon admission, patient found to have elevated wbc count to 23. she was empirically started on antibiotics. her cortisol found to be wnl. patient continued to be afebrile with negative chest xrays. on , antibiotics were discontinued, and she remained hemodynamically stable and afebrile. her wbc remained elevated, but decreased from admission between 15-18 to normal. she remained afebrile. . 4) elevated bun/cr: on the 3rd hospital day, patient was noted to have elevated bun/cr. it was noted that she had been on high doses of ibuprofen for an undisclosed reason. the ibuprofen was discontinued. moreover, the patient was on lasix and failing to diurese. she was admitted to the ccu and her bun/cr improved by holding her anti-hypertensives. she was transferred to the floor, and once again experienced elevation in her bun/cr while on a lasix drip. she was admitted to the ccu a second time. while there, they stopped her bp meds. her bp improved, as did her bun/cr. she then responded to lasix after fluid mobilization with stockings and ambulation. her transient renal insufficiency was thought secondary to intravascular depletion/pre-renal, as it improved with increased bp and increased renal perfusion. . 5) cad: chest pain resolved with sl nitro and tylenol. mi was ruled out and patient to be under medical management. ***importantly, her pcp may wish to consider re-starting her statin, which was discontinued with her elevated liver enzymes.*** . 6) transaminitis: her elevated lfts were thought due to drug effect (statin), vs hypoperfusion secondary to hypotension. her lfts improved and she remained asymptomatic. . anticoagulation: the patient was started on warfarin due to her echo findings of decreased ef and hypokinesis. her inr was stable, but her warfarin was stopped upon her second admission to the ccu for biv pacemaker. she was started instead on aspirin and plavix. she tolerated this well. she tolerated aspirin 81mg without incident, despite previous history of dyspepsia on higher aspirin doses. . anemia: remained stable in mid 30s. was consistent with anemia of chronic disease. . diabetes: her blood sugars were difficult to control. she was on dosing of lantus (30units/60units), but had episodes of hypoglycemia. on her second admission to the ccu, her lantus was changed to 25units qam plus a humalog sliding scale. this regimen was later changed to lantus 35units qpm, 10 units qam plus the sliding scale. her sugars fluctuated in the 200s. further titration of her insulin will be needed as an outpatient . hypothyroidism: stable during admission on home regimen. . code: she was initially dni, but later changed her status to full code once the procedures were explained to her. . outstanding issues: 1. she will need close follow up and monitoring of her chf, particularly with regards to her blood pressure medications (? add spironolactone, statin, titrate beta blocker/acei), diet, and weights. . 2. her biv pacemaker will need to be followed by ep. . 3. her blood sugars were running high throughout admission. she will need further adjustment of her diabetes regimen. . 4. vna will be following her as an outpatient. . 5. pcp should address sleep habits. medications on admission: levoxyl 125mcg qd digoxin 125 mcg enteric coated asa 81mg furosemide 160mg qam, 160qpm imdur 30 mg qd metoprolol 50 mg spironolactone 25mg qd atorvastatin 20 qhs lantus 60u qam 60uqpm humalog albuterol prn ativan 1mg qhs prn ultram 50mg po bid prn tylenol occassionally lactulose 2 tbsp qhs colace 100mg vitb-12 1000mcg qd discharge medications: 1. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 3. tramadol 50 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 4. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 5. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. disp:*30 tablet(s)* refills:*0* 6. valsartan 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. furosemide 80 mg tablet sig: two (2) tablet po bid (2 times a day): please take at 8am and 4pm. disp:*120 tablet(s)* refills:*2* 9. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 10. lantus 100 unit/ml solution sig: thirty five (35) units subcutaneous at dinner. disp:*1 vial* refills:*2* 11. lantus 100 unit/ml solution sig: ten (10) units subcutaneous in the morning. disp:*1 vial* refills:*2* 12. humalog 100 unit/ml solution sig: per scale units subcutaneous qachs. disp:*1 vial* refills:*2* 13. albuterol 90 mcg/actuation aerosol sig: one (1) puff inhalation every six (6) hours as needed for cough: take as needed. disp:*1 1* refills:*0* 14. nitroglycerin 0.4 mg tablet, sublingual sig: tablet, sublinguals sublingual prn (as needed) as needed for chest pain: take 1 sublingual nitro for chest pain, if persists can repeat every 5 minutes x2 additional tablets. call 911 if no relief. disp:*30 tablet, sublingual(s)* refills:*0* 15. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po qpm (once a day (in the evening)). disp:*60 capsule, sustained release(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary: 1. heart failure secondary: 1. coronary artery disease 2. diabetes mellitus 3. hypothyroidism discharge condition: good condition, vital signs stable, discharged to home with services and follow-up arranged. discharge instructions: you have been evaluated and treated for shortness of breath. you were found to have an exacerbation of your congestive heart failure (chf). your medications were changed; see the list included in your discharge paperwork. please take all medications as directed and keep all follow-up appointments. . please weigh yourself every morning, and call your pcp if your weight increases more than 3 lbs. please limit your sodium intake to 2 grams per day. do not take in more than 2 liters of fluid per day. . if you develop further shortness of breath, chest pain, nausea/vomiting, lightheadedness/dizziness, or any other symptom that is concerning to you, please call your pcp or go to the nearest hospital emergency department. followup instructions: 1. an appointment has been made for you to follow-up with your pcp, . (), on at 8:40am. . 2. an appointment has been made for you to follow up with dr. from cardiology on at 1 pm () . 3. an appointment has been made for you to follow up with the pacemaker device clinic on thurs, at 12:30pm () , and with dr. on thurs, at 1:00pm () Procedure: Division of sympathetic nerve or ganglion Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P] Diagnoses: Hyperpotassemia Anemia of other chronic disease Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Aortocoronary bypass status Mitral valve insufficiency and aortic valve insufficiency Paroxysmal ventricular tachycardia Rheumatic heart failure (congestive) Other specified forms of chronic ischemic heart disease Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Diseases of tricuspid valve Volume depletion, unspecified

allergies: penicillins attending: chief complaint: obtundation major surgical or invasive procedure: hemodialysis nasogastric intubation history of present illness: 70yo woman with h/o of esrd on hd, htn, dementia, and bipolar disorder with paranoia presents with obtundation and uncontrolled hypertension in the setting of missing several sessions of dialysis. . patient was referred to the ed from dialysis, where she had presented with lethargy and htn after 10-12 days without dialysis. of note, she has a history of paranoia with refusal of medications and dialysis, per her nephrologist's report (dr. ). her pcp had begun discussions with pt's health care proxy and her son about moving toward comfort care but son felt that patient always agreed to care when he is with her, but refuses when he leaves. in the ed, initial vs: 98 0 100% nrb. bs 147. patient was unresponsive to voice/touch but withdrew from pain. labs significant for abg 7.54/30/159 and ptt 150 with a lactate of 1.7. blood cultures were sent and she was given 1 dose of levaquin 750mg iv. she also received labetalol 20mg iv x 1 and then was put on labetalol gtt with decrease in bp from peak of 240/120 to 198/112 over 2 hours. she was admitted to the for emergent hemodialysis and bp mgmt. past medical history: esrd on hd lithium (nephrologist, dr. ) htn diabetes insipidus lithium bipolar disorder vascular dementia (s/p neurobehavioral testing ) paranoia mgus: +monoclonal igg kappa detected seizure disorder: witnessed during admission to multiple admissions with refusal to undergo dialysis x weeks with subsequent mental status change following dialysis recent admission with fevers and hypertension, fevers resolved without antibiotics social history: lives at rehab. graduated college, used to work as tech at . widowed with two children. son lives in . is hcp and personal care assistant for last 4 years. family history: n/c physical exam: on admission - ed vitals as noted. upon transfer to medical floor: pt lethargic, not responding to command, eventually said ", that hurts" to repeated sternal rub. pupils small but reactive to light. ngt in place. lungs with coarse breath sounds anteriorly. rrr s1s2, ii/vi sem abd soft, nd, nt, nabs le no edema, feet warm, 1+ dp pulses babinski equivocal b/l, dtr 1+ patellar & brachial. access: r ij tunnelled hd catheter, lue piv pertinent results: 10:44pm potassium-6.9* 09:13pm glucose-112* urea n-54* creat-7.9* sodium-136 potassium-6.6* chloride-97 total co2-25 anion gap-21* 09:13pm calcium-10.1 phosphate-4.6*# magnesium-2.5 09:13pm wbc-8.2 rbc-4.10* hgb-13.6 hct-42.8 mcv-104* mch-33.2* mchc-31.8 rdw-16.4* 10:44pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:50pm phenytoin-<0.6* imaging: cxr : there is a dual-lumen dialysis catheter via right internal jugular approach whose tip terminates in the right atrium. the patient is angled and slightly rotated, which limits assessment. there is increased linear and patchy opacity in the retrocardiac left lower , represent atelectasis or developing pneumonia. there is no definite pulmonary vascular congestion. lung volumes are low. no definite pleural effusions are noted. . ct head : the extracalvarial soft tissues are unremarkable. the calvarium and skull base are intact without fracture or suspicious osseous lesion. a calcified plaque is noted in the cavernous and supraclinoid portions of the internal carotid arteries. the included paranasal sinuses and mastoid air cells are clear. the globes are intact with lenses in place. intracranially, the ventricles are prominent but midline. likewise, the cortical sulci and subarachnoid cisterns are prominent. these findings reflect an overall generalized brain parenchymal volume loss which is within normal limits accounting for the patient's stated age. there has been no significant progression since the prior examination. a small lacunar infarct is less conspicuous in the head of the right caudate nucleus, slightly more conspicuous around low attenuation lesion within the right basal ganglia, also likely due to lacunar infarction versus a prominent perivascular space. the - white matter interface is well defined. there is no intracranial hemorrhage or ct evidence of acute cortical stroke. brief hospital course: a/p: 70yo woman who lives at rehab with bipolar d/o, dementia, ckd stage v on hd, htn, seizure d/o, admitted to with obtundation after missing several sessions of hd. . # altered mental status in setting of baseline dementia: improved dramatically after several hemodialysis sessions. two cts of head where done to eval for evolving stroke and these were without stroke. she was found to have sub therapuetic levels of dilantin and so this was re-loaded and maintenance with keppra and dilantin re-started. please note speech and swallow eval of . she was treated initially with vancomycin for possible line infection in setting of mild leukocytosis but blood cx's remained negative and so this was discontinued. . # ckd stage v: renal following closely, getting daily hd. pth within normal and so cinacalcet discontinued. last hd was . . # low-grade fever on admission: no localizing signs/sx, hd tunnelled line without evidence of infection. received empiric levofloxacin in ed, also vancomycin dosed at hd by level. follow blood cultures and redose vanco by trough. if blood cultures grow, then hd catheter may have to be removed. if blood cx remain negative, then can discontinue vanco. . # hypertensive urgency: stabilized in on labetalol gtt and after several dialysis sessions, pt required only po lopressor and intermittent hydralazine. on discharge she should restart norvasc, lisinopril, and toprol. . # bipolar d/o: off all neuroleptics & sedatives while mentation cleared, and did have some early morning agitation. risperidone should be restarted. of note, ativan 0.25mg iv given with marked sedation. . #f/e/n: see speech and swallow eval. . # code: dnr/dni medications on admission: medications (per discharge summary): risperidone 1 mg po bid aspirin 325 mg daily acetaminophen 325-650 q6h prn amlodipine 10mg daily cinacalcet 30 mg daily folic acid 1 mg daily sevelamer 800 mg tid w/ meals simvastatin 40 mg daily levetiracetam 500 mg po bid phenytoin sodium extended 300mg daily senna 8.6 mg daily docusate sodium 100 mg cholecalciferol (vitamin d3) 1000 units daily metoprolol succinate 25 mg daily calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). lisinopril 10 mg daily lorazepam 0.5 mg po q4h prn anxiety discharge medications: 1. risperidone 1 mg tablet sig: one (1) tablet po twice a day. 2. aspirin 325 mg tablet sig: one (1) tablet po once a day. 3. tylenol 325 mg tablet sig: one (1) tablet po once a day. 4. norvasc 10 mg tablet sig: one (1) tablet po once a day. 5. folic acid 1 mg tablet sig: one (1) tablet po once a day. 6. simvastatin 40 mg tablet sig: one (1) tablet po once a day. 7. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 8. phenytoin 100 mg/4 ml suspension sig: three hundred (300) mg po q24h (every 24 hours). 9. senna 8.6 mg tablet sig: two (2) tablet po at bedtime. 10. colace 100 mg capsule sig: two (2) capsule po twice a day as needed for constipation. 11. cholecalciferol (vitamin d3) miscellaneous 12. calcium acetate 667 mg capsule sig: two (2) capsule po three times a day. 13. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 14. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: delerium discharge condition: stable discharge instructions: please contact dr. if patient refuses any medication or if patient in increasingly confused, febrile, or has other concerning symptoms. followup instructions: please follow up with dr. md Procedure: Hemodialysis Insertion of other (naso-)gastric tube Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Hyperpotassemia End stage renal disease Epilepsy, unspecified, without mention of intractable epilepsy Hypertensive encephalopathy Personal history of noncompliance with medical treatment, presenting hazards to health Other bipolar disorders Vascular dementia, uncomplicated Cerebral atherosclerosis Delusional disorder

allergies: penicillins attending: chief complaint: unresponsive major surgical or invasive procedure: none history of present illness: 68 year old female with pmh esrd on hd, bipolar disorder was admitted to the hospital on section 12 for hd, since she missed 2 weeks of dialysis, likely due to underlying psych issues. concern for paranoia and inability to care for herself at home. on admission, bp was in 230s. on arrival to , pt was confused and unable to provide good history. during dialysis, bp acutely fell to 100s systolic. after dialysis, pt was noted to be unresponsive. head ct showed new hypodense lesion in right midbrain c/w infarction or edema. bp returned to 170-220s systolic after hd. . pt was evaluated by neurology/stroke team who noted neuro abnormalities as follows. "patient groans to noxious stimuli and flexes left arm. vertical skew of eyes at rest with right eye depressed. there is impaired adduction of both eyes on doll's eye manuever. pt was withdrawing left side to pain but right side was hypotonic, with depressed reflexes and flexion response only to noxious." initial thinking was acute cerebral infarct vs. ischemia secondary to low flow state in setting of acute bp drop. cta showed no evidence of thrombus in the vertebrobasilar system. mri showed diffuse subacute infarct of the brainstem. . ros: per nightfloat admission note from . no f/c/n/v. no h/a. no visual changes. no abdominal pain/dysuria. no diarrhea or change in bowel habits. no ah/vh. no racing thoughts. could not quantify how much she was sleeping. no feelings of depression/guilt/ or feeling blue. no si/hi. past medical history: 1. ? bipolar disorder (psych history is unclear) 2. diabetes insipitus ( lithium use) 3. esrd on hd - secondary to lithium 4. htn social history: pt is a homemaker. she used to work at as a technician. no history of smoking or etoh. no drugs. graduated college. she is widowed and has two children. family history: no psychiatric disorders in the family. physical exam: vs: t98.4, p95, 170/87, rr10, 100% 2l gen: somnolent, somewhat arousable to sternal rub heent: perrl (3mm) cvs: rrr, nl s1 s2, holosystolic murmur @ apex lungs: poor inspiratory effor, grossly ctab abd: soft, nd, decr bs ext: no edema neuro: able to say full name. squeezes bilateral hands. unable to wiggle hands or feet. upgoing toes bilaterally. 3+ knee and ankle reflexes, hypertonia of lower extremities (l>r) pertinent results: ua: mod leuk, sm blood, neg nitrite, wbc, mod bacteria . urine and serum tox negative . ekg: sinus at 100. lad. normal intervals. no st changes. . radiology: cxr:mild cardiomegaly but no chf. . head ct: hypodense appearance of the mid brain and brain stem concerning for infarction or possibly edema. mri with diffusion-weighted images is recommended for further evaluation . cta head/neck: no evidence of thrombus in the vertebrobasilar system . mri brain: diffuse involvement of the brainstem by t2 hyperintensity and relatively abnormal diffusion. there is involvement of the middle cerebellar peduncles, the thalami, left greater than right and left internal capsule, all of which are consistent with extensive subacute infarction with edema and expansion of the brainstem itself. the presence of an underlying neoplastic process would be less likely given the acute nature of the events. followup mri with diffusion images, and correlation with mra of the posterior circulation would be helpful. the findings could be related to an acute hypoxic event, which could have happened during dialysis. followup imaging of the brain would be recommended as clinically indicated. 08:35pm wbc-8.1 rbc-3.79* hgb-11.6* hct-35.4* mcv-93 mch-30.5 mchc-32.6 rdw-17.6* 08:35pm neuts-79.8* lymphs-14.5* monos-2.2 eos-2.6 basos-0.8 08:35pm plt count-284# 08:35pm urine blood-sm nitrite-neg protein-100 glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 08:35pm urine rbc-0-2 wbc-* bacteria-mod yeast-none epi-0-2 08:35pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 08:35pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:35pm glucose-107* urea n-117* creat-10.9*# sodium-140 potassium-5.7* chloride-106 total co2-10* anion gap-30* 08:35pm calcium-8.7 phosphate-6.8* magnesium-3.1* cholesterol, total 200* mg/dl triglycerides 117 mg/dl 0 - 149 cholesterol, hdl 76 mg/dl cholesterol ratio (total/hdl) 2.6 ratio cholesterol, ldl, calculated 101 mg/dl echo: 1. no atrial septal defect is seen by 2d or color doppler. 2. there is moderate 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%). 3. the aortic valve leaflets are severely thickened/deformed. 4. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. brief hospital course: hospital course, discussed by problem: . 1) esrd on hd: patient was admitted to the nephrology service and received hemodialysis three times weekly. her initial two hemodialysis sessions were complicated by acute hypotension and unresponsiveness, as described below. thereafter, she was dialyzed with less aggressive ultrafiltration, which she tolerated. however, she also began to cut dialysis sessions short and occasionally even refuse dialysis altogether. her electrolytes were monitored closely. she had a persistently elevated anion gap. she had one episode of hyperkalemia to 6.7. ekg showed slightly peaked t waves. as she had only a hd catheter for access and refused piv placement, iv calcium, as well as insulin and d50 could not be given (she refused these things as well). she did take kayexelate, and she was taken for an extra hd session that day. potassium level remained stable thereafter. she maintained on nephrocaps daily, phosphate binders, and eventually bicitra as well. . 2) altered mental status: patient was admitted on a section 12 for having missed hd x 2 weeks. at her initial hemodialysis session on hd #2, her sbp acutely dropped from 230s to 100s, and she became unresponsive. a cta of the head and neck was without evidence of thrombus in the vertebrobasilar system. a subsequent mri was consistent with extensive infarction of the brainstem and right midbrain. she was therefore thought to have a poor prognosis and low likelihood of regaining normal consciousness. however, within a few hours, the patient regained consciousness, with intact cranial nerves, moving all 4 extremities and interacting appropriately. the neurology stroke service was consulted. a repeat mri with contrast demonstrated persistent lesions, which were thought to represent changes secondary to electrolyte disturbances and hypotension induced by dialysis. during her second dialysis session, she again became hypotensive and became unresponsive. as described above, it was decided to dialyze her more cautiously to avoid precipitating hypotension. in addition, her blood pressure was allowed to autoregulate with goal 170s-200s. the remainder of her hospital course was without further episodes of altered mental status. . 3) hypertension: on admission, she was hypertensive to 230. despite having fluid removed at dialysis, her blood pressure would continually increase to 200 systolic. she was started on amlodipine followed by lisinopril with some effect. her blood pressure trended down as she tolerated longer dialysis sessions with ultrafiltration. bp was well controlled at the time of discharge. . 4) anemia: patient was noted to be anemic, with a hct ~30, presumed secondary to esrd. she was noted to also have hematochezia during hospitalization. however, it was small volume blood coating stools, and thought unlikely to fully explain her anemia. she had previously insisted on colace warmed in hot water and multiple fleets enemas. it was thought that the small amount of blood was secondary to a superficial abrasion secondary to excessive use of these agents. iron studies in , and repeat studies during this hospitalization demonstrated normal serum iron levels. it was noted that she had never had a colonoscopy, and was therefore discharged with instructions to follow up with a gastroenterologist for an outpatient colonoscopy. . 5) bipolar disorder: pt carries a diagnosis of bipolar disorder under the care of a psychiatrist. she was followed by the psychiatry consultation service during hospitalization who was in contact with her outpatient psychiatrist (dr. ) and was started on zyprexa, which she would take intermittently. she also underwent extensive neuropsychiatric testing that demonstrated a executive impairment consistent with a frontal temporal dementia. she was started on aricept. a team meeting with her inpatient medical team, psychiatry consultation service, and outpatient dialysis social worker revealed a pattern of repeated noncompliance with dialysis despite involvement by multiple social services. it was therefore decided to pursue guardianship. . 6) leukocytosis: patient was noted to have a leukocytosis with wbc in the 20s, though likely to represent a stress reaction. she was without localizing signs and symptoms of infection and an infectious workup was entirely negative. she did received a brief empiric course of levofloxacin for a presumed uti. the leukocytosis subsequently resolved. . 7) coagulopathy: patient was noted to have a transient coagulopathy of unclear etiology. this resolved without intervention, and patient remained without evidence of bleeding diathesis. . 8) code status: full code. per patient's caretaker, the patient has a living will but we were unable to obtain a copy. . medications on admission: sennakot discharge medications: 1. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 caps* refills:*2* 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. sevelamer 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 6. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 7. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 8. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. calcium carbonate 500 mg tablet, chewable sig: two (2) tablet, chewable po daily (daily). disp:*60 tablet, chewable(s)* refills:*2* 10. lanthanum 250 mg tablet, chewable sig: two (2) tablet, chewable po tid w/meals (3 times a day with meals). disp:*60 tablet, chewable(s)* refills:*2* 11. olanzapine 7.5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: cqregroup discharge diagnosis: 1. bipolar disorder 2. diabetes insipitus ( lithium use) 3. esrd on hd - secondary to lithium (immature r avf and r subclavian hd catheter placed ) 4. htn discharge condition: good discharge instructions: if you experience fever, chills, chest pain, shortness of breath, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. . please continue taking all medications as prescribed. . please make all of your dialysis appointments. followup instructions: on monday, please return to , 7 for your dialysis appointment. you will commence outpatient dialysis in on wednesday, . you should make an appointment for a colonoscopy as an outpatient, since you have never had one. you should also call to make an appt. Procedure: Hemodialysis Transfusion of packed cells Diagnoses: End stage renal disease Anemia, unspecified Urinary tract infection, site not specified Other persistent mental disorders due to conditions classified elsewhere Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Personal history of noncompliance with medical treatment, presenting hazards to health Bipolar disorder, unspecified Other and unspecified coagulation defects Other specified disorders resulting from impaired renal function Nephrogenic diabetes insipidus Legal circumstances Other psychotropic agents causing adverse effects in therapeutic use Hypotension of hemodialysis

allergies: penicillins attending: chief complaint: altered mental status major surgical or invasive procedure: mri, mra, ct, hemodialysis history of present illness: 68 year old woman with hx esrd and hx noncompliance with hd at times, recently admitted between and following an initial episode of unresponsiveness at dialysis, who returns apparently after missing several sessions of hemodialysis. her vna had reported her to be "confused" at home. she was brought to the ed and was noted to be "leaning to the left" when she walked. the patient was seen after receiving some ativan, and is fairly inattentive, thus unable to provide a more detailed account. she is unaccompanied in the ed. she was seen by neurology on for unresponsiveness following emergent hemodialysis after missing hemodialysis for two weeks - her outpatient nephrologist dr. had signed a section 12 order to have her brought into the hospital for hemodialysis, and she had arrived on . she had been found on imaging to have an area of hypodensity on head ct in right midbrain thought to be c/w infarction or edema. mri revealed a more extensive area of hyperintensity bilaterally throughout the brainstem, cerebellar and middle cerebral peduncles, the differential of which included central pontine myelinolysis, infarction, encephalitis, demyelination. overnight she had woken up with a nearly normal neuro exam the following day. she subsequently had a lengthy hospital course that involved initial hypertension, then hypotension and unresponsiveness following further hemodialysis, refusal of dialysis sessions and subsequent imbalance of electrolytes, anemia, hematochezia thought to be related to abrasion with enemas though no colonoscopy during the admission, followed by psychiatry for her bipolar disorder and for advice on pursuing guardianship, uti treated with levaquin, coagulopathy of unknown origin. please see excellent discharge summary from the department of medicine for further details. she was eventually discharged home with vna. she had imaging that included a cta of the head and neck with no evidence of thrombus in the vertebrobasilar system; mri as detailed above (discharge summary reads: "consistent with extensive infarction of the brainstem and right midbrain" - however, her clinical appearance was not consistent with this diagnosis. see above differential.) past medical history: 1. ? bipolar disorder (psych history is unclear) 2. diabetes insipitus ( lithium use) 3. esrd on hd - secondary to lithium 4. htn social history: pt is a homemaker. she used to work at as a technician. no history of smoking or etoh. no drugs. graduated college. she is widowed and has two children. family history: no psychiatric disorders in the family. physical exam: examination: afeb, bp 230s/90s (pt moving arm), hr 84 rr 18 general appearance: well appearing, keeps eyes closed, slightly disheveled head/neck: mmm, neck supple, anicteric sclera heart: regular rate and rhythm lungs: clear to auscultation bilaterally abdomen: soft, nontender +bs extremities: warm, well-perfused mental status: the patient is awake but inattentive. she is oriented to , "end of ," " day," says "i never had much use for date" when asked about year. she knows that vna recommended she come to ed but will not provide information about why. denies difficulty walking. of note, recently received ativan per nsg, and is in restraints. cannot perform dow bkwds (repeats "sunday" several times). language fluent, names fingers but not knuckles, little interest in naming other items. repetition intact, cannot recall at 30 seconds. no agnosia. keeps eyes closed. cranial nerves: the visual fields are full to confrontation. the optic discs are normal in appearance. eye movements are slightly restricted with upgaze, but normal horizontally with no nystagmus. pupils react equally to light 3 to 2 mm, both directly and consensually. sensation on the face is intact to light touch, pin prick. facial movements are normal and symmetrical. hearing is intact to finger rub. the palate elevates in the midline. the tongue protrudes in the midline and is of normal appearance. motor system: appearance and tone is normal in all 4 limbs; there is motor impersistence and poor effort in the deltoids, bilateral finger extensors, triceps and biceps of the left arm, ileopsoas of the right leg, bilateral hamstrings, and foot plantar and dorsiflexors. strength appears normal in the biceps and triceps of the right arm, bilateral wrist extensors, finger flexors, bilateral quads, ileopsoas on the left. she is in restraints bilaterally and exam is further limited. there is a postural tremor in the left hand; there is no myoclonus, nor fasciculations. reflexes: dtrs are very brisk throughout, with 3-4 beats of clonus in each ankle, and crossed adductors at the knees. the plantar reflexes are extensor bilaterally, is present on the right. sensory: sensation is intact to pin prick, light touch, vibration sense, and position sense in all extremities. coordination: there is some slow finger tapping bilaterally and difficulty following further directions for coordination testing. gait: gait could not be assessed, as pt must stay in restraints. physical exam on discharge patient is alert and awake. her speech is fluent and her comprehension is full. thought content is disorganized and tangential. there is no focal motor weakness. she is able to walk with some minor assistance most likely secondary to deconditioning. lungs are clear heart ii/vi sem abdomen: soft nt nd ext: no edema pertinent results: 07:30am blood wbc-6.4 rbc-3.51* hgb-10.8* hct-34.6* mcv-99* mch-30.8 mchc-31.3 rdw-16.9* plt ct-226 05:00am blood wbc-7.5 rbc-3.77* hgb-11.9* hct-37.0 mcv-98 mch-31.5 mchc-32.0 rdw-17.8* plt ct-204 11:25am blood wbc-7.2 rbc-3.99* hgb-12.6 hct-39.0 mcv-98 mch-31.5 mchc-32.2 rdw-17.2* plt ct-260 09:30am blood wbc-8.8 rbc-4.10* hgb-12.7 hct-40.6 mcv-99* mch-31.0 mchc-31.3 rdw-17.5* plt ct-258 03:00am blood wbc-12.2* rbc-4.55 hgb-14.4 hct-45.0 mcv-99* mch-31.6 mchc-32.0 rdw-18.4* plt ct-291 07:20pm blood wbc-9.6 rbc-4.41 hgb-13.8 hct-43.2 mcv-98 mch-31.2 mchc-31.9 rdw-18.4* plt ct-294 07:30am blood plt ct-226 05:00am blood plt ct-204 06:29am blood esr-7 07:30am blood glucose-98 urean-53* creat-7.1*# na-141 k-4.1 cl-103 hco3-22 angap-20 05:00am blood glucose-101 urean-31* creat-5.3*# na-141 k-3.9 cl-103 hco3-27 angap-15 11:25am blood glucose-137* urean-37* creat-6.4* na-142 k-4.6 cl-102 hco3-25 angap-20 05:25am blood glucose-82 urean-40* creat-7.0*# na-140 k-5.2* cl-101 hco3-22 angap-22* 07:59am blood glucose-122* urean-27* creat-5.3*# na-141 k-5.2* cl-101 hco3-26 angap-19 05:25am blood amylase-72 02:29pm blood ck(cpk)-174* 06:29am blood alt-22 ast-23 alkphos-141* amylase-45 totbili-0.4 05:30am blood ck(cpk)-94 08:30pm blood ck(cpk)-40 05:25am blood lipase-11 06:29am blood lipase-15 02:29pm blood ck-mb-10 mb indx-5.7 ctropnt-0.06* 05:30am blood ck-mb-notdone ctropnt-0.04* 08:30pm blood ctropnt-0.04* 07:30am blood albumin-3.4 calcium-9.6 mg-2.2 iron-pnd 05:00am blood calcium-9.8 phos-4.1# mg-2.0 11:25am blood calcium-9.9 phos-6.3* mg-2.1 05:25am blood calcium-10.2 phos-6.5* mg-2.2 11:00am blood pth-68* 06:29am blood crp-1.1 11:00am blood phenyto-10.7 phenyfr-1.8 %phenyf-17* 08:30pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:07am blood lactate-1.2 eeg findings: abnormality #1: throughout the recording the background rhythm was slow and disorganized, typically remaining at 5 hz or slower much of the time. the background was of much higher voltage and more chaotic early in the recording. there were a few sharp features in the right hemisphere but no spike and slow wave discharges. abnormality #2: there were additional bursts of generalized slowing and some suppressive bursts with a relative attenuation of the background in all areas for one second or so. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: the patient appeared to have some pattern suggestive of sleep toward the end of the recording though no normal waking or sleeping morphologies were present overall. cardiac monitor: showed a generally regular rhythm. impression: abnormal portable eeg due to the slow and disorganized background and bursts of generalized slowing or suppression. these findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. the recording could also represent a post-ictal state, especially as the beginning was more chaotic and slower in background than the end. there were a few sharp features on the right side but no overtly epileptiform abnormalities. there were no electrographic seizures during the recording. mr head w & w/o contrast 5:31 pm mri: there are no new abnormal areas of restricted diffusion to suggest acute infarction. there is no evidence of acute hemorrhage. again seen are multiple areas of abnormal increased t2 signal. again seen are areas of increased signal in the periventricular white matter of both cerebral hemispheres, consistent with chronic microvascular infarction. there is also evidence of increased t2 signal in the area of the posterior limb/internal capsule bilaterally, suggesting old microvascular infarction versus extrapontine myelinolysis. again seen is uniform and confluent increased t2- signal throughout the pons and middle cerebellar peduncles, slightly more clearly defined on today's study compared to prior, likely representing central pontine myelinolysis. compared to prior study, there are new areas of increased t2-signal in the parietal/occipital regions bilaterally without associated restricted diffusion, suggesting posterior reversible leukoencephalopathy (hte), perhaps related to missed dialysis and hypertension. also seen on today's study are tiny foci of susceptibility within the pons, likely representing small petechial hemorrhage. no new areas of pathologic enhancement are seen within the brain. there is no shift of normally midline structures or evidence of mass lesion. mra: there appears to be hypoplastic a1 segment of the left aca, with a prominent acom. otherwise, the major vessels of the circle of appear patent without evidence of significant stenosis or aneurysmal dilatation identified. impression: no evidence of acute infarct or hemorrhage. multiple areas of increased abnormal t2 signal, likely representing a combination of chronic microvascular infarction as well as established central pontine and possible extrapontine myelinolysis. new and relatively symmetric increased signal in the parietal/occipital regions, bilaterally, without associated restricted diffusion, in this context, suggestive of hypertensive encephalopathy. also seen is evidence of small petechial hemorrhage within the pons, likely hypertensive and of indeterminate age. mr hypoplastic left a1 vessel with prominent acom, but otherwise patent vessels of the circle of . ct head w/o contrast 7:19 pm findings: there is no evidence of acute intracranial hemorrhage. no mass effect. no shift of normally midline structures. again note is made of hypodensity in the pons and brainstem, as noted on the prior exam, corresponding to the finding on prior mri. note is made of somewhat prominent ventricles, as well as slight increase of the size of 3rd ventricle measuring up to 13 mm in width. the osseous and soft tissue structures are unremarkable. impression: no acute intracranial hemorrhage. hypodensity in pons and brainstem, probably corresponding to the finding on mri. somewhat prominent 3rd ventricle. mri is recommended for further evaluation. the information was flagged to ed dashboard. picc line placement radiology preliminary report picc w/o port 7:30 am the procedure was performed entirely by dr. , attending radiologist. following standard preparation and local anesthesia, under ultrasound guidance, a 21-gauge needle was used to puncture the brachial vein in the mid right upper forearm. hard copy ultrasound images were obtained before and after venous access documenting vessel patency. a guidewire was advanced centrally. a 31 cm 4- french picc line was then placed with the tip in the distal svc under flouroscopic guidance, above svc/right atrial junction. no complications encountered. the line appear to aspirate and inject easily. impression: ultrasound-guided puncture of the right brachial vein in the upper brief hospital course: ms. was admitted to the medical icu for control of malignant hypertension and altered mental status. she was noted to have a single seizure episode lasting 2-3 minutes with right face and arm shaking with residual paralysis that then resolved. she was loaded with dilantin and maintained on a daily maintenance dose. brain mri showed new t2 hyperintensity in the bilateral parietal occipital areas consitent with reversible hypertensive leukoencephalopathy. her mental status gradually improved and she was trasnferred to the neurology service for continued care. her mental status continued to improved until she was near her baseline, according to her caretaker/guardian. 1. hypertension - secondary to renal failure and non-compliance with hemodialysis. also the likely cause of her seizure. she continues to be fairly well-controlled on amlodipine and lisinopril. she has required, and responded well to, occasional doses of hydralazine prn 2. altered mental status - mostly if not totally resolved. also, likely secondary to profound electrolyte imbalances, uremia, and malignant hypertension 3. seizure - hte. currently on dilantin 300 daily. levels have been therapuetic range. if seizure-free for 6 months, dilantin should likely be weaned under the supervision of a neurologist. 4. esrd - requires hd and at least three times weekly. she should have her electrolytes checked regularly. she is currently on sevelamer (renagel), nepho-caps, cinacalcet. 5. bipolar - patient with continued odd thought content with frequent paranoid feature. continue zyprexa and lanthanum. guardianship has been court-appointed. 6. code status - full 7. abnormal pontine lesion - this is of unclear etiology. unlikely to be central pontine myelinolysis as there is no clear history of rapid correction of hyponatremia nor does the lesion have typical appearance for cpm. 8. patient self-removed her picc line. medications on admission: b complex-vitamin c-folic acid 1 mg atorvastatin 10 mg cinacalcet 30 mg aspirin 81 mg sevelamer 800 mg tabs, two po tid w/meals donepezil 5 mg tablet hs amlodipine 10 mg lisinopril 20 mg calcium carbonate 1000 mg lanthanum 500 mg tid w/meals olanzapine 7.5 mg hs discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). disp:*1 month supply* refills:*2* 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 6. olanzapine 7.5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 7. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. lanthanum 250 mg tablet, chewable sig: four (4) tablet, chewable po tid (3 times a day). disp:*360 tablet, chewable(s)* refills:*2* 9. lisinopril 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. sevelamer 800 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 13. dilantin 100 mg capsule sig: three (3) capsule po hs. disp:*90 capsule(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: hypertensive encephalopathy pontine t2 signal abnormality esrd bipolar disorder hypertension discharge condition: improved discharge instructions: please take your medication please follow-up with your dialysis schedule please follow-up followup instructions: neurology follow-up at within 2-4 weeks - md, Procedure: Venous catheterization, not elsewhere classified Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease End stage renal disease Acute kidney failure, unspecified Personal history of noncompliance with medical treatment, presenting hazards to health Bipolar disorder, unspecified Electrolyte and fluid disorders not elsewhere classified Diabetes insipidus Other specified paralytic syndrome Abnormal function study of brain and central nervous system, unspecified

service: neonatology history of present illness: is the former 3.36 kg product of a 37 week gestation pregnancy born to a 28-year-old g3, p2 to 3 caucasian female. prenatal screens: blood type ab+, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta for myasthenia diagnosed in . she underwent a thymectomy in . she also has a history of depression treated with zoloft. she is treated with mestinon, but was taken off during this pregnancy. there is also maternal medical history of asthma. the pregnancy was uncomplicated. on fetal survey, mild left hydronephrosis was noted. she presented in labor. rupture delivery. the mother was treated with antepartum antibiotics for greater than four hours during delivery. infant was born by spontaneous vaginal delivery under epidural anesthesia. apgars were 8 at 1 minute and 9 at 5 minutes. he was admitted to the neonatal intensive care unit for observation due to the mother's myasthenia . admission physical exam: weight 3.36 kg, length 52.5 cm, head circumference 34.5 cm, all 90th percentile of 37 weeks. general: non-dysmorphic term male. head, ears, eyes, nose and throat: anterior fontanelles soft and flat, palate intact, symmetric facies. chest: clear breath sounds, no murmur. skin: normal pulses, good perfusion, pink in room air. abdomen: soft, three vessel cord, no hepatosplenomegaly. genitourinary: normal male genitalia, testes descended, patent anus. spine: no sacral dimple. skeletal: no hip click. neurologic: normal tone, toes upgoing, 2+ deep tendon reflexes in the lower extremities, symmetric morrow, good suck. hospital course by systems including pertinent laboratory data: 1. respiratory: had some oxygen desaturations in the first 24 hours of life. he also had some initial grunting, flaring and retracting that resolved within a few hours after birth. for the 48 hours prior to discharge, he has had no episodes of desaturation. 2. cardiovascular: has maintained normal heart rates and blood pressures. no murmurs have been noted. 3. fluids, electrolytes and nutrition: was initially npo and maintained on intravenous fluids. enteral feeds were started late in the date of birth and well tolerated. he takes enfamil 20 po ad lib in good volumes. weight on the day of discharge is 3.29 kg. 4. infectious disease: as his mother had received greater than four hours of antepartum antibiotic prophylaxis, did not require evaluation for sepsis. 5. gastrointestinal: clinical jaundice was observed on day of life #4 and his serum bilirubin was obtained which was a total of 9.2/0.2 direct for an indirect of 9.0. 6. neurologic: has maintained a normal neurological exam throughout his period of observation. there were no neurological concerns at the time of discharge. 7. renal: as noted on prenatal ultrasound, was identified as having mild left hydronephrosis. we recommend a repeat renal ultrasound at one month of age. 8. sensory: had hearing screening performed with automated auditory brain stem responses. he passed in both ears. discharge condition: good discharge disposition: home with parents. primary pediatrician: care is to be provided by pediatric associates, , , , phone number , fax number . care and recommendations at the time of discharge: 1. ad lib po feeding enfamil 20 calories medications: none state newborn screen was sent on day of life #3 with no notification of abnormal results to date. hepatitis b vaccine was administered on . passed a car seat screening test. immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: 1. born at less than 32 weeks 2. born between 32 and 35 weeks with plans for daycare during rsv season with a smoker in the household or with preschool siblings. 3. chronic lung disease influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. discharge diagnoses: 1. 37 week gestation 2. transitional respiratory distress 3. mild left hydronephrosis on prenatal ultrasound , m.d. dictated by: medquist36 d: 07:04 t: 07:00 job#: Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Circumcision Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis 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 Routine or ritual circumcision Nonspecific (abnormal) findings on radiological and other examination of genitourinary organs

history of present illness: mr. is a 48-year-old male resident at rentham developmental center, who has a problem with chronic severe aspiration. this problem was first noticed around eight years ago. he had a gastrostomy tube placed in . he continued to have reflux, however, with aspiration and recurrent pneumonia. in , he developed right pleural effusion. he had a thoracoscopy and chest tube placement. the fluid was an exudate with no infection or malignancy. due to the recurrent nature of the problem, he was scheduled for a tracheoesophageal separation by total laryngectomy with dr. on . past medical history: 1. chronic aspiration. 2. pulmonary fibrosis secondary to macrodantin. 3. chronic constipation. 4. acne. 5. pre-procedural anxiety. 6. contractures. 7. hypothyroidism. 8. hypothermia. 9. atypical psychosis/frontal lobe syndrome. 10. seizure disorder. 11. dysphagia. 12. history of urinary tract infections. 13. mental retardation. hospitalizations: 1. at hospital for respiratory distress, pleural effusions, pseudomonas urinary tract infection. 2. on returned to hospital for vomiting with respiratory distress. allergies: ampicillin that causes swelling and rash. medications: 1. calcium carbonate 1250 mg q day. 2. dilantin 300 mg q day. 3. keflex 500 mg q6h. 4. metronidazole 250 mg q8h. 5. olanzapine 2.5 mg q day. 6. senna four tablets daily. 7. levothyroxine 25 mcg q day. 8. milk of magnesia 60 cc daily. 9. topamax 250 mg . 10. fludrocortisone 0.1 mg q day. 11. albuterol/ipratropium nebulizers qid. 12. dulcolax suppository qod. 13. fleet's enemas q2-3 days prn. diet: his diet includes 3/4 strength 2-cal hn 70 cc/g tube q hour with 1/4 strength jevity plus x12 hours q day along with two tablespoons of promod . family history: maternal parents colon cancer. paternal parents significant cardiac disease. father died of transient ischemic attack and stroke. mother developed diabetes in her 60s. brother and maternal aunt diagnosed with multiple sclerosis. on examination, preoperative: in general, this is a 48-year-old male with multiple physical handicaps, who is alert, nonverbal, and cooperative. skin: good turgor, scattered scars including permanent scar in right hip. eyes: left exotropia. pupils are equal, round, and reactive to light. visual acuity appears intact. fundoscopic examination limited, but grossly normal. ears normal, hearing acuity with bilateral cerumen. nose: nares patent. dental hygiene fair. no abnormal tongue movements. neck is supple, no thyromegaly or lymphadenopathy. cyst noted at base of the skull. lungs: occasional rhonchi, decreased breath sounds at bases. heart: normal sinus rhythm, no audible murmurs. abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. g tube in place mid abdomen. g site clean. rectal examination deferred. extremities: light contractures of right upper extremity. significant contractures of the left upper extremity with left hand flexed. no skin breakdown. all four limbs can be extended left greater than right. neurologic: mental status: alert, minimally verbal, follows simple requests. cranial nerves ii through xii intact except for exotropia. deep tendon reflexes hyperreflexive lower extremities, normal reflexes upper extremities. preoperative chest x-ray: showed pleural thickening with no acute consolidation or change. preoperative electrocardiogram: within normal limits, rate 80, normal sinus rhythm, no change since previous electrocardiogram in . patient underwent a total laryngectomy on with dr. . there were no complications. he received 4800 cc of crystalloid. urine output 425 cc, 200 cc estimated blood loss. he was transferred to the intensive care unit postoperatively. hospital course and treatment: 1. otolaryngology: the patient had bacitracin applied to his wounds throughout his stay. they continued to heal well. staples were removed prior to discharge. he received humidified o2 by trache collar which was gradually weaned to 35% fio2. he was on aspiration precautions throughout his stay to prevent reflux. postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. he continued to improve throughout his stay. his ionized calcium postoperatively was 1.15, which dropped to 0.97 and returned to 1.15 prior to discharge. he was transferred to the floor on postoperative day three, . his drains were originally to wall suction with high output around 100 cc a day until and 2nd when they are switched to bulb suction, and the output came down to between 50-70 cc a day. jp #2 was removed on after putting out 30 cc over 24 hours. jp #1 was removed on prior to discharge. 2. neurologic: the patient's dilantin level postoperatively was 4.3. he was loaded with 500 mg iv x1 and then placed on a maintenance dose of 100 mg tid. he did have seizure activity during his stay. his dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. his atypical psychosis and mr throughout his stay. 3. gi: immediately, postoperatively the g tube was placed to gravity. his tube feeds were resumed on , postoperative day one with a nutrition team following him. he had very low residuals and no problems with aspiration into the oropharynx. 4. infectious disease: the patient was afebrile throughout his stay. he was on ancef and flagyl after the surgery. he had a urinalysis that was positive and was placed on cipro throughout the length of his stay. 5. respiratory: he continued to have thick secretions requiring frequent suctioning and chest pt. he received respiratory care multiple times a day. wheezing was controlled with albuterol and atrovent nebulizers. 6. endocrine: he had a tsh of 0.78 postoperatively. he received his normal dose of synthroid. no changes were made. he was on an insulin-sliding scale throughout his stay. on , staples and drains were discontinued. the patient was in good condition with continuing needs for frequent suctioning. he was discharged to rentham with antibiotics, pain medication, and instructed to followup with dr. in weeks. , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Complete laryngectomy Diagnoses: Esophageal reflux Urinary tract infection, site not specified Unspecified acquired hypothyroidism Other convulsions Postinflammatory pulmonary fibrosis Severe intellectual disabilities Gastrostomy status

chief complaint/history of present illness: mr. is a 61-year-old man referred by dr. for outpatient cardiac catheterization because of a positive exercise tolerance test. this is a 61-year-old man experiencing chest pain for several years which has always been relieved with belching. over the past few months, he started to have left shoulder twinges and tingling in his hands. the patient reports that these episodes are fleeting and sometimes occur separately. he states that the episodes are not brought on by any particular activity and occur approximately once a day. a stress test done on revealed that the patient exercised for 6 1/2 minutes, stopped due to fatigue and shortness of breath. the maximal heart rate was 98% predicted. he does not have any chest pain. there were 2 to 3 mm horizontal downsloping st segment depressions in the inferior leads and in v3 through 6. myoview showed a small mild reversible defect at the base of the lateral wall. the ef was 62%. past medical history: 1. hypertension. 2. hypercholesterolemia. 3. hepatitis in the , cannot identify which type. 4. hernia repair. 5. shoulder repair. 6. pilonidal cyst removal. 7. positive tobacco use. allergies: the patient has no known drug allergies. medications prior to admission: 1. aspirin 325 q.d. 2. avapro 150 q.d. 3. toprol 25 q.d. 4. sublingual nitroglycerin. social history: the patient works for . he has a wife and three children. laboratory data prior to cardiac catheterization: white count 9.6, hematocrit 41.9, platelets 269,000. inr 1.0. sodium 141, potassium 4.4, chloride 102, c02 27, bun 17, creatinine 0.7. physical examination on admission: vital signs: heart rate in the 80s, sinus, blood pressure 135/80, respiratory rate 20. neurologic: nonfocal examination. respiratory: clear to auscultation bilaterally. cardiac: regular rate and rhythm, s1, s2. abdomen: soft, nontender, nondistended, with normoactive bowel sounds. extremities: warm and well perfuse with good pulses throughout and no varicosities noted. hospital course: on the day of admission, the patient went for cardiac catheterization. please see the cath report for full details. in summary, the cath showed an ef of 65%, left main 70% lesion, lad 70% lesion, left circumflex with an 80% lesion, and rca with a small nondominant diffusely diseased. ct surgery was consulted. the patient was seen and accepted for coronary artery bypass grafting. prior to being brought to the operating room, the patient had carotid dopplers which showed no significant hemodynamic lesions on either the right or left carotid. on , the patient was brought to the operating room. please see the or report for full details. in summary, the patient had a cabg times four with a lima to the lad, saphenous vein graft to the diagonal, saphenous vein graft to the ramus and saphenous vein graft to om. his bypass times 92 minutes, cross-clamp time was 74 minutes. he tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient had neo-synephrine at 0.3 micrograms per kilogram per minute and propofol at 30 micrograms per kilogram per minute. the patient did well in the immediate postoperative period. his anesthesia was reversed. he was weaned from the ventilator and successfully extubated. on postoperative day number one, he continued to be hemodynamically stable off all pressors. beta blockade and diuresis was begun. the patient remained in the intensive care unit because no bed was available on the floor on that day. on postoperative day number two, the patient remained hemodynamically stable. his chest tubes, foley catheter, and central venous access were discontinued and he was sent to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor, the patient's activity level was increased with the assistance of the nursing staff and physical therapy. on postoperative day number three, it was determined that the patient was stable and most likely ready for discharge to home on the following postoperative day. at this time, the patient's physical examination is as follows. vital signs: temperature 96.8, heart rate 59, sinus rhythm, blood pressure 100/50, respiratory rate 18, 02 saturation 97% on room air. weight preoperatively 96 kilograms, at discharge 98.7 kilograms. the laboratory data revealed a white count of 9.4, hematocrit 25.9, platelet 163,000. sodium 137, potassium 3.9, chloride 105, c02 21, bun 17, creatinine 1.0, glucose 105. the patient was alert and oriented times three, moves all extremities, follows commands. respiratory: clear to auscultation bilaterally. heart sounds: regular rate and rhythm, s1, s2, no murmur. sternum is stable. the incision was with steri-strips, open to air, clean and dry, with no erythema or exudate. abdomen: soft, nontender, nondistended, with normoactive bowel sounds. extremities: warm and well perfused with 2+ edema bilaterally. discharge medications: 1. aspirin 325 q.d. 2. lasix 20 q.d. times ten days. 3. potassium chloride 20 q.d. times ten days. 4. plavix 75 mg q.d. times one month. 5. metoprolol 50 mg b.i.d. 6. percocet 5/325 one to two tablets q. four hours p.r.n. condition at discharge: good. discharge diagnosis: 1. cad, status post coronary artery bypass grafting times four with lima to lad, saphenous vein graft to diagonal, saphenous vein graft to ramus, and saphenous vein graft to obtuse marginal. 2. hypertension. 3. hypercholesterolemia. 4. hepatitis. 5. status post hernia repair. 6. status post shoulder repair. 7. status post pilonidal cyst removal. follow-up: the patient is to have follow-up in the clinic in two weeks. follow-up with his primary care in two to three weeks and follow-up with both dr. and dr. , his cardiologist, in one month. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Personal history of tobacco use Other and unspecified angina pectoris

allergies: penicillins attending: chief complaint: brbpr and hypotension major surgical or invasive procedure: egd colonoscopy history of present illness: this is a 72 yo woman with h/o dementia, dm2, cad s/p mi ', af, chf, pud, ?gib , on asa/coumadin for afib, who was brought on day of admission to the ed at with c/o failure to thrive. per family she refused to eat or bathe and she had been c/o feeling weak. when taken to the bathroom, noted to have old dried blood and passed bright red stool. pt thinks this started yesterday, uncertain (poor historian). she has been c/o diffuse abdominal pain over the last 2 mos. denies constipation or diarrhea. states her appetite has been poor. family not helpful c history. in ed she was noted to be 6.4 and hc 26.bp remained stable 140/80. she was transfused 1u prbc and 1 . she received approx 2 lt of fluids . she had an elevated k of 6.2 , elevated glucose of 240 c gap of 21 . she was given fluids and transfered to ed . pt's vs c bp 82/60 hr 95-120 spo2 100% she was given 1000 cc ns with bp coming back to 127/54. at ed there was trouble drawing labs and getting iv access.labs were drawn through r femoral vein. no ffp or rbc were given d/2 this issue. pt was sent to the micu past medical history: a fib on coumadin and digoxin gib in with erosive gastritis and duodenitis and ascending colonic polyp htn mi dm type 2 dementia hypothyroidism social history: the patient is a housemaker. she lives with her grandson. hcp is pts son . she is a heavy smoker with one pack of cigarettes per day for more than 50 years, but stopped in . she occasionally drinks alcohol. she has not been tolerating living at home and will likely need placement. family history: mother died of a heart attack and stroke. father died of lung cancer. she has a sister who is living and healthy. physical exam: vs: t 98.1 bp 163/56 p 92 r24 sat 95%ra i/o 625/920, los +2195 gen aao, nad heent pallor conjunctiva, dry mm, jvp to ear chest ctab with bibailar crackles way up cv irregularly, irregular abd soft nt/nd, +bs ext no edema, 2+dp pulses bialterally pertinent results: labs on admission 01:30am blood wbc-10.9 rbc-2.62*# hgb-7.9*# hct-22.6*# mcv-86 mch-30.1 mchc-35.0 rdw-14.7 plt ct-220 01:30am blood pt-32.3* ptt-30.9 inr(pt)-3.5* 01:30am blood glucose-121* urean-50* creat-1.6* na-142 k-4.9 cl-105 hco3-18* angap-24* 01:30am blood albumin-3.3* 03:45am blood albumin-3.5 calcium-7.3* phos-4.5 mg-1.0* 02:59pm blood caltibc-251* ferritn-87 trf-193* labs on discharge 08:50am blood wbc-9.9 rbc-4.30 hgb-12.7 hct-37.3 mcv-87 mch-29.6 mchc-34.1 rdw-14.1 plt ct-451* 08:50am blood plt ct-451* 08:50am blood pt-13.9* ptt-21.8* inr(pt)-1.2* 08:50am blood glucose-126* urean-21* creat-1.1 na-142 k-4.0 cl-103 hco3-25 angap-18 cxr impression: findings may represent vascular engorgement or an interstitial process, and followup with pa and lateral chest radiographs, which offer better resolution, is recommended for further evaluation. recommendation discussed with dr. at 11:50 a.m. on . ct abdomen impression: no evidence of intestinal obstruction. suggestion of right renal stone. brief hospital course: a/p 72 yo om chronic anticoagulation here with brbpr with negative egd for further work up. . gibleed: *micu course: the patient remained hd stable while in the micu. she received 2 u prbcs and 2 u ffp. she was started on a protonix gtt amd she was evaluated by gi, and underwent egd which was unrevealing. a colonscopy was later done which revealed a plastic object in her colon. the patient received 2u of prbcs throughout her course. due to her gib, her coumadin was held and her inr was reversed. her coumadin was later restarted after her hct had stabilized. the patient's hct was 37.3 at the time of discharge. the patient was scheduled to follow up with gi at the time of discharge. . . ckd: creatinine today is 1.1. . afib: the patient was monitored on telemetry. her coumadin was initially held due to her bleeding. it was later restarted once her hct had stabilized. the patient's bb was also held because of her bleeding and later restarted. at the time of discharge the patient was on her home regimen of lopressor, coumadin and digoxin. . chf: ef 30%, after resolution of her bleeding the patient was restarted on her anti-hypertensives. . diabetes: the patient glucose levels were elevated toward the latter part of her course. this was attributed to her uti. she was discharge on insulin with vna follow up for diabetic teaching. . uti: she was d/c on levaquin for an additional 4 more days to complete a 7 day course. . hypothyroidism: the patient was maintained on synthroid. . dementia: the patient was at baseline in terms of her dementia . fen: clears, follow lytes . proph: pneumoboots . dispo: home w/ vna medications on admission: coumadin 5mg qd lasix 20mg synthroid 50mcg qd lopressor 50mg qam/25mg qpm lipitor 40mg qd glucovance 2.5mg/5000mg 2tabs asa digoxin 250mcg qd lisinopril 20mg qd carafate 1gm qid discharge medications: 1. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). disp:*30 tablet(s)* refills:*2* 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. levothyroxine 25 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days. disp:*4 tablet(s)* refills:*0* 6. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 8. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed). disp:*qs vials/ bottles* refills:*2* 9. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 10. glargine sig: 10 units at bedtime disp: qs refills: 20 11. glucometer please provide patient with glucometer. disp: qs refills: 1 12. glucose test strips sig: asdir disp: qs refills: 10 13. lancets sig: asdir disp: qs refills: 5 14. syringes please provide patient with 50cc syringes disp: qs refills: 20 discharge disposition: home with service facility: discharge diagnosis: bright red blood per rectum secondary to foreign object in gastrointestinal tract . secondary diagnosis atrial fibrillation on coumadin and digoxin gastrointestinal bleed in with erosive gastritis and duodenitis and ascending colonic polyp hypertension mi dm type 2 dementia hypothyroidism discharge condition: good, vitals stable, patient eating, hematocrit is stable discharge instructions: seek medical services immediately if you should have any bleeding per rectum, chest pain, fevers, chills or any other worrisome symptom. . please take your medications as prescribed. . please keep all follow up appointments . please monitor your blood sugars before meals and at bedtime. keep a diary of this to bring to your primary care physician. followup instructions: please follow up with your primary care physician 1 week of discharge. . you have follow up set up with dr. (gastroenterologist) on wednesday at 1pm on 7. the phone number is . Procedure: Other endoscopy of small intestine Colonoscopy Endoscopic polypectomy of large intestine Transfusion of packed cells Transfusion of other serum Removal of intraluminal foreign body from large intestine without incision Diagnoses: Acidosis Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Other persistent mental disorders due to conditions classified elsewhere Cellulitis and abscess of leg, except foot Old myocardial infarction Long-term (current) use of anticoagulants Hemorrhage of gastrointestinal tract, unspecified Benign neoplasm of colon Foreign body in intestine and colon Foreign body accidentally entering other orifice

allergies: aspirin / sulfa (sulfonamides) / codeine attending: chief complaint: transfer from mwh for cardiac catheterization for cp with trops elevation to 0.79, likely nstemi (non st elevation myocardial infarction) major surgical or invasive procedure: cardiac catheterization history of present illness: 84yo male with cad - cabg x5 in (lim to lad, svg to da, svg to , svg to pda, svg to lt ventr branches), mi in , s/p aaa repair, s/p fem- bypass, crf on hd is transferred from mwh for cath for ?dx of mi. patient initially presented to mwh ed on with c/o continuous 7 out 10 shoulder to shoulder chest pain with no radiation. he denied sob or diaphoresis. took nitro at home x2 with no relief. in ed, he had +trop 0.79, ekg 100% paced, received iv nitro and morphine, plavix and heparin. no aspirin given (as per gi) because of the h/o severe gi bleed on aspitrin. pt had 2 subsequent episodes of cp overnight relieved by morphine. , pt was transferred to for cath. past medical history: cad - mi , cabg x5 in at s/p aaa repair ppm bilateral fem- bypass crf-hd on t-th-sat (last dialysis , tolerated well) severe duodenal ulcer bleed - received 11 prbc chrone's dx diverticulosis social history: past tobacco family history: . physical exam: pe: pt in bed, looks comfortable, no acute distress t 98.7 bp 130/72, hr 60, rr 18, 96% r/a heent: symm neck, mouth clear, no ln, flat jbp chest: limited exam, clear, gaeb cvs: rrr, n s1s2, syst gr ii-iii/vi murm over precordium : soft, n bs, nt extrem: no edema, varicose veins pulses: normal carotid, radial, doplerable pedal neuro: alert, oriented x3, grossly n lt groin: no hematoma (4pm) pertinent results: 06:55pm ck-mb-30* mb indx-13.8* ctropnt-0.89* 03:00am ck-mb-129* mb indx-20.4* 06:40am ck-mb-155* mb indx-20.9* ctropnt-2.54* 06:55pm wbc-7.1 rbc-3.25* hgb-11.4* hct-33.7* mcv-104* mch-35.0* mchc-33.7 rdw-15.8* 06:55pm plt smr-normal plt count-178 06:55pm glucose-74 urea n-52* creat-6.4* sodium-135 potassium-5.3* chloride-92* total co2-21* anion gap-27* cardiac cath:1. coronary and grft angiography showed a previous right dominant system. the lmca was diffusely disesed with no focal or critical lesions. the lad tapered off in the mid segment until a large s2 where it is totally occluded. the d1 and d2 are small vessels and are diffusely diseased. the d3 which recived a svg is not seen in the lmca injection. the mid and the distal lad receives the lima. the cx vessel it self has no lesions. it gives a lengthy collateral. the om1 arises close to the lmca and is small. the om2 too arises close to the lmca and is large. this has a proximal lesion of 80%. the om3 recives the svg and is not seen on lmca injection. the om4/postero latateral branch arises distally and is a small vessel. the rca is occluded proximally. the distal rca including the pda and the plv are collateralised by the left system. the pda is poorly filled and has a mid 60% lesion. the lima , the lima-lad anastomosis and the distal lad are free of disease. the lima fills the lad retrogradely to supply the proximal lad and the d3. the d3 has an ostial 70% lesion with timi iii flow. the sv grafts to the rca and the plb are occluded completely and are seen as stumps in the aorta. the graft to the diagonal could not be located, but is likely to be occluded given the other angiogaphic findings. the svg to the om3 shows diffuse disease with a mid lengthy lesion of 99 % and the whole vessel showed timi ii flow. there were no collaterals for this om. 2. left ventriculography was not performed. 3. predilation using 1.5 x 15 maverick balloon, stenting using 3.0 x 28 and 3.0 x 33 otw cypher stents and thrombus extraction using export catheter with gradual deterioration of flow of the svg to the om3. the flow deteriorated from timi i to timi 0. final diagnosis: 1. three vessel native coronary artery disease with functioning lima to the lad. 2. acute occlusion of the svg to the om and chronically occluded sv grafts to the pda, plb and diagonal. 3. unable to restore flow in the svg to the om despite stenting, pharmacotherapy and thrombus aspiration. . echo: . the left atrium is mildly dilated. 2. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. basal inferior hypokinesis is present. 3. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis. 4. the mitral valve leaflets are mildly thickened. 5. there is mild pulmonary artery systolic hypertension. . ct scan: 1. no evidence of intrahepatic gas as suggested on prior ultrasound. repeat ultrasound is suggested given this change in appearance. 2. bibasilar dependent atelectatic changes/consolidation with associated effusions. 3. gas distended loops of bowel with air-fluid levels but without transition suggesting ileus. stool distended rectum. 4. small infrarenal abdominal aortic aneurysm. brief hospital course: he was admitted with unstable angina, had total occlusion of all svg grafts with a patent lima to lad, and received 2 cypher stents. his catheterization was compicted by failed thrombus extractuib abd a timi 0. after catherization he had persistent cp and evidence of a nstemi. initially he was not treated with asa because of a past gi bleed, but with persistent ischemia, it was added to the plavix. he required a significant of morphine to controll his pain. through discussions between the micu team and the family pain control was determined to be the only option for him. his code status was changed to dnr/dni/. due to ongoing ischemia, he had persistent hypotension that required multiple pressors. his hd was changed to cvvh because of his low blood presssure. he also had intermittent nsvt. he had been transferred from the team to the micu team due to hypotension at hd after his cardiac catheterization out of concern for possible sepsis. there was a concern that he had an acute abdomen but he appeared to be impacted with stool. he was disimpacted and received an aggresive bowel regimen. his distension and pain improved. he had low grade temperatures and was initially treated for pneumonia because he was hypoxic. no source of infection was identified. it is more likely that he was in cardiogenic shock with fluid overload. a repeat bedside echo did not reveal worsening ventricular function. he required blood transfusions for persistently dropping hct in the setting of very frequent blood draws. he also had a coagulopathy which did not appear to be from dic. he required vitamin k supplementation. he expired at 6:45am on after an episode of severe chest pain. medications on admission: plavix 300mg x2 mg starting lopressor 12.5mg foslo 667mg x4 tid quinine 324mg daily pentasa 250mg x4 qid mvi mirtazapine 15mg qhs colace 100mg protonix 40mg daily morphine prn nitro prn discharge medications: none discharge disposition: expired discharge diagnosis: sinus tachycardia nsvt cardiogenic shock coagulopathy obstipation nstemi esrd discharge condition: expired discharge instructions: . followup instructions: . Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Left heart cardiac catheterization Other and unspecified coronary arteriography Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Infusion of vasopressor agent Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Anemia in chronic kidney disease End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Aortic valve disorders Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Constipation, unspecified Cardiogenic shock Hypovolemia Other and unspecified coagulation defects Hypotension of hemodialysis

allergies: penicillins attending: chief complaint: sob major surgical or invasive procedure: s/p aortic valve replacement w/19mm ce perimount magna, mitral valve replacement w/ 25mm mosaic, endarterectomy of left main and aorta history of present illness: patient is a 77 y/o russian speaking female with a history of critical as, chronic pleural effusions, rbbb, who presented to hospital with increasing sob over the past 2 days. pt. also admits to decreased exercise tolerance over the past two months. past medical history: critical as hypertension ^chol hypothyroidism chronic pleural effusions right brca s/p masectomy xrt lymphedema in right arm post herpetic neuralgia l thorax social history: she lives with . family history: mother died of unknown cancer in her 40's, father with dm died at 74, sister with ? heart disease physical exam: pex: t 98.1 hr 94 bp 99/63 rr 18 o2sat 96 2l nc ht 5'6" wt 129 gen: lying in bed in nad skin: w/d, -lesions heent: perrla, eomi, nc/at neck: supple no lad lungs: decreased breath sounds at the bases bilaterally, no crackles or wheeze heart: rr rapid +s1s2, 4/6 sem w/ radiation to carotids abd: soft, nt/nd +bs ext: 1+ edema, scattered varicosities, swollen r arm neuro: cn 2-12 intact, non-focal pertinent results: cxr -worsening bilateral pleural effusions and lower lung zone atelectasis, left greater than right. cxr -no evidence of a pneumothorax following chest tube removal ekg -sinus tachycardia. right bundle-branch block. cath 4/12/05-1. two vessel coronary artery disease. 2. severe/critical rheumatic and calcific aortic stenosis 3. mitral stenosis could not be confirmed or excluded. at least mild mitral regurgitation seen. 4. normal lv systolic function. moderate-severe lv diastolic dysfunction. 5. no hemodynamic evidence of hypertrophic cardiomyopathy. 6. mild-moderate pulmonary hypertension. 08:20am blood wbc-7.3 rbc-3.48* hgb-11.0* hct-32.4* mcv-93 mch-31.6 mchc-33.9 rdw-13.7 plt ct-189 12:36pm blood wbc-8.8 rbc-3.11* hgb-9.5* hct-26.9* mcv-87 mch-30.6 mchc-35.3* rdw-15.0 plt ct-58*# 03:40pm blood hct-35.4*# plt ct-106*# 10:13am blood wbc-6.1 rbc-3.62* hgb-10.3* hct-31.1* mcv-86 mch-28.3 mchc-33.0 rdw-15.9* plt ct-150# 08:20am blood pt-12.4 ptt-24.9 inr(pt)-1.0 10:13am blood pt-12.7 ptt-26.4 inr(pt)-1.0 08:20am blood glucose-169* urean-15 creat-0.8 na-140 k-4.1 cl-105 hco3-29 angap-10 06:48am blood glucose-101 urean-16 creat-0.7 na-140 k-4.4 cl-106 hco3-27 angap-11 08:00am blood urean-21* creat-0.8 k-4.7 08:20am blood calcium-9.4 phos-3.6 mg-1.9 08:20am blood alt-28 ast-28 ck(cpk)-67 alkphos-76 amylase-64 totbili-0.5 06:15am blood %hba1c-5.0 -done -done 08:05am blood tsh-10* 02:20am urine color-straw appear-clear sp -1.045* 02:20am urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 02:20am urine rbc-* wbc-0-2 bacteri-none yeast-none epi-0-2 07:22am blood heparin dependent antibodies-negative brief hospital course: pt was initially diuresed in ed. admitted and medically managed for several days. cardiac surgery was then consulted to see this pt. pt. was initially seen before cardiac cath and then again following cath on . pt. first needed carotid u/s and dental consult/panorex before surgery. following dental clearance and carotid u/s(- stenosis), pt. was brought to the operating room on and underwent an avr/mvr/endarterectomy of lm & aorta. please see op note for full surgical details. pt. tolerated the procedure well with a total bypass time of 188 minutes and x-clamp time of 162 minutes. pt. was transferred to the csru on vasopressin, levophed, and propofol with a map of 68, cvp 5, pad 12, 17, and hr of 80 av paced. pt. remained on ventilator overnight and on pod #1 pt was weaned from propofol and mech vent and extubated. pt. was awake, alert, oriented and following commands. pod #2/hd 9, pt. remained on neo for bp support. chest tubes and swan-ganz cathetor were removed. lasix and lopressor were started. pod #3/hd 10 pt remained in the csru due pt. cont. to need neo for bp support. lasix was stopped today for increase bun/cr. nutrion consult for poor appetite. hit panel done for decreased platelets. pod #4/hd 11 neo was weaned off. pt. transferred to telemetry floor. hit panel negative. pod #5/hd 12 pt. progressing well. hemodynamically stable. pe unremarkable. foley d/c'd today. lasic restarted. pod #6/hd 13 no events overnight. central line d/c'd. piv placed. pt. cont. to receive pt/ot. pod #7/hd 14 pt. appears to be doing well. level 5 today. pacing wires removed. pe unremarkable. by pod#10, patient was cleared by pt to d/c home with home pt, and patient was discharged medications on admission: 1. levoxyl 50 mcg qd 2. lasix 20 mg qd 3. lipitor 40 mq qd 4. asa 325 mg qd 5. doxepin 5%tp discharge medications: 1. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. levothyroxine sodium 50 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. 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* 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 7. tylenol-codeine #3 300-30 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 8. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 7 days. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* discharge disposition: home facility: - discharge diagnosis: aortic stenosis, mitral stenosis, s/p aortic valve replacement w/19mm ce perimount magna, mitral valve replacement w/ 25mm mosaic, endarterectomy of left main and aorta chf hypertension hypercholesterolemia hypothyroidism rbbb right brca s/p masectomy xrt lymphedema in right arm post herpetic neuralgia l thorax discharge condition: stable discharge instructions: do not take bath. can take shower and wash incision with warm water and gentle soap. do not apply lotions, creams, ointments, powders to incision. do not life more than 10 pounds for 2 months. do not drive for 1 month. keep all follow-up appointments. p instructions: follow-up at clinic in 2 in 2 weeks follow-up with pcp in dr. 1-2 weeks follow-up with dr. in 4 weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Non-invasive mechanical ventilation Open and other replacement of aortic valve with tissue graft Open and other replacement of mitral valve with tissue graft Endarterectomy, aorta Open chest coronary artery angioplasty Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Rheumatic heart failure (congestive) Right bundle branch block Mitral valve stenosis and aortic valve stenosis

allergies: benadryl / iodine; iodine containing / sulfa (sulfonamides) / penicillins / morphine / ambien attending: chief complaint: confusion major surgical or invasive procedure: lumbar puncture history of present illness: the pt is a 74 year-old right-handed woman with multiple medical problems who presented with alteration in consciousness. the pt was unable to offer a history at the time of my encounter. therefore, the following history is per the medical record, and the pt's daughter who was present at bedside. the pt had been complaining to her daughter of generalized malaise over the past two days. she had no known fever or focal signs of infection such as cough, abdominal pain, vomiting, diarrhea, dysuria. she had been otherwise her usual interactive, relatively independent self. at approximately 2pm today, she awoke from a nap and complained to her daughter of right temporal headache. she described the headache as sharp. at about this time, the pt decided to check her fsbs and her daughter noted that the pt was having difficulty managing putting the test strips into the glucometer and appeared confused. her daughter helped her and her fsbs was 357. she complained of not feeling well, so her daughter helped her to her bedroom. there, she became more confused and per the daughter was answering some questions inappropriately. the daughter noted that she seemed to be perseverating on certain answers to questions. after another half an hour, the pt's speech became unintelligible and she became less and less responsive to her name. her daughter called ems. ems reports that on their arrival, the pt was "awake, non verbal, not following commands". they also document gaze to left. she was taken to an osh where she was noted to have "lip smacking and bilateral limb jerking." work-up included reportedly "negative ct", normal cbc, electrolytes notable for glucose of 317 and creatinine of 1.2. no temperature was documented on osh records. at the osh, she received 2g iv ceftriaxone, 800mg iv acyclovir, 2mg iv ativan. she was transferred to for further management. the pt was unable to offer a review of systems. past medical history: -hypertension -hyperlipidemia -type ii diabetes mellitus, insulin dependent, with neuropathy -pvd s/p fem- bypass -cad with h/o mi -h/o cataracts s/p removal -h/o barrett's esophagus -hypothyroidism -h/o multiple "tias"--symptoms were disorientation per omr social history: pt lives with her daughter, but is fully independent in all adls. daughter describes her as "sharp". no history of tobacco, alcohol, illicit drug abuse. family history: no history of seizures or neurological disease. physical exam: vitals: t: 101.4f pr p: 107 r: 16 bp: 168/p sao2: 97% 3l nc general: lying in bed with eyes closed. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: no nuchal rigidity pulmonary: lungs cta bilaterally without r/r/w cardiac: tachycardic, rr, nl. s1s2, no m/r/g noted abdomen: some ttp in epigastrium noted. extremities: no c/c/e bilaterally skin: no rashes or lesions noted. neurologic: -mental status: does not respond to verbal command but opens eyes briskly noxious stimuli. she mutters incomprehensible sounds. she does not follow commands. -cranial nerves: perrl 3 to 2mm and brisk. funduscopic exam technically impossible as pt firmly holds eyelids closed on attempted examination of fundi. eomi to oculocephalic maneuver. corneal reflex and nasal tickle present bilaterally. no overt facial asymmetry. gag reflex intact. -motor: normal bulk throughout. paratonic throughout. withdraws briskly to noxious stimuli in all four extremities. irregular orobuccal movements noted (old per daughter, and attributed to use of reglan in the past). pt did have episodes of bilateral limb myoclonus, occurring in each limb independently. -sensory: grimaces to noxious stimuli in all four extremities. -dtrs: tri pat ach l 3 3 3 3 4 r 3 3 3 3 4 plantar response was extensor bilaterally. pertinent results: 07:35pm blood wbc-10.8 rbc-4.35# hgb-13.6# hct-38.9# mcv-89 mch-31.3 mchc-35.0 rdw-13.2 plt ct-561*# 05:05am blood wbc-10.6 rbc-3.28* hgb-10.1* hct-30.1* mcv-92 mch-30.7 mchc-33.4 rdw-14.1 plt ct-485* 03:31am blood pt-13.4* inr(pt)-1.2* 07:35pm blood glucose-316* urean-27* creat-1.1 na-134 k-4.5 cl-94* hco3-25 angap-20 08:53am blood glucose-141* urean-16 creat-1.4* na-140 k-3.6 cl-110* hco3-17* angap-17 07:35pm blood alt-20 ast-22 ck(cpk)-47 alkphos-100 amylase-30 totbili-0.3 03:31am blood albumin-3.7 calcium-8.0* phos-3.3 mg-1.6 01:50am blood tsh-2.9 03:31am blood osmolal-331* 11:14am blood osmolal-299 11:14am blood crp-22.1* 01:50am blood phenyto-7.7* 05:05am blood phenyto-14.1 07:35pm blood asa-5 ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:00pm urine color-yellow appear-clear sp -1.019 11:00pm urine blood-mod nitrite-neg protein-neg glucose-1000 ketone-15 bilirub-neg urobiln-neg ph-7.0 leuks-neg 11:00pm urine rbc-* wbc-0-2 bacteri-none yeast-none epi-0 11:00pm urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-neg ----- 09:10pm cerebrospinal fluid (csf) wbc-2 rbc-950* polys-71 lymphs-17 monos-12 09:10pm cerebrospinal fluid (csf) wbc-4 rbc-665* polys-72 bands-1 lymphs-23 monos-4 09:10pm cerebrospinal fluid (csf) totprot-51* glucose-152 hsv pcr neg. ---- bcx neg ucx neg : ct head w/o contrast findings: no intra- or extra-axial hemorrhage is identified. there is no mass effect or shift of normally midline structures. there is no hydrocephalus. again seen is a 5 mm hypodensity in the white matter of the left frontal lobe posteriorly consistent with a remote lacunar infarct. the visualized paranasal sinuses and mastoid air cells are clear. surrounding soft tissue structures appear unremarkable. impression: no evidence of intracranial hemorrhage or mass effect. eeg (): abnormality #1: throughout this recording the presence of diffusely slowed mixed frequency background rhythms in the delta and theta range were observed. abnormality #2: generalized bursts of mixed frequency delta slowing followed by periods of suppression were observed. abnormality #3: there were infrequent brief bursts of sharp theta slowing seen over the left temporal region. no sustained epileptiform activity was observed. background: described as above. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no definitive sleep wake cycles were observed. cardiac monitor: showed a sinus tachycardia with a rate of approximately 100 bpm. impression: this is an abnormal eeg due to the presence of diffusely slowed background rhythms along with bursts of generalized mixed frequency delta and theta slowing. no suppressions following these. in addition there appears to a focal area of irritability over the left temporal region with frequent bursts over theta activity seen here. no electrographic seizures were recorded. no sustained epileptiform activity was seen. this is most consistent with a moderate causes of an encephalopathy included: medications, metabolic changes, and infectious processes. origin and correlation should done to rule out a focus in the left temporal region as sharp features were observed here during this recording. eeg (): findings: abnormality #1: throughout the recording there were frequent bursts of generalized mixed frequency slowing, often in the delta range. abnormality #2: the background rhythm was slow and disorganized typically reaching a hz maximum in most areas. abnormality #3: there was occasional additional slowing in the temporal regions bilaterally followed more on the left. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular rhythm. impression: abnormal portable eeg due to the bursts of generalized slowing and slow background along with occasional temporal slowing. the first two abnormalities signify a widespread encephalopathic condition affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. the temporal slowing raises the possibility of additional subcortical dysfunction in each hemisphere, but the etiology cannot be specified by the tracing. there were occasional sharp features but no overtly epileptiform abnormalities. mr head w & w/o contrast; mra brain w/o contrast (): mri brain: this examination is severely limited by patient motion. no evidence of severe hydrocephalus, large hematoma, or herniation is seen. evaluation of the brain parenchyma, signal intensity, and patterns of contrast enhancement are limited given the presence of severe motion. scattered areas of abnormal signal seen in the periventricular white matter and pons are unchanged compared to . mra brain: both internal carotid arteries, anterior cerebral arteries, posterior cerebral arteries, middle cerebral arteries, and the basilar artery are patent; however, evaluation of the intracerebral arterial vasculature is severely limited by patient motion. impression: severely limited examination secondary to patient motion shows no hydrocephalus, large hematoma, or herniation. if warranted, repeat imaging could be performed (if patient motion artifact could be improved). mr head w & w/o contrast; mr contrast gadolin (): findings: the diffusion images demonstrate no evidence of slow diffusion to indicate acute infarct. the ventricles and extraaxial spaces are mildly prominent due to mild brain atrophy. a few small foci of t2 hyperintensity are noted in the white matter including a chronic lacune in the left corona radiata. these findings are unchanged from the previous study of . there is no evidence of acute or chronic blood products seen. no mass effect or hydrocephalus. impression: somewhat limited study due to motion. gadolinium-enhanced images could not be obtained as patient was unable to continue. unchanged appearances compared with with small vessel disease and chronic left basal ganglia lacune. no acute infarct. brief hospital course: 1. neuro: the pt is a 74 year-old woman with multiple medical problems who presented with fever and altered mental status. on neurologic examination, she was profoundly encephalopathic with episodic myoclonus and has brisk but symmetric reflexes with ankle clonus and upgoing toes. otherwise, there were no lateralizing signs. the presence of fever and altered mental status was concerning for central nervous system infection. there was also concern for infectious and toxic-metabolic processes. a cxr was normal. a head ct showed a 5 mm hypodensity in the white matter of the left frontal lobe posteriorly consistent with a remote lacunar infarct only. she had a mildly elevated wbc ct in the serum. an lp showed 4 wbcs and 600-950 rbcs. protein was slightly elevated and glucose was normal. gram stain was negative. she was started on vancomycin, ampicillin, acyclovir (with ivf bolus to prevent arf), and ceftriaxone. she was initially admitted to the icu for close monitoring. she was initially very confused and agitated without verbal output. she then slowly improved over the next several days, gradually speaking more and following more commands. she became more oriented to her surroundings and less agitated. the antibiotics were stopped after cultures were negative for 3 days. the acyclovir was stopped after her hsv returned negative. tox screens showed only + opiates which she is on at home. opiate overdose was considered, but not consistent with her presentation. she had an eeg which showed generalized slowing and a focal area of irritability over the left temporal region with frequent bursts over theta activity and sharp features. it was ultimately postulated that her presentation was likely due to seizure. she had no observed seizure activity. she was on dilantin for most of the hospital stay, but she easily developed toxic levels. she was therefore switched to keppra prior to discharge. two mris were performed in attempt to identify seizure focus, but the pt was unable to tolerate these studies very well due to underlying anxiety and superimposed tardive dyskinesia. therefore, no clear seizure focus was elucidated. she will follow-up in clinic after discharge. 2. cad/htn:we continued her home plavix and asa. her antihypertensives were initially held, but were then restarted when her bp began to be elevated. these were norvasc and metoprolol. she was also started on a clonidine patch. this controlled her bp well. 3. endocrine: she was continued on her home levoxyl. she was also continued on glargine and riss without problems. she was initially hyperglycemic, and serum osms were checked and returned at 331. hyperosmolar coma was considered, but her glucose was not high enough for this diagnosis. a repeat osm ~6 hours later, after glucose was corrected was normal at 290. 4. funguria: the pt was found to have yeast in the urine. she was treated with a 7 day course of oral fluconazole. 5. clostridium difficile gastroenteritis: the pt complained of nausea and abdominal pain once her mental status cleared. she developed diarrhea which was positive for c.diff. she was treated with a fourteen day course of metronidazole, to be completed as an outpatient. 6. anemia: the pt did have a slight drop in her hematocrit and was found to have guaiac positive stool. she did require a transfusion of one unit of prbcs. gastroenterology was called and they felt that further work-up could be done on an outpatient basis after her hematocrit stabilized following transfusion. 7. anxiety: the pt was seen by the psychiatry service as she had complaints of worsening anxiety. they recommended discontinuing effexor, buspar and amitriptyline and starting seroquel. she responded well to this change. 8. arf: the pt had a slight bump in her creatinine to 1.4 after treatment with acyclovir which normalized after aggressive ivf and discontinuation of this drug. medications on admission: -lipitor 10mg po daily -gabapentin 600mg po tid -asa 81mg po daily -protonix 40mg po daily -effexor 75mg po daily -buspirone 5mg po bid -insulin glargine and humalog sliding scale -levothyroxine 25mg po daily -plavix 75mg po daily -amitriptyline 50mg po qhs -vicodin prn discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 3. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 6. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 10 days. disp:*30 tablet(s)* refills:*0* 7. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. disp:*2 tablet(s)* refills:*0* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 10. levetiracetam 500 mg tablet sig: one (1) tablet po daily (daily) for 3 days: take one tablet per day for three days, then take one tablet for three days, then take one tablet in the morning and two tablets in the evening for three days, then take two tablets thereafter. disp:*120 tablet(s)* refills:*2* 11. insulin please continue your insulin regimen as prior to admission 12. quetiapine 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: centrus home care discharge diagnosis: -probable seizure -hypertension -diabetes mellitus -funguria -clostridium difficile enterocolitis discharge condition: stable. neurologic examination notable for orobuccal dyskinesias but otherwise normal. discharge instructions: please call your primary care physician or return to the emergency room if you experience loss of consciousness, limb shaking, new onset numbness or weakness, difficulty speaking, difficulty walking, or other concerning symptoms. please continue all medications as prescribed and attend all follow-up appointments. followup instructions: provider: phone: date/time: 2:00 provider: study phone: date/time: 10:30 provider: study phone: date/time: 11:00 please follow-up with your primary care doctor within 7-10 days after discharge. neurology: drs. and at clinical center, . at 4pm. md, Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Other convulsions Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Anxiety state, unspecified Intestinal infection due to Clostridium difficile Other and unspecified mycoses

allergies: benadryl / iodine; iodine containing / sulfa (sulfonamides) / penicillins / morphine / ambien / codeine attending: chief complaint: fever, mental status changes major surgical or invasive procedure: none history of present illness: ms. is a 73yo female with pmh significant for cad, pad, cva and dm who is being transferred from the icu. she initially presented on to with fever and confusion. at the osh she was given cetriaxone for questionable pneumonia. on transfer to she was found to be hypotensive with sbp in the 90's and febrile with t~102.8. she had leukocytosis of 15.0 and an elevated lactate of 4.3. she received 4-5l of ns, vancomycin and flagyl in the ed and a lumbar puncture was done which was negative. she was transferred to the icu for sepsis/sirs with no indentifiable source of infection. in the icu her blood pressure quickly stabilized with ivfs. she has remained afebrile since she was transferred from the ed. her antibiotic regimen was changed to levoquin, flagyl, primaquine & clindamycin (for pcp ). per patient she had not been feeling well on the day of admission to the osh. she had an uneasy feeling in her stomach. she admits to an episode of loose stools last friday and then had a large bm yesterday on transfer to the ed. she has not had any more bms since then. she denies any sob, chest pain, dizziness, nausea, vomiting, fevers, or chills at home. she does note that she has not been feeling well overall for the past several months. past medical history: 1)htn 2)hyperlipidemia 3)type 2 dmii, complicated by amyotrophy 4)peripheral arterial disease s/p fem- bypass x2 5)cad s/p mi 6)hypothyroidism 7)h/o cva (left basal ganglia) 8)seizures 9)depression social history: . no smoking or etoh. family history: nc physical exam: vital signs t 98.8 tmax 99.2 bp 134/53 ar 67 rr 18 gen: pleasant female, nad heent: mm dry, perrla heart: distant heart sounds, nl s1/s2, no s3/s4, no m,r,g lungs: ctab, +crackles @ posterior lung bases, good air movement abdomen: soft, diffusely tender, tympanic to percussion, +bs extremities: <1+ bilateral edema, 2+ dp/pt pulses bilaterally neuro: intact to time and place, equal muscle strength in upper and lower extremities pertinent results: laboratory results: 12:20pm blood wbc-15.0*# rbc-3.66* hgb-11.5* hct-34.5* mcv-94 mch-31.6 mchc-33.5 rdw-14.3 plt ct-420 07:05am blood wbc-9.9 rbc-3.55* hgb-11.2* hct-33.1* mcv-93 mch-31.7 mchc-33.9 rdw-14.8 plt ct-378 12:20pm blood pt-11.9 ptt-25.2 inr(pt)-1.0 12:20pm blood glucose-255* urean-48* creat-1.3* na-139 k-4.5 cl-103 hco3-23 angap-18 12:20pm blood alt-19 ast-27 ld(ldh)-380* alkphos-50 amylase-26 totbili-0.1 12:20pm blood totprot-5.2* albumin-2.9* globuln-2.3 calcium-8.0* phos-3.2 mg-1.7 12:20pm blood crp-45.4* relevant imaging: 1)cxray ():increased effusions are noted compared to the prior study with some mild increase in interstitial markings but no new focal consolidation 2)ct scan abdomen & pelvis (): bilateral pleural effusions and atelectasis versus aspiration. interstitial prominence at the lung bases suggestive of pulmonary edema. 3)le doppler (): no evidence of deep venous thrombosis in either lower extremity. 4)echo (): the left atrium is mildly dilated. left ventricular systolic function is hyperdynamic (ef>75%). 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. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. brief hospital course: ms. is a 74 yo female with mmps as listed above who initially presented with fever and hypotension and met sirs criteria, now being transferred from the icu to the medical floor. 1) hypotension: likely became hypotensive in the context of possible occult infection given her leukocytosis, elevated temperature, and her lactic acidosis. there was no identifiable source of infection. no consolidation on cxray, u/a negative, and blood cultures remained negative during her stay. her blood pressure slowly normalized upon transfer to the medical floor after having received liters of fluid in the icu. anti-hypertensives were initially held but then restarted at time of discharge. 2) fever, leukocytosis: there appears to be no clear source of infection based on the imaging and culture data. given her recent history of loose stools and "uneasy feeling" in her stomach c. diff was entertained. she has also been on steroids for several months and given her elevated ldh and new o2 requirements, pcp was also on the initial differential. he had bilateral pleural effusions on ct scan and was started on levoquin, flagyl, clindamycin, primaquine in the icu. blood cultures remained negative. levoquin and flagyl were continued on the medical floor but flagyl was then stopped. 3) hypoxia: patient found to have new oxygen requirement upon transfer to medical floor. be secondary to atelectasis and bilateral effusions shown on cxray. no evidence of pulmonary edema on cxray and clinical exam. echo was done with no major changes from prior study. she underwent agressive chest pt and was given an incentive spirometer. 4) cad: patient presents with no chest pain or signs of myocardial ischemia on this admission. no new ekg changes. she had not been taking her plavix for 1 week and was initially held on admission for steroid injection she will be receiving on tuesday. she was given one dose in the icu with recommendations to restart after the steroid injection. 5) diabetes: patient on insulin (glargine & regular)at home. she was continued on home regimen but the dose since she was npo. she was restarted on regular regimen at time of discharge. 6)chronic pain: patient has pain in her lower extremities secondary to diabetic amytrophy. given the severity of her pain, the pain service was consulted. she was started on pregabalin and methadone with mild improvement in her symptoms. she was also scheduled for steroid injection but had to be postponed since she had received plavix in the icu. plavix was held for the remainder of her admission until she was seen in the pain clinic as an outpatient. 7) pad: no current issues. s/p fem- bypass x2. 8) cva: no acute cva and neuro exam without focal deficit 9) seizure: ct keppra and topamax 10) hypothyroid: ct outpatient regimen of synthroid 11)depression: ct outpatient regimen of seroquel medications on admission: medications at home: hydrochlorothiazide 25 mg tablet daily levetiracetam 1000 mg po bid topiramate 50 mg tablet po qhs quetiapine 25 mg po qhs metoprolol succinate 100 mg tablet sustained release daily citalopram 30 mg po qam aspirin 81 mg tablet pantoprazole 40 mg po q12h (every 12 hours). nifedipine 30 mg tablet sustained release po daily levothyroxine 37.25 mcg po prednisone 30 mg daily docusate sodium 100 mg po bid acetaminophen 1000 mg po q8h nortriptyline 25 mg capsule senna bisacodyl 5 mg tablet methadone 15 mg po q8h insulin regular human glargine 15u sq qnoon medications on transfer: levofloxacin 750 mg iv daily metronidazole 500 mg iv q8h aspirin 81 mg po daily methadone hcl 10 mg po tid clindamycin 600 mg iv q8h metoprolol 25 mg po tid dolasetron mesylate 12.5 mg iv q8h:prn pantoprazole 40 mg po q12h prednisone 30 mg po daily heparin 5000 unit sc q8h primaquine 30 mg po daily insulin sc sliding scale quetiapine fumarate 25 mg po hs levetiracetam 500 mg po bid topiramate 50 mg po hs levothyroxine sodium 37.5 mcg po 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. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. topiramate 25 mg tablet sig: two (2) tablet po hs (at bedtime). disp:*60 tablet(s)* refills:*2* 4. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. disp:*5 tablet(s)* refills:*0* 5. quetiapine 25 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. levothyroxine 25 mcg tablet sig: 1.5 tablets po daily (daily). disp:*60 tablet(s)* refills:*2* 8. methadone 10 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* 9. pregabalin 25 mg capsule sig: two (2) capsule po qhs (once a day (at bedtime)). disp:*60 capsule(s)* refills:*0* 10. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. prednisone 10 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*0* 12. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*2* 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 14. celexa 20 mg tablet sig: 1.5 tablets po qam. disp:*30 tablet(s)* refills:*1* 15. bisacodyl 5 mg tablet sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. disp:*60 tablet, delayed release (e.c.)(s)* refills:*0* 16. insulin glargine 100 unit/ml cartridge sig: six (6) units subcutaneous in the morning. disp:*1 cartridge* refills:*2* 17. humalog insulin sliding scale please use as directed (please see attached) discharge disposition: home with service facility: gentiva discharge diagnosis: primary diagnoses: 1)fever 2)hypotension 3)type 2 diabetes 4)peripheral vascular disease secondary diagnoses: 1)seizure history 2)hypothyroidism 3)depression discharge condition: stable discharge instructions: 1)please take all medications as listed in the discharge instructions. please note that some changes have been made to your medications. 2)please do not take your plavix until you have undergone the steroid injection on tuesday. please resume plavix the day after the injection. 3)you are currently on daily steroids. please talk with your primary care physician regarding stopping your steroids once you have received the steroid injection next week. 4)you are scheduled with the nurse practitioner and pain clinic next week. please see below for date and times of your appointments. 5)if you experience any chest pain, sob, dizziness or any other concerning symptoms please return to the emergency department. followup instructions: 1)provider: 4 pain management center date/time: 11:00 2)provider: , : date/time: 11:10 3)provider: . phone: date/time: 3:30 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Unspecified septicemia Unspecified acquired hypothyroidism Other convulsions Depressive disorder, not elsewhere classified Sepsis Other and unspecified hyperlipidemia Hypotension, unspecified Personal history of other diseases of circulatory system Old myocardial infarction Hypoxemia Atherosclerosis of native arteries of the extremities, unspecified Diverticulosis of colon (without mention of hemorrhage) Myasthenic syndromes in diseases classified elsewhere Diabetes with neurological manifestations, type II or unspecified type, uncontrolled

allergies: nkda s/p left parietal crani and tumor excision (oligodendroglioma) hospital course: to pacu then to sicu post-op in nad. goal sbp <160 met at all times without use of nipride. neurologically intact, no issues, vss. pt with a ? syncopal episode/seizure while oob in chair with period of unresponsiveness, drop in hr and bp. right facial tremors noted during incident. returned to bed, bp back to 100's, pt became responsive, hr returned to . ? vagal response. dilantin d/, pt remains on tegretol. no further incidents. condition update : d/a: t max 96.9 neuro: remains intact @ baseline. pleasant and cooperative, a+ox3, perl, speech clear. right weak, pt able to squeeze but not able to use well, right lower extremity able to lift and hold but unable to do flexion/extension of foot. this is pt's baseline for right side since his surgery in . left side normal strengths. pt denies pain or headache. head dressing c,d+i. pt is to remain on bedrest and can change position of hob slowly, however do not go below 15 degrees. no s+s of seizure activity. tegretol level wnl's this am. cv: hr 60's nsr, abp 114/83. right radial aline will be d/c'd prior to tx to floor. right hl patent with kvo fluids. + ppp with generalized +1 edema throughout. resp: ls clear, diminished at bases. o2 sat 97% on 3l/m o2. pt is using is q 1 hour and c+db often with reminding. no sob, no cough. gi: tolerating regular diet. pt on a 1500cc fluid restriction for total po and ivf's . no nausea. gu: foley to bsd with clear yellow urine > 50cc/hr. sx: wife present at bedside. a/r: afebrile, neurologically intact @ baseline, no pain, vss, no s+s of seizure activity, tegretol level wnl's. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Malignant neoplasm of brain, unspecified Epilepsy, unspecified, without mention of intractable epilepsy

service:neurosurgery history of present illness: this 59 year old right handed man was initially found to have a left parasagittal frontoparietal glioma in . he had right leg weakness developing back in . by the time he was operated on he had recurrent focal seizures and was having severe right virtually no fine motor control at the ankle or foot. his right upper extremity was affected as well, but to a much lesser extent. he had moderate fine movement in the right hand. he underwent surgical excision and there was malignant alteration with increased cellularity and single cell necrosis and extensive multifocal tissue necrosis with large diffusely infiltrating histologic benign component typical of required reoperation. at that time he had radiation therapy carried out near his home at hospital in , . he did well again until when he was found to have a small recurrence in the posterior margin of the removal cavity. he underwent focal radiation at . the area of gadolinium enhancement on mr scan cleared and he did well until the summer of when he started having focal partial seizures involving the right hand. repeat mri scan showed recurrence of a gadolinium enhanced tumor again in the posterior margin of the removal cavity in the parietal region posteriorly. repeat spect scan with thallium was consistent with tumor recurrence. this was compared with a prior thallium scan in prior to his high energy beam radiation to that site. the overall recommendation of radiation therapy was to reoperate and remove this area rather than consider any further high energy beam radiation at this time. it was thought that the risks outweighed the benefits and that since the area was one which could be approached surgically without high risk to function, removal of as much active tumor as possible was the best course of treatment. past medical history: he has known esophageal reflux. he did not use tobacco or alcohol. he had l5-s1 lumbar fusion many years before in the for spondylolisthesis of l-5 on s-1. he had the prior left parietal craniotomies in and . allergies: no known drug allergies. medications: he was taking zantac each day and 200 mg of tegretol four times a day. he was started on 2 mg of decadron four times a day the day prior to admission. physical examination: vital signs were blood pressure of 142/81, pulse 65, height 5'", weight 210 pounds. head, ear, nose and throat exams were normal. neck was supple with no adenopathy, no thyromegaly and trachea midline. chest was clear to auscultation and percussion. cardiac exam showed regular rate and rhythm, normal s1, s2 with no murmurs. abdominal exam showed no organomegaly, no masses or tenderness and all bowel sounds to be present. extremities showed no joint deformities, no peripheral edema and full pulses throughout. neurologic exam showed that the patient had normal cognitive function. he had right upper extremity weakness and fairly severe fine movement deficit now in the right upper extremity which was worse than prior to the tumor recurrence. lower extremities showed minimal movement of the foot at the right ankle in dorsiflexion with no separate toe movement. gross strength in the right lower extremity was good. he walked with a limp favoring the right side. sensory exam showed hyperesthesia in the right ring and little fingers without splitting of the ring finger. this was leading to a question of whether he might have some ulnar nerve entrapment syndrome at the elbow. reflexes were hypoactive in the upper extremities, 3+/4 at the right knee, at the left knee. laboratory data: admission cbc, pro time, ptt and platelet count were all normal. his post op tegretol level was 5+ but by the day of discharge was 10+ on 1000 mg per day. hospital course: following admission the patient was immediately taken to the operating room where the left craniotomy was reopened utilizing the navigational assistance of the viewscope for excision of the tumor recurrence. results of pathology were pending at the time of this dictation. postoperatively the patient did extremely well. on the second day of his post-op course he had a syncopal episode while sitting up for half an hour and had a focal seizure involving the right side. he had transient increased right sided weakness which cleared within several hours. from that point on he had no further problems. tegretol dose was increased from 800 to 1000mg per day. he had very little headache. he had no drainage from the incision site. he was afebrile. his right upper extremity deficit remained approximately the same as it had been prior to surgery. he was kept on 4 mg of decadron four times per day for the first four days postoperatively and then started on a decadron taper on the day of discharge, lowing his dosage by 0.5 mg each day, so that on the day of discharge he was to receive 3.5 mg on a four times per day basis, the day following that 3.0 mg dose of decadron four times per day and then taper carried out through the next several weeks. he had a tegretol level post-op that was in the 5 range and his tegretol dose was increased to five 100 mg tablets per day. however, on the day of discharge repeat level was over 10 and he was instructed to cut back to four per day again. discharge diagnoses: 1. recurrent left parietal oligodendroglioma. 2. esophageal reflux by history. 3. epilepsy secondary to diagnosis #1. discharge status: approved disposition: discharged home with followup appointments to be arranged. , m.d. dictated by: medquist36 Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Malignant neoplasm of brain, unspecified Epilepsy, unspecified, without mention of intractable epilepsy

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right ruptured globe, multiple facial fractures s/p mvc major surgical or invasive procedure: right eye partial ruptured globe repair with tarsorraphy open reduction internal fixation of facial fractures trauma septo/rhinoplasty history of present illness: 19 yo male unrestrained driver mvc with + face vs. windshield trauma. no loc. brought to trauma bay via ems. + windshield starring. negative fast exam. head ct showed no ich or shift, c-spine ct no fracture ct showed: extensive intraocular hemorrhage on the right with apparent extension beyond the expected posterior margin of the globe with abnormal contour of the right globe concerning for rupture. 2. numerous comminuted fractures involving the facial bones notably with bilateral medial orbital wall fractures with fragments producing lateral displacement of the left medial rectus muscle and impinging upon both inferior rectus muscles. past medical history: none social history: lives in , denies etoh use family history: nc physical exam: 98.5, 65, 161/54, 27, 99% gen: a&o, conversant heent: tm's clear with blood in ext. canal bilaterally; nasal septum lacerated. right eye proptotic, non-reactive pupil. left eye perrla, trachea midline cv: rrr resp: ctab abd: soft, nt/nd; + seat belt bruising, good rectal tone, guaic negative ext: 2+ pulses bilaterally, no gross deformities pertinent results: 01:00pm blood wbc-14.1* rbc-5.01 hgb-15.5 hct-42.9 mcv-86 mch-30.8 mchc-36.0* rdw-12.9 plt ct-336 05:30am blood wbc-11.9* rbc-3.20* hgb-9.9* hct-27.4* mcv-86 mch-31.1 mchc-36.3* rdw-12.8 plt ct-303 05:30am blood glucose-103 urean-14 creat-0.5 na-137 k-4.1 cl-100 hco3-29 angap-12 brief hospital course: pt was intially intubated in the ed for airway protection. he was taken to the operating room on hd#1 with opthalmology for globe rupture where it was determined that his right eye could not be saved. he was admitted post-op to the tsicu where he remained intubated. hd#3 pt went to or with plastic surgery where he underwent orif of multiple facial fx's via a coronal incision as well as a trauma septo/rhinoplasty. on hd#4 pt was extubated and progressed to a regular diet. on hd#5 he left the tsicu and was transferred out to the floor where he continued to do well. his drain was d/c on hd #5. he was d/c on hd#7 in stable condition and should f/u in plastic surgery clinic this friday. pt should also f/u with occuloplastics for right eye enucleation and prosthesis placement. medications on admission: none discharge medications: 1. erythromycin 5 mg/g ointment sig: one (1) app ophthalmic qid (4 times a day). disp:*qs 1 month* refills:*2* 2. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic (2 times a day). disp:*qs one month* refills:*2* 3. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane tid (3 times a day): swish and spit. disp:*qs one month* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 5. clindamycin hcl 300 mg capsule sig: two (2) capsule po q8h (every 8 hours) for 3 days. disp:*9 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: multiple facial fractures and right eye globe rupture discharge condition: good discharge instructions: you were admitted to the hospital for multiple facial trauma. you should call your doctor or return to the er should you experience any of the following: severe increase in drainage or redness at incision sites severe increase in pain from incision sites fever > 101 severe pain to face numbness/tingling/paralysis severe dizziness nausea/vomiting severe chest pain/sob any other symptoms that worry you. you were admitted to the hospital for multiple facial trauma. you should call your doctor or return to the er should you experience any of the following: severe increase in drainage or redness at incision sites severe increase in pain from incision sites fever > 101 severe pain to face numbness/tingling/paralysis severe dizziness nausea/vomiting severe chest pain/sob any other symptoms that worry you. followup instructions: please follow-up with dr. of eye plastic surgery in weeks. you should call ( to schedule an appointment. please follow-up in plastic surgery clinic on friday . please call ( to schedule an appointment. please follow-up with your primary care doctor. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Linear repair of laceration of eyelid or eyebrow Insertion of synthetic implant in facial bone Elevation of skull fracture fragments Other open reduction of facial fracture Open reduction of nasal fracture Suture of laceration of sclera Diagnoses: Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle Ocular laceration with prolapse or exposure of intraocular tissue Open fracture of nasal bones Closed fracture of other facial bones Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness Optic nerve injury Contusion of chest wall Orthostatic hypotension

allergies: tetracycline cardiac: on ntg .48mcg/kg/min and integrillin 2mcg/kg/min. hr 86-88 bp 113/45 given 25mg po at 4pm within 10minutes hr dropped to 30's,diaphoretic,grey,vomitted small amount clear. given 1 amp atropine. bp did not drop during episode. started captopril 6.25 at 5pm and ntg weaned to off. hr now 84 bp 107/54 no cp. potassium repleted with 40meq of oral potassium.rt sheath site d&i,pulses palpable resp: lungs clear,sats 95-98 on 2l np,does smoke pack/day for 25-30yrs gu: had not voided with bradycardia foley cath placed put out 500cc gi: ate small amount of sandwhich for dinner id: afebrile neuro: alert and orientedx3 social: married with 2 children at home and three other daughters from previous marriage. 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 Tobacco use disorder Acute myocardial infarction of other anterior wall, initial episode of care Paroxysmal ventricular tachycardia Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Injury to superficial femoral artery

history of present illness: the patient is a 56 year old man with no prior cardiac history who presents with acute anterior myocardial infarction. the patient was golfing on the morning of admission when he developed chest pain. he presented immediately to complaining of chest pain. electrocardiogram there revealed st elevations in v2 through v6, as well as in 1 and f. his blood pressure was 150/100. the patient received an aspirin, lopresor, plavix, and was started on heparin and integrilin and transferred to for further care. at baseline, the patient is an active male. he plays golf routinely and runs three miles a day. on further review of systems, the patient reported only on the morning of presentation. he denied dyspnea on exertion prior to this. also denied paroxysmal nocturnal dyspnea, orthopnea, shortness of breath or lower extremity edema. the patient also denied any syncopal or pre-syncopal events. the patient denied any bowel or bladder symptoms, and in particular denied any bright red blood per rectum or melena. past medical history: 1. status post appendectomy. importantly, the patient denies hypertension, hypercholesterolemia or diabetes. allergies: tetracycline. medications: none. social history: the patient owns an exercise equipment store and sells exercise equipment. he is married. currently smokes half a pack per day. denies alcohol use. denies drug use. there is no family history of early coronary disease. physical examination on admission: the patient was afebrile. blood pressure 142/76, heart rate 86, respirations 14. good oxygen saturations. heent: pupils are equal, round, and reactive to light. oropharynx is clear. mucous membranes are moist. lungs: clear to auscultation anteriorly. cardiac: examination with regular rate and rhythm, normal s1 and s2, no murmurs appreciated. he did have an s4 on examination. abdomen: soft, nontender, nondistended. good bowel sounds. extremities: 1+ dorsalis pedis pulses bilaterally. warm and well perfused. no evidence of edema. hospital course: 1. cardiac. coronary artery disease - the patient presented with an acute st elevation myocardial infarction of his left anterior descending. on cardiac catheterization, the patient was found to have a 100% left anterior descending lesion which was stented. there was no evidence for myocardial blush after stenting, and therefore the patient was transferred to the ccu for further monitoring. post-intervention, the patient's electrocardiogram revealed persistent st elevations in 1, l and v2 through v6 and q waves in v1 through v4. also found at cardiac catheterization was an right coronary artery with a mid 60-70% lesion and a proximal 50% lesion. right atrial pressure was 11, wedge of 20, cardiac output of 3.8, with index of 1.9. the patient was continued on an aspirin, plavix and statin. he was also given a beta blocker and an ace inhibitor, which were titrated up as tolerated. in addition, this patient was given atorvastatin for cholesterol. the patient's enzymes trended down after cardiac catheterization, and he was transferred to the floor in stable condition. the patient will follow up with a cardiologist in for general cardiology. 2. pump. the patient had an echocardiogram which revealed decreased ejection fraction. in the setting of his recent myocardial infarction and decreased ejection fraction, the patient had an e.p. consultation. he will follow up with electrophysiology with dr. in four weeks for risk stratification for sudden cardiac death. 3. rhythm. the patient had nsvt post-procedure. however, at times greater than 48 hours, this had resolved. he was continued on his beta blocker and was monitored and maintained in normal sinus rhythm at the time of discharge. 4. vascular. the patient was noted to have a bruit over the site of his cardiac catheterization, and ultrasound revealed an a-v fistula of the superficial artery and vein. vascular surgery was consulted, and the decision was made to not pursue this further at the time of this admission. this should be monitored, and the patient will follow up with dr. of vascular surgery in approximately six weeks, and have a repeat femoral ultrasound for further evaluation at that time. condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. st elevation myocardial infarction. status post left anterior descending stent. 2. superficial femoral a-v fistula. discharge medications: 1. aspirin 325 q day. 2. plavix 75 q day. 3. atorvastatin 80 q day. 4. coumadin 7.5 q h.s. 5. toprol-xl 100 q day. 6. lisinopril 5 q day. 7. lovenox 60 mg b.i.d. until therapeutic on coumadin. 8. eplerenone 25 mg p.o. q day. followup plans: the patient will follow up with his primary care physician in the week following discharge for further check of his inr and dose adjustment of his coumadin. in addition to this, they will follow up on his liver function tests, as the patient has a history of elevated liver function tests, and in the setting of starting atorvastatin this should be further monitored. the primary care physician will also follow up with a repeat hematocrit to ensure stable hematocrit, as well as chem-7 to ensure stable renal function. the patient will follow up with cardiology in one month's time. he will be seeing , who can be reached at , for his cardiology followup in . he will follow up with the cardiologist in one month. in addition, this patient will follow up with dr. of electrophysiology with a repeat echocardiogram and then an appointment on . the patient will follow up with vascular surgery, dr. , on . , 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 Tobacco use disorder Acute myocardial infarction of other anterior wall, initial episode of care Paroxysmal ventricular tachycardia Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Injury to superficial femoral artery

history of present illness: this is a -year-old female with a history of critical aortic stenosis, status post aortic valvuloplasty in by dr. , now presenting as a direct admission by dr. for worsening shortness of breath and dyspnea on exertion increasing over the last several weeks. she has also had weight loss over the last several weeks. the patient denies chest pain or syncope. the patient presented for an echocardiographic evaluation of her heart and will undergo aortic valvuloplasty on . past medical history: 1. hypertension. 2. ovarian islet cell tumor. 3. decreased hearing. 4. poor gait and balance. 5. critical aortic stenosis. 6. status post aortic valvuloplasty in with aortic valve area going from 0.4 to 0.7; previous echocardiogram in showed an ejection fraction of 55%, moderate-to-severe aortic stenosis, 1 to 2+ aortic regurgitation, 1 to 2+ mitral regurgitation. allergies: the patient has no known drug allergies. medications on admission: 1. multivitamin 1 tablet p.o. q.d. 2. lasix 40 mg p.o. q.d. 3. ditropan 5 mg p.o. b.i.d. 4. lanoxin 0.125 mg p.o. q.d. 5. aspirin 81 mg p.o. q.d. 6. iron sulfate 300 mg p.o. q.d. 7. potassium chloride 20 meq p.o. q.d. 8. celebrex 100 mg p.o. q.d. 9. ibuprofen 200 mg p.o. b.i.d. 10. peri-colace p.r.n. 11. vitamin c and vitamin e. 12. aricept 10 mg p.o. q.d. social history: the patient does not smoke. she uses occasional alcohol. she lives in an facility. physical examination on presentation: vital signs revealed temperature of 95.3, blood pressure of 122/72, heart rate of 82, respirations of 20, 98% on 2 liters. head, eyes, ears, nose, and throat revealed normocephalic and atraumatic. mucous membranes were moist. the neck had no jugular venous distention. the lungs had faint crackles at the bases. cardiovascular revealed a regular rate and rhythm. first heart sound and second heart sound. a high-pitched systolic ejection murmur. the abdomen was soft, nontender, and nondistended. extremities revealed 1+ edema. pertinent laboratory data on presentation: laboratories revealed white blood cell count of 8.7, hematocrit of 30.5, platelets of 213. sodium of 143, potassium of 3.9, chloride of 105, bicarbonate of 27, blood urea nitrogen of 24, creatinine of 1.4, glucose of 108. digoxin level of 1.4. pt of 13.3, ptt of 24.5, inr of 1.2. calcium of 8.5, magnesium of 1.9, phosphorous of 3.6. creatine kinase of 150, mb of 2. troponin i was less than 0.3. radiology/imaging: electrocardiogram had a left bundle-branch block at rate of 79; this was new compared to . chest x-ray showed slight congestive heart failure. an echocardiogram revealed an ejection fraction of 20%, aortic valve area was 0.4, peak in the 70s, and mean in the 40s, moderate-to-severe mitral regurgitation. hospital course: the patient was admitted. an echocardiogram was obtained which had the results as above. although is elderly and has an overall poor prognosis, it was felt that she would obtain benefit for aortic valvoplasty, as she was not a surgical candidate. for her congestive heart failure, she was continued on lasix 40 mg p.o. q.d. she was continued on digoxin. she was continued on aspirin q.d. she was continued on aricept for her dementia. on , the patient underwent a left heart catheterization, coronary angiography, aortic valvuloplasty, rvtpm and rhc. indications were coronary artery disease, unstable angina, congestive heart failure, and critical aortic stenosis. findings revealed the patient had a right-dominant system. her left main coronary artery had mild calcification. the left anterior descending artery had no significant lesions. the left circumflex was a nondominant vessel without critical lesions. the right coronary artery was a dominant vessel without critical lesions. an aortic valvuloplasty was performed with and increase in the aortic valve are from 0.3 cm2 to 0.6 cm2. cardiac index remained very low at 1.7 l/min/kg. the patient was transferred to the coronary care unit until hemodynamic stability was obtained. she was placed on dobutamine to maintain mean arterial pressure. the patient went into complete heart block and had a transvenous pacemaker placed. the complete heart block spontaneously resolved and was felt to be due to irritation of the right bundle-branch in the setting of the left bundle-branch block. on , the patient was called out to the floor as she remained hemodynamically stable and did not re-enter into complete heart block with her transvenous pacing discontinued. on , the patient was doing well with no complaints. she was afebrile with stable vital signs. her blood pressure was 129/72. her examination was unremarkable. her groin had no hematoma, oozing, or bruits. a physical therapy consultation was requested, and her diet was supplemented with boost shakes three times per day. a physical therapy evaluation was obtained on . the patient was able to ambulate 60 feet with slow gait and frequent standing and rest breaks. physical therapy recommended further physical therapy treatments. on , the patient was doing well with no complaints. her blood pressure was stable at 110/58. her examination was unchanged. laboratories were significant for a hematocrit of 29, a potassium of 3.4, and a magnesium of 1.8. potassium was supplemented with 40 meq of p.o. potassium chloride. magnesium was supplemented as well. case management was consulted concerning placement of the patient versus going back to her facility with 24-hour nursing. the family felt that they would prefer the second option. on , the patient was doing well with no complaints of chest pain or shortness of breath. she report some mild nausea which is chronic in nature. her blood pressure was stable at 105/61. she tolerated 1420 p.o. on the previous day. her examination was unchanged. her laboratories were significant for a hematocrit of 30.4, potassium of 4.3, an albumin of 3.1, and a magnesium of 1.9. telemetry revealed a normal sinus rhythm with premature ventricular contractions. issues: 1. cardiovascular: we will continue the lasix and digoxin for the patient's congestive heart failure and maintain her fluid balance. her blood pressure remained stable. 2. nutrition: we need to continue to encourage p.o. and supplement with boost three times per day. the patient should have a cardiac low-salt diet. 3. physical therapy: we need to continue physical therapy and encourage ambulation and strength training. 4. hematology: the patient's hematocrit is stable at 30.4. 5. gastrointestinal: the patient has had nausea and reflux for months. she should continue on her prilosec, and she should consider an outpatient gastrointestinal workup. discharge disposition: discharged to facility with 24-hour nursing and physical therapy. discharge followup: the patient was to follow up with dr. in six to eight weeks. code status: the patient's code status is no chest compression and do not intubate. condition at discharge: condition on discharge was fair. discharge status: discharged to facility with 24 nursing care. discharge diagnoses: 1. critical aortic stenosis. 2. status post aortic valvuloplasty. 3. congestive heart failure. 4. elderly. 5. cardiac cachexia. 6. anemia. 7. ovarian islet cell tumor. 8. decreased hearing. 9. poor gait and balance. medications on discharge: 1. multivitamin 1 tablet p.o. q.d. 2. lasix 40 mg p.o. q.d. 3. ditropan 5 mg p.o. b.i.d. 4. lanoxin 0.125 mg p.o. q.d. 5. iron sulfate 300 mg p.o. q.d. 6. potassium chloride 20 meq p.o. q.d. 7. celebrex 100 mg p.o. q.d. 8. aricept 10 mg p.o. q.h.s. 9. enteric-coated aspirin 81 mg p.o. q.d. 10. colace 100 mg p.o. b.i.d. 11. prilosec 20 mg p.o. q.d. 12. oxycodone 5 mg p.o. q.6h. p.r.n. for pain. 13. maalox 30 cc p.o. t.i.d. p.r.n. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Angiocardiography of left heart structures Insertion of temporary transvenous pacemaker system Percutaneous balloon valvuloplasty Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Mitral valve disorders Congestive heart failure, unspecified Cardiac complications, not elsewhere classified Aortic valve disorders Abnormality of gait Other persistent mental disorders due to conditions classified elsewhere Atrioventricular block, complete

his past medical history is significant with chronic anemia, history of pe with an ivc filter in place, chronic venous stasis ulcers and disease, colon cancer status post colectomy in the 70s. medications: he was on aspirin. he was on a heparin drip. he was on imdur 30 mg q day, hydroxyzine, and lisinopril. he had no known drug allergies. his lungs were clear to auscultation bilaterally. his heart was regular rate, but bradycardic. his abdomen was soft, nontender, nondistended. bowel sounds are present. he had a positive colectomy. he had good pulses. he was taken to the operating room on where a cabg x2 was performed. the patient had a lima to left anterior descending artery, a -tex graft to the right rda and a left radial to om. the patient was transferred to the sicu postoperatively. he was slowly weaned from his ventilator and was extubated. he was also started on plavix for his radiograph as well as for his -tex graft. he continued to do well. the patient's monitor was slowly turned off, and he was found to be significantly bradycardic and electrophysiology was consulted. electrophysiology saw the patient and found that he has had bradycardic heart rate. it was decided at that time for a pacemaker to be placed, and it is scheduled to be done after discharge at a cardiac rehab facility. physical therapy was also consulted to assess ambulation, and he did well. however, physical therapy agreed with electrophysiology in requesting patient go to rehabilitation for potential increased physical therapy and range of motion. patient was transferred to the floor postoperatively and he continued to improve. foley was removed. he was unable to urinate, therefore foley was replaced. patient was not started on beta blockade because for his sinus bradycardia and for antinodal blockade. the patient was continued on the pacemaker at that time and continued on imdur and plavix for his graft. his pacer was set for ddi at 60. he continued to improve at that time. on postoperative day #7, the patient was discharged to rehab facility in stable condition with plan to have a pacer placement at that time. the patient was discharged. discharge medications include imdur 30 mg po q day, plavix 75 mg po q day, captopril 12.5 mg po tid, percocet 1-2 tablets po q4 hours prn, aspirin 325 mg po q day, zantac 150 mg po bid, colace 100 mg po bid, lasix 20 mg po bid, and 20 meq po bid. patient is discharged to rehabilitation in stable condition instructed to followup with primary care physician weeks. also follow up with cardiology after his pacer as needed and follow up with dr. in four weeks. the patient was discharged to rehab in stable condition. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Congestive heart failure, unspecified Hematoma complicating a procedure Personal history of malignant neoplasm of large intestine Other second degree atrioventricular block

allergies: penicillins / tetracyclines / plaquenil / chloroquine / sulfonamides / floxin attending: chief complaint: (positive blood cultures) major surgical or invasive procedure: hickman line insertion picc line insertion history of present illness: 49 y/o with hx. lupus and pah on flolan who developed night sweats approximately 10 days ago at which time she was started on levaquin as an outpatient. subsequent to this, her night sweats improved, but on follow up with her outpatient pulmonolgist, peripheral blood cultures were obtained (two days ago, and after 6 days of levaquin) which have grown gram positive cocci in both aerobic bottles, in clusters, speciation and sensitivity pending. she is admitted for line change by dr. of surgery. she is in the ccu owing to her flolan infusion. past medical history: pmh: pulmonary artery hypertension treated with flolan infusion systemic lupus erythematosus (22 years) treated with prednisone and intermittent plaquenil, mycophenolate, methotrexate, and cyclophosphamide glomerulonephritis in type 2 diabetes fibromyalgia migraines sinusitis frequent urinary tract infections social history: sh: denies etoh, illicits. has never smoked. family history: fh: negative for cad physical exam: blood pressure was 117/79 mm hg while seated. pulse was 116 beats/min and regular, respiratory rate was 14 breaths/min. 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 of 7 cm. the carotid waveform was normal. there was no thyromegaly. the were no chest wall deformities, scoliosis or kyphosis. the respirations were not labored and there were no use of accessory muscles. the lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . palpation of the heart revealed the pmi to be located in the 5th intercostal space, mid clavicular line. there were no thrills, lifts or palpable s3 or s4. the heart sounds revealed a normal s1 and the s2 was normal. there were no rubs, murmurs, clicks or gallops. . the abdominal aorta was not enlarged by palpation. there was no hepatosplenomegaly or tenderness. the abdomen was soft nontender and nondistended. the extremities had no pallor, cyanosis, clubbing or 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+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: imaging: fluoro guid plct/replct/remove central line 1:56 pm impression: successful exchange for new 51 cm dual lumen picc with tip in the svc, ready for use. . micro: blood cx: micrococcus spp catheter tip: probable micrococcus spp - blood cx: ngtd . labs: 01:43pm pt-19.6* ptt-26.8 inr(pt)-1.9* 01:43pm wbc-6.0 rbc-4.05* hgb-12.0 hct-34.9* mcv-86 mch-29.5 mchc-34.3 rdw-14.2 01:43pm calcium-8.9 phosphate-3.6 magnesium-1.5* 01:43pm estgfr-using this 01:43pm glucose-242* urea n-11 creat-0.7 sodium-139 potassium-3.6 chloride-103 total co2-22 anion gap-18 . operative report: preoperative diagnosis: pulmonary hypertension on continuous flolan drip with need for long-term central venous access. postoperative diagnosis: pulmonary hypertension on continuous flolan drip with need for long-term central venous access. name of procedure: placement of 9.6-french single-lumen hickman catheter via left subclavian vein with fluoroscopy. assistant: none anesthesia: mac with local. indications for procedure: ms. is a 49-year-old lady with a history of pulmonary artery hypertension who has been on a flolan drip through a central venous catheter since of last year. she had an indwelling single-lumen catheter in place but was admitted several days ago with a line infection with coagulase-negative staphylococcus and micrococcus species. the line was removed on and she has been receiving intravenous vancomycin via a picc line in the interim. she presents now for placement of a new tunneled line for the long-term administration of flolan. the flolan drip was to be continued throughout this operation via an indwelling picc line in the right arm. the risks and benefits of this procedure were discussed with the patient and the consent signed. description of procedure in detail: the patient was identified in the preoperative holding area and taken to the operating room where she was positioned supine on the operating room table with her arms tucked at her side. after the adequate induction of monitored anesthesia, her bilateral upper chest and lower neck were sterilely prepped and draped in the usual fashion. a timeout was performed identifying the patient and the procedure to be performed. intravenous vancomycin had been administered in the icu. the left infraclavicular space was anesthetized with a 1:1 mixture of 1% lidocaine with epinephrine and 0.5% marcaine plain. with the patient placed in the trendelenburg position, the left subclavian vein was easily accessed on first pass with a needle. a wire was placed centrally by seldinger technique and confirmed to be in the central circulation by intraoperative fluoroscopy. additional local anesthetic was infiltrated upon the planned path of tunneling along the left chest wall. an incision was made contiguous with the wire exit site and a counter incision made more inferiorly on the left chest wall. a 9.6-french single-lumen hickman catheter was then secured to a tunneling device and was then advanced through the tunnel, positioning the cuff in the mid-portion of the tunnel. the catheter was then cut to an appropriate length. a dilator peel-away sheath assembly was advanced over the wire and into the left subclavian vein without resistance. the dilator and wire were removed together with venous backbleeding from the sheath. the catheter was advanced through the sheath which was in turn removed. the tip of the catheter was located in the proximal right atrium by intraoperative fluoroscopy. the catheter was secured at the skin exit site with a single 2-0 prolene suture. the catheter easily aspirated venous blood and was flushed with dilute heparinized saline and then with heparinized saline 100 units per ml. sterile dressings were applied. the patient tolerated the procedure well. there were no complications. she was transferred back to the intensive care unit in good condition. brief hospital course: # bacteremia: most likely source is permanent flolan catheter which was removed. blood cultures from showed 2/2 bottles with gram positive cocci, probable micrococcus spp. she was started on vancomycin empirically and monitored with daily serial blood cultures, all negative since initial antibiotic therapy. once blood cultures were negative for 2 consecutive and surgery successfully placed a new hickman catheter for flolan administration. patient remained afebrile and had a successful picc placement for the remainder of her vancomycin therapy. . # pulmonary artery hypertension: likely secondary to lupus. patient was maintained on flolan infusion through peripheral iv until central access was obtained. she was also continued on prednisone. she was maintained on heparin anticoagulation while in house for her pulmonary artery hypertension and anti-phospholipid antibodies, and outpatient warfarin was held due to procedures. patient had a successful hickman catheter placement for flolan infusion. she was started on lovenox prior to discharge as a bridge to warfarin and was to have her inr checked as an outpatient. . . after discussion with the patient and the medical staff, all were in agreement that was a suitable candidate for discharge. medications on admission: fluconazole 150 daily tylenol#3 prn gabapentin 1800, once daily warfarin 1 mg daily fluticasone nasal spray fexofenadine ambien premarin allopurinol metformin 850 discharge medications: 1. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) spray nasal daily (daily). 2. prednisone 5 mg tablet sig: two (2) tablet po daily (daily). 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 5. gabapentin 300 mg capsule sig: two (2) capsule po daily (daily). 6. warfarin 1 mg tablet sig: one (1) tablet po once a day: start after 2 days of 5mg daily of coumadin. disp:*30 tablet(s)* refills:*0* 7. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 8. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime). 9. conjugated estrogens 0.625 mg tablet sig: one (1) tablet po daily (daily). 10. metformin 850 mg tablet sig: one (1) tablet po twice a day. 11. line maintenance line maintenance as per ccs protocol. 12. vancomycin 1,000 mg recon soln sig: one (1) intravenous every twelve (12) hours for 8 days. disp:*16 * refills:*0* 13. amitriptyline 50 mg tablet sig: four (4) tablet po hs (at bedtime). 14. warfarin 1 mg tablet sig: five (5) tablet po daily (daily) for 2 days. disp:*10 tablet(s)* refills:*0* 15. outpatient lab work patient will require inr levels every 3 days and these will need to be faxed to vna of . 16. lovenox 120 mg/0.8 ml syringe sig: one (1) subcutaneous once a day for 14 days. disp:*14 14* refills:*0* discharge disposition: home with service facility: vna assoc. of discharge diagnosis: catheter-related bloodstream infection . secondary diagnoses: systemic lupus pulmonary artery hypertension lupus anticoagulant discharge condition: vital signs stable, afebrile, with new flolan infusion access and consecutive negative blood cultures. discharge instructions: you were admitted due to infection from your flolan infusion iv line. you were treated with antibiotics and your line was changed. you should continue to take the antibiotic as prescribed and complete the whole course, even if your symptoms resolve. please call your physician or return to the emergency room if you notice fevers, chills, night sweats, or any other concerning symptoms. your fluconazole was stopped due to elevated liver enzymes - please don't restart this until instructed by your doctor. you will be taking 5mg daily of coumadin for 2 days, and then decreasing your dose back to 1mg daily. please have your inr(coumadin level) checked by your visiting nurse in a few days. continue your daily lovenox injections until your coumadin level is normalized. vancomycin (antibiotic) will be continued twice daily for 8 more days through your picc line. followup instructions: please follow-up with your pulmonologist in weeks after discharge. . provider: phone: date/time: 10:00 provider: , m.d. phone: date/time: 10:30 provider: , intepretation billing date/time: 10:30 Procedure: Venous catheterization, not elsewhere classified Incision with removal of foreign body or device from skin and subcutaneous tissue Insertion of totally implantable vascular access device [VAD] Diagnoses: Systemic lupus erythematosus Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Infection and inflammatory reaction due to other vascular device, implant, and graft Myalgia and myositis, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Chronic pulmonary heart disease, unspecified

allergies: penicillins / tetracyclines / plaquenil / chloroquine / sulfonamides / floxin / heparin agents attending: chief complaint: hypotension major surgical or invasive procedure: transesophageal picc line placement history of present illness: the pt is a 51-year-old woman with sle and severe pah diagnosed in with excellent response to flolan, recently admitted and discharged on day pta for right heart cardiac cath performed for progressive hypoxemia with increased need for supplemental oxygen despite an improved and six-minute walk test distanceand renal biopsy for proteinuria, transferred from hospital with hypotension sbps 60s-70s. patient discharged from , awoke this am around noon with confusion, lethargy, dizziness with standing. on arrival to ed bp 73/48,hr 103, rr18 95% 4l, t98.2. prior to transfer bp 85/53, 100% ra. only osh lab data wbc 4.2 hct 30, plt 133. cxr low lung volumes with no acute process. piv x 2 placed, received 4l ns and linezolid x 1 and transferred to micu. upon arrival pt's vitals 100.7 hr 106 bp 95/57 rr19 74-99% o2 sats. she reports she has had dizziness, low bps and overall malaise x 2-3 days. also reports subjective fevers, no chills, and tenderness at line site x 1 week but no purulent drainage or erythema. she has had line x 1 year and reports prior h/o similar presentations with line sepsis. has minimal pain at left flank site of biopsy, no pain in right groin where had cath. only other complaint is chronic headache and recurrence of chronic bilateral shoulder pain x 2 days. recent medictaion changes include addition of lisinopril 1 week prior and holding of coumadin for procedure (renal biopsy) planned to be restarted . denies change in chronic dyspnea or le edema, denies cough, chest pain, le pain, dysuria, hematuria, melena, hematochezia, numbness/weakness. past medical history: -systemic lupus erythematosus with history of pleuritis, glomerulonephritis () -diabetes mellitus type 2 -pulmonary arterial hypertension on flolan -atrial septal defect of the secundum type (versus a stretched pfo) -obstructive sleep apnea on home oxygen -anticardiolipin antibody (although disputed in recent heme-onc notes, recent tests negative) -type 1 heparin induced thrombocytopenia (although questionable per heme/onc) -obesity -restrictive pulmonary disease -migraines -history of sinusitis -fibromyalgia. -history of a miscarriage psh s/p cholecystectomy, s/p hysterectomy social history: she has not ever worked outside the home. she lives in . she has no tobacco or alcohol use. she has four children. family history: her father died of colon cancer at age 73. her mother is healthy as are her brother and sisters. physical exam: vitals - t 100.7 hr 106 bp 95/57 rr 19 o2sat 74-99% general: patient sitting back in bed with nasal cannula oxygen, nad, speaking in full sentences. cushingoid appearance heent: dry mm. ncat. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: thick. unable to appreciate jvd. cv: tachy. prominent split s2. no thrills, lifts. no s3 or s4. chest: crackles in bases l>r. no wheezes or rhonchi. right chest tunneled hickmans with mild tenderness just superior to line. no purulence or drainage. minimal erythema. abd: obese. hypoactive bs. somewhat distended, soft, nt. no hsm or tenderness. no cva tnederness. no palpable hematoma over left ext: trace edema. no clubbing or cyanosis. r groin dsg c/d/i. no femoral bruits or thrills. skin: thinning, ecchymoses rle, ue bl, erythema over anterior chest and back neuro: cn 2-12 intact. aao x 3 pertinent results: imaging: cxr: azygos distention reflects increased intravascular fluid volume. pulmonary circulation is borderline engorged but there is no edema. mild cardiomegaly stable. no pleural effusion or pneumothorax. right subclavian line tip projects over the mid svc. no pneumothorax chest ct: impressions: 1. main pulmonary artery enlargement is little changed compared to , and is consistent with the history of pulmonary hypertension. cardiac enlargement, with prominence of the right ventricle, is unchanged. 2. no evidence of interstitial lung disease or other new intrathoracic process is seen to account for increasing oxygen requirement. 3. small pericardial effusion may be related to the patient's underlying lupus. 4. mild small airway obstruction. 5. allowing for differences in technique, sub-4 mm right lower lobe nodule is not changed from . without strong risk factor for intrathoracic malignancy, no further followup is recommended guidelines. tte: the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the estimated pulmonary artery systolic pressure is slightly higher. tee: the left atrium is mildly dilated. the right atrium is moderately dilated. there is a small secundum atrial septal defect with mild bidirectional shunting across the interatrial septum at rest. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the pulmonic valve leaflets are thickened. no masses or vegetations are seen on the aortic, mitral, triucuspid and pulmonary valves the tricuspid valve leaflets are mildly thickened. the main pulmonary artery is dilated. there is no pericardial effusion. impression: no valvular vegetations seen. small secondum asd with bidirectional shunt (small). dilated main pulmonary artery. mild-to-moderate tricuspid regurgitation. globally hypokinetic rv. renal u/s: no evidence of hematoma or abscess s/p biopsy head ct: impression: no evidence of acute intracranial hemorrhage or mass effect. lucent area seen within the right frontal bone, most likely a venous ; however, please correlate clinically with history of prior surgery or history of underlying malignancy. mri may be obtained for the latter. studies cardiac catheterization final diagnosis: 1. severe pulmonary arterial hypertension despite supplemental oxygen and flolan infusion. 2. mild right ventricular diastolic dysfunction. 3. normal left-sided filling pressures as reflected in the pcw. ct chest 1. main pulmonary artery enlargement is little changed compared to , and is consistent with the history of pulmonary hypertension. cardiac enlargement, with prominence of the right ventricle, is unchanged. 2. no evidence of interstitial lung disease or other new intrathoracic process is seen to account for increasing oxygen requirement. 3. small pericardial effusion may be related to the patient's underlying lupus. 4. mild small airway obstruction. 5. allowing for differences in technique, sub-4 mm right lower lobe nodule is not changed from . without strong risk factor for intrathoracic malignancy, no further followup is recommended guidelines. echo the left atrium is normal in size. the right atrial pressure is indeterminate. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is no aortic valve stenosis. the mitral valve appears structurally normal with trivial mitral regurgitation. the tricuspid valve leaflets are mildly thickened. there is mild to moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the rv has decreased in size (less dilated) and the estimated pa systolic pressure has decreased. abg: 7.35/42/87 crp: 26.7 esr: > 100 cre: 0.9 on admission, 0.8 on discharge hct stable in high 20s to low 30s cks flat, trop 0.02 on admission. brief hospital course: # sepsis: likely in setting hickman line infection, which patient has had in the past (). patient was initially septic on admission, meeting sirs criteria for fever, tachycardia, elevated wbc, and positive blood cultures. no evidence of endocarditis on tte or tee. no evidence of pna or uti. no evidence of septic hematoma from recent procedures (renal biopsy or right heart cath). she was initially treated with fluid boluses, daptomycin and levofloxacin, and became hemodynamically stable without requiring pressors. vancomycin sensitive strep viridans and cns were subsequently noted to be growing on osh cultures. id was consulted for antibiotics management and recommended a rule out for endocarditis and removal of the hickman catheter for culture and removal of infection nidus. however, per dr. and dr. , the decision was made that the hickman line was to be kept in place for her continuous flolan, due to the difficulty and the danger to her general health of discontinuing the infusion. she will receive 4 weeks of vancomycin as an outpatient through the picc line taht was placed. surveillence cultures were noted to have microccoccus spp, subsequent cultures neg. she will need repeat blood cultures if febrile as outpatient. she will have blood cultures, cbc, lfts, bun and cre, and vancomycin trough checked weekly as an outpatient while on vancomycin. #pulmonary hypertension: recent cardiac cath demonstrated severe pulm htn despite flolan. flolan was continued. lasix was held low bps and can be reinitiated as an outpatient. supplemental oxygen was continued to maintain o2 sats >93%. she was restarted on her coumadin prior to discharge for prevention of chronic pulmonary emboli that may have contributed to her pulm htn. # lupus nephritis: patient has lupus nephritis with recent worsening of proteinuria, most recently protein/creatinine ratio 8, improved from 15-16 . her renal biopsy showed an igg immune deposition, diabetic nephropathy, and lupus nephritis. no treatment regimen was recommended at this time per nephrology consult given her other medical issues. lisinopril was inititally administered, but she was unable to tolerate it and had issues with hypotension and ams (see below.) she will follow up with them as an outpatient and has been scheduled into dr. clinic. #ams: likely initiated by hypotension. patient trigged for hypotension 10-12 hours after being administered lisinopril with sbps into the 70s. she was noted to be somnolent. no hypoglycemia was noted. pt did not take more than her usual vicodin and tylenol #3, but out of concern for narcotics overdose, narcan was administered. akathisia-like movements were then noted after narcan administration, which were relieved with benadryl and benztropine. pt reports similar event one week ago at home in setting of low blood pressure with ams and loss of memory of events. her lisinopril and lasix were subsequently held and her sbps were maintained > 100. her mental status was at baseline on discharge. patient should have another head ct in months. # dm: oral hypoglycemics were held and she was controlled on iss while hospitalized # depression/anxiety: pt on multiple meds at home. originally there was some concern for serotonin syndrome given multiple medications and received linezolid at osh however her hypotension resolved after the linezolid was discontinued and the other antiobiotics were started. continued cymbalta, amitriptyline, holding wellbutrin #migraines: continued amitrityline medications on admission: medications: tylenol with codeine allopurinol 100 mg once a day amitriptyline 200 mg q.h.s. wellbutrin 150 mg twice a day premarin 0.625 mg once a day cymbalta 60 mg once a day flolan 15 ng/kg/minute continuous iv vitamin d fexofenadine furosemide 40 mg twice daily gabapentin 1600 mg twice a day vicodin prn lisinopril metformin nystatin prednisone 10 mg once a day. 4 mg of warfarin (held x 1 week) ambien fluconazole 150 mg qmwf lorazepam 0.5 mg q four hours prn anxiety. supplemental oxygen, 4l x approx. 14 hours per day discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 2. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 3. bupropion 75 mg tablet sig: two (2) tablet po bid (2 times a day). 4. amitriptyline 50 mg tablet sig: four (4) tablet po hs (at bedtime). 5. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 6. gabapentin 400 mg capsule sig: four (4) capsule po qhs (once a day (at bedtime)) as needed. 7. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 8. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 9. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 10. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. epoprostenol 0.5 mg recon soln sig: one (1) recon soln intravenous infusion (continuous infusion). 12. fluconazole 150 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 13. insulin lispro 100 unit/ml solution sig: variable units subcutaneous asdir (as directed): per sliding scale. 14. vancomycin 1,000 mg recon soln sig: 1250 (1250) mg intravenous twice a day for 4 weeks: start date end date . disp:*48 doses* refills:*0* 15. warfarin 2 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 16. outpatient lab work please check weekly cbc with differential, chem 7, and liver function tests. results should be faxed to . 17. normal saline flushes sig: 5-10 cc asdir for 30 days: please use pre and post dose. no heparin given allergy to heparin agents. . disp:*150 flushes* refills:*0* discharge disposition: home with service facility: accredo iv home infusion discharge diagnosis: sepsis likely from hickman catheter infection discharge condition: the patient was afebrile and hemodynamically stable prior to discharge. discharge instructions: 1) you were admitted to the hospital with low blood pressure. this was from an infection of the catheter in your chest. you were given antibiotics for this infection. you should continue these antibiotics for the full course described below. you will need to take your antibiotics (vancomycin) for four weeks, starting from until . you had a semipermanent line called a picc line placed for this reason. 2) the following changes were made to your medications: your lasix was stopped due to low blood pressure. your lisinopril was stopped due to low blood pressure. 3) please keep all of your followup appointments 4) please call your doctor or come back to the hospital if you experience light-headedness, dizziness, chest pain, shortness of breath, rash, itchiness, fevers, abdominal pain, nausea, vomiting, pain with urination, diarrhea, leg swelling, or any other concerning symptoms. . 5) you should have a repeat head ct in months for further evaluation of findings noted on your imaging studies from this hospitalization. followup instructions: please call for a follow up appointment with your pcp , . at in 2 weeks. please follow up with your pulmonologist dr. within 1-2 weeks after discharge. please discuss restarting your lisinopril and lasix with her at this time. please follow up with renal as an outpatient for treatment of your nephritis. you are scheduled to see dr. on at 3:00 pm. the phone number for the renal clinic is 61- in case you need to schedule. you will be contact by the renal clinic if an earlier availability opens up, per dr. . other appointments: provider: , md phone: date/time: 1:00 provider: function lab phone: date/time: 2:30 provider: ,interpret w/lab no check-in intepretation billing date/time: 2:30 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Systemic lupus erythematosus Other iatrogenic hypotension Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Obstructive sleep apnea (adult)(pediatric) Other chronic pulmonary heart diseases Sepsis Dysthymic disorder Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Ostium secundum type atrial septal defect Other diseases of lung, not elsewhere classified Primary hypercoagulable state Obesity, unspecified Encephalopathy, unspecified Other and unspecified infection due to central venous catheter Streptococcal septicemia Myalgia and myositis, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Pain in joint, shoulder region Unspecified sinusitis (chronic) Pleurisy without mention of effusion or current tuberculosis Lung involvement in other diseases classified elsewhere Heparin-induced thrombocytopenia (HIT)

allergies: penicillins / tetracyclines / plaquenil / chloroquine / sulfonamides / floxin attending: chief complaint: direct admit for chf and pulmonary hypertension management major surgical or invasive procedure: tunneled central venous catheter placement flolan titration. history of present illness: hpi: 49 year old with hx of lupus, pulmonary hypertension, rv enlargement and failure and an asd who is being admitted for management of chf/pulm htn. the patient has had progressively worsening dyspnea over the past one year. she has noticed diminished exercise tolerance. was able to climb the stairs in her home without difficulty. now she becomes dyspnea. also becomes dyspneic when ambulating on flat ground. occasionally notices a sensation of pressure across chest and arms. pt was seen by dr. in cardiology on for evaluation. as part of his work-up the pt had a tte which demonstarted moderate to severe pulmonary hypertension, markedly dilated right ventricle and r to l shunting c/w an asd/pfo. a p-mibi demosnstrated a markedly increased right ventricular cavity size with severe global hypokinesis with evidence of right-sied pressure and volume overload. the patient is to be admitted to 6 for further evaluation of the pt's pulm htn and management of her chf. past medical history: pmh: systemic lupus erythematosus (22 years) treated with prednisone and intermittent plaquenil, mycophenolate, methotrexate, and cyclophosphamide glomerulonephritis in type 2 diabetes fibromyalgia migraines sinusitis frequent urinary tract infections social history: sh: denies etoh, illicits. has never smoked. family history: fh: negative for cad physical exam: temp 96.9 bp 110/85 pulse 113 resp 18 o2 sat 92% ra gen - alert, no acute distress heent - mucous membranes moist neck - jvp 7 cm, no cervical lymphadenopathy chest - minimal crackles way up b/l cv - normal s1/s2, rrr, no murmurs appreciated abd - soft, nontender, nondistended, with normoactive bowel sounds back - no costovertebral angle tendernes extr - 1+ pitting edema above ankles b/l. 2+ dp pulses bilaterally neuro - alert and oriented x 3, non-focal skin - no rash pertinent results: echo conclusions: the left atrium is elongated. the right atrium is moderately dilated. a right-to-left shunt across the interatrial septum is seen at rest after contrast injection consistent with and asd/pfo. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is markedly dilated. there is severe global right ventricular free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is moderate to severe pulmonary artery systolic hypertension. . impression: moderate to severe pulmonary hypertension. markedly dilated right ventricle. severe right ventricular dysfunction. right to left shunting across interatrial septum at rest c/w asd/pfo. . p-mibi impression: 1. normal myocardial perfusion. 2. normal left ventricular cavity size and systolic function. 3. markedly increase right ventricular cavity size with severe global hypokinesis with evidence of right-sied pressure and volume overload . 05:19pm glucose-149* urea n-15 creat-0.8 sodium-141 potassium-4.4 chloride-106 total co2-24 anion gap-15 05:19pm calcium-9.0 phosphate-3.5 magnesium-1.6 05:19pm estgfr-using this 05:19pm wbc-3.7* rbc-4.19* hgb-14.1 hct-41.5 mcv-99* mch-33.7* mchc-34.0 rdw-13.8 05:19pm pt-12.9 ptt-21.8* inr(pt)-1.1 brief hospital course: hospital course: 49 year old with hx of lupus, pulmonary hypertension, rv enlargement and failure and an asd who is being admitted for management of chf and treatment of pulmonary artery hypertension. . while in the ccu, the patient underwent a r heart cath which showed: 1.resting hemodynamics revealed normal right and left sided pressures (mean ra pressure was 5mmhg, mean pcwp was 9mmhg). there was severe pulmonary hypertension (mean pap was 50mmhg, pvr 667 (dyne*sec)/cm5). cardiac index was normal at 2.4l/min/m2. 2.with 100% o2 therapy alone, the mean pap was 41mmhg with pvr 553 (dyne*sec)/cm5. 3.with 100% o2 and nitric oxide vasodilator, the mean pap was 46mmhg with pvr 693 (dyne*sec)/cm5. . an echo as done that showed a small secundum atrial septal defect/stretched pfo with bidirectional shunting. two right sided pulmonary veins and one large common left pulmonary vein are seen entering the left atrium. there was no evidence of partial anomalous pulmonary venous return. . the patient was then transferred to the micu team to begin treatment with flolan for her pulmonary artery htn. . pulmonary hypertension: likely from lupus. an hiv test was negative. patient was monitored in the icu with a swan ganz catheter, showing elevated pulmonary artery pressures and pulmonary vascular resistence. flolan was titrated up, with improvement in pulmonary vascular flow and patient's dyspnea. at a rate of 14, the patient began feeling flushed, with severe headache and pain in her jaw. additionally, her foward pulmonary flow did not improve after the increase from , and her pcwp rose precipitously, and it was settled that 12 would be her dosage for discharge from the hospital. she had extensive teaching from the flolan educators about needs at home. the patient learned well and is ready for the home infusions. she was also set up with home and pulse oximeter. a tunneled groshaun line was placed and is in working order. . chf: the patient was diuresed with lasix over the course of her hospital stay, and will be discharged on lasix 20mg po qd. . thrombocytopenia: it was noticed that the patient's platelets dropped during her stay. heparin was discontinued and a hit antibody test was negative. the hematology team was consulted, and concluded that her thrombocytopenia is likely due to either hit (even with a negative screen), or flolan. at the end of her stay, the platelets stabilized at 108, and she will need a followup cbc in 1 week to further evaluate. . uti: during her hospital stay, ms. developed a urinary tract infection that grew cipro sensitive klebsiella. she was treated for 3 days with cipro, and a repeat urine culture was negative. . dm2: she was treated with an insulin sliding scale during her stay, and upon discharge, will restart her metformin at ome dose. . sle: she was continued on her home prednisone regimen. . fibromyalgia: she was continued on her home regimen of amitryptiline, gabapentin, and pain meds prn . the patient is full code. medications on admission: meds: amiloride 5 mg once daily allopurinol 100 mg daily relafen 1500 mg daily metformin 850 b.i.d. prednisone 10 mg (varying between 10 and 60 mg mg, depending on the activity of her lupus) premarin 0.625 mg daily 180 mg daily fluconazole 100 mg daily amitriptyline 200 mg q.i.d. (for fibromyalgia) ambien 10 mg q.p.m. gabapentin 600 mg three tablets daily (for fibromyalgia) hydrocodone/apap 5/500 . all: tetracyclines, sulfa drugs (rash), penicillin, plaquenil (rash), chloroquine (rash), imuran (depression), cyclophosphamide (nausea), methotrexate (fatigue), cellcept (nausea) discharge medications: home 2-4 liters continuous allopurinol 100 mg qd prednisone 10 mg tablet qd conjugated estrogens fexofenadine 60 mg qd amitriptyline 50 mg 4 tabs qhs zolpidem 5 mg 2 qhs gabapentin 300 mg 2 qam gabapentin 400 mg 3 qhs nabumetone 500mg 3 tabs qam hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. epoprostenol 0.5 mg recon soln sig: one (1) recon soln intravenous infusion (continuous infusion) as needed for pulmonary htn: 12ng/kg/minute infusion. loperamide pulse oximeter furosemide 20 mg qd potassium chloride 10 meq 2 tabs qd saturation monitor to monitor saturations. patient to md saturation less than 92% discharge disposition: home with service facility: medical discharge diagnosis: pulmonary arterial hypertension lupus thrombocytopenia discharge condition: stable. discharge instructions: please continue to take all medications as prescribed. your flolan infusion should be continued at a rate of 12. you should avoid all heparin products until instructed by dr. . . if you have worsening headaches, flushing, jaw pain or other difficulties please bring this up with dr. . if you have fevers, chills, light headedness, easy bruising, bleeding, or rash please seek medical attention. . we have started you on a new medicine called lasix. you should take this for a week until you see dr. . she will need to check your potassium level with this medicine. followup instructions: provider: , m.d. phone: date/time: 11:00 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using a single catheter Diagnostic ultrasound of heart Right heart cardiac catheterization Administration of inhaled nitric oxide Diagnoses: Systemic lupus erythematosus Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other chronic pulmonary heart diseases Ostium secundum type atrial septal defect Myalgia and myositis, unspecified

allergies: penicillins / tetracyclines / plaquenil / chloroquine / sulfonamides / floxin / heparin agents attending: chief complaint: fever, hypotension. major surgical or invasive procedure: removal of left subclavian line. placement of right internal jugular line. history of present illness: 49 year old female with h/o pulm htn dm lupus on flolan via hickman presenting for possible line infection. a new hickman line was placed 3 weeks ago after line became infected and she is s/p 14d vanco course for micococcus. micrococcus was grown out of cultures on and . subsequent cultures on were all negative. hickman line insertion (for flolan) was on and picc line (for vanco) insertion was on . . she comes in with 2 days sweats, chills, as well as tenderness, warmth and drainage from line. blood sugars 220, usually 100-200. it also has been draining a clear green fluid. she was apparently scheduled for a dental procedure tomorrow for ? infected tooth. no other ros positive. mult drug allergies. exam: crusting and purulence at site. . in the ed: her initial vitals were 98.1 103 145/82 12 94ra, she was started on vancomycin but developed itching and rash, benadryl given, -> continued vanco at slower rate -> got worse -> stopped. this is strange since she finished off a 14 day course of vancomycin dating from her recent visit. . on arrival to the floor she was noted be hypotensive 70s, 1l ns in ed, and received 500cc ns, and 2nd iv was placed. past medical history: -diabetes mellitus type 2 -pulmonary arterial hypertension on flolan -atrial septal defect of the secundum type (versus a stretched pfo) -obstructive sleep apnea on home oxygen -anticardiolipin antibody -type 1 heparin induced thrombocytopenia -systemic lupus erythematosus with history of pleuritis, glomerulonephritis () -obesity -restrictive pulmonary disease -migraines -history of sinusitis -fibromyalgia. social history: significant for the absence of current tobacco use. there is no history of alcohol abuse. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: on admisison to floor: vs: t 95.5 bp 82/38 hr 104 rr27 o2 5lnc gen: wdwn middle aged male in mild distress heent: ncat. sclera anicteric. perrl, eomi. op clear, dry mm neck: supple, cv: s1 s2 no mrg chest: ant cta b/l no w/r/r, hickman 2cm erythema around site, no discharge 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, pertinent results: labwork on admission: 11:10pm wbc-4.0 rbc-4.60 hgb-14.3 hct-40.9 mcv-89 mch-31.0 mchc-34.9 rdw-16.1* 11:10pm plt count-198# 11:10pm neuts-64.6 lymphs-28.6 monos-5.3 eos-0.4 basos-1.1 11:10pm glucose-150* urea n-16 creat-0.7 sodium-141 potassium-4.0 chloride-102 total co2-24 anion gap-19 11:27pm pt-20.5* ptt-28.2 inr(pt)-2.0* 11:36pm lactate-2.6* 12:25am urine rbc-0 wbc-0-2 bacteria-rare yeast-none epi- 12:25am urine blood-neg nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 09:16am cortisol-39.3* 09:16am alt(sgpt)-25 ast(sgot)-51* ld(ldh)-262* alk phos-40 tot bili-0.2 . chest (pa & lat) impression: no evidence of pneumonia. . echo study date of conclusions: the left atrium is mildly dilated. the estimated right atrial pressure is >20 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is markedly dilated. right ventricular systolic function appears depressed. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic root is moderately dilated athe sinus level. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is at least moderate to severe pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. no vegetations seen (cannot definitively exclude). compared with the prior study (images reviewed) of , the ivc is now more dilated. brief hospital course: 49 f pmh pulmonary htn on flolan, sle, apa syndrome, underwent recent hickman change due to line infection who returned with likely line sepsis. . #) sepsis: most likely due to hickman line infection. she was in the icu for sepsis for a few days where she received several liters of fluids, pressors which were quickly weaned, high dose antibiotics and stress dose steroids. she was subsequently transferred to the floor when off pressors x 48 hours. ua/culture remained negative. cxr negative for infection. of note, her hickman was removed and a rij placed. she was treated with gentamycin/linezolid since until when daptomycin replaced linezolod (see "headache" section below) and then on we switched gentamycin to levofloxacin to prevent gentamycin induced toxicity. all of the antibiotic regimens were per id recs. no blood or catheter tip cultures grew out any organisms during this admission. on the floor she remained hemodynamically stable and afebrile with no further signs of sepsis. she had a midline placed for 8 more days of home antibiotics (per id) to end and she had her hickman replaced by surgery without event on . . #) pulmonary htn: she had a right heart cath on which revealed pulmonary hypertension with mean pa pressure of 47mmhg with pa systolic of 70. the pvr was 513. there was elevation of ra pressure with mean ra of 15mmhg. the pcwp was near normal at 13mmhg. the cardiac index was preserved. based on this, and concersations with dr. (pulmonology) we will continue flolan at home for now via her hickman. she has follow up scheduled with dr. to discuss further management of her pulmonary htn. . #) tooth pain: pt with right questionable tooth infection prior to admission. she had considerable pain and headaches off amitriptyline. based on this we got panorex films of her jaw and a dental consult. per dental recs, there was no obvious source of infection/abscess and she was recommended for outpatient dental workup. . #) sle: stable throughout admission. we continued steroid taper for a few days after stress dose steroids. as she has had recurrent infections in the past few months, we consulted dr. (rheum) re: tapering her home prednisone which may be contributing to her susceptibility to infections. per dr. recs, we will discharge ms. on 9mg daily prednisone and she will follow in the outpatient setting and consider a further taper. . #) migraine ha: patient was off amytriptilline for migraine prophylaxis while on linezolid (due to increased risk of seratonin syndrome). her headaches were significantly worse off her home meds. we temporized with toradol, and dilaudid prn and eventually switched from linezolid to daptomycin per id so we could resume amytriptilline which we did a few days prior to discharge. her headaches subsequently improved significantly. . #) apa syndrome/history of hit: stable. coumadin was held for procedures/line placements and she remained off heparin products without event. we resumed coumadin on day of discharge which she is on for line patentcy. she will follow inrs in the outpatient setting. . #) dm: stable. fs qid, ssi while in house. we resumed oral agents prior to discharge. . #) osa: stable. on home oxygen during admission with stable o2 sats. . medications on admission: 1. allopurinol 100 mg daily 2. amitriptyline 50 mg qhs 3. estrogens conjugated 0.625 mg po daily 4. fexofenadine 60 mg 5. fluticasone 50 mcg spray daily 6. furosemide 20 mg daily 7. gabapentin 300 mg po daily 8. gabapentin 600 mg po hs 9. metformin 850 mg 10. prednisone 10 mg daily 11. warfarin 1 mg daily 12. zolpidem tartrate 10 mg po hs discharge medications: 1. daptomycin 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours) for 8 days: last dose 5/18. disp:*8 recon soln(s)* refills:*0* 2. warfarin 1 mg tablet sig: one (1) tablet po daily (daily). 3. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). disp:*120 tablet(s)* refills:*2* 4. prednisone 5 mg tablet sig: one (1) tablet po once a day: take with four 1mg tablets for a total of 9mg a day. disp:*30 tablet(s)* refills:*2* 5. epoprostenol 0.5 mg recon soln sig: one (1) recon soln intravenous infusion (continuous infusion). 6. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 7. fluticasone 50 mcg/actuation aerosol, spray sig: one (1) nasal once a day. 8. gabapentin 300 mg capsule sig: two (2) capsule po hs (at bedtime). 9. gabapentin 300 mg capsule sig: one (1) capsule po daily (daily). 10. fexofenadine 60 mg tablet sig: one (1) tablet po twice a day. 11. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime). 12. conjugated estrogens 0.625 mg tablet sig: one (1) tablet po daily (daily). 13. amitriptyline 50 mg tablet sig: four (4) tablet po hs (at bedtime). 14. metformin 850 mg tablet sig: one (1) tablet po twice a day. 15. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days: last dose 5/18. disp:*8 tablet(s)* refills:*0* 16. potassium chloride 10 meq capsule, sustained release sig: four (4) capsule, sustained release po once a day. disp:*120 capsule, sustained release(s)* refills:*2* 17. lasix 20 mg tablet sig: one (1) tablet po once a day. 18. flush please flush midline catheter with saline flushes before and after antibiotics daily 19. saline flush 0.9 % syringe sig: one (1) injection twice a day for 8 days: before and after antibiotics. disp:*8 days* refills:*0* discharge disposition: home with service facility: vna assoc. of discharge diagnosis: sepsis -diabetes mellitus type 2 -pulmonary arterial hypertension -obstructive sleep apnea -systemic lupus erythematosus -migraines discharge condition: fair discharge instructions: you were admitted for sepsis secondary to a presumed hickman line infection. the line was pulled and you were placed on antibiotics and did quite well. you had the hickman replaced and are now ready for discharge on antibiotics through . . seek medical attention immediately if you experience new symptoms including shortness of breath, chest pain, fainting, arm/jaw pain or numbness, coughing, blood in sputum, worsening diarrhea or other concerning symptoms. . follow up as per below. have your potassium checked by your doctor this week as well as your inr (to assess coumadin level). . take all medications as prescribed. followup instructions: -, l. call today for an appointment within 1 week. have your inr and potassium checked this week provider: , m.d. phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Pulmonary artery pressure monitoring Diagnoses: Systemic lupus erythematosus Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Cellulitis and abscess of trunk Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Asthma, unspecified type, unspecified Sepsis Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Hypotension, unspecified Ostium secundum type atrial septal defect Long-term (current) use of insulin Diarrhea Infection and inflammatory reaction due to other vascular device, implant, and graft Obesity, unspecified Myalgia and myositis, unspecified Home accidents Chronic pulmonary heart disease, unspecified Other forms of migraine, without mention of intractable migraine without mention of status migrainosus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: reason for transfer : hypoxemia major surgical or invasive procedure: none history of present illness: mr is a 78 to man diagnosed c cml 3 weeks ago . evaluated by hematologist at osh , pt refused chemotherapy. has been on ohurea since then.pt has been c/o progressive weakness and sob pt presented to ed today c severe sob , tachypneic spo2 70% on ra. pt was placed on nrb spo2 improved to 93%. abgs: 6.9/15/99/3 pt initially able to speak , c difficulty. past medical history: cml social history: etoh (-) smoking (-) worked as a physician . family history: nc physical exam: vs hr 120 bp 122/70. t 94.3 gen: elderly man in acute respiratory distress, somnolent, responsive to pain stimuli only chest: bilateral crackles diffuse cv: rrr, no m/r/g abdomen: + splenomegaly 17 cm ext : no edema pertinent results: 06:20pm pt-19.7* ptt-31.2 inr(pt)-1.9* 06:20pm ck-mb-5 10:44pm type-art po2-99 pco2-15* ph-6.93* total co2-3* base xs--29 08:00pm wbc-326.0* rbc-unable to hgb-unable to hct-39* mcv-unable to mch-unable to mchc-unable to rdw-unable to 08:00pm neuts-24* bands-0 lymphs-4* monos-18* eos-0 basos-0 atyps-0 metas-2* myelos-0 young-25* blasts-3* other-24* 08:00pm hypochrom-normal anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-normal polychrom-normal burr-1+ 08:00pm plt smr-unable to plt count-unable to 06:38pm type- comments-not specif 06:38pm hgb-8.5* calchct-26 06:20pm glucose-105 urea n-36* creat-1.8* sodium-133 potassium-4.8 chloride-94* total co2-10* anion gap-34* 06:20pm alt(sgpt)-1632* ast(sgot)-2386* ld(ldh)-4836* ck(cpk)-247* alk phos-273* amylase-35 tot bili-3.3* 06:20pm lipase-45 brief hospital course: pt was transferrred to micu initially to receive blood transfusion and non invasive mechanical intubation.pt code status was dnr/dni. upon arrival to micu, pt remained hypotensive bp 70/p , spo2 unreadable , rr 35. he had declining mental status, becoming responsive to only verbal stimuli. wbc count was 326.000 . discussed at length c family and health care proxy ( nephew , and considering pt's prior wishes and poor prognosis, family decided to make him cmo . pt remained in clear respiratory distress spo 2 70% on fm (100%)or bipap. pt was not intubated considering his prior wishes. pt expired less than an hour after admission medications on admission: hydroxyurea 1 g lisinopril 10 asa discharge medications: none discharge disposition: expired discharge diagnosis: chronic myeloid leukemia blast crisis multifocal pneumonia ?bacterial ? leukemia acute respiratory failure acute renal failure severe metabolic acidosis tumor lysis syndrome discharge condition: expired discharge instructions: none followup instructions: n/a Procedure: Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Acute and subacute necrosis of liver Unspecified acquired hypothyroidism Acute respiratory failure Cardiac arrest Old myocardial infarction Chronic myeloid leukemia, without mention of having achieved remission