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Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Gemfibrozil / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: positive blood culture Major Surgical or Invasive Procedure: None History of Present Illness: ___ ___ woman with a history of CAD, sCHF (EF 40-45%), CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p colectomy with ileostomy was referred to ED for positive blood cx after recent admission ___ for possible viral gastroenteritis and shortness of breath possibly ___ aspiration. Blood cultures drawn ___ grew GPR's today c/w corynebacterium or propionibacterium species and so patient was referred to ED where she endorsed possible subjective fevers, denied CP/SOB, abd pain. While in the ED she had an episode reportedly of leg weakness and vomiting, she tells me it was not so much weakness as pain in her L thigh which now persists, this is a new pain for her. She also says the episode of vomiting was very small, it happened after getting up after urinating and feeling lightheaded.Initial Vitals 16:10 0 97.7 62 150/54 18 96%. Labs: Na 132, K 5.9 (lipemic specimen), hco3 21, BUN 60, Cr 2.9, Glu 204, WBC 7.7 62%N Hgb 10.1. She was given insulin, glucose, calcium, and 1L NS. repeat K was 5.4 with lactate 1.4, EKG unchanged from prior, CXR non-acute with enlarged heart and mild pulm edema. Vitals prior to xfer Today 21:29 0 98.5 71 151/55 20 93% RA with FSG 167. On the floor, says she had cramping in her L thigh which has been intermittent over the past few days, now resolving. Review of Systems: (+) per HPI (-) 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: CAD, --___, ___. LAD everolimus eluting stent DM2 c/b nephropathy --HbA1C 10.3% in ___ CKD Stage IV ___ HTN, DM) Pseudomembranous colitis s/p colectomy with ileostomy h/o severe pneumonia c/b respiratory/cardiac arrest HTN MDD Hypertriglyceridemia ?COPD/Asthma ?Stroke in ___, p/w L facial/arm weakness, worked up at ___ vertigo anemia Social History: ___ Family History: Unknown Physical Exam: ADMISSION EXAM: ================ Vitals - 97.8 185/61, 80, 20, 97%RA GENERAL: NAD, WD/WN, husband at bedside ___: Oriented to place, ___ but did not know month/date or season- per husband this is baseline HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, ___ known systolic murmur at apex, no gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. No epigastric ttp, stoma is pink with soft brown stool in bag. EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose, LUE fistula with thrill PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: =============== Vitals: 98.5 98.5 128-153/52-61 ___ 18 90-96% RA General: Awake, alert, no acute distress HEENT: NC/AT, MMM, sclera anicteric Lungs: CTAB; no wheezes, rales, rhonchi CV: RRR, normal S1/S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place with soft brown output GU: No Foley present Ext: Warm, well perfused, no edema Pertinent Results: ADMISSION LABS: =============== ___ 05:40PM BLOOD WBC-7.7 RBC-3.41* Hgb-10.1* Hct-29.1* MCV-86 MCH-29.7 MCHC-34.7 RDW-15.1 Plt ___ ___ 05:40PM BLOOD Neuts-62.8 ___ Monos-7.0 Eos-4.2* Baso-0.4 ___ 05:40PM BLOOD Glucose-204* UreaN-60* Creat-2.9* Na-132* K-5.9* Cl-107 HCO3-21* AnGap-10 ___ 05:40PM BLOOD Lipase-60 ___ 05:40PM BLOOD Cortsol-10.3 ___ 05:57PM BLOOD Lactate-1.4 K-5.4* ___ 07:30PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:30PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 07:30PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-2 TransE-<1 PERTINENT LABS: ================ ___ 06:02AM BLOOD Ret Aut-3.2 ___ 06:55AM BLOOD ALT-45* AST-358* LD(LDH)-818* ___ AlkPhos-85 TotBili-0.3 ___ 03:10PM BLOOD ALT-47* AST-309* LD(LDH)-581* AlkPhos-89 TotBili-0.3 ___ 06:18AM BLOOD ___ ___ 06:09AM BLOOD CK(CPK)-6153* ___ 05:52AM BLOOD CK(CPK)-5373* ___ 05:50AM BLOOD ALT-36 AST-97* CK(CPK)-3496* AlkPhos-81 TotBili-0.4 ___ 06:12AM BLOOD CK(CPK)-2050* ___ 06:02AM BLOOD LD(LDH)-228 TotBili-0.4 ___ 06:12AM BLOOD proBNP-2571* ___ 06:55AM BLOOD CK-MB-10 MB Indx-0.0 cTropnT-0.02* ___ 03:10PM BLOOD CK-MB-7 cTropnT-0.03* ___ 06:12AM BLOOD calTIBC-299 Hapto-21* Ferritn-112 TRF-230 ___ 06:02AM BLOOD Hapto-77 ___ 06:55AM BLOOD Triglyc-782* ___ 06:55AM BLOOD Cortsol-25.6* ___ 06:18AM BLOOD CRP-1.3 ___ 07:30PM URINE RBC-2 WBC-38* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 DISCHARGE LABS: =============== ___ 06:11AM BLOOD WBC-7.0 RBC-3.33* Hgb-10.0* Hct-29.3* MCV-88 MCH-30.0 MCHC-34.1 RDW-15.1 Plt ___ ___ 06:11AM BLOOD Glucose-185* UreaN-62* Creat-3.7* Na-135 K-4.8 Cl-99 HCO3-21* AnGap-20 ___ 06:11AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0 MICROBIOLOGY: ============= Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: <10,000 organisms/ml. Blood Culture, Routine (Final ___: NO GROWTH. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. VIRAL CULTURE (Final ___: ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== ___ CXR: Moderate cardiomegaly with mild edema. ___ CXR: In comparison with the study of ___, there is again substantial enlargement of the cardiac silhouette with relatively mild vascular congestion. This discordance the raises the possibility of pericardial effusion or cardiomyopathy. Minimal small bilateral pleural effusions with probable atelectatic changes at the bases. ___ilateral dependent atelectasis. Subtle bilateral ground-glass opacities may represent mild pulmonary edema. No evidence of pneumonia. Moderate cardiomegaly. Coronary artery calcifications. 8 mm splenic hypodensity, likely representing a cyst or hemangioma. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. HydrALAzine 50 mg PO Q8H 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Pravastatin 40 mg PO QPM 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. Sodium Bicarbonate 650 mg PO TID 11. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral Q Weekly 12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 13. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD 14. Humalog ___ 30 Units Breakfast Humalog ___ 30 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. HydrALAzine 50 mg PO Q8H 6. Humalog ___ 30 Units Breakfast Humalog ___ 30 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Sodium Bicarbonate 1300 mg PO TID 10. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral Q Weekly 11. Fish Oil (Omega 3) ___ mg PO BID RX *docosahexanoic acid-epa [Fish Oil] 120 mg-180 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 RX *docosahexanoic acid-epa [Fish Oil] 120 mg-180 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 12. Gabapentin 100 mg PO DAILY RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 13. Ferrous Sulfate 325 mg PO DAILY 14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD 15. Outpatient Lab Work ICD-9 585.9 Please Chem10 panel including Creatinine and fax results to: Name: ___ Location: ___ Address: ___ Phone: ___ Fax: ___ 16. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Rhabdomyolysis Hypoxia Adenoviral gastroenteritis bacteremia Secondary: chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ female with positive blood cultures. Evaluate for pneumonia. TECHNIQUE: Frontal and lateral chest radiographs were obtained with the patient in the upright position. COMPARISON: Radiographs from ___ and ___. FINDINGS: The heart continues to be moderately enlarged with mild edema. No focal consolidation, pleural effusion or pneumothorax is seen. IMPRESSION: Moderate cardiomegaly with mild edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman p/w rhabdomyolysis now with new DOE and O2 requirement s/p significant IVF hydration. // ? pulm edema ? pulm edema IMPRESSION: In comparison with the study of ___, there is again substantial enlargement of the cardiac silhouette with relatively mild vascular congestion. This discordance the raises the possibility of pericardial effusion or cardiomyopathy. Minimal small bilateral pleural effusions with probable atelectatic changes at the bases. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman initially presenting with rhabdomyolysis, now with ongoing O2 requirement in setting of IVF hydration. Hypoxia not resolving with diuresis, would like to assess for other etiologies for hypoxia. // ?interstitial lung disease TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: DLP: 480 mGy-cm COMPARISON: CT torso ___. FINDINGS: The thyroid is normal. There is a 1.0 cm right paratracheal lymph node. There are other prominent but not pathologically enlarged mediastinal lymph nodes. The axillary lymph nodes are prominent but non pathologically enlarged bilaterally and contains fatty hilum. Supraclavicular and hilar lymph nodes are not enlarged. Aorta and pulmonary arteries are normal size. There is moderate cardiomegaly. Coronary artery calcifications. No pericardial effusion. There is no focal consolidation, pleural effusion or pneumothorax. Linear opacities at the lung bases are most consistent with atelectasis. Subtle bilateral ground-glass opacities may represent mild pulmonary edema. The airways are patent to the subsegmental level. No suspicious bony lesions are identified. There is an 8 mm hypodensity in the spleen. The remainder of the partially visualized intra-abdominal organs are unremarkable. IMPRESSION: Bilateral dependent atelectasis. Subtle bilateral ground-glass opacities may represent mild pulmonary edema. No evidence of pneumonia. Moderate cardiomegaly. Coronary artery calcifications. 8 mm splenic hypodensity, likely representing a cyst or hemangioma. Gender: F Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Abnormal labs Diagnosed with HYPERKALEMIA, BACTEREMIA NOS temperature: 97.7 heartrate: 62.0 resprate: 18.0 o2sat: 96.0 sbp: 150.0 dbp: 54.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ because you had positive blood cultures from your previous admission. We found that the bacteria in the blood culture was likely just a contaminant and did not need to be treated with antibiotics. You were having muscle cramping so we checked labs which showed that you had some injury to your muscle cells called rhabdomyolysis. Because of the rhabdomyolysis you received IV fluid hydration and your labs have normalized. You also had a viral gastroenteritis causing you to have diarrhea. However, this improved with IV fluids as well. You also developed shortness of breath. You had chest x-rays which showed that you may have had some fluid in your lungs so we gave you some medication to get rid of the extra fluid. Your breathing has now improved and is back to normal. You also developed some foot pain which we think is due to your nerve tissue in your legs so you were started on a new pain medication. Please ___ with your outpatient providers as instructed tomorrow. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Thank you very much for allowing us to participate in your care. All best wishes for your recovery. Sincerely, Your ___ medical team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea/vomiting, headaches Major Surgical or Invasive Procedure: Tunneled dialysis catheter placement ___ Pan-retinal photocoagulation ___ History of Present Illness: Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy and likely gastroparesis vs. cannabis hyperemesis syndrome who presents with nausea/vomiting, headaches and blurry vision. Pt has been admitted multiple times in the last few months with similar complaints thought to be a combination of cannabis hyperemesis syndrome vs. diabetic gastroparesis and hypertensive urgency. He has questionable medication compliance at home and has left AMA for most of these admissions. He was last hospitalized ___ for similar complaints. He was initially sent to the MICU for BP control as it was initially thought that his headaches and blurry vision were representative of hypertensive urgency. However, on further optho eval, it was felt that his vision changes were due to more chronic changes associated with diabetic retinopathy and poorly controlled HTN. This hospitalization was also c/b worsening renal function with a Cr that was in the ___ range whereas priors were noted to be creeping up from 2->4 in the last few months. He was evaluated by renal who did not feel he necessitated RRT at this time but a recent note mentioned concern for rapidly progressive nephropathy (of note, pt had also been on immunosuppression in the past for what was felt to be FSGS.) BP meds were titrated this admission, however, pt left AMA prior to optimization of BP meds. On presentation, pt reports that he left from his most recent admission b/c he felt very anxious and needed to be with family, especially in light of his birthday tomorrow. He has not been taking all of his meds given intractable nausea and vomiting at home. He also reports persistent LUQ pain which is fairly chronic for him. He also reports severe headache that has been persistent for the last few weeks and vision changes that have become more severe for the last 2 weeks as well. States he can only see outlines of shadows and reports new R eye pain. He denies CP, SOB, dizziness/lightheadedness, fevers, chills, cough, or dysuria. In the ED, VS initially notable for B P: 206/120 which improved to 140's/90's with administration of home labetalol and hydral. Exam notable for visual deficits but CN's otherwise intact. Labs notable for Cr: 6.1 (was ___ when pt left AMA.) Hb stable at 7.0. Pt was was also given reglan and morphine for nausea/pain. Also given CTX for possible UTI and admitted for further management of HTN, ___ on CKD, and symptom control. ROS: Rest of 10-point ROS reviewed and is negative except as noted above. Past Medical History: Type 1 diabetes cyclic vomiting with multiple admissions for symptom control Presumed ___ tear in the setting of gastroparesis flare PUD HTN FSGS Social History: ___ Family History: Insulin dependent diabetes in multiple family members Physical ___: ADMISSION EXAM: VITALS: ___ ___ Temp: 98.2 PO BP: 147/90 HR: 88 RR: 16 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: laying in bed head covered with pillow, appears uncomfortable EYES: no scleral icterus, no conjunctival injection, pt reports being able to see number of fingers with L eye, only outline of my head with R eye ENT: MMM, clear OP, normal hearing NECK: Supple, no appreciable LAD RESP: CTA b/l, no w/r/r, non-labored breathing CV: RRR, no m/r/g GI: Soft, Mildly TTP in LUQ, non-distended, normoactive BS GU: no foley EXT: wwp, no edema SKIN: no lesions, no rashes NEURO: AOx3, moving all extremities purposefully PSYCH: normal mood and affect DISCHARGE EXAM GENERAL: Alert and in no apparent distress, lying in bed EYES: Anicteric, noninjected ENT: Ears and nose without visible erythema, masses, or trauma. Chest wall: tunneled line without significant erythema or discharge CV: RRR systolic murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. SKIN: No rashes or ulcerations noted EXTR: wwp no edema NEURO: Alert, interactive, face symmetric, speech fluent PSYCH: patient upset throughout encounter Pertinent Results: PERTINENT LABS: WBC 6.9-9.0 from ___ -> 10.2 (___) -> 12.4 (___) Hgb 6.7 - 8.1 Plts 240s-280s Cre up to 6.6 before HD initiated Alb 2.3 - 2.7 Hep B nonimmune Hep C neg Blood, urine cx ___ neg IMAGING: CXR ___ In comparison with the study of ___, the left central catheter has been removed. There is an placement of a right hemodialysis catheter with the tip in the upper right atrium. No evidence of post procedure pneumothorax. No acute pneumonia or vascular congestion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Metoclopramide 10 mg PO Q8H 3. NIFEdipine (Extended Release) 120 mg PO QPM 4. Pantoprazole 40 mg PO Q12H 5. Losartan Potassium 50 mg PO DAILY 6. HydrALAZINE 50 mg PO Q6H 7. Labetalol 800 mg PO TID 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN 9. Glargine 10 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache 2. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice dailu Disp #*60 Tablet Refills:*0 3. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 4. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT 6. Glargine 9 Units Bedtime Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Humalog 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Atorvastatin 80 mg PO QPM 8. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 9. Metoclopramide 10 mg PO Q8H RX *metoclopramide HCl [Reglan] 10 mg 1 tablet by mouth up to three times daily as needed Disp #*90 Tablet Refills:*0 10. NIFEdipine (Extended Release) 120 mg PO QPM 11. Pantoprazole 40 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: End-stage renal disease Diabetic retinopathy with blindness HTN Insulin Dependent Diabetes Suspected gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with ESRD, needs dialysis// needs TLC for dialysis COMPARISON: US of right upper extremity veins TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 2 min, 4 mGy PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing dialysis catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: renal failure. HD catheter placed, patient pulled on HD catheter, want to confirm tip is still in the RA.// HD catheter placement Contact name: ___: ___ IMPRESSION: In comparison with the study of ___, the left central catheter has been removed. There is an placement of a right hemodialysis catheter with the tip in the upper right atrium. No evidence of post procedure pneumothorax. No acute pneumonia or vascular congestion. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, Headache, LUQ abd pain Diagnosed with Essential (primary) hypertension temperature: 98.8 heartrate: 92.0 resprate: 18.0 o2sat: 98.0 sbp: 190.0 dbp: 119.0 level of pain: 8 level of acuity: 3.0

You came in with nausea, vomiting, headaches and blurry vision. We think that this may have been due to at least in part a buildup of toxins from your progressive kidney failure. You were started on dialysis and had some improvement in your symptoms, although not full resolution. During the admission in addition to starting dialysis we also adjusted the medications for your blood pressure and diabetes, and you underwent a procedure for your right eye. Because of your aunt's illness you left against medical advice on ___, with a plan to return shortly thereafter. It is of utmost importance that you follow the instructions to keep your dialysis catheter clean while you are out of the hospital. We have also provided prescriptions for the medications that you do not have and a list of changes to your medications that we have made. At this point your blood pressure remains poorly controlled, and so it will be important for your medical team to keep working on this when you return. It will also be important for you to return for further dialysis. Upon your return our medical team will also discuss further with the eye doctors the future plans for your eye treatments. For your insulin our diabetes team has recommended 9 units of long acting per day, as well as 5 units of short acting with each meal plus the sliding scale. You can take 5 units at night if you have a late meal, but if not then you can just use the sliding scale. Similarly if you do not eat at other meal times you can just use the sliding scale alone.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: 1. Chest tube placement - right side for his pneumothorax - d/c on ___ History of Present Illness: ___ year old M adm s/p fall ___ feet from rope swing. +head strike, +LOC. Pt was admitted ___ and found to have R sided rib fractures and R small pneumothorax s/p CT placement. Chest tube now discharged. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: Discharge exam: Vitals reviewed during discharge exam and WNL Heart: s1, s2 no m/r/g Lungs: CTAB Abdomen: soft, nt, nd. Prior chest tube site healing well, no erythma or discharge appreciated Ext: no edema Pertinent Results: ___ WBC-9.6 RBC-4.37* Hgb-14.1 Hct-41.1 MCV-94 MCH-32.3* MCHC-34.3 RDW-14.5 Plt ___ ___ WBC-7.7 RBC-3.92* Hgb-12.6* Hct-36.5* MCV-93 MCH-32.1* MCHC-34.5 RDW-14.4 Plt ___ ___ ___ PTT-24.8* ___ ___ ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ Glucose-87 Lactate-2.9* Na-145 K-4.1 Cl-106 calHCO3-20* CT head (___) IMPRESSION: 1. No acute intracranial process. 2. Depressed nasal bone, please correlate for acuity. CT chest: (___) IMPRESSION: 1. Right lateral ninth, tenth, and eleventh rib fractures with associated small right anterior pneumothorax, and air in the right lateral chest wall. The ninth rib fracture is mildly displaced, and the tenth and eleventh rib fractures are nondisplaced. 2. No evidence of solid organ injury in the abdomen or pelvis. CT C-SPINE W/O CONTRAST (___) IMPRESSION: No fracture or traumatic malalignment CXR ___: IMPRESSION: Slight interval increase in the small right pneumothorax. CRX ___: IMPRESSION: No pneumothorax or effusion. CXR ___: IMPRESSION: Status post removal of the right-sided chest tube. There is a 1 cm right apical lateral pneumothorax without evidence of tension. Minimal atelectasis at the right lung bases. Unchanged appearance of the left lung and the heart. CXR ___ IMPRESSION: As compared to the previous image, the extent of the known right pneumothorax is constant. No evidence of tension. Better apparent than on previous images is a slightly displaced fracture of the ninth and tenth rib on the right. Normal appearance of the left lung. CXR ___ IMPRESSION: Small right apical pneumothorax, overall unchanged. Medications on Admission: not recorded Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation hold for loose stools RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain do NOT drive while taking this medication. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q3-6H Disp #*40 Tablet Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD QAM R rib pain leave on for 12 hours and then remove for 12 hours RX *lidocaine-menthol [LidoPatch] 4 %-1 % Apply one patch to the affected area daily Qam Disp #*30 Patch Refills:*0 4. Baclofen 10 mg PO TID RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp #*33 Tablet Refills:*0 5. OxyCODONE SR (OxyconTIN) 20 mg PO QAM Duration: 4 Days RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth QAM Disp #*4 Tablet Refills:*0 6. OxyCODONE SR (OxyconTIN) 10 mg PO QHS Duration: 4 Days After four days, please take one pill in the morning and one at night for another week. RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth at bedtime Disp #*18 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: right-sided rib fractures ___, small right pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: TRAUMA TORSO INDICATION: ___ with 20-foot fall, right chest and flank pain. Evaluate for injury. TECHNIQUE: Contiguous axial MDCT images of the chest abdomen and pelvis were obtained following the uneventful administration of 130 cc Omnipaque intravenous contrast. Coronal and sagittal reformations were performed. DLP: 1150 mGy-cm. COMPARISON: None FINDINGS: CHEST: The thyroid gland is homogeneous. The great vessels of the neck enhance normally. The heart is normal in size with no pericardial effusion. There is no axillary, mediastinal, or hilar lymphadenopathy. Lungs demonstrate moderate dependent bilateral atelectasis with no focal consolidation or pleural effusion. There are right lateral ninth, tenth, and eleventh rib fractures with adjacent subcutaneous gas in the right lateral chest wall (02:56), and a small right anterior pneumothorax. The ninth rib fracture is mildly displaced, and the tenth and eleventh rib fractures are nondisplaced. The esophagus follows a normal course and is normal in caliber. No thoracic spine fractures are seen. ABDOMEN: The liver is normal in attenuation with no focal hepatic lesions. The portal and hepatic veins are patent. Gallbladder is within normal limits, with no stones. The pancreas is normal in attenuation with no duct dilatation or stranding. Spleen is normal in size and attenuation. The adrenal glands are morphologically normal bilaterally. The kidneys enhance and excrete contrast symmetrically. The distal esophagus, stomach, and small bowel are normal in caliber. Incidentally noted duodenal diverticulum (2:71). The appendix is normal. The colon is unobstructed with no evidence of colitis. There is no free fluid in the abdomen. PELVIS: No free fluid or lymphadenopathy in the pelvis. The bladder, prostate, and seminal vesicles are normal. VESSELS: The abdominal aorta demonstrates mild atherosclerotic calcification, however no aneurysmal dilatation. OSSEOUS STRUCTURES: Aside from the aforementioned rib fractures, no osseous injuries detected. Bilateral pars defects are noted at L5-S1, with no alignment abnormality. Well corticated densities posterior to the left ischial tuberosity may represent sequela of prior avulsion injury. IMPRESSION: 1. Right lateral ninth, tenth, and eleventh rib fractures with associated small right anterior pneumothorax, and air in the right lateral chest wall. The ninth rib fracture is mildly displaced, and the tenth and eleventh rib fractures are nondisplaced. 2. No evidence of solid organ injury in the abdomen or pelvis. NOTIFICATION: The findings were discussed by Dr. ___ with the trauma team, in person ___ at 4:38 ___, upon discovery of the findings. Radiology Report EXAMINATION: PA and lateral chest radiographs INDICATION: ___ year old man with PTX // interval eval COMPARISON: Chest radiograph dated ___. CT chest dated ___. FINDINGS: A small right pneumothorax persists and was not clearly seen on the prior radiograph, suggesting interval increase. No evidence of tension. Platelike atelectasis in the right lower lung is mild. Left infrahilar atelectasis persists. No focal consolidation, pleural effusion, or pulmonary edema. The heart size is normal. Multiple right lateral rib fractures are again noted in better seen on CT. Nonspecific gaseous distension of the imaged bowel without pneumoperitoneum. IMPRESSION: Slight interval increase in the small right pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with right pneumothorax s/p right pigtail catheter placement // pneumothorax, pigtail placement pneumothorax, pigtail placement COMPARISON: Prior chest radiographs ___ and ___ at 10:55. IMPRESSION: Right pneumothorax has almost entirely resolved following insertion of a new pleural drainage catheter. Moderate right basal atelectasis is stable. Pneumomediastinum may be present. Left lung is clear aside from mild basal atelectasis. Heart size is normal. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p fall now s/p R chest tube placement // confirm R chest tube placement confirm R chest tube placement COMPARISON: Previous chest radiographs ___, most recently 20:37. IMPRESSION: There is minimal if any right pneumothorax, and no pleural effusion, following insertion of a replacement right apical pleural drainage catheter. Moderate right basal atelectasis has not yet resolved. Left lung is fully expanded and clear. Heart size is normal. Radiology Report EXAMINATION: Portable AP chest radiograph INDICATION: ___ s/p fall with R rib fx, interval chest tube placement; assess for interval change // ___ s/p fall with R rib fx, interval chest tube placement; assess for interval change. please perform at 0600 COMPARISON: Multiple chest radiographs from ___ before and after placement of the right chest tube. FINDINGS: The right chest tube projects over the upper right hemithorax. No pneumothorax. The lungs are clear. No focal consolidation or pleural effusion. Elevation of the right hemidiaphragm persists and may suggest some volume loss. The heart size is normal. Right lateral rib fractures are incompletely imaged . IMPRESSION: No pneumothorax or effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p CT placement for pneumothorax after fall // eval interval change - chest tube on water seat eval interval change - chest tube on water seat COMPARISON: Prior chest radiographs ___. IMPRESSION: Left pleural drainage catheter has been withdrawn to the level of the right third anterior interspace. I cannot be sure it is actually intra thoracic. Right pneumothorax is tiny. No right pleural effusion. Mild bibasilar atelectasis, slightly greater on the right, unchanged. Normal cardiomediastinal and hilar silhouettes. Radiology Report EXAMINATION: CHEST (PA, LAT AND OBLIQUES) INDICATION: ___ year old man s/p fall w pneumothorax s/p CT removal // Please complete standing end expiratory to eval pneumothorax s/p CT removal COMPARISON: ___ IMPRESSION: Status post removal of the right-sided chest tube. There is a 1 cm right apical lateral pneumothorax without evidence of tension. Minimal atelectasis at the right lung bases. Unchanged appearance of the left lung and the heart. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man s/p fall w pneumothorax // Please eval inter change. Complete standing end expiratory COMPARISON: ___, 22:18 IMPRESSION: As compared to the previous image, the extent of the known right pneumothorax is constant. No evidence of tension. Better apparent than on previous images is a slightly displaced fracture of the ninth and tenth rib on the right. Normal appearance of the left lung Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man s/p fall w pneumothorax // Please eval interval change after chest tube removal. Standing end expiratory. Please complete test at 22pm COMPARISON: ___, 18:53 IMPRESSION: As compared to the previous radiograph, there is no substantial change in appearance of the approximately 1 cm right apical pneumothorax without evidence of tension. Radiology Report EXAMINATION: PA and lateral chest radiograph INDICATION: ___ year old man w pneumothorax. // Eval interval change Please standing end expiratory. please complete at 6 am prior to rounds. COMPARISON: Chest radiograph dated ___. FINDINGS: The small right apical pneumothorax has not increased in size and is perhaps minimally decreased from the prior exam. No evidence of tension. The size of the pneumothorax does not appreciably change with inspiration and expiration. The lungs are otherwise clear. No focal consolidation, pleural effusion, or pulmonary edema. The heart is normal in size. The mediastinum is not widened. Multiple right lateral rib fractures are unchanged. IMPRESSION: Small right apical pneumothorax, overall unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ male status post trauma, with pneumothorax. TECHNIQUE: Portable chest radiograph COMPARISON: CT of the torso obtained concurrently FINDINGS: Aside from bilateral infrahilar opacities likely representing atelectasis, there is no pleural effusion or focal consolidation. Heart size is within normal limits given the portable technique. Lung volumes are low. Small pneumothorax and right lateral rib fractures are better appreciated on the concurrent CT of the torso. IMPRESSION: Traumatic findings of right pneumothorax and right lateral rib fractures are better seen on the concurrent CT of the torso. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with 20-foot fall, right chest/flank pain. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 891 mGy-cm CTDI: 40 mGy COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or large mass. The ventricles and sulci are normal in size and configuration. Compressed nasal bone is of unclear chronicity. There is moderate mucosal thickening of the maxillary sinuses and anterior ethmoid air cells bilaterally. The sphenoid sinuses, frontal sinuses, and mastoid air cells bilaterally are clear. The middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Depressed nasal bone, please correlate for acuity. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with 20-foot fall TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 750 mGy DLP: 37 mGy-cm COMPARISON: None FINDINGS: Alignment is normal. No fractures are identified. There is no evidence of spinal canal or neural foraminal narrowing. IMPRESSION: No fracture or traumatic malalignment. Gender: M Race: UNKNOWN Arrive by AMBULANCE Chief complaint: FALL Diagnosed with FX MULT RIBS NOS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL-1 LEVEL TO OTH NEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Dear Mr. ___, You were admitted to the ED at ___ after sustaining a fall. You had an x-ray and a CT scan which showed you to have several right rib fractures and a small right lung injury. You had a CT of your spine and head which showed no acute injuries. You were admitted to the Acute Care Surgery team for pain control and respiratory monitoring. You are now medically cleared to be discharged to home. Please note the following discharge instructions: * Your injury caused right rib fractures ___ which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Pain regimen: ___ - ___ - Take Oxycontin 20mg in the AM - Take Oxycontin 10mg in the ___ - Dilaudid 2mg every 3 to 6hrs as needed for pain (for 5 days from discharge) - After complete your Dilaudid regimen, you can take Tylenol OR Advil for pain. You can by them over the counter. - Baclofen 10mg three times a day (for eleven days after discharge) ___ - ___ - Take Oxycontin 10 mg - one in the morning and one in the afternoon

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Paxil / hydrochlorothiazide / Lipitor / metoprolol / Prinivil / fluoxetine Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: 1) ___: Pacemaker procedure: Battery at ERI s/p generator replacement. Lower rate was changed to 75 bpm. 2) ___: TTE: Well-seated, normally functioning bileaflet mitral valve prosthesis. Mildly depressed global left ventricular systolic function in the setting of beat-to-beat variability in LVEF secondary to atrial fibrillation. Severe tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, a mild reduction in global left ventricular systolic function is now appreciated. The right ventricle was not able to be accurately accessed History of Present Illness: ___ y/o woman with complicated cardiac history, including CAD s/p PCI, Afib, sick sinus syndrome s/p PPM, MV replacement, and severe TR that resulted in significant cardiac ascites presenting with syncopal event on ___. Patient states that she had walked to the restroom and had just sat down on the toilet when she felt like a "sheet was coming over her". She subsequently woke up on the ground and had bruises on her right shoulder and wrist. She is unsure of headstrike. She was not confused when she woke up and noticed that 15 minutes had passed. No incontinence of urine or tongue biting. She decided to "sleep it off" and came in today at the request of her son. She has not experienced any chest pain, HA, palpitations. She has a chronic SOB which is unchanged. She reports having difficulty walk ___ a city block and climing stairs that has been ongoing for the past couple months. She denies any recents fevers, chills, nausea, vomiting, diarrhea, dizziness. Patient states she was seen in ___ to have her pacemaker interrogated and was told battery needed replacement, but has not had that done due to a change in her cardiologist Patient also recently increased lasix dose per PCP ___ 100mg qAM and 80mg qPM. Has not taken for past 3 days in case it may have led to her fall. In the ED, initial vitals were: 97.7 65 144/46 18 100% RA - Labs were significant for: 11.0 5.1 >--< 179 33.7 N:66.9 L:21.3 M:9.6 E:1.2 Bas:0.6 ___: 0.4 137 102 9 --------------< 60 5.2 25 0.8 ___: 24.9 PTT: 40.4 INR: 2.3 K:4.5 Glu:49 Lactate:1.0 - Imaging revealed: CT head with no acute intracranial process. CXR No acute cardiopulmonary process. No significant interval change. - The patient was not given any medication. Cards consult recs: No high rates on interrogation, but PPM at ERI so will require admission for generator change. Please admit to ___ under ___. NPO after midnight. Vitals prior to transfer were: HR 60 137/56 16 97% RA Upon arrival to the floor patient denies any chest pain, SOB, lightheadedness, dizziness Past Medical History: Rheumatic fever at age ___. Coronary artery disease status post PCI and stents x2 in ___. History of diastolic dysfunction with congestive heart failure. History of mechanical mitral valve replacement in ___. History of paroxysmal atrial fibrillation s/p cardioversion in ___. History of anxiety and depression. Sinus node dysfunction, s/p ___ dual chamber pacemaker. Dyslipidemia Hypertension Social History: ___ Family History: Mother with diabetes and coronary artery disease. No FH of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7 119/90 65 20 100%RA Orthostatics: Laying 114/48 68, standing 156/63 65 General: Alert, oriented, very anxious HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, firm S1 + S2, no appreciable murmur Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ___ 04:00PM BLOOD WBC-5.1 RBC-3.80* Hgb-11.0* Hct-33.7* MCV-89 MCH-28.9 MCHC-32.6 RDW-15.9* RDWSD-51.6* Plt ___ ___ 04:00PM BLOOD Neuts-66.9 ___ Monos-9.6 Eos-1.2 Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-1.09* AbsMono-0.49 AbsEos-0.06 AbsBaso-0.03 ___ 04:00PM BLOOD Plt ___ ___ 04:07PM BLOOD ___ PTT-40.4* ___ ___ 04:00PM BLOOD Glucose-60* UreaN-9 Creat-0.8 Na-137 K-5.2* Cl-102 HCO3-25 AnGap-15 ___ 04:09PM BLOOD Glucose-49* Lactate-1.0 K-4.5 DISCHARGE LABS: PERTINENT LABS: Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 1 mg PO BID:PRN anxiety 2. Metoprolol Tartrate 50 mg PO DAILY 3. Dofetilide 250 mcg PO Q12H 4. Warfarin 5 mg PO DAILY16 5. Rosuvastatin Calcium 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO DAILY 7. Spironolactone 25 mg PO DAILY 8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN sob 9. Vitamin D 1000 UNIT PO DAILY 10. Furosemide 100 mg PO QAM 11. Furosemide 80 mg PO QHS Discharge Medications: 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN sob 2. Ferrous Sulfate 325 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Spironolactone 25 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Lorazepam 1 mg PO BID:PRN anxiety 7. Furosemide 100 mg PO QAM 8. Furosemide 80 mg PO QHS 9. Warfarin 3 mg PO DAILY16 RX *warfarin 2 mg 1.5 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Metoprolol Tartrate 50 mg PO BID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 11. Cephalexin 500 mg PO BID Duration: 3 Days Take one dose tonight; continue taking one pill twice a day, your last day will be ___. RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp #*7 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Sick Sinus Syndrome s/p PPM Cardiac Arrest secondary to Torsade Syncope Atrial Fibrillation Secondary Diagnoses: Diastolic Congestive Heart Failure Anxiety COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ PMH mitral valve replacement and pacemaker presents w Fall on ___ // Acute cardiopulmonary change TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Left-sided pacer device is stable in position. The cardiac silhouette remains mildly enlarged. Mediastinal contours are stable unremarkable. No focal consolidation is seen. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. No significant interval change. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ female on Coumadin with a fall on ___. Evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformats were also performed. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 14.0 s, 14.2 cm; CTDIvol = 55.1 mGy (Head) DLP = 780.4 mGy-cm. Total DLP (Head) = 780 mGy-cm. COMPARISON: CT from ___. FINDINGS: There is no evidence of acute intracranial hemorrhage, midline shift, mass effect, or acute large vascular territorial infarct. . Mildly prominent ventricles and sulci are likely secondary to involutional changes. No acute fracture is seen. The paranasal sinuses and middle ear cavities are clear. Chronic partial opacification of the right mastoid air cells is noted, and the left mastoid air cells are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with PPM s/p generator change and attempted RV lead placement. // Rule out PTX Contact name: ___: ___ Rule out PTX IMPRESSION: In comparison with the study of ___, there is little overall change in the appearance of the dual-channel pacer and leads. Specifically, there is no evidence of pneumothorax. No pneumonia or vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CHF, arrhythmia // Please evaluate for pulmonary edema COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is seen. Moderate cardiomegaly with mild elongation of the descending aorta. Left pectoral Port-A-Cath. No pleural effusions. No pneumonia, no pulmonary edema. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Syncope, Lightheaded Diagnosed with SYNCOPE AND COLLAPSE temperature: 97.7 heartrate: 65.0 resprate: 18.0 o2sat: 100.0 sbp: 144.0 dbp: 46.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ came to the hospital because ___ lost consciousness. While ___ were here ___ had a part of your pacemaker replaced. ___ also received too much of your Tikosyn which caused your heart to stop briefly and ___ were shocked back to a normal rhythm. ___ were brought to the ICU for monitoring and were taken off the Tikosyn. Your metoprolol was increased to control your atrial fibrillation. ___ should also make sure your blood levels of the coumadin are monitored closely; your INR was elevated at discharge. A visiting nurse will be coming to your home to check your levels. Please follow up with your PCP and your cardiologist. It was a pleasure taking care of ___! -Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Open right distal radioulnar joint dislocation, right distal radius fracture Major Surgical or Invasive Procedure: ___: I&D, ORIF radius, DRUJ pinning ___, ___. History of Present Illness: ___ year old female w/ PMHx including Alzheimer's dementia and HLD, RHD, unwitnessed fall possibly down stairs, walked to family holding her right arm with bone exposed. C/o some pain to left forearm. Poor historian given dementia, no other complaints and history obtained from family. At baseline she is mobile on her own, knows her close family, can feed herself (right hand), needs help getting dressed. Past Medical History: Alzheimers HLD RHD Social History: ___ Family History: NC Physical Exam: Gen: NAD, A&Ox1, lying on stretcher. HEENT: Normocephalic. CV: RRR RUE: volar splint in place. right upper ext dressing c/d/i. fingers wwp, cap refill < 2 sec, makes a fist. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Sertraline 10 mg PO DAILY 4. Memantine 10 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, HA, T>100 degrees 2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain Partial fill ok. Wean. No driving/heavy machinery. RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as needed Disp #*25 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Memantine 10 mg PO BID 5. Pravastatin 40 mg PO QPM 6. Sertraline 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right open distal radius fracture and ulnar dislocation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: History: ___ with right arm open compound fracture s/p fall.// Fracture? Dislocation? Bleed? TECHNIQUE: CHEST (SINGLE VIEW) COMPARISON: None. FINDINGS: Portable AP view of the chest. No grossly displaced rib fractures identified. Apparent discontinuity of a left posterior lower rib is favored to represent overlapping structures. Scoliotic spine. The lungs are well expanded and clear. Cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. IMPRESSION: No grossly displaced rib fractures are identified. Radiology Report EXAMINATION: DX FOREARM AND WRIST INDICATION: History: ___ with right arm open compound fracture s/p fall.// Fracture? Dislocation? Bleed? TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right wrist. COMPARISON: None. FINDINGS: There is an open fracture dislocation of the wrist with comminuted, intra-articular fractures of the distal radial metaphysis/epiphysis, and ulnar styloid process, and complete volar and radial displacement of the hand and distal radial fracture fragment. The carpal arcs are relatively preserved. There is chondrocalcinosis and a type 2 lunate. There are moderate to severe degenerative changes of the basal joints of the thumb. There is mild cortical irregularity of the radial head, and a nondisplaced fracture is difficult exclude on this nondedicated study. IMPRESSION: Open fracture dislocation of the right wrist, with complete volar and radial displacement of the hand and distal radial fragment. Fracture of the ulnar styloid process. Mild cortical irregularity of the radial head, suboptimally evaluated. If there is clinical concern for radial head fracture recommend dedicated elbow radiographs. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with right arm open compound fracture s/p fall.// Fracture? Dislocation? Bleed? TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. IMPRESSION: Atrophy. Otherwise normal study. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with right arm open compound fracture s/p fall.// Fracture? Dislocation? Bleed? TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.2 s, 20.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 469.2 mGy-cm. Total DLP (Body) = 469 mGy-cm. COMPARISON: None. FINDINGS: Diffuse osteopenia limits evaluation. No fractures are identified. Alignment is normal. There is no prevertebral edema. There are multilevel degenerative changes. At C2-3 intervertebral osteophytes mildly encroach on the spinal canal. Facet and uncovertebral osteophytes produce moderate bilateral neural foraminal narrowing. At C3-4, intervertebral osteophytes mildly encroach on the spinal canal. Facet and uncovertebral osteophytes produce moderate left and severe right neural foraminal narrowing. At C4-5, intervertebral osteophytes encroach on the spinal canal and may contact the spinal cord. Facet and uncovertebral osteophytes produce severe right and moderate left neural foraminal narrowing. At C5-6, intervertebral osteophytes encroach on the spinal canal and likely deform the spinal cord. Facet and uncovertebral osteophytes produce severe right and moderate left neural foraminal narrowing. At C6-7, intervertebral osteophytes encroach on the spinal canal and may contact the spinal cord. The facet and uncovertebral osteophytes produce moderate bilateral neural foraminal narrowing. There is no spinal canal or neural foraminal narrowing at C7-T1 or the included portions of the upper thoracic spine. The thyroid and included lung apices appear. IMPRESSION: 1. Diffuse osteopenia limits evaluation for subtle fractures. 2. No evidence of fracture or subluxation. 3. Multilevel degenerative disease with spinal canal and neural foraminal narrowing. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Oth intartic fx lower end r radius, init for opn fx type I/2, Fall on same level, unspecified, initial encounter temperature: 96.0 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 172.0 dbp: 81.0 level of pain: 0 level of acuity: 2.0

INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non-weightbearing right upper extremity, light activities of daily living only (hair brushing, tooth brushing, etc) MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB FOLLOW UP: Please follow up with your Hand Surgeon, Dr. ___. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Physical Therapy: Non-weight bearing right upper extremity, minimal activities of daily living ROM OK at elbow and shoulder, OK for digit ROM Splint to remain in place until clinic f/u, keep clean and dry Patient to maintain functional mobility Treatments Frequency: Keep splint clean and dry Cover with a plastic bag to shower Splint to remain on until clinic followup No dressing care needed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: afferent loop obstruction abdominal pain Major Surgical or Invasive Procedure: ___, PLACEMENT OF JEJUNOSTOMY History of Present Illness: ACS Consult H&P ___ Hx obtained from chart, daughter (who translated), and Ms. ___. HPI: ___ is a ___ w/ hx of total gastrectomy w/ RNY esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy (since removed) ___ for T2aN0 gastric adenoCA who is presenting here to the ED for a <1 day hx of acute onset lower abd pain i/s/o a ~1 wk hx of intermittent epigastric pain. She has had similar sx before, being hospitalized for pancreatitis ___. She also had a remote hospitalization in ___ for SBO (?closed loop obstruction) that was managed non-operatively. Yesterday she also noted some nausea, no vomiting. She is continuing to have BMs and is passing gas. She denies f/c/s, lightheadedness and/or dizziness, chest pain, SOB, blurry vision, h/a's, change in BMs, BRBPR, melena, difficulty urinating, myalgias, arthralgias, or skin changes; ROS is o/w -ve except as noted before. A CT A/P was obtained which showed dilated small bowel thought to be from the biliary limb, c/f afferent loop obstruction, for which we were consulted. Past Medical History: HTN T2aN0 adenocarcinoma s/p total gastrectomy ___ migraines vertigo OA multinodular goiter pancreatitis ___ macrocytic anemia PSHx: total gastrectomy w/ RNY esophagojejunostomy and D2 lymphadenectomy ___ diagnostic lap ___, RFA of L GSV ___ Social History: ___ Family History: Mother with thyroid disease, early MI Physical Exam: Admission PEx: VS - 97.8 67 139/63 16 100% RA Gen - NAD CV - RRR Pulm - non-labored breathing, no resp distress, satting Abd - soft, mild to mod distension, mild periumbilical/epigastric ttp w/ no guardine or rebound MSK & extremities/skin - no leg swelling observed b/l Discharge PEx: VS - 97.8 67 139/63 16 100% RA Gen - NAD CV - RRR Pulm - non-labored breathing, no resp distress, satting Abd - soft, nodistended, J tube in place MSK & extremities/skin - no leg swelling observed b/l Pertinent Results: Admission Labs: ___ 11:00PM BLOOD WBC-7.9 RBC-2.74* Hgb-9.4* Hct-30.5* MCV-111* MCH-34.3* MCHC-30.8* RDW-21.2* RDWSD-86.4* Plt ___ ___ 11:00PM BLOOD Plt ___ ___ 06:18AM BLOOD ___ PTT-28.8 ___ ___ 11:00PM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-142 K-5.0 Cl-106 HCO3-23 AnGap-13 ___ 11:00PM BLOOD ALT-19 AST-23 AlkPhos-72 TotBili-0.7 ___ 11:00PM BLOOD Lipase-834* ___ 11:00PM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.4* ___ 12:52AM BLOOD Lactate-1.1 Discharge Labs: Imaging: CT A/P ___ 1. Findings concerning for small bowel obstruction, potentially of the afferent limb near the jejunojejunostomy, although no definite transition point is identified. No obvious evidence of ischemia or perforation within the limitations of paucity of intra-abdominal fat. Surgical consultation recommended. Additionally, small-bowel follow-through series with Gastrografin may be obtained for further assessment. 2. Slight increase in mild-to-moderate intrahepatic biliary ductal dilatation, which is nonspecific, could further suggest afferent limb obstruction. CT Head ___ 1. Small posterior falx subdural hematoma extending to the tentorium and adjacent small subarachnoid hemorrhage. 2. Large right occipital parietal scalp hematoma without fracture. CXR ___ Hyperinflated lungs compatible with emphysema with no acute cardiopulmonary process. CT Head No Contrast ___ Interval increase in size of a posterior falx subdural hematoma extending to the tentorium and now the anterior falx. There has been interval increase in the degree of posterior left parietal subarachnoid hemorrhage as well as new left frontal lobe and possibly posterior right parietal lobe subarachnoid hemorrhage. No midline shift. CT Head No Contrast ___ 1. Prominent subdural hemorrhage along the superior falx and left tentorial leaflet and multiple areas of subarachnoid hemorrhage involving in the left frontal and temporal lobes are not significantly changed. 2. Several areas of subarachnoid hemorrhage in the right frontal and temporal lobes are new or increased in prominence. CT Head No Contrast ___ 1. No evidence of infarction or new intracranial hemorrhage. 2. Redemonstration of prominent subdural hemorrhage along the superior falx and left tentorial membrane, minimally decreased in size compared to prior study. 3. Several areas of subarachnoid hemorrhage in the bilateral frontal and temporal lobes appear slightly less conspicuous than on prior study. 4. Large right parietal subgaleal hematoma appears significantly increased in size compared to prior study, now measuring up to 1.6 cm. Hip XR ___ No comparison. A pelvis over view as well as 2 projections of the left hip are provided. Moderate degenerative changes at the level of both hip joints. No evidence of fracture. Multiple phleboliths project over the pelvis. Mild degenerative changes at the level of the sacroiliac joints. US Abd Limited ___ 5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the midline laparotomy site, differential diagnosis includes hematoma or a complex seroma. Unilat Lower Ext Veins ___ Moderate to severe soft tissue swelling overlying the right posterior knee. No evidence of deep venous thrombosis in the right lower extremity veins. Medications on Admission: Active Medication list as of ___: Medications - Prescription 18" CHROME GRAB BAR - 18" chrome grab bar . use for safety as directed daily as needed dx: R26.81 18INCH CHROME GRAB BAR - 18inch chrome grab bar . use as instructed daily Dx: ADULT BRIEFS- SMALL - adult briefs- small . use ___ and prn for incontinence BEDSIDE COMMODE - bedside commode . unsteady gait 781.2 DEXAMETHASONE - dexamethasone 1.5 mg tablet. 1 tablet(s) by mouth daily LORAZEPAM - lorazepam 0.5 mg tablet. TAKE 1 TABLET BY MOUTH AT BEDTIME AS NEEDED FOR ANXIETY MECLIZINE - meclizine 12.5 mg tablet. TAKE 1 TABLET BY MOUTH TWO TIMES A DAY AS ___ OR USE MACHINERY WORK WHILE ON MEDS OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1 CAPSULE(S) BY MOUTH DAILY SHOWER BENCH - shower bench . use when showering/bathing daily as needed VERAPAMIL - verapamil 40 mg tablet. 1 and ___ tablet(s) by mouth daily Medications - OTC ACETAMINOPHEN [CHILDREN\'S PAIN-FEVER RELIEF] - Children\'s Pain and Fever Relief 160 mg/5 mL oral liquid. TAKE 4 TEASPOONS BY MOUTH EVERY 6 HOURS FOR PAIN CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12 500 mcg tablet. 1 TABLET(S) BY MOUTH DAILY DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL ___ - Artificial Tears (dextran 70-hypromellose) eye drops. ONE DROP ___. free tears/gel. Let warm water fall on CLOSED lids for 2 mins in shower. Massage edges of lids/lashes for 30 secs. FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 TABLET(S) BY MOUTH DAILY FOOD SUPPLEMT, LACTOSE-REDUCED [ENSURE] - Ensure oral liquid. 1 to 2 cans by mouth daily vanilla flavor dx: weight loss MULTIVITAMIN [DAILY-VITE] - Daily-Vite tablet. 1 TABLET(S) BY MOUTH DAILT Discharge Medications: 1. Omeprazole 40 mg PO DAILY 2. Verapamil 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: afferent loop obstruction abdominal pain subarachnoid hemorrhage subdural hemorrhage traumatic brain injury Discharge Condition: Clear and coherent Followup Instructions: ___ Radiology Report INDICATION: NO_PO contrast; History: ___ with R and L lower quad abd pn NO_PO contrast// ? appendicitis ? diverticulitis TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 4.8 s, 38.1 cm; CTDIvol = 7.8 mGy (Body) DLP = 297.9 mGy-cm. Total DLP (Body) = 308 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: As with prior studies, exam is moderately limited secondary to paucity of intra-abdominal fat, limiting the potential visualization of inflammatory changes. LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Again seen are multiple subcentimeter hypodensities throughout the liver, similar in appearance to the prior study, and likely representing simple cyst. The liver otherwise demonstrates homogenous attenuation throughout. Mild-to-moderate intrahepatic biliary ductal dilatation appears slightly worse than the prior study, especially within the more superior segments. There is stable extrahepatic biliary dilatation measuring 1.2 cm (02:18). The gallbladder appears distended with a mild amount of surrounding free fluid, similar to prior. No gallstones identified. PANCREAS: The pancreas is not well seen, but has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Few subcentimeter hypodensities throughout the bilateral kidneys are too small to characterize but likely represent cysts. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The patient is status post total gastrectomy and Roux-en-Y esophagojejunostomy. There are moderately distended loops of jejunum in the left mid abdomen to pelvis which contain fecalized material and measure up to 4.9 cm (601:18). This loop of bowel appears to represent the afferent limb, although it is unclear. Potential transition point is seen near the jejunojejunal anastomosis. No obvious abnormal wall enhancement. No free air. Evaluation for mesenteric free fluid limited by body habitus. The colon and rectum mildly decompressed but contain fecal material and air. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Grade 1 anterolisthesis of L4 on L5 is grossly unchanged. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Findings concerning for small bowel obstruction, potentially of the afferent limb near the jejunojejunostomy, although no definite transition point is identified. No obvious evidence of ischemia or perforation within the limitations of paucity of intra-abdominal fat. Surgical consultation recommended. Additionally, small-bowel follow-through series with Gastrografin may be obtained for further assessment. 2. Slight increase in mild-to-moderate intrahepatic biliary ductal dilatation, which is nonspecific, could further suggest afferent limb obstruction. RECOMMENDATION(S): Recommend small-bowel follow-through series with Gastrografin for further assessment. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:49 am, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old ___ speaking woman with afferent loop syndrome with plan to go to operating room tomorrow// pre-operative assessment Surg: ___ (ex-lap, ?SBR) TECHNIQUE: Chest PA and lateral COMPARISON: Chest CT dated ___ FINDINGS: The lungs are hyperinflated compatible with emphysema. No lobar consolidation. Cardiomediastinal silhouette is within normal range. No pleural effusions or pneumothorax. Likely calcified right hilar lymph node. Degenerative changes of the thoracic spine seen. IMPRESSION: Hyperinflated lungs compatible with emphysema with no acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with afferent limb syndrome who fell getting out of bed with headstrike// ?hematoma other other pathology secondary to a fall with headstrike TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is hyperdensity along the posterior falx extending to the left tentorial leaflet. There is a focus of subarachnoid hemorrhage in the left occipital parietal region. There is no evidence of acute large territory infarction, edema,or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is a large right occipital parietal scalp hematoma and overlying laceration. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Small posterior falx subdural hematoma extending to the tentorium and adjacent small subarachnoid hemorrhage. 2. Large right occipital parietal scalp hematoma without fracture. NOTIFICATION: Discussed with night resident who accompanied the patient to the ED. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman s/p fall with SDH and IPHPlease perform at 10am// interval change in SDH and IPH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: Prior head CT dated ___ 01:55 FINDINGS: In comparison to prior exam there has been significant interval accumulation of hyperdense blood products along the posterior falx extending along the left tentorial leaflet. Blood is seen to involve the anterior falx as well. A focus subarachnoid hemorrhage in the left occipital parietal region is increased from prior. There is new subarachnoid hemorrhage involving the posterior left parietal lobe and overlying the left frontal lobe (03:20). There is a suggestion of foci of subarachnoid blood in the posterior right parietal lobe (03:19). There is no acute large territorial infarction. The ventricles and sulci are otherwise unchanged in appearance. There is no midline shift. Basal cisterns appear patent. A right occipital parietal scalp hematoma is similar appearance to the prior. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Interval increase in size of a posterior falx subdural hematoma extending to the tentorium and now the anterior falx. There has been interval increase in the degree of posterior left parietal subarachnoid hemorrhage as well as new left frontal lobe and possibly posterior right parietal lobe subarachnoid hemorrhage. No midline shift. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:41 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with traumatic brain injury s/p fall with head strike// please evaluate for interval change in ___ and ___ TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT head from ___. FINDINGS: Prominent subdural hemorrhage along the superior falx and left tentorial leaflet is not significantly changed. Several areas of subarachnoid hemorrhage in the right frontal and temporal lobes are new or increased in prominence. Multiple areas subarachnoid hemorrhage are again seen involving the left frontal and temporal lobes. There is no evidence of acute large territorial ischemic infarction or mass effect. There is prominence of the ventricles and sulci suggestive of atrophy. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. A right occipital scalp hematoma is smaller. IMPRESSION: 1. Prominent subdural hemorrhage along the superior falx and left tentorial leaflet and multiple areas of subarachnoid hemorrhage involving in the left frontal and temporal lobes are not significantly changed. 2. Several areas of subarachnoid hemorrhage in the right frontal and temporal lobes are new or increased in prominence. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:15 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with hx total gastrectomy RNY esophagoJ ___ for gastric adenoCA p/w 1 wk abd pain CT c/f afferent loop obs c/b inpt fall ___ s/p ___ enteroenterostomy, feeding J-tube placement, chest now fell and hit head. Evaluation for interval change, acute hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Comparison to noncontrast head CT from ___. FINDINGS: Redemonstration of prominent subdural hemorrhage along the superior falx and left tentorium, minimally decreased in size compared to prior study. Several areas of subarachnoid hemorrhage in the bilateral frontal and temporal lobes appear slightly less conspicuous than on prior study. No evidence of infarction or new intracranial hemorrhage. There is prominence of the ventricles and sulci suggestive of involutional changes. A large right parietal subgaleal hematoma appears significantly increased in size compared to prior study, now measuring up to 1.6 cm. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of infarction or new intracranial hemorrhage. 2. Redemonstration of prominent subdural hemorrhage along the superior falx and left tentorial membrane, minimally decreased in size compared to prior study. 3. Several areas of subarachnoid hemorrhage in the bilateral frontal and temporal lobes appear slightly less conspicuous than on prior study. 4. Large right parietal subgaleal hematoma appears significantly increased in size compared to prior study, now measuring up to 1.6 cm. Radiology Report EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT INDICATION: ___ hx total gastrectomy RNY esophagoJ ___ for gastric adenoCA p/w 1 wk abd pain CT c/f afferent loop obs c/b inpt fall SAH/SDH s/p ___ enteroenterostomy, feeding J-tube placement// Recent fall. Trauma? Recent fall. Trauma? IMPRESSION: No comparison. A pelvis over view as well as 2 projections of the left hip are provided. Moderate degenerative changes at the level of both hip joints. No evidence of fracture. Multiple phleboliths project over the pelvis. Mild degenerative changes at the level of the sacroiliac joints. Radiology Report EXAMINATION: US ABD LIMIT, SINGLE ORGAN INDICATION: ___ year old woman with afferent loop obstruction s/p ___ enteroenterostomy, feeding J tube placement.// Evaluate for seroma/hematoma. TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the midline laparotomy wound. COMPARISON: CT abdomen and pelvis ___ FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the midline laparotomy wound. Deep to the surgical staple line, there is a 5.0 x 1.2 x 2.1 cm heterogeneous, hypoechoic collection, consistent with a hematoma or complex seroma. No internal color flow is seen. A drain is demonstrated deep to the fascia. IMPRESSION: 5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the midline laparotomy site, differential diagnosis includes hematoma or a complex seroma. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old woman with RLE swelling.// DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: No relevant comparison identified. FINDINGS: There is moderate to severe soft tissue swelling overlying the right posterior knee. There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: Moderate to severe soft tissue swelling overlying the right posterior knee. No evidence of deep venous thrombosis in the right lower extremity veins. Gender: F Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Other partial intestinal obstruction, Epigastric pain temperature: 97.4 heartrate: 66.0 resprate: 18.0 o2sat: 99.0 sbp: 169.0 dbp: 72.0 level of pain: 7 level of acuity: 3.0

Dear Ms. ___, You came here with abdominal pain and were found to have a bowel obstruction on imaging. You were taken to the OR where you underwent an enteroenterostomy. A J-tube was placed to ensure you are getting adequate nutrition. You hospitalization was complicated by 2 falls. Initial imaging demonstrated a brain bleed but repeat imaging was stable so neurosurgery did not feel operative management was appropriate. We do think your brain bleed did lead to low sodium levels in the hospital (a condition called SIADH). We anticipate that your sodium level will improve with time. In the meantime please restrict your fluid intake by mouth to less than 1L. The rehab facility will check your sodium levels as well. You should follow up with Dr. ___ our surgery clinic in ___ weeks. You can reach his office at ___ to set up an appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amoxicillin / strawberry / Cephalosporins / vancomycin / valproic acid / olanzapine Attending: ___. Chief Complaint: elevated LFTs Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ y/o male w/ a PMHx of recently diagnosed seizures, GAS meningitis & bacteremia, s/p multiple ENT surgical procedures for source control of mastoiditis/cranial abscess and DRESS ___ anti-epileptics and/or multiple abx received during prior admission who presents from ___ office after having LFTs checked that showed uptrending LFTs. He was first hospitalized ___ for seizures in the setting of marijuana use and fall then found to have GAS meningitis & bacteremia then received multiple ENT surgical procedures for source control of who was again hospitalized ___ where he initially presented with facial swelling & rash, ultimately diagnosed with DRESS & drug-induced liver injury thought to be secondary to previous anti-epileptic or antibiotic therapy. His LFTs downtrended prior to discharge but when rechecked at PCP had ___ again. Patient reports no symptoms, stating that he feels as if his rash is over all better. He denies any chest pain, shortness of breath or numbness, weakness, tingling, nausea, vomiting. He denies any burning or itching. He states that he has been compliant with his medications. He has not had any further headaches, visual changes, or seizure/neurologic symptoms. In the ED, initial VS were: T98.0, HR 122, BP 156/89, RR16, SaO2 100% RA ECG: Labs showed: 14.7>12.5/38.0<270 135|100|15 ============<138 4.4|24|0.7 ALT: 581 AP: 76 Tbili: 0.4 Alb: 3.9 AST: 128 Imaging showed: CXR Left upper extremity PICC terminates in the mid to low SVC. There is no focal consolidation. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits Consults: Hepatology- admit to medicine for DILI work up Patient received: No medications in ED Transfer VS were:T 97.7, HR 87, BP132/75, RR16, SaO2 98% RA On arrival to the floor, patient recounts the above history Past Medical History: - Asthma - Multiple bilateral ear infections, s/p bilateral tympanostomy tubes and reported "mastoid procedures" - seizures - meningitis - R temporal lobe abscess - bilateral mastoiditis ___: Right mastoidectomy, myringotomy w/tube insertion ___: Stereotactic drainage of right temporal abscess ___: Right craniotomy for resection/evacuation of abscess Social History: ___ Family History: Diabetes Physical Exam: ADMISSION PHYSICAL EXAM VS: T98.4 PO, BP118/68, HR 85 SaO297%RA GENERAL: NAD, sitting up in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, mild swelling on left zygomatic arch area. No tenderness to palpation on skull or face, no fluctuance NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, CN2-12 intact SKIN: Diffusely mildly erythematous on face and UE (improved per patient), some healing scabs which patient reports he picked on UE, dry desquamation of ___, no active looking lesions DISCHARGE PHYSICAL EXAM VS: 97.8 PO 133 / 86 69 18 100 RA GENERAL: NAD, lying down in bed HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM, mild swelling on left zygomatic arch area. No tenderness to palpation on skull or face, no fluctuance HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Diffusely mildly erythematous on face and UE (improved per patient), some healing scabs which patient reports he picked on UE, improved desquamation of ___ ___ Results: ADMISSION LABS ___ 02:42PM WBC-13.9* RBC-3.84* HGB-12.3* HCT-38.4* MCV-100* MCH-32.0 MCHC-32.0 RDW-14.9 RDWSD-53.9* ___ 02:42PM ALT(SGPT)-639* AST(SGOT)-198* ALK PHOS-78 TOT BILI-0.4 ___ 09:44PM WBC-14.7* RBC-3.96* HGB-12.5* HCT-38.0* MCV-96 MCH-31.6 MCHC-32.9 RDW-14.6 RDWSD-51.2* ___ 09:44PM NEUTS-66.2 ___ MONOS-7.4 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-9.71* AbsLymp-3.70 AbsMono-1.08* AbsEos-0.01* AbsBaso-0.03 ___ 09:44PM ___ PTT-25.6 ___ ___ 09:44PM GLUCOSE-138* UREA N-15 CREAT-0.7 SODIUM-135 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-11 ___ 09:44PM ALT(SGPT)-581* AST(SGOT)-128* ALK PHOS-76 TOT BILI-0.4 ___ 09:44PM ALBUMIN-3.9 ___ 09:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 09:49PM LACTATE-1.6 PERTINENT/DISCHARGE LABS ___ 06:23AM BLOOD WBC-14.1* RBC-3.79* Hgb-12.2* Hct-37.0* MCV-98 MCH-32.2* MCHC-33.0 RDW-14.7 RDWSD-53.1* Plt ___ ___ 06:23AM BLOOD ALT-511* AST-105* LD(LDH)-229 AlkPhos-72 TotBili-0.4 ___ 05:41AM BLOOD WBC-14.0* RBC-4.01* Hgb-12.7* Hct-39.4* MCV-98 MCH-31.7 MCHC-32.2 RDW-14.9 RDWSD-53.8* Plt ___ ___ 05:41AM BLOOD Glucose-83 UreaN-17 Creat-0.5 Na-139 K-4.0 Cl-104 HCO3-26 AnGap-9* ___ 05:41AM BLOOD ALT-428* AST-71* CK(CPK)-16* AlkPhos-97 TotBili-0.3 ___ 05:41AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.0 IMAGING/STUDIES MRI brain w/ and w/o contrast ___- Interval decrease in size of the known right temporal abscess with associated decrease in surrounding vasogenic edema. The right dural/pachymeningeal enhancement appear similar to slightly improved compared to prior. Opacification of the right mastoid air cells and middle ear cavity appear similar compared to prior, but no restricted diffusion to suggest abscess formation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with PICC// PICC placement? COMPARISON: Chest radiograph ___ FINDINGS: Portable AP view of the chest provided. Left upper extremity PICC terminates in the mid to low SVC. There is no focal consolidation. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: Left upper extremity PICC terminates in the mid to low SVC. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with h/o GAS meningitis and abscess please evaluate for interval change// evaluate prior abscess TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Prior MR done ___ FINDINGS: The right temporald rim enhancing collection is decreased in size currently measuring 22 x 18 mm in diameter (26 x 27 mm previously) with the superolateral extending surgical drainage tract also being decreased in size currently measuring 7 mm in diameter (previously 10 mm). Previously noted restricted diffusion as well as surrounding edema in the right temporal lobe is improved compared to prior. The right dural/pachymeningeal enhancement appear similar to slightly improved compared to prior. There is mild dilatation of the temporal horn of the right lateral ventricle which may be ex vacuo in nature. There is persistent opacification of the right middle ear cavity and mastoid air cells with mild enhancement, but no restricted diffusion (suggesting granulation tissue). The pituitary appears normal. The craniocervical junction appears normal. The orbits appear normal. The paranasal sinuses are clear. The intracranial arteries demonstrate normal T2 flow void. IMPRESSION: Interval decrease in size of the known right temporal abscess with associated decrease in surrounding vasogenic edema. The right dural/pachymeningeal enhancement appear similar to slightly improved compared to prior. Opacification of the right mastoid air cells and middle ear cavity appear similar compared to prior, but no restricted diffusion to suggest abscess formation. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs, Rash Diagnosed with Gen skin eruption due to drugs and meds taken internally, Adverse effect of cephalospor/oth beta-lactm antibiot, init, Oth places as the place of occurrence of the external cause, Acute viral hepatitis, unspecified, Epilepsy, unsp, not intractable, without status epilepticus temperature: 98.0 heartrate: 122.0 resprate: 16.0 o2sat: 100.0 sbp: 156.0 dbp: 89.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. Why was I admitted to the hospital? - Your primary care doctor got labs that showed your liver function tests were elevated What was done while I was in the hospital? - Your Keppra was switched to a different anti-seizure medication called lacosamide - Your antibiotic was switched from meropenem to a different one called daptomycin - Your labs showed that the liver function tests began to go down relatively quickly What should I do when I get home from the hospital? - Be sure to continue to take your home medications, especially your lacosamide and daptomycin as prescribed - If you have fevers, chills, a seizure, confusion, dizziness, new rash, abdominal pain, changes in your skin color, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: low grade fevers i/s/o robotic pyelolithotomy and previous urine leak Major Surgical or Invasive Procedure: ___: right ureteral stent exchange History of Present Illness: Ms. ___ is a ___ y/o female well known to our service who underwent right robotic partial nephrectomy and pyelolithotomy (for a large staghorn calculus) on ___. The renal pelvic tissue was thin and friable due to inflammation from the stone and the closure was poor; she developed a urine leak and was discharged home with Foley catheter, ureteral stent, and surgical drain in place. She was subsequently readmitted ___ - ___ with an infected urinoma for which she had a drain placed by ___. Blood and urine cultures on admission were negative but culture of the purulent material from the urinoma grew multiple organisms; initially only Pseudomonas aeruginosa was speciated and she was sent home on a 14-day course of PO ciprofloxacin. Full speciation/sensitivities were requested on the culture and Enterococcus and E. coli were additionally isolated. In the interval she has done well. Her surgical ___ drain and Foley catheter have been removed, leaving only the ___ drain still in place. Her prednisone dose was tapered to 2.5 mg, then to 1 mg and was discontinued entirely ___ days ago. Her methotrexate was increased from 7.5 to 10 mg. She completed the PO ciprofloxacin two days ago. This morning she felt very well, but around 1330 today she began to feel hot. Her temperature was approximately 100 degrees at that time and subsequently increased to 101.3. She had some somewhat increased fatigue but no chills, sweats, or other localizing symptoms. She has been having BMs and passing flatus. There has been no dysuria, frequency, urgency, or change in the appearance of the urine. She called in and was advised to present to the ED for evaluation. In triage her HR was elevated to 133; it subsequently decreased to the 100s without intervention. Her temperature was initially 100.8 and uptrended to 101.3 while she was being evaluated. Past Medical History: - depression - sarcoidosis Social History: ___ Family History: noncontributory Physical Exam: Exam on admission: - AAOx4, WDWN female resting comfortably in bed, NAD - skin WWP, non-diaphoretic - breathing unlabored on RA - abd soft, ND with minimal tenderness to even deep palpation of RUQ/RLQ; well-healed robotic port sites, no erythema, induration, discharge, fluctuance; ___ drain in place to right flank draining clear straw-colored fluid - no CVAT - no ___ edema or tenderness Exam on discharge: - AAOx4, WDWN female resting comfortably in bed, NAD - skin WWP, non-diaphoretic - breathing unlabored on RA - abd soft, ND, NT; no CVAT - ___ drain site intact with c/d/i dressing in place - no ___ edema or tenderness Pertinent Results: ___ 08:30PM BLOOD WBC-9.8 RBC-3.93# Hgb-11.1* Hct-34.8 MCV-89 MCH-28.2 MCHC-31.9* RDW-13.2 RDWSD-43.2 Plt ___ ___ 09:15AM BLOOD WBC-7.5 RBC-3.30* Hgb-9.4* Hct-29.3* MCV-89 MCH-28.5 MCHC-32.1 RDW-13.3 RDWSD-43.7 Plt ___ ___ 07:40AM BLOOD WBC-5.1 RBC-3.38* Hgb-9.5* Hct-30.1* MCV-89 MCH-28.1 MCHC-31.6* RDW-13.5 RDWSD-44.0 Plt ___ ___ 08:30PM BLOOD Glucose-126* UreaN-13 Creat-1.4* Na-134 K-4.0 Cl-97 HCO3-23 AnGap-18 ___ 09:15AM BLOOD Glucose-160* UreaN-11 Creat-1.2* Na-138 K-3.7 Cl-102 HCO3-23 AnGap-17 ___ 07:40AM BLOOD Glucose-111* UreaN-8 Creat-1.2* Na-143 K-4.3 Cl-105 HCO3-25 AnGap-17 ___ 09:21AM BLOOD Glucose-164* UreaN-13 Creat-1.3* Na-141 K-3.8 Cl-102 HCO3-26 AnGap-17 ___ 08:40PM BLOOD Lactate-2.0 ___ 09:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 09:15PM URINE RBC-3* WBC-18* Bacteri-FEW Yeast-NONE Epi-2 ___ 9:15 pm URINE URINE CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL. ___ 11:31 am URINE Site: CYSTOSCOPY RIGHT RENAL PELVIC . **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. ~400 CFU/mL. CTU ___: Final Report EXAMINATION: CTU with contrast, including delayed imaging INDICATION: ___ w/ complicated urologic history, h/o urinoma now with fever. please obtain ct urogram w/wo contrast with DELAYED CUTS to eval for collecting system extravasation. TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in prone position. The non-contrast scan was done with low radiation dose technique. The contrast scan was performed with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 651.5 mGy-cm. 2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 3) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 652.2 mGy-cm. Total DLP (Body) = 1,313 mGy-cm.; Acquisition sequence: 1) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 11.4 mGy (Body) DLP = 614.3 mGy-cm. Total DLP (Body) = 614 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The left adrenal gland is unremarkable. The right adrenal gland is not well visualized. URINARY: There is a right double-J ureteral stent is unchanged, but the proximal pigtail is inferior to the obstructed renal pelvis, as before. There is a right posterior approach pigtail catheter at the site of a prior right perinephric fluid collection. The fluid collection has largely resolved. There is trace fluid and fibrofatty proliferation surrounding in this region. There is a 0.5 cm stone in the right renal pelvis (___). Again seen a prominent right renal collecting system, consistent with hydronephrosis. There are post-treatment changes from prior partial nephrectomy. There is a 1.2 cm hypodense lesion in the left kidney, with Hounsfield units slightly above expected for a simple cyst, possibly representing a hemorrhagic cyst. There is a 0.4 cm nonobstructive nephrolith in the left kidney. The distal ureters and bladder are unremarkable. On delayed imaging, there is a right persistent striated nephrogram without evidence of extravasated contrast. A persistent striated nephrogram, likely secondary to obstruction. A portion of the cortex is nonenhancing (___) at the site of the prior partial nephrectomy. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Punctate nonobstructive appendiceal stone (___). The appendix is otherwise normal. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There are few prominent, though nonenlarged right aortocaval lymph nodes, measuring up to 1.0 x 0.6 cm (___). There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of collecting system extravasation. No urinoma. 2. The previously seen right perinephric fluid collection has largely resolved with minimal persistent trace fluid. 3. There is a right double-J ureteral stent and a right posterior approach pigtail catheter at the site of the previous right perinephric fluid collection. The superior pigtail of the double-J ureteral stent is inferior to the obstructed renal pelvis, as before. 4. On delayed imaging, there is a right persistent striated nephrogram without evidence of extravasated contrast. A persistent striated nephrogram, likely secondary to obstruction. A portion of the cortex is nonenhancing at the site of the prior partial nephrectomy. KUB ___: INDICATION: ___ year old woman s/p right ureteral stent exchange // assess stent position TECHNIQUE: Supine abdominal radiographs were obtained. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: Compared to ___, the right double-J ureteral stent has been moved is such that the proximal and is present in the expected location of the right renal pelvis and the distal and is coiled in the right side of the bladder. A right-sided percutaneous nephrostomy tube is in unchanged position. Contrast fills the bladder. There are no abnormally dilated loops of large or small bowel. There is a nonspecific, nonobstructive bowel gas pattern. There is no free intraperitoneal air. Osseous structures are notable for degenerative changes of the lumbar spine. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: The proximal end of the right double-J ureteral stent is now curled in the expected location of the right renal pelvis and the distal end is curled in the right side of the bladder. A right-sided percutaneous nephrostomy tube is in unchanged position. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methotrexate Sodium P.F. 10 mg IT QWED 2. FLUoxetine 20 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Duration: 7 Days RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 6. FLUoxetine 20 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Methotrexate Sodium P.F. 10 mg IT QWED Discharge Disposition: Home Discharge Diagnosis: fever and partial right renal obstruction following robotic pyeloplasty Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTU with contrast, including delayed imaging INDICATION: ___ w/ complicated urologic history, h/o urinoma now with fever. please obtain ct urogram w/wo contrast with DELAYED CUTS to eval for collecting system extravasation. // ___ w/ complicated urologic history, h/o urinoma now with fever. please obtain ct urogram w/wo contrast with DELAYED CUTS to eval for collecting system extravasation. ; NO_PO contrast; History: ___ with recent CTU now need please obtain delayed phase CT scan in ___ mins in order to assess for accumulation of IV contrast outside kidney.NO_PO contrast // STAT NON-CON per urology: please obtain delayed phase CT scan in ___ mins in order to assess for accumulation of IV contrast outside kidney. TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in prone position. The non-contrast scan was done with low radiation dose technique. The contrast scan was performed with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 651.5 mGy-cm. 2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 3) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 652.2 mGy-cm. Total DLP (Body) = 1,313 mGy-cm.; Acquisition sequence: 1) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 11.4 mGy (Body) DLP = 614.3 mGy-cm. Total DLP (Body) = 614 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The left adrenal gland is unremarkable. The right adrenal gland is not well visualized. URINARY: There is a right double-J ureteral stent is unchanged, but the proximal pigtail is inferior to the obstructed renal pelvis, as before. There is a right posterior approach pigtail catheter at the site of a prior right perinephric fluid collection. The fluid collection has largely resolved. There is trace fluid and fibrofatty proliferation surrounding in this region. There is a 0.5 cm stone in the right renal pelvis (___). Again seen a prominent right renal collecting system, consistent with hydronephrosis. There are post-treatment changes from prior partial nephrectomy. There is a 1.2 cm hypodense lesion in the left kidney, with Hounsfield units slightly above expected for a simple cyst, possibly representing a hemorrhagic cyst. There is a 0.4 cm nonobstructive nephrolith in the left kidney. The distal ureters and bladder are unremarkable. On delayed imaging, there is a right persistent striated nephrogram without evidence of extravasated contrast. A persistent striated nephrogram, likely secondary to obstruction. A portion of the cortex is nonenhancing (___) at the site of the prior partial nephrectomy. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Punctate nonobstructive appendiceal stone (___). The appendix is otherwise normal. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There are few prominent, though nonenlarged right aortocaval lymph nodes, measuring up to 1.0 x 0.6 cm (___). There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of collecting system extravasation. No urinoma. 2. The previously seen right perinephric fluid collection has largely resolved with minimal persistent trace fluid. 3. There is a right double-J ureteral stent and a right posterior approach pigtail catheter at the site of the previous right perinephric fluid collection. The superior pigtail of the double-J ureteral stent is inferior to the obstructed renal pelvis, as before. 4. On delayed imaging, there is a right persistent striated nephrogram without evidence of extravasated contrast. A persistent striated nephrogram, likely secondary to obstruction. A portion of the cortex is nonenhancing at the site of the prior partial nephrectomy. Radiology Report INDICATION: ___ year old woman s/p right ureteral stent exchange // assess stent position TECHNIQUE: Supine abdominal radiographs were obtained. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: Compared to ___, the right double-J ureteral stent has been moved is such that the proximal and is present in the expected location of the right renal pelvis and the distal and is coiled in the right side of the bladder. A right-sided percutaneous nephrostomy tube is in unchanged position. Contrast fills the bladder. There are no abnormally dilated loops of large or small bowel. There is a nonspecific, nonobstructive bowel gas pattern. There is no free intraperitoneal air. Osseous structures are notable for degenerative changes of the lumbar spine. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: The proximal end of the right double-J ureteral stent is now curled in the expected location of the right renal pelvis and the distal end is curled in the right side of the bladder. A right-sided percutaneous nephrostomy tube is in unchanged position. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Urinary tract infection, site not specified, Fever, unspecified temperature: 100.8 heartrate: 133.0 resprate: 16.0 o2sat: 98.0 sbp: 130.0 dbp: 72.0 level of pain: 2 level of acuity: 1.0

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency as long as the stent is in place. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal distention, cough Major Surgical or Invasive Procedure: ___: Transjugular hepatic core biopsy History of Present Illness: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin and abdominal distension. She has noticed this increasing abdominal distension over the last month to weeks with associated weight gain. She denies any abdominal pain other than mild twinges across the right flank. She also endorses decreased exercise tolerance over the last year which she attributes to starting on nadolol but no SOB at rest or chest pain. She denies any fevers, chills, vomiting, melena. She is keeping to her low salt diet and is compliant with her home diuretic regimen. Patient denies tylenol use but took Dayquil for sore throat earlier today. She reports flu like symptoms 4 days prior to presentation. In the ED, initial vitals were: - Labs notable for: AST/ALT 242/82, ALP 216, Tbili 5.7. Dbili 2.7, Lip 88, Na 127, Cr 0.9, CO2 18, lactate 1.6, U/A with mod ___, few bact, 7 WBC, 2 Epi, serum/urine tox negative, APAP 8 - Imaging: bedside us-minimal ascites not amenable to drainage - No medications given. - Repeat Chem7 notable for Na 132, CO2 21 Hepatology was consulted who recommended bedside ultrasound and albumin 25% 1g/kg if dry. Upon arrival to the floor, patient reports right sided abdominal pain and a chest cold. Abd pain for 2 weeks, ___, distractable, non-radiating. Patient is having 3 BM per day. Denies fevers, chills, dysphagia, sore throat, chest pain, peripheral edema, orthopnea, SOB, DOE with normal activities, other abd pain, N/V/D, black or bloody stools, dysuria, hematuria, focal weakness, numbness or falls. Past Medical History: - Primary biliary cirrhosis * Liver biopsy (___): features of PBC with gramulomas around the bile dicts and positive AMA * ___ positive at 1:640 but no features of autoimmune hepatitis * EGD (___) with grade I varices, mild gastropathy Social History: ___ Family History: - Mother had PBC - No other history of familial disease Physical Exam: ADMISSION PHYSICAL EXAM ================= VITAL SIGNS - 98.4 121/70 70 16 98% RA GENERAL - WNWD female in NAD, laying in bed HEENT - trace icterus, PERRL, EOMI, MOM, OP clear NECK - supple, no LAD, no elevated JVD CARDIAC - RRR, normal S1S2, no M/R/G LUNGS - NLB on RA, CTAB ABDOMEN - soft, distended, tympanitic, non-tender except for an isolated point on lower right axillary line, no rebound/guarding, NABS EXTREMITIES - WWP, no cyanosis or edema NEUROLOGIC - A&O, CN II-XII intact grossly, SILT, MAE, no asterixis SKIN - warm, dry, jaundiced DISCHARGE PHYSICAL EXAM ================== VITAL SIGNS - 98.2 103/67-121/63 58-62 18 96%RA GENERAL - ___ female in NAD, laying in bed HEENT - trace icterus, PERRL, EOMI, MOM, OP clear NECK - supple, no LAD, no elevated JVD CARDIAC - RRR, normal S1S2, no M/R/G LUNGS - NLB on RA, lungs clear to auscultation bilaterally ABDOMEN - soft, mildly distended, non-tender except for an isolated point on lower right axillary line, no rebound/guarding, NABS. Para site dressed, clean dry and intact EXTREMITIES - WWP, no cyanosis. trace pedal edema bilaterally. NEUROLOGIC - A&O, CN II-XII intact, no asterixis SKIN - warm, dry, jaundiced Pertinent Results: ADMISSION LABS ========== ___ 05:37PM BLOOD WBC-3.2* RBC-3.19* Hgb-11.6 Hct-33.2* MCV-104* MCH-36.4* MCHC-34.9 RDW-17.2* RDWSD-65.3* Plt ___ ___ 05:37PM BLOOD Neuts-68.9 Lymphs-14.3* Monos-12.5 Eos-3.7 Baso-0.3 Im ___ AbsNeut-2.21 AbsLymp-0.46* AbsMono-0.40 AbsEos-0.12 AbsBaso-0.01 ___ 05:37PM BLOOD ___ PTT-34.5 ___ ___ 05:37PM BLOOD Glucose-107* UreaN-21* Creat-0.9 Na-127* K-7.0* Cl-97 HCO3-18* AnGap-19 ___ 11:55AM BLOOD ALT-94* AST-169* AlkPhos-243* TotBili-7.7* DirBili-4.8* IndBili-2.9 ___ 05:37PM BLOOD Albumin-2.5* Calcium-8.6 Phos-3.1 Mg-2.1 ___ 05:24AM BLOOD calTIBC-161* Ferritn-166* TRF-124* ___ 05:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG NOTABLE LABS ========= ___ 05:31AM BLOOD ALT-65* AST-122* AlkPhos-216* TotBili-4.9* ___ 05:55AM BLOOD ALT-50* AST-97* AlkPhos-180* TotBili-4.0* ___ 05:37PM BLOOD Lipase-88* ___ 05:24AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.6 Iron-67 Cholest-122 ___ 05:24AM BLOOD calTIBC-161* Ferritn-166* TRF-124* ___ 05:55AM BLOOD %HbA1c-4.2 eAG-74 ___ 05:24AM BLOOD Triglyc-65 HDL-19 CHOL/HD-6.4 LDLcalc-90 ___ 09:45PM BLOOD Osmolal-283 ___ 05:24AM BLOOD 25VitD-9* ___ 05:17AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative ___ 05:17AM BLOOD AMA-NEGATIVE ___ 05:24AM BLOOD CEA-8.1* ___ 05:17AM BLOOD ___ * Titer-1:160 ___ 11:55AM BLOOD AFP-2.9 ___ 05:17AM BLOOD IgG-1060 IgM-117 ___ 11:55AM BLOOD IgA-1416* ___ 05:31AM BLOOD HIV Ab-Negative ___ 11:55AM BLOOD tTG-IgA-15 ___ 05:17AM BLOOD HCV Ab-Negative ___ 05:15PM BLOOD CMV VL-NOT DETECT CA ___ 12 MICROBIOLOGY ========= QUANTIFERON(R)-TB GOLD INDETERMINATE Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ASCITES FLUID ========= ___ 10:45AM ASCITES WBC-118* RBC-458* Polys-0 Lymphs-23* ___ Mesothe-12* Macroph-65* ___ 10:45AM ASCITES TotPro-0.8 Glucose-116 Creat-0.7 LD(LDH)-57 TotBili-0.8 Albumin-0.4 PATHOLOGY ======== Liver, transjugular needle core biopsy: Markedly fragmented hepatic parenchyma demonstrating: 1. Features consistent with cirrhosis (confirmed by trichrome stain). 2. Focally moderate portal/septal mononuclear inflammation, including prominent plasma cells, with focal periportal extension and mild associated collapse (confirmed by reticulin stain). 3. Focally prominent balloon degeneration with abundant intracytoplasmic hyalin, minimal predominantly small droplet steatosis, and associated neutrophils. 4. Frequent lobular neutrophils, including scattered neutrophilic aggregates; immunohistochemical stain for CMV is negative, with satisfactory control. 5. Mild intrahepatocytic and focal canalicular cholestasis. 6. Lymphocytic cholangitis with bile duct damage and foci of ductular proliferation with scattered associated neutrophils 7. No absolute bile ductopenia identified (immunohistochemical stain for CK7 is evaluated). Note: The features appear to be those of two concomitant processes: involvement by patient's known PBC with autoimmune hepatitis overlap syndrome (as evidenced by the lymphoplasmacytic inflammation with focal ___ extension and mild associated collapse), and a superimposed toxic/metabolic injury (demonstrated by abundant hyalin and focally prominent lobular neutrophils with focal balloon degeneration). Compared to the patient's prior biopsy (___), the mononuclear inflammatory features compatible with patient's known PBC/AIH overlap syndrome share very focal morphologic similarity to the current sample, with now evident cirrhosis and the above described toxic/metabolic injury. Dr. ___ was notified of the preliminary results via telephone on ___. The case was reviewed with Dr. ___, who concurs. IMAGING/STUDIES =========== ___ ABDOMINAL ULTRASOUND 1. Mild ascites. 2. Very nodular heterogeneous coarse hepatic architecture consistent with the patient's known cirrhosis. Although the degree of heterogeneity makes it difficult for ultrasound to assess for lesions no gross liver mass is visualized. 3. Patent hepatic vasculature. A patent umbilical vein is noted. 4. Splenomegaly. ___ CXR PA/LAT 1. Increased prominence of the bilateral hila since ___ can be concerning for sarcoidosis. 2. Low lung volumes with left basilar opacities, which may be due to atelectasis. However, concurrent pneumonia is difficult to exclude in the appropriate clinical setting. ___ CT CHEST 1. Diffuse bronchial wall thickening may reflect bronchitis. 2. Multiple small nodular opacities measuring 4 mm or less may reflect mild atypical pneumonia or inflammatory changes. Consider follow-up chest CT after resolution of acute illness. 3. Mild bilateral lower lobe atelectasis. 4. Liver cirrhosis with ascites and splenomegaly. ___ MRI LIVER Images are compromised by patient motion. Hepatic cirrhosis. Large volume ascites. Varices. Mild splenomegaly. There is no liver mass. Consider mild cholangitis. Patent portal vein. Multiple pancreatic side-branch IPMNs, some have enlarged, largest 1.1 cm. ___ TTE The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 70 %). The estimated cardiac index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. High normal estimated PA systolic pressure. Mild biatrial enlargement. Compared with the prior study (images reviewed) of ___, the findings are similar. DISCHARGE LABS ========== ___ 06:33 WBC7.4 Hb10.7* Hct31.9* Plt111* ___ 06:33 PT17.0* PTT 34.3 INR 1.6* ___ 06:33 Glucose 78 BUN 24* Cr 0.7 Na 140K4.1Cl 103 HCO3 25 AG16 ___ 06:33 ALT 57* AST 87* ALK PHOS173* TBILI 5.4* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nadolol 20 mg PO DAILY 2. Ursodiol 1000 mg PO QAM 3. Furosemide 20 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Alendronate Sodium 70 mg PO QSAT 6. AzaTHIOprine 75 mg PO DAILY 7. Budesonide 6 mg PO DAILY 8. Ocaliva (obeticholic acid) 5 mg oral DAILY 9. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 10. Ursodiol 500 mg PO QPM Discharge Medications: 1. Calcium Carbonate 500 mg PO BID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth Every 12 hours Disp #*60 Tablet Refills:*1 2. Levofloxacin 750 mg PO DAILY Last dose is on ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*6 Tablet Refills:*0 3. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*3 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 5. Vitamin D ___ UNIT PO 1X/WEEK (TH) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth Once Weekly on ___ Disp #*11 Capsule Refills:*0 6. AzaTHIOprine 125 mg PO DAILY RX *azathioprine 50 mg 2.5 tablet(s) by mouth Daily Disp #*90 Tablet Refills:*2 7. Ursodiol 500 mg PO BID RX *ursodiol 500 mg 1 tablet(s) by mouth Every 12 hours Disp #*60 Tablet Refills:*3 8. Furosemide 20 mg PO DAILY 9. Nadolol 20 mg PO DAILY 10. Spironolactone 50 mg PO DAILY 11. HELD- Budesonide 6 mg PO DAILY This medication was held. Do not restart Budesonide until you discuss this with your liver doctor 12. HELD- Ocaliva (obeticholic acid) 5 mg oral DAILY This medication was held. Do not restart Ocaliva until you discuss this with your liver doctor Discharge Disposition: Home Discharge Diagnosis: Primary: Primary biliary cirrhosis with autoimmune hepatitis Community acquired pneumonia, suspected bacterial source Secondary: Ascites Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with decompensated PBC with worsening abd distension // paracentesis TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis COMPARISON: Abdominal ultrasound dated ___ FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the right lower quadrant was selected for paracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A 5 ___ catheter was advanced into the largest fluid pocket in the right lower quadrant and 3 L of clear, straw-colored fluid were removed. Fluid samples were submitted to the laboratory for cell count, differential, and culture. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 3 L of fluid were removed. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with PBC presenting with elevated LFT and cough // evidence of infiltrate TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: The lungs are hypoinflated with bronchovascular crowding and left basilar opacities, possibly representing atelectasis but concurrent infection is difficult to exclude in the appropriate clinical setting. Increased prominence of the bilateral hila can be concerning for sarcoidosis. There is no pulmonary edema or pneumothorax. The cardiomediastinal silhouette is unchanged. IMPRESSION: 1. Increased prominence of the bilateral hila since ___ can be concerning for sarcoidosis. 2. Low lung volumes with left basilar opacities, which may be due to atelectasis. However, concurrent pneumonia is difficult to exclude in the appropriate clinical setting. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:20 ___, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin and abdominal distension. // evaluation for liver mass, portal venous thrombosis TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist. COMPARISON: CT ___, MRI ___ FINDINGS: Patient motion compromises images. Lower Thorax: There is trace right pleural effusion. Right basilar opacities, likely represent atelectasis. There is minimal left basilar atelectasis. Liver: There is large volume ascites, significantly increased since prior exam. Nodular, shrunken appearance of the liver, consistent with hepatic cirrhosis. There upper abdominal varices, including paraesophageal varices. There are no hepatic masses. Small focus of subtle enhancement in the segment 7 right hepatic lobe series 1001, image 68, has branching pattern, consider cholangitis. Biliary: There is mild gallbladder wall edema, without enhancement, likely reactive. There is no bile duct dilatation. Pancreas: There few small nonenhancing pancreatic cystic lesions, consistent with side branch IPMNs, some have enlarged, largest measures 1.1 cm, compared with 0.8 cm on prior. Spleen: Spleen is enlarged measuring 14 cm, mildly more prominent since prior. Adrenal Glands: Normal Kidneys: Normal Gastrointestinal Tract: No abnormalities Lymph Nodes: No adenopathy Vasculature: Patent portal vein. Varices. Patent major visualized arteries. Osseous and Soft Tissue Structures: No abnormalities. IMPRESSION: Images are compromised by patient motion. Hepatic cirrhosis. Large volume ascites. Varices. Mild splenomegaly. There is no liver mass. Consider mild cholangitis. Patent portal vein. Multiple pancreatic side-branch IPMNs, some have enlarged, largest 1.1 cm. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin and abdominal distension with cough and possible pneumonia on CXR // evaluate for evidence of inflammation or pneumonia TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 36.5 cm; CTDIvol = 11.6 mGy (Body) DLP = 422.1 mGy-cm. Total DLP (Body) = 422 mGy-cm. COMPARISON: None prior FINDINGS: Thyroid is unremarkable. Supraclavicular, axillary, and mediastinal lymph nodes are not pathologically enlarged. Thoracic aorta and main pulmonary artery are normal caliber. There is no pleural effusion or pericardial effusion. Diffuse bronchial wall thickening is noted. Small peribronchovascular dense airspace opacities are likely atelectasis. Mild ground-glass opacities in both lungs posteriorly are likely mild pulmonary edema. Multiple nodular opacities in a peripheral distribution are noted. Largest nodule measures 4 mm in right upper lobe (4:86). Other nodules are smaller (4:62, 102, 109, 122) Limited evaluation of the upper abdomen is notable for liver cirrhosis. Enlarged spleen measures 13.8 cm. Ascites is small to moderate size. Trace amount of pneumoperitoneum is likely related to recent paracentesis. IMPRESSION: 1. Diffuse bronchial wall thickening may reflect bronchitis. 2. Multiple small nodular opacities measuring 4 mm or less may reflect mild atypical pneumonia or inflammatory changes. Consider follow-up chest CT after resolution of acute illness. 3. Mild bilateral lower lobe atelectasis. 4. Liver cirrhosis with ascites and splenomegaly. Radiology Report INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin. // Concern for autoimmune hepatitis vs. PBC vs. fibrotic changes COMPARISON: CT of the chest dated ___. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: 0.25 mcg of fentanyl IV. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None. CONTRAST: 5 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 6.9 min, 41 mGy PROCEDURE: 1. Right internal jugular venous access using ultrasound. 2. Right atrial and hepatic venous and balloon-occluded portal pressure measurements. 3. Transjugular hepatic core biopsy with 4 passes. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The neck was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Hard copy ultrasound images were obtained before and after intravenous access. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. A small incision was made at the needle entry site. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a Amplatz wire was advanced distally into the IVC. A 9 ___ sheath was advanced over the wire into the inferior vena cava. Using a C2 Cobra catheter and a glide wire, access was obtained in the right hepatic vein. Appropriate position was confirmed with contrast injection and fluoroscopy. The glide wire was exchanged for ___ wire and the sheath was advanced into the proximal right hepatic vein. Then, a 0.5 mm occlusion balloon was advanced over the wire into the distal right hepatic vein. The wire was then removed and right atrial and hepatic venous and balloon-occluded portal pressure measurements were obtained after balloon occlusion. The balloon was then removed and a liver access sheath was advanced into the liver in appropriate position. The biopsy needle was advanced through the liver access sheath and four 18 gauge core biopsies were acquired while pointing the biopsy sheath anteriorly. The core biopsies were placed in formalin and labeled for pathology. The wire, catheters and core biopsy needle were then removed, pressure held until hemostasis was achieved and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Right atrial pressure of 13 and balloon-occluded portal pressure measurement of 29. 2. Four 18G core biopsies of the liver acquired through transjugular access. IMPRESSION: 1. Successful transjugular liver biopsy. 2. Portosystemic gradient of 16 mmHg Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Jaundice, Abdominal distention Diagnosed with Cholangitis temperature: 98.2 heartrate: 74.0 resprate: 16.0 o2sat: 100.0 sbp: 140.0 dbp: 78.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ with elevated liver tests and swelling in the abdomen. You also had a cough and were found to have a pneumonia. To treat the ascites, a paracentesis was done that removed 3 liters from your abdomen. You were given diuretics to help remove the fluid. A liver biopsy was done to assess how your liver is doing. It showed inflammation. You were given an increased dose of azathioprine that you need to take every day. You were also given steroids to help treat inflammation. It is very important that you avoid all types of alcohol, including with cooking, going forward. You had a cough for one week before coming into the hospital. Chest CT was done and showed that you have a pneumonia. You had one fever in the hospital. You were treated with antibiotics and your symptoms improved. You should keep taking the medication called Levoquin for a total of two weeks. Your last day of antibiotics is ___. If you experience fevers, chills, swelling in the abdomen, vomiting blood, black or bloody stools, shortness of breath, or worsening cough, please call your doctor or return to the emergency department. It was a pleasure taking care of you. We wish you the best in your health. Sincerely, Your ___ Liver Team

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: shellfish Attending: ___. Chief Complaint: Fall from 25ft roof Major Surgical or Invasive Procedure: 1. Right femur ORIF ___, ___ 2. Left wrist ORIF ___, ___ History of Present Illness: ___ w/ no signficant PMHx fell off roof this morning and suffered open R femur fracture. He slipped on frozen piece of roof and fell 25' to ground, landing on his R side. He denies LOC. Reports headache and pain on R chest wall, R leg. Open fracture w/ exposed femur noted by EMS and pt placed in traction splint. Brought to ___ where he recieved Ancef, tetanus. He has remained alert and oriented. Denies weakness, numbness in RLE. Denies other extremity pain. Past Medical History: None Social History: ___ Family History: NC Physical Exam: Boarded & collared, RLE traction splint in place. A&Ox3, GCS 15 Vitals: afebrile, VSS Right upper extremity: Skin intact Soft, non-tender arm and forearm Full, painless AROM/PROM of shoulder, elbow, wrist, and digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions +Radial pulse Left upper extremity: Skin intact Ecchymosis, mild swelling, TTP over distal radius. Mild pain w/ ROM at wrist. Full, painless AROM/PROM of shoulder, elbow, digits +EPL/FPL/DIO (index) fire +SILT axillary/radial/median/ulnar nerve distributions +Radial pulse Right lower extremity: Open fracture of distal femur w/ exposed bone, appear anteriorly dislocated. 5cm skin laceration overlying fracture. Soft thigh and leg ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Left lower extremity: Skin intact Soft, non-tender thigh and leg Full, painless AROM/PROM of hip, knee, and ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Pertinent Results: ___ 07:33PM WBC-11.6* RBC-4.78 HGB-13.7* HCT-40.5 MCV-85 MCH-28.6 MCHC-33.7 RDW-13.0 ___ 07:33PM PLT COUNT-185 ___ 09:09AM COMMENTS-GREEN TOP ___ 09:09AM GLUCOSE-138* LACTATE-2.1* NA+-138 K+-3.5 CL--106 TCO2-23 ___ 09:08AM UREA N-13 CREAT-0.8 ___ 09:08AM estGFR-Using this ___ 09:08AM LIPASE-38 ___ 09:08AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 09:08AM WBC-11.5* RBC-5.54 HGB-15.2 HCT-45.9 MCV-83 MCH-27.4 MCHC-33.1 RDW-12.5 ___ 09:08AM PLT COUNT-174 ___ 09:08AM ___ PTT-29.1 ___ ___ 09:08AM ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain, Fever 2. Cephalexin 500 mg PO Q6H Duration: 6 Days 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 8.6 mg PO BID 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Open right distal femur fracture s/p I&D and ORIF 2. Left distal radius fx/ scaphoid fx/ scapholunate widening s/p ORIF 3. Right metatarsal & ___ phalanx fractures 4. Facial laceration s/p suture repair by plastics Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Fall from height. Chest wall tenderness bilaterally. Open femur fracture. TECHNIQUE: Contiguous axial images of the torso were obtained following the uneventful administration of 130 cc Omnipaque intravenous contrast. Coronal and sagittal reformations were obtained. DLP: 585 mGy-cm CTDIvol: 9 mGy COMPARISON: None available. FINDINGS: Lungs: The thyroid is normal. No axillary, hilar, or mediastinal lymphadenopathy. The heart and great vessels are grossly normal and there is no pericardial effusion or aortic pathology. Minimal right pneumothorax. Old left 4th rib fracture is identified. No other rib fractures are seen. Bilateral dependent atelectasis is noted, otherwise the lungs are clear with no effusions, consolidations, or nodules. The esophagus is normal with no hiatal hernia. Abdomen: The liver enhances homogeneously with a hypodensity in segment 4A measuring 10 mm, likely a cyst or biliary hamartoma. There is no intra or extrahepatic biliary dilatation and the portal veins are patent. The gallbladder is normal with no radiopaque stones or pericholecystic fluid. The pancreas is normal with no peripancreatic fat stranding. The spleen enhances homogeneously with no focal lesions. The adrenal glands are normal in size and morphology. The kidneys enhance symmetrically with no focal lesions or hydronephrosis. There is symmetric contrast excretion. The stomach, small bowel, and large bowel is normal in caliber with no evidence of obstruction. The appendix is normal. No intra-abdominal free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy. Pelvis: The bladder is well distended and normal appearing. The prostate and seminal vesicles are normal. No pelvic free fluid. No pathologically enlarged pelvic sidewall or inguinal lymphadenopathy. Vessels: The abdominal aorta is normal in caliber. The aorta and its major branches are patent. Bones: No blastic or lytic lesions suspicious for malignancy or infection. No thoracolumbar spine or pelvic fractures. IMPRESSION: 1. Tiny right pneumothorax. 2. Old left 4th rib fracture. No other thoracic or abdominal injuries identified. Radiology Report HISTORY: 25 ft fall with nose injury. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm-reconstructed images were acquired. DLP: 891 mGy-cm. CTDIvol: 48 mGy. COMPARISON: None available. FINDINGS: There is no hemorrhage, mass effect or midline shift, edema, or infarct. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent and there is normal gray-white matter differentiation. Comminuted, depressed bilateral nasal bone and frontal process of the maxilla fractures are noted. The bony nasal septum is also fractured distally. Mucosal thickening in the right maxillary sinus and ethmoid air cells bilaterally are mild. Otherwise, the paranasal sinuses, mastoid air cells and middle ear cavities are clear. IMPRESSION: Comminuted bilateral nasal bone, frontal process of the maxilla, and bony nasal septum fractures. No other acute process. Radiology Report HISTORY: 25 ft fall with facial injury. Evaluate for traumatic injury. COMPARISON: None available. Technique: Contiguous axial images of the cervical spine were obtained without intravenous contrast. Coronal, sagittal, and bone algorithm formatted images were obtained. DLP: 729 mGy-cm. CTDIvol: 37 mGy. FINDINGS: There is no fracture or traumatic malalignment. The prevertebral soft tissues are normal. No significant degenerative changes are noted. Evaluation of the aerodigestive tract is unremarkable. Lung apices demonstrate minimal right apical pneumothorax. The soft tissues of the neck are normal. IMPRESSION: Minimal right apical pneumothorax. No cervical spine fracture or traumatic malalignment. Radiology Report HISTORY: Open right femur fracture after 25 foot fall. TECHNIQUE: Right femur, 2 views, right knee, 2 views and right tibia and fibula, 2 views. COMPARISON: None. FINDINGS: Comminuted open fracture of the distal femoral diaphysis is noted with dorsal displacement of the dominant distal fracture fragment by approximately ___ shaft width. The fracture line extends to involve the lateral femoral condyle and articular surface with slight widening of the lateral joint space. There is extensive subcutaneous gas and soft tissue swelling about the fracture site with subcutaneous gas noted tracking along the medial aspect of the thigh. Air is also noted within the suprapatellar recess. No other fracture or dislocation is identified. The ankle mortise appears symmetric. The talar dome is smooth. IMPRESSION: Open comminuted fracture of the distal femoral diaphysis with extension to the lateral femoral condyle and articular surface. Radiology Report HISTORY: Open fracture of the right femur. TECHNIQUE: AP view of the pelvis. COMPARISON: CT abdomen and pelvis obtained the same day. FINDINGS: There is no acute fracture or dislocation. Hips and sacroiliac joints are preserved. No diastasis of the pubic symphysis is noted. Contrast is seen within the bladder from recent CT exam. IMPRESSION: No acute fracture or dislocation. Radiology Report HISTORY: Open fracture of the right femur. TECHNIQUE: Right foot, 2 views. COMPARISON: None. FINDINGS: Assessment of the left foot is somewhat limited by an overlying external fixator device and lack of an oblique projection. Given these limitations, there appears to be an oblique linear lucency involving the base of the proximal phalanx of the ___ toe as well as the head of the ___ metatarsal, which could reflect non-displaced intra-articular fractures. No dislocation is identified. Assessment of the calcaneus is limited. IMPRESSION: Limited exam. Possible intra-articular fractures involving the base of the ___ proximal phalanx and head of the ___ metatarsal. Radiology Report HISTORY: Fall from height with facial laceration. Evaluate for facial bone fractures. TECHNIQUE: Contiguous axial images through the facial bones were obtained without intravenous contrast. Coronal, sagittal, and bone algorithm were formatted images were obtained. DLP: 488 mGy-cm CTDIvol: 26 mGy COMPARISON: None available. FINDINGS: There are bilateral comminuted fractures of the nasal bones, frontal processes of the maxilla, and the bony nasal septum. There is associated soft tissue swelling around the nose and mucosal thickening in the ethmoid sinuses and right maxillary sinus. No other facial bone fractures identified. Mastoid air cells are well aerated. Periapical lucencies are noted in several maxillary teeth. Additionally, dental caries are seen in multiple maxillary and mandibular teeth. The deep soft tissues of the face are normal. Evaluation of the aerodigestive tract is unremarkable. IMPRESSION: 1. Comminuted bilateral nasal bone, frontal processes of the maxilla, and bony nasal septum fractures with associated soft tissue swelling. 2. Periodontal disease and dental caries of several mandibular and maxillary teeth. Radiology Report HISTORY: Fall with left wrist pain and swelling over the distal radius. TECHNIQUE: 4 views of the left wrist. COMPARISON: None. FINDINGS: Longitudinally oriented fracture through the distal radius with intra-articular extension is noted with approximately 4 mm of medial displacement of the medial fracture fragment. There is widening of the scapholunate interval and there is a linear lucency through the waist of the scaphoid concerning for a nondisplaced fracture. Additionally a tiny osseous fragment is noted dorsally on the lateral view, suspicious for triquetrial fracture. No dislocation is identified. There is diffuse soft tissue swelling. IMPRESSION: 1. Mildly displaced distal radial fracture with intra-articular extension. 2. Triquetrial fracture. 3. Widening of the scapholunate interval suggests ligamentous injury with nondisplaced fracture through the waist of the scaphoid. Radiology Report HISTORY: Fracture fixation. 10 intraoperative radiographs of the right distal femur are obtained during placement of a lateral plate and multiple screws across the markedly comminuted distal femoral fracture (as shown on images from seven hours earlier on same day). There are several additional interfragmentary screws. Radiology Report HISTORY: Fracture reduction. A single AP bedside radiograph of the left wrist again shows the widened scapholunate space suggesting ligamentous injury. The unusual vertical intra-articular fracture of the distal radius seen exam 6 hour previous is not identified, which may reflect fracture reduction or simply positioning. Radiology Report INDICATION: Left carpal fractures, CT scan to evaluate fractures. TECHNIQUE: Axial MDCT images were acquired through the wrist without intravenous contrast. Coronal and sagittal reformats were produced and reviewed. COMPARISON: Left wrist radiograph ___. FINDINGS: Images were obtained in a cast. There is a vertically oriented fracture through the distal radius with intra-articular extension (___). This disrupts the articular surface by approximately 1.3 mm. There is widening of the scapholunate interval measuring 6mm (500B:41), concerning for injury to the scapholunate ligament. The ligament itself cannot be visualized on this study, due to limitations of the modality. There is a subtle linear lucency throught the waist of the scaphoid which is only visualized on the sagittal reformats (501b:38). The apperances are concerning for a non-displaced scaphoid waist fracture. There is a tiny oblique fracture of the dorsal aspect of the triquetrum (501B:59). The donor site is also seen at this level. There are very mild degenerative changes at thumb carpometacarpal joint (500B:29). There is diffuse subcutaneous edema. Possible small wrist effusion. The tendons of the carpal tunnel are within normal limits given the limitations of the imaging technique. IMPRESSION: 1. Vertically oriented fracture of the distal radius with intra-articular extension and disruption of the articular surface by 1.3 mm. 2. Small fracture at the dorsal aspect of the triquetrum. 3. Apparent widening of the scapholunate interval, concerning for scapholunate ligament injury. 4. Subtle linear lucency in the waist of the scaphoid concerning for an non-displaced fracture. No radiographic correlate is identified, though this difference could reflect increased sensitivity for CT. The pertinent findings were posted to the critical results dashboard at 5pm on ___. Radiology Report HISTORY: Left wrist pain, question fracture. LEFT WRIST, THREE VIEWS. COMPARISON: Left wrist radiographs from ___. Cast is in place, obscuring fine bony detail. Allowing for this, there is scapholunate widening measuring up to 6.1 mm. Again seen is the longitudinal fracture subtending the ulnar aspect of the distal radius, extending to the articular surface, with very mild depression of the ulnar fragment. Alignment is otherwise anatomic. The subtle fracture line through the scaphoid waist identified on today's CT scan is not definitely visualized, as there is overlying artifact related to the cast. Radiology Report INDICATION: Open fracture status post ORIF, question of fever, pneumonia. COMPARISON: None available. FINDINGS: AP view of the chest. Low lung volumes. There is no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal and hilar contours are normal. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ year old man polytrauma, fall ___ w/ open femur fx ___ s/p ORIF, w/ tachy+ SOB + chest pain at rest. // Rule out PE TECHNIQUE: MDCT data were acquired through the chest after the uneventful administration of intravenous contrast. Images were displayed in two axial slice thicknesses and multiple planes including oblique maximum intensity projections. DOSE: DLP: 191 mGy cm COMPARISON: Chest radiograph earlier today FINDINGS: CTPA: The pulmonary arterial tree is well opacified to the subsegmental level. There is no pulmonary embolism or other filling defect. The main pulmonary artery is not enlarged. The aorta and proximal great vessels have normal caliber and appearance. There is no aneurysm or dissection. There are no coronary artery or aortic arch calcifications. CT CHEST: The lungs are well expanded and clear. There is a 5 mm solid nodule identified in the left upper lobe (06:35, 8:43) There is no focal consolidation, effusion, or pneumothorax. Airways are patent to the subsegmental level. The thyroid enhances homogeneously. There is no mediastinal, hilar, or axillary adenopathy. The size of the heart is normal. There is no pericardial effusion. A tiny right pneumothorax is unchanged. This exam is not tailored to evaluate the intra-abdominal structures. Visualized portions of the upper abdomen show no abnormality. There are no concerning osseous lesions. IMPRESSION: 1. No pulmonary embolism 2. 5 mm left upper lobe nodule. As per the ___ Pulmonary Nodule Guidelines, followup chest CT is recommended in 12 months for a low risk patient and ___ months for a high risk patient. 3. Tiny right pneumothorax unchanged. Radiology Report CLINICAL HISTORY: Fracture of scaphoid with scapho/lunate widening, intraoperative repair. Vertical fracture of the distal radius also. Post-operative films. Multiple pins are seen through the scaphoid and other carpal bones. Screws and plate are present along the distal radius. The alignment appears good. Radiology Report HISTORY: ORIF. FINDINGS: Images from the operating suite show placement of multiple fixation devices about fractures of the scaphoid and distal radius. Further information can be gathered from the operative report. Radiology Report HISTORY: ORIF. FINDINGS: In comparison with the operative study of ___, there is little change in the appearance of the extensive fixation device about the long comminuted and apparently intra-articular fracture of the distal tibia. No evidence of hardware-related complication. Little if any callus formation is appreciated. Gender: M Race: SOUTH AMERICAN Arrive by HELICOPTER Chief complaint: 25"FALL Diagnosed with FX FEMUR NOS-OPEN, OTHER FALL temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - You have completed your 2 week course of Lovenox for anticoagulation. WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - TDWB RLE in ___ unlocked - NWB LUE in splint Physical Therapy: - TDWB RLE in ___ knee brace - NWB LUE in splint Treatments Frequency: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on left hand until follow up appointment unless otherwise instructed - Do NOT get splint wet

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abnormal MRI finding Recent diagnosis of cirrhosis and HCV Major Surgical or Invasive Procedure: Upper endoscopy (___) Packed red blood cell transfusion (1 unit on ___ History of Present Illness: Mr. ___ is a ___ with history of Wilms Tumor s/p chemo/XRT and nephrectomy at age ___, recently diagnosed HCV genotype 1, and chronic EtOH use, referred to ___ for evaluation of new cirrhosis and possible IVC occlusion seen on outpatient MRI. He has had anemia for about ___ years, which has been slowly worsening per outpatient labs. This was initially thought to be secondary to iron deficiency but he took oral iron supplements with no effect. Recently Hct was ~25 at PCP, down from ~30 in ___. He has noticed increasing fatigue which has correlated with his declining hematocrit. He describes difficulty climbing up the hill to get to his house in ___, and needs to rest several times on the way. He remains able to walk ___ miles on flat ground. He was formerly able to work 11 hour shifts as a ___ but recently has had to take time off due to fatigue. He has also been experiencing ~2 months of abdominal discomfort, bloating, gassiness, and increasingly diarrhea, though in retrospect the diarrhea may have started as long as ___ years ago. Over the past months his daily bowel frequency has increased from ~3 bowel movements a day to ___ loose bowel movements a day. He saw his PCP ~1 month ago, where labs were notable for mildly elevated transaminases (he had a history of transamnitis to ~3x upper limit of normal dating back to ___ and positive HCVAb. He was referred to Dr. ___, gastroenterologist. Additional labs done recently showed elevated ALT/AST, normal TBili and INR, AFP elevated to 17.8 and HCV titer ~970,000 IUs. Per verbal report from outside providers, an MRI performed at ___ MRI on ___ in ___ showed cirrhotic appearing liver, ascites, and 2 small enchancing lesions in segment I and VI and possible splenorenal varices and possible IV thrombosis. A colonoscopy was done ___ with normal appearance, biopsies pending. The patient also has history of daily ETOH ___ years. There were periods of heavy daily Whiskey (~1 bottle/week) surrounding breakup with his fiance, but until 1 month ago he had been having 2 beers every evening. Since he learned of his HCV diagnosis ___ weeks ago, he has not had any more alcohol. Suspected source of HCV exposure is blood transfusion that he received at age ___ at the time of his Wilms tumor resection at ___. No other transfusions. In the ED, initial vital signs were: 98.7, 95, 117/81, 18, 100% RA. Initial labs were significant for AST/ALT of 93/41, Albumin 2.7, Hct 22. Abdominal ultrasound was notable for echogenic liver consistent with cirrhosis, mild to moderate ascites without easily accessible pocket for drainage, cholelithiasis, and no ultrasound evidence of IVC thrombosis or hepatic lesions. CXR showed small right pleural effusion. The patient received no medications in the ED and was transferred to the general medical floor for further management. On arrival to the floor, patient reports no acute complaints. Review of Systems: Positive for: Increasing fatigue and windedness on exertion. Chills, increasing ___ edema and abdominal girth, chronic dyspnea, recent cough. Also has left ankle rash for months, and recent "ringworm" on stomach. (-) Denies fever. Denies chest pain or tightness, palpitations. Denies wheezes. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. No numbness/tingling in extremities. All other systems negative. No hematemesis, melena, hematochezia. Past Medical History: - Nephrectomy at age ___ followed by chemotherapy and radiation for Wilms tumor. Question of spread to heart, requiring sternotomy and heart surgery. - Hypothyroidism after total thyroidectomy for cysts seen ___ years ago which were concerning given his history of radiation. - Possible asthma - Bronchiectasis - Pulmonary nodule - +asbestos exposure at theater where he worked Social History: ___ Family History: Paternal grandfather and aunt with brain tumor. Maternal relatives with heart disease and stroke. No known family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: 98.6 112/60 73 18 100RA GEN: Pale appearing man seated in bed in NAD, pleasant and conversant HEENT: Sclera anicteric, conjunctiva pale. MMM, oropharynx clear. Neck: Supple. No JVD, no LAD. Thyroidectomy scar noted. Chest: RRR, S1/S2, no m/r/g. Median sternotomy scar noted. Mild gynecomastia. Lungs: Clear to auscultation bilaterally Abdomen: Minimally tender, no rebound/guarding, mildly distended, normoactive BS. Tympanic to percussion at apex, dull at bases. Ext: Warm/well perfused. Trace ___ edema. Neuro: AAOx3. No asterixis. Skin: No jaundice. Brown hyperpigmented spots on medial surface of left foot. No spider angiomata, no caput medusa, no palmar erythema. DISCHARGE PHYSICAL EXAM: 98.7 98.4 109-123/60s 76 18 99RA GEN: Pale appearing man seated in bed in NAD, pleasant and conversant HEENT: Sclera anicteric, conjunctiva pale. MMM, oropharynx clear. Neck: Supple. No JVD, no LAD. Thyroidectomy scar noted. Chest: RRR, S1/S2, no m/r/g. Median sternotomy scar noted. Mild gynecomastia. Lungs: Clear to auscultation bilaterally Abdomen: Minimally tender, no rebound/guarding, mildly distended, normoactive BS. Tympanic to percussion at apex, dull at flanks. Ext: Warm/well perfused. Trace ___ edema. Neuro: AAOx3. No asterixis. Skin: No jaundice. Brown hyperpigmented spots on medial surface of left foot. No spider angiomata, no caput medusa, no palmar erythema. Pertinent Results: IMAGING STUDIES ***Abdominal MRI performed at ___ ___ Comparison of in and out of phase imaging does not show significant signal dropout to suggest fatty infiltration. Left lobe of the liver appears somewhat prominent. There is somewhat lobular reticulated pattern [sic] the hepatic parenchyma seen on T1 imaging suggestive of diffuse liver disease, fibrosis and cirrhosis. Early arterial imaging shows somewhat heterogeneous patt4ern of enhancement. There are noted to be slightly more prominent foci of enchancement seen in hepatic segment 1, please see series 12 image 57 and in hepatic segment 6, please see axial series 12 image 38. There are a few scattered subcentimeter nonenhancing T2 hyperintensities within the right lobe of the liver suggestive of cysts. The infrahepatic IVC is not visualized and there are prominent right pararenal varices as welll as paraspinal varices. There is abdominal fluid, ascites. There is [sic] some areas of soft tissue thickening around the liver, please see series 3 image 79, without enhancement which may represent adhesions. Left kidney is not visualized consistent with provided history of Wilms tumor, prior surgery as child. Right kidney appears prominent, possibly at due to compensatory hypertrophy without suspicious focal lesion. There does not appear to be enlargement of the right adrenal gland although it is not well seen due to patient motion. No suspicious splenic lesion is seen. No suspicious pancreatic lesion is identified. Impression: Cirrhotic liver. Early arterial postcontrast imaging shows heterogeneous hepatic enhancement with two slightly more prominent foci of enhancement as described above; these findings may be due to transient hepatic vascular differences however continued surveillance is suggested. Ascites. Infra-hepatic IVC appears occluded and there are prominent right-sided pararenal, paraspinal varices. --- Informal review of the MRI images here revealed: --- Nodular cirrhosis with ascites. Left nephrectomy. Right kidney is hypertrophied. The spleen measures 9.3 cm, no evidence of splenomegaly. There are two cysts/hamartomas in the right hepatic lobe which are non-enhancing. There is a 9-10 mm area of enhancement in the caudate but given no washout, is less concerning for HCC. No clear evidence of IVC thrombosis. Abd US with Duplex Doppler ___: 1. Coarsened liver may be due to fatty infiltration and/or cirrhosis. Other more advanced forms such as fibrosis/cirrhosis not excluded on this study. 2. No hepatic lesions are identified. However, MRI is more sensitive for detection of small hepatic lesions. 3. Wall-to-wall color flow in the visualized IVC. No evidence of IVC thrombosis seen sonographically. Recommend correlation with prior examinations when they become available or MRV/CTV. 4. Small amount of ascites. 5. Cholelithiasis with no evidence of acute cholecystitis. 6. Mild pelviectasis of the right kidney CXR ___: Small right pleural effusion. LABORATORY RESULTS ___ 12:41PM BLOOD WBC-5.8 RBC-1.94* Hgb-6.5* Hct-22.0* MCV-114* MCH-33.6* MCHC-29.6* RDW-17.3* Plt ___ ___ 10:50AM BLOOD WBC-6.0 RBC-2.17* Hgb-7.6* Hct-23.8* MCV-109* MCH-35.0* MCHC-32.0 RDW-18.5* Plt ___ ___ 12:41PM BLOOD Neuts-52.4 ___ Monos-7.5 Eos-6.1* Baso-0.5 ___ 10:50AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-OCCASIONAL ___ 12:41PM BLOOD ___ PTT-38.5* ___ ___ 10:50AM BLOOD ___ PTT-46.7* ___ ___ 12:41PM BLOOD Glucose-79 UreaN-14 Creat-1.0 Na-136 K-4.1 Cl-109* HCO3-19* AnGap-12 ___ 10:50AM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-136 K-4.4 Cl-109* HCO3-19* AnGap-12 ___ 12:41PM BLOOD ALT-41* AST-93* AlkPhos-96 TotBili-0.3 ___ 10:50AM BLOOD ALT-37 AST-82* AlkPhos-85 TotBili-0.9 ___ 10:50AM BLOOD Calcium-7.5* Phos-3.0 Mg-1.7 ___ 12:41PM BLOOD Albumin-2.7* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath, wheezing 2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. milk thistle 140 mg oral Daily Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath, wheezing 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 5. milk thistle 140 mg oral Daily 6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 7. Outpatient Lab Work Please check Na, K, Cl, HCO3, BUN, Cr, Ca, Phos, Mg, CBC on ___. (ICD-9 code: ___) Fax results to: ___ MD [Fax: ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: HCV cirrhosis Esophagitis Chronic macrocytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: History: ___ with hep C p/w ascites and ? occluded IVC // eval for flow, cirrhosis, ascites TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver demonstrates coarsened echotexture. There is no focal liver mass identified. Main portal vein is patent with hepatopetal flow. There is mild to moderate moderate abdominal ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm. GALLBLADDER: The gallbladder is collapsed with a few gallstones seen. Cholecystitis. PANCREAS: Pancreas is partially obscured by bowel gas, but visualized portion is unremarkable. SPLEEN: Normal echogenicity, measuring 10.2 cm. KIDNEYS: The right kidney measures 13.7 cm. The left kidney is surgically absent. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There are no masses or stones in the right kidney. There is mild pelviectasis seen in the right kidney. RETROPERITONEUM: There is wall to wall color flow in the visualized IVC. There is no evidence of IVC thrombosis. IMPRESSION: 1. Coarsened liver may be due to fatty infiltration and/or cirrhosis. Other more advanced forms such as fibrosis/cirrhosis not excluded on this study. 2. No hepatic lesions are identified. However, MRI is more sensitive for detection of small hepatic lesions. 3. Wall-to-wall color flow in the visualized IVC. No evidence of IVC thrombosis seen sonographically. Recommend correlation with prior examinations when they become available or MRV/CTV. 4. Small amount of ascites. 5. Cholelithiasis with no evidence of acute cholecystitis. 6. Mild pelviectasis of the right kidney. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with hep c and abdominal pain // eval infiltrate TECHNIQUE: Chest Frontal and Lateral COMPARISON: None. FINDINGS: The lungs are relatively hyperinflated. No focal consolidation is seen. There is blunting of the right costophrenic angle consistent with a small right pleural effusion. The cardiac and mediastinal silhouettes are unremarkable. The patient is status post median sternotomy with the inferior-most wire possibly fractured. Multiple surgical clips are noted in the upper abdomen. IMPRESSION: Small right pleural effusion. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ASCITES Diagnosed with CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA temperature: 98.7 heartrate: 95.0 resprate: 18.0 o2sat: 100.0 sbp: 117.0 dbp: 81.0 level of pain: 2 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital for work-up of your liver disease and due to concern on your recent MRI that you could have a clot in the IVC vein. You had an ultrasound performed, which showed no evidence of clot, and your MRI images were reviewed by our radiologists who felt that there was no clear evidence of clot in the IVC vein. While in the hospital, you were given a blood transfusion in order to treat your anemia. You also had an endoscopy which showed no esophageal varices (distended veins, which are a complication of cirrhosis), but did show irritation of the esophagus, for which you were started on omeprazole to protect your esophageal lining. After discharge, please continue to eat a low-sodium diet as you discussed with the nutritionist. Also be sure to follow up with your regular providers (details below).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / amiodarone Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old man with atrial fibrillation, non-ischemic cardiomyopathy with EF 45% with hx of VT s/p ICD placement who presented with fevers and malaise, admitted from the ED due to hypotension and concern for sepsis. Patient was recently hospitalized at ___ in ___ and ___ for fevers and rigors, found to have Strep infantarius bacteremia ___ bottles). Per the ID outpatient note, "The portal of entry of the strep infantarius bacteremia remained unclear, as Strep infantarius is part of the strep bovis species (type II bovis), commonly associated with the GI tract, but may be implicated by more upper GI, hepatobiliary origin rather than the lower colonic of strep gallolyticus (type I bovis). TEE without evidence of endocarditis or vegetation on ICD lead." He was treated with a 6 week course of CTX, finished in ___ Now, the patient reports a 1 day history of decreased appetite, fevers, and weakness. Overnight, he was unable to get out of bed to use the restroom due to weakness (uses cane at baseline). He checked his temperature overnight as he was feeling feverish, and found it to be 100.8F. Did feel briefly dyspneic while lying in bed this AM, but denies chest pain or cough. Similarly no sore throat, palpitations, abdominal pain, diarrhea, dysuria, or increased urinary frequency. In the ED, initial vitals: 101.9 60 112/49 18 97% RA. Labs notable for: H/H 11.9/37.7. PLT 93. Cr of 1.3 (baseline of 1.0-1.1). Lactate 2.0. FLU A/B negative. UA notable for PROT 30 but negative for ___. Imaging: CXR was negative for pneumonia. Patient received: ___ 09:31 PO Acetaminophen 1000 mg ___ 09:50 IVF NS 500 mL ___ 11:10 IV Vancomycin (1000 mg ordered) ___ 11:15 IV CefTRIAXone 1 gm Consults: no consults were requested. Vitals on transfer: 69 87/62 16 98% RA Upon arrival to ___, patient endorsed the above story. REVIEW OF SYSTEMS: (+) Per HPI (-) Otherwise Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - s/p ICD 3. OTHER PAST MEDICAL HISTORY Permanent atrial fibrillation c/b CVA (___) Monomorphic ventricular tachycardia, s/p ICD in ___ h/o CVA Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Brother had isolated episode of a fib. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 97.6, HR 74, BP 93/65, Sat 97% on RA GENERAL: Pleasant, alert and interactive. NAD. HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear NECK: JVP not elevated, no LAD LUNGS: No increased work of breathing. Left basilar crackles, but lungs otherwise clear. No wheezes or rales. CV: Irregularly irregular rhythm, Audible S1 and S2. Faint systolic murmur best heard at apex. ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No visible rashes or other lesions. NEURO: A&Ox3 + situation. Moving all 4 extremities. No visible facial asymmetry. ACCESS: PIVx2 DISCHARGE PHYSICAL EXAM: ___ 0502 Temp: 97.6 PO BP: 115/77 L Lying HR: 70 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: NAD, appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, no oral lesions HEART: irregular rhythm, normal rate, systolic murmur throughout precordium LUNGS: bibasilar crackles and coarse breath sounds without ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 1+ DP pulses bilaterally Pertinent Results: ADMISSION LABS: =============== ___ 09:10AM BLOOD WBC-8.1 RBC-4.26* Hgb-11.9* Hct-37.7* MCV-89 MCH-27.9 MCHC-31.6* RDW-14.3 RDWSD-45.5 Plt Ct-93* ___ 09:10AM BLOOD Neuts-88.7* Lymphs-3.7* Monos-6.4 Eos-0.4* Baso-0.2 Im ___ AbsNeut-7.18* AbsLymp-0.30* AbsMono-0.52 AbsEos-0.03* AbsBaso-0.02 ___ 01:54AM BLOOD ___ PTT-37.4* ___ ___ 09:10AM BLOOD Glucose-102* UreaN-31* Creat-1.3* Na-139 K-5.1 Cl-102 HCO3-23 AnGap-14 ___ 09:10AM BLOOD ALT-18 AST-27 LD(LDH)-245 AlkPhos-98 TotBili-0.7 ___ 09:10AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.2 Mg-1.9 ___ 12:17AM BLOOD ___ pO2-44* pCO2-39 pH-7.37 calTCO2-23 Base XS--2 RELEVANT LABS: ============== ___ 09:10AM BLOOD proBNP-5811* ___ 09:33AM BLOOD Lactate-2.0 MICROBIOLOGY: ============= Urine culture - negative Blood cultures - NGTD ___ 1:10 pm Rapid Respiratory Viral Screen & Culture Site: NASOPHARYNX Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. RELEVANT IMAGING: ================= ___ CXR IMPRESSION: No evidence of pneumonia. Small right pleural effusion. ___ CXR IMPRESSION: Increased opacities in the left lower lung possibly reflective of lower pleural fluid and overlying atelectasis/consolidation. DICHARGE LABS: ============== ___ 06:18AM BLOOD WBC-8.5 RBC-4.25* Hgb-11.7* Hct-37.7* MCV-89 MCH-27.5 MCHC-31.0* RDW-14.6 RDWSD-46.2 Plt ___ ___ 06:18AM BLOOD Glucose-98 UreaN-35* Creat-1.2 Na-141 K-4.2 Cl-101 HCO3-26 AnGap-14 ___ 06:18AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.4 Radiology Report INDICATION: History: ___ with fever, dyspnea*** WARNING *** Multiple patients with same last name!// ? pneumonia TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph dated ___. Chest CT dated ___. FINDINGS: Left-sided pacer with its lead terminating in the right ventricle is in unchanged position. There is bibasilar atelectasis. No focal consolidation to suggest pneumonia. No pulmonary edema. There is small right pleural effusion. No pneumothorax. Moderate cardiomegaly persists. Mediastinal silhouette is unremarkable. No acute osseous abnormalities. IMPRESSION: No evidence of pneumonia. Small right pleural effusion. Radiology Report INDICATION: ___ year old man with new onset sob and wheezing// ?consolidation, pleural effusions TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: A left chest wall single lead AICD is present. The size of the cardiac silhouette is markedly enlarged unchanged. Retrocardiac opacities are increased since prior and may reflect atelectasis and/or consolidation. A layering pleural effusion is also suspected. There is no pneumothorax. No focal consolidation within the right lung. IMPRESSION: Increased opacities in the left lower lung possibly reflective of lower pleural fluid and overlying atelectasis/consolidation. Radiology Report INDICATION: ___ year old man with Afib, HTN, recent strep infantarius bacteremia, presenting with fevers and hypotension. Run of VT overnight, now with new basilar crackles// please assess for pulmonary edema, other interval change TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Left-sided single lead pacemaker with the lead in the right ventricle. Overall no changes prior. Moderate cardiomegaly. No pulmonary edema. Unchanged retrocardiac opacities. No focal consolidation or pneumothorax. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Fever Diagnosed with Sepsis, unspecified organism, Fever, unspecified, Bacteremia, Severe sepsis with septic shock, Dyspnea, unspecified temperature: 101.9 heartrate: 60.0 resprate: 18.0 o2sat: 97.0 sbp: 112.0 dbp: 49.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, What happened while you were in the hospital? - You came to the hospital because of fevers and feeling unwell. What happened while you were here? - You were treated for a pneumonia. - Your heart arrhythmia, ventricular tachycardia, became worse after your quinidine was held. - You were then started on a new medication, mexiletine, for your arrhythmia. You did not have any more arrhythmia once this medication was started. What should you do when you leave the hospital? - You should continue to take all of your medications as prescribed. - You were started on two new medications: Mexiletine 150 mg PO Q8H (to be taken three times per day), torsemide 5 mg daily. - Your metoprolol was increased from 25 mg a day to 50 mg a day - You should STOP taking quinidine - Please weigh yourself every day and call your cardiologist if your weight increases by three or more pounds - Please follow up with your doctor ___- we have scheduled you with Dr. ___ Dr. ___. It was a pleasure taking care of you. Best, Your ___ Team

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Amoxicillin / Cephalosporins / benzonate Attending: ___. Chief Complaint: Cough and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of CLL/SLL with pulmonary parenchymal involvement diagnosed in ___ s/p chemotherapy (last in ___ c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA,bronchiectasis, chronic systolic heart failure (LVEF 40-45% in___), and atrial fibrillation on rivaroxaban (TIA while onwarfarin) who presents with subacute progressively worsening cough and SOB and new hypoxia. Patient reports that several weeks ago, he developed nocturnal wheezing that would wake him from sleep, associated with productive cough, chest congestion, orthopnea, and new dyspnea on exertion. These symptoms felt similar to those he has had in the past with lung infections. He used his albuterol nebs, which helped somewhat. Of note, he also reports developing ___ edema around this time, which is new for him.Patient presented to primary care clinic on ___, at which timeCXR was unremarkable, BNP was 100, and CBC and BMP were stable.He was treated with a one-week course of prednisone for presumed asthma exacerbation. Symptoms initially improved after tis course but then a few days later, his dyspnea worsened, and he spiked a fever to 102.6 (___). He contacted his PCP over the phone and was prescribed levofloxacin 500 mg x 10 d (now has 4 days left) and 5additional days of prednisone (completed) without symptomatic relief. He presented to clinic again today with persistent symptoms and was noted to have hypoxia to 89% on RA so came toBIDMC. In the ED, initial VS were notable for T 98.9, HR 96, BP 119/47,RR 18, SpO2 95% on 5L NC. (Patient notes he was febrile to 102 inthe ED, but this was not recorded in the dash.) Labs notable forCBC with WBC 11.5 (76.9% neutrophils, 15.9% lymphocytes), Hgb11.7, platelets 168. BMP with Na 129, K 4.3, bicarb 21, BUN 18,Cr 1.0. Lactate 1.5. EKG with LBBB. CXR with opacities in the lung bases. Received albuterol and ipratropium nebs and PO doxy100 mg. Started on NSS at 75 cc/hr. Upon arrival to the floor, he reports continued SOB/DOE and orthopnea. Denies chills, weight loss, N/V, CP, arm/jaw pain,palpitations, abdominal pain, diarrhea/constipation, hematochezia/melena, dysuria/increased frequency/urgency, myalgias. No history of blood clots, no recent prolonged immobilization/travel.Of note, he was supposed to get IVIG today for hypogammaglobulinemia; last got it 1 month ago as scheduled. Past Medical History: PAST ONCOLOGIC HISTORY: CLL per HPI PAST MEDICAL HISTORY: 1. SLL/CLL with pulmonary parenchymal involvement see HPI for details 2. Chronic sinusitis with nasal polyp. 3. Hypogammaglobulinemia. Receives monthly IV IgG. 4. History of recurrent multifocal as well as aspiration pneumonitis 5. Nonischemic cardiomyopathy. EF of 20% which has improved to 35-40% a few months ago. Last cardiac cath done at ___ in ___ showed normal coronary arteries. 7. Paroxysmal atrial fibrillation status post DC cardioversion, on Coumadin. 8. Left bundle branch block. 9. History of SIADH during diuresis, requiring hypertonic saline. 10. Chronic bronchiectasis. 11. History of H. influenzae in the sputum during admission at ___ in ___, is on chronic doxycycline prophylaxis. 12. Mild to moderate intermittent asthma. 13. GERD/reflux esophagitis. 14. History of possible dysphagia and aspiration pneumonitis. 15. Colon polyps. 16. Thyroid nodule/possible hypothyroidism. 17. BPH. 18. Status post bronchoscopy in ___ showed CLL/SLL. OTHER PMH per ___ records: Asthma THYROID NODULE COLONIC ADENOMAS Foot drop (uses brace) plantar fasciitis, right Rotator cuff tear Social History: ___ Family History: Family history of melanoma - daughter Physical ___: ADMISSION PHYSICAL EXAM ========================= GENERAL: Alert and interactive, in no acute distress but mildly tachypneic, on 6L NC. Productive cough with yellow/brown viscous sputum. HEENT: NCAT, PERRL, EOMI. Sclera anicteric and without injection. NECK: JVP difficult to assess but may be elevated to the angle of the mandible. CARDIAC: Regular rhythm, mildly tachycardic. S1 and S2. No murmurs/rubs/gallops. LUNGS: Tachypneic, intermittent inspiratory and expiratory wheeze, rhonchorous breath sounds and crackles from mid lung fields to bases, decreased breath sounds at the bases bilaterally. BACK: No CVA tenderness. ABDOMEN: Soft, non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 2+ pitting edema of the lower extremities bilaterally from ankles distally. SKIN: Warm, no rash. R-sided chest port without erythema, c/d/I. Punctate area of skin breakdown on R buttock. NEUROLOGIC: AOx3. DISCHARGE PHYSICAL EXAM ======================== Temp: 98.4 (Tm 98.4), BP: 97/57 (91-108/47-65), HR: 91 (80-93), RR: 18 (___), O2 sat: 96% (90-97), O2 delivery: Ra, Wt: 153.6 lb/69.67 kg Last 24 hours Total cumulative -893ml IN: Total 480ml, PO Amt 480ml OUT: Total 1373ml, Urine Amt 1373ml GENERAL: Sitting in bed, comfortable HEENT: NCAT, PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: Regular rhythm, rate. S1 and S2. No murmurs/rubs/gallops. LUNGS: Inspiratory and expiratory scattered wheeze, coarse rhonchorous breath sounds from mid lung fields to bases, decreased breath sounds at the bases bilaterally ABDOMEN: Soft, non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: trace pitting edema bilaterally in dorsum of feet. SKIN: Warm, no rash. R-sided chest port without erythema, c/d/I. NEUROLOGIC: AOx3. Pertinent Results: ADMISSION LABS ================== ___ 04:30PM WBC-11.5* RBC-3.40* HGB-11.7* HCT-33.8* MCV-99* MCH-34.4* MCHC-34.6 RDW-13.1 RDWSD-46.7* ___ 04:30PM NEUTS-76.9* LYMPHS-15.9* MONOS-5.5 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-8.86* AbsLymp-1.83 AbsMono-0.63 AbsEos-0.06 AbsBaso-0.02 ___ 04:30PM PLT COUNT-168 ___ 04:30PM GLUCOSE-88 UREA N-18 CREAT-1.0 SODIUM-129* POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-13 ___ 04:47PM LACTATE-1.5 ___ 04:30PM proBNP-1200* ___ 04:47PM LACTATE-1.5 ___ 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:07PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 10:51PM ___ PO2-57* PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP ___ 10:51PM LACTATE-0.9 DISCHARGE LABS ================== Right-sided Port-A-Cath with its tip in the right atrium. ___ 06:50AM BLOOD WBC-12.8* RBC-2.86* Hgb-9.8* Hct-29.0* MCV-101* MCH-34.3* MCHC-33.8 RDW-12.8 RDWSD-48.4* Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-77 UreaN-39* Creat-0.9 Na-136 K-4.1 Cl-93* HCO3-30 AnGap-13 ___ 06:50AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.1 MICRO =================== ___ Blood culture x2 negative ___ Legionella Urinary antigen negative IMAGING/STUDIES =================== CXR ___ FINDINGS: Right sided Port-A-Cath tip terminates in the low SVC. Heart size is normal. Atherosclerotic calcifications are noted at the aortic knob. Prominent mediastinal and hilar contours are unchanged, likely reflective of underlying lymphadenopathy. Pulmonary vasculature is not engorged. Patchy opacities are noted in the lung bases, in the region of known bronchiectasis. No pleural effusion or pneumothorax. No acute osseous abnormality. IMPRESSION: Patchy opacities in the lung bases in a region of bronchiectasis, which may reflect pneumonia. TTE ___ The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is normal left ventricular wall thickness with a normal cavity size. There is mild global left ventricular hypokinesis. Quantitative biplane left ventricular ejection fraction is 50 %. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. A filamentous strand(s) is seen on the aortic valve c/w Lambl's excresence (normal variant). There is no aortic valve stenosis. There is a centrally directed jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild global left ventricular systolic dysfunction. MIld aortic regurgitation. CT CHEST ___ IMPRESSION: Diffuse bilateral ground-glass opacification somewhat patchy, could represent pulmonary edema. Atypical pneumonia can have a similar appearance. Small volume mediastinal and hilar adenopathy is unchanged. CXR ___ IMPRESSION: Subtle bilateral parenchymal opacities appear worse compared to radiograph from ___ however, have subtly improved compared to chest CT from ___. CXR ___ IMPRESSION: Comparison to ___. Stable right apical calcifications, 1 of which is nodular in appearance. Stable parenchymal morphology. Stable correct position of the right pectoral Port-A-Cath. Normal size and shape of the cardiac silhouette. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/cough 2. Lisinopril 2.5 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Mirtazapine 7.5 mg PO QHS 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 6. Rivaroxaban 20 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0 2. Calcium Carbonate 1000 mg PO DAILY RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Furosemide 60 mg PO DAILY RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 4. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 5. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 6. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 7. Metoprolol Succinate XL 12.5 mg PO QHS RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/cough 10. Atorvastatin 40 mg PO QPM 11. Mirtazapine 7.5 mg PO QHS 12. Omeprazole 20 mg PO DAILY 13. Rivaroxaban 20 mg PO DAILY 14. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until your doctor tells you to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute hypoxic respiratory failure Bronchiectasis exacerbation Acute on chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with SOB// r/o acute process TECHNIQUE: Chest PA and lateral COMPARISON: Chest CT ___ and chest radiograph ___ FINDINGS: Right sided Port-A-Cath tip terminates in the low SVC. Heart size is normal. Atherosclerotic calcifications are noted at the aortic knob. Prominent mediastinal and hilar contours are unchanged, likely reflective of underlying lymphadenopathy. Pulmonary vasculature is not engorged. Patchy opacities are noted in the lung bases, in the region of known bronchiectasis. No pleural effusion or pneumothorax. No acute osseous abnormality. IMPRESSION: Patchy opacities in the lung bases in a region of bronchiectasis, which may reflect pneumonia. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with history of CLL/SLL with pulmonary parenchymalinvolvement diagnosed in ___ s/p chemotherapy (last in ___ now with acute hypoxic respiratory failure secondary to bronchiectasis, HFrEF and likely pneumonia// Progression of bronchiectasis Progression of bronchiectasis TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. The technical details of the protocol are consistent with the ___ of Radiology (___) requirements for low-dose CT lung cancer screening* DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 12.7 mGy (Body) DLP = 502.9 mGy-cm. Total DLP (Body) = 503 mGy-cm. COMPARISON: To a prior study done on ___ FINDINGS: THORACIC INLET: There is a right-sided Port-A-Cath with its tip in the right atrium there are multiple small bilateral supraclavicular lymph nodes mildly enlarged, unchanged since the prior study BREAST AND AXILLA : There are multiple small bilateral axillary lymph nodes not enlarged by size criteria measuring up to 6 mm, also unchanged. MEDIASTINUM: The mediastinal lymph nodes are enlarged and unchanged since the prior study the right paratracheal node measures 9 mm. The right lower paratracheal node measures 16 mm. The left paratracheal node measures 9 mm. There are small bilateral hilar lymph nodes. The subcarinal node measures 11 mm. There is moderate cardiomegaly. There are multiple small periesophageal lymph nodes. There is a small hiatus hernia. PLEURA: There is no pleural effusion. LUNG: Evaluation of lung parenchyma is somewhat limited due to respiratory motion. There is multifocal bilateral parenchymal opacities, somewhat in a perihilar distribution, most likely represents pulmonary edema. There is bibasilar atelectasis. BONES AND CHEST WALL : Review of bones shows degenerative changes involving the thoracic spine. UPPER ABDOMEN: Limited sections through the upper abdomen shows a small hiatus hernia. There is atherosclerotic calcification involving the aorta. There are multiple bilateral renal cysts. No adrenal masses are seen in the left adrenal is diffusely thickened. Small upper abdominal lymph nodes are unchanged IMPRESSION: Diffuse bilateral ground-glass opacification somewhat patchy, could represent pulmonary edema. Atypical pneumonia can have a similar appearance. Small volume mediastinal and hilar adenopathy is unchanged. Right-sided Port-A-Cath with its tip in the right atrium. Radiology Report INDICATION: ___ with history of CLL/SLL with pulmonary parenchymal involvement diagnosed in ___ s/p chemotherapy (last in ___ c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA, bronchiectasis, chronic systolic heart failure (LVEF 40-45% in ___, and atrial fibrillation on rivaroxaban (TIA while on warfarin) who presents with subacute progressively worsening cough and SOB and new hypoxia.// Question of PNA progression vs other intrapulmonary process TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs, most recent dated ___. FINDINGS: Lungs are fully expanded. Subtle bilateral parenchymal opacities appear worse compared to radiograph from ___ however, have subtly improved compared to chest CT from ___. This could represent a resolving pneumonitis or atypical pneumonia. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. Calcified tortuous thoracic aorta. Single-lumen port seen projecting over the right hemithorax and terminates in the mid-distal SVC. IMPRESSION: Subtle bilateral parenchymal opacities appear worse compared to radiograph from ___ however, have subtly improved compared to chest CT from ___. RECOMMENDATION(S): Recommend repeat chest radiograph in ___ weeks to ensure resolution of parenchymal opacities. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with PNA, ?pneumonitis and improving lung exam after diuresis and steroids// Change in CXR compared to prior, any evidence of pulmonary edema Change in CXR compared to prior, any evidence of pulmonary edema IMPRESSION: Comparison to ___. Stable right apical calcifications, 1 of which is nodular in appearance. Stable parenchymal morphology. Stable correct position of the right pectoral Port-A-Cath. Normal size and shape of the cardiac silhouette. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Cough, Dyspnea Diagnosed with Other pneumonia, unspecified organism, Dyspnea, unspecified temperature: 98.9 heartrate: 96.0 resprate: 18.0 o2sat: 94.0 sbp: 119.0 dbp: 47.0 level of pain: 0 level of acuity: 2.0

====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the Hospital because you were coughing and having trouble breathing. This is likey due to your heart not pumping as well, and your bronchiectasis acting up. It is also possible that you had a pneumonia and a condition called hypersensitivity pneumonitis. WHAT HAPPENED TO ME IN THE HOSPITAL? - We tested your blood and sputum for infection. You received antibiotics to treat a possible pneumonia. You also received IV diuretics to help your heart pump better and to get rid of the excess fluid in your legs and lungs. You received chest ___ to help loosen up the phlegm in your chest. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - Please clean your musical instruments (such as bag pipes) regularly. - Please continue airway clearance at home with acapella 10 breaths at least twice daily. We wish you the best! Sincerely, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with a history of recent babesiosis infection, HTN, HLD, and T2DM, who presented initially with dyspnea on exertion, and is transferred from ___ for "pre-tamponade." He was admitted to ___ from ___ with sepsis, renal failure, and hyperkalemia, where he was noted to have splenomegaly to 15cm, and Babesia Microti PCR positive. He was treated with Atovaquone and Azithromycin. Since then, he has had significant bilateral lower extremity edema, dyspnea on exertion, and orthopnea. These symptoms started 2 weeks ago, but have been improving. Otherwise, he feels well, with no chest pain, nausea, vomiting, or abdominal pain. Earlier today, he presented for routine follow-up TTE, was found to have EF 51%, a small circumferential pericardial effusion with 30% respiratory variation, diastolic RA collapse, dilated IVC suggesting high artery filling pressures with findings suggestive of pre-tamponade physiology. He was subsequently referred to the ER where he had lab testing showing a BNP of 73 troponin of 0.03, normal LFTs, mild anemia with a hemoglobin of 12. Cardiology was consulted there and are recommended transport here. - In the ED initial vitals were: 98.0, 75, 188/88, 17, 94% RA - EKG: NSR, nonspecific ST changes, Low voltage - Labs/studies notable for: WBC 6.3 Hb 11.5 Plt 205 Prst smear negative Cr 1.1 Trop < 0.01 lactate 1.4 Imaging showed: CXR: Opacities at the posterior costophrenic angles could be due to small effusions and atelectasis noting that infection is not excluded. No pulmonary edema. Patient was given: no medications Cardiology was consulted, and recommended admission to ___ for repeat TTE & workup of ___. ID was called, and recommended Atovaquone and Azithro only if patient decompensates, pending smear (which ultimately was negative) Vitals on transfer: 77 147/80 16 96% RA On the floor, he reports no current dyspnea, chest pain/pressure, palpitations, lightheadedness, n/v, fevers, diaphoresis, myalgias, or any other complaints. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY Social History: ___ Family History: FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.4 ___ Pulsus: 10 mmHg GENERAL: NAD HEENT: NCAT. Sclera anicteric. MMM. NECK: No jugular venous distention. CARDIAC: RRR, murmurs, rubs, or gallops heard in upright or supine position LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No tenderness. EXTREMITIES: 2+ pitting edema bilaterally Discharge Exam: PHYSICAL EXAMINATION: VS: Temp: 98.4 HR 78 BP: 138/72 94% RA GENERAL: feeling well in NAD laying in bed watching TV HEENT: Sclera anicteric. mucus membranes are moist, EOMI NECK: JVP not appreciated on exam CARDIAC: RRR, no murmurs, rubs, or gallops heard in upright or supine position LUNGS: breathing was unlabored, no wheezes, rhonchi or rales, clear to auscultation in all lung fields ABDOMEN: Soft, No tenderness. EXTREMITIES: 2+ pitting edema bilaterally to mid calf, most notable in the ankles up to his knees bilaterally SKIN: no rash MSK: No obvious joint effusion Pertinent Results: ADMISSION LABS: ___ 01:30PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:30PM PARST SMR-NEG ___ 01:30PM URINE UHOLD-HOLD ___ 01:35PM PLT COUNT-205 ___ 01:35PM PLT COUNT-205 ___ 01:35PM NEUTS-63.4 ___ MONOS-8.8 EOS-4.9 BASOS-1.1* IM ___ AbsNeut-4.01 AbsLymp-1.36 AbsMono-0.56 AbsEos-0.31 AbsBaso-0.07 ___ 01:35PM WBC-6.3 RBC-4.03* HGB-11.5* HCT-36.0* MCV-89 MCH-28.5 MCHC-31.9* RDW-14.2 RDWSD-46.0 ___ 01:35PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.6 ___ 01:35PM CK-MB-3 cTropnT-0.01 ___ 01:35PM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-54 ALK PHOS-81 TOT BILI-0.5 ___ 01:35PM estGFR-Using this ___ 01:35PM GLUCOSE-184* UREA N-31* CREAT-1.1 SODIUM-140 POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14 ___ 05:00PM ___ PTT-27.6 ___ ___ 05:20PM LACTATE-1.4 Imaging/Studies: CXR ___ IMPRESSION: Opacities at the posterior costophrenic angles could be due to small effusions and atelectasis noting that infection is not excluded. No pulmonary edema. ECHO ___ TTE The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 70%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Small pericardial effusion; no cardiac tamponade. Head CT: ___ FINDINGS: There is a chronic appearing lacune in the left putamen. There is no evidence of acute large territorial infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in size and configuration for age. There are minimal calcifications in the right carotid siphon. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Tiny chronic left putamen lacune. Microbiology ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ (LYME)Lyme IgG-FINAL; Lyme IgM-FINAL NegativeINPATIENT ___ CULTUREBlood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINALEMERGENCY WARD ___ (LYME)Lyme IgG-FINAL; Lyme IgM-FINALEMERGENCY WARD ___ CULTUREBlood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS EPIDERMIDIS}; Anaerobic Bottle Gram Stain-FINALEMERGENCY WARD ___ CULTURE-FINALEMERGENCY WARD Discharge Labs: ___ 05:55AM BLOOD WBC-6.3 RBC-4.35* Hgb-12.5* Hct-40.3 MCV-93 MCH-28.7 MCHC-31.0* RDW-14.3 RDWSD-48.2* Plt ___ ___ 05:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1 ___ 06:30AM BLOOD TSH-2.8 ___ 01:30PM URINE Hours-RANDOM Creat-29 Albumin-129.0 Alb/Cre-4448.3* ___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Aspirin 81 mg PO DAILY 3. Furosemide Dose is Unknown PO DAILY 4. Glargine 65 Units Bedtime 5. Lisinopril 20 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth Once daily in the morning Disp #*30 Tablet Refills:*0 3. Glargine 65 Units Bedtime 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Lisinopril 20 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: acute on chronic diastolic heart failure hypertension diabetes, insulin dependent GPC bacteremia SECONDARY DIAGNOSES: history of babesiosis history of acute kidney injury, now resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with SOB// ?pulm edmea TECHNIQUE: PA and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Opacity projects over the posterior costophrenic angles on the lateral view. Superiorly, lungs are clear. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities, degenerative changes seen at the right shoulder and hypertrophic changes noted in the spine. IMPRESSION: Opacities at the posterior costophrenic angles could be due to small effusions and atelectasis noting that infection is not excluded. No pulmonary edema. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with a history of recent babesiosis infection, HTN, HLD, and T2DM, who presented with SOB and fluid overloaded, found to have GPC bacteremia now with worsening severe headache.// ?Abscess/acute intracranial pathology TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 844 mGy-cm. COMPARISON: None. FINDINGS: There is a chronic appearing lacune in the left putamen. There is no evidence of acute large territorial infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in size and configuration for age. There are minimal calcifications in the right carotid siphon. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Tiny chronic left putamen lacune. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Leg swelling, XFER Diagnosed with Disease of pericardium, unspecified temperature: 98.0 heartrate: 75.0 resprate: 17.0 o2sat: 94.0 sbp: 188.0 dbp: 88.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___: -What happened on this hospital stay: You were admitted to ___ with swelling in your legs and difficulty breathing. Your repeat echo did not show any concerning fluid around the heart. It did show some changes in the heart that can be seen with long term high blood pressure. You also had positive blood cultures that grew bacteria. You were treated with vancomycin. Ultimatley your blood did grow a specific bacteria called staph epidermidis which is a common contaminant from the skin. To be sure that you were not growing any dangerous bacteria we checked blood cultures on you after we had stopped antibiotics to ensure that you were not growing anything else. These cultures were pending on your discharge. You were given medications to help get fluid off and to treat your blood infection. You also had heart imaging to make sure that it was pumping properly and not infected. -When you leave the hospital is very important that you: See your regular doctor tomorrow to have them follow up on your blood cultures to ensure that they are negative. It is very important that you come to the hospital if you have any symptoms such as fever or chills, chest pain, cough or anything that you are concerned about. When you leave please weigh yourself daily and call your doctor if your weight increases >3 lbs. It is also important to take your medications as prescribed. It was a pleasure to care for you, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: acute right-sided weakness, ataxia and dysarthria Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo RH male with HTN/HLD p/w with acute onset right-sided weakness, clumsiness and dysarthria. The patient went to work ___ around 7 AM and was reportedly feeling well. Works as a ___ and worked through the AM. Around 11 AM the patient appeared diaphoretic, seen by coworkers tripping over objects at work. His boss encouraged him to relax and cool off in the AC. About an hour or so later, he apeared well, speaking normally and walking fine.. Around 2:30 ___ the patient's boss again noticed him appearing very clumsy. He told him to go to the ED. He called his brother to come pick him up and his brother reports that he was dysarthric and falling to the right. After subsequent interviews and clarification the patient reported, that he did not feel well at 11 and never returned to baseline. He reported having dyasrthria around 1 ___ and having a clumsy hand while working on the cars in the afternoon. He then later felt as though his right leg was clumsy as well - around 2:30. In the ED, the patient reports chest pain and tingling in his bilateral fingertips. The chest pain he gets on almost a daily basis without clear pattern. Can occur at rest, with exertion or when lying down. On arrival the patient's pressure was 208/110 and was given labetalol and then placed on a nicardipine drip. A foley was placed per tPA protocol. EKG demonstrate ST elevations in V1-V3 and T wave inversions in V4-6. The findings were discussed with Cardiology who felt this was consistent to LVH related to HTN. Review of Systems: No HA, loss of vision, lightheadedness, vertigo, diplopia, dizziness, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae, except as above. No bowel or bladder incontinence. Gait problems. Past Medical History: HTN Hyperlipidemia Social History: ___ Family History: Strong family hx of HTN. No strokes Physical Exam: Admission Physical Exam: Vitals: T: 98.4 P: 98, R: 16 BP: 218/104 SaO2: 100 % RA Neurologic: -Mental Status: Alert, oriented x name, place and month, and year. Relates history, albeit needs clarification over three exams. Speech is dysarthric. Language is fluent. Normal prosody. Reading intact. There were no paraphasic errors. Pt. was able to name high, but not low frequency objects. Able to follow one and two step commands crossing the midline. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation, although intially had some trouble counting fingers that was likely attentional. III, IV, VI: EOMI with nystagmus on left lateral gaze. Normal saccades. V: Facial sensation intact to light touch. VII: No facial asymmetry. Normal facial movements. VIII: Hearing intact to voice. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and tone. Pronator drift on the right. No adventitious movements, such as tremor, noted. No asterixis noted. Impaired finger tapping and coordinated movements in the right hand. Delt Bic Tri WrE WrF FFl FE IP Quad Ham TA ___ L 5 ___ ___- ___ 5 5 5 R 5 ___ ___- ___ 5 5 5 -Sensory: No deficits to light touch, pinprick b/l. Extinction to DSS on the RUE. -DTRs: Bi ___ Pat Ach L 2 2 2 2 R 2 2 2 2 Plantar response was flexor bilateraly. No clonus. - Coordination: Dysmetria on FNF and heel to shin on the right. -Gait: Not assessed. Pertinent Results: ___ 07:55PM GLUCOSE-124* UREA N-16 CREAT-1.2 SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 ___ 07:55PM cTropnT-<0.01 ___ 07:55PM URINE HOURS-RANDOM SODIUM-98 POTASSIUM-11 CHLORIDE-81 ___ 07:55PM URINE OSMOLAL-369 ___ 07:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 04:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 03:56PM GLUCOSE-99 NA+-141 K+-3.8 CL--101 TCO2-26 ___ 03:45PM CREAT-1.5* ___ 03:45PM UREA N-18 ___ 03:45PM estGFR-Using this ___ 03:45PM cTropnT-<0.01 ___ 03:45PM OSMOLAL-289 ___ 03:45PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:45PM WBC-6.5 RBC-5.29 HGB-17.0 HCT-48.9 MCV-93 MCH-32.2* MCHC-34.7 RDW-12.6 ___ 03:45PM PLT COUNT-290 ___ 03:45PM ___ PTT-36.1 ___ Head CT: No intracranial hemorrhage, edema, mass, or mass effect. CTA: Carotid arteries and vertebral arteries in the neck are widely patent without dissection, hematoma, filling defects. The circle of ___ and its principal branches are patent. There is no large aneurysm, vascular malformation, occlusion, or high grade stenosis. CTP: No vascular territorial perfusion abnormalities are seen. MRI ___: Slow diffusion is identified in the posterior limb of the left internal capsule, demonstrated on the DWI and ADC maps, this area measures approximately 5 x 21 mm in transverse dimension, there is no evidence of susceptibility changes to suggest hemorrhagic transformation, no significant mass effect is identified, there is no evidence of hydrocephalus. The FLAIR sequence and T2-weighted images demonstrate a focal area of high signal intensity in the subcortical white matter of the left frontal lobe, possible. IMPRESSION: Slow diffusion is identified in the posterior limb of the left internal capsule, likely consistent with an acute ischemic event. There is no evidence of hemorrhagic transformation or mass effect. 2D ECHO: Marked symmetric left ventricular hypertrophy with normal regional and low normal global systolic function. Mild-moderate mitral regurgitation. Incresaed PCWP. No PFO/ASD identified. No definite cardiac source of embolism identified. EKG ___: Sinus rhythm. Left atrial abnormality. Left axis deviation. Left ventricular hypertrophy with secondary repolarization change. Compared to the previous tracing of ___ no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 142 80 434/449 60 -23 174 Medications on Admission: Nil Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Fluoxetine 20 mg PO DAILY 5. Metoprolol Tartrate 50 mg PO BID 6. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Cerebral embolism with infarction Hypertension, Hyperlipidemia, Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report STUDY: CTA of the head and neck. CLINICAL INDICATION: ___ male patient with history of ataxia, evaluate posterior fossa for intracranial hemorrhage or ischemia. COMPARISON: No prior examinations are available. TECHNIQUE: Axial non-contrast images were obtained through the brain. Subsequently, axial MDCT images were obtained from the aortic arch through the head convexity with intravenous contrast material, axial, coronal, and sagittal thick-slab multiplanar reformations were generated. Curved reformations and 3D volume-rendered reconstructions of the intracranial and cervical circulations were also generated at the separate workstation by the advanced imaging lab. CT PERFUSION: Also perfusion sequence was obtained, and color maps for detection of the mean transit time, blood flow, and blood volume were obtained. FINDINGS: NON-CONTRAST HEAD CT: There is no evidence of intracranial hemorrhage, mass, mass effect, or shifting of the normally midline structures. The ventricles and sulci are normal. The orbits are unremarkable, the paranasal sinuses and mastoid air cells are clear. CTA OF THE HEAD: There is vascular anatomical variation consistent with hypoplasia of the A1 segment on the right. The right posterior communicating artery is patent with fetal pattern. The anterior communicating artery demonstrates three anterior cerebral arteries. There is atherosclerotic plaque at the bifurcation of the left middle cerebral artery, with tortuosity of the inferior branch, no aneurysms larger than 3 mm in size are seen. There is no evidence of vascular malformation or high-grade stenosis. CTA OF THE NECK: The aortic arch demonstrates a three-vessel branch morphology, the common carotid arteries are widely patent as well as the vertebral arteries with no evidence of flow stenotic lesion. CTA PERFUSION: There is no evidence of abnormal mean transit time, blood flow, or cerebral blood volume to indicate areas of ischemia or penumbra. If there is persistent or significant clinical concern for acute infarction, correlation with MRI of the brain is advised. Radiology Report HISTORY: ___ man with CVA and worsening mental status. COMPARISON: ___ nonenhanced head CT and head CTA. TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain without administration of IV contrast. Coronal and sagittal reformations, and thin slice bone algorithm reconstructions were reviewed. FINDINGS: Hypodensity in the anterior limb of the left internal capsule (2:18) is slightly more conspicuous than on the exam 4 hours prior, but this could be accounted for by differences in patient positioning, volume averaging, and slice selection. There is no evidence of hemorrhage, mass effect, or large territorial infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. The pineal gland is slightly prominent measuring approximately 15 mm in anterio-posterior by 14 mm in transverse dimension and partially calcified. No fracture is identified. A mucous retention cyst is present in the right maxillary sinus. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are otherwise clear. IMPRESSION: No definite change since the study 4 hours prior. Apparent increase in conspicuity of a focal hypodensity in the anterior limb of the left internal capsule could be accounted for by differences in technique. Radiology Report STUDY: MRI of the head. CLINICAL INDICATION: ___ man with ataxia, hemiparesis, stroke. COMPARISON: Prior CTA of the head dated ___. TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility, and axial diffusion-weighted sequences were obtained through the brain. FINDINGS: Slow diffusion is identified in the posterior limb of the left internal capsule, demonstrated on the DWI and ADC maps, this area measures approximately 5 x 21 mm in transverse dimension, there is no evidence of susceptibility changes to suggest hemorrhagic transformation, no significant mass effect is identified, there is no evidence of hydrocephalus. The FLAIR sequence and T2-weighted images demonstrate a focal area of high signal intensity in the subcortical white matter of the left frontal lobe, possibly consistent with lacunar ischemic change. The major vascular flow voids are present, the orbits are unremarkable, the paranasal sinuses demonstrate a mucus-retention cyst on the right maxillary sinus, the mastoid air cells are clear. IMPRESSION: Slow diffusion is identified in the posterior limb of the left internal capsule, likely consistent with an acute ischemic event. There is no evidence of hemorrhagic transformation or mass effect. These findings were discovered and communicated via phone call to Dr. ___ ___ at 17:30 hours on ___ by Dr. ___. Radiology Report HISTORY: Right ataxia hemiparesis syndrome, status post t-PA. Evaluate for hemorrhage. TECHNIQUE: Contiguous axial images were obtained of the brain. No contrast was administered. COMPARISON: CT head on ___. FINDINGS: There is no evidence of acute hemorrhage, edema, mass, mass effect, or CT evidence of acute territorial infarction. The ventricles sulci are normal in size and configuration for the patient's age. The previously seen hypodensity in the anterior limb of the internal capsule is not well seen. Visualized paranasal sinuses and mastoid air are well aerated. IMPRESSION: No evidence of acute hemorrhage. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: R Weakness Diagnosed with TRANS CEREB ISCHEMIA NOS temperature: 98.4 heartrate: 98.0 resprate: 16.0 o2sat: 97.0 sbp: 218.0 dbp: 104.0 level of pain: nan level of acuity: 1.0

Dear Mr ___, It was a pleasure to take care of you at ___ ___. You were admitted with acute weakness, clumsiness and trouble speaking. After extensive laboratory and radiology workup, it was determined that the cause of your symptoms was a stroke. The stroke was caused by risk factors that include high blood pressure, tobacco abuse and elevated cholesterol. We did tests to look at your heart which did not show acute abnormalities, but it is important that you follow up with your primary care and cardiology appointments. After you are discharged, please continue taking aspirin and atorvastatin for your stroke, as well as a few medications for your high blood pressure.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: ___ - cerebral angiogram History of Present Illness: Mr. ___ is a ___ year-old male with history of hepatitis C, sleep apnea, peptic ulcer disease, presenting to the ___ ED directly from radiology with an acute right-sided SDH. He reports approximately 1 week of worsening headache. He denies any trauma or minor headstrike. He had an episode of nausea & vomiting 3 days ago, with mild nausea since. His family reports decreased appetitite and general malaise. He was seen in urgent care yesterday and had a scheduled MRI this afternoon which revealed an acute right convexity SDH. He was referred directly to the ED for Neurosurgical evaluation. He is prescribed Aspirin 81mg daily for "general health". He reports taking more Aspirin than prescribed this week (162mg-325mg daily) for headaches. No history of stroke or aneurysm. Today, he does admit to mild headache. Denies visual changes, new numbness or weakness in arms or legs. He does report slight difficulty using his right hand. No difficulties with speech. Past Medical History: Colorectal polyps Sleep apnea, severe BPH (benign prostatic hyperplasia) PEPTIC ULCER DISEASE Social History: ___ Family History: father - well in his ___ [OTHER] Mother liver ca [OTHER] Physical Exam: On admission O: T: 97.0 BP: 150/95 HR: 67 RR: 18 O2Sats: 99% Gen: WD/WN, mildly uncomfortable with eyes closed. HEENT: No external signs of trauma. Neck: Supple. Full ROM without pain. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not assessed II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength slightly diminished on left UE & ___, 4+/5 throughout. No pronator drift. Sensation: Intact to light touch. Coordination: No dysmetria with finger-nose-finger. Slowed fine motor movements on left. On discharge Neurologically intact, groin CDI with no edema, non tender Pertinent Results: ___ NCHCT Moderate acute right hemispheric subdural hematoma measuring approximately 1.2 cm in maximal thickness, with mild leftward shift of midline structures. Close interval followup is recommended. ___ CTA head Unchanged right hemispheric subdural hematoma resulting in 4 mm leftward midline shift. No acute infarct or new hemorrhage. Essentially unremarkable CTA of the head. No evidence of vascular malformation or active contrast extravasation. ___ No significant interval change to the right hemispheric subdural hematoma measuring up to 1.5 cm from the inner table. 2. Grossly stable mass effect with associated 6 mm leftward midline shift. 3. Ventricles are stable in size. ___ CXR Lungs are fully expanded and clear. Mediastinum in the region of the ascending thoracic aorta is slightly bulged to the right likely due to dilated or tortuous ascending thoracic aorta. Heart is normal size, pulmonary vasculature is not dilated and there is no pleural abnormality. ___ cerebral angiogram No abnormal arterial malformations identified cause of the patient's a Preliminary Reporttraumatic subdural hemorrhage. ___ NCHCT Stable right hemispheric subdural hematoma, measuring up to 15 mm, with layering along the right tentorium, as described. 2. Grossly stable 5 mm leftward midline shift. 3. No new hemorrhage is identified. Medications on Admission: Asa 81 daily and 162-325 PRN headache, omeprazole, amlodipine Discharge Medications: 1. Amlodipine 2.5 mg PO BID 2. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Omeprazole 20 mg PO DAILY 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours as needed Disp #*15 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN Constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth Daily as needed Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with acute subdural hematoma. Evaluate for progression TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 1003 mGy-cm CTDI: 55 mGy COMPARISON: None. FINDINGS: No comparisons are available. There is a hyperdense extra-axial hematoma along the right cerebral hemisphere, from the vertex to the inferior temporal lobe. Maximal thickness of the subdural hematoma is 1.2 cm and there is effacement of the adjacent sulci along the right cerebral hemisphere. There is resultant mass effect of the cerebral hemisphere with mild midline shift to the left by 6 mm, as well as mass effect upon the right lateral ventricle. The basal cisterns are patent. No overlying fracture or soft tissue swelling is seen. There is minimal mucosal thickening of the maxillary sinuses bilaterally, otherwise the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Incidentally noted are osteomas of the left mastoid air cells. IMPRESSION: Moderate acute right hemispheric subdural hematoma measuring approximately 1.2 cm in maximal thickness, with mild leftward shift of midline structures. Close interval followup is recommended. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS INDICATION: ___ man with nontraumatic subdural hematoma. Evaluate for underlying vascular lesion and stability of hemorrhage. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed through the brain during infusion of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated. This report is based on interpretation of all of these images. DOSE: DLP: 1859.06 mGy-cm; CTDI: 205.39 mGy COMPARISON: CT head without contrast of ___. FINDINGS: Head CT: Essentially unchanged size of right hemispheric subdural hematoma also layering along the right tentorial leaflet measuring up to 1.3 cm in greatest thickness. There is right hemispheric sulcal effacement as well as 4 mm leftward midline shift, unchanged from prior exam. There is unchanged minimal effacement of the right ambient cistern. No new hemorrhages. There is no evidence of acute infarct. Minimal mucosal thickening of the right maxillary sinus. Otherwise the paranasal sinuses are clear. The orbits are unremarkable. The mastoid air cells and middle ear cavities are well pneumatized and clear. Head CTA: There are prominent right hemispheric superficial draining veins, without evidence of arterial venous malformation. The prominence is likely secondary to congestion and crowding from local mass effect from the hematoma. There are no intracranial vascular abnormalities. There is no evidence of aneurysm, stenosis or occlusion. IMPRESSION: 1. Stable right hemispheric subdural hematoma resulting in 4 mm leftward midline shift. 2. No new hemorrhage. 3. Essentially unremarkable CTA of the head. 4. No evidence of vascular malformation or active contrast extravasation identified. 5. Paranasal sinus disease as described. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with history of right-sided subdural hemorrhage, now with worsening headache. Evaluate for progression of bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 897 mGy-cm CTDI: 54 mGy COMPARISON: ___ head CTA, ___ Head CT. FINDINGS: There is redemonstration of a right hemispheric subdural hematoma measuring up to 1.5 cm from the inner table at the vertex, not significantly changed since prior study. There is also blood layering along the right tentorium cerebelli. There is mass effect on the right lateral ventricle, unchanged effacement of the right cerebral sulci as well as a 6 mm leftward shift of midline structures. The ventricles are unchanged in size and configuration. There is no evidence of downward herniation. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No significant interval change to the right hemispheric subdural hematoma measuring up to 1.5 cm from the inner table. 2. Grossly stable mass effect with associated 6 mm leftward midline shift. 3. Ventricles are stable in size. Radiology Report EXAMINATION: CHEST (PRE-OP AP ONLY) INDICATION: ___ year old man preop cxr // preop preop COMPARISON: There are no prior chest radiographs. IMPRESSION: Lungs are fully expanded and clear. Mediastinum in the region of the ascending thoracic aorta is slightly bulged to the right likely due to dilated or tortuous ascending thoracic aorta. Heart is normal size, pulmonary vasculature is not dilated and there is no pleural abnormality. Radiology Report CLINICAL HISTORY ___ year old man with ___ r/o vascular malformation // diagnostic cerebral angiogram in morning on ___ EXAMINATION: Patient presented for diagnostic catheter angiography. The following vessels were selectively catheterize injected: Right common carotid artery, right internal carotid artery including Three dimensional rotational angiography and postprocessing on separate work station with concurrent physician supervision with images being used for final interpretation, right external carotid artery, right vertebral artery, left common carotid artery including Three dimensional rotational angiography and postprocessing on separate work station with concurrent physician supervision with images being used for final interpretation, left vertebral artery,. ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 65 during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site TECHNIQUE: OPERATORS: ___, and Dr. ___ physician performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. PROCEDURE: Patient was brought to the fluoroscopy suite, ID confirmed via wrist band. The patient is placed supine on the fluoroscopy table in the bilateral groins were prepped and draped in usual sterile manner. Time-out procedure was performed per institutional guidelines. Next the location the right mid femoral head was located using anatomic and radiographic landmarks. 10 cc of lidocaine was infused in the subcutaneous tissue. A micropuncture kit was used to gain access to the right femoral artery, serial dilation was undertaken until a short 5 ___ groin sheath connected to a continuous heparinized saline flush was inserted. A ___ catheter was advanced over the 0.038 glidewire in used to select the innominate followed by the right common carotid artery. Cervical biplane road map imaging was undertaken. Next, under road mapping technique, the right internal carotid artery was selected. Intracranial biplane magnified biplane oblique views along with 3 dimensional rotational angiography and processing a separate 3D workstation was undertaken from this vessel. The catheter was then pulled back into the right common carotid artery, new road map was undertaken, and the right external carotid artery was then selected. Extracranial biplane imaging was then undertaken. Next the catheter was pulled back into the aorta in used to select the right innominate artery followed by the right vertebral artery. ___ lateral views were then undertaken. The catheter was then pulled back and the aorta used to select the left common carotid artery. Intracranial biplane along with cervical biplane imaging was undertaken from this vessel. 3 dimensional rotational angiography with separate processing on a separate 3D workstation was also undertaken from this vessel. Catheter was then pulled back into the aorta used to select the left subclavian artery, followed by the left vertebral artery. Left vertebral artery injection was undertaken in the intracranial biplane. The catheter was then pulled back into the aorta and then fully removed from the body. No compression pressure was held over the right femoral artery for approximately 25 min until hemostasis was achieved. At the conclusion the procedure, the patient was is neurologic baseline. FINDINGS: Right common carotid artery: Cervical bifurcation is well visualized, there is mild tortuosity at the origin of the right common carotid artery off of the innominate artery. There is no significant carotid stenosis or carotid atheromatous disease. Right internal carotid artery: The distal right ICA, proximal distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering, there is no evidence of abnormal early venous drainage, or arteriovenous shunting. There is no evidence of vasculitis or aneurysm formation. Patient is a very prominent ophthalmic artery, however there is no evidence of abnormal anastomoses with the venous circulation, or early draining vein identified. There is however it is normal anastomoses with the external carotid artery circulation. There is no evidence of a dilated superior ophthalmic vein, the timing of normal venous drainage is seen, the cavernous sinus is also seen to be filling. Right external carotid artery: The internal maxillary artery, occipital artery, middle meningeal artery, superior temporal artery are well-visualized. Vessel caliber smooth and tapering. There is no evidence of vasculitis, or abnormal arteriovenous shunting, or abnormal extracranial to intracranial anastomoses. There is no identification of a pathologic early draining vein. Right vertebral artery: The right vertebral artery, right ___, basilar artery, reflux down the left vertebral artery to the ___, basilar artery, bilateral AICA, the, SCA, PCAs are also visualized. Vessel caliber smooth and tapering, there is no identification of aneurysms, or abnormal early venous drainage. There is no identification of abnormal arteriovenous shunting. In the high cervical views, posterior muscular branches along with the posterior meningeal artery are identified off of the right vertebral artery however there is no abnormal fistulous connection to a sinus, or cortical vein. Left common carotid artery: The distal left ICA, proximal distal MCA and ACA branches are well-visualized. This caliber smooth and tapering. There is no evidence of abnormal early venous drainage, or abnormal arteriovenous shunting. No aneurysms are identified. Of the ECA vessels visualized, the STA, middle meningeal, I max are seen. There is no evidence of abnormal arteriovenous shunting or abnormal extracranial to intracranial anastomoses. Left vertebral artery: Origin of the left vertebral artery throughout the cervical plane is visualized. There is no evidence of dissection or abnormal anastomoses. The left vertebral artery, left ___, basilar artery, bilateral at AICA and PCA and SCA is are well-visualized. vessel caliber smooth and tapering. There is no evidence of aneurysm formation, early venous drainage, or abnormal arteriovenous shunting. IMPRESSION: 1. No abnormal arterial malformations identified cause of the patient's a traumatic subdural hemorrhage. Dr. ___ was personally present, an performed the procedure. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old male with age indeterminate right cerebral hemisphere subdural hemorrhage, no definite history of prior trauma and negative cerebral angiogram study. Evaluate stability of subdural hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 935 mGy-cm CTDI: 54 mGy COMPARISON: ___ and ___ head CT studies. FINDINGS: Again seen, is a right hemispheric primarily hyperdense subdural hematoma measuring up to 15 mm in greatest width (series 3, image 19). There is also subdural blood and layering along the right tentorium. There is local mass effect and continued mild effacement of the right lateral ventricle. There is approximately 5 mm of leftward shift of midline structures, not significantly changed. The basal cisterns remain patent and there is preservation of gray-white matter differentiation. No new areas of hemorrhage are identified. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Stable right hemispheric subdural hematoma, measuring up to 15 mm, with layering along the right tentorium, as described. 2. Grossly stable 5 mm leftward midline shift. 3. No new hemorrhage is identified. Gender: M Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Headache Diagnosed with HEADACHE temperature: 97.0 heartrate: 67.0 resprate: 18.0 o2sat: 99.0 sbp: 150.0 dbp: 95.0 level of pain: 9 level of acuity: 2.0

•We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •***You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. What You ___ Experience: •You may have difficulty paying attention, concentrating, and remembering new information. •Emotional and/or behavioral difficulties are common. •Feeling more tired, restlessness, irritability, and mood swings are also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You ___ Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •The medication may make you bleed or bruise easily. •Fatigue is very normal. •Do not go swimming or submerge yourself in water for five (5) days after your procedure.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ankle pain Major Surgical or Invasive Procedure: external fixator device History of Present Illness: HPI: Pt is a ___ who presents as a transfer from ___ w/ a R trimalleolar ankle fracture. Pt was painting on a ladder when he unfortunately had a fall, landing on his R ankle. He had immediate pain, deformity, and inability to bear weight. He presented to ___, was found to have a R trimalleolar ankle fracture and was transferred to ___ for further management. He reports no pain elsewhere. Past Medical History: ___ Social History: ___ Family History: nc Physical Exam: General: Comfortable MSK: RLE: ex fix intact. Pin sites are c/d/I. Intact gastroc, TA, ___, EDL/FDL. SILT distally. warm and well perfused. Soft compartments. Pertinent Results: ___ 06:47PM GLUCOSE-121* UREA N-15 CREAT-1.0 SODIUM-141 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-20 Medications on Admission: see admit med list Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 500 mg 2 capsule(s) by mouth every 8 hours for pain Disp #*100 Capsule Refills:*1 2. Aspirin 325 mg PO DAILY VTE prophylaxis RX *aspirin 500 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID This is a new medication to prevent constipation. please hold for loose stools. RX *docusate sodium 100 mg 2 tablet(s) by mouth twice per day Disp #*80 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate wean this medication as pain improves RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as needed for severe pain Disp #*80 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation This is a new medication to prevent constipation. please hold for loose stools. RX *sennosides [senna] 8.6 mg 2 tabs by mouth at bedtime Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ankle fracture Discharge Condition: AVSS NAD, A&Ox3 Followup Instructions: ___ Radiology Report EXAMINATION: CT of the right ankle without contrast INDICATION: ___ year old man with R pilon fracture// better characterize fracture pattern around ankle. TECHNIQUE: Multiplanar CT images of the right ankle without intravenous contrast. DOSE: Total DLP (Body) = 302 mGy-cm. COMPARISON: Right ankle radiographs ___. FINDINGS: There is a pilon type fracture at the ankle with transverse/oblique fractures of the distal fibula and the medial malleolus. There is also a vertically oriented fracture of the anterior distal tibia with intra-articular extension and disruption of the articular surface measuring approximately 1.5 cm and transverse dimension (series 602:61). There are bony fragments within this area of distraction. The medial and lateral aspect of the ankle mortise appears congruent without definite evidence of widening. No evidence of tendon entrapment. IMPRESSION: 1. Pilon fracture of the right ankle with a vertically oriented tibial fracture extending to the articular surface of the tibial plafond. Transverse/oblique fractures of the distal fibula and medial malleolus also noted. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: RT ANKLE FX. ORIF TECHNIQUE: Intraoperative fluoroscopic radiographs of the ankle obtained without a radiologist present. Total fluoroscopy time: 13.5 seconds. COMPARISON: ___. Radiographs of the right ankle ___. FINDINGS: Intraoperative radiographs demonstrate placement of external fixation with screws in the tibial shaft and calcaneus. There are comminuted fractures of the distal fibula and tibia better assessed on previous dedicated CT. Overall alignment is unchanged on these limited projections. IMPRESSION: Intraoperative radiographs. For further details please refer to the operative report in the ___ medical record. Radiology Report INDICATION: ___ year old man with right ankle fracture// evaluate fracture extension into tibia TECHNIQUE: Right knee, two views and right tibia and fibula, two views COMPARISON: Right ankle radiographs from outside institution ___ at 12:12 FINDINGS: An overlying splint limits fine osseous detail. Re-demonstrated is a comminuted intra-articular fracture involving the distal tibia and medial malleolus, with alignment appearing nearly anatomic. Comminuted distal fibular fracture with mild lateral and ventral displacement of the dominant distal fracture fragment appears unchanged. No additional fracture is seen. No dislocation is identified. The ankle mortise appears symmetric. There are no concerning lytic or sclerotic osseous abnormalities. The imaged right knee demonstrates mild degenerative spurring. No gross knee joint effusion is seen, though assessment is somewhat limited. No radiopaque foreign bodies are identified. Moderate-sized plantar calcaneal spur is again seen. IMPRESSION: Re-demonstration of comminuted distal tibial and fibular fractures without significant change in alignment. No dislocation. Radiology Report INDICATION: ___ year old man with ankle fracture status post splint placement TECHNIQUE: Right ankle, three views COMPARISON: Right tibia and fibula ___ at 17:59, right ankle radiographs ___ at 12:12 FINDINGS: Overlying splint limits fine osseous detail. Comminuted distal fibular fracture demonstrates improved alignment with mild ventral and lateral displacement of the dominant distal fracture fragment. Intra-articular comminuted distal tibial fracture with involvement of the medial malleolus also demonstrates improved alignment significant displacement. Ankle mortise appears symmetric. Talar dome is is smooth. No dislocation or additional fracture is seen. IMPRESSION: Slight interval improvement in alignment of the comminuted distal fibular fracture. No significant interval change in appearance of nondisplaced comminuted intra-articular distal tibial fracture with involvement of the medial malleolus. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with ankle fracture, post op// eval for cardiopulmonary abnormality TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: None. FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lung volumes are low with patchy opacities in the lung bases likely reflective of areas of atelectasis. No focal consolidation is identified. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with mild patchy bibasilar atelectasis. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Ankle injury, Transfer Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall on and from ladder, initial encounter temperature: 98.3 heartrate: 75.0 resprate: 16.0 o2sat: 99.0 sbp: 131.0 dbp: 80.0 level of pain: 6 level of acuity: 3.0

Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - touch down weight bearing RLE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin daily for 4 weeks WOUND CARE: - Do not get your external fixator device wet. - Monitor pin sites for severe pain, redness or drainage. - Keep the pin site area clean.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: chest pain, shortness of breath, hemoptysis Major Surgical or Invasive Procedure: MIBI ___ History of Present Illness: Mr. ___ is a ___ male with history of CAD, hypertension, diabetes, CKD on ___ dialysis last yesterday, presents with back pain radiating to his chest associated with shortness of breath. Patient notes exertional shortness of breath, orthopnea and low volume hemoptysis as well as epistaxis for the past month. This is associated with chest pain on exertion which he states is a radiation of his back / left flank pain but also associated with shortness of breath and present with exertion and feels more severe than his prior episodes of MI. He states he has had this same back pain every time he has dialysis since he began dialysis last month. Additionally, he was recently admitted ___ weeks ago for flash pulmonary edema in the setting of hypertensive emergency and NSTEMI. He denies known fevers or chills. He notes a 20 pound weight loss but this is in the setting of starting HD recently. He has had a mild mostly nonproductive cough but associated with occasional blood tinged sputum. In the ED: VS: 98.0, 82, 154/63, 18, 100% RA ECG: nonischemic PE: CTAB, nonlabored breathing, no edema Labs: troponin 0.02 -> 0.03, BNP 2810 Imaging: CTA chest negative for PE but notable for enlarging pulmonary nodules concerning for malignancy Impression: rule out angina, concern for malignancy admit for pharm nuc stress test and bronch with biopsy Interventions: home meds Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Diabetes complicated by retinopathy, nephropathy - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD - ___ (EF 55%) 3. OTHER PAST MEDICAL HISTORY - Diverticulosis - Vitamin D deficiency - PAD (peripheral artery disease) - Anemia - Renal artery stenosis - CKD V - Obesity - Secondary hyperparathyroidism of renal origin Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. History of DMII in brothers. Physical Exam: ADMISSION EXAM: VS: 98.6, 160/69, 83,18, 100% RA Gen - tired appearing, NAD Eyes - PERRLA with mild conjunctival injection ENT - MMM Heart - RRR, no r/m/g Lungs - scant bibasilar rales otherwise CTAB, unlabored breathing Abd - soft ntnd Ext - no pedal edema Skin - no rashes noted on cursory skin exam Vasc - WWP Neuro - A&Ox4 Psych - pleasant, calm cooperative Discharge Exam: Afebrile, aVSS Breathing comfortably on room air. Ambulatory sats 92-96% on RA. Lungs clear to auscultation bilaterally. Pertinent Results: ADMISSION LABS: ___ 12:06AM BLOOD WBC-7.7 RBC-2.72* Hgb-7.8* Hct-25.7* MCV-95 MCH-28.7 MCHC-30.4* RDW-14.4 RDWSD-47.5* Plt ___ ___ 12:06AM BLOOD Neuts-73.5* Lymphs-13.1* Monos-10.7 Eos-1.3 Baso-0.7 Im ___ AbsNeut-5.63 AbsLymp-1.00* AbsMono-0.82* AbsEos-0.10 AbsBaso-0.05 ___ 07:10AM BLOOD ___ PTT-33.4 ___ ___ 12:06AM BLOOD Glucose-229* UreaN-38* Creat-3.8* Na-131* K-4.0 Cl-87* HCO3-26 AnGap-18 ___ 12:06AM BLOOD ALT-12 AST-19 AlkPhos-87 TotBili-0.3 ___ 12:06AM BLOOD cTropnT-0.02* proBNP-2810* ___ 07:10AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.6* Mg-2.4 Iron-44* ___ 07:10AM BLOOD calTIBC-241* VitB12-619 Folate->20 Ferritn-1446* TRF-185* ___ 07:20AM BLOOD 25VitD-40 ___ 07:00AM BLOOD ANCA-NEGATIVE B ___ 07:00AM BLOOD CRP-54.6* No labs on day of discharge MIBI: 1. Partially reversible, medium sized, moderate severity perfusion defect involving the RCA territory. 2. Normal left ventricular cavity size and systolic function. CT-A chest: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Multiple, spiculated, nodules and masses throughout the mid right middle and lower lobes, in a perilymphatic distribution, show minimal surrounding ground-glass with air bronchograms in multiple areas. There are few areas of airway obliteration beyond the subsegmental level. Largest mass is seen in the medial right lung base, measuring 4.1 x 2.2 x 1.6 cm. Neoplastic etiology is favored for these findings, much less likely infectious. Recommend tissue diagnosis for further evaluation. 3. Large right hilar soft tissue adenopathy, likely neoplastic in etiology. This area could also be considered for tissue diagnosis. 4. Multiple additional calcified mediastinal lymph nodes and calcified granulomas throughout the lungs, likely sequela of prior granulomatous disease. Microbiology: - AFBs negative x3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Losartan Potassium 100 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS 9. Furosemide 40 mg PO EVERY OTHER DAY 10. Ranitidine 150 mg PO BID 11. Calcitriol 0.25 mcg PO 3X/WEEK (___) 12. HydrALAZINE 50 mg PO TID 13. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth DAily Disp #*30 Capsule Refills:*0 3. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. TraMADol 50 mg PO Q4H:PRN BREAKTHROUGH PAIN RX *tramadol 50 mg 1 tablet(s) by mouth Q4 Disp #*30 Tablet Refills:*0 5. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 6. Furosemide 40 mg PO 4X/WEEK (___) 7. HydrALAZINE 25 mg PO TID RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 8. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. amLODIPine 10 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Calcitriol 0.25 mcg PO 3X/WEEK (___) 12. Losartan Potassium 100 mg PO QHS 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 16. Ranitidine 150 mg PO BID 17. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right sided lung opacities with lymphadenopathy Chest pain, stable coronary artery disease GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with cough, shortness of breath// Pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior comparisons, most recent chest radiograph from ___ chest radiographs ___, and thirty-first. FINDINGS: Both the bulk of the right hilum and multiple nodular lesions in the right lung have increased since ___. Chest radiographs read in conjunction with subsequent chest CTA. Findings are pose Ling. The CT findings suggest malignancy, but the rapid progression would be very unusual IMPRESSION: Increased in conspicuity of the patchy opacities in the lung bases, right greater than left, which may reflect sequela of recurrent aspiration and possible underlying pneumonia. Combination of peripheral unilateral lung nodules and central adenopathy progressing over 2 weeks could be unusual infection or rapidly progressive malignancy such as lymphoma. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with chest pain radiating to back, tender thoracic spine// eval for aortic dissection, thoracic spine injury TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 12.6 mGy (Body) DLP = 423.1 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 3.3 mGy-cm. Total DLP (Body) = 428 mGy-cm. COMPARISON: Prior PET-CT from ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There is no axillary or supraclavicular lymphadenopathy. There are multiple, calcified, enlarged mediastinal lymph nodes, measuring up to 1.7 cm in the subcarinal station (series 301; image 106). There is no left hilar lymphadenopathy. Soft tissue density nodules are seen in the right hilum, which surround, but did not appear to invade the right hilar pulmonary vasculature (series 601; image 28, series 301; image 98). PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There is moderate background centrilobular emphysema, most notable at the bilateral lung apices. There is lingular and left basilar atelectasis without left lung focal consolidation. There are multiple, spicular, nodules and masses throughout the right middle and lower lobes, in a perilymphatic distribution. These show minimal surrounding ground-glass with air bronchograms in multiple areas. There are also a few areas of airway obliteration beyond the subsegmental level. Largest mass is seen in the medial right lung base measuring 4.1 x 2.2 x 1.6 cm (series 601; image 36, series 301; image 160). Neoplastic etiology is favored for these findings, much less likely infectious. Recommend tissue diagnosis for further evaluation. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. There is a small hiatal hernia. There is nonspecific thickening of the bilateral adrenal glands. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Multiple, spiculated, nodules and masses throughout the mid right middle and lower lobes, in a perilymphatic distribution, show minimal surrounding ground-glass with air bronchograms in multiple areas. There are few areas of airway obliteration beyond the subsegmental level. Largest mass is seen in the medial right lung base, measuring 4.1 x 2.2 x 1.6 cm. Neoplastic etiology is favored for these findings, much less likely infectious. Recommend tissue diagnosis for further evaluation. 3. Large right hilar soft tissue adenopathy, likely neoplastic in etiology. This area could also be considered for tissue diagnosis. 4. Multiple additional calcified mediastinal lymph nodes and calcified granulomas throughout the lungs, likely sequela of prior granulomatous disease. RECOMMENDATION(S): Recommend tissue diagnosis of likely neoplastic process in the right lung. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Other chest pain, Dyspnea, unspecified, Chronic kidney disease, unspecified temperature: 98.5 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 143.0 dbp: 43.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You were admitted to ___ with chest pain and trouble breathing. You had a stress test which showed that you have some blockages in the blood vessels in your heart, but they are similar to the ones you've had before. You were started on more medications to prevent chest pain from the blockages. You also were seen by the lung doctors for ___ that were found in your lungs. You will see them in the pulmonology clinic to decide if you need a biopsy of these lesions. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / Allopurinol Attending: ___. Chief Complaint: Chest pain, acute renal failure, dyspepsia, cramps Major Surgical or Invasive Procedure: Upper GI endoscopy, exercise stress test, Echocardiogram. History of Present Illness: ___ with pmh significant for morbid obesity, OSA, HTN, CAD s/p MI with stenting, gout, who presented to his PCP office for follow evaluation of his serum chemistries which showed worsening renal failure. He went into his PCP's office today for laboratory evaluation. He was referred to the emergency department secondary to the patients elevated creatinine. Patient was recently admitted for hyperkalemia and at that time his lisinopril was held. Upon review of systems, the patient endorses 8 lb weigh loss from his lasix, nausea, dyspepsia, dysphagia for solids, diffuse muscle cramps lasting for a few seconds, right knee pain and back pain. He notes that he has been constipated recently. He denies any chest pain or shortness of breath. Patient denies decreased exercise tolerance. The patient denies PND, orthopnea, ___ swelling. He notes that he has recently stopped his lisinopril 8 days ago. He notes that he has been using nsaid's for pain and he takes no more than 4 in a day. Past Medical History: - Obesity - DM 2 - Obstructive sleep apnea - Status post corneal transplant ___ - Obesity - High cholesterol - CAD - h/o MI - Gout - Chronic kidney disease - Dermatitis - HTN Social History: ___ Family History: Mother passed away from renal failure, family history of CAD, pancreatic cancer, atherosclerosis Physical Exam: Vital signs: 98.6, 146/75, HR 80, 95% RA, ___ 160. Gen: NAD, Obese, conversant, missing left eye Eyes: EOML, PERRL Neck: no LAD, no JVD Cardiovascular: regular rate, nl s1 s2. No murmurs, rubs or gallops. Extremities: no c/c/e Respiratory: CTA ___ GI: Soft, obese, rotund, nt/nd, no rebound or guarding. Bowel sounds+. Neuro: AA0x3, CN ___ intact, motor ___ ___. Pertinent Results: Studies) Echocardiogram: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. 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. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Renal Ultrasound: The right kidney measures 12.8 cm and the left kidney measures 12.1 cm. There is no hydronephrosis. No stone or cyst or solid mass is seen in either kidney. The pre-void bladder is unremarkable but is only minimally distended. Incidentally noted on limited images of the right upper quadrant the liver is diffusely echogenic consistent with fatty infiltration. Exercise Stress Test: XERCISE RESULTS RESTING DATA EKG: SINUS, IVCD HEART RATE: 64BLOOD PRESSURE: 144/74 PROTOCOL GERVINO - TREADMILL STAGETIMESPEEDELEVATIONHEARTBLOODRPP (MIN)(MPH)(%)RATEPRESSURE ___ ___ ___ TOTAL EXERCISE TIME: 10% MAX HRT RATE ACHIEVED: 90 SYMPTOMS:NONE INTERPRETATION: This ___ yo man with 3V CAD s/p MI ___ and CKD was referred to the lab from the floor for evaluation of chest discomfort. The patient exercised for 10 minutes of a Gervino protocol and was stopped for fatigue. The peak estimated MET capacity was 5.2, which represents a poor exercise tolerance for his age. There were no reports of chest, back, neck, or arm discomforts during the study. At peak exercise, there was 0.5-1 mm horizontal ST segment depression with biphasic T waves in lead V6 only, returning back to baseline by 10 minutes of recovery. Rhythm was sinus with rare isolated APBs. The heart rate response was blunted in the presence of beta blockade. The blood pressure response was appropriate during exercise and recovery. IMPRESSION: No anginal type symptoms or diagnostic EKG changes at a high cardiac demand and poor functional capacity. -------------- Upper GI Endoscopy: Esophagitis in the gastroesophageal junction (biopsy) Friability and erythema in the antrum and duodenal bulb compatible with gastritis (biopsy) and duodenitis. Otherwise normal EGD to third part of the duodenum -------- ___ 08:00AM BLOOD WBC-7.4 RBC-3.76* Hgb-11.1* Hct-32.3* MCV-86 MCH-29.6 MCHC-34.5 RDW-13.7 Plt ___ ___ 07:48AM BLOOD WBC-8.7 RBC-3.81* Hgb-11.4* Hct-31.9* MCV-84 MCH-29.9 MCHC-35.7* RDW-14.1 Plt ___ ___ 12:45PM BLOOD WBC-9.5 RBC-3.94* Hgb-12.2* Hct-32.8* MCV-83 MCH-30.9 MCHC-37.1* RDW-13.6 Plt ___ ___ 08:00AM BLOOD ALT-26 AST-22 AlkPhos-103 TotBili-0.4 ___ 08:09PM BLOOD cTropnT-<0.01 ___ 12:45PM BLOOD cTropnT-<0.01 ___ 08:00AM BLOOD Albumin-4.1 Calcium-9.2 Phos-3.1 Mg-1.9 ___ 10:03AM URINE Hours-RANDOM UreaN-1221 Creat-181 Na-37 K-47 Cl-28 TotProt-13 Phos-84.1 Uric Ac-38.0 Prot/Cr-0.1 ___ 10:03AM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:42PM URINE Color-Straw Appear-Clear Sp ___ ___ 10:03AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ##H Pylori: PENDING###### Medications on Admission: Norvasc 10mg qd Metoprolol xl 50mg qam Lipitor 20mg Euloric 40mg Byetta 10mg Iron 325mg once a day MVI Metformin 1g'' ASA 81' Lasix po 20mg'' Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) injection Subcutaneous twice a day: Before meals . 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Esophagitis 2. Gastritis 3. Acute kidney injury secondary to dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Patient with intermittent chest pain. COMPARISONS: None available. FINDINGS: Frontal and lateral views of the chest demonstrate normal lung volumes. There is no pleural effusion, focal consolidation, or pneumothorax. Hilar and mediastinal silhouettes are unremarkable. Heart size is normal. There is no pulmonary edema. Partially imaged upper abdomen is unremarkable. An old left anterolateral fracture without displacement is noted along the eighth rib. IMPRESSION: No evidence of acute cardiopulmonary process. Radiology Report INDICATION: ___ man with morbid obesity, diabetes, acute on chronic renal failure. COMPARISON: Renal ultrasound, ___. FINDINGS: The right kidney measures 12.8 cm and the left kidney measures 12.1 cm. There is no hydronephrosis. No stone or cyst or solid mass is seen in either kidney. The pre-void bladder is unremarkable but is only minimally distended. Incidentally noted on limited images of the right upper quadrant the liver is diffusely echogenic consistent with fatty infiltration. IMPRESSION: 1. No hydronephrosis. 2. The liver is incidentally noted to be diffusely echogenic consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: NAUSEA/MALIASE/WEAKNESS Diagnosed with CHEST PAIN NOS, MYALGIA AND MYOSITIS NOS, NAUSEA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.1 heartrate: 66.0 resprate: 16.0 o2sat: 100.0 sbp: 120.0 dbp: 99.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, You were admitted for workup of your atypical chest pain. During your visit, you were consulted by nephrology and your creatinine (which is a surrogate marker for your kidney function improved). The renal doctors feel ___ your kidneys have improved because you were slightly dehydrated. You have been experiencing a lot of heartburn and upset stomach lately. For this reason, we performed an upper GI endoscopy. This showed gastritis or irritation of your stomach. The GI doctors also performed a biopsy. For this reason you should follow up with them. They will mail you the results of the biopsy in ___ weeks. If you do not hear from them within 3 weeks, please call the office of Dr. ___ to enquire about the biopsy results. We also wanted to make sure that your pain was not caused by your heart. Your exercise stress test was normal. In addition, your cardiac enzymes were normal. Also, we evaluated your heart with an echocardiogram. It showed that your heart was somewhat enlarged. It also showed that your heart was pumping bloody normally without any valve or motion abnormalities. For this reason, we can safely say that you have not recently had a heart attack. However, you should try to maintain a healthy diet, regular exercise, and close follow up with your physicians. Please resume your normal home medications. We made the following changes to your medications. 1. START: Please take lasix 20mg once a day 2. START: Please take omeprazole 40mg once a day 3. STOP: Indocin. If you experience any of the danger symptoms listed below please call Dr. ___ consider coming in to the emergency department.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celebrex Attending: ___. Chief Complaint: right flank pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ woman with a history of arthritis, hypertension, and diabetes mellitus, seronegative RA - p/w right flank pain. Pt states that flank pain started 1 week ago, gradual onset, she went to ___ clinic and given cipro for UTI. UA at that time showed trace leuks, Since then the pain has progressively worsened now ___ in right flank non-radiating, sharp. No dysuria, hematuria. No bowel changes. Denies f/c/cp/sob/abd pain. Pt notably went to clinic because of the flank pain which started somewhat acutely and had simultaneous oiliguria but more frequent urination. Never had hematuria or dysuria and never had these symptoms in the past. Notes very different from rheumatoid arthritis flares int he past involving knees and sometimes her elbows. Has never involved her hip. Furthermore, pt notes no changes in activity or exercise, no recent travel, no changes in medications. Pt has never had subjective fevers at home and is unclear why she is having this severe sharp pain in her flank radiating down to her buttocks and upper thigh. She has not had midline back pain either upper or lower. She is still able to walk with the pain although it is uncomfortable and notes that she needs assistance sometimes given the pain but otherwise is fully functional at home with ADLs. Pt notes that with effort, she is able to lift herself from a supine position to sitting and from sitting to standing but it is not easy for her given the pain. Pt has had a brief history ___ Cr 1.4 (baseline 0.6-1.0) and this was concerning for possible renal injury from celecoxib which she had taken for her RA in the past. Now she is on pred 5 and methotrexate injections. She has not seen her rheumatologist for some time and notes that given lack of flares and controlled pain, she has not required to see her rheumatologist. When she saw her nephrologist for her ___, a renal ultrasound at that time was done with no evidence of hydrnpehoriss or obstruction. Repeat Cr shortly after celecoxib was discontinue and pt encouraged to increase po intake, Cr trended down to 1.0-1.1 In the ED, initial VS were 97.9 HR95 BP 130/112 RR 16 100% RA. Labs notable for hyponatremia Na 127, UA is contaminated but WBC 8 no bacteria. Pt noted severe pain and was given Tylenol. Given concern of a stone in setting of no fever or leukocytosis, pt underwent a CTU which did not show any abnormalities. A urine culture was sent but additional labs including CRP, ESR, CK were not done. Pt noted to have persistnet oliguria although increased frequency of urination. On the floors, pt was stable and able to walk around although with difficulty. She is surrounded by her family who is able to translate for her and notes that they are concerned about the uncontrolled pain also are unclear that this is entirely due to a urinary tract infection. Pt is not short of breath, no chest pain, no other joint pain, no nausea, vomiting. No GI symptoms overall and does not endrose decreased po intake despite her low sodium and confirms that her diet has remained consistent. Past Medical History: diabetes mellitus rheuatmoid arthritis (Seronegative) acute kidney injury hypertension vertigo Social History: ___ Family History: No contributory family history of rheumatologic or renal disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.8 88 141/88 16 99% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: Right CVAT EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM Unchanged Pertinent Results: ADMISSION LABS ___ 08:45AM BLOOD WBC-8.5 RBC-3.51* Hgb-10.9* Hct-33.2* MCV-95 MCH-31.1 MCHC-32.8 RDW-13.6 RDWSD-46.3 Plt ___ ___ 08:45AM BLOOD Glucose-166* UreaN-13 Creat-1.1 Na-129* K-4.5 Cl-89* HCO3-21* AnGap-24* ___ 11:15AM BLOOD ALT-24 AST-32 AlkPhos-70 TotBili-0.3 ___ 11:15AM BLOOD Lipase-75* DISCHARGE LABS ___ 05:45AM BLOOD WBC-6.6 RBC-3.07* Hgb-9.6* Hct-28.7* MCV-94 MCH-31.3 MCHC-33.4 RDW-14.1 RDWSD-47.5* Plt ___ ___ 05:45AM BLOOD Glucose-152* UreaN-15 Creat-1.0 Na-132* K-4.3 Cl-96 HCO3-25 AnGap-15 ___ 05:45AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.7 IMAGING CXR: ___ IMPRESSION: No acute cardiopulmonary process. CTU: ___ IMPRESSION: 1. Cholelithiasis without gallbladder wall thickening or pericholecystic fluid. Correlate for clinical signs of cholecystitis. 2. Hepatic steatosis. 3. No acute bowel pathology. 4. Diverticulosis without evidence of active inflammation. 5. No evidence of nephrolithiasis or renal pathology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Lisinopril 20 mg PO DAILY 3. LOPERamide 2 mg PO DAILY:PRN GI upset 4. Meclizine 25 mg PO Q6H:PRN dizziness 5. ClonazePAM 0.25 mg PO BID:PRN vertigo 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Vitamin E 400 UNIT PO DAILY 13. pilocarpine HCl 5 mg oral TID 14. cevimeline 30 mg oral BID 15. Magnesium Oxide 400 mg PO ONCE 16. Methotrexate 25 mg SC 1X/WEEK (___) rheuamtoid arthritis 17. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation One bowel movement daily RX *docusate sodium 100 mg 1 capsule(s) by mouth up to two times daily Disp #*30 Capsule Refills:*0 2. TraMADol 25 mg PO BID:PRN Pain - Moderate RX *tramadol 50 mg ___ tablet(s) by mouth up to two times daily Disp #*10 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. cevimeline 30 mg oral BID 5. ClonazePAM 0.25 mg PO BID:PRN vertigo 6. Ferrous Sulfate 325 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Lisinopril 20 mg PO DAILY 9. LOPERamide 2 mg PO DAILY:PRN GI upset 10. Magnesium Oxide 400 mg PO ONCE Duration: 1 Dose 11. Meclizine 25 mg PO Q6H:PRN dizziness 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Methotrexate 25 mg SC 1X/WEEK (___) rheuamtoid arthritis 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. pilocarpine HCl 5 mg oral TID 17. PredniSONE 5 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY 19. Vitamin E 400 UNIT PO DAILY 20.Outpatient Lab Work ICD 276.1. hyponatermia Please check Chem 10 on ___. Attn: ___. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Flank pain Hyponatremia Seronegative arthritis Hypertension Diabetes Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with question of pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: ___. FINDINGS: The lungs are well inflated and clear. Heart size and mediastinal contours are normal. No pleural effusion or pneumothorax. Osseous structures are intact. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ with left flank pain // eval for kidney stone/appendcitiis TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in prone position. The contrast scan was performed with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 922 mGy-cm. COMPARISON: Renal ultrasound from ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates borderline low attenuation throughout, compatible with hepatic steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis. There is no perinephric abnormality. There is no evidence of focal renal lesions. There is no evidence of urothelial lesions. The distal ureters and bladder are unremarkable. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is diverticulosis of the sigmoid colon without evidence of active inflammation. The appendix is not visualized. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no acute fracture. There is moderate facet arthropathy throughout the lumbar spine. Symmetric sclerosis about the sacroiliac joints bilaterally is likely degenerative. Widening of the left S1-S2 neural foramen suggests underlying Tarlov cyst. No concerning osseous lesion. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Cholelithiasis without gallbladder wall thickening or pericholecystic fluid. Correlate for clinical signs of cholecystitis. 2. Hepatic steatosis. 3. No acute bowel pathology. 4. Diverticulosis without evidence of active inflammation. 5. No evidence of nephrolithiasis or renal pathology. Gender: F Race: HISPANIC/LATINO - GUATEMALAN Arrive by WALK IN Chief complaint: R Flank pain, R Leg pain Diagnosed with Hypo-osmolality and hyponatremia temperature: 97.9 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 130.0 dbp: 112.0 level of pain: 5 level of acuity: 3.0

Ms. ___, You were admitted for your hip and flank pain. You were found not to have a urinary tract infection. For your hip pain, you were evaluated by physical therapy. Thank you for allowing us to participate in your care ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Blurred vision/LUE paresthesias Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female transferred from ___ with right parietal occipital edema on head CT concerning for an underlying lesion. She states that she experienced a headache, transient blurred vision and numbness, tingling weakness of the right upper extremity yesterday and occasionally into the left upper extremity over the past two days. These symptoms came on quickly and self resolved both days after several hours. She became concerned and presented to ___ today at which time she underwent a CT of the head which was concerning for a brain lesion. She was transferred to ___ for further evaluation. At the time of the physical examination, she denies headache, dizziness, blurred vision, diplopia, chest pain, shortness of breath, nausea, vomiting, fever, chills or parasthesias and weakness of the extremities bilaterally. She endorses a cough which has been present for several days. Past Medical History: Hypertension s/p left shoulder surgery Social History: ___ Family History: Denies family history of brain lesions or cancer. Physical Exam: T: 99.5 BP: 108/76 HR: 66 RR: 18 O2Sats 95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-3mm bilaterally. EOMs intact throughout. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift. Sensation: Intact to light touch bilaterally throughout all four extremities. Handedness: Right ON DISCHARGE: Non-focal Pertinent Results: Pertinent results available in OMR Medications on Admission: Lisinopril 10mg-HCTZ 12.5mg PO daily ASA 81mg PO daily, last dose ___ Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Do not exceed 4GM acetaminophen in 24 hours 2. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth Every evening Disp #*30 Tablet Refills:*0 3. Enoxaparin Sodium 0 mg SC DAILY Continue taking until INR for Coumadin is therapeutic (___) for 24 hours RX *enoxaparin 80 mg/0.8 mL 0.8 mL SC Daily Disp #*5 Syringe Refills:*0 4. Nicotine Patch 14 mg TD DAILY RX *nicotine [Nicoderm CQ] 14 mg/24 hour Daily Disp #*14 Patch Refills:*0 5. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lisinopril 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ischemic infarction Occlusive thrombus in the left brachial artery Discharge Condition: * Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR spectroscopy INDICATION: ___ year old woman with nonenhancing right occipital lesion// eval for tumor vs stroke work up. please include DWI sequences as well if able. TECHNIQUE: Axial FLAIR and diffusion images of the brain were performed. Subsequently, MR spectroscopy images were obtained on a 3 tesla magnet with 144 TE with voxel overlying the occipital lobes with acquisition of multi voxel spectroscopy. In addition, single voxel spectroscopy was performed with voxel placed over the right occipital lobe. Findings are based on interpretation of all images. COMPARISON: MR ___ FINDINGS: MR ___: The provided axial FLAIR and diffusion images demonstrate interval evolution of slow diffusion within the right occipital lobe with associated FLAIR hyperintensity. The ventricles are normal in size without mass effect or midline shift. There are a few nonspecific subcortical FLAIR hyperintensities, likely a sequela of chronic small vessel ischemic disease. MR spectroscopy: Single voxel spectroscopy with voxel placed over the region of signal abnormality in the right occipital lobe demonstrates elevated lactate peak at 1.3 ppm (7:1). Multi voxel spectroscopy demonstrates nonspecific spectroscopy pattern with majority of the proximal small in the region of interest demonstrating no significant elevation in choline to NAA ratio. IMPRESSION: Evolution of signal abnormality in the right occipital lobe with corresponding single voxel spectroscopy demonstrating lactate peak. Constellation of findings are most suggestive of evolving infarction in the distribution of the right posterior cerebral artery rather than an underlying malignancy. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old woman with new suspected right PCA territory infarct// eval of head/neck vessels for stroke work up TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. 2) Spiral Acquisition 4.5 s, 35.5 cm; CTDIvol = 11.4 mGy (Body) DLP = 402.8 mGy-cm. 3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP = 8.9 mGy-cm. Total DLP (Body) = 412 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: MR head with and without ___, outside CT head ___, CT chest ___ FINDINGS: CT HEAD WITHOUT CONTRAST: There is redemonstration of focal hypodensity within the right parieto-occipital lobe corresponding to findings on recent MRI and similar to prior CT head from ___. There is prominence of the ventricles and sulci related to diffuse parenchymal volume loss. There is no evidence of mass effect or midline shift. There is no evidence of intracranial hemorrhage. There is mild mucosal thickening of the bilateral ethmoid air cells. The remaining paranasal sinuses appear clear. The bilateral mastoid air cells appear clear. CTA HEAD: The bilateral anterior middle cerebral arteries appear patent. The bilateral posterior cerebral arteries appear patent. The basilar artery and bilateral vertebral arteries appear patent. There is a dominant right vertebral artery. The bilateral intracranial internal carotid arteries appear patent. There is no evidence of dissection. The dural venous sinuses appear patent. CTA NECK: There are mild vascular calcifications of the aortic arch. There is a linear filling defect along the lateral margin of the aortic arch (03:27), difficult to visualize on the coronal sagittal reconstruction images, and not seen on the recent CT chest ___, likely artifactual. There is noncalcified plaque causing mild luminal narrowing of the proximal left subclavian artery (3:65). There is a right dominant vertebral artery. The bilateral vertebral arteries appear patent. The bilateral common carotid arteries and internal carotid arteries appear patent without internal carotid artery stenosis by NASCET criteria. OTHER: The thyroid gland appears unremarkable. There is moderate centrilobular emphysema. There are multilevel degenerative changes of the cervical spine. There is no evidence of lymphadenopathy per size criteria. IMPRESSION: 1. Stable right parieto-occipital lobe hypodensity, likely corresponding to evolving subacute infarction. No evidence of intracranial hemorrhage. 2. Patency of the major intracranial vasculature without stenosis, occlusion, or aneurysm. 3. Patency of the bilateral carotid arteries and vertebral arteries, without internal carotid artery stenosis by NASCET criteria. 4. Linear defect of the lateral aspect of the left carotid bulb due to a carotid web, an incidental finding. 5. Probable artifact creating linear filling defect within the lateral margin of the aortic arch, not seen on the recent CT chest ___. 6. Noncalcified plaque resulting in mild luminal narrowing of the proximal left subclavian artery. 7. Moderate centrilobular emphysema. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with LUE pain x3 days, please evaluate for DVT.// Evaluate for DVT in LUE, patient is complaining of constant general pain in the bicep/tricep area TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. There is occlusive thrombus in the left brachial artery. IMPRESSION: -Occlusive thrombus in the left brachial artery. -No evidence of deep vein thrombosis in the left upper extremity. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 2:20 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA torso INDICATION: ___ year old woman with L arm pain found to have occlusive thrombus in the L brachial artery on Ultrasound// Include L arm to evaluate anatomy. Evaluate for source of thrombus causing occlusive thrombus in the L brachial artery such as aortic plaque. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 815 mGy-cm. COMPARISON: CT chest ___. CT abdomen and pelvis ___. Left upper extremity Doppler ultrasound ___ FINDINGS: VASCULAR: There is moderate atherosclerotic disease of the abdominal aorta and bilateral common iliac arteries. There is mild atherosclerotic disease in the takeoff of the left subclavian artery, left common carotid artery, and right brachiocephalic trunk. There is no evidence of occlusion of the thoracic aorta, abdominal aorta and its major branches. Limited evaluation of the left arm, but there is an abrupt cutoff in the left brachial artery (series 3: 74-75) with reconstitution of flow distally likely corresponding to focal thrombus seen on left upper extremity ultrasound ___ CHEST: HEART AND VASCULATURE: Although not optimized for evaluation of the pulmonary vasculature, there is no evidence of a filling defect of the pulmonary vessels to the lobar level. Heart is normal in size. There is no pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There is mild biapical scarring. There is severe centrilobular emphysema. Punctate micro nodules in the right upper and left lower lobes (series 3:28, 47) are again seen, minimally changed in appearance from CT chest ___. Calcified granulomas in the right upper lobe (series 3:57) and left lower lobe (series 3: 83) are again noted. There is no consolidation. Airways are patent to the subsegmental levels. BASE OF NECK: The thyroid is unremarkable ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is a segment IV hypoattenuated focus measuring 1.5 cm(series 3:96) and a subcentimeter hypoattenuated focus in the left lobe (series 3:99) which is too small to characterize but likely represents a biliary hamartoma versus a simple cyst. There is no intra or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. A splenule is noted. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is a wedge shaped area of hypoattenuation in the upper pole of the right kidney (series 3:127) which is new from ___. Heterogeneity of the left renal parenchyma is minimally changed from ___. There is no definite evidence of invasion into the renal pelvis. There is no hydronephrosis or perinephric abnormality. GASTROINTESTINAL: Oral contrast is seen to the level of the rectum. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no free intraperitoneal fluid or free air. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild to moderate atherosclerotic disease of the takeoff of the left subclavian artery, left common carotid artery, and right brachiocephalic trunk. There is moderate atherosclerotic disease of the abdominal aorta. There is no evidence of occlusion, thrombus, or a large plaque of the thoracoabdominal aorta and its major branches. 2. Wedge-shaped area of hypoattenuation in the upper pole of the right kidney (series 3:127) which is new as compared to CT abdomen pelvis ___. This could represent infarction or focal pyelonephritis. 3. Heterogeneous enhancement of the left kidney is grossly unchanged from CT abdomen and pelvis ___ and most suggestive of pyelonephritis. Follow-up CT is recommended following treatment to ensure improvement or resolution. 4. Limited evaluation of the arm, but there is an abrupt cutoff in the left brachial artery (series 3: 74-75) with reconstitution of flow distally likely corresponding to focal thrombus seen on left upper extremity ultrasound ___. NOTIFICATION: The findings were discussed by Dr. ___ with NP ___ ___ on the telephone on ___ at 8:56 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with blurry vision, numbness, headache, right upper extremity weakness with recent CT demonstrating right parieto-occipital lobe edema. Evaluate for underlying mass. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 5 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head ___ FINDINGS: There is slow diffusion within the right parieto-occipital lobe with associated FLAIR hyperintensity. There is no enhancing mass or abnormal enhancement. There is no evidence of intracranial hemorrhage. There are no other areas of diffusion abnormality. The ventricles are normal in size without mass effect or midline shift. The dural venous sinuses appear patent on the postcontrast images. There is mild mucosal thickening of the bilateral ethmoid air cells. The remaining paranasal sinuses appear clear. There is minimal fluid opacification of the bilateral mastoid air cells. The orbits appear unremarkable. The visualized soft tissues appear unremarkable. IMPRESSION: 1. Acute to early subacute infarction in the distribution of the right posterior cerebral artery. 2. No evidence of intracranial hemorrhage. No evidence of enhancing mass or abnormal enhancement. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:39 am, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT abdomen pelvis with contrast INDICATION: ___ year old woman with new brain mass. TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 1.9 s, 30.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 172.2 mGy-cm. 2) Spiral Acquisition 4.3 s, 68.7 cm; CTDIvol = 7.4 mGy (Body) DLP = 510.0 mGy-cm. 3) Spiral Acquisition 1.8 s, 29.2 cm; CTDIvol = 5.6 mGy (Body) DLP = 164.0 mGy-cm. 4) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 13.9 mGy (Body) DLP = 7.0 mGy-cm. Total DLP (Body) = 853 mGy-cm. COMPARISON: MR examination of the head from ___. Reference CT examination from ___. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There are 2 hepatic hypodensities with the largest in segment IV measuring 1.3 cm, likely compatible with hepatic cysts versus biliary hamartomas. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is heterogeneity of the left renal parenchyma with multiple foci of cortical hypoenhancement and mild adjacent fatty stranding (series 3, image 64, 66). No dominant lesion is seen. No definite invasion into the renal pelvis is seen. There is no hydronephrosis. The right kidney is of normal size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. There is an accessory left renal artery (series 3, image 62). BONES: Degenerative changes are seen in the lumbar spine most notable for mild retrolisthesis L2 on L3. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multiple heterogeneous foci of hypoenhancement throughout the left renal cortex with mild stranding, most suggestive of pyelonephritis. Given the absence of a definite malignancy on recent head MR and presence of a markedly elevated WBC, infection remains the likely cause. An infiltrative neoplasm can be considered, but is less likely in this clinical setting. Follow-up CT is recommended following initial treatment to ensure improvement/resolution. 2. No abdominopelvic lymphadenopathy. Radiology Report EXAMINATION: CT CHEST WITH CONTRAST INDICATION: ___ woman with "new brain mass" . Assess for primary malignancy. Please note, overnight brain MRI revealed acute to early subacute infarction rather than the presence of an intracranial malignancy. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: None FINDINGS: HEART AND VASCULATURE: Mild cardiomegaly. No pericardial effusion. The thoracic aorta is normal in caliber. Mild aortic and great vessel origin atherosclerosis. Minimal coronary atherosclerosis. The main pulmonary artery is normal in caliber. No central pulmonary embolus. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Mild biapical scarring. Severe centrilobular emphysema. Few punctate micro nodules, right upper and lower lobes (series 302, images 59, 108, 168). Calcified granulomas in the right upper and left lower lobes (series 4, images 116 and 169). The airways are patent to the subsegmental level. Mild diffuse bronchial wall thickening suggests chronic airway inflammation. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Heterogeneous left renal parenchyma with foci of hypoenhancement and adjacent fat stranding. Please refer to separate report for same-day CT abdomen/pelvis for description of the abdominal findings. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Left pyelonephritis. 2. No evidence of intrathoracic malignancy. 3. Severe centrilobular emphysema. 4. Chronic small airway inflammation. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:41 am, less than 15 minutes after discovery of the findings. Gender: F Race: WHITE - BRAZILIAN Arrive by AMBULANCE Chief complaint: Headache, R Hand numbness, Transfer Diagnosed with Other specified disorders of brain temperature: 99.5 heartrate: 66.0 resprate: 18.0 o2sat: 95.0 sbp: 108.0 dbp: 76.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were hospitalized due to symptoms of headache, blurry vision, and right upper extremity numbness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: 1. Smoking 2. Hypertension Please start taking Atorvastatin 40mg every evening. Please also start taking Lovenox 80mg subcutaneously every day while also taking Warfarin 5mg daily for blood thinner therapy. You may stop taking Lovenox when INR (level used to check for efficacy of Warfarin) is between 2 and 3 for 24 hours. Due to starting to take Coumadin, please stop taking Aspirin at this time. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. Please call ___ to arrange to have a repeat ultrasound of your L arm 1 month following discharge to determine if previously seen blood clot has improved. Please call ___ to arrange for follow up in ___ to discuss findings of this ultrasound. Please see your primary care doctor, ___, on ___ at 3pm at ___ follow up and to have your INR checked while you are being initiated on Coumadin. Please obtain labwork provided in form as outpatient at Lab Services here at ___. Please follow up in ___ in ___ (phone number: ___ in near future to follow up these labs to evaluate for propensity to form blood clots. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Please make sure you follow-up with the Cardiology Department to receive Kings of Hearts. You will also require a Cardiology procedure called "TEE" in which will be scheduled for you and the department will reach out to you. Sincerely, Your ___ Neurology/Neurosurgery Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspena on exertion Major Surgical or Invasive Procedure: Right and left heart cath ___ TEE without cardioversion ___ History of Present Illness: ___ referred to ED by PCP for volume overload and HTN management. Was seen by PCP last week as new patient (first time seeing an MD in ___ years) with dyspnea on exertion, progressive, over several months. Found to be in Afib with rapid ventricular response and signs of CHF. Started on furosemide, aspirin, metoprolol. Returned to ___ on day of admission for further med titration and to begin anticoagulant. Pt reported to PCP that new medications made his abdomninal distention felt worse and he stopped the meds as so ___. He believes he lost a few pounds, weighing on his scale this am 175.9. He did not have lightheadedness or dizziness. He feels stable to worse re: dyspnea, with more difficulty wearing his 15 lb equipment/gun belt at work (works for ___ and ___). The patient is normally an "avid jogger," running regularly and completing one marathon per year. He now struggles to climb stairs. Labwork from first PCP visit is significant for mild elev transaminase & LDH, and A1c in diabetic range (6.8). Also mild normocytic anemia. Echocardiogram report from ___ reported this am shows: IMPRESSION: EF ___ Marked symmetric left ventricular hypertrophy with normal cavity size and severe biventricular hypokinesis in a pattern most suggestive of a non-ischemic cardiomyopathy. Moderate pulmonary artery hypertension. Mild-moderate mitral regurgitation. Mild-moderate tricuspid regurgitation. Prominent bilateral pleural effusions. Mildly dilated ascending aorta. Increased PCWP. In the absence of a history of prominent systolic hypertension, an infiltrative process (e.g., amyloid) should be considered. In the ED, initial vitals were T98.1 HR115 BP145/77 RR18 100%RA. Labs notable for proBNP of 6985, K of 5.6 (moderately hemolyzed), Cr 1.3. Chest xray showed cardiomegaly, small bilateral pleural effusions, mild pulmonary edema. Given aspirin 325mg, Diltiazem 70mg (60 PO, 10 IV), furosemide 20mg IV x1. Admitted for further management. Pt endorses filling two urinals since getting lasix, UO not recorded. Denies fever, chills, cp, sob at rest, abd pain, n/v/d, dysuria. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: DOE Carpal Tunnel Syndrome Partial thumb amputation Social History: ___ Family History: Father had diabetes. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. One younger sister, estranged, died of unknown causes. 4 other siblings are healthy. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T98.6, BP123/83, HR93, RR16, O296RA General: well-appearing man lying in bed in NAD HEENT: NCAT, MMM, EOMI Neck: JVD to mandible at 60 degrees CV: irregularly irregular, no m/r/g appreciated, normal S1S2 Lungs: mild bibasilar crackles present, no wheezing appreciated Abdomen: soft, NT, ND, +BS Extr: no c/c/e, 2+ DP pulses bilaterally, missing portion of left thumb, 2+ pitting edema in ___ Neuro: A&Ox3, strength grossly intact DISCHARGE PHYSICAL EXAM: Vitals: 98.4, 93 (80-99), 114/83 (97-137/57-93), 15, 99%RA I/O: 8h: ___ 24h: 1340/5250 Wt: 66.7 kg <- 70.5 <- 70.9 <- 71.1 <-72.4 <- 73.1 <- 75.7 <- 76.4 <- 77.1 General: well-appearing man lying in bed in NAD HEENT: NCAT, MMM, EOMI Neck: JVD to mandible at 60 degrees, + Kussmaul sign CV: irregularly irregular, no m/r/g appreciated, S3 present Lungs: fine bibasilar crackles present, no wheezing appreciated Abdomen: soft, NT, ND, +BS Extr: no c/c/e, 2+ DP pulses bilaterally, missing portion of left thumb, trace pitting edema in ___ Neuro: A&Ox3, strength grossly intact Pertinent Results: ADMISSION LABS: ___ 10:15AM WBC-4.8 RBC-4.75 HGB-14.1 HCT-44.8 MCV-94 MCH-29.7 MCHC-31.5* RDW-15.7* RDWSD-54.2* ___ 10:15AM GLUCOSE-92 UREA N-21* CREAT-1.3* SODIUM-140 POTASSIUM-5.6* CHLORIDE-104 TOTAL CO2-21* ANION GAP-21* ___ 10:15AM CALCIUM-9.7 PHOSPHATE-4.3 MAGNESIUM-2.0 ___ 10:15AM cTropnT-0.05* ___ 10:15AM CK-MB-7 proBNP-6985* ___ 10:15AM CK(CPK)-147 DISCHARGE LABS: ___ 05:30AM BLOOD WBC-4.2 RBC-5.00 Hgb-14.7 Hct-45.7 MCV-91 MCH-29.4 MCHC-32.2 RDW-15.0 RDWSD-50.3* Plt ___ ___ 05:30AM BLOOD Glucose-94 UreaN-25* Creat-1.0 Na-141 K-3.9 Cl-99 HCO3-30 AnGap-16 ___ 05:30AM BLOOD Calcium-9.4 Phos-5.0* Mg-1.8 ___ 05:30AM BLOOD ALT-33 AST-36 CK(CPK)-66 AlkPhos-245* TotBili-0.9 OTHER LABS: ___ 03:48AM BLOOD calTIBC-399 Ferritn-117 TRF-307 ___ 05:40AM BLOOD b2micro-2.3* ___ 03:25PM BLOOD IgG-1403 IgA-321 IgM-85 ___ 03:25PM BLOOD FreeKap-26.7* ___ Fr K/L-1.51 ___ 03:30PM BLOOD PEP-NO SPECIFI ___ 09:20PM URINE U-PEP-NO PROTEIN MICROBIOLOGY: none PATHOLOGY: Right ventricular endomyocardial biopsy ___: - AMYLOID HEART DISEASE. - The extensive amyloid deposits are highlighted by a Trichrome stain. IMAGING/STUDIES: L UE/neck u/s ___: No evidence of deep vein thrombosis in the left upper extremity. Left subclavian vein is widely patent. RHC/LHC cath ___: LAD 50% mid stenosis Circumflex has 70% stenosis, OM1 80% stenosis at level of a bifurcation RCA is dominant with 80% stenosis in proximal portion Elevated right and left heart filling pressures: RA mean 14, RV 56/18, PCW mean 32, PA: 56/28, LV 117/29, Cardiac index: 2.19, cardiac output 3.95 Moderate pulmonary artery systolic hypertension Biopsies taken, see pathology above Cardiac MRI ___: Impression: Mild concentric LVH with severely increased overall mass index, borderline increased end diastolic volume index, and severely depressed global left ventricular systolic function. Moderately depressed global right ventricular systolic function. The suboptimal myocardial nulling and diffuse late gadolinium enhancement of the left ventricle may be seen in amyloid cardiomyopathy. Mild mitral regurgitation. Adrenal nodule for which dedicated imaging could be considered. Extracardiac findings: Incidentally noted is a bovine arch. There are moderate bilateral pleural effusions, slightly larger on the right than the left. There is trace perihepatic ascites. There is a 9 mm T2 dark round lesion in the right adrenal gland (1702, 14), which is incompletely evaluated, though statistically a benign lesion such as an adenoma or myelolipoma. TEE report ___: IMPRESSION: Probable ___ thrombus. Moderate to severe ___ spontaneous echo contrast. Severely depressed left ventricular systolic function. Mild mitral regurgitation. Abdominal u/s ___: IMPRESSION: 1. Hyperdynamic waveforms noted in the hepatic veins in the main portal vein suggesting heart failure. 2. Unremarkable appearance of the liver and bile ducts. 3. Large pleural effusions are present. A scant trace of ascites is noted in the abdomen. TTE: ___: The left atrial volume index is severely increased. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size and severe global left ventricular hypokinesis (LVEF = ___. Systolic function of apical segments is relatively preserved. The estimated cardiac index is depressed (<2.0L/min/m2). Right ventricular chamber size is normal with severe global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. There are prominent bilateral pleural effusions. CXR ___: Cardiomegaly, small bilateral pleural effusions, mild pulmonary edema. ECG: In ER ___: a-fib, rate 129, low voltage Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Aspirin 325 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Enoxaparin Sodium 80 mg SC BID atrial fibrillation bridging to warfarin take twice a day until directed otherwise by ___ clinic RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*28 Syringe Refills:*0 5. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Warfarin 5 mg PO DAILY16 atrial fibrillation take this dose until directed otherwise by the ___ clinic RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Cardiac amyloidosis Atrial fibrillation Left atrial appendage thrombus Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with? chf // eval for sob COMPARISON: None FINDINGS: PA and lateral views of the chest provided. Cardiomegaly is moderate with hilar congestion and mild pulmonary edema. There are small bilateral pleural effusions noted. No pneumothorax. No definite signs of pneumonia though difficult to exclude a subtle lower lobe consolidation. The mediastinal contour is normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Cardiomegaly, small bilateral pleural effusions, mild pulmonary edema. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old man with decompensated systolic heart failure in the setting of ?infiltrative cardiomyopathy. // ?infiltrative process TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. There is scant trace of ascites in the abdomen. Large bilateral pleural effusions are noted. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The head, body and tail of the pancreas are within normal limits, without masses or pancreatic ductal dilatation. SPLEEN: Normal echogenicity, measuring 9.6 cm. A tiny granuloma measuring 4 mm is incidentally noted in the spleen. KIDNEYS: The right kidney measures 10.8 cm. The left kidney measures 10.4 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow. Undulating waveforms noted within the main portal vein. The hepatic veins are patent and demonstrate hyperdynamic waveforms. IMPRESSION: 1. Hyperdynamic waveforms noted in the hepatic veins a in the main portal vein suggesting heart failure. 2. Unremarkable appearance of the liver and bile ducts. 3. Large pleural effusions are present. A scant trace of ascites is noted in the abdomen. Radiology Report INDICATION: Decompensated heart failure in the setting of atrial fibrillation with RVR. Evaluate for infiltrative process. TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology. IMPRESSION: Please note that this report only contains extracardiac findings. Incidentally noted is a bovine arch. There are moderate bilateral pleural effusions, slightly larger on the right than the left. There is trace perihepatic ascites. There is a 9 mm T2 dark round lesion in the right adrenal gland (1702, 14), which is incompletely evaluated, though statistically a benign lesion such as an adenoma or myelolipoma. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. RECOMMENDATION(S): If indicated, the adrenal nodule could be further evaluated with dedicated imaging. Radiology Report EXAMINATION: US NECK, SOFT TISSUE INDICATION: ___ year old man with new sCHF likely ___ infiltrative cardiomyopathy, s/p cardiac catheterization today with myocardial biopsy, concern for possible L subclavian stenosis // ?L subclavian stenosis TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The left internal jugular and axillary veins are patent and compressible with transducer pressure. The left brachial, basilic, and cephalic veins are patent, compressible with transducer pressure and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Left subclavian vein is widely patent. RECOMMENDATION(S): If there is concern for arterial stenosis, a separate dedicated ultrasound could be obtained to evaluate the subclavian artery. NOTIFICATION: Findings and recommendation were telephoned to Dr. ___ ___ by ___ on ___ at 10:40am. Gender: M Race: BLACK/AFRICAN Arrive by WALK IN Chief complaint: Dyspnea on exertion Diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC temperature: 98.1 heartrate: 115.0 resprate: 18.0 o2sat: 100.0 sbp: 145.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for shortness of breath. We found that you had heart failure and an irregular condition called atrial fibrillation. The testing that we did made us concerned that you had a heart condition called amyloidosis. We did a biopsy that confirmed the diagnosis of amyloidosis. We have sent the tissue to a specialized lab to determine exactly what kind of amyloidosis it is, since that will determine treatment. We treated your heart failure symptoms with diuretics and you urinated out your extra fluid. We are discharging you home on your home furosemide. In terms of the atrial fibrillation, you could not undergo cardioversion since you had a blood clot in your heart. Instead, now we are treating the blood clot with a medication called Coumadin (warfarin). You need to follow-up with our ___ CLinic for management of your Coumadin dose. For now, you also need to inject yourself with Lovenox twice a day until the Coumadin levels are appropriate. Your cardiologist here, Dr. ___ like to see you in his clinic for further management of your heart failure and amyloidosis. We have made an appointment for you, information is below. Please weigh yourself every morning and record your weights, and bring them to the clinic. On behalf of your medical team, take care. -___ medical team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: ___ Right Craniotomy for evacuation of Subdural Hematoma ___ Right Craniotomy for re-evacuation of Subdural Hematoma History of Present Illness: ___ M s/p fall 2 days ago, found unresponsive. CTH with 1.2cm right frontoparietal aSDH, 9mm MLS. EtOH 303. Confused, intoxicated, but full strength. Past Medical History: ETOH abuse Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON DISCHARGE: A&Ox3. No drift. PERRL. FC, MAE ___. requires some assistance with ambulation through walker or assistance from another person as contact guard. Pertinent Results: CXR ___: No acute cardiopulmonary process CT C-Spine ___: Degenerate changes without evidence of acute fracture CT Head ___: 1. Slight increase in right subdural hematoma with stable 9 mm of midline shift. No sign of downward herniation. 2. Small amount of subarachnoid blood in the right sylvian fissure CT Torso ___: 1. No intra-abdominal or intrathoracic solid organ injury. 2. Minimally displaced fractures of the posterior left ___ and 12th ribs. 3. Fatty liver. 4. Mildly dilated right ureter, perhaps due to reflux, although non-specific in nature. 5. Cholelithiasis without cholecystitis CXR ___: The heart size, mediastinal and hilar contours are normal. Lungs and pleural surfaces are clear. The eleventh and twelfth ribs are only partially imaged on this radiograph, and known fractures in these regions are seen to better detail on recent CT of one day earlier. CT head ___ Post-op: 1. Slightly decreased right convexity subdural hematoma s/p craniotomy. Slightly decreased associated mass effect. 2. Nondisplaced right parietal bone fracture extending into the squamous temporal bone, without petrous involvement. CT Head ___: Increasing size of right frontoparietal subdural hematoma with increased mass effect resulting in increased subfalcine herniation and concern for downward transtentorial herniation. Chest X-Ray ___: ET tube is in standard position. Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. The appearance of the mediastinum is unchanged. CT Head ___: Interval placement of a right-sided drain status post evacuation of subdural contents with overall decreasing shift of the midline structures. Chest X-Ray ___: NG tube tip is out of view below the diaphragm, the side port is in the stomach. Cardiomediastinal contours are normal. ET tube is in standard position. The lungs are clear. Chext X-Ray ___: Endotracheal tube has been advanced approximately 1-1.5 cm and now terminates approximately 2.4 cm above the level of the carina. CT Head ___: Interval increase of the right subdural hematoma with more blood identified along the anterior and posterior convexity. There is increase in associated mass effect and compression of the ventricles. CT Head ___: No significant change in right subdural hematoma, mass effect or leftward shift of midline structures since ___. External drain in appropriate and stable position CT Head ___: No significant change in postoperative appearance of right subdural hematoma and degree of local mass effect and subfalcine herniation LENIS ___: No evidence of DVT in the right or left lower extremity CXR ___: Overall, there has been little change in the appearance of the chest since the recent study except for development of subtle patchy and linear opacities at the left lung base, which could be due to atelectasis, aspiration, or early pneumonia. Followup radiographs may be helpful in this regard. CT Head ___: Interval removal of right frontal approach drain with slight increase in pneumocephalus overlying the right frontal convexity. No other significant change in the appearance of right subdural hematoma and degree of local mass effect. CXR ___: Interval re-positioning of a feeding tube, which now terminates in the proximal stomach but the proximal portion of the tip is just above the GE junction level. Nasogastric tube terminates in the region of the pylorus. Endotracheal tube is in standard position. Cardiomediastinal contours are normal, and imaged portions of the lungs are clear (small portion of right lung laterally has been excluded). Medications on Admission: seroquel,? depakote Discharge Medications: 1. Acetaminophen IV 1000 mg IV Q8H:PRN PAIN 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. CloniDINE 0.1 mg PO TID:PRN hypertension 4. Docusate Sodium (Liquid) 100 mg PO BID 5. Heparin 5000 UNIT SC TID 6. LeVETiracetam 500 mg PO BID 7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 8. Multivitamins 5 mL PO DAILY 9. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting 10. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain 11. Senna 1 TAB PO BID:PRN Constipation 12. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Found down. COMPARISON: None. TECHNIQUE: Single portable view of the chest. FINDINGS: The lungs are clear. Cardiac silhouette is normal in size. There is no pleural effusion, pneumothorax or pulmonary edema. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: Found down with subdural hematoma seen on outside hospital study. COMPARISON: Outside hospital head CT ___. TECHNIQUE: Axial MDCT images were obtained through the brain without the administration of IV contrast. Coronal and sagittal reformats were also examined. FINDINGS: Again seen is a right cerebral convexity subdural hematoma with a maximum depth of 13.8 mm from the inner table, increased by 1 mm compared to the prior study. There is 9 mm of midline shift. There is also a small amount of subarachnoid blood in the right sylvian fissure. The basal cisterns remain patent. An old left frontal infarct is noted. There is a fracture of the right temporal bone without involvement of the skull base. No other fractures are identified. A right frontal subgaleal hematoma is also present. Deformity of the right zygomatic arch is noted, likely chronic. There is mucosal thickening in the maxillary sinuses and bilateral ethmoid air cells. IMPRESSION: 1. Slight increase in right subdural hematoma with stable 9 mm of midline shift. No sign of downward herniation. 2. Small amount of subarachnoid blood in the right sylvian fissure. Radiology Report HISTORY: Trauma. Found down. COMPARISON: Outside hospital CT from 1 earlier. TECHNIQUE: MDCT of the cervical spine without contrast with axial, coronal and sagittal reformations. FINDINGS: Multilevel multifactorial degenerative changes are noted with anterior and posterior osteophyte formation, the worst at the C5-C6 level. At this level there is minimal canal narrowing from a posterior disc osteophyte complex. There is no evidence of fracture. There is minimal loss of lordosis is likely due to degenerative changes. The dens is intact. There is no prevertebral soft tissue swelling The lung apices demonstrate emphysematous changes with scarring and blebs. Mucosal sinus thickening is noted bilaterally. IMPRESSION: Degenerate changes without evidence of acute fracture. Radiology Report HISTORY: Found down. Trauma. TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. Coronal and sagittal reformations were reviewed. Oral contrast was not administered. COMPARISON: None FINDINGS: LOWER CHEST: There is no mediastinal hilar or axillary lymphadenopathy by CT criteria. The aorta and great vessels unremarkable. There is no mediastinal hematoma. The heart is of normal size. The lungs are clear. ABDOMEN: The liver is diffusely hypodense. There are no focal liver lesions. The main portal vein is patent. The gallbladder contains numerous stones but no evidence of cholecystitis. The spleen, pancreas and bilateral adrenal glands are normal. Bilateral kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or suspicious renal masses. The right kidney is chronically scared with loss of cortex in a focal segment of the upper pole. On the right there is a mildly dilated ureter throughout its course without an obvious obstruction such as stone or mass. The abdominal aorta is normal in course and caliber. There is no abdominal free fluid or lymphadenopathy. The stomach, small, and large bowel are normal in course and caliber. Appendix is normal. PELVIS: The bladder is distended. The prostate, and rectum are unremarkable. There is no pelvic free fluid or lymphadenopathy. A penile prosthesis is noted. BONES: There are acute appearing minimally displaced fractures of the posterior left 12th rib and the posterior lateral left 11th rib. The lateral left 10th rib is slightly deformed, likely due an an old injury. IMPRESSION: 1. No intra-abdominal or intrathoracic solid organ injury. 2. Minimally displaced fractures of the posterior left ___ and 12th ribs. 3. Fatty liver. 4. Mildly dilated right ureter, perhaps due to reflux, although non-specific in nature. 5. Cholelithiasis without cholecystitis Radiology Report PORTABLE CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: The heart size, mediastinal and hilar contours are normal. Lungs and pleural surfaces are clear. The eleventh and twelfth ribs are only partially imaged on this radiograph, and known fractures in these regions are seen to better detail on recent CT of one day earlier. Radiology Report INDICATION: ___ male with history of right frontal subdural hematoma status post evacuation. Assess for postoperative hemorrhage. COMPARISON: Preoperative non-contrast head CTs from ___ TECHNIQUE: MDCT axial images of the brain were obtained without intravenous contrast. Bone and soft tissue algorithms were reviewed. Coronal and sagittal reformations were prepared. NON-CONTRAST HEAD CT: The patient is status post right craniotomy. Right convexity subdural hematoma remains present, but slightly decreased in size. Right extraaxial pneumocephalus is now present. There is decreased leftward shift of midline structures and decreased right subfalcine herniation. There is no uncal herniation or compression of basal cisterns. Subarachnoid blood within the right sylvian fissure has decreased in density. The right lateral and third ventricles remain compressed, and the left lateral ventricle remains mildly dilated. A chronic left frontal white matter infarct with periventricular as well as subcortical involvement is again seen. Again seen is a nondisplaced right parietal bone fracture posterior to the craniotomy, extending into the squamous portion of the temporal bone. Right mastoid is underpneumatized, likely from prior chronic infections, but the pneumatized bilateral mastoid air cells are well aerated. Mucosal thickening is seen within the ethmoid air cells, inferior frontal sinuses, and imaged portions of the maxillary sinuses. A right zygomatic arch fracture is partially visualized, thought to be chronic on prior studies on which it was better assessed. IMPRESSION: 1. Slightly decreased right convexity subdural hematoma s/p craniotomy. Slightly decreased associated mass effect. 2. Nondisplaced right parietal bone fracture extending into the squamous temporal bone, without petrous involvement. Radiology Report HISTORY: ___ man status post right subdural hematoma evacuation, evaluate for interval change. TECHNIQUE: Contiguous axial MDCT images of the brain were obtained without the administration of IV contrast. CTDIvol: 70.73 mGy. DLP: 1202 mGy-cm. COMPARISON: Non-enhanced CT of the head from ___. FINDINGS: Comparison to the most recent prior CT is limited by differences in the tilt of the patient's head. The patient is status post right craniotomy. There has been interval enlargement of the right subdural hematoma, with increase in leftward shift of midline structures and subfalcine herniation compared to approximately 15 hours earlier. Right lateral and third ventricles remain effaced. There is interim enlargement of the atrium and occipital horn of the left lateral ventricle, indicating entrapment, with new surrounding hypodensity indicating subependymal CSF migration. Though there is new mild distortion of the midbrain due to increased shift of midline structures, there is no uncal herniation and no compression of basal cisterns. There has been interval decrease in pneumocephalus. Small subarachnoid blood in the right sylvian fissure is stable. A left frontal chronic white matter infarct is again seen. A nondisplaced right parietal bone fracture is again noted posterior to the craniotomy, extending into the squamous portion of the temporal bone. A chronic right zygomatic arch fracture is also seen. Mild mucosal thickening is again seen in the ethmoid air cells. IMPRESSION: Interval increase in right subdural hematoma with increased leftward shift of midline structures and subfalcine herniation. Findings were discussed with ___ by Dr. ___ telephone at 10:45 AM on ___. Radiology Report HISTORY: ___ alcoholic male found down with right subdural hematoma and right subarachnoid hemorrhage. Patient is status post evacuation and is now presenting with change in mental status. Assess for interval change. COMPARISON: Non-contrast head CTs dating back to ___, most recent from ___, at 8:57 a.m. TECHNIQUE: MDCT axial images of the brain were obtained without intravenous contrast. Bone and soft tissue algorithms were reviewed. Coronal and sagittal reformations were prepared. NON-CONTRAST HEAD CT: The patient is status post evacuation of a right subdural hematoma with expected postoperative changes. However, there has been interval increase in the size of the right frontal component measuring up to 17 mm (2a:18). Additionally, there is increased mass effect upon the right cerebral hemisphere with increased shift of the usually midline structures to the left, now measuring 13 mm as compared to 9 mm on most recent prior examination from the same day. Additionally, there is increased effacement of the suprasellar cistern with concern for downward transtentorial herniation. Dilatation of the occipital horn of the left lateral ventricle with evidence of transependymal CSF flow is similar to prior and consistent with entrapment. A previusly seen small amount of subarachnoid hemorrhage within the right sylvian fissure is not clearly evident on the current examination. No new left-sided hemorrhage is identified. A nondisplaced right temporal bone fracture is similar to prior. Mucosal thickening is seen within the ethmoid air cells. The mastoid air cells remain well aerated. IMPRESSION: Increasing size of right frontoparietal subdural hematoma with increased mass effect resulting in increased subfalcine herniation and concern for downward transtentorial herniation. Dr. ___ communicated the above results to Dr. ___ at 6:41 p.m. on ___, immediately after discovery. Findings were known to the surgical team and patient was being sent emergently to the operating room for decompression. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess ET tube. ET tube is in standard position. Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. The appearance of the mediastinum is unchanged. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Assess NG tube. NG tube tip is out of view below the diaphragm, the side port is in the stomach. Cardiomediastinal contours are normal. ET tube is in standard position. The lungs are clear. Radiology Report HISTORY: Re-evacuation of right subdural hematoma. Question interval change. COMPARISON: ___. TECHNIQUE: Non-contrast head CT. FINDINGS: In the interval since the prior study, there is now a drain in place within the right subdural collection of hemorrhage and air. The resultant shift of the midline structures has decreased, now at approximately 6 mm. Effacement of the right-sided sulci as well as the right lateral ventricle still remains. The basal cisterns are patent. No new hemorrhage is identified and there is no evidence of cytotoxic or vasogenic edema. IMPRESSION: Interval placement of a right-sided drain status post evacuation of subdural contents with overall decreasing shift of the midline structures. Radiology Report EXAM: Chest, single semi-upright AP portable view. CLINICAL INFORMATION: Intracranial bleed status post right craniotomy. ___. FINDINGS: Endotracheal tube is seen, terminating approximately 2.4 cm above the level of the carina which has advanced approximately 1 cm since the prior study. Enteric tube is seen coursing below the level of the diaphragm into the left upper quadrant inferior aspect not included on the image. External artifact projects over the right lung apex making this area difficult to assess. Elsewhere, there is no focal consolidation. No pleural effusion or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: Endotracheal tube has been advanced approximately 1-1.5 cm and now terminates approximately 2.4 cm above the level of the carina. Clear lungs. Radiology Report HISTORY: ___ man status post right craniotomy and evacuation of subdural hematoma x2. Rule out hemorrhage. Please perform portable head CT. TECHNIQUE: Contiguous axial MDCT images of the brain were acquired without the administration of IV contrast. COMPARISON: Nonenhanced CT of the head from ___. FINDINGS: The patient is status post right craniotomy for subdural hematoma evacuation. There has been interval increase of the right subdural hematoma with associated increase in mass effect and leftward shift of midline structures. More subdural blood is seen along the anterior and posterior convexity of the brain. There is increased mass effect causing bilateral ventricle compression. An external subdural drain is in stable and appropriate position. A prior left frontal infarct is again noted. There are no new areas of hemorrhage or infarction, and the basal cisterns are patent. The globes are unremarkable. IMPRESSION: Interval increase of the right subdural hematoma with more blood identified along the anterior and posterior convexity. There is increase in associated mass effect and compression of the ventricles. Radiology Report AP CHEST, 4 A.M., ___ HISTORY: Subdural evacuation. Respiratory distress. Still intubated. IMPRESSION: AP chest compared to ___: ET tube and nasogastric tube in standard placements respectively. No pneumothorax, pleural effusion or atelectasis. Lungs clear. Heart size normal. Radiology Report HISTORY: ___ male, followup bleed. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. COMPARISON: None and CT scan from ___. FINDINGS: The patient is status post right craniotomy following subdural hematoma evacuation. An external drain is in appropriate and stable position. The right subdural hematoma persists without any significant change in size. There continues to be effacement of the sulci and lateral ventricle. A leftward shift of midline structures is unchanged. A prior left frontal infarct is again noted. There are no areas of hemorrhage or infarction, and the basal cisterns are patent. The globes are unremarkable. IMPRESSION: No significant change in right subdural hematoma, mass effect or leftward shift of midline structures since ___. External drain in appropriate and stable position. Radiology Report PORTABLE CHEST X-RAY, ___ COMPARISON: ___. FINDINGS: Overall, there has been little change in the appearance of the chest since the recent study except for development of subtle patchy and linear opacities at the left lung base, which could be due to atelectasis, aspiration, or early pneumonia. Followup radiographs may be helpful in this regard. Radiology Report INDICATION: Right subdural hematoma, right subarachnoid hemorrhage. Evaluate for interval change. COMPARISON: CT head ___ and ___. Also, outside CT head ___. TECHNIQUE: Axial MDCT images were obtained through the brain without IV contrast. Some images were repeated due to motion artifact with improved outcome. Coronal, sagittal and thin section bone algorithm reconstructed images were generated. TOTAL BODY DLP: 1665 mGy-cm. FINDINGS: The patient is status post right craniotomy and evacuation of right subdural hemorrhage. Post-surgical soft tissue edema of the scalp persists. There is no significant appreciable change in size and extent of subdural collection layering over the right cerebral convexity, with surgical drain unchanged in position. Pneumocephalus has decreased. There is persistent effacement of the right hemispheric sulci and gyri, with persistent effacement of the lateral ventricles, right greater than left, with midline shift of approximately 5 mm, stable. The prior focus of subarachnoid hemorrhage along the sylvian fissure is no longer appreciated. Chronic left frontal lobe subcortical infarct is redemonstrated. The patient remains intubated. The left middle ear cavity is clear. There is partial opacification of several left mastoid air cells. The underdeveloped right mastoid air cells are nearly completely opacified but the right middle ear cavity is clear. There is stable mucosal thickening and partial opacification of the partially visualized paranasal sinuses. IMPRESSION: No significant change in postoperative appearance of right subdural hematoma and degree of local mass effect and subfalcine herniation. Radiology Report INDICATION: Subarachnoid hemorrhage, now with new fever of SQH, evaluate for DVT. COMPARISON: None. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation was performed on the bilateral lower extremity veins. FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, proximal femoral, mid femoral, distal femoral and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of DVT in the right or left lower extremity. Radiology Report INDICATION: Subdural and subarachnoid hemorrhage requiring emergent decompression. Evaluate for acute change. COMPARISON: Non-enhanced head CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes and thin section bone algorithm reconstructed images were acquired. DLP: 1026 mGy-cm. CTDI volume: 61 mGy. FINDINGS: Compared to the prior study of ___, there has been removal of a right frontal-approach drain. The patient is status post right craniotomy and evacuation of right subdural hemorrhage. There is slight interval increase in pneumocephalus. There is unchanged appearance of size and extent of the subdural collection layering over the right cerebral convexity. There is persistent effacement of the right hemispheric sulci and right lateral ventricle with unchanged 5-mm leftward shift of normally midline structures. The basal cisterns appear patent. Chronic left frontal lobe subcortical infarct is unchanged. There is unchanged opacification of the right underdeveloped mastoid air cells. The left mastoid air cells are clear. Partial opacification of the bilateral ethmoid air cells and a right maxillary mucous retention cyst are noted. IMPRESSION: Interval removal of right frontal approach drain with slight increase in pneumocephalus overlying the right frontal convexity. No other significant change in the appearance of right subdural hematoma and degree of local mass effect. Radiology Report SERIES OF PORTABLE CHEST RADIOGRAPHS OF ___ COMPARISON: Study of earlier the same date. Three serial radiographs of the chest are submitted for interpretation. On the initial radiograph, a feeding tube coils in the esophagus and is subsequently directed cephalad with tip terminating above the thoracic inlet level. On the second radiograph, the tube coils in the lower thoracic esophagus with a similar cephalad course and termination above the thoracic inlet level. On the final radiograph, there is no longer coiling of the tube, but the tip is located at the GE junction level. At the time of this dictation, a repeat chest radiograph has been obtained and dictated separately, documenting advancement of this tube. With the exception of the above described feeding tube placement and re-positioning, there has not been a substantial change in the appearance of the chest since the previous study of earlier the same date. Radiology Report PORTABLE CHEST X-RAY, ___ COMPARISON: Study of earlier the same date. FINDINGS: Interval re-positioning of a feeding tube, which now terminates in the proximal stomach but the proximal portion of the tip is just above the GE junction level. Nasogastric tube terminates in the region of the pylorus. Endotracheal tube is in standard position. Cardiomediastinal contours are normal, and imaged portions of the lungs are clear (small portion of right lung laterally has been excluded). Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: ETOH, s/p Fall, Head injury, Transfer Diagnosed with SUBARACHNOID HEM-NO COMA, ACCIDENT NOS temperature: 98.6 heartrate: 72.0 resprate: 18.0 o2sat: 97.0 sbp: 133.0 dbp: 99.0 level of pain: 13 level of acuity: 2.0

•Have a friend/family member check your incision daily for signs of infection. •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. •You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion or change in mental status. •Any numbness, tingling, weakness in your extremities. •Pain or headache that is continually increasing, or not relieved by pain medication. •Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. •Fever greater than or equal to 101.5° F.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Codeine / Vicodin / Penicillins / Aspirin Attending: ___ Chief Complaint: dyspnea lower extremity pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with HTN, dCHF (EF >55% ___, recurrent MRSA infections, TURP, CKD stage 3 (baseline 1.5-1.7), h/o L leg split-thickness skin graft and chronic LLE lymphedema and pannus edema who presents to emergency Department with SOB and ___ ulcer. Patient states that on ___ he developed an allergic reaction with severe swelling and hives and shortness of breath. He decided to go off his medications for this allergic reaction and since then he is not taking any of his medications. He since has also stopped taking his oxygen at home because he felt like he had an allertic reaction to it. He is coming in to the emergency room today because he felt like he had difficulty ambulating in the setting worsening left ankle pain as well as increased shortness of breath. He has not been able to take any of his Medication for fear of an allergic reaction. In the ED, initial vitals were: 99.5 88 135/43 26 88% RA - Labs were significant for H&H ___, WBC of 8.4, Chem 7 significant for BUN/Cr of ___. Tnt <0.01, BNP of 1243, UA without infection. - Imaging w/ chest xray showed Cardiomegaly with pulmonary vascular congestion. - The patient was given 80 IV lasix, 25 mg of Carvedilol, 800 mg of Ibuprofen, and Tylenol. Vitals prior to transfer were: Upon arrival to the floor, pt states he is not far from baseline. He speaks in full sentences but states he has had to sleep upright for the last two weeks (coinsides with stopping all medications). He denies cough, chest pain, fevers/chills. He states ___ edema and chronic venous stasis is at baseline. No changes in pannus. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: PAST MEDICAL HISTORY: 0. dCHF (EF >55% ___ 1. Recurrent MRSA infections. 2. Lower extremity lymphedema. 3. Asthma. 4. Gout. 5. Hypertension. 6. Morbid obesity. 7. Bilateral inguinal hernia repairs presumably with mesh ___ at ___. 8. Left leg injury and subsequent surgery including a split-thickness skin graft. 9. TURP. 10. Sleep apnea. 11. Thyroid nodule. Social History: ___ Family History: + for CAD, DM and alcoholism Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: HR 71 91RA 98.6 126/48 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: Supple, unable to determine JVP due to neck size CV: S3, soft systolic ejection murmur at the upper left sternal border with radiation to the upper right sternal border, and a very soft apical holosystolic murmur that radiates to the left axilla Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Obese, no rebound or guarding, large, woody panus formation GU: No foley Ext: Chronic venous stasis and lymphedema, 2+ nonpitting edema. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. PHYSICAL EXAM ON DISCHARGE: VS: T 97.9 BP 103-134/63-77 HR ___ R 18 SpO2 95-98% ___ Wgt: 154kg TELE: SR ___, satting 92-97%2L desat to 82% overnight GENERAL: Morbidly obese, On O2NC in NAD. Mood, affect appropriate HEENT: PERRL, EOMI, moist mucous membranes NECK: Unable to determine JVP due to body habitus CV: S3, soft systolic ejection murmur at the LUSB with radiation to the RUSB, and a soft apical crescendo-decrescendo murmur that radiates to the left axilla Lungs: CTAB, no crackles, rales, rhonchi Abdomen: Morbidly obese, large, woody panus formation Ext: Chronic venous stasis and lymphedema bilaterally with 1+ edema to thighs, dry ulcer on posterior left heel and medial L lower calf which is dry Pertinent Results: ADMIT LABS: ___ WBC-8.4 RBC-3.52* Hgb-10.8* Hct-32.4* MCV-92 MCH-30.7 MCHC-33.3 RDW-13.2 RDWSD-43.5 Plt ___ ___ ___ PTT-32.0 ___ ___ Glucose-118* UreaN-21* Creat-1.4* Na-136 K-3.9 Cl-96 HCO3-31 AnGap-13 ___ proBNP-1243* ___ cTropnT-<0.01 ___ Calcium-8.8 Phos-3.2 Mg-2.1 UricAcd-11.8* ___ FreeKap-46.4* FreeLam-44.2* Fr K/L-1.05 CXR ___: Cardiomegaly with pulmonary vascular congestion. CXR ___ Since ___, cardiomegaly is accompanied by worsening pulmonary vascular congestion and mild interstitial edema. No definite areas of consolidation to suggest a site of infectious pneumonia. CXR ___: Mild pulmonary edema, mild cardiomegaly. ___ TTE The left atrium is elongated. The estimated right atrial pressure is ___ mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Severe symmetric LVH with a small LV cavity and hyperdynamic systolic function. At least mild aortic stenosis (may be underestimated). ___ Renal U/S IMPRESSION: 1. No evidence of hydronephrosis, stones or obstruction. 2. Collapsed urinary bladder, though visualization limited secondary to body habitus. MICRO: Blood cultures ___ and ___ - final no growth Urine culture ___ >3colonies consistent with skin flora Throat culture HSV - No HSV - final Sputum culture ___ - final, commensal respiratory flora OTHER PERTINENT LABS: see below HA1c: ___ FreeKap 46.4, FreeLam 44.2, Fr K/L 1.05 UA unremarkable DISCHARGE LABS: ___ WBC-8.8 RBC-3.94* Hgb-11.7* Hct-37.6* MCV-95 MCH-29.7 MCHC-31.1* RDW-13.0 RDWSD-45.1 Plt ___ ___ Glucose-106* UreaN-56* Creat-1.8* Na-138 K-3.8 Cl-89* HCO3-37* AnGap-16 ___ Calcium-10.0 Phos-4.2 Mg-2.2 ___ METHYLMALONIC ACID- *PENDING* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO QAM 2. Carvedilol 25 mg PO BID 3. Amlodipine 5 mg PO DAILY 4. Furosemide 80 mg PO DAILY 5. Ibuprofen 800 mg PO Q8H:PRN pain 6. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Acetaminophen 650 mg PO Q4H:PRN pain take one every 6 hours as needed for pain 3. Allopurinol ___ mg PO EVERY OTHER DAY take this medication every day to prevent gout flairs 4. Amlodipine 10 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of breath take 2 puffs as needed for shortness of breath 6. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm Take as needed for muscle spasm 7. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain take daily as needed for back pain 8. Torsemide 40 mg PO DAILY Take daily for heart failure 9. Fexofenadine 60 mg PO BID pruritis Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Diastolic heart failure exacerbation Acute on chronic kidney disease SECONDARY DIAGNOSIS: Moderate Aortic Stenosis Hypertensive Urgency Bronchitis Gout flare Contact Dermatitis Adjustment reaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with hypoxia COMPARISON: ___ and ___. FINDINGS: AP portable upright view of the chest. The heart is mildly enlarged and there is hilar engorgement compatible with pulmonary vascular congestion. There is no frank pulmonary edema, effusion or pneumothorax. No convincing signs of pneumonia. Bony structures are intact. IMPRESSION: Cardiomegaly with pulmonary vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fever and CHF // r/o pneumonia IMPRESSION: Since ___, cardiomegaly is accompanied by worsening pulmonary vascular congestion and mild interstitial edema. No definite areas of consolidation to suggest a site of infectious pneumonia. Radiology Report INDICATION: ___ year old man with cough and increased sputum // r/o pna TECHNIQUE: Chest PA and lateral FINDINGS: Compared to ___, pulmonary vascular congestion has slightly worsened. No acute focal consolidation. No pleural effusions.Mild cardiomegaly. IMPRESSION: Mild pulmonary edema, mild cardiomegaly. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with heart failure now s/p diuresis, CKD and persistent ___ and uremia // Obstruction? TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 13.4 cm. The left kidney measures 11.5 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The urinary bladder is poorly visualized, given the patient's body habitus, though appears collapsed. IMPRESSION: 1. No evidence of hydronephrosis, stones or obstruction. 2. Collapsed urinary bladder, though visualization limited secondary to body habitus. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hypoxia, Leg pain Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOXEMIA temperature: 99.5 heartrate: 88.0 resprate: 26.0 o2sat: 88.0 sbp: 135.0 dbp: 43.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You came to the hospital because you were having increased difficulty breathing and increased pain in your legs in the setting of feeling like you were having an allergic reaction to your medications. In the midst of stopping your medications for blood pressure and heart failure, we found that you were experiencing a heart failure exacerbation where your heart was not as able to pump fluid around the body causing some of it to back up into your lungs. We treated your heart failure by giving you a medication called lasix to help take the extra fluid off of your lungs. While in the hospital, you developed a cough which we treated with an antibiotic called azithromycin with improvement in your cough. In terms of your joint pain, it appeared that you were having a gout flare, which we treated with a steroid and allopurinol, a medicine to decrease the uric acid buildup in your body. This helped improve your gout. We also suspect that you developed musculoskeletal pain from deconditioning during your hospital stay. This pain improved with Tylenol and working with physical therapy. We recommend that you take a medications called beta-blockers (e.g. carvedilol or labetolol), or other medications, to help control your blood pressure and to optimize your heart function. Unfortunately, however, you refused to take these medications while you were with us. We recommend continuing to address this with your cardiologist and your primary care doctor as we think this would benefit you in the long term. We Recommend: - Weigh yourself every morning right after you urinate, call your doctor if your weight goes up more than 3 lbs. - Take your medications every day as prescribed. You can see a list of these medications below. You should bring this list with you to your next doctor's appointment. - Work with physical therapy to regain strength and range of motion as this will improve your pain and mobility. - Follow up as below It was a pleasure caring for you at ___. We are glad that you are feeling better. Take care, Your ___ Cardiology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Nausea/Vomiting, Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old gentleman with hx of malrotation s/p surgery who presents with abdominal pain. At baseline, patient reports that he has had repeated episodes of severe nausea and vomiting, but never abdominal pain. Since ___ patient has been experiencing extreme nausea, vomiting, and new abdominal pain, which he found concerning. He has been seen in ED three times this week. He is unable to tolerate PO well, but reports still having a good appetite. He reports that he has been having waxing and waning symptoms of his GI symptoms that ranges from hours to days. States that his symptoms are the worst at night and in the morning. He describes his abdominal pain as diffuse, twisting ___ pain that does not radiate. Pt took omeprazole and Zofran ODT at home this morning pt states he threw both of them up. Denies taking any pain medications. Reports that he had diarrhea once this morning. Denies blood in stool or vomit. Has been having associated chills with the abdominal pain along with mild migraines and SOB. He does endorse heavy marijuana use everyday, last used on ___. Denies any relief of N/V with showering. Denies any fevers, CP, sick contacts, recent travel, or new ingestions. Patient has hx of malrotation of gut s/p surgery in ___. Reports having had a gastric emptying study that revealed slow motility. Past Medical History: Malrotation of Gut s/p surgery in ___ Bicuspid aortic heart valve Social History: ___ Family History: Pt adopted. Does not know family history Physical Exam: ON ADMISSION: Physical Exam: Vitals- T 98 BP 129/79 HR 46 RR 18 O2sat99% RA GENERAL: pleasant young man laying comfortably in NAD HEENT: Normocephalic, atraumatic. Sclera anicteric. No conjunctival pallor or injection. PERRL. EOMI. Moist mucous membranes, good dentition. Oropharynx is clear. CARDIAC: RRR. bradycardic. Normal S1, S2. No m/r/g LUNGS: CTA b/l. No wheezes, crackles, rhonchi ABDOMEN: Hypoactive BS. Soft, nondistended, tender diffusely but worse in the RLQ. EXTREMITIES: Warm, well, perfused. No ___ edema. Palpable pulses SKIN: No evidence of ulcers, rash or lesions. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. ON DISCHARGE: Physical Exam: Vitals- T 98.4 BP 109-129/53-79 HR 46-51 R 18 O2sat 99% on RA GENERAL: pleasant young man laying comfortably in NAD HEENT: Normocephalic, atraumatic. Sclera anicteric. No conjunctival pallor or injection. PERRL. EOMI. Moist mucous membranes, good dentition. Oropharynx is clear. CARDIAC: RRR. bradycardic. Normal S1, S2. No m/r/g LUNGS: CTA b/l. No wheezes, crackles, rhonchi ABDOMEN: +BS. Soft, nondistended, mildly tender in RUQ, worse in RLQ. EXTREMITIES: Warm, well, perfused. No ___ edema. Palpable pulses SKIN: No evidence of ulcers, rash or lesions. dry skin in the back NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Pertinent Results: ADMISSION LABS: ___ 11:00AM BLOOD WBC-11.8* RBC-4.58* Hgb-14.6 Hct-42.4 MCV-93 MCH-31.9 MCHC-34.4 RDW-12.0 RDWSD-40.7 Plt ___ ___ 11:00AM BLOOD Neuts-83.1* Lymphs-9.2* Monos-6.6 Eos-0.3* Baso-0.2 Im ___ AbsNeut-9.77* AbsLymp-1.08* AbsMono-0.78 AbsEos-0.03* AbsBaso-0.02 ___ 11:00AM BLOOD Plt ___ ___ 11:00AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-143 K-4.2 Cl-104 HCO3-26 AnGap-17 ___ 11:00AM BLOOD Lipase-36 ___ 11:00AM BLOOD Albumin-4.7 DISCHARGE LABS: ___ 08:00AM BLOOD WBC-6.0 RBC-4.15* Hgb-13.2* Hct-38.9* MCV-94 MCH-31.8 MCHC-33.9 RDW-12.3 RDWSD-42.2 Plt ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD Glucose-98 UreaN-8 Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-26 AnGap-14 ___ 08:00AM BLOOD HIV Ab-Negative MICROBIOLOGY: ___ 1:50 pm URINE Source: ___. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Pending): URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. IMAGING: CT A&P (___): No bowel obstruction. Congenitally malrotated bowel is unchanged in configuration to prior CT. No acute abdominopelvic process. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Abdominal Pain Secondary: Intestinal Malrotation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: +PO contrast; History: ___ with n/v, abd pain, hx of malrotation+PO contrast // malrotation? SBO? TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.8 s, 52.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 399.0 mGy-cm. 2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP = 16.9 mGy-cm. Total DLP (Body) = 416 mGy-cm. COMPARISON: CT abdomen ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The majority of the small bowel is in the right abdomen and the majority of the large bowel is in the left abdomen, similar to prior and compatible with provided history of malrotation. The colon and rectum are otherwise within normal limits. The appendix is surgically absent. PELVIS: The urinary bladder and distal ureters are unremarkable. Bilateral ureteral jets are seen. There is no free fluid in the pelvis. Left lower quadrant surgical clips are similar to prior. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: No bowel obstruction. Congenitally malrotated bowel is unchanged in configuration to prior CT. No acute abdominopelvic process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Vomiting, unspecified temperature: 98.4 heartrate: 47.0 resprate: 18.0 o2sat: 100.0 sbp: 168.0 dbp: 107.0 level of pain: 10 level of acuity: 3.0

Dear Dr. ___, ___ was a pleasure taking care of you. You were admitted because of severe nausea, vomiting, and abdominal pain. You were given IV fluids and Zofran for your nausea. Your GI symptoms improved and you were stable for discharge. You can take Tylenol for your abdominal pain. Please follow up with your PCP and your gastroenterologist. You also complained of urinary burning. We have a urine culture and gonorrhea and chlamydia testing pending at discharge and will call you with the results. Please be sure to engage in safe sexual practices, wearing a condom every time you engage in sexual activity to protect you from sexually transmitted infections. We wish you the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PODIATRY Allergies: Penicillins / Cephalosporins / ampicillin Attending: ___. Chief Complaint: Left Foot Infection Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with PMH of HTN and history of osteomyelitis of the R foot presenting to the ED with c/o worsening L foot infection. She presents with swelling and erythema of the left great toe and dorsum of foot. 2 weeks ago noticed a blister on the tip of her left great toe. She saw her podiatrist who did a debridement and put her on antibiotics. Xrays taken several weeks ago were negative of signs of osteo of the L hallux. The wound improved but did not completely resolve. On ___, she noticed redness and swelling of the great toe that subsequently spread to the dorsum of her foot and became warm. She does not have any pain in the area but is neuropathic. She denies fevers, nausea, vomiting or other systemic symptoms of infection. Past Medical History: Right TKR Left toe osteomyelitis s/p amputation Obesity Hypertension Depression Osteoarthritis Social History: ___ Family History: Father has history of MI Physical Exam: On Admission: VS: 98.7 80 119/70 14 97% RA GEN: NAD, A&Ox3 LLE: ___ pulses palpable. Cap refill <3 seconds to all digits. L hallux with edema and erythema. erythema does not extend up the foot and is localized to the L hallux. callus to the distal aspect of the L hallux which after debridement revealed an ulceration which probes deeply to bone. No purulence expressed from the wound. hallux rigidus deformity with no ROM of the L ___ MPJ. No motion noted at the hallux IPJ. On Discharge: AVSS GEN: NAD, A&Ox3 RESP: CTA CV: RRR ABD: Soft, NT, ND. LLE: ___ pulses palpable. Cap refill <3 seconds to all digits. L hallux with edema and erythema. erythema does not extend up the foot and is localized to the L hallux decreased from admission. ulceration to the distal aspect of the hallux 0.5 x 0.5 cm which probes deeply to bone. No purulence expressed from the wound. hallux rigidus deformity with no ROM of the L ___ MPJ. No motion noted at the hallux IPJ. No pain on palpation of the L hallux. NEURO: CNII-XII intact. mentating appropriately. light touch sensation diminished to b/l ___. Pertinent Results: On admission: ___ 05:30PM BLOOD WBC-11.2* RBC-4.51 Hgb-12.9 Hct-39.9 MCV-89 MCH-28.6 MCHC-32.3 RDW-13.2 RDWSD-42.2 Plt ___ ___ 05:30PM BLOOD Neuts-76.1* Lymphs-15.6* Monos-6.3 Eos-1.1 Baso-0.4 Im ___ AbsNeut-8.49* AbsLymp-1.74 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.04 ___ 05:30PM BLOOD Plt ___ ___ 05:30PM BLOOD Glucose-131* UreaN-24* Creat-0.8 Na-134 K-6.8* Cl-97 HCO3-24 AnGap-20 ___ 05:52PM BLOOD Lactate-2.3* K-4.7 ___ 05:30PM BLOOD CRP-43.3* On Discharge: ___ 06:14AM BLOOD WBC-8.7 RBC-4.03 Hgb-11.8 Hct-36.6 MCV-91 MCH-29.3 MCHC-32.2 RDW-12.9 RDWSD-42.8 Plt ___ ___ 06:14AM BLOOD Plt ___ ___ 06:14AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-142 K-3.8 Cl-101 HCO3-28 AnGap-17 ___ 06:14AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 IMAGING: L Foot X-Ray ___: A bandage overlies the big toe. Soft tissue defect is noted at the big toe, likely ulceration. There is lucency through the distal aspect of the first distal phalanx, worrisome for acute osteomyelitis. Additional region of lucency just proximal to this appears to have subtle early sclerotic margins and may not be acute. Moderate osteoarthritic changes are seen at the first interphalangeal joint in the distal phalanx is subluxed laterally in relation to the first proximal phalanx. Hammertoe deformities are seen. A plantar calcaneal spur is seen. There is also posterior calcaneal enthesophyte. Degenerative changes are seen along the dorsal aspect of the tarsal bones. MICRO: ___ 7:53 pm SWAB Source: L Foot . GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.25 mg PO BID 2. Hydrochlorothiazide 50 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. FLUoxetine 40 mg PO DAILY 5. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. ClonazePAM 0.25 mg PO BID 2. FLUoxetine 40 mg PO DAILY 3. Hydrochlorothiazide 50 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 6. Docusate Sodium 100 mg PO BID:PRN cosntipation 7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain Ok to take non narcotic alternative RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 8. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild take with food 9. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 10. Clindamycin 300 mg PO Q8H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8) hours Disp #*42 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: L Foot Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with left foot pain, redness, swelling, fluctuance, recent ulceration. // ?osteomyelitis, abcess TECHNIQUE: Left foot, four views COMPARISON: ___ FINDINGS: A bandage overlies the big toe. Soft tissue defect is noted at the big toe, likely ulceration. There is lucency through the distal aspect of the first distal phalanx, worrisome for acute osteomyelitis. Additional region of lucency just proximal to this appears to have subtle early sclerotic margins and may not be acute. Moderate osteoarthritic changes are seen at the first interphalangeal joint in the distal phalanx is subluxed laterally in relation to the first proximal phalanx. Hammertoe deformities are seen. A plantar calcaneal spur is seen. There is also posterior calcaneal enthesophyte. Degenerative changes are seen along the dorsal aspect of the tarsal bones. IMPRESSION: Findings highly worrisome for acute osteomyelitis of the distal aspect of the first distal phalanx; lucency through the distal aspect of the first distal phalanx, worrisome for acute osteomyelitis. Additional region of lucency just proximal to this appears to have subtle sclerotic margins and may not be acute. A bandage overlies the first toe and there is underlying ulceration and possibly soft tissue gas. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Local infection of the skin and subcutaneous tissue, unsp temperature: 98.7 heartrate: 80.0 resprate: 14.0 o2sat: 97.0 sbp: 119.0 dbp: 70.0 level of pain: 2 level of acuity: 3.0

Ms. ___, It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service for treatment of your left foot infection. You were given IV antibiotics while here. You are being discharged home on oral antibiotics with the following instructions: ACTIVITY: There are restrictions on activity. Please try to stay off the Left Foot as much as possible. When ambulating wear the surgical shoe provided and keep weight off the front of your Left foot. You should keep this site elevated when ever possible (above the level of the heart!) 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 6 weeks. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. 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. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, 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 ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Head and facial Trauma Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old, previously healthy, ___ speaking male who presents to emergency room s/p facial trauma. Per ED notes, patient fell from 10 to 12 feet while at work lifting hay. This story was corroborated by his coworker. There was no loss of consciousness, or inciting event noted. Per patient he denies experiencing any new onset headache, dizziness, changes in vision, heart palpitations, or lightheadedness prior to the fall. He states that he hit his face first and got up woozy, but finds it difficult to recall events afterwards. He was taken to ___ for evaluation, where a CT Head was significant for a Left orbital floor fracture, and pneumocephalus. No intracranial bleed or hematoma was noted. He was then transferred to ___ hemodynamically stable for further evaluation. Currently he complains about left face pain, and right knee pain. No nausea, vomiting, fatigue, malaise, signs of increased intracranial pressure, or signs of CSF leak. Past Medical History: none Social History: ___ Family History: N/C Physical Exam: Vitals: 98.3 70 112/61 18 100%RA GEN: A&Ox3, NAD HEENT: Left orbital mild swelling, mild tender to palpation along orbit. EOMI, PERRL, no lacerations, auditory canal intact, no hemotympanum. No cervical neck tenderness, +FROM, ___ strength. CV/Chest: RRR, no sternal/rib tenderness, no retractions, no trauma, no lacerations PULM: No respiratory distress Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No TTP Right knee, minimal pain with AROM, no pain with PROM. +FROM. No ___ edema, ___ warm and well perfused Pertinent Results: ___ 02:15PM ___ 02:15PM ___ PTT-24.7* ___ ___ 02:15PM PLT COUNT-270 ___ 02:15PM WBC-17.4* RBC-5.17 HGB-13.5* HCT-41.1 MCV-80* MCH-26.1 MCHC-32.8 RDW-13.8 RDWSD-39.9 ___ 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:15PM LIPASE-18 ___ 02:15PM estGFR-Using this ___ 02:15PM UREA N-16 CREAT-0.8 ___ 02:29PM HGB-14.2 calcHCT-43 ___ 02:29PM COMMENTS-GREEN TOP Radiology Report INDICATION: ___ with fall off height // eval for trauma COMPARISON: None FINDINGS: AP, lateral, oblique views of the right knee provided. No fracture, dislocation or evidence of joint effusion. An enthesophytes is seen along the superior pole of the patella. No significant degenerative joint disease. Mild prepatellar soft tissue swelling is noted. IMPRESSION: No fracture. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD INDICATION: History: ___ with facial fracture, pneumocephalus. Eval for acute process. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. Please note that there were some technical issues during the contrast injection for the CTA and a second contrast bolus was injected. As a result, the CTA is a combination of arterially and venous phase. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 1,003.4 mGy-cm. 4) Sequenced Acquisition 6.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 301.0 mGy-cm. 5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP = 32.7 mGy-cm. 6) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 7) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 31.3 mGy (Head) DLP = 730.8 mGy-cm. Total DLP (Head) = 2,098 mGy-cm. COMPARISON: Prior head CT from ___. FINDINGS: The study is moderately degraded by motion. Within these confines: CT HEAD WITHOUT CONTRAST: There is no evidence of infarction or hemorrhage. The ventricles and sulci are normal in size and configuration. No midline shift is seen. There are multiple fractures including a fracture through the left temporal bone as seen on image to 2a: 20, lateral wall of the left orbit on image 2a:16, superior wall of the left orbit extending into the left frontal sinus, left zygomatic arch on image 2a:14, medial wall of the left orbit on image 2a : 19. There is a possible fracture through the lateral wall of the right sphenoid sinus. The previously seen fracture through the lateral wall of the left maxillary sinus is not well visualized on the current CT. There is associated intracranial and intraorbital pneumocephalus, increased compared to the prior study with air within the subdural and subarachnoid space. Air in the subdural space along the left frontal convexity exerts minimal mass effect on the underlying brain parenchyma. There is layering fluid in the left maxillary sinus. Also seen is fluid opacification of bilateral ethmoid air cells and layering fluid in the right sphenoid sinus. Bilateral mastoid air cells are clear. There is pneumocephalus within the left orbit related to the known fracture of medial orbital wall. The orbit is otherwise unremarkable without retrobulbar hematoma. Left preorbital soft tissue swelling and subcutaneous hematoma and emphysema on image 2a: 19- 32. CTA HEAD: Of note there is a technical issue regarding the contrast injection and a second contrast bolus was given, so to the CTA represents a combination of venous and arterial phases. The vessels of the circle of ___ and their principal intracranial branches appear normal with no evidence of stenosis,occlusion or aneurysm. The dural venous sinuses are patent. Incidentally seen is dominant left vertebral artery and hypoplastic right A1 segment of the anterior cerebral artery. IMPRESSION: 1. Allowing for normal anatomic variations, unremarkable head CTA. 2. No acute intra infarct or hemorrhage. 3. Multiple fractures involving the calvarium with slight interval progression of intracranial pneumocephalus as described above. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ s/p fall at work p/f OSH with Pneumocephalus, L frontal sinus fx, L temporal bone fx, L orbital floor fx, L sphenoid fx, L maxillary sinus fx. Interval assessment. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 1404.79 mGy CTDI: 50.1 mGy COMPARISON: CTA head ___. FINDINGS: Slightly limited evaluation due to patient motion. Interval decrease in pneumocephalus including a collection overlying the left frontal lobe, with scattered locules of air overlying the bilateral convexities and extending into the basal cisterns as well as overlying the cerebellum. There is mild mass effect from the collection overlying the left frontal lobe effacing the sulci without shift of normally midline structures. The basal cisterns are patent. No acute large territorial infarction. No intracranial hemorrhage. Numerous facial fractures including nondisplaced fractures of the left superior orbital rim with mildly displaced medial, and lateral orbital rim fractures with extension to the left frontal sinus. Mildly displaced transverse fracture through the left zygomatic arch is unchanged. Fracture extends through the Left temporal bone and lateral wall of the left maxillary sinus. Possible nondisplaced right sphenoid sinus fractures again noted. Layering blood products are again seen within the left maxillary sinus, right sphenoid sinus and within the ethmoidal air cells. Again seen is a moderate subgaleal hematoma along the left temporal bone. Subcutaneous emphysema seen along the left globe with retrobulbar are involvement. No retrobulbar hematoma. Globes are intact. No evidence of vitreous hemorrhage. Interval increase in deformity of the left optic nerve. The ventricles and sulci are normal in size and configuration. The additional visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are intact. IMPRESSION: 1. Decrease in pneumocephalus with no significant change in multiple facial fractures with blood products within the left maxillary sinus, right sphenoid sinus, and ethmoidal air cells. 2. Progression of left optic nerve deformity by the lateral orbital wall fracture. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 6:22 AM, minutes after discovery of the findings. Radiology Report EXAMINATION: CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB INDICATION: ___ year old man with tbone fx. Temporal bone CT to eval fx. Thin slices please per ENT request. TECHNIQUE: Routine MDCT study of temporal bone was performed with coronal reconstructions. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.5 s, 11.4 cm; CTDIvol = 138.9 mGy (Head) DLP = 1,578.3 mGy-cm. Total DLP (Head) = 1,578 mGy-cm. COMPARISON: CT head without contrast ___. FINDINGS: Slightly limited evaluation due to patient motion. Left : A minimally displaced left temporal bone fracture is seen. The external auditory canal is normal. The middle ear cavity is clear. The ossicles and tegmen are intact. There is no evidence for enlarged vestibular aqueduct or superior semicircular canal dehiscence. The facial nerve follows a normal course through the middle ear. There is no evidence for inner ear dysplasia. The mastoids are clear. Right: The external auditory canal is normal. The middle ear cavity is clear. The ossicles and tegmen are intact. There is no evidence for enlarged vestibular aqueduct or superior semicircular canal dehiscence. The facial nerve follows a normal course through the middle ear. There is no evidence for inner ear dysplasia. The mastoids are clear. Other: Facial fractures as described in previous noncontrast head CT as well as hemorrhage within the left maxillary sinus, right sphenoid sinus and ethmoidal air cells. IMPRESSION: 1. Minimally displaced left squamus temporal bone fracture with multiple facial fractures better characterized on prior head CT, including left lateral and medial maxillary wall, and left zygomatic arch fractures with hemorrhage in the left maxillary sinus, right sphenoid sinus and ethmoidal air cells. 2. Otherwise normal temporal bone CT. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with pneumocephalus. Assess pneumocephalus. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Noncontrast head CT ___, CT orbits ___. FINDINGS: Decrease in pneumocephalus, with small amount of air along the left frontal lobe with few locules of air along the falx and left frontal lobe. There is persistent but improved mass effect along the left frontal lobe with mild sulcal effacement. No shift of normally midline structures. The basal cisterns are patent. No acute large territorial infarction. No intracranial hemorrhage. The ventricles and sulci are normal in size in appearance. Again seen are multiple facial fractures including nondisplaced fracture of the left superior orbital rim, mildly displaced medial and lateral orbital rim fractures with extension to the left frontal sinus. Mildly displaced transverse fractures of left zygomatic arch is unchanged. Fractures extend through the left temporal bone and lateral wall of the left maxillary sinus. Again seen is a possible nondisplaced fracture through the right sphenoid sinus. Layering blood products are seen within the right sphenoid sinus and within the ethmoidal air cells. Left temporal soft tissue subgaleal hematoma has decreased in size. Subcutaneous emphysema is seen along the left globe with retrobulbar involvement. No retrobulbar hematoma. Globes are intact. No evidence of vitreous hemorrhage. Again seen is deformity of the left optic nerve, which is unchanged since prior examination. IMPRESSION: 1. Decreased pneumocephalus without significant change in multiple facial fractures with blood products within the right sphenoid sinus and ethmoidal air cells. 2. Persistent left optic nerve deformity by the lateral orbital wall fracture. Gender: M Race: WHITE - BRAZILIAN Arrive by AMBULANCE Chief complaint: Head injury Diagnosed with Oth fracture of base of skull, init for clos fx, Unsp intracranial injury w/o loss of consciousness, init, Fracture of orbital floor, init encntr for closed fracture, Maxillary fracture, unspecified side, init, Other specified disorders of brain, Other fall from one level to another, initial encounter temperature: 97.9 heartrate: 70.0 resprate: 14.0 o2sat: 100.0 sbp: 132.0 dbp: 81.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, You were transferred to ___ on ___ after suffering a fall. You were experiencing head and facial injuries. you will need to follow up with the plastic surgery and ENT team as out patient clinic in the following dates listing down. You are now medically cleared to be discharged to home. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, 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. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Novocain / Lipitor / Codeine / Crestor / metoprolol / Zetia / atenolol / gabapentin / pravastatin Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with history of CAD on plavix, hip fracture, hypertension, bradycardia and falls presenting after a recurrent fall. Patient cannot give a history as she does not remember the event but was found on the floor of her room at ___ and had a hematoma on her head. The fall was unwitnessed. Patient is confused at baseline. Denies any pain, lightheadedness, headache, worsening confusion, difficulty speaking, shortness of breath, chest pain, abdominal pain and dysuria. She says she feels fine but knows she is here because of a fall. ROS: Pertinent positives and negatives as noted in the HPI. All other systems (10) were reviewed and are negative. ED Course: VSS, BP 101/60 forehead hematoma, TTP in suprapubic region WBC 11.4, UA positive CT head/neck unremarkable Received one dose CTX for UTI. Past Medical History: Abdominal pain Stercoral versus infectious colitis Severe constipation Weakness Bradycardia Diet-controlled Type II diabetes Hypertension Coronary artery disease Carotid stenosis Hypothyroidism Hyperlipidemia GERD Neuropathy Social History: ___ Family History: - mother - deceased - heart disease - father - deceased - lung cancer Physical Exam: AFVSS GENERAL: Alert and in no apparent distress. Lying almost flat in bed. EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen is soft, non-distended, minimally tender to palpation in lower abdomen without rebound or guarding. Bowel sounds present. GU: No suprapubic tenderness MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rash noted. NEURO: Alert, oriented to person but not place ("I'm in a clinic") or year (___). Knows she is here for a fall. Face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Patient examined on day of discharge. Pertinent Results: ADMISSION/SIGNIFICANT LABS: =========================== ___ 01:05PM BLOOD WBC-9.3 RBC-3.72* Hgb-11.8 Hct-38.0 MCV-102* MCH-31.7 MCHC-31.1* RDW-14.6 RDWSD-54.9* Plt ___ ___ 01:05PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-140 K-4.4 Cl-104 HCO3-28 AnGap-8* ___ 12:55AM BLOOD ALT-6 AST-10 AlkPhos-84 TotBili-0.2 MICRO: ===== ___ UA with > 182 WBCs ___ UA with 12 WBCs ___ UCx pending on discharge URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. GRAM POSITIVE RODS. >100,000 CFU/mL. UNABLE TO IDENTIFY FURTHER. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. IMAGING/OTHER STUDIES: ===================== CT Head ___ IMPRESSION: Small focus of subarachnoid hemorrhage in a left frontal sulcus is stable in size with decreased density. No new intracranial hemorrhage. CT C-spine ___ IMPRESSION: No evidence for a fracture. No subluxation. LABS ON DISCHARGE: ================= ___ 01:05PM BLOOD WBC-9.3 RBC-3.72* Hgb-11.8 Hct-38.0 MCV-102* MCH-31.7 MCHC-31.1* RDW-14.6 RDWSD-54.9* Plt ___ ___ 01:05PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-140 K-4.4 Cl-104 HCO3-28 AnGap-8* Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 5 mg PO BID 2. Clopidogrel 75 mg PO DAILY 3. Gabapentin 400 mg PO TID 4. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Senna 17.2 mg PO BID 8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 9. Docusate Sodium 100 mg PO BID 10. Fleet Enema (Saline) ___AILY:PRN No bowel movement in 24 hours despite other medications 11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Pain and irritation 12. Witch ___ 50% Pad ___SDIR QID PRN 13. Linzess (linaCLOtide) 145 mcg oral DAILY 14. Pravastatin 20 mg PO QPM 15. Esomeprazole 40 mg PO DAILY 16. Ciprofloxacin HCl 500 mg PO Q12H 17. MetroNIDAZOLE 500 mg PO Q8H Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 3. Docusate Sodium 100 mg PO BID 4. Esomeprazole 40 mg PO DAILY 5. Fleet Enema (Saline) ___AILY:PRN No bowel movement in 24 hours despite other medications 6. Gabapentin 400 mg PO TID 7. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Pain and irritation 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Linzess (linaCLOtide) 145 mcg oral DAILY 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Pravastatin 20 mg PO QPM 12. Senna 17.2 mg PO BID 13. ___ ___ 50% Pad ___SDIR QID PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # mechanical fall # recurrent UTI # urinary retention # Subarachnoid hemorrhage Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with fall, belly pain, anticoagulated// eval brain bleed, eval c spine injury, eval pneumothorax, eval abdominal bleed TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph performed ___. FINDINGS: Lungs are moderately well aerated. No large pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. No evidence of acute cardiac decompensation. IMPRESSION: Normal chest radiograph. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with fall, found on the floor with head bruising. Evaluate for intracranial injury. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Brain MRI performed ___. Head CT from ___. FINDINGS: Mild motion artifact is present. A single linear hyperdense focus in a left frontal sulcus is seen on coronal and sagittal reformatted images (601:24, 401:59), which may reflect a small focus of his subarachnoid hemorrhage, versus motion artifact. No other evidence for intracranial hemorrhage. No evidence for an acute major vascular territorial infarct, edema, or mass effect. Mild periventricular and subcortical white matter hypodensities are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. Moderate global parenchymal volume loss is again seen with prominent ventricles and sulci. There is extensive calcification of bilateral carotid siphons and left greater than right intracranial vertebral arteries. There is mild right parietal subgaleal soft tissue swelling. There is no evidence of fracture. There is minimal mucosal thickening in the ethmoid air cells. Mastoid air cells and middle ear cavities are clear. The orbits appear grossly unremarkable allowing for motion artifact. IMPRESSION: 1. Possible single focus of subarachnoid hemorrhage in a left frontal sulcus, versus motion artifact. No other evidence for intracranial hemorrhage. 2. No edema or CT evidence for an acute major vascular territorial infarction. RECOMMENDATION(S): Repeated head CT for reassessment of the questionable small focus of subarachnoid hemorrhage. NOTIFICATION: The final interpretation and recommendation for repeat head CT were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:06 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with status post fall with head trauma. Evaluate for cervical spine injury. TECHNIQUE: Non-contrast helical multidetector CT of the cervical spine was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.8 s, 19.0 cm; CTDIvol = 22.7 mGy (Body) DLP = 431.9 mGy-cm. Total DLP (Body) = 432 mGy-cm. COMPARISON: CT cervical spine performed ___. FINDINGS: No fractures are identified. No evidence for prevertebral soft tissue swelling. No acute subluxation. Disc protrusions and endplate osteophytes mildly indent the ventral thecal sac at multiple levels. Neural foraminal narrowing by uncovertebral and facet osteophytes is seen at C3-C4 on the left, C4-C5 and C5-C6 bilaterally, and C6-C7 on the right, up to moderate in severity. Concurrent head CT is reported separately. Right common and internal carotid arteries are medialized, indenting the posterior pharyngeal wall. Bilateral carotid artery calcifications are noted. The thyroid is small and low in density, suggesting low iodine content. Visualized lung apices are unremarkable. IMPRESSION: No evidence for a fracture. No subluxation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman on Plavix s/p unwitnessed fall with question of subarachnoid hemorrhage vs artifact on initial CT head. Repeated head CT is requested. TECHNIQUE: Noncontrast head CT sagittal and coronal reformatted image. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.8 mGy (Head) DLP = 861.5 mGy-cm. 2) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP = 752.0 mGy-cm. Total DLP (Head) = 1,614 mGy-cm. COMPARISON: Head CT from ___ at 01:51, approximately 11 hours prior. FINDINGS: The previously noted small focus of linear hyperdensity in a left frontal sulcus is stable in extent with decreased density, images 10:15, 11:15. No new intracranial hemorrhage is seen. No edema, mass effect, or evidence for an acute major vascular territorial infarction. Mild periventricular and subcortical white matter hypodensities are again noted, nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. Moderate global parenchymal volume loss is again seen with prominent ventricles and sulci. Extensive calcification of bilateral carotid siphons and left greater than right intracranial vertebral arteries is again noted. Mild soft tissue swelling is again seen in the right parietal scalp. No evidence for a fracture. Paranasal sinuses and mastoid air cells appear grossly well-aerated allowing for absence of dedicated bone algorithm images. IMPRESSION: Small focus of subarachnoid hemorrhage in a left frontal sulcus is stable in size with decreased density. No new intracranial hemorrhage. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Urinary tract infection, site not specified temperature: 98.6 heartrate: 78.0 resprate: 17.0 o2sat: 99.0 sbp: 101.0 dbp: 60.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a privilege to care for you at the ___ ___. You were admitted after a fall and found to have a recurrent urinary tract infection. We did not find any concerning underlying cause of your fall such as a heart arrhythmia, and suspect your fall was related to general muscle weakness. Your fall resulted in a small bleed in your head for which our neurosurgeons were consulted and recommended no intervention. However, your Plavix was discontinued as this can worsen current bleeding and causes increased risk of future bleeding. Also while you were here you were noted to be retaining urine and a foley catheter was placed. This can attempted to be removed at your living facility. Please continue to take all medications as prescribed. We wish you the best! Sincerely, Your ___ Team

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Lipitor / Inapsine / Iodine / Tetanus / Cefodizime / Doxycycline Hyclate / IV Dye, Iodine Containing Contrast Media / Fosamax / Livalo / ampicillin / ___ / isoniazid / red acetaminophen Attending: ___. Chief Complaint: Pain Major Surgical or Invasive Procedure: Bilateral Trochanteric Bursa Steroid Injections (___) History of Present Illness: Ms. ___ is a ___ female with the past medical history of polymyalgia rheumatica, arthritis, bursitis, HTN, hypothyroidism, fibromyalgia, chronic abdominal pain with dyspepsia, osteopenia, and spinal stenosis s/p recent lumbar laminectomy and posterior spinal fusion on ___ by Dr. ___, presenting with bilateral hip pain. History is obtained from the patient as well as the nursing supervisor at her facility. She states that she has had various pains over the course of the past ___ years after a fall. She is usually maintained on Tylenol and Oxycodone by her PCP and also sees a pain specialist. She was hospitalized from ___ on orthopedics for L4-S1 lumbar laminectomy, L5-S1 posterior fusion on ___ and discharged to rehab. She reports that she was able to participate in the exercises initially with tolerable pain, but over the next ___ days, had progressive, right and left hip pain which was both sharp and throbbing. It was worse with walking, and not precipitated by trauma. RNs tried giving her dilaudid, position changes, ice packs, and salicylate cream, but these did not help. She noted that this is not at the site of her surgery which she refers to as her "bum" pain, which is still present, but reasonably well controlled. She noted no leg numbness/tingling that is new (chronic RLE numbness for months), changes in bowel or bladder function, fevers, shaking chills, or dysuria. She states that the pain in her other joints is not particularly different that it is at baseline. As far as she knows, her prednisone dose has not changed significantly over the past month, though her MDs are trying to wean it down. Vitals in the ER: 98.3 99 123/56 16 99% RA There, the patient was seen by ortho who did not think that there were any complications from the procedure and advised admission to medicine. She received: Morphine 2mg IV Tylenol 1g PO Gabapentin 100mg PO Oxycodone 10mg PO ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: HTN Fibromyalgia Polymyalgia rheumatic on chronic prednisone (5mg/d) h/o arthritis and bursitis bilaterally in her shoulders. Chronic abdominal pain; work-up with GI reveals gastritis and dyspepsia Hepatic hemangiomas Hoarse voice with likely laryngopharyngeal reflux per ENT Spinal stenosis. Osteopenia. Cataracts bilaterally. Hypothyroidism s/p cholecystectomy. h/o deviated septum s/p repair. Insomnia Chronic fatigue syndrome. Allergic rhinitis (Reported) Frequent asymptomatic urinary tract infections. ?Dermatographism (per patient) ___ s/p L4-S1 lumbar laminectomy, L5-S1 posterior fusion Social History: ___ Family History: Mother - diabetes ___, hypertension. Father - CVA. Two aunts with breast cancer. 1 child with gastritis (stress related?) Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: (see eFlowsheet) GENERAL: Alert and in no apparent distress, awake, interactive EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular rate; normal perfusion, no appreciable JVD RESP: Symmetric breathing pattern with no stridor. Breathing is non-labored GI: Abdomen soft, non-distended, no hepatosplenomegaly appreciated. GU: No suprapubic fullness or tenderness to palpation MSK: right and left hip have pain with passive internal and external rotation, right moreso with slight external rotation, straight leg raise negative, some tenderness to palpation of hips, Neck supple, normal muscle tone SKIN: No rashes or ulcerations noted, back incision is healing well, non-erythematous or tender NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: normal thought content, logical thought process, appropriate affect DISCHARGE PHYSICAL EXAM: VS: 97.6 PO 152 / 64 R Lying 76 16 ___ppearing, comfortable lying in bed MMM, OP clear clear lungs throughout ___ systolic murmur at RUSB Abdomen mildly distended, soft, nontender, no rebound MSK: normal muscle tone in bilateral lower extremities, no ttp over bilateral tronchanteric bursa or hips Skin: Clean incision over lumbar spine Neuro: ___ strength in bilateral lower extremities throughout, oriented x3 Pertinent Results: ADMISSION LABS: ___ 08:30PM BLOOD WBC-13.2* RBC-3.66* Hgb-10.9* Hct-33.2* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.8* RDWSD-51.5* Plt ___ ___ 08:30PM BLOOD Neuts-73.9* Lymphs-15.9* Monos-6.9 Eos-0.5* Baso-0.2 Im ___ AbsNeut-9.78* AbsLymp-2.10 AbsMono-0.92* AbsEos-0.07 AbsBaso-0.03 ___ 08:30PM BLOOD Plt ___ ___ 08:30PM BLOOD Glucose-107* UreaN-20 Creat-0.8 Na-135 K-5.6* Cl-95* HCO3-23 AnGap-17 ___ 05:06AM BLOOD Mg-1.9 ___ 05:03AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1 ___ 08:30PM BLOOD CRP-40.2* IMAGING: - XR Hips (___): 1. No acute fracture, dislocation, or radiographic evidence of inflammatory arthropathy. 2. Mild degenerative changes of the bilateral hips, which have not significantly progressed compared to most recent prior radiographs and MRI. DISCHARGE LABS ___ 06:10AM BLOOD WBC-10.1* RBC-3.28* Hgb-9.7* Hct-31.0* MCV-95 MCH-29.6 MCHC-31.3* RDW-16.2* RDWSD-56.6* Plt ___ ___ 07:47AM BLOOD K-4.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Levothyroxine Sodium 88 mcg PO DAILY 3. Cyclobenzaprine 10 mg PO TID 4. Acetaminophen 1000 mg PO TID 5. PredniSONE 9 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Calcium Carbonate 500 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Cetirizine 10 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Furosemide 20 mg PO DAILY 13. Ascorbic Acid ___ mg PO DAILY 14. Gabapentin 100 mg PO TID 15. Metoprolol Tartrate 37.5 mg PO BID 16. HydrALAZINE 10 mg PO BID 17. Docusate Sodium 100 mg PO BID 18. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 19. Salonpas (methyl salicylate-menthol) ___ % topical DAILY 20. Senna 17.2 mg PO QHS 21. Fleet Enema (Saline) ___AILY:PRN constipation 22. Bisacodyl ___AILY:PRN constipation 23. LORazepam 0.5 mg PO Q8H:PRN anxiety 24. Ondansetron ODT 4 mg PO Q8H:PRN nausea 25. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN 26. Heparin 5000 UNIT SC BID Discharge Medications: 1. Aspirin 81 mg PO DAILY Please continue for 1 month 2. Narcan (naloxone) 4 mg/actuation nasal ONCE 3. Polyethylene Glycol 17 g PO DAILY 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Acetaminophen 1000 mg PO TID 6. Ascorbic Acid ___ mg PO DAILY 7. Bisacodyl ___AILY:PRN constipation 8. Calcium Carbonate 500 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Cyclobenzaprine 10 mg PO TID 12. Docusate Sodium 100 mg PO BID 13. Fluticasone Propionate NASAL 2 SPRY NU DAILY 14. Furosemide 20 mg PO DAILY 15. Gabapentin 100 mg PO TID RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day Disp #*6 Capsule Refills:*0 16. HydrALAZINE 10 mg PO BID 17. Levothyroxine Sodium 88 mcg PO DAILY 18. LORazepam 0.5 mg PO Q8H:PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth every eight (8) hours Disp #*3 Tablet Refills:*0 19. Metoprolol Tartrate 37.5 mg PO BID 20. Multivitamins 1 TAB PO DAILY 21. Omeprazole 20 mg PO DAILY 22. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 23. PredniSONE 9 mg PO DAILY 24. Salonpas (methyl salicylate-menthol) ___ % topical DAILY 25. Senna 17.2 mg PO QHS 26. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bilateral Trochanteric Bursitis Inability to Ambulate Elevated CRP Thrombocytosis Pseudohyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS INDICATION: ___ year old woman with prior PMR, recent spinal surgery, presenting with bilateral lateral hip pain (more over trochanter,), symmetrical// ? fx, inflammatory changes. TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of bilateral hips. COMPARISON: Radiographs of the pelvis and bilateral hips ___. MRI pelvis ___. FINDINGS: RIGHT HIP: There is diffuse osteopenia. There is no fracture or dislocation. There are mild degenerative changes of the right hip. A linear calcific density adjacent to the greater trochanter is unchanged and may represent calcific tendinosis of the gluteal tendons. LEFT HIP: There is diffuse osteopenia. There is no fracture or dislocation. Mild degenerative changes are again noted. There is no suspicious lytic or sclerotic lesion. There is no soft tissue calcification or radio-opaque foreign body. PELVIS: Posterior spinal fusion hardware is seen at the lumbosacral junction. IMPRESSION: 1. No acute fracture, dislocation, or radiographic evidence of inflammatory arthropathy. 2. Mild degenerative changes of the bilateral hips, which have not significantly progressed compared to most recent prior radiographs and MRI. Radiology Report EXAMINATION: ULTRASOUND-GUIDED THERAPEUTIC STEROID/ANALGESIC INJECTION OF THE RIGHT AND LEFT GREATER TROCHANTERIC BURSA INDICATION: ___ year old woman with bilateral trochanteric bursa inflammation/pain causing inability to ambulate- rheum recommending b/l trochanteric bursa steroid injections by ___// b/l trochanteric bursa steroid injections TECHNIQUE: The risks, benefits, and alternatives were explained to the patient and written informed consent obtained and documented in the chart. A pre-procedure timeout confirmed three patient identifiers. Under ultrasound guidance, an appropriate spot was marked overlying the right trochanteric bursa. The area was prepared and draped in standard aseptic fashion. 5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent ultrasound guidance, a 22-gauge spinal needle was advanced into the right trochanteric bursa. Then, a solution containing 40mg of Kenalog and 2cc of 0.25% bupivicaine was injected into the right trochanteric bursa. Needle removed, bandage applied. Under ultrasound guidance, an appropriate spot was marked overlying the left trochanteric bursa. The area was prepared and draped in standard aseptic fashion. 5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent ultrasound guidance, a 22-gauge spinal needle was advanced into the left trochanteric bursa. Then, a solution containing 40mg of Kenalog and 2cc of 0.25% bupivicaine was injected into the left trochanteric bursa. Needle removed, bandage applied. . The patient tolerated the procedure well and left the department in good condition. There were no immediate complications. Informed discharge given. COMPARISON: None FINDINGS: On the right, there is trace fluid in the greater trochanteric bursa. On the left, enthesopathic changes of the posterior facet of the greater tuberosity, with tendinosis and probable partial thickness tears of the gluteus medius. IMPRESSION: Technically successful and uncomplicated ultrasound-guided injection of anesthetic and steroid into the greater trochanteric bursa bilaterally. I Dr. ___ personally supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain, Wound eval Diagnosed with Other acute postprocedural pain temperature: 97.8 heartrate: 90.0 resprate: 20.0 o2sat: 96.0 sbp: 130.0 dbp: 50.0 level of pain: 10 level of acuity: 3.0

Dear ___, ___ were admitted to the hospital with increased pain in your hips. ___ were evaluated by the spinal surgeons who felt this was not related to your recent spine surgery. ___ were also evaluated by our rheumatologists who thought your symptoms were due to inflammation in your bursa of your hips. ___ received steroid injections to improve your pain with good effect. Your pain is much improved! Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if ___ develop a worsening or recurrence of the same symptoms that originally brought ___ to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern ___. It was a pleasure taking care of ___! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: scrotal cellulitis Major Surgical or Invasive Procedure: none History of Present Illness: ___ h/o morbid obesity, obesity hypoventillation on chronic 02, not compliant with nocturnal bipap, diastolic CHF, current resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis with question of ___ Gangrene. Urology at ___ evaluated patient and there is no signs of necrotizing infection either clinically or with evaluation with CT pelvis performed at ___. Patient has not had fevers. He is poor historian other than remarking on recent chills. Has had issues with chronic scrotal swelling. SNF progress note by Dr. ___ on ___ documents: acute diastolic heart failure with significant scrotal edema for which physician ordered scrotal elevation, increased lasix dose to 80mg and use of zaroxolyn 2.5mg every other day. Scrotum is mildly tender 13pt review only notable for singificant >100kg weight gain in past ___ years after depressive episode and psych hospitilzation for suicidal ideation. Past Medical History: morbid obesity obesity hypoventilation nocturnal bipap, not compliant diastolic chf hypertension type 2 diabetes on insulin hypercholesterolemia anxiety/depression gerd Social History: ___ Family History: not pertinent to current admit dx Physical Exam: 98.3 110/64 80 22 84% on RA, 92% on 4L NC morbidly obese poor dental hygeine, dry lips clear BS, regular s1 and s2 jvp obscured by habitus soft obese non-tender abd inverted penis, large swollen scrotum with erythema, no crepitus or areas of skin necrosis, no perineal fluctuance or pustules. poor skin hygeine in groin pitting peripheral edema with chronic venous stasis changes aox3, odd affect Discharge exam afebrile, VSS, hypoxic at night without BiPAP morbidly obese poor dental hygeine, MMM clear lungs bilaterally regular s1 and s2 jvp obscured by habitus soft obese non-tender abd inverted penis, large swollen scrotum without erythema, no crepitus or areas of skin necrosis, no perineal fluctuance or pustules. poor skin hygeine in groin trace peripheral edema with chronic venous stasis changes A and O x 3, anxious at times Pertinent Results: ___ 10:20PM BLOOD WBC-12.0* RBC-4.86 Hgb-14.1 Hct-44.4 MCV-91 MCH-29.0 MCHC-31.7 RDW-14.1 Plt ___ ___ 10:20PM BLOOD Glucose-159* UreaN-20 Creat-1.0 Na-139 K-3.8 Cl-89* HCO3-38* AnGap-16 ___ 10:20PM BLOOD Neuts-71.9* Lymphs-17.9* Monos-5.8 Eos-3.6 Baso-0.8 ___ 10:20PM BLOOD Calcium-8.8 Phos-2.3* Mg-1.8 ___ 11:30PM BLOOD Lactate-1.0 ct pelvis ___ ___ M ___ ___ Radiology Report CT PELVIS W/O CONTRAST Study Date of ___ 1:46 AM ___ ___ 1:46 AM CT PELVIS W/O CONTRAST Clip # ___ Reason: eval for ___, gas UNDERLYING MEDICAL CONDITION: NO_PO contrast; History: ___ with scrotal swelling, edema REASON FOR THIS EXAMINATION: eval for ___, gas CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: ___ SAT ___ 3:32 AM Extensive anterior abdominal wall and pannus skin thickening and fat stranding extending into the scrotum with large bilateral hydroceles. No subcutaneous gas detected. Although no subcutaneous gas is detected, Forniere's gangrene cannot be definitively excluded. Wet Read Audit # 1 ___ SAT ___ 3:31 AM Extensive anterior abdominal wall and pannus skin thickening and fat stranding extending into the scrotum with large bilateral hydroceles. No subcutaneous gas detected. Findings are concerning for Forniere's gangrene. Final Report HISTORY: ___ male with scrotal swelling and edema. COMPARISON: Outside hospital CT dated ___. TECHNIQUE: CT of the pelvis was performed without intravenous contrast. Multiplanar reformatted images were reviewed. FINDINGS: Extensive subcutaneous edema is seen in the anterior pelvic subcutaneous fat with skin thickening and edema of the pannus. This edema extends into the scrotum and is very severe. There are very large bilateral hydroceles. No subcutaneous gas is detected. The urinary bladder and imaged colon contain contrast material. No other acute abnormalities are detected in the imaged portion of the pelvis. Degenerative changes in the lumbar spine are not well evaluated on this study. IMPRESSION: Extensive subcutaneous and scrotal edema and fluid without CT evidence for subcutaneous gas. The study and the report were reviewed by the staff radiologist. cxr: IMPRESSION: Low lung volumes without acute findings in the upper lung fields. Small right pleural effusion cannot be excluded. Discharge labs: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 8.1 4.85 14.5 46.5 96 29.9 31.2 13.9 337 UreaN Creat Na K Cl HCO3 15 0.9 140 3.9 91* 43 urine culture no growth blood culture no growth ultrasound: No evidence of deep vein thrombosis in the left lower extremity Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 14 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. BusPIRone 50 mg PO TID 5. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 6. Fluoxetine 60 mg PO DAILY 7. glimepiride 2 mg oral qd 8. HydrOXYzine 25 mg PO Q6H:PRN itch 9. Ibuprofen 600 mg PO Q8H:PRN pain 10. MetFORMIN (Glucophage) 850 mg PO BID 11. Simvastatin 20 mg PO DAILY 12. Tamsulosin 0.4 mg PO HS 13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze 14. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN wheeze 15. nystatin 100,000 unit/gram topical bid 16. Furosemide 100 mg PO DAILY 17. Bisacodyl 10 mg PO DAILY:PRN constipation 18. Milk of Magnesia 30 mL PO Q6H:PRN upset stomach Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze 2. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN wheeze 3. Amlodipine 5 mg PO DAILY 4. BusPIRone 30 mg PO TID 5. Fluoxetine 60 mg PO DAILY 6. Furosemide 100 mg PO DAILY 7. HydrOXYzine 25 mg PO Q6H:PRN itch 8. Ibuprofen 600 mg PO Q8H:PRN pain 9. Tamsulosin 0.4 mg PO HS 10. Aspirin 81 mg PO DAILY 11. Bisacodyl 10 mg PO DAILY:PRN constipation 12. Simvastatin 20 mg PO DAILY 13. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 14. Glargine 14 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 15. MetFORMIN (Glucophage) 850 mg PO BID 16. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 17. Sulfameth/Trimethoprim DS 1 TAB PO BID last day ___ 18. Cephalexin 500 mg PO Q6H last day ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: morbid obesity scrotal cellulitis and edema obesity hypoventillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with scrotal swelling and edema. COMPARISON: Outside hospital CT dated ___. TECHNIQUE: CT of the pelvis was performed without intravenous contrast. Multiplanar reformatted images were reviewed. FINDINGS: Extensive subcutaneous edema is seen in the anterior pelvic subcutaneous fat with skin thickening and edema of the pannus. This edema extends into the scrotum and is very severe. There are very large bilateral hydroceles. No subcutaneous gas is detected. The urinary bladder and imaged colon contain contrast material. No other acute abnormalities are detected in the imaged portion of the pelvis. Degenerative changes in the lumbar spine are not well evaluated on this study. IMPRESSION: Extensive subcutaneous and scrotal edema and fluid without CT evidence for subcutaneous gas. Based on discussion with Dr. ___ by Dr. ___ prior to performing this CT, the clinical team is aware of these findings and the possibility of early ___ gangrene in the absence of subcutaneous gas. Radiology Report HISTORY: Left calf pain. TECHNIQUE: Grey scale, color and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep vein thrombosis in the left lower extremity. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: TESTICULAR SWELLING Diagnosed with EDEMA, MALE GENITAL ORGN temperature: 98.9 heartrate: 97.0 resprate: 14.0 o2sat: 97.0 sbp: 144.0 dbp: 77.0 level of pain: 8 level of acuity: 3.0

You were admitted with swelling and infection of your scrotum. You received antibiotics and improved. A foley catheter was placed, and will need to remain in place until you follow up with Urology. Please try to keep your scrotum elevated/supported as much as possible. It is important that you use BiPAP every night to help treat your sleep apnea. You were also noted to have a rash in your low back that may be shingles, but is no longer infectious. Please see below for your follow up appointments and medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ludwig's angina Major Surgical or Invasive Procedure: ___: extra/intraoral I&D of deep neck space History of Present Illness: ___ is a ___ female with history of poor oral dentition who presents from OSH with diagnosis of Ludwig's angina.She has had progressive pain and swelling of her left face and neck for the past few days and at OSH was found on CT neck showed periapical abscess of her remaining left mandibular molar withsurrounding cellulitis extending into the parapharyngeal space,and to a lesser extent the retropharyngeal space. She was transferred on RA, received zosyn at OSH. On presentation patient was unable to speak in full sentences and had difficulty handling secretions. The decision was made to intubate in the ED to secure airway and plan for OR with OMFS for incision and drainage of deep neck/facial infection. Past Medical History: Past Medical History: HTN, HLD, ?psych history Past Surgical History: Left knee replacement Social History: ___ Family History: NC Physical Exam: Vitals: 102.5 112 177/99 GEN: Intubated, sedated HEENT: No scleral icterus, mucus membranes moist, L jaw is markedly swollen that extends to upper neck. CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 100 mg PO QHS:PRN sleep 2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON 3. timolol maleate 5 mg oral DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate 6. Verapamil 160 mg PO Q8H 7. LORazepam 1 mg PO QHS:PRN sleep 8. Atorvastatin 20 mg PO QPM 9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 10. Topiramate (Topamax) 200 mg PO BID 11. Cyproheptadine 4 mg PO Q8H:PRN headache 12. Gabapentin 300 mg PO TID 13. Amitriptyline 50 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild Reason for PRN duplicate override: switching to PO Do not exceed 4000 mg daily. 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX *hydromorphone 4 mg 1 tablet(s) by mouth Q3H Disp #*30 Tablet Refills:*0 4. Ibuprofen 400-800 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 6. Amitriptyline 50 mg PO QHS 7. Atorvastatin 20 mg PO QPM 8. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON 9. Cyproheptadine 4 mg PO Q8H:PRN headache 10. Gabapentin 300 mg PO TID 11. LORazepam 1 mg PO QHS:PRN sleep 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. timolol maleate 5 mg oral DAILY 14. Topiramate (Topamax) 200 mg PO BID 15. TraZODone 100 mg PO QHS:PRN sleep 16. Verapamil 160 mg PO Q8H Discharge Disposition: Home Discharge Diagnosis: Ludwig's angina Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with intubated, eval tube position// intubated, eval tube position TECHNIQUE: Single portable view of the chest. COMPARISON: None. FINDINGS: Endotracheal tube tip is 5.3 cm from the carina. Enteric tube passes below the field of view. Lung volumes are relatively low. There is no confluent consolidation. Probable retrocardiac atelectasis. No large effusion. Cardiomediastinal silhouette is within normal limits. Old healed right posterior fourth and fifth rib fractures are noted. IMPRESSION: Endotracheal tube tip is 5.3 cm from the carina. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman w/ Ludwig's angina s/p drainage w/ OMFS still intubated for airway protection// location of ETT/OGT location of ETT/OGT IMPRESSION: Compared to chest radiographs ___. Lungs clear. Heart size normal. No pleural abnormality. ET tube in standard placement. Nasogastric tube ends in the stomach. Radiology Report EXAMINATION: Chest AP view. INDICATION: ___ year old woman with tooth abscess tracking to neck s/p drainage by OMFS, now with wheezing, soft BP// ? infiltrates TECHNIQUE: Chest AP view COMPARISON: ___ n IMPRESSION: The ET tube, NG tube have been removed in the interim. Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is unremarkable. There is no pleural effusion. No pneumothorax is see Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Transfer Diagnosed with Cellulitis and abscess of mouth temperature: 102.1 heartrate: 99.0 resprate: 16.0 o2sat: 97.0 sbp: 190.0 dbp: 99.0 level of pain: 10 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ for surgery to drain an abscess in your mouth. You have recovered well and are now ready for discharge home. Please follow the instructions provided to you by the Oral and Maxillofacial Surgeons to ensure a speedy recovery: ACTIVITY: -You may resume your normal activity. MEDS: -You may resume your normal medications. -You are being provided with a prescription for a 10 day course of Augmentin. as well as pain medication. -You may take a stool softener (such as Colace) or a laxative (such as Senna) as needed for constipation while taking narcotic pain medicine. FOLLOW-UP: -Follow up with OMFS as scheduled. RETURN TO ED or call the office for: -worsening pain not controlled by medication -fever >101.5 -worsening swelling of the face -erythema of the wound or purulent drainage -difficulty breathing -any other reason that concerns you Thank you for allowing us to participate in your medical care. Sincerely, Your ___ Surgery Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / lisinopril Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old woman with extensive stage small cell lung cancer currently on carboplatin and etoposide + radiation who is admitted from the ED with profound weakness and dyspnea. Patient reports approximately two days of progressive weakness and tremulousness. Her weaekness progressed to the point she couldn't stand up without assistance, and felt like a 'piece of spaghetti'. Additionally, when attempting to stand her entire body would shake with tremors. She notes mild associated dyspnea. She has a chronic cough occasionally associated with white sputum and has some throat discomfort and odynophagia with radiation. Her appetite has been very poor. She has no other focal complaints. No headaches. No visual changes (chronic left eye blurriness). She has no recent URTI symtpoms. No CP. No N/V or abodminal pain. She has intermittent constipation, last BM was yesterday. No dysuria. No myalgias. No leg pain or swelling. No new rashes. Patient was seen in radiation oncology today for fraction ___ of planned 3500 cGy. There she was noted to be very weak and tremulous and requiring assistance with ambulation. She was transported to the ED. In the ED, initial VS were pain 0, T 98.6, HR 88, BP 148/49, RR 18, O2 99%RA. Initial labs were notable for Na 134, K 6.2 (hemolyzed, repeat 5.3 whole blood 5.3), HCO3 20, Cr 1.5, Ca 9.0, Mg 2.2, P 4.3, WBC 7.1, HCT 26.2, PLT 176, UA negative. Rapid flu swab negative. CXR showed no evidence of pneumonia and interval improvement in known RUL mass. Patient was given normal saline and po lorazepam. VS prior to transfer were T 98.3, HR 79, BP 134/61, RR 16, O2 100%RA. Past Medical History: PAST ONCOLOGIC HISTORY: Ms. ___ is a ___ yrs. female who has a remote history of cigarette smoking, quit about ___ years ago and a long-standing history of emphysema. She presented with persistent dry cough since about 2 months ago and began to developed blood tinged sputum in mid ___. She has noticed some increased shortness of breath. She has been on Advair for emphysema which was no longer helpful. She has more dyspnea especially when she lies down. She has lost her appetite and lost about 15 pounds over several months. Due to these complaints, she underwent the following workup: ___: CXR - 1. Soft tissue opacity right hilar region. Focal opacity superior segment right lower lobe which may represent infiltrate, pneumonia or lung lesion. Follow-up contrast enhanced CT scan of the chest is recommended to exclude malignancy. ___: CT of chest - 1. Large right upper lobe mass and a small mass superior segment right lower lobe. 2. Bulky right hilar/suprahilar mass. Subcarinal adenopathy. Pretracheal adenopathy. 3. Bilateral thyroid nodules. Correlate with nonemergent thyroid ultrasound. Findings are highly suspicious for malignancy. Tissue sampling and PET CT advised. ___: PET/CT - 1. FDG avid right perihilar mass measuring up to 7 cm demonstrates a max SUV of 23.56, suspicious for primary lung neoplasm. There is compression upon the bronchus to the posterior segment of the right upper lobe and probable associated atelectasis of the right upper lobe. 2. FDG avid subcarinal lymphadenopathy, FDG avid right axillary lymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right lower lobe with max SUVs of 11.33, 13.67, and 13.93, respectively, likely representing metastatic disease. FDG avid epicardial lymph node with a max SUV of 3.69, likely representing metastatic disease. 3. FDG avid left cervical chain level IV lymph node with a max SUV of 6.01, likely representing metastatic disease. 4. Two FDG avid subcutaneous soft tissue nodules in the left posterior upper back superficial to the deltoid muscle and left gluteal region superficial to the gluteus maximus muscle with max SUVs of 20.22 and 15.41, respectively, likely representing metastatic disease. - ___: bronchoscopy, EBUS FNA positive for small cell lung cancer of level 7, 10R, 11R lymph nodes. - ___ - ___: C1 carboplatin and etoposide. - ___: seen by Dr. ___ recommends adding radiation after 2 cycles of chemotherapy. - ___: C2D1 carboplatin and etoposide. - ___: starting concurrent XRT, Dr. ___. - ___: C3D1 carboplatin and etoposide. - ___: C4D1 carboplatin and etoposide. PAST MEDICAL HISTORY: - Latent TB s/p treatment - CAD s/p LAD stent in ___ - Paroxysmal Afib on ASA, atrial tachycardia - PVD - DM - Hypertension - Hyperlipidemia - CKD Stage IV - COPD - HLD - Basal Cell Carcinoma Social History: ___ Family History: Her mother and sister died of lung cancer. Her father had prostate cancer. And one brother had stomach cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.2 HR 84 BP 121/79 RR 22 SAT 100% O2 on RA GENERAL: Fatigued elderly woman sitting up in bed EYES: Anicteric sclerea, PERLL, EOMI; ENT: MMM, Oropharynx clear without lesion, JVD not appreciated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears mildly tachypneic and speakinig in short sentences, soft inspiratory wheeze throughout. Fair air movement GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; prominent ventral hernia; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Decreased bulk. NEURO: Alert, oriented, CN III-XII intact, Bilateral ___ strength is ___ throughout. After exertion she developed rhythmic fasiculations at about 3Hz in her RLE that persisted for several minutes. Similar but less pronounced tremeors in LLE. SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 823) Temp: 98.5 (Tm 98.5), BP: 127/48 (112-135/48-59), HR: 84 (74-84), RR: 17 (___), O2 sat: 99% (97-100), O2 delivery: RA, Wt: 100.8 lb/45.72 kg GEN: laying in bed comfortably HEENT: healing rash in V1 distribution, no further vesicles CV: NR, RR. Nl S1, S2. No m/r/g. CHEST: CTAB, redness over chest and back largely resolved GI: Soft, nontender. NEURO: Alert, oriented. Pertinent Results: ADMISSION LABS ============== ___ 06:00PM BLOOD WBC-7.1 RBC-3.02* Hgb-8.4* Hct-26.2* MCV-87 MCH-27.8 MCHC-32.1 RDW-20.2* RDWSD-62.9* Plt ___ ___ 06:00PM BLOOD Neuts-86.1* Lymphs-8.4* Monos-3.2* Eos-1.1 Baso-0.6 Im ___ AbsNeut-6.13* AbsLymp-0.60* AbsMono-0.23 AbsEos-0.08 AbsBaso-0.04 ___ 06:50AM BLOOD ___ PTT-22.8* ___ ___ 06:00PM BLOOD Glucose-95 UreaN-43* Creat-1.5* Na-134* K-6.2* Cl-100 HCO3-20* AnGap-14 ___ 06:50AM BLOOD ALT-<5 AST-11 LD(LDH)-125 CK(CPK)-18* AlkPhos-69 TotBili-0.2 ___ 06:00PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2 ___ 06:50AM BLOOD ___ 06:50AM BLOOD TSH-1.1 ___ 06:50AM BLOOD Cortsol-21.1* DISCHARGE LABS ============== ___ 06:18AM BLOOD WBC-5.3 RBC-3.08* Hgb-8.8* Hct-26.6* MCV-86 MCH-28.6 MCHC-33.1 RDW-17.5* RDWSD-55.2* Plt Ct-83* ___ 06:18AM BLOOD Neuts-85* Lymphs-6* Monos-4* Eos-5 Baso-0 AbsNeut-4.51 AbsLymp-0.32* AbsMono-0.21 AbsEos-0.27 AbsBaso-0.00* ___ 06:18AM BLOOD Plt Smr-LOW* Plt Ct-83* STUDIES ======= ___ CXR: No radiographic findings to suggest pneumonia. Interval decrease in size of right upper lobe lung mass compatible with known malignancy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 2. aMILoride 5 mg PO DAILY 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY 7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 9. Senna 8.6 mg PO BID 10. Torsemide 20 mg PO QAM 11. Torsemide 10 mg PO QPM 12. Vitamin D ___ UNIT PO DAILY 13. Lactulose 30 mL PO Q6H:PRN constipation 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. Glargine 12 Units Bedtime Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 14 Days DO NOT APPLY TO FACE 3. Sarna Lotion 1 Appl TP TID:PRN pruritis 4. ValACYclovir 1000 mg PO DAILY Duration: 9 Days 5. Glargine 12 Units Bedtime 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 7. aMILoride 5 mg PO DAILY 8. Amiodarone 100 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 11. Lactulose 30 mL PO Q6H:PRN constipation 12. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY 13. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 16. Senna 8.6 mg PO BID 17. Torsemide 20 mg PO QAM 18. Torsemide 10 mg PO QPM 19. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: #Localized Herpes Zoster Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with sob// pna TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ and head CT ___ FINDINGS: Heart size is normal. The mediastinal and hilar contours are unchanged with dense atherosclerotic calcifications again noted at the aortic knob. The pulmonary vasculature is normal. Ill-defined focal opacification in the right upper lobe corresponds to the the patient's known malignancy, grossly decreased in size and extent when compared to the scout image from the PET-CT. Remainder of the lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No radiographic findings to suggest pneumonia. Interval decrease in size of right upper lobe lung mass compatible with known malignancy. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Weakness Diagnosed with Weakness temperature: 98.6 heartrate: 88.0 resprate: 18.0 o2sat: 99.0 sbp: 148.0 dbp: 49.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ because of weakness and difficulty breathing. We didn't find any signs of infection. We talked about doing an MRI of your head but you declined. You then developed some pain on your forehead and we found a rash there, consistent with shingles and started you on an antiviral. We asked the ophthalmology doctor ___ doctor) to evaluate you because of the shingles and she noted that there was an abnormality on the back of your eye. It's unclear if this is something that has been there before or something new. It could potentially be related to your cancer or an infection. It is very important for you to see your eye doctor within ___ week of leaving the hospital. When you get home, continue your medications. It was a pleasure caring for you, and we wish you the best. Sincerely, Your ___ Oncology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ibuprofen / tramadol / Gadavist / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: chest pain s/p assault Major Surgical or Invasive Procedure: 1. pigtail chest tube placement History of Present Illness: Ms ___ is a ___, PMH significant for obesity s/p RNYGB, depression, abuse, presented to ___ today after an assault by her boyfriend. Patient relays that she was shoved by her assailant, causing her to land on the railroad track. There were no head strikes or loss of consciousness. She was brought to ___ where she was found to have right sided chest right fractures with associated pneumothorax. Symptoms are as expected with pleuretic chest pain, without dyspnea at first. She therefore declined placement of chest tube despite the moderately sized pneumothorax. Patient was subsequently transferred to ___ for trauma evaluation. In the ED, she reports increasing pain as well as increased difficulty breathing. A pigtail was placed on the right side with re-expansion of her lungs on repeat chest XR. Currently she has complaints of pain with deep breaths, chronic history of right shoulder pain (due to abuse), osteoarthritis in her thumbs bilaterally. Aside from her various chronic pains, she reports noother acute issues. Past Medical History: PMH: 9 SUICIDE ATTEMPTS ANEMIA ANXIETY DEPRESSION ATTENTION DEFICIT DISORDER WITH HYPERACTIVITY RIGHT KNEE PAIN CARPAL TUNNEL TENDONITIS HEAD TRAUMA (CAR ACCIDENT ___ PSH: GASTRIC BYPASS ___ KNEE SURGERY ___ right knee OVARIAN CYSTECTOMY HIP DYSPLASIA ___ Social History: ___ Family History: FH:Father-living , rheumatic heart disease, arthritis, ___ heart disease and stroke Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R. Site of previous R chest tube with dressing c/d/i. ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 05:20AM BLOOD WBC-11.0* RBC-3.99 Hgb-10.7* Hct-36.1 MCV-91# MCH-26.8# MCHC-29.6* RDW-24.5* RDWSD-76.9* Plt ___ ___ 05:15AM BLOOD WBC-7.7 RBC-3.74* Hgb-10.3* Hct-33.4* MCV-89 MCH-27.5 MCHC-30.8* RDW-23.9* RDWSD-74.4* Plt ___ CXR (___): No evidence of substantial pneumothorax after interval placement of right pigtail drain. CXR ___ am): 1. The right pigtail catheter has changed in position, and some of the side ports are now external to the pleural space. Associated accumulation of a small right pleural effusion and worsening right lower lobe atelectasis. 2. Minimal subcutaneous emphysema of the soft tissues overlying the lateral right seventh and eighth rib fractures. CXR ___ pm):Comparison to ___, 10:23. The drained pleural effusion on the right has further decreased in extent. There is no evidence for the presence of a right pneumothorax. Stable appearance of the heart and of the left lung. CXR (___): Comparison to ___. The right pigtail catheter is in unchanged position. There is no evidence for the presence of a right pneumothorax. The right pleural effusion has not Re occurred. Stable normal appearance of the cardiac silhouette and of the left lung. CXR ___ comparison with the study of ___, with the chest tube on water seal, there is no evidence of pneumothorax. Mild opacification at the right base laterally is essentially unchanged. The remainder the study is stable. CXR (___) Cardiomediastinal silhouette is within normal limits. No pneumothoraces are seen. There is likely a small right-sided pleural effusion and there is some increased soft tissue density, likely related to the prior pleural catheter entry site. There is no overt pulmonary edema. Medications on Admission: ASA 81' Effexor XR 300' atorvastatin 40' gabapentin 800'''' isosorbide mononitrate ER 30 PRN metoprolol succinate ER 100' nitroglycerin 0.3 PRN omeprazole 40'' trazodone 50 PRN alprazolam 0.25 PRN Discharge Medications: 1. Docusate Sodium 100 mg PO BID Hold if loose stools 2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - Moderate Do not combine with other narcotics or alcohol. Do not drive while taking RX *oxycodone [___] 5 mg 2 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Gabapentin 800 mg PO QID 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. LORazepam 0.25 mg PO QHS:PRN insomnia 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain 10. Omeprazole 40 mg PO BID 11. TraZODone 50 mg PO QHS:PRN insmonia 12. Venlafaxine XR 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. right pneumothorax 2. right pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with ptx with pig tail; please do standing expiratory film // interval change TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph FINDINGS: In comparison to ___ chest radiograph, there is a new small right pleural effusion obscuring the right hemidiaphragm. Additionally, the right pigtail catheter appears to have changed position; some of the side ports are now external to pleural surface resulting in accumulation of the right pleural fluid. There is also interval worsening of the right lower lung atelectasis. The left lung is well-expanded and clear. The right lateral seventh and eighth rib minimally displaced fractures are again seen; there is mild subcutaneous emphysema of the overlying soft tissue. The cardiomediastinal and hilar contours are stable. There is no pulmonary edema or pneumothorax. IMPRESSION: 1. The right pigtail catheter has changed in position, and some of the side ports are now external to the pleural space. Associated accumulation of a small right pleural effusion and worsening right lower lobe atelectasis. 2. Minimal subcutaneous emphysema of the soft tissues overlying the lateral right seventh and eighth rib fractures. RECOMMENDATION(S): Discussed findings with ___ at 11:45 via telephone conversation (___). The impression and recommendation above was entered by Dr. ___ on ___ at 11:47 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ s/p assault with right PTX, prior pigtail malpositioned, now s/p removal and placement of new pigtail // ? position of new tube and ? PTX ? position of new tube and ? PTX IMPRESSION: Comparison to ___, 10:23. The drained pleural effusion on the right has further decreased in extent. There is no evidence for the presence of a right pneumothorax. Stable appearance of the heart and of the left lung. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with R PTX s/p re-placement of pigtail yesterday // placement of pigtail,status of PTX placement of pigtail,status of PTX IMPRESSION: Comparison to ___. The right pigtail catheter is in unchanged position. There is no evidence for the presence of a right pneumothorax. The right pleural effusion has not Re occurred. Stable normal appearance of the cardiac silhouette and of the left lung. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with R PTX s/p pigtail placement on water seal // please eval for resolution of PTX please eval for resolution of PTX IMPRESSION: In comparison with the study of ___, with the chest tube on water seal, there is no evidence of pneumothorax. Mild opacification at the right base laterally is essentially unchanged. The remainder the study is stable. Radiology Report INDICATION: ___ year old woman with R ptx s/p pigtail placed 3 days ago // please eval for resolution R PTX, pleural effusion COMPARISON: Radiographs from ___. IMPRESSION: There is a right basilar pigtail catheter. There is a tiny pleural effusion versus scarring which is unchanged. Lungs are grossly clear. Heart size is within normal limits. No pneumothoraces are seen. There are no pneumothoraces. Radiology Report INDICATION: ___ year old woman with R ptx s/p pigtail placed 3 days ago // please eval for resolution PTX, pleural effusion COMPARISON: Radiographs from ___ IMPRESSION: Cardiomediastinal silhouette is within normal limits. No pneumothoraces are seen. There is likely a small right-sided pleural effusion and there is some increased soft tissue density, likely related to the prior pleural catheter entry site. There is no overt pulmonary edema. Radiology Report INDICATION: ___ year old woman with rib fx s/p pigtail removal for ptx // Assess for pneumo/hemothorax COMPARISON: Radiographs from ___ IMPRESSION: The right basilar pigtail catheter has been removed. No pneumothoraces are seen. Heart size is within normal limits. Lungs are clear without focal consolidation or overt pulmonary edema There is some increase soft tissue density at the right costophrenic angle at the insertion of the previous pleural catheter. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Assault, Pneumothorax Diagnosed with Traumatic pneumothorax, initial encounter, Asslt by strike agnst or bumped into by another person, init temperature: 97.8 heartrate: 87.0 resprate: 16.0 o2sat: 98.0 sbp: 148.0 dbp: 75.0 level of pain: 8 level of acuity: 2.0

You were admitted for management of a pneumothorax and associated pleural effusion with pigtail chest tube placement and pain control optimization. Both conditions resolved and the chest tube was removed prior to discharge. Please follow the below directions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, 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. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Epinephrine / Xylocaine / Novocaine / Ampicillin / aspirin Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: Colonoscopy Video capsule endoscopy History of Present Illness: Ms. ___ is a ___ with history of myeloproliferative disorder, cerebrovascular accident x2 (___), esophageal varices complicated by remote gastrointestinal bleed with splenorenal shunt status post splenectomy, gastritis, and L1 fracture (___) who presents with subjective weakness. She was in her usual state of health until approximately 4 weeks prior to admission, when she developed subjective generalized weakness and fatigue, which she attributed, at least in part, to continued recovery from recent L1 fracture, with progression over that period. Although she is not bedbound, she ambulates minimally around the house and rarely leaves. She is not limited by lightheadedness, chest pain, dyspnea on exertion, or low back pain (reports well-controlled and weaned from TLSO brace to lumbar corset), but rather by fatigue. She has no difficulty brushing her hair or rising from a chair without support, though she does require a walker for assistance with ambulation. Over the same period, she notes persistent loose stools, consistent in frequency with baseline attributable to irritable bowel syndrome; she does endorse occasionally grossly bloody stools due to hemorrhoids, as well as rarely melanotic stools less than once a month. She denies bleeding from any other orifice. Her appetite has been poor in general, and she recalls a few-pound unintentional weight loss over an uncertain period (weeks), though her appetite is robust at this moment. Ultimately persuaded by her family, she notes that she was reluctant to see her primary care provider until the day prior to admission, when urinalysis/urine culture were positive for E. coli at ___. Despite 3 doses of nitrofurantoin, she remains weaker than expected. She denies fevers/chills, abdominal pain, or dysuria/hematuria. In the ED, initial vital signs were as follows: 99.0 91 149/66 20 98%. Admission labs were notable for white blood cell count of 14 (variable baseline leukocytosis), hematocrit of 26 (down from recent value of 30, but variable baseline), platelets of 100 (up from ___ at baseline), INR of 2.4 (on Coumadin), and negative urinalysis. Stool was guiac-positive. 2 large-bore peripheral intravenous lines were placed. The gastroenterology service was consulted, with colonoscopy and/or video capsule endoscopy planned. On transfer, vital signs were: 98.4 80 151/78 18 95%. On arrival to the floor, patient reports extreme hunger, but she is otherwise comfortable. Past Medical History: Myeloproliferative disorder (polycythemia ___ and/or essential thrombocythemia) Hypertension Cerebrovascular accident x2 (___) Remote gastrointestinal bleed secondary to esophageal varices complicated by splenorenal shunt status post splenectomy Bilateral total knee replacement Osteoarthritis L1 fracture in ___ Social History: ___ Family History: Hypertension in multiple family members. Half-brother diagnosed with leukemia at advanced age. Physical Exam: On admission: VS: 98.9, 148/68, 78, 18, 96% RA Weight: 55kg GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclerae pale, but anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g BACK no CVAT or spinous/paraspinous tenderness EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, strength ___ throughout, sensation grossly intact throughout SKIN notable pallor, no ulcers or lesions At discharge: VS: AF/98.8, 148/62 (130s-160s/60s-70s), 82 (70s-80s), 18 (___), 97% (97-98% RA) Orthostatic VS 110/50 -> 100/48 -> 104/46 GEN Alert, oriented, anxious-appearing in NAD HEENT MMM EOMI sclerae pale, but anicteric, OP clear NECK supple, no JVD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g BACK no CVAT or spinous/paraspinous tenderness EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, strength ___ throughout, sensation grossly intact throughout SKIN notable pallor, no ulcers or lesions Pertinent Results: On admission: ___ 12:48PM BLOOD WBC-14.0*# RBC-3.71* Hgb-7.0* Hct-26.0* MCV-70*# MCH-18.8*# MCHC-26.9* RDW-21.5* Plt ___ ___ 12:48PM BLOOD Neuts-66 Bands-0 ___ Monos-1* Eos-6* Baso-0 ___ Myelos-0 NRBC-12* ___ 01:30PM BLOOD ___ PTT-39.1* ___ ___ 01:30PM BLOOD Glucose-97 UreaN-14 Creat-0.5 Na-139 K-3.6 Cl-106 HCO3-24 AnGap-13 ___ 05:50AM BLOOD Albumin-3.0* Calcium-7.6* Phos-3.0 Mg-2.1 Iron-12* ___ 05:50AM BLOOD calTIBC-412 Ferritn-107 TRF-317 ___:30PM BLOOD TSH-2.6 ___ 01:34PM BLOOD Lactate-1.2 ___ 03:01PM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:01PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG At discharge: ___ 06:10AM BLOOD WBC-16.7* RBC-3.98* Hgb-7.5* Hct-27.9* MCV-70* MCH-18.8* MCHC-26.8* RDW-21.4* Plt Ct-63* ___ 06:10AM BLOOD ___ PTT-35.2 ___ ___ 06:10AM BLOOD Glucose-85 UreaN-12 Creat-0.6 Na-142 K-4.1 Cl-107 HCO3-27 AnGap-12 ___ 06:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3 Microbiology: Blood culture (___) x2: No growth to date Imaging: EKG (___): Sinus rhythm. Left ventricular hypertrophy. Minor ST-T wave abnormalities. Since the previous tracing of ___ ventricular premature beats are no longer seen and the rate is decreased. IntervalsAxes ___ ___ CXR PA/lateral (___): Small bilateral pleural effusions, right greater than left. Subtle opacity at the right lung base is concerning for pneumonia. Colonoscopy (___): Internal hemorrhoids Linear friability, erythema and petechiae in the distal rectum compatible with scope trauma Nonbleeding rectal varix seen in distal rectum Stool in the whole colon Foreign body in the sigmoid colon and distal rectum Diverticulosis of the whole colon Otherwise normal colonoscopy to cecum Video capsule endoscopy (___): Internal hemorrhoids Linear friability, erythema and petechiae in the distal rectum compatible with scope trauma Nonbleeding rectal varix seen in distal rectum Stool in the whole colon Foreign body in the sigmoid colon and distal rectum Diverticulosis of the whole colon Otherwise normal colonoscopy to cecum Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY Hold for SBP<100 2. Citalopram 10 mg PO DAILY 3. Diazepam 5 mg PO HS:PRN insomnia 4. Losartan Potassium 100 mg PO DAILY Hold for SBP<100 5. Nitrofurantoin (Macrodantin) 50 mg PO Q6H 6. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (___) 7. Propranolol 40 mg PO DAILY:PRN palpitations 8. Ranitidine 150 mg PO DAILY 9. Simvastatin 20 mg PO DAILY 10. Warfarin 2.5 mg PO 2X/WEEK (MO,FR) 11. Warfarin 5 mg PO 5X/WEEK (___) 12. Vitamin D 1000 UNIT PO DAILY 13. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY Hold for SBP<100 2. Citalopram 10 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Hold for SBP<100 5. Diazepam 5 mg PO HS:PRN insomnia 6. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (___) 7. Propranolol 20 mg PO DAILY:PRN palpitations 8. Ranitidine 150 mg PO DAILY 9. Simvastatin 20 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Enoxaparin Sodium 80 mg SC DAILY RX *enoxaparin 80 mg/0.8 mL Please inject 1 80-mg syringe Daily Disp #*10 Syringe Refills:*0 13. Warfarin 5 mg PO DAILY16 Please take 5mg daily unless directed to change your dose by your primary care doctor. Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary: Acute-on-chronic microcytic anemia Urinary tract infection Secondary: Myeloproliferative disorder History of cerebrovascular accidents Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Weakness, question pneumonia. FINDINGS: PA and lateral views of the chest were provided. There are clips again noted in the left upper quadrant. There has been interval development of a small right pleural effusion with increasing ground-glass opacity at the right lower lung which could indicate pneumonia. There is mild blunting of the left CP angle which is stable and may represent a chronic small effusion or pleural thickening. The heart and mediastinal contours appear stable. There is no pneumothorax. Bony structures appear intact. IMPRESSION: Small bilateral pleural effusions, right greater than left. Subtle opacity at the right lung base is concerning for pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: UTI COMPLAINTS Diagnosed with ANEMIA NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS temperature: 99.0 heartrate: 91.0 resprate: 20.0 o2sat: 98.0 sbp: 149.0 dbp: 66.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking part in your care during your admission to ___. As you know, you were admitted because you were feeling weak and tired, likely due to multiple factors, including low red blood cell count, urinary tract infection, and deconditioning after your recent fall. Although you have a low red blood cell count at baseline due to your myeloproliferative disorder, there was some concern that you were bleeding slowly from your gastrointestinal tract. You were evaluated by the gastrointestinal doctors, who suggested a study of your large intestine (colonoscopy). Colonoscopy did not show any active bleeding, and you also underwent a second study (video capsule endoscopy), the results of which are pending at discharge. In anticipation of colonoscopy, your warfarin was held, and you received another blood thinning medication (heparin) while your INR (a measure of your blood's clotting ability) was low. Following colonoscopy, your warfarin was resumed, and you were starting on another blood thinning medication (enoxaparin), which you will need to continue for a few days until directed otherwise by your primary care doctor. You also completed treatment for urinary tract infection. You were evaluated by the physical therapists, who felt that you were safe to go home without rehabilitation services. The following changes were made to your medications: - Please STOP nitrofurantoin since you have completed your antibiotic course for urinary tract infection. - Please CONTINUE warfarin 5mg daily and enoxaparin 80mg ONCE A DAY unless directed otherwise by your primary care doctor. You will be able to stop enoxaparin injections once your INR (a measure of your blood's clotting ability) falls into an appropriate range.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: amoxicillin Attending: ___. Chief Complaint: Patient is an ___ yr old G1 at 24 weeks with fever and flu like illness. Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo G1 at 24 weeks 2 days w mild intermittent asthma who presents with three days of fevers, chough, and malaise. She started feeling ill on ___. She progressively became more fatigued with diffuse myalgias and cough. The patient reports that she had a fever to 103 on ___, when she presented to an outside urgent care facility. There, she was diagnosed with a upper respiratory infection and given azithromycin. She took two doses prior to presentation. Her symptoms did not improve, and she feels worse today. She reports decreased appetite, 2 episodes of emesis, and decreased output of concentrated urine. She also reports cough productive of scant white sputum, and mild shortness of breath. Denies contractions, leakage of fluid, vaginal bleeding. Active fetal movement. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes, RUQ/epigastric pain. Denies chest pain, shortness or breath, palpitations. Denies abd pain. Denies recent falls or abd trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. Past Medical History: PNC: - ___ ___ by LMP c/w first tri US - O + ab neg/ HIV-/ HbSag-/ RI/ RPRNR /GC-/CT-/Trich- - Varicella immune by hx - Declined screening - FFS wnl, LLP [ ] GLT not yet done - Issues *) Low lying placenta on FFS (___) OBHx: - G1 current, spontaneous GynHx: - regular menses - No paps - denies fibroids, endometriosis, ovarian cysts - denies STIs, including HSV PMH: - asthma: one hospitalization in childhood; no intubations PSH: breast reduction Social History: ___ Family History: non contributory Physical Exam: On admission: Physical Exam ___ ___: 116 ___ 22:55MSpO2: 100% ___ 18:15Temp.: 101.0°F ___ 16:20MSpO2: 100% ___ 15:25BP: 106/67 (76) ___ 15:24Temp.: 100.1°F Gen: A&O, comfortable CV: RRR, no m/r/g Pulm: nl work of breathing and rate; on initial presentation, diffuse wheezing per Dr. ___. S/p nebulizer treatment, lungs are CTAB. Air movement in all lung fields Abd: soft, gravid, nontender Ext: no calf tenderness, no edema On discharge: Vitals ___ 0411 Temp: 97.7 PO BP: 95/57 HR: 101 RR: 18 O2 sat: 98% O2 delivery: RA Pain Score: ___ ___ 0000 Temp: 98.2 PO BP: 102/64 HR: 109 RR: 20 O2 sat: 97% O2 delivery: RA Pain Score: ___ Fetal Monitoring: FHR: 145-155 FM: Present Fluid Balance (last updated ___ @ 414) Last 8 hours Total cumulative 50ml IN: Total 1250ml, IV Amt Infused 1250ml OUT: Total 1200ml, Urine Amt 1200ml Last 24 hours Total cumulative -792ml IN: Total 3308ml, PO Amt 1020ml, IV Amt Infused 2288ml OUT: Total 4100ml, Urine Amt 4100ml Gen: NAD, speaking in full sentence es CV: tachycardic to low 100s, regular rate Resp: no evidence of respiratory distress, CTAB Abd: soft, gravid, non-tender Ext: no edema, non-tender Pertinent Results: ___ 04:10PM BLOOD WBC-7.4 RBC-3.59* Hgb-10.2* Hct-30.5* MCV-85 MCH-28.4 MCHC-33.4 RDW-12.5 RDWSD-38.4 Plt ___ ___ 04:10PM BLOOD Neuts-83.9* Lymphs-6.5* Monos-8.8 Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.22* AbsLymp-0.48* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.01 ___ 06:26AM BLOOD Glucose-83 UreaN-3* Creat-0.3* Na-140 K-3.8 Cl-107 HCO3-22 AnGap-11 ___ 09:40AM BLOOD Glucose-101* UreaN-2* Creat-0.4 Na-140 K-3.3* Cl-108 HCO3-22 AnGap-10 ___ 04:10PM BLOOD Glucose-91 UreaN-3* Creat-0.4 Na-138 K-3.8 Cl-103 HCO3-21* AnGap-14 ___ 4:10 pm URINE Source: ___. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 07:50PM OTHER BODY FLUID FluAPCR-POSITIVE* FluBPCR-NEGATIVE Medications on Admission: PNV, albuterol PRN Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in a day RX *acetaminophen 500 mg 1 tablet(s) by mouth Q6H PRN Disp #*50 Tablet Refills:*1 2. GuaiFENesin ___ mL PO Q6H:PRN Cough RX *guaifenesin 100 mg/5 mL 200 mg by mouth Q4H PRN Refills:*2 3. OSELTAMivir 75 mg PO BID Duration: 5 Days Please continue entire course RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*7 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Influenza A Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old woman, 24 weeks pregnant with cough, fever, asthma// eval for consolidation/pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lungs are well expanded and clear. There is no pulmonary edema, pleural effusion or pneumothorax. Cardiomediastinal silhouette is unremarkable. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: ILI, Pregnant Diagnosed with Oth pregnancy related conditions, second trimester, Fever, unspecified, Myalgia, unspecified site, Diseases of the resp sys comp pregnancy, second trimester, Other pneumonia, unspecified organism, 24 weeks gestation of pregnancy temperature: 99.3 heartrate: 115.0 resprate: 20.0 o2sat: 99.0 sbp: 115.0 dbp: 85.0 level of pain: 3 level of acuity: 3.0

Dear ___, You were admitted to the antepartum unit for treatment of influenza. You were started on oseltamivir (Tamiflu) for treatment as well as Tylenol for fever reduction. You were given IV fluids for rehydration. Your strep test is still pending. At this time, you are safe for discharge to home. Please follow these instructions: - Complete your course of Tamiflu for a total of 5 days. - You may take acetaminophen 500-1000mg every 6 hours for pain - You maybe take guaifenesin 10mL (200mg) every four hours as needed for cough Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Amoxicillin / benzocaine Attending: ___. Chief Complaint: sob Major Surgical or Invasive Procedure: none History of Present Illness: ___ year-old female with the history below who presented to the ED today complaining of dyspnea. She reported 3 dd of cough, increased sputum production, URI symptoms, and her sob became worse last night. In the ED she was found to have hypoxemia (ra sat high ___. CXR had some ? atypical infiltrate. She was given azith, pred, neb, and improved. She was admitted. Past Medical History: PAST ONCOLOGIC HISTORY: 1. Patient had a protracted course of pneumonia starting in ___ required two months of antibiotics. 2. Presented to PCP in early ___ with symptoms of headache, chest discomfort, right shoulder pain, right arm weakness/tingling, and difficulty swallowing. A CT scan was performed on ___ and showed extensive adenopathy, paratracheal, posterior to the SVC, compressing the SVC, and enveloping the right main pulmonary artery. There was also extensive hilar adenopathy, precarinal adenopathy, and azygoesophageal adenopathy. 3. Patient was subsequently admitted to ___ from ___ to ___. Bronchoscopy with biopsy of level 7 and 4L lymph nodes was performed. Note that stenting of right bronchus intermedius was also performed. Pathology was notable for malignant cells, consistent with small cell carcinoma. Completion of staging evaluation revealed no brain or osseous metastases; patient was considered to have limited stage disease. 4. Cycle 1 of chemotherapy was started on ___ cisplatin 75 mg/m2 on day 1 and etoposide 100 mg/m2 on days ___. 5. Initial visit with radiation oncology on ___. Radiation was initiated on ___ (31 treatments planned). 6. Patient reported increased tinnitus and hearing loss at visit on ___. She was evaluated by audiologist (Dr. ___ with findings notable for high frequency sensorineural hearing loss. Cycle 2 of cisplatin and etoposide administered on ___ without modification (note that cisplatin administered on day 3 of cycle). 7. Patient subsequently developed chest and upper abdominal discomfort associated with odynophagia. This was attributed to GERD with possible contribution from mucositis and she was started on omeprazole 20 mg QD and magic mouthwash as needed. 8. Patient noted to have new onset right calf swelling on ___. A lower extremity ultrasound was negative for DVT. 9. Bronchial stent was removed on ___. 10. Patient presented to clinic on ___ with chills, sore throat, shortness of breath, and cough. Patient was admitted to the hospital for further evaluation and care. CXR was negative for pneumonia. Blood and urine cultures were negative. Patient was treated with IVF and sucralfate was added to regimen. She was discharged home the following day. 11. Cultures from bronchial stent removal returned positive for stenotrophomonas maltophilia. Patient completed a two week course of Bactrim (15 mg/kg/day). 12. Cycle 3 of cisplatin and etoposide initiated on ___. Cycle was complicated by poor PO intake, hypovolemia, and orthostasis requiring multiple visits to ___ IVF. 13. Follow up audiology evaluation revealed progressive hearing loss. Carboplatin AUC 6 was substituted for cisplatin in cycle 4 of therapy (administered with etoposide on ___. 14. Radiation therapy end date was ___. Patient received a total dose of 5580 cGy. 15. Prophylactic cranial irradiation initiated on ___. PAST MEDICAL HISTORY: Small cell lung carcinoma Stage II IDC of breast Chronic obstructive pulmonary disease Tobacco abuse Vertebral degenerative disc disease Chronic back pain Scoliosis Left shoulder bursitis Osteoporosis History of pneumonia Social History: ___ Family History: 2 cousins (1 maternal, 1 paternal) both diagnosed with BC in ___. Mom with Lung ca, Dad throat ___ Physical Exam: Afebrile and vital signs stable (reviewed - see according flowsheets and or bedside record); specific comments regarding VSS FSBG (if recorded): General Appearance: pleasant, comfortable, no acute distress Eyes: PERRL, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, oropharynx without exudate or lesions, no supraclavicular or cervical lymphadenopathy, no JVD, no carotid bruits, no thyromegaly or palpable thyroid nodules Respiratory: CTA b/l with good air movement throughout Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM Extremities: no cyanosis, clubbing or edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert, oriented to self, time, date, reason for hospitalization. Cn II-XII intact. ___ strength throughout all extremities and symmetric. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps. No asterixis, no pronator drift, fluent speech. Psychiatric: pleasant, appropriate affect GU: no urinary catheter in place Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache 3. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb 7. Mirtazapine 7.5 mg PO QHS 8. Morphine SR (MS ___ 60 mg PO Q12H 9. Omeprazole 20 mg PO DAILY 10. Bisacodyl 10 mg PO DAILY:PRN c 11. Multivitamins 1 TAB PO DAILY 12. Thiamine 100 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 3 Days RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb neb q 6 H Disp #*60 Ampule Refills:*0 3. Nicotine Patch 21 mg TD DAILY RX *nicotine [Nicoderm CQ] 21 mg/24 hour 1 patch daily Disp #*30 Patch Refills:*0 4. PredniSONE 40 mg PO DAILY Duration: 3 Days RX *prednisone 10 mg 4 tablets(s) by mouth daily Disp #*12 Dose Pack Refills:*0 5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 7. Bisacodyl 10 mg PO DAILY:PRN c 8. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. FoLIC Acid 1 mg PO DAILY 11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb 12. Mirtazapine 7.5 mg PO QHS 13. Morphine SR (MS ___ 60 mg PO Q12H 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: AECOPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with sob // PNA? PNA? IMPRESSION: Compared to chest radiographs ___. Mild interstitial abnormality is new, either edema or atypical pneumonia. There is no consolidation to suggest bacterial pneumonia. Heart size is normal though increased compared to ___. No pleural effusion. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation temperature: 98.6 heartrate: 103.0 resprate: 16.0 o2sat: 97.0 sbp: 137.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

stop smoking as we discussed. Keep your follow up appointments take medications as prescribed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Lamictal / Dilantin Attending: ___. Chief Complaint: falls Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ year-old R-handed woman with PMHx of HTN, HL, possible epilepsy and spinal stenosis who presents with multiple falls. Pt reports that starting ___ years ago she began to have intermittent slurring of her speech (___) and stiffening of her legs (1x/month) that would always resolve within 10 mins. She would also occasionally have difficulty with writing "my handwriting would become chicken scratch", which would also resolve within 10 mins. These episodes were thought to be seizures, but she has had multiple LTM admissions (most recently at ___ in ___ that did not capture any of these events and did not find any EEG abnormalities. She had an EEG done in ___ in ___ where the "thought they saw some changes in the temporal lobe". She was initially put on dilantin, but this gave her a rash and so she was switched to different medications. She is followed by Dr. ___ here at ___, and in ___, she was referred to Dr. ___ consultation on if the above events could be TIAs. He reviewed her OSH MRI and determined that both hx and imaging were not c/w strokes or TIA's. Pt then feel in Novemeber onto her head on the R side where her glasses broke and lacerated her R forehead. Pt reports that she felt like she got a "sudden push" from behind in the middle of her back that propelled her forwards associated with stiff legs. She was unable to get herself up on her own, so she had an ambulance come and take her to ___. ___, where a CT head was done that was negative for acute process. She saw Dr. ___ at the end of ___ and she was changed from generic keppra to brandname keppra (which was actually started by the patient in the middle of ___. She then had some sensation of her legs stiffening in the beginning of ___, but these were c/w her prior episodes where it disappeared within 10 mins. She saw Dr. ___ again in early ___ who put her on trileptal with the plan to uptitrate the trileptal and wean off the keppra. Pt increased her trileptal dose yesterday from 300mg BID to ___ QAM and 450mg QPM. . Yesterday pt woke up feeling fine, got out of bed, ate breakfast, but then at around 8am was walking into the kitchen and fell, hitting her L hand and L forehead. She reports that she had the same sensation of being propelled forwards with stiff legs as she did in ___. However, the leg stiffness lasted for 1.5hrs this time. She was able to get over to a chair and allow it to subside. She reports that she started to feel mildly nauseated at this time, but did not vomit. She denies any associated H/A, numbness/tingling, vision disturbance, difficulty with speech production or comprehension, weakness, vertigo or any other associated sx at that time. She then "puttered around the house" and went to make lunch at around noon and "felt the stiffness coming on" along with a sensation of feeling off-balance (but not vertiginous), and she was able to make it to a couch. Again the sensation of stiff legs lasted for 1.5 hours. She got up after it dissipated and ate lunch, but then at 6pm when she went to have dinner she felt the stiffening again and her husband was able to help her get to the couch. This episode of stiffening lasted 3 hours, but did eventually go away and she was able to sleep. . This morning, she woke up, and got out of bed, but as soon as she took a few steps away from the bes, she felt both legs stiffen. She was able to walk over to the couch, where she stayed until 1:30pm. Her daughter came to visit, and noticed that when the pt tried to eat soup her arm appeared too stiff to lift the soup to her mouth. Also, when the daughter tried to take the spoon out of her mother's hand she had to "pry it out of her hand", as pt's hand was "clasped" around the spoon. Pt was also having slurred (but appropriate) and mumbled speech at this time, that was similar to her prior events of slurred speech. Pt's husband and daughter felt that the stiffness was too severe to attempt to get the patient downstairs and into the car themselves so they called ___ to be taken to the ED. Her sx had resolved by the time she got to the ED. . In the ED, pt's daughter noted that the pt had another episode of slurred speech, but that this was more subtle and lasted for only a few mins. . On neuro ROS, the pt denies current headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. . On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - HTN - HL - osteopenia - spinal stenosis (per pt report) - above described intermittent episodes of slurred speech, stiff legs and handwriting difficulties thought to be epilepsy Social History: ___ Family History: Her father had coronary artery disease. Her mother had pancreatic cancer. No neurological history in family, including no seizure disorders. Physical Exam: ADMISSION Physical Exam: Vitals: T:98.4 P: 74 R: 16 BP:155/89 SaO2: 97% on 2L NC General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, pt with bruising over L eye and forehead Neck: Supple, no carotid bruits appreciated. No nuchal rigidity 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. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally, abrasion on dorsal surface of L hand. . Neurologic: . -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. . -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. . -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5- ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 . -Sensory: No deficits to light touch, pinprick, vibratory sense, proprioception throughout. No extinction to DSS. Pt had impaired temperature sensation in her proximal R arm, her R leg and her proximal L leg (felt tuning fork as warm). . -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 1 R 2 2 2 3 1 Plantar response was flexor on the R and extensor on the L. . -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. . -Gait: Good initiation. Hesistant walk with small steps, but this gait appeared self-imposed as pt afraid of falling. Able to walk in tandem for 5 steps without falling. Romberg absent. Pertinent Results: ___ 03:35PM WBC-5.6 RBC-4.37 HGB-14.2 HCT-39.1 MCV-90 MCH-32.5* MCHC-36.3* RDW-12.7 ___ 03:35PM NEUTS-68.5 ___ MONOS-6.1 EOS-0.5 BASOS-1.0 ___ 03:35PM PLT COUNT-146* ___ 03:35PM CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-2.1 ___ 03:35PM GLUCOSE-127* UREA N-10 CREAT-0.7 SODIUM-131* POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-26 ANION GAP-13 ___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 06:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:49PM cTropnT-<0.01 ___ CT head No acute intracranial process ___ C-spine Flex/Ext Xray There are extensive degenerative changes demonstrated, as well as diffuse osteopenia. Alignment is preserved. For precise details, please review MRI of the cervical spine obtained the same ___ earlier. ___ MR ___, T, L spine FINDINGS: Evaluation of the cervical spine demonstrates mild disc bulges at C4-C5 and C2-C3 without significant compromise of the canal or foramina.Bilateral foraminal narrowing is noted at C4-C5 which is moderate. There is apparent prominence of the posterior epidural fat. Evaluation of the thoracolumbar spine demonstrates no abnormality of marrow signal, vertebral body height, and alignment. Mild disc bulges are seen at L4-L5 and L5-S1. No evidence of cord signal abnormality or cord compression. Bilateral facet DJD at L4-L5 and L5-S1. No pathologic enhancement. There are apparent prominent veins in the bilateral occipital lobes. Consider MRI of the brain for further evaluation. IMPRESSION: Mild degenerative changes as described. No evidence of significant canal compromise or cord compression. No cord signal abnormality. Apparent prominent veins in the bilateral occipital lobes. Consider MRI of the brain for further evaluation. Medications on Admission: - Diovan 160mg QD - keppra XR 500mg Q24hrs - fish oil QD - vitamin D3 1,000 units QD - ASA 81mg QD - verapamil 360mg QD - HCTZ 12.5mg QD - alendronate 70mg QWeek - simvastatin 40mg QD - levothyroxine 125mcg QD - folic acid ___ QD - trileptal 300mg QAM and 450mg QPM Discharge Medications: 1. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Keppra XR 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 8. verapamil 120 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO Q24H (every 24 hours). 9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 1. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Keppra XR 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 8. verapamil 120 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO Q24H (every 24 hours). 9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Outpatient Physical Therapy As per ___ Discharge Disposition: Home Discharge Diagnosis: Cervical Spondylosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with weakness and trauma, rule out pneumonia. COMPARISON: No relevant comparisons available. TWO VIEWS OF THE CHEST: The lungs are low in volume but clear. The cardiac silhouette is top normal. The mediastinal silhouette and hilar contours are normal. An opacity in the right lower lobe likely represents summation of structures related to the ribs. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: ___ female with weakness, trauma, rule out pneumonia, rule out intracranial hemorrhage. COMPARISON: No relevant comparisons available. TECHNIQUE: MDCT images were acquired through the head without contrast. Standard soft tissue algorithms, bone algorithms and multiplanar reformations were obtained and reviewed. FINDINGS: There are small bilateral basal ganglia punctate areas of hyperattenuation consistent with calcifications. No acute intracranial hemorrhage, large vascular territory infarct, shift of midline structures or mass effect is present. Mild hypoattenuation of the bihemispheric periventricular white matter is consistent with sequalae of small vessel ischemic disease. The ventricles and sulci are mildly prominent consistent with age-related atrophy. The visible paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial process. Radiology Report REASON FOR EXAMINATION: Recurrent fall. AP, lateral, and flexion position of the cervical spine were reviewed. There are extensive degenerative changes demonstrated, as well as diffuse osteopenia. Alignment is preserved. For precise details, please review MRI of the cervical spine obtained the same day earlier. Radiology Report TECHNIQUE: MRI of the complete spine without and with gad. HISTORY: Falls and stiffening, assess for acute process. COMPARISON: None. FINDINGS: Evaluation of the cervical spine demonstrates mild disc bulges at C4-C5 and C2-C3 without significant compromise of the canal or foramina.Bilateral foraminal narrowing is noted at C4-C5 which is moderate. There is apparent prominence of the posterior epidural fat. Evaluation of the thoracolumbar spine demonstrates no abnormality of marrow signal, vertebral body height, and alignment. Mild disc bulges are seen at L4-L5 and L5-S1. No evidence of cord signal abnormality or cord compression. Bilateral facet DJD at L4-L5 and L5-S1. No pathologic enhancement. There are apparent prominent veins in the bilateral occipital lobes. Consider MRI of the brain for further evaluation. IMPRESSION: Mild degenerative changes as described. No evidence of significant canal compromise or cord compression. No cord signal abnormality. Apparent prominent veins in the bilateral occipital lobes. Consider MRI of the brain for further evaluation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with OTHER MALAISE AND FATIGUE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, CHEST PAIN NOS temperature: 98.4 heartrate: 74.0 resprate: 16.0 o2sat: 97.0 sbp: 155.0 dbp: 89.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ on ___ for evaluation of possible seizures. You were placed on long term monitoring by EEG. Your EEG did not show any seizure activity during these episodes of slurred speech or dizziness. You also had a consult by the spine specialists in regards to cervical and lumbar spinal canal stenosis. At this time there is no recommendation for surgical intervention. You should follow up in the spine clinic as instructed (their number is below). You should begin to taper off your Keppra and Trileptal as per the instructions given to you by Dr. ___. If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of multiple myeloma diagnosed ___ currently undergoing radiation therapy for L5 plasmacytoma presenting today with chief complaint of new fevers, chills and body aches (tmax 101.1 on morning of admission) and fatigue. She completed a 2 week dexamethasone course on ___. She has yet to receive chemotherapy treatment though feels very anxious and emotional regarding the prospect of chemotherapy. Overnight she began feeling feverish with chills and took 2 Tylenol. She again felt feverish this morning and had a fever to 101.1. In the ED initial vitals were 100.7 76 107/47 18 98%. Labs were notable for WBC of 2.7 (83 % PMNs). CXR showed no acute process. UA was without evidence of UTI. Blood and urine cultures were sent. The patient was given vancomycin and cefepime and admitted to OMED for further evaluation. On the floor the patient appears comfortable. She endorses a mild ___ frontal headache though denies neck stiffness, light sensitivity, nausea, vomiting. She denies cough, chest pain, or shortness of breath. She denies abdominal pain, diarrhea, or constipation, though her last bowel movement was yesterday. She denies dysuria, myalgias, chills, or fevers at this time. Her current back pain is ___ in severity. She notes that this morning she felt a "shift" in her lower back, but denies current pain, bowel or bladder incontinence, worsening weakness, numbness or tingling in her lower extremities. She denies sick contacts, recent travel, though was in the hospital on ___ for evaluation of back pain. Past Medical History: Onc: Multiple myeloma without treatment. IgG level os 3196 on ___. IFE shows monoclonal IgG kappa of 38%. PMHx: - motor vehicle accident in ___ - endometriosis - fibroids in her uterus - benign tumors in the breast removed in her early ___ - hypothyroidism for which she was on a Synthroid, however, it developed palpitations and stopped the medication on her own. She states that her PCP has not repeated her thyroid stimulating hormone levels since she stopped the medication. - asthma attack in ___. She believes this was related to paint exposure. Social History: ___ Family History: -Brother died at age ___ of an aneurysm in his stomach. He was also obese. -Mother died at age ___ of colon cancer. -Father died at age ___. Had diabetes, myocardial infarction, and a gangrenous infection. -Sister who is alive and well with a history of hypothyroid and hypertension. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: 98.8 104/42 69 18 94% RA General: Very pleasant woman, lying in bed in NAD, face mask on HEENT: Oropharynx clear, moist mucous membranes, no LAD, no photosensitivity with flashlight, PERRL, scleara anicteric Neck: Soft, without LAD, no meningismus CV: Regular rate and normal rhythm, no m/r/g Lungs: CTAB, no wheezes, rhonchi, crackles Abdomen: Normoactive BS, no tenderness to palpation, no rebound or guarding GU: No foley Ext: Warm and well perfused, no edema. Point tenderness to palpation in ASIS bilaterally Neuro: CN II-XII intact, ___ strength in upper extremities bilaterally, ___ strength in lower extremities bilaterally, sensation to light touch intact bilaterally. Straight leg test negative bilaterally. DISCHARGE PHYSICAL EXAM VITALS: Tc 98.0 100/58 62 18 100% RA GENERAL: Pleasant, NAD, alert, interactive HEENT: Oropharynx clear, moist mucous membranes, no LAD, no photosensitivity with flashlight, PERRL, sclerae anicteric LUNGS: Clear to auscultation, no wheezes, crackles, rhonchi HEART: Regular rate and normal rhythm, no m/r/g ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP, no edema. SKIN: Faint isolated erythematous 1-3mm macules on the cheeks bilaterally, L>R NEURO: awake, A&Ox3, strength ___ in lower extremities bilaterally, sensation intact to light touch in ___. Straight leg test negative bilaterally. Pertinent Results: ADMISSION LABS ___ 01:40PM BLOOD WBC-2.7* RBC-3.58* Hgb-11.2* Hct-34.2* MCV-95 MCH-31.4 MCHC-32.9 RDW-14.1 Plt ___ ___ 01:40PM BLOOD Neuts-83.7* Lymphs-6.4* Monos-9.4 Eos-0.3 Baso-0.2 ___ 01:40PM BLOOD Plt ___ ___ 01:40PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-131* K-5.9* Cl-99 HCO3-23 AnGap-15 ___ 01:40PM BLOOD ALT-26 AST-61* AlkPhos-95 TotBili-0.7 ___ 01:40PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.0 Mg-2.2 ___ 01:43PM BLOOD Lactate-1.2 DISCHARGE LABS ___ 07:51AM BLOOD WBC-2.4* RBC-3.47* Hgb-11.0* Hct-32.9* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.0 Plt ___ ___ 07:51AM BLOOD Neuts-78.4* Lymphs-15.4* Monos-4.9 Eos-1.1 Baso-0.3 ___ 07:51AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-137 K-3.7 Cl-107 HCO3-22 AnGap-12 ___ 06:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0 CXR ___ COMPARISON: ___. FINDINGS: PA and lateral views of the chest. Slightly lower lung volumes seen on the current exam. The lungs however remain clear. There is no consolidation or effusion. The cardiomediastinal silhouette is unchanged given differences in technique. No acute osseous abnormalities detected. IMPRESSION: No acute cardiopulmonary process ___: EBV: Pending Parvovirus: Pending CMV DNA: Negative ___: Blood culture x2 No growth to date ___ 3:00 pm URINE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain 2. Acetaminophen 1000 mg PO Q8H:PRN fever, pain 3. Docusate Sodium 100 mg PO BID 4. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever, pain 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain 4. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Fever and fatigue Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with dyspnea and fevers. History of multiple myeloma and chemotherapy. COMPARISON: ___. FINDINGS: PA and lateral views of the chest. Slightly lower lung volumes seen on the current exam. The lungs however remain clear. There is no consolidation or effusion. The cardiomediastinal silhouette is unchanged given differences in technique. No acute osseous abnormalities detected. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED temperature: 100.7 heartrate: 76.0 resprate: 18.0 o2sat: 98.0 sbp: 107.0 dbp: 47.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, You were admitted because you had an episode of fever, chills, and body aches. We started you on antibiotics given concern for infection. Since you have been here you have had no further episodes of fever, which is reassuring. Your blood cultures have not grown any bacteria and your urine did not reveal a source of infection. Your chest Xray was normal. We monitored you for 24 hours after discontinuing the antibiotics and you did very well. We feel that you are safe for discharge home today. However, please return as soon as possible if you do have another episode of fever as it will be important to pursue further investigation regarding the cause. Thank you for allowing us to be a part of your care, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / latex Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ F with a history of angioedema, known 3 VD (was being evaluated as outpt for CABG), MI ___ and recent CCU admission ___ for STEMI when she received DES x2 to the LAD, POBA of LCX and was diagnosed with acute sCHF with 35%EF with dyspnea. On her previous admission she presented with CP, diaphoresis and fatigue; it was noted that she had declined CABG for her known 3V CAD ___ years ago. During her previous admission she declined numerous treatments including a statin; but eventually agreed to rosuvastatin once weekly. She was discharged on a BB, ACE, ASA, ticagrelor and 20mg PO lasix. The morning of ___ she called the heart line and stated that since her discharge she was having progressive shortness of breath and palpitations. She also had difficulty sleeping at night with orthopnea, but continued to perform ADL's. She denied chest discomfort, but endorsed lightheadedness, presyncope and cold sweats when sitting up at night. It was recommended that that the patient come to the ED for evaluation however she was not amenable to this plan and stated that her primarycare physician makes home visits and that she would call him. He saw her at home and she still did not want to come in, but later her dyspnea worsened and eventually she came to the ED the morning of ___. On arrival she denied CP, fevers, abd pain, n/v. Initial vitals were HR 99, T 97.8, 139/83, 80% on RA with a good pleth. She was put on a non-rebreather and was 96% with a RR of 27, working hard to breath and put on CPAP at 100% ___ and was satting 100%. She stated she was DNR/DNI and did not want to be cathed but wanted everything else done to be comfortable. Exam was significant for crackles and JVD. EKG showed NSR at 99, inf/lat STD's. CXR showed bilateral pulmonary edema. Initial labs showed: VBG: pH 7.37, CO2 41, pO2 41 lactate of 4.4. Trop 4.5 from 5.07 on ___. Na 141, K 5.4, Cl 103, HCO3 21, BUN 39, Cr 1.2 (from 0.8 on discharge). LFT's WNL. WBC 16.7, HCT 34.4, PLT 507, 88.8% N. INR 1.2. She was given lasix 40mg IV and started on a nitro gtt. Vitals on transfer were HR 89 122/70 RR 25 100% cpap. Sent to the CCU for CPAP/BiPap and monitoring. ___ was placed prior to transfer, but she had not yet put out to lasix which she received approximately 5:00. On arrival to the CCU she is uncomortable with the cpap mask on, otherwise has no complaints. She notes that after leaving the hospital she did not take lasix "because it's too much". She only took the metoprolol, aspirin, and one other medication. She noted a cough, not productive. Denied dysuria. One loose stool yesterday. She thinks her weight is up 2lbs even though she has not been eating or drinking much. Past Medical History: - Myocardial infarction - ___ - Coronary artery disease: 3VD, no cath records available - Hypertension - Hyperlipidemia - GERD - Anaphylaxis/angioedema: Multiple ED visits/admissions for anaphylaxis/angioedema without clear precipitant. Left AMA. - Meniere's disease - Skin cancer - left forearm - Adenomatous colon polyps - Herpes Zoster - Osteoarthritis and Osteoporosis - Sciatica - Spinal stenosis - Hiatal hernia - Infected sebaceous cyst Social History: ___ Family History: Daughter: allergic to almonds and walnuts Mother: HTN, "heart attack" Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.8 89 137/79 22 100% on BiPAP ___: tired-appearing woman sitting up in bed BiPAP mask in place, AOx3 HEENT: head atraumatic; dry MM Neck: JVP appears 10cm but difficult to evalute with CPAP on CV: RRR; no m/r/g Lungs: breathing comfortably; slight crackles at bases Abdomen: soft; nontender; nondistended; normoactive bowel sounds GU: foley Ext: WWP; no edema Neuro: A and O x3; moving all four extremities DISCHARGE PHYSICAL EXAM: ======================== VS 98.2 76 115/52 22 96% ___: NAD, AOx3 HEENT: head atraumatic; dry MM Neck: JVP appears 10cm but difficult to evalute CV: RRR; no m/r/g Lungs: breathing comfortably; slight crackles at bases Abdomen: soft; nontender; nondistended; normoactive bowel sounds GU: no foley Ext: WWP; no edema Neuro: A and O x3; moving all four extremities Pertinent Results: ADMISSION LABS: =============== ___ 03:25AM BLOOD WBC-16.7* RBC-3.63* Hgb-10.5* Hct-34.4* MCV-95 MCH-29.1 MCHC-30.6* RDW-14.9 Plt ___ ___ 03:25AM BLOOD Neuts-88.8* Lymphs-5.7* Monos-5.2 Eos-0.2 Baso-0.2 ___ 03:25AM BLOOD ___ PTT-22.0* ___ ___ 03:25AM BLOOD Glucose-264* UreaN-39* Creat-1.2* Na-141 K-5.4* Cl-103 HCO3-21* AnGap-22* ___ 03:25AM BLOOD ALT-39 AST-37 AlkPhos-79 TotBili-0.5 ___ 03:25AM BLOOD cTropnT-4.50* ___ 10:30AM BLOOD CK-MB-7 cTropnT-4.18* ___ 10:30AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.5# Mg-2.2 ___ 03:29AM BLOOD ___ pO2-41* pCO2-41 pH-7.37 calTCO2-25 Base XS--1 ___ 03:29AM BLOOD Lactate-4.4* ___ 10:30AM URINE Color-Straw Appear-Clear Sp ___ ___ 10:30AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 10:30AM URINE RBC-2 WBC-18* Bacteri-NONE Yeast-NONE Epi-<1 ___ 10:30AM URINE CastHy-8* ___ 10:30AM URINE Mucous-RARE PERTINENT LABS: =============== ___ 03:29AM BLOOD Lactate-4.4* ___ 11:02AM BLOOD Lactate-2.8* ___ 05:59PM BLOOD Lactate-1.5 ___ 03:25AM BLOOD cTropnT-4.50* ___ 10:30AM BLOOD CK-MB-7 cTropnT-4.18* PERTINENT IMAGING/STUDIES: ========================== ECG ___: Sinus rhythm. Biatrial abnormality. Right bundle-branch block with left anterior fascicular block. Probable prior anterior wall myocardial infarction. No major change from the previous tracing. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 ___ 57 -69 110 CXR ___: IMPRESSION: Severe pulmonary edema. CXR ___: FINDINGS: As compared to the previous radiograph, the pleural effusions have slightly increased in extent, but the signs indicative of centralized pulmonary edema has decreased in severity. The size of the cardiac silhouette remains enlarged. Atelectasis at both lung bases, but no evidence of pneumonia. No pneumothorax. PERTINENT MICRO/CYTOLOGY: ========================= ___ 10:30 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. BCx ___: Pending (NGTD) DISCHARGE LABS: =============== ___ 05:55AM BLOOD WBC-10.3 RBC-3.61* Hgb-10.3* Hct-33.3* MCV-92 MCH-28.5 MCHC-30.9* RDW-15.3 Plt ___ ___ 05:55AM BLOOD Glucose-110* UreaN-40* Creat-0.9 Na-141 K-4.4 Cl-103 HCO3-28 AnGap-14 ___ 05:55AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TiCAGRELOR 90 mg PO BID 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Lorazepam 0.125 mg PO HS:PRN insomnia 4. Aspirin EC 81 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL PRN chest pain 8. Rosuvastatin Calcium 5 mg PO 1X/WEEK (MO) Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Rosuvastatin Calcium 5 mg PO 1X/WEEK (MO) 6. TiCAGRELOR 90 mg PO BID 7. Lorazepam 0.125 mg PO HS:PRN insomnia 8. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic systolic heart failure ST elevation myocardial infarction Acute Kidney Injury Leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath. COMPARISON: Chest radiograph ___. FINDINGS: Single AP view of the chest was reviewed. Cardiomediastinal and hilar contours are normal. There is no pneumothorax. Dense parenchymal opacities, especially in the lower lung zones, are consistent with severe pulmonary edema. There is no large pleural effusion. Displacement of the trachea to the left may be the result of a goiter in the right lobe of the thyroid. IMPRESSION: Severe pulmonary edema. Radiology Report CHEST RADIOGRAPH INDICATION: Lung edema, evaluation for pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the pleural effusions have slightly increased in extent, but the signs indicative of centralized pulmonary edema has decreased in severity. The size of the cardiac silhouette remains enlarged. Atelectasis at both lung bases, but no evidence of pneumonia. No pneumothorax. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: RESP DISTRESS Diagnosed with PULM EMBOLISM/INFARCT temperature: nan heartrate: 99.0 resprate: nan o2sat: 92.0 sbp: 139.0 dbp: 83.0 level of pain: 0 level of acuity: 2.0

It was a pleasure taking care of you at ___. You were admitted from home with shortness of breath. This was caused by accumulation of fluid in your lungs, which happened because you were not taking one of your medicines as prescribed (Lasix). You were treated with BIPAP and medicines to remove extra fluid. Your weight at discharge is 102 pounds - this should be considered your "dry weight" (that is, weight without any excess fluid in your body). Your kidney function declined briefly because of your heart failure, but it was improving at discharge. It is EXTREMELY important that you take all of your medicines every day to help your heart pump effectively and avoid another hospitalization from heart failure. Please weigh yourself every morning, call Dr. ___ weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Thank you for allowing us to participate in your care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Lipitor Attending: ___ Chief Complaint: Weight gain, face and leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with past medical history of T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney transplantation in ___, repeated skin cancers related to immune suppression, hx of Hep C (undetectable vital load in ___, HTN, who came to the ED with weight gain, swelling over face and legs. Patient was hospitalized recently for upper respiratory tract infection in ___ with short hospital stay (per patient). Group home personnel noticed weight increase of ___ lbs in 5 days with swelling in his face and bilateral lower extremities. Patient denies SOB, orthopnea, PND, chest pain or syncope. Patient denies subjective fevers, chills, nausea, vomiting or abdominal pain. Of note, patient had kidney biopsy in ___ likely due to proteinuria. Biopsy results are not back yet. -In the ED, vitals were: T 98.8; HR 81; BP 142/78; RR 20; SpO2 100% RA -Exam: 2+ pitting edema symmetric Diffuse abdominal tenderness most prominent in the right lower quadrant over multiple evaluations brown stool guaiac negative -Labs: 9.0>9.0/28.8<173 Na 139 | K 5.1 | Cl 106 | HCO3 21 | BUN 27 | Cr 1.8 Albumin 3.3 | proBNP: 3281 -Studies: ========== CT Abdomen/Pelvis w/out contrast - ___ 1. Mild bladder wall thickening, which could be secondary to underdistention and/or chronic outlet obstruction, although cystitis could have a similar appearance. Recommend correlation with urinalysis. 2. Moderate hydronephrosis of the right lower quadrant transplant kidney, as seen on prior ultrasound. 3. Stable, 3 mm nonobstructing stone within the upper pole of the transplant kidney. 4. Small, bilateral pleural effusions. 5. 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT follow-up is recommended. Renal Transplant U/S - ___ 1. Redemonstration of moderate transplant hydronephrosis. Small amount of perinephric free fluid. 2. Patent renal transplant vasculature. CXR - ___ Streaky left upper lung opacity is seen similar to prior from ___, and may be chronic. There are trace bilateral pleural effusions. There may be mild pulmonary edema superimposed on chronic lung changes. Cardiac and mediastinal silhouettes are stable. -They were given: ___ 18:44 IV Furosemide 40 mg REVIEW OF SYSTEMS: ================== Complete ROS obtained and is otherwise negative. Past Medical History: -ANEMIA -ESRD S/P KIDNEY TRANSPLANT -DEPRESSION -HEPATITIS C elevated LFTs along with + HCV Ab, HBcAb + in ___ but subsequently negative; ___: evaluated by Dr. ___, with HCV RNA PCR >750,000 copies, HepB viral DNA <10, HBeAg/HBeAb negative. plan to defer treatment. ___: patient with unstable social situation - intermittently homeless. currently not a candidate for interferon treatment. will refer to GI if social situation changes. ___: depression stable, though still homeless. as LFTs continue to rise, will refer to Dr. ___ recommendations ___: ALT 55, ___ 61, ___ - 52. ___: AST 47, ___ 63, ___ 45 -INSULIN DEPENDENT DIABETES MELLITUS c/b NEPHROPATHY, RETINOPATHY AND NEUROPATHY -SCHIZOAFFECTIVE DISORDER -HYPERTENSION -MELANOMA -HYPERLIPIDEMIA -CATARACT -H/O SEIZURE DISORDER -H/O TUBERCULOSIS -Pt. received three drug therapy for one year (___) Social History: ___ Family History: Mother had ___ and pacemaker. Physical Exam: ADMISSION PHYSICAL EXAM: T: 98.5PO | BP: 176/92 R Lying | HR: 104 | RR:18 | SpO2: 98 Ra GENERAL: Pleasant man. Appears older than stated age. Gross coarse tremors that he attributes to meds side effects. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. faint systolic murmur heard over the apex. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Non distended, focal tenderness over right flank (above the graft and not over it). No organomegaly. + BS EXTREMITIES: +2 pitting edema in left foot (no appreciable edema over right shins). Right leg: + pitting edema up to knee level SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC/extremities: AOx3. Moving all 4 limbs spontaneously. CN2-12 intact. ___ strength in upper extremities and ___ in lower extremities. Decreased sensation in stocking distribution. Charcot feet. Onychomycosis. DISCHARGE PHYSICAL EXAM: VS 98.2 BP 162 / 83 HR 86 RR18 O2 94 RA Gen: older man in no acute distress HEENT: right neck with linear scar, JVP not elevated CV: regular rate and rhythm, no murmur Pulm: clear to auscultation bilaterally Abd: soft, nontender, nondistended; renal graft nontender Ext: trace pitting edema of lower extremities Neuro: alert and oriented, moving extremities spontaneously. Pertinent Results: ADMISSION LABS: = = = = = = = = = = = ================================================================ ___ 01:45PM BLOOD WBC-9.0 RBC-3.25* Hgb-9.0* Hct-28.8* MCV-89 MCH-27.7 MCHC-31.3* RDW-14.7 RDWSD-47.8* Plt ___ ___ 01:45PM BLOOD Glucose-186* UreaN-27* Creat-1.8* Na-139 K-5.1 Cl-106 HCO3-21* AnGap-12 ___ 01:45PM BLOOD ALT-15 AST-22 AlkPhos-87 TotBili-0.3 ___ 01:45PM BLOOD cTropnT-<0.01 proBNP-3281* ___ 01:45PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.4 Mg-1.8 Iron-19* ___ 01:45PM BLOOD calTIBC-285 Ferritn-74 TRF-219 ___ 01:45PM BLOOD %HbA1c-7.4* eAG-166* ___ 01:45PM BLOOD tacroFK-11.9 URINE STUDIES: = = = = = = = = = = = ================================================================ ___ 03:02PM URINE Hours-RANDOM Creat-81 TotProt-130 Prot/Cr-1.6* ___ 02:14AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG IMAGING: = = = = = = = = = = = ================================================================ ECHO ___ CONCLUSION: The left atrial volume index is moderately increased. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild (non-obstructive) focal basal septal hypertrophy. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 63 %. Left ventricular cardiac index is normal (>2.5 L/ min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. No valvular pathology or pathologic flow identified. Mildly increased right atrial pressure. Mild pulmonary artery systolic hypertension. CT ABD/PELV NON CONT ___ IMPRESSION: 1. Moderate hydronephrosis of the right lower quadrant transplant kidney, as seen on prior ultrasound. 2. Stable, 3 mm nonobstructing stone within the upper pole of the transplant kidney. 3. Small, bilateral pleural effusions. 4. Trabeculated bladder wall, likely secondary to chronic outlet obstruction. 5. 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT follow-up is recommended. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ RENAL TRANSPLANT U/S ___: IMPRESSION: 1. Redemonstration of moderate renal transplant hydronephrosis. Small amount of perinephric free fluid. 2. Patent renal transplant vasculature. Resistive indices range from 0.6-0.8. CXR IMPRESSION: ___ Streaky left upper lung opacity is similar compared to ___ be chronic. Small bilateral pleural effusions. Possible mild pulmonary edema superimposed on chronic lung changes. PATHOLOGY = = = = = = = = = = = ================================================================ RENAL BIOPSY ___: PATHOLOGIC DIAGNOSIS: Renal Allograft needle biopsy ___ years post-transplantation): Diabetic nephropathy with nodular glomerulosclerosis, see note. DISCHARGE LABS: = = = = = = = = = = = ================================================================ ___ 05:13AM BLOOD WBC-8.8 RBC-3.36* Hgb-9.5* Hct-29.5* MCV-88 MCH-28.3 MCHC-32.2 RDW-14.6 RDWSD-46.9* Plt ___ ___ 05:13AM BLOOD Glucose-110* UreaN-27* Creat-1.8* Na-142 K-4.1 Cl-102 HCO3-26 AnGap-14 ___ 06:35AM BLOOD ALT-14 AST-16 LD(LDH)-239 AlkPhos-88 TotBili-0.4 ___ 05:13AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.1 ___ 05:13AM BLOOD tacroFK-12.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sulfameth/Trimethoprim SS 1 TAB PO Q48H 2. Glargine 24 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. Vitamin D ___ UNIT PO DAILY 4. Labetalol 600 mg PO BID 5. Ketoconazole 2% 1 Appl TP BID 6. Clozapine 200 mg PO BID 7. ARIPiprazole 5 mg PO QHS 8. Senna 17.2 mg PO QHS 9. Rosuvastatin Calcium 10 mg PO QPM 10. Sodium Bicarbonate 650 mg PO BID 11. FoLIC Acid 1 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Tamsulosin 0.4 mg PO QHS 14. Vitamin B Complex 1 CAP PO DAILY 15. Tacrolimus 1 mg PO Q12H 16. Omeprazole 20 mg PO DAILY 17. amLODIPine 10 mg PO DAILY 18. Oyst-Cal-500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 19. Ascorbic Acid ___ mg PO DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*0 2. Torsemide 10 mg PO DAILY RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. ARIPiprazole 5 mg PO QHS 5. Ascorbic Acid ___ mg PO DAILY 6. Clozapine 200 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Glargine 24 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Ketoconazole 2% 1 Appl TP BID 10. Labetalol 600 mg PO BID 11. Mycophenolate Mofetil 500 mg PO BID 12. Omeprazole 20 mg PO DAILY 13. Oyst-Cal-500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 14. Rosuvastatin Calcium 10 mg PO QPM 15. Senna 17.2 mg PO QHS 16. Sodium Bicarbonate 650 mg PO BID 17. Sulfameth/Trimethoprim SS 1 TAB PO Q48H 18. Tacrolimus 1 mg PO Q12H 19. Tamsulosin 0.4 mg PO QHS 20. Vitamin B Complex 1 CAP PO DAILY 21. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Acute kidney injury on chronic kidney disease Lower extremity edema Secondary: ESRD s/p renal transplant Iron deficiency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with dyspnea// chf TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Streaky left upper lung opacity is seen similar to prior from ___, and may be chronic. There are small bilateral pleural effusions. There may be mild pulmonary edema superimposed on chronic lung changes. Cardiac and mediastinal silhouettes are stable. IMPRESSION: Streaky left upper lung opacity is similar compared to ___ ___ be chronic. Small bilateral pleural effusions. Possible mild pulmonary edema superimposed on chronic lung changes. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: History: ___ with renal txplt, swelling// transplant eval, thrombosis TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal ultrasound from ___ FINDINGS: There is redemonstration of moderate hydronephrosis. There is a small amount of perinephric free fluid. The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. The resistive index of intrarenal arteries ranges from 0.6-0.8. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 95 centimeters/second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Redemonstration of moderate renal transplant hydronephrosis. Small amount of perinephric free fluid. 2. Patent renal transplant vasculature. Resistive indices range from 0.6-0.8. Radiology Report EXAMINATION: CT abdomen and pelvis. INDICATION: ___ with abd pain, recent biopsy, ___ on CKDN// eval for perf, infection/abscess TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 557 mGy-cm. COMPARISON: CT abdomen and pelvis ___. Renal transplant ultrasound ___. FINDINGS: LOWER CHEST: Small bilateral pleural effusions. Ground-glass opacities in the right lower lobe likely reflect atelectasis. A pulmonary nodule of the right lower lobe measures 3 mm (3:5). A trace pericardial effusion is stable. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas is mildly atrophic. The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The native bilateral kidneys are atrophic. Again seen is a transplant kidney within the right lower quadrant, demonstrating moderate hydronephrosis. A nonobstructing stone within the upper pole of the transplant kidney measures 3 mm, not significant changed from prior. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. A moderate amount stool is within the colon. The colon and rectum are otherwise within normal limits. PELVIS: The bladder wall is mildly thickened and trabeculated, likely secondary to chronic outlet obstruction. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild-to-moderate atherosclerotic disease is noted. BONES: A superior endplate deformity of the L5 vertebral body appears stable, likely a Schmorl's node. No evidence of acute fracture or worrisome osseous lesions. SOFT TISSUES: A focal calcification of the left anterior abdominal wall (03:46) appears stable. Mild diffuse subcutaneous edema. Otherwise, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Moderate hydronephrosis of the right lower quadrant transplant kidney, as seen on prior ultrasound. 2. Stable, 3 mm nonobstructing stone within the upper pole of the transplant kidney. 3. Small, bilateral pleural effusions. 4. Trabeculated bladder wall, likely secondary to chronic outlet obstruction. 5. 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT follow-up is recommended. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Leg swelling Diagnosed with Acute kidney failure, unspecified temperature: 98.8 heartrate: 81.0 resprate: 20.0 o2sat: 100.0 sbp: 142.0 dbp: 78.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. Why was I admitted to the hospital? - You had increased swelling in your legs - Your kidney tests were a little bit elevated What was done while I was in the hospital? - You were started on a diuretic (water pill) to remove the extra fluid in your legs - Your labs were monitored What should I do when I get home from the hospital? - Continue to take all of your medications as prescribed, including your water pill - Please have your labs checked in 1 week to ensure that your kidney tests are stable - Make sure to go to all of your follow-up appointments - If you have fevers, chills, worsening swelling in your legs or belly, or generally feel unwell, please call your doctor or go to the emergency room Sincerely, Your ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization ___ History of Present Illness: ___ transferred from ___ with chest pain found to have NSTEMI. Patient was in his USOH until 1am on ___, when he developed the acute onset of ___ burning substernal chest and back pain that awoke him from sleep. He had no associated SOB, N/V/D or diarphoresis. He noted the pain somewhat improved by later that morning, but he continued to have a ___ 'ache' substernally. He then presented to ___, where he was given ASA 325 and nitro 0.4 x 3 without effect. He then received morphine 5mg at 1830 which caused bradycardia to the ___ with a BP of 79/40. He was placed in ___ and given IVF with return of vital signs. OSH labs were notable for trop of 1.0, CKMB of 76.4, INR 1.1, HCT 39.7, and plt 165. He was then transferred for further management. In the ___ intial vitals were pain 2, T 98.7, HR 65, BP 116/67, RR 20, O2 99%3LNC. EKG was notable for qwaves V5-V6,I, and AVL with TWI in I and AVL. Initial labs were notable for troponin of 1.35. CXR showed mediastinum of ~8cm and signficant subcutaneous tissue. Patient received plavix 300mg and started on a heparin gtt before admission to cardiology for futher management. On the floor, patient reports he is chest pain free. He denies recent fevers or chills. No shortness of breath or cough. He denies orthopnea or PND. No recent nausea, vomiting or diarrhea. No symptoms of claudication. He does have baseline urinary urgency and some left elbow pain. Review of systems otherwise unremarkable. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -BPH -Glaucoma Social History: ___ Family History: FAMILY HISTORY: Father died of MI at age ___. No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VSS General: Well appearing man in NAD. Pleasant and appropriate HEENT: Anicteric sclerae, PERLL, OP clear Neck: JVD not appreciably elevated CV: Soft S1/S2. No appreciated murmurs, rubs or gallops. Lungs: CTAB. Nonlabored on NC Abdomen: Soft, NT/ND GU: Deferred Ext: Warm, well perfused. 2+ peripheral pulses throughout. Neuro: Alert, oriented x3. CNII-XII intact. Moving all extremities equally. Gait deferred. Skin: Warm, no rashes or lesions noted DISCHARGE EXAM: Pertinent Results: ADMISSION LABS: ___ 04:15AM BLOOD WBC-9.1 RBC-3.95* Hgb-12.1* Hct-36.4* MCV-92 MCH-30.5 MCHC-33.2 RDW-12.1 Plt ___ ___ 04:15AM BLOOD ___ PTT-55.0* ___ ___ 04:15AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-106 HCO3-25 AnGap-13 ___ 04:15AM BLOOD CK(CPK)-719* ___ 04:15AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0 Cholest-160 OTHER RELEVANT LABS: ___ 09:05PM BLOOD cTropnT-1.35* ___ 04:15AM BLOOD CK-MB-41* MB Indx-5.7 cTropnT-1.81* ___ 03:15AM BLOOD CK-MB-13* MB Indx-2.8 cTropnT-2.66* ___ 04:15AM BLOOD %HbA1c-5.6 eAG-114 ___ 04:15AM BLOOD Triglyc-67 HDL-47 CHOL/HD-3.4 LDLcalc-100 DISCHARGE LABS: IMAGING: EKG ___: Sinus arrhythmia. Borderline first degree A-V delay. Probable left ventricular hypertrophy. Possible lateral myocardial infarction of indeterminate age. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. CXR ___: FINDINGS: Frontal and lateral views of the chest were obtained. There is no focal consolidation, pleural effusion or pneumothorax. Heart size is top-normal. Mediastinal silhouette and hilar contours are normal without evidence of mediastinal widening. IMPRESSION: Normal mediastinum. TTE ___: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior, inferolateral, and lateral walls. The remaining segments contract normally (LVEF = 50-55 %). The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary arterial systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Regional dysfunction c/w CAD (circumflex distribution) with overall low-normal global systolic function. Mildly dilated ascending aorta with mild aortic regurgitation. The patient has a mildly dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in ___ year; if previously known and stable, a follow-up echocardiogram is suggested in ___ years. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Terazosin 10 mg PO HS Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Terazosin 10 mg PO HS 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 4. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: NSTEMI: 100% occlusion of left circumflex artery, s/p DES ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Chest pain. Evaluate for widened mediastinum. COMPARISON: Portable radiograph ___ FINDINGS: Frontal and lateral views of the chest were obtained. There is no focal consolidation, pleural effusion or pneumothorax. Heart size is top-normal. Mediastinal silhouette and hilar contours are normal without evidence of mediastinal widening. IMPRESSION: Normal mediastinum. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE temperature: 98.7 heartrate: 65.0 resprate: 20.0 o2sat: 99.0 sbp: 116.0 dbp: 67.0 level of pain: 2 level of acuity: 2.0

You came to the hospital because you had chest pain. You were transferred from ___ because were felt to be having a heart attack. You had a catheterization which showed a complete obstruction of one the arteries that feed your heart. The cardiologists unplugged the blockage and put in a drug-eluting ___. You were started on 2 very important medications to prevent any obstructions within your ___: full dose aspirin, and clopidogrel [plavix]. You need must take these medications every day. You were also started on: - atorvastatin, which lowers cholesterol and prevents progression of coronary artery disease - lisinopril, which helps protect the structure of the heart and lowers blood pressure - metoprolol, which lowers heart rate and blood pressure and decreases the stress on the heart.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Candesartan / lactose / baclofen Attending: ___ Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of CKD on dialysis, CAD, diastolic CHF, and diabetes presents with respiratory distress. Patient noted to have significant cough and feeling generally unwell. DNR/DNI status confirmed. No reports of vomiting, chest pain, abdominal pain, leg swelling, rash, dysuria. In the ED, initial vitals were: Temp 98.4, HR 88, BP 118/92, RR 18, 93% NRB - Labs notable for: WBC 16.2 (88% Neutrophils), Hg 10.4, platelets 234 Na 131, K 5.7, Cl 87, bicarb 19, BUM=N 66, Cr 4.5 ___: 34___, Trop-T 0.06, lactate 2.4 Flu A PCR positive. - Imaging was notable for: 1. Consolidation in the right lower and left upper and lower lobes, concerning for multifocal pneumonia. 2. No evidence of colitis or other acute intra-abdominal process. 3. Extensive atherosclerotic disease, including severe calcification of the celiac axis and SMA. Evaluation for mesenteric ischemia is limited on this noncontrast study. 4. Extensive multilevel degenerative changes of the imaged spine, not significantly changed compared to ___. - Patient was given: IV Piperacillin-Tazobactam 4.5 g IV Vancomycin 100 mg PO/NG OSELTAMivir 75 mg IV Morphine Sulfate 2 mg Patient noted to be dyspneic over the last week days also with nausea/vomiting. Per daughter noted mostly to be phlegm like. She was also noted to have chills at home. Patient lives at rehab facility--at that time she had CXR, UA, and blood tests that her daughter notes were normal. She has a prior history of aspiration pneumonia. Per daughter patient denied abdominal pain, chest pain, or diarrhea. Has chronic back pain and body aches. At baseline, patient is typically alert and oriented X 2 per daughter. Upon arrival to the floor, patient is able to shake her head yes/no to questions. She denies pain, chest pain, shortness of breath, fever, or chills. Past Medical History: -HTN -HLD -DM -CKD on dialysis -Coronary artery disease s/p bypass in ___ years prior -seizure history---occurs with UTI or infection -seizure typically rhythmic movements of hands and legs per daughter Social History: ___ Family History: Two children have died, two children with cancer (prostate, liver). +HTN, +DM type II Physical Exam: ADMISSION PHYSICAL EXAM: ============================== VITAL SIGNS: Temp. 98.2 BP 149 / 64 HR 81 RR 20 ___ GENERAL: comfortable appearing, elderly woman in no acute distress. Shakes head yes/no to questions CARDIAC: RRR LUNGS: bilateral rhonci in all lung fields ABDOMEN: soft, non-tender to palpation EXTREMITIES: no edema, warm and well-perfused NEUROLOGIC: grossly moving all extremities SKIN: Stage II decub at sacrum. Foot ulcers on ___ toe of both feet. DISCHARGE PHYSICAL EXAM: ============================== VITAL SIGNS: T 98-98.6, BP 149-174/64-71, P 95-106, RR ___, O2sat 89-100% on ___ NC GENERAL: pleasant, thin elderly female, no acute distress HEENT: MMM, EOMI CARDIAC: RRR, normal S1/S2 no m/r/g. LUNGS: b/l wheezing in upper posterior lung fields, inspiratory crackles diffusely ABDOMEN: soft, non-tender to palpation EXTREMITIES: no edema, warm and well-perfused NEUROLOGIC: grossly moving all extremities, A&Ox3, nonfocal SKIN: Stage II decub at sacrum. Foot ulcers on ___ toe of feet bilaterally Pertinent Results: ADMISSION LABS: ===================== ___ 05:45PM BLOOD WBC-16.2*# RBC-3.61* Hgb-10.4* Hct-34.2 MCV-95 MCH-28.8 MCHC-30.4* RDW-15.5 RDWSD-53.6* Plt ___ ___ 05:45PM BLOOD Neuts-88.6* Lymphs-3.8* Monos-6.9 Eos-0.1* Baso-0.1 Im ___ AbsNeut-14.34*# AbsLymp-0.62* AbsMono-1.11* AbsEos-0.01* AbsBaso-0.02 ___ 05:45PM BLOOD ___ PTT-33.2 ___ ___ 03:00PM BLOOD Glucose-175* UreaN-66* Creat-4.5*# Na-131* K-5.7* Cl-87* HCO3-19* AnGap-31* ___ 03:00PM BLOOD ___ ___ 03:00PM BLOOD cTropnT-0.06* ___ 03:00PM BLOOD Phos-4.2 ___ 03:19PM BLOOD Lactate-2.4* ___ 04:10PM OTHER BODY FLUID FluAPCR-POSITIVE FluBPCR-NEGATIVE OTHER RELEVANT LABS: ====================== ___ 06:35AM BLOOD WBC-17.4* RBC-3.50* Hgb-10.0* Hct-31.7* MCV-91 MCH-28.6 MCHC-31.5* RDW-15.3 RDWSD-50.8* Plt ___ ___ 06:30AM BLOOD WBC-9.3 RBC-3.37* Hgb-9.7* Hct-32.3* MCV-96 MCH-28.8 MCHC-30.0* RDW-15.6* RDWSD-54.2* Plt ___ ___ 06:04AM BLOOD WBC-8.0 RBC-3.11* Hgb-8.9* Hct-29.2* MCV-94 MCH-28.6 MCHC-30.5* RDW-15.8* RDWSD-53.3* Plt ___ ___ 02:59PM BLOOD WBC-8.3 RBC-3.06* Hgb-8.7* Hct-29.2* MCV-95 MCH-28.4 MCHC-29.8* RDW-15.7* RDWSD-55.3* Plt ___ ___ 06:35AM BLOOD Glucose-110* UreaN-76* Creat-5.4* Na-130* K-6.2* Cl-88* HCO3-20* AnGap-28* ___ 06:30AM BLOOD Glucose-171* UreaN-14 Creat-1.9* Na-140 K-4.0 Cl-98 HCO3-29 AnGap-17 ___ 06:04AM BLOOD Glucose-220* UreaN-42* Creat-3.6* Na-133 K-5.0 Cl-92* HCO3-28 AnGap-18 ___ 02:59PM BLOOD Glucose-261* UreaN-12 Creat-1.4*# Na-135 K-4.7 Cl-96 HCO3-31 AnGap-13 ___ 07:55AM BLOOD CK-MB-3 cTropnT-0.12* ___ 04:00PM BLOOD CK-MB-3 cTropnT-0.12* ___ 06:35AM BLOOD Calcium-8.5 Phos-5.1* Mg-2.2 ___ 06:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1 ___ 02:59PM BLOOD Calcium-7.7* Phos-2.6* Mg-1.8 MRSA SCREEN (Final ___: No MRSA isolated. Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. DISCHARGE LABS: ======================== ___ 07:00AM BLOOD WBC-10.4* RBC-3.24* Hgb-9.2* Hct-30.8* MCV-95 MCH-28.4 MCHC-29.9* RDW-15.8* RDWSD-55.0* Plt ___ ___ 07:00AM BLOOD Glucose-244* UreaN-22* Creat-2.2* Na-136 K-3.7 Cl-94* HCO3-32 AnGap-14 ___ 07:00AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.9 CXR (___): IMPRESSION: Interval progression of the parenchymal opacity in the left mid lung worrisome for pneumonia. CT Abdomen and Pelvis without contrast (___): 1. Multifocal pneumonia. 2. No evidence of colitis or other acute intra-abdominal process. 3. Extensive atherosclerotic disease, including severe calcification of the celiac axis and SMA. 4. Extensive multilevel degenerative changes of the imaged spine, not significantly changed compared to ___. TTE ___: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. At least moderate pulmonary hypertnesion. Medications on Admission: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Famotidine 20 mg PO DAILY 4. LevETIRAcetam 500 mg PO BID 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 6. Aspirin 81 mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. LevETIRAcetam 500 mg PO THREE TIMES PER WEEK POST HD 12. Lidocaine 5% Patch 1 PTCH TD QPM Discharge Medications: 1. Benzonatate 100 mg PO TID Duration: 10 Days 2. Carvedilol 12.5 mg PO BID Hold for SBP < 110 or HR < 60. 3. GuaiFENesin ___ mL PO Q6H cough Duration: 10 Days 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 5. Levofloxacin 500 mg PO Q48H Duration: 1 Dose To be given POST-dialysis on ___ to complete her course. 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Hold for SBP < 110. 7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Citalopram 20 mg PO DAILY 11. Clopidogrel 75 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Famotidine 20 mg PO DAILY 14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 15. LevETIRAcetam 500 mg PO THREE TIMES PER WEEK POST HD 16. LevETIRAcetam 500 mg PO BID 17. Lidocaine 5% Patch 1 PTCH TD QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Influenza Health-care associated pneumonia New-onset atrial fibrillation Chronic Kidney Disease Stage 4 Secondary Chronic heart failure with preserved EF Coronary artery disease Hyperlipidemia Seizure disorder Glaucoma GERD Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with cough, sob // PNA TECHNIQUE: AP and lateral views the chest. COMPARISON: Elevation of the right hemidiaphragm is again seen. FINDINGS: There is been interval progression of the parenchymal opacity in the left mid and lower lung since prior. Irregular opacities in the right suprahilar region are not significantly changed. Cardiac silhouette is unchanged. Median sternotomy hardware is again noted. No acute osseous abnormalities. IMPRESSION: Interval progression of the parenchymal opacity in the left mid lung worrisome for pneumonia. Radiology Report EXAMINATION: CT abdomen pelvis without contrast INDICATION: ___ with diffuse abdominal pain and low grade fevers. Evaluate for colitis or other acute intra-abdominal process. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection.Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 531 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: New consolidation in the right lower and left upper and lower lobes, concerning for pneumonia. Cardiomegaly with extensive 3 vessel coronary artery calcification. There are post CABG changes. There is extensive atherosclerotic calcification of the aortic arch and head and neck vessels. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. Mild intrahepatic biliary dilatation and dilatation of the CBD is likely secondary to cholecystectomy. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There are unchanged partially calcified cysts in the right kidney. The bilateral kidneys are atrophic. There is an unchanged left renal cyst. The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Mild fecal loading. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. Again seen is extensive calcification of the celiac axis and SMA. There is a stent in the SMA. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Unchanged grade 2 anterolisthesis of L4 on L5 with bilateral pars defects. Minimal grade 1 retrolisthesis of L2 on L3. There are extensive multilevel degenerative changes, evidenced by disc space narrowing, endplate sclerosis, vacuum disc phenomena and facet hypertrophy. Median sternotomy wires are partially imaged. The patient is status post left total hip arthroplasty. SOFT TISSUES: There are multiple calcifications in the posterior subcutaneous soft tissues overlying the gluteal musculature, likely representing injection granulomas. There multiple subcutaneous nodules in the anterior pelvis subcutaneous fat, possibly representing injection granulomas. IMPRESSION: 1. Multifocal pneumonia. 2. No evidence of colitis or other acute intra-abdominal process. 3. Extensive atherosclerotic disease, including severe calcification of the celiac axis and SMA. 4. Extensive multilevel degenerative changes of the imaged spine, not significantly changed compared to ___. Radiology Report INDICATION: ___ year old woman with influenza and superimposed bacterial pneumonia // ? interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Persisting opacities throughout the left mid and lower lung zones. New and increasing opacities in the right upper lobe as well as at the right lung base are also noted. No pneumothorax. The appearance of the cardiomediastinal silhouette is unchanged. IMPRESSION: Persisting multifocal pneumonia as described above. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Pneumonia, unspecified organism temperature: 98.4 heartrate: 88.0 resprate: 18.0 o2sat: 93.0 sbp: 118.0 dbp: 92.0 level of pain: UTA level of acuity: 2.0

Dear Ms. ___, You were admitted because you had the flu and an infection in your lungs. We treated you with medications for this. You should continue taking your antibiotic (levofloxacin) until ___ for your pneumonia. We also found your heart rhythm to be going fast so we have given you a heart monitor that you should use when you leave the hospital. Your cardiologist will follow up on these results. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you, Sincerely your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Seizure, Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ man with a history of atrial fibrillation, CAD s/p multiple stents and recent 3V CABG ___, ___ w/ LVEF 22% (___), CKD, cirrhosis s/p liver transplant (___) on tacro, IDDM, and peripheral arterial disease s/p multiple stents, who presents to the ED after transfer from an outside hospital for first time seizure at rehab. History is obtained from prior documentation, as he is unable to provide any history. He has been staying at ___ since his recent hospitalization for CABG in ___. He has generally been well, although there is mention of a possible fall with head strike approximately 2 weeks ago. It is not clear that any further medical workup was pursued at that time. The circumstances of the fall are otherwise unclear. Notably, lab work drawn yesterday at rehab showed a calcium of 3.4 and a magnesium was also very low, although the exact value is not documented. He was also found to have a positive UA with 3+ bacteria and many bacteria on the culture. It is not clear if any of these were acted upon. Today, he was witnessed to have a seizure, described as a tonic-clonic seizure, lasting approximately 3 minutes. Afterwards, it is documented that he was confused but otherwise his exam was nonfocal. He has no history of seizure. Glucose at the time was found to be 66. He was brought to ___ ___, where his calcium was found to be 5.1, and again his magnesium was very low. He was given 2 g of magnesium and transferred here. He was not given any benzodiazepine or antiepileptic drugs. In the ED, initial VS were: 98.0 79 132/78 17 95% RA. Vitals remained stable at time of transfer. Exam notable for: alert, oriented to name only ___ nystagmus, pupils sluggish but symmetrically reactive neuro exam otherwise normal well healing sternotomy scar EKG: inverted T waves similar to prior s/p CABG, no new STTW changes, SR Labs showed: Ca 6.4 -> 6.5 after two doses of IV calcium albumin 2.7. Mg 1.4 -> ___ s/p IV mag. INR 2.0. Cr 1.1. Lactate normal. Trop 0.12 x2. Imaging showed: CXR w/ no PNA. Consults: neurology recommended hypoCa w/u, no imaging, AEDs, or LP at this time. Patient received: ___ 14:32 IV Calcium Gluconate 2 g ___ 15:34 IV Calcium Gluconate 2 g ___ 22:16 IV Calcium Gluconate 2 g ___ 18:20 IV Magnesium Sulfate 4 g ___ 20:23 PO Tacrolimus 1.5 mg ___ 20:33 PO/NG Atorvastatin 80 mg ___ 20:33 PO/NG Warfarin .5 mg On arrival to the floor, patient reports *** REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Alcoholic cirrhosis s/p orthotopic deceased donor liver transplant ___ Coronary artery disease, stents to LAD and LCX on ___, DES to proximal and mid RCA on ___, DES to OM1 on ___ with diseased RCA that was not amenable to PCI Atrial fibrillation on rivaroxaban HFpEF (55%-60%) Diabetes, insulin-dependent Hyperlipidemia CKD (baseline Cr ~1.2-1.3) Peripheral arterial disease His vascular history includes the following: 1. ___, angioplasty and stenting of left superficial femoral artery by Dr. ___. 2. ___, angiogram by Dr. ___. 3. ___nd proximal superficial femoral endarterectomy with Dacron patch angioplasty by Dr. ___. 4. ___, right groin exploration with removal of Dacron patch and redo patch angioplasty with ipsilateral greater saphenous vein under general anesthesia by Dr. ___. 5. ___, left groin cutdown with left common femoral artery endarterectomy with transition to left external iliac artery to superficial femoral artery Dacron bypass with interposition graft. Reimplantation of profunda femoral artery at the Dacron bypass graft. 6. ___, treatment of right popliteal occlusion with Zilver 7 x 40 mm stent, treatment of left superficial femoral artery occlusion with a Zilver 7 x 60, then two Zilver 7 x 80 stents. Social History: ___ Family History: Father died ___ years old from MI. Mother also had heart disease but unsure what kind. Physical Exam: Admission Physical Exam ========================= GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge Physical Exam =========================== GENERAL: Well-developed, well-nourished male laying in bed. NAD. HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Sclera anicteric. No oropharyngeal lesions. CV: RRR, normal S1/S2, no murmurs, rubs, or gallops. Well-healed sternotomy scar noted. RESP: CTAB, no wheezes, rales, or rhonchi. GI: Soft, nontender, nondistended. NABS. No rebound or guarding. Well-healed OLT scar noted. SKIN: No lesions or rashes NEURO: AAOx3 this AM (waxes and wanes). CNII-XII intact. ___ strength throughout. No focal deficits. Able to follow commands. No asterixis or nystagmus present. Able to perform days of week backwards. Normal heal-shin and finger-nose. PSYCH: Appropriate mood and affect. Pertinent Results: Admission Labs =============== ___ 03:09PM BLOOD WBC-6.2 RBC-3.81* Hgb-11.0* Hct-32.8* MCV-86 MCH-28.9 MCHC-33.5 RDW-15.9* RDWSD-50.3* Plt ___ ___ 03:09PM BLOOD ___ PTT-29.9 ___ ___ 03:09PM BLOOD Glucose-118* UreaN-26* Creat-1.1 Na-142 K-3.9 Cl-104 HCO3-24 AnGap-14 ___ 03:09PM BLOOD ALT-64* AST-63* CK(CPK)-375* AlkPhos-58 TotBili-0.8 ___ 03:09PM BLOOD Albumin-2.7* Calcium-6.4* Phos-3.7 Mg-1.4* ___ 03:09PM BLOOD tacroFK-2.8* ___ 03:35PM BLOOD Lactate-1.3 Pertinent Interval Labs ======================== ___ 03:09PM BLOOD Albumin-2.7* Calcium-6.4* Phos-3.7 Mg-1.4* ___ 07:40PM BLOOD Calcium-6.5* Phos-3.5 Mg-1.9 ___ 09:00AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.5* ___ 07:46AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.7 ___ 08:04AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.8 ___ 07:34AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.4* ___ 07:40PM BLOOD 25VitD-14* ___ 03:42PM BLOOD PTH-54 ___ 01:34AM BLOOD freeCa-0.89* Discharge Labs =============== ___ 07:34AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.0* Hct-29.3* MCV-85 MCH-29.1 MCHC-34.1 RDW-15.3 RDWSD-47.3* Plt ___ ___ 07:34AM BLOOD Glucose-155* UreaN-24* Creat-1.1 Na-138 K-4.2 Cl-104 HCO3-22 AnGap-12 ___ 07:34AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.4* ___ 07:34AM BLOOD tacroFK-3.4* Imaging Studies ================ CXR ___ Lungs are low volume with no evidence of pneumonia. There are old healed right-sided rib fractures. Cardiomediastinal silhouette is stable. Vascular calcifications again seen. Previously visualized right IJ line has been removed in the interim. There is no pleural effusion. No pneumothorax is seen Microbiology ============= Blood and urine cultures - no growth to date Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 1000 mg PO BID 4. Creon 12 3 CAP PO QIDWMHS 5. Fenofibrate 145 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Magnesium Oxide 400 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Tacrolimus 1.5 mg PO Q12H 13. Amiodarone 200 mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Lactulose 30 mL PO DAILY 18. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal conjestion 19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 20. ___ MD to order daily dose PO DAILY16 21. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 22. Warfarin 0.5 mg PO ONCE atrial fibrillation 23. Ferrous Sulfate 325 mg PO BID 24. Furosemide 20 mg PO ONCE 25. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 26. Meclizine 25 mg PO Q8H:PRN vertigo 27. Milk of Magnesia 30 mL PO QAM:PRN Constipation 28. Potassium Chloride 20 mEq PO DAILY 29. TraZODone 25 mg PO Q6H:PRN Agitation 30. Ondansetron 8 mg PO Q8H:PRN Nausea Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY 2. Thiamine 100 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Amiodarone 200 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcium Carbonate 1000 mg PO BID 9. Creon 12 3 CAP PO QIDWMHS 10. Docusate Sodium 100 mg PO BID 11. Fenofibrate 145 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 15. Lactulose 30 mL PO DAILY 16. Lisinopril 10 mg PO DAILY 17. Magnesium Oxide 400 mg PO DAILY 18. Meclizine 25 mg PO Q8H:PRN vertigo 19. Metoprolol Succinate XL 25 mg PO DAILY 20. Milk of Magnesia 30 mL PO QAM:PRN Constipation 21. Multivitamins W/minerals 1 TAB PO DAILY 22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 23. Ondansetron 8 mg PO Q8H:PRN Nausea 24. Pantoprazole 40 mg PO Q12H 25. Polyethylene Glycol 17 g PO DAILY:PRN constipation 26. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal conjestion 27. Tacrolimus 1.5 mg PO Q12H 28. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 29. TraZODone 25 mg PO Q6H:PRN Agitation 30. ___ MD to order daily dose PO DAILY16 31. HELD- Furosemide 20 mg PO ONCE This medication was held. Do not restart Furosemide until seen by pcp or rehab provider 32. HELD- Potassium Chloride 20 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until seen by pcp or rehab provider Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses =================== Seizure Hypocalcemia Vitamin D deficiency Secondary Diagnoses ==================== S/p Liver Transplant Transaminitis Delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with seizure// ?cpd TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with no evidence of pneumonia. There are old healed right-sided rib fractures. Cardiomediastinal silhouette is stable. Vascular calcifications again seen. Previously visualized right IJ line has been removed in the interim. There is no pleural effusion. No pneumothorax is seen Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Seizure Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus temperature: 98.0 heartrate: 79.0 resprate: 17.0 o2sat: 95.0 sbp: 132.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ from ___ to ___ after having a seizure at your rehab center, WHY WAS I ADMITTED? ==================== - You were admitted because you had a seizure. We investigated the cause and found that your calcium levels were critically low. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ============================================= - We gave you IV calcium to get your levels back to an acceptable range. - We gave you vitamin D, which helps to keep your calcium levels up. - You were seen by neurology, who did not feel as though there were any other reasons for your seizure. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================= - Follow up with your doctors as listed below. - Take all of your medications as prescribed. It was a pleasure caring for you! Sincerely, Your ___ Care Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with the past medical history notable for PE at 7wks gestation (___), IVC clot 2wks post-partum s/p catheter-directed thrombolysis and IVC filter s/p removal, and submassive PE in ___ who presented to the emergency department for evaluation of pleurtic chest pain. She was seen at ___ where she was found to have bilateral PEs with evidence of right heart strain. She was started on TPA and received a total of 5 mg during transfer and this was DC'd upon arrival to ___. At ___ her initial vitals were: 98.7, 85, 110/87, 18, 98% RA. She was placed on a heparin drip with a initial bolus of 5200 units. Head CT was negative. BNP was negative, trop was 0.05. Remainder of her labs were unremarkable. Head CT was negative. MASCOT recommended the following: Ok for admission to floor (medicine). Continue heparin. Obtain echo and LENIs. Check APLS antibodies (anticardiolipin Ab, beta2 glycoprotein). Check BNP. Vascular medicine to follow as inpatient. Transfer Vitals: 97.9, 88, 119/94, 22, 98% RA. On arrival to the floor the patient confirms the above history. She continues to report pleuritic chest pain, worse with deep inspiration and located on the left without radiation. She also reports sub-sternal chest pain that she reports is sharp in nature and without radiation. Nothing makes that better or worse. She specifically denies dyspnea or dyspnea exertion. She also reports that she developed presyncope while walking earlier in the morning and she fell down and struck her knees, but denied head strike of full loss of consciousness. She reports that she has not missed any doses of her rivaroxaban. She takes it at ___ every night with a snack like crackers. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: -Possible AT3 deficiency => not likely per -History of pulmonary emboli now on lifelong anticoagulation. -History of Preeclampsia -History of IUGR -Migraine headaches w/o aura Social History: ___ Family History: No family history of bleeding/clotting disorders. Grandmother with possible DM. Physical Exam: VITALS: ___ 1545 Dyspnea: 0 RASS: 0 Pain Score: ___ ___ 1614 Temp: 98.3 PO BP: 130/81 HR: 89 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, ___ SEM, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ___ 12:00PM BLOOD WBC: 7.3 RBC: 4.38 Hgb: 13.3 Hct: 38.0 MCV: 87 MCH: 30.4 MCHC: 35.0 RDW: 13.0 RDWSD: 40.___ ___ 12:00PM BLOOD Neuts: 66.3 Lymphs: ___ Monos: 7.4 Eos: 0.7* Baso: 0.5 Im ___: 0.4 AbsNeut: 4.87 AbsLymp: 1.81 AbsMono: 0.54 AbsEos: 0.05 AbsBaso: 0.04 ___ 12:00PM BLOOD ___: 13.8* PTT: 24.0* ___: 1.3* ___ 12:00PM BLOOD Glucose: 86 UreaN: 14 Creat: 0.8 Na: 138 K: 4.3 Cl: 107 HCO3: 21* AnGap: 10 ___ 12:00PM BLOOD cTropnT: 0.05* ___ 12:00PM BLOOD proBNP: 40 I personally reviewed the [X-ray, ECG] and my interpretation is: EKG: Sinus at 86bpm. Normal Axis. Normal interval. S1Q3T3 (new). CONCLUSION: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 54 % (normal 54-73%). Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild to moderate [___] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. Mild-moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 20 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Discharge Medications: 1. Enoxaparin Sodium 100 mg SC Q12H RX *enoxaparin 100 mg/mL 1 Injection SC every twelve (12) hours Disp #*60 Syringe Refills:*1 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Discharge Disposition: Home Discharge Diagnosis: Acute pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with s/p fall, on blood thiner// eval for bleed TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: Prior exam is dated ___ FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with chronic VTE presents with recurrent PE and SOB// bilat ___ to eval for new DVT, clot burden TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Ultrasound from ___. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by AMBULANCE Chief complaint: Chest pain, PE, Transfer Diagnosed with Other pulmonary embolism without acute cor pulmonale temperature: 98.7 heartrate: 85.0 resprate: 18.0 o2sat: 98.0 sbp: 110.0 dbp: 87.0 level of pain: 7 level of acuity: 2.0

You were admitted with a blood clot to your lungs. You were seen by the hematology and vascular medicine teams. We have stopped your rivaroxaban and have started enoxaparin (Lovenox). It is very important that you take this medication as prescribed twice daily and follow up with your hematologist as scheduled

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd Pain, Confusion, Diarrhea, Nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH ESRD due to lithium toxicity s/p LRRT ___ years ago on azathioprine, prednisone, and tacrolimus, baseline creatinine ~0.9, IBS with chronic diarrhea, OSA on CPAP and 2L O2 at night, anemia, HTN, severe bipolar disorder, presenting with nausea (no vomiting), RLQ/vague abdominal pain, and diarrhea for the past week, with one day of confusion/delirium. Family reports confusion since yesterday. History per son primarily though patient adds in additional points. Reports having nausea for the last week on and off though progressive and more frequent last ___ days, with periumbilical/ RLQ pain. Decreased PO intake of food and water. Denies fever, chills, chest pain, cough, sob. Son reports she has been forgetful in last 2 days that is not her baseline. Forgot her meds this morning, intermittently didn't know where she was, reports this is very abnormal for her. Denies dysuria though has had UTIs in the past as well as CDiff. Has baseline diarrhea, denies worsening symptoms recently. Denies changes in medications. Denies fall or trauma. In the ED, initial VS were: 98.6 132/78 80 16 98/RA ECG: poor quality, sinus, some possible STD in anterior leads which were present in prior EKG. Labs showed: - Nl CBC - Cr 1.3 Bicarb 17 AG 17 BUN 47 Mg 1.4 phos 2.6 Ca ___ lytes otherwise WNL - Trop <0.01 - Lactate 1.2 - INR 1.2 - UA w/ 26 rbc, tr pro - PTH 148 Imaging showed: - CTU: Acute uncomplicated diverticulitis of the descending colon. - Transplant US: Normal renal transplant ultrasound. - CXR: Low lung volumes. No evidence of acute cardiopulmonary process. Consults: Renal: admit to medicine, transplant team will follow on the weekend Patient received: ___ 21:10 IVF NS ___ Started ___ 21:10 IV Magnesium Sulfate ___ Started ___ 22:08 IVF NS 1000 mL ___ Stopped (___) ___ 22:08 IV Magnesium Sulfate 2 gm ___ Stopped (___) ___ 22:09 IVF NS ___ Started ___ 23:34 IVF NS 1000 mL ___ Stopped (1h ___ ___ 23:34 IVF NS ( 1000 mL ordered) ___ Started ___ 00:03 IV Ciprofloxacin (400 mg ordered) ___ Started On arrival to the floor, patient reports ongoing nausea with mild abdominal pain. Denies confusion, alert and oriented during our discussion. Past Medical History: - ESRD due to lithium toxicity s/p LRRT ___ on azathioprine, prednisone, and tacrolimus, baseline creatinine ~0.9, formerly undergoing plasma exchange for renal sensitization - IBS with chronic diarrhea - OSA on CPAP - anemia - femur fracture - HTN - Questionable history of temporal arteritis versus polymyalgia rheumatica - Severe bipolar disorder - Hyperparathyroidism with hypercalcemia related to lithium - Vertigo - Gastroesophageal reflux disease - Cholecystectomy in ___ - Right knee replacement in ___ - Left benign breast tumor resection ___ - Status post appendectomy - History of difficult intubation - ___ ex lap, LOA for ___ Social History: ___ Family History: Breast cancer in aunt, heart disease; denies hx colon cancer, diverticulosis. Physical Exam: ADMISSION PHYSICAL EXAM: VS: ___ 0138 Temp: 98.3 PO BP: 136/86 L Lying HR: 74 RR: 20 O2 sat: 98% O2 delivery: RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, mild tenderness to deep palpation worse periumbilical and RLQ, no rebound/guarding EXTREMITIES: no cyanosis, clubbing; trace edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, CN ___ intact, strength ___ and sensation intact throughout SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1000) Temp: 98.0 (Tm 98.3), BP: 125/82 (108-125/70-82), HR: 63 (63-69), RR: 18, O2 sat: 97% (95-97), O2 delivery: Cpap GENERAL: Resting in chair in NAD. Oriented x3. Mood, affect appropriate. HEENT: Very poor dentition. NECK: Supple with no LAD or JVD. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA bilaterally. No crackles, wheezes or rhonchi. ABDOMEN: NTND. +BS. EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric. SKIN: Warm, dry, no rashes or obvious lesions. Pertinent Results: ADMISSION LABS: ___ 06:00PM BLOOD WBC-7.2 RBC-3.96 Hgb-12.2 Hct-34.9 MCV-88 MCH-30.8 MCHC-35.0 RDW-12.6 RDWSD-40.1 Plt ___ ___ 06:00PM BLOOD Neuts-60.0 ___ Monos-9.1 Eos-3.5 Baso-0.7 Im ___ AbsNeut-4.30 AbsLymp-1.86 AbsMono-0.65 AbsEos-0.25 AbsBaso-0.05 ___ 06:00PM BLOOD ___ PTT-28.2 ___ ___ 06:00PM BLOOD Glucose-82 UreaN-47* Creat-1.3* Na-138 K-4.6 Cl-104 HCO3-17* AnGap-17 ___ 06:00PM BLOOD Albumin-3.6 Calcium-10.9* Phos-2.6* Mg-1.4* ___ 10:09PM BLOOD PTH-148* IMAGING: CXR ___: FINDINGS: Low lung volumes cause bronchovascular crowding and bibasilar atelectasis. There is no focal consolidation or pleural effusion, pulmonary edema, or pneumothorax. IMPRESSION: Low lung volumes. No evidence of acute cardiopulmonary process. RENAL TRANSPLANT US ___: FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.62 to 0.68, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 108 cm/s. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. CTU ___: IMPRESSION: Optimal evaluation of organ pathology and vasculature is limited without the benefit of intravenous contrast. Within this limitation, acute uncomplicated diverticulitis involving a short segment of the descending colon, located in the left lower quadrant. No surrounding drainable fluid collection. MICROBIOLOGY: ___ 7:50 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood cultures negative C diff negative DISCHARGE LABS: ___ 09:10AM BLOOD Glucose-79 UreaN-18 Creat-1.0 Na-140 K-4.0 Cl-105 HCO3-23 AnGap-12 ___ 09:10AM BLOOD tacroFK-4.8* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Divalproex (DELayed Release) 250 mg PO TID 3. LamoTRIgine 200 mg PO QHS 4. LamoTRIgine 150 mg PO QAM 5. Cinacalcet 30 mg PO DAILY 6. ARIPiprazole 5 mg PO DAILY 7. Metoprolol Tartrate 12.5 mg PO BID 8. Alendronate Sodium 35 mg PO QSUN 9. AzaTHIOprine 75 mg PO DAILY 10. Tacrolimus 4 mg PO Q12H 11. Vitamin D 1000 UNIT PO DAILY 12. Venlafaxine XR 300 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*21 Tablet Refills:*0 2. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide 2 mg 2 mg by mouth qid prn Disp #*30 Capsule Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8 Disp #*31 Tablet Refills:*0 4. Tacrolimus 2 mg PO Q12H 5. ARIPiprazole 5 mg PO DAILY 6. AzaTHIOprine 75 mg PO DAILY 7. Cinacalcet 30 mg PO DAILY 8. Divalproex (DELayed Release) 250 mg PO QAM 9. Divalproex (DELayed Release) 500 mg PO QPM 10. LamoTRIgine 25 mg PO QAM 11. LamoTRIgine 50 mg PO QPM 12. PredniSONE 5 mg PO DAILY 13. Venlafaxine XR 75 mg PO QPM 14. Venlafaxine XR 300 mg PO QAM 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with nausea, evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Prior chest radiographs dating back to ___, most recently ___ FINDINGS: Low lung volumes cause bronchovascular crowding and bibasilar atelectasis. There is no focal consolidation or pleural effusion, pulmonary edema, or pneumothorax. IMPRESSION: Low lung volumes. No evidence of acute cardiopulmonary process. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ with pain over transplanted kidney, evaluate for hydronephrosis or change in flow. TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Prior renal transplant ultrasound dated ___. FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.62 to 0.68, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 108 cm/s. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: ___ with abd pain, nausea, confusion evaluate for stones, diverticulitis, or colitis. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP = 530.35 mGy-cm. COMPARISON: Prior CT of the abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is not visualized. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Bilateral native kidneys are severely atrophic.. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. The right iliac fossa transplant kidney is without evidence of hydronephrosis or focal lesions within limitations of an unenhanced scan. No stones are seen within this transplant kidney. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. There is wall thickening and fat stranding around approximately 7 cm segment of the descending colon consistent with diverticulitis. There is no associated fluid collection. No free air to suggest perforation. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus contains a calcified fibroids.. No adnexal abnormalities are seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Hardware in the left femoral neck and shaft is noted. SOFT TISSUES: Fat containing umbilical hernia is noted. Low right lower quadrant ventral abdominal hernia contains a loop of small bowel without evidence of obstruction. IMPRESSION: Optimal evaluation of organ pathology and vasculature is limited without the benefit of intravenous contrast. Within this limitation, acute uncomplicated diverticulitis involving a short segment of the descending colon, located in the left lower quadrant. No surrounding drainable fluid collection. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:08 pm, 5 minutes after discovery of the findings. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Abd pain, Confusion, Diarrhea, Nausea Diagnosed with Unspecified abdominal pain temperature: 98.6 heartrate: 80.0 resprate: 16.0 o2sat: 98.0 sbp: 132.0 dbp: 78.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. Why was I here? -You were here because you had nausea, confusion, and abdominal pain. What was done while I was here? -You were found to have inflammation of your colon on a CT scan - this is called "diverticulitis". -You were treated with antibiotics. These were switched to oral once you were feeling up to taking oral meds. What should I do when I go home? -You should continue taking your antibiotics for a total of 14 days. The last day will be ___. -You should continue taking all of your other medications as directed on this paperwork. We wish you the best! Sincerely, Your ___ Medicine Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / latex / walnuts Attending: ___ Chief Complaint: pelvic subcutaneous fluid collection Major Surgical or Invasive Procedure: ___ drainage of pelvic fluid collection Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, minimally tender, mildly erythematous around the drain site improved from admission, no induration or fluctuance noted, no rebound/guarding, RLQ JP drain intact with serosanguinous fluid Ext: no TTP Pertinent Results: ___ 12:24PM BLOOD Hct-36.2# ___ 05:32AM BLOOD WBC-5.7 RBC-3.22* Hgb-9.6* Hct-28.6* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.5 RDWSD-44.0 Plt ___ ___ 03:40AM BLOOD WBC-7.1 RBC-4.04 Hgb-11.7 Hct-35.4 MCV-88 MCH-29.0 MCHC-33.1 RDW-13.5 RDWSD-43.5 Plt ___ ___ 04:00AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.0* Hct-33.7* MCV-88 MCH-28.6 MCHC-32.6 RDW-13.8 RDWSD-44.0 Plt ___ ___ 05:13AM BLOOD WBC-7.8 RBC-4.27 Hgb-12.3 Hct-37.5 MCV-88 MCH-28.8 MCHC-32.8 RDW-14.0 RDWSD-45.2 Plt ___ ___ 07:33AM BLOOD WBC-9.6 RBC-3.92 Hgb-11.4 Hct-34.6 MCV-88 MCH-29.1 MCHC-32.9 RDW-14.4 RDWSD-46.1 Plt ___ ___ 10:00PM BLOOD WBC-12.5* RBC-4.14 Hgb-11.9 Hct-36.8 MCV-89 MCH-28.7 MCHC-32.3 RDW-14.3 RDWSD-46.1 Plt ___ ___ 05:32AM BLOOD Neuts-49 Bands-0 ___ Monos-13 Eos-2 Baso-0 ___ Myelos-0 AbsNeut-2.79 AbsLymp-2.05 AbsMono-0.74 AbsEos-0.11 AbsBaso-0.00* ___ 03:40AM BLOOD Neuts-58 Bands-0 ___ Monos-8 Eos-4 Baso-1 Atyps-3* ___ Myelos-0 AbsNeut-4.12 AbsLymp-2.06 AbsMono-0.57 AbsEos-0.28 AbsBaso-0.07 ___ 04:00AM BLOOD Neuts-53.4 ___ Monos-9.8 Eos-4.9 Baso-0.4 Im ___ AbsNeut-4.11 AbsLymp-2.39 AbsMono-0.75 AbsEos-0.38 AbsBaso-0.03 ___ 05:13AM BLOOD Neuts-52.2 ___ Monos-9.1 Eos-4.9 Baso-0.4 Im ___ AbsNeut-4.07 AbsLymp-2.57 AbsMono-0.71 AbsEos-0.38 AbsBaso-0.03 ___ 07:33AM BLOOD Neuts-46.2 ___ Monos-9.6 Eos-5.9 Baso-0.4 Im ___ AbsNeut-4.41 AbsLymp-3.57 AbsMono-0.92* AbsEos-0.56* AbsBaso-0.04 ___ 10:00PM BLOOD Neuts-53.8 ___ Monos-8.9 Eos-5.0 Baso-0.6 Im ___ AbsNeut-6.71* AbsLymp-3.87* AbsMono-1.11* AbsEos-0.63* AbsBaso-0.08 ___ 07:33AM BLOOD ___ PTT-31.7 ___ ___ 10:00PM BLOOD Glucose-179* UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 ___ 12:24PM BLOOD CK(CPK)-50 ___ 04:00AM BLOOD ALT-38 AST-20 ___ 12:24PM BLOOD CRP-3.6 ___ 10:21PM BLOOD Lactate-1.8 Imaging: ___ CT A/P IMPRESSION: 1. A lower anterior abdominal wall peripherally enhancing fluid collection containing locules of air is decreased in size from prior, currently measuring up to 9.6 cm, compared with 14.2 cm previously, however is again concerning for infected seroma/abscess. This would be amenable to percutaneous drainage if desired. 2. A 2.7 cm left adrenal lesion is not significantly changed from prior, however is again incompletely characterized. Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization if no prior imaging is available. 3. Hepatic steatosis. ___ CXR PICC IMPRESSION: Right-sided PICC line at the appropriate position. Micro: ___ Abscess Culture GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ENTEROCOCCUS SP.. SPARSE GROWTH. Daptomycin Susceptibility testing requested by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LINEZOLID------------- 2 S PENICILLIN G---------- 8 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Medications on Admission: albuterol, symbicort, fluvoxamine 50mg, glipizide ER 5mg, hydroxyzine pamoate 50mg, lamotrigine 100mg, lithium carbonate ER 600mg, metformin 500mg BID, omeprazole 20mg, polyethylene glycol, prazosin 2mg, simvastatin 20mg, zolpidem 10mg, docusate sodium, loratidine 10mg, florastor 250mg Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 2. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0 4. Levofloxacin 750 mg PO Q24H RX *levofloxacin 750 mg 1 tablet(s) by mouth every 24 hours Disp #*15 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*45 Tablet Refills:*0 6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing 7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN heartburn 8. Daptomycin 400 mg IV Q24H RX *daptomycin 500 mg 400 mg IV every 24 hours Disp #*15 Vial Refills:*0 9. Fluvoxamine Maleate 75 mg PO DAILY 10. GlipiZIDE XL 5 mg PO DAILY 11. HydrOXYzine 25 mg PO BID 12. LamoTRIgine 100 mg PO QHS 13. Lithium Carbonate SR (Lithobid) 600 mg PO QHS Lithobid SR 14. Loratadine 10 mg PO DAILY 15. MetFORMIN (Glucophage) 500 mg PO BID 16. Omeprazole 20 mg PO BID 17. Prazosin 2 mg PO QHS 18. Simvastatin 20 mg PO QPM 19. Zolpidem Tartrate 10 mg PO QHS 20.Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, TB, ALK PHOS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cellulitis and pelvic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: NO_PO contrast; History: ___ with hx recurrent abscesses p/w worsening pain, swelling x1dNO_PO contrast// anterior abdominal wall abscess? TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP = 14.4 mGy-cm. 2) Spiral Acquisition 5.2 s, 57.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 959.0 mGy-cm. Total DLP (Body) = 973 mGy-cm. COMPARISON: CT abdomen and pelvis on ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation throughout, consistent with hepatic steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in size and shape. A 2.7 x 2.3 cm left adrenal lesion is not significantly changed, however is again incompletely characterized. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Subcentimeter cortical hypodensities bilaterally are too small to characterize, however likely represent cysts. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The dome of the bladder wall again abuts an anterior pelvic wall collection, with little to no fat plane between the bladder in the collection. Inflammatory flat stranding again extends deep to the collection, bordering the anterior peritoneum. The distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Multiple old right-sided healed rib fractures are noted. There are mild degenerative changes in the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A lower anterior pelvic wall peripherally enhancing fluid collection containing locules of air is decreased in size from prior, currently measuring 9.6 x 3.8 x 7.0 cm in greatest dimension, compared with 14.2 x 4.7 x 10.4 cm previously (2:85, 601:24). The attenuation is again of simple fluid. There is surrounding fat stranding in the anterior abdominal wall, decreased from prior. IMPRESSION: 1. A lower anterior abdominal wall peripherally enhancing fluid collection containing locules of air is decreased in size from prior, currently measuring up to 9.6 cm, compared with 14.2 cm previously, however is again concerning for infected seroma/abscess. This would be amenable to percutaneous drainage if desired. 2. A 2.7 cm left adrenal lesion is not significantly changed from prior, however is again incompletely characterized. Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization if no prior imaging is available. 3. Hepatic steatosis. RECOMMENDATION(S): Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization of a left adrenal lesion if no prior imaging is available. Radiology Report INDICATION: ___ year old woman with postop cellulitus and recurrent abscess currently receiving IV antibioitcs// assess PICC placement TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Cardiomediastinal shadow is normal. No airspace consolidation. No suspicious pulmonary nodules or masses. No pleural effusions. No pulmonary edema. Right-sided PICC line in situ with the tip at the cavoatrial junction. No right-sided pneumothorax. IMPRESSION: Right-sided PICC line at the appropriate position. Radiology Report EXAMINATION: Ultrasound-guided collection drainage. INDICATION: ___ year old woman with history of post-operative lower abdominal fluid collection s/p drainage, now readmitted with likely re-accumulation of cellulitis/ lower abdominal fluid collection.// characterization of lower abdominal subcutaneous fluid collection, drainage of this collectio COMPARISON: CT abdomen and pelvis ___ PROCEDURE: Ultrasound-guided drainage of an anterior abdominal wall collection. OPERATORS: Dr. ___ Dr. ___ trainees and Dr. ___, ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, ___ Exodus drainage catheter was advanced via trocar technique into the collection. A sample of fluid was aspirated, confirming catheter position within the collection. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Approximately 60 cc of cloudy fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Lidocaine local anesthesia only. FINDINGS: Intraprocedural sonographic images re-demonstrate a large, complex collection in the subcutaneous tissues of the anterior abdominal wall. Postprocedure images demonstrate appropriate positioning of the pigtail catheter within the collection. IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the collection. Sample was sent for microbiology evaluation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abscess Diagnosed with Cellulitis of abdominal wall temperature: 97.8 heartrate: 100.0 resprate: 16.0 o2sat: 99.0 sbp: 141.0 dbp: 86.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, You were admitted to the gynecology service for treatment of your cellulitis and abscess. A drain was placed in the fluid collection and you were started on antibiotics. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Cellulitis/Abscess: * You were discharged home with a drain in place. A visiting nurse ___ come to your home to help you take care of the drain and monitor its output. The nurse will be in contact with the interventional radiologist on when to have it removed. * Please take all your antibiotics as directed. You will continue with the daptomycin infusions, which your visiting nurse ___ help with. * You will also be scheduled for an MRI on ___. If your drain is still in place then, please call ___ between 8AM & 6PM to reschedule the MRI Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: New DLBCL Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ F with ___ biopsied Right neck & Left upper forehead mass. Oncology fellow was called by Pathology regarding her tissue biopsy returning as DLBCL. She reports a history of 'large cell lymphoma in her abdomen' in ___ for which she received 6 cycles of CHOP ('was clean after 5'). She had drenching night sweats at that time. Currently, she feels well and denies fevers, chills, night sweats, unintentional weight loss. She has npo SOB or CP at this time. No other sx per pt. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): History of 'large cell lymphoma in her abdomen' in ___ for which she received 6 cycles of CHOP PAST MEDICAL HISTORY: -Cataracts -Retinitis pigmentosa -Hypertension -Shingles -Lymphoma -Hematuria -Pylonephritis -Hypercholesterolemia -Obesity -Knee pain mastoidectomy, removal of bilateral cataracts. Social History: ___ Family History: Brother with sturge weber syndrome Physical Exam: ADMISSION PHYSICAL EXAM: ======================== General: NAD VITAL SIGNS: 98.6 PO 178 / 82 90 20 97 Ra HEENT: Multiple hard nodules in R cervical, Anterior jugular notch, L preauricular, one in nape of the neck. CV: RR, NL S1S2 ___ SEM in R and L 2ICS PULM: CTAB ABD: BS+, soft, NTND, LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown DISCHARGE PHYSICAL EXAM: ======================== VS- 97.9 PO 127 / 61 68 18 97 RA General: NAD, well appearing HEENT: Sclera anicteric, MMM LYMPH: Multiple firm, non-tender ~1-2cm nodules in R anterior cervical chain, one on posterior neck, decreased in size and softer. R supraclavicular with bandage and drain in place from surgery. Small nodule at R axilla improved in size, softer. CV: RRR, normal S1, S2. No m/r/g. Port in place w/ minimal erythema Lungs: CTAB Abdomen: Soft, nt, nd Ext: WWP, 2+ pitting edema b/l lower ankles Neuro: A&O x3 Pertinent Results: ADMISSION LABS: =============== ___ 09:16PM BLOOD WBC-6.6 RBC-4.24 Hgb-12.9 Hct-38.3 MCV-90 MCH-30.4 MCHC-33.7 RDW-13.3 RDWSD-44.3 Plt ___ ___ 09:16PM BLOOD Neuts-63.9 ___ Monos-9.8 Eos-2.4 Baso-0.5 Im ___ AbsNeut-4.25 AbsLymp-1.50 AbsMono-0.65 AbsEos-0.16 AbsBaso-0.03 ___ 09:16PM BLOOD ___ PTT-31.1 ___ ___ 09:16PM BLOOD Glucose-114* UreaN-19 Creat-1.0 Na-135 K-3.8 Cl-96 HCO3-25 AnGap-18 ___ 09:16PM BLOOD ALT-21 AST-23 LD(LDH)-213 AlkPhos-90 TotBili-0.2 ___ 09:16PM BLOOD Albumin-4.6 Calcium-9.9 Phos-3.9 Mg-2.0 UricAcd-7.3* ___ 09:16PM BLOOD HBsAg-Negative HBsAb-Negative ___ 09:16PM BLOOD HIV Ab-Negative ___ 09:16PM BLOOD HCV Ab-Negative IMAGING/STUDIES: ================ TTE ___: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CT NECK ___: 1. Interval resection of large right supraclavicular mass with postoperative changes in the resection bed. 2. Multiple soft tissue masses, as detailed above, almost all of which have increased in size from CT neck ___. The largest mass is abutting the right sternohyoid muscle at the level of the thyroid now measures 1.7 x 2.2 x 2.9 cm, previously measuring 1.2 x 1.4 x 2.4 cm on CT neck ___. CT CHEST ___: Multiple subcutaneous soft tissue nodules/lymph nodes, with a few lymph nodes in the superior chest subcutaneous tissue appear mildly increased in size compared to prior CT neck done ___. Suspicious pericardial, pleural (intercostal) and a few internal mammary lymph nodes, but no pathologically enlarged superior mediastinal lymph nodes. No conclusive findings to suggest pulmonary involvement. Moderate aortic valve calcification. Mild coronary artery calcification. CT ABD/PELV ___: 1. Numerous soft tissue nodules within the subcutaneous fat and anterior abdominal wall measure up to 18 x 9 mm as described in the findings. These are uncertain in etiology, possibly lymphomatous. However, alternative etiologies such as melanoma should be considered. Recommend percutaneous sampling. 2. No splenomegaly or lymphadenopathy in the abdomen or pelvis. DISCHARGE LABS: =============== ___ 12:00AM BLOOD WBC-5.2 RBC-3.47* Hgb-10.4* Hct-29.7* MCV-86 MCH-30.0 MCHC-35.0 RDW-13.2 RDWSD-41.6 Plt ___ ___ 12:00AM BLOOD Neuts-92.7* Lymphs-6.3* Monos-0.4* Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.85 AbsLymp-0.33* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD ___ PTT-25.4 ___ ___ 12:00AM BLOOD Glucose-136* UreaN-27* Creat-0.8 Na-130* K-3.6 Cl-97 HCO3-21* AnGap-16 ___ 08:03AM BLOOD Na-132* ___ 12:00AM BLOOD ALT-28 AST-18 LD(LDH)-180 AlkPhos-58 TotBili-0.3 ___ 12:00AM BLOOD TotProt-5.7* Albumin-3.6 Globuln-2.1 Calcium-8.5 Phos-2.7 Mg-2.0 UricAcd-4.5 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth BID: PRN Disp #*30 Capsule Refills:*0 4. Dronabinol 2.5 mg PO BID RX *dronabinol 2.5 mg 1 capsule(s) by mouth BID: PRN Disp #*30 Capsule Refills:*0 5. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by mouth QID: PRN Disp #*30 Capsule Refills:*0 6. LORazepam 0.5-1 mg PO QHS:PRN insomnia RX *lorazepam [Ativan] 0.5 mg ___ tablet by mouth qhs: PRN Disp #*15 Tablet Refills:*0 7. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8h: PRN Disp #*30 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth qday: PRN Disp #*10 Packet Refills:*0 9. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ============================ -Diffuse large B-cell lymphoma Secondary Diagnosis: =========================== -Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman with hx of Lymphoma, new R neck mass biopsy of which showed DLBCL.// For expedited staging. History notable for excision of right neck and left upper forehead mass positive for dL BCL TECHNIQUE: Imaging was performed after administration of ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 34.4 cm; CTDIvol = 7.1 mGy (Body) DLP = 238.2 mGy-cm. Total DLP (Body) = 238 mGy-cm. COMPARISON: CT neck ___ FINDINGS: Since ___, there has been interval resection of the large right supraclavicular mass. There is fatty stranding, subcutaneous edema, and foci of air in the resection bed all of which are likely postoperative changes. Abutting the right sternal hyoid muscle at the level of the thyroid, , there is a enhancing soft tissue mass measuring 1.7 x 2.2 x 2.9 cm (AP by TV by CC, 2:61, 5:42), increased in size from CT neck ___, previously measuring 1.2 x 1.4 x 2.4 cm. Abutting the trapezius muscle, there is a enhancing soft tissue mass which measures 1.1 x 2.2 x 1.5 cm (AP by TV by CC, 2:40, 5:29) increased in size from ___, previously measuring 1.2 x 1.9 x 1.0 cm. There is a soft tissue mass at the posterior midline at the C3 level which measures 1.9 x 1.3 cm (02:39), decreased from ___, previously measuring 1.3 x 1.1 cm. There is a smaller adjacent soft tissue nodule measuring 0.7 x 0.6 cm, grossly unchanged from ___. There is a soft tissue nodule abutting the right sternocleidomastoid muscle measuring 1.5 x 1.2 cm (02:40), increased from ___, previously measuring 1.3 x 1.1 cm. There is a nodule in the right breast (2:80) which is partially visualized but appears larger in size from ___. Neck vessels are patent.The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. IMPRESSION: 1. Interval resection of large right supraclavicular mass with postoperative changes in the resection bed. 2. Multiple soft tissue masses, as detailed above, almost all of which have increased in size from CT neck ___. The largest mass is abutting the right sternohyoid muscle at the level of the thyroid now measures 1.7 x 2.2 x 2.9 cm, previously measuring 1.2 x 1.4 x 2.4 cm on CT neck ___. Radiology Report EXAMINATION: CT abdomen/pelvis INDICATION: ___ year old woman with hx of Lymphoma, new R neck mass biopsy of which showed DLBCL. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 17.5 s, 0.2 cm; CTDIvol = 297.6 mGy (Body) DLP = 59.5 mGy-cm. 3) Spiral Acquisition 10.4 s, 67.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 596.8 mGy-cm. Total DLP (Body) = 658 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is not visualized. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Renal cysts measure up to 12 mm on the right and 18 mm on the left. Some hypoattenuating lesions are too small to completely characterize, but likely reflect additional cysts. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There is a small periampullary duodenal diverticulum. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is anteverted. The adnexae are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. Incidental note is made of an accessory inferior right hepatic vein. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is grade 1 anterolisthesis of L4 on L5. Small sclerotic lesions in the pelvis likely reflect bone islands. SOFT TISSUES: Scattered soft tissue nodules throughout the subcutaneous tissues are uncertain in etiology (series 4, image 50, 54, 55, 58, 60, 70, 82, 84, 100, 105). Additional nodules are located within the anterior abdominal wall adjacent to the rectus abdominus musculature (series 4, images 52, 65, 74, 82, 90). The largest nodule in the superior anterior abdominal wall measures 18 x 9 mm (series 4, image 52). The largest nodule in the subcutaneous fat is located just above the gluteal region on the left and measures 12 x 11 mm (series 4, image 78). Small foci of subcutaneous emphysema in the anterior abdominal wall presumably reflect medication injection. IMPRESSION: 1. Numerous soft tissue nodules within the subcutaneous fat and anterior abdominal wall measure up to 18 x 9 mm as described in the findings. These are uncertain in etiology, possibly lymphomatous. However, alternative etiologies such as melanoma should be considered. Recommend percutaneous sampling. 2. No splenomegaly or lymphadenopathy in the abdomen or pelvis. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ woman with history of lymphoma, new right neck mass: Biopsy of which showed diffuse large B-cell lymphoma. Expedited staging. TECHNIQUE: Contrasted CT neck, chest, abdomen and pelvis. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 17.5 s, 0.2 cm; CTDIvol = 297.6 mGy (Body) DLP = 59.5 mGy-cm. 3) Spiral Acquisition 10.4 s, 67.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 596.8 mGy-cm. Total DLP (Body) = 658 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Prior neck CT done ___ FINDINGS: There are numerous subcutaneous soft tissue nodules (lymph nodes) for example in the right prepectoral area (4, 7) measuring 15 mm in length (previously measuring 12 mm in length). Small left prepectoral soft tissue nodule/lymph node currently measuring 9 x 6 mm (previously measuring 6 x 7 mm). Soft tissue nodule in the lower neck anterior to the right lobe of thyroid (4, 5) measures 17 mm in diameter (previously 13 mm). Multiple other subcutaneous soft tissue nodules the largest in the right lateral chest wall measuring 22 x 22 mm. A few subcentimeter axillary lymph nodes. No suspicious thyroid lesions. Small hiatal hernia. Pericardial lymph node (4, 43) is enlarged measuring 8 mm in diameter. Few mildly enlarged internal mammary lymph nodes. Right lower pleural/intercostal lymph node measuring 19 x 8 mm (5, 168). Normal cardiac configuration. No pericardial effusion. No cardiomegaly. Moderate aortic valve calcification. Mild coronary artery calcification. The pulmonary artery measures at the upper limits of normal. No filling defects on this nondedicated study. The esophagus is not patulous. The airways are patent to the subsegmental level. No bronchiectasis. A couple of pulmonary micro nodules are nonsuspicious. A couple of small intrapulmonary lymph nodes. No airspace consolidation. No diffuse lung disease. No diffuse lung disease. Spondylotic changes of the thoracic spine. No lytic/destructive bony lesions concerning for bony involvement. IMPRESSION: Multiple subcutaneous soft tissue nodules/lymph nodes, with a few lymph nodes in the superior chest subcutaneous tissue appear mildly increased in size compared to prior CT neck done ___. Suspicious pericardial, pleural (intercostal) and a few internal mammary lymph nodes, but no pathologically enlarged superior mediastinal lymph nodes. No conclusive findings to suggest pulmonary involvement. Moderate aortic valve calcification. Mild coronary artery calcification. For neck, abdomen and pelvis findings please refer to their respective reports. Radiology Report INDICATION: ___ year old woman with new DLBCL, needs port placement for chemotherapy// Please place double lumen chest port need both access for ___ aware COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___, attending radiologist, performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 15 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Versed, fentanyl, 1% lidocaine CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.4 min, 2 mGy PROCEDURE 1. Left internal jugular approach chest double lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire was advanced distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ Prolene sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-Strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The both port lumens were accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abnormal labs Diagnosed with Oth types of foliclar lymph, nodes of head, face, and neck temperature: 98.8 heartrate: 104.0 resprate: 17.0 o2sat: 100.0 sbp: 191.0 dbp: 71.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___! WHY YOU WERE ADMITTED: -Your biopsy showed diffuse large B-cell lymphoma (DLBCL) and you were admitted to have labs checked and staging workup WHAT HAPPENED IN THE HOSPITAL: -You had an echocardiogram of your heart which showed good cardiac function -Your drain from the surgery was removed -You received chemotherapy for your DLBCL, and tolerated it very well. Your nodules shrunk in size. WHAT YOU SHOULD DO AT HOME: -Continue taking allopurinol ___ daily for 1 week after you are discharged -Please return to clinic on ___ to receive your neulasta -Please keep all of your appointments below -Take all your medications as indicated Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Lipitor / Omeprazole / Benicar / alendronate sodium Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ washout, 10cm SBR, re-anastamosis D4-distal jejunum ___ Washout, resection 40cm proximal jejunum ___ Ex-lap, SMA stent, SBR resection History of Present Illness: Mr. ___ is an ___ y/o male PMHx of carotid stenosis s/p CEA, Left femoral endarterectomy and left common iliac artery stent, claudication, HLD, HTN, DM, CKD III, C diff colitis (___), pancreatitis ___ ETOH s/p x3 debridements, who presents to ___ after multiple episodes of coffee ground emesis, nonbloody diarrhea, and increasing abdominal pain beginning ___. CT abdomen/pelvis obtained while in ED showed portal venous gas and pneumatosis in the duodenum and jejunum in concerning for bowel necrosis. Past Medical History: - CAD s/p rca stent ___ - DM (IDDM) diagnosed after severe pancreatitis in ___ - Hypercholesterolemia - Hypertension - Pancreatitis ___ EtOH s/p 3 debridements for evacuation of pseudocyst - S/p rectal fistula repair - S/p cholecystectomy - S/p L CEA ___ - PAD w/ LLE claudication & h/o left heel ulcer - Lymphocytic colitis - Dysphagia of unknown etiology - C. diff colitis (___) Social History: ___ Family History: No family history of coronary artery disease, diabetes, or hypertension. Physical Exam: Physical Exam: upon admission: ___: Vitals:T:98.0, HR:100 BP:122/71 RR:30 Sats:99%RA GEN: In acute distress, unable to redirect, HEENT: No scleral icterus, mucus membranes moist CV: Tachycardic, regular rhythm PULM: Clear to auscultation b/l, tachypneic ABD: Soft, mildy distended, peritoneal, guarding, multiple abdominal scars GU:Foley in place Ext: No ___ edema, ___ warm and well perfused, ecchymosis left hip Discharge Physical Exam: VS: GEN: HEENT: CV: PULM: ABD: EXT: Pertinent Results: ___ 03:54AM BLOOD WBC-8.4 RBC-2.51* Hgb-7.7* Hct-25.3* MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-58.4* Plt ___ ___ 04:42AM BLOOD WBC-10.3* RBC-2.75* Hgb-8.4* Hct-27.3* MCV-99* MCH-30.5 MCHC-30.8* RDW-16.0* RDWSD-57.6* Plt ___ ___ 04:14AM BLOOD WBC-20.0* RBC-4.57* Hgb-14.0 Hct-43.1 MCV-94 MCH-30.6 MCHC-32.5 RDW-13.5 RDWSD-44.5 Plt ___ ___ 04:14AM BLOOD Neuts-82* Bands-4 Lymphs-3* Monos-11 Eos-0* Baso-0 NRBC-0.2* AbsNeut-17.20* AbsLymp-0.60* AbsMono-2.20* AbsEos-0.00* AbsBaso-0.00* ___ 06:16AM BLOOD ___ PTT-29.8 ___ ___ 03:54AM BLOOD Glucose-113* UreaN-33* Creat-0.5 Na-141 K-3.7 Cl-109* HCO3-26 AnGap-6* ___ 04:42AM BLOOD Glucose-133* UreaN-30* Creat-0.6 Na-137 K-4.0 Cl-110* HCO3-22 AnGap-5* ___ 11:58AM BLOOD ALT-103* AST-17 LD(LDH)-282* AlkPhos-124 TotBili-0.9 ___ 04:14AM BLOOD ALT-153* AST-201* AlkPhos-152* TotBili-2.0* ___ 01:21AM BLOOD cTropnT-0.15* ___ 01:38PM BLOOD CK-MB-4 cTropnT-0.16* ___ 04:35AM BLOOD cTropnT-0.14* ___ 03:54AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9 Iron-23* ___ 03:54AM BLOOD calTIBC-135* VitB12-852 Ferritn-505* TRF-104* ___ 11:58AM BLOOD Triglyc-65 ___ 03:47AM BLOOD freeCa-1.23 IMAGING: ___: CT Abdomen/Pelvis: 1. Extensive portal venous gas and pneumatosis in the duodenum and long segment of the jejunum in the right abdomen which is nonenhancing and highly concerning for bowel necrosis. No pneumoperitoneum. No central occlusion of the mesenteric arteries although there is severe atherosclerotic calcification and narrowing at their origin in both the celiac axis, SMA, and their branches. The ileum and colon appears spared. 2. Heterogeneous hepatic parenchyma with areas of hypoenhancement in the right hepatic lobe which could suggest infarction. 3. Distended stomach with fluid-filled dilated partially visualized thoracic esophagus putting the patient at risk for aspiration. 4. Trace aspiration or mild atelectasis in the left lung base. ___: KUB: Intraoperative images were obtained during retrograde stenting of a proximal SMA stenosis. Please refer to the operative note for details of the procedure. ___: ECHO: LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Normal RA size. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Cannot exclude regional systolic dysfunction. No ventricular septal defect. No resting outflow tract gradient. Indeterminate diastolic function. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTIC VALVE (AV): Valve not well seen. No stenosis. No regurgitation. MITRAL VALVE (MV): Mildly thickened leaflets. No systolic prolapse. Moderate MAC. Mild chordal thickening. Trivial regurgitation. Regurgitation severity could be UNDERestimated due to acoustic shadowing. PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation. TRICUSPID VALVE (TV): Normal leaflets. Physiologic regurgitation. Normal pulmonary artery systolic pressure. PERICARDIUM: Very ___: Dx Portable PICC: Right PICC line tip is at the cavoatrial junction. NG tube tip is in the stomach. Left internal jugular line tip is at the left brachycephalic vein and does not reach SVC. It Bilateral pleural effusions are small on the right and moderate on the left. No appreciable pneumothorax. No pulmonary edema. ___: CT Abdomen/Pelvis: 1. Patient is status post surgery for mesenteric ischemia, with an anastomosis of the distal duodenum to the distal jejunum. There is a large nonspecific loculation of fluid located in the anterior aspect of the abdominal cavity with an air-fluid level. No evidence of extraluminal contrast. 2. Newly developed fractures including a wedge fracture of T12 and a fracture of the posterior element of T11. 3. Dense material located in the hilum of the liver, likely reflux of oral contrast into the biliary system. Correlate clinically. 4. Small bilateral pleural effusions. ___: Procedure: Successful US-guided drainage of serosanguineous abdominal collection. Sample was sent for microbiology evaluation. ___: Procedure: Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum past the anastamosis. The gastric port should not be used for 24 hours. ___: CT Chest: Widespread broncho pneumonia, right lower and left upper lobes. Collapsed left lower lobe. Severe compression fracture, T12 vertebral body. If there is concern about neurologic compromise, MRI should be obtained. ___: CT Abdomen/Pelvis: 1. Contrast administered through the gastrojejunostomy tube passes into the colon with no evidence of leak. 2. Interval decrease in size of a thin rim enhancing loculated fluid collection in the anterior abdomen as well as a small amount of free air, consistent with resolving postsurgical collections. This collection is more organized compared to the prior exam. 3. Small left pleural effusion is not significantly changed, right pleural effusion is decreased in size. 4. Small consolidation at the right lung base is likely due to aspiration. ___: RUE US: No evidence of deep vein thrombosis in the right upper extremity. ___: Procedure: Successful US-guided placement of ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. ___: G/GJ/GI TUBE CHECK PORT: No evidence of leak identified after the administration of water-soluble contrast through the gastrojejunostomy tube. ___: CXR: In comparison with the study of ___, there are improved lung volumes. Cardiomediastinal silhouette is stable. There has been some improvement in the substantial pulmonary edema, much of which could merely reflect the improved lung volumes. In asymmetric opacification in the left mid to lower lung is again seen. In the appropriate clinical setting, this would raise the possibility of aspiration/pneumonia. Obscuration of the left hemidiaphragm with retrocardiac opacification is consistent with pleural fluid and volume loss in left lower lobe. MICROBIOLOGY: ___ 6:10 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LINEZOLID------------- 2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>___ R VANCOMYCIN------------ 1 S Medications on Admission: 1. Acetaminophen 650 mg PO 5X/DAY 2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC DAILY for 4 weeks RX *enoxaparin 40 mg/0.4 mL 1 syringe subcu once a day Disp #*28 Syringe Refills:*0 5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 6. Glucose Gel 15 g PO PRN hypoglycemia protocol 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. NPH 23 Units Breakfast NPH 10 Units Bedtime Insulin SC Sliding Scale using REG Insulin 10. Rosuvastatin Calcium 10 mg PO QPM 11. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 2. LORazepam 0.5-1 mg IV Q4H:PRN anxiety/agitation 3. Morphine Sulfate ___ mg IV Q4H:PRN Pain/Dyspnea 4. Ondansetron ___ mg IV Q8H:PRN Nausea/Vomiting - First Line 5. OxyCODONE (Immediate Release) 2.5 mg NG Q6H:PRN Pain - Moderate 6. QUEtiapine Fumarate 25 mg PO QAM 7. QUEtiapine Fumarate 25 mg PO Q6H:PRN agitation 8. QUEtiapine Fumarate 50 mg PO QHS 9. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 10. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: small bowel necrosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with abdominal pain and concern for perf// eval for free air TECHNIQUE: Chest AP COMPARISON: Lungs are moderately well expanded with platelike atelectasis versus trace aspiration in the lung bases. No pulmonary edema or consolidation concerning for pneumonia. Cardiomediastinal silhouette and hila are normal. No pneumothorax or pleural effusion. No evidence of pneumoperitoneum. Portal venous gas overlying the liver is far better appreciated on subsequent abdominal CT. FINDINGS: 1. No evidence of pneumoperitoneum. 2. Portal venous gas overlying the liver is far better appreciated on subsequent abdominal CT. 3. Atelectasis versus trace aspiration in the lung bases. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with diffuse abd pain, N/VNO_PO contrast// eval for intra-abdominal process TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP = 18.1 mGy-cm. 2) Spiral Acquisition 7.3 s, 57.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 806.9 mGy-cm. Total DLP (Body) = 825 mGy-cm. COMPARISON: CT of the abdomen and pelvis from ___. Fluoroscopic images from left hip nailing from ___. CT pelvis from ___. FINDINGS: LOWER CHEST: Mild left basilar opacity suggests atelectasis and possibly trace aspiration. Thoracic esophagus is distended and fluid-filled. Severe coronary artery calcifications. No pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: There is extensive diffuse portal venous gas. Visualized parenchyma is heterogeneous specially hypoattenuating right hepatic lobe and hepatic dome. No evidence of focal lesion. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: Severely atrophic and fatty replaced. No evidence of focal lesions or peripancreatic stranding. SPLEEN: The spleen shows normal size, without evidence of focal lesions. Heterogeneity is likely due to contrast mixing. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of hydronephrosis. Both kidneys contain numerous small hypodensities which are too small to characterize but suggestive of cysts. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is distended. There is extensive diffuse pneumatosis involving the duodenum and very long segment of jejunum which is dilated and demonstrates nonenhancing wall compatible with bowel necrosis. Ileum and colon appear spared. There is no pneumoperitoneum to suggest perforation. There is trace mesenteric edema in the right upper quadrant. No drainable fluid collection E. the appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is not severely enlarged and contains calcifications. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Patent aorta. There is severe atherosclerotic calcification in the abdominal arteries. Notably there is extremely dense calcification at the origins of the mesenteric arteries which are severely stenosed with multiple other areas of severe calcification and stenosis in the celiac axis worse than the SMA although there is contrast visualized in these vessels and there is no central occlusion. The portal vein, hepatic veins, and IVC are patent. Air is seen in the SMV. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Severe degenerative changes of the lumbar spine. Severe compression deformity of T12 vertebral body demonstrates 2 mm of retropulsion, new from ___, likely subacute as suggested by sclerosis, without soft tissue changes to suggest it is acute. Chronic T11 spinous process fracture. Post left proximal femur ORIF with gamma nail and transfemoral screw with redemonstrated code trochanteric fracture. SOFT TISSUES: Mild anasarca. No drainable fluid collection. IMPRESSION: 1. Extensive portal venous gas and pneumatosis in the duodenum and long segment of the jejunum in the right abdomen which is nonenhancing and highly concerning for bowel necrosis. No pneumoperitoneum. No central occlusion of the mesenteric arteries although there is severe atherosclerotic calcification and narrowing at their origin in both the celiac axis, SMA, and their branches. The ileum and colon appears spared. 2. Heterogeneous hepatic parenchyma with areas of hypoenhancement in the right hepatic lobe which could suggest infarction. 3. Distended stomach with fluid-filled dilated partially visualized thoracic esophagus putting the patient at risk for aspiration. 4. Trace aspiration or mild atelectasis in the left lung base. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:21 am, immediately after discovery of the findings. Findings subsequently discussed with the surgical team in person, who plan on taking the patient to the operating room Radiology Report EXAMINATION: ABDOMEN (SUPINE ONLY) INDICATION: ___ male with bowel ischemia undergoing exploratory laparotomy and retrograde superior mesenteric artery stenting. TECHNIQUE: Fluoroscopic images were obtained intraoperatively. COMPARISON: CT abdomen and pelvis ___ FINDINGS: 14 intraoperative images were acquired without a radiologist present. Images show retrograde cannulation of the superior mesenteric artery and passage of a wire through a proximal area of stenosis, followed by balloon dilatation and stent placement. Contrast injection after the intervention demonstrating recanalization of the proximal SMA stenosis.. IMPRESSION: Intraoperative images were obtained during retrograde stenting of a proximal SMA stenosis. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p intubated// Eval ETT COMPARISON: Chest radiograph ___ FINDINGS: Portable AP view of the chest provided. Endotracheal tube terminates in the right mainstem bronchus. A left internal jugular line likely terminates at the junction of the left internal jugular and brachiocephalic veins. Enteric tube passes into the expected location stomach beyond the field of view of the image. Lung volumes are low. Patchy bibasilar opacities likely reflect atelectasis, unchanged. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: Endotracheal tube terminates in the proximal right mainstem bronchus. Recommend retracting. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:47 pm, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ischemic gut// enteric tube placed correctly? TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiographs ___. IMPRESSION: The endotracheal tube terminate 5.4 cm above the carina. Advancement by 2 cm is recommended. There has been interval placement of an enteric tube which terminates in the body of the stomach. A left internal jugular Swan-Ganz catheter terminates in the distal left brachiocephalic vein. There are small bilateral pleural effusions with bibasilar atelectasis. There is mild pulmonary edema. There is no focal consolidation or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There are no acute osseous abnormalities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ischemic bowel, moving towards extubation soon// please evaluate lung fields TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: The endotracheal tube terminates 5.1 cm above the carina. A an enteric tube crosses the diaphragm and terminates outside of the field of view. Hazy bibasilar opacities are unchanged from prior study most likely represent trace pleural effusions. There is no focal consolidation, pulmonary edema or pneumothorax. The cardiomediastinal silhouette is normal in appearance. There is central pulmonary vascular congestion without overt pulmonary edema. No acute osseous abnormalities are identified. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ischemic bowel s/p SMA stenting and removal of small bowel x2; now with closed abdomen.// ICU CXR IMPRESSION: In comparison with the study of ___, the monitoring and support devices are stable, as is the cardiomediastinal silhouette. Mild elevation of pulmonary venous pressure with bilateral layering pleural effusions and compressive atelectasis at the bases. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with Right PICC// Right PICC 39cm, ___ ___ Contact name: ___: ___ Right PICC 39cm, ___ ___ IMPRESSION: Right PICC line tip is at the cavoatrial junction. NG tube tip is in the stomach. Left internal jugular line tip is at the left brachycephalic vein and does not reach SVC. It Bilateral pleural effusions are small on the right and moderate on the left. No appreciable pneumothorax. No pulmonary edema. Radiology Report EXAMINATION: Single-contrast upper GI INDICATION: ___ year old man s/p ex-lap, small bowel resection, SMA stenting on ___// ? anastomosis open TECHNIQUE: Single contrast upper GI. DOSE: Acc air kerma: 28.6 mGy; Accum DAP: 719.56 uGym2; Fluoro time: 11.3 minutes COMPARISON: CT abdomen pelvis ___ FINDINGS: Water-soluble contrast (Optiray) was administered with the patient supine. Contrast opacified the stomach with no significant passage into the duodenum despite advancement of the tube and repositioning of the patient. After ejection of approximately 250 cc of Optiray, the patient was noted to be aspirating at which point the nasogastric tube with set to suction a nasal cannula was applied. A ___ feeding tube was placed into the stomach and post pyloric advancement was attempted, however was unsuccessful due to a closed pylorus. A small amount of water-soluble contrast passed through the pylorus, demonstrating two duodenal diverticula. The anastomotic site at the ligament of Treitz was not visualized. IMPRESSION: 1. The anastomotic site was not visualized due to poor transit of the injected contrast into the duodenum with resultant back up and gastroesophageal reflux and patient aspiration, which required suction and induction of oxygen therapy. 2. A ___ feeding tube was placed within the stomach as it could not be advanced past the pylorus. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___ p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed// possible aspiration TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of a right PICC line projects over the upper right atrium, approximately 2 cm beyond the cavoatrial junction. 2 tubes project over the expected location of the esophagus. Dense contrast material is seen within the stomach. There are new dense branching opacities in the medial lower lungs bilaterally, likely reflecting aspirated Optiray from today's upper GI study. Superimposed pneumonia would be hard to exclude. There is no pneumothorax or large pleural effusion. The size of the cardiomediastinal silhouette is within normal limits. IMPRESSION: Aspirated Optiray is seen within the lower lungs bilaterally. Radiology Report INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___ p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed. Please evaluate for possible obstruction// possible obstruction TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: CT dated ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Oral contrast material is seen within the distal small bowel, ascending colon and proximal transverse colon. 2 enteric tubes project over the stomach. Assessment for free intraperitoneal air is limited on supine radiographs. If there is clinical concern for pneumoperitoneum, advise upright or left lateral decubitus radiograph, or cross-sectional imaging. Osseous structures are notable for orthopedic hardware in the proximal left femur. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No evidence of a small bowel obstruction. Oral contrast material is seen within the distal small bowel and proximal colon. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with aspiration of contrast// lung fields lung fields IMPRESSION: Comparison to ___. The lung volumes are normal. Moderate cardiomegaly without evidence of pulmonary edema. Retrocardiac atelectasis, right basilar atelectasis, likely presence of a small left pleural effusion. The course of the feeding tubes and the position of the right PICC line are stable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p ex lap and SBR with aspiration of PO contrast// lung fields lung fields IMPRESSION: Comparison to ___. No relevant change is noted. 1 of the feeding tubes was removed. The second feeding tube is in stable position. Stable position of the right PICC line. Minimal decrease in severity of the bilateral parenchymal atelectasis, the extent of the mild to moderate pleural effusions is unchanged. No evidence of pulmonary edema. Borderline size of the cardiac silhouette. Radiology Report INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___ p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed// eval for obstruction, progression of contrast TECHNIQUE: Portable AP supine radiograph of the abdomen and pelvis COMPARISON: ___ FINDINGS: All the oral contrast now appears to be within the colon. There is a paucity of small bowel gas. The colon is not dilated. NG tube is seen within the stomach. No evidence of free air on this supine radiograph. Incidental note is made of calcification of the vas deferens. A wound VAC is noted. Visualized portions of the left femoral gamma nail intramedullary rod have the expected appearance. IMPRESSION: No evidence of obstruction with passage of oral contrast completely into the colon. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ year old man s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed// evaluate for anastomotic stricture- oral contrast only (do NOT use IV contrast) TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 54.2 cm; CTDIvol = 19.0 mGy (Body) DLP = 1,030.6 mGy-cm. 2) Sequenced Acquisition 0.5 s, 16.0 cm; CTDIvol = 6.3 mGy (Body) DLP = 101.4 mGy-cm. Total DLP (Body) = 1,132 mGy-cm. COMPARISON: CT from ___. FINDINGS: LOWER CHEST: There are bilateral pleural effusions measuring 28 mm on the left and 26 mm on the right. There are mild atelectatic changes in both lung bases. ABDOMEN: HEPATOBILIARY: Liver demonstrates a 5 x 2 cm (series 2, image 5) hypodense area, could represent subcapsular fluid in an area of previous liver concavity. there is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. Dense material is seen in the hepatic hilum, likely some oral contrast that refluxed in the biliary system. PANCREAS: The pancreas is severely atrophic and not well assessed on this unenhanced study. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. Bilateral renal cysts are seen, including a dense 8 mm cyst, likely hemorrhagic. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: An enteric tube is seen with its tip in the stomach. The patient is status post anastomosis of the distal duodenum to the distal jejunum. There is no evidence of extraluminal contrast. The small bowel loops are nondilated. The walls of the colon are less thickened than on prior study and there is no pneumatosis. There is a large lenticular loculation of air and fluid level measuring 26.8 cm x 7.4 cm, located at the anterior aspect of the abdomen, slightly inferiorly to the level of the stomach. PELVIS: The urinary bladder contains air and a Foley catheter. The distal ureters are unremarkable. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. A stent is seen in the SMA. BONES: There is no evidence of worrisome osseous lesions. There is recent left hip pinning, a newly developed wedge fracture involving the T12 as well as the posterior elements of T11. There are also fractures involving the left lower ribs, these were present previously. There is multilevel degenerative changes. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Patient is status post surgery for mesenteric ischemia, with an anastomosis of the distal duodenum to the distal jejunum. There is a large nonspecific loculation of fluid located in the anterior aspect of the abdominal cavity with an air-fluid level. No evidence of extraluminal contrast. 2. Newly developed fractures including a wedge fracture of T12 and a fracture of the posterior element of T11. 3. Dense material located in the hilum of the liver, likely reflux of oral contrast into the biliary system. Correlate clinically. 4. Small bilateral pleural effusions. Radiology Report INDICATION: ___ year old man, s/p exp lap, SMA stent, SBR, ngt tube in place// please check for placement of NGT TECHNIQUE: Single portable upright AP view of the upper abdomen is provided. COMPARISON: Chest and abdominal radiographs ___ FINDINGS: No dilated loops of bowel to suggest obstruction. Likely small bilateral pleural effusions. Mild bibasilar atelectasis is improved compared to ___. There is no pneumothorax. The cardiomediastinal silhouette is at the upper limits of normal, unchanged. A righted sided PICC line terminates at the low SVC. Nasogastric tube is again seen coiled within the stomach. IMPRESSION: 1. Nasogastric tube overlies the stomach. 2. Improved mild bibasilar atelectasis. Radiology Report EXAMINATION: Ultrasound-guided drainage. INDICATION: ___ year old man s/p exp lap, SMA stent, SBR, now with ant. loculated abdominal fluid collection// requesting drainage of abdominal fluid collectcion COMPARISON: CT abdomen and pelvis dated ___. PROCEDURE: Ultrasound-guided drainage of abdominal collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, ___ drainage catheter was advanced via trocar technique into the collection. A sample of fluid was aspirated, confirming catheter position within the collection. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Approximately 900 cc of serosanguineous fluid was drained with a sample sent for microbiology evaluation. The ultrasound demonstrated no residual collection and subsequently the drainage catheter was removed. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was not given. FINDINGS: Preprocedural ultrasound of the abdomen demonstrated simple fluid collection in the abdomen. IMPRESSION: Successful US-guided drainage of serosanguineous abdominal collection. Sample was sent for microbiology evaluation. Radiology Report INDICATION: ___ year old man with exp lap, SBR, SMA stenting, continues to have high NG output, decrease nutritional intake// please place GJ tube past the Ligament of Treitz COMPARISON: CT abdomen and pelvis ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___ resident performed the procedure. Dr. ___ supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: General anesthesia. MEDICATIONS: 0.5 mg of glucagon IV CONTRAST: 50 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 31 minutes 8 seconds, 221 mGy PROCEDURE: 1. Placement of a ___ MIC gastrojejunostomy tube. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. The stomach was insufflated through the indwelling nasogastric tube. Using a marker, the skin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Ultrasound images were stored. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilutecontrast. The needle trajectory was directed towards the pylorus. In implants wire was introduced and coiled within the stomach. A small skin incision was made along the needle and the needle was removed. A Kumpe catheter was then introduced over the wire and the ___ was exchanged for a Glidewire. There was a tight narrowing at the gastrojejunal anastomosis through which the Glidewire cannot past. The Glidewire was exchanged for an Amplatz, which was also unsuccessful in crossing the stenosis anastomosis. The Amplatz was exchanged for a stiff Glidewire and the Kumpe was exchanged for a Sos catheter. The stiff Glidewire and the RIM catheter were advanced past the tight narrowing at the gastrojejunal anastomosis. The stiff Glidewire was then exchanged for an Amplatz wire which is further advanced into the jejunum. The Sos catheter was removed over the wire. A 16 ___ dilator was used to dilate the tract. Then, a 22 ___ peel-away sheath was placed over the wire. A 18 ___ MIC gastrojejunostomy catheter was advanced over the wire into position. The sheath was then peeled away. The wire and sheath were removed. The catheter was locked by instilling 7 ml of dilute contrast into the balloon in the jejunum after confirming the position of the catheter with a contrast injection. The catheter was then flushed and capped. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in the jejunum. 2. There was a tight narrowing at the duodenojejunal anastomosis, through which the distal end of the gastrojejunostomy tube was passed. IMPRESSION: Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum past the anastamosis. The gastric port should not be used for 24 hours. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with respiratory distress s/p emesis// please eval for aspiration TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Right-sided PICC line projects to the cavoatrial junction. The NG tube has been removed. Lungs are low volume with bibasilar atelectasis. Bilateral effusions have resolved. Cardiomediastinal silhouette is stable. No pneumothorax is seen Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD, HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with retrograde stenting of SMA, open abdomen, 150 cm small bowel resection, D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for hypernatremia and need for an insulin gtt. ___ triggered on the floor, delirious, vomiting bilious and bloody material and WBC increase from 8 to 31. New left sided retrocardiac and LLL infiltrate. ACS concerned he aspirated.// daily eval IMPRESSION: In comparison with the study of ___, there is engorgement of ill defined pulmonary vessels consistent with worsening pulmonary edema in this patient with left lower lobe collapse and left pleural effusion. Area of increased opacification in the left upper zone was shown to represent a more prominent area of consolidation than expected merely from the plain radiograph. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___ p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed// ?anastomosis leak ?vialibility of abdomen(please give PO contrast through G tube and clamp J tube) TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.6 s, 73.7 cm; CTDIvol = 12.5 mGy (Body) DLP = 917.5 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.7 mGy (Body) DLP = 8.3 mGy-cm. Total DLP (Body) = 928 mGy-cm. COMPARISON: CT abdomen and pelvis on ___ and ___, CT abdomen and pelvis on ___ FINDINGS: LOWER CHEST: Small left pleural effusion and adjacent atelectasis is similar to prior. There is a trace right pleural effusion which is decreased in size from prior. There is a small consolidation at the right lung base likely representing aspiration. Dense mitral annular calcifications are partially seen. ABDOMEN: HEPATOBILIARY: Heterogeneity of the liver parenchyma is improved from prior, with minimal residual areas hypodensity at the dome. There is no evidence of focal lesions. There is extensive pneumobilia in the left hepatic lobe, likely due to prior sphincterotomy or incompetent sphincter of Oddi given pneumobilia has been present since at least ___. There is no portal venous gas. There is no intrahepatic biliary duct dilatation. Prominence of the common bile duct is stable from priors and consistent with postcholecystectomy state. The gallbladder is surgically absent. PANCREAS: The pancreas is severely atrophic. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are bilateral simple renal cysts measuring up to 3.7 cm in the left kidney. Multiple additional subcentimeter cortical hypodensities bilaterally are too small to characterize, however likely represent cysts. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: GJ tube is present in the stomach, the jejunal limb terminating in the jejunum left mid abdomen. Patient is status post small bowel resection. Remaining small bowel loops demonstrate normal caliber. There is wall thickening of small bowel loops in the anterior abdomen adjacent to a fluid collection which is reactive (2:70). There is no pneumatosis. Oral contrast administered through a G-tube passes into the colon with no evidence of leak. The colon and rectum are within normal limits. The appendix is normal. Loculation of fluid within the anterior abdomen is decreased in size from prior, currently spanning 18.5 x 4.8 cm compared with 26.8 x 7.4 cm, with interval decrease in amount of free air. PELVIS: A Foley catheter is present in the bladder. The distal ureters are unremarkable. There is trace free fluid in the pelvis, decreased from prior. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. There is heavy calcification of the vas deferens bilaterally. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. Patient is status post SMA stent, with the more distal SMA appearing patent. There is heavy atherosclerotic calcification at its takeoff of the celiac axis which appears patent. BONES: Again noted are old left-sided rib fractures. A compression deformity of the T12 vertebral body and a fracture of the posterior elements at T11 are not significantly changed. Multilevel degenerative changes in the lumbar spine are not significantly changed. Patient is status post gamma nail fixation of a left femoral fracture. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There are postsurgical changes along the anterior abdominal wall. There is diffuse subcutaneous edema. IMPRESSION: 1. Contrast administered through the gastrojejunostomy tube passes into the colon with no evidence of leak. 2. Interval decrease in size of a thin rim enhancing loculated fluid collection in the anterior abdomen as well as a small amount of free air, consistent with resolving postsurgical collections. This collection is more organized compared to the prior exam. 3. Small left pleural effusion is not significantly changed, right pleural effusion is decreased in size. 4. Small consolidation at the right lung base is likely due to aspiration. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___ p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR, anastomosis D4 to distal jejunum, abd closed// ?anastomosis leak ?vialibility of abdomen(please give PO contrast through G tube and clamp J tube) TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.6 s, 73.7 cm; CTDIvol = 12.5 mGy (Body) DLP = 917.5 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.7 mGy (Body) DLP = 8.3 mGy-cm. Total DLP (Body) = 928 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Compared to chest CT ___ FINDINGS: CHEST PERIMETER: No thyroid findings need any further imaging evaluation. Supraclavicular and axillary lymph nodes are not enlarged. No soft tissue abnormalities in the chest wall. Findings below the diaphragm will be reported separately. CARDIO-MEDIASTINUM:Moderate dilatation of the esophagus is long-standing, more pronounced today than in ___, with retention of the fluid in the upper esophagus. Findings suggest significant esophageal dysmotility and/or reflux, rather than mass, but contrast swallow would be required for assessment. Atherosclerotic calcification is severe in left subclavian artery and throughout coronary arteries. Aorta and pulmonary arteries are not dilated. Calcification is extremely heavy in the mitral annulus which predisposes to mitral regurgitation but left atrium is normal size. Pericardium is physiologic.. THORACIC LYMPH NODES: As follows: Thoracic outlet, 11 mm, 2:8, unchanged since ___. Left upper paratracheal mediastinum, 11 mm, 02:24, 8 mm in ___. Right posterior paraesophageal mediastinum, 11 mm, 02:34, 8 mm in ___. No appreciable hilar lymph node enlargement. LUNGS, AIRWAYS, PLEURAE: Moderate nonhemorrhagic left, and tiny right pleural effusions layer posteriorly. Left lower lobe is collapsed; in the absence of bronchial obstruction this is attributable to the left pleural effusion. Parenchymal abnormalities in the left lower lobe would not be appreciated. Extensive bronchiolar nodulation and peribronchial infiltration in the right lower and left upper lobes is probably multifocal pneumonia. CHEST CAGE: Severe compression fracture, T12 vertebral body with blastic and possible lytic components could be pathologic. No obvious retropulsion. IMPRESSION: Widespread broncho pneumonia, right lower and left upper lobes. Collapsed left lower lobe. Severe compression fracture, T12 vertebral body. If there is concern about neurologic compromise, MRI should be obtained. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD, HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with retrograde stenting of SMA, open abdomen, 150 cm small bowel resection, D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for hypernatremia and need for an insulin gtt. ___ triggered on the floor, delirious, vomiting bilious and bloody material and WBC increase from 8 to 31. New left sided retrocardiac and LLL infiltrate. ACS concerned he aspiration. Now new-onset RUE edema.// r/o right upper extremity DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular, axillary, and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The right basilic, and cephalic veins are patent, compressible and show normal color flow. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report EXAMINATION: Left hip radiographs, two views, and pelvis radiograph, single AP view, portable. INDICATION: Status post left total hip replacement. Multiple abscesses in the pelvis. Multifocal pneumonia. Altered mental status. COMPARISON: CT is available from the prior day. FINDINGS: Patient is status post open reduction internal fixation of the left femur with a gamma nail. Alignment appears normal. No dislocation. Hardware appears intact without loosening. Hip joint spaces appear preserved in with. Bones appear demineralized. Vascular calcification is extensive. Each vas deferens is also calcified. IMPRESSION: Status post open reduction internal fixation of the left femur. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with multifocal pneumonia on broad spectrum antibiotics, fluid overload, abdominal abscesses, SMA stent, and altered mental status (A Ox1)// eval for interval change IMPRESSION: In comparison with the study of ___, the cardiomediastinal silhouette is stable, as is the degree of pulmonary edema. Opacification at the left base is consistent with volume loss in left lower lobe and pleural effusion. Radiology Report INDICATION: ___ year old man with rim-enhancing superficial anterior abdominal collection and leukocytosis, concerning for infection// requesting aspiration/drainage of collection COMPARISON: Prior CT done ___. PROCEDURE: Ultrasound-guided drainage of abdominal collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position in his bed in the ward. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, 18G ___ needle was inserted into the collection. 0.038 ___ wire was placed through the needle and needle was removed. A sample of fluid was aspirated, confirming needle position within the collection. This was followed by placement of ___ Exodus catheter into the collection. The stiffener and the wire were removed. Pigtail was deployed, and the position of the pigtail was confirmed within the collection via ultrasound. Approximately 5 cc of serous fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was not provided FINDINGS: Straw-colored serous fluid was aspirated and 5 cc was sent for microbiology evaluation. IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD, HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with retrograde stenting of SMA, open abdomen, 150 cm small bowel resection, D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for hypernatremia and need for an insulin gtt. ___ triggered on the floor, delirious, vomiting bilious and bloody material and WBC increase from 8 to 31. New left sided retrocardiac and LLL infiltrate. ACS concerned he aspiration.// daily eval TECHNIQUE: Portable semi-upright chest AP. COMPARISON: Chest radiograph from ___ FINDINGS: There is interval improvement of pulmonary congestion, mainly on the right side likely due to dependent positioning. Diffuse opacity over the left lung is not significantly changed. Worsening right lower lobe atelectasis. Cardiomegaly is unchanged in size.Right PICC line is unchanged. IMPRESSION: Diffuse left lung opacities are not significantly changed. Interval improvement of pulmonary congestion. Radiology Report EXAMINATION: G/GJ/GI TUBE CHECK INDICATION: ___ year old man with GJ tube, found to have bilious drainage around drain site. Evaluation for gastrojejunostomy tube check. TECHNIQUE: Scout view of the abdomen was obtained in the AP projection. Administration of 20 cc of water-soluble contrast was hand injected via the tube. Postcontrast image of the abdomen was obtained in the AP projection. COMPARISON: Comparison to CT abdomen/pelvis from ___. FINDINGS: A gastrojejunostomy tube is seen projecting over the mid abdomen, with balloon inflated within the stomach. After the administration of water-soluble contrast through the tube, a small quantity of contrast is visualized within the duodenum and jejunum, without evidence of leakage into the abdomen. A duodenal diverticulum and jejunal diverticulum are incidentally noted. Small amount of residual enteric contrast is noted within the colon. There is a nonspecific, nonobstructive bowel gas pattern. A pigtail drainage catheter projects over the mid abdomen. Few clips are seen projecting over the left upper quadrant. Partial visualization of surgical fixation hardware within the left proximal femur. IMPRESSION: No evidence of leak identified after the administration of water-soluble contrast through the gastrojejunostomy tube. Radiology Report INDICATION: Emesis, G tube to gravity. Please evaluate for distention. TECHNIQUE: Portable frontal radiographs of the abdomen and pelvis, compared with ___. IMPRESSION: Gastrostomy tube is again seen, unchanged. Pigtail catheter extending to the midline abdomen is again seen, similar orientation as the prior. Enteric contrast is now within the colon. Bowel gas pattern is unremarkable. No significant bowel distention. Consolidative opacities seen in the lungs, left greater than right. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new sob and desats after emesis// please eval for aspiration TECHNIQUE: Portable chest AP upright. COMPARISON: Chest radiograph from ___. FINDINGS: New right lower and mid lobe focal opacity concerning for aspiration however may also represent pulmonary edema. Small bilateral pleural effusions no evidence of pneumothorax. Cardiac silhouette is unchanged. Right PICC line terminates at the distal SVC. IMPRESSION: New right lower and mid lobe opacities may represent aspiration or pulmonary edema Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with bilateral pulmonary infiltrates s/p diuresis// please eval for interval change please eval for interval change IMPRESSION: Compared to chest radiographs, ___ through ___ at 05:30. Upper lobe pulmonary vascular congestion has improved, while bilateral perihilar opacification has improved on the right, not on the left. This could be edema, changing in distribution depending on patient positioning, but the lower lobes are still densely consolidated. Moderate bilateral pleural effusions are unchanged. No pneumothorax. Heart size is stable, not appreciably enlarged and mediastinal veins are not engorged. Right PIC line ends in the mid to low SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p exp lap, SMA stenting with GJ tube, now with vomiting, coughing// compare interval change IMPRESSION: In comparison with the study of ___, there are improved lung volumes. Cardiomediastinal silhouette is stable. There has been some improvement in the substantial pulmonary edema, much of which could merely reflect the improved lung volumes. In asymmetric opacification in the left mid to lower lung is again seen. In the appropriate clinical setting, this would raise the possibility of aspiration/pneumonia. Obscuration of the left hemidiaphragm with retrocardiac opacification is consistent with pleural fluid and volume loss in left lower lobe. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, n/v/d Diagnosed with Other specified diseases of intestine, Unspecified abdominal pain temperature: 96.0 heartrate: 100.0 resprate: 30.0 o2sat: nan sbp: 122.0 dbp: 71.0 level of pain: 10 level of acuity: 1.0

Dear Mr. ___, You are being discharged to ___ house to receive comfort measures and to pass comfortably.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / bee pollen Attending: ___. Major Surgical or Invasive Procedure: none attach Pertinent Results: DISCHARGE EXAM: CV: RRR Respiratory: No increased work of breathing Skin: pink patch on b/l feet with areas of desquamation without surrounding erythema. Papular rash on arms, chest, back, and legs with some areas that appear excoriated, overall improved from yesterday NEURO: Fine resting tremor Psych: Appropriate mood and affect Labs on admission: ___ 12:07AM BLOOD WBC-9.9 RBC-4.54 Hgb-11.4 Hct-36.7 MCV-81* MCH-25.1* MCHC-31.1* RDW-13.0 RDWSD-37.5 Plt ___ ___ 12:07AM BLOOD Neuts-87.6* Lymphs-9.5* Monos-1.8* Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.62* AbsLymp-0.94* AbsMono-0.18* AbsEos-0.01* AbsBaso-0.02 ___ 12:07AM BLOOD ___ PTT-41.1* ___ ___ 12:07AM BLOOD Glucose-203* UreaN-15 Creat-0.7 Na-142 K-4.7 Cl-107 HCO3-19* AnGap-16 ___ 12:07AM BLOOD ALT-21 AST-29 LD(LDH)-349* AlkPhos-343* TotBili-0.3 ___ 12:07AM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.8 Mg-1.8 ___ 12:07AM BLOOD T4-11.6 Free T4-1.9* ___ 12:07AM BLOOD CRP-95.5* Interim Labs: ___ 06:58AM BLOOD T3-164 Free T4-1.7 ___ 12:07AM BLOOD TSH-<0.01* MICRO ___ 8:17 pm TISSUE Source: Skin biopsy r/o hsv. RIGHT FOOT. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. TISSUE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated. Blood culture- NGTD x2 Urine culture- Negative Imaging: Foot xray: IMPRESSION: No evidence of subcutaneous gas of the right or left feet. No bony erosive changes. No acute fracture or dislocation. ___: IMPRESSION: ___ No evidence of deep venous thrombosis ___ the right or left lower extremity veins. PATHOLOGY: Prelim Skin biopsy pathology (final pending): - There are acute and chronic changes. - Ulceration (appears more c/w excoriation changes) with impetiginized scale crust (surface bacteria ___ H&E slides). Stains to look for dermal organisms are pending. - Pan dermal mixed cell inflammation - eos, neuts, lymphs, histiocytes. - Not much epidermis to judge. - The eos suggest a florid hyp rxn - the depth of inflammation is more than usually observed with typical contact dermatitis. Cant exclude a "dermal contactant" - The neuts are somewhat unusual for hyp rxn so and with background chronic changes with histiocytes cant exclude a component of resolving cellulitis. - No vasculitis seen. - Overall: Question dermal hyp rxn with superimposed, possibly resolving infection. - The ulcer really isn't typical of an ischemic ulcer. Has extruded collagen which we see ___ excoriations and acquired perf dermatoses (reactive perf collag). Would favor excoriated but would like to know if she has that hx. Might consider superimposed acquired perf dermatosis ___ diabetic if she has more similar and/or punctate crusted lesions away from this. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 75 mg PO QHS 2. MetFORMIN (Glucophage) 500 mg PO BID 3. amLODIPine 5 mg PO DAILY 4. MethIMAzole 10 mg PO DAILY 5. DULoxetine ___ 60 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth q12 Disp #*13 Tablet Refills:*0 3. Atenolol 50 mg PO DAILY RX *atenolol 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 5. Hydrocortisone Oint 2.5% 1 Appl TP BID Face Rash RX *hydrocortisone 2.5 % Apply to face and neck twice a day Refills:*0 6. Mupirocin Ointment 2% 1 Appl TP BID RX *mupirocin 2 % Apply to open area on top of feet twice a day Refills:*0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone [Oxaydo] 5 mg ___ tab by mouth BID PRN Disp #*16 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by mouth twice a day Disp #*60 Packet Refills:*0 9. Senna 17.2 mg PO QHS RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 3 tab by mouth at bedtime Disp #*60 Tablet Refills:*0 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID rash on trunk and extremites RX *triamcinolone acetonide 0.1 % Apply to trunk and extremities twice a day Refills:*0 11. Amitriptyline 75 mg PO QHS 12. amLODIPine 5 mg PO DAILY 13. DULoxetine ___ 60 mg PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO BID 15. HELD- MethIMAzole 10 mg PO DAILY This medication was held. Do not restart MethIMAzole until you see your Endocrine doctor 16.Equipment Rx: Rolling walker Dx: bilateral lower extremity rash L30.9 Px: good ___: 13 mo Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #Contact dermatitis with superimposed infection #Thyrotoxicosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: FOOT AP,LAT AND OBL BILATERAL INDICATION: History: ___ with b/l ___ rash // eval for soft tissue gas TECHNIQUE: Multiple views of the bilateral feet. COMPARISON: No relevant prior studies available for comparison. FINDINGS: Right: No acute fractures or dislocation are seen. There are no significant degenerative changes. Tiny plantar calcaneal spur. Mineralization is normal. There are no erosions. Os peroneus. No evidence of subcutaneous gas. Left: No acute fractures or dislocation are seen. There are degenerate changes of the midfoot, best seen on lateral view. Tiny plantar calcaneal spur. Mineralization is normal. There are no erosions. Os peroneus. No evidence of subcutaneous gas. IMPRESSION: No evidence of subcutaneous gas of the right or left feet. No bony erosive changes. No acute fracture or dislocation. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with b/l foot rash. Now with unequal edema R>L. // ?dvt TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: CT of the abdomen pelvis from ___. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Prominent left-sided groin lymph nodes measuring up to 1.1 cm along the short axis, unchanged from prior, with normal morphology. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Foot swelling, Rash Diagnosed with Rash and other nonspecific skin eruption temperature: 97.5 heartrate: 131.0 resprate: 20.0 o2sat: 99.0 sbp: 187.0 dbp: 90.0 level of pain: 10 level of acuity: 1.0

Ms. ___, It was a pleasure taking care of you during your admission to ___. You were admitted with a rash on your feet. You were seen by the dermatologists who think that this rash is from contact dermatitis with an infection. You were treated with topical creams and with antibiotics. Please follow up with dermatology after discharge. You have been prescribed a strong pain medication to take if you have severe pain ___ your feet. This medication can cause sleepiness and constipation. Please use this medication (oxycodone) as little as possible. You should continue taking antibiotic Augmentin until ___. While you were hospitalized, you were also noted to have high thyroid hormone levels. You were seen by the endocrinologists who discussed options for treatment. You have elected radioactive iodine treatment. You are scheduled for a thyroid uptake scan on ___ at 10 AM, and ___ at 10 AM (this is a two day scan). Please do not eat anything after midnight prior to this scan. Please do not consume ANY seafood, seaweed, sushi, or kelp prior to this test. After the test, you will follow-up with your Endocrinologist on ___ as below. You have been started on medication atenolol to help control heart rate, blood pressure and tremor which are side-effects of high thyroid levels. You are being sent home with home nursing and home physical therapy support. They will meet you at your house to start the services. We wish you the best ___ your recovery! -- Your medical team RASH and WOUND INSTRUCTIONS: - Apply mupirocin to open areas on the top of the feet. Keep covered with xeroform (rather than dry gauze) to reduce pain with dressing changes. - Apply COPIOUS Triamcinolone 0.1% ointment twice daily to rash on trunk and extremities for up to 2 weeks (started ___. DO NOT apply the OPEN AREAS on dorsal feet but can apply to all other itchy areas). - Apply hydrocortisone 2.5% ointment twice daily to rash on face and neck for up to 2 weeks - Apply ***COPIOUS moisturizer (E.g. Vaseline or Eucerin cream) to the extremities twice daily

Name: ___ #1 TO ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: The patient is a ___ without ___ medical history who presented to the ED today complaining of headache. The patient reports that she previously presented to the ED on ___ complaining of three days of sore throat, migraine-like headache, nausea, subjective fevers and chills, and body aches. She did have some C7 point tenderness at the time, but did not have photophobia or meningeal signs. She was thought to have a viral syndrome and was discharged after fluid resuscitation. She represented to the ED today with continuing headache. The patient notes that her viral symptoms have largely resolved. She describes a right temporal to frontal headache, ___ at worst, but currently ___. She notes that it is worse when she is lying flat than sitting upright. She previously had minimal photophobia, but is currently without symptoms. The patient reports that she has had chronic headache similar in quality to her present headache. She gets these every one to two weeks, generally aborts with ibuprofen. The difference between this headache and her usual headaches is the duration (now multiple days) and the fact that it prevents her from falling asleep. Her usual headaches are usual accompanied by mild photophobia and some nausea. She denies vomiting, diplopia, or visual phenomena. . In the ED, initial vital signs were 99.2 82 127/76 18 100%. A CT head was performed which did not demonstrated intracranial bleed. A lumbar puncture was performed in the ED with a WBC count of 16 (N6, L90) and RBC 715 which improved to 36 over subsequent vials. Protein and glucose were normal at 21 and 54, respectively. Past Medical History: No significant past medical history. Social History: ___ Family History: Father: DM Brother/twin sister: asthma ___ sister: anemia No family history of thrombosis Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 98.4 113/67 96 18 96RA GEN: AOx3, comfortable-appearing in NAD HEENT: NCAT, EOMI, anicteric sclera, MMM, OP clear, no sinus tenderness NECK: Supple without LAD or thyromegaly PULM: CTA b/l without wheeze, rhonchi, crackles, or focal dullness COR: RRR (+)S1/S2 no m/r/g appreciated ABD: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley EXTREM: Warm and well perfused, 2+ pulses NEURO: Mentating well, CNII-XII intact by testing, strength ___ x4 extrem, sensation intact, PERRLA, no meningeal signs, no photophobia . PHSYICAL EXAM ON DISCHARGE: VS: 99.6 99/53 98 18 98 GEN: AOx3, non-toxic and comfortable-appearing in NAD HEENT: NCAT, EOMI, MMM, OP clear, no sinus tenderness NECK: Supple without LAD or thyromegaly PULM: CTA b/l without wheeze, rhonchi, crackles, or focal dullness COR: RRR (+)S1/S2 no m/r/g appreciated ABD: Soft, non-tender, non-distended, bowel sounds present, EXTREM: Warm and well perfused, 2+ pulses NEURO: Mentating well, CNII-XII intact by testing, strength ___ x4 extrem, sensation intact, PERRLA, no meningeal signs, no photophobia Pertinent Results: LABS ON ADMISSION: ___ 07:40PM BLOOD WBC-6.0 RBC-4.67 Hgb-13.4 Hct-40.4 MCV-87 MCH-28.8 MCHC-33.2 RDW-12.2 Plt ___ ___ 07:40PM BLOOD Neuts-67.3 ___ Monos-6.1 Eos-0.2 Baso-0.4 ___ 07:40PM BLOOD Glucose-129* UreaN-5* Creat-0.8 Na-140 K-3.8 Cl-104 HCO3-28 AnGap-12 ___ 07:40PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9 . LABS ON DISCHARGE: ___ 08:37AM BLOOD WBC-5.9 RBC-4.83 Hgb-14.3 Hct-41.8 MCV-87 MCH-29.6 MCHC-34.2 RDW-12.4 Plt ___ ___ 08:37AM BLOOD Glucose-81 UreaN-7 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-29 AnGap-11 . CSF FINDINGS: (First tube) ___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-16 RBC-715* Polys-6 ___ Monos-4 (Tube #2-#4) ___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-15 RBC-36* Polys-1 ___ ___ 04:45PM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-54 . IMAGING: ___ CT Head There is no evidence of acute intracranial hemorrhage, edema, large vessel territory infarctions or shift of midline structures. The ventricles and sulci are normal in size and configuration. Gray-white matter differentiation is well preserved. No acute fractures are identified. There is mild ethmoidal and sphenoidal mucosal thickening; otherwise, the remainder of the visualized mastoid air cells and paranasal sinuses are clear. . ___ CXR The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours, pleural surfaces are normal. There is no pleural effusion or pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: There were no new medications at the time of discharge. The patient was recommended to take OTC acetaminophen or NSAIDs +/- caffeine for headache relief. She was cautioned on limiting her daily acetaminophen intake to ___ max. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Migraine headache . Secondary diagnosis: Viral syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Cough. Evaluate for pneumonia. TECHNIQUE: Upright PA and lateral radiographs of the chest. COMPARISON: None. FINDINGS: The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours, pleural surfaces are normal. There is no pleural effusion or pneumothorax. IMPRESSION: Normal radiograph of the chest. Radiology Report HISTORY: Headache. COMPARISON: None available. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Multiplanar reformatted images were prepared and reviewed. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, large vessel territory infarctions or shift of midline structures. The ventricles and sulci are normal in size and configuration. Gray-white matter differentiation is well preserved. No acute fractures are identified. There is mild ethmoidal and sphenoidal mucosal thickening; otherwise, the remainder of the visualized mastoid air cells and paranasal sinuses are clear. IMPRESSION: No acute intracranial injury. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: HEADACHE Diagnosed with HEADACHE, UNSPEC VIRAL INFECTION temperature: 99.2 heartrate: 82.0 resprate: 18.0 o2sat: 100.0 sbp: 127.0 dbp: 76.0 level of pain: 10 level of acuity: 3.0

Ms. ___, You were admitted with a severe headache. A work-up for brain mass, bleed, or infection was negative. Most likely, you were having one of your chronic headaches that was worse than usual. Many of your symptoms that you described are consistent with migraines. We have made an appointment with the ___ Headache ___ further evaluation, please find the details below. You were not taking medications at the time of admission and have not been discharged on new medications. For headaches in the future, you can use acetaminophen (Tylenol) or an NSAID like ibuprofen (Motrin) or naproxen (Aleve). Sometimes caffeine helps to relieve headaches. You can also consider an over-the-counter migraine reliever which contains either acetaminophen or ibuprofen with caffeine. Please do not take more than ___ (___) of acetaminophen daily, regardless of whether in a migraine reliever or on its own. Appointment have been made on your behalf with the ___ Headache Center and a new PCP at ___. Please find the details below. It was a pleasure participating in your care, thank you for choosing ___!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left long finger pain, r/o flexor tenosynovitis Major Surgical or Invasive Procedure: Incision and drainage, flexor sheath, left long finger. History of Present Illness: ___, RHD, transferred from OSH s/p puncture wound to left third finger with concern for flexor tenosynovitis. The patient was doing landscaping 3 days ago, when he must have gotten some sort of puncture wound to his left third finger, although he does not remember the exact trauma. He noticed that the distal finger tip got swollen that evening and has become progressively swollen, red, and painful, tracking down his finger, over the past 2 days. The patient has baseline depression. He states he has been lying in bed at home because the finger pain has been so bad. Denies fevers or chills. Prior to transfer, patient received Unasyn. Xrays at OSH negative for foreign body or fracture. Last meal was last night. Past Medical History: depression Social History: ___ Family History: NC Physical Exam: Exam on hospital discharge: AVSS NAD Left middle finger with incision c/d/i Mild preincisional erythema Mild swelling that is much improved compared to initial presentation No tenderness along tendon sheath Long finger not held in flexed position FPL/EPL/IO intact SITLT in M/R/U distribution Exam on presentation to ED: Left middle finger with 4 positive Kanavel signs. There is a puncture wound over the finger pad, oozing clear fluid. Tenderness along the flexor sheath extends to mid palm. Sensation intact in all three nerve distributions. Medications on Admission: prozac 80' Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. DiphenhydrAMINE 25 mg PO Q6H:PRN itch, insomnia 3. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 4. Fluoxetine 80 mg PO DAILY 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain RX *Dilaudid 2 mg 1 Tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 6. Levofloxacin 750 mg PO Q24H Duration: 5 Days RX *Levaquin 750 mg 1 Tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 7. Nafcillin 2 g IV Q4H Duration: 14 Days From ___ RX *nafcillin in D2.4W 2 gram/100 mL Infuse 2gm every 4hrs via antibiotic pump every four (4) hours Disp #*60 Bag Refills:*0 8. Nicotine Patch 14 mg TD DAILY 9. traZODONE 100 mg PO HS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left third finger infection Right upper/middle lobe pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with new PICC. COMPARISONS: None. Portable upright frontal radiograph of the chest was obtained. New right PICC terminates in the mid SVC. Right upper lung opacity with air bronchograms and second right midlung opacity are concerning for multifocal pneumonia. Cardiomediastinal contours are unremarkable. No pleural effusion or pneumothorax. IMPRESSION: 1. Satisfactory position of right PICC 2. Multifocal right sided pneumonia. Consider 4 week radiograph to document resolution. Preliminary Findings were discussed with ___ by Dr. ___ at 13:25 on ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: HAND INFECTION Diagnosed with TENOSYNOV HAND/WRIST NEC temperature: 98.8 heartrate: 93.0 resprate: 16.0 o2sat: 96.0 sbp: 153.0 dbp: 92.0 level of pain: 8 level of acuity: 3.0

You were treated at ___ for a left long/middle finger infection and then developed a right lung pneumonia according to a chest xray. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: codeine Attending: ___ Chief Complaint: Hemorrhagic conversion Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo right-handed man with PMH significant for atrial fibrillation, pancreatic cancer (stage IV with known hepatic metastases) and a left sided stroke in ___ (with fluent aphasia) who presents now as a transfer for incidental finding of a very small amount of hemorrhagic conversion of his prior stroke. The patient was DCed from the stroke service to rehab (___) on therapeutic lovenox for his afib and cancer related hypercoagulable state. Mr ___ only recently returned home from rehab and has been living with his sister who is very involved in his care. She reported to me (via phone) that the patient has been getting very upset and frustrated with her. He does not want her to prepare any of his medications (of which there are ~25) without him. He becomes somewhat paranoid that some of the pills will kill him. He will refuse to eat at times as well. On the day of presentation he told his niece that he wanted to kill himself. This promoted a call to his PCP to whom he said "I'm done with it". The patient was then section 12ed and taken to the ED at ___. For very unclear reasons that ED ordered a NCHCT which showed the very small amount of hemorrhagic conversion of his prior ischemic stroke. The patient was then sent to ___ for further eval. At no point was the patient experiencing any worsening of his symptoms. His language has, if anything, been improving. On neuro ROS: the pt denies headache, loss of vision, blurred vision, diplopia, oscilopsia, dysarthria, dysphagia, drop attacks, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties comprehending speech. Denies focal weakness, numbness, paresthesias. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general ROS: the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - pancreatic cancer with known liver mets - Afib - HTN - HLD - prior MI s/p catheterization - asthma, COPD - DM - depression Social History: ___ Family History: - unable to be obtained Physical Exam: ADMISSION EXAM: GENERAL MEDICAL EXAMINATION: General appearance: alert, in no apparent distress HEENT: Sclera are non-injected. Mucous membranes are moist. CV: Heart rate is irregular Lungs: Breathing comfortably on RA Abdomen: soft but tender Extremities: No evidence of deformities. No contractures. Skin: No visible rashes. Warm and well perfused. Psych: patient is able to express frustration with his medically complex situation. He denies current active SI. NEUROLOGICAL EXAMINATION: Mental Status: Alert and oriented to person place ("BI") and time ___"). Comprehension seem intact, patient is able to follow multistep commands which cross the midline. He responds correctly to simple Yes/No questions (are the lights on in this room) and points to objects in the room correctly by command. His speech is fluent with frequent paraphasic errors (neologisms, phonemic and semantic error) He is able to repeat words but not phrases, not phonemically complex words and not grammatically complex short phrases. He is able read with frequent phonemic errors. He can name most high and low frequency objects by spelling the word aloud and then saying it (he does still make many errors). Normal prosody. Speech was not dysarthric. No neglect, left/right confusion or finger agnosia. Cranial Nerves: I: not tested II: visual fields full to confrontation III-IV-VI: pupils equally round, reactive to light. Normal conjugated, extra-ocular eye movements in all directions of gaze. No nystagmus or diplopia. V: Symmetric perception of LT in V1-3 VII: R NLFF but symmetric with activation; symmetric speed and excursion with smile. VIII: Hearing intact to finger rub bl IX-X: Palate elevates symmetrically XI: Shoulder shrug and head rotation ___ bl XII: No tongue deviation or fasciculations Motor: Normal muscle bulk and tone throughout. No pronator drift or rebound Strength: Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 Reflexes: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Toes up on the left down on the right Sensory: normal and symmetric perception of pinprick, light touch, vibration and temperature. Proprioception is intact. Coordination: Finger to nose without dysmetria bilaterally. No intention tremor. RAM were symmetric with regard to cadence and speed, no dysdiadochokinesia noted. DISCHARGE EXAM: Unchanged from admission Pertinent Results: ___ 10:48PM ___ PTT-47.1* ___ ___ 10:48PM WBC-8.4 RBC-3.42* HGB-11.2* HCT-34.0* MCV-99* MCH-32.7* MCHC-32.9 RDW-15.0 RDWSD-53.1* ___ 10:48PM PLT COUNT-172 ___ 10:48PM NEUTS-79.8* LYMPHS-11.4* MONOS-5.9 EOS-2.0 BASOS-0.4 IM ___ AbsNeut-6.74* AbsLymp-0.96* AbsMono-0.50 AbsEos-0.17 AbsBaso-0.03 ___ 10:48PM GLUCOSE-117* UREA N-36* CREAT-1.5* SODIUM-144 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-17 ___ 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 05:20AM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-1.7 ___ ___: Re-demonstrated is a subacute infarct in the left posterior temporal lobe with known intraparenchymal hemorrhage and a small amount of subarachnoid hemorrhage in the region, with mild extension into the left tentorium (image 11, series 3). There is no evidence of intraventricular hemorrhage. There is no midline shift or mass effect. No fractures are identified. The ventricles and sulci are normal in size and configuration. There is some mucosal thickening in the left ethmoid sinus. The other visualized portions of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Redemonstrated infarct in the left posterior temporal lobe, with known intraparenchymal hemorrhage, and small amount of regional subarachnoid hemorrhage and left tentorial subdural blood. There is no midline shift or mass effect. 2. No fractures are identified. NCHCT ___: The study is slightly limited by motion artifacts. Late subacute infarction involving the left parietal and posterior temporal lobes is again seen. Small amount of gyriform hyperdensity within the infarcted territory, which may represent a combination of hemorrhage and pseudolaminar necrosis, is stable. Thin adjacent subdural hematoma, which extends along the left posterior falx and along the left tentorium, is also stable. No new hemorrhage is seen. There is no significant mass effect. The ventricles and the sulci uninvolved by infarct are age-appropriate in size. There is no evidence for a fracture. The imaged paranasal sinuses and mastoid air cells are grossly well-aerated, allowing for motion artifact. IMPRESSION: Stable appearance of late subacute infarction involving the left parietal and posterior temporal lobes compared to 1 day earlier, with small amount of gyriform hyperdensity, compatible with a combination of hemorrhage in pseudolaminar necrosis. Thin adjacent subdural hematoma, which extends along the left posterior falx and left tentorium, is also stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 140 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 2. Lantus 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Levothyroxine Sodium 25 mcg PO DAILY 4. GlyBURIDE 10 mg PO BID 5. Allopurinol ___ mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Paroxetine 20 mg PO DAILY 8. Prochlorperazine 10 mg PO DAILY 9. Metoprolol Tartrate 100 mg PO QAM 10. Metoprolol Tartrate 150 mg PO QPM 11. Pantoprazole 40 mg PO Q24H 12. Gabapentin 300 mg PO QAM 13. Gabapentin 300 mg PO QPM 14. Gabapentin 600 mg PO QHS 15. Potassium Chloride 10 mEq PO BID 16. MetFORMIN (Glucophage) 1000 mg PO BID 17. Indomethacin 75 mg PO BID 18. BuPROPion (Sustained Release) 150 mg PO BID 19. Furosemide 40 mg PO BID:PRN fluid retention 20. LaMOTrigine 200 mg PO QHS Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Lantus 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 4. LaMOTrigine 200 mg PO QHS 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Paroxetine 20 mg PO DAILY 9. Furosemide 40 mg PO BID:PRN fluid retention 10. Gabapentin 300 mg PO QAM 11. Gabapentin 300 mg PO QPM 12. Gabapentin 600 mg PO QHS 13. GlyBURIDE 10 mg PO BID 14. Indomethacin 75 mg PO BID 15. Metoprolol Tartrate 100 mg PO QAM 16. Metoprolol Tartrate 150 mg PO QPM 17. Potassium Chloride 10 mEq PO BID Hold for K > 18. Prochlorperazine 10 mg PO DAILY 19. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Intraparenchymal and subarachnoid hemorrhage Left MCA stroke Secondary diagnosis: Acute kidney injury Depression Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with bleed into bed of prior stroke. check for stability. thank you. // Please perform between ___ if possible. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.2 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: Comparison is made with prior CT head from ___ and MRI from ___. FINDINGS: Re-demonstrated is a subacute infarct in the left posterior temporal lobe with known intraparenchymal hemorrhage and a small amount of subarachnoid hemorrhage in the region, with mild extension into the left tentorium (image 11, series 3). There is no evidence of intraventricular hemorrhage. There is no midline shift or mass effect. No fractures are identified. The ventricles and sulci are normal in size and configuration. There is some mucosal thickening in the left ethmoid sinus. The other visualized portions of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Redemonstrated infarct in the left posterior temporal lobe, with known intraparenchymal hemorrhage, and small amount of regional subarachnoid hemorrhage and left tentorial subdural blood. There is no midline shift or mass effect. 2. No fractures are identified. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST. INDICATION: ___ man with metastatic pancreatic cancer on palliative treatment, evaluate for interval changes. TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by scan of the abdomen in equilibrium (3-min delay) phase. IV Contrast: 130 mL Omnipaque. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: This study involved 8 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 5) Stationary Acquisition 10.0 s, 0.5 cm; CTDIvol = 48.1 mGy (Body) DLP = 24.1 mGy-cm. 6) Spiral Acquisition 6.9 s, 75.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 1,252.0 mGy-cm. 7) Spiral Acquisition 2.8 s, 31.0 cm; CTDIvol = 16.6 mGy (Body) DLP = 512.9 mGy-cm. 8) Spiral Acquisition 1.2 s, 13.0 cm; CTDIvol = 15.4 mGy (Body) DLP = 199.2 mGy-cm. Total DLP (Body) = 1,991 mGy-cm. COMPARISON: Comparison is made to CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Please see separate dictation for details on same-day intrathoracic findings. ABDOMEN: HEPATOBILIARY: Since prior, there has been interval enlargement of a segment VIII hypodense lesion which now measures approximately 32 x 23 mm (series 2, image 55) previously 21 x 16 mm. Other hepatic lesions have not significantly changed in size including the second largest 7 mm hypodense lesion in hepatic segment VII. The gallbladder is unremarkable. There is no intrahepatic biliary duct dilation. PANCREAS: The pancreatic tail and body are atrophic with dilation of the pancreatic duct, unchanged from prior. Again seen, is abrupt transition from dilated to decompressed duct at the level of the pancreatic neck with a 14 x 14 mm hypodense mass in this region (series 2, image 64) (previously 11 x 13 mm). SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys enhance and excrete contrast symmetrically. A subcentimeter renal hypodensity in the right upper pole is too small to characterize but statistically likely represents a simple cyst and is unchanged from prior. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: The abdominal aorta is mildly ectatic below the level of the renal arteries without aneurysmal dilation. There is moderate atherosclerotic calcification. The celiac axis, SMA, and ___ are patent. The portal vein, splenic vein, and SMA are also patent. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. Mild compression deformity of the T12 vertebral body is unchanged. Mild retrolisthesis of L4/S1 is also unchanged. IMPRESSION: 1. Interval enlargement of the segment VIII hepatic metastatic lesion. The remaining liver lesions have not significantly changed from ___. Mild interval increase in a hypodense mass in the pancreatic body (now measuring 14 x 14 mm) with upstream pancreatic duct dilation and atrophy of the pancreatic tail. 3. Please see separate dictations for details on intrathoracic findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ yo right-handed man with PMH significant for atrial fibrillation on lovenox, pancreatic cancer (stage IV with known hepatic metastases), and a left sided stroke in ___ (with fluent aphasia), who presented as a transfer for incidental finding of a very small amount of hemorrhagic conversion of his prior stroke. Now s/p re-initation of lovenox. AV for change in size of parenchymal and subarachnoid hemorrhage. TECHNIQUE: Noncontrast head CTwith sagittal and coronal reformatted images.. DLP 803 mGy cm. COMPARISON: ___ noncontrast head CT. ___ brain MRI. ___ the head and neck CTA. FINDINGS: The study is slightly limited by motion artifacts. Late subacute infarction involving the left parietal and posterior temporal lobes is again seen. Small amount of gyriform hyperdensity within the infarcted territory, which may represent a combination of hemorrhage and pseudolaminar necrosis, is stable. Thin adjacent subdural hematoma, which extends along the left posterior falx and along the left tentorium, is also stable. No new hemorrhage is seen. There is no significant mass effect. The ventricles and the sulci uninvolved by infarct are age-appropriate in size. There is no evidence for a fracture. The imaged paranasal sinuses and mastoid air cells are grossly well-aerated, allowing for motion artifact. IMPRESSION: Stable appearance of late subacute infarction involving the left parietal and posterior temporal lobes compared to 1 day earlier, with small amount of gyriform hyperdensity, compatible with a combination of hemorrhage in pseudolaminar necrosis. Thin adjacent subdural hematoma, which extends along the left posterior falx and left tentorium, is also stable. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man with metastatic pancreatic cancer on treatment with palliative intent. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and axial maximal intensity projection images were submitted to PACS and reviewed. DOSE: This study involved 8 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 5) Stationary Acquisition 10.0 s, 0.5 cm; CTDIvol = 48.1 mGy (Body) DLP = 24.1 mGy-cm. 6) Spiral Acquisition 6.9 s, 75.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 1,252.0 mGy-cm. 7) Spiral Acquisition 2.8 s, 31.0 cm; CTDIvol = 16.6 mGy (Body) DLP = 512.9 mGy-cm. 8) Spiral Acquisition 1.2 s, 13.0 cm; CTDIvol = 15.4 mGy (Body) DLP = 199.2 mGy-cm. Total DLP (Body) = 1,991 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: CT chest dated ___. FINDINGS: Neck/cardiomediastinal: The imaged thyroid is unremarkable. There is no evidence of supraclavicular or axillary lymphadenopathy. A sub-carinal necrotic lymph node measures 2.2 cm, previously 1.8 cm. The degree of hilar lymphadenopathy has increased. As an example, a left inferior hilar lymph node now measures 1.1 cm (301:132), previously measuring 0.7 cm. A right hilar lymph node measures 1.2 cm (301:113), previously measuring 1.0 cm. Mediastinal lymphadenopathy has overall increased. A right ___ lymph node measures 1.5 cm, previously measuring 0.9 cm. The heart is normal in size. There is a trace pericardial effusion. The aorta and main pulmonary artery are top-normal. Lungs/airways: The tracheobronchial tree is patent to the subsegmental level. There has been interval development of a small right pleural effusion with the suggestion of pleural nodularity (301:137). Bilateral upper lobe predominant centrilobular ground-glass and peribronchial opacities are new. Areas of ___ are seen in the right lower lobe. There appears to be increased interstitial markings and thickening of the lower lobe interlobular septa. Abdomen: Please refer to abdomen/pelvic CT for evaluation of infra diaphragmatic structures. Bones and soft tissues: There are no suspicious bony or soft tissue lesions. IMPRESSION: 1. Short term interval development of predominately upper lobe peribronchial and centrilobular opacities suggests an infectious etiology, A rapidly developing malignancy cannot be excluded, but substantially less likely. 2. Findings compatible with progression of disease, such as slight interval increase in lymphadenopathy as described. See same day CT abdomen/pelvis for details regarding infra-diaphragmatic structures. 3. Interstitial finding compatible with volume overload. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ service) on the telephone on ___ at 5:08 ___, 5 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SAH, Transfer Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, INTRACRANIAL HEMORR NOS temperature: 98.6 heartrate: 80.0 resprate: 16.0 o2sat: 96.0 sbp: 127.0 dbp: 93.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ with a small amount of blood in the area of your prior stroke. Your neurologic exam was improved from when you were last admitted. Your lovenox was held for 1 day and then restarted. In consultation with your cardiologist and your oncologist, you will start on apixaban instead of lovenox. You will start this medication tonight. You will follow-up with your oncologist, cardiologist and stroke neurologists as an outpatient. Please follow up with your oncologist regarding the findings on your Chest CT that was done during this admission. It was a pleasure taking care of you, Your ___ Neurologists

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Hydralazine Attending: ___. Chief Complaint: Pneumoperitoneum Major Surgical or Invasive Procedure: none. Observation only History of Present Illness: ___ M with a recent diagnosis of small vessel vasculitis on 60 mg of prednisone daily, transferred from ___ for evaluation of incidental pneumoperitoneum on CXR. 2d ago, patient's ICD detected rapid runs of SVT. Since he had a routine follow up appointment in the ___ clinic at ___ today, his cardiologist ordered EKG and CXR for further evaluation. After he went home, he received a call that his CXR showed new pneumoperitoneum. He then presented to the ED at ___, where he had a CT scan that showed pneumoperitoneum and R colon pneumatosis. Of note, he reports ~ 25 lb weight loss since his diagnosis of vasculitis several months ago. He denies nausea, vomiting, diarrhea, fevers, chills, blood in stools. He is having good oral intake and normal bowel movements. He has had a dull abdominal pain for the last 2 days which he did not think was anything significant. He thought it was reflux and he took some Tums. He denies recent use of NSAIDs, and history of peptic or duodenal ulcers. He did not have recent surgeries. He had a normal colonoscopy in ___. Past Medical History: COPD Hypertension Diabetes mellitus, type II Atrial fibrillation Nonischemic cardiomyopathy with an EF of 30% ___ Heart Association class II, heart failure ICD in ___ ___ Left knee surgery for meniscal tear Right meniscal tear Right foot surgery for hammertoe Left rotator cuff tear Arthritis Social History: ___ Family History: No h/o autoimmune dz Sister, deceased, lung ca (smoker) Mother, deceased, breast ca Physical Exam: PE: Vitals: ___ 154/77 17 100%RA General: comfortable, in no acute distress HEENT: sclera anicteric, mucus membranes moist, nares clear, trachea at midline CV: irregular rate and rhythm. No appreciable murmurs, rubs, gallops Pulm: clear to auscultation bilaterally Abd: Soft/ND/NT. No hernias, masses or scars. No rebound, no guarding. + bowel sounds MSK: warm, well perfused Rectal: brown stool in vault, no gross blood, guaiac negative Neuro: alert, oriented to person, place, time PE on discharge: VS: VSS, afebrile Gen: A&O x3, moving around comfortably, no distress CV: irregular rate and rhythm. No appreciable murmurs, rubs, gallops Pulm: clear to auscultation bilaterally Abd: Soft/ND/NT. No hernias, masses or scars. No rebound, no guarding. + bowel sounds MSK: warm, well perfused Pertinent Results: ___ 06:00AM BLOOD WBC-6.1 RBC-4.48* Hgb-10.2* Hct-33.2* MCV-74* MCH-22.9* MCHC-30.9* RDW-18.7* Plt ___ ___ 05:55AM BLOOD WBC-6.4 RBC-4.39* Hgb-10.0* Hct-32.6* MCV-74* MCH-22.9* MCHC-30.8* RDW-18.6* Plt ___ ___ 06:00AM BLOOD Glucose-112* UreaN-37* Creat-1.7* Na-140 K-3.9 Cl-100 HCO3-31 AnGap-13 ___ 05:55AM BLOOD Glucose-75 UreaN-45* Creat-2.0* Na-140 K-3.3 Cl-98 HCO3-34* AnGap-11 ___ 06:00AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.4 ___ 05:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3 Imaging: ___ CXR IMPRESSION: New moderate pneumoperitoneum. ___ OSH CT Torso (___) Wet red: Pneumoperitoneum with R colon pneumatosis and portal venous gas Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO 1X/WEEK (___) 2. Amiodarone 400 mg PO BID 3. Bumetanide 2 mg PO BID 4. Carvedilol 12.5 mg PO BID 5. CycloSPORINE (Sandimmune) 75 mg PO Q24H 6. Digoxin 0.125 mg PO DAILY 7. Lantus (insulin glargine) 30 u subcutaneous qpm 8. isosorbide mononitrate 30 mg oral daily 9. Metolazone 2.5 mg PO DAILY 10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 11. Potassium Chloride 20 mEq PO DAILY 12. PredniSONE 60 mg PO DAILY 13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 14. Valsartan 40 mg PO DAILY 15. Warfarin 2.5 mg PO 2X/WEEK (___) 16. Warfarin 1.25 mg PO 5X/WEEK (___) Discharge Medications: 1. Amiodarone 400 mg PO BID Amiodarone Taper: 400mg 2x/day for 7 days 300mg 2x/day for 2 weeks then 200mg 2x/day 2. Carvedilol 12.5 mg PO BID 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 4. PredniSONE 60 mg PO DAILY 5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 7. Alendronate Sodium 70 mg PO 1X/WEEK (___) 8. Bumetanide 2 mg PO BID 9. CycloSPORINE (Sandimmune) 75 mg PO Q24H 10. Lantus (insulin glargine) 30 u SUBCUTANEOUS QPM 11. Metolazone 2.5 mg PO DAILY 12. Potassium Chloride 20 mEq PO DAILY 13. Valsartan 40 mg PO DAILY 14. Warfarin 1.25 mg PO DAILY16 15. Digoxin 0.125 mg PO EVERY OTHER DAY Take every other day Discharge Disposition: Home Discharge Diagnosis: Pneumoperitoneum - unknown source Discharge Condition: Mental status: clear and coherent Ambulation: independent Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with runs of SVT rapid afib. // Pt starting amiodarone Pt starting amiodarone COMPARISON: Chest radiographs since ___ most recently ___. Impression IMPRESSION: New moderate pneumoperitoneum. Unless the patient has had an invasive procedure introducing air in to the abdomen, this is an indication of an intestinal perforation. Moderate cardiomegaly, unchanged since ___. Lungs well expanded and clear. There is no pleural effusion. Trans subclavian right ventricular pacer defibrillator lead unchanged in position since at least ___, continuous from the left pectoral PET generator. NOTIFICATION: Dr. ___ reported the findings to ___ by telephone on ___ at 3:25 ___, 0.5 minutes after discovery of the findings. Dr. ___ reported the findings to Dr ___ by telephone on ___ at 3:27 ___, 3 minutes after discovery of the findings. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: PERFORATED BOWEL, Transfer Diagnosed with PERITONEAL DISORDER NEC temperature: 98.0 heartrate: 65.0 resprate: 17.0 o2sat: 100.0 sbp: 154.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital due an incidental pneumoperitoneum on CXR and CT scan (air into your abdominal cavity). The reason for this finding is unkown. This usually happens after an abdominal procedure when air enter the abdominal cavity during the procedure or if you have a bowel perforation. Therefore it was reasonable to admit your to the hospital for observation despite the fact that you are asymptomatic (without any symptoms). You were closely monitored daily with labs and vitais signs. As you continue to be stable we felt you could be discharge home with close follow up with your PCP. There was no signs of bowel perforation on your CT image, your clinical presentation is stable therefore no surgical intervention was recommended. We would like that you follow-up with your PCP/or Rheumatology (Dr. ___ in order to revise your home medication. You might need to decrease the amount of prednisone as this medication can thin your bowel wall and predispose you to an air leak inside your belly. We spoked with your Rheumatology team yesterday about this and they would like to see you back in clinic to revise your home medication dose. Dr. ___ who is currently prescribing your prednisone will be better able to acces the risk/benefits to decrease this medication. We alwo hold off your warfarin during your hospital stay as your INR level was higher than recommended during your first day(3.4). At discharge your INR level was 2.5 which is within the desired range. Please follow-up with your PCP to have the dose readjusted if necessary. You should have a repeated CT in the next couple of months (if still asymptomatic) to monitor interval change. Please have your PCP schedule this for you. You will be discharged home with a two weeks ___ of antibiotic. These medications can help control the bacteria that usually grows inside your gastrointestinal tract. You do not have evidence of an infection but we would like to make sure that if the air is coming from the bowel, that any bacteria that might have spilled into your belly is contained. It was a pleasure taking care of you during this hospitalization. Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Vancomycin / Aspirin / AmBisome Attending: ___. Chief Complaint: headache, fevers, chills, neck stiffness, myalgias Major Surgical or Invasive Procedure: lumbar puncture ___ History of Present Illness: Ms. ___ is a ___ with a history of HIV on HAART (last CD4 ___ ___ that has been complicated by previous noncompliacne, PCP pneumonia, cryptococcal pneumonia, possible recurrent aseptic meningitis- also with ___ malformation abd migraine headaches who presents to the ED with headache, fevers, chills and malaiase. On arrival to the ED, her initial vitals were T100.0 98 108/59 16 98%RA. A lumbar puncture was bland with a single WBC and RBC on tube 4. and a normal glucose and protein. CT head revealed no intracranial bleeds or masses (within the confines of a noncontrast study), and CXR unremarkable. Due to a history of cryptococcal meningitis and possible aseptic meningitis, she was admitted for full workup. On arrival to the medicine floor, the patient feels much better. She describes a progressive 1 week syndrome that began with a dry cough, throat irritation, and general malaise. Three days ago, she developed chest tightness and shortness of breath reminiscent of her typical asthma symptoms though they did not respond to inhalers. Two days ago she developed overwhelming myalgias, arthralgias, and a headache, which was severe. The headache was ___, assumed a circular distribution around the entirety of the head with the epicenter located at the right temple- the area where her previous VP shunt exited. There was tenderness at the base of the skull with tightness of the neck radiating down the paraspinal musculature. She complaines of "spots" in her vision, but no lack of acuity. There is photo and phonophobia. The headache is similar to migrains which she gets on a weekly basis and which respond to exedrine. She measuired temps of 101.2 on ___, and had further fevers and chills yesteday. She complains of some nausea and a few bouts of vomiting three days ago. She complains of 5 days of watery nonbloody diarrhea occurring ___ times a day. Coughing, chest tightness and phlegm production continue, along with body aches. Her mom also had cold-like symptoms this week, and a son had strep throat two months ago. She received a flu shot one month ago. She thinks that initially her symptoms were similar to previous episodes of aseptic meningitis, but they resolved much quicker than usual with conservative treatment. She has not tried any OTC meds at this point. She denies recent confusion, odd behavior, speech difficulties, seizures, incontinence. She has had a number of presentations of headache and neck stiffness previously. She was admitted ___ with HA/neck stiffness however two LPs were quite bland and infectious workup including toxo, crypto, HSV, VZV were negative. Neuro felt it consistent with migraines and she was treated successfully with muscle relaxants. In ___ she was admitted with headache, vertigo, and neck stiffness and again underwent an infectious workup with bland LP, negative HSV, and a normal MRI of the brain. She improved with muscle relaxants during this admission as well. She was admitted ___ and ___ with a headache, and had normal LPs each time- she was diagnosed with migraines. ___ she presented with head, fever, stiff neck and was actuially diagnosed with cryptococcal meningitis requiring VP shunt for elevated intracranial pressure. She had cryptococceemia in ___ with normal LP. She was diagnosed with aseptic meningitis in ___ with a CSF WBC of 45 without positive cultures. Her first admit was ___ with HA/neck stiffness and URI symptoms with a negaitve LP. Past Medical History: 1) HIV/AIDS- diagnosed in ___ when she presented with streptococcal pharyngitis and an aseptic meningitis. She has intermittently been engaged in care. She initated HAART in ___ with Truvada and Atazanvir. She notes intermittent compliance with this regimen since then. last CD4 count ___ 826 2) Disseminated crypto and meningitis ___, recurrences of cryptococcemia in ___ and ___ VP shunt; s/p shunt removal 3) Hx of PJ pneumonia ___ Recurrent STDS (Chlamydia, gonorrhea, trich, HSV) 5) recurrent sinusitis 6) 2x aseptic meningitis 7) migraines 8) asthma 9) depression 10) hx zoster 11) M. ___ isolated from sputum in ___ Chiari malformation 13) Tobacco use 14) Dental work- teeth removed ___. 15) LEEP; laser ablation of condyloma of cervix, vagina and vulva; and laser ablation of vulvar intraepithelial neoplasia (___) Social History: ___ Family History: Mother and father both with migraines. Physical Exam: Admission exam: VS - Temp99.1 BP106/62 , HR65 , RR18 , O2-sat 99% RA GENERAL: well appearing, mildly fatigued HEENT: MMM, oropharynx is clear, normal EOM, PERRLA. fundoscopic exam limited due to pupillary constriction and color but could not appreciate papilledema. NECK: no adenopathy, normal ROM PULM: CTAB without RRW HEAERT: RRR normal S1 S2 no MRG ABD: soft without tenderness to palpation SKIN: no signs of infection BACK: tenderness to palp of trapezius bilaterally and all posterior paraspinal musculature. NEURO: cranial nerves all intact bilaterally, strength ___ throughout, normal sensory exam to soft touch. full ROM of the neck- can touch chin to chest. Negative kernig and brudzinski tests bilaterally. finger to nose, RAM, HTS all in tact. MSE: fully oriented and appropriate with all questioning Discharge Exam: afebrile, decreased neck stiffness and back pain, otherwise unchanged Pertinent Results: Admission Labs: ___ 02:10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 12:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0 ___ ___ 12:09PM CEREBROSPINAL FLUID (CSF) PROTEIN-29 GLUCOSE-62 ___ 09:50AM GLUCOSE-93 UREA N-12 CREAT-0.6 SODIUM-136 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION GAP-12 ___ 09:50AM WBC-4.4 RBC-3.83* HGB-12.0 HCT-36.6 MCV-96 MCH-31.4 MCHC-32.8 RDW-12.8 ___ 09:50AM NEUTS-47* BANDS-1 ___ MONOS-9 EOS-2 BASOS-0 ___ MYELOS-0 ___ 09:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 09:50AM PLT SMR-NORMAL PLT COUNT-207 Discharge Labs: ___ 06:15AM BLOOD WBC-3.0* RBC-3.69* Hgb-11.5* Hct-35.7* MCV-97 MCH-31.1 MCHC-32.2 RDW-12.7 Plt ___ ___ 06:15AM BLOOD Neuts-22* Bands-0 Lymphs-61* Monos-15* Eos-1 Baso-0 Atyps-1* ___ Myelos-0 ___ 06:15AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-139 K-4.2 Cl-107 HCO3-23 AnGap-13 ___ 06:15AM BLOOD ALT-17 AST-22 AlkPhos-67 TotBili-0.1 ___ 06:15AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8 Microbiology: ___ 12:09 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take ___ weeks to grow.. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. ___ 9:50 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8:14 am Influenza A/B by ___ Source: Nasopharyngeal swab. **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. Imaging: NONCONTRAST HEAD CT ___: No acute intracranial abnormality CXR ___: No acute intrathoracic abnormality Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Darunavir 800 mg PO DAILY 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Fluconazole 200 mg PO Q24H 4. Raltegravir 400 mg PO BID 5. RiTONAvir 100 mg PO DAILY 6. albuterol inhaler Discharge Medications: 1. Darunavir 800 mg PO DAILY 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Fluconazole 200 mg PO Q24H 4. Raltegravir 400 mg PO BID 5. RiTONAvir 100 mg PO DAILY 6. Cyclobenzaprine 10 mg PO TID:PRN neck pain or stiffness RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*10 Tablet Refills:*0 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/tightness RX *albuterol sulfate 90 mcg ___ puffs inhaled every ___ Disp #*1 Inhaler Refills:*1 8. Medical equipment please provide nebulizer machine diagnosis: Asthma 493.9 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/tightness RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb(s) every ___ hours Disp #*1 Box Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Acute viral infection migraine headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Headache, cough and fever. COMPARISON: Chest radiograph ___. FINDINGS: PA and lateral views of the chest were obtained. The lungs are clear bilaterally with no evidence of focal consolidation or pulmonary edema. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. There are no bony abnormalities. There is no free air below the right hemidiaphragm. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: Headache, cough, and fever. COMPARISON: CT head ___. TECHNIQUE: MDCT axial images were acquired through the brain without the administration of IV contrast. Sagittal, coronal and thin section bone algorithm reformats were obtained. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, masses or mass effect. Ventricles and sulci are normal in size and configuration. Basal cisterns are patent. Gray-white differentiation is preserved. Right frontal burr hole again noted. The visualized portions of the paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No mass or acute intracranial process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: NECK STIFFNESS Diagnosed with TORTICOLLIS NOS temperature: 100.0 heartrate: 98.0 resprate: 16.0 o2sat: 98.0 sbp: 108.0 dbp: 59.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ with headaches, fevers, chills, and muscle aches. You underwent a spinal tap in the ED which was quite reassuring- you do not have meningitis. We suspect that you had a very mean viral infection that led to a migraine and muscle spasms. We treated you effectively with medicine and you felt better. The following changes were made to your medications: 1. START CYCLOBENZAPRINE 10mg every 8 hours as needed for muscle spasms 2. RESUME EXEDRINE for your migraines You can also use ibuprofen or naproxen for neck/back pain Please be sure to take your HAART therapy every single day due to your elevating viral load!! It was a pleasure taking care of you, Ms. ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: Cardiac catherization History of Present Illness: ___ PMHx significant for severe vascular diseae & hypertension presents with 4 days of ___ and epigastric pain, inability to tolerate PO. He states that the pain is constant, hasn't changed since the onset. He had had multiple vascular interventions in the abdomen and bilateral extremities, but no previous open abdominal surgeries. He denied fever, hematochezia, dysuria, hematuria. He has vomited all the food he has attempted to eat. No history of diverticulitis. He has never had colonoscopy. In the ED, initial vitals were: pain ___, T 99.2, HR 75, BP 152/75, R 20, SpO2 96%/RA And patient was given ___ 21:14 IVF 1000 mL NS 1000 mL ___ ___ 00:01 IV Furosemide 20 mg ___ ___ 07:54 PO/NG Amlodipine 10 mg ___ ___ 07:54 PO/NG Aspirin 325 mg ___ ___ 07:54 PO/NG Lisinopril 20 mg ___ ___ 07:54 PO Omeprazole 20 mg ___ ___ 08:05 PO Potassium Chloride 40 mEq ___ ___ 08:05 IV Magnesium Sulfate 2 gm ___ ___ 08:05 IV Furosemide 20 mg ___ ___ 08:07 IH Tiotropium Bromide 1 CAP ___ - Labs were notable for: leukopenia (3.3), hyponatremia (128), pro-BNP 7781, UA with moderate blood, >600 proteinuria, 70 glucose, lactate 1.5, trop-T 0.01 - Patient was given: 1L NS then 20 mg IV furosemide x 2 - CT Abd/Pelvis was obtained, showing mild cardiomegaly with small bilateral pleural effusions. Lower lung GGOs could represent atypical edema, but difficult to exclude early pneumonia in LLL. Extensive vascular disease with aortiiliac stent in place. No findings to account for ___ abdominal pain. - CXR showing pulmonary vascular congestion & mild to moderate pulmonary edema with a small rigth pleural effusion; no free air below the diaphragm. - EKG showed NSR, with IVCD and TW flattening/inversions in lateral precordial leads On the floor, Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: ====================== PAST MEDICAL HISTORY ====================== HTN DMII PAD/claudication ED GERD . ====================== VASCULAR HISTORY ====================== -___: Bilateral common iliac artery kissing stent placement, Bilateral external iliac artery stent placement -___: Bilateral simultaneous angioplasty of common iliac artery stents -___: Placement of a 7 mm x 59 mm iCAST stent into the left common iliac artery.Placement of kissing stents into the bilateral common iliac artery origins measuring 7 mm x 37 mm, Express LD stents. Social History: ___ Family History: coronary artery disease, MI, diabetes, thromboembolism Physical Exam: ADMISSION VS: 98.7 130/76 65 16 99RA General: NAD, comfortable, pleasant HEENT: NCAT, PERRL, EOMI Neck: supple, no JVD CV: regular rhythm, no m/r/g Lungs: CTAB, no w/r/r Abdomen: soft, NT/ND, BS+ Ext: WWP, no c/c/e, 2+ distal pulses bilaterally Neuro: moving all extremities grossly DISCHARGE Weight: 75.4 kg (standing) VS: T 98.1F BP 113/59 P 61 RR 18 O2 99% RA General: NAD, comfortable, pleasant HEENT: PERRL, EOMI Neck: supple, no JVD CV: RRR, no MRGs; normal S1/S2. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. Ext: Warm, and well-perfused. R radial pulse 2+. Neuro: A&Ox3; MAEx4 Pertinent Results: ADMISSION ___ 05:03PM BLOOD WBC-3.3*# RBC-5.12# Hgb-15.7# Hct-46.0# MCV-90 MCH-30.7 MCHC-34.1 RDW-14.7 RDWSD-48.0* Plt ___ ___ 05:03PM BLOOD Glucose-151* UreaN-19 Creat-1.2 Na-128* K-4.3 Cl-94* HCO3-22 AnGap-16 ___ 05:00AM BLOOD ALT-36 AST-27 AlkPhos-93 TotBili-0.4 ___ 06:00AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.8 ___ 05:18PM BLOOD Lactate-1.5 DISCHARGE ___ 04:52AM BLOOD WBC-5.6 RBC-4.67 Hgb-14.0 Hct-42.8 MCV-92 MCH-30.0 MCHC-32.7 RDW-14.1 RDWSD-47.4* Plt ___ ___ 04:52AM BLOOD Glucose-136* UreaN-17 Creat-0.8 Na-133 K-4.7 Cl-101 HCO3-23 AnGap-14 ___ 04:52AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 CXR ___ Pulmonary vascular congestion and mild to moderate pulmonary edema with small right pleural effusion. No signs of free air below the right hemidiaphragm. CT ABD/PELVIS ___ 1. Mild cardiomegaly with small bilateral pleural effusions. Lower lung ground-glass opacities may represent atypical edema, difficult to exclude an early pneumonia in the left lower lobe. 2. Extensive vascular disease with aortoiliac stent in place, appearing patent. 3. No findings the left lower quadrant to account for pain. TRANSTHORACIC ECHOCARDIOGRAM (___): Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = ___ %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal with depressed free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CARDIAC CATHETERIZATION (___): Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is without obstructive dz. * Left Anterior Descending The LAD has a 70% long distal stenosis. The ___ Diagonal is not obstructed. * Circumflex The Circumflex is 80% narrowed proximally. The ___ Marginal is minimall diseased. * Right Coronary Artery The RCA is engaged non-selsctively and has a long proximal 80% stenosis. The Right PDA is not well visualized but look patent. Impressions: 1. 3 vessel disease in a diabetic with reduced EF 2. Extreme tortuosity making selective engagement of RCA difficult, so non selective injections obtained ___ DUP EXTEXT BIL (MAP) (___): FINDINGS: Right lower extremity: Both the great and small saphenous veins are patent in the right lower extremity. The great saphenous vein caliber ranges from 0.12-0.27 cm. The small saphenous vein caliber ranges from 0.17-0.24 cm. Left lower extremity: Both the great and small saphenous veins are patent in the left lower extremity. The great saphenous vein caliber ranges from 0.22-0.36 cm. The small saphenous vein caliber ranges from 0.18-0.31 cm. IMPRESSION: Patent bilateral great and small saphenous veins. For detailed description of calibers please refer to sonographer report in PACs. CAROTID SERIES COMPLETE (___): IMPRESSION: Mild homogeneous atherosclerotic plaque in the left ICA and mild intimal thickening in the right ICA resulting in less than 40% stenosis bilaterally. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN PAIN 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. Labetalol 400 mg PO BID 6. MetFORMIN (Glucophage) 850 mg PO TID 7. Docusate Sodium 100 mg PO DAILY 8. Cyclobenzaprine 5 mg PO TID 9. Fluticasone Propionate NASAL 1 SPRY NU DAILY 10. Amlodipine 10 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CHEST PAIN 13. TraMADOL (Ultram) 50 mg PO BID:PRN PAIN 14. Clopidogrel 75 mg PO DAILY 15. Aspirin 325 mg PO DAILY 16. GlipiZIDE 10 mg PO BID 17. Albuterol Inhaler 2 PUFF IH Q6H:PRN DYSPNEA Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN PAIN 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN DYSPNEA 3. Amlodipine 10 mg PO DAILY 4. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at night Disp #*90 Tablet Refills:*0 5. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. Gabapentin 300 mg PO TID 8. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 9. Cyclobenzaprine 5 mg PO TID 10. Docusate Sodium 100 mg PO DAILY 11. GlipiZIDE 10 mg PO BID 12. MetFORMIN (Glucophage) 850 mg PO TID 13. TraMADOL (Ultram) 50 mg PO BID:PRN PAIN 14. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ------------------ ACUTE SYSTOLIC HEART FAILURE CORONARY ARTERY DISEASE VIRAL GASTROENTERITIS SECONDARY DIAGNOSIS -------------------- DIABETES Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with epigastric pain COMPARISON: Prior exam from ___. Outside hospital CT exam from ___. FINDINGS: PA and lateral views of the chest provided. Lateral view suboptimal due to underpenetration. There is hilar congestion with mild to moderate interstitial pulmonary edema. A small pleural effusion on the right is noted. No pneumothorax. Heart size is normal. Bony structures appear intact. No free air below the right hemidiaphragm. IMPRESSION: Pulmonary vascular congestion and mild to moderate pulmonary edema with small right pleural effusion. No signs of free air below the right hemidiaphragm. Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: ___ with LLQ pain TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 621 mGy-cm. COMPARISON: Prior CT abdomen pelvis performed at an outside hospital on ___. FINDINGS: LOWER CHEST: Small bilateral pleural effusions are present. There is mild compressive lower lobe atelectasis. Areas of ground-glass and nodular opacity in the left lower lobe may represent an atypical pneumonia versus asymmetric pulmonary edema. Small hilar calcified lymph nodes are partially visualized. The heart is mildly enlarged. ABDOMEN: The liver enhances normally without focal concerning lesion. The gallbladder appears normal. No intrahepatic or extrahepatic biliary ductal dilation. Main portal vein is patent. The spleen is normal. Adrenal glands are normal bilaterally. The pancreas appears normal. The kidneys enhance symmetrically and excrete contrast promptly. There is an area of scarring along the left midpole at the site of prior infarction. A simple appearing left upper pole renal cyst is again noted. The stomach is decompressed. The duodenum appears normal. Loops of small bowel demonstrate no signs of ileus or obstruction. No mesenteric fluid or adenopathy. The abdominal aorta contains extensive atherosclerosis as on prior with distal aortoiliac stents again noted which remain patent. No retroperitoneal adenopathy or hematoma. PELVIS: The appendix is normal. The colon contains a mild fecal load and is without wall thickening or signs of acute inflammation. No abnormality in the left lower quadrant to account for pain. No pelvic free fluid. No pelvic sidewall or inguinal adenopathy. The urinary bladder is decompressed. Distal ureters opacify normally. BONES: No worrisome lytic or blastic osseous lesion is seen. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild cardiomegaly with small bilateral pleural effusions. Lower lung ground-glass opacities may represent atypical edema, difficult to exclude an early pneumonia in the left lower lobe. 2. Extensive vascular disease with aortoiliac stent in place, appearing patent. 3. No findings the left lower quadrant to account for pain. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old man with 3vd undergoing w/u for CABG. Please perform carotid ultrasound TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None available FINDINGS: RIGHT: The right carotid vasculature shows mild intimal thickening. The peak systolic velocity in the right common carotid artery is 56 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 42, 60, and 79 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 30 cm/sec. The ICA/CCA ratio is 1.4. The external carotid artery has peak systolic velocity of 304 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild homogeneous atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 53 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 73, 70, and 63 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 36 cm/sec. The ICA/CCA ratio is 1.4. The external carotid artery has peak systolic velocity of 79 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: Mild homogeneous atherosclerotic plaque in the left ICA and mild intimal thickening in the right ICA resulting in less than 40% stenosis bilaterally. Radiology Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ year old man with ___ undergoing w/u for CABG. Please perform lower extremity vein mapping pre-CABG. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: Right lower extremity: Both the great and small saphenous veins are patent in the right lower extremity. The great saphenous vein caliber ranges from 0.12-0.27 cm. The small saphenous vein caliber ranges from 0.17-0.24 cm. Left lower extremity: Both the great and small saphenous veins are patent in the left lower extremity. The great saphenous vein caliber ranges from 0.22-0.36 cm. The small saphenous vein caliber ranges from 0.18-0.31 cm. IMPRESSION: Patent bilateral great and small saphenous veins. For detailed description of calibers please refer to sonographer report in PACs. Gender: M Race: ASIAN - ASIAN INDIAN Arrive by WALK IN Chief complaint: LLQ abdominal pain Diagnosed with Heart failure, unspecified temperature: 99.2 heartrate: 75.0 resprate: 20.0 o2sat: 96.0 sbp: 152.0 dbp: 75.0 level of pain: 8 level of acuity: 3.0

Mr. ___, You were hospitalized because of nausea, vomiting, shortness of breath. Likely you had a viral illness of your GI tract. However, you were diagnosed with a new diagnosis of "heart failure" this admission. This means you have a weak heart. As part of the evaluation of this diagnosis you underwent a "catherization" which reveal a lot of heart disease. In order to fix this, you need heart surgery. Please DO NOT take your Plavix from now on. You aspirin dose has been changed to 81mg from 325mg You are scheduled for heart surgery (called a "CABG") on ___. Stop your metformin on ___. Stop your lisinopril on ___. Please weight yourself every day, and call the cardiology office in order to see if you need a diuretic (a medication to remove the extra fluid). If you feel short of breath or notice leg swelling you should also call. Please follow the directions in the book the surgeons gave you before the surgery. It was a pleasure taking care of you at ___, We wish you well Your Team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ with history of asthma, depression/anxiety, active tobacco smoking who presents with acute onset chest pain with exertion. Patient describes nearly ten minutes of left sided chest pain, dull in quality and non-radiating while walking to work. There was some associated shortness of breath, though he is a smoker and also thought he was affected by the humid weather. No nausea, palpitations, or lightheadedness/dizziness. After the pain resolved spontaneously, patient experienced two subsequent short-lived episodes in quick succession. Throughout the day, he then noticed some left hand numbness, which he attributed to known carpal tunnel. Later on in the afternoon, patient presented for a previously scheduled dental procedure, which was deferred iso hypertension (163/109). Patient was instructed to undergo evaluation at an urgent ___, which he did. ECG showed a new RBBB compared to ___ and so patient was loaded with aspirin and told to present to the ___ ED. Upon initial evaluation in the ED, patient experienced another episode of the same chest discomfort, dull and left-sided, self-limited and without any significant associated symptoms. In the ED initial vitals were: 97.7 89 149/93 18 97% RA Past Medical History: Past Medical History: -Depression -Anxiety Past Surgical History: -Ventral hernia repair as a child -Lithotripsy -Oral mucosal bx Social History: ___ Family History: Denies history of IBD or GI cancer. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= VS: 24 HR Data (last updated ___ @ 1125) Temp: 98.1 (Tm 98.1), BP: 138/83 (138/83-87), HR: 77 (74-77), RR: 18 (___), O2 sat: 97% (97-98), O2 delivery: Ra GENERAL: Well developed, well nourished man in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. CARDIAC: Regular rate, normal rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No peripheral edema. SKIN: No significant skin lesions or rashes. ======================= DISCHARGE PHYSICAL EXAM ======================= VS: 24 HR Data (last updated ___ @ 328) Temp: 98.5 (Tm 98.5), BP: 114/78 (114-168/77-96), HR: 68 (66-78), RR: 17 (___), O2 sat: 96% (94-98), O2 delivery: ra GENERAL: Well developed, well nourished man in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. CARDIAC: Regular rate, normal rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No peripheral edema. SKIN: No significant skin lesions or rashes. Pertinent Results: ============== ADMISSION LABS ============== ___ 05:45PM URINE MUCOUS-RARE* ___ 05:45PM URINE RBC-11* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 05:45PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 05:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:45PM ___ PTT-25.9 ___ ___ 05:45PM PLT COUNT-209 ___ 05:45PM NEUTS-60.7 ___ MONOS-4.9* EOS-2.3 BASOS-0.8 IM ___ AbsNeut-5.18 AbsLymp-2.64 AbsMono-0.42 AbsEos-0.20 AbsBaso-0.07 ___ 05:45PM WBC-8.5 RBC-4.97 HGB-16.7 HCT-45.0 MCV-91 MCH-33.6* MCHC-37.1* RDW-12.5 RDWSD-41.1 ___ 05:45PM URINE UHOLD-HOLD ___ 05:45PM URINE HOURS-RANDOM ___ 05:45PM cTropnT-<0.01 ___ 05:45PM estGFR-Using this ___ 05:45PM GLUCOSE-83 UREA N-13 CREAT-0.8 SODIUM-144 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 ___ 08:45PM cTropnT-<0.01 ___ 11:51PM cTropnT-<0.01 ================= PERTINENT STUDIES ================= EKG ___: NSR (84bpm), right access deviation, wide QRS with RBBB, TWIs III/aVF/aVR/V1, anterolateral STDs. Cardiac perfusion study ___: FINDINGS: The image quality is adequate but limited due to soft tissue attenuation. There is motion. Left ventricular cavity size is normal. Rest and stress perfusion images reveal a reversible, mild reduction in photon counts involving the distal anterior wall and the apex. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 56% with an EDV of 105 ml. IMPRESSION: 1. Reversible, mild, small perfusion defect involving the LAD territory. 2. Normal left ventricular cavity size and systolic function. CXR ___: IMPRESSION: No acute intrathoracic process ============== DISCHARGE LABS ============== No labs on day of discharge ___ 11:50AM BLOOD WBC-6.8 RBC-4.91 Hgb-16.7 Hct-45.6 MCV-93 MCH-34.0* MCHC-36.6 RDW-12.5 RDWSD-42.5 Plt ___ ___ 11:50AM BLOOD ___ PTT-37.8* ___ ___ 11:50AM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-142 K-4.3 Cl-104 HCO3-25 AnGap-13 ___ 11:50AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0 Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth every night Disp #*30 Tablet Refills:*0 3. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with chest pain// Please eval for PNA, effusion COMPARISON: CT of the chest from ___ FINDINGS: AP portable upright view of the chest. Low lung volumes. Overlying EKG leads noted. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. No signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 97.7 heartrate: 89.0 resprate: 18.0 o2sat: 97.0 sbp: 149.0 dbp: 93.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You are leaving the hospital against medical advice. Why was I here? -You had chest pain What was done for me while I was here? -You had a cardiac perfusion study that showed you have poor flow through one of your coronary arteries -We started you on medications to lower your risk of having a heart attack -We recommended that you have a Cardiac catheterization done on ___. You left before this procedure was done. What should I do when I go home? -Take your medications as prescribed. -Make appointments to see your primary care provider and ___ cardiologist when you leave. We wish you the best in the future. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: abd pain, N/V Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with a PMH of chronic Hep B, H/ pylori s/p treatment with Prevpac, laparoscopic cholecystectomy for biliary colic in ___, who presents with abdominal pain. Patient reports that two days ago she was in her usual state of health until two days ago. She ate lunch and went to her appointment in ___ clinic. She reports that while there she suddenly felt sweaty, followed by sudden onset of sharp, severe abdominal pain in the epigastric area, associated with nausea. She went to the ED, where she reports she had an ultrasound and labs. Her symptoms resolved, and she was discharged home. However, the following day she ate oatmeal, and around 30 minutes later again suddenly became diaphoretic with epigastric pain and nausea. She again presented to the ED. She reports no fevers or chills, no rashes, no change in bowel movements. In the ED: Initial vital signs were notable for: T 97.9, HR 65, BP 123/81, RR 16, 100% RA Exam notable for: Tenderness to palpation to the epigastric region. Labs were notable for: - CBC: WBC 6.6 (52%n), hgb 13.8, plt 201 - Lytes: 143 / 107 / 13 AGap=17 ------------- 80 4.2 \ 19 \ 0.7 - LFTs: AST: 405 ALT: 393 AP: 176 Tbili: 1.3 Alb: 4.2 - lipase 22 - lactate 1.4 - u/a with lg leuks, trace blood, trace protein, 40 ketones, >182 WBCs, negative nitrites, no bacteria Upon arrival to the floor, patient reports continued abdominal pain and nausea which comes and goes. She feels that the nausea may have been from her morphine. Otherwise she recounts the history as above. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - chronic hep B infection - biliary colic s/p laparoscopyic cholecystectomy - hypertension - peptic ulcer disease - liver hemangiomas - renal cyst - plantar fasciitis - Alopecia areata Social History: ___ Family History: - Mother Living ___ BREAST CANCER - Father ___ ___ HYPERTENSION, DIABETES TYPE II, STROKE - Brother Living ___ HYPERTENSION - Aunt Deceased ___ PANCREATIC CANCER Physical Exam: VITALS: T 97.9, HR 68, BP 109/73, RR 18, 98% RA GENERAL: Alert and in no apparent distress, appearing in pain EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Hypoactive bowel sounds. Abdomen soft, non-distended, moderately tender to palpation in epigastric area. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM: 98.2 127/___ GEN: female in NAD HEENT: MMM, no scleral icterus CV: RRR no m/r/g RESP: CTAB no w.r ABD: soft, NT, ND, NABS GU: no foley EXTR: warm, no edema NEURO: alert, appropriately, moving all extremities PSYCH: calm, pleasant affect Pertinent Results: ___ 07:25PM BLOOD WBC-6.6 RBC-4.53 Hgb-13.8 Hct-42.6 MCV-94 MCH-30.5 MCHC-32.4 RDW-12.8 RDWSD-44.4 Plt ___ ___ 07:30AM BLOOD WBC-5.4 RBC-4.48 Hgb-13.7 Hct-42.3 MCV-94 MCH-30.6 MCHC-32.4 RDW-12.6 RDWSD-43.8 Plt ___ ___ 07:25PM BLOOD Glucose-80 UreaN-13 Creat-0.7 Na-143 K-4.2 Cl-107 HCO3-19* AnGap-17 ___ 07:30AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-146 K-3.8 Cl-107 HCO3-27 AnGap-12 ___ 07:25PM BLOOD ALT-393* AST-405* AlkPhos-176* TotBili-1.3 ___ 12:53PM BLOOD ALT-574* AST-425* AlkPhos-207* TotBili-2.5* ___ 06:32AM BLOOD ALT-408* AST-174* AlkPhos-191* TotBili-0.9 ___ 07:30AM BLOOD ALT-283* AST-69* AlkPhos-174* TotBili-0.5 RUQ US ___: 1. Mild intrahepatic biliary ductal dilation in this patient post cholecystectomy. No definite evidence for a retained obstructing duct stone. 2. Echogenic foci within the right kidney, similar to prior likely representing angiomyolipomas. 3. Hepatic hemangioma again noted. RUQ U/s ___ile duct is seen to measure up to 10 mm, likely slightly increased as it was previously seen to measure up to 7 mm. No retained stone is seen in the visualized portion of the duct. MRCP: Mild dilation of the extrahepatic bile duct with focal caliber change in the distal CBD near the ampulla, without definite evidence of an obstructing stone or lesion. Further evaluation with EUS/ERCP is recommended. Urine Cx negative for growth Cdiff PCR negative Stool Culture pending at the time of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Vitamin D ___ UNIT PO DAILY 3. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg intrauterine continuous Discharge Medications: 1. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg intrauterine continuous 2. Vitamin D ___ UNIT PO DAILY 3. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you are seen by your primary care physician ___: Home Discharge Diagnosis: Biliary obstruction Possible Common bile duct abnormality Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRCP INDICATION: ___ year old woman with PMH cholecystectomy, chronic hep B, presenting with worsening abdominal pain with ultrasound showing dilated CBD. ERCP team requesting MRCP// eval for cause of CBD dilation TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Abdominal ultrasound ___ FINDINGS: Lower Thorax: There are trace bilateral pleural effusions. Liver: Liver demonstrates homogeneous signal intensity throughout, without significant drop in signal on opposed phase imaging to suggest hepatic steatosis. In segment 5, there is a 19 mm T2 hyperintense lesion demonstrating mild internal enhancement, which likely represents a hemangioma (04:20). A small cyst is seen along the periphery of segment 4 (04:22), and in segment 7 (4:29). No suspicious hepatic lesion. Biliary: Gallbladder is surgically absent. The extrahepatic bile duct is slightly prominent, measuring up to 7 mm. However, there is focal caliber change at the distal CBD close to the ampulla, where there is suggestion of a T2 hypointense filling defect (03:20, 8:1). However, this would be atypical in appearance for a stone. No evidence of differential enhancement or definite obstructing lesion identified. The central intrahepatic bile ducts are mildly prominent. The right posterior duct drains into the left hepatic duct, a normal variant. Pancreas: There is normal intrinsic T1 hyperintense signal throughout the pancreas. No focal parenchymal lesions or ductal dilation. Spleen: Spleen is normal in size, without focal lesions. Adrenal Glands: Normal in size and shape. Kidneys: Kidneys are normal in size and shape. No solid parenchymal lesions are identified. There is no hydronephrosis. Gastrointestinal Tract: Stomach is unremarkable. There is no bowel obstruction or ascites. Lymph Nodes: Retroperitoneal and mesenteric lymph nodes are not enlarged by size criteria. Vasculature: Abdominal aorta is not aneurysmal. Celiac artery, superior mesenteric artery, and bilateral renal arteries are patent. Osseous and Soft Tissue Structures: There is a T1 hyperintense lesion along the superior endplate of T11, which may represent focal fat or a hemangioma. IMPRESSION: Mild dilation of the extrahepatic bile duct with focal caliber change in the distal CBD near the ampulla, without definite evidence of an obstructing stone or lesion. Further evaluation with EUS/ERCP is recommended. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Epigastric pain temperature: 97.9 heartrate: 65.0 resprate: 16.0 o2sat: 100.0 sbp: 123.0 dbp: 81.0 level of pain: 5 level of acuity: 3.0

You were admitted with abdominal pain, nausea, vomiting and abnormal liver function tests. You underwent imaging of the biliary tree with MRCP that shows possible blockage at the distal common bile duct. You have been evaluated by the ERCP and have been advanced a diet without any recurrent symptoms. The liver function tests are rapidly improving and the ERCP/GI team will be reviewing all your information at the multidisciplinary conference tomorrow evening. They will be contacting you in the following days to help coordinate a follow up procedure to further evaluate this finding. You should continue on a low fat diet and monitor for any recurrent symptoms of abdominal pain, nausea, vomiting or fevers. Please returns for urgent evaluation if these occur. We have been holding your Lisinopril due to mild dehydration on admission. Please do not restart it until you are seen by your primary care physician. Best wishes from your team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Nausea, Vomiting, Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o firefighter with Crohns disease managed with mesalamine and mercaptopurine, and multiple SBOS in the past year, who presents to the ED with ~20 hours of abdominal distension, nausea, and vomiting. He has had multiple episodes of brown-green emesis, decreased flatus, and no bowel movements since yesterday. He denies any fevers/chills. He has been found on colonoscopy and CT to have primary TI disease, and was scheduled for a right colectomy with Dr. ___ on ___. We are consulted to assist in the management of recurrent SBO. Past Medical History: 1. Crohns Disease- diagnosed ___. -S/P end sigmoid colostomy at OSH in ___ due to LLQ abscess. -S/P sigmoid colectomy with reversal of colostomy and end-end anatamosis ___ at ___ -Last colonoscopy ___ of Crohns inflammation at 30 cm (chronic inactive crohns) and at 60 cm (focal active colitis) from anus 2. Rectal polyp ___. Colonic polyp ___ adenomatous with low-grade dysplasie. 4. Esophageal ring on EGD- ___ ?Hep A 6. s/p multiple hernia repairs 7. s/p cholecystectomy ___. Right patellar bone ___ likely secondary to steroids Social History: ___ Family History: F: died at ___ of emphysema. Aunt with colon ___. No IBD in family. Physical Exam: VSS General: NAD HEENT: NCAT OP Clear MMM CV: rrr s1s2 no mrg Resp: CTAB Abd: obese, soft, ntnd +BS, no organomegaly Ext: wwp no c/c/e Pertinent Results: HISTORY: Abdominal pain with history of Crohn's and small-bowel obstructions. COMPARISON: AXR ___, CT ___. FINDINGS: Supine and upright views of the abdomen were obtained. There is dilation of small bowel to 6.5 cm in the left hemiabdomen. There is no free air under the diaphragm. Cholecystectomy clips and clips projecting over the right hemiabdomen are in place. No acute osseous abnormality is identified. IMPRESSION: Findings consistent with small bowel obstruction. No definite free air. Findings discussed with Dr. ___ (___) by phone at 9:30pm on ___. The study and the report were reviewed by the staff radiologist. ___ 05:55AM BLOOD WBC-10.8# RBC-4.54* Hgb-13.9*# Hct-41.0# MCV-90 MCH-30.6 MCHC-33.8 RDW-14.8 Plt ___ ___ 08:40PM BLOOD WBC-23.4*# RBC-5.64 Hgb-17.3 Hct-51.4 MCV-91 MCH-30.7 MCHC-33.7 RDW-14.1 Plt ___ ___ 08:40PM BLOOD Neuts-89.8* Lymphs-5.2* Monos-4.2 Eos-0.4 Baso-0.4 ___ 05:55AM BLOOD Plt ___ ___ 08:40PM BLOOD Plt ___ ___ 08:40PM BLOOD ___ PTT-31.7 ___ ___ 07:00AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-139 K-4.1 Cl-104 HCO3-26 AnGap-13 ___ 05:55AM BLOOD Glucose-104* UreaN-35* Creat-0.9 Na-139 K-3.9 Cl-102 HCO3-27 AnGap-14 ___ 08:40PM BLOOD Glucose-154* UreaN-41* Creat-1.2 Na-137 K-4.5 Cl-95* HCO3-25 AnGap-22* ___ 05:55AM BLOOD ALT-41* AST-21 AlkPhos-59 TotBili-1.8* ___ 07:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 ___ 05:55AM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.7 Mg-1.9 ___ 08:40PM BLOOD Albumin-5.0 Calcium-10.1 Phos-4.6*# Mg-2.2 ___ 08:44PM BLOOD Lactate-2.1* Medications on Admission: Amlodipine 2.5', Lisinopril-HCTZ ___, Pentasa ___, Vitamin D, ASA 81', Mercaptopurine 75', Pantoprazole 40' Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 4. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Mercaptopurine 75 mg PO DAILY 8. Mesalamine 500 mg PO QID 9. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*15 Tablet Refills:*0 10. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Abdominal pain with history of Crohn's and small-bowel obstructions. COMPARISON: AXR ___, CT ___. FINDINGS: Supine and upright views of the abdomen were obtained. There is dilation of small bowel to 6.5 cm in the left hemiabdomen. There is no free air under the diaphragm. Cholecystectomy clips and clips projecting over the right hemiabdomen are in place. No acute osseous abnormality is identified. IMPRESSION: Findings consistent with small bowel obstruction. No definite free air. Findings discussed with Dr. ___ (ACS) by phone at 9:30pm on ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ABDOMINAL PAIN Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.3 heartrate: 108.0 resprate: 16.0 o2sat: 96.0 sbp: 123.0 dbp: 80.0 level of pain: 4 level of acuity: 3.0

Mr. ___, You were admitted to the ___ Department of Colorectal Surgery for a small bowel obstruction. You received a nasogastric tube, which allowed your intestines to decompress, until your bowel function returned. Once your bowel function returned, your tube was removed. You were then progressed from sips to clear liquids to a regular diet at the time of discharge. Now that you are tolerating oral medication and food, you may now return home for the remainder of your recovery. Please pay close attention to your discharge instructions. *Medications* Please continue to take all medications as prescribed. *Diet* You may continue to eat a regular diet as tolerated. *Abdominal Pain/Danger Signs* If you notice any return of abdominal pain combined with nausea and vomiting or any of the "Danger Signs" listed below, please discontinue eating food and call your physician or go to your nearest emergency department for prompt evaluation. Good luck with the remainder of your recovery. We wish you the best.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / prednisone Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ PMH afib on warfarin, CKD, DM, CHF presents after falling. Pt was at ___ yesterday when he went to the bathroom, missed a step, and fell on his side. He has severe pain in his L hip. He is unsure if he hit his head. Not clear if this was a syncopal episode as the patient has baseline cognitive impariment and is a poor historian. He recalls being confused during this event. Per note in OMR, he has been confused and lightheaded recently. (Per OMR note) ___ for ___ called to report that she has been seeing the patient for the past 6 weeks and he has become increasing pale and disoriented. Pt is very dehydrated. He only drinks 2 cups of tea everyday. He refuses to drink water because he doesn't like it. Today when he checked in for his appt. he became extremely disoriented and wandered off and got lost. He ended up falling. EMTs on-site checked him out and his vitals were stable. Wife took him home. ___ thinks ___ should see him or speak to him about the importance of drinking fluids. In the ED, initial vital signs were 0 98.8 78 158/78 20 99% 2L Nasal Cannula. In ED, EKG showed afib with normal ventricular response. CXR was negative. UA was negative. CT head, C-spine, and pevlis were prelim neg for fracture or acute injury. Patient was given morphine, zofran. Pt did not ambulate well, so was admitted. On the floor, T98.6 148/82 hr 84 rr 20 93RA. Pt c/o nausea and SOB. Denies chest pain, back pain, lower ext pain, dysuria, abd pain, diarrhea. has chr constipation Review of Systems: (+) (-) Past Medical History: CHF, (EF 54%) with 3+ TR, and ___ MR ___ syncope with profound carotid sinus hypersensitivity DM chronic renal insufficiency Cr 1.7-1.9 Atrial fibrillation on warfarin and rate controlled s/p PPM in ___ with generator change in ___, which is a single chamber device. PFTs showed severe mixed obstructive and restrictive defect with long standing smoking history BPH polyneuropathy cognitive impairment ___ pain S/P PARTIAL GASTRECTOMY FOR ULCERS ___ Social History: ___ Family History: mother- died throat cancer age ___ father - died ___, alcohol abuse No history of immunologic disease or other cancers in family Physical Exam: ADMIT Vitals- 98.6 148/82 hr 84 rr 20 93RA General: NAD alert and oriented x3 HEENT: MMM CV: irregular rate nl s1 s2 Lungs: CTAb bibasilar rales no wheezes/rhonchu Abdomen: +BS soft nontender nondistended Ext: WWP Neuro: CN ___ intact. Upper extremities ___ strength in biceps/triceps. Lower extremities LLE hip flexion 0-1/5, left knee flexion ___, left dorsi/plantarflex ___ RLE ___ hip flexion, ___ right knee flex/extension, right dorsi/plantarflex ___. Skin: left thigh macular erythematous rash nontender, no e/o of left sided ecchymosis from fall. Left knee and left hadn ___ digit excoriations from fall DISCHARGE Vitals- 98.1 126/82 hr 74 rr 18 98RA ___ General: NAD alert and oriented x3 HEENT: MMM CV: irregular rate nl s1 s2 Lungs: CTAb bibasilar rales no wheezes/rhonchu Abdomen: +BS soft nontender nondistended Ext: WWP Neuro: CN ___ intact. Upper extremities ___ strength in biceps/triceps. Lower extremities LLE hip flexion 3+/5, left knee extension 3+/5, left dorsi/plantarflex ___ RLE ___ hip flexion, ___ right knee flex/extension, right dorsi/plantarflex ___. Skin: left thigh macular erythematous rash nontender, no e/o of left sided ecchymosis from fall. Left knee and left hadn ___ digit excoriations from fall Pertinent Results: ADMIT ======================== ___ 10:15AM BLOOD WBC-8.4# RBC-3.83* Hgb-10.2* Hct-32.6* MCV-85 MCH-26.7* MCHC-31.3 RDW-16.3* Plt ___ ___ 10:15AM BLOOD Neuts-74.4* Lymphs-17.0* Monos-5.9 Eos-2.1 Baso-0.6 ___ 08:50AM BLOOD ___ ___ 10:15AM BLOOD ___ PTT-36.0 ___ ___ 10:15AM BLOOD Glucose-123* UreaN-36* Creat-1.8* Na-135 K-4.3 Cl-102 HCO3-23 AnGap-14 ___ 07:40AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0 ___ 10:15AM BLOOD VitB12-GREATER TH DISCHARGE ========================== ___ 07:15AM BLOOD WBC-6.5 RBC-3.65* Hgb-9.9* Hct-30.7* MCV-84 MCH-27.1 MCHC-32.3 RDW-16.4* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD ___ PTT-34.0 ___ ___ 07:15AM BLOOD Glucose-109* UreaN-31* Creat-1.5* Na-135 K-4.3 Cl-104 HCO3-22 AnGap-13 ___ 07:15AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 IMAGING =========================== ___ CT C-SPINE without Con There is no evidence of fracture or acute malalignment in the cervical spine. Multilevel multifactorial degenerative changes are again noted with prominent anterior osteophyte formation, more extensive than on the most recent CT of the neck from ___, as well as persistent ossification of the posterior longitudinal ligament (OPLL) involving the C3-C4 through C7 levels with a similar degree of spinal canal narrowing, most significant at the C3-C4 level where the spinal canal narrowing is at least moderate, along with severe right neural foraminal narrowing due to facet arthropathy at the same level. No prevertebral soft tissue swelling is present. No lymphadenopathy is seen. The visualized lung apices are unremarkable. IMPRESSION: 1. No fracture or acute malalignment in the cervical spine. 2. Multilevel degenerative changes of the cervical spine, as described above resulting in at least moderate canal narrowing. ___ CT HEAD without Con There is no evidence of intracranial hemorrhage, edema, mass, mass effect or acute vascular territorial infarction. Persistent enlargement of the lateral and ___ ventricles is unchanged in extent since the prior study, and is disproportionate to the degree of sulcal prominence, reflecting either preferential central atrophy or communicating hydrocephalus. Periventricular white matter hypodensities are unchanged, and reflect chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of the gray-white matter differentiation. There is no fracture identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are essentially clear. The globes are intact bilaterally. There are no cranial or facial soft tissue abnormalities present. IMPRESSION: 1. No acute intracranial process. 2. Persistent ventriculomegaly, reflecting either preferential central atrophy or communicating hydrocephalus, is unchanged in extent since ___. ___ PELVIS AP IMPRESSION: Though there is no radiographic evidence for displaced fracture of the left hip, given the clinical history of inability to bear weight after sustaining a fall, an occult fracture cannot be completely excluded and further imaging is recommended if clinical suspicion for fracture exists. ___ HIP Unilat Min 2 Views Though there is no radiographic evidence for displaced fracture of the left hip, given the clinical history of inability to bear weight after sustaining a fall, an occult fracture cannot be completely excluded and further imaging is recommended if clinical suspicion for fracture exists. ___ CHEST Single supine view of the chest. Left chest wall single lead pacing device is again noted. The lungs are grossly clear noting some respiratory motion which limits detailed evaluation. Cardiomediastinal silhouette is unchanged with possible mild cardiomegaly. No definite displaced fracture identified. Surgical clips project over the upper abdomen. Likely posttraumatic changes seen at the distal right clavicle and degenerative changes at the right shoulder. IMPRESSION: No definite acute cardiopulmonary process. ___ CT PELVIS WITHOUT CON IMPRESSION: 1. No evidence of fracture or abnormal alignment of the left hip. 2. Degenerative changes of the bilateral femoroacetabular joints, sacroiliac joints and lumbar spine, as described above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Doxazosin 4 mg PO HS 3. Furosemide 20 mg PO DAILY 4. Warfarin 4 mg PO DAILY16 5. Cyanocobalamin 1000 mcg PO DAILY 6. Vitamin D Dose is Unknown PO DAILY 7. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rash on chest, groin, face 8. Ketoconazole 2% 1 Appl TP QAM face, chest, groin 9. sulfacetamide sodium *NF* 10 % Topical daily:prn face and chest 10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID body Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hypovolemia Orthostatis Shingles Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Pain status post fall with severe left hip pain. COMPARISON: Comparison is made to radiographs of the hips from ___ as well as ___. FINDINGS: There is no evidence of displaced fracture or abnormal alignment within the hip joints. The trabecular pattern of the bilateral femurs are normal. Osteophytes are present and degenerative changes are seen at the bilateral femoroacetabular joints. Spurring is present of the left superior acetabulum, as before. There is no diastases of the pubic symphysis and sacroiliac joints. Degenerative changes are again seen within the lower lumbar spine. IMPRESSION: Though there is no radiographic evidence for displaced fracture of the left hip, given the clinical history of inability to bear weight after sustaining a fall, an occult fracture cannot be completely excluded and further imaging is recommended if clinical suspicion for fracture exists. Radiology Report HISTORY: ___ male with fall and mid chest discomfort. COMPARISON: ___. FINDINGS: Single supine view of the chest. Left chest wall single lead pacing device is again noted. The lungs are grossly clear noting some respiratory motion which limits detailed evaluation. Cardiomediastinal silhouette is unchanged with possible mild cardiomegaly. No definite displaced fracture identified. Surgical clips project over the upper abdomen. Likely posttraumatic changes seen at the distal right clavicle and degenerative changes at the right shoulder. IMPRESSION: No definite acute cardiopulmonary process. Radiology Report HISTORY: Fall with mild headache. Patient on warfarin. Evaluation for acute injury. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of intravenous contrast. Reformatted coronal, sagittal and thin slice bone images were reviewed. COMPARISON: Comparison is made to CT of the head from ___ as well as CT of the head from ___. FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass, mass effect or acute vascular territorial infarction. Persistent enlargement of the lateral and ___ ventricles is unchanged in extent since the prior study, and is disproportionate to the degree of sulcal prominence, reflecting either preferential central atrophy or communicating hydrocephalus. Periventricular white matter hypodensities are unchanged, and reflect chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of the gray-white matter differentiation. There is no fracture identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are essentially clear. The globes are intact bilaterally. There are no cranial or facial soft tissue abnormalities present. IMPRESSION: 1. No acute intracranial process. 2. Persistent ventriculomegaly, reflecting either preferential central atrophy or communicating hydrocephalus, is unchanged in extent since ___. Radiology Report HISTORY: Fall with mild headaches. Evaluation for acute injury. TECHNIQUE: Axial helical MDCT images were obtained through the cervical spine without the use of intravenous contrast. Reformatted coronal and sagittal images were also reviewed. COMPARISON: Comparison is made to CT of the neck from ___ as well as CT of the cervical spine from ___. FINDINGS: There is no evidence of fracture or acute malalignment in the cervical spine. Multilevel multifactorial degenerative changes are again noted with prominent anterior osteophyte formation, more extensive than on the most recent CT of the neck from ___, as well as persistent ossification of the posterior longitudinal ligament (OPLL) involving the C3-C4 through C7 levels with a similar degree of spinal canal narrowing, most significant at the C3-C4 level where the spinal canal narrowing is at least moderate, along with severe right neural foraminal narrowing due to facet arthropathy at the same level. No prevertebral soft tissue swelling is present. No lymphadenopathy is seen. The visualized lung apices are unremarkable. IMPRESSION: 1. No fracture or acute malalignment in the cervical spine. 2. Multilevel degenerative changes of the cervical spine, as described above resulting in at least moderate canal narrowing. Radiology Report HISTORY: ___ male with left hip pain after fall. Evaluation for possible hip fracture. TECHNIQUE: MDCT images were obtained through the pelvis without the administration of oral or IV contrast. Reformatted coronal and sagittal images were also reviewed. COMPARISON: Comparison is made to radiographs of the left hip from ___ as well as ___. FINDINGS: There is no evidence of fracture or abnormal alignment. The bilateral femoral heads are well seated within the acetabulua bilaterally. There is no diastasis of the pubic symphysis or sacroiliac joints. Degenerative changes and fusion with osteophyte formation of the bilateral sacroiliac joints is present. There is redemonstration of spurring and subchondral sclerosis of the bilateral femoroacetabular joints, consistent with degenerative change. Enthesopathy of the right greater trochanter is again seen. No lytic or sclerotic lesions suspicious for malignancy is present. Additionally, degenerative changes are noted within the lumbar spine seen with anterior osteophyte formation at the L5 level. No significant soft tissue swelling is noted. The bladder is distended, and is unremarkable in appearance. Atherosclerotic calcifications are noted within the iliac arteries. The rectum and sigmoid appear unremarkable and hyperdense pill fragments are seen within the sigmoid. No pelvic sidewall or inguinal lymphadenopathy is present. IMPRESSION: 1. No evidence of fracture or abnormal alignment of the left hip. 2. Degenerative changes of the bilateral femoroacetabular joints, sacroiliac joints and lumbar spine, as described above. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with SYNCOPE AND COLLAPSE, HERPES ZOSTER NOS, HYPERTENSION NOS, CARDIAC PACEMAKER STATUS temperature: 98.8 heartrate: 78.0 resprate: 20.0 o2sat: 99.0 sbp: 158.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0

Dear ___ ___ were admitted after a fall that caused ___ to have left leg pain and inability to walk because of the pain. Imaging of your head / left hip / pelvis did not show any acute injury from your recent fall. We gave ___ tylenol to control your pain, and ___ worked with ___ to improve your ambulation, which ___ did. . It is very important that ___ try to drink more water by mouth, because ___ were lightheaded when ___ came to the hospital because ___ were not drinking enough water. . ___ also are having pain from your shingles on your left leg. ___ can take tylenol for this pain.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amoxicillin Attending: ___. Chief Complaint: Gastroenteritis, Transaminitis, Hemolysis Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old Male who presents with 8 days of fevers to 102, nausea/vomitting, hemolysis and transaminitis. The patient is at baseline healthy, when 8 days prior to admission he notes lethargy, nasuea and vomitting. He was at college, and went to the ___ health ___, who performed a liver scan which was reportedly normal. He continued with his symptoms, after returning home for ___. He denies knowing others with the same symptoms. He also describes headaches, palpitations and sore throat along with the other symptoms. He notes that several days prior to admission his urine became darkly colored. He came to the ___ ED on ___ where he was noted with splenomegally on imaging and transaminitis. An LP was negative and a rapid strep test was also negative. He was discharged with a presumed diagnosis of mononucleosis. He returned on ___ with continue nausea and vomitting and fevers. He was noted in the ED with fevers to 102. He was agressively hydrated, along with IV antiemetics with good result. He reports some improvement in his symptoms. Past Medical History: Kidney surgery as child for repair of congenital defect in the collecting system Social History: ___ Family History: No liver or hematologic diseases Physical Exam: ROS: GEN: + fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding, + Sore Throat CARDIAC: - Chest Pain, - Palpitations, - Edema GI: + Nausea, + Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 102.9, 106/55, 107, 18, 97% GEN: NAD Pain: ___ HEENT: EOMI, MMM, Kissing Tonsils PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Non-Focal Pertinent Results: ___ 05:38AM BLOOD WBC-5.1 RBC-3.74* Hgb-11.8* Hct-32.5* MCV-87 MCH-31.5 MCHC-36.3* RDW-13.5 Plt ___ ___ 06:45AM BLOOD WBC-5.4 RBC-4.06* Hgb-12.5* Hct-35.1* MCV-86 MCH-30.7 MCHC-35.5* RDW-13.4 Plt ___ ___ 05:40AM BLOOD WBC-6.5 RBC-4.18* Hgb-12.9* Hct-35.9* MCV-86 MCH-30.8 MCHC-35.8* RDW-13.2 Plt ___ ___ 05:38AM BLOOD Neuts-34* Bands-0 ___ Monos-13* Eos-0 Baso-0 Atyps-14* ___ Myelos-0 ___ 06:45AM BLOOD Neuts-62 Bands-0 ___ Monos-7 Eos-1 Baso-0 ___ Myelos-0 ___:40AM BLOOD Neuts-53 Bands-3 ___ Monos-10 Eos-0 Baso-0 Atyps-10* Metas-1* Myelos-0 ___ 05:38AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ ___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:38AM BLOOD ___ PTT-39.2* ___ ___ 06:00AM BLOOD ___ PTT-38.1* ___ ___ 05:38AM BLOOD ___ 06:45AM BLOOD Parst S-NEGATIVE ___ 05:38AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-135 K-3.5 Cl-102 HCO3-22 AnGap-15 ___ 06:45AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-135 K-3.5 Cl-99 HCO3-25 AnGap-15 ___ 05:38AM BLOOD ALT-244* AST-254* LD(LDH)-805* AlkPhos-51 TotBili-3.3* ___ 06:45AM BLOOD ALT-180* AST-170* LD(___)-708* AlkPhos-50 TotBili-2.6* DirBili-1.3* IndBili-1.3 ___ 05:40AM BLOOD ALT-121* AST-145* AlkPhos-48 TotBili-1.7* ___ 05:38AM BLOOD Albumin-3.5 Calcium-8.0* Phos-1.7* Mg-1.9 ___ 06:45AM BLOOD Albumin-3.9 ___ 05:40AM BLOOD Albumin-4.3 Calcium-9.0 Phos-2.9 Mg-1.9 ___ 06:45AM BLOOD Hapto-<5* ___ 06:45AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND IgM HAV-PND ___ 07:06AM BLOOD Lactate-1.3 ___ 05:10PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND ___ 02:23PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM-PND ___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG ___ 02:00PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 ___ 07:18AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0 ___ Macroph-40 ___ 07:18AM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-58 Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm Blood (EBV) ___ VIRUS VCA-IgG AB (Pending): ___ VIRUS EBNA IgG AB (Pending): ___ VIRUS VCA-IgM AB (Pending): Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm Blood (CMV AB) CMV IgG ANTIBODY (Pending): CMV IgM ANTIBODY (Pending): Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Pending): Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm SEROLOGY/BLOOD LYME SEROLOGY (Pending): ___ 2:00 pm URINE **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). ___ 5:57 am SEROLOGY/BLOOD ADDED FROM ___ ON ___ AT 09:02. **FINAL REPORT ___ MONOSPOT (Final ___: NEGATIVE by Latex Agglutination. (Reference Range-Negative). LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 7:27 AM IMPRESSION: 1. Trace sludge within an otherwise unremarkable gallbladder without evidence of cholecystitis. 2. Prominent splenomegaly of unclear etiology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. OSELTAMivir 75 mg PO Q12H Duration: 5 Days RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary: EBV mono, low grade DIC, hepatitis, flu Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH INDICATION: Cough, questionable pneumonia. COMPARISON: No comparison available at the time of dictation. FINDINGS: A single portable view is provided. Normal lung volumes. Azygos lobe as anatomical variant. Normal size of the cardiac silhouette. No pleural effusions. No pulmonary edema. No pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: NAUSEA/VOMITING Diagnosed with FEVER, UNSPECIFIED, HEADACHE temperature: 100.1 heartrate: 119.0 resprate: 22.0 o2sat: 97.0 sbp: 104.0 dbp: 51.0 level of pain: 0 level of acuity: 3.0

Dear ___, It has been a pleasure taking care of you in the hospital. You were admitted for fevers, nausea, and vomiting. You had a workup and were found to have EBV mono (EBV is a common virus that causes mono) and the flu. You were treated with intravenous fluids and anti-emetics. You had hepatitis which means inflammation of the liver from the virus. You were seen by infectious disease doctors and ___ team as well. You continued to improve. It is important you not play contact sports for 3 months so you dont get a splenic rupture because you have an enlarged spleen from the mono. You were also started on tamiflu for the flu.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Erythromycin Base / Amoxicillin / clindamycin Attending: ___. Chief Complaint: difficulty writing Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ F w PMHx of HLD, depression, and rheumatoid arthritis who presents to ___ ED after sudden onset of difficulty writing and visual disturbance - her symptoms resolved within ~1 hour. A code stroke was called upon arrival. Ms. ___ has significant difficulty in recalling the events prior to her admission, so much of the history is supplied by her partner, ___. They both agree that Ms. ___ was "exhausted" today, more so than normal. They were at a camera shop around 3:30PM when Ms. ___ tried to write a check to pay for their items. She found she had great difficulty writing and her handwriting was extremely messy. She was able to grip the pen and did not feel weak, persay, though her hand "wasn't doing what I wanted it to." With some effort, she was able to write the check and the clerk was able to read it. She and ___ got in the car to drive to Ms. ___ previously scheduled doctor's appointment. ___ was driving. About 5 minutes after leaving the store, Ms. ___ began to complain of a mild left sided headache and associated blurry vision on her right side. She did not cover one eye to see if the blurry vision was monocular or binocular. At her doctor's appointment today, Ms. ___ recounted the story to the physician who did ___ screening examination for stroke. Ms. ___ deficits had apparently resolved, but the physician referred Ms. ___ to ___ "to get an MRI." Currently, Ms. ___ states that her headache and blurry vision have resolved - she estimates that they lasted ~1 hour. Her handwriting is also back to her baseline and she does not endorse any difficulty controlling the right hand. She denies any associated weakness, numbness, difficulty speaking or comprehending speech. Notably, Ms. ___ has been suffering from "severe exhaustion" for at least the past week. Her partner and her friends having been concerned about her and urged her to make the above doctor's appointment. Ms. ___ partner also states that Ms. ___ memory has been quite poor for sometime - though she believes it was worse today. Ms. ___ reports a similar event ___ years ago. She was admitted to ___ with the presenting complaint of transient total vision loss. She is unsure if she was diagnosed with a TIA. When it was time for her to be discharged, she was "completely unable" to sign her name on the discharge sheet. The event differs from her current event because at that time she was unable to write any words down at all. It is unclear what additional work-up was done at that time. Ms. ___ also reports a long standing problem with memory. She has been evaluated several times due to concern for Alzheimer's disease. She tells me that several years ago she was evaluated by a neurologist and told that her symptoms were not consistent with Alzheimer's disease. Past Medical History: - HLD - depression - rheumatoid arthritis - vitamin D deficiency - GERD - sleep apnea on CPAP - prior ASD repair x2 - ?TIA for visual loss ___ years ago, seen at ___ Social History: ___ Family History: Father - ___ Mother - ___ Disease Physical Exam: ADMISSION PHYSICAL EXAM: VS T97.9 HR64 BP110/70 RR18 Sat97%RA GEN - obese female, pleasant and cooperative, NAD HEENT - NC/AT, MMM NECK - supple, good ROM CV - RRR RESP - normal WOB ABD - obese, soft, NT, ND EXTR - warm and well perfused ___ Stroke Scale - Total [0] 1a. Level of Consciousness - 0 1b. LOC Questions - 0 1c. LOC Commands - 0 2. Best Gaze - 0 3. Visual Fields - 0 4. Facial Palsy - 0 5a. Motor arm, left - 0 5b. Motor arm, right - 0 6a. Motor leg, left - 0 6b. Motor leg, right - 0 7. Limb Ataxia - 0 8. Sensory - 0 9. Language - 0 10. Dysarthria - 0 11. Extinction and Neglect - 0 NEUROLOGICAL EXAMINATION: MS - awake and alert; oriented to self, place, and date (says ___ or ___ able to recite MOYB slowly but accurately; great difficulty recounting recent medical history, is vague in supplying details and ask partner for help with answer many simple questions; speech is otherwise fluent, with intact naming, reading, and comprehension; she is able to write a full sentence and believes the handwriting appears completely normal; there is no dysarthria; no evidence of apraxia or neglect CN - [II] PERRL 4->2 brisk. VF full to number counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] There is very mild R eye ptosis vs redundant skin, though her partner states that she has not noticed this before; symmetric activation. [VIII] Hearing intact to voice. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline with full ROM. MOTOR - Normal bulk and tone; No pronation, no drift - though she is unable to fully supinate the RUE d/t long standing orthopedic injury. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 SENSORY - No deficits to light touch or pinprick throughout. REFLEXES - [Bic] [Tri] [___] [Quad] [Gastroc] L 1 1 1 1 0 R 1 1 1 1 0 Plantar response mute bilaterally. COORD - No dysmetria on FNF bilaterally; good speed and intact cadence with rapid alternating movements. GAIT - Normal initiation, narrow base; normal stride length and arm sway. ======================================= DISCHARGE PHYSICAL EXAM: Tm 97.8 ___ 53-57 20 99% RA Alert, interactive, speech fluent, no dysarthria. Able to recall events of admission but trouble remembering the details surrounding her headache and vision changes. Able to say the months of the year backwards. Able to calculate $1.75 is 7 quarters. Registers ___ objects, recalls ___ at 5 minutes and ___ with prompting. No graphesthesia. CN: EOMI, no nystagmus, VFF, smile symmetric Motor: ___ Reflexes: 2 in all but achilles which is 1, symmetric Toes down No dysmetria on FNF Pertinent Results: ADMISSION LABS: ___ 08:00PM BLOOD WBC-7.0 RBC-4.71 Hgb-14.0 Hct-43.1 MCV-92 MCH-29.7 MCHC-32.5 RDW-13.3 RDWSD-45.1 Plt ___ ___ 08:00PM BLOOD Neuts-80.3* Lymphs-12.2* Monos-5.3 Eos-0.6* Baso-0.6 Im ___ AbsNeut-5.62 AbsLymp-0.85* AbsMono-0.37 AbsEos-0.04 AbsBaso-0.04 ___ 08:00PM BLOOD ___ PTT-32.3 ___ ___ 08:00PM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-139 K-4.9 Cl-104 HCO3-26 AnGap-14 ___ 08:00PM BLOOD ALT-17 AST-20 AlkPhos-56 TotBili-0.3 ___ 08:00PM BLOOD cTropnT-<0.01 ___ 05:26AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:00PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.6 Mg-2.1 ___ 05:26AM BLOOD VitB12-PND Folate-PND ___ 08:17PM BLOOD %HbA1c-6.5* eAG-140* ___ 05:26AM BLOOD Triglyc-132 HDL-67 CHOL/HD-2.7 LDLcalc-91 ___ 08:00PM BLOOD TSH-0.67 ___ 08:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CT HEAD ___: 1. No acute intracranial process. CXR ___: No acute cardiopulmonary process. No significant interval change. CTA HEAD AND NECK ___: 1. Normal head and neck CTA. 2. No acute intracranial abnormality. 3. Interval increase in the size of bilateral thyroid nodules. Further evaluation with ultrasound of the thyroid can be performed. TTE ___: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 60%). The right ventricular free wall thickness is normal. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. MRI BRAIN (PRELIM) ___: 1. No evidence of infarction. 2. Similar appearance of non-specific periventricular and subcortical white matter T2/FLAIR hyperintensities, suggestive of chronic small vessel ischemic changes. 3. Unchanged appearance of punctate foci of GRE susceptibility in the right frontal white matter, which may represent vessels or a sequela or prior hemorrhage. DISCHARGE LABS: NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm 3. Furosemide 40 mg PO DAILY:PRN peripheral edema 4. Lorazepam 0.5 mg PO DAILY:PRN anxiety 5. Escitalopram Oxalate 20 mg PO DAILY 6. PredniSONE 15 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 9. Zolpidem Tartrate 5 mg PO QHS:PRN anxiety Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Escitalopram Oxalate 20 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. PredniSONE 15 mg PO DAILY 5. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm 8. Furosemide 40 mg PO DAILY:PRN peripheral edema 9. Lorazepam 0.5 mg PO DAILY:PRN anxiety 10. Zolpidem Tartrate 5 mg PO QHS:PRN anxiety Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Possible TIA Secondary diagnosis: Hyperlipidemia Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ED CODE STROKE ONLY CT Q13 CT HEAD INDICATION: History: ___ with acute onset inability to write, vison change // eval for infarct TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformats were also examined. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 55.8 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: Head CT ___. FINDINGS: There is no evidence of acute intracranial hemorrhage, midline shift, mass effect, or acute large vascular territorial infarct. Ventricles and sulci are mildly prominent, suggestive of age-related involutional changes. Gray-white differentiation is preserved. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with acute onset difficulty writing, eval for infarct. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: This study involved 4 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 81.7 mGy (Head) DLP = 40.8 mGy-cm. 4) Spiral Acquisition 5.5 s, 42.9 cm; CTDIvol = 35.4 mGy (Head) DLP = 1,518.0 mGy-cm. Total DLP (Head) = 1,559 mGy-cm. COMPARISON: Head CT from ___, MR MRA of the brain from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs are clear. The thyroid gland is enlarged with hypointense nodule in the left lobe measuring 2.7 x 2.6 cm and in the right lobe measuring 2.7 x 2 cm. These nodules have increased in size compared to the prior CT chest from ___. Further evaluation with ultrasound of the thyroid should be performed. Mild degenerative changes involving the visualized cervical spine. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Normal head and neck CTA. 2. No acute intracranial abnormality. 3. Interval increase in the size of bilateral thyroid nodules. Further evaluation with ultrasound of the thyroid can be performed. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with difficulty writing and visual disturbance // TIA eval TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___ head/neck CTA. ___ head/neck MRA, and brain MRI FINDINGS: The study is motion degraded. Within these confines: There is no evidence of edema, masses, mass effect, midline shift or infarction. Again noted are two small foci of T2/FLAIR periventricular and subcortical white matter hyperintensities in the left parietal region (12:15), which is similar in appearance compared to the ___ MRI, and may represent chronic small vessel ischemic changes. Additional note is made of two punctate foci of GRE susceptibility in the deep white matter of the right frontal lobe (11:18, 19) that may represent vessels or a sequela of prior hemorrhage, but also unchanged from ___. Previously mentioned tiny T2 hyperintense/T1 hypointense focus in the left cerebellum may represent prominent perivascular space versus prior lacunar infarct (13:3, 12:3). Ventricles and sulci are prominent, suggestive of age-related involutional changes. Major intracranial vascular flow voids are preserved. Minimal mucosal thickening in the ethmoid air cells bilaterally. Remainder of the visualized paranasal sinuses are well aerated. Trace fluid signal is seen in the right mastoid tip (13:6). Left mastoid air cells are clear. Orbits are unremarkable. IMPRESSION: 1. No evidence of infarction. 2. Similar appearance of non-specific periventricular and subcortical white matter T2/FLAIR hyperintensities, suggestive of chronic small vessel ischemic changes. 3. Unchanged appearance of punctate foci of GRE susceptibility in the right frontal white matter, which may represent vessels or a sequela or prior hemorrhage. Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with ams // eval for infection TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy. Cardiac and mediastinal silhouettes are stable. Left mid lung with linear atelectasis/scarring is stable. No focal consolidation is seen. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. No significant interval change. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: CODE STROKE Diagnosed with OTHER MALAISE AND FATIGUE, VISUAL DISTURBANCES NEC, HEADACHE temperature: 97.9 heartrate: 64.0 resprate: 18.0 o2sat: 97.0 sbp: 110.0 dbp: 70.0 level of pain: 0 level of acuity: 1.0

Dear Ms. ___, You were admitted to ___ with difficulty writing and concern for stroke. You had a CT and MRI which did not show any stroke but your story is concerning for a possible transient ischemic attack or TIA. You were started on aspirin. You had an ultrasound of your heart which did not show any evidence of clot. You will need a wear a heart monitor to look for evidence of atrial fibrillation which may have caused your symptoms. Please call ___ and ask to be transferred to the cardiology Holter monitor lab. Then you can pick up the ___ of Hearts monitor at the hospital. You will follow-up with Dr. ___ at the appointment scheduled below. It was a pleasure taking care of you, Your ___ Neurologists

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: epinephrine / Codeine / Zoloft Attending: ___. Chief Complaint: episodes of heart racing and palpitations followed by unresponsiveness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year-old right-handed woman with a past medical history of migraines, renal stones and possible POTS (postural orthostatic tachycardia syndrome) who was admitted for recurrent episodes of loss of consciousness. This history is obtained from discussion with the patient and data from ___. Other records are not available for review. She reports that she was previously healthy until ___. At that time she developed an obstructing kidney stone. The stone was removed and a stent was placed. Immediately following the procedure, Ms. ___ developed symptoms of her heart racing every time she would stand up. She called her urologist who instructed her to "take it easy" for a couple of weeks, however her symptoms persisted. Her symptoms were and have remained very stereotyped. Within a few minutes of standing, she develops a sensation that her heart is racing. She has measured her HR in the past and states that once the HR is > 120 bpm, she feels palpitations. She will also experience a sensation of chest pressure and shortness of breath "like I just ran up a mountain". She will then feel "tingling and numbness" in her hands and feet symmetrically followed by "tingling" starting at the base of her neck. These facial paresthesias will rapidly spread up to her mouth at which point she will be unable to speak. She will bit her lip frequently voluntarily but will be unable to produce sounds. She remains able to hear others speaking to her. The tingling will then spread to her nose at which point she becomes unresponsive. The duration of the unresponsiveness may range from 5 minutes to 45 minutes. She has not had abnormal limb movements, gaze deviation, incontinence or tongue biting in the past. She states that at the rehab facility, they have tried to revive her using pain, cold, laying her flat, and using ammonia all without effect. When she regains consciousness, she is confused only for less than a minute at most and is then aware of her surroundings. In the more recent months, she has begun to have "low oxygen" during the episodes, although this has not been a problem in the past. There was no other prodrome, exposure, illness or other precipitating factor aside from the renal stone removal and stenting. Of note, she had a prior renal stone about ___ years ago which was removed without sequelae. Triggers: standing, exercise, washing her hair (although she is not certain if this is due to the prolonged standing in the shower). She does not feel that hot environments or eating trigger symptoms. Ms. ___ has experienced these episodes from sitting in the past as well. Alleviating factors: lying down, her current medication regimen (Florinef, midodrine, metoprolol and pyridostigmine). She does not recall the sequence of these medication trials and believes that they were started sequentially. She states that did not recall feeling any improvement until the entire regimen was initiated. With this regimen, she has been able to stand up for a longer duration without developing symptoms (max 8 minutes) Prior work-up: She states that she was admitted for EEG LTM in the past and several events were captured without any identified abnormality. She was evaluated by a cardiologist who did a tilt table test and diagnosed her with POTS. She also believes that she has had an echocardiogram which she believes was normal. She has not had any recent brain imaging, but believes that she may have had an MRI in the past when she developed migraines. Prior treatment: as above. She was also prescribed salt tablets and instructed to have 10 grams of sodium in her daily diet but has not done this. Associated symptoms: as above. Intermittent tunnel vision, this does not always occur with the episodes. She also feels that her legs feel tired at times. She denies feelings of anxiety or impending doom. During ANS testing on ___ Ms. ___ had one of her typical events. She became unresponsive to verbal stimuli during the tilt up portion of the test. Her BP remained elevated and she had a sinus tachycardia. After she was tilted down, her eye lids fluttered and there was resistance to eyelid opening. She did not respond to verbal or noxious stimulus. There was no gaze deviation. Pupils were dilated (5 mm) and her O2 sat was as low as 79% on RA but increased with Ambu bag. BG was 96. A code was called and the event lasted 5 minutes after which she began to respond to voice and was fully oriented. There was no abnormal limb movements, tongue laceration or incontinence. She was taken to the ED and then admitted for LTM. Past Medical History: - migraines starting after hysterectomy - s/p hysterectomy - s/p bladder suspension surgery - s/p kidney stone surgery with stenting - loss of consciousness after receiving "Novocaine and epinephrine" at the dentist x 2. She reports that she had received the injection of both medications and then used the bathroom after which she had LOC. EMS was called. She was told by the dentist that the LOC was likely secondary to the epinephrine. Social History: ___ Family History: -mother: HTN, HLD -father: ___, prostate CA -sister: anorexia, migraines Physical Exam: Vitals: R: 15 -Supine: 125/65 HR 60's -Standing after 4 minutes: (patient asymptomatic) BP 135/60 HR 70's General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no distal edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. CN I: not tested II,III: VFF to confrontation, pupils 5mm->2mm bilaterally III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical, symm forehead wrinkling VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline XI: SCM/trapezeii ___ bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone, no rigidity; no asterixis or myoclonus. No pronator drift. Delt Bi Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5 ___ 5 5 5 R 5 ___ 5 5 5 IP Quad ___ PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 ___ R 5 5 5 ___ Reflex: No clonus Bi Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L ___ 2 ___ Flexor R ___ 2 ___ Flexor -Sensory: No deficits to light touch Decreased pinprick and cold sensation up to bellow the knees bilaterally. Minimally decreased vibratory sense at the toes bilaterally. Normal proprioception throughout. No extinction to DSS. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: testing deferred given patient history -Romberg: absent DISCHARGE EXAM: unchanged, distal small fiber neuropathy in ___ Pertinent Results: ___ 01:40PM BLOOD WBC-6.6 RBC-4.70 Hgb-15.4 Hct-45.2 MCV-96 MCH-32.7* MCHC-34.0 RDW-12.8 Plt ___ ___ 01:40PM BLOOD Neuts-70.3* ___ Monos-4.0 Eos-1.2 Baso-0.7 ___ 06:00AM BLOOD ___ PTT-30.2 ___ ___ 01:40PM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-140 K-4.4 Cl-105 HCO3-22 AnGap-17 ___ 06:00AM BLOOD ALT-25 AST-20 LD(LDH)-123 CK(CPK)-53 AlkPhos-80 TotBili-0.7 ___ 06:00AM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.2 Mg-2.2 ___ 06:00AM BLOOD TSH-1.7 ___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CXR: No acute cardiopulmonary process. EKG: Sinus rhythm with non-specific repolarization abnormalities. No previous tracing available for comparison. EEG: This continuous video monitoring study captured two episodes of unresponsiveness preceded by typical presyncopal symptoms of palpitations, lightheadedness, tunnel vision, and difficulty speaking followed by loss of consciousness. Both of these events occurred while she was sitting and trying to get up from the commode. The EEG during these two episodes showed an alpha rhythm consistent with a normal waking background, and there was no electrographic evidence of seizures. However, the single channel EKG demonstrated significant sinus arrhythmia with large heart rate variations ranging between 66 bpm to 144 bpm. There were no clear epileptiform discharges or electrographic seizures. Additionally, prominent sinus arrhythmia could be seen at other times during wakefulness, at rest, with heart rates ranging between 60-120 bpm. These findings raise concern for a primary cardiac rhythm abnormality. MRI BRAIN with thin cuts through brainstem: 1. There is no evidence of acute intraparenchymal pathology. 2. Incidentally noted is a T1 hypo-, T2 hyper-intense nonenhancing lesion arising from the dorsal clivus and extending exophytically into the prepontine cistern which may represent an ecchordosis physaliphora at the dorsal wall of the clivus. This may be further evaluated with a sagittal CISS sequence and thin axial pre and post gad images and a CT of the skull base. Medications on Admission: - metoprolol 25mg BID - mestinon 30mg QID - fludrocortisone 0.2mg QHS - topamax 10mg QD - klonipin 0.5mg QHS - amitriptyline 20mg QD - estradiol 1 mg daily Discharge Medications: 1. Nadolol 40 mg PO DAILY hold if HR<60 or sBP<100 RX *nadolol 40 mg 1 (One) Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 2. Estradiol 1 mg PO DAILY RX *estradiol 1 mg 1 (One) Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Citalopram 10 mg PO DAILY Please stop taking if develope shortness of breath or hives RX *Celexa 10 mg 1 (One) Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*6 4. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: inappropriate sinus tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam normal except decreased sensation to temp and pin in gradient at distal lower extremities Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ female with syncope. FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear. There is no effusion or pneumothorax. Cardiomediastinal silhouette is normal. Osseous and soft tissue structures are unremarkable. Surgical clips in the right upper quadrant suggest prior cholecystectomy. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ woman with intermittent tachycardia and posturally mediated episodes of unresponsiveness. COMPARISON: None. TECHNIQUE: MRI of the head was obtained with and without contrast. Sagittal T1, axial T1, axial T2 star GRE, axial FLAIR, axial T2 images were obtained without the administration of contrast. Following the administration of contrast, axial T1 and sagittal MP-RAGE images were obtained. Diffusion-weighted and ADC maps were also generated and reviewed. FINDINGS: No evidence of acute intracranial hemorrhage, brain edema, mass effect, or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. There is no diffusion abnormality. There is no evidence of acute major vascular territory infarction. A FLAIR hyperintensity within the left periventricular white matter (series 7, image 15) is nonspecific. A T1 hypointense, T2 hyperintense nonenhancing lesion arising from the dorsal wall of the clivus and extending exophytically into the prepontine cyst (series 9, image 121) may represent ecchordosis physaliphora at the dorsal wall of the clivus. Bilateral mastoid air cells and visualized paranasal sinuses are clear. The orbits and conus are symmetric. IMPRESSION: 1. There is no evidence of acute intraparenchymal pathology. 2. Incidentally noted is a T1 hypo-, T2 hyper-intense nonenhancing lesion arising from the dorsal clivus and extending exophytically into the prepontine cistern which may represent an ecchordosis physaliphora at the dorsal wall of the clivus. This may be further evaluated with a sagittal CISS sequence and thin axial pre and post gad images and a CT of the skull base. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: LOC Diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC temperature: 98.8 heartrate: 92.0 resprate: 16.0 o2sat: 100.0 sbp: 157.0 dbp: 92.0 level of pain: 0 level of acuity: 2.0

You were admitted for episodes of unresponsiveness. You underwent an extensive neurologic, autonomic and cardiologic workup. Your MRI of the brain was normal. Your EEG was normal during the events, so seizures are very unlikely. Cardiology diagnosed you with inappropriate sinus tachycardia syndrome, and treated you with nadolol (a beta blocker) which helped your heart rate stay under control. You should be able to return to your regular activities, but increase your level of exertion slowly and stop if you experience symptoms of racing heart, palpitations, or any other abnormal symptoms.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: erythromycin base Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___ THORACENTESIS History of Present Illness: ___ F with a history of atrial fib on ___ with recent fall resulting in ___ in ___ complicated by rib fractures and right sided pleural effusion that required drainage presents with recurrent effusion and SOB. In terms of her pleural effusion, her daughter reports that it was first discovered by the patients cardiologist after Ms. ___ was complaining of shortness of breath. A CXR was done for further evaluation which revealed a pleural effusion. The pleural effusion, however, is noted on prior CXRs from ___ (unavaible in our system, only per reports in radiology reports). She was going to be evaluated by IP but then she suffered a ___ and her pleural effusion was managed as an inpatient (see below). She was last hospitalizated from ___ where she had a ___ and also underwent drainage of the known pleural effusion. She had an uncomplicated removal of 2.5 liters of exudative effusion (Tprot pleural fluid/Tprot serum >0.5). CT chest after drainage showed trapped lung with residual pneumothorax but no effusion. She was going to follow-up with IP as an outpatient for further management of her pleural effusion. The pleural effusion was thought to be secondary to trauma from rib fractures related to her fall. She presents from ___ today for increasing SOB. Her SOB was intermittent after her time post-discharge. She noted that it was worse when it was going to rain. She went her PCP on ___ for a follow-up visit where a CXR showed reaccumulation of right effusion. She became increasingly SOB with exertion the day prior to admission and SOB worse with lying flat so she went for evaluation at ___. She also described wheezing and cough. She was then transferred to ___ for further management. In the ED, initial vitals were: 97.8 85 170/111 18 98% Labs in the ED notable for WBC 4.9, Hg 12.1, Plts 106. Chem 7 with sodium 141, potassium 4.1, Cl 104, BUN 24, BUN 16, Cr 1.0, INR 1.3. On the floor, she reports feeling comfortable in bed in terms of her respiratory status. She does have a headache. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - traumatic small right-sided SDH and left parietal SAH - atrial fibrillation (off coumadin since ___ - silent L cerebellar CVA (seen on imaging, patient denies this) - hypertension - hyperlipidemia - osteoarthritis - L knee replacement - R hip replacement Social History: ___ Family History: Mother - CVA in her ___ Father - MI in his ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.8 ___ 94%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds over the right lung, CTA on the left CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: WWP, no edema Neuro: CN II-XII intact DISCHARGE PHYSICAL EXAM: Vitals: T: 97.9 BP:114/87 P:86 RR:18 O2stat:98%RA General: Alert, oriented, anxious, normal speech. HEENT: No JVD, no LAD Lungs: Right lung with crackles and diminished aeration at base, but much improved from ___. Left lung with crackles at the base. CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes or lesions Neuro: Alert & oriented, no focal neuro deficit, no facial assymetry, MSK: On hands bilaterally, there is ulnar deviation of the digits. No ulnar deviation at the wrists. ___ nodes; rare Heberdon's nodes. Hallux abducto valgus deformity of the feet bilaterally. Skin: No rash Pertinent Results: ADMISSION LABS: ___ 06:40PM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-141 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 ___ 06:40PM estGFR-Using this ___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8* BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34 AbsEos-0.57* AbsBaso-0.06 ___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8* BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34 AbsEos-0.57* AbsBaso-0.06 ___ 06:40PM PLT COUNT-279 ___ 06:40PM ___ PTT-32.3 ___ ___ 04:35PM URINE HOURS-RANDOM ___ 04:35PM URINE HOURS-RANDOM ___ 04:35PM URINE UHOLD-HOLD ___ 04:35PM URINE GR HOLD-HOLD ___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG PERTINENT RESULTS: PLEURAL FLUID STUDIES ___ 12:40PM PLEURAL WBC-460* RBC-1090* Polys-0 Lymphs-11* Monos-2* Eos-86* NRBC-2* Macro-1* ___ 12:40PM PLEURAL Hct,Fl-UNABLE TO ___ 12:40PM PLEURAL TotProt-3.1 Glucose-122 Creat-0.9 LD(LDH)-132 Amylase-27 Albumin-2.0 Cholest-51 ___ 12:40PM PLEURAL Misc-PRO BNP = DISCHARGE LABS: ___ 07:07AM BLOOD WBC-5.8 RBC-3.53* Hgb-11.9 Hct-37.1 MCV-105* MCH-33.7* MCHC-32.1 RDW-14.0 RDWSD-53.3* Plt ___ ___ 07:07AM BLOOD Plt ___ ___ 07:07AM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 IMAGING: ___ CXR FROM ___ HOSP: large right sided pleural effusion ___ CXR In comparison with the study of ___, there is little change in the pleural effusion extending upward to the midportion of the right lung with associated volume loss in the right lower and possibly right middle lobe. The left lung is essentially clear and there is no evidence of vascular congestion. ___ CXR Right pleural effusion is resolved. No pneumothorax Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. Apixaban 2.5 mg PO BID 3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID 2. Carvedilol 25 mg PO BID 3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. LaMOTrigine 50 mg PO QHS RX *lamotrigine 100 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 RX *lamotrigine 100 mg ___ tablet(s) by mouth twice/day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Pleural effusion 2. Possible partial temporal lobe seizures. SECONDARY DIAGNOSES: 1. Hypertension 2. Atrial fibrillation 3. Arthritis 4. H/o ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with known effusion // eval for any interval change in pleural effusion eval for any interval change in pleural effusion IMPRESSION: In comparison with the study of ___, there is little change in the pleural effusion extending upward to the midportion of the right lung with associated volume loss in the right lower and possibly right middle lobe. The left lung is essentially clear and there is no evidence of vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pleural effusion, now with increased SOB, sat's stable at 98 on 2L, please eval for growing effusion // please eval for growing effusion please eval for growing effusion COMPARISON: Prior chest radiographs ___. IMPRESSION: Moderate to large right pleural effusion is unchanged. No pneumothorax. Right lung base is obscured and substantially atelectatic. Apparent increase in cardiac silhouette size is due in part to adjacent pleural effusion. Left lung clear. Heart size normal. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with ___ year old woman on heparin drip, hx of sdh/sah, nwo with word finding difficulties, concern for tia vs stroke. // any head bleed or evidence of acute stroke? TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 5.6 s, 14.6 cm; CTDIvol = 53.8 mGy (Head) DLP = 785.0 mGy-cm. Total DLP (Head) = 785 mGy-cm. COMPARISON: ___ noncontrast CT head. FINDINGS: There is no evidence of major vascular territory infarction, new intracranial hemorrhage, edema, or mass. The ventricles and sulci are mildly prominent, suggestive of age-related involutional changes. Scattered periventricular white-matter hypodensities are present, consistent with chronic small vessel ischemic disease. There is evidence of mild encephalomalacia in the left posterior occipital, unchanged from prior imaging. No osseous abnormalities are seen. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. No evidence of new hemorrhage. Radiology Report INDICATION: ___ year old woman with right pleural effusion s/p thoracentesis. // assess for PTX or other complication of thoracentesis EXAMINATION: CHEST (PORTABLE AP) TECHNIQUE: Portable chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Previously seen large right pleural effusion is now resolved. There is no consolidation or pneumothorax. Cardiomediastinal silhouette is normal size. Tortuous aortic contour is stable. IMPRESSION: Right pleural effusion is resolved. No pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea on exertion Diagnosed with PLEURAL EFFUSION NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT temperature: 97.8 heartrate: 85.0 resprate: 18.0 o2sat: 98.0 sbp: 170.0 dbp: 111.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___: You were admitted to ___ for shortness of breath. We found that the fluid in your right lung had built up again. You were seen by the Interventional Pulmonology team, who did a procedure to drain the fluid. You had some episodes of confusion while you were here, so you were seen by the neurology team, who thought these might be due to seizures and started you on a new medicine to prevent seizures. If you feel short of breath again, you should go to the emergency room. Here is the dosing schedule for this new seizure medicine, lamotrigine: ___: 50 mg once daily ___: 50 mg twice a day ___: 50 mg in the AM, 100 mg at night ___: 100 mg twice daily You should follow up with your neurologist about dosing after this point. If you have a new rash, call your doctor immediately. It was a pleasure taking care of you! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin / Cephalosporins Attending: ___. Chief Complaint: Right third toe pain Major Surgical or Invasive Procedure: Right third toe amputation (___) History of Present Illness: FROM ADMISSION NOTE: Ms. ___ is an ___ y/o woman with type II diabetes, hypertension, hypercholestermia, and diabetic neuropathy and recurrent cellulitis with a past history of DVT and PE, presenting with right toe pain. Ms. ___ has a history of chronic leg and foot pain. About two weeks ago, she noted worsened pain in her right toes. Her daughter noticed that there was blood on the patient's sock. Subsequently, the patient's daughter noticed that her toes were frequently bleeding and had a new foul odor. Her daughter tried to treat the foot with athlete's foot spray and foot powder, but there was no improvement in symptoms. The pain continued to worsen over the week reaching ___ pain. Due the pain, it was difficult for the patient's daughter to closely examine the foot but she did note that the skin was broken down between the second and third toe on the right foot. The pain was localized to the toe and did not radiate. The patient denies any fevers, chills, nausea, or vomiting. Due to worsening pain the patient went to her podiatrist. She had radiographs taken of her foot which were suggestive of osteomyelitis, and the physician recommended admission to ___ for possible surgery. She has a history of cellulitis and was admitted to ___ in ___ for IV Vanc after failing doxycycline as an outpatient. Separately, Ms. ___ noted that she had bilateral lower extremity swelling for the past three weeks, with left>right extending from the knee to the toes. ___ at the OSH was negative for LLE DVT. She has a history of DVT in her leg with subsequent PE in her ___, for which she is on life long anticoagulation with warfarin. She denies miscarriages, a family history of clotting, although her mother died in her ___ or ___s from a stroke. She denies having been on any estrogen containing medications at the time of her DVT/PE. Her primary care doctor ordered ___ chest ___ which revealed "mild vascular redistribution consistent with mild CHF" She was started on 20 furosemide PO. The right lower extremity swelling improved but the left lower extremity swelling only improved minimally. Her PCP increased the dose to 40mg daily. She has a long standing history of "heart murmur," but denies any other problems with her heart. She remembers getting a stress test about ___ years ago, and a cardiac echo ___ years ago. She denies lightheadedness, vision changes, SOB, and chest pain. She sleeps sitting up, but this may be related to dizziness more that orthopnea. Per Dr ___ DPM podiatry note ___ -------------- DM, neuropathy right lower leg with worsening pain. Pt has been wearing surgical shoe because any pressure on the skin is painful.Right ___ digit medial aspect full thickness ulceration. Radiographs today: from my view, there is erosive changes of the proximal phalanx head medially with dislocation of the middle and distal phalanx laterally. I reviewed radiographs with her daughter and discussed seriousness of this condition. She will most likely need a toe amputation due to amount of bone destruction. I recommended that she take her to the ER at ___ for evaluation, admission and likely surgery. She will discuss this with her mother and will either take her today or tomorrow. If she does take her tomorrow, I recommended that she apply betadine soaked gauze in between the toes. I provided her with supplies. Pt's daughter understands the seriousness of this condition. If she delays much longer, infection can worsen and she may become septic. See note form her podiatry visit today And xray with likely osteomyelitis of her rt ___ toe In the ED, initial vitals: Temp 99.7 F HR 73 148/73 RR 20 100% RA - Exam notable for: A&Ox3 - Labs notable for: WBC 5.4 hgb 10.0 MCV 83 plt 258 ___ 1.4 PTT 29 Na+ 142 K+ 4.7 BUN 15 Cr 0.7 BCx 2X, - Imaging notable for: XRAY ___ Atrius Bone loss at the distal end of proximal phalanx with PIP dislocation as above. Osteomyelitis suspected. LENIs ___ Limited study due to severe soft tissue swelling at the left calf, obscuring visualization of the posterior tibial and peroneal veins. No deep vein thrombosis is identified in the remaining deep venous system in the left leg. MRI ___ IMPRESSION: Bilateral lower lower leg subcutaneous edema and perifascial edema, left worse than right. - Pt given: Vancomycin 1 g Flagyl 500 mg Cipro 400 mg - Vitals prior to transfer: Temp 99 HR 76 134/62 RR 18 99% RA On the floor, she reports feeling about the same, with now minimal pain in her R toe. Her daughter was present and able to account for her medications. Past Medical History: FROM ADMISSION NOTE: DM (diabetes mellitus), type 2 Recurrent DVTs with PE Recurrent Cellulitis Thrombophlebitis/phlebitis Hypertension, essential HLD Recurrent UTIs Pelvic floor dysfunction, uterine prolapse, has pessary Osteoarthritis h/o Breast Cancer - DCIS Ocular hypertention, cataracts, CME (cystoid macular edema) Hematuria Anemia Osteoarthritis Positive PPD Social History: ___ Family History: FROM ADMISSION NOTE: mother had stroke and died in her ___ Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: T98.4 BP144/75 HR73 RR18 ___ 96 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM CV: Regular rate and rhythm, normal S1 + S2, ___ ejection murmur LUSB, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no organomegaly, no rebound or guarding, well healed V incision below umbilicus, nystatin powder under pannus GU: No foley Ext: Warm, well perfused, 1+ pitting edema from to tibial tuberosity, no clubbing, cyanosis, purulent ulcer about 1cm in diameter on medial surface of the third toe and the lateral surface of the second toe, maceration between all toes ___. Chronic venous stasis changes, woody skin texture to mid tibia. R>L foot swelling. DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 98.4, HR 71, BP 149/82, RR 16, O2 98% RA GENERAL: NAD, sitting upright in chair HEENT: PERRL, EOMI, MMM, conjunctival pallor, no sublingual pallor NECK: supple, no LAD CV: RRR, III/VI systolic crescendo-decrescendo murmur heard best at RUSB, radiation to neck, S1/S2, no rubs or gallops RESP: unlabored, CTAB GI: soft, non-distended, non-tender, normoactive BS GU: no suprapubic tenderness, no Foley MSK: right foot bandage c/d/i, atrophic, discolored nails, 1+ pitting edema to mid-shin bilaterally, chronic venous stasis dermatitis SKIN: no erythema NEURO: non-focal Pertinent Results: ADMISSION LABS: =============== ___ 11:23AM BLOOD WBC-5.4 RBC-3.98 Hgb-10.0* Hct-32.9* MCV-83 MCH-25.1* MCHC-30.4* RDW-14.8 RDWSD-44.2 Plt ___ ___ 11:23AM BLOOD Neuts-55.1 ___ Monos-11.7 Eos-0.9* Baso-0.6 Im ___ AbsNeut-2.96 AbsLymp-1.67 AbsMono-0.63 AbsEos-0.05 AbsBaso-0.03 ___ 11:23AM BLOOD ___ PTT-29.2 ___ ___ 11:23AM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-142 K-4.7 Cl-104 HCO3-24 AnGap-14 ___ 11:23AM BLOOD ALT-11 AST-23 LD(LDH)-192 AlkPhos-84 TotBili-0.2 ___ 11:23AM BLOOD Albumin-3.7 ___ 12:27AM URINE Color-Yellow Appear-Cloudy* Sp ___ ___ 12:27AM URINE Blood-SM* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG ___ 12:27AM URINE RBC-88* WBC->182* Bacteri-NONE Yeast-NONE Epi-2 ___ 06:20AM BLOOD SED RATE-87 DSICHARGE LABS: ============== ___ 05:39AM BLOOD WBC-4.4 RBC-3.58* Hgb-9.3* Hct-29.5* MCV-82 MCH-26.0 MCHC-31.5* RDW-15.4 RDWSD-45.3 Plt ___ ___ 05:39AM BLOOD ___ ___ 05:39AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-141 K-4.0 Cl-105 HCO3-24 AnGap-12 RADIOLOGY: ========= FOOT AP,LAT & OBL RIGHT PORT (___) IMPRESSION: Proximal phalanx of the right third toe has been partially resected,, at a level 12 mm from the proximal interphalangeal joint. There is no subcutaneous emphysema. No other changes since preoperative foot radiograph on ___. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 2. Oxymorphone HCl 30 mg po BID 3. Nystatin Ointment 1 Appl TP TID:PRN itchy 4. Furosemide 20 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Amitriptyline 25 mg PO QHS 7. OXcarbazepine 300 mg PO MORNING AND NOON 8. OXcarbazepine 150 mg PO QHS 9. Nitrofurantoin (Macrodantin) 50 mg PO QHS chronic recc uti 10. Warfarin 5 mg PO 4X/WEEK (___) 11. Warfarin 3.75 mg PO 3X/WEEK (___) 12. trospium 20 mg oral DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*70 Tablet Refills:*0 3. Docusate Sodium 100 mg PO DAILY constipation 4. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*105 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY 7. Vancomycin 1000 mg IV Q 12H RX *vancomycin 500 mg 1000 mg IV q12hrs Disp #*140 Vial Refills:*0 8. Warfarin 2.5 mg PO DAILY16 9. Amitriptyline 25 mg PO QHS 10. Furosemide 20 mg PO DAILY 11. Nystatin Ointment 1 Appl TP TID:PRN itchy 12. OXcarbazepine 300 mg PO MORNING AND NOON 13. OXcarbazepine 150 mg PO QHS 14. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 15. Oxymorphone HCl 30 mg po BID 16. Simvastatin 20 mg PO QPM 17. trospium 20 mg oral DAILY 18. HELD- Nitrofurantoin (Macrodantin) 50 mg PO QHS chronic recc uti This medication was held. Do not restart Nitrofurantoin (Macrodantin) until you see your primary care and you are done with your antibiotic medication for your toe Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ female with right foot wound here for evaluation of osteomyelitis. TECHNIQUE: Three views of the right foot. COMPARISON: None available. FINDINGS: Osteolysis along the medial aspect of distal portion of the proximal phalanx of the third toe with soft tissue swelling is concerning for osteomyelitis. The third toe is dislocated at the PIP joint with the middle phalanx laterally dislocated relative to the proximal phalanx. There is no acute fracture. Moderate degenerative changes are seen at the first MTP joint, PIP joints the ___ to ___ digits, and midfoot. There is a small calcaneal spur. There is diffuse demineralization. No subcutaneous emphysema. IMPRESSION: 1. Osteolysis along the medial aspect of the distal portion of the proximal phalanx of the third toe with soft tissue swelling, concerning for osteomyelitis. 2. Dislocated third toe at the PIP joint. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ female presenting with left leg swelling here for evaluation of DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Lower extremity ultrasound dated ___. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. The posterior tibial and peroneal veins are not visualized due to severe soft tissue swelling. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: Limited study due to severe soft tissue swelling at the left calf, obscuring visualization of the posterior tibial and peroneal veins. No deep vein thrombosis is identified in the remaining deep venous system in the left lower extremity. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old woman s/p r third toe amputation// eval post op eval post op IMPRESSION: Proximal phalanx of the right third toe has been partially resected,, at a level 12 mm from the proximal interphalangeal joint. There is no subcutaneous emphysema. No other changes since preoperative foot radiograph on ___. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ year old woman with picc// r picc 50cm iv ___ ___ Contact name: ___: ___ TECHNIQUE: Single portable upright frontal chest radiograph. COMPARISON: None. FINDINGS: Limited evaluation due to patient rotation. A right PICC tip terminates in the right atrium. The lungs are moderately well inflated. Right lower lobe atelectasis noted. Trace left pleural effusion noted. No right pleural effusion. No pneumothorax. IMPRESSION: 1. Right PICC tip in right atrium. Considering withdrawing 1.5 cm for better positioning. 2. Right lower lobe atelectasis. 3. Trace left pleural effusion. NOTIFICATION: The findings were discussed with ___, IV nurse by ___ ___, M.D. on the telephone on ___ at 6:04 pm, 1 minutes after discovery of the findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: R Foot pain Diagnosed with Type 2 diabetes mellitus with other specified complication, Other acute osteomyelitis, right ankle and foot temperature: 99.7 heartrate: 73.0 resprate: 20.0 o2sat: 100.0 sbp: 148.0 dbp: 73.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___! WHY WERE YOU ADMITTED? You had an infection of your toe bone. WHAT HAPPENED IN THE HOSPITAL? Your toe was removed. You received antibiotics for the infection in your toe. WHAT SHOULD YOU DO AT HOME? -Please take your three antibiotics as prescribed for an additional five weeks --Vancomycin twice daily through your PICC line --Ciprofloxacin twice daily by mouth --Metronidazole three times daily by mouth -Please follow-up with OPAT weekly Thank you for allowing us be involved in your care, we wish you all the best! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Dilaudid Attending: ___. Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: NGT History of Present Illness: ___ M with advanced metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary presents with worsening of abdominal pain, nausea, vomiting. Per review of records, initially presented for care in ___ in ___. At that point, she was having abdominal pain, diarrhea, bloating, decreased appetite, early satiety, and a 25-pound weight loss over the preceding few months. She underwent a CT scan, which showed a right adnexal hypodense lesion. A pelvic ultrasound showed a multiseptated cystic lesion without vascularization. On ___, she underwent an exploratory laparotomy and drainage of 20 mL of ascites that showed malignancy on pathology. There was a biopsy of a right ovarian mass, which showed inflammation but no evidence of malignancy. A biopsy of an omental mass was positive for metastatic adenocarcinoma. She had elevated CEA and CA-125. She subsequently moved to the ___ area where she presented for care. An omental biopsy on ___, showed metastatic mucinous adenocarcinoma. The differential diagnosis included a GI or appendiceal primary, pancreaticobiliary, ovarian, or uterine/cervical primary. She underwent a thorough GI evaluation, which was negative. She was started on neoadjuvant chemotherapy with carboplatin and paclitaxel with the assumption that this represented a gynecologic malignancy. The patient was last seen at ___ ___ for similar symptoms, s/p chemo most recently last year with carbotaxol but did not elect to pursue further chemotherapy if intent was purely palliative. Underwent ex-lap in ___ for planned surgical debulking, extensive tumor burden at that time resulted in failure of debulking procedure, pt was advised to pursue HIPEC at ___, unclear if she established care. She did elect to return to ___ to spend time with family; developed worsening abdominal distension approximately 3 weeks ago with some serous leakage of fluid around her umbilicus. This was managed with an ostomy appliance, has not noted any drainage for past 4 days. Now having worsening abd pain, nausea, vomiting, and inability to tolerate PO. Last BM 4 days ago, underwent CT scan in ED that showed concern for mass effect from tumor on small bowel. In the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam notable for cachectic woman, with distended abdomen, hypoactive bowel sounds, with ostomy in place without output in the bag, severe tenderness to light palpation, with diffuse guarding. Labs showed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for Na of 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS unremarkable with an alk phos of 150. Lactate 1.2. Imaging showed marked progression of primary and metastatic tumor burden. Received 2 mg IV morphine and was started on LR. ACS was consulted and recommended NG tube decompression. Decision was made to admit to medicine for further management. On the floor, patient reports the history above and c/o abdominal pain. Review of systems: 10-point ROS was performed and is negative except as noted in the HPI. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, ___, ___ ___: - ___ (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late ___ - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since ___ - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: ___ Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: UPON ADMISSION: Vital Signs: 98.7 PO 94 / 60 79 16 95 RA General: ___ woman crying, in moderate distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LUQ, +rebound tenderness GU: No foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. UPON DISCHARGE: VS: 98.2 100 / 56 80 16 95% ra General: ___ female, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LLQ, +rebound tenderness, area of localized hyperpigmented skin overlying umbilicus with no drainage GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS UPON ADMISSION: ___ 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3 MCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt ___ ___ 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131* K-3.9 Cl-95* HCO3-23 AnGap-17 ___ 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4 ___ 10:05PM BLOOD Albumin-2.9* LABS UPON DISCHARGE ___ 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4* MCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt ___ ___ 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 ___ 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3 ___ 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5* EKG on admission: Sinus rhythm. There is an early transition that is non-specific. Low voltage in the precordial leads. Non-specific ST-T wave changes. The Q-T interval is prolonged. Compared to the previous tracing of ___ these findings are new. CT abdomen and pelvis w/contrast: IMPRESSION: 1. Markedly increased primary and metastatic tumor burden. Metastatic deposits extend through the anterior wall defect into the "ostomy". 2. Distention of proximal loops of small bowel with relative decompression but node discrete transition point in the distal ileum, compatible with partial obstruction likely due to mass effect by the large intra-abdominal cystic mass. Abdominal KUB: IMPRESSION: No intraperitoneal free air. Normal bowel gas pattern. CXR: IMPRESSION: In comparison with the study of ___, there are lower lung volumes. No evidence of vascular congestion or acute focal pneumonia. There has been placement of a nasogastric tube that extends to the lower body of the stomach. Residual contrast material is seen in the colon. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Place on skin every three days Disp #*3 Patch Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Disp #*170 Gram Refills:*0 ALSO DISCHARGED WITH PRESCRIPTIONS FOR: "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Metastatic intraperitoneal mucinous adenocarcinoma Partial small bowel obstruction Hypotension Thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: +PO contrast; History: ___ with ostomy, abdominal pain, vomiting, no ostomy output+PO contrast // eval for obstruction TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.7 mGy (Body) DLP = 643.0 mGy-cm. Total DLP (Body) = 650 mGy-cm. COMPARISON: CT abdomen/pelvis from ___. FINDINGS: LOWER CHEST: There is dependent atelectasis in the visualized lung bases. No pleural or pericardial effusion is seen. ABDOMEN: HEPATOBILIARY: The liver is homogeneous in background attenuation, without focal lesion or intra or extrahepatic biliary duct dilation. The contour is lobulated secondary to pseudomyxoma peritonei. The main portal vein appears patent. The gallbladder is within normal limits. PANCREAS: Pancreas is atrophic but normal in attenuation without mass, ductal dilation, or peripancreatic stranding or fluid collection. SPLEEN: Spleen is normal in size. Several cystic lesions are again seen, similar in appearance and distribution compared to ___. ADRENALS: The adrenal glands are normal in caliber and configuration bilaterally. URINARY: The kidneys are symmetric and normal in size. There is an unchanged hypodensity arising from the interpolar region of the right kidney, possibly a cyst. There is no hydronephrosis. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops are distended with contrast proximally, with relative decompression at the level of the distal ileum likely due to mass effect from the cystic mass. There is no discrete transition point. The colon and rectum are within normal limits. The large cystic mass which appears to originate in the right lower quadrant, presumably the suspected appendiceal mucinous carcinoma, has increased in size, now measuring 13.6 x 19.6 x 24.3 cm (previously 11.5 x 18.1 x 13.9 cm). There are increased omental deposits and omental caking. Mucinous material throughout the abdomen is increased and again compatible with pseudomyxoma peritonei. This material also extends through an anterior abdominal wall defect, presumably into the "ostomy" . There may also be a component of ascites, but is difficult to differentiate from the mucinous deposits throughout the abdomen. PELVIS: The urinary bladder and distal ureters are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is an anterior wall defect as described above, without evidence of enterostomy or colostomy. Peritoneal wall deposits extend through the defect. Additional low density lesions in the subcutaneous tissues of the right anterior abdominal wall are likely additional metastatic implants. IMPRESSION: 1. Markedly increased primary and metastatic tumor burden. Metastatic deposits extend through the anterior wall defect into the "ostomy". 2. Distention of proximal loops of small bowel with relative decompression but node discrete transition point in the distal ileum, compatible with partial obstruction likely due to mass effect by the large intra-abdominal cystic mass. Radiology Report INDICATION: ___ year old woman with partial SBO, diffusely guaerding and peritontic // eval for free air TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis dated ___ at 02:50. FINDINGS: Contrast material is seen in the ascending and transverse colon and bladder consistent with recent CT abdomen and pelvis performed earlier on the same day. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are notable for degenerative disease of the lumbar spine. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No intraperitoneal free air. Normal bowel gas pattern. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old woman with NGT placement for SBO eval position // eval ngt eval ngt IMPRESSION: In comparison with the study of ___, there are lower lung volumes. No evidence of vascular congestion or acute focal pneumonia. There has been placement of a nasogastric tube that extends to the lower body of the stomach. Residual contrast material is seen in the colon. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Abd pain, Vomiting Diagnosed with Unspecified intestinal obstruction temperature: 97.6 heartrate: 82.0 resprate: 16.0 o2sat: 100.0 sbp: 106.0 dbp: 67.0 level of pain: 8 level of acuity: 2.0

Dear Ms ___, **WHY DID YOU COME TO THE HOSPITAL?** -You came to the hospital with belly pain **WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?** -We took a picture of your belly (CT scan) and it showed that you have a small blockage in your bowels and growing size of your cancer -We placed a tube through your nose in your belly to help with your bloating, nausea and pain **WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?** -You will be going home with hospice care. You and your family will receive help from nurses. -___ have an appointment with your oncologist at ___ on ___ (see below for more details). It was a pleasure taking care of you. Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Exelon / Aricept / Penicillins Attending: ___. Chief Complaint: Ground level fall Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms. ___ is a ___ year old female with dementia who presents today after an unwitnessed fall in her assisted living facility ___.) The patient is unable to provide a history and does not participate completely with physical examination. In the ___ ED, initial vitals were T 99.0 BP 138/70 RR 14 SpO2 98% on RA. ED exam notable for abrasions on the R UE and L UE and A&Ox1. - Initial labs notable for K 6.1 (5.1 on repeat). - Imaging showed a T12 compression fracture with retropulsion. CT head was negative for acute process. Chest, pelvis, hip, tibial films were negative for fracture. - Ortho spine was consutled and recommended non-operative management with TLSO brace and outpatient f/u in 2 weeks. Per discussion with ortho resident, fracture is not unstable and patient may be activity as tolerated. - Patient was given 4mg ondansetron, APAP 650mg, and olanzapine 5mg Prior to transfer, vitals were T 97.8 HR 67 BP 112/67 RR 16 SpO2 99% on RA Currently, the patient reports feeling well but endorses fatigue. Her history is tangential and does not recall the events of the fall. A significant portion of the history is obtained from her daughter ___ who is present at the bedside. Unfortunately, she is not aware of the specifics of the events at ___ last night surrounding the fall. Per ___ (RN at ___), the patient's fall was unwitnessed, but someone had been in the room several minutes previously. When she was found, she was consciousness, and at her baseline mental status. There was no incontinence. She was apparently complaining only of back pain and left leg pain. Past Medical History: - Dementia diagnosed with Alzheimer's type in ___. - GERD - Osteoporosis - Hepatitis C, which has been untreated. According to the patient's daughter, it is a form that responds poorly to interferon. - Patent foramen ovale. - Right frontal/temporal meningioma for which she has had no evaluation for the last ___ years. - History of ___ diverticulum which caused a bowel obstruction in ___. The patient had multiple bowel obstructions until the late ___ due to adhesions, but has not had an obstruction since. - Status post hysterectomy for unclear reasons. - Left breast cancer, DCIS, status post reconstruction. - Osteoarthritis. - History of herpes zoster and possible postherpetic neuralgia. - Rosacea Social History: ___ Family History: The patient's mother and two of her sisters had dementia. Father had a ___ diverticulum and died in his ___ of a bowel obstruction. Brother has multiple sclerosis and some type of autoimmune disorder. Physical Exam: ADMISSION EXAM -------------- VS - T 98.0 BP 154/75 HR 72 RR 17 SpO2 98% on RA Weight: 49.2 kg General: Appears well, alert, interactive HEENT: Vision grossly impaired. Does not make direct eye contact. Unable to tell how many fingers I am holidng up at 4 feet. Neck: No JVD CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, nontender Back: Minimal tenderness to palpation of lower thoracic spine. No gross deformity. Ext: Laceration on LLE is bandaged. Not examined underneath bandage. Neuro: Oriented to self only. CN II-XII grossly intact. Sensation intact to light touch in upper and lower extremities and is symmetric. No saddle anesthesia. Able to move all four extremities without difficulty. DISCHARGE EXAM -------------- General: Appears well. She is alert and interactive CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, nontender Back: Minimal tenderness to palpation of lower thoracic spine. No gross deformity. No step-off or spinal process tenderness. Ext: Laceration on LLE is bandaged with sutures in place. 8cm wound approximately. R elbow has steri-strips covering smaller laceration. Neuro: Oriented to self only. CN II-XII grossly intact. Sensation intact to light touch in upper and lower extremities and is symmetric. She has 4+ strength throughout, appropriate for her muscle bulk. There is no asymmetry in strength. Her DTRs are 2+ in the patellae, 1+ in Achilles. Babinski is down bilaterally. Pertinent Results: ADMISSION LABS -------------- ___ 11:00PM BLOOD WBC-7.5 RBC-4.41 Hgb-12.9 Hct-37.3 MCV-85 MCH-29.3 MCHC-34.7 RDW-14.5 Plt ___ ___ 11:00PM BLOOD Neuts-73.3* ___ Monos-6.7 Eos-1.6 Baso-0.2 ___ 11:00PM BLOOD ___ PTT-29.9 ___ ___ 11:00PM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-135 K-6.1* Cl-100 HCO3-26 AnGap-15 ___ 11:00PM BLOOD ALT-87* AST-163* LD(LDH)-757* AlkPhos-60 TotBili-0.8 ___ 11:00PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.8 Mg-2.1 ___ 11:00PM BLOOD TSH-1.8 ___ 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:16AM BLOOD K-5.1 ___ 09:02PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 09:02PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 09:02PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 ___ 09:02PM URINE CastHy-6* IMAGING ------- CT C-spine w/o contrast: IMPRESSION: Multilevel, multifactorial degenerative changes with no evidence of acute injury. Moderate canal narrowing at C4-5. Moderate to severe foraminal narrowing at C4-5, C5-6 and mild to moderate at C6-7 level. Correlate clinically to decide on the need for further workup or followup. Nodules in the thyroid. CT head w/o contrast: IMPRESSION: No acute intracranial hemorrhage or mass effect or acute fracture. Other details as above. Correlate clinically to decide on the need for further workup or followup. CT L-spine w/o contrast: IMPRESSION: Compression fracture of T12 as described in the thoracic spine CT report. Consider MRI of the thoracic spine if not contraindicated for better assessment of the acuity and exclusion of an underlying lesion. No evidence of acute lumbar spine fracture. Other details as above. CT T-spine w/o contrast: IMPRESSION: Compression deformity of the T12 vertebral body with burst fracture and mild retropulsion of the superior aspect. CT is limited for evaluation of intrathecal components, and if there is concern for spinal cord injury, MRI is recommended if not contra-indicated for better characterization of the acuity and any underlying lesion and intrathecal details. Mild bulging ___ posteriorly indenting the thecal sac outline series 603b, image 32. Diffuse osteopenia with heterogeneous attenuation and multiple scattered lucent foci, which may relate to fat deposition or marrow abnormality. This can be better assessed with MRI if not contraindicated. XRAY TIB/FIB (AP AND LAT) LEFT IMPRESSION: No evidence of fracture or dislocation. XRAY PELVIS IMPRESSION: No evidence of fracture or dislocation of the pelvis or hips. CHEST XRAY: IMPRESSION: Partial limited examination with no evidence of pneumonia. ---------- ECG: Sinus rhythm. A-V conduction delay. Left ventricular hypertrophy. No previous tracing available for comparison. ---------- MICROBIOLOGY: NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 2. Gabapentin 100 mg PO TID 3. Memantine 10 mg PO BID 4. meloxicam 15 mg oral QD 5. Omeprazole 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. ARIPiprazole 2.5 mg PO QHS Discharge Medications: 1. ARIPiprazole 2.5 mg PO QHS 2. Memantine 10 mg PO BID 3. Omeprazole 20 mg PO DAILY 4. Sertraline 50 mg PO DAILY 5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 6. Gabapentin 100 mg PO TID 7. meloxicam 15 mg ORAL QD Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #T12 compression fracture without spinal cord impingement #Dementia, mixed alzheimer's and vascular type #Chronic hepatitis C Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with fall // rib injury, pneumonia TECHNIQUE: AP upright and lateral radiographs COMPARISON: None FINDINGS: The examination is partially limited by suboptimal patient positioning.No strong evidence for pneumonia. No pleural effusion or pneumothorax. No evidence of pulmonary edema. No definite rib fracture. IMPRESSION: Partial limited examination with no evidence of pneumonia. Radiology Report EXAMINATION: DX ABDOMEN W CROSS TABLE LATERAL INDICATION: History: ___ with questionable findings on x-ray. Evaluate for fracture. TECHNIQUE: Single AP pelvis and diffuse is a right hip COMPARISON: Pelvic radiographs from earlier on the same evening. FINDINGS: No fracture or dislocation of the right hip. Sacroiliac joints and lower lumbar spine are unremarkable. Visualized bowel loops are normal. IMPRESSION: No fracture or dislocation of the right hip. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Laceration Diagnosed with FX DORSAL VERTEBRA-CLOSE, OPEN WND KNEE/LEG/ANKLE, OPEN WOUND OF ELBOW, UNSPECIFIED FALL, TETANUS-DIPHT. TD DT temperature: 99.0 heartrate: 70.0 resprate: 14.0 o2sat: 98.0 sbp: nan dbp: nan level of pain: 3 level of acuity: 3.0

Ms. ___, it was a pleasure caring for ___ at ___ ___. ___ were seen here for a fall that ___ had at your nursing home. In the ER, x-rays showed a compression fracture of one of your spine bones called T12. ___ were fitted for a brace to help with back pain. It is recommended that ___ wear this until ___ see orthopedics in clinic in 2 weeks. We wish ___ well!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Aspirin Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with chronic pancreatitis ___ gallstones previous h/o Puestow procedure (___) and h/o choledocholithiasis with recent ERCP, sphincterotomy, and multiple stone extraction presents to ___ for abdominal pain. Pain was similar to last time she was admitted (late ___ where they discovered she had choledocholithiasis. Per patient, she has been experiencing 1 day of colicky abd pain with associated nausea and bilious emesis. Poor PO intake. Diarrhea but no flatus. Pain has been getting worse since presentation to ___. Last C-scope ___ years ago and per patient no masses or polyps found. At ___, CT scan performed showing SBO. Patient was then transferred here for further management. NGT placed, approximately ___ilious/contrast material out. Past Medical History: PMhx: chronic pancreatitis, gallstones, fibromylagia, chronic abdominal pain, Hep C PShx: Peustow, TAH, TKR Social History: ___ Family History: Cousin with U.C. Physical Exam: Admission PE: 98.3 65 146/85 18 95% RA A+OX3, appears in pain no scleral icterus RRR CTAB Soft, ND, TTP epigastrium and R periumbilical and RLQ, previous cheveron scar seen no hernias guiac negative, no masses felt Discharge PE: ___ GEN:AAOx3, NAD HEART: RRR S1S2 LUNGS: CTAB AB: mild tenderness left lower quadrant EXT: peripheral pulses intact bilaterally Pertinent Results: ___ 01:45PM BLOOD WBC-5.2 RBC-4.48 Hgb-13.6 Hct-37.3 MCV-83 MCH-30.3 MCHC-36.5* RDW-13.6 Plt ___ ___ 05:09AM BLOOD WBC-5.0 RBC-4.48 Hgb-13.6 Hct-38.2 MCV-85 MCH-30.4 MCHC-35.6* RDW-13.5 Plt ___ ___ 01:45PM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-116* UreaN-3* Creat-0.8 Na-138 K-4.4 Cl-111* HCO3-23 AnGap-8 ___ 06:00AM BLOOD Glucose-130* UreaN-6 Creat-0.7 Na-139 K-3.9 Cl-106 HCO3-23 AnGap-14 ___ 05:09AM BLOOD ALT-11 AST-20 AlkPhos-59 TotBili-0.5 ___ 07:00AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.3 ___ 06:00AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.1 ___: chest x-ray: No evidence of acute cardiopulmonary process. NG tube in appropriate position. ___: abdominal x-ray: On the current exam, the bowel gas pattern is nonspecific. Air is seen in few scattered loops of non-dilated small bowel. Air and stool are seen scattered throughout non-distended loops of colon, including within the rectum. No free air is seen on the decubitus film. Lung bases are not well evaluated on these views.Multiple injection granulomas are again noted. ___: left venous duplex: No evidence of deep vein thrombosis. Medications on Admission: Nexium 40", valium 10", oxycontin 80''', oxycodone 60 QID, lyrica 100''', PEG, colace, MTV, Creon 10K TID Discharge Medications: 1. Diazepam 10 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. NexIUM Packet (esomeprazole magnesium) 40 mg Oral BID 4. OxycoDONE (Immediate Release) 60 mg PO Q6H:PRN pain 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 6. Pregabalin 100 mg PO TID 7. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with recent ERCP and partial small bowel obstruction from outside institution CT, with NG tube placed for decompression. Evaluate for location of the NG tube. COMPARISON: CT abdomen from outside institution from ___. TECHNIQUE: Frontal AP and lateral chest radiograph. FINDINGS: The lungs are well expanded. Bibasilar streaky opacities likely represent subsegmental atelectases. Cardiomediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. An NG tube ends in the distal stomach. IMPRESSION: No evidence of acute cardiopulmonary process. NG tube in appropriate position. Radiology Report HISTORY: Partial small-bowel obstruction, question ileus. ABDOMEN, TWO VIEWS INCLUDING LEFT DECUBITUS FILM WITH THE RIGHT SIDE UP. On the current exam, the bowel gas pattern is nonspecific. Air is seen in few scattered loops of non-dilated small bowel. Air and stool are seen scattered throughout non-distended loops of colon, including within the rectum. No free air is seen on the decubitus film. Lung bases are not well evaluated on these views.Multiple injection granulomas are again noted. Wet reading was provided to Dr. ___ at approximately 11:40 a.m. on ___ by Dr. ___ by phone. Radiology Report INDICATION: Left lower extremity swelling. Evaluation for DVT. TECHNIQUE: Gray-scale and pulse wave Doppler of left lower extremity. COMPARISON: None. FINDINGS: There is normal respiratory phasicity in the common femoral veins bilaterally. There is normal compressibility, flow, and augmentation of the left common femoral, superficial femoral, and popliteal veins. Normal flow and compressibility is demonstrated in the left posterior tibial and deep peroneal veins. IMPRESSION: No evidence of deep vein thrombosis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V, +SBO Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.4 heartrate: 66.0 resprate: nan o2sat: 98.0 sbp: 134.0 dbp: 83.0 level of pain: 13 level of acuity: 3.0

You were admitted to the Acute Care Surgery service with abdominal pain, and were found to have a partial small bowel obstruction. You were treated with bowel rest and pain medications, and are now ready to return to home. Please follow the instructions below: -You are being given a prescription for narcotic pain medication. Do not drive or drink alcohol if taking narcotic pain medication. -No strenuous exercise or heavy lifting for at least two weeks. -Resume all of your home medications unless advised otherwise. -If you do not already have an appointment scheduled, call the APS office at ___ to make an appointment in ___ days. -Call the ___ clinic if you have any questions. -Call the ___ clinic or go to the nearest emergency room if you have fevers > ___ F, abdominal pain, or for anything else that is troubling you.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: phenytoin Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ERCP ___ GDA embolization History of Present Illness: ___ yo M with PMH of seizure disorder s/p TBI, ETOH abuse and T2DM presents with abdominal pain. Patient initially presented to ___ with first right sided abd pain ___ weeks ago that migrated to left sided abdominal pain of 2 days ago. He has had a similar pain in the past 6 months ago for which he was hospitalized at ___ for alcohol pancreatitis. At ___ he received IVF, IV Ativan and toradol. Labs were notable for CO2 22, Anion gap 26, ALT 52, AST 134, T bili 1.4, D bili .6, lipase >528, Trop <.03. ETOH 217. A CT A/P showed possible choledocholithiasis and a RUQUS reportedly showed a stone in the common bile duct though this was not noted in the report. The patient was transferred to ___ for ERCP evaluation. In ED initial VS: T 100.2 HR 118 BP 145/99 RR 20 O2 Sat 98% on RA Labs significant for: Lactate 6.2, HCO3 20, Anion gap 31, ALT 46, AST 106, Lipase 1142, AP 143, T bili 1.7, Direct bili .8 Patient was given: Pip-Tazo 4.5g 2L NS Dilaudid .5mg Phenobarbital 740mg Phenobarbital 180mg 1L LR Consults: ERCP: NPO, Abx, IVF, admit East to ___, ERCP today VS prior to transfer: 99.0 116 131/96 22 96% 2L NC On arrival to the FICU, patient notes feeling pain is somewhat better. notes pain had been ___ waxing/waning the past week, but became more constant 2 days ago prompting ED. No fevers, but had cold sweats mostly at night. 1 episode of nonbloody emesis after clam dinner two nights ago. No diarrhea, hematochezia, melena, dysuria, hematuria. No SOB, headache, changes to vision. Past Medical History: Seizure disorder s/p TBI in ___ after MVA ETOH abuse ETOH withdrawal w/ seizures Alcoholic pancreatitis T2DM Social History: ___ Family History: Family history of T2DM No family history of seizure disorders Physical Exam: ON ADMISSION VITALS: ___ 20 97% 2L NC GENERAL: Alert, oriented, slightly tremulous and anxious appearing HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, normal rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: psoriatic changes on lower legs bilaterally. NEURO: A&Ox3, moving all extremities with purpose, somewhat tremulous per above EXAM(>=2) ___ 0749 Temp: 99.9 PO BP: 127/82 HR: 98 RR: 18 O2 sat: 95% O2 delivery: RA FSBG: 110 non toxic, aox3 ctab regular pulse no abd tenderness to palpation no peripheral edema. Pertinent Results: ___ 09:24AM LACTATE-2.5* ___ 09:10AM ALT(SGPT)-37 AST(SGOT)-84* ALK PHOS-115 TOT BILI-1.6* DIR BILI-0.9* INDIR BIL-0.7 ___ 09:10AM CK-MB-2 cTropnT-<0.01 ___ 09:10AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:10AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30* GLUCOSE-TR* KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 09:10AM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 06:50AM LACTATE-3.8* ___ 05:13AM LACTATE-6.2* ___ 05:00AM GLUCOSE-134* UREA N-4* CREAT-0.5 SODIUM-140 POTASSIUM-4.1 CHLORIDE-89* TOTAL CO2-20* ANION GAP-31* ___ 05:00AM ALT(SGPT)-46* AST(SGOT)-106* ALK PHOS-143* TOT BILI-1.7* DIR BILI-0.8* INDIR BIL-0.9 ___ 05:00AM LIPASE-1142* ___ 05:00AM ALBUMIN-4.2 ___ 05:00AM WBC-6.6 RBC-3.69* HGB-13.1* HCT-38.4* MCV-104* MCH-35.5* MCHC-34.1 RDW-12.6 RDWSD-48.6* ___ 05:00AM NEUTS-72.5* LYMPHS-15.4* MONOS-11.0 EOS-0.0* BASOS-0.3 IM ___ AbsNeut-4.79 AbsLymp-1.02* AbsMono-0.73 AbsEos-0.00* AbsBaso-0.02 ___ 05:00AM ___ PTT-27.7 ___ Imaging CXR (___): No prior chest radiographs available. Symmetric bibasilar opacification could be pneumonia, but atelectasis is more likely. Pleural effusions small if any. No pneumothorax. Upper lungs clear. Heart size normal. RUQ US (___): 1. Cirrhotic liver with evidence of portal hypertension including ascites and splenomegaly. No focal lesions. No specific sonographic findings to explain the patient's increasing transaminitis. 2. Cholelithiasis without evidence of cholecystitis. CT ap (___): 1. No evidence of active hemorrhage in the region of the ampulla, adjacent to metallic CBD stent, or elsewhere in the abdomen or pelvis. 2. Severe hepatic steatosis. Mild nonspecific contour nodularity of the liver. No focal hepatic lesion. 3. Trace ascites in the abdomen, most notable in the right lower quadrant. 4. Splenomegaly, measuring 13.9 cm in length. 5. 7.1 x 4.1 cm intraparenchymal fluid collection in the pancreatic tail. Additional intraparenchymal fluid collection in the pancreatic uncinate process measuring 3.1 x 2.1 cm. Findings likely represent necrotic fluid collections from recent acute pancreatitis. Peripancreatic stranding seen on outside CT from ___ has largely resolved. 6. Wall thickening of the second portion of the duodenum, likely postprocedural in nature. Stent extending from the proximal common hepatic duct to the second portion of the duodenum, containing air throughout. 7. Small bilateral pleural effusions, right greater than left, with adjacent, compressive atelectasis. Mesenteric arteriogram (___): 1. No large SMA branches to the region of the stent. 2. Patent celiac artery and GDA. 3. Post embolization demonstrates no residual flow in the GDA. IMPRESSION: Technically successful coil and Gel-Foam embolization of the gastroduodenal artery. CTA CHEST: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral upper lobe predominant multifocal pneumonia. 3. Small to moderate right greater than left bilateral pleural effusions with compressive atelectasis of the bilateral dependent lung bases. 4. Hepatic steatosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. glimepiride 4 mg oral DAILY 2. MetFORMIN (Glucophage) 500 mg PO BID 3. LevETIRAcetam 1250 mg PO BID 4. Humira (adalimumab) 00 mg subcutaneous Unknown Discharge Medications: 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 2 grams per day 2. Levofloxacin 750 mg PO DAILY Duration: 3 Days RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 3. Humira (___) 00 mg subcutaneous Frequency is Unknown 4. LevETIRAcetam 1250 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO BID 6. HELD- glimepiride 4 mg oral DAILY This medication was held. Do not restart glimepiride until follow up with your doctors ___: Home Discharge Diagnosis: Acute necrotizing gallstone/alcohol pancreatitis Alcoholic hepatitis Bacterial pneumonia GI bleeding DM2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with pancreatitis and imaging c/f cholangitis at OSH, being treated for alcohol withdrawal// ? Aspiration pneumonitis or pneumonia ? Aspiration pneumonitis or pneumonia IMPRESSION: No prior chest radiographs available. Symmetric bibasilar opacification could be pneumonia, but atelectasis is more likely. Pleural effusions small if any. No pneumothorax. Upper lungs clear. Heart size normal. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with hx EtOh abuse presenting with abdominal pain s/p ERCP// Bedside as patient is clinically unstable, find cause of rising Tbili TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Outside facility abdominal ultrasound from ___. FINDINGS: LIVER: The patent parenchyma is diffusely echogenic and coarsened with a nodular contour in keeping with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is small volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: There is cholelithiasis without gallbladder wall edema. PANCREAS: Pancreas is not well seen, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 13.6 cm. KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver with evidence of portal hypertension including ascites and splenomegaly. No focal lesions. No specific sonographic findings to explain the patient's increasing transaminitis. 2. Cholelithiasis without evidence of cholecystitis. Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old man with significant bleeding after sphinterotomy, metal stent placed in ampulla to attempt tamponade but still bleeding, ___ requests mesenteric protocol prior to planned embolization// ___ year old man with significant bleeding after sphinterotomy, metal stent placed in ampulla to attempt tamponade but still bleeding, ___ requests mesenteric protocol prior to planned embolization TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.6 s, 62.4 cm; CTDIvol = 3.4 mGy (Body) DLP = 209.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 3) Stationary Acquisition 5.1 s, 0.2 cm; CTDIvol = 86.0 mGy (Body) DLP = 17.2 mGy-cm. 4) Spiral Acquisition 9.6 s, 62.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 425.3 mGy-cm. 5) Spiral Acquisition 9.6 s, 62.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 425.3 mGy-cm. Total DLP (Body) = 1,080 mGy-cm. COMPARISON: Outside CT abdomen pelvis from ___ liver gallbladder ultrasound from ___ FINDINGS: VASCULAR: There is no evidence of active extravasation in the region of the ampulla, adjacent to metallic CBD stent, or elsewhere in the abdomen or pelvis. There are mild atherosclerotic calcifications of the aortoiliac vessels. There is no abdominal aortic aneurysm. The celiac artery, SMA, bilateral renal arteries (noting an accessory left renal artery supplying the upper pole) and ___ are patent, without high-grade stenosis. Portal vasculature is patent. LOWER CHEST: There are small bilateral pleural effusions, right greater than left with adjacent compressive atelectasis. No concerning focal consolidation is seen at the lung bases. ABDOMEN: HEPATOBILIARY: Liver is diffusely decreased in attenuation consistent with severe steatosis. There is mild nodularity of the liver contour. No focal hepatic lesions are identified. Evaluation of the gallbladder is limited due to intraluminal contrast. There are multiple stones in the gallbladder. A stent extends from the proximal common hepatic duct to the second portion of the duodenum, containing air throughout. There is no pneumobilia. PANCREAS: Pancreas is mildly atrophic with multiple calcifications seen on noncontrast examination likely sequelae of prior episodes of pancreatitis. The pancreatic parenchyma enhances heterogeneously. In the pancreatic tail, there is a 7.1 x 4.1 cm intraparenchymal fluid collection. There is an additional ill-defined intraparenchymal fluid collection, with internal calcifications, in the pancreatic uncinate process, measuring 3.1 x 2.1 cm (series 6; image 78). These likely represent necrotic fluid collections from recent acute pancreatitis. There is no main pancreatic ductal dilatation. Peripancreatic stranding seen on outside CT from ___ has largely resolved. SPLEEN: Spleen is enlarged measuring 13.9 cm in the coronal plane. No focal splenic lesions are seen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is wall thickening of the second portion of the duodenum, likely postprocedural in nature. Small bowel loops otherwise demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are otherwise within normal limits. Multiple prominent mesenteric lymph nodes are seen, likely reactive. There is trace ascites in the abdomen, most notable in the right lower quadrant. RETROPERITONEUM: Mildly enlarged left para-aortic lymph nodes measuring up to 10 mm in short axis (series 6; image 82) are also likely reactive. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. REPRODUCTIVE ORGANS: Visualized prostate and seminal vesicles are unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of active hemorrhage in the region of the ampulla, adjacent to metallic CBD stent, or elsewhere in the abdomen or pelvis. 2. Severe hepatic steatosis. Mild nonspecific contour nodularity of the liver. No focal hepatic lesion. 3. Trace ascites in the abdomen, most notable in the right lower quadrant. 4. Splenomegaly, measuring 13.9 cm in length. 5. 7.1 x 4.1 cm intraparenchymal fluid collection in the pancreatic tail. Additional intraparenchymal fluid collection in the pancreatic uncinate process measuring 3.1 x 2.1 cm. Findings likely represent necrotic fluid collections from recent acute pancreatitis. Peripancreatic stranding seen on outside CT from ___ has largely resolved. 6. Wall thickening of the second portion of the duodenum, likely postprocedural in nature. Stent extending from the proximal common hepatic duct to the second portion of the duodenum, containing air throughout. 7. Small bilateral pleural effusions, right greater than left, with adjacent, compressive atelectasis. Radiology Report INDICATION: ___ year old man with significant bleeding after sphincterotomy, metal stent placed in ampulla to attempt tamponade but still bleeding// ___ year old man with significant bleeding after sphincterotomy, metal stent placed in ampulla to attempt tamponade but still bleeding COMPARISON: CTA of the abdomen pelvis dated ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure and was assisted by Dr. ___. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 90 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, Versed, 1% lidocaine CONTRAST: 100 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 43.1, 594 mGy PROCEDURE: 1. Right common femoral artery access. 2. Celiac arteriogram. 3. Superior mesenteric arteriogram. 4. Coil and Gel-Foam embolization of the gastroduodenal artery. 5. Right common femoral angiography and closure device placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the health care proxy. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. Both groins were prepped and draped in the usual sterile fashion. Using palpatory and fluoroscopic guidance, the right common femoral artery was punctured using a micropuncture set at the level of the mid-femoral head. A 0.018 wire was passed easily into the vessel lumen. A small skin incision was made over the needle. Then the inner dilator and wire were removed and a ___ wire was advanced under fluoroscopy into the aorta. The micropuncture sheath was exchanged for a 5 ___ sheath which was attached to a continuous heparinized saline side arm flush. A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire was removed and the superior mesenteric artery was selectively cannulated and a superior mesenteric arteriogram was performed. The C2 catheter was exchanged for an SOS catheter which was used to select celiac. A celiac arteriogram was performed. A renegade ___ microcatheter and Transcend wire was advanced into the GDA down to the gastroepiploic artery. The catheter was pulled back in a branch off the GDA was selected. This was embolized with a 4 mm Concerto coil. Post angiogram demonstrates a good result. The catheter was withdrawn into the main GDA and passed down to the gastroepiploic origin. An 8 mm Concerto coil was deployed in this location. While the coil initially appeared well seated, it subsequently embolized more distally into the gastroepiploic artery. A 7 mm micro snare was used to snare the coil and pull it back into the GDA. Despite this repositioning, the coil again migrated more distally into the gastroepiploic artery. 10 mm and 12 mm Concerto coils were used to embolize the GDA in addition to Gel-Foam. The initial 10 mm coil was anchored in a GDA branch to prevent further chance of embolization of the coil more distally. A 12 mm coil was used to embolize the GDA more proximally. Post angiography from the common hepatic artery and celiac demonstrated no residual flow into the GDA. Right common femoral arteriogram demonstrated satisfactory puncture site for a closure device. A 6 ___ Angio-Seal was successfully deployed the right groin. +2 right common femoral pulse was noted post closure. There was no hematoma. Additional manual pressure was held. A dressing was applied. The patient tolerated the procedure well without any immediate complications. FINDINGS: 1. No large SMA branches to the region of the stent. 2. Patent celiac artery and GDA. 3. Post embolization demonstrates no residual flow in the GDA. IMPRESSION: Technically successful coil and Gel-Foam embolization of the gastroduodenal artery. RECOMMENDATION(S): Continue to monitor for evidence of further bleeding. Radiology Report INDICATION: ___ year old man with pleurisy, low grade temps, hypoxia and sinus tachycardia, concern for PE// rule out PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 4.7 mGy (Body) DLP = 0.9 mGy-cm. 2) Stationary Acquisition 5.2 s, 0.2 cm; CTDIvol = 44.8 mGy (Body) DLP = 9.0 mGy-cm. 3) Spiral Acquisition 5.2 s, 33.7 cm; CTDIvol = 6.4 mGy (Body) DLP = 210.1 mGy-cm. Total DLP (Body) = 220 mGy-cm. COMPARISON: None FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. Coronary artery calcifications noted. There is no evidence of pericardial effusion. Moderate simple right greater than left pleural effusions are noted, extending into the major fissures. There are patchy and multifocal ground-glass opacities within the bilateral upper lobes , middle lobe and lingula demonstrating a peribronchovascular distribution suggestive of multifocal pneumonia. There is moderate compressive atelectasis of the dependent lung bases bilaterally. Small amount of debris is noted within the right upper trachea (06:49). The remainder of the airways are patent to the subsegmental level. Limited images of the upper abdomen is notable for hepatic steatosis and a partially visualized biliary stent. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral upper lobe predominant multifocal pneumonia. 3. Small to moderate right greater than left bilateral pleural effusions with compressive atelectasis of the bilateral dependent lung bases. 4. Hepatic steatosis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:51 pm, 1 minutes after discovery of the findings. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Abd pain, ETOH Diagnosed with Cholangitis temperature: 100.2 heartrate: 118.0 resprate: 20.0 o2sat: 93.0 sbp: 145.0 dbp: 99.0 level of pain: 8 level of acuity: 2.0

You were admitted with inflammation in your pancreas (pancreatitis) and significant liver injury. You were diagnosed with cirrhosis of the liver. You had an ERCP to look at the bile ducts and had some bleeding from this. You were also diagnosed with a pneumonia and will need to complete a course of antibiotics. It is very important that you avoid any future alcohol. Please follow up with your PCP as scheduled. We recommend referral to a GI doctor to monitor your liver and pancreas and to consider removal of the gallbladder. IF you wish to see Dr. ___ at ___, please call the number below. You will need to return for another ERCP in 4 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "transfer from OSH for work up of abdominal mass." Major Surgical or Invasive Procedure: colonoscopy with biopsy History of Present Illness: This is a ___ yo M with aPMHx of colonic polyps (last c-scope was ___ years ago) and bacterial overgrowth s/p ___ year of antibiotics who p/f ___ for further work up of an abdominal mass. . The patient began to have body aches and upper abdominal pain about 7 days PTA. He tried multiple over the counter medications and they were ineffective. The patient went on vacation to ___ this weekend and on ___ the patient reports having one blood streaked, solid stool. Then around noon, the patient had ___ blood from his rectum. Denies frank pre-syncopal symptoms. He then drove to ___ were imaging revealed an ascending colonic mass with cecal dilation and mild stranding. He was then transfered to ___ for further work up. . Patient currently complain of mild stiffness in his upper abdomen (RUQ/LUQ). Denies n/v. Is passing gas but has not had a stool in 24 hours. His last stool was small and semiformed with some blood. The patient denies w/l, f/c. . 10 point ROS is otherwise negative, except per above Past Medical History: - HTN - HLD - ___ colonic polyps-last was ___ years ago, where multiple polyps were removed at ___ Health-unsure of GI physicians name - ___ bleeding ulcer in UGI tract, s/p ___ year of antibiotics -? ___ liver cysts in past Social History: ___ Family History: sister had colon cancer at ___ yo, died at ___ other sister had breast cancer and is still living mother had breast cancer father was healthy Physical Exam: Admission PE 98.2 129/86 79 18 98 RA General: ___, in NAD HEENT: OP clear, MM somewhat dry CV: RRR, no RMG Lungs: CTAB no wrr Abdomen: obese, mild distention, mild TTP in RUQ, no palpable HSM, active BS, no rebound, no guarding Extremities: WWP, no CCE Neuro: CN and MS grossly intact, strength and sensation also grossly intact Psyc: mood and affect wnl Pertinent Results: . ___ CT AP with IV contrast -circumferential wall thickening of the mid right colon, cecum is markedly distended measuring 12X9 cm, adjacent stranding noted involving the cecum, multiple liver lesions, largest 2 cm -imp: findings are most consistent with adenocarcinoma of the mid-right colon with metastatic disease to the liver . labs at OSH wnl . . ___ data: ___ 06:20AM BLOOD WBC-8.5 RBC-4.56* Hgb-13.8* Hct-40.7 MCV-89 MCH-30.2 MCHC-33.8 RDW-13.7 Plt ___ ___ 06:45AM BLOOD WBC-7.6 RBC-4.58* Hgb-14.1 Hct-40.7 MCV-89 MCH-30.9 MCHC-34.7 RDW-13.7 Plt ___ ___ 08:03AM BLOOD WBC-8.4 RBC-4.73 Hgb-14.3 Hct-42.7 MCV-90 MCH-30.1 MCHC-33.4 RDW-13.6 Plt ___ ___ 06:45AM BLOOD Neuts-61.9 ___ Monos-8.6 Eos-6.5* Baso-0.3 ___ 08:03AM BLOOD Neuts-60.5 ___ Monos-7.9 Eos-4.1* Baso-0.5 ___ 06:45AM BLOOD ___ PTT-27.9 ___ ___ 08:03AM BLOOD ___ PTT-27.6 ___ ___ 06:45AM BLOOD Glucose-105* UreaN-14 Creat-0.8 Na-138 K-4.1 Cl-103 HCO3-22 AnGap-17 ___ 08:03AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-98 HCO3-29 AnGap-14 ___ 06:45AM BLOOD ALT-35 AST-37 AlkPhos-93 TotBili-0.8 ___ 06:45AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 ___ 06:45AM BLOOD CEA-158* AFP-4.1 ___ 12:56PM BLOOD Lactate-0.7. . CXR ___: SINGLE FRONTAL VIEW: There is mild cardiomegaly. The lungs are clear. Aside from minimal atelectasis in the right base, there is no pneumothorax or pleural effusion. There is no evidence of free air within the abdomen . PATHOLOGY: ___ ___ Pathology Examination Name ___ Age Sex Pathology # ___ MRN# ___ ___ ___ Male ___ ___ Report to: ___. ___ ___ by: ___. ___, ___ SPECImEN SUBMITTED: gi bx (3 jars) Procedure date Tissue received Report Date Diagnosed by ___ ___. ___/___ DIAGNOSIS: A Hepatic flexure mass biopsies: Adenocarcinoma. Slides reviewed with Dr. ___. ___. Transverse colon polypectomy: Adenoma. . Colonoscopy: Limitations: Obstructing mass when the hepatic flexure was reached. The exam was interrupted. Findings: Protruding Lesions A single sessile 2 mm non-bleeding polyp of benign appearance was found in the transverse colon. A single-piece polypectomy was performed using a cold forceps in the transverse colon. The polyp was completely removed. Other Mass was noted at the hepatic flexure with surrounding ulceration, edema and friability. The lumen was narrowed and angulated and the scope could not traverse the lesion. Multiple biopsies were obtained. Cold forceps biopsies were performed for histology at the hepatic flexure. Impression: Mass was noted at the hepatic flexure with surrounding ulceration, edema and friability. The lumen was narrowed and angulated and the scope could not traverse the lesion. Multiple biopsies were obtained. (biopsy) Polyp in the transverse colon (polypectomy) Otherwise normal colonoscopy to hepatic flexure Recommendations: Rush pathology results follow up per inpatient gi team recommendations Oncology consult Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Pravastatin 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: lower GI bleeding ___ to colon mass suspicion for colon ca and possible liver metastasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Patient with abdominal mass and tenderness. Evaluate for free air. SINGLE FRONTAL VIEW: There is mild cardiomegaly. The lungs are clear. Aside from minimal atelectasis in the right base, there is no pneumothorax or pleural effusion. There is no evidence of free air within the abdomen. Gender: M Race: PORTUGUESE Arrive by AMBULANCE Chief complaint: ABDOMINAL PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ABDOM/PELV SWELL/MASS UNSP SITE temperature: 98.6 heartrate: 82.0 resprate: 16.0 o2sat: 97.0 sbp: 135.0 dbp: 54.0 level of pain: 6 level of acuity: 2.0

You were transferred from another hospital for further evaluation of colon mass with suspicion for possible liver metastasis. You had a colonoscopy that also confirmed suspicion for colon cancer, however the biopsy is PENDING at the time of discharge. You will need evaluation by a surgeon, which your family has arranged at ___. In addition, you will need to follow up with an oncologist. Your family has suggested following up at ___ after biospy results. Please be sure to see your PCP and these specialists to help in determining the next steps in your care. You may need a biopsy of the liver lesions as well. Your symptoms improved during admission and you were able to tolerate a regular diet.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ with CABGx3 (___), anterior MI (___), ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off coumadin ___ noncompliance), chronic chest and R leg pain, and multiple prior ED visits and admissions for syncope and/or chest pain, now presenting with chest pain. He has had intermittent pain in the L chest for 2 days. He says this pain is equivalent to pain he has had for "some time", but has gotten worse over the last few days. The pain is not provoked or relieved by exercise (walking), and is worse when leaning forward. He reports that it is relieved by oxycodone but not nitryglycerin. Notably he says he was having this pain when he had a syncopal episode in church 2 weeks ago, leading to his most recent admission. The pain is ___, though at times worse than the ___ pain in his R leg. No radiation to anywhere else in the body. He endorses pain in his R leg which is related to his past MVA and unchanged from baseline. He endorses no fevers, no cough, no abd pain, no n/v. Notably, the patient has >20 hospital admissions over the past year, with repeatedly negative workups. He was last discharged from ___ 10 days ago. He was admitted for syncope. At that time the patient had unchanged EKG, negative troponins x 2, pacemaker interrogation revealed normal function, and no events on telemetry monitoring. He had an unchanged stress test in ___, and a negative CTA performed in ___. In the ED, initial VS were HR 76, RR 18, BP 116/76, O2 99RA. He was afebrile. He received aspirin 325 x2. Troponin-T was <0.01 x2. EKG revealed delayed R-wave progression, T wave inversions in I and AVL as well as lateral T-wave changes that were unchanged from his exam on ___. Vital signs remained stable, and his chest pain improved. He was admitted to the general medicine floor for further workup and monitoring. On arrival to the floor, patient reports his chest pain has improved. Still complains of leg pain. He reports drinking "20 glasses" of water per day due to a desire to avoid drinking soda and juice, which he knows is bad for him. REVIEW OF SYSTEMS: 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. Mood is good. Denies recent stressors. Denies desire to hurt self or others. All other 10-system review negative in detail. Past Medical History: - CAD s/p MI in ___ and CABG for 3-VD in ___ - CHF with LVEF of ___ in per ___ TTE. Patient now s/p ICD. - Delusional and affective thought disorder - Hypertension - Hyperlipidemia - Type 2 diabetes. Not currently on medications. - History of LV thrombus. Failed Coumadin per ___ notes in ___ due to noncompliance and supratherapeutic INR's - History of DVT and PE in ___. Previously on Coumadin. - Chronic chest pain due to sternotomy - Chronic back pain - MVC (struck pedestrian) in ___ - Possible PTSD due to MVC - Diverticulosis - History of thyroid nodule Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION EXAM: VS 98.0 115/70 74 16 100RA GENERAL: Lying in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CHEST: RRR, S1/S2, no murmurs, gallops, or rubs. Endorses tenderness over R pectoralis muscle. Denies pain at sternotomy scar or over implanted pacemaker (overlies LUQ of L pectoralis). LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Moves all extremities, no cyanosis, clubbing or edema appreciated. Right lower extremity is wrapped, and the patient does not allow it to be unwrappped to be examined (this is location of his previous injury). Able to move foot and toes. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact PSYCH: Alert and oriented to person and location, but not day of week (___). Recall ___ ("ball, table, truth") after 5 minutes. Good fund of general knowledge (names past 3 presidents). Impaired ability to make abstractions (when asked similarity between apple and orange, says "you can peel an orange and just eat an apple", asked to explain "people in glass houses shouldn't throw stones" says "you'll break something"). SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: VS 97.9 109/62 69 16 100RA GENERAL: Lying in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, nontender supple neck, no LAD, no JVD CHEST: RRR, S1/S2, no murmurs, gallops, or rubs. Stable tenderness over R pectoralis muscle. No pain elsewhere over chest. LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding. EXTREMITIES: Moves all extremities, no cyanosis, clubbing or edema appreciated. Right lower extremity is wrapped, and the patient does not allow it to be unwrappped to be examined (this is location of his previous injury). Able to move foot and toes. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact PSYCH: A/O x2, oriented to day of week but not date. SKIN: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ___ 07:25PM cTropnT-<0.01 ___ 08:40AM cTropnT-<0.01 ___ 02:30AM cTropnT-<0.01 ___ 02:30AM GLUCOSE-131* UREA N-20 CREAT-1.6* SODIUM-136 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-10 ___ 02:30AM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-58 TOT BILI-0.3 ___ 02:30AM LIPASE-60 ___ 02:30AM ALBUMIN-4.3 ___ 02:30AM WBC-5.6 RBC-4.07* HGB-11.6* HCT-35.9* MCV-88 MCH-28.5 MCHC-32.3 RDW-13.6 ___ 02:30AM ___ PTT-28.8 ___ ___ 06:55AM BLOOD WBC-3.9* RBC-4.15* Hgb-11.6* Hct-36.3* MCV-87 MCH-27.9 MCHC-31.9 RDW-13.3 Plt Ct-UNABLE TO ___ 06:55AM BLOOD Glucose-104* UreaN-21* Creat-1.4* Na-138 K-4.2 Cl-105 HCO3-25 AnGap-12 ___ 06:55AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0 CXR ___: No acute process EKG ___: Sinus rhythm. Extensive ST segment changes prominently in leads V1-V4 suggestive of anterior wall myocardial infarction. Compared to the previous tracing of ___ ST segment changes are similar. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Benztropine Mesylate 1 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Haloperidol 5 mg PO BID 6. Lidocaine 5% Ointment 1 Appl TP TID:PRN lower extremity pain 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H PRN pain 11. Pantoprazole 40 mg PO Q24H 12. Psyllium 1 PKT PO DAILY:PRN constipation 13. QUEtiapine Fumarate 50 mg PO QHS 14. Sertraline 200 mg PO DAILY 15. Senna 8.6 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Benztropine Mesylate 1 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Haloperidol 5 mg PO BID 6. Lidocaine 5% Ointment 1 Appl TP TID:PRN lower extremity pain 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H PRN pain 11. Pantoprazole 40 mg PO Q24H 12. Psyllium 1 PKT PO DAILY:PRN constipation 13. QUEtiapine Fumarate 50 mg PO QHS 14. Senna 8.6 mg PO BID 15. Sertraline 200 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== # Musculoskeletal chest pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man with chest pain. COMPARISON: ___. FINDINGS: AP upright and lateral views of the chest were obtained. Cardiomediastinal silhouette is stable. A dual-chamber pacemaker is unchanged in position. Lung volumes are low. No focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No acute process. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, AORTOCORONARY BYPASS temperature: 98.0 heartrate: 80.0 resprate: 18.0 o2sat: 98.0 sbp: 106.0 dbp: 66.0 level of pain: 6 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for chest pain. You were having intermittent chest pain for many weeks, but the pain was worse in the 2 days prior to your admission. You were also having leg pain from your prior accident. You were worked up for acute myocardial infarction or other cardiovascular events, and EKG, cardiac enzymes, and continuous monitoring all failed to show any evidence of a cardiac etiology of your chest pain. Your discomfort is most likely due to musculoskeletal pain, which you have also had in the past. Please continue your home medications; no new medications were prescribed for you. Please follow up with your primary care physician, ___ as instructed below, for further management of your leg and chest pain. Please continue to weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right face and arm numbness and weakness Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ w/ Afib, CAD s/p 4x CABG, HLD, HTN who was taken of warfarin 3 weeks ago in setting of normal Holter and two days ago presented with Afib w/ RVR in setting of pneumonia and restarted on warfarin, who presents with 10 minutes of right finger numbness and right facial weakness. The patient was in his usual state of health when two days ago (___), he presented to the BI ED for tachycardia and fever, and found to have a right lower lobe pneumonia and Afib w/ RVR. He was discharged yesterday on levofloxacin and has been afebrile since. This morning he was in his usual state of health when he noted diffuse right finger anesthesia, not including palm or arm. This started at around 10:00am, and when he told his wife, she noted a few minutes of right lower facial weakness. He also had difficulty lifting a bag with his right hand, unclear if there was superimposed weakness. There was also a lower pitch to his voice. All symptoms resolved after 10 minutes. After calling his cardiologist, he was recommended to come to the ED for evaluation. Review symptoms positive for recent fevers, previous palpitations but none today, chronic hearing loss. On review of systems, the patient denies the following: - Neurologic: headache, confusion, difficulty producing speech, difficulty understanding speech, vision loss, diplopia, vertigo, dysarthria, dysphagia, focal limb weakness, sensory loss, gait imbalance. - Constitutional: fever, rigors, night sweats, unintentional weight loss. - Cardiovascular: chest pain, lightheadedness. - Gastrointestinal: nausea, emesis, diarrhea, constipation. - Genitourinary: dysuria, urinary urgency, urinary incontinence. - Ear, Nose, Throat: tinnitus, rhinorrhea, odynophagia. - Hematologic: bleeding, easy bruising. - Musculoskeletal: arthralgia, myalgia. - Psychiatric: anxiety, depression. - Respiratory: dyspnea, cough, hematemesis. - Skin: rash, new skin lesions. Past Medical History: CAD, s/p small MI ___ (Med RX/No prior catheterization) Angina Right Frontal Ischemic Stroke ___ (No residual deficits) Small infrarenal AAA Hypertension Dyslipidemia Moderate Aortic Regurgitation PFO Sleep apnea (no cpap currently) Osteoporosis Gout Social History: ___ Family History: Premature coronary artery disease- Father died at age ___ from heart disease in ___ Physical Exam: Admission Physical Examination: VS T: 99.0 HR: 70 BP: 127/88 RR: 18 SaO2: 100% RA - General/Constitutional: Lying in bed comfortably, well-appearing. - Eyes: Round, regular pupils. No conjunctival icterus, no injection. - Ear, Nose, Throat: No oropharyngeal lesions. Normal appearance of the tongue. - Neck: No meningismus. - Musculoskeletal: Range of motion with neck rotation full bilaterally. No focal spinal tenderness. - Skin: No rashes. No concerning lesions appreciated. - Cardiovascular: Regular rate. - Respiratory: No increased work of breathing, retractions or wheeze. - Gastrointestinal: Nontender. Nondistended. - Psychiatric: Mood congruent with affect. Intact insight. ___ Stroke Scale - Total [0] 1a. Level of Consciousness - 0 1b. LOC Questions - 0 1c. LOC Commands - 0 2. Best Gaze - 0 3. Visual Fields - 0 4. Facial Palsy - 0 5a. Motor arm, left - 0 5b. Motor arm, right - 0 6a. Motor leg, left - 0 6b. Motor leg, right - 0 7. Limb Ataxia - 0 8. Sensory - 0 9. Language - 0 10. Dysarthria - 0 11. Extinction and Neglect - 0 Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards. Recalls a coherent history. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension (though with some repetition due to language barrier). Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. No apraxia. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - [II] PERRL 4->2 brisk. VF full to number counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial movement asymmetry with forced eyelid closure or volitional smile. [VIII] Chronic difficulty hearing finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. No pronation, no drift. No orbiting with arm roll. No tremor or asterixis. ___ strength in the proximal and distal UEs and LEs. - Sensory - No deficits to light touch or pinprick in upper extremities. Feet with intact sensation to pinprick bilaterally. Decreased vibration sense in right foot 0 seconds, 6 seconds in left foot. Bilateral decreased proprioception, R worse than L. No extinction to double simultaneous tactile stimulation. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L ___ 1 1 R ___ 1 1 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose or heel-shin testing. - Gait - Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. No Romberg. Mild difficulty with tandem gait. ============= Discharge Physical Exam: General exam: unremarkable Neurologic exam: MS intact. CN intact bilaterally. Full strength in the proximal and distal UEs. Reflexes diminished symmetrically (1+ throughout). Coordination intact. Independent, narrow-based gait. Pertinent Results: ___ 03:00PM BLOOD WBC-9.9 RBC-4.85 Hgb-11.5* Hct-37.7* MCV-78* MCH-23.7* MCHC-30.5* RDW-18.7* RDWSD-50.8* Plt ___ ___ 03:00PM BLOOD Neuts-70.2 Lymphs-18.2* Monos-10.5 Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.93* AbsLymp-1.80 AbsMono-1.04* AbsEos-0.04 AbsBaso-0.02 ___ 04:45AM BLOOD ___ ___ 04:45AM BLOOD Glucose-82 UreaN-29* Creat-1.4* Na-140 K-4.5 Cl-107 HCO3-22 AnGap-16 ___ 04:45AM BLOOD cTropnT-<0.01 ___ 03:00PM BLOOD cTropnT-<0.01 ___ 04:45AM BLOOD %HbA1c-5.4 eAG-108 ___ 04:45AM BLOOD Triglyc-83 HDL-34 CHOL/HD-4.3 LDLcalc-94 ___ 04:45AM BLOOD TSH-2.6 ============= IMAGING: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. Mild prominence of ventricles and sulci is likely related to age related involutional changes. The basilar cisterns are patent, and there is otherwise good preservation gray-white matter differentiation. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. Note is made of a fetal type origin of the right PCA. The posterior circulation is otherwise well preserved. Incidental note is made a fenestrated proximal basilar artery, immediately at the junction of the vertebral arteries. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. Mild atherosclerotic calcification is seen at the carotid siphons bilaterally. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No acute intracranial abnormalities identified. 2. Unremarkable CTA of the head, with a patent circle of ___. 3. Unremarkable CTA of the neck, without evidence of internal carotid artery stenosis by NASCET criteria. MRI Brain: Linear cortical left parietal restricted diffusion, with questioned minimal T2/FLAIR hyperintensity, without definite associated increase susceptibility is noted (see 3, 04:24, 9, 10, 11: 18). Right frontal linear T2 and FLAIR hyperintensity is noted. There is no evidence of hemorrhage or midline shift. There is prominence of the ventricles and sulci suggestive involutional changes. Minimal bilateral ethmoid air cell mucosal thickening. IMPRESSION: 1. Left parietal acute to subacute infarct without definite hemorrhagic transformation, as described. 2. Right frontal nonspecific white matter changes, which may represent microangiopathic changes are sequela of prior trauma or infarct. 3. Minimal paranasal sinus disease as described. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levofloxacin 750 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q6H:PRN pain 3. Allopurinol ___ mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Warfarin 2 mg PO DAILY16 8. Metoprolol Succinate XL 150 mg PO DAILY 9. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 80 mg SC BID Start: ___, First Dose: First Routine Administration Time use until INR is ___ RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous twice a day Disp #*1 Package Refills:*0 4. Allopurinol ___ mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Levofloxacin 750 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Metoprolol Succinate XL 150 mg PO DAILY 9. Warfarin 2 mg PO DAILY16 10. HELD- Aspirin EC 81 mg PO DAILY This medication was held. Do not restart Aspirin EC until you discontinue lovenox Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: acute ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with recent admission for RLL PNA, here w episode of R hand numbness and R facial droop // Eval for acute process, change in PNA, stroke TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy and CABG. Tortuous, unfolded aorta is similar in appearance compared the prior study. The cardiac silhouette is stable.No focal consolidation is seen. There is minor left base atelectasis. There is persistent blunting of the right costophrenic angle suggesting a trace right pleural effusion. No overt pulmonary edema. IMPRESSION: Trace right pleural effusion again seen. No definite focal consolidation. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with recent admission for RLL PNA, here w episode of R hand numbness and R facial droop // Eval for acute process, change in PNA, stroke TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP = 32.7 mGy-cm. 3) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,357.7 mGy-cm. Total DLP (Head) = 2,400 mGy-cm. COMPARISON: MRI of the brain from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. Mild prominence of ventricles and sulci is likely related to age related involutional changes. The basilar cisterns are patent, and there is otherwise good preservation gray-white matter differentiation. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. Note is made of a fetal type origin of the right PCA. The posterior circulation is otherwise well preserved. Incidental note is made a fenestrated proximal basilar artery, immediately at the junction of the vertebral arteries. CTA NECK: The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. Mild atherosclerotic calcification is seen at the carotid siphons bilaterally. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No acute intracranial abnormalities identified. 2. Unremarkable CTA of the head, with a patent circle of ___. 3. Unremarkable CTA of the neck, without evidence of internal carotid artery stenosis by NASCET criteria. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ year old male with history of Afib, multiple cardiovascular risk factors, now with transient right hand numbness, and right facial and hand weakness. Evaluate for acute infarct. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___ head and neck CTA. ___ noncontrast brain MRI/ MRA. FINDINGS: Linear cortical left parietal restricted diffusion, with questioned minimal T2/FLAIR hyperintensity, without definite associated increase susceptibility is noted (see 3, 04:24, 9, 10, 11: 18). Right frontal linear T2 and FLAIR hyperintensity is noted. There is no evidence of hemorrhage or midline shift. There is prominence of the ventricles and sulci suggestive involutional changes. Minimal bilateral ethmoid air cell mucosal thickening. IMPRESSION: 1. Left parietal acute to subacute infarct without definite hemorrhagic transformation, as described. 2. Right frontal nonspecific white matter changes, which may represent microangiopathic changes are sequela of prior trauma or infarct. 3. Minimal paranasal sinus disease as described. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 13:39 into the Department of Radiology critical communications system for direct communication to the referring provider. The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:41 ___, 10 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Numbness Diagnosed with Transient cerebral ischemic attack, unspecified temperature: 99.0 heartrate: 70.0 resprate: 18.0 o2sat: 100.0 sbp: 127.0 dbp: 88.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of right hand and face numbness and weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - atrial fibrillation - high cholesterol - high blood pressure We are changing your medications as follows: - start lovenox injections and take until your INR is ___ - HOLD aspirin while taking lovenox (you can restart this once you stop lovenox) Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. Please get your INR checked in 2 days, ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: ___: Open reduction, internal fixation anterior pelvic ring and posterior pelvic ring injury with 7.3 mm screws History of Present Illness: This patient is a ___ year old male brought in by medics light from the scene after a reported 30 foot fall through skyline all performing snow maintenance building roof. Extrication time was approximately 40 minutes from the building. The patient was brought in with concern for pelvis injury. He is wearing a cervical collar, awake, alert, and oriented x3. Positive LOC according to bystanders. Patient is ___ only. He complains of abdominal pain and mild shortness of breath. Vital signs are normal on arrival. Has received 100 mcg of fentanyl prior to arrival. He denies significant headache, vision changes, nausea, vomiting. He states he has no medical history, allergies, medications, or surgical history. Past Medical History: none Family History: noncontributory Physical Exam: PHYSICAL EXAMINATION O(2)Sat: 99 Normal Constitutional: Mildly uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Nondistended, mildly diffusely tender without guarding. No bruising or flank pain Extr/Back: No cyanosis, clubbing or edema, no obvious deformity. Pelvis appears stable Skin: Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation ___: No petechiae PE on discharge: VS: 98.3, 79, 110/40, 18, 98%ra Gen: A&O x3, NAD Chest: LS ctab CV: HRR, normal s1/s2 Abd: soft, NT/ND. left pelvic and left hip staples Ext: no edema Pertinent Results: ___ 06:20AM BLOOD WBC-4.0 RBC-3.13* Hgb-9.9* Hct-27.5* MCV-88 MCH-31.7 MCHC-36.1* RDW-13.1 Plt ___ ___ 07:55PM BLOOD Hct-27.3* ___ 01:00PM BLOOD Hct-26.9* ___ 06:05AM BLOOD WBC-4.3 RBC-2.97* Hgb-9.3* Hct-26.0* MCV-88 MCH-31.4 MCHC-35.8* RDW-12.8 Plt ___ ___ 12:13AM BLOOD Hct-27.7* ___ 07:28PM BLOOD Hct-30.4* IMAGING: CT C-SPINE 1. No evidence of fracture or dislocation. CT HEAD No evidence of acute intracranial abnormality. CT CHEST; CT ABD & PELVIS 1. Moderate right pneumothorax and pneumomediastinum. Multiple right lung contusions. 2. Grade 2 liver injury. Small amount of perihepatic hemorrhage tracking inferiorly into the pelvis. 3. Possible tiny contusion in the superior aspect of the spleen. 4. Nondisplaced right seventh rib fracture. Fractures of the superior inferior left pubic rami. Fractures of the left sacral ale and left ischial tuberosity. WRIST XRAY No fracture or dislocation. Carpal rows appear intact. No radiopaque foreign body. Soft tissues unremarkable. CXR ___ As compared to the previous image, there is no substantial change in dimension of the right apical pneumothorax. The patient shows no evidence of tension. The pre described subtle right lower lung parenchymal opacity has completely resolved, a small atelectasis in the infra hilar right lung regions persists. Unremarkable left lung. Normal size of the cardiac silhouette. No pneumonia or pleural effusions. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Outpatient Physical Therapy Medical Dx / ICD9: 959.9/trauma 850.9/Concussion Activity Orders: L ___: TDWBING, R ___: WBAT Goals: Gait training 5. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*14 Syringe Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1: Fall from 30 feet 2: Grade 2 liver laceration, small splenic injury 3: Anterior and posterior pelvic ring fracture, left-sided 4: moderate left-sided pneumothorax with pulmonary contusion 5: Right 7th rib fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS (AP, INLET AND OUTLET) IN O.R. INDICATION: PELVIS FX TECHNIQUE: 51 intraoperative fluoroscopic spot images of the pelvis were obtained without the radiologist present. Total fluoroscopy time is 01:00 29 seconds. COMPARISON: Radiographs of the pelvis and CT of the torso ___. FINDINGS: Sequential images demonstrate localizing devices over the right inferior pubic ramus, the sacrum and the left iliac bone with subsequent fixation of left sacroiliac joint diastasis with a lag screw and fixation of a fracture through the left superior pubic ramus with an additional lag screw. There is no evidence of hardware complication. There is redemonstration of a left inferior pubic ramus fracture. IMPRESSION: Open reduction internal fixation of a fracture through the left superior pubic ramus and left sacroiliac joint diastasis. Please see the operative report for further details. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with fall from 30 ft // eval ptx IMPRESSION: AS COMPARED TO THE PREVIOUS RADIOGRAPH FROM EARLIER THE SAME DATE, A SMALL RIGHT APICAL PNEUMOTHORAX IS SIMILAR TO THE PRIOR STUDY. RIGHT LOWER LOBE OPACITY HAS PARTIALLY RESOLVED, AND REMAINDER OF THE LUNGS AND PLEURA ARE UNCHANGED. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with +LOC, polytrauma, grade 2 liver lac, infr pubic rami/iliac frx, R PTX, R 7th rib frx // Evaluation of pneumothorax COMPARISON: ___. IMPRESSION: As compared to the previous image, there is no substantial change in dimension of the right apical pneumothorax. The patient shows no evidence of tension. The pre described subtle right lower lung parenchymal opacity has completely resolved, a small atelectasis in the infra hilar right lung regions persists. Unremarkable left lung. Normal size of the cardiac silhouette. No pneumonia or pleural effusions. Radiology Report INDICATION: ___ year old man with fall from 30 ft // eval fracture TECHNIQUE: Three views right wrist. COMPARISON: None FINDINGS: No fracture or dislocation. Carpal rows appear intact. No radiopaque foreign body. Soft tissues unremarkable. IMPRESSION: No fracture or dislocation of the wrist. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with fall from 30 ft // trauma TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 891 mGy-cm CTDI: 53 mGy COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. Gray-white matter differentiation is preserved. No osseous abnormalities seen. There is mucosal thickening in the right frontal sinus and frontoethmoidal recess. There is opacification of bilateral anterior ethmoid air cells. There is minimal mucosal thickening in the sphenoid sinuses and mild mucosal thickening in the partially imaged maxillary sinuses. The mastoids are underdeveloped but clear. The middle ear cavities are clear. IMPRESSION: Minimal paranasal sinus inflammatory changes. Otherwise normal study. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with fall from 30 ft // trauma trauma TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 37 mGy DLP: 817 mGy-cm COMPARISON: None FINDINGS: Alignment is normal. No fractures are identified. There is no evidence of spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. There is partially imaged right apical pneumothorax. The palatine tonsils are enlarged with several tonsilliths. There are prominent but symmetric cervical lymph nodes likely within normal limits for patient's age. IMPRESSION: 1. No evidence of fracture or dislocation. Right apical pneumothorax partially imaged. 2. Enlarged palatine tonsils with several tonsilliths. 3. Prominent cervical all lymph nodes likely within normal limits for patient's age. Radiology Report INDICATION: History: ___ with fall from 30 ft // trauma TECHNIQUE: Frontal radiographs of the chest and pelvis. COMPARISON: CT of the torso performed on ___ at 11:42am. FINDINGS: CHEST: The lungs are well expanded and clear. Cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax, pleural effusion, or consolidation. No acute displaced rib fractures are identified. PELVIS: Frontal radiograph of the pelvis demonstrates fractures involving the left inferior pubic ramus and left iliac bone, and through the superior pubic ramus as well. IMPRESSION: 1. Fractures of the left inferior pubic ramus, left iliac bone, and superior pubic ramus. 2. No acute cardiopulmonary process. Radiology Report INDICATION: History: ___ with fall from 30 ft // trauma TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen and pelvis after administration of 130 cc of Omnipaque IV contrast. Multiplanar axial, coronal and sagittal images were generated. DOSE: Total body DLP: 445 mGy-cm COMPARISON: None FINDINGS: CT CHEST WITH CONTRAST: Partially imaged thyroid unremarkable. No lymphadenopathy. Esophagus normal. Heart size is normal without pericardial effusion. Aorta and main thoracic vessels wall opacified. Main pulmonary artery is normal in caliber. There is pneumomediastinum. There is moderate right pneumothorax. Multiple rounded peripheral opacities throughout the right lung are compatible with lung contusions. There is no pleural effusion. Left lung is essentially clear. The tracheobronchial tree is patent to the subsegmental level. CT ABDOMEN WITH CONTRAST: There is a 5.6 x 3.1 x 9.3 cm intraparenchymal contusion in the liver (series 602B image 21). There is small amount of hemorrhage around the liver which tracks inferiorly along the paracolic gutter into the pelvis. There is no intra or extrahepatic biliary duct dilation. The gallbladder is normal. 6 mm hypodense peripheral focus in the upper aspect of the spleen may be a small contusion. There is no perisplenic hemorrhage. The spleen, adrenal glands, and kidneys are normal. Kidneys excrete contrast symmetrically without hydronephrosis. The ureters are normal throughout their visualized course. The stomach, small large bowel are normal in caliber without obstruction. The abdominal aorta and iliac arteries are normal in caliber. CT PELVIS WITH CONTRAST: The urinary bladder and rectum are normal. As mentioned above hemorrhagic free fluid tracks into the right hemipelvis. Trace amount of hemorrhage is also seen in the left hemipelvis. BONES AND SOFT TISSUES: There is a nondisplaced fracture of the right seventh rib laterally (series 2, image 35). There are fractures of the superior and inferior left pubic rami. There also fractures of the left sacral ala and the left ischial tuberosity (series 2, image 89). There are small anterior fractures of the right and left pubic bones (2:109) at the pubic symphysis. IMPRESSION: 1. Moderate right pneumothorax and pneumomediastinum. Multiple right lung contusions. Nondisplaced right seventh rib fracture. 2. Grade two liver injury as detailed above. Small amount of perihepatic hemorrhage tracking inferiorly into the pelvis. 3. Possible tiny contusion in the superior aspect of the spleen. 4. Fractures of the superior and inferior left pubic rami. Fractures of the left sacral ale and left ischial tuberosity. Small anterior fractures of the right and left pubic bones at the pubic symphysis NOTIFICATION: Fracture of the pubic symphysis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p fall with rib frx, pneumothorax, pneumomediastinum // Pls perform at 6 ___. please look for interval change in pneumothorax/pneumomediastinum Pls perform at 6 ___. please look for interval change in , pn COMPARISON: Chest radiographs and chest CT performed between 11 and 11:45 today. IMPRESSION: Heterogeneous consolidation in the right lower lobe, new since earlier in the day is local bleeding due to contusion and small laceration seen on the chest CT scan. Followup advised. Small right pneumothorax, confirmed by the chest CT scan, is most readily seen along the right lower costal surface and is no larger now than it was earlier in the day. Small pneumomediastinum is unchanged. In the setting of closed chest trauma this need not indicate disruption of the esophagus or tracheal bronchial tree, either of which would probably produce more air in the mediastinum and conceivably hemo mediastinal hematoma. Otherwise the cardiomediastinal silhouette has a normal appearance. Left lung is clear and there is no left pleural abnormality. Detection of chest wall trauma is more reliable with torso CT. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ yo male s/p 30 ft fall with multiple injuries // assess for interval changes. expiratory, sit up as much as possible assess for interval changes. expiratory, sit up as much as p COMPARISON: Chest radiographs on ___, read in conjunction with torso CT also ___. IMPRESSION: The expiration view was obtained on the instructions of the requesting physician. This may account for the apparent increase in size of the small right pneumothorax which, in reality, may be unchanged. It may also exaggerate the confluence of the previous consolidation in the right lower lobe due to local bleeding. I have discussed the advisability of retaining of obtaining full inspiratory chest radiographs hereafter. Interval increase in heart size and mediastinal venous caliber is due in part to lower lung volumes, but most likely increased intravascular volume as well. Left lung is clear and there is no left pleural abnormality. NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on ___ at 10:44 AM, 5 minutes after discovery of the findings. The explained that the patient has no findings to suggest continued bleeding in the lung or pneumonia. Gender: M Race: HISPANIC/LATINO - GUATEMALAN Arrive by HELICOPTER Chief complaint: 30 FOOT FALL Diagnosed with LIVER INJURY NOS, PELVIC FRACTURE NOS-CLOS, UNSPECIFIED FALL temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

You were admitted to ___ after falling 30 feet through a skylight. You sustained multiple injuries, including a liver laceration, pelvic fracture, and rib fracture. You were taken to the operating room and had your pelvis fixed by the Orthopedic team. You have worked with Physical Therapy and Occupational Therapy, and you are cleared for discharge home to continue your recovery. Please note the following discharge instructions: Liver/ Spleen lacerations: *AVOID contact sports and/or any activity that may cause injury to your abdominal area for the next ___ weeks. *If you suddenly become dizzy, lightheaded, feeling as if you are going to pass out go to the nearest Emergency Room as this could be a sign that you are having internal bleeding from your liver or spleen injury. *AVOID any blood thinners such as Motrin, Naprosyn, Indocin, Aspirin, Coumadin or Plavix for at least ___ days unless otherwise instructed by the MD/NP/PA. Rib Fractures: * Your injury caused one rib fracture which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, 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. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: s/p ablation of atrial flutter ___ History of Present Illness: ___ with PMH HTN, COPD, and DMII p/w SOB. Pt woke up at 3am gasping for breath and that is why she came in. She has had DOE for many years now but this SOB was much worse and she "didn't feel good." No CP but admits to a "tightening" sensation in the ___ her chest, which she can point to. Also admits to lightheadedness with the SOB and also with the DOE that is chronic. Cough has been worse recently and productive of more sputum. No f/c/s, N/V/D, no dysuria. No blood in stool but stool is "dark" after starting iron supplements. Denies ___ edema. Denies orthopnea. Denies palpitations or syncope. Called EMS and O2 sat was 92% so she was placed on O2 NC by EMT. In the ED, initial VS 97.1, ___, 42, 98% 4L. And EKG showed aflutter with RVR to 140s. No prior history of aflutter or afib. Labs significant for Cr 1.5 (at baseline), negative troponins, and Hct 34.3 (most recent baseline 33). CXR showed "Moderate cardiomegaly, mild pulmonary edema and small bilateral pleural effusions consistent with CHF." She was given aspirin 325, duonebs, diltiazem 10mg IV plus 30mg po for RVR. HR improved to 100s and then to ___ prior to transfer. On arrival to floor VS 97.3, 152/93, 115, 24, 90% RA. Pt has no c/o currently. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: 3. OTHER PAST MEDICAL HISTORY: -HTN -DM2 -Iron deficiency anemia -Hypercholesterolemia -Gout -COPD with FEV1 42% of predicted in ___ (most recent testing) -Obesity -GI bleeding: ___ diverticular, ___ duodenal AVMs s/p cautery, ___ angioectasias of fundus s/p injections and thermal therapy Social History: ___ Family History: Father died of stroke at ___ years of age. Mother died of diabetes complications in her ___. ___ brother had MI, 1 brother died of colon cancer at ___ Physical Exam: ADMISSION: VS: 97.3, 152/93, 115, 24, 90% RA General: morbidly obese female in NAD HEENT: moist mucous membranes Neck: no JVD CV: faint heart sounds, RRR no m/r/g Lungs: poor air movement bilaterally, no wheezes, rales, rhonchi Abdomen: soft, NT, obese, NABS Ext: 2+ pulses, no edema Skin: warm and well-perfused DISCHARGE: VS: 98.3 (max 99.0) 145/72 (120s-150s/50s-70s) 80 (60s-90s) 20 94% RA (94-96% RA, 96-100% on 1.5-2L NC) Weight: 100.2kg (I/O 145___ for 24hrs; 104/475 since MN) Fasting blood sugar: 183 (FSBG on day prior: ___ General: No apparent distress HEENT: EOMI, anicteric Neck: +JVD in upright position CV: RRR, no m/g/r Pulm: No audible crackles bilaterally, no wheeze Abd: +BS, soft, nontender, nondistended Ext: Warm, right lower leg with mild pitting edema, no edema on left. R groin with light purple patch in inguinal region. No hematoma, no active bleeding, no bruit. Mildly tender to palpation, improved. Right DP pulse 2+. Neuro: Alert, nonfocal. R ankle flexion/extension intact. Psych: Calm, appropriate Pertinent Results: ADMISSION LABS ___ 05:10AM ___ PTT-31.1 ___ ___ 05:10AM PLT COUNT-295 ___ 05:10AM NEUTS-78.5* LYMPHS-13.8* MONOS-5.4 EOS-1.7 BASOS-0.6 ___ 05:10AM WBC-10.9 RBC-4.74 HGB-10.1* HCT-34.3* MCV-72* MCH-21.3* MCHC-29.4* RDW-17.7* ___ 05:10AM cTropnT-<0.01 ___ 05:10AM estGFR-Using this ___ 05:10AM GLUCOSE-216* UREA N-32* CREAT-1.5* SODIUM-143 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-20 ___ 12:35PM URINE MUCOUS-RARE ___ 12:35PM URINE HYALINE-1* ___ 12:35PM URINE RBC-1 WBC-29* BACTERIA-MANY YEAST-NONE EPI-<1 ___ 12:35PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD ___ 12:35PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 07:26PM TSH-2.3 ___ 07:26PM CK-MB-2 cTropnT-<0.01 ___ 07:26PM CK(CPK)-81 MICROBIOLOGY Time Taken Not Noted Log-In Date/Time: ___ 6:02 pm URINE TAKEN FROM 648B. **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. ___ MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 64 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S INTERIM LABS / LAB TRENDS ___ 05:10AM BLOOD cTropnT-<0.01 ___ 07:26PM BLOOD CK-MB-2 cTropnT-<0.01 DISCHARGE LABS ___ 05:35AM BLOOD WBC-8.3 RBC-4.27 Hgb-9.0* Hct-30.4* MCV-71* MCH-21.1* MCHC-29.6* RDW-18.3* Plt ___ ___ 05:35AM BLOOD Plt ___ ___ 05:35AM BLOOD ___ PTT-99.7* ___ ___ 05:35AM BLOOD Glucose-162* UreaN-29* Creat-1.4* Na-139 K-3.5 Cl-97 HCO3-30 AnGap-16 ___ 05:35AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0 CXR PA/lateral ___ Thereis hyperinflation, consistent with background COPD. There is increased diffuse parenchymal opacities bilaterally, more prominent at the bases consistent with mild pulmonary edema. There are small bilateral pleural effusions layering posteriorly, left greater than right. There is fluid in the major fissure seen on the lateral view. There is moderate cardiomegaly. No pneumothorax. The left hemidiaphragm is elevated laterally. IMPRESSION: Moderate cardiomegaly, mild pulmonary edema and small bilateral pleural effusions consistent with CHF. TTE ___ The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild-moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity dilation with free wall hypokinesis. Pulmonary artery hypertension. Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function. Compared with the prior study (images reviewed) of ___, the right ventricular cavity dilation, free wall hypokinesis and pulmonary artery hypertension are new. This constellation of new findings is suggestive of an acute pulmonary process (e.g., pulmonary embolism, etc.) CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. V/Q scan ___ INTERPRETATION: Both ventilation and perfusion images demonstrate patchy radiotracer activity, worse on the ventilation series, but without areas of V/Q mismatch. Soft tissue attenuation is seen in both the ventilation and perfusion images. No segmental defects are noted. Chest x-ray shows moderate cardiomegaly, mild pulmonary edema, and small bilateral pleural effusions consistent with CHF. IMPRESSION: Low likelihood ratio for acute pulmonary embolism. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral BID 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. MetFORMIN (Glucophage) 850 mg PO Frequency is Unknown 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Torsemide 5 mg PO DAILY 7. Tiotropium Bromide 1 CAP IH DAILY 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 9. Advair Diskus (fluticasone-salmeterol) Dose is Unknown Unknown Inhalation daily Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral BID 6. MetFORMIN (Glucophage) 850 mg PO Frequency is Unknown 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Torsemide 5 mg PO DAILY 9. Enoxaparin Sodium 100 mg SC Q 12 HRS Start: ___, First Dose: Next Routine Administration Time Please continue this medication until instructed to stop it by your doctor. RX *enoxaparin 100 mg/mL 100 mg SC q 12 hrs Disp #*14 Syringe Refills:*0 10. Warfarin 5 mg PO DAILY16 RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*200 Tablet Refills:*0 11. Advair Diskus (fluticasone-salmeterol) 0 Unknown INHALATION DAILY 12. Nystatin Cream 1 Appl TP BID 13. Outpatient Lab Work Diagnosis: atrial flutter, ICD-9 427.32 Date of labs: ___ Send to: Dr. ___, ___ for nurse ___ ___ Lab to check: ___, INR, Na, K, Cl, bicarb, BUN, Cr, hemoglobin, hematocrit Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: atrial flutter s/p ablation, decompensated diastolic heart failure Secondary: COPD, diabetes, hypertension, hyperlipidemia, history of gastrointestinal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with cane. Followup Instructions: ___ Radiology Report INDICATION: Shortness of breath. COMPARISON: Chest radiograph on ___. FINDINGS: AP and lateral views of the chest. Thereis hyperinflation, consistent with background COPD. There is increased diffuse parenchymal opacities bilaterally, more prominent at the bases consistent with mild pulmonary edema. There are small bilateral pleural effusions layering posteriorly, left greater than right. There is fluid in the major fissure seen on the lateral view. There is moderate cardiomegaly. No pneumothorax. The left hemidiaphragm is elevated laterally. IMPRESSION: Moderate cardiomegaly, mild pulmonary edema and small bilateral pleural effusions consistent with CHF. Gender: F Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by AMBULANCE Chief complaint: SOB Diagnosed with ATRIAL FLUTTER, CHRONIC AIRWAY OBSTRUCTION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 97.1 heartrate: 149.0 resprate: 42.0 o2sat: 98.0 sbp: 171.0 dbp: 112.0 level of pain: nan level of acuity: 1.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. As you know, you originally went to the hospital due to shortness of breath, and you were found to have an abnormally fast rhythm. You were started on oral medications and then underwent a procedure to have the abnormal rhythm fixed. Also, you were started on a blood thinner to reduce the risk of a blood clot due to the abnormal way the heart squeezes. In addition, you were found to have excess fluid in your system, and you were given intravenous medication to help you urinate out more fluid. Please see the attached sheets for changes to your home medication regimen. Please notify your doctor immediately if you notice any blood in your stool, or if you have dark black or tarry stools. Also notify your doctor if you notice any other abnormal bleeding such as nosebleeds or blood in your urine. Continue Lovenox at home until you are told to stop taking it. Apply over-the-counter Lotrimin to groin for skin irritation as necessary. We wish you the very best in the recovery process.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R pilon fracture Major Surgical or Invasive Procedure: right pilon fracture ORIF ___ History of Present Illness: Patient is a ___ right hand-dominant male, previously healthy who presents w/ trimalleolar fracture s/p fall. Patient's mechanism of injury was a fall down 25 feet from room while at work, onto grass surface. Reports that he landed on right ankle and fell onto right side w/ headstrike. Denies loss of conscioussness. Was unable to ambulate due to pain. Denies numbness, tingling weakness of tingling of ___. Denies any loss of bowel or bladder tone. Has been NPO all day. Denied any headache, visual changes, dizziness/lightheadedness. Denies nausea, vomiting, chest pain, dyspnea, back pain or abdominal pain. Went to ___ and was therein transferred to ___ for operative fixation. He was hemodynamically stable and neurovascular intact. In the ED at the ___, initial vitals were 99.2 80 140/90 16 98%. Per the ED, the patient's exam did not suggest neurovascular symptoms. Patient has not prior history of injury or surgery to this region. Past Medical History: ___ GSWx3 (bilateral knees and left shoulder) Social History: ___ Family History: non contributory Physical Exam: VSS, afebrile Gen - NAD Cardiac - RRR Pulm - no respiratory distress Abd - soft, ___ - External fixator intact with dressings c/d/i, hardware in good position Pertinent Results: ___ 09:00PM GLUCOSE-89 UREA N-9 CREAT-0.6 SODIUM-139 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12 ___ 09:00PM WBC-10.6 RBC-4.34* HGB-12.7* HCT-39.1* MCV-90 MCH-29.2 MCHC-32.5 RDW-12.4 ___ 09:00PM NEUTS-81.6* LYMPHS-12.7* MONOS-5.4 EOS-0.1 BASOS-0.2 ___ 09:00PM ___ PTT-32.0 ___ Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain RX *oxycodone 5 mg ___ capsule(s) by mouth q4-6h Disp #*40 Capsule Refills:*0 4. Senna 8.6 mg PO BID RX *sennosides [___] 8.6 mg 1 tab by mouth twice a day Disp #*30 Tablet Refills:*0 5. Enoxaparin Sodium 30 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe im at bedtime Disp #*14 Syringe Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: right pilon fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report REASON FOR EXAMINATION: External fixation of the right ankle in the OR. Sixteen spot fluoroscopic views demonstrate the process of open reduction internal fixation of complicated ankle fracture. Note is made that the radiologist was not attending the procedure. For precise details, please review procedure report. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX TRIMALLEOLAR-CLOSED, FALL FROM BUILDING temperature: 99.2 heartrate: 80.0 resprate: 16.0 o2sat: 98.0 sbp: 140.0 dbp: 90.0 level of pain: 9 level of acuity: 2.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: NWB RLE Danger Signs: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: NWB to injured extremity Treatments Frequency: Please perform pin care with xeroform and dry sterile gauze to pin sites qd

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: shortness of breath, submassive PE Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with history of BMI> 40, remote provoked DVT/PE in ___ s/p 6mo warfarin, multiple sclerosis, bilateral total knee arthroplasties and recent T2-T4 laminectomy for spinal stenosis (___) who presents with progressive dyspnea on exertion. She underwent thoracic laminectomies ~1 month ago, with 3 days of immobility. Subsequently able to walk, and recently traveled to ___ for one week, returning back to ___ 1 day prior to admission (___). Flights were two 1.5hr flights as she had a stopover in ___. She developed dyspnea on exertion, which progressed over the weekend. Using a friend's pulse oximeter, her SpO2 was low 80's/high90's, whereas her normal SpO2 is 95-96% on room air, prompting her to present to ___ ON ___. There, she had a CTA with multiple PEs and c/f right heart strain. She was transferred to ___ for consideration of lysis. On the floor, she O2 sat in high ___ on 6L, so she was increased to 10L on oxymizer. She reports still having dyspnea on exertion, and feeling tired after walking to the bathroom with oxymizer on. She has had no recent leg or arm injury. She does report a resolved L leg pain after surgery, prompting ultrasound at ___ ___ ___ which showed no DVT. She reports significant family history of cancer, brother with leukemia age ___, sister with ?stomach cancer died age ___, sister with breast cancer age ___. She had negative mammography and L breast ultrasound ___. Last pap smear ___ yr ago, normal. Last colonscopy ___ yr ago, normal. Of note, during ___ admission for laminectomy, she had increased O2 requirement difficult to wean after surgery. ___ CTA chest was performed and called "Severely limited examination due to respiratory motion artifact. Within these limitations, no large central pulmonary embolism," and showed pulmonary artery hypertension. Medicine was consulted and though more likely d/t obesity, recent surgery, and known OSA, and should improve with rehab and mobilization. She was weaned off oxygen, bridged from enoxaparin to warfarin, and discharged. Past Medical History: Dyslipidemia PE (___) OSA w/ CPAP Multiple sclerosis Right side trigeminal neuralgia Obesity S/p bilateral total knee replacements S/p C-section ___ S/p Bunionectomy Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.0 HR 76 BP 119/80 SpO2 91%on 6L nc GEN: well-appearing woman sitting upright in bed with oxymizer on, in NAD. HEENT: NCAT, PERRL, EOMI, MMM NECK: unable to assess JVP d/t adipose tissue CV: nl rate, reg rhythm, nl S1, S2. RESP: distant BS though clear bilaterally, no crackles or wheezes GI: ND, NT MSK: warm, b/l knee scars, legs w/o erythema or edema, no TTP. SKIN: no rashes NEURO: AAOx3, conversant, face symmetric, moves all 4 w purpose DISCHARGE PHYSICAL EXAM: ======================== PHYSICAL EXAM: VITALS: Temp: 97.6 PO BP: 159/87 HR: 59 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: Well-appearing woman, in NAD HEENT: NC/AT, EOMI, MMM CARDIAC: RRR, normal S1/S2, no m/r/g LUNGS: CTAB, breathing comfortably on RA without use of accessory muscles, no wheezes or crackles ABDOMEN: Soft, nontender, nondistended, active bowel sounds EXTREMITIES: No c/c/e SKIN: Warm, well-perfused, no rashes NEUROLOGIC: Alert, moving all extremities with purpose, no facial asymmetry Pertinent Results: ADMISSION LABS: =============== ___ 08:14PM BLOOD WBC-6.0 RBC-3.74* Hgb-11.6 Hct-36.4 MCV-97 MCH-31.0 MCHC-31.9* RDW-14.8 RDWSD-50.1* Plt ___ ___ 08:14PM BLOOD Neuts-62.6 ___ Monos-7.5 Eos-3.3 Baso-0.5 Im ___ AbsNeut-3.74 AbsLymp-1.54 AbsMono-0.45 AbsEos-0.20 AbsBaso-0.03 ___ 08:14PM BLOOD ___ PTT-150* ___ ___ 08:14PM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-142 K-4.1 Cl-103 HCO3-24 AnGap-15 ___ 08:14PM BLOOD proBNP-159 ___ 08:14PM BLOOD cTropnT-0.11* ___ 08:20PM BLOOD ___ pO2-59* pCO2-36 pH-7.46* calTCO2-26 Base XS-1 ___ 08:20PM BLOOD Lactate-2.1* PERTINENT LABS: ================ ___ 08:14PM BLOOD cTropnT-0.11* ___ 04:46AM BLOOD cTropnT-0.04* ___ 08:14PM BLOOD proBNP-159 ___ 08:20PM BLOOD ___ pO2-59* pCO2-36 pH-7.46* calTCO2-26 Base XS-1 ___ 08:20PM BLOOD Lactate-2.1* ___ 04:59AM BLOOD Lactate-1.1 ___ 05:56AM BLOOD ___ PTT-36.6* ___ ___ 06:10AM BLOOD ___ ___ 06:30AM BLOOD ___ ___ 06:27AM BLOOD ___ ___ 06:00AM BLOOD ___ PTT-33.0 ___ PERTINENT IMAGING: ================== ___ CT Angiogram Chest for PE (at ___ 1. Extensive, acute, pulmonary arterial embolic burden bilaterally, as described. 2. Moderately enlarged main pulmonary artery and minimal bowing of the interventricular septum toward the left ventricle, suggesting pulmonary arterial hypertension and very early right heart strain, respectively. 3. Atherosclerosis. 4. Hepatic steatosis. ___ CXR The cardiopericardial silhouette is borderline enlarged. The aorta is unremarkable. The lungs are well expanded and clear. The costophrenic angles are sharp. There is no pneumothorax ___ ___ (at ___ No evidence of DVT on the left. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Calcium Carbonate 1500 mg PO DAILY 4. Carbamazepine (Extended-Release) 400 mg PO BID 5. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK 6. Hydrochlorothiazide 25 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Vitamin D 5000 UNIT PO DAILY 9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line 11. Docusate Sodium 100 mg PO BID 12. Heparin 5000 UNIT SC BID 13. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line 14. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Enoxaparin Sodium 110 mg SC Q12H RX *enoxaparin 120 mg/0.8 mL 110 mg SC once a day Disp #*15 Syringe Refills:*0 2. Warfarin 1 mg PO DAILY16 Please take 5mg on ___. Subsequent dosing TBD by PCP. RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*150 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Aspirin 81 mg PO DAILY 5. Atenolol 25 mg PO DAILY 6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line 7. Calcium Carbonate 1500 mg PO DAILY 8. Carbamazepine (Extended-Release) 400 mg PO BID 9. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK 10. Docusate Sodium 100 mg PO BID 11. Hydrochlorothiazide 25 mg PO DAILY 12. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line 13. Polyethylene Glycol 17 g PO DAILY 14. Simvastatin 40 mg PO QPM 15. Vitamin D 5000 UNIT PO DAILY 16.Outpatient Lab Work Labs: INR to be drawn on ___ ICD code: ___ Fax results to: Dr. ___ at ___ ___, fax ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ==================== Submassive pulmonary embolism Acute hypoxic respiratory failure SECONDARY DIAGNOSIS: ======================= Obesity History of DVT/PE Spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with PE// rule out DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow demonstrated in the posterior tibial and peroneal veins. Grayscale images the calf veins were limited due to body habitus and soft tissue edema. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Other pulmonary embolism without acute cor pulmonale, Dyspnea, unspecified temperature: 97.8 heartrate: 76.0 resprate: 24.0 o2sat: 98.0 sbp: 142.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted to the hospital because you were feeling short of breath and were found to have multiple blood clots in your lungs. What was done for me while I was in the hospital? - In the hospital, you were given oxygen to help you breathe more easily and were started on an intravenous blood thinner called heparin to treat your blood clots. - You were then transitioned to two blood thinners called warfarin (a pill) and lovenox (an injection), which you will continue to take after you leave the hospital. Ultimately, you will only take warfarin to treat your blood clots, but your INR (a lab that is checked to monitor warfarin levels in the blood) was not in the recommended range prior to discharge, so you will continue lovenox until your INR is in the target range (___). Your primary care doctor ___ follow your INR levels and advise you on how much warfarin you should take each day. What should I do when I leave the hospital? - Please go to your follow up appointments as scheduled (see below for appointment information). Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please take 5mg of warfarin the evening of ___. - It is VERY important that you have your labs (INR) drawn the morning of ___. Your labwork results will be faxed to your primary care doctor, and she will let you know how much warfarin to take on ___ (and thereafter). - Please monitor for new/or worsening symptoms including, but not limited to, shortness of breath and chest pain. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. It was a privilege caring for you, and we wish you well! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Gluten / Gentamicin Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ year-old gentleman with history of HFrEF(iCMP, EF 31%), MDS and relapsed high-grade ___ lymphoma with Burkitt-like features, last treated with R-EPOCH (___) presenting following a fall with headstrike found to be neutropenic with low grade temperatures. Per report Mr. ___ was in his usual state of health until this morning when he walked to the bathroom wearing loose socks. His daughter heard a thud on the floor and found him conscious with epistaxis which resolved with pressure. A small laceration in the bridge of the nose was noted as well as an abrasion in the left shin. He was seen in ___ clinic this morning where he did not recall tripping on anything. He reported having frequent bowel movements upon discharge a couple of days ago which improved. In clinic he had a temperature to 99.5F and was sent in to ED for further work-up, initiation of IV antibiotics and admission. ED initial vitals were 98.6 84 121/63 19 100% RA Prior to transfer vitals were 98.4 94 110/64 17 98% RA Exam in the ED showed : "1 cm abrasion/laceration to the bridge of this nose. No hemotympanum. No septal hematoma. 8 cm abrasion to the left anterior shin. skin tear with xeroform on left anterior shin." ED work-up significant for: -CBC: WBC: 0.4*. HGB: 8.0*. Plt Count: 82*. Neuts%: 70 -Chemistry: Na: 142 . K: 4.3 . BUN: 23*. Creat: 1.1. Ca: 8.5. Mg: 1.7. PO4: 2.0*. -Lactate: 2.5 -LFTs: ALT: 12. AST: 15. Alk Phos: 109. Total Bili: 0.7. -UA: RBC 1, WBC 1 -CT head/neck: No acute intracranial process or C-spine fracture ED management significant for: -Medications: Vancomycin 1g, Cefepime 2g -Procedures: Nasal bridge abrasion closed with dermabond On arrival to the floor, patient reports that his fall was purely mechanical by slipping on oversized sock. He reports recalling the whole event and not having any syncopal/presyncopal symptoms. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: - Type II diabetes mellitus - HLD - Hypertension - CAD status post CABG (___) - VT ablation ___ - HFrEF - MDS - Zoster esophagitis - Vestibular nerve damage secondary to gentamicin - BPH status post laser surgery - Spinal stenosis status post laminectomy in ___ - Celiac disease - Small bowel perforation status post resection and repair with CMV inclusion bodies on the bowel biopsy after two cycles of R-CHOP Social History: ___ Family History: Son was diagnosed with thyroid cancer at age ___, doing well now. Brother with prostate cancer. No other known cancers in the family. Mother died of an MI in ___. Father also had diabetes, died of unknown cause in ___. Physical Exam: ADMISSION EXAM ============================ VS: ___ Temp: 98.9 PO BP: 111/65 L Sitting HR: 95 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: Well- appearing gentleman in no distress sitting in bed comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: Alert and oriented, good attention, linear thought process. CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: small abrasion in bridge of nose and ___ fold, 2x2cm well-healing erosion in dorsum of L foot w/o erythema or secretion, 1x1cm similar in dorsum of R foot, 1x2cm similar in back of left foot. New left shin erosions with significant serous drainage covered with damp gauze. DISCHARGE EXAM ============================ VITALS: 98.4 104 / 69 92 18 95 Ra GENERAL: Older appearing man, comfortable, lying in bed NEURO: Oriented to location, month, year. Moving all four extremities, follows commands. Pupils equal and reactive bilaterally. HEENT: Mild abrasion over nasal bridge. No JVD CARDIAC: Very distant heart sounds, RRR, no murmurs PULMONARY: Decreased breath sounds bilaterally at the bases ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: 1+ pitting edema bilaterally, both feet are wwp SKIN: No significant rashes but abrasions on shins and right dorsal foot Pertinent Results: ADMISSION LABS ___: ============================ WBC-0.4* RBC-2.71* Hgb-8.0* Hct-26.0* MCV-96 MCH-29.5 MCHC-30.8* RDW-15.8* RDWSD-54.3* Plt Ct-82* Neuts-70 Bands-0 ___ Monos-4* Eos-1 Baso-0 ___ Metas-0 Myelos-0 AbsNeut-0.28* AbsLymp-0.10* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00* ___ PTT-26.8 ___ UreaN-23* Creat-1.1 Na-142 K-4.3 ALT-12 AST-15 LD(LDH)-180 AlkPhos-109 TotBili-0.7 Albumin-3.2* Calcium-8.5 Phos-2.0* Mg-1.7 UricAcd-5.7 BLOOD Lactate-2.5* URINE Color-Yellow Appear-Clear Sp ___ URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG PERTINENT LABS ============================ ___ tTG-IgA-5 antiDGP-1 ___ cTropnT-0.03* ___ cTropnT-0.03* ___ CK-MB-1 cTropnT-0.01 ___ Hapto-345* ___ TSH-2.0 ___ ___ ___ Ret Aut-3.1* Abs Ret-0.08 ___ calTIBC-143* ___ Hapto-352* Ferritn-2636* TRF-110* ___ %HbA1c-6.5* eAG-140* ___ Triglyc-199* HDL-24* CHOL/HD-5.4 LDLcalc-66 ___ CK-MB-<1 cTropnT-0.06* ___ ___ cTropnT-0.05* DISCHARGE LABS ___: ============================ WBC-9.1 RBC-2.85* Hgb-8.1* Hct-25.9* MCV-91 MCH-28.4 MCHC-31.3* RDW-19.3* RDWSD-63.3* Plt ___ Glucose-87 UreaN-20 Creat-1.1 Na-144 K-4.6 Cl-103 HCO3-28 AnGap-13 Calcium-8.5 Phos-3.2 Mg-2.2 PERTINENT MICRO ============================ ALL BLOOD AND URINE CULTURES WITH NO GROWTH TO DATE ___ 4:15 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). PERTINENT STUDIES ============================ CT HEAD (___) No acute intracranial process. CT C-SPINE (___) No fracture is identified. CT HEAD (___) 1. No acute intracranial abnormality on noncontrast head CT. Specifically no evidence of intracranial hemorrhage or acute large territory infarct. 2. Additional findings described above. CXR (___) Heart size is enlarged. Hiatal hernia is large. There is mild vascular congestion. There is no appreciable pleural effusion. There is no pneumothorax. CXR (___) There is a new right-sided PICC line with distal tip at the cavoatrial junction. Heart size is prominent but stable. Opacity along the right heart border is due to a very large hiatal hernia. There are no pneumothoraces. CXR (___) Right PIC line ends in the right atriumd approximately 3 cm below the estimated location of the superior cavoatrial junction. Small to moderate right pleural effusion and large gastrointestinal hiatus hernia projecting to the right of midline, are long-standing. The hernia exaggerates the size of mildly to moderately enlarged heart. Upper lungs are clear. There is pulmonary edema and no pneumothorax. CXR (___) Bilateral lower lobe collapse unchanged. Small right pleural effusion decreased. No pneumothorax. Mild cardiomegaly stable. No pulmonary edema or mediastinal widening. Right PICC line ends in the upper right atrium as before. CT HEAD (___) Atrophy. No significant changes since ___. No evidence of hemorrhage. RENAL US (___) No hydronephrosis. ECHO (___) IMPRESSION: Suboptimal image quality. Left ventricular cavity enlargement with regional and global systolic dysfunction suggestive of multivessel CAD or other diffuse process. Mild aortic regurgitation. Compared with the prior study (images reviewed) of ___, the severity of mitral regurgitation is reduced (may be due to technical quality rather than a true change). CT CHEST (___) -Bilateral small layering pleural effusions are larger since prior, right greater the left. Adjacent consolidations, left greater than right are likely due to aspirations, particularly in the presence of large hiatal hernia. -Increased fat stranding surrounding the partially imaged left kidney could represent infection, for clinical correlation. CXR (___) There is bilateral lower lobe atelectasis, similar to previous. Superimposed pneumonia cannot be excluded. There is pulmonary vascular congestion. There is a small right pleural effusion, not significantly changed. There may be a trace left effusion. There is mild cardiomegaly, similar to previous. The tip of the right PICC appears stable in position. Sternal wires appear intact. CXR (___) 1. Interval increase in bilateral interstitial opacities, consistent with worsening pulmonary edema. 2. Focal increase in opacification at the right lower lobe, which may represent superimposed infection, aspiration, or asymmetric edema. 3. Small bilateral pleural effusions, right greater than left. CT ABD/PELVIS (___) 1. Stable mild stranding involving the omentum on the right complete similar to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence of hydronephrosis. Recommend clinical correlation to exclude underlying infection. 3. No other interval change. CT CHEST (___) 1. No evidence of lymphadenopathy. 2. Stable airspace opacification in the left lower lobe suggestive of consolidation. New small scattered areas of ground-glass opacities in the right upper and middle ___ represent infectious etiology. Clinical correlation recommended. 3. Mild interval increase in bilateral pleural effusions which are moderate. Stable bibasilar passive atelectasis. MRI HEAD (___) Multiple (approximately 7) bilateral punctate supra and infra tentorial acute infarct. These are most likely embolic in nature. No hemorrhagic transformation. No intracranial hemorrhage or mass. Generalized cerebral atrophy with white matter microangiopathic changes. CXR (___) A new right PICC line projects over the mid SVC. Bilateral pleural effusions with subjacent atelectasis/consolidation. CTA HEAD/NECK (___) The study is degraded by incorrect bolus timing and motion artifact. No acute hemorrhage or large territorial infarct. Known bilateral punctate supra and infratentorial acute infarctions are better appreciated on prior MRI head done ___. These infarcts are most likely embolic in nature. Within the limits of the study there is no intracranial arterial aneurysm or occlusion. No ICA occlusion. No obvious ICA stenosis by NASCET criteria. Increased soft tissues surrounding the junction of V3 and V4 segment of the right vertebral artery may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CTA is advised. CXR (___) Comparison to ___. Stable low lung volumes. Stable bilateral pleural effusions of moderate extent. Stable subsequent bilateral areas of atelectasis. Today's radiograph shows signs of mild pulmonary edema. Unchanged alignment of the sternal wires. Unchanged right PICC line. BEDSIDE ECHO (___) There is moderate-severe regional left ventricular systolic dysfunction with severe hypokinesis/ akinesis of the basal to mid inferoseptum, inferior, and inferolateral walls and the distal inferior wall (see schematic) and severe global hypokinesis of the remaining segments. The visually estimated left ventricular ejection fraction is ___. Mildly dilated right ventricular cavity with mild global free wall hypokinesis. There is mild [1+] aortic regurgitation. There is mild [1+] mitral regurgitation. IMPRESSION: Adequate image quality. Compared with the prior TTE of (images reviewed) of ___ , the findings are similar (right ventricle also appeared borderline/ mildly dilated). LEFT VENTRICLE (LV) Visual Ejection Fraction: ___ (nl M:52-72;F:54-74) LEFT VENTRICLE (LV): Moderate-severe focal systolic dysfunction. The visually estimated left ventricular ejection fraction is ___. RIGHT VENTRICLE (RV): Dilated cavity. Mild global free wall hypokinesis. AORTIC VALVE (AV): Mild [1+] regurgitation. MITRAL VALVE (MV): Mild [1+] regurgitation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY PCP ___ 2. Filgrastim-sndz 480 mcg SC Q24H 3. Doxycycline Hyclate 100 mg PO Q12H 4. Acyclovir 400 mg PO Q12H 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Levofloxacin 500 mg PO Q24H 8. Ranitidine 150 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Senna 8.6 mg PO BID:PRN constipation 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 12. LORazepam 0.5 mg PO Q8H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Apixaban 5 mg PO BID 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. Docusate Sodium 100 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Metoprolol Succinate XL 75 mg PO DAILY 9. Acyclovir 400 mg PO Q12H 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 11. Ranitidine 150 mg PO BID 12. Senna 8.6 mg PO BID:PRN constipation 13. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ------------------- ___ lymphoma with Burkitt's features Sepsis Neutropenic Fever Embolic cerebral vascular accidents Acute on chronic systolic heart failure Ischemic cardiomyopathy Coronary artery disease status post coronary artery bypass graft Atrial fibrillation, new SECONDARY: ------------------- Type II NSTEMI Toxic metabolic encephalopathy Normocytic anemia Acute kidney injury Acute urinary retention Benign prostatic hypertrophy Ureteral stricture Mechanical fall Diarrhea Oropharyngeal candidiasis Celiac disease Type II Diabetes Gastroesophageal reflux disease Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with fall with head strike// evaluate for intra-cranial bleed, fracture TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 22.1 mGy (Body) DLP = 362.1 mGy-cm. Total DLP (Body) = 362 mGy-cm. COMPARISON: CT head without contrast ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with fall with head strike// evaluate for intra-cranial bleed, fracture evaluate for intra-cranial bleed, fracture TECHNIQUE: Non-contrast helical multidetector CT was performed through the cervical spine. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.5 s, 21.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 493.4 mGy-cm. 2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP = 30.0 mGy-cm. 3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP = 30.0 mGy-cm. Total DLP (Body) = 553 mGy-cm. COMPARISON: None. FINDINGS: No traumatic malalignment is identified.No fractures are identified.There is no prevertebral soft tissue swelling. Mild posterior narrowing of disc space at C3-4 and C4-5 are likely degenerative. Severe degenerative changes of the cervical spine is notable for endplate and uncovertebral joint osteophytes causing severe neural foraminal narrowing on the right side at C5-6. IMPRESSION: No fracture is identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with thrombocytopenia and acute altered mental status// intracranial bleed? TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.0 s, 20.5 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,068.6 mGy-cm. Total DLP (Head) = 1,069 mGy-cm. COMPARISON: CT head from ___. FINDINGS: There is no evidence of acute large territorial infarction,hemorrhage,edema, or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease. Nasal bone fracture deformities are unchanged from prior exam. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality on noncontrast head CT. Specifically no evidence of intracranial hemorrhage or acute large territory infarct. 2. Additional findings described above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with heart failure// pulmonary edema? pulmonary edema? IMPRESSION: Heart size is enlarged. Hiatal hernia is large. There is mild vascular congestion. There is no appreciable pleural effusion. There is no pneumothorax. Radiology Report INDICATION: ___ year old man with new R PICC 45cm// new R PICC ___ Contact name: ___: ___ COMPARISON: ___ IMPRESSION: There is a new right-sided PICC line with distal tip at the cavoatrial junction. Heart size is prominent but stable. Opacity along the right heart border is due to a very large hiatal hernia. There are no pneumothoraces. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with chronic afib with rates 90-120 w/bursts to 160 that are HD stable now w/ new hypoxia, possibly from over volume resuscitation// degree of pulm edema, effusions, if worsened cardiomegaly, please comment on PICC if think needs to be pulled back given concern if irritating atria degree of pulm edema, effusions, if worsened cardiomegaly, please comment on PICC if think needs to be pulled back given concern if irritating atria IMPRESSION: Compared to chest radiographs ___ through ___. Right PIC line ends in the right atriumd approximately 3 cm below the estimated location of the superior cavoatrial junction. Small to moderate right pleural effusion and large gastrointestinal hiatus hernia projecting to the right of midline, are long-standing. The hernia exaggerates the size of mildly to moderately enlarged heart. Upper lungs are clear. There is pulmonary edema and no pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ cough and dyspnea// pneumonia? pneumonia? IMPRESSION: Compared to chest radiographs ___ through ___. Bilateral lower lobe collapse unchanged. Small right pleural effusion decreased. No pneumothorax. Mild cardiomegaly stable. No pulmonary edema or mediastinal widening. Right PIC line ends in the upper right atrium as before. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ w/ severe thrombocytopenia and altered mental status// intracranial hemorrhage? TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.5 s, 21.5 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,120.5 mGy-cm. Total DLP (Head) = 1,121 mGy-cm. COMPARISON: Head CT ___. FINDINGS: There been no significant changes since the prior study. There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are enlarged in an atrophic pattern. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: Atrophy. No significant changes since ___. No evidence of hemorrhage. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ w/ relapsed lymphoma and ___// hydronephrosis? TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: ___. FINDINGS: The right kidney measures 8.9 cm. The left kidney measures 10.8 cm. Evaluation of the renal parenchyma is limited due to poor penetration and difficulty positioning the patient. Within these limitations, there is no hydronephrosis or shadowing calculi. The bladder is moderately well distended and unremarkable. IMPRESSION: No hydronephrosis. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ w/ B-cell lymphoma, heart failure with dyspnea and cough// pulm edema and/or pneumonia? TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.0 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. No contrast agent was administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.0 s, 37.2 cm; CTDIvol = 11.3 mGy (Body) DLP = 421.6 mGy-cm. Total DLP (Body) = 422 mGy-cm. COMPARISON: CT of the chest ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: No pathologic enlargement of lymph nodes in the supraclavicular or axillary stations. There is new mild diffuse chest wall edema which is more pronounced at the level of the flanks. CHEST CAGE: Minimal degenerative changes at the level of the thoracic vertebra. L1 severe wedge compression fracture is mildly more sclerotic in comparison to ___. There is no evidence of lytic or sclerotic metastatic osseous destructive lesions the level of the ribs, sternum or vertebra. UPPER ABDOMEN: There is relative atrophy of the partially imaged right kidney which is stable. Increased fat stranding surrounding the left kidney is nonspecific, for clinical correlation since could represent infection. Remaining unenhanced upper abdominal organs are with no gross findings. MEDIASTINUM: Almost the entire stomach included a in large hiatal hernia, unchanged since prior and upper esophagus is patulous as before. There is no lymphadenopathy in the mediastinum and hilar silhouettes suggest no gross lymphadenopathy. HEART and PERICARDIUM: Heart is normal in size. There are signs of mild anemia. Patient is status post sternotomy and CABG, there are extensive dense calcifications of native coronaries. There is no pericardial effusion. Minimal calcifications along the normal caliber thoracic aorta, main pulmonary artery is normal in caliber. PLEURA and LUNG: Bilateral small layering pleural effusions are larger since prior, right greater the left. Adjacent consolidations containing air bronchograms reflect pneumonia, particularly in the left lower lobe (4:149), possibly due to aspirations, particularly in the presence of large hiatal hernia. Tracheobronchial tree is centrally patent. In the right upper lobe linear scar-like opacity with linear pleural tag is unchanged since ___ (4:109). No new pulmonary nodules. IMPRESSION: -Bilateral small layering pleural effusions are larger since prior, right greater the left. Adjacent consolidations, left greater than right are likely due to aspirations, particularly in the presence of large hiatal hernia. -Increased fat stranding surrounding the partially imaged left kidney could represent infection, for clinical correlation. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ w/ B-cell lymphoma, a-fib w/ new dysphagia// mass lesion or evidence of CVA? TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT brain done ___ FINDINGS: Multiple (approximately 7) bilateral punctate supra and infratentorial acute infarcts. No hemorrhagic transformation. Generalized cerebral atrophy with ex vacuo dilatation of the ventricular system. Moderate periventricular deep white matter T2 and FLAIR hyperintense changes are most likely sequela of microangiopathy. There is no abnormal enhancement after contrast administration. The orbits appear normal. Mild mucosal thickening involving the paranasal sinuses. The intracranial arteries demonstrate normal T2 flow voids. The pituitary appears normal. The craniocervical junction appears normal. IMPRESSION: Multiple (approximately 7) bilateral punctate supra and infra tentorial acute infarct. These are most likely embolic in nature. No hemorrhagic transformation. No intracranial hemorrhage or mass. Generalized cerebral atrophy with white matter microangiopathic changes. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:25 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest x-ray INDICATION: ___ with AML with worsening cough// pneumonia? TECHNIQUE: Portable chest x-ray COMPARISON: Chest x-ray 438 FINDINGS: There is bilateral lower lobe atelectasis, similar to previous. Superimposed pneumonia cannot be excluded. There is pulmonary vascular congestion. There is a small right pleural effusion, not significantly changed. There may be a trace left effusion. There is mild cardiomegaly, similar to previous. The tip of the right PICC appears stable in position. Sternal wires appear intact. IMPRESSION: As above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ B-cell lymphoma, CHF with worsening cough. Evaluation for pulm edema vs. worsening pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Comparison to radiograph from ___. Comparison to CT chest from ___. FINDINGS: Median sternotomy wires are intact and well aligned. Right sided PICC line appears to end at the low SVC. Cardiomediastinal silhouette is stable. Interval increase in bilateral interstitial opacities is consistent with worsening pulmonary edema. Focal increase in opacification at the right lower lobe may represent pneumonia or aspiration. There are small bilateral pleural effusions, right greater than left. No pneumothorax is seen. IMPRESSION: 1. Interval increase in bilateral interstitial opacities, consistent with worsening pulmonary edema. 2. Focal increase in opacification at the right lower lobe, which may represent superimposed infection, aspiration, or asymmetric edema. 3. Small bilateral pleural effusions, right greater than left. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ w/ history B-cell lymphoma s/p recent EPOCH// repeat staging/ response to chemotherapy? TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis without intravenous contrast. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 12.2 mGy (Body) DLP = 809.6 mGy-cm. Total DLP (Body) = 810 mGy-cm. COMPARISON: ___ FINDINGS: Please note that the images are degraded by motion artifact. Liver: Liver demonstrates normal parenchymal morphology. No focal lesions given limitations of an unenhanced study. Biliary: The gallbladder is normally distended. No intra or extrahepatic biliary dilatation. Pancreas: Pancreas shows homogeneous signal intensity. No evidence of pancreatic ductal dilatation. Spleen: Normal size without evidence of focal lesions. Adrenal Glands: Normal size bilaterally. Kidneys: Stable atrophic right kidney. No evidence of nephrolithiasis. There is mild perinephric stranding surrounding the left kidney, which is new compared to the prior CT from ___. There is no hydronephrosis. Gastrointestinal Tract: Large hiatus hernia containing almost entire stomach filled with oral contrast. The small and large bowel loops are normal in caliber. Trace free fluid seen in the abdomen. There is minimal residual stranding in the omentum in the right (series 2, image 77), similar to the findings on the prior CT from ___. Lymph Nodes: No retroperitoneal or mesenteric lymphadenopathy. Pelvis: Urinary bladder is decompressed and shows Foley bulb in situ. Vascular: Moderate aortic atherosclerotic changes. Stable aneurysmal dilatation of the left common iliac artery measuring 2.4 cm. Osseous and Soft Tissue Structures: Stable significant compression fracture involving L1 vertebral body with buckling of the posterior coursed cortex causing spinal canal stenosis at this level. Multilevel degenerative disc disease. No new abnormality identified. IMPRESSION: 1. Stable mild stranding involving the omentum on the right complete similar to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence of hydronephrosis. Recommend clinical correlation to exclude underlying infection. 3. No other interval change. Radiology Report EXAMINATION: Noncontrast CT chest INDICATION: ___ male with history of B-cell lymphoma, status post recent EPOCH, repeat staging, response to chemotherapy. TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Recent CT chest from 3 days ago (___). FINDINGS: BASE OF NECK: Visualized portions of the base of the neck show no abnormality. HEART AND VASCULATURE: Right upper extremity PICC seen with its tip in proximal right atrium. The thoracic aorta is normal in caliber. The heart, pericardium, and great vessels are within normal limits based on an unenhanced scan. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is present. PLEURAL SPACES: Moderate pleural effusions bilaterally with minimal increase in the amount compared to the recent prior CT.. LUNGS/AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. Again seen is evidence of airspace opacification involving the left lower lobe. There are few new scattered areas of ground-glass opacities for example in the right upper lobe (series 3, image 93, right middle lobe (series 3, image 166 and 188). Stable appearance of bilateral subsegmental passive atelectasis in both lower lobes. ABDOMEN: Large hiatus hernia with stomach filled with oral contrast seen above the diaphragmatic hiatus. Please refer to the separately dictated report of CT abdomen and pelvis. BONES: Stable significant wedge compression fracture involving L1 vertebral body with more than 75% vertebral body height loss and buckling of the posterior cortex. Stable appearance of the median sternotomy wires in situ. IMPRESSION: Compared to 3 days prior: 1. No evidence of lymphadenopathy. 2. Stable airspace opacification in the left lower lobe suggestive of consolidation. New small scattered areas of ground-glass opacities in the right upper and middle ___ represent infectious etiology. Clinical correlation recommended. 3. Mild interval increase in bilateral pleural effusions which are moderate. Stable bibasilar passive atelectasis. Radiology Report INDICATION: ___ s/p prior PICC placement// re-assessment of PICC location TECHNIQUE: AP portable chest radiograph COMPARISON: ___ CT chest FINDINGS: There are bilateral pleural effusions with subjacent atelectasis and/or consolidation. A hiatal hernia is again noted. The size of the cardiac silhouette is enlarged but unchanged. The tip of a right PICC line projects over the mid SVC. No pneumothorax. IMPRESSION: A new right PICC line projects over the mid SVC. Bilateral pleural effusions with subjacent atelectasis/consolidation. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ w/ a-fib and newly diagnosed embolic infarcts// rule out vascular etiology for acute infarcts TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 3) Stationary Acquisition 1.4 s, 0.2 cm; CTDIvol = 21.9 mGy (Head) DLP = 4.4 mGy-cm. 4) Spiral Acquisition 6.2 s, 40.1 cm; CTDIvol = 32.7 mGy (Head) DLP = 1,289.3 mGy-cm. Total DLP (Head) = 2,152 mGy-cm. COMPARISON: Prior brain MR done ___ FINDINGS: The study is degraded by incorrect bolus timing and motion artifact. CT HEAD WITHOUT CONTRAST: There is no evidence of hemorrhage. Known, bilateral, punctate super and infratentorial acute infarctions are better appreciated MRI head from ___ at 07:55. Generalized cerebral atrophy with ex vacuo dilatation of the ventricular system. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: Within the limits of the study there is no intracranial arterial aneurysm or arterial occlusion. CTA NECK: Within the limits of the study there is no carotid arterial occlusion or aneurysm. No obvious ICA stenosis by NASCET criteria. Increased soft tissues surrounding the junction of V3 and V4 of the right vertebral artery, poorly characterized, may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CT or correlation with an MR study is advised. The left vertebral artery appears patent. OTHER: Patulous esophagus. Bilateral pleural effusions and interstitial thickening most likely representing pulmonary edema. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. Evidence of prior CABG procedure IMPRESSION: The study is degraded by incorrect bolus timing and motion artifact. No acute hemorrhage or large territorial infarct. Known bilateral punctate supra and infratentorial acute infarctions are better appreciated on prior MRI head done ___. These infarcts are most likely embolic in nature. Within the limits of the study there is no intracranial arterial aneurysm or occlusion. No ICA occlusion. No obvious ICA stenosis by NASCET criteria. Increased soft tissues surrounding the junction of V3 and V4 segment of the right vertebral artery may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CTA is advised. RECOMMENDATION(S): Increased soft tissues surrounding the junction of V3 and V4 segment of the right vertebral artery may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CTA or MR is advised if clinically indicated. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with dyspnea after blood transfusion// interval change, ? pulmonary edema interval change, ? pulmonary edema IMPRESSION: Comparison to ___. Stable low lung volumes. Stable bilateral pleural effusions of moderate extent. Stable subsequent bilateral areas of atelectasis. Today's radiograph shows signs of mild pulmonary edema. Unchanged alignment of the sternal wires. Unchanged right PICC line. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Laceration, s/p Fall Diagnosed with Laceration without foreign body of nose, initial encounter, Fall on same level, unspecified, initial encounter temperature: 98.6 heartrate: 84.0 resprate: 19.0 o2sat: 100.0 sbp: 121.0 dbp: 63.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___. Why you were in the hospital: - fall at home - fever What was done for you in the hospital: - you were treated for severe infection using IV antibiotics - you were transfused blood products while your blood counts were low following your latest cycle of chemotherapy - you were given heart medications and blood thinners to treat atrial fibrillation - you underwent an MRI of your brain that showed evidence of strokes, possibly due to your atrial fibrillation - you underwent repeat CT scans of your chest and abdomen to assess for progression of your lymphoma, these demonstrated that your lymphoma is stable What you should do after you leave the hospital: - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - Please take your medications as detailed in the discharge papers. If you have questions about which medications to take, please contact your oncologist to discuss. - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your oncologist to discuss or return to the emergency room. We wish you the best! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / Sulfa (Sulfonamide Antibiotics) / trimethoprim / crab Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: trach change on ___ ___ gastrostomy tube on ___ left triple-lumen IJ catheter with tip in the SVC on ___. History of Present Illness: ___ morbidly obese female with recent diagnosis of substernal multinodular goiter, right > left, with tracheal compression status post open thyroid biopsy and tracheostomy (___), also found to have concurrent DVT/PE in the setting of aforementioned compression in R IJ and subclavian vein as well as significant R-sided PE burden (right main, lobar, segmental and subsegmental), currently subtherapeutic on Coumadin on arrival to ___ ED, who presented from ___ with persistent, severe anemia over the past 3 days. Per report, the patient had a negative guaiac, negative C. difficile and was subsequently transferred to ___ for further evaluation of persistent anemia. No known trauma history. Supposedly, the patient had been less responsive over the past few days, only opening her eyes and looking around which is worse than her baseline (per last ___ admission, responds to some questions, mouths some words). No vomiting, diarrhea. No fevers or chills. In the ED, the patient was placed on mechanical ventilation (CMV Vt:380 RR:14 FiO2:0.4) for tachypnea and high minute volume needs. In the ED, initial vitals: 99.0, 120, 129/69, 22, 96% trach mask Exam notable for: Morbidly obese, opens her eyes and looks around, otherwise unresponsive. Bilateral upper extremity swelling with intact pulses Lungs diminished RRR +S1S2 tachycardic No spinal tenderness, no CVAT Abd with diffuse mild tenderness without clear focality BLE with 1+ edema to the mid-shin with ___ intact Rectal tube with brown stool, Guaiac negative Labs notable for: WBC: 23.2 (90% neuts) Hgb:5.6 Plt:257 138 / 93 /27 / AGap=13 ------------- 200 3.5 / 32 /0.7\ ___: 19.7 PTT: 150 INR: 1.8 Lactate 2.1 -> 1.7 Trop <0.01 Alb:23, AST:49, ALT:61, Alk Phos:103, TBili:0.6 Lipase: 55 Flu Negative UA: Mod Blood, Large Leuks, Few Bacs, Many Yeast Urine and Blood Cultures: Pending Imaging: CTA Abd Pelvis ___ 1. Large right iliacus and right iliopsoas hematomas without active extravasation. 2. On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh without active extravasation. 3. Bibasilar airspace opacities, similar on the right and decreased on the left. Recommend clinical correlation to assess for the possibility of pneumonia. 4. Decreased size of a moderate pericardial effusion. No evidence of mass effect. CT Head w/o Contrast ___ 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. Increased bilateral mastoid effusions with extension into the left middle ear cavity raising the possibility of otomastoiditis. No evidence of osseous erosion. 3. New partial opacification of the paranasal sinuses with aerosolized secretions raising the possibility of acute sinusitis. CXR ___ Bibasilar airspace opacities may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. Persistent small bilateral pleural effusions with probable mild pulmonary vascular congestion. Superior mediastinal mass compatible with known thyroid goiter is better assessed on previous CT. CTA Chest ___ 1. Pulmonary embolism in the right lower lobe is not well seen and may be obscured due to artifact. Additional potential filling defects in the bifurcation of the right pulmonary artery may be artifactual or represent additional pulmonary emboli. 2. Re-demonstrated large retro sternal goiter that displaces and compresses the trachea. 3. Re-demonstrated attenuation of the bilateral internal jugular vein and right subclavian vein. The brachiocephalic and SVC are patent. 4. Mild pericardial effusion is unchanged. 5. Additional findings above. Patient received: IV CefePIME IVF NS (1000 mL ordered) IV CefePIME 2 g IV Heparin ___ units/hr IV Vancomycin 1500 mg Consults: ENT-Appears to be moving air though trach tube well (crusting on inner cannula cleaned by RT). Tracheoscopy clear to carina. Neck soft and without evidence of hematoma (no ecchymosis, no oozing from incision lines, no firmness aside from palpably enlarged thyroid). No evident source for hematocrit drop on H&N exam. Vitals on transfer: 98.0, 128, 96/44, 24, 100% vent Upon arrival to ___, the patient was unresponsive. ___ (RN from ___ reported that the patient had been unresponsive the entire time she was at the ___ and had intermittent perioral twitching. Per daughter ___, the patient had been mostly unresponsive since her thyroid biopsy but occasionally was able to mouth a few words. REVIEW OF SYSTEMS: (+) Per HPI (-) Otherwise Past Medical History: Anterior mediastinal mass with tracheal compression Right vocal fold paralysis DVT/PE- presented to hospital from OSH with active DVT Dyspnea/stridor Hypothyroidism Sensorineural hearing loss Obesity Breast Cancer Social History: ___ Family History: Per records, unknown family member with thyroid nodules Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 99.5, 137/85, 130, 20, 98% GENERAL: unresponsive HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVP not elevated, no LAD LUNGS: occasional crackles, diminished breath sounds at the bases CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, obese, non-tender, non-distended, bowel sounds present EXT: Warm, well perfused, 2+ pitting edema in UEs and ___ ___: No obvious rashes NEURO: reactive pupils, unresponsive DISCHARGE PHYSICAL EXAM: ======================== ___ 0757 Temp: 98.2 PO BP: 120/63 R Lying HR: 114 RR: 20 O2 sat: 96% O2 delivery: TM FSBG: 128 GENERAL: Awake in bed, appears in no acute distress, writing on board HEENT: Sclerae anicteric; trach site with light pink secretions but site looks c/d/i, LIJ site c/d/i CARDIOVASCULAR: Tachycardic, no murmurs LUNGS: Anteriorly clear ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, PEG with tubefeeds running EXTREMITIES: both arms grossly edematous with trace pitting edema of right and 2+ of left. Both feet warm with 2+ pulses, unable to appreciate prior right thigh hematoma, right leg greater than left, bilateral ankle with 2+ edema NEURO: Face grossly symmetric. Moving all extremities spontaneously but is bed bound. AOx3 and able to write and mouth responses. Pertinent Results: ADMISSION LABS: =============== ___ 05:55PM BLOOD WBC-23.2*# RBC-1.97* Hgb-5.6* Hct-18.2* MCV-92 MCH-28.4 MCHC-30.8* RDW-16.5* RDWSD-53.0* Plt ___ ___ 05:55PM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-3* Eos-0 Baso-2* ___ Myelos-0 AbsNeut-20.88* AbsLymp-1.16* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.46* ___ 05:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:55PM BLOOD ___ PTT-150* ___ ___ 05:55PM BLOOD Plt Smr-NORMAL Plt ___ ___ 05:55PM BLOOD Glucose-200* UreaN-27* Creat-0.7 Na-138 K-3.5 Cl-93* HCO3-32 AnGap-13 ___ 05:55PM BLOOD ALT-49* AST-61* AlkPhos-103 TotBili-0.6 ___ 05:55PM BLOOD cTropnT-<0.01 ___ 05:55PM BLOOD Albumin-2.3* ___ 03:38AM BLOOD Albumin-2.3* Calcium-7.1* Phos-3.7 Mg-2.2 ___ 06:06PM BLOOD ___ Comment-GREEN TOP ___ 11:29PM BLOOD ___ pO2-25* pCO2-46* pH-7.48* calTCO2-35* Base XS-8 ___ 06:06PM BLOOD Lactate-2.1* ___ 11:29PM BLOOD O2 Sat-42 RELEVANT LABS: ============== ___ 03:38AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:55PM BLOOD cTropnT-<0.01 ___ 03:38AM BLOOD TSH-3.7 ___ 03:38AM BLOOD Free T4-0.9* ___ 03:38AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG ___ 03:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:38AM BLOOD HCV Ab-NEG ___ 03:46AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG ___ 09:37PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 06:39AM BLOOD Ret Aut-8.0* Abs Ret-0.24* ___ 06:39AM BLOOD calTIBC-228* VitB12-1131* Hapto-<10* Ferritn-887* TRF-175* ___ 09:29AM BLOOD Hapto-<10* ___ 06:36AM BLOOD %HbA1c-4.8 eAG-91 ___ 06:39AM BLOOD TSH-6.5* ___ 07:29AM BLOOD 25VitD-13* ___ 06:00AM BLOOD 25VitD-16* RELEVANT STUDIES/IMAGING: ========================= CTA AP ___: 1. Large right iliacus and right iliopsoas hematomas without active extravasation. 2. On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh without active extravasation. 3. Bibasilar airspace opacities, similar on the right and decreased on the left. Recommend clinical correlation to assess for the possibility of pneumonia. 4. Decreased size of a moderate pericardial effusion. No evidence of mass effect. CT Head w/o Contrast ___: 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. Increased bilateral mastoid effusions with extension into the left middle ear cavity raising the possibility of otomastoiditis. No evidence of osseous erosion. 3. New partial opacification of the paranasal sinuses with aerosolized secretions raising the possibility of acute sinusitis. CXR ___: Bibasilar airspace opacities may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. Persistent small bilateral pleural effusions with probable mild pulmonary vascular congestion. Superior mediastinal mass compatible with known thyroid goiter is better assessed on previous CT. EEG ___: This telemetry captured no pushbutton activations. Throughout, it showed a widespread mildly slow and disorganized background with occasional bursts of generalized slowing, all suggesting a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing. There were no epileptiform features or electrographic seizures. CT AP ___: 1. Extensive intramuscular hematomas involving several right thigh compartments, with involvement of the entire thigh to the level of the knee as described above. Upper thigh involvement appears slightly more extensive compared to ___, but there is no active extravasation. 2. Minimal decrease in size of a now 11.1 x 8.1 x 4.7 cm right iliacus muscle hematoma. 3. Incidental 2.6 x 2.2 cm right adnexal lesion with a coarse calcification, for which the differential includes fibroma, cystadenofibroma ___ tumor. In the absence of prior imaging documenting stability, a pelvic ultrasound is recommended for further evaluation. 4. Similar right greater than left bibasilar consolidations, likely representing atelectasis. Pneumonia is unlikely in the absence of clinical symptoms. 5. Small pericardial effusion is likely similar accounting for redistribution. TTE ___: IMPRESSION: Focused stat ICU study, suboptimal image quality. Moderate, predominantly posterior pericardial effusion with brief RV diastolic collapse consistent with impaired filling. Compared with the prior study (images reviewed) of ___ the effusion is slightly larger, still predominantly posterior and there is now brief RV diastolic collapse. Image quality suboptimal. Tachycardia now present. IVC not well visualized. CTA AORTA/BIFEM/ILIAC ___: 1. Multiple, unchanged large intramuscular hematomas involving the iliacus and anterior and medial compartments of the right thigh. No new collection or evidence of active extravasation, allowing for limitations of assessment. There is extensive right lower extremity soft tissue edema. 2. Ventral abdominal wall hernia contains a loop of small bowel without complication. TTE ___: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a small to moderate sized pericardial effusion. The effusion appears loculated and layers posteriorly. No significant fluid is seen in the subcostal views. No respiratory variation in inflow velocities is seen. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of ___, RV diastolic collapse is no longer present on the parasternal long axis views. The effusion appears similar in size to slightly smaller. Heart rate has normalized. LUE DOPPLER ___: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Nonocclusive superficial thrombosis of the proximal cephalic vein, extending to the junction of the subclavian vein. 3. Fluid collection within the left biceps measure up to 6 cm in long dimension; this would be amenable to ultrasound-guided aspiration if needed. CT AP ___: 1. Interval increase in bibasilar atelectasis. 2. No significant change to a moderate pericardial effusion. 3. Worsening intra- and extrahepatic biliary dilation with the common bile duct measuring up to 2.9 cm (previously 2.2 cm). 4. No findings to explain hematuria. Specifically, no urinary calculi, renal or urothelial lesion. 5. Stable right adnexal cyst with coarse calcification. 6. Evolving right iliopsoas and sartorius hematomas. The sartorious is slightly expanded from ___. 7. Incompletely assessed are severe degenerative changes of the left wrist with apparent osseous fusion of the carpal bones. CT NECK W/ CONTRAST ___: 1. Re-identified is a 5.7 cm heterogeneous ill-defined left thyroid mass demonstrating central cystic components and coarse scattered calcifications. Since the prior examination of ___, interval resolution of postoperative pneumocephalus and soft tissue inflammatory stranding. 2. There remains loss of defined fascial plane between the mass and the adjacent trachea, esophagus and thyroid cartilage. In addition, the lesion exerts right lateral mass effect on the right common carotid artery, with obscuration of intervening fascial plane, which appears progressed from prior examination. Although the mass does not appear significantly increased in size since examination of ___, the lack of improvement in stranding and obscuration of adjacent fascial planes raises concern for possible malignant process. 3. In addition, there is increased soft tissue prominence incompletely characterized at the visualized superior mediastinum posterior to the trachea as well as apparent increased size of a 1.6 cm paratracheal lymph node (series 304, image 147). 4. A spiculated left upper lobe lesion now measures 1 cm, previously measuring 5-6 mm. A 4 mm right upper lobe pulmonary nodule has also increased in size from prior examination. Recommend further evaluation with dedicated CT chest. 5. Additional findings described above. TRACHEAL BIOPSY PATHOLOGY ___: Endotracheal biopsy: Squamous cell carcinoma, see n ote. Note: Lesional cells are positive for p40, CK5/6, a nd PAX8. The carcinoma is morphologically similar to the carcinoma seen in the patient's thyr oid biopsy (___). Case reviewed by Drs. ___ and ___, who concur. THYROID BIOPSY PATHOLOGY ___: 1. Thyroid/mediastinal mass, biopsy: - Squamous cell carcinoma. - Papillary thyroid carcinoma with extensive necros is. Note: The squamous cell carcinoma cells are positi ve for p40, CK5/6, TTF-1, and PAX8. They are negative for GATA3 and calcitonin. If the clinical and radiologic findings are consistent with a primary thyroid tumor, the overall findings are in keeping with a squamous cell carcinoma of the thyroid, tantamount to undifferentiated / anaplasti c thyroid carcinoma. The necrotic papillary carcinoma in the background is suggestive of origin from a differentiated thyroid carcinoma. 2. Thyroid mass, biopsy: Scant necrotic tumor with papillary architecture, favor necrotic papillary carcinoma. CXR ___: Compared to chest radiographs since ___ most recently ___. Lung volumes remain quite low. Atelectasis has worsened at the left lung base. Bilateral pleural effusions are likely, but not large. Moderate to severe cardiomegaly is chronic. Tracheostomy tip projects over the upper trachea. No pneumothorax or mediastinal widening. Left jugular line ends in the low SVC. IP bronch ___: PROCEDURE: flexible bronchoscopy, rigid bronchoscopy, therapeutic aspiration of secretions, tracheostomy revision OPERATORS: ___ FINDINGS: significant granulation tissue and mass noted on posterior portion of trachea, no active bleeding. TTE ___: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. There is a small pericardial effusion, primarily posterior to the left ventricle. There is no free fluid anterior to the RV. IMPRESSION: Small loculated pericardial effusion DISCHARGE LABS ___ 06:09AM BLOOD WBC: 12.6* RBC: 3.00* Hgb: 8.7* Hct: 29.4* MCV: 98 MCH: 29.0 MCHC: 29.6* RDW: 14.9 RDWSD: 53.6* Plt Ct: 223 ___ 06:09AM BLOOD ___: 12.2 PTT: 25.4 ___: 1.1 ___ 06:09AM BLOOD Glucose: 148* UreaN: 17 Creat: 0.4 Na: 139 K: 4.5 Cl: 94* HCO3: 39* AnGap: 6* ___ 06:09AM BLOOD ALT: 12 AST: 14 LD(LDH): 222 AlkPhos: 106* TotBili: 0.4 ___ 06:09AM BLOOD Calcium: 9.2 Phos: 3.3 Mg: 2.1 ___ 05:19AM BLOOD Lupus: Pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE Liquid 5 mg PO Q6H:PRN BREAKTHROUGH PAIN 2. Docusate Sodium 100 mg PO BID 3. Metoprolol Tartrate 75 mg PO Q8H 4. Senna 8.6 mg PO BID 5. amLODIPine 10 mg PO DAILY 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Acetaminophen (Liquid) 975 mg PO Q8H:PRN Pain - Mild/Fever 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 10. Ranitidine 150 mg PO BID 11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 12. Omeprazole 40 mg PO DAILY 13. Warfarin 4 mg PO DAILY16 Discharge Medications: CURRENT MEDICATIONS ___ as of 15:13 --------------- --------------- --------------- --------------- Active Inpatient Medication list as of ___ at 1514: Medications - Standing Levothyroxine Sodium 50 mcg PO/NG DAILY Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush Multivitamins W/minerals Liquid 15 mL PO/NG DAILY Acetaminophen 650 mg PO/NG Q8H Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush Acetylcysteine 20% ___ mL NEB Q4H shortness of breath, increased secretions Albuterol 0.083% Neb Soln 1 NEB IH Q4H Dyspnea Guaifenesin-Dextromethorphan 5 mL PO/NG Q6H OxyCODONE (Immediate Release) 2.5 mg PO/NG Q6H ClonazePAM 0.25 mg PO/NG TID Vitamin D 1000 UNIT PO/NG DAILY Heparin 5000 UNIT SC TID Polyethylene Glycol 17 g PO/NG DAILY Medications - PRN Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Glucose Gel 15 g PO PRN hypoglycemia protocol Docusate Sodium 100 mg PO/NG BID:PRN constipation Ramelteon 8 mg PO/NG QHS:PRN insomnia Artificial Tears ___ DROP BOTH EYES PRN dry eyes Heparin Flush (10 units/ml) 1 mL IV PRN and PRN, line flush LORazepam 0.5 mg PO/NG Q6H:PRN anxiety OxycoDONE Liquid 5 mg PO/NG Q4H:PRN pain, dyspea Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB Senna 8.6 mg PO/NG DAILY:PRN constipation Bisacodyl 10 mg PR QHS:PRN constipation Lidocaine Viscous 2% 15 mL PO TID:PRN toothache --------------- --------------- --------------- --------------- Discharge Disposition: Extended Care Discharge Diagnosis: Anaplastic thyroid cancer Chronic respiratory failure secondary to obstruction from goiter Hemorrhagic shock from right ___ acquired pneumonia Pulmonary embolism Right internal jugular thrombus Pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with tachycardia, evaluate for pneumonia TECHNIQUE: Semi-upright AP view of the chest COMPARISON: CT chest and chest radiograph ___ FINDINGS: Tracheostomy tube is in unchanged position. Left-sided PICC tip terminates at the SVC/right atrial junction. Enteric tube tip is within the stomach. Lung volumes are low. Moderate cardiac silhouette enlargement is re-demonstrated. Mediastinal and hilar contours are similar with known superior mediastinal mass better assessed on the previous CT. Crowding of bronchovascular structures is noted with probable mild pulmonary vascular congestion. Bibasilar airspace opacities likely reflect areas of atelectasis, though infection is not completely excluded in the left lung base. Small bilateral pleural effusions are likely not substantially changed in the interval. No pneumothorax is identified. No acute osseous abnormalities detected. Clips in the right upper quadrant of the abdomen are noted. IMPRESSION: Bibasilar airspace opacities may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. Persistent small bilateral pleural effusions with probable mild pulmonary vascular congestion. Superior mediastinal mass compatible with known thyroid goiter is better assessed on previous CT. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with ___ with altered mental status. Eval for intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 6.4 s, 17.4 cm; CTDIvol = 46.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 0.8 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: ___ noncontrast head CT FINDINGS: There is no evidence of acute territorial infarction,hemorrhage,edema, or mass. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. A 2.7 x 1.1 cm subcutaneous soft tissue nodule overlying the right occiput is unchanged since 2 weeks prior. There is no evidence of fracture. Incidental mild hyperostosis frontalis interna. There is new partial opacification of the right frontal sinus, ethmoid air cells, sphenoid sinuses, right maxillary sinus, and right nasal cavity with aerosolized secretions. A nasoenteric catheter is partially imaged. There is increased patchy opacification of the bilateral mastoid air cells with new extension through the left aditus ad antrum into the left middle ear cavity. The right petrous apex is pneumatized with partial opacification. No evidence of osseous erosion. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. Increased bilateral mastoid effusions with extension into the left middle ear cavity raising the possibility of otomastoiditis. No evidence of osseous erosion. 3. New partial opacification of the paranasal sinuses with aerosolized secretions raising the possibility of acute sinusitis. Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ with H/H drop on heparin. minimally responsive with difficult physical exam. eval for intra-abd bleeding. TECHNIQUE: Noncontrast abdomen/pelvis CT: Axial images were obtained through the abdomen and pelvis. Subsequent CTA through the pelvis was performed. Coronal and sagittal reformats were performed. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 27.7 mGy (Body) DLP = 1,467.8 mGy-cm. 2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 11.4 mGy-cm. 3) Spiral Acquisition 5.4 s, 42.3 cm; CTDIvol = 14.9 mGy (Body) DLP = 628.4 mGy-cm. 4) Spiral Acquisition 5.4 s, 42.3 cm; CTDIvol = 14.9 mGy (Body) DLP = 628.4 mGy-cm. Total DLP (Body) = 2,736 mGy-cm. COMPARISON: ___ CT abdomen ___ chest CTA FINDINGS: LOWER CHEST: A simple moderate size pericardial effusion appears slightly smaller since ___ without evidence of mass effect. There is a trace right pleural effusion. There is persistent right basilar atelectasis/consolidation with air bronchograms. There is decreased left basilar atelectasis/consolidation with air bronchograms. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions within limitations of noncontrast CT. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas is moderately atrophic. No focal lesions or pancreatic ductal dilation identified. No peripancreatic fat stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits, noting placement of a rectal catheter. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder is decompressed with a Foley catheter in place. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is anteverted with a calcified fibroid in the right aspect of the uterine fundus. VASCULAR: No infrarenal abdominal aortic aneurysm. Calcified atherosclerosis is mild. Dilated gonadal veins bilaterally with prominent pelvic varices may suggest pelvic congestion syndrome in the correct clinical setting. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is mild bilateral hip osteoarthritis. SOFT TISSUES: A right iliacus hematoma measures 12.9 x 9.1 x 5.9 cm (series 601, image 43; series 3, image 62). A right iliopsoas hematoma measures at least 16.5 x 5.5 x 4.6 cm (series 601, image 38; series 3, image 91). On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh. There is no active extravasation. Note is made of mild anasarca. There are bilateral fat containing inguinal hernias and a small fat containing umbilical hernia. IMPRESSION: 1. Large right iliacus and right iliopsoas hematomas without active extravasation. 2. On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh without active extravasation. 3. Bibasilar airspace opacities, similar on the right and decreased on the left. Recommend clinical correlation to assess for the possibility of pneumonia. 4. Decreased size of a moderate pericardial effusion. No evidence of mass effect. Radiology Report INDICATION: ___ year old woman with chronic trach concern for pneumonia// evaluate for progression of infiltrate TECHNIQUE: Frontal radiograph of the chest. COMPARISON: ___. IMPRESSION: Opacity of the left lung base appears similar may reflect left pleural effusion and atelectasis, however consolidative opacity cannot be excluded. Mild bilateral pulmonary edema similar to slightly increased from prior exam. Tracheostomy is partially visualized. NG tube is seen with tip projecting over left upper quadrant, side-hole may be near the GE junction, similar to prior exam. Left-sided PICC is seen with tip projecting over the right atrium, similar to prior exam. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with left sided PICC with LUE>RUE swelling with known R IJ and R Subclavian DVT secondary to substernal thyroid goiter// LUE DVT? TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: ___. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. PICC is seen within the left cephalic vein. Again seen is a superficial fluid collection in the left biceps area measuring approximately 8.7 x 2.5 x 3.2 cm. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Unchanged superficial fluid collection in the left anterior upper arm. Radiology Report INDICATION: ___ year old woman with respiratory distress// is there pneumonia, mucus plug? TECHNIQUE: Frontal radiograph of the chest. COMPARISON: ___. IMPRESSION: Left-sided PICC is seen with tip projecting at the cavoatrial junction/right atrium. NG tube is seen with tip projecting over left upper quadrant and side-hole likely at the GE junction. Tracheostomy catheter is again seen. Low lung volumes. Opacity at the left lung base appears similar and may reflect a combination of effusion and atelectasis. Consolidative opacity cannot be excluded. Mild bilateral pulmonary edema appears similar. Likely small right pleural effusion. The cardiac silhouette appears unchanged. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with pneumonia and respiratory distress.// pulmonary edema? worsening infiltrate TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___ 05:00 IMPRESSION: Compared to the earlier same day examination, upper enteric tube and tracheostomy tube as well as a left-sided PICC are unchanged. Lung volumes remain very low. Retrocardiac consolidation appears similar. There may be a tiny right-sided effusion, unchanged. There is no pneumothorax. The upper lung zones remain clear. Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old woman presented with thigh hematomas, now restarted heparin gtt, R thigh now indurated, patient tachycardic/hypotensive and Hgb 7.6-> 6.0// looking for active extravasation into thigh hematomas, most notably on the R TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis, including the thighs. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Total DLP: 1435 mGy-cm COMPARISON: CTA abdomen and pelvis ___ FINDINGS: VASCULAR: Abdominal aorta is non aneurysmal. Celiac artery and its branches are patent. SMA, ___, and bilateral renal arteries are patent. Bilateral internal and external iliac arteries are patent. Normal right femoral artery. LOWER CHEST: Right greater than left enhancing bibasilar consolidations likely represent atelectasis. No pleural effusion. Small pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is is resected. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: Urinary bladder is collapsed around a Foley catheter, with post instrumentational intraluminal air. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Calcified fibroid in the uterus. Right adnexal lesion measures approximately 2.6 x 2.2 cm, containing a coarse calcification (10:122). No adnexal masses are identified on the left. BONES: No acute fracture. Bony structures demineralized. SOFT TISSUES: Intramuscular hematoma in the right iliacus muscle measures 4.7 x 8.1 x 11.1 cm TV x AP x CC (6:126, 8:62), measuring up to 4.9 x 8.8 x 12.8 cm on ___. Evaluation of the soft tissues is notable for extensive areas of intramuscular hematoma involving several compartments of the right thigh. For instance, hematoma measures up to 18.4 x 8.6 cm in the right sartorius muscle (08:43). There is expansion of the entire vastus lateralis muscle, measuring up to 34.9 x 9.9 cm CC x TV (08:50). There is also intramuscular hematoma in the adductor compartment, measuring up to 14.7 x 6.4 cm (8:79). When compared to the prior study on ___, the hematomas within the upper thigh muscles appear slightly expanded, but was not fully imaged on the prior study. However, there is no evidence of active extravasation on the arterial or venous phase. Additionally, there is significant subcutaneous edema that has increased from prior. Limited evaluation of the partially imaged right knee joint shows a small joint effusion. IMPRESSION: 1. Extensive intramuscular hematomas involving several right thigh compartments, with involvement of the entire thigh to the level of the knee as described above. Upper thigh involvement appears slightly more extensive compared to ___, but there is no active extravasation. 2. Minimal decrease in size of a now 11.1 x 8.1 x 4.7 cm right iliacus muscle hematoma. 3. Incidental 2.6 x 2.2 cm right adnexal lesion with a coarse calcification, for which the differential includes fibroma, cystadenofibroma ___ tumor. In the absence of prior imaging documenting stability, a pelvic ultrasound is recommended for further evaluation. 4. Similar right greater than left bibasilar consolidations, likely representing atelectasis. Pneumonia is unlikely in the absence of clinical symptoms. 5. Small pericardial effusion is likely similar accounting for redistribution. RECOMMENDATION(S): Nonurgent pelvic ultrasound is recommended if prior imaging is not available for comparison. NOTIFICATION: The findings and recommendation were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 8:21 am, 2 minutes after discovery of the findings. Radiology Report INDICATION: ___ with goiter causing tracheal narrowing now s/p trach ___, also with history of PE's on Coumadin who presents with thigh hematomas causing anemia, found to have fevers, leukocytosis, and worsening mental status. Suspect HCAP, treating with Zosyn.// NG placement TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Tracheostomy tube and NG tube are unchanged. There is subsegmental atelectasis in the right lung base. Cardiomediastinal silhouette is stable. Small bilateral effusions are stable. No pneumothorax is seen. Lungs are low volume. There is no evidence of pulmonary edema. Right upper lobe atelectasis has improved. Radiology Report EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS INDICATION: ___ year old woman with hematomas in pelvis thighs, and ongoing bleeding requiring pressors. possible ___ embolization// Please do CTA of pelvis proximal lower extremities (to the knees). She has known hematomas there TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 12.8 s, 83.4 cm; CTDIvol = 1.8 mGy (Body) DLP = 144.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 5.8 mGy (Body) DLP = 1.2 mGy-cm. 3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 23.0 mGy (Body) DLP = 4.6 mGy-cm. 4) Stationary Acquisition 6.6 s, 0.2 cm; CTDIvol = 111.7 mGy (Body) DLP = 22.3 mGy-cm. 5) Spiral Acquisition 12.8 s, 83.2 cm; CTDIvol = 17.5 mGy (Body) DLP = 1,443.0 mGy-cm. Total DLP (Body) = 1,616 mGy-cm. COMPARISON: CT ___ FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. The SMA and ___ are patent. The celiac artery is not entirely visualized. Intramuscular hematoma within the right iliacus is unchanged from ___ with the iliacus measuring up to 8.6 x 5.0 cm. Several large intramuscular hematomas involving primarily the anterior and medial compartment are unchanged. For example, the sartorius, rectus femoris, vastus lateralis, vastus intermedius, vastus medialis, are significantly increased in size but unchanged from ___. Allowing for single phase contrast enhanced technique, no new collection or active extravasation. ABDOMEN: (Upper abdomen partially visualized.) HEPATOBILIARY: The visualized liver is unremarkable. The gallbladder is surgically absent. PANCREAS: The visualized pancreas is unremarkable. SPLEEN: The visualized spleen is within normal limits. ADRENALS: The visualized adrenal glands unremarkable. URINARY: No suspicious renal mass identified. No hydronephrosis. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Fibroid uterus is noted. No adnexal abnormality. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Subchondral cystic degenerative change noted at the hip joints, bilaterally. There is a small right knee joint effusion. The patient is status post ORIF of a left tibial fracture. No evidence of hardware complication. SOFT TISSUES: Ventral abdominal hernia containing a loop of small bowel without evidence of complication. IMPRESSION: 1. Multiple, unchanged large intramuscular hematomas involving the iliacus and anterior and medial compartments of the right thigh. No new collection or evidence of active extravasation, allowing for limitations of assessment. There is extensive right lower extremity soft tissue edema. 2. Ventral abdominal wall hernia contains a loop of small bowel without complication. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with trach and recently tx for PNA. Now with increased respiratory distress.// Assess for worsening PNA vs pulmonary edema. TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___. IMPRESSION: Compared to the prior examination, lung volumes are lower, further accentuating the cardiac silhouette and pulmonary vasculature. Tracheostomy tube, left PICC, and upper enteric tube are unchanged. There is moderate cardiomegaly. No gross consolidation is seen. There are probable small persistent bilateral pleural effusions. There is no pneumothorax. Radiology Report INDICATION: ___ year old woman with NGT// NGT placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The patient is rotated. A tracheostomy tube is present. The tip of the nasogastric tube projects over the stomach. The left PICC line tip loops back on itself pointing cranially and may be malpositioned in the azygos vein. Low bilateral lung volumes cause bronchovascular crowding. There are small bilateral pleural effusions with subjacent atelectasis. Superimposed pulmonary vascular congestion is likely present. The appearance of the cardiac silhouette is unchanged. IMPRESSION: The tip of the feeding tube projects over the stomach. Suspected malpositioned left PICC line with the tip appearing to project over the azygos vein. A repeat frontal radiograph without patient rotation is recommended. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:25 pm, 2 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with ? of a malpositioned PICC. Please confirm PICC line tip placement. PICC line has been power flushed// ? of a malpositioned PICC in azygous vein on previous CXR. Please confirm placement. TECHNIQUE: AP portable chest radiograph COMPARISON: Chest radiograph from earlier today IMPRESSION: There are low bilateral lung volumes and the patient is again noted to be rotated. The left PICC line tip is now flipped downward and leftward, still appearing malpositioned. Unchanged cardiopulmonary findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: Ms. ___ is a ___ year old woman with hypothyroidism, goiter since ___, sensorineural hearing loss, morbid obesity and recent admission ___ for tracheal obstruction and right vocal cord paralysis secondary to enlarged goiter requiring tracheostomy, with course complicated by diagnosis of PE/RIJ DVT/R subclavian DVT discharged on warfarin, who was admitted ___ from her LTACH with hemorrhagic shock from right iliopsoas/thigh hematoma and HCAP. Her course has been complicated by pericardial effusion and volume overload.// increased tachypneaincreased tachypnea IMPRESSION: Compared to chest radiographs ___ through ___. Previous mild pulmonary edema has resolved, although vessels are crowded by chronically elevated right hemidiaphragm. Moderate cardiomegaly is chronic. Small pleural effusions are likely. No pneumothorax. Tracheostomy tube midline. Nasogastric drainage tube passes into the stomach and out of view. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: hypothyroidism, goiter since ___, sensorineural hearing loss, morbid obesity and recent admission ___ for tracheal obstruction and right vocal cord paralysis secondary to enlarged goiter requiring tracheostomy, with course complicated by diagnosis of PE/RIJ DVT/R subclavian DVT discharged on warfarin, who was admitted ___ from her LTACH with hemorrhagic shock from right iliopsoas/thigh hematoma and HCAP. Her course has been complicated by pericardial effusion and volume overload. Worsening LUE swelling compared to right TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial and basilic veins are patent, compressible and show normal color flow and augmentation. At the junction of the left subclavian vein, the cephalic vein is mildly distended, noncompressible, and demonstrates decreased flow on color Doppler imaging, consistent with nonocclusive superficial thrombosis. At this time a thrombosis does not extend into the subclavian vein. Additionally, within the left biceps, a fluid collection measuring 2.9 x 2.1 x 6.0 cm is identified without increased peripheral vascularity. This would be amenable to ultrasound-guided aspiration if desired. IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Nonocclusive superficial thrombosis of the proximal cephalic vein, extending to the junction of the subclavian vein. 3. Fluid collection within the left biceps measure up to 6 cm in long dimension; this would be amenable to ultrasound-guided aspiration if needed. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, RDMS on the telephone on ___ at 11:55 am, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: Ultrasound-guided aspiration INDICATION: ___ year old woman with goiter s/p trach, diffuse overload, large LUE fluid collection// LUE collection to be drained by US, spoke to US team COMPARISON: ___ PROCEDURE: Ultrasound-guided drainage of a left arm collection. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a 15 gauge needle was advanced into the left arm collection. Approximately 2 cc of sanguinous fluid was aspirated and sent for microbiology evaluation. The remainder of the fluid could not be aspirated due to the consistency of the collection. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: No sedation was provided. FINDINGS: Preprocedure ultrasound re-demonstrated a collection in the left upper arm. IMPRESSION: US-guided aspiration of a collection in the left upper arm, yielding 2 cc of sanguinous fluid. This most likely represents a hematoma. Aspirate was sent for microbiology evaluation. Radiology Report INDICATION: ___ year old woman with goiter, rij clot and left cephalic clot with BUE swelling and RLE swelling from hematoma, makes exam difficult and want to assess volume status and need for diuresis// eval for pulm edema TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. Tracheostomy tube remains in place. The NG tube is unchanged. Cardiomediastinal silhouette is stable. There are stable small bilateral pleural effusions no pneumothorax is seen Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman with goiter s/p trach, evaluating swelling and need for repeat biopsy// evaluate neck/throat swelling TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.0 s, 23.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 195.0 mGy-cm. Total DLP (Body) = 195 mGy-cm. COMPARISON: CTA chest with without contrast of ___, CT neck without contrast of ___, outside hospital CT chest of ___. FINDINGS: Re-identified is 5.6 x 4.2 x 5.7 cm (AP, TRV, SI) heterogeneous ill-defined left thyroid mass, demonstrating central cystic components and coarse scattered coarse calcifications extending into the superior mediastinum. As on prior examinations, the fascial planes between the lesion and the adjacent trachea and esophagus (series 304, image 139) and thyroid cartilage (series 304, image 87) remains obscured. The lesion abuts the right common carotid artery (series 304, image 147), with right lateral displacement, overall similar to prior examination, however the intervening fascial plane is also obscured, with possible increasing surrounding stranding (series 304, image 126). Interval resolution of postsurgical subcutaneous emphysema. The patient is status post tracheostomy, unchanged in appearance from prior examination. The left lobe of the thyroid is also mildly enlarged and heterogeneous, with coarse calcifications and hypoattenuating nodules, unchanged from prior examination. The fascial planes between the left lobe and adjacent structures appear grossly preserved. An enteric tube is also identified. No cervical lymphadenopathy is identified. However, there appears to be increased soft tissue density in the visualized superior mediastinum posterior to the trachea with interval increased size of a lymph node adjacent to the esophagus at the level of the aortic arch (series 304, image 147). Allowing for sequela of tracheostomy and enteric tube, the remainder of the aerodigestive tract is grossly unremarkable. The major salivary glands are unremarkable. A spiculated left upper lobe pulmonary nodule measuring 1 cm has significantly increased in size since examination of ___ (series 304, image 108). A 4 mm nodule in the right upper lobe (series 304, image 147) appears slightly increased in size as well. Dependent mucus is seen in the visualized right maxillary sinus and there is near complete opacification of the visualized sphenoid sinuses. Near complete opacification of the bilateral mastoid air cells is also noted. No acute osseous abnormality. IMPRESSION: 1. Re-identified is a 5.7 cm heterogeneous ill-defined left thyroid mass demonstrating central cystic components and coarse scattered calcifications. Since the prior examination of ___, interval resolution of postoperative pneumocephalus and soft tissue inflammatory stranding. 2. There remains loss of defined fascial plane between the mass and the adjacent trachea, esophagus and thyroid cartilage. In addition, the lesion exerts right lateral mass effect on the right common carotid artery, with obscuration of intervening fascial plane, which appears progressed from prior examination. Although the mass does not appear significantly increased in size since examination of ___, the lack of improvement in stranding and obscuration of adjacent fascial planes raises concern for possible malignant process. 3. In addition, there is increased soft tissue prominence incompletely characterized at the visualized superior mediastinum posterior to the trachea as well as apparent increased size of a 1.6 cm paratracheal lymph node (series 304, image 147). 4. A spiculated left upper lobe lesion now measures 1 cm, previously measuring 5-6 mm. A 4 mm right upper lobe pulmonary nodule has also increased in size from prior examination. Recommend further evaluation with dedicated CT chest. 5. Additional findings described above. RECOMMENDATION(S): Recommend further evaluation of impression 4 with dedicated CT chest with without contrast. Radiology Report INDICATION: ___ year old woman with goiter s/p trach with RIJ clot and now with left cephalic/subclavian likely triggered by midline in the left, which is now more distal but she needs heparin for the clot// ***spoke to ___ ___ place temporary left IJ and remove left midline due to clot, patient also scheduled for PEG, ___ aware ; ___ year old woman with goiter causing tracheal compression now s/p trach by ENT, per speech and swallow not yet safe to take POs or in the immediate future and will need G tube. **Of note, patient on heparin gtt and receiving tubefeeds through NGT at this time. Patient is also hard of hearing and requires writing for communication// G tube placement COMPARISON: CT from ___ TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service time of 25 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl and Versed for moderate sedation as above, 1% local lidocaine, 1% lidocaine with epinephrine, 1 mg glucagon CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.9 min, 16 mGy PROCEDURE: 1. Placement of triple lumen left internal jugular catheter 2. Placement of a MIC gastrostomy tube placement. PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left neck was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and ___ wire was advanced into the IVC. A triple-lumen central venous catheter was advanced over the wire into the superior vena cava with the tip in the cavoatrial junction. All 3 access ports were aspirated, flushed and capped. The catheter was secured to the skin with a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. Attention was then turned to the placement of the feeding tube. A scout image of the abdomen was obtained. The stomach was insufflated through the indwelling nasogastric tube. Using a marker, theskin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Permanent ultrasound images were stored. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. A ___ wire was introduced into the stomach. A small skin incision was made along the needle and the needle was removed. After sequential dilation using serial dilators, a ___ gastrostomy catheter was advanced over the wire into position. The catheter was secured by forming the retaining loop in the stomach after confirming the position of the catheter with a contrast injection.. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate FINDINGS: 1. Successful placement of a ___ gastrostomy tube. 2. Successful placement of left triple-lumen IJ catheter with tip in the SVC. IMPRESSION: Successful placement of a ___ gastrostomy tube and triple-lumen catheter. Radiology Report INDICATION: ___ year old woman with goiter s/p trach with RIJ clot and now with left cephalic/subclavian likely triggered by midline in the left, which is now more distal but she needs heparin for the clot// ***spoke to ___ ___ place temporary left IJ and remove left midline due to clot, patient also scheduled for PEG, ___ aware ; ___ year old woman with goiter causing tracheal compression now s/p trach by ENT, per speech and swallow not yet safe to take POs or in the immediate future and will need G tube. **Of note, patient on heparin gtt and receiving tubefeeds through NGT at this time. Patient is also hard of hearing and requires writing for communication// G tube placement COMPARISON: CT from ___ TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service time of 25 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl and Versed for moderate sedation as above, 1% local lidocaine, 1% lidocaine with epinephrine, 1 mg glucagon CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.9 min, 16 mGy PROCEDURE: 1. Placement of triple lumen left internal jugular catheter 2. Placement of a MIC gastrostomy tube placement. PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left neck was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and ___ wire was advanced into the IVC. A triple-lumen central venous catheter was advanced over the wire into the superior vena cava with the tip in the cavoatrial junction. All 3 access ports were aspirated, flushed and capped. The catheter was secured to the skin with a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. Attention was then turned to the placement of the feeding tube. A scout image of the abdomen was obtained. The stomach was insufflated through the indwelling nasogastric tube. Using a marker, theskin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Permanent ultrasound images were stored. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. A ___ wire was introduced into the stomach. A small skin incision was made along the needle and the needle was removed. After sequential dilation using serial dilators, a ___ gastrostomy catheter was advanced over the wire into position. The catheter was secured by forming the retaining loop in the stomach after confirming the position of the catheter with a contrast injection.. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate FINDINGS: 1. Successful placement of a ___ gastrostomy tube. 2. Successful placement of left triple-lumen IJ catheter with tip in the SVC. IMPRESSION: Successful placement of a ___ gastrostomy tube and triple-lumen catheter. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST INDICATION: ___ year old woman with goiter s/p trach, multiple clots on heparin gtt, with new hematuria// CT urogram to evaluate hematuria*patient going down for neck CT today, would appreciate if could do at same time as she has a trach and needs nursing to go with her* TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in supine position. The non-contrast scan was done with low radiation dose technique. The contrast scan was performed with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.7 s, 58.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 328.7 mGy-cm. 2) Spiral Acquisition 4.4 s, 58.7 cm; CTDIvol = 24.3 mGy (Body) DLP = 1,423.3 mGy-cm. 3) Stationary Acquisition 8.5 s, 0.5 cm; CTDIvol = 47.0 mGy (Body) DLP = 23.5 mGy-cm. Total DLP (Body) = 1,775 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: LOWER CHEST: Bibasilar atelectasis has increased from 2 weeks prior. Trace bilateral pleural effusions are unchanged. A moderate pericardial effusion is grossly unchanged. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. The common bile duct is significantly dilated measuring up to 2.9 cm, previously 2.4 cm. There is moderate intrahepatic ductal dilation. The gallbladder is surgically absent PANCREAS: Pancreas is atrophic. Remaining pancreatic parenchyma is normally enhancing. No focal lesions or ductal dilation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis. There is no perinephric abnormality. Several bilateral subcentimeter hypodensities are too small to characterize, but most likely represent simple cysts. There is no evidence of urothelial lesions. The distal ureters are unremarkable. The bladder contains a Foley catheter and is otherwise grossly unremarkable. GASTROINTESTINAL: An enteric tube terminates in the mid stomach. There is also a percutaneous gastrostomy tube also terminating in the gastric body. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not seen. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: There are calcified fibroids in the uterus. A right adnexal cyst with internal calcification measures 3 cm, unchanged. No left adnexal lesion is identified. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Subacute left 7th rib fracture is noted. A left 6th rib fracture is chronic. Incompletely evaluated is severe degenerative change to the left wrist with apparent fusion of the carpal bones. SOFT TISSUES: There has been interval evolution of a hematoma involving the right iliacus and extending into the iliopsoas. Hematoma in the right sartorius muscle is also noted, and the muscle appears slightly expanded measuring 5.0 x 8.5 cm (3:106) IMPRESSION: 1. Interval increase in bibasilar atelectasis. 2. No significant change to a moderate pericardial effusion. 3. Worsening intra- and extrahepatic biliary dilation with the common bile duct measuring up to 2.9 cm (previously 2.2 cm). 4. No findings to explain hematuria. Specifically, no urinary calculi, renal or urothelial lesion. 5. Stable right adnexal cyst with coarse calcification. 6. Evolving right iliopsoas and sartorius hematomas. The sartorious is slightly expanded from ___. 7. Incompletely assessed are severe degenerative changes of the left wrist with apparent osseous fusion of the carpal bones. RECOMMENDATION(S): MRCP for further evaluation of worsening biliary dilation. Pelvic ultrasound. Left wrist radiographs. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with goiter, unsure if cancer, with increasing size of spiculated lung nodule, evaluate spiculated nodule TECHNIQUE: MDCT axial images were obtained through the chest after the uneventful administration of intravenous contrast. Coronal and sagittal and axial MIPS reformatted images were obtained. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 34.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 696.8 mGy-cm. 2) Spiral Acquisition 0.7 s, 11.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 228.0 mGy-cm. Total DLP (Body) = 925 mGy-cm. COMPARISON: CTA chest ___, CTA neck ___ FINDINGS: Again seen is a massively enlarged right neck soft tissue mass compatible with the known thyroid mass with central cystic components and coarse calcifications extending beyond the thoracic inlet in into the anterior mediastinum. Overall size has not significantly changed compared to prior examinations, and measures 6.7 x 7.8 x 7.3 cm. There is again mass effect on the trachea with loss of intervening fat planes and leftward displacement. A tracheostomy tube is in place and the airway is open. There is also loss of fat plane between this mass and the esophagus and thyroid cartilage as well as the right common carotid artery. There is no right carotid narrowing. Unable to evaluate for venous anatomy patency given phase of contrast. The left thyroid is also enlarged with multiple coarsely calcified nodules, but does not extend below the thoracic inlet. Heart is moderately enlarged. There is a small pericardial effusion. Numerous mildly enlarged mediastinal lymph nodes are unchanged measuring up to 1.0 cm in the precarinal station. There is no axillary adenopathy. The airways are patent to the segmental level bilaterally. There are small right greater than left pleural effusions with bibasilar atelectasis also more pronounced on the right. Again seen is a 1.0 cm left apical pulmonary nodule which demonstrates interval increase in size since CTs from 1 month prior but no change compared to yesterday's CT (series 302, image 30). There is no pneumothorax. A nasoenteric tube is in place ending in the stomach. Limited views of the upper abdomen are unremarkable. There is no suspicious bony lesion. Multiple healing rib fractures are noted involving the left lateral fourth through seventh ribs. There is a leftward upper thoracic scoliosis. Note is made of a left humeral fixation plate and interlocking screws. IMPRESSION: 1. No change in size of the known large partially cystic right thyroid mass causing contralateral (left lower) displacement and compression of the adjacent trachea with obscuration of the fascial plane between the esophagus, trachea, thyroid cartilage, and right internal carotid artery. The trachea is patent via presence of a tracheostomy tube in appropriate position. 2. 1.0 cm left apical pulmonary nodule, given short interval increase in size, favors a benign process such as inflammation or infection, although short-term follow-up is recommend. 3. Right greater than left small pleural effusions with associated atelectasis. 4. Short-term stability of mildly enlarged mediastinal lymph nodes. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with goiter, trach, hemoptysis// evaluate hemoptysis per IP evaluate hemoptysis per IP IMPRESSION: Compared to chest radiographs since ___ most recently ___. New left internal jugular line ends in the upper SVC. No attendant mediastinal widening. Lung volumes remain quite low. Small left pleural effusion is likely, unchanged. Moderate enlargement of cardiac silhouette is stable. Bibasilar atelectasis is mild to moderate. No pneumothorax. Nasogastric drainage tube ends in the stomach. Tracheostomy tube midline. Radiology Report INDICATION: ___ year old woman with hemoptysis s/p rigid bronch w biopsy// r/o PTX TECHNIQUE: Portable chest x-ray COMPARISON: Portable chest x-ray ___ FINDINGS: Lines and supporting devices appear unchanged compared to the previous study. There are low lung volumes. No pneumothorax is appreciated. There is a small left effusion, similar to previous. Atelectatic changes persist in the lower lobes. The heart size is not adequately assessed given the low lung volumes. The aorta is atherosclerotic and tortuous. The patient's chin obscures the lung apices. The bones are diffusely osteopenic. Degenerative changes are evident in the spine. IMPRESSION: Low lung volumes with atelectatic changes at the lung bases, and small left effusion. Findings are similar to the previous study from ___. Radiology Report EXAMINATION: CT-guided thyroid mass biopsy. INDICATION: ___ year old woman with goiter s/p trach, c/f malignancy. CORE BIOPSY please. COMPARISON: CT neck ___. PROCEDURE: CT-guided thyroid mass biopsy. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CTscan of the intended biopsy area was performed. Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the lesion. An 18 gauge core biopsy device with a 20 mm throw was used to obtain 6 core biopsy specimens, which were sent for pathology. The specimen was evaluated by onsite cytologist. The more superficial samples showed adequate tissue sample, but without definite atypia. Deeper samples showed atypia but evaluation was limited by extensive necrosis. After multiple intact cores were obtained, a decision was made to stop sampling. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 16.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 149.5 mGy-cm. 2) Stationary Acquisition 11.0 s, 1.4 cm; CTDIvol = 82.9 mGy (Body) DLP = 119.4 mGy-cm. Total DLP (Body) = 279 mGy-cm. FINDINGS: 1. Large heterogeneous right thyroid lobe mass is again demonstrated. This deviates the trachea to the left. Tracheostomy tube is present. 2. Multiple samples were taken from the superficial component of the right thyroid mass as well as the middle and posterior portions medially along the tracheal border. IMPRESSION: Successful CT-guided thyroid mass biopsy as above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with goiter s/p trach, on heparin gtt with increasing bloody secretions, intermittently desatting// eval tachypnea, desat IMPRESSION: In comparison with the study of ___, there is little change. Monitoring support devices are stable. Continued low lung volumes with basilar atelectatic changes and small left effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with goiter s/p trach with worsening resp status// eval desat eval desat IMPRESSION: Compared to chest radiographs since ___ most recently ___. Lung volumes remain quite low. Atelectasis has worsened at the left lung base. Bilateral pleural effusions are likely, but not large. Moderate to severe cardiomegaly is chronic. Tracheostomy tip projects over the upper trachea. No pneumothorax or mediastinal widening. Left jugular line ends in the low SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p rigid bronch please r/p PTX// r/p PTX r/p PTX IMPRESSION: Compared to chest radiographs ___: No pneumothorax. Small pleural effusions unchanged. Lung volumes remain quite low. Moderate to severe cardiomegaly is chronic. No pulmonary edema. Tracheostomy tube midline. Left central venous catheter ends in the low SVC. Radiology Report INDICATION: ___ year old woman with grossly bloody tracheostomy secretions. Hypoxia to ___. Intrapulmonary hemorrhage. TECHNIQUE: AP portable semi upright. COMPARISON: ___ AP chest radiograph ___ chest CT IMPRESSION: Patient rotation and low lung volumes limit evaluation. Tracheostomy is again noted. Left-sided central venous catheter terminates in the region of the distal SVC, unchanged. No evidence for pneumothorax. Unchanged mild blunting of bilateral costophrenic angles, compatible with small pleural effusions versus pleural thickening. Bibasilar atelectasis without evidence for new consolidation. Cardiomediastinal silhouette is not optimally assessed. Right upper mediastinal widening was shown to be secondary to right thyroid mass on prior chest CT. Internal fixation hardware is partially visualized in the proximal left humerus. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Anemia, PE Diagnosed with Altered mental status, unspecified temperature: 99.0 heartrate: 120.0 resprate: 22.0 o2sat: 96.0 sbp: 129.0 dbp: 69.0 level of pain: UA level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you during your hospitalization at the ___. WHY WAS I ADMITTED TO THE HOSPITAL? ==================================== - You had a bleed into your right thigh/pelvis, likely because of being on warfarin. - You also had a pneumonia. - You had difficulty breathing because of a thyroid mass found to be cancer. WHAT WAS DONE FOR ME IN THE HOSPITAL? ====================================== - You were initially admitted to the intensive care unit, where you received multiple blood transfusions. Your bleeding stopped on its own. - You were seen by the lung (interventional pulmonary) doctors and the ___ doctors for your ___. The tube used for the tracheostomy was changed while you were in the hospital. - You were also seen by the endocrinology/thyroid team, and you had a biopsy of your thyroid/goiter. - Unfortunately, the biopsy showed something called anaplastic thyroid cancer. - You were seen by our oncology (cancer) team, and they told you and your family that this is a very aggressive disease. - You were restarted on anticoagulation/blood thinning medication (called heparin) because of the clots you have in your neck and lungs. However, you started to bleed from your trachea and previously bled into your urine as well. - Decision was made to NOT give you blood thinners, because the risk of bleeding currently outweighs the risk of forming new clots. - After many discussions with the oncology team, you will be transferred to ___ for additional evaluation and treatment WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? =========================================== - Continue to take medication as prescribed. - Continue to follow up with your team of doctors. We wish you all the best. Warmly, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine and Iodide Containing Products / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Thiazides Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Left-sided intrapleural fibrinolysis (___) Right-sided thoracentesis (___) History of Present Illness: Extracted from Admission History and Physical ___ with PMH of HTN, severe AS, moderate MR, Afib on warfarin, chronic pleural effusion ___ valvular disease s/p L pleural catheter placement, CKD3/4, who is presenting with erythema and purulent drainage around pleural catheter site. Patient was first referred to ___ clinic in ___ for bilateral L>R pleural effusion. She underwent thoracentesis with evaluation of sampled fluid and the effusion was eventually attributed to severe valvular disease. Despite up-titration of diuretics, she continued to have worsening dyspnea so she underwent L pleural catheter placement ___ (Dr. ___. After the procedure, her dyspnea dramatically improved. She was recently admitted for similar issue from ___ to the medicine service after she had increasing erythema at pleurex site and increasing cloudy/bloody drainage. She failed outpatient Keflex treatment and was treated for a 13 day course of initially vanc/CTX then narrowed to doxycycline/cefpodoxime for cellulitis. There was also initially concern for empyema but pleural fluid analysis seemed more consistent with transudative process and cultures were negative. Patient presented to ___ clinic today with worsening shortness of breath after her pleurex had drained minimal fluid over the last week. Per notes, IP team was considering pulling pleurex this week given minimal output over last few weeks and patient was holding warfarin. On exam, her catheter was foul smelling and skin surrounding was indurated and erythematous concerning for cellulitis. Fibrinolytics were instilled in clinic with only 5cc drained which was sent off for fluid studies. Given concern for the infection, sent to the ED for further evaluation. In the ED: - Initial vital signs were notable for: T 96.7 HR 64 BP 147/67 RR 18 SpO2 96% RA - Exam notable for: Resp: Decreased breath sounds at the bilateral bases R>L. no respiratory distress. pleurex catheter in place on the left. CV: RRR, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Capillary refill <2 sec. Abd: Soft, Nontender, Nondistended, no rigidity or guarding Skin: Erythema on the left chest wall surrounding the Pleurx catheter. Scant seropurulent discharge on the wound dressing. No fluctuance or discharge expressed. Neuro: Alert and following commands, moving all extremities spontaneously, sensation intact to light touch, speech fluent - Labs were notable for: WBC 5.7, Cr 1.9. Pleural fluid: LDH 81, Glucose 109, WBC 460, RBC ___ - Studies performed include: ___ CT Chest w/o contrast: 1. Unchanged catheter position. Small residual pleural collection at the base of the left hemithorax, probably organized, nonspecific although infection cannot be excluded. Small quantity of air in the residual pleural collection may be due to catheter placement; this can perhaps be explained by presence of a catheter although bronchopleural fistula is not excluded by this study. 2. Increased, now moderate to large, right-sided pleural effusion. 3. Persistent substantial chronic atelectasis at each lung base, left greater than right. ___ CXR: Left-sided PleurX catheter is unchanged. Bilateral pleural effusions are moderate volume and are also unchanged. Cardiomediastinal silhouette is stable. No pneumothorax. The there is mild pulmonary vascular congestion. There is near complete atelectasis of both lower lobes left greater than right, unchanged. - Patient was given: ___ 00:15 IV Vancomycin 750 mg - Consults: IP consulted Vitals on transfer: T 98.1 HR 76 BP 138/64 RR 22 SpO2 94% RA Upon arrival to the floor, patient states she feels fine other than having worsening shortness of breath with exertion over the last several weeks. She denies any trouble breathing at rest but states if she were to get up and walk around she would become very dyspneic. She otherwise denies any pain at the pleurex site, fevers/chills, N/V, or pleurisy." Past Medical History: -Chronic bilateral transudative effusions. -Severe aortic stenosis/moderate mitral regurgitation. -Paroxysmal atrial fibrillation. -Chronic kidney disease. -Iron deficiency anemia. -Hypertension. -Hyperlipidemia. Social History: ___ Family History: Review and non-contributory for pleural effusion or cellulitis. Physical Exam: ADMISSION PHYSICAL EXAM ====================== VITALS: T 98.1 HR 76 BP 138/64 RR 22 SpO2 94% RA GENERAL: Alert and interactive EYES: EOMI. Sclera anicteric and without injection. ENT: MMM. No JVD. CARDIAC: Regular rhythm, normal rate. III/VI systolic murmurs at the RUSB and apex. RESP: No increased work of breathing. Decreased breath sounds at the bases bilaterally. Basilar crackles on L. Left chest tube site with mild surrounding erythema w/o induration. No tenderness to palpation. ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation MSK: No spinous process tenderness. No CVA tenderness. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM ====================== VITALS: T 97.5, HR 70, BP 120/67, RR 17, O2 95% RA GENERAL Well appearing elderly female. She occasionally winces from pain when moving her trunk. HEENT: Anicteric sclerae. Oropharynx clear. NECK: JVP estimated at 12 cm. CV: Regular rate and rhythm. S1/diminished S2. Systolic ejection murmur. No S3. PMI is not displaced. PULMONARY: Comfortable. Air movement is fair at bases. There are residual crackles there as well. CHEST WALL: There is erythema in the vicinity of the tunneled pleural catheter insertion site. There is no discharge from the tract. There is no tenderness or fluctuance. ABDOMEN: Soft. Non-distended. EXTREMITIES: Warm. No peripheral edema. NEURO: Non-focal. Pertinent Results: ADMISSION LABS ============= ___ 06:52PM BLOOD WBC-5.7 RBC-3.61* Hgb-10.5* Hct-33.5* MCV-93 MCH-29.1 MCHC-31.3* RDW-13.6 RDWSD-46.0 Plt ___ ___ 06:52PM BLOOD Neuts-76.5* Lymphs-11.0* Monos-10.8 Eos-0.7* Baso-0.5 Im ___ AbsNeut-4.32 AbsLymp-0.62* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03 ___ 06:52PM BLOOD ___ PTT-35.7 ___ ___ 06:52PM BLOOD Glucose-158* UreaN-30* Creat-1.9* Na-135 K-3.7 Cl-97 HCO3-21* AnGap-17 PLEURAL FLUID ============ ___ 04:00PM PLEURAL TNC-460* RBC-___* Polys-2* Lymphs-47* Monos-15* Macro-1* Other-35* ___ 04:00PM PLEURAL TotProt-2.8 Glucose-109 LD(LDH)-81 Cholest-32 ___ 10:08AM PLEURAL TNC-110* RBC-201* Polys-16* Lymphs-79* Monos-4* Meso-1* ___ 10:08AM PLEURAL TotProt-3.3 Glucose-117 LD(LDH)-75 Cholest-39 ___ ___ Cytology-Negative for malignant cells DISCHARGE LABS ============== ___ 05:31AM BLOOD WBC-4.3 RBC-3.46* Hgb-10.0* Hct-31.7* MCV-92 MCH-28.9 MCHC-31.5* RDW-13.4 RDWSD-44.4 Plt ___ ___ 06:35AM BLOOD ___ PTT-37.0* ___ ___ 06:35AM BLOOD Glucose-94 UreaN-39* Creat-2.1* Na-139 K-3.9 Cl-99 HCO3-22 AnGap-18 ___ 06:35AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.7 ___ 06:35AM BLOOD proBNP-5831* STUDIES ======= CXR (___) IMPRESSION: Left-sided PleurX catheter is unchanged. Bilateral pleural effusions are moderate volume and are also unchanged. Cardiomediastinal silhouette is stable. No pneumothorax. The there is mild pulmonary vascular congestion. There is near complete atelectasis of both lower lobes left greater than right, unchanged. CT CHEST WITHOUT CONTRAST (___) IMPRESSION: 1. Unchanged catheter position. Small residual pleural collection at the base of the left hemithorax, probably organized, nonspecific although infection cannot be excluded. Small quantity of air in the residual pleural collection may be due to catheter placement; this can perhaps be explained by presence of a catheter although bronchopleural fistula is not excluded by this study. 2. Increased, now moderate to large, right-sided pleural effusion. 3. Persistent substantial chronic atelectasis at each lung base, left greater than right. CXR (___) IMPRESSION: 1. Small bilateral pleural effusions, decreased on the right status post thoracentesis. No pneumothorax. 2. Increased moderate pulmonary vascular congestion. 3. Decreased right basilar atelectasis. Unchanged left basilar atelectasis. CXR (___) IMPRESSION: 1. Unchanged small bilateral pleural effusions and pulmonary vascular congestion. 2. Unremarkable appearance of the left pleural catheter. No pneumothorax. AORTA AND BRANCHES ULTRASOUND (___) IMPRESSION: Patent abdominal aorta and common iliac arteries with no evidence of stenosis. The abdominal aorta is very tortuous in the setting of severe atherosclerotic burden Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 120 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Torsemide 30 mg PO DAILY 5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral DAILY 6. Warfarin 2 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO TID:PRN Pain 2. Cephalexin 500 mg PO TID RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day Disp #*15 Tablet Refills:*0 3. Doxycycline Hyclate 100 mg PO BID RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Tablet Refills:*0 4. Torsemide 40 mg PO DAILY 5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral DAILY 6. Diltiazem Extended-Release 120 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Warfarin 2 mg PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY -Acute on chronic dyspnea on exertion. SECONDARY -Bilateral pleural effusions. -Tunneled pleural catheter site cellulitis. -Severe aortic stenosis/moderate mitral regurgitation. -Stage III/IV chronic kidney disease. -Paroxysmal atrial fibrillation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pleural effusion s/p ___ on R // s/p thoracentesis, r/o pneumothorax TECHNIQUE: Portable AP view of the chest. COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Positioning of the left PleurX catheter is unchanged. The lungs are well expanded. Left basilar atelectasis is unchanged. Right basilar atelectasis is decreased. Cardiomediastinal silhouette is moderately enlarged but unchanged. Moderate pulmonary vascular congestion is increased. Small left pleural effusion is unchanged. Small right pleural effusion is decreased, status post thoracentesis. There is no pneumothorax. Spine is scoliotic. IMPRESSION: 1. Small bilateral pleural effusions, decreased on the right status post thoracentesis. No pneumothorax. 2. Increased moderate pulmonary vascular congestion. 3. Decreased right basilar atelectasis. Unchanged left basilar atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ female w bilateral effusions. Exquisite pain in vicinity of left tunneled pleural catheter. // Pneumothorax. TECHNIQUE: Chest frontal radiograph COMPARISON: Multiple priors most recently chest radiograph from ___ FINDINGS: Left-sided pleural catheter is unchanged. Heart size and mediastinal and hilar contours are stable. Small bilateral pleural effusions are not significantly changed. Pulmonary vascular congestion is not significantly changed. No focal consolidation. No pneumothorax. There is slightly improved aeration at the left base. IMPRESSION: 1. Unchanged small bilateral pleural effusions and pulmonary vascular congestion. 2. Unremarkable appearance of the left pleural catheter. No pneumothorax. Radiology Report EXAMINATION: AORTA AND BRANCHES INDICATION: ___ year old woman with severe aortic stenosis // pre-TAVR evaluation TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta and common iliac arteries was performed. COMPARISON: None. FINDINGS: The lumen of the aorta measures 2.0 in the proximal portion, 1.8 in mid portion and 1.9 cm in the distal abdominal aorta. There is severe calcified atherosclerotic plaque with no evidence of luminal narrowing. Wall-to-wall color flow is seen within the aorta and common iliac arteries. The right common iliac artery lumen measures 0.8 and the left common iliac artery lumen measures 2.7 cm. There is no evidence of luminal narrowing. The right kidney measures 9.5 cm and the left kidney measures 10.5 cm. Limited views of the kidneys are unremarkable without hydronephrosis. IMPRESSION: Patent abdominal aorta and common iliac arteries with no evidence of stenosis. The abdominal aorta is very tortuous in the setting of severe atherosclerotic burden Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Pleural effusion, not elsewhere classified, Cellulitis of chest wall temperature: 96.7 heartrate: 64.0 resprate: 18.0 o2sat: 96.0 sbp: 147.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

Dear ___, It was a pleasure caring for you at ___ ___. You were hospitalized for difficulty breathing due to fluid surrounding your lungs called pleural effusions. More than a liter was drained from the right side. The tunneled pleural catheter on the left side drained well after your interventional pulmonologist instilled a medication to dissolve adhesions. We treated a skin infection around the catheter insertion site too. Please continue two antibiotics as prescribed. See the attached medication reconciliation for details. As you know, the effusions are due to aortic stenosis, so we hoped to assess your candidacy for a transcatheter aortic valve replacement (TAVR) while you were here. In the end, we postponed the pre-TAVR coronary angiogram due to your kidney function. The structural heart team will revisit the possibility of a TAVR when you follow-up with them in clinic. We increased your torsemide to 40 mg daily to slow the accumulation of fluid until then. You previously took three 10-milligram pills. You should take four 10-milligram pills now. If you prefer, you can take two 10-milligram pills twice per day as discussed. This might lessen your hand cramping. We wish you all the best. Sincerely, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: peritonitis Major Surgical or Invasive Procedure: Peritoneal dialysis catheter removal Peritoneal dialysis catheter replacement- ___ Tunnelled hemodialysis line placement- ___ Hemodialysis- ___ History of Present Illness: Mr. ___ is a ___ with a history of ESRD on Peritoneal Dialysis since ___ who presents as a direct admission from ___ for a recurrent episode of bacterial peritonitis. The patient reports that approximately 4 weeks ago he began to have symptoms of peritonitis including abdominal pain. He self treated with cipro for 2 weeks which initially helped with his symptoms. However his symptoms began to recur and he developed cloudy peritoneal fluid. He had no fevers or chills but he did endorse night sweats. No diarrhea, nausea or vomiting. Yesterday (___) the patient had fluid drained from his peritoneal catheter which reportedly showed over 600 WBCs. He was treated with 2 grams of Intraperitoneal vancomycin. Of note this is the patient's ___ episode of bacterial peritonitis. He has had recurrent infections with gram positive organisms. When he was evaluated by Dr. ___ in transplant surgery in ___, the plan was to replace his PD catheter if he develops another episode of peritonitis. Therefore the patient was admitted to have catheter replaced. Currently, the patient reports moderate abdominal tenderness but otherwise has no acute complaints. ROS: per HPI, denies fever, chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - ESRD from hypertensive nephropathy on Peritoneal Dialysis since ___ - HYPOtension, since starting PD the patient's has had frequent episodes of low BP and had to stop all anti-hypertensives. His nephrologist has him on a high sodium diet. - Morbid Obesity. Previously weighed over 350 pounds but now down to 250. Social History: ___ Family History: No inherited renal disease Physical Exam: PHYSICAL EXAM ON ADMISSION: VS - Temp 97.7F, BP 118/66 , HR 80 , R20 , 97% RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - moderate diffuse tenderness. No rebound or guarding. Peritoneal catheter site clean with dressing intact. No surrounding erythema. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout. Gait not assessed PHYSICAL EXAM ON DISCHARGE: VS - Temp 99.4F, BP 135/85 , HR 90 , R17 , 97% RA ABDOMEN: old PD catheter dc'd and a new one is placed. Mild diffuse tenderness, no rebound or guarding Pertinent Results: ___ 03:20PM BLOOD WBC-7.8 RBC-2.66* Hgb-8.8* Hct-25.7* MCV-97 MCH-33.1* MCHC-34.1 RDW-16.2* Plt ___ ___ 06:36AM BLOOD WBC-9.2 RBC-2.53* Hgb-7.9* Hct-24.1* MCV-95 MCH-31.4 MCHC-32.9 RDW-15.9* Plt ___ ___ 03:20PM BLOOD ___ PTT-37.7* ___ ___ 03:20PM BLOOD Glucose-73 UreaN-80* Creat-24.3* Na-139 K-4.4 Cl-96 HCO3-23 AnGap-24* ___ 06:00AM BLOOD Glucose-113* UreaN-79* Creat-23.4* Na-137 K-4.0 Cl-94* HCO3-26 AnGap-21* ___ 06:30AM BLOOD Glucose-81 UreaN-87* Creat-28.1*# Na-140 K-4.6 Cl-98 HCO3-26 AnGap-21* ___ 06:35AM BLOOD Glucose-87 UreaN-91* Creat-29.5*# Na-139 K-4.6 Cl-97 HCO3-23 AnGap-24* ___ 06:00AM BLOOD Glucose-89 UreaN-101* Creat-32.1*# Na-139 K-4.9 Cl-97 HCO3-26 AnGap-21* ___ 06:10AM BLOOD Glucose-88 UreaN-107* Creat-33.9*# Na-139 K-5.5* Cl-97 HCO3-25 AnGap-23* ___ 06:25AM BLOOD Glucose-71 UreaN-112* Creat-35.2*# Na-138 K-5.3* Cl-98 HCO3-23 AnGap-22* ___ 05:40PM BLOOD Na-136 K-5.3* Cl-95* ___ 09:52PM BLOOD Na-137 K-5.2* Cl-94* ___ 06:20AM BLOOD Glucose-79 UreaN-117* Creat-36.5*# Na-139 K-5.0 Cl-96 HCO3-23 AnGap-25* ___ 06:36AM BLOOD Glucose-69* UreaN-119* Creat-38.0*# Na-135 K-4.5 Cl-93* HCO3-21* AnGap-26* ___ 03:20PM BLOOD ALT-10 AST-11 LD(LDH)-119 AlkPhos-50 TotBili-0.4 ___ 03:20PM BLOOD Lipase-29 ___ 03:20PM BLOOD Albumin-3.4* Calcium-8.0* Phos-10.5* Mg-2.1 ___ 06:36AM BLOOD Calcium-8.3* Phos-8.7* Mg-2.3 ___ 06:00AM BLOOD PTH-996* ___ 06:36AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 03:20PM BLOOD Vanco-19.6 ___ 06:10AM BLOOD Vanco-18.9 ___ 06:30AM BLOOD Vanco-16.0 ___ 06:00AM BLOOD Vanco-19.9 ___ 06:10AM BLOOD Vanco-22.8* ___ 06:25AM BLOOD Vanco-19.1 ___ 06:20AM BLOOD Vanco-19.5 ___ 06:36AM BLOOD Vanco-18.5 ___ 06:36AM BLOOD HCV Ab-PND ___ 02:30PM URINE Color-Straw Appear-Hazy Sp ___ ___ 02:30PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR ___ 02:30PM URINE RBC-70* WBC-9* Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 ___ 02:30PM URINE Mucous-RARE ___ 3:00 pm URINE Source: ___. URINE CULTURE (Pending): ___ 5:22 pm PERITONEAL FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. Reported to and read back by ___ ___ AT 1217. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Peritoneal fluid cytology (___) NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, macrophages, lymphocytes and numerous neutrophils. Abdominal X-ray (___) IMPRESSION: PD catheter is curled within the pelvis. Mild ileus. Tunnelled HD line placement (___)- prelim 1. Placement of a tunneled hemodialysis line into the right atrium via the right internal jugular vein under ultrasound and fluoroscopic visualization. 2. The line is ready to use. Lab Results on Discharge: ___ 06:40AM BLOOD WBC-7.2 RBC-2.40* Hgb-7.3* Hct-23.5* MCV-98 MCH-30.6 MCHC-31.2 RDW-15.8* Plt ___ ___ 06:40AM BLOOD Glucose-90 UreaN-71* Creat-24.0*# Na-138 K-4.3 Cl-100 HCO3-24 AnGap-18 ___ 06:40AM BLOOD Calcium-8.7 Phos-7.1* Mg-2.2 ___ 06:40AM BLOOD Vanco-20.4* ___ 06:36AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 06:36AM BLOOD HCV Ab-PND Medications on Admission: vancomycin dosed ___ IP allopurinol ___ asa 81mg daily calcium acetate 667 tid w meals cinecalcet 90mg qdinner calciferol 2.5mcg 2 capsules daily (5mcg daily) ferrous gluconate 324mg tid lactulose 60cc prn constipation prn senna miralax 17gm daily sevelamer (800mg tablets) 5 tablets tid with meals, and 2 tablets with snacks simvastatin 20mg hs dilavite vitamin b complex daily epogen ___ units once weekly sq Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. vancomycin 1,000 mg Recon Soln Sig: One (1) bag Intravenous with HD: please dose by vancomycin level. With HD. 4. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours) as needed for pain: hold for sedation, RR < 12. 7. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal twice a day as needed for constipation. 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation: hold for loose stools. 11. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q8H (every 8 hours) as needed for constipation. 12. Epogen 2,000 unit/mL Solution Sig: One (1) injection Injection once a week. 13. sevelamer carbonate 800 mg Tablet Sig: Five (5) Tablet PO three times a day: with meals, 2 tabs with snacks. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Medicine IV iron with hemodialysis Discharge Disposition: Extended Care Discharge Diagnosis: Primary- Peritonitis ESRD- initiated hemodialysis Secondary- History of hypertension prior to initiation of PD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ gentleman with end-stage renal disease, bacterial peritonitis, status post replacement of peritoneal catheter, now starting PD dialysis with no return of fluid exchange, assess location of tip. FINDINGS: Upright and supine abdominal radiographs reveal a catheter entering the left lower quadrant and curling dependently within the pelvis, likely reflecting the peritoneal dialysis catheter. Prominent small and large bowel loops are seen with mild dilatation in air-fluid levels in small bowel, possibly reflecting mild ileus with air and stool seen in the colon and rectum. Centralization of bowel loops may reflect ascites. Imaged lung bases are unremarkable. IMPRESSION: PD catheter is curled within the pelvis. Mild ileus. Radiology Report TUNNELED HEMODIALYSIS LINE PLACEMENT CLINICAL INDICATION: ___ man with end-stage renal disease on peritoneal dialysis, failing the use of new peritoneal dialysis catheter, needs tunneled hemodialysis line. Informed consent for the procedure was obtained after risks, benefits, and potential complications had been discussed. The patient was placed on the angiographic table in supine position and the skin of the right anterior neck and right anterior chest wall was prepped and draped in a sterile fashion. Timeout protocol was carried out prior to the procedure according to the ___ ___ policy. PHYSICIANS: ___ MD ___ MD (___) and ___ MD ___ physician). ANESTHESIA: Local, 1% lidocaine. MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored conscious sedation. The patient received a total quantity of 1 mg of Versed and 100 mcg of fentanyl intravenously during the procedural time of 21 minutes, while his hemodynamic parameters and pulse oximetry were continually monitored by trained radiology nurse. After generous infiltration of the subcutaneous soft tissues by 1% lidocaine, and under real-time ultrasound guidance, the patent and fully compressible right internal jugular vein was punctured using 21-gauge micropuncture needle. Over a 0.018 guide wire, micropuncture needle was exchanged for a 4 ___ micropuncture sheath. A 0.035 ___ guide wire was then advanced through the 4 ___ micropuncture sheath into the right atrium and prospective length of a tunneled hemodialysis line was calculated. ___ guide wire was subsequently reintroduced into the right atrium and advanced into the inferior vena cava. The attention was then diverted to the right anterior chest wall. After generous infiltration of subcutaneous soft tissues by 1% lidocaine without and with epinephrine, a narrow skin incision was made inferior and lateral to the right internal jugular venipuncture. A soft tissue tunnel was created by blunt dissection between the chest wall incision and right internal jugular venipuncture. A new 24-cm long 14 ___ hemodialysis catheter was then pulled through the tunnel. After appropriate dilatation of the needle tract, the tip of the catheter was advanced into the right atrium through the appropriate peel-away sheath which was subsequently removed. Right internal jugular venipuncture was sutured using 4.0 Vicryl suture. The hemodialysis catheter was secured to the skin outside the tunnel using 0 silk sutures and covered with sterile dressing. Dr. ___, the attending physician, supervised this interventional procedure. CONCLUSION: 1. Placement of a tunneled hemodialysis line into the right atrium via the right internal jugular vein under ultrasound and fluoroscopic visualization. 2. The line is ready to use. Gender: M Race: BLACK/AFRICAN Arrive by UNKNOWN Chief complaint: PERITIONITIS Diagnosed with END STAGE RENAL DISEASE temperature: 98.6 heartrate: 87.0 resprate: 16.0 o2sat: 100.0 sbp: 144.0 dbp: 81.0 level of pain: 5 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking part in your care. You were admitted to the hospital because you had an infection of the peritoneum. We believe this is because of your peritoneal dialysis catheter. Your peritoneal dialysis catheter was removed and you were treated with antibiotics. Your PD catheter was replaced but the peritoneal dialysis did not go as well as we hoped. Given that, an HD line was placed and you were started on hemodialysis, which you tolerated well. You are being discharged on hemodialysis but we have left your PD catheter in place as you may be able to resume this after discharge. The following changes were made to your medications: 1. Start vancomycin with hemodialysis for at least ___ weeks. The final course will be determined by your outpatient providers. STOP the intraperitoneal vancomycin. 2. Start dulcolax per rectum as needed for constipation 3. Stop oral iron and start IV iron with hemodialysis 4. Stop taking calciferol 5. Start taking acetaminophen 650mg by mouth every 6 hours as needed for pain. 6. Start taking oxycodone ___ by mouth every 8 hours as needed for pain. Please keep your follow-up appointments.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / contrast dye Attending: ___. Chief Complaint: Low back pain Major Surgical or Invasive Procedure: Spinal Decompression Surgery ___ - Laminectomy L1-L2, L2-L3, L3-L4 - Far-lateral decompression, L4-5 procedure - Laminectomy L5-S1 Coronary Cath ___ History of Present Illness: Mr. ___ is a ___ with a history of CHF, CAD s/p DES in and RCA, and DMII presenting with low back pain. Per ED, patient states that he has had worsening low back pain over the past month but over the past few days has had multiple episodes of loss of bladder or bowel control. Associated with multiple falls he states the falls are secondary to his legs giving out from underneath him because of weakness. He does use a walker at home. He denies fevers chills chest pain shortness of breath or abdominal pain. He denies saddle anesthesia history of IV drug abuse. Upon arrival to the floor pt clarifies that about 1 month ago, he went to sit on the toilet seat, slipped, and fell to the floor. He experienced difficulty walking and R side low back pain after falling. For the past ___ weeks, he has experienced bowel and bladder incontinence and has noticed that his hands fall asleep at night. He has had 15 additional falls over the past month. He denies saddle anesthesia. Prior to fall, he was ambulating with a walker and could walk about 1 block with his walker before getting SOB. Recently, for the past month, he notes increased SOB while ambulating, can only walk from bed to hall before getting SOB. Associated cough with sputum production. In the ED, VS T 96.39, HR 74, BP 133/66, RR 19, O2 99% RA. Physical exam was notable for ___ strength and normal sensation in bilateral lower extremities, normal rectal tone, and tenderness to palpation over L4. ED labs reviewed and notable for urine and serum tox negative, UA negative, Cr 1.8, WBC 10.2, Hgb 8.8, INR 1.2. Code cord was called after imaging revealed radiographic findings concerning for cord compression. Spine was consulted and noted that patient would likely need decompressive surgery for symptoms and narrowing at multiple levels of the lumbar spine, however, recommend cardiology and medical optimization prior to surgery. ___ was also consulted and is following. Past Medical History: - Asthma - CHF - CAD s/p DES x2- Proximal LAD and Distal RCA -DM II complicated by diabetic nephropathy - Hyperlipidemia - Hypertension - Osteoarthritis - Prostate cancer - Eczema - CKD - Anemia of chronic disease Social History: ___ Family History: Father died due to epilepsy. Mother died due to a stroke. No early CAD or sudden cardiac death. Daughter has RA. Physical Exam: ================================== Physical Examination on admission: ================================== VS: T 98.0 BP 149/62 HR 71 RR 18 O2 96% Ra GENERAL: Alert, in NAD, resting comfortably in bed HEENT: NC/AT, EOMI, PEERL, MMM, dentures NECK: Supple, non-tender, no LAD HEART: RRR, normal S1/S2, no JVD, no m/r/g LUNGS: Mildly prolonged expiratory phase, otherwise CTAB, breathing comfortably without use of accessory muscles ABDOMEN: Soft, non-tender to palpation, + bowel sounds GU: no foley EXTREMITIES: No cyanosis or clubbing, no ___ edema SKIN: Multiple ecchymoses in ___ upper extremities, dry, flaky skin on ___ lower extremities, warm and well perfused NEURO: CN II-XII grossly intact, ___ strength in upper extremities, markedly reduced strength to dorsiflexion in L hip (___) and foot (___), intact sensation in ___ lower extremities, negative Babinski ___ ================================== Physical Examination on discharge: ================================== VITALS: Tm 98.3 BP 153/60 HR 63 RR 18 SPO2 100% RA PHYSICAL EXAM: General: Sitting up in bed, in NAD, interacting appropriately HEENT: MMM Cardio: RRR. Nl s1/s2. No m/r/g. Pulm: Lungs clear. No wheezes or rhonchi. good air movement Abdomen: soft, non-tender, non-distended, normoactive BS GU: Foley in place. Ext: Trace ___ edema Back: Dressing in place Skin: Warm and well-perfused perfused Neuro: AAOx3. Strength 4+/5 in hip flexion bilaterally. ___ left plantar flexion, ___ left dorsiflexion. ___ right plantar flexion ___ right dorsiflexion; largely unchanged. Patient has a difficult time every day with ankle flexion/extension Pertinent Results: =============== Admission labs =============== ___ 03:23PM WBC-10.2* RBC-3.58* HGB-8.8* HCT-29.5* MCV-82# MCH-24.6* MCHC-29.8* RDW-14.9 RDWSD-44.6 ___ 03:23PM ALT(SGPT)-9 AST(SGOT)-24 ALK PHOS-82 TOT BILI-0.3 ___ 03:23PM GLUCOSE-83 UREA N-31* CREAT-1.8* SODIUM-138 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-21* ANION GAP-19* ======================= Pertinent interval labs ======================= ___ 06:10PM BLOOD WBC-8.4 RBC-3.15* Hgb-7.8* Hct-25.9* MCV-82 MCH-24.8* MCHC-30.1* RDW-15.1 RDWSD-45.2 Plt ___ ___ 11:57PM BLOOD WBC-12.8* RBC-3.08* Hgb-7.6* Hct-26.2* MCV-85 MCH-24.7* MCHC-29.0* RDW-15.3 RDWSD-47.2* Plt ___ ___ 07:20AM BLOOD WBC-17.3* RBC-3.30* Hgb-8.6* Hct-28.5* MCV-86 MCH-26.1 MCHC-30.2* RDW-15.4 RDWSD-48.3* Plt ___ ___ 03:30AM BLOOD WBC-10.5* RBC-3.09* Hgb-8.1* Hct-25.6* MCV-83 MCH-26.2 MCHC-31.6* RDW-15.4 RDWSD-46.5* Plt ___ ___ 05:20AM BLOOD ___ PTT-26.3 ___ ___ 06:10PM BLOOD Glucose-163* UreaN-26* Creat-1.5* Na-137 K-4.5 Cl-102 HCO3-23 AnGap-12 ___ 07:20AM BLOOD Glucose-230* UreaN-33* Creat-2.0* Na-142 K-5.4* Cl-102 HCO3-16* AnGap-24___ 01:20PM BLOOD Glucose-277* UreaN-38* Creat-2.1* Na-136 K-4.6 Cl-100 HCO3-20* AnGap-16 ___ 06:52AM BLOOD Glucose-135* UreaN-40* Creat-2.2* Na-136 K-4.3 Cl-101 HCO3-20* AnGap-15 ___ 03:30AM BLOOD Glucose-141* UreaN-37* Creat-1.8* Na-134 K-5.0 Cl-102 HCO3-20* AnGap-12 ___ 07:20AM BLOOD Albumin-2.8* Calcium-7.8* Phos-5.4* ___ 01:20PM BLOOD Calcium-7.3* Phos-4.5 Mg-1.7 ___ 03:30AM BLOOD WBC-10.5* RBC-3.09* Hgb-8.1* Hct-25.6* MCV-83 MCH-26.2 MCHC-31.6* RDW-15.4 RDWSD-46.5* Plt ___ ___ 07:05AM BLOOD WBC-9.8 RBC-3.30* Hgb-8.5* Hct-27.4* MCV-83 MCH-25.8* MCHC-31.0* RDW-15.9* RDWSD-47.7* Plt ___ ___ 03:30AM BLOOD Glucose-141* UreaN-37* Creat-1.8* Na-134 K-5.0 Cl-102 HCO3-20* AnGap-12 ___ 07:05AM BLOOD Glucose-109* UreaN-28* Creat-1.2 Na-139 K-4.7 Cl-104 HCO3-21* AnGap-14 ___ 07:05AM BLOOD cTropnT-0.11* ___ 07:56PM BLOOD cTropnT-0.09* ___ 06:15AM BLOOD Glucose-179* UreaN-24* Creat-1.1 Na-140 K-4.5 Cl-105 HCO3-21* AnGap-14 ___ 06:15AM BLOOD cTropnT-0.09* ___ 07:00AM BLOOD WBC-8.9 RBC-3.24* Hgb-8.2* Hct-27.0* MCV-83 MCH-25.3* MCHC-30.4* RDW-15.9* RDWSD-48.6* Plt ___ ___ 07:00AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-139 K-4.6 Cl-105 HCO3-21* AnGap-13 =============== Discharge labs =============== ___ 07:20AM BLOOD WBC-9.0 RBC-3.28* Hgb-8.4* Hct-27.5* MCV-84 MCH-25.6* MCHC-30.5* RDW-16.0* RDWSD-49.3* Plt ___ ___ 07:20AM BLOOD Glucose-163* UreaN-14 Creat-1.0 Na-140 K-5.0 Cl-105 HCO3-18* AnGap-17* ___ 01:10AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:10AM URINE Blood-SM* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 01:10AM URINE RBC-6* WBC-42* Bacteri-FEW* Yeast-NONE Epi-<1 =============== Studies =============== Pharmacologic stress test (___): The image quality is adequate but limited due to soft tissue and left arm attenuation. There is motion. Left ventricular cavity size is increased. Rest and stress perfusion images reveal a partially reversible, severe reduction in photon counts involving the entire inferior wall. Gated images reveal hypokinesis of the basal inferior wall. The calculated left ventricular ejection fraction is 44% with an EDV of 160 ml. IMPRESSION: 1. Partially reversible, medium sized, severe perfusion defect involving the RCA territory. 2. Increased left ventricular cavity size. Mild systolic dysfunction with hypokinesis of the basal inferior wall. CXR (___): IMPRESSION: Increased patchy opacities at both lung bases may reflect atelectasis or aspiration/pneumonia. CARDIAC CATH (___): Impressions: 1. Calcific two vessel coronary artery disease with patent prior drug-eluting stents, progression of disease in the mid LAD, new severe heavily calcified ostial RCA disease (likely with contribution from guiding catheter trauma from prior PCI) and moderate proximal-edge restenosis in a hyperdominant RCA. 2. Systemic systolic arterial hypertension with wide aortic pulse pressure. 3. Normal average left ventricular end diastolic pressure. L-spine XR (___): IMPRESSION: Degenerative changes. With intervertebral disc space narrowing at all lumbar levels. CT head without contrast (___): IMPRESSION: 1. No acute intracranial abnormalities. 2. Chronic microangiopathy and age related global atrophy. MRI spine w/o contrast (___): 1. Severe spondylotic changes of the lumbar spine most prominent from at L2-3 and L3-4 where there is severe spinal canal stenosis resulting redundancy of the cauda equina nerve roots superiorly. There is multilevel severe neural foraminal narrowing as detailed above. 2. Compression deformity of the T12 vertebral body with signal characteristics indicating possible acute to subacute stage. Consider further evaluation with a CT lumbar spine for better evaluation of bony detail. CT spine w/o contrast (___): 1. Mild anterolisthesis of the of C4 on C5 and C7 on T1 is likely degenerative in etiology. No acute fracture identified. 2. Extensive degenerative changes of the cervical spine with multilevel moderate vertebral canal and multilevel severe neural foraminal stenosis, as described above. 3. Mottled appearance of the bone may be related to osteoporosis. However, correlation with history of malignancy is recommended. If there is clinical concern, a nonemergent bone scan can be obtained for further evaluation. =============== Microbiology =============== Urine culture (___): pending Blood culture (___): Negative Stool studies (___): Negative for campylobacter, c. diff Urine culture (___): No growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation ___ 2. Pulmicort (budesonide) 180 mcg inhalation BID 3. Bumetanide 1 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 8. Omeprazole 20 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. TraMADol 50 mg PO Q8H 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Give no more than 4g per day RX *acetaminophen 500 mg 2 capsule(s) by mouth every six (6) hours Disp #*240 Capsule Refills:*0 2. amLODIPine 10 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth q24h Disp #*30 Tablet Refills:*0 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet Refills:*0 4. Cefpodoxime Proxetil 200 mg PO ONCE Duration: 1 Dose To be given on ___ at ___ RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*2 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % q24h Disp #*30 Patch Refills:*0 7. Senna 8.6 mg PO BID constipation 8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days Stop date: ___. Aspirin 81 mg PO DAILY 10. Bumetanide 1 mg PO DAILY 11. GlipiZIDE 10 mg PO BID 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Omeprazole 20 mg PO DAILY 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation ___ 16. Pulmicort (budesonide) 180 mcg inhalation BID 17. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you see your primary care provider ___: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: #Cauda Equina Syndrome/Cord Compression #Type I NSTEMI #CAP #Delirium #Urinary tract infection Secondary Diagnosis: #HFrEF #Acute Kidney Injury #Anion gap metabolic acidosis #Type 2 diabetes mellitus #Acute on chronic anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with weakness// eval for PNA TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Cardiac silhouette is mildly enlarged as on prior. The lungs are clear besides mild left basilar atelectasis. There is no edema nor effusion. No acute osseous abnormalities. IMPRESSION: Cardiomegaly without superimposed acute cardiopulmonary process. Radiology Report EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE. INDICATION: History: ___ with with atraumatic back pain associated with urinary and bowel incontinenceIV contrast to be given at radiologist discretion as clinically needed// eval for cauda equina TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: CT lumbar spine ___. FINDINGS: The study is partially degraded due to motion. There is mild broad-base convex-right curvature of the lumbar spine and a slight retrolisthesis at L1-L2. There is approximately 25% height loss of the T12 vertebral body demonstrating central T1/T2 linear low signal and superimposed surrounding T2 hyperintensity possibly reflecting acute to subacute fracture pathology. There are superimposed multilevel degenerative endplate changes and marginal osteophytes. Multilevel disc space narrowing is most prominent from L2-3 through L4-5. Multilevel moderate to severe spinal canal stenosis as detailed below results in clumping of the cauda equina nerve roots at L1-2. There is no cord signal abnormality. The conus medullaris terminates normally at the level of L1. No evidence of infection or neoplasm. T11-12: Ligamentum flavum hypertrophy and facet arthropathy results in mild-to-moderate bilateral neural foraminal narrowing and mild spinal canal stenosis. T12-L1: Ligamentum flavum hypertrophy and facet arthropathy with mild-to-moderate bilateral neural foraminal narrowing and mild spinal canal stenosis. L1-2: Diffuse disc bulging, a slight retrolisthesis, ligamentum flavum hypertrophy and facet arthropathy result in moderate to severe spinal canal stenosis, severe right and severe left neural foraminal narrowing. L2-3: Diffuse disc bulging, ligamentum flavum hypertrophy and facet arthropathy result in severe spinal canal stenosis, moderate to severe right and moderate to severe left neural foraminal narrowing, as well as crowding of the nerve roots within thecal sac. L3-4: Diffuse disc bulging, ligamentum flavum hypertrophy and facet arthropathy result in severe spinal canal stenosis, moderate right and moderate to severe left neural foraminal narrowing. L4-5: Diffuse disc bulging, ligamentum flavum hypertrophy and facet arthropathy result in moderate to severe spinal canal stenosis, moderate to severe right and severe left neural foraminal narrowing. L5-S1: Diffuse disc bulging results an mild spinal canal stenosis, moderate to severe right and moderate left neural foraminal narrowing. Other: The right kidney is mildly atrophic relative to the left. IMPRESSION: 1. Severe spondylotic changes of the lumbar spine most prominent from at L2-3 and L3-4 where there is severe spinal canal stenosis resulting redundancy of the cauda equina nerve roots superiorly. There is multilevel severe neural foraminal narrowing as detailed above. 2. Compression deformity of the T12 vertebral body with signal characteristics indicating possible acute to subacute stage. Consider further evaluation with a CT lumbar spine for better evaluation of bony detail. NOTIFICATION: The primary team was aware of these findings at the time of this interpretation. Additional the findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:18 am, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with history multiple falls// eval for bleed eval for c-spine fracture TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 1,003.4 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute major vascular territory infarction,hemorrhage,edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Ill-defined periventricular subcortical white matter hypodensities are nonspecific but likely due to small vessel ischemic disease. Mild atherosclerotic calcifications are seen in bilateral carotid siphons. There is no evidence of fracture. Mild mucosal thickening is seen in the maxillary sinuses, left greater than right, with hyperostosis of the sinus walls suggesting chronic inflammation. Otherwise, the remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens resections. A superficial 1.2 x 1.8 cm soft tissue lesion is seen in the base of the left occiput, likely sebaceous cyst. IMPRESSION: 1. No acute intracranial abnormalities. 2. Chronic microangiopathy and age related global atrophy. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with history multiple falls// eval for bleed eval for c-spine fracture eval for bleed eval for c-spine fracture TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 23.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 536.2 mGy-cm. Total DLP (Body) = 536 mGy-cm. COMPARISON: No relevant comparison exams. FINDINGS: There is mild anterolisthesis of C4 on C5 and C7 on T1, likely degenerative in etiology. No acute fractures are identified. There is no prevertebral soft tissue edema. Extensive degenerative changes are seen throughout the cervical spine with fusion of the C5-C6 vertebral level, loss of intervertebral disc height, subchondral sclerosis, and extensive osteophyte formation. There is a mottled appearance of the osseous structures diffusely with multiple small rounded lucencies, possibly related to osteoporosis. There is multilevel moderate vertebral canal narrowing due to posterior osteophyte and disc bulges with deformation of the spinal cord, most pronounced at C3-4, C5-6 and C6-7. Multilevel uncovertebral and facet joint hypertrophy causes severe neural foraminal stenosis at the left C3-C4, left C4-C5, right C5-C6 and right C6-C7 vertebral levels. There is no evidence of infection or neoplasm. The visualized thyroid gland is unremarkable. Emphysematous changes are seen in the lung apices. IMPRESSION: 1. Mild anterolisthesis of the of C4 on C5 and C7 on T1 is likely degenerative in etiology. No acute fracture identified. 2. Extensive degenerative changes of the cervical spine with multilevel moderate vertebral canal and multilevel severe neural foraminal stenosis, as described above. 3. Mottled appearance of the bone may be related to osteoporosis. However, correlation with history of malignancy is recommended. If there is clinical concern, a nonemergent bone scan can be obtained for further evaluation. Radiology Report EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT) INDICATION: ___ year old man with severe lumbar spinal stenosis// pre op planning, eval for spondylolisthesis. STANDING FLEX EX FILMS pre op planning, eval for spondylolisthesis. STANDING FLEX EX FILMS TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine. COMPARISON: CT scan lumbar spine from ___. MRI of the lumbar spine from ___. FINDINGS: The bone is a diffusely osteopenic. There is mild dextroscoliosis of the lumbar spine. There is mild retrolisthesis of L1 on L2 and L2 on L3. Intervertebral disc space narrowing is seen at all lumbar levels. There is a fracture of the T12 vertebral body with approximately 50% loss of height, unchanged compared to the recent MRI. Severe degenerative changes are seen at all lumbar levels. Vascular calcification is evident. IMPRESSION: Degenerative changes. With intervertebral disc space narrowing at all lumbar levels. Radiology Report EXAMINATION: Intraoperative radiograph INDICATION: ___ man with laminectomy. TECHNIQUE: Single view of the lumbar spine in the OR. COMPARISON: Radiographs from ___ MRI from ___ FINDINGS: 1 intraoperative image was acquired without a radiologist present during an invasive procedure. Multiple hardware projects over the posterior elements of the lumbar spine. Severe degenerative changes of the lumbar spine is better evaluated on the prior MRI from ___. IMPRESSION: Intraoperative images were obtained during invasive procedure without a radiologist present. Please refer to the operative note for details of the procedure. Radiology Report INDICATION: ___ year old man with CAD, CHF, type II DM, and recent decompression of lumbar spine now with productive cough// r/o PNA TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Increased patchy opacities at both lung bases may reflect atelectasis or aspiration/pneumonia. No pleural effusion or pneumothorax is identified. The size of the cardiac silhouette is mildly enlarged, similar to prior. IMPRESSION: Increased patchy opacities at both lung bases may reflect atelectasis or aspiration/pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Lower back pain, Urinary incontinence Diagnosed with Low back pain temperature: 96.39 heartrate: 74.0 resprate: 19.0 o2sat: 99.0 sbp: 133.0 dbp: 66.0 level of pain: 8 level of acuity: 2.0

Dear Mr. ___, Thank you for letting us take care of you during your hospital stay at ___. What Happened on this admission: - You were admitted for leg weakness caused by pressure on your spinal cord. You had a spinal surgery to relief that pressure around your nerve roots. - You had a coronary catheterization performed in order to see if you were having a heart attack. No stents were put in your arteries because you needed to go to surgery. - You had a follow-up stress test done to see if you needed stents placed in your heart, but since you were not having chest pain or other symptoms, the decision was made to not give you stents. - You were given 1 unit of blood to restore your blood levels after your surgery. - You were treated with fluids for a kidney disease, which improved back to your baseline - You were treated for suspected pneumonia with antibiotics for 7 days - You were started on treatment for a urinary tract infection that you will take for 7 days When you leave the hospital it is important that you: - Follow up with your orthopedic surgeon for follow up on your spinal surgery - Follow up with Cardiology about your heart - Take all of your medications as prescribed - Avoid salty foods including canned foods, chips, processed meats and foods etc. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Timolol Attending: ___. Chief Complaint: Vomiting Major Surgical or Invasive Procedure: EGD with metal duodenal stent History of Present Illness: Dr. ___ is a pleasant ___ gentleman with history of metastatic cholangiocarcinoma who recently underwent removal of a plastic stent with placement of a metal stent in the hepatic duct at ___ on ___, was discharged on ___ and returns today for vomiting and early satiety. He was initially seen by his PCP in ___, ___ was performed there showing duodenal wall thickening and he was transferred here for further evaluation. Pt states that his sxs have been gradually worsening over the last 3 wks, however he expected improvement with his recent procedure and has found that his symptoms are worsening. In the ED, initial vitals were 98.2 77 147/95 16 98%. Exam was notable for soft abd, NT/ND, no peritoneal signs. Labs were notable for elevated AST/ALT/AP. CT showed duodenal thickening and distended stomach. GI was consulted and requested ___ campus admission for duodenal stenting in the AM. The patient had no further episodes of N/V while in the ED. On arrival on the floor, pt c/o mild abd pain and distension. He denies nausea, last episode of vomiting was nearly 24 hrs ago. He has not eaten since the morning of presentation and at that time was only able to eat ___ package of ramen noodles. He does have some anxiety and insomnia which he states did not improve with 1 mg of ativan given in the ED. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Last BM was 1 day ago. He states that he is passing flatus. Past Medical History: PMH: Exercise induced asthma, hx. prostate cancer, glaucoma, cholangiocarcinoma PSH: ORIF R wrist (___), intraocular lens replacement, TURP, ERCP (___) Social History: ___ Family History: No family history of cholangiocarcinoma. Father with MM, brother with prostate CA. Physical Exam: VS - 97.8 181/73 67 18 100% RA GENERAL - thin, well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - hyperactive BS, well healed surgical scars, soft/mildly tender throughout without rebound or guarding, non-distended, no masses or HSM EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission labs: ___ 11:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:50PM GLUCOSE-103* UREA N-8 CREAT-0.7 SODIUM-136 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 ___ 08:50PM ALT(SGPT)-107* AST(SGOT)-64* ALK PHOS-412* TOT BILI-0.7 ___ 08:50PM LIPASE-55 ___ 08:50PM ALBUMIN-3.7 ___ 08:50PM WBC-6.7 RBC-4.16* HGB-12.4* HCT-35.9* MCV-86 MCH-29.8 MCHC-34.5 RDW-14.2 ___ 08:50PM NEUTS-66.5 ___ MONOS-6.4 EOS-3.2 BASOS-0.6 ___ 08:50PM PLT COUNT-184 CT abd: -Biliary stent in appropriate position -Distended stomach with marked wall thickening of the proximal duodenum -Moderate intra-hepatic biliary ductal dilatation slightly increased since most recent prior -Significant fat stranding extending from the porta hepatis inferior to the liver with focal areas of nodularity. More extensive as compared to ___. Differential includes spread of cholangiocarcinoma vs non-specific inflammatory changes -Small focus of air in the gallbladder fossa, possibly within a collapsed gallbladder -New scalloping along the liver capsule - concerning for metastatic disease -Mild abdominal ascites CXR ___: PA AND LATERAL CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: New left lower lobe opacity is associated with volume loss, manifested by posterior displacement of the left major fissure. A left pleural effusion has increased in size, and is now moderate with a likely subpulmonic component. New poorly-defined somewhat nodular opacities have developed in the right upper lobe. Cardiomediastinal contours are stable in appearance except for slight inferior displacement of the left hilum. Small right pleural effusion has slightly increased in size and is associated with adjacent opacity in the right retrocardiac area. IMPRESSION: 1. New left lower lobe opacity. Rapid development and associated volume loss favor atelectasis over infectious pneumonia. 2. New poorly defined opacities in right upper lobe, which could represent developing bronchopneumonia or an acute aspiration event. 3. Moderate left pleural effusion with apparent subpulmonic component. Small right pleural effusion. ___. ___ ___ 07:00AM BLOOD WBC-6.7 RBC-3.90* Hgb-11.3* Hct-33.8* MCV-87 MCH-28.9 MCHC-33.3 RDW-14.9 Plt ___ ___ 07:00AM BLOOD Glucose-99 UreaN-4* Creat-0.5 Na-135 K-3.8 Cl-100 HCO3-27 AnGap-12 ___ 07:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7 Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 4. Montelukast Sodium 10 mg PO DAILY 5. Famotidine 20 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days Discharge Medications: 1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Benzonatate 100 mg PO TID:PRN Cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough RX *codeine-guaifenesin [Guaiatussin AC] 100 mg-10 mg/5 mL 5 ml by mouth twice a day Disp #*1 Bottle Refills:*0 5. Docusate Sodium 100 mg PO BID 6. Famotidine 20 mg PO BID 7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 8. Montelukast Sodium 10 mg PO DAILY 9. Metoclopramide 10 mg PO TID:PRN hiccups stop immediately if diffuculty with speech or opening jaw RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth three times a day Disp #*24 Tablet Refills:*0 10. Levofloxacin 750 mg PO Q24H Duration: 3 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Small bowel obstruction 2. Pneumonia, aspiration 3. Metastatic Cholangiocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with recent diagnosis of cholangiocarcinoma. Patient is status post ERCP five days prior with placement of a metallic common bile duct stent. Patient is now presenting with vomiting. COMPARISON: CT abdomen and pelvis from ___ and CT abdomen and pelvis from ___. TECHNIQUE: Outside hospital images from ___ were presented for second opinion review. Multidetector CT images of the abdomen from the lung bases to the iliac crests were displayed with 5-mm slice thickness. Intravenous contrast was administered. Coronal and sagittal reformations were prepared. CT ABDOMEN WITH INTRAVENOUS CONTRAST: Redemonstrate is focal bronchiectasis with probable mucous plugging in the right middle lobe, unchanged from prior (3:2). No pulmonary nodule or effusion is identified. The imaged cardiac apex is within normal limits. Redemonstrated is an irregular soft tissue density mass extending from the hepatic hilum along the biliary tree, findings consistent with patient's known history of cholangiocarcinoma. Additionally, there is marked fat stranding and irregular soft tissue density extending inferiorly from the porta hepatis to surround the ascending colon and proximal duodenum. As compared to CT abdomen from ___, this soft density is more extensive and now has a nodular appearance. Differential considerations include spread of primary tumor or non-specific inflammatory changes. Additionally, there is new scalloping along the liver capsule (3:11, 18, 20), which is concerning for metastatic spread. There is moderate intrahepatic biliary ductal dilatation, which has progressed since the most recent prior examination from ___. A metallic stent within the common bile duct appears in expected position. A punctate foci of air is seen in the gallbladder fossa, likely within a decompressed gallbladder (3:30). The hepatic veins and portal venous system are grossly patent. The stomach is markedly distended and filled with fluid. There is severe diffuse wall thickening of the proximal duodenum (3:32) as it courses medial to the porta hepatis in the above described region of irregular soft tissue density. The lumen of the proximal duodenum appears compressed likely due to extrinsic mass effect. More distal loops of small bowel are normal in caliber and with signs of acute inflammation. There is a mild amount of free fluid throughout the abdomen. The spleen appears normal. The adrenal glands are symmetric without focal nodule. There is symmetric enhancement and excretion of both kidneys without suspicious focal lesion or hydronephrosis. Redemonstrated is atrophy of the pancreatic tail and irregular upstream dilatation of the pancreatic duct, unchanged from prior. The pancreatic duct is not visualized in the region of the head and neck, similar to prior, though no discrete mass lesion is identified at the site of transition. Scattered subcentimeter hypodense lesions in the pancreatic parenchyma may represent dilated side branches of the duct or small cystic lesions, similar to the prior. Known enlarged lymph nodes within the portacaval and peripancreatic region are not well seen secondary to significant stranding in this region. Incidental note is made of a duplicated IVC. BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is identified. IMPRESSION: 1. Dilated stomach with marked wall thickening of the proximal duodenum as it passes near the porta hepatis at site of infiltrative tumor, consistent with duodenal outlet obstruction with possible infiltration of the duodenum. 2. Progressive irregular soft tissue density extending from the hepatic hilum inferiorly. Then nodular character of this density suggests progression of primary tumor and less likely non-specific inflammatory changes 3. Scalloping along the liver capsule concerning for metastases. 4. Common bile duct stent in expected position, though progression of intrahepatic biliary ductal dilatation. Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Right upper quadrant pain, question free air. ___. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence of free air is seen beneath the diaphragm. IMPRESSION: No acute cardiopulmonary process. No evidence of free air beneath the diaphragm. Radiology Report PA AND LATERAL CHEST, ___ COMPARISON: ___ radiograph. FINDINGS: New left lower lobe opacity is associated with volume loss, manifested by posterior displacement of the left major fissure. A left pleural effusion has increased in size, and is now moderate with a likely subpulmonic component. New poorly-defined somewhat nodular opacities have developed in the right upper lobe. Cardiomediastinal contours are stable in appearance except for slight inferior displacement of the left hilum. Small right pleural effusion has slightly increased in size and is associated with adjacent opacity in the right retrocardiac area. IMPRESSION: 1. New left lower lobe opacity. Rapid development and associated volume loss favor atelectasis over infectious pneumonia. 2. New poorly defined opacities in right upper lobe, which could represent developing bronchopneumonia or an acute aspiration event. 3. Moderate left pleural effusion with apparent subpulmonic component. Small right pleural effusion. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: N/V Diagnosed with VOMITING temperature: 97.7 heartrate: 63.0 resprate: 18.0 o2sat: 97.0 sbp: 151.0 dbp: 78.0 level of pain: 2 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you on this admission. You came to the hospital because you were having vomiting due to intestinal obstruction from your tumor. You had an EGD where a stent was placed to open up your duodenum. Your symptoms improved and your diet was advanced. You had an elevated white count, cough, and probable pneumonia on CXR. You were started on levfloxacin 750mg once a day for 5 days.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: ___ w/ hx HTN, DMII, ___ (EF>55%), ESRD on ___ HD since ___, ex-smoker (quit 1970s), presumed myelodysplastic syndrome, p/w dyspnea and mild somnolence today preceded by ___ weeks nonproductive cough. HE was seen by ___ who found him to O2 82% on RA (normally runs 96-100%). He was sent to ___ by ___ MD. ___ triggered for hypoxia at triage for O2 sat 88%RA (not on home O2). Wife noted that ___ has had a dry cough for 1 week but unknown if he has had fevers. He remains at baseline with 2 pillow orthopnea and wheelchair bound. ___ did have scheduled HD yesterday and has not recently missed any sessions, though dialysis schedule this week was MTF because of the holidays. Review of systems negative for any fevers, chills, chest pain, nausea, vomiting, diarrhea. Of note, ___ is oliguric at baseline. Further history obtained from daughter was that ___ started getting URI symptoms on ___ with seemingly productive cough on ___ though he was unable to produce sputum. He did have a low grade temperature of 99.5 and was noted to be sluggish. His daughter noted that ___ started having what appeared to be a productive cough though he was never actually able to produce sputum. ___ has not had any sick contacts. He did not get the flu shot. ___ denies any myalgias. He has had multiple hospitalizations over the last ___ years for hyperkalemia in the setting of missed dialysis session (___), anemia with guaic positive stools and supratherapeutic INR (etiology not identified - ___, pneumonia (___), and CHF (___) at which time BNP was 3600. In the ED initial vitals were: 17:25- 0 99.1 66 157/38 22 88% ea - Labs were significant for lactate 2.4, VBG 7.42/50, trop 0.09, BNP 31074 (BNP 3600 in ___ at time of chf exacerbation), leukocytosis 35.7, h/h 12.5/38.1, thrombocytosis 838 (Noted 550 on ___ - Bedside u/s showed no pericardial effusion but with b/l pleural effusions - ___ was given 1g vanc, 4.5g IV pip-tazo empirically for possible HCAP Vitals prior to transfer were: 20:24- 0 82 24 96% Nasal Cannula On the floor, ___ denies any shortness of breath, chest pain, or discomfort. Past Medical History: 1. Hypertension. 2. Diabetes mellitus, type 2. 3. Diastolic dysfunction 4. Peripheral vascular disease with possible left carotid stenosis, followed by Dr. ___ at ___ 5. possible history of past TIA. 6. Macrocytic anemia/ presumed myelodysplastic syndrome (not biopsy-proven) 7. History of squamous cell carcinoma. 8. History of gout, on allopurinol 9. chronic kidney disease stage V, started HD ___ Social History: ___ Family History: No family history of cardiac disease or cancer that he knows of Physical Exam: ADMISSION: Vitals - T97.7 159/59 HR74 RR30 96%6L NC 93.7kg (Dry weight: unclear, 92.5kg ___ GENERAL: appears to be in mild distress (thoughe he denies), speaking in 5 word sentences, audible expiratory coarse breath sounds, persistent coughing during interview HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, unable to assess JVD CARDIAC: irregularly irregular, bradycardic, S1/S2, ___ sys murmur LUSB LUNG: coarse breath sounds throughout, wheezing on expiration, some use of accessory muscles ABDOMEN: soft, rounded with accessory muscle use, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: 2+ pitting edema extending up to knees, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, sensation intact throughout SKIN: warm and well perfused, no excoriations or lesions, no rashes bilateral toes with some eschar though no evidence of active infection DISCHARGE: 98.4 116/41-139/49 ___ 95% RA GEN: NAD HEENT: conjunctiva pink, sclera anicteric NECK: supple, no LAD, no SCM use, JVP difficult to appreciated CV: ___, no m/r/g LUNG: rhonchi diffusely, prolong expiratory wheezes, both improved from admission ABD: obese, soft, nt nd EXT: trace pitting edema b/l NEURO: grossly intact b/l Pertinent Results: ADMISSION: ___ 05:40PM BLOOD WBC-35.7*# RBC-3.42*# Hgb-12.5*# Hct-38.1*# MCV-111* MCH-36.5* MCHC-32.8 RDW-20.5* Plt ___ ___ 05:40PM BLOOD Neuts-74* Bands-4 Lymphs-12* Monos-9 Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-1* ___ 05:40PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Target-1+ Stipple-OCCASIONAL Tear ___ ___ 05:40PM BLOOD Plt Smr-VERY HIGH Plt ___ ___ 05:40PM BLOOD ___ PTT-30.2 ___ ___ 05:40PM BLOOD Glucose-127* UreaN-36* Creat-5.8* Na-140 K-4.9 Cl-95* HCO3-27 AnGap-23* ___ 05:40PM BLOOD CK(CPK)-24* ___ 05:40PM BLOOD CK-MB-1 cTropnT-0.09* ___ ___ 05:40PM BLOOD Calcium-9.6 Phos-4.5 Mg-2.2 ___ 05:47PM BLOOD Lactate-2.4* DISCHARGE: ___ 06:25AM BLOOD WBC-24.3* RBC-2.83* Hgb-10.4* Hct-31.1* MCV-110* MCH-36.8* MCHC-33.4 RDW-20.3* Plt ___ ___ 06:25AM BLOOD Plt Smr-VERY HIGH Plt ___ ___ 06:25AM BLOOD Glucose-111* UreaN-56* Creat-7.5*# Na-136 K-5.0 Cl-93* HCO3-26 AnGap-22* ___ 06:25AM BLOOD Calcium-9.0 Phos-6.5* Mg-2.1 IMAGINE: CXR IMPRESSION: Persistent small to moderate size right pleural effusion with right basilar opacity, likely compressive atelectasis. Minimal streaky left basilar atelectasis. Mild pulmonary vascular congestion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS 3. Aspirin 81 mg PO DAILY 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Renagel 300 mg Other TID 8. Acetaminophen Dose is Unknown PO Q6H:PRN muscle aches Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN muscle aches 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS 8. Renagel 300 mg Other TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: viral URI acute on chronic dCHF ESRD on Dialysis CHRONIC: HTN PVD DMII MDS AFib GOUT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with dyspnea TECHNIQUE: Portable upright AP view of the chest COMPARISON: ___ FINDINGS: Heart size remains mildly enlarged. Mediastinal and hilar contours are similar. Mild pulmonary vascular congestion is noted. A small right pleural effusion persists with associated right basilar compressive atelectasis. Streaky left opacity in the left lung base also likely reflects atelectasis. No pneumothorax is identified. Moderate multilevel degenerative changes are re- demonstrated in the thoracic spine. IMPRESSION: Persistent small to moderate size right pleural effusion with right basilar opacity, likely compressive atelectasis. Minimal streaky left basilar atelectasis. Mild pulmonary vascular congestion. Radiology Report EXAMINATION: CHEST PA AND LATERAL INDICATION: ___ hx dCHF (EF>55%), ESRD on MWF HD, ex-smoker (quit 1970s) p/w dyspnea and mild somnolence today preceded by ___ weeks nonproductive cough with concern for hcap and acute on chronic dCHF. Evaluate for acute cardiopulmonary process, ?PNA. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs from ___, and ___. FINDINGS: The heart remains mildly enlarged, without significant change in the mediastinal and hilar contours. There is a persistent right pleural effusion, largely unchanged, with likely right basilar atelectasis. There is also a streaky left lung base opacity which may be atelectasis, also unchanged. Moderate degenerative changes of thoracic spine are demonstrated. IMPRESSION: 1. Largely unchanged chest radiograph since ___, with a similar appearing right pleural effusion. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with SEMICOMA/STUPOR temperature: 99.1 heartrate: 66.0 resprate: 22.0 o2sat: 88.0 sbp: 157.0 dbp: 38.0 level of pain: 0 level of acuity: 1.0

Mr ___: You were hospitalized at ___ for difficulty breathing. You were given an extra dialysis session which helped your breathing. During your stay here, you had a fall. You were evaluated by physical therapy who determined that it would be beneficial for you to receive home physical therapy. You and your family expressed understanding about your risk to fall at home and decided against rehabilitation at this time. We will send you home with physical therapy services. We did not make any changes to your medications. You should continue with your home medications as prescribed by your doctor. You should also continue with your dialysis sessions every MWF. All the best for a speedy recovery! Sincerely, ___ Treatment Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: morphine / Cefzil / Dilantin Attending: ___. Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: Lumbar puncture ___ History of Present Illness: Ms. ___ is a ___ woman with epilepsy who presents from clinic with seizures. PER ___ note: "She has suffered from complex partial epilepsy since the age of ___ with secondary generalization. Seizure semiology begins with aura of gastric rising sensation, followed by right facial twitching, right arm flexion. She has semi-purposeful movements and slightly impaired awareness. She calls these "small seizures" but notes that if she has generalization to a larger seizure, which includes leg twitching and what she describes as a stronger gastric sensation, she notes that she typically has seizure clusters. She did not endorse any gastric rising sensations to me leading up to the event. When she feels as if she will cluster, she typically reaches for her rescue 1mg dissolvable clonazepam. She goes to the ED every time she has a seizure over 5 minutes or if she has seizure clusters. She has had to be admitted to the hospital frequently and has had multiple ED visits over the past month. In our system, she was admitted in ___ and ___ (just discharged last week). The patient herself notes thats she has had many hospitalizations with at least two intubations secondary to medication non-adherence. She notes that while she was in school at ___, and even now, she occasionally (several times a week) misses her medications, particularly her morning doses, as she forgets to take them or when she remembers she is sometimes too embarrassed to take them in public. Seizure frequency is at least once or twice a month. She has had two hospitalizations in ___ (most recently at ___ last week, earlier in ___ she was in ___). She was also hospitalized at ___ (intubated) and intubated at ___ in ___ for management of status. On all occasions, she notes triggers/exacerbations included medication non-adherence (at baseline, missing at least ___ morning doses a week) in the setting of: sleep deprivation (staying up late, ___ practice division 1 waking up early, running in heat, and around her menses potentially. Regarding a possible association of her seizures with menses, she notes that she recently received a hormone implant in her arm and that has made her period even more irregular. On two of her different hospitalizations, she was given Dilantin and broke out into hives. She also reports a period of Dilantin toxicity, where she was "walking into walls" at ___. In her last hospitalization at ___ last week, she initially presented to ___ and was transferred to our facility after having a witnessed GTC with right gaze deviation. She was given 500mg IV keppra and 1mg IV Ativan and transferred to ___ ED where she progressed into status epilepticus in the setting of missed lamotrigine and keppra doses. She was loaded with lacosamide, which was discontinued on discharge given her return to baseline and normalized cvEEG. Her AED regimen on discharge was unchanged and included lamictal 150/175 and keppra 1g BID as well as clonazepam 0.25mg BID (which the patient says she has not been taking for 3 weeks with exception of hospital admission last week where she was given it). Since discharge from hospital, she says she has been adherent with her medications. She has been sleeping well but does have some stress related to medical leave of absence from ___. She took this in ___ and moved back in with her mother and her mother's boyfriend, which she says is "not ideal" wishing that she can return to college living ("but without the college.") No recent sicknesses, colds, dysuria." She now presenst to ___ ED for breakthough seizure. Per OMR note: "During her clinic visit, she suffered a complex partial seizure with secondary generalization. The event began during physical exam and after history was obtained. As I asked her to extend her extremities for evaluation of pronator drift, she developed a subtle right hand tremor. She continued to talk to me throughout the tremor, noting that sometimes her hand shakes a little from "nerves." Within seconds, she developed a right facial twitch with right eye and then left eye twitching. She was still responding to me and was regarding me with semi-purposeful movements during this episode but I called for assistance with bracing the patient concerned that she will soon generalize. She then became unresponsive to me but with warm extremities, a strong and regular pulse, and normal respirations. I turned her to lie on her right side on the table. Her eyes then deviated to the right, her teeth chattered, she was foaming at the mouth but did not turn blue. Her right arm flexed, curling towards her core, her left arm stiffened, and both her lower extremities stiffened for <3 seconds followed by low-grade convlusions. This generalized episode (right arm flexion, bilateral leg twitching, right head deviation, eye deviation to the right) lasted approximately ___ seconds and then resolved although without return to baseline status, with relaxed extremities and midline gaze although with ongoing ocular flutter. She remained in the more-relaxed phase for approximately 1 minute followed by successive ~40-second generalized seizures. Time span was roughly 10 minutes prior to EMS arrival. I gave her 2x 1mg disintegrating clonazepam (which I took out of her bag as she told me she carries an emergency supply) while awaiting for EMS. On EMS team arrival, vitals were stable, she was saturating 98% on RA. IV was placed but Ativan was not available as part of code cart. She was taken urgently downstairs by EMS team and a call-in was placed to the ED. She remained unresponsive to voice and verbal stimuli throughout her event, starting at approximately ___ (EMS departure time)." On arrival to ___ ED patient note to be seizing with head and eyes devaited to the right as wella s RUE stiffening. She was given Ativan a ___ of 6 mg and loaded with keppra 1g and lacosamide 200mg x1 with resolution of seizure. ___, ___ adter she bgean seizing again and was intubated. Prior AEDs tried: - lacosamide (was discontinued on discharge from last hospitalization) Past Medical History: Complex partial seizures with secondary generalization Social History: ___ Family History: Per mother, negative for seizures, but father's family history unknown. Physical Exam: EXAM ON ADMISSION: ================= Vitals: P67, BP117/86, RR20, 100% RA General: seizing with RUE stiffening and head to the right and eyes deviated to right HEENT: Unable to assess CV: RRR Pulm: CTAB Abd: s/nt/nd Ext: no c/c/e Neuro: -MS: currently seizing unable to assess MS -CN:PERRL, right gaze deviation, face symmetric. Corneal reflexes/lash stimulation present bilaterally. -Motor: moves all 4's antigravity but R<L DTRs: 2+ throughout, toes mute Discharge Exam ================ 24 HR Data (last updated ___ @ 1525) Temp: 98.6 (Tm 98.6), BP: 104/67 (93-106/58-68), HR: 56 (49-77), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: Ra - General: Awake, cooperative, EEG leads in place - HEENT: NC/AT - Neck: Supple - Pulmonary: no increased WOB - Cardiac: warm and well perfused - Abdomen: non distended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Speech is fluent, follows both axial and appendicular commands -Cranial Nerves: 3 to 2mm and brisk. EOMI without nystagmus, face symmetric, tongue midline -Motor: Normal bulk, tone throughout. High frequency low amplitude tremor noted with arms outstretched. No pronator drift, spontaneous and antigravity throughout, able to kick my hands bilaterally and hold antigravity for >5 mins. -DTRs: deferred -___: No deficits to light touch -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: deferred, but patient up walking to bathroom without issues Pertinent Results: Admission Labs =============== ___ 03:36AM BLOOD WBC-9.9 RBC-3.94 Hgb-10.2* Hct-30.9* MCV-78* MCH-25.9* MCHC-33.0 RDW-13.0 RDWSD-37.1 Plt ___ ___ 03:36AM BLOOD ___ PTT-25.7 ___ ___ 03:36AM BLOOD Glucose-115* UreaN-4* Creat-0.7 Na-141 K-3.9 Cl-106 HCO3-23 AnGap-12 ___ 03:36AM BLOOD CK(CPK)-1087* ___ 06:22PM BLOOD Lipase-66* ___ 06:22PM BLOOD cTropnT-<0.01 ___ 03:36AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.8* ___ 06:28PM BLOOD Lactate-1.5 K-3.8 ___ 06:32PM BLOOD LEVETIRACETAM (KEPPRA)-PND ___ 06:32PM BLOOD LAMOTRIGINE-PND CSF === ___ 05:32PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 Polys-0 ___ ___ 05:32PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-66 Discharge Labs ============== ___ 05:05AM BLOOD WBC-5.5 RBC-4.53 Hgb-11.4 Hct-35.6 MCV-79* MCH-25.2* MCHC-32.0 RDW-13.2 RDWSD-37.6 Plt ___ ___ 05:05AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-140 K-4.1 Cl-102 HCO3-26 AnGap-12 Imaging ======== MRI ___ There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are within expected limits in caliber and configuration. Bilateral hippocampal formations and mammillary bodies are preserved in signal and configuration. There is no disproportionate medial temporal atrophy. There is no focal lobar encephalomalacia. There are no focal cortical dysplasias or gray matter heterotopia noted. IMPRESSION: 1. Unremarkable contrast enhanced MRI brain. 2. No evidence of focal cortical dysplasia, focal lobar encephalomalacia, gray matter heterotopia or mesial temporal sclerosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 40 mg PO DAILY 2. LamoTRIgine 150 mg PO QAM 3. LamoTRIgine 175 mg PO QPM 4. LevETIRAcetam 1000 mg PO Q12H 5. ClonazePAM 1 mg PO QID:PRN anti seizure Discharge Medications: 1. LamoTRIgine 300 mg PO BID Follow separate instructions on how to increase slowly to this dose RX *lamotrigine 150 mg 2 tablet(s) by mouth every 12 hours Disp #*120 Tablet Refills:*5 RX *lamotrigine 25 mg ___ tablet(s) by mouth every 12 hours Disp #*180 Tablet Refills:*0 2. ClonazePAM 1 mg PO QID:PRN anti seizure 3. FLUoxetine 40 mg PO DAILY 4. LevETIRAcetam 1000 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Breakthrough seizures complex partial epilepsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ___ CLINIC PROTOCOL W/O CONTRAST T7721 MR HEAD INDICATION: ___ year old woman with hx of seizure d/o of unclear etiology// Evaluate for intracranial pathology TECHNIQUE: Sagittal 3D FLAIR, axial GRE, coronal FSTIR, axial DTI, images were obtained. Additional sagittal and axial reformatted images of the MPRAGE images were then produced. All images were reviewed in the production of this report. The examination was performed using a 3.0T MRI scanner. COMPARISON: None available. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are within expected limits in caliber and configuration. Bilateral hippocampal formations and mammillary bodies are preserved in signal and configuration. There is no disproportionate medial temporal atrophy. There is no focal lobar encephalomalacia. There are no focal cortical dysplasias or gray matter heterotopia noted. IMPRESSION: 1. Unremarkable contrast enhanced MRI brain. 2. No evidence of focal cortical dysplasia, focal lobar encephalomalacia, gray matter heterotopia or mesial temporal sclerosis. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Seizure Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Ms. ___, It was a pleasure taking care of you at ___! You were admitted with several seizures. You were very sleepy because of the seizures and the medicines we needed to give you to stop the seizures, and you needed a breathing tube for a short period. We did some additional testing to make sure there were no other treatable reasons for you to have epilepsy. You had an MRI scan, which looked normal. You also had a spinal tap, which was normal. Keep taking the levetiracetam (Keppra) without change. Increase your lamotrigine as directed below: Date AMPM ___ daily dose 150 mg tabs 25 mg tabs 150 mg tabs 25 mg tabs ___ ___ mg ___ ___ For more epilepsy information, you may want to look at the following web sites: ___ ___ Epilepsy Foundation ___ International League Against Epilepsy These sites have very reliable information about seizures, diagnosis, medications and other treatments, written by medical professionals with expertise in epilepsy care. They also have helpful tools to help you manage your seizures, such as seizure diaries, medication information sheets, and seizure preparedness plans. Finally, several of the sites have online patient support groups and links to additional information. You can also reach our local Epilepsy Foundation affiliate, Epilepsy Foundation ___, ___ Island, ___ & ___ for local educational events, programs, and support groups at: ___/ Phone: ___ Toll free ___ _______________________________________________________________ FIRST AID FOR SEIZURES _______________________________________________________________ Don't panic. Stay calm during the seizure. Speak calmly to the person and to others in the area. Don't expect the person to talk during the seizure. Look for identification or a medical alert bracelet. Realize that you cannot stop the seizure. Don't try to bring the person out of the seizure by using cold water, or by slapping or shaking the person. GENERALIZED TONIC-CLONIC SEIZURE (GRAND MAL) During the seizure: The person may fall, stiffen, and make jerking movements. The person may turn pale or blue from difficult breathing. 1. Help the person into a lying position and put something soft under the head. 2. Remove glasses and loosen any tight clothing. 3. Clear the area of hard or sharp objects. 4. Do not put anything into the person's mouth or force anything between his/her teeth. It is impossible to swallow the tongue. You don't need to try to keep the person from swallowing his or her tongue. 5. Do not try to restrain the person; you cannot stop the seizure and you may injure them. 6. Turn the person onto his or her side as soon as possible to help breathing and to allow saliva to drain from the mouth. After the seizure: The person will awaken confused and disoriented. 1. Stay with the person until he or she is fully alert 2. Do not offer the person any food or drink until fully awake. 3. Let the person rest or sleep. Be reassuring. COMPLEX PARTIAL SEIZURES (TEMPORAL LOBE, PSYCHOMOTOR) During the seizure: The person may have a glassy stare; give no response or inappropriate responses when questioned; sit, stand, or walk about aimlessly; make lip smacking or chewing motions; fidget with clothes; appear to be drunk, drugged, or confused. 1. Do not try to stop or restrain the person unless there is danger - for example, if the person could fall down stairs or walk into traffic. 2. Try to remove harmful objects from the person's pathway or coax the person away from them. 3. Do not upset the person. 4. When alone, do no approach the person who appears to be angry or aggressive. After the seizure: 1. The person may be confused or disoriented after regaining consciousness and should not be left alone until fully alert. IT IS RARELY NECESSARY TO CALL FOR MEDICAL HELP UNLESS: 1. You know that the person does NOT have epilepsy. 2. You know that the person has diabetes or low blood sugar. 3. The person does not start breathing after the seizure. Begin mouth-to-mouth resuscitation. 4. The person has one seizure right after another, or a seizure lasting longer than ___ minutes. 5. The person is pregnant, ill, or injured. 6. The seizure occurred in water, because the person may have inhaled or swallowed water. 7. The person requests an ambulance. ________________________________________________________________ SEIZURE SAFETY ________________________________________________________________ The following tips will help you to make your home and surroundings as safe as possible during or following a seizure. Some people with epilepsy will not need to make any of these changes. Use this list to balance your safety with the way you want to live your life. Make sure that everyone in your family and in your home knows: - what to expect when you have a seizure - correct seizure first aid - first aid for choking - when it is (and isn't) necessary to call for emergency help Avoid things that are known to increase the risk of a seizure: - forgetting to take medications - not getting enough sleep - drinking a lot of alcohol - using illegal drugs In the kitchen: - As much as possible, cook and use electrical appliances only when someone else is in the house. - Use a microwave if possible. - Use the back burners of the stove. Turn handles of pans toward the back of the stove. - Avoid carrying hot pans; serve hot food and liquids directly from the stove onto plates. - Use pre-cut foods or use a blender or food processor to limit the need for sharp knives. - Wear rubber gloves when handling knives or washing dishes or glasses in the sink. - Use plastic cups, dishes, and containers rather than breakable glass. In the living room: - Avoid open fires. - Avoid trailing wires and clutter on the floor. - Lay a soft, easy-to-clean carpet. - Put safety glass in windows and doors. - Pad sharp corners of tables and other furniture, and buy furniture with rounded corners. - Avoid smoking or lighting fires when you're by yourself. - Try to avoid climbing up on chairs or ladders, especially when alone. - If you wander during seizures, make sure that outside doors are securely locked and put safety gates at the top of steep stairs. In the bedroom: - Choose a wide, low bed. - Avoid top bunks. - Place a soft carpet on the floor. In the bathroom: - Unless you live on your own, tell a family member ___ before you take a bath or shower. - Hang the bathroom door so it opens outward, so it can be opened if you have a seizure and fall against it. - Don't lock the bathroom door. Hang an "Occupied" sign on the outside handle instead. - Set the water temperature low so you won't be hurt if you have a seizure while the water is running. - Showers are generally safer than baths. Consider using a hand- held shower nozzle. - If taking a bath, keep the water shallow and make sure you turn off the tap before getting in. - Put non-skid strips in the tub. - Avoid using electrical appliances in the bathroom or near water. - Use shatterproof glass for mirrors. At work: ___ Out and about: - Carry only as many medications with you as you will need, and 2 spare doses. - Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy. - Stand well back from the road when waiting for the bus and away from the platform edge when taking the subway. - If you wander during a seizure, take a friend along. - Don't let fear of a seizure keep you at home. Sports: - Use common sense to decide which sports are reasonable. - Exercise on soft surfaces. - Wear a life vest when you are close to water. - Avoid swimming alone. Make sure someone with you can swim well enough to help you if you need it. - Wear head protection when playing contact sports or when there is a risk of falling. - When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads. Avoid high traffic areas; ride or skate on side roads or bike paths. Driving: - You may not drive in ___ unless you have been seizure- free for at least 6 months. - Always wear a seatbelt. Parenting: - Childproof your home as much as possible. - If you are nursing a baby, sit on the floor or bed with your back supported so the baby will not fall far if you should lose consciousness. - Feed the baby while he or she is seated in an infant seat. - Dress, change, and sponge bathe the baby on the floor. - Move the baby around in a stroller or small crib. - Keep a young baby in a playpen when you are alone, and a toddler in an indoor play yard, or childproof one room and use safety gates at the doors. - When out of the house, use a bungee-type cord or restraint harness so your child cannot wander away if you have a seizure that affects your awareness. - Explain your seizures to your child when he or she is old enough to understand. _______________________________________________________________ EPILEPSY AND DRIVING IN ___ _______________________________________________________________ One of the most uncomfortable discussions that doctors and ___ have with patients with epilepsy involve restrictions on driving, because your driver's license may seem essential to your independence. Although most state laws about driving and epilepsy are now less restrictive than they were many years ago, these laws were written to lessen the chance of harm to yourself or others resulting from you having a seizure while driving. Therefore, every state regulates driver's license eligibility for people with epilepsy. As a driver's license holder, it is your responsibility to know the regulations in your state. The most common requirement is that you must be seizure-free for a certain period of time before you can be allowed to drive. The seizure- free period varies from state to state. Some states do not specify a set seizure-free period. Instead, they ask for your doctor's recommendation about whether you can drive safely. Although physicians can offer an opinion on your ability to drive safely, the department of motor vehicles makes the final decision. In some states, the physician can offer such an opinion if your seizures do not interfere with consciousness or control of movement, you may be able to continue driving, if your seizures occur only at certain times (especially during sleep) or if you always have an aura that would warn you to pull off the road before a seizure begins. In a few states, some people with seizures can get a restricted license, which allows them to drive under certain conditions. If you are still having seizures, don't hide it from your doctor in order to keep your driver's license. Not reporting seizures makes it impossible for your doctor to treat your epilepsy effectively. The doctor may be able to prevent more seizures from occurring by making a small change in the dosage of your seizure medicine, for instance, but that won't happen if the doctor doesn't know that it's necessary. Inadequate treatment may lead to more seizures and then you or someone else may be injured. If your seizures make it unsafe for you to drive, you will need to find other means of transportation. Public transportation, carpooling, van transportation, and even bicycle riding can be used to preserve your sense of independence while keeping you and others safe. Remember that restrictions do not always last a lifetime. They may be temporary, just until your seizures are under good control. If your seizures are well controlled, use your driving privileges as a reason to take good care of yourself. If you always take your seizure medicines as prescribed, get enough sleep, limit your alcohol consumption, and visit your doctor regularly, you will be more likely to be able to continue driving safely and legally. Below are the driving laws in ___ You must be free of seizures for at least 6 months. In some cases, your doctor can submit a statement concerning your ability to drive safely, which may lessen the time before you can drive. You must report your seizures to the ___ department of motor vehicles and voluntarily surrender your license, or be subject to suspension or revocation. If your license is surrendered, your doctor must submit a letter stating that you have been seizure free for 6 months before you can begin driving. All the best, Your Neurology Care Team!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: codeine Attending: ___ Chief Complaint: Speech difficulty Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ yo man with a PMHx of a L MCA stroke in ___ with resulting fluent-aphasia, pancreatic cancer with known liver mets, afib on Eliquis, HTN and HLD who presents to the ED with worsening slurred speech and word finding difficulties with MRI revealing subacute to late acute bilateral cerebellar hemispheres and left temporal lobe embolic infarcts. On ___, pt resumed chemotherapy with FOLFIRINOX. Pt had been off while recovering from his previous stroke. After the therapy, pt initially felt well. On ___, he felt generalized weakness and almost passed out. He also felt "burning everywhere" and a sore mouth and throat. Over the weekend, pt developed progressive confusion. For instance, he was trying to "test his blood with a TV remote" per sister. On ___, sister found pt to be "not making sense" and felt pt was having a worsening of his baseline aphasia. She then emailed the oncology nurse to make an urgent appt. During the appt on day of presentation, ___, a STAT MRI was ordered. This revealed subacute to late acute bilateral cerebellar hemispheres and left temporal lobe embolic infarcts prompting referral to ED. At the time of my assessment, sister was present and reported that pt's symptoms were now gradually improving. Pt reported feeling weak but felt that his speech was improving. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies loss of vision, blurred vision, diplopia, vertigo, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria or rash. Past Medical History: - pancreatic cancer with known liver mets - Afib - HTN - HLD - prior MI s/p catheterization - asthma, COPD - DM - depression Social History: ___ Family History: - unable to be obtained Physical Exam: HR: 100s prior to discharge General: NAD, resting in bed comfortably HEENT: NCAT, no oropharyngeal lesions ___: Irregularly irregular Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and time. Speech with improved fluency, still with added words but overall coherent speech. Improved naming of low frequency objects ___ on stroke card, w/ phonemic errors w/ "hammock" and "cactus". Repetition with phonemic and semantic errors. Mild dysarthria. No evidence of hemineglect. - Cranial Nerves - PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk, power and tone. No drift. No tremor or asterixis. - Sensory - No deficits to light touch bilaterally. Plantar response extensor on the L, mute on the R. - Coordination - Mild overshoot w/ L > R on FNF in upper extremities. Good speed and intact cadence with rapid alternating movements. - Gait - Deferred. Pertinent Results: ___ 04:08PM BLOOD WBC-3.0* RBC-3.01* Hgb-9.0* Hct-28.4* MCV-94 MCH-29.9 MCHC-31.7* RDW-14.8 RDWSD-50.6* Plt Ct-57* ___ 04:45AM BLOOD WBC-3.7* RBC-3.12* Hgb-9.2* Hct-29.8* MCV-96 MCH-29.5 MCHC-30.9* RDW-15.0 RDWSD-52.3* Plt Ct-27* ___ 10:20AM BLOOD WBC-5.4 RBC-3.40* Hgb-10.3* Hct-32.6* MCV-96 MCH-30.3 MCHC-31.6* RDW-14.9 RDWSD-51.8* Plt Ct-48*# ___ 06:50AM BLOOD ___ ___ 06:50AM BLOOD Glucose-162* UreaN-11 Creat-0.9 Na-139 K-3.6 Cl-103 HCO3-26 AnGap-14 ___ 04:30PM BLOOD ALT-22 AST-22 AlkPhos-156* TotBili-0.5 Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old man with cva, pancreatic cancer, worsens speech and fatigue // Eval status of cva TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 9 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: MRI head with without contrast of ___, CT head without contrast of ___. FINDINGS: The examination particularly the postcontrast sequences are motion degraded. Within these confines: There are 3 new foci of slow diffusion of the bilateral cerebellar hemispheres, 2 in the left (series 502, image 2 and 3) and 1 in the right (series 502, image 1). An additional punctate focus of slow diffusion of inferior temporal lobe (series 502, image 7) appear separate from the prior temporal infarct described in ___. These lesions demonstrate associated FLAIR hyperintense signal, compatible with late acute to subacute infarct. There is no clear associated enhancement, however postcontrast sequences are severely motion limited. Additional scattered foci of subtle cortical diffusion-weighted hyperintense signal of the right frontal lobe (series 502, image 24), right postcentral gyrus (series 502, image 223) and left medial frontal lobe along the precentral gyrus (series 502, image 22) are noted without clear ADC correlate and with equivocal associated FLAIR hyperintense signal are also suspicious with additional foci of subacute infarct. In the region of previous acute infarct, there is now developing encephalomalacia with mildly enhancing gyriform cortical diffusion-weighted hyperintense signal of the left temporal lobe and pseudo normalized ADC correlate, compatible with subacute infarct. This region demonstrates T1 intrinsic hyperintense signal compatible with cortical laminar necrosis. There is also superimposed gradient echo susceptibility blooming artifact within the region of prior infarct, corresponding to known hemorrhagic transformation demonstrated on CT examination of ___. The major intracranial flow voids are preserved. The dural venous sinuses are patent. The paranasal sinuses are clear. The patient is status post right lens replacement, otherwise orbits are unremarkable. The mastoid air cells demonstrate trace fluid signal at the tips. IMPRESSION: 1. Multiple new foci of slow diffusion involving the bilateral cerebellar hemispheres and left temporal lobe, demonstrating associated FLAIR hyperintense signal without definitive enhancement, compatible with a combination of late acute to subacute infarcts of varying chronicity. 2. Additional scattered foci of diffusion-weighted hyperintense signal without clear ADC hypointensity and equivocal FLAIR hyperintense signal of the bilateral frontal and right parietal lobes, concerning for subacute infarcts. 3. The above combination of findings would suggest a central/ embolic etiology. 4. Subacute left temporal lobe infarct, now demonstrating encephalomalacia and mildly enhancing gyriform diffusion-weighted cortical hyperintensity with pseudo normalization on ADC and associated pseudo laminar necrosis. There is gradient echo susceptibility blooming artifact within the subacute infarct compatible with hemorrhagic transformation, noted on prior CT examination. 5. Potentially, the gyriform diffusion-weighted hyperintense signal of the left temporal lobe could be seen in setting of seizure activity, however there is no cortical thickening to suggest edema. 6. Postcontrast examination is severely motion degraded. No clear enhancing mass lesions are identified. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 3:45 ___, at the time of discovery of the findings. Radiology Report EXAMINATION: Chest radiographs. INDICATION: ___ with increase confusion // eval for pna TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs dated ___, CT chest dated ___. FINDINGS: Left central venous line terminates at the cavoatrial junction. Multiple bilateral pulmonary nodules are better characterized on recent CT chest examination. Bibasilar atelectasis is noted without lobar consolidation, pleural effusion, pneumothorax, or pulmonary edema. The cardiomediastinal silhouette is unchanged. IMPRESSION: Bibasilar atelectasis without lobar consolidation. Numerous pulmonary nodules are better visualized on prior CT chest examination. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ male with with acute infarct on MRI. Evaluate for aneurysm. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 5) Spiral Acquisition 4.9 s, 38.5 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,234.2 mGy-cm. Total DLP (Head) = 2,161 mGy-cm. COMPARISON: CT from ___ and MRI from ___. FINDINGS: CT HEAD WITHOUT CONTRAST: Evolving cerebellar and left temporal lobe infarcts are seen with developing encephalomalacia. There is a focus of encephalomalacia in the right frontal lobe, likely from prior lacunar infarction. There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The visualized portion of the mastoid air cells, and middle ear cavities are clear. Right cataract extraction changes are seen. There is minimal mucosal thickening in the ethmoid sinuses. Cerumen is seen in the bilateral external auditory canals. CTA HEAD: There is minimal atherosclerotic calcification of the cavernous carotid arteries. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is minimal atherosclerotic calcification at the origin of the great vessels and the bilateral carotid bulbs. Medialization of the internal carotid arteries is seen. Otherwise, the carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: Multiple enlarging nodules are seen in the bilateral lung apices, better visualized on the dedicated CT chest from ___. Multiple small mediastinal lymph nodes are seen. There is a partially visualized left central venous catheter. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. Degenerative changes are noted throughout the cervical spine. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. Evolving cerebellar and left temporal lobe infarctions. 2. No evidence of aneurysm greater than 3 mm, dissection or vascular malformation, or significant luminal narrowing. 3. Multiple enlarging lung nodules seen on CT chest from ___ which likely represents progressive metastatic disease. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Altered mental status, Facial droop Diagnosed with Cerebral infarction, unspecified temperature: 98.3 heartrate: 116.0 resprate: 16.0 o2sat: 100.0 sbp: 94.0 dbp: 62.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the ___ on ___ with slurred speech and word finding difficulty. MRI that you had a number of tiny strokes on both sides of your brain, which we think may be related to atrial fibrillation and hypercoagulability from cancer. While you were here we transitioned you from elequis to lovenox. We did an echocardiogram to look for a source of stroke coming from your heart and we found no pathology. Your exam showed stable to slightly improved and physical therapy felt that you were safe for discharge home with services. Incidentally, we found that your platelet count was quite low on this admission (27) and with input from your oncologist we transfused you a unit of platelets. Your counts improved (to 57), but it is important that we monitor the levels closely, going forward. You will follow up in Oncology on ___ Please follow up in stroke clinic as listed below and remain on the medications listed in your discharge packet. It was a pleasure taking care of you during this hospitalization. Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amoxicillin / levofloxacin / vancomycin Attending: ___. Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: ___ Gastric Emptying Study Markedly abnormal gastric emptying with only trace activity leaving the stomach for the small bowel after 4 hours. ___ PERC G/G-J TUBE PLMT Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The gastric port should not be used for 24 hours. History of Present Illness: In brief, this is a ___ female with PMHx significant for IDDM c/b neuropathy, severe gastroparesis with frequent flares, macular degeneration with legal blindness, and obesity, who is presenting with nausea, vomiting, and abdominal pain. She was admitted two weeks ago for a gastroparesis flare and had a temporary NJ tube placed for a tube feeding trial with a plan to have a follow up emptying study. Her feeding cycle was 16hr continuous/8hr off. 4 days prior to admission and about 9hrs into her feed, she felt her stomach becoming uncomfortably full, which triggered her to become nauseated and vomit (NB, bilious) and displaced her NJ tube. Following this episode, she reports severe (___) LLQ abdominal pain. She denies fevers, chills, chest pain, shortness of breath, dysuria, headache. Past Medical History: Diabetes x ___ years; last HgB A1C 8 Retinopathy (legally blind) Glaucoma Macular degeneration Neuropathy in hands & feet Severe gastroparesis x ___ years (had gastric emptying study) Depression Anxiety h/o frequent UTIs Hypertension Social History: ___ Family History: Notable for depression and DM in several family members. Physical Exam: ADMISSION PHYSICAL EXAM =============================== VS 98.5 155 / 89 91 16 98 RA GENERAL: Pleasant, obese female, NAD, quite tearful. HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: soft, TTP in LLQ, non-distended, no rebound or guarding. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash on limited exam NEUROLOGIC: A&Ox3, no focal deficits DISCHARGE PHYSICAL EXAM =============================== VS 97.7 | 142/64 | 88 | 18 | 96% RA GENERAL: Pleasant, obese female, NAD. HEENT: no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: soft, mildly tender around GJ site, dressing c/d/I, no discharge or erythema. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash on limited exam NEUROLOGIC: A&Ox3, no focal deficits Pertinent Results: ADMISSION LABS ==================== ___ 07:25PM BLOOD WBC-9.4 RBC-4.20 Hgb-12.1 Hct-36.7 MCV-87 MCH-28.8 MCHC-33.0 RDW-14.0 RDWSD-44.4 Plt ___ ___ 07:25PM BLOOD Neuts-72.5* Lymphs-18.7* Monos-7.9 Eos-0.2* Baso-0.3 Im ___ AbsNeut-6.83* AbsLymp-1.76 AbsMono-0.74 AbsEos-0.02* AbsBaso-0.03 ___ 07:25PM BLOOD Glucose-256* UreaN-20 Creat-0.9 Na-137 K-4.1 Cl-96 HCO3-29 AnGap-16 ___ 07:25PM BLOOD ALT-10 AST-9 AlkPhos-71 TotBili-0.3 ___ 07:15AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7 ___ 07:33PM BLOOD Lactate-1.4 STUDIES ==================== ___ Gastric Emptying Study IMPRESSION: Markedly abnormal gastric emptying with only trace activity leaving the stomach for the small bowel after 4 hours. ___ GJ tube placement 1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. DISCHARGE LABS ==================== ___ 08:00AM BLOOD WBC-7.7 RBC-4.14 Hgb-11.9 Hct-36.3 MCV-88 MCH-28.7 MCHC-32.8 RDW-13.6 RDWSD-43.4 Plt ___ ___ 08:35AM BLOOD Glucose-231* UreaN-14 Creat-0.6 Na-138 K-4.0 Cl-97 HCO3-31 AnGap-14 ___ 01:23PM BLOOD ALT-12 AST-16 LD(LDH)-145 AlkPhos-66 TotBili-0.5 DirBili-0.1 IndBili-0.4 ___ 08:35AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Bisacodyl 10 mg PR QHS:PRN c 3. Docusate Sodium 100 mg PO BID 4. DULoxetine 60 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. LORazepam 1 mg PO Q8H:PRN anxiety, nausea 7. Omeprazole 20 mg PO BID 8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain 9. Dronabinol 2.5 mg PO BID 10. Simethicone 40-80 mg PO QID:PRN gassy feeling 11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 12. Glargine 60 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 10 Units Dinner Discharge Medications: 1. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 65 ml/hr oral DAILY 65cc/hr for 16 hours per day RX *nut.tx.gluc.intol,lac-free,soy [Glucerna 1.5 Cal] 65 cc/hr by mouth daily Disp #*1000 Milliliter Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Bisacodyl 10 mg PR QHS:PRN c 4. Docusate Sodium 100 mg PO BID 5. Dronabinol 2.5 mg PO BID 6. DULoxetine 60 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. LORazepam 1 mg PO Q8H:PRN anxiety, nausea 9. Omeprazole 20 mg PO BID 10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain 11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 12. Simethicone 40-80 mg PO QID:PRN gassy feeling 13. Glargine 50 Units Bedtime Humalog 12 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 50 Units at bedtime Disp #*1 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 12 units at mealtimes Disp #*1 Syringe Refills:*0 14. ___ 12 Units Q24H RX *insulin NPH and regular human [Humulin ___ KwikPen] 100 unit/mL (70-30) AS DIR 12 Units at start of tube feed every night Disp #*3 Syringe Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== Gastroparesis flare, with nausea/vomiting/abdominal pain SECONDARY DIAGNOSES ====================== IDDM with Retinopathy, Neuropathy, Gastropathy Biliary ductal dilation Depression Chronic pain Primary Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with IDDM and severe gastroparesis // please place GJ tube for severe gastroparesis COMPARISON: Nasointestinal tube placement ___. CT abdomen ___. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 250 mcg of fentanyl and 4.5 mg of midazolam throughout the total intra-service time of 1 hr 30 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. CONTRAST: 75 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 51.7 min, 766 mGy PROCEDURE: 1. Placement of a 16 ___ MIC gastrojejunostomy tube. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. A Kumpe catheter was inserted using a stiff glidewire as an NG-tube in order to insufflate the stomach. The abdomen was then prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. The stomach was insufflated through the indwelling nasogastric tube. A lateral spot view confirmed that no colon was interposed between the stomach in the anterior abdominal wall. Using a marker, the skin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. The needle trajectory was directed towards the pylorus. A ___ wire was introduced and coiled within the stomach. A small skin incision was made along the needle and the needle was removed. An 8 ___ sheath was placed after dilatation with 6 and 8 ___ serial dilators. A combination of multiple catheters and wires were used to attempt access into the small bowel, including a Kumpe, C2, ___ 1, angled glidewire, straight glidewire, and ___ wire. This was very difficult given severe gastroparesis with no contrast seen in the small bowel at any point prior to small bowel access. Eventually, access was obtained into the small bowel using a combination of the Cobra catheter and the ___ wire. The ___ wire was exchanged for ___ wire, over which the sheath was advanced into the small bowel. The Cobra catheter was then exchanged for the ___ 1 catheter and the ___ wire was advanced into the distal small bowel utilizing the curved leading edge of the ___ 1 catheter. The catheter and sheath were then removed over the wire. Dilation of the percutaneous tract was attempted using serial dilators, but this was unsuccessful. The dilators were removed and a 7 mm balloon was advanced into the percutaneous tract and gently inflated. The 20 ___ peel-away sheath was then able to be advanced into the stomach. The inner dilators were withdrawn over the wire. Next, a 16 ___ MIC gastrojejunostomy catheter was advanced over the wire into position. The sheath was then peeled away. The wire and sheath were removed. The catheter was locked by instilling 7 ml of dilute contrast into the balloon in the stomach after confirming the position of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with 0-silk sutures and the retention disc. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. IMPRESSION: Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The gastric port should not be used for 24 hours. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Vomiting Diagnosed with Type 1 diabetes w diabetic autonomic (poly)neuropathy, Long term (current) use of insulin, Gastroparesis temperature: 98.3 heartrate: 108.0 resprate: 22.0 o2sat: 100.0 sbp: 130.0 dbp: 102.0 level of pain: 10 level of acuity: 2.0

Dear Ms. ___, You were admitted to ___ because you were experiencing nausea, vomiting, and diarrhea due to a condition called gastroparesis -- this is a condition where your stomach does not process food correctly, which causes all of the symptoms you were experiencing. Your care team offered you medications to help control the pain and nausea, and preformed a procedure that placed a tube in your small intestine to allow for food to bypass the stomach so you do not experience the symptoms you were experiencing before you came to the hospital. When you leave the hospital, this is how you will feed yourself: Glucerna 1.5 at 65 mL/hr x 16 hours Your insulin regimen has changed, and when you leave the hospital, this is how you should take your insulin: Take 12 units of 70/30 insulin at the start of your tube feed Take 50 units of lantus at bedtime Take 12 units of Humalog with meals, plus your usual sliding scale It was a pleasure caring for you!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Wall Infection Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ with history of depression with prior suicide attempt c/b exploratory laparotomy, anxiety, and dyslipidemia who presents with abdominal wall erythema and pain. Of note, patient was seen in ___ surgery clinic ___ given hx of RUQ abdominal pain and cholelithiasis. Biliary colic was considered most likely, patient was offered elective laparoscopic cholecystectomy with Dr. ___ ___. This past ___, patient first noticed a small, red bump just below his umbilicus (slightly tender). He denies any trauma or insect/tick bite in the area (no known exposures or recent travel, no sick contacts). He aggravated the lesion somewhat and it grew somewhat in size. Throughout this time, patient was applying the standard pre-operative cleansing solution he had been told to use prior to elective CCY in addition to an OTC antimicrobial cream he had at home. Over the weekend, the lesion did not change markedly in appearance, ~1cm in diameter, erythematous and locally tender. On ___, patient was able to express a modicum of purulent drainage. Starting ~12PM on ___ patient describes rapid progression of erythema, exquisite pain (involving the mons pubis and L groin), and swelling across his abdomen (now extending ~20cm in total around the initial lesion). Patient denies any fever/chills. No sensory loss in the area. Given the acute change in his symptoms, patient decided to present to the ___ ED for further evaluation and treatment. In the ED, initial VS were: 97.1 95 138/92 17 100% RA Exam notable for: Benign cardiopulmonary exam Well-appearing male 20 cm area of edema and erythema with a head of eschar, nondraining. The area is markedly tender to palpation. There is severe tenderness and pain extending beyond the erythema, down towards the groin ending just at the pubic symphysis. No crepitus. Labs showed: CBC 9.3>13.6/40.5<224 (76.2% PMNs) BMP ___ ALT 15 AST 23 ALP 81 Tbili .4 Albumin 4.6 CRP 6.9 CK 190 Lactate .8 Imaging showed: CT A/P with contrast ___ IMPRESSION: 1. Fat stranding in the anterior abdominal wall inferior to the umbilicus consistent with reported history of cellulitis. No abscess or subcutaneous gas is identified. 2. No acute process within the abdomen or pelvis. 3. Cholelithiasis without cholecystitis. 4. Dilated common bile duct to 0.8 cm without visualized calcified stone or mass identified. Non urgent MRCP can provide further evaluation for underlying etiology if desired clinically. Consults: ACS (no acute surgical intervention, recommend broad spectrum abx, CCY likely postponed) Patient received: ___ 20:22 IV Clindamycin ___ 20:42 IV Piperacillin-Tazobactam ___ 21:22 IV Piperacillin-Tazobactam 4.5 g ___ 22:40 IV Vancomycin (1000 mg ordered) Transfer VS were: 98.7 82 113/76 16 98% RA On arrival to the floor, patient recounts the history as above. He continues to deny any fevers/chills. Severe pain only with palpation of his abdominal skin lesion. No sensory loss. No further drainage. Patient says that his symptoms have improved greatly after the administration of antibiotics. 10-point ROS is otherwise NEGATIVE. Past Medical History: Depression c/b SI with past suicide attempts Anxiety H pylori infection s/p prior treatment with evidence of cure Dyslipidemia Cholelithiasis Hypertriglyceridemia Exploratory laparotomy iso ASA overdose ___ ago) Social History: ___ Family History: Father with prostate Cancer (___) Mother with atypical polyp/colon cancer (43), breast cancer (65) MGF deceased iso MI ___ Physical Exam: ADMISSION PHYSICAL ================== VS: 99.1 116/80 77 18 96 RA GENERAL: NAD, comfortable appearin HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: No JVP elevation. HEART: RRR, S1/S2, no murmurs, gallops, or rubs. LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles. ABDOMEN: Nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. Skin exam as below. EXTREMITIES: No cyanosis, clubbing, or edema. Tender, swollen 2cm mobile L inguinal LN. PULSES: 2+ DP pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused. Area ~20cm in diameter (demarcated with pen) of erythema with mild swelling, warm to touch and appropriately tender to palpation, no crepitus. Visible head of granulation tissue and eschar just below and to the left of the umbilicus, no drainage. DISCHARGE PHYSICAL ================== ___ 0810 Temp: 98.4 PO BP: 104/63 HR: 63 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: NAD HEENT: EOMI, dry MM HEART: RRR, S1/S2, no murmurs LUNGS: CTAB ABDOMEN: Nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. Tender, swollen 2cm mobile L inguinal LN. PULSES: 2+ DP pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: area of erythema (demarcated with pen) much improved, warm and tender, no crepitus. 1x2cm eschar. Pertinent Results: ADMISSION LABS ============== ___ 08:03PM BLOOD WBC-9.3# RBC-4.58* Hgb-13.6* Hct-40.5 MCV-88 MCH-29.7 MCHC-33.6 RDW-12.1 RDWSD-39.3 Plt ___ ___ 08:03PM BLOOD Neuts-76.2* Lymphs-16.8* Monos-5.5 Eos-0.8* Baso-0.4 Im ___ AbsNeut-7.08* AbsLymp-1.56 AbsMono-0.51 AbsEos-0.07 AbsBaso-0.04 ___ 08:03PM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-139 K-4.4 Cl-99 HCO3-27 AnGap-13 ___ 08:03PM BLOOD ALT-15 AST-23 CK(CPK)-190 AlkPhos-81 TotBili-0.4 ___ 08:03PM BLOOD Albumin-4.6 ___ 08:09PM BLOOD Lactate-0.8 MICRO ===== Blood Cultures ___: Pending - No Growth to Date IMAGING ======= CT Abd and Pelvis w/ Contrast ___. Fat stranding in the anterior abdominal wall inferior to the umbilicus consistent with reported history of cellulitis. No abscess or subcutaneous gas is identified. 2. No acute process within the abdomen or pelvis. 3. Cholelithiasis without cholecystitis. 4. Dilated common bile duct to 0.8 cm without visualized calcified stone or mass identified. Non urgent MRCP can provide further evaluation for underlying etiology if desired clinically. DISCHARGE LABS ============== ___ 05:20AM BLOOD WBC-6.6 RBC-4.48* Hgb-13.2* Hct-38.0* MCV-85 MCH-29.5 MCHC-34.7 RDW-12.4 RDWSD-37.9 Plt ___ ___ 05:20AM BLOOD Neuts-69.1 ___ Monos-7.0 Eos-2.0 Baso-0.6 Im ___ AbsNeut-4.56 AbsLymp-1.39 AbsMono-0.46 AbsEos-0.13 AbsBaso-0.04 ___ 05:20AM BLOOD Glucose-103* UreaN-9 Creat-1.0 Na-140 K-4.1 Cl-101 HCO3-29 AnGap-10 ___ 05:20AM BLOOD ALT-12 AST-14 LD(LDH)-111 AlkPhos-76 TotBili-0.4 Medications on Admission: None Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days Through ___. RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth every twelve (12) hours Disp #*9 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days Through ___. RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= Abdominal wall cellulitis Secondary Diagnoses =================== Hyperlipidemia Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with ventral abdominal cellulitis, rapid spreading inferiorly, ttp out of proportion // r/o nec fas TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 13.6 mGy (Body) DLP = 686.2 mGy-cm. Total DLP (Body) = 693 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: There are bilateral dependent atelectasis. No focal consolidation to suggest pneumonia. No pericardial or pleural effusions. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones at the neck does not particularly distended. The CBD is dated to 0.8 cm without obstructing stone or mass identified. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no hydronephrosis in either kidney. Subcentimeter hypoattenuating lesions in the right kidney are too small to characterize. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Otherwise the stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not clearly delineated though no inflammatory changes identified. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative changes of the lumbar spine are mild. SOFT TISSUES: Fat stranding in the anterior abdominal wall inferior to the umbilicus (series 2, image 51 and series 602, image 45) is consistent with reported history of cellulitis. No rim enhancing fluid collection is identified. No subcutaneous gas. IMPRESSION: 1. Fat stranding in the anterior abdominal wall inferior to the umbilicus consistent with reported history of cellulitis. No abscess or subcutaneous gas is identified. 2. No acute process within the abdomen or pelvis. 3. Cholelithiasis without cholecystitis. 4. Dilated common bile duct to 0.8 cm without visualized calcified stone or mass identified. Non urgent MRCP can provide further evaluation for underlying etiology if desired clinically. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Wound eval Diagnosed with Cellulitis of abdominal wall temperature: 97.1 heartrate: 95.0 resprate: 17.0 o2sat: 100.0 sbp: 138.0 dbp: 92.0 level of pain: 5 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you in the hospital! Why was I admitted to the hospital? -You came to the hospital because you had a skin infection on your abdomen What happened while I was admitted to the hospital? -You were started on broad-spectrum antibiotics to treat your skin infection -Your lab numbers were closely monitored and you were continued on your home medications –Your surgeons (Dr. ___ evaluated you and determined that your elective cholecystectomy to remove your gallbladder needed to be pushed back because of your active skin infection –The surgical coordinator will be in contact with you to determine your surgery date -Your being discharged with oral antibiotics that you should continue to take What should I do after I leave the hospital? -Please continue taking all of your medications as prescribed, details below -Keep all of your appointments as scheduled We wish you the very best! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine / Codeine / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: RECURRENT INCISIONAL HERNIA Major Surgical or Invasive Procedure: ventral herniography w/ mesh History of Present Illness: ___ PMH EtOH abuse, diverticuitis s/p ___ w/ reversal, c/b incisional hernia s/p laparoscopic mesh repair c/b recurrence, now w/ roughly 7 days of nausea, vomiting, and abdominal pain. He states that the pain is worst over his known, longstanding recurrent incisional hernia. He reports having generally been able to stay hydrated and denies drinking alcohol for ___ years. When his symptoms worsened, he decided to present to the ED for treatment of his hernia and requests that his hernia be repaired expeditiously. A CT A/P was performed in the ED which showed herniated bowel with some evidence of intermittent incarceration. though no current vascular compromise or obstruction. ___ surgery was consulted for further management Past Medical History: DM2, HTN, HL, history of EtOH abuse, Depression. PSH: colectectomy with colostomy, colostomy reversal, bilateral inguinal hernia repairs Social History: ___ Family History: non-contributory Physical Exam: VS: Temp:98.2 BP:122/69 HR:77 RR16 O2:92Ra GEN: A&Ox3, NAD, resting comfortably HEENT: NCAT, EOMI, sclera anicteric CV: RRR PULM: no respiratory distress ABD: soft, appropriately tender. Dressing CDI EXT: warm, well-perfused, no edema PSYCH: normal insight, memory, and mood Pertinent Results: ___ 06:09AM BLOOD WBC-7.8 RBC-4.10* Hgb-12.7* Hct-37.3* MCV-91 MCH-31.0 MCHC-34.0 RDW-13.1 RDWSD-43.4 Plt ___ ___ 06:06AM BLOOD WBC-7.5 RBC-4.20* Hgb-13.0* Hct-38.4* MCV-91 MCH-31.0 MCHC-33.9 RDW-13.5 RDWSD-45.6 Plt ___ ___ 05:45AM BLOOD WBC-14.5* RBC-4.56* Hgb-14.2# Hct-42.1 MCV-92 MCH-31.1 MCHC-33.7 RDW-13.6 RDWSD-46.1 Plt ___ ___ 11:20PM BLOOD WBC-18.0*# RBC-5.71# Hgb-17.6*# Hct-52.0*# MCV-91 MCH-30.8 MCHC-33.8 RDW-13.4 RDWSD-45.1 Plt ___ ___ 11:20PM BLOOD Neuts-89.6* Lymphs-3.5* Monos-5.9 Eos-0.4* Baso-0.3 Im ___ AbsNeut-16.16* AbsLymp-0.64* AbsMono-1.06* AbsEos-0.07 AbsBaso-0.06 ___ 06:09AM BLOOD Plt ___ ___ 06:09AM BLOOD ___ PTT-PND ___ ___ 06:06AM BLOOD Plt ___ ___ 06:06AM BLOOD ___ PTT-27.3 ___ ___ 10:18AM BLOOD ___ PTT-25.1 ___ ___ 05:45AM BLOOD Plt ___ ___ 11:20PM BLOOD Plt ___ ___ 06:09AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141 K-4.3 Cl-105 HCO3-24 AnGap-12 ___ 06:06AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-142 K-4.4 Cl-108 HCO3-23 AnGap-11 ___ 10:18AM BLOOD K-4.7 ___ 05:45AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-142 K-5.1 Cl-105 HCO3-22 AnGap-15 ___ 11:20PM BLOOD Glucose-180* UreaN-13 Creat-1.0 Na-140 K-5.2* Cl-99 HCO3-23 AnGap-18 Medications on Admission: Denies Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: RECURRENT INCISIONAL HERNIA WITH OBSTRUCTION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: ___ with multiple abdominal surgeries w/ abdominal pain and vomitingNO_PO contrast// evaluate for bowel obstruction, hernia incarceration/strangulation TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 20.0 mGy (Body) DLP = 952.8 mGy-cm. 3) Spiral Acquisition 1.1 s, 8.6 cm; CTDIvol = 11.5 mGy (Body) DLP = 99.1 mGy-cm. 4) Spiral Acquisition 0.6 s, 4.6 cm; CTDIvol = 13.5 mGy (Body) DLP = 62.7 mGy-cm. Total DLP (Body) = 1,128 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Mild bibasilar atelectasis, right greater than left. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver dome is excluded from the study. The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. No hydronephrosis. Bilateral subcentimeter hypodense lesions are too ___ to characterize but likely represent cysts (2; 38). There is no perinephric abnormality. GASTROINTESTINAL: ___ hiatal hernia. Within a single ventral hernia, there are loops of ___ bowel without evidence of ___ bowel enhancement or evidence of obstruction. However, there is trace free fluid surrounding the right lateral aspect of the loop of ___ bowel within the hernia (2; 35), which may be suggestive of intermittent strangulation. ___ bowel loops are normal in caliber but there appears to be relative decreasing caliber of the ___ bowel as it exits the hernia sac (2; 30). In addition, stranding of the fat adjacent to a loop of ___ bowel (2; 27). No extraluminal or free air. Patient is status post colectomy for diverticulitis with reversal of colostomy. The colon is distended with fluid and air. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Compression deformity of the superior endplate of L3 is likely chronic (602; 40). SOFT TISSUES: Single ventral hernia containing a loop of ___ bowel with neck of the hernia measuring 3.0 cm. Patient is status post prior incisional hernia repair. There is a left inguinal hernia containing fat. IMPRESSION: 1. Single ventral hernia containing a loop of ___ bowel with hernia neck measuring approximately 3.0 cm. The loop of ___ bowel within the hernia is not dilated and has normal wall enhancement. However there is adjacent free fluid stranding lateral to the right aspect of that loop of bowel could be seen in the setting of intermittent incarceration. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 3:52 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man add-on for ventral hernia repair// pre-op cxr Surg: ___ (ventral hernia repair) PRE-OP IMPRESSION: Compared to chest radiographs one ___. Patient has had median sternotomy. Heart size is normal. Lungs are clear. Mediastinal and hilar contours and pleural surfaces are normal. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Vomiting Diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene temperature: 97.5 heartrate: 83.0 resprate: 16.0 o2sat: 96.0 sbp: 92.0 dbp: 57.0 level of pain: 8 level of acuity: 3.0

Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, 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. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pressure on Exertion Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: This is a ___ ___ speaking man with a history of CAD (s/p DES to ___ at ___ ___ and DES to LCX and LMCA into bifurcation of LAD and LCX in ___ ___, severe AS, who presents with worsening chest pressure on exertion for the past few days. He reported developing chest pressure and shortness of breath within minutes of activities such as washing dishes or walking. He even noted it when trying to turn the steering wheel to make a tight UTurn. The symptoms improve after severe minutes rest. No lightheadedness, diaphoresis, chest pressure at rest, headaches, nausea, vomiting, loss of consciousness. The time course seems to be slowly progressive rather than acute. Given worsening symptoms, he was sent to the ED. In the ED initial vitals were: 97.2 77 161/74 16 98% RA - His exam was notable for ___ SEM, mild RUQ tenderness, 1+ left, 2+ right ___ edema. Right stasis skin changes. Given RUQ tenderness he underwent RUQ that was negative and ___ that was also negative. - Labs/studies notable for: Trop negative x 2. Cr 1.6 (baseline Cr 1.4-1.5), UA was negative. - Patient was given: Aspirin 243mg, Atenolol 100mg, Warfarin 2mg, Plavix 75mg, Losartan 50mg. - Vitals on transfer: 98.1 72 129/60 16 98% RA On the floor, he reports no chest discomfort and complains only of shortness of breath with moving. Of note, he is scheduled to see Dr. ___ on ___ for evaluation for AVR and CABG. Past Medical History: - Anemia - Aortic Stenosis - Atrial Fibrillation - Benign Prostatic Hypertrophy - Cerebrovascular Accident - Chronic Kideny Disease - Colonic Adenoma - Coronary Artery disease s/p DES to LMCA at ___ ___ and DES to LCX and LMCA into bifurcation of LAD and LCX in ___ ___ - Gastritis - Glaucoma - Glucose Intolerance - Hyperlipidemia - Hypertension - Nephrolithiasis - Osteopenia - Spinal Stenosis Social History: ___ Family History: Unknown. Physical Exam: Admission Physical Exam: VS: 98.2 83 18 145/68 97/RA Weight: 71.2kg GENERAL: In no acute distress, very pleasant. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Dry mucous membranes. No xanthelasma. NECK: Supple with JVP just at the clavicle at 90 degrees. CARDIAC: Regular rate and rhythm, II/VI systolic murmur LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use.Few bibasilar crackles, R>L. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm, well perfused, weakly palpable pulses. 2+ edema and brawny skin changes of the right leg, 1+ of the left NEURO: A&OX3, CN II-XII grossly intact. Gait within normal limits. Discharge Physical Exam: Afebrile, otherwise unchanged. Pertinent Results: =============== Admission Labs: =============== ___ 05:30PM BLOOD WBC-6.4 RBC-2.78* Hgb-9.0* Hct-27.9* MCV-100* MCH-32.4* MCHC-32.3 RDW-14.9 RDWSD-54.9* Plt ___ ___ 05:30PM BLOOD ___ PTT-45.1* ___ ___ 05:30PM BLOOD Glucose-103* UreaN-34* Creat-1.6* Na-141 K-3.9 Cl-104 HCO3-23 AnGap-18 ___ 05:30PM BLOOD ALT-20 AST-30 AlkPhos-52 TotBili-0.8 ___ 05:30PM BLOOD Lipase-77* ___ 05:30PM BLOOD cTropnT-<0.01 proBNP-2991* =============== Discharge Labs: =============== ___ 08:50AM BLOOD WBC-5.6 RBC-3.00* Hgb-9.8* Hct-30.7* MCV-102* MCH-32.7* MCHC-31.9* RDW-15.2 RDWSD-56.7* Plt ___ ___ 08:50AM BLOOD ___ PTT-48.3* ___ ___ 08:50AM BLOOD Glucose-221* UreaN-29* Creat-1.5* Na-137 K-4.5 Cl-104 HCO3-21* AnGap-17 ___ 08:50AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:55PM BLOOD Albumin-4.7 Calcium-9.9 Phos-4.4 Mg-2.1 Iron-67 ___ 02:55PM BLOOD calTIBC-313 Ferritn-PND TRF-241 ___ 09:10AM BLOOD %HbA1c-6.4* eAG-137* ======== Imaging: ======== Right Lower Extremity US ___ 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. 4.3 cm ___ cyst. CXR ___ 1. No focal consolidation. 2. Prominent interstitial markings which could represent vascular congestion or chronic underlying interstitial process. RUQ ___ Impression: Normal gallbladder. No intra or extrahepatic biliary ductal dilatation. Carotid Ultrasound ___ Read Pending ============= Microbiology: ============= Staph Aureus Screen ___ - Negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 3. Atenolol 100 mg PO BID 4. Vitamin D ___ UNIT PO DAILY 5. Doxazosin 2 mg PO HS 6. Furosemide 20 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8. Losartan Potassium 50 mg PO BID 9. Pantoprazole 20 mg PO Q12H 10. Simvastatin 20 mg PO QPM 11. Warfarin 2 mg PO DAILY16 12. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO BID 3. Doxazosin 2 mg PO HS 4. Furosemide 20 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 6. Losartan Potassium 50 mg PO BID 7. Pantoprazole 20 mg PO Q12H 8. Simvastatin 20 mg PO QPM 9. Vitamin D ___ UNIT PO DAILY 10. Warfarin 2 mg PO DAILY16 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Severe Aortic Stenosis Secondary Diagnosis: - Coronary Artery Disease - Chronic Kidney Disease - Atrial Fibrillation - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old man with CAD s/p sent ___, HTN, HLD, AS being evaluated for surgery vs. TAVR. // Carotid US to eval for stenosis TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None. FINDINGS: RIGHT: The right carotid vasculature has mild heterogeneous atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 64 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 75, 83, and 64 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 29 cm/sec. The ICA/CCA ratio is 1.3. The external carotid artery has peak systolic velocity of 93 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has mild heterogeneous atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 89 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 65, 62, and 64 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 24 cm/sec. The ICA/CCA ratio is 0.7. The external carotid artery has peak systolic velocity of 80 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: Mild bilateral heterogeneous plaque within the extracranial internal carotid arteries. No significant stenosis bilaterally (less than 40%). Gender: M Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with Chest pain, unspecified, Dyspnea, unspecified temperature: 97.2 heartrate: 77.0 resprate: 16.0 o2sat: 98.0 sbp: 161.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ with shortness of breath and chest pain. Your symptoms are likely due to your aortic stenosis. Blood tests showed that you were not having a heart attack and did not have any damage to your heart. It does appear that your weight has been stable. You were evaluated by Cardiac Surgery for potential surgery to repair your aortic valve. You had some preliminary blood tests and carotid ultrasound. You will follow-up with Cardiac Surgery to determine a plan for your surgery. Please avoid strenuous activities while at home. You should also limit your salt intake. Please call your Cardiologist if you gain more than 3 pounds in 24 hours or 5 pounds in one week. All the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: codeine Attending: ___ Chief Complaint: s/p fall, back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with left spastic hemiparesis from a stroke in ___ who presented s/p mechanical fall this morning. At baseline, he has spastic hemiparesis on the left but is able to ambulate with a walker despite being unsteady. He lives at home with his wife. He has a history of hoarding and his home is apparently quite cluttered. He has a mechanical fall this morning and injured his back. He was not able to get up from the floor due to intense back pain. There was no LOC or prodromal symptom. His wife called EMS who brought him to ___. CT head shows expected right frontal-parietal-temporal encephalomalacia consistent with previous stroke but there is no evidence of bleed. C-spine was cleared at OSH. CT L-spine revealed L1 compression fracture with 30% height loss and 1-2mm retropulsion. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies new focal weakness, numbness, parasthesiae. No bowel or bladder or retention though he does have baseline incontinence (both urinary and fecal) for years. Past Medical History: 1. Hypertension. 2. History of carotid artery dissection. 3. Hyperlipidemia. 4. Urge incontinence. 5. Seizure disorder. 6. Depression. 7. COPD, not oxygen dependent. 8. Status post left hip hemiarthroplasty. 9. History of PFO. 10. Short-term memory loss. 11. Atypical chest pain. 12. History of recurrent cellulitis on the left foot. 13. History of MRSA infection. 14. History of stroke with left-sided hemiparesis in ___. 15. Tinea pedis. 16. History of alcohol abuse. 17. Bipolar disorder. 18. History of pulmonary nodules. 19. Lower extremity edema. Social History: ___ Family History: His mother had ___ disease, and his father died of an MI. He has a sister with rheumatoid arthritis Physical Exam: On Admission: Vitals: T: 98.2 P: 96 R: 18 BP: 151/106 SaO2: 93%RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Spine: midline tenderness in the upper lumbar region. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Grossly attentive. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5 mm and brisk. VFF to confrontation. No visual extinction on DSS. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left face droop, though activation is more or less symmetric VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk throughout. Normal rectal tone (per ED resident) Spastic on the left hemibody. Left arm contracted. No pronator drift on the right. He has action and postural tremors. Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ L 4 5 0 0 0 0 3 0 0 0 0 0 R 5 ___ ___ 5 5 5 5 5 -Sensory: Decreased but present light touch, pinprick in the left hemibody. Normal on the right. No saddle anesthesia (per ED resident) -DTRs: Bi Tri ___ Pat Ach L 3 3 3 4 4 R 2 2 2 2 1 Plantar response was flexor on the right and extensor on the left. -Coordination: No dysmetria on the right arm and leg. Unable to test left arm and leg due to weakness. -Gait: Deferred On Discharge: AAO x 3. Baseline L face droop and L spastic hemiparesis. Full on the right. Also left hemi-sensory deficit (decreased but present). LUE contracted; LLE antigravity. Midline tenderness in the upper lumbar spine. Rectal tone normal. No saddle anesthesia. Pertinent Results: HIP UNILAT MIN 2 VIEWS LEFT ___ No acute fracture CXR ___ As compared to the previous radiograph, the lung volumes have decreased. Areas of atelectasis are seen at the right lung basis. However, there is no evidence of pneumonia or pulmonary edema. No larger pleural effusions. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. ___ MRI L spine Acute compression fracture of the L1 vertebral body with mild retropulsion of the dorsal cortex into the spinal canal causing mild to moderate narrowing of the thecal sac, but no compression of the conus medullaris. ___ CXR Mild pulmonary edema, increased from prior study. ___hronic occlusion of the right proximal ICA with reconstitution in the distal ICA as well as the intracranial segment which is small and thread-like in caliber. No acute infarction. ___ CT chest/abdomen/pelvis 1. No evidence of hemorrhage in the chest, abdomen, or pelvis. 2. Moderate emphysema. 3. Multiple pulmonary nodules, the largest which measures 6 mm. Recommend a repeat chest CT in 6 months. 4. L1 compression fracture, better evaluated on the recent MRI. 5. Probable median arcuate ligament syndrome. Recommend correlation with symptoms. ___ CXR Comparison is made to prior study from ___. The heart size is upper limits of normal but stable. There is again seen minimal pulmonary edema and some atelectasis at the lung bases. There are no pneumothoraces. ___ BLE LENIS No evidence of DVT in the bilateral lower extremities. ___ EEG: Abnormal continuous EEG because of (1) Nearly continuous right temporal discharges, occurring periodically up to every one to three seconds, consistent with marked focal cortical irritability; and (2) right hemispheric slowing, most prominent in the temporal leads, consistent with focal dysfunction. There were no organized electrographic seizures. ___ MRI/MRA 1. Chronic infarction, causing extensive area of encephalomalacia involving the right middle cerebral artery territory as described in detail above, causing encephalomalacia, ex vacuo dilatation of the lateral ventricle, and asymmetry of the right cerebral peduncle. 2. Occlusion of the right proximal internal carotid artery, with collateral flow via the external carotid artery and right posterior communicating artery. No aneurysms are identified. ___ 03:30PM BLOOD WBC-6.6 RBC-3.63* Hgb-12.0* Hct-36.5* MCV-101* MCH-33.0* MCHC-32.7 RDW-12.7 Plt ___ ___ 03:30PM BLOOD ___ PTT-35.5 ___ ___ 03:30PM BLOOD Glucose-103* UreaN-13 Creat-0.8 Na-142 K-4.2 Cl-107 HCO3-30 AnGap-9 ___ 03:45PM BLOOD ALT-22 AST-21 LD(LDH)-200 AlkPhos-66 TotBili-0.2 ___ 03:30PM BLOOD Calcium-8.7 Phos-2.2* Mg-1.9 ___ 06:55PM BLOOD Carbamz-7.7 Medications on Admission: He endorses taking ASA 81 daily 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aripiprazole 30 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Benzonatate 100 mg PO QID:PRN cough 5. Carbamazepine 200 mg PO QAM 6. Carbamazepine 400 mg PO QHS 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. HydrALAzine 10 mg PO BID 9. LaMOTrigine 200 mg PO BID 10. Lisinopril 40 mg PO DAILY 11. Mirtazapine 15 mg PO HS 12. Simvastatin 40 mg PO DAILY 13. Tamsulosin 0.4 mg PO BID 14. Venlafaxine XR 150 mg PO DAILY 15. Ketoconazole 2% 1 Appl TP BID RX *ketoconazole 2 % Apply to bilateral toes, webspaces, and feet twice a day Disp #*1 Tube Refills:*0 16. LOPERamide 2 mg PO QID:PRN constipation 17. lactobacillus acidophilus 1 pill oral bid 18. Amoxicillin-Clavulanic Acid ___ mg PO Q8H ___ RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 19. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain/fever 2. Aripiprazole 30 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Carbamazepine 200 mg PO DAILY 6. Carbamazepine 400 mg PO QHS 7. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days 8. Docusate Sodium 100 mg PO BID 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. Heparin 5000 UNIT SC TID 11. Ketoconazole 2% 1 Appl TP BID 12. LaMOTrigine 200 mg PO BID 13. LeVETiracetam 1000 mg PO BID 14. Mirtazapine 15 mg PO HS 15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 16. Senna 17.2 mg PO BID 17. Simvastatin 40 mg PO DAILY 18. Tamsulosin 0.4 mg PO HS 19. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L1 compression fracture Right temporal epileptiform discharges Multiple pulmonary nodules Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with fall, left hip pain // ?fracture TECHNIQUE: AP view of the pelvis and AP and cross-table lateral views of the left hip. COMPARISON: ___ FINDINGS: There is no visualized acute fracture. Left hip bipolar hemiarthroplasty is seen without evidence of periprosthetic lucency or fracture. There is no dislocation. IMPRESSION: No acute fracture. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with s/p fall, desat to 79%. // ?atelactasis, pna. COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the lung volumes have decreased. Areas of atelectasis are seen at the right lung basis. However, there is no evidence of pneumonia or pulmonary edema. No larger pleural effusions. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST INDICATION: ___ year old man with s/p fall with L1 compression fracture. Evaluate for abnormal cord signal/ hematoma/ infarct TECHNIQUE: Multiplanar, multi sequence MR images of the lumbar spine were obtained. COMPARISON: CT lumbar spine ___. FINDINGS: There is an acute compression fracture of the L1 vertebral body (less than 50% loss of height) with retropulsion of the dorsal cortex into the spinal canal, causing mild to moderate narrowing of the thecal sac, but no compression of the conus medullaris. The posterior longitudinal ligament is disrupted. No other fracture or abnormal bone marrow signal is identified. Lumbar spine alignment is preserved. The remainder of the vertebral body heights and disc spaces are maintained. There are mild multilevel degenerative changes without significant spinal canal or neural foraminal narrowing. Atrophy of the left psoas muscle is noted. The conus medullaris is normal in morphology and signal intensity and terminates at the level of L1-L2. No large epidural hematoma is identified. IMPRESSION: Acute compression fracture of the L1 vertebral body with mild retropulsion of the dorsal cortex into the spinal canal causing mild to moderate narrowing of the thecal sac, but no compression of the conus medullaris. Radiology Report INDICATION: Low O2 sats, evaluate for congestion. COMPARISON: ___. FINDINGS: AP portable view of the chest. Low lung volumes. Compared to prior study, there is an increase in pulmonary edema. No significant pleural effusion. No pneumothorax. Cardiomediastinal and hilar contours are stable. IMPRESSION: Mild pulmonary edema, increased from prior study. Radiology Report TECHNIQUE: CTA of the head and neck with contrast. HISTORY: Dysarthria and confusion. COMPARISON: ___. FINDINGS: On the unenhanced scan, there is encephalomalacia in the right MCA territory with changes from a prior craniotomy. There is a chronic-appearing subdural collection with calcifications within the neck. There is occlusion of the right proximal ICA with reconstitution distally of a thread-like ICA via collaterals with continued thread-like opacification of the intracranial ICA. There is diminution of the right MCA branches and prominent ECA collaterals. Evaluation of the left ICA demonstrates no aneurysm or high-grade stenosis. There is a hypoplastic right A1 segment. In the neck, the left carotid artery demonstrates no significant stenosis. Bilateral vertebral arteries are patent. There are chronic lung changes of emphysema and opacities at the lung apices. IMPRESSION: Chronic occlusion of the right proximal ICA with reconstitution in the distal ICA as well as the intracranial segment which is small and thread-like in caliber. No acute infarction. Radiology Report INDICATION: New onset dysarthria, confusion, hypotension, and dropping hematocrit. Evaluate for hemorrhage. TECHNIQUE: MDCT axial images were obtained through the torso after the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. DOSE: DLP: 1161.95 mGy-cm. COMPARISON: MRI of the lumbar spine from ___. Pelvic CT from ___. FINDINGS: CHEST: The imaged portions of the thyroid gland are normal. There is no axillary, mediastinal, or hilar lymphadenopathy. The heart is normal size. Trace pericardial fluid is within the normal physiologic range. The thoracic aorta is normal in caliber without evidence of acute aortic pathology. There are no significant atherosclerotic calcifications. The main pulmonary artery trunk is mildly dilated, measuring 3.5 cm. This suggests mild underlying pulmonary hypertension. The airways are patent to the subsegmental levels. Evaluation of the pulmonary parenchyma is limited by respiratory motion and moderate bibasilar dependent atelectasis. Moderate emphysematous changes are noted. There are several sub 4 mm pulmonary nodules in the right middle lobe (2; 22, 24, and 25). There is a 6 mm pleural-based nodule in the right lower lobe (2, 26). There is no pulmonary edema or focal airspace consolidation to suggest pneumonia. There is no pleural effusion or pneumothorax. ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic lesions. The portal veins are patent. The gallbladder is mildly distended, but there is no CT evidence of cholecystitis. The spleen pancreas, and adrenal glands are normal. In the lower pole of the left kidney, there is a 23 mm cyst. No other renal lesions are identified. There is no hydronephrosis or pyelonephritis. The kidneys enhance and excrete contrast symmetrically. The stomach and small bowel are normal in caliber. There is no evidence of obstruction, free air or free fluid. There is no retroperitoneal hematoma. There is no periportal, retroperitoneal, or mesenteric lymphadenopathy. The origin of the celiac artery is compressed by the diaphragmatic crus with moderate to severe narrowing and post stenotic dilation. There is no atherosclerotic disease. This finding can be seen in median arcuate ligament syndrome. The remainder of the arterial vasculature is normal with trace atherosclerotic calcifications. PELVIS: Evaluation of the pelvis is limited by metallic artifact from the left total hip arthroplasty. Within the limitations, the imaged portions of the large bowel are normal without focal inflammatory changes or evidence of a mass. A Foley catheter is present within the bladder. The bladder and prostate are otherwise unremarkable. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. There is evidence of a prior abdominal wall hernia repair in the right lower quadrant. Soft tissue stranding in the anterior abdominal wall fat is likely from recent subcutaneous injections. OSSEOUS STRUCTURES: The patient is status post a total left hip arthroplasty. There are old healing fractures in the left superior and inferior pubic rami. A compression fracture of L1 is better evaluated on the recent MRI of the lumbar spine. No other compression fractures are identified. There are no concerning lytic or sclerotic osseous lesions. IMPRESSION: 1. No evidence of hemorrhage in the chest, abdomen, or pelvis. 2. Moderate emphysema. 3. Multiple pulmonary nodules, the largest which measures 6 mm. Recommend a repeat chest CT in 6 months. 4. L1 compression fracture, better evaluated on the recent MRI. 5. Probable median arcuate ligament syndrome. Recommend correlation with symptoms. Radiology Report EXAMINATION: MRI and MRA Head, MRA of the neck. INDICATION: ___ year old man with MS change // stroke? please perform DWI sequence TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained with and without contrast, including axial and sagittal FLAIR sequence, axial T2, axial T1, axial magnetic susceptibility and axial diffusion-weighted images. The T1 weighted images were repeated after the administration of gadolinium contrast in axial T1, sagittal MP-RAGE with multiplanar reconstructions. MRA of the head, non contrast 3D time-of-flight MRA of the brain was performed, maximal intensity projection images and multiplanar reconstructions were reviewed. COMPARISON: CTA of the head and neck dated ___. Prior head CT without contrast dated ___. FINDINGS: MR Head: Th there is an extensive area of encephalomalacia in the vascular territory of the right middle cerebral artery, causing ex vacuo dilatation of the lateral ventricle and asymmetry of the right cerebral peduncle. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. The patient is status post right frontal parietal craniotomy. There is a chronic appearing subdural collection with mild enhancement along the right frontal temporal region mild no significant mass effect, unchanged since the prior head CT dated ___. The examination is partially limited due to patient motion On the axial images without contrast, there is a punctate focus of enhancement in the pons (image 8, series 17), likely artifactual, which is not visible in other sequence. The vascular flow void of the right internal carotid is not detected, likely consistent with chronic conclusion. MRA Head: There is occlusion of the right proximal internal carotid artery, apparently there is reconstitution of the distal branches via collateral flow from the right external carotid artery and right posterior communicating artery. The vascular signal throughout the right middle severe artery appears decreased. The basilar artery appears patent as well as the vertebral arteries, the left internal carotid artery is tortuous with mild narrowing of the distal middle cerebral artery, suggesting arteriosclerotic disease, the right posterior cerebral artery appears patent with fetal origin. No aneurysms are identified. IMPRESSION: 1. Chronic infarction, causing extensive area of encephalomalacia involving the right middle cerebral artery territory as described in detail above, causing encephalomalacia, ex vacuo dilatation of the lateral ventricle, and asymmetry of the right cerebral peduncle. 2. Occlusion of the right proximal internal carotid artery, with collateral flow via the external carotid artery and right posterior communicating artery. No aneurysms are identified. Radiology Report STUDY: AP chest, ___. CLINICAL HISTORY: ___ male with pulmonary edema. Worsening infiltrate. FINDINGS: Comparison is made to prior study from ___. The heart size is upper limits of normal but stable. There is again seen minimal pulmonary edema and some atelectasis at the lung bases. There are no pneumothoraces. Radiology Report INDICATION: ___ male with mental status change. Evaluate for evidence of DVT. COMPARISON: Bilateral lower extremity ultrasonographic examination of the veins from ___. TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. FINDINGS: Significant soft tissue edema in the left lower extremity limits exam of the left calf. There is normal compressibility, flow, and augmentation of the bilateral common femoral, proximal superficial femoral, mid superficial femoral, distal superficial femoral, and popliteal veins bilaterally. Normal color flow and compressibility was obtained of the right posterior tibial and peroneal veins. Wall-to-wall flow is seen in the left posterior tibial and peroneal veins, but no compressibility could be assessed due to significant lower extremity edema. IMPRESSION: No evidence of DVT in the bilateral lower extremities. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: s/p Fall, L1 COMPRESSION FX Diagnosed with FX LUMBAR VERTEBRA-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT temperature: 98.2 heartrate: 96.0 resprate: 18.0 o2sat: 93.0 sbp: 151.0 dbp: 106.0 level of pain: 9 level of acuity: 2.0

•No pulling up, lifting more than 10 lbs., or excessive bending or twisting. •Limit your use of stairs to ___ times per day. •Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. Pain medication should be used as needed when you have pain. You do not need to take it if you do not have pain. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. for two weeks. •Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: •Pain that is continually increasing or not relieved by pain medicine. •Any weakness, numbness, tingling in your extremities. •Loss of control of bowel or bladder functioning

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right second toe ulceration Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with known peripheral arterial disease noticed an ulcer on his right second toe that progressively had became more painful, black and swollen. He presents to the ER for evaluation. Past Medical History: PMH: HTN, dyslipedmia, CAD s/p LAD stent (___) c/b coronary perf requiring coil embolization, mild AR, hypothyroidism PSH: ___ b/l ___ angiogram with PTA and stenting of L EIA (Dr. ___, b/l knee replacements Physical Exam: Physical Exam: Alert and oriented x 3 although short term memory is poor. VS:BP 118/60 HR 78 RR 16 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left Femoral dop, DP dop ,___ dop Right Femoral dop, DP - ,___ - Feet warm. Right second toe edematous, tender and darkly discolored. Dry eschar 3mm x 3mm on tip of right second toe. Pertinent Results: ___ 12:23PM BLOOD WBC-4.7 RBC-3.78* Hgb-12.4* Hct-36.4* MCV-96 MCH-32.8* MCHC-34.1 RDW-13.7 RDWSD-48.1* Plt ___ ___ 07:15AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-135 K-3.8 Cl-102 HCO3-23 AnGap-14 ___ 07:15AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9 ABI/PVR ___ FINDINGS: On the right, the femoral and popliteal waveforms are monophasic and the posterior tibial and dorsalis pedis Doppler waveforms are absent at the ankle. The digit waveform is flat. . The right ABI was not obtainable due to absence of Doppler signals.. On the left side, the femoral waveform was triphasic but the popliteal and tibial waveforms were monophasic. The PPG digit waveform was flat. The left ABI was not obtainable due to noncompressible vessels.. The left great toe pressure is 33 mm of mercury yielding a TBI of 0.24. Pulse volume recordings showed symmetric amplitudes bilaterally at all level with flat waveforms at the metatarsal level. IMPRESSION: Evidence of right ileo-femoral and left femoral-popliteal occlusive disease with severe ischemia Right Foot Xray: ___ IMPRESSION: No radiographic evidence of osteomyelitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Moexipril 15 mg PO BID 2. Carvedilol 12.5 mg PO BID 3. Chlorthalidone 25 mg PO DAILY 4. Rosuvastatin Calcium 20 mg PO QPM 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Aspirin 325 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Chlorthalidone 25 mg PO DAILY 4. Moexipril 15 mg PO BID 5. Rosuvastatin Calcium 20 mg PO QPM 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Peripheral Arterial Disease with ulceration Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ with PVD and new ulcer at tip of second toe presenting with worsening pain at the toe, erythema and warmth. // Please evaluate for evidence of osteomyelitis. TECHNIQUE: Three views of the right foot. COMPARISON: None. FINDINGS: Moderate to severe degenerative changes seen at the first metatarsophalangeal joint. Osseous structures are otherwise unremarkable without focal erosions. Joint spaces are otherwise preserved. Small vessel atherosclerotic calcifications are noted. IMPRESSION: No radiographic evidence of osteomyelitis. Radiology Report INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent ___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please evaluate ABIs, PVRs TECHNIQUE: Non-invasive evaluation of the arterial system in the lower extremities was performed with Doppler signal recording, pulse volume recordings and segmental limb pressure measurements. COMPARISON: None FINDINGS: On the right, the femoral and popliteal waveforms are monophasic and the posterior tibial and dorsalis pedis Doppler waveforms are absent at the ankle. The digit waveform is flat. . The right ABI was not obtainable due to absence of Doppler signals.. On the left side, the femoral waveform was triphasic but the popliteal and tibial waveforms were monophasic. The PPG digit waveform was flat. . The left ABI was not obtainable due to noncompressible vessels.. The left great toe pressure is 33 mm of mercury yielding a TBI of 0.24. Pulse volume recordings showed symmetric amplitudes bilaterally at all level with flat waveforms at the metatarsal level. IMPRESSION: Evidence of right ileo-femoral and left femoral-popliteal occlusive disease with severe ischemia Radiology Report EXAMINATION: VENOUS MAPPING INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent ___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please evaluate for conduit TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral upper extremity veins. COMPARISON: None. FINDINGS: RIGHT: The cephalic vein is patent with measurements of 0 point 1 5 proximally to 0.12 cm distally. The basilic vein is patent with measurements of 0.15 cm proximally to 0.22 cm distally LEFT: The cephalic vein is patent with measurements of 0.13 cm proximally to 0.07 cm distally. There is an IUD in a within a thick-walled segment at the antecubital fossa. The basilic vein is patent with measurements of 0.15-0.12 cm. IMPRESSION: Patent cephalic and basilic veins bilaterally with small diameters. Please see the scanned vascular worksheet for a detailed diameters. Radiology Report EXAMINATION: VENOUS MAPPING INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent ___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please evalaute for conduit TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral lower extremity veins. COMPARISON: None. FINDINGS: RIGHT: The great saphenous vein is patent with diameters ranging from 0.47 to 0. 3 4 cm. The right small saphenous vein is patent with diameters ranging from 0.45 to 0.41 cm. LEFT: The great saphenous vein is patent with diameters ranging from 0.31 to 0.18 cm. The left small saphenous vein is patent with diameters ranging from 0.29 to 0.15 cm. Calcification is noted in the distal lesser saphenous vein. IMPRESSION: The great and small saphenous veins are patent bilaterally. Please see digitized image on PACS for formal sequential measurements. Radiology Report EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS INDICATION: ___ male former smoker with peripheral tear disease bilateral iliac disease status post right external iliac artery stent on ___. The patient was lost to follow-up not presents with a one-month non healing right second toe ulcer an worsening pain. TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous and delayed phase images were acquired through abdomen and pelvis Oral contrast was not administered MIP reconstructions were performed on independent workstation and reviewed on PACS. DLP: 3889 mGy-cm (abdomen and pelvis). IV Contrast: 130 mL of Omnipaque COMPARISON: CT from ___. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is diffuse atherosclerotic disease involving the abdominal aorta, bilateral iliac arteries and lower extremity arteries. Calcified atherosclerotic disease is noted in the bilateral common femoral arteries causing approximate 50% stenosis. Diffuse atherosclerotic disease of the bilateral superficial femoral artery causing multilevel significant stenosis and occlusion to the level of the popliteal arteries bilaterally is unchanged. There is extensive atherosclerotic disease and multiple areas of stenoses of the tibial vessels with three vessel runoff on the left, two vessel runoff on the right (peroneal and posterior tibial).. LOWER CHEST: The visualized lung bases are clear without focal consolidation, pleural effusion or pneumothorax. The heart is normal in size without pericardial effusion. Coronary artery calcifications are noted. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Multiple bilateral renal cysts are noted. The kidneys have normal nephrograms. A left renal defect is again noted, likely reflective of prior ischemic insult. There is no evidence of stones or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Diverticulosis is noted without evidence of diverticulitis. . There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate is enlarged. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: Diffuse atherosclerotic disease involving the abdominal aorta, iliac arteries and lower extremity runoff as described above. Heavy atherosclerotic calcifications cause stenosis and eventual occlusion of the superficial femoral arteries to the level of the popliteal arteries bilaterally. The popliteal arteries are difficult to identify due to bilateral total knee replacements.Though extensive atherosclerotic disease and multiple areas of stenoses, the three vessel runoff appears on the left, two vessel runoff on the right. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Toe pain Diagnosed with CIRCULATORY DISEASE NEC temperature: 97.8 heartrate: 85.0 resprate: 18.0 o2sat: 98.0 sbp: 125.0 dbp: 76.0 level of pain: 7 level of acuity: 3.0

Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital with a worrisome painful ulcer on your ___ right toe. We did multiple tests that showed the blood flow to your foot is severely compromised. You are safe to go home on oral antibiotics but we plan to have you return to the hospital for an angiogram. At that time we hope to place a stent in the blocked arteries to improve your circulation and promote healing of this wound. If that is not possible, we may need to do a bypass surgery to get this wound to heal. Please keep the toe dry and clean.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo ___ speaking female presents with lower back and neck pain with associated bilateral hand numbness. She is currently displaced from ___ due to the hurricane. She says that during the hurricane, she was using a bucket to try to get water out of her house when she strained her back and her lower back pain got much worse. Since that time she says she has had to sleep sitting up because of the pain. The pain does not radiate down from her back and she denies any radicular symptoms of the bilateral lower extremities. She is also having numbness of both hands, R > L but is currently denying neck pain. She says the neck pain has basically resolved. Her hand numbness is isolated to her hands and is generalized, without specific finger distribution. No bowel or bladder incontinence. Otherwise denies gait instability, loss of dexterity, change in handwriting, tripping, falling, dizziness, vision changes, chest pain, shortness of breath, nausea or vomiting. Past Medical History: HTN, MI, CAD s/p cardiac cath (in ___ with unknown stent placement Social History: ___ Family History: Non contributory Physical Exam: On Admission: ============= Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right5 5 5 5 5 Left5 5 5 5 5 IPQuadHamATEHLGast Right5 5 5 5 5 5 Left5 5 5 5 5 5 [x]Sensation intact to light touch On Discharge: ============= GENERAL: NAD HEENT: PERRL, EOMI; no LAD in neck axilla or groin NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no w/r/c, no accessory muscle use ABDOMEN: obese, soft NTND EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, no FND on exam, sensory intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 03:40PM BLOOD WBC-7.0 RBC-4.40 Hgb-13.8 Hct-43.7 MCV-99* MCH-31.4 MCHC-31.6* RDW-13.4 RDWSD-48.7* Plt ___ ___ 03:40PM BLOOD Neuts-67.4 ___ Monos-8.9 Eos-1.4 Baso-0.1 Im ___ AbsNeut-4.72 AbsLymp-1.53 AbsMono-0.62 AbsEos-0.10 AbsBaso-0.01 ___ 03:40PM BLOOD ___ PTT-31.7 ___ ___ 03:40PM BLOOD Plt ___ ___ 03:40PM BLOOD Glucose-102* UreaN-19 Creat-0.7 Na-141 K-6.1* Cl-101 HCO3-27 AnGap-13 DISCHARGE LABS: =============== ___ 07:30AM BLOOD WBC-6.0 RBC-4.14 Hgb-12.9 Hct-40.1 MCV-97 MCH-31.2 MCHC-32.2 RDW-13.2 RDWSD-47.4* Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 06:00AM BLOOD ___ PTT-30.4 ___ ___ 05:15AM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-143 K-3.7 Cl-101 HCO3-29 AnGap-13 ___ 05:15AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0 MRI: ==== GENERAL: NAD HEENT: PERRL, EOMI; no LAD in neck axilla or groin NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no w/r/c, no accessory muscle use ABDOMEN: obese, soft NTND EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, no FND on exam, sensory intact SKIN: warm and well perfused, no excoriations or lesions, no rashes CT: === 9 mm right upper lobe nodule is suspicious for malignancy given the presence of right hilar and mediastinal lymphadenopathy. Options for follow-up include an FDG PET-CT now or repeat chest CT in 3 months. Attention should also be paid to a 6 mm left upper lobe nodule on follow-up imaging. Mild pulmonary edema. Compression fracture of the T7 vertebral body with 50% height loss is more completely assessed on thoracic spine MRI of ___. No additional fractures in the thoracic spine or rib cage. 10 mm left breast nodule is incompletely evaluated on this study. Recommend mammography if it has not been recently performed. Please see the separately dictated CT abdomen and pelvis report from the same date for description of subdiaphragmatic findings. RECOMMENDATION(S): FDG PET-CT now or chest CT in 3 months for continued assessment of 9 mm right upper lobe pulmonary nodule. Medications on Admission: - Ramipril 2.5 mg tablet, 1 tab PO daily - Metoprolol succinate ER 50 mg tablet,extended release 24 hr oral 1 tablet extended release 24 hr(s) Once Daily - Omeprazole 40 mg capsule,delayed release oral, 1 capsule PO daily - Atorvastatin 40 mg tablet oral, 1 tab PO daily - Aspirin 81 mg tablet oral 1 tab PO daily - Diclofenac potassium 50 mg tablet oral, 1 tab PO daily - Nitroglycerin 0.4 mg sublingual tablet sublingual, 1 tab PRN Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 325 mg 2 capsule(s) by mouth every eight (8) hours Disp #*60 Capsule Refills:*0 2. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Furosemide 20 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 8. Omeprazole 40 mg PO DAILY 9. Ramipril 2.5 mg PO DAILY 10. HELD- Diclofenac Sodium ___ 50 mg PO BID This medication was held. Do not restart Diclofenac Sodium ___ ___ directed by your new PCP ___: Home With Service Facility: ___ Discharge Diagnosis: T7 and L1 Compression Fracture Lung nodule Breast nodule Vitamin D deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE. INDICATION: ___ year old woman with neck pain, complaint of arm weakness// Cord compression, disc herniation. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of 7 mL of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: CT lumbar spine ___. FINDINGS: CERVICAL: There is no evidence of vertebral body height loss within the cervical spine. There is minimal, 1-2 mm of retrolisthesis of C5 on C6 and C6 on C7. The bone marrow signal is normal. There is a background of minimal congenital cervical spinal canal narrowing, which combines with degenerative changes as follows: C1-C2, C2-C3: There is no definite spinal canal stenosis or neural foraminal narrowing. C3-C4: There is a minimal posterior disc bulge which results in mild canal stenosis with uncovertebral joint hypertrophy resulting in moderate bilateral neural foraminal narrowing. C4-C5: A posterior disc bulge flattens the ventral thecal sac resulting in mild-to-moderate canal stenosis with moderate bilateral neural foraminal narrowing. C5-C6: A posterior disc bulge results in moderate canal stenosis with mild right and moderate left neural foraminal narrowing. C6-C7: A posterior disc bulge indents the ventral thecal sac resulting in moderate canal stenosis with uncovertebral joint hypertrophy resulting in mild right and mild-to-moderate left neural foraminal narrowing. C7-T1: There is a minimal disc bulge at this level with no significant canal stenosis and with mild left neural foraminal narrowing. Small bilateral perineural cysts are seen. THORACIC SPINE: There is a severe compression fracture involving the T7 vertebral body with mild increased STIR signal, which may reflect a subacute fracture. No significant bony retrolisthesis or retropulsion is seen at this level. The remainder of the thoracic vertebral bodies demonstrate normal height. The sagittal spinal alignment is grossly maintained. There is no suspicious bone marrow signal identified. A mild posterior disc bulge is seen at T7-T8 which indents the ventral thecal sac resulting in mild canal stenosis. Otherwise, no significant spondylosis is seen within the thoracic spine. LUMBAR: There is an acute appearing fracture with severe compression of the L1 vertebral body, with approximately 4 mm of bony retropulsion of the largest fracture fragment. This results in mild thecal sac indentation and canal stenosis at this level, with patent neural foramina bilaterally. Otherwise, the remainder of the lumbar vertebral bodies demonstrate normal height and alignment. There is no concerning focal bone marrow signal abnormality. The conus medullaris terminates at the level of L1. There is a small posterior disc bulge at L5-S1 with no canal stenosis and mild left neural foraminal narrowing. Of note, the disc bulge at this level minimally contacts the exiting left L5 nerve root. A left-sided perineural cyst is also noted at this level. Otherwise, minimal posterior disc bulging at L2-3, L3-4, L4-5 are seen without significant canal stenosis or neural foraminal narrowing. There is no evidence for abnormal intramedullary or epidural enhancement. There is fatty atrophy of the bilateral paraspinal musculature. Otherwise, the visualized paraspinal soft tissues are grossly unremarkable in appearance. IMPRESSION: 1. Severe compression fracture of the T7 vertebral body, likely subacute and without significant retropulsion. 2. Acute appearing, severe compression fracture of L1 with mild bony retropulsion causing mild canal stenosis. No evidence for epidural collection, hematoma, or abnormal enhancement. 3. Posterior disc bulges at C5-6 and C6-7 resulting in moderate canal stenosis. 4. Multiple additional levels of background spondylosis throughout the cervical, thoracic, and lumbar spine, as detailed above. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:11 am, 20 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with multiple vertebral compression fractures.// CT torso with and without to evaluate for fractures and malignancy TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.9 s, 64.1 cm; CTDIvol = 17.7 mGy (Body) DLP = 1,132.3 mGy-cm. 2) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP = 16.8 mGy-cm. Total DLP (Body) = 1,149 mGy-cm. COMPARISON: Reportedly with recent MR of the spine. No prior CT abdomen for comparison. FINDINGS: The exam is limited due to excessive motion. LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: The liver demonstrates multiple hypodense lesions some of which are cysts while others are too small to characterize. The gallbladder is within normal limits. There is no biliary ductal dilatation. The pancreas, adrenal glands, spleen and kidneys are unremarkable. . GASTROINTESTINAL: The appendix is unremarkable. There is no intestinal obstruction or ascites. Calcified nodules in the sigmoid mesocolon are likely sequela of prior epiploic appendagitis. PELVIS: There is no free fluid in the pelvis.There is endometrial thickening versus fluid within the endometrial cavity. A simple appearing right adnexal cyst measures 5 cm. The left ovary is unremarkable for age.. LYMPH NODES: No enlarged abdominal or pelvic lymph nodes. VASCULAR: There is no abdominal aortic aneurysm. BONES: Compression fracture of L1 is noted. Please refer to the recent MRI of the spine. SOFT TISSUES: Rectus diastasis. Injection granulomas are seen in the gluteal regions. IMPRESSION: 1. No findings of primary malignancy or metastatic disease in the abdomen or pelvis. 2. Incidental findings such as 5 cm simple appearing right adnexal cyst and endometrial thickening versus fluid in the endometrial cavity. Consider pelvic ultrasound. 3. Redemonstration of thoracolumbar compression fractures, better assessed on recent MRI of the spine. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ female with multiple vertebral body compression fractures. Evaluate for fractures and malignancy. TECHNIQUE: Multi detector axial CT images were obtained through the chest after the uneventful administration of 130 cc of Omnipaque 350 intravenous contrast as part of a CT torso. Coronal, sagittal, axial thin slice and axial maximum intensity projection images were produced and reviewed on PACs. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.9 s, 64.1 cm; CTDIvol = 17.7 mGy (Body) DLP = 1,132.3 mGy-cm. 2) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP = 16.8 mGy-cm. Total DLP (Body) = 1,149 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: MR total spine of ___ FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Nonenlarged supraclavicular lymph nodes measure up to 5 mm (302:32). Axillary lymph nodes are not enlarged. 10 mm nodule in the left breast is incompletely evaluated (302:110). UPPER ABDOMEN: Please see the separately dictated CT abdomen and pelvis report from the same date for description of subdiaphragmatic findings. MEDIASTINUM: There is mediastinal lymphadenopathy measuring up to 15 mm in the right low paratracheal station (302:76). HILA: A right hilar lymph node measures 11 mm (302:99) no enlarged left hilar lymph nodes. HEART and PERICARDIUM: Heart size is normal. Coronary artery calcifications are moderate and diffuse. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: Respiratory motion moderately limits evaluation for fine detail. The background of ground-glass opacity is probably mild pulmonary edema. A right upper lobe spiculated nodule measures 8 x 9 mm (302:53). The nodule abuts but does not appear to extend into the pleura. There is also a 6 mm left upper lobe nodule (302:86). 2. AIRWAYS: Airways are patent to the subsegmental level bilaterally. 3. VESSELS: The main, right and left pulmonary arteries are normal in caliber. While this study is not optimized for the evaluation of pulmonary vasculature, no central pulmonary embolism is detected. The thoracic aorta is normal in caliber with moderate calcified atherosclerotic plaque. CHEST CAGE: Compression fracture of the T7 vertebral body with 50% height loss and no significant retropulsion is more completely assessed on MRI of the thoracic spine of ___. No additional fractures or suspicious lytic or sclerotic osseous lesions are detected. IMPRESSION: 9 mm right upper lobe nodule is suspicious for malignancy given the presence of right hilar and mediastinal lymphadenopathy. Options for follow-up include an FDG PET-CT now or repeat chest CT in 3 months. Attention should also be paid to a 6 mm left upper lobe nodule on follow-up imaging. Mild pulmonary edema. Compression fracture of the T7 vertebral body with 50% height loss is more completely assessed on thoracic spine MRI of ___. No additional fractures in the thoracic spine or rib cage. 10 mm left breast nodule is incompletely evaluated on this study. Recommend mammography if it has not been recently performed. Please see the separately dictated CT abdomen and pelvis report from the same date for description of subdiaphragmatic findings. RECOMMENDATION(S): FDG PET-CT now or chest CT in 3 months for continued assessment of 9 mm right upper lobe pulmonary nodule. Mammography if it has not been recently performed. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with thoracic and lumbar compression fractures found to have right adnexal cyst and endometrial thickening versus fluid in the endometrial cavity on CT// evaluate adnexal cyst and endometrial thickening vs fluid TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT abdomen pelvis ___ FINDINGS: The uterus is anteverted and measures 3.9 x 1.9 x 4.0 cm cm. The endometrium is homogenous and measures 2 mm. Simple appearing fluid is seen in the endometrial cavity. The ovaries are not visualized. A simple appearing right adnexal cystic lesion measures 5.4 x 4.4 x 4.5 cm. There is no free fluid in the pelvis. IMPRESSION: 1. Simple appearing fluid in the endometrium suggesting cervical stenosis. No endometrial thickening. 2. 5.4 cm simple appearing right adnexal cystic lesion. RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year to assess right adnexal cystic lesion. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Lower back pain Diagnosed with Low back pain temperature: 97.4 heartrate: 94.0 resprate: 18.0 o2sat: 97.0 sbp: 120.0 dbp: 96.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? - You came to the hospital because you had worsening back pain. WHAT HAPPENED WHILE YOU WERE HERE? - You had imaging which showed two fractures in your spine, one older one newer. - The neurosurgeons evaluated you and did not feel you needed surgery. - You were given a brace to help with your back pain. - You had imaging which showed some concerning findings that you should follow up with as noted below. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Please continue to take all of your medications as directed, and follow up with all of your doctors. - Please continue to use your TLSO brace anytime you are out of bed. - Please follow up with your new primary care doctor ___ information below.) - ****Please follow up with the Spine Surgeons in ___ weeks. You can call to schedule an appointment at ___ Again, it was a pleasure taking care of you! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: Right ankle pain Major Surgical or Invasive Procedure: Status post right ankle I&D/open reduction internal fixation ___, ___ History of Present Illness: ___ female with Diabetes, CHF, COPD, CAD status post CABG (per the patient's daughter), GERD, gout, fibromyalgia, CKD who presents with right ankle fracture dislocation. There are 2 transverse lacerations approximately 5 cm above the medial malleolus. It is difficult on exam to tell if these probes deeply and communicate with the fracture. She was given Ancef in the ED and tetanus was confirmed. She underwent closed reduction with propofol sedation. this injury will require surgical fixation. Past Medical History: Diabetes, high cholesterol, morbid obese, smoker, kidney disease, stents on the leg, stroke, heart attack, asthma, arthritis, gout, thyroid problems. Social History: ___ Family History: n/c Physical Exam: General: Well-appearing female in no acute distress. Right lower extremity: -There are 2 horizontal lacerations approximately 5 cm proximal to the medial malleolus. More proximal laceration is approximately 4 cm in length. More distal laceration is approximately 2 cm. There is scattered ecchymosis - Fires weak ___ - SILT S/S/SP/DP/T distributions though she does have decreased sensation in her great toe - 2+ palpable DP, 2+ ___ pulse by Doppler, WWP Medications on Admission: Gabapentin 300 mg nightly Allopurinol ___ mg PO DAILY Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry eyes Atorvastatin 40 mg PO QPM Furosemide 80 mg PO DAILY Insulin SC Sliding Scale Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing Levothyroxine Sodium 175 mcg PO DAILY Losartan Potassium 25 mg PO DAILY Omeprazole 20 mg PO DAILY Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN wheezing Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Cephalexin 500 mg PO Q6H Duration: 14 Days 3. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasms RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth q8 PRN Disp #*40 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously at bedtime Disp #*30 Syringe Refills:*0 6. Gabapentin 300 mg PO BID RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q4 PRN Disp #*40 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO DAILY 9. Senna 8.6 mg PO BID:PRN Constipation - First Line 10. Allopurinol ___ mg PO DAILY 11. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry eyes 12. Atorvastatin 40 mg PO QPM 13. Furosemide 80 mg PO DAILY 14. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 15. Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing 16. Levothyroxine Sodium 175 mcg PO DAILY 17. Losartan Potassium 25 mg PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN wheezing Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right open ankle fracture Discharge Condition: AVSS NAD, A&Ox3 RLE: Foot resting in short leg splint that is clean, dry, and intact. Fires exposed toes, sensation intact light touch and exposed toes, warm and well-perfused exposed Foley catheter in place Followup Instructions: ___ Radiology Report EXAMINATION: Right ankle radiographs, three views. INDICATION: Right ankle fracture status post reduction. COMPARISON: Earlier on the same day. FINDINGS: Right ankle has been reduced. Fractures again involve the distal fibula, the medial malleolus, and the anterior lip of the distal tibia. These fractures all show small residual displacements. Medial ankle mortise is mildly widened. Bony detail is partly obscured by overlying splinting material. IMPRESSION: Status post reduction. Radiology Report EXAMINATION: Q61R INDICATION: ___ year old woman with right ankle fracture// eval tight ankle fracture CT mid shin to foot. TECHNIQUE: ___ MD CT imaging was performed through the right lower extremity from the mid calf to the toes. Coronal and sagittal reformats were produced and reviewed. Additional reformats were performed on PACS for further evaluation. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 46.9 cm; CTDIvol = 11.8 mGy (Body) DLP = 554.6 mGy-cm. Total DLP (Body) = 555 mGy-cm. COMPARISON: Right ankle radiographs ___ FINDINGS: There is a trimalleolar right ankle fracture with a transverse fracture through the medial malleolus (10:2), minimally displaced posterior malleolus fracture (401:46) and a comminuted oblique fracture through the distal fibular diaphysis above the level of the syndesmosis (10:3). The ankle mortise is congruent on these nonstress views. There is an additional fracture along the anterolateral aspect of the tibial plafond and (10:4) at the expected site of attachment of the anterior tibiofibular ligament, highly suspicious for disruption of this ligament. Multiple small calcifications are seen in the expected location of the posterior talofibular ligament (2:112) as well as in the deltoid ligament (2:110) likely reflecting remote injuries. Evaluation of the soft tissue structures around the ankle is limited, no definite tendon entrapment seen. There is diffuse soft tissue swelling around the ankle but no definite tibiotalar joint effusion. There is a multipartite os navicularis a likely reflecting chronic enthesopathic changes at the posterior tibialis insertion (2: 119). Moderate vascular calcification. No additional fracture seen. IMPRESSION: 1. Trimalleolar ankle fracture, minimally displaced although imaging is performed in a cast. 2. Small bony fragments along the anterolateral aspect of the tibial plafond and highly suspicious for disruption of the anterior tibiofibular ligament. 3. Evidence of remote sprains of the posterior tibiofibular and deltoid ligaments. 4. Diffuse soft tissue swelling. 5. Extensive vascular calcification. Radiology Report EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT INDICATION: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT, fluoroscopic guidance for intraoperative internal fixation TECHNIQUE: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT COMPARISON: ___ FINDINGS: 6 intraoperative images were acquired without a radiologist present. Images show shows evidence of internal fixation of the tibia and fibula fracture. IMPRESSION: Intraoperative images were obtained during internal fixation of the tibial and fibular fractures. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CHF and hypotension// Rule out flash pulmonary edema IMPRESSION: No previous images. There are low lung volumes that accentuate the prominence of the transverse diameter of the heart. Relatively mild pulmonary vascular congestion. No evidence of acute focal consolidation. Intact midline sternal wires following apparent CABG procedure. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ DM2, CHF (2 pillow orthopnea, Lasix at home), CAD (s/p CABG in ___, CKD (baseline 1.6), fibromyalgia, GERD, Gout p/w open right ankle fracture s/p I D and open reduction internal fixation of anklefracture and subsequently closed reduction with propofol sedation. Was getting discharged today. Noted to have elevation in Cr and hypotension to SBP ___. Concern for sepsis. There was a concern for new onset Afib but EKG does not appear to be Afib.// evaluate interval change IMPRESSION: In comparison with the study ___, there are slightly improved lung volumes. Continued substantial enlargement of the cardiac silhouette with some increase in engorgement of indistinct pulmonary vessels consistent with elevated pulmonary venous pressure. The left hemidiaphragmatic contour is no longer seen, suggesting a combination of pleural fluid and volume loss in the left lower. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer Diagnosed with Oth fx upper and low end r fibula, init for opn fx type I/2, Fall same lev from slip/trip w/o strike against object, init temperature: 98.1 heartrate: 84.0 resprate: 16.0 o2sat: 100.0 sbp: 164.0 dbp: 86.0 level of pain: 8 level of acuity: 3.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing right lower extremity in splint MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add gabapentin, Flexeril, and as a last resort oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks URINARY STATUS: - Patient experienced difficulty voiding postoperatively. She was straight cathed multiple times with failure to void post straight cath. A foley was ultimately placed, with plans for a void trial at rehab in ___ days. Physical Therapy: Nonweightbearing right lower extremity in splint Treatments Frequency: WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Unless you are in a splint, incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If splinted, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Catheterization with drug eluting stent placement History of Present Illness: Mr. ___ is an ___ year old man with a PMHx s/f CAD, lung cancer, and prostate cancer who presented to his PCP's office with 2 months of worsening angina and shortness of breath. He states that for the last 2 months he has had worsening exertional non-pleuritic chest tightness. The pain worsens with activity, and improves with rest. It has been worsening in its duration, whereas previously the pain would improve in several minutes, over the last several days the pain has taken several hours to improve. He has not used nitroglycerin for the pain. . Mr. ___ also notes anorexia and dramatic weight loss of 60 lbs. over 60 days. Upon review of his flowsheets however, he has only lost 6 lbs over 60 days. He also espouses occassional "shaking in the face", as well as constipation. ROS is also positive for dysuria. . In the ED, initial VS were 96.7 47 142/67 16 99% RA. CXR was significant for left upper lung linear opacity and worsening of RLL opacity. Troponins were negative x 1. He was given levofloxacin, and 1L NS. . ROS: per HPI, denies fever, chills, night sweats, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, hematuria. Past Medical History: 1. Lung cancer - The patient is followed by Dr. ___ at the ___. He was treated on a study protocol and is now considered to be in remission. However, he may have a recurrence of his malignancy given his current symtpoms. 2. Weight loss - The patient has lost a significant amount of weight since his last clinic visit. 3. Lower extremity pain - Now resolved with daily streching exercises. 4. Type 2 diabetes mellitus - The patient's finger sticks have been running quite high. He will follow up with Dr. ___ in the next couple of weeks. 5. Depression - The patient feels that he is doing well in respect to his depression at this time. 6. Decreased hearing 7. Cataracts 8. Prostate cancer status post prostatectomy - followed by Dr. ___ 9. Memory concerns 10. Urinary incontinence 11. Falls 12. Gait instability 13. Diplopia 14. Groin infection - ___ 15. Full-thickness rotator cuff tear of his right shoulder PAST SURGICAL HISTORY: 1. Status post prostatectomy 2. Status post artificial urinary sphincter implantation 3. Status post cholecystectomy Social History: ___ Family History: Father with CAD and brain cancer, mother with AD Physical Exam: Upon Admission: VS - Temp ___ F, 116/51 BP , 49 HR , 18 R , 99 O2-sat % RA GENERAL - cachectic man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . VS - 98.6 104/49-135/45 ___ 18 98%RA GENERAL - cachectic man in NAD, comfortable, appropriate NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) Pertinent Results: ADMISSION LABS ___ 10:40AM BLOOD WBC-5.6 RBC-4.23* Hgb-12.7* Hct-38.6* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 Plt ___ ___ 10:40AM BLOOD Neuts-78.2* Lymphs-16.4* Monos-3.7 Eos-1.3 Baso-0.3 ___ 04:10PM BLOOD ___ PTT-82.6* ___ ___ 10:40AM BLOOD Glucose-124* UreaN-23* Creat-1.1 Na-142 K-4.9 Cl-108 HCO3-29 AnGap-10 ___ 10:40AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.3 . DISCHARGE LABS ___ 06:50AM BLOOD WBC-6.2 RBC-3.70* Hgb-10.8* Hct-34.0* MCV-92 MCH-29.3 MCHC-31.9 RDW-13.7 Plt ___ ___ 06:40AM BLOOD Neuts-77.5* Lymphs-15.5* Monos-4.3 Eos-2.6 Baso-0.1 ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-90 UreaN-18 Creat-1.1 Na-143 K-4.3 Cl-110* HCO3-29 AnGap-8 ___ 12:50PM BLOOD CK(CPK)-28* ___ 12:50PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:40AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0 Cholest-95 ___ 06:40AM BLOOD Triglyc-124 HDL-38 CHOL/HD-2.5 LDLcalc-32 . CARDIAC ENZYMES ___ 10:40AM BLOOD CK-MB-2 ___ 10:40AM BLOOD cTropnT-<0.01 ___ 05:17PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:47PM BLOOD CK-MB-2 ___ 06:40AM BLOOD CK-MB-2 ___ 12:50PM BLOOD CK-MB-2 cTropnT-<0.01 . PERTINENT LABS ___ 08:45AM BLOOD HIV Ab-NEGATIVE ___ 08:45AM BLOOD Lithium-0.9 ___ 10:40AM BLOOD Lactate-1.1 ___ 08:45AM BLOOD Lipase-35 ___ 08:45AM BLOOD Amylase-102* . PERTINENT STUDIES Chest X ray: ___ IMPRESSION: 1. Left upper lung linear opacity may represent lingering/residual pneumonia or an area of bronchiectatic inflammation - reimaging after treatment may be considered. 2. Increase in right lower lung nodule size; reimaging with nipple markers may be considered. . Stress Test: ___ IMPRESSION: Anginal type symptoms with ischemic ECG changes at a fair functional capacity. Nuclear report sent separately. . Nuclear Perfusion Scan: ___ IMPRESSION: Normal myocardial perfusion study. Normal left ventricular size and function. Previously noted reversible defect has improved. . Cath: ___ COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. The ___ had no angiographically significant coronary artery disease. The LAD had an 80% in-stent restenosis within the mid LAD, and a 50% stenosis in the distal LAD. The very distal LCX had an 80% stenosis. The RCA was small calibur and diffusely diseased with a 90% ostial stenosis and an 80% proximal stenosis. 2. Limited resting hemodynamics revealed mild systemic arterial hypertension with a central aortic blood pressure of 142/51. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. In-stent restenosis of the mid LAD 3. Mild systemic arterial hypertension. . TTE ___ The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are not well seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Medications on Admission: aspirin 325 mg daily, Plavix 75 mg daily metoprolol succinate 25 mg daily, isosorbide mononitrate 30 mg daily, pravastatin 40 mg daily, lithium 300 mg daily, omeprazole 40 mg daily, calcium 600-400 BID Ferrous Sulfate 325mg daily Cyanocobalamin 1000 mcg daily loratidine 10mg daily multivitamin daily Senna/Colace Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day) as needed for constipation. 13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 14. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: ___ MLs PO QID (4 times a day) as needed for heartburn. 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Coronary Artery Disease Depression Prior Lung Cancer, in remission Prior Prostate Cancer s/p prostectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report HISTORY: ___ male with chest tightness. STUDY: Portable AP upright chest radiograph. COMPARISON: ___. FINDINGS: The cardiomediastinal and hilar contours are normal. The lungs show an area of linear density in the left upper lung which correlates to an area of consolidation on ___ CT. The nodular density projecting over the left hemidiaphragm likely represents a nipple shadow and was seen on prior exam; the nodular density over the right hemidiaphragm correlates to a nodule seen on ___ CT and has increased in size. There is no pleural effusion or pneumothorax. IMPRESSION: 1. Left upper lung linear opacity may represent lingering/residual pneumonia or an area of bronchiectatic inflammation - reimaging after treatment may be considered. 2. Increase in right lower lung nodule size; reimaging with nipple markers may be considered. Findings were posted to the Critical Results Dashboard at 15:11 on ___ by ___ Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST TIGHTNESS Diagnosed with CHEST PAIN NOS, WEIGHT LOSS, ABNORMAL, PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, CAD UNSPEC VESSEL, NATIVE OR GRAFT temperature: 96.7 heartrate: 47.0 resprate: 16.0 o2sat: 99.0 sbp: 142.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted with unstable angina and were found to have restenosis (or blockage) of the stent in one of the main arteries supplying your heart. Another stent was placed. You complained of persistent mild chest pains after the procedure but these were felt to be related to indigestion as they resolved with Maalox. You were sent to rehab to help you build up your strength. . The following medication changes have been made: NO MEDICATION CHANGES . You should NOT STOP TAKING YOUR PLAVIX OR ASA UNLESS otherwise instructed by your cardiologist

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Valium / Biaxin / Levaquin / Ace Inhibitors / Bactrim / Ciprofloxacin / Vicodin ES / metoprolol / Dilaudid / Macrobid / tramadol / Zetia Attending: ___ ___ Complaint: sore throat Major Surgical or Invasive Procedure: Bedside ENT scope ___ History of Present Illness: Ms. ___ is a ___ woman with a history of hypertension, paroxysmal atrial fibrillation (on home anticoagulation), pacemaker for tachybrady syndrome, and peripheral vascular disease, who is presenting with fever and sore throat for three days. Patient first noted an "ache" in her mouth and right side of her neck 3 days ago. She was also having subjective fevers and difficulty swallowing. No difficulty breathing. She first presented to her doctor yesterday, who prescribed her an unknown antibiotic. However, she developed increased neck swelling overnight, and so presented to the ED. In the ED, initial vitals: 100.2 97 ___ 98% RA - Exam notable for submental edema and tenderness with induration. - Labs were notable for a white count of 16.9, normal lactate, Cr 1.1, INR 1.4. - A CT neck w/ contrast was done, which showed sialadenitis involving the right ___ duct and submandibular gland with reactive lymphadenopathy and substantial adjacent inflammation extending into the right sublingual space, parapharyngeal space, and carotid space without an organized fluid collection identified. Inflammatory change extending into the right sublingual space raises the possibility of Ludwig's angina. - Patient was given unasyn 3g, dexamethasone 10mg, and 1L NS - ENT was consulted, and did a bedside scope showing some mild airway edema. Patient was admitted to the ICU for airway monitoring. On arrival to the MICU, patient feeling much improved and would like to try eating something soft. Past Medical History: - HTN - Autonomic dysfunction - Overweight - Sleep apnea - Anemia - CRI on HCTZ, now improved off HCTZ - Post-herpetic neuralgia treated with gabapentin - PVD with right toe amputations ___ - Atrial fibrillation - GERD - Osteoporosis - Admitted ___ to ___ for fever ? due to virus - L4 compression fracture ___ from dizziness (HCTZ induced) and fall - Palpitations. Resolved on atenolol, which has now been stopped due to fatigue; infrequent palpitations now. - Low vitamin D level. Continue vitamin D ___ IU daily. - Elevated alkaline phosphatase thought due to vertebral fracture. - Adhesive capsulitis secondary to seat belt syndrome PSH: - ___ amputations of right toes 2,3 & 4 and left great toe - Left fem-pop bypass and first toe amp on ___ - ___ - right SFA to BK popliteal bypass with PTFE - ___ common femoral artery endarterectomy with vein patch angioplasty - Total abdominal hysterectomy/BSO ___ - s/p appendectomy - s/p tonsillectomy and adenectomy Social History: ___ Family History: mother - hypertension father - pancreatic cancer brother - CAD Physical ___: ADMISSION EXAM: Vitals: reviewed in metavision Gen: Patient speaking in full sentences HEENT: Significant LAD on right side of neck, nonpainful to palpation. Mouth with swelling of right side of tongue. Able to express purulent materal from ___ duct. NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, systolic ejection murmur LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no edema. Left and right toe amputations PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact Pertinent Results: =============== ADMISSION LABS =============== ___ 10:04AM BLOOD WBC-16.9*# RBC-4.19 Hgb-10.4* Hct-34.1 MCV-81* MCH-24.8* MCHC-30.5* RDW-14.9 RDWSD-43.8 Plt ___ ___ 10:04AM BLOOD Neuts-83.9* Lymphs-5.9* Monos-9.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-14.14*# AbsLymp-1.00* AbsMono-1.51* AbsEos-0.01* AbsBaso-0.05 ___ 10:04AM BLOOD Plt ___ ___ 10:04AM BLOOD Glucose-108* UreaN-19 Creat-1.1 Na-137 K-4.1 Cl-100 HCO3-21* AnGap-20 ___ 05:02AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 ___ 10:12AM BLOOD Lactate-1.0 ============ MICROBIOLOGY ============ ___ 6:15 pm ABSCESS Source: Oral abscess. Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): =============== IMAGING =============== CT Neck w/ Contrast ___: 1. Sialadenitis involving the right ___ duct and submandibular gland with reactive lymphadenopathy and substantial adjacent inflammation extending into the right sublingual space, parapharyngeal space (including right infratemporal fossa), and carotid space without an organized fluid collection identified. Inflammatory change extending into the right sublingual space raises the possibility of Ludwig's angina. No definite involvement of the retropharyngeal space. 2. No definite enhancing confluent fluid collection. CXR ___: Right sided PICC tip in the mid SVC. No pneumothorax. =============== DISCHARGE LABS =============== Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Diltiazem Extended-Release 180 mg PO DAILY 2. Ketoconazole 2% 1 Appl TP DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY ___ MD to order daily dose PO DAILY16 6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 7. Vitamin D ___ UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #*12 Tablet Refills:*0 2. Warfarin 3 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily as instructed Disp #*18 Tablet Refills:*0 3. Warfarin 3 mg PO DAILY16 4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 5. Diltiazem Extended-Release 180 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ketoconazole 2% 1 Appl TP DAILY 8. Losartan Potassium 25 mg PO DAILY 9. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY 10. Senna 8.6 mg PO BID:PRN constipation 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Sialadenitis and sialolith Secondary Diagnosis: - Atrial Fibrillation - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ with sore throat, febrile, and difficulty tolerating secretions. TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 31.9 cm; CTDIvol = 12.7 mGy (Body) DLP = 405.2 mGy-cm. 2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8 mGy-cm. 3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8 mGy-cm. Total DLP (Body) = 423 mGy-cm. COMPARISON: ___ cervical spine CT, ___ noncontrast neck CT FINDINGS: Dental amalgam artifact limits evaluation at the level of dentition. There are calcifications within the right ___ duct measuring 4 and 5 mm (02:46) with proximal dilatation of ___ duct up to 7 mm (02:45). There is substantial adjacent fat stranding extending into the right sublingual space, parapharyngeal space (including right infratemporal fossa), and carotid space with mass effect on the ipsilateral aerodigestive tract. There is a small amount of fluid in the piriform sinuses with effacement of the right piriform sinus, but the aerodigestive tract is otherwise patent. There is no definite extension of inflammatory change into the retropharyngeal space. There is asymmetric heterogeneous enhancement of the ipsilateral submandibular gland. The remaining salivary glands enhance normally and are without mass or adjacent fat stranding. A right level 1B lymph node measures 1.1 cm (02:51), a right level IIa lymph node measures 1.2 cm (02:45), and a right level 4 lymph node measures 1.8 cm (02:57), likely reactive. The thyroid gland appears normal. The neck vessels are patent. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. Limited evaluation the paranasal sinuses reveals partial opacification of the right sphenoid sinus and ethmoid air cells. IMPRESSION: 1. Sialadenitis involving the right ___ duct and submandibular gland with reactive lymphadenopathy and substantial adjacent inflammation extending into the right sublingual space, parapharyngeal space (including right infratemporal fossa), and carotid space without an organized fluid collection identified. Inflammatory change extending into the right sublingual space raises the possibility of Ludwig's angina. No definite involvement of the retropharyngeal space. 2. No definite enhancing confluent fluid collection. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with PICC placement. TECHNIQUE: Portable AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: A right-sided PICC tip terminates in the mid SVC. No pneumothorax. Left-sided pacer device is noted with leads terminating in the right atrium and right ventricle. Mild cardiomegaly is re- demonstrated. The aorta is diffusely calcified. The mediastinal and hilar contours are unchanged. Pulmonary vasculature is not engorged. Streaky opacities in the lung bases likely reflect areas of atelectasis. No pleural effusion or pneumothorax is present. Osseous structures are diffusely demineralized. IMPRESSION: Right sided PICC tip in the mid SVC. No pneumothorax. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Sore throat, ILI Diagnosed with Sialoadenitis, unspecified temperature: 100.2 heartrate: 97.0 resprate: 20.0 o2sat: 98.0 sbp: 201.0 dbp: 93.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted for swelling in your neck and found to have an infected and obstructed salivary gland. You were seen by the ear nose and throat doctors who agreed that antibiotics and aggressive drainage was the best treatment option. We gave you antibiotics and your symptoms improved. You will need to complete a course of oral antibiotics as an outpatient and follow up with the ear nose and throat doctors. It was a pleasure caring for you in the hospital. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right hip pain Major Surgical or Invasive Procedure: Open reduction and internal fixation of right intertrochanteric femur fracture with TFN- ___ History of Present Illness: ___ otherwise fairly healthy presenting after fall onto right side today. She was walking her dog when there was a sharp tug on the leash causing her to lose her balance and land on the right side. Immediate onset of pain and inability to bear weight. No numbness, tingling, no head strike. The patient denies LOC, premonitory symptoms and ROS is otherwise at baseline. Past Medical History: HTN Benign breast biopsy lichen sclerosus osteoporosis basal cell cancer retinal detachment L1 vertebral fractures status post MVA in ___ Palpitations Social History: She is a nonsmoker. Does not drink alcohol or abuse drugs. She works as a ___. She is in a long-term relationship. She has 2 daughters. Physical Exam: Exam on Admission: AVSS, AA0x3 Boarded and collared, moving all extremities, responding appropriately MSK: RUE - No pain with ROM of the shoulder, elbow, or wrist, NVI. LUE - No pain with ROM of the shoulder or elbow, some pain with ROM of the wrist and digits, TTP about the wrist. RLE - Significant swelling of the ankle, skin intact. TTP. No obvious deformity, NVI. No pain with ROM of the hip or knee. LLE - No pain with ROM of the hip, knee, or ankle. Exam on Discharge: AVSS NAD RLE: Incision with staples intact, no erythema or drainage Firing ___, FHL, TA, ___ Sensation intact SP, DP, Sa, ___, T Warm and well-perfused Pertinent Results: ___ 07:20AM BLOOD WBC-6.8 RBC-2.78* Hgb-8.6* Hct-25.5* MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt ___ Medications on Admission: METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg tablet,extended release 24 hr. 1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 1250 mg PO TID 4. Diazepam 5 mg PO Q6H:PRN muscle spasm 5. Docusate Sodium 100 mg PO BID 6. Heparin 5000 UNIT SC TID Duration: 14 Days 7. Metoprolol Succinate XL 25 mg PO DAILY 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*80 Tablet Refills:*0 9. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R. INDICATION: ORIF. TECHNIQUE: Several intraoperative fluoroscopic spot images were acquired of the right hip, without a radiologist present. COMPARISON: Hip radiographs from ___. FINDINGS: Intraoperative fluoroscopic spot images of the right hip demonstrate ORIF of a comminuted intertrochanteric fracture. There is no evidence of hardware complication. For additional details, please see the operative report in the ___ medical record. The total fluoroscopic time was 52.6 seconds. IMPRESSION: As above. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with INTERTROCHANTERIC FX-CL, OTHER FALL, ACTIVITIES INVOLVING WALKING AN ANIMAL, HYPERTENSION NOS temperature: 98.5 heartrate: 74.0 resprate: 18.0 o2sat: 99.0 sbp: 137.0 dbp: 68.0 level of pain: 6 level of acuity: 3.0

Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take heparin three times daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out in 2 weeks at rehab. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Weight-bearing as tolerated Physical Therapy: Weight-bearing as tolerated in right lower extremity. Treatments Frequency: Please assess wound daily for erythema, drainage, or other signs of infection. Please remove stables ___ days after the operation. Please provide physical therapy. Please provide anticoagulation for DVT prophylaxis for 2 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Augmentin / morphine / Percocet Attending: ___. Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ F w/ hx of COPD, DM and hypothyroidism who presents with 1 day of dyspnea and hemoptysis. Patient reported having blood tinged sputum with increasing amounts of blood since yesterday (___). No prior hemoptysis or ongoing cough. She also had fatigue and decreased appetite for the past 2 weeks. Patient denied chest pain or palpitations. She denied any lower extremity pain or swelling, history of blood clots, recent travel, recent surgeries, incarceration. Approximately 3 weeks ago, patient had a complicated nosebleed s/p surgery at ___. There was no prior episode of epistaxis, and it has not recurred. One week later, she was admitted to ___ from ___ for weakness, found to have anemia (hct 23.9 from baseline of 36) and CT chest notable for bronchiectasis and diffuse lymphadenopathy. Past Medical History: DM COPD Hypothyroidism History of tobacco use Social History: ___ Family History: DM, aplastic anemia, CAD. No family history of lupus, vasculitis, RA. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: Temp 98.6, BP 148/69, HR 98, RR 18, O2 sat 94 on 3L NC. GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric. NECK: No JVD. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, ___ to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. ___ intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 519) Temp: 98.1 (Tm 98.3), BP: 157/74 (___), HR: 79 (___), RR: 18, O2 sat: 94% (___), O2 delivery: Ra (2L NC -3 LNC), Wt: 176.37 lb/80 kg GENERAL: Pleasant woman, comfortable breathing on RA, sitting up in chair, speaking in full sentences without breaks or coughs HEENT: Anicteric, EOMI, MMM without OP lesions CARDIAC: RRR. LUNG: Breathing comfortably, in no respiratory distress, mild wheezing diffusely in posterior lung fields with improved breath sounds, no cough; air movement throughout ABD: Soft, ___, positive bowel sounds EXT: Warm, well perfused, no lower extremity edema/swelling. NEURO: A&Ox3, no focal neurological deficits, linear thought SKIN: No significant rashes. Pertinent Results: INITIAL RESULTS: ============= ___ 02:30PM URINE ___ ___ 02:30PM URINE ___ ___ 02:30PM URINE ___ ___ ___ 02:30PM URINE ___ ___ ___ ___ 02:30PM URINE ___ SP ___ ___ 02:30PM URINE ___ ___ 02:30PM URINE ___ ___ 02:40PM RET ___ ABS ___ ___ 02:40PM ___ ___ 02:40PM PLT ___ PLT ___ ___ 02:40PM ___ ___ ___ 02:40PM ___ ___ REVI ___ 02:40PM ___ ___ IM ___ ___ ___ 02:40PM ___ ___ ___ 02:40PM ___ ___ 02:40PM cTropnT-<0.01 ___ ___ 02:40PM LD(LDH)-252* TOT ___ DIR BILI-<0.2 INDIR ___ ___ 02:40PM ___ this ___ 02:40PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 02:43PM ___ ___ 02:43PM ___ TOTAL ___ BASE ___ TOP ___ 09:25PM ___ ___ 09:25PM ___ ___ 09:25PM ___ ___ 09:25PM cTropnT-<0.01 IMAGES: ====== ___ CHEST PA & LAT IMPRESSION: Abnormal increased parenchymal opacification of the right upper and middle lobes. Main differential considerations include multifocal infection and/or hemorrhage. ___ CT CHEST W/O CONTRAST IMPRESSION: 1. Extensive centrilobular ___ opacities and consolidations in both lungs, likely represent multifocal infection and/or alveolar hemorrhage. Lymphatic involvement of the lungs is considered less likely. 2. Extensive lymphadenopathy throughout the chest and imaged upper abdomen is consistent with history of ___ lymphoma. 3. Mild fluid overload with small right pleural effusion and small pericardial effusion. 4. 1.7 x 2.2 cm right adrenal adenoma. 5. 1.4 cm right posterior hepatic lobe hypodensity, potentially a cyst or hemangioma, but incompletely characterized. Comparison with prior imaging is suggested, and if none available, an ultrasound can be obtained for further assessment. ___ BILAT LOWER EXT VEINS IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Enlarged bilateral inguinal lymph nodes compatible with known history of lymphoma. ___ RENAL US IMPRESSION: 1. Normal renal ultrasound. No evidence of masses, renal calculi or hydronephrosis.. 2. Small bilateral pleural effusions, right greater than left. ___ CHEST PORTABLE AP IMPRESSION: 1. Significant worsening of known pulmonary hemorrhage. Superimposed infection cannot be excluded on the basis of this examination. 2. Small left pleural effusion is likely. ___ TTE IMPRESSION: Normal left ventricular wall thickness and biventricular cavity sizes and regional/global biventricular systolic function. Moderate pulmonary hypertension. The patient has evidence of high output syndrome (e.g. anemia, thyrotoxicosis, thiamine deficiency, peripheral shunt, etc.). ___ CXR Overall improvement of bilateral diffuse ___ opacities when compared to prior studies, with slightly increased opacity in right upper lobe which could represent continued bleeding. Left upper extremity inserted PICC line with the tip at the cavoatrial junction. There is no pleural effusion or pneumothorax PATHOLOGY: ========== ___ MPO ANTIBODIES >8.0 U ___ PR3 ANTIBODIES <0.2 U DISCHARGE LABS: =============== ___ 12:00AM BLOOD ___ ___ Plt ___ ___ 12:00AM BLOOD ___ ___ Im ___ ___ ___ 12:00AM BLOOD ___ ___ ___ 12:00AM BLOOD ___ LD(LDH)-323* ___ ___ ___ 12:00AM BLOOD ___ OTHER PERTINENT LABS ==================== ___ 10:55AM BLOOD ___ ___ 02:40PM BLOOD cTropnT-<0.01 ___ ___ 06:13AM BLOOD ___ ___ 02:40PM BLOOD ___ ___ 04:41AM BLOOD ___ ___ 11:49AM BLOOD ___ ___ 04:34AM BLOOD HAV ___ ___ 10:55AM BLOOD ___ ___ 09:25PM BLOOD ___ ___ 07:20PM BLOOD ___ ___ 09:25PM BLOOD ___ ___ 04:41AM BLOOD ___ ___ 04:00PM BLOOD ___ SPECIFI ___ ___ Fr ___ ___ 09:25PM BLOOD ___ ___ 10:55AM BLOOD HIV ___ ___ 10:55AM BLOOD HCV ___ ___ 05:11AM BLOOD ___ ___ Base XS--1 ___ TOP ___ 02:43PM BLOOD ___ ___ Base ___ TOP ___ 19:20 CRYOGLOBULIN Test Result Reference Range/Units CRYOGLOBULIN, QL NEGATIVE CRYOGLOBULIN, QL NEGATIVE ___ 09:49AM BLOOD ___ Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD PLUS, INDETERMINATE A NEGATIVE 4T, INCUBATED ___ 09:25PM BLOOD ___ Test Result Reference Range/Units GLOMERULAR BASEMENT MEMBRANE <1.0 AI ANTIBODY (IGG) ___ 09:25PM BLOOD SED ___ Test Result Reference Range/Units SED RATE BY MODIFIED 79 H < OR = 30 mm/h ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. ___ Diskus (250/50) 1 INH IH BID 3. FLUoxetine 40 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO DAILY 5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4h:PRN 6. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Atovaquone Suspension 1500 mg PO DAILY PJP prophylaxis RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0 3. Azithromycin 250 mg PO/NG 3X/WEEK (___) RX *azithromycin 250 mg 1 tablet(s) by mouth ___, ___ Disp #*20 Tablet Refills:*0 4. Calcium Carbonate 1000 mg PO DINNER Do not take with thyroid medication. RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 5. Ensure (food supplemt, ___ 1 unit oral DAILY:PRN RX *food supplemt, ___ [Ensure] 1 unit by mouth daily prn Refills:*0 6. NPH 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin RX *blood sugar diagnostic [OneTouch Ultra Blue Test Strip] Please use with the OneTouch meter. four times a day Disp #*120 Strip Refills:*0 RX ___ meter [OneTouch Ultra2 Meter] Please check your blood glucose at breakfast, lunch, dinner, and bedtime. Disp #*1 Kit Refills:*0 RX *insulin lispro 100 unit/mL AS DIR Up to 6 Units QID per sliding scale Disp #*5 Syringe Refills:*0 RX *lancets [OneTouch Delica Lancets] 33 gauge Please use OneTouch Ultra 2. four times a day Disp #*120 Each Refills:*0 RX *insulin NPH isoph ___ human [Humulin N NPH Insulin KwikPen] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; Disp #*2 Syringe Refills:*0 7. PredniSONE 60 mg PO DAILY vasculitis Continue until your rheumatology appointment. 8. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 50 mcg (2,000 unit) 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 9. FLUoxetine 40 mg PO DAILY 10. ___ Diskus (250/50) 1 INH IH BID 11. Levothyroxine Sodium 112 mcg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4h:PRN 14. HELD- MetFORMIN (Glucophage) 500 mg PO DAILY This medication was held. Do not restart MetFORMIN (Glucophage) until instructed by your doctor. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================ ___ vasculitis Mantle cell lymphoma SECONDARY DIAGNOSIS =================== Acute hypoxic respiratory failure Paroxysmal atrial fibrillation ___ ventricular tachycardia Chronic obstructive pulmonary disease Type II Diabetes Mellitus, insulin dependent Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with hemoptysis// PNA TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: The cardiomediastinal silhouettes are within normal limits. There is asymmetric increased parenchymal opacification of the right upper and middle lobes. Lesser patchy opacities also affect the left upper lobe. There is no pulmonary edema or pneumothorax. Trace bilateral pleural effusions are noted. No acute osseous abnormality. IMPRESSION: Abnormal increased parenchymal opacification of the right upper and middle lobes. Main differential considerations include multifocal infection and/or hemorrhage. RECOMMENDATION(S): Follow-up imaging is appropriate depending on clinical circumstances to show resolution of opacities within about 8 weeks. Otherwise, chest CT should be considered. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: History: ___ with hemoptysis// hemorrhage vs infection TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. Heart size is normal. Coronary artery calcifications are mild. Main pulmonary artery diameter is within normal limits. There is a small pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: There is extensive, diffuse supraclavicular, bilateral axillary, mediastinal and bilateral hilar lymphadenopathy, consistent with history of B-cell lymphoma. PLEURAL SPACES: There is a small dependent right pleural effusion. No pneumothorax. LUNGS/AIRWAYS: There are extensive ground-glass opacities and consolidations in both lungs in a somewhat centrilobular distribution, associated with interlobular septal thickening. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: A small, coarse calcification is seen in the left thyroid lobe. ABDOMEN: There is a small hiatus hernia. A 1.4 cm hypodensity is seen in the posterior right hepatic lobe (4:218), potentially a cyst or hemangioma, incompletely characterized. Multiple prominent gastrohepatic and periaortic lymph nodes are seen. 1.7 x 2.2 cm right adrenal nodule is compatible with an adenoma. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Extensive centrilobular ground-glass opacities and consolidations in both lungs, likely represent multifocal infection and/or alveolar hemorrhage. Lymphatic involvement of the lungs is considered less likely. 2. Extensive lymphadenopathy throughout the chest and imaged upper abdomen is consistent with history of B-cell lymphoma. 3. Mild fluid overload with small right pleural effusion and small pericardial effusion. 4. 1.7 x 2.2 cm right adrenal adenoma. 5. 1.4 cm right posterior hepatic lobe hypodensity, potentially a cyst or hemangioma, but incompletely characterized. Comparison with prior imaging is suggested, and if none available, an ultrasound can be obtained for further assessment. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman presenting with shortness of breath with concern for DVT/PE.// ___ year old woman with concern for DVT/PE. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Large bilateral inguinal lymph nodes are compatible with known history of lymphoma. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Enlarged bilateral inguinal lymph nodes compatible with known history of lymphoma. Radiology Report EXAMINATION: RENAL U.S. INDICATION: Hemoptysis, dyspnea; rising creatinine// Is there renal involvement of malignancy? TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: Left kidney: The bladder is moderately well distended and normal in appearance. Small bilateral pleural effusions, right greater than left. A incidentally noted 1.1 cm simple hepatic cyst is noted in the right lobe of the liver. IMPRESSION: 1. Normal renal ultrasound. No evidence of masses, renal calculi or hydronephrosis.. 2. Small bilateral pleural effusions, right greater than left. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hx lung hemorrhage and tachypnea// ?intraparenchymal hemorrhage, ?worsening lung process TECHNIQUE: Portable chest AP. COMPARISON: Chest CT dated ___ FINDINGS: Low lung volumes. Cardiac silhouette is mildly enlarged. There has been increased number of ill-defined opacities throughout both lungs suggesting worsening of the known pulmonary hemorrhage. However, a superimposed infection cannot be excluded. Small left pleural effusion is likely. No pneumothorax. IMPRESSION: 1. Significant worsening of known pulmonary hemorrhage. Superimposed infection cannot be excluded on the basis of this examination. 2. Small left pleural effusion is likely. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with new L PICC// L DL Power PICC 45cm ___ ___ Contact name: ___: ___ TECHNIQUE: Portable chest AP. COMPARISON: Chest radiograph from ___ and ___. FINDINGS: Tip of left upper extremity PICC projects over the cavoatrial junction. Overall similar aeration with redemonstration of bilateral airspace opacities, similar to the prior study. Trace left pleural effusion. No pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: 1. Tip of left PICC projects over the cavoatrial junction. 2. Similar radiation with redemonstration of bilateral airspace opacities, similar to the prior study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pANCA vasculitis, DAH, mantle cell lymphoma with continued dyspnea on 4LNC/50% shovel mask// ?progression of DAH TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. FINDINGS: Overall improvement of bilateral diffuse ill-defined opacities when compared to prior studies, with slightly increased opacity in right upper lobe which could represent continued bleeding. Left upper extremity inserted PICC line with the tip at the cavoatrial junction. There is no pleural effusion or pneumothorax IMPRESSION: Improvement of bilateral diffuse opacities. Radiology Report INDICATION: ___ year old woman with mantle cell lymphoma, anca+ vasculitis needs port for continued treatment// Double lumen chest port placement leave both accessed for ___ aware COMPARISON: Chest x-ray dated ___. TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. Dr. ___ supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1 g of Ancef CONTRAST: None FLUOROSCOPY TIME AND DOSE: 0.06 minutes, 2.4 mGy PROCEDURE 1. Right internal jugular approach chest double lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ prolene sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The port was accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Hemoptysis Diagnosed with Hemoptysis temperature: 98.6 heartrate: 88.0 resprate: 18.0 o2sat: 95.0 sbp: 159.0 dbp: 62.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, It was a privilege to care for ___ at ___. WHY WAS I IN THE HOSPITAL? ___ had trouble breathing and were coughing up blood. WHAT HAPPENED TO ME IN THE HOSPITAL? - We took pictures of your lungs, which suggested that they had blood in them. This was due to a disease called "vasculitis," which means the blood vessels in your lungs were irritated and inflamed. We treated ___ with ___ steroids and other immunosuppressive drugs, as below. - Your biopsy results returned while ___ were in the hospital, and ___ were found to have a type of cancer called "mantle cell lymphoma." We started treatment for your cancer. These immunosuppressive drugs also helped your vasculitis. We also placed a port on your chest to better deliver the drugs. - Throughout your stay, ___ met with our kidney, lung, and rheumatology doctors, who helped us manage your conditions. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? Continue to take all your medicines and keep your appointments. ___ will be seen by the oncology and diabetes team this upcoming week. - Continue taking prednisone 80 mg daily until ___ and then decrease to 60mg daily. ___ will continue this dose until instructed to decrease by a physician - ___ should follow up in the ___ clinic with Dr. ___ ___ ongoing management of your cancer - Monitor your blood glucose at home. Please call your primary care provider or Dr. ___ blood glucose is <70 or >400. We wish ___ the best. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: Anterior odontoid screw fixation History of Present Illness: HPI: ___ s/p mechanical fall, fell off of a 3 foot platform while painting in his house and struck his forehead. Occurred 2 days ago. Has had persistent neck pain since that time. PMH: Necrotizing pancreatitis with sepsis ___, insulin-dependent diabetes MED: Insulin NovoLog, insulin Lantus, nortriptyline, Ativan, lisinopril, Prilosec, MiraLax, multivitamins, vitamin C ALL: NKDA PE: Vitals: 98 103 159/91 20 99% General: NAD Mental Status: AAOx3 Cranial nerves II-XII grossly intact. Sensory: UEC5C6C7C8T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) Rintact intact intact intact intact Lintact intact intact intact intact T2-L1 (Trunk) intact ___ L2 L3 L4 L5S1S2 (Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) Rintactintactintactintact intactintact Lintact intactintactintact intactintact Motor: UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1) R 5 5 5 5 ___ L 5 5 5 5 ___ ___ Flex(L1)Add(L2) ___ R ___ 5 5 5 5 L 5 5 5 5 5 5 5 Reflexes Bic(C4-5)BR(C5-6)Tri(C6-7)Pat(L3-4)Ach(L5-S1) R 1 1 1 1 1 L 1 1 1 1 1 Estimated Level of Cooperation: good Estimated Reliability of Exam: good LABS: IMAGING: CT C-spine wet read: Type II dens fracture is displaced anteriorly by 4 mm. Complete fracture through the anterior arch of C1, and bilateral posterior arches ___ burst fracture). Moderate to severe multi-level DJD. IMPRESSION & RECOMMENDATIONS: ___ s/p fall, with dens fracture and C1 arch fratures, neurologically intact. We will take to OR today vs. tomorrow for ORIF of dens. Discussed surgery, benefits, risks, alternatives at length with patient and wife and obtained informed consent Past Medical History: see HPI Social History: ___ Family History: see HPI Physical Exam: see HPI Pertinent Results: ___ 03:35PM GLUCOSE-209* UREA N-22* CREAT-1.2 SODIUM-134 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16 ___ 03:35PM estGFR-Using this ___ 03:35PM CALCIUM-10.7* PHOSPHATE-3.3 MAGNESIUM-1.9 ___ 03:35PM WBC-8.7 RBC-4.92 HGB-15.8 HCT-48.8 MCV-99* MCH-32.0 MCHC-32.3 RDW-13.2 ___ 03:35PM PLT COUNT-263 ___ 03:35PM ___ PTT-30.9 ___ Medications on Admission: Insulin NovoLog sliding scale, insulin Lantus 28 units QHS, nortriptyline 50 TID, Ativan 1 BID, lisinopril 5 daily, Prilosec 40 daily, multivitamins, vitamin C 1000 daily Discharge Medications: 1. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ascorbic acid ___ mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain/fever. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day) as needed for constipation. 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. oxycodone 5 mg Tablet Sig: 1 to 3 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 11. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal BID (2 times a day) for 4 days. Disp:*1 bottle* Refills:*0* 12. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 13. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Type 2 Dens fracture. Undisplaced ___ fracture Frontal bone fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man status post fall, landing on head, presenting with neck pain, dizziness, persistent cervical pain; evaluate for bleed. TECHNIQUE: MDCT data were acquired through the head without intravenous contrast. Images were reconstructed using bone and soft tissue kernels and displayed in multiple planes. FINDINGS: There is a non-displaced fracture through the midline of the frontal bone (3:36-41). The fracture extends into both frontal air cells, where there are slight cortical step-offs (3:22); there is also involvement of the right paramedian "inner table" of the left frontal air cell, though there is no pneumocephalus at this site or elsewhere. There is blood and air filling the frontal sinuses and extending into the left anterior ethmoid air cells. There is hyperdense fluid layering and air-fluid levels in both maxillary air cells as well as air mixed in the right. The density suggests that this is blood. No orbital or other fracture is identified as the lead point. Hyperdense fluid also layers mixed with air in both sphenoid sinuses. There is no large subgaleal or other superficial hematoma. IMPRESSION: 1. No acute intracranial process. 2. Non-displaced midline frontal bone fracture with blood in the frontal, maxillary and sphenoid sinuses. A maxillofacial CT has been suggested for further evaluation of these and any additional facial fractures. NOTE ADDED IN ATTENDING REVIEW: There is no intra- or extra-axial hemorrhage or evidence of cerebral edema. No pneumocephalus is seen. Radiology Report INDICATION: ___ man status post fall from ___ steps, landing on head, now with persistent neck pain. FINDINGS: A type II dens fracture is displaced anteriorly, approximately 4 mm. There is ___ burst-type fracture of C1. There are fractures of the anterior arch and bilateral posterior arches of C1 (2:15). The remainder of the cervical spine is well aligned. There are no additional cervical spine fractures. Degenerative changes are mild to moderate. There is severe loss of disc height at C4-C5 accompanied by left-sided facet fusion at this level. Mild multilevel posterior disc osteophyte complexes do not cause more than mild spinal canal narrowing at any level. There is mild prevertebral soft tissue swelling at the C1 level. Otherwise, there is no pre- or para-vertebral soft tissue swelling. The airway is patent. The visualized lung apices are clear. IMPRESSION: 1. Displaced type II fracture of the odontoid process, with 4 mm anterior displacement of the distal dens fragment, but no spinal canal compromise. 2. ___ burst fractures of the anterior and posterior neural arches of C1, again without canal compromise. 3. Multilevel degenerative disease with foraminal but no "critical" canal stenosis. Radiology Report INDICATION: ___ man status post 3-feet fall from platform, presenting with headache, facial pain, neck pain. COMPARISONS: Head and C-spine CT earlier same day demonstrating a midline frontal fracture and extensive sinus opacification. TECHNIQUE: Contiguous MDCT data were acquired through the frontal sinuses. Images were reconstructed using bone and soft tissue kernels. Images were displayed in multiple planes. FINDINGS: A non-displaced midline fracture through the frontal bone to the frontal sinus is re-demonstrated. There is hyperdense blood and air in the frontal sinus and anterior left ethmoid air cells. Additional hyperdense fluid and air with air-fluid levels are seen in the maxillary and sphenoid sinuses. A ___ burst fracture of C1 is seen at the lower edge of the field of view but better visualized on preceding C-spine CT. Osteomeatal units are patent bilaterally. The cribriform plates and lamina papyracea are intact. IMPRESSION: Re-demonstration of non-displaced midline frontal bone fracture and C1 ___ burst fracture. No additional fractures. Extensive fluid and air in the maxillary and sphenoid sinuses may represent the sequela of acute sinusitis or additional blood. Radiology Report CHEST RADIOGRAPH performed on ___. ___. CLINICAL HISTORY: Preop chest radiograph. COMPARISON: None. FINDINGS: PA and lateral views of the chest are obtained. Lungs are clear. No focal consolidation, effusion or pneumothorax. Cardiomediastinal silhouette is normal. Bony structures appear intact. IMPRESSION: No acute intrathoracic process. Radiology Report STUDY: Cervical ___. CLINICAL HISTORY: Patient with ORIF of C2. FINDINGS: Comparison is made to the CT scan from ___. AP and lateral views of the upper cervical spine demonstrates placement of a screw through the fracture involving the dens of C2. There is good positioning and no signs of hardware-related complications. Please refer to the operative note for additional details. Radiology Report CERVICAL SPINE 2 VIEWS: ___. HISTORY: ___ male with odontoid screw fixation. FINDINGS: AP and lateral views of the cervical spine are compared to previous intraop films from ___. The odontoid screw is identified transfixing the odontoid fracture. There is no evidence of new displaced fracture based on plain film. Known C1 ___ type burst fracture is not well seen on the current exam. The other vertebral bodies are maintained in height and alignment throughout noting degenerative changes in the mid-to-lower cervical spine as previously detailed. Mild prevertebral soft tissue swelling seen at the C1-C2 level, not unexpected given patient's recent postoperative state. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: NECK PAIN.HA S/P FALL Diagnosed with FX C2 VERTEBRA-CLOSED, FALL-1 LEVEL TO OTH NEC, FX C1 VERTEBRA-CLOSED, CLOSED SKULL VAULT FX, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN temperature: 98.0 heartrate: 103.0 resprate: 20.0 o2sat: 99.0 sbp: 159.0 dbp: 91.0 level of pain: 9 level of acuity: 2.0

You have undergone the following operation: Open Reduction Internal Fixation Odontoid Fracture - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. o Isometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. - Swallowing:Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. - - Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodon, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. o We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenobarbital / levofloxacin Attending: ___. Chief Complaint: Right-sided Chest Pain, Dyspnea, Cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with DM, COPD, peripheral vascular disease with claudication and polymyalgia rheumatica presenting with right sided chest pain. Pt states that she fell two weeks ago, tripped over baby's walker, landed on the L side. She reports R-sided chest pain started two days ago. She describes the pain as sharp and stabbing worsened with breathing and movement. She denies any radiation of the pain and associated dyspnea, diaphoresis, nausea, or vomiting. The pain is intermittent and only improved with standing still. She also reports associated dyspnea, increased cough and sputum production compared to her baseline. She denies any fevers, chills, nausea, or vomiting. The patient continued to take her oxycodone for her chronic back pain, but has not provided any relief in her R-sided chest pain. She continues to smoke, denies any recent travels or sick contacts. In the ED, initial VS were 99.4 HR: 91 BP: 131/75 Resp: 20 O(2)Sat: 95 on 3L NC. Exam was most notable for pain in right upper lateral aspect of chest that was reproducible by palpation and both active and passive motions. CXR was notable for L-sided atelectasis. EKG was unchanged from baseline and trop negative x3. CTA was negative for PE. There was an initial concern for COPD exacerbation and pneumonia, thus the patient was given Prednisone and Azithromycin as well as IV Ceftriaxone. On the floor, the patient continued to complain of right-sided chest wall pain. She also endorsed dyspnea and increased productive cough. Otherwise, she denied any palpitations, lightheartedness, lower extremity edema, fevers, chills, nausea, or vomiting. Past Medical History: ADULT ONSET DIABETES MELLITUS ___ CARPAL TUNNEL SYNDROME CHRONIC OBSTRUCTIVE PULMONARY DISEASE COLONIC ADENOMA ___ one DEPRESSION hospitalized ___ DYSPHAGIA ___ GASTROESOPHAGEAL REFLUX 92 HYPERCHOLESTEROLEMIA ___ SMOKER SOCIAL daughter died of AIDS, hx abusive relationship, grandaughter died age ___ AML STRESS INCONTINENCE 96 LOW BACK PAIN ___ MRI 03 Degenerative disease at multiple levels (degenerative disc and spine disease) PERIPHERAL VASCULAR DISEASE legs , severe pvd on doppler, claudication POLYMYALGIA RHEUMATICA Social History: ___ Family History: Depression, no other medical problems reported Physical Exam: ON ADMISSION: VS T 98.7 HR 73 BP 110/67 RR 22 SpO2 93% 5L NC General: Patient in pain in mild distress HEENT: Sclera clear, MMM, no oropharyngeal lesions Neck: Supple, no JVD, no cervical lymphadenopathy CV: RRR, no m,r,g. Normal S1 and S2. Chest: Pain on palpation of R upper lateral chest wall worsened with movement. No erythema or dermatomal rashes. No ecchymoses. Lungs: R base inspiratory crackles, otherwise no wheezing or rhonci. Abdomen: Soft, NT, ND. +Normoactive bowel sounds. Ext: Warm, well-perfused. No ___ edema. Neuro: Moving all extremities with purpose. No facial assymetry. Skin: No rashes, ecchymoses, or petechiae. ON DISCHARGE: VS T 98.4 HR 87 BP 127/85 RR 18 ___ NC General: Patient in pain in mild distress HEENT: Sclera clear, MMM, no oropharyngeal lesions Neck: Supple, no JVD, no cervical lymphadenopathy CV: RRR, no m,r,g. Normal S1 and S2. Chest: Mild to moderate on palpation of R upper lateral chest wall worsened with movement. No erythema or dermatomal rashes. No ecchymoses. Lungs: R base inspiratory crackles, otherwise no wheezing or rhonci. Abdomen: Soft, NT, ND. +Normoactive bowel sounds. Ext: Warm, well-perfused. No ___ edema. Neuro: Moving all extremities with purpose. No facial assymetry. Skin: No rashes, ecchymoses, or petechiae. Pertinent Results: ON ADMISSION: ___ 03:12PM BLOOD WBC-15.4* RBC-4.35 Hgb-13.5 Hct-41.3 MCV-95 MCH-30.9 MCHC-32.6 RDW-14.8 Plt ___ ___ 03:12PM BLOOD Neuts-80.0* Lymphs-13.2* Monos-5.8 Eos-0.6 Baso-0.3 ___ 03:12PM BLOOD Plt ___ ___ 03:12PM BLOOD Glucose-198* UreaN-26* Creat-1.3* Na-138 K-4.7 Cl-98 HCO3-28 AnGap-17 ___ 03:12PM BLOOD cTropnT-<0.01 ___ 03:22PM BLOOD Lactate-1.8 ON DISCHARGE: ___ 07:00AM BLOOD WBC-7.1# RBC-3.56* Hgb-11.1* Hct-34.5* MCV-97 MCH-31.3 MCHC-32.2 RDW-14.8 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-83 UreaN-25* Creat-1.3* Na-143 K-5.1 Cl-100 HCO3-33* AnGap-15 ___ 07:00AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.4* IMAGING: CT C-SPINE W/O CONTRAST ___: IMPRESSION: 1. No acute cervical spine fractures identified. Moderate to severe degenerative changes seen throughout the cervical spine. 2. Partial atelectasis of the left upper lobe is better evaluated on the dedicated CT of the chest performed on the same day. CT HEAD W/O CONTRAST ___: FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect or acute large territorial infarction. Periventricular, and subcortical white matter hypodensities, is likely secondary to age related small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. The basilar cisterns are patent, and there is otherwise good preservation of the gray-white matter differentiation. No acute fracture is identified. There is mild mucosal polypoid thickening along the sphenoid sinus. The visualized paranasal sinuses are otherwise unremarkable. The mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No acute intracranial abnormalities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. BuPROPion (Sustained Release) 100 mg PO QAM 3. Divalproex (DELayed Release) 250 mg PO BID 4. Fluoxetine 40 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 6. Furosemide 20 mg PO DAILY 7. Guaifenesin ___ mL PO Q6H:PRN cough 8. Omeprazole 20 mg PO BID 9. OxycoDONE (Immediate Release) 15 mg PO 5X/DAY pain 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. PredniSONE 10 mg PO 2X/WEEK (MO,FR) 12. Propranolol 60 mg PO DAILY 13. Simvastatin 40 mg PO DAILY 14. TraZODone 150 mg PO HS:PRN insomnia 15. Tiotropium Bromide 1 CAP IH DAILY 16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 17. Calcium Carbonate 200 mg PO QID:PRN heartburn 18. cilostazol 100 mg ORAL BID 19. GlipiZIDE 2.5 mg PO DAILY 20. MetFORMIN (Glucophage) 500 mg PO BID 21. Nicotine Lozenge 4 mg PO DAILY 22. PredniSONE 7.5 mg PO 5X/WEEK (___) 23. Vitamin D 1000 UNIT PO DAILY 24. Cepastat (Phenol) Lozenge 1 LOZ PO Q6H:PRN throat pain Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. BuPROPion (Sustained Release) 100 mg PO QAM 3. Calcium Carbonate 200 mg PO QID:PRN heartburn 4. Cepastat (Phenol) Lozenge 1 LOZ PO Q6H:PRN throat pain 5. cilostazol 100 mg ORAL BID 6. Divalproex (DELayed Release) 250 mg PO BID 7. Fluoxetine 40 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 9. Furosemide 20 mg PO DAILY 10. Guaifenesin ___ mL PO Q6H:PRN cough 11. Nicotine Lozenge 4 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. OxycoDONE (Immediate Release) 15 mg PO 5X/DAY pain 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. PredniSONE 10 mg PO 2X/WEEK (MO,FR) 16. PredniSONE 7.5 mg PO 5X/WEEK (___) 17. Propranolol 60 mg PO DAILY 18. Simvastatin 40 mg PO DAILY 19. TraZODone 150 mg PO HS:PRN insomnia 20. Vitamin D 1000 UNIT PO DAILY 21. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 22. GlipiZIDE 2.5 mg PO DAILY 23. MetFORMIN (Glucophage) 500 mg PO BID 24. Tiotropium Bromide 1 CAP IH DAILY 25. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 26. Azithromycin 500 mg PO Q24H Duration: 6 Days RX *azithromycin 500 mg 1 tablet(s) by mouth once daily Disp #*6 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with right chest pain and cough. history of COPD. COMPARISON: Prior chest radiograph from ___. CTA chest performed concurrently. FINDINGS: AP upright and lateral views of the chest provided. The lungs appear hyperinflated with left mid lung opacity which is compatible with atelectasis better assessed on the CTA performed concurrently. Emphysematous changes are noted. No large effusion or pneumothorax. Cardiomediastinal silhouette appears stable. Bony structures are intact. IMPRESSION: Emphysema, left mid lung atelectasis. Please refer to subsequent CTA chest for further details. Radiology Report INDICATION: ___ with right humerus pain status post fall. COMPARISON: None FINDINGS: Two views of the right humerus were provided. No fracture is identified. Degenerative spurring is seen along the inferior aspect of the right humeral head. Subchondral cystic changes are present within the humeral head. There is right AC joint arthropathy with productive bony changes noted. Limited views of the right elbow are unremarkable. No soft tissue injuries are seen. IMPRESSION: Degenerative changes without acute fracture or dislocation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History of fall. Please evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial images images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. CTDIvol: 54 mGy DLP: 891 mGy-cm COMPARISON: None. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect or acute large territorial infarction. Periventricular, and subcortical white matter hypodensities, is likely secondary to age related small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. The basilar cisterns are patent, and there is otherwise good preservation of the gray-white matter differentiation. No acute fracture is identified. There is mild mucosal polypoid thickening along the sphenoid sinus. The visualized paranasal sinuses are otherwise unremarkable. The mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: No acute intracranial abnormalities. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History of fall 2 weeks prior. Please evaluate for fracture. TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 37 mGy DLP: 720 mGy-cm COMPARISON: None FINDINGS: There is no evidence of acute cervical spine fracture, malalignment, or prevertebral soft tissue swelling. Moderate to severe degenerative changes are seen throughout the cervical spine with evidence of intervertebral disc space narrowing, severe subchondral sclerosis and subchondral cysts, and anterior/ posterior osteophytosis. There is mild thecal sac narrowing, secondary to intervertebral disk protrusion worse from C2/C3, and C6/C7. The thyroid is normal. There is no cervical lymphadenopathy. The visualized left maxillary sinus demonstrates polypoid mucosal sinus thickening. Partial left upper lobe atelectasis is better evaluated on the recent CT of the chest performed on the same day. IMPRESSION: 1. No acute cervical spine fractures identified. Moderate to severe degenerative changes seen throughout the cervical spine. 2. Partial atelectasis of the left upper lobe is better evaluated on the dedicated CT of the chest performed on the same day. Radiology Report EXAMINATION: CTA chest. INDICATION: History shortness of breath, chest wall pain. Please evaluate. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 396 mGy-cm COMPARISON: CT from ___. FINDINGS: The thyroid is normal. There is no axillary, hilar, or supraclavicular lymphadenopathy. There is mild prominence of the mediastinal lymph nodes, measuring up to 1 cm, series 2, image 40. The heart size is normal. There is no evidence of a pericardial effusion. Note is made of mild atherosclerotic calcification of the coronary arteries, as well as moderate annular calcifications. There is a small hiatal hernia. The esophagus is otherwise unremarkable without evidence of wall thickening. CTA: The aorta is normal without evidence of aneurysm or dissection. Mild enlargement of the main, and right pulmonary arteries is unchanged compared to the prior exam, consistent with pulmonary hypertension. The main, lobar, segmental, and subsegmental pulmonary arteries, are well opacified without evidence of filling defects concerning for a pulmonary embolus. There is new partial atelectasis of the left upper lobe. A 5 mm nodule is seen in the posterior right upper lobe (series 3, image 56), new compared to the prior exam. Note is made of mild bronchiectasis with subtle areas of mucoid impaction, (series 3 image 68) overall similar to the prior exam. Note is made of a granuloma at the left lower lobe series 3, image 98. Left lower lobe nodule measuring 6 mm, series 3, image 145 is new compared to the prior exam. There is no pleural effusion or pneumothorax. This study is not tailored for the evaluation of the subdiaphragmatic structures the however hypodensities within the liver are too small to characterize by CT, and likely secondary dose simple hepatic cyst. The 1.3 cm hypodense lesion in the superior pole of the left kidney is unchanged compared to the prior exam, and too small to characterize by CT. No acute intra-abdominal abnormalities identified. OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are identified. IMPRESSION: 1. No evidence of a pulmonary embolism or aortic abnormality. 2. New partial atelectasis of the left upper lobe, is likely secondary to bronchial impaction. A superimposed infectious process cannot be excluded. 3. New 6 mm nodule in the left lower lobe (3;98). A six-month followup is recommended for further evaluation. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with CHEST PAIN NEC, RESPIRATORY ABNORM NEC temperature: 99.4 heartrate: 91.0 resprate: 20.0 o2sat: 95.0 sbp: 131.0 dbp: 75.0 level of pain: 9.5 level of acuity: 2.0

Dear Ms. ___, It was a pleasure to take care of you at ___ ___. You were admitted for chest pain and cough. A CT scan of your chest showed a pneumonia for which you received antibiotics. Your pain is likely related to the musculoskeletal system and not to your heart or lungs. The pain should improve over time with conservative measures such as Tylenol and local heat/cold compresses. Please take your medications as prescribed and follow up with the appointments listed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: Teeth extraction with OMFS History of Present Illness: ___ year old male has ETOH cirrhosis complicated by varices, ascites, SBP on cipro prophylaxis, listed for liver txp with MELD 30, GAD, OA of bilateral hips s/p right THR (___) presenting for hyponatremia iso recent decrease in diuretic dose. Multiple recent admissions for hyponatremia and volume overload, most recently last week. His labs from ___ came back with sodium 124 and we recommended he come into the ED but he declined, wanted to see his liver doctor ___ in clinic today. At clinic, repeat sodium was 123, so they sent him to the ED. In the ED, sodium worsened to 117, has been improving (now ___ with diuresis. Per renal team, volume overloaded, so now diuresing. No pocket of ascites to target on bedside U/S per ED. Past Medical History: Alcohol use disorder Alcoholic cirrhosis c/b grade 1 varies, new onset ascites, SBP Gout GAD HTN Avascular necrosis of hips bilaterally s/p hip arthroplasty on R Bilateral inguinal hernia report MDD SDH (___) Social History: ___ Family History: Heart disease/AD/HTN in father, ___ cancer in mother, heart disease in brother Physical Exam: Admission Physical Exam ======================= VITALS: ___ 1613 Temp: 98.1 PO BP: 134/55 L Lying HR: 71 RR: 20 O2 sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ General: AO x 3 no acute distress HEENT: scleral icterus present CV: systolic murmur loudest at right sternal border. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, mildly distended, no rebound or guarding Ext: Mild peripheral edema. Skin: Slightly jaundiced Neuro: Able to move limbs approrpiately Discharge Physical Exam ======================= General: Well-appearing. In no acute distress HEENT: Scleral icterus. Right sided jaw swelling with ecchymosis on right side, under jaw and small area on left. Cardiac: Systolic murmur ___ appreciated at right sternal border Respiratory: Lungs clear to auscultation bilaterally Derm: Jaundiced Abdomen: Mildly distended. Nontender to palpation. Prominent ventral hernia. Peripheral: 1+ bilateral ___ edema Pertinent Results: Admission Labs: =============== ___ 10:30AM BLOOD WBC-3.8* RBC-2.68* Hgb-9.0* Hct-25.9* MCV-97 MCH-33.6* MCHC-34.7 RDW-15.4 RDWSD-55.3* Plt Ct-35* ___ 10:30AM BLOOD Plt Ct-35* ___ 10:30AM BLOOD ___ ___ 10:30AM BLOOD UreaN-12 Creat-0.6 Na-123* K-4.7 Cl-88* HCO3-21* AnGap-14 ___ 10:30AM BLOOD ALT-27 AST-68* AlkPhos-183* TotBili-8.5* Imaging: ======== CT Head Non-contrast ___: IMPRESSION:No evidence of acute intracranial abnormality identified on noncontrast head CT. CT Chest with contrast ___: No evidence of metastasis to the chest. Moderate-sized hiatus hernia. Paraesophageal varices. Evidence of cirrhosis with portal hypertension. Multiple collaterals within the upper abdomen. Ill-defined hypodense lesion within the right lobe of liver has been better characterized by an MRI done on ___. CXR ___: 1. No pneumonia. 2. Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved from ___. Discharge Labs: =============== ___ 06:20AM BLOOD WBC-1.8* RBC-2.07* Hgb-7.1* Hct-22.2* MCV-107* MCH-34.3* MCHC-32.0 RDW-16.3* RDWSD-63.0* Plt Ct-31* ___ 06:20AM BLOOD Neuts-39.6 Lymphs-18.1* Monos-23.7* Eos-16.4* Baso-1.1* Im ___ AbsNeut-0.70* AbsLymp-0.32* AbsMono-0.42 AbsEos-0.29 AbsBaso-0.02 ___ 06:20AM BLOOD Plt Ct-31* ___ 06:20AM BLOOD ___ PTT-40.2* ___ ___ 06:20AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-132* K-4.1 Cl-97 HCO3-26 AnGap-9* ___ 06:20AM BLOOD ALT-26 AST-59* LD(LDH)-267* AlkPhos-137* TotBili-5.1* ___ 06:20AM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.6 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild/Fever 2. Bisacodyl ___ID:PRN Constipation - Second Line 3. Cholestyramine 4 gm PO BID 4. Ciprofloxacin HCl 500 mg PO Q24H 5. FoLIC Acid 1 mg PO DAILY 6. Lactulose 30 mL PO QID 7. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain - Moderate 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 9. rifAXIMin 550 mg PO BID 10. Spironolactone 100 mg PO BID 11. TraZODone 50-100 mg PO QHS:PRN insomnia 12. Ursodiol 300 mg PO BID 13. Torsemide 10 mg PO DAILY 14. Thiamine 100 mg PO DAILY Discharge Medications: 1. Aminocaproic Acid 25 % Oral Rinse 5 gm PO TID RX *aminocaproic acid [Amicar] 250 mg/mL 20 ml by mouth twice a day Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine (bulk) Hold in mouth for as long as can tolerate Two times per day prior to Amicar Refills:*0 4. Tolvaptan 30 mg PO QAM RX *tolvaptan [Jynarque] 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild/Fever 6. Bisacodyl ___ID:PRN Constipation - Second Line 7. Cholestyramine 4 gm PO BID 8. Ciprofloxacin HCl 500 mg PO Q24H 9. FoLIC Acid 1 mg PO DAILY 10. Lactulose 30 mL PO QID 11. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain - Moderate 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 13. rifAXIMin 550 mg PO BID 14. Thiamine 100 mg PO DAILY 15. TraZODone 50-100 mg PO QHS:PRN insomnia 16. Ursodiol 300 mg PO BID 17. HELD- Spironolactone 100 mg PO BID This medication was held. Do not restart Spironolactone until you talk with your liver doctors 18. HELD- Torsemide 10 mg PO DAILY This medication was held. Do not restart Torsemide until you discuss with your liver doctors ___: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Hyponatremia Secondary Diagnosis =================== ETOH Cirrhosis c/n varices Tooth Infection Insomnia Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with cough,volume overload// eval for pna TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph from ___. FINDINGS: Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved.: Less no opacification in the right lower lobe was present on ___, 9, and 20 second and could be either due asymmetric edema or concurrent pneumonia.. There is no pleural abnormality. IMPRESSION: 1. Possible right lower lobe pneumonia. 2. Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved from ___. NOTIFICATION: The findings were discussed with ___ Resident ___, by ___, M.D. on the telephone at 08:00 immediately following discovery of the findings. IMPRESSION: 1. No pneumonia. 2. Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved from ___. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with cirrhosis// eval for PVT, ascites TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI liver from ___. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. A 1.8 cm hypoechoic nodule in the right hepatic lobe likely corresponds to dysplastic nodule seen on prior MRI study. The main portal vein is patent with hepatopetal flow. The right anterior and posterior portal veins are patent, although slow flow is seen within the right posterior portal vein. The left portal vein is patent, but has reversed flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 16.4 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 12.5 cm Left kidney: 12.8 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver with splenomegaly. No ascites. 2. Patent portal veins, although there is slow flow in the right posterior portal vein and reversed direction flow in the left portal vein. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with cirrhosis here for hyponatremia// rule out infection, mass, lesion IMPRESSION: In comparison with the study of ___, the questioned increased opacification at the right base is no longer seen. There is the vague suggestion of some increased opacification at the left base. This could merely represent atelectatic changes, though in the appropriate clinical setting a developing aspiration could be considered. Cardiomediastinal silhouette is stable. There is minimal indistinctness of pulmonary vessels that could represent mild elevation in pulmonary venous pressure. No evidence of pleural effusion. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with encepholopathy and hypoNa// Any lung masses TECHNIQUE: Multi detector CT of the chest was performed after the administration of intravenous contrast. Axial coronal and sagittal reconstructions were acquired. Maximum intensity projections were also acquired DOSE: Acquisition sequence: 1) Spiral Acquisition 2.5 s, 39.2 cm; CTDIvol = 16.4 mGy (Body) DLP = 640.6 mGy-cm. Total DLP (Body) = 641 mGy-cm. COMPARISON: No prior CT chest is available for comparisons. FINDINGS: THORACIC INLET: The thyroid is unremarkable. There are no enlarged supraclavicular lymph nodes. BREAST AND AXILLA : There are no enlarged axillary lymph nodes. Note is made of a bilateral gynecomastia. MEDIASTINUM: There are no enlarged mediastinal hilar lymph nodes. Heart size is normal. There is moderate coronary artery calcification. There is a moderate-sized hiatus hernia. There is no pericardial effusion. The aorta and pulmonary arteries are normal in caliber. PLEURA: There is no pleural effusion. There is no pericardial effusion. LUNG: There is minimal bibasilar atelectasis. No lung nodules are seen. BONES AND CHEST WALL : Review of bones shows no lytic or sclerotic lesions concerning for metastasis. UPPER ABDOMEN: Limited sections through the upper abdomen shows evidence of cirrhosis with portal hypertension. Multiple collaterals are seen within the gastrohepatic ligament and also along the esophagus. There is an ill-defined hypodense lesion within segment 7 of the liver. Multiple collaterals are seen in the upper abdomen (2, 67). IMPRESSION: No evidence of metastasis to the chest. Moderate-sized hiatus hernia. Paraesophageal varices. Evidence of cirrhosis with portal hypertension. Multiple collaterals within the upper abdomen. Ill-defined hypodense lesion within the right lobe of liver has been better characterized by an MRI done on ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with ETOH cirrhosis complicated by varices, ascites, SBP, presenting for asymptomatic hyponatremia despite on tolvaptan. Evaluation for pathology to explain possible SIADH. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: Comparison to noncontrast head CT from ___. FINDINGS: There is no evidence of intracranial hemorrhage, acute large territorial infarction, edema,or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical hypodensities are nonspecific, though likely sequela of chronic small vessel ischemic disease. There is no evidence of fracture. There is an unchanged chronic defect in the left lamina papyracea and an atelectatic left maxillary sinus. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No evidence of acute intracranial abnormality identified on noncontrast head CT. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abnormal sodium level Diagnosed with Hypo-osmolality and hyponatremia temperature: 98.2 heartrate: 72.0 resprate: 16.0 o2sat: 98.0 sbp: 155.0 dbp: 52.0 level of pain: 7 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for a low sodium WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? -Your sodium was monitored -You had scans of your teeth and chest -You were started on medication for low sodium -You had 5 teeth taken out WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I don't know why I am here" Major Surgical or Invasive Procedure: CBI in ED History of Present Illness: Patient is a ___ y/o male with htn, dementia, hypothyroidism, referred from admission after his NH found blood in toilet - ? if from stool or urine so they sent him to the emergency room. He was found to be retaining urine in ___ staff reported to RN that over past 3 weeks he has been much more confused, is eating less and has lost 25 lbs. Patient is very confused on exam, and cannot provide any information as to why he is in hospital nor as to prior symptoms. At present, he denies nausea, vomiting, sob, cp, ha, abdominal pain, fevers. 10 point ROS otherwise negative. Per RN, he was having frequent diarrhea in ED. Past Medical History: -Dementia, hypothyroid, HTN -Remote history of prostate and breast cancer. Sister believes he had radiation for prostate cancer and possibly surgery, but she is not sure. She reports mastectomy for breast cancer. Social History: ___ Family History: He is unable to provide Physical Exam: ADMISSION PHYSICAL EXAM 98.3 155 / 70 67 18 99 RA Gen: Thin older gentleman, pleasant, not agitated, NAD HEENT: ? exophthalmos No palpable thyroid CV: RRR Abd: Nabs, soft, mild distesion, no hsm Foley in place draining slightly blood tinged urine Ext: no edema No cervical ___: Oriented to person, city only. Follows commands, but provides incoherent answers to all other questions. For example, "here to watch the turkeys". He likes that "it is not too crowded here". DISCHARGE PHYSICAL EXAM -Vitals: 99.3F, HR 78, BP 150/84, RR 18, SpO2 99$ -General: pleasant, lying in bed -HEENT: Anicteric, moist mucus membranes, exopthalmous -Cardiovascular: RRR, no murmur -Pulmonary: clear b/l, no wheeze -Gastroinestinal: Soft, non-tender, distended, bowel sounds present, obese -GU: in the morning foley with clear urine and clots settled at the bottom of the bag. No suprapubic tenderness. In the afternoon patient without foley and no change in exam. -MSK: No edema -Skin: No rashes or ulcerations evident -Neurological: AAO to self, no focal neurological deficits otherwise -Psychiatric: pleasant, appropriate affect Pertinent Results: Head CT There is no definite evidence of subacute infarcts, although, underlying moderate to severe chronic small vessel ischemic changes decreased sensitivity of this exam in detecting deep white matter subacute infarcts. There is generalized brain parenchymal atrophy. 2 subtle foci of abnormality in the anterior frontal lobes are likely an artifact. Paranasal sinus disease, as above. ___ 07:30AM BLOOD WBC-11.3* RBC-4.11* Hgb-10.6* Hct-33.6* MCV-82 MCH-25.8* MCHC-31.5* RDW-13.5 RDWSD-40.6 Plt ___ ___ 05:58AM BLOOD Glucose-96 UreaN-8 Creat-1.3* Na-140 K-3.9 Cl-104 HCO3-23 AnGap-17 ___ 05:24AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG Urine culture: no growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID 4. Donepezil 10 mg PO QHS 5. Simvastatin 20 mg PO QPM 6. TraZODone 25 mg PO Q6H:PRN agitation Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. Levothyroxine Sodium 150 mcg PO DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. TraZODone 25 mg PO Q6H:PRN agitation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hematuria with urinary retention Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with dementia with worsening confusion, admitted with leukocytosis, cultures negative, please assess for aspiration// ? aspiration IMPRESSION: No previous images. There is hyperexpansion of the lungs suggesting underlying chronic pulmonary disease. Enlargement of the cardiac silhouette with left ventricular prominence and dense calcification in the descending thoracic aorta. No evidence of pulmonary vascular congestion, pleural effusion, or acute focal pneumonia. Surgical clips are seen in the region of the left breast. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with dementia, mild, but significantly worse memory just over past month, accompanied by poor po intake. assess for subacute strokes that may explain his decline.// ? subacute stroke TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.5 s, 21.5 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,120.5 mGy-cm. Total DLP (Head) = 1,121 mGy-cm. COMPARISON: None available FINDINGS: There is no evidence of acute cortical infarction,definite evidence of hemorrhage,edema,or mass. There is small chronic left cerebellar infarct. There is probably benign prevascular space in the inferior left basal ganglia, less likely chronic lacunar infarct. There are moderate to severe chronic small vessel ischemic changes, which decreased sensitivity in detecting deep white matter subacute infarcts. There is advanced generalized brain parenchymal atrophy. There are 2 linear foci involving anterior bilateral frontal lobes seen on same image series 2 image 12, 1 on each side, which likely represent an artifact, foci of cortical laminar necrosis related to subacute to chronic infarcts or small focus of parenchymal hemorrhages very unlikely. There is no adjacent brain edema or gyral expansion to suggest underlying process. There is no evidence of fracture. There is near complete opacification of the left frontal sinus, with chronic osteitis, consistent with mild acute on chronic inflammation. There is chronic osteitis and partial opacification of the visualized very top of left maxillary sinus. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: There is no definite evidence of subacute infarcts, although, underlying moderate to severe chronic small vessel ischemic changes decreased sensitivity of this exam in detecting deep white matter subacute infarcts. There is generalized brain parenchymal atrophy. 2 subtle foci of abnormality in the anterior frontal lobes are likely an artifact. Paranasal sinus disease, as above. Radiology Report EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS INDICATION: ___ year old man with dementia, HTN, and hypothyroid found to have right hip pain with difficulty ambulating. In setting of dementia he is unable to provide history of trauma. Imaging to assess for fracture ___ lesion.// ?hip fracture or bone lesion TECHNIQUE: Pelvis single view, bilateral hips two views each side. COMPARISON: None FINDINGS: There is moderate degenerative arthritis of bilateral hips with hypertrophic changes, chondrocalcinosis, and mild joint space narrowing, more prominent on the left. There are no fractures. There are extensive arterial calcifications. Benign inter sub petit right iliac bone. Partially seen are degenerative changes in the lumbar spine. IMPRESSION: No fractures. Degenerative changes bilateral hips. No worrisome osseous lesions. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Hematuria Diagnosed with Hematuria, unspecified, Acute kidney failure, unspecified temperature: 98.3 heartrate: 68.0 resprate: 16.0 o2sat: 97.0 sbp: 143.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Mr. ___, You were admitted with urinary retention and blood in your urine, which required a foley catheter while you were admitted. The foley was removed today and you were able to urinate without any difficulty. You will follow up with urology to further discuss bloody urine.