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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation history of present illness: mr. is an 84 year old patient of who presented to the ed today after 2 episodes vomiting and diarrhea. per his son, he lives independently and was doing well until he woke up this morning with nausea, a single episode of vomiting, a loose nonbloody stool, chills, and general malaise. he called his son who brought him to the . . in the waiting room, he had an episode of possible syncope. he felt sob and looked ill, and his family noticed that he seemed confused. he was taken to the core area where he was found to have 80% on ra. ekg showed no ischemic changes. cxr was unremarkable. labs notable for lactic acidosis with lactate 8. ct torso was done to rule out pe. this showed diffuse ground glass opacities in the lungs and aaa. vascular surgery service saw him. . in the ed waiting room, patient had a brief episode of near syncope during which he was feeling sob and confused and "looked bad." he was tachycardic and tachypneic. o2 sat was 80% on ra with venous ph 7.1, prompting intubation. serial ekgs were without ischemic changes. he was noted to be acidotic with lactate 8. ct torso was done to rule out pe. no pe was demonstrated, but there were diffuse ground glass opacities concerning for multifocal pneumonia. he was given vancomycin, zosyn, levofloxacin. ct also showed 3.8 cm infrarenal aaa. vascular surgery service saw him in the ed. he was intubated and admitted to the micu for further managemenet. past medical history: gerd hyperlipidemia vertigo bph social history: lives with wife. is her primary care taker as she has suffered a recent stroke. remote smoking history (30 pkyr). occasional alcohol use. no history of illicit drug use. family history: the patient has a mother who had htn and father who had a stroke. physical exam: admission exam: vs: t 100.0, hr 88, bp 130/70rr 32, o2 100% on psv with 100% fio2, gen: intubated, sedated, doesn't open eyes to voice or follow commands heent: ncat. sclera anicteric. eomi. op clear, no exudates or ulceration. neck: jvp flat, rij in place cv: rrr, normal s1, s2. no m/r/g. chest: diffuse crackles. abd: soft, ntnd. no hsm or tenderness. ext: no edema skin: no stasis dermatitis, ulcers, scars. neuro: perrl, does not follow commands pertinent results: admission labs: 01:30pm wbc-3.7* rbc-4.82 hgb-14.4 hct-45.2 mcv-94 mch-29.9 mchc-31.9 rdw-13.0 01:30pm neuts-47* bands-17* lymphs-26 monos-4 eos-0 basos-0 atyps-1* metas-3* myelos-2* 01:30pm glucose-229* urea n-26* creat-1.2 sodium-138 potassium-4.6 chloride-100 total co2-21* anion gap-22* 01:30pm calcium-9.3 phosphate-4.6*# magnesium-2.0 brief hospital course: an 84 year-old man presents with likely sepsis secondary to pneumonia. . # respiratory failure: patient was intubated in ed for hypoxemic respiratory failure, likely secondary to pneumonia. due to initial aggressive fluid resuscitation, patient had to be diuresed over several days before extubation. during the course of intubation, patient intermittently hyperventilated regardless of ventilator settings and failed repeated sbts. benzodiazepenes and opiates briefly brought down respiratory rate. at one point, family considered making patient cmo and terminal extubation. however, patient was gradually more alert and once asked declined terminal extubation and agreed that if extubation was unsuccessful, re-intubation would be okay. patient was successfully extubated on and called out to the medicine floor. patient remained comfortable on 4l with improved breath sounds. . # mrsa pneumonia: patient presented with bandemia and leukopenia, fevers, and ct with multilobar infiltrates diagnostic of severe pneumonia. vancomycin, zosyn, and levofloxacin were started. he initially required levophed to maintain map >65. sputum cultures grew mrsa. antibiotics were narrowed to vancomycin. levophed was weaned, and bp remained normal to hypertensive. however, a few days into his micu course, he was again febrile and clinically tenuous, so antibiotic regimen was broadened back to include cefepime and ciprofloxacin in addition to the iv vancomycin. he finished his course of antibiotics on and he has been stable on 4l of o2 with gradually improving breath sounds. . # rue edema/weakness - upper extremity ultrasound showed an age indeterminate midcephalic vein clot with signs of distal flow. vascular surgery was consulted, recommended no anticoagulation. warm packs, elevation, and nsaids were used. head ct was performed with no signs of intracranial process to explain weakness. patient will require physical rehabilitation of right arm. . # hct drop: hct fell from 35 on admission to 27, likely secondary to fluids, and was subsequently stable. . # hyperlipidemia: atorvastatin was continued. . # aaa: 3 cm, newly discovered. patient was seen by vascular in ed who recommended repeat us in 6 months . code status: full code medications on admission: aspirin 81 mg daily lipitor 20 mg daily omeprazole 20 mg daily multivitamin discharge medications: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 2. docusate sodium 100 mg capsule : one (1) capsule po twice a day. 3. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 4. quetiapine 25 mg tablet : one (1) tablet po tid (3 times a day). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob, wheezing. 6. ipratropium bromide 0.02 % solution : one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob, wheezing. 7. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 8. atorvastatin 20 mg tablet : one (1) tablet po daily (daily). 9. aspirin 81 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po once a day. 10. multivitamin tablet : one (1) tablet po daily (daily). 11. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 12. ibuprofen 400 mg tablet : one (1) tablet po q8h (every 8 hours) as needed for pain. discharge disposition: extended care facility: newbridge on the discharge diagnosis: primary diagnosis: mrsa pneumonia secondary diagnosis: gerd hyperlipidemia vertigo bph discharge condition: mental status: confused - sometimes level of consciousness: alert and interactive activity status: out of bed with assistance to chair or wheelchair discharge instructions: you were admitted to for respiratory distress. you were found to have a mrsa pneumonia, and you needed to be admitted to the icu and required intubation to help with your breathing. you received a course of antibiotics to help clear your infection. you are being transferred to a rehabilitation facility to help you improve your breathing functions. your medications have changed. please take only the medications as listed below: aspirin 81 mg daily albuterol nebulizer every 6 hours as needed for shortness of breath or wheezing atorvastatin 20 mg daily docusate sodium 100 mg twice a day heparin 5000 units injected under the skin three times a day ipratropium nebulizer every 6 hours as needed for shortness of breath and wheezing lansoprazole 30 mg daily multivitamin 1 tablet daily ibuprofen 400 mg every 8 hours as needed for pain tylenol 325-650 mg every 6 hours as needed for pain, fever quetiapine 25 mg three times a day if you experience chest pain, worsening shortness of breath, or any other worrisome symptoms please return to the emergency room followup instructions: please follow up with your primary care physician, . (), after discharge from the pulmonary rehabilitation facility md, Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Unspecified septicemia Severe sepsis Personal history of tobacco use Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Acute respiratory failure Peripheral vascular complications, not elsewhere classified Septic shock Other constipation Abdominal aneurysm without mention of rupture Mixed acid-base balance disorder Dizziness and giddiness Personal history of Methicillin resistant Staphylococcus aureus Methicillin resistant pneumonia due to Staphylococcus aureus Muscle weakness (generalized) Acute venous embolism and thrombosis of superficial veins of upper extremity

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain and dyspnea major surgical or invasive procedure: 1. urgent coronary artery bypass graft x3 -- left internal mammary artery to the diagonal, vein graft to the distal left anterior descending artery, and vein graft to the right coronary artery. 2. aortic valve replacement with a size 23 mm magna ease tissue valve. history of present illness: 71 y/o hispanic male with pmh significant for pvd, dm, and hypertension who presented with fatigue after walking 2 to 3 blocks. presented with chest discomfort in upper chest unrelated to activity. echo on showed mild concentric lvh with ef of 60-65%, sever as with mean gradient of 53 mm hg and of .63 cm2. cardiac cath today showed severe as with mean gradient of 54 mm hg and of .77 cm2, 50% ostial lesion of rca, 70% d1 and diffuse disease of lcx. transferred to for further evaluation and treatment past medical history: coronary artery disease iddm hyperlipidemia moderate aortic valve stenosis with a valve area of .2 cm2 psoriasis social history: the patient lives with his wife in an apartment complex. he is primarly spanish speaking and denies tobacco, alcohol, or illicit drug use. family history: n/c physical exam: general: nad, alert, cooperative skin: dry intact heent: perrla eomi neck: supple full rom x chest: lungs clear bilaterally heart: rrr irregular murmur grade _3-4/6 sem across precordium_____ abdomen: soft non-distended non-tender x bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none + left pretibial edema with stasis dermatitis and amputation of rightsecond and third toes neuro: grossly intact pulses: femoral right: +1 left:+1 dp right:+1 left:+1 pt : +1 left:+1 radial right: +1 left:+2 carotid bruit right:murmur transmits to carotid left:murmur transmits to carotid pertinent results: carotid ultrasound impression: right ica less than 40% stenosis. left ica less than 40% stenosis . cta 1. no evidence of aortic aneurysm. no ascending aortic calcifications with calcifications seen only at the level of the aortic valve. 2. extensive calcifications of the aortic valve itself consistent with known aortic valve stenosis. extensive coronary calcifications. 3. right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. additional pulmonary nodules mentioned in the body of the report can be reassessed at the same time. echo pre-bypass: the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. 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%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results before surgical incision. post-bypass: preserved biventricular systolic functin. lvef 55%. intact thoracic aorta. the bioprosthetic valve in the native aortic position is well seated and moving well. the peak is 15 and mean is 5 mm of hg. trivial mr> . head ct arterial calcifications and signs of chronic sphenoid sinus inflammation, otherwise normal study. cxr : intact sternomy wires. aortic valve prosthesis. unchanged l hemidiaphragm elevation and atelectasis. 06:02am blood wbc-6.4 rbc-3.37* hgb-9.3* hct-29.7* mcv-88 mch-27.7 mchc-31.4 rdw-13.6 plt ct-113* 06:02am blood plt ct-113* 02:58am blood pt-15.4* ptt-36.7* inr(pt)-1.4* 06:02am blood glucose-148* urean-21* creat-1.0 na-138 k-3.9 cl-104 hco3-24 angap-14 04:30am blood alt-117* ast-133* ld(ldh)-310* alkphos-130 totbili-1.0 brief hospital course: mr. was transferred to the on for surgical management of his aortic valve and coronary artery disease. he was worked-up in the usual preoperative manner. a carotid duplex ultrasound was obtained which showed less then a 40% bilateral internal carotid artery stenosis. a dental consult was obtained which found no contraindication for surgery after obtaining a panorex x-ray of his teeth. a chest ct scan was performed which showed no significant aortic calcifications but did note a right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. labs showed that he had elevated liver function studies. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and replacement of his aortic valve with a tissue valve. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. over the next several hours he awoke and was extubated. he was noted to have some confusion, hallucinations and somnolence. a head ct scan was obtained which was negative. the stroke service was consulted who suspected a metabolic or possible infectious etiology to his confusion- no acute infection was detected. all narcotics were discontinued and his pain was managed with tylenol only. over the next day, his mental status cleared. aspirin, beta blocker, statin therapy and diabetic management were continued. mild confusion noted again on pod#4 and ultram was discontinued.. confusion improved. pod#5 he went into rapid a-fib and remained in it for several hours, was started on amio and returned to sr for 24 hours prior to discharge. he failed first and second voiding trial, urology was consulted and it was determined that he would be discharged to home with the foley in place and will follow up with urology as an outpatient. after second foley placement his urine was noted to be cloudy. a ua c&s was sent and he was started on cipro. cultures were negative and cipro was discontinued. he was noted to have some serosanguinous drainage from his mid sternal pole. he was afebrile, cxr showed intact wires, and wbc was normal. he was sent home on no antibiotics and will return for a wound check on . he was seen by the physical therapy department and cleared for discharge. by time of discharge on pod #6 he was deemed safe for discharge to home. follow-up appointments were advised. medications on admission: aspirin 81 mg qd, glipizide 5 mg qd, glucophage 1000 mg , lisinopril 5 mg qd, metoprolol extended release 50 mg qd discharge medications: 1. acetaminophen 650 mg po q4h:prn pain/fever rx *acetaminophen 325 mg q 6 hours disp #*60 tablet refills:*0 2. aspirin ec 81 mg po daily rx *adult low dose aspirin 81 mg daily disp #*30 tablet refills:*2 3. metformin (glucophage) 1000 mg po bid rx *glucophage 1,000 mg twice daily disp #*90 tablet refills:*0 4. simvastatin 20 mg po daily rx *simvastatin 20 mg daily disp #*60 tablet refills:*2 5. tamsulosin 0.4 mg po hs rx *tamsulosin 0.4 mg bedtime disp #*30 tablet refills:*0 6. potassium chloride 20 meq po q12h duration: 7 days hold for k+ > 4.5 rx *k-tab 10 meq twice daily disp #*28 tablet refills:*0 7. glargine 24 units bedtime 8. amiodarone 400 mg po bid for 6 more days starting then 400mg daily for 1 week, then 200mg daily rx *amiodarone 200 mg twice a day disp #*90 tablet refills:*2 9. glipizide xl 10 mg po daily rx *glipizide 10 mg daily disp #*60 tablet refills:*2 10. metoprolol tartrate 50 mg po bid hold for hr < 55 or sbp < 90 and call medical provider. *lopressor 50 mg twice a day disp #*90 tablet refills:*2 11. furosemide 40 mg po daily rx *furosemide 40 mg daily disp #*7 tablet refills:*0 12. potassium chloride 20 meq po daily duration: 7 days hold for k > rx *potassium chloride 20 meq daily disp #*7 tablet refills:*0 discharge disposition: home with service facility: all care vna of greater discharge diagnosis: aortic stenosis coronary artery disease diabetes peripheral disease hypertension post-op urinary retention discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tylenol only incisions: sternal - healing well, no erythema, no tenderness - minimal serosanginous drainage from mid sternal pole leg left - healing well, no erythema or drainage. edema trace lower extremity edema discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage. 2) please no lotions, cream, powder, or ointments to incisions. 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) no driving for approximately one month and while taking narcotics. driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns keep your urine catheter in place until you are advised by the vna or your primary care doctor to remove it. **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: the office will call you and schedule the following appointments your surgeon: dr. : at 2:15p cardiologist: at 8:45a wound check: 10:45 clinic for voiding trial: , at 4:00 pm with crohn, np - shipiro building please call to schedule appointments with your primary care dr. in weeks ***nodular opacity of ct scan seen on this admission - needs follow up ct scan in 6 months*** scheduled appointments: provider: lab phone: date/time: 9:45 provider: , md phone: date/time: 10:30 **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Open and other replacement of aortic valve with tissue graft Replacement of indwelling urinary catheter Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Aortic valve disorders Other and unspecified hyperlipidemia Long-term (current) use of insulin Metabolic encephalopathy Atherosclerosis of native arteries of the extremities, unspecified Other alteration of consciousness Other specified retention of urine Hallucinations

allergies: codeine attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: aortic valve replacement (23mm st. tissue) history of present illness: 69 year old male with no prior cardiac history who was recently treated for squamous cell carcinoma of the left vocal cord. over the last several months, he has noted dyspnea on exertion and chest pain while walking. he noted this to his oncologist during a follow-up appointment who referred him to dr. . an exercise tolerance test was done which was stopped due to near syncope. an echocardiogram showed severe aortic stenosis. in preparation for surgery, a cardiac catheterization was performed which showed mild non-obstuctive coronary artery disease. currently he denies syncope, pre-syncope, orthopnea, pnd and pedal edema. he had prviously never been told he had a heart mumrur. he presents for surgical evaluation. past medical history: aortic stenosis, s/p aortic valve replacement pmh: mild coronary artery disease - squamous cell carcinoma of the left vocal cord, s/p chemotherapy/radiation - dyslipidemia - gerd past surgical history: - tonsillectomy - appendectomy - repair of anal fissure - feeding tube during chemo/radiation. this has been removed. social history: lives with: wife in , ma contact: phone # occupation: retired cigarettes: smoked no yes last cigarette 1.5 years ago hx: ppd for 50 years. other tobacco use: etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use family history: denies premature coronary artery disease. mother died of aneurysm at age 74 physical exam: vital signs sheet entries for : bp: 152/79. heart rate: 73. resp. rate: 16. o2 saturation%: 100. height: 72" weight: 170lb general: wdwni in nad. voice is hoarse. skin: warm, dry and intact heent: ncat, perrla, eomi, sclera anicteric, op benign. edentulous neck: supple full rom no jvd chest: lungs clear bilaterally heart: rrr iii/vi sem, nl s1-s2 abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused no edema varicosities: none neuro: grossly intact pulses: femoral right:2 left:2 dp right:2 left:2 pt :2 left:2 radial right:2 left:2 carotid bruit - tranmitted murmur vs. bruit pertinent results: intra-op tee conclusions pre bypass: the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post-bypass: for the post-bypass study, the patient was receiving vasoactive infusions including phenylepherine. patient is av paced. a well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 19-20 mmhg). no aortic regurgitation is seen. regional and global left ventricular systolic function are normal. aortic contours intact. all findings discussed with surgeons at the time of the exam. 04:32am blood wbc-7.7 rbc-3.60* hgb-11.2* hct-33.6* mcv-93 mch-31.2 mchc-33.4 rdw-13.1 plt ct-190 06:00am blood wbc-9.3 rbc-3.48* hgb-11.1* hct-32.5* mcv-93 mch-31.8 mchc-34.1 rdw-13.1 plt ct-130* 04:50am blood wbc-12.5* rbc-3.38* hgb-10.6* hct-31.3* mcv-93 mch-31.4 mchc-33.9 rdw-13.2 plt ct-107* 04:32am blood pt-12.3 inr(pt)-1.1 01:45am blood pt-12.9* ptt-24.2* inr(pt)-1.2* 12:23pm blood pt-13.5* ptt-26.7 inr(pt)-1.3* 10:48am blood pt-16.5* ptt-30.3 inr(pt)-1.6* 04:32am blood glucose-125* urean-13 creat-0.9 na-136 k-4.4 cl-99 hco3-27 angap-14 06:00am blood na-134 k-4.2 cl-96 04:50am blood glucose-150* urean-14 creat-0.8 na-129* k-4.4 cl-95* hco3-27 angap-11 01:45am blood glucose-102* urean-7 creat-0.7 na-133 k-4.2 cl-104 hco3-21* angap-12 brief hospital course: the patient was brought to the operating room on where the patient underwent aortic valve replacement with dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. he demonstrated a few episodes of brief, rate-controlled atrial fibrillation. he converted to sinus rhythm with amiodarone and was in sinus rhythm at the time of discharge. anti-coagulation was initiated with coumadin. he has received 3 mg on pod3 and was to receive 5 mg on for an inr of 1.1. inr to be checked on by vna. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home in good condition with appropriate follow up instructions. medications on admission: omeprazole - (prescribed by other provider) - 40 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth twice a day simvastatin - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth once a day medications - otc multivitamin - (prescribed by other provider) - tablet - 1 tablet(s) by mouth once a day omega-3 fatty acids-vitamin e - (prescribed by other provider) - 1,000 mg capsule - 1 capsule(s) by mouth once a day discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*100 tablet, delayed release (e.c.)(s)* refills:*2* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. 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:*1* 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. disp:*30 ml(s)* refills:*0* 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 9. furosemide 20 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 10. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 7 days. disp:*7 tablet, er particles/crystals(s)* refills:*0* 11. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): x 1 week then 400 mg daily x 1 week then 200 mg daily x 1 month. disp:*80 tablet(s)* refills:*0* 12. coumadin 5 mg tablet sig: one (1) tablet po once a day: take as directed for inr goal 2.0-2.5. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna, discharge diagnosis: aortic stenosis, s/p aortic valve replacement pmh: mild coronary artery disease - squamous cell carcinoma of the left vocal cord, s/p chemotherapy/radiation - dyslipidemia - gerd past surgical history: - tonsillectomy - appendectomy - repair of anal fissure - feeding tube during chemo/radiation. this has been removed. discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage trace edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: wound check at cardiac surgery office at at 10:00a cardiologist: dr. at 12:00p surgeon dr. at at 1:30p please call to schedule the following: primary care dr. , c. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr coumadin for atrial fibrillation goal inr 2.0-2.5 first draw day after discharge then please do inr checks monday, wednesday, and friday for 2 weeks then decrease as directed by dr. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Hyposmolality and/or hyponatremia Atrial fibrillation Aortic valve disorders Personal history of tobacco use Other and unspecified hyperlipidemia Personal history of irradiation, presenting hazards to health Personal history of malignant neoplasm of larynx

allergies: oxycontin attending: chief complaint: hypotension in setting of ativan administration major surgical or invasive procedure: diagnostic paracentesis history of present illness: mr. is a 54 year old gentlamen with etoh cirrhosis complicated by ascites and encephalopathy admitted for transient hypotension. the patient was scheduled for outpatient mri liver today, for which he was prescribed 0.5 mg po ativan taken 1 hour prior to arrival. while awaiting mri in the waiting room, the patient became dizzy and states that he "couldn't see" and that he "lost focus." at that time, he lay down on the floor and was noted to have an sbp 70s from a baseline sbp 90-100s. he received 1l ivf, and was transferred to the ed for further evaluation. of note, the patient reports that he last ate at 8 am this morning, with his meal consisting of a bowl of cereal. he does report that he had assocaited nausea, but denies any cp, f/c/s, ha, diaphoresis, palpitations, orthopnea, pnd, le swelling, pain in his legs. he does report chronic diarrhea since starting lactulose. of note, the patient was admitted to county hospital ( ri) from for hepatic encephalopathy, during which he was treated with lactulose and had a large volume paracentesis. in addition, the patient underwent rhc on with 21 mmhg. . in the ed, initial vs 98.0 74 92/58 16 100%ra. he received 1 l ns, had a negative cxr, with labs notable for hyponatremia to 118 and creatinine 2.9, with only prior creatinine 2.6 on . he had a diagnostic paracentesis that was negative for sbp, and was admitted to the micu at the request of liver. . currently, the patient is resting comfortably. he does state on ros that he has had worsening sob over the past 3 days such that he is unable to walk 20 feet without feeling fatigued. past medical history: 1. etoh cirrhosis complicated by diuretic refractory ascites and encephalopathy currently undergoing transplant eval. reports having large volume paracentesis q2wks since . 2. etoh abuse 3. acute kidney injury. 4. hypertension. social history: he denies a history of intravenous drug use. he has a 25- pack year history of tobacco use quitting 15 years ago. he has a history of extensive alcohol use in the past quitting 7 months ago (etoh - last drink ). he is married and has 2 daughters ages 24 and 28. family history: a grandparent had alcoholism. his mother died at age 75 and his father at age 77. there is a history of diabetes and colon cancer in the family. physical exam: on admission: vs - temp 97.3f, 100/63 bp , 90hr , 18r , o2-sat 98% 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 - obese, no fluid waves, soft, nabs, soft/nt/nd, 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 pertinent results: on admission: 08:00pm ascites glucose-125 ld(ldh)-37 albumin-less than 08:00pm ascites wbc-240* rbc-670* polys-10* lymphs-55* monos-28* eos-1* mesotheli-1* macrophag-5* 04:20pm glucose-99 urea n-77* creat-2.9* sodium-118* potassium-4.3 chloride-89* total co2-19* anion gap-14 04:20pm alt(sgpt)-83* ast(sgot)-144* ld(ldh)-235 tot bili-2.0* 04:20pm lipase-182* 04:20pm albumin-1.8* 04:20pm wbc-8.4 rbc-3.09* hgb-11.1* hct-31.9* mcv-103* mch-35.9* mchc-34.8 rdw-14.0 04:20pm plt count-130* 04:20pm plt count-130* 03:04pm creat-2.9* 03:04pm estgfr-using this . cxr: findings: frontal and lateral views of the chest are obtained. blunting of the right posterior costophrenic angles raises concern for small pleural effusion. minimal left mid-to-lower lung atelectasis is noted. no discrete focal consolidation is seen. the cardiac and mediastinal silhouettes are unremarkable. impression: small right pleural effusion. mild left base atelectasis. . echo: no atrial septal defect is seen by 2d or color doppler but a patent foramen ovale is suggested with premature appearance of saline contrast in the left heart with cough. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate sized pericardial effusion around the right atrium. there is a prominent pleural effusion. impression: patent foramen ovale. loculated pericardial effusion suggestive of a pericardial cyst. . renal u/s: impression: 1. technically limited study, however patent bilateral main renal arteries and veins. 2. large amount of ascites. . mri/mrv: impression: non-obstructive infrarenal partial thrombus in ivc, without extension beyond the bifurcation. . lenis: negative for dvt . egd: esophagus: protruding lesions 1 cords of grade i varices were seen in the gastroesophageal junction. the varices were not bleeding. stomach: contents: food was found in the stomach mucosa: diffuse erythema, congestion and mosaic appearance of the mucosa with no bleeding were noted in the stomach. these findings are compatible with portal gastropathy. . on discharge: 04:50am blood wbc-5.3 rbc-2.50* hgb-9.1* hct-25.9* mcv-104* mch-36.2* mchc-35.0 rdw-13.9 plt ct-112* 04:50am blood pt-17.1* ptt-97.3* inr(pt)-1.5* 04:50am blood glucose-105* urean-58* creat-2.4* na-132* k-4.0 cl-100 hco3-21* angap-15 04:50am blood alt-28 ast-57* alkphos-241* totbili-1.7* 08:00pm ascites wbc-240* rbc-670* polys-10* lymphs-55* monos-28* eos-1* mesothe-1* macroph-5* . meld = 19 brief hospital course: mr. is a 54 year old gentleman with etoh cirrhosis complicated by refractory ascites and encephalopathy admitted for transient hypotension. . # hypotension: the patient became hypotensive after taking ativan prior to receiving his outpatient mri for hcc screening. he was briefly dizzy but that felt normal within minutes. he was transported to the ed where he was given ns boluses. he was then admitted to the icu overnight for observation. blood pressures remained stable with sbp in the 80s-90s overnight. the patient was then transferred to the floor where orthostatics were neagative. the patient was asymptomatic with systolics in the 80s-90s. . # hyponatremia: na was 118 on admission. the patient reported having been drinking lots of fluid because he was told it would help his kidneys. he was placed on salt restriction and 1500 - 2l fluid restriction. his sodium gradually improved and was 132 on the day of discharge. he was taught about the importance of salt-restriction in his diet. urine osm/na showed perceived decreased effective circulating volume secondary to cirrhosis. . # prolonged pr: new 1st degree avb compared to prior ecg. he was kept briefly on telemetry without events. . # acute on chronic renal failure: creatinine was 2.9 on admission; past labs revealed a cr of 2.6 on . the patient reported having frequent large volume paracenteses without the administration of albumin. he also reported that he thought his creatinine was usually ~2. he was briefly treated for hepatorenal syndrome (with albumin, octreotide, and midodrine) without much improvement in his creatinine. he had normal urine output. on discharge, cr was 2.4. he was scheduled to see nephrology for consultation for possible renal transplant in addition to liver transplant. . # etoh cirrhosis c/b portal hypertension with ascites and recent admission at osh for hepatic encephalopathy: the patient's transplant evaluation was completed with echo, mri, and egd. egd showed grade i varices and portal hypertensive gastropathy. he was presented to the transplant committee and was listed for transplant. unfortunately, the mri showed an incidental ivc thrombus (see below). he was also scheduled for renal follow-up for possible renal transplant listing. rifaximin and lactulose were continued on discharge. a diagnostic paracentesis on admission was negative for sbp. . # ivf thrombus: infrarenal, non-occlusive thrombus was seen on mri. occupying 30% vessel. likely a result of cirrhosis and decreased anticoagulant proteins. heparin gtt was initially started and was continued for 3 days. coumadin was started. inr was 1.5 on discharge with plans for repeat inr check in 2 days at pcp . goal inr 2-2.5 with anticoagulation for at least 6 weeks. . # etoh abuse: patient reports his last drink was in . he was scheduled to begin substance relapse prevention program at kodak shortly after discharge. . transitional issues: - sodium monitoring - renal function monitoring, possible listing for renal/liver transplant - anticoagulation for ivc thrombus - substance relapse prevention medications on admission: rifaxamin 550 mg dexilant 60 mg daily ciprofloxacin 250 mg daily vicodin prn vitamin d 50,000 units weekly discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po every eight (8) hours as needed for pain or fever: do not exceed 2g in 24 hours (caution: as vicodin contains acetaminophen). 2. ciprofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a week. 7. dexilant 60 mg cap, delayed rel., multiphasic sig: one (1) cap, delayed rel., multiphasic po once a day. 8. vicodin 5-500 mg tablet oral 9. warfarin 1 mg tablet sig: five (5) tablet po once a day: daily at 4pm; requires frequent monitoring of inr; goal inr 2-2.5. disp:*150 tablet(s)* refills:*2* 10. outpatient lab work please draw inr on and provide results to dr. (ph: ). patient should have twice weekly inrs with goal 2-2.5. 11. lactulose 10 gram/15 ml solution sig: 15-30 ml po three times a day: please titrate to soft bowel movements per day. disp:*1 bottle* refills:*2* discharge disposition: home discharge diagnosis: primary: hypotension inferior vena cava thrombus cirrhosis - alcoholic acute vs. chronic kidney disease . secondary: gerd discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure caring for you at the . you were admitted after you became hypotensive prior to your mri. we completed your liver transplant evaluation and you were presented to the transplant committee. dr. would also like for you to see a transplant nephrologist to be evaluated for a possible kidney transplant as your kidney function is abnormal. we incidentally discovered a small thrombus in your inferior vena cava for which you will need to be anticoagulated for at least 6 weeks. coumadin requires very close monitoring with twice weekly inrs - your goal inr is 2-2.5. . we made the following changes to your medications: we started coumadin (warfarin) 5 mg per day; you will need to have your inr checked twice per week - first check this thursday on . we continued lactulose, which you should use to titrate to soft bowel movements per day . we called dr. office and he is willing to manage your coumadin. . your follow-up information is listed below. followup instructions: department: transplant center when: friday at 9:20 am with: , md building: lm campus: west best parking: garage department: echo lab when: friday at 1 pm with: echocardiogram building: gz building (felbeerg/ complex) campus: east best parking: main garage department: endo suites when: thursday at 9:00 am md Procedure: Other endoscopy of small intestine Percutaneous abdominal drainage Diagnoses: Other iatrogenic hypotension Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Portal hypertension Personal history of tobacco use Chronic kidney disease, unspecified Ostium secundum type atrial septal defect Esophageal varices in diseases classified elsewhere, without mention of bleeding Other venous embolism and thrombosis of inferior vena cava Esophageal varices without mention of bleeding Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use

allergies: oxycontin attending: chief complaint: etoh cirrhosis, esrd major surgical or invasive procedure: liver transplant history of present illness: mr. is a 54m with etoh cirrhosis, esrd not on hd, hx of ivc thrombus on coumadin presenting for liver and kidney transplantation. he was recently hospitalized for worsening renal function, however he continues to not require hemodialysis. the patient states that he continues to have baseline urine output and denies lower extremity swelling. he continues to require frequent therapeutic paracentesis; last performed 2 weeks ago at which time 14l were drained; planned on next tap in 1 week. pt received 2 units of prbc this past tuesday. he states that he feels "great" and denies any specific symptoms or complaints. he denies nausea, vomiting, diarrhea, constipation, hematemesis, or melena. . past medical history: - etoh cirrhosis complicated by diuretic refractory ascites and encephalopathy currently undergoing transplant evaluation. frequent large volume paracentesis - etoh abuse - acute kidney injury recent baseline 3.0, multifactorial htn and hrs - ivc thrombus, on coumadin social history: he denies a history of intravenous drug use. he has a 25-pack-year history of tobacco use quitting 15 years ago. he has a history of extensive alcohol use in the past quitting . he is married and has 2 daughters ages 24 and 28. family history: a grandparent had alcoholism. his mother died at age 75 and his father at age 77. there is a history of diabetes and colon cancer in the family. physical exam: vitals: 96.8, 68, 121/86, 16, 100% ra wt: 88.1 kg general: alert, oriented, no acute distress heent: ncat, minimal scleral icterus, lateral nystagmus noted bilaterally; moderately dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi cv: regular rate and rhythm, no murmurs, rubs, gallops abdomen: soft, distended with ascites, bowel sounds present, no rebound tenderness or guarding ext: warm, no clubbing, cyanosis or edema; eschar noted on r forearm, minimal ecchymosis . labs: wbc-9.1 rbc-3.77* hgb-12.7* hct-37.8* mcv-100* mch-33.8* mchc-33.7 rdw-15.2 plt ct-162 pt-40.5* ptt-41.8* inr(pt)-4.2* fibrino-230 alt-45* ast-93* alkphos-419* totbili-2.8* albumin-3.6 calcium-9.3 phos-4.5 mg-2.4 . urine color-yellow appear-clear sp -1.014 urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg urine rbc-0 wbc-1 bacteri-few yeast-none epi-0 urine casthy-29* urine mucous-rare . hepatitis hbsag hbsab hbcab hav ab pnd pnd pnd pnd 05:10 negative negative negative 12:55 negative negative negative positive . hepatitis c serology hcv ab 16:45 pnd 05:10 negative 12:55 negative . hiv serology hiv ab 16:45 pnd 12:55 negative . - virus vca-igg ab (): positive - virus ebna igg ab ():positive - virus vca-igm ab ():negative . toxoplasma igg antibody (): positive . cmv igg antibody (): negative cmv igm antibody (): negative . varicella-zoster igg serology (): positive . rubella igg/igm antibody (): positive . rapid plasma reagin test (): nonreactive . rubeola antibody, igg (): positive . ekg: nsr at 87, poor r wave progression; no st-t changes, no twi . cxr: pre-lim - right pleural effusion, similar to . trace/minimal left pleural effusion. no ptx or new findings compared to prior imaging. . renal us: echogenic kidneys suggestive of medical renal disease. no calculi or hydronephrosis noted. splenomegaly with moderate amount of ascites. . cardiac stress: no anginal symptoms or ischemic st segment changes. appropriate hemodynamic response to the persantine infusion. nuclear report sent separately. . echo: no atrial septal defect is seen by 2d or color doppler but a patent foramen ovale is suggested with premature appearance of saline contrast in the left heart with cough. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate sized pericardial effusion around the right atrium. there is a prominent pleural effusion. impression: patent foramen ovale. loculated pericardial effusion suggestive of a pericardial cyst. . mrv abd/pelvis: non-obstructive infrarenal partial thrombus in ivc, without extension beyond the bifurcation. . pertinent results: 05:22am blood wbc-5.3 rbc-3.17* hgb-10.1* hct-29.1* mcv-92 mch-32.0 mchc-34.9 rdw-16.2* plt ct-176 05:22am blood pt-16.4* ptt-85.3* inr(pt)-1.4* 05:22am blood glucose-78 urean-10 creat-0.8 na-137 k-4.2 cl-105 hco3-23 angap-13 05:22am blood alt-26 ast-11 alkphos-107 totbili-0.5 05:22am blood albumin-2.6* calcium-8.1* phos-2.8 mg-1.7 05:22am blood tacrofk-7.8 brief hospital course: on , he underwent kidney and liver transplant. surgeon was dr. . please refer to operative note for details. he was sent to the sicu for management. postop duplex of liver and kidney demonstrated patent vasculature, no hydro or biliary ductal dilatation. he was hypotensive on postop day 1 and required iv hydration and blood products. hct remained stable. lfts and creatinine improved daily. urine output was excellent. jp drainage was non-bilious. he developed an ileus. ng remained in place until when ileus resolved. diet was slowly advanced and tolerated. pain medication was switched to oral dilaudid. lateral jp drain was removed on and medial on . generalized anasarca improved daily and he only required only lasix x1. weight decreased to 85.8 (down 10 kg from admission wt). in fact, he developed orthostatic hypotension. midodrine was started with improvement. heparin drip was started for h/o ivc thrombus. a few days later, coumadin was started a 1mg daily. dose was increased to 2mg . on , inr was 1.4. dose was increased to 3mg and patient was instructed to get pt/inr done as an outpatient on and . pt worked with him and recommended home pt. vna care of was arranged. he was ambulating with a walker. he tolerated steroid taper to 20mg daily, cellcept and prograf dosing. prograf levels increased to 15.2 on . dose was held and decreased to 1mg . he will go to stay at his sister's home in ri with f/u on . of note, a tte was done when he was in sicu for hypotension. mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the anterior septum and anterior walls, distal septum were noted with ef of 50%. cardiology recommended asa, bb and statin. given orthostatic hypotension, metoprolol was stopped on . asa was on hold as patient was switched from iv heparin to lovenox on day of discharge to home. a f/u cardiology appointment was scheduled for . he will also f/u with hematology given h/o ivc thrombus. he was found to have 60% activity of antithrombin iii. recommendation was to continue anticoagulation and follow-up with dr. to determine the optimal length of anticoagulation. see note from . he was discharged to home in stable condition. medications on admission: ciprofloxacin - 250 mg tablet - 1 tablet(s) by mouth once a day dexlansoprazole - (prescribed by other provider) - 60 mg cap, delayed rel., multiphasic - 1 cap(s) by mouth daily ergocalciferol (vitamin d2) - 50,000 unit capsule - 1 capsule(s) by mouth qweek hydrocodone-acetaminophen - (prescribed by other provider) - 5 mg-500 mg tablet - 1 tablet(s) by mouth as needed lactulose - (prescribed upon d/c) - 10 gram/15 ml solution - 15-30 solution(s) by mouth three times a day please titrate to soft bowel movements per day midodrine - 7.5 mg by mouth three times a day rifaximin - 550 mg by mouth twice a day warfarin - 5mg by mouth daily discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 4. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (tu). 7. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 8. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 9. warfarin 1 mg tablet sig: three (3) tablet po once a day. disp:*90 tablet(s)* refills:*2* 10. tacrolimus 1 mg capsule sig: one (1) capsule po q12h (every 12 hours). 11. outpatient lab work wednesday then every and thursday 12. prednisone 5 mg tablet sig: four (4) tablet po once a day: folow transplant clinic taper. 13. midodrine 5 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 14. enoxaparin 100 mg/ml syringe sig: ninety (90) mg subcutaneous (2 times a day). 15. outpatient lab work wednesday and saturday for stat pt/inr with results called to attn: transplant coordinator 16. colace 100 mg capsule sig: one (1) capsule po twice a day. discharge disposition: home with service facility: vna care discharge diagnosis: etoh cirrhosis s/p liver and kidney transplant ileus orthostatic hypotension h/o ivc thrombus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: please call the transplant office if you have any of the following: fever, chills, nausea, vomiting, jaundice, inability to take any of your medications, increased abdominal distension or pain, incision redness/bleeding/drainage, decreased urine output, weight gain of 3 pounds in a day or any concerns you will need to have blood drawn on wednesday at quest then every and thursday for labs no heavy lifting no driving if taking narcotic pain medications you may shower, no tub baths or swimming followup instructions: department: transplant center when: thursday at 2:10 pm with: , md building: lm campus: west best parking: garage department: transplant social work when: thursday at 3:00 pm with: transplant social worker building: lm bldg () campus: west best parking: garage department: cardiac services when: friday at 9:40 am with: , md building: sc clinical ctr campus: east best parking: garage department: transplant center when: at 9:00 am with: , md building: lm campus: west best parking: garage department: hematology when: wednesday at 2:20 pm with: , md Procedure: Other transplant of liver Other kidney transplantation Total hepatectomy Other operations on lacrimal gland Transplant from cadaver Other operations on lacrimal gland Transplant from cadaver Diagnoses: End stage renal disease Anemia, unspecified Alcoholic cirrhosis of liver Hepatorenal syndrome Other and unspecified alcohol dependence, in remission Other chronic pulmonary heart diseases Personal history of tobacco use Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Nausea with vomiting Long-term (current) use of anticoagulants Paralytic ileus Personal history of venous thrombosis and embolism Hypoxemia Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Accidents occurring in residential institution Orthostatic hypotension Other fluid overload

allergies: no known allergies / adverse drug reactions attending: chief complaint: wound infection, intra-abdominal abscess major surgical or invasive procedure: ct guided drainage of abscess with pigtail drain placement history of present illness: 17 m s/p appendectomy at on for perforated appendicitis. the patient recovered well and had an initial improvement in his symptoms and leukocytosis. on pod2 the patient started experiencing worsening abdominal pain, nausea and vomiting and was transferred to the osh icu where a ct was obtained showing postoperative changes and continued inflammation but no clear abscess. he was taken to the operating room for a exploratory laporotomy on where, per report, an enterotomy or perforation was identified in the terminal ileum. an ileal resection was performed and an end ileostomy was placed, and the patient was taken to the icu for further recovery. following the procedure the patient continued to have abdominal pain and increasing leukocytosis up to . his midline laparotomy wound was opened wound infection. the patient had been receiving zosyn and flagyl and was then switched to imipenem per id recommendation. a repeat ct was obtained on and demonstrated multiple fluid collections and the patient was transferred to for further management. past medical history: pmh: hypogammaglobulinemia psh: appendectomy , ex-lap loa, end ileostomy social history: senior in high school, no etoh, tobacco or drugs, active football player family history: no immunodeficiencies, 2 siblings - one with ? diagnosis of sle, other healthy physical exam: on discharge: avss gen: resting comfortably, nad cv: rrr lungs: ctab abd: open midline abdominal wound with wet/dry dressing in place. appropriately tender around the wound. ostomy pink/viable. ext: warm, well perfused pertinent results: 04:05am blood wbc-18.0* rbc-3.82* hgb-11.3* hct-34.3* mcv-90 mch-29.7 mchc-33.0 rdw-13.9 plt ct-543* 06:35am blood wbc-8.6 rbc-3.59* hgb-10.6* hct-32.2* mcv-90 mch-29.6 mchc-33.0 rdw-13.9 plt ct-642* 04:05am blood glucose-106 urean-11 creat-0.9 na-137 k-5.1 cl-101 hco3-27 angap-14 06:35am blood glucose-86 urean-9 creat-0.7 na-139 k-4.8 cl-102 hco3-28 angap-14 ct abd/pel (): impression: 1. two discrete collections are again visualized throughout the abdomen and pelvis. the previously aspirated, but not drained collection along the right paracolic gutter appears relatively unchanged with a focus of air consistent with prior instrumentation. the right lower quadrant collection with extension to pelvis which was aspirated and had a drain placed appears smaller with resolution of the lateral and superficial portion of the collection anterior to the right psoas muscle. 2. moderate left pleural effusion, which is increased in size in comparison to prior study with adjacent atelectasis. small right pleural effusion with adjacent atelectasis. brief hospital course: mr. was transferred to our trauma surgical intensive care unit from early in the am of . he was seen by dr and his team, and based on the fluid collections seen on osh ct scan, he was sent to ir for percutaneous drainage. the ir team aspirated the right paracolic gutter collection and left a drain in the pelvic collection. this fluid was sent for culture. the patient was initially tachycardic upon admission to the icu, but was otherwise hemodynamically stable. he was transferred to the floor on hd4 in good condition. neuro: his pain was initially well controlled on intermittent iv dilaudid. when tolerating po intake, the patient was switched to vicodin, which was well tolerated. cv: he arrived tachycardic with stable blood pressure. this improved quickly during his hospital stay, and he had no other issues. resp: he had significant oxygen demand upon arrival and cxr showed bilateral effusions and atelectasis. sputum cultures were drawn that were insufficient. patient was concurrently being treated with vancomycin and meropenem for his intra-abdominal abscesses, which was determined to be sufficient for presumed pneumonia as well. the patient was also given intermittent lasix to improve his respiratory status as his lungs looked fluid overloaded. these effusions were followed with serial cxrs and improved throughout his stay. he was weaned off of oxygen on the floor and his breathing remained comfortable. gi/gu/fen: the patient was initially npo/ivf upon admission. his diet was advanced to regular by hd3 and this was well tolerated. ostomy output was nearly 2 liters the first 24 hours of admission. the output remained high the first few days of his hospital stay, but then decreased on its own to an appropriate level without medical intervention. his electrolytes and fluid status were closely monitored and patient was repleted as needed. his open abdominal wound was treated with wet/dry dressing changes tid, and showed continued healing and improvement during his stay. id: he was seen by our id team upon arrival who recommended switching imipenem to meropenem. he was also started on vancomycin at arrival for presumed pna. his abdominal wound was packed with wet to dry dressings. abdominal fluid collections showed vanc sensitive enterococcus and , so fluconazole was added as well. the patient was kept on this antibiotic regimen during his hospital stay. picc line was placed on to continue atbx as an outpatient. repeat ct scan was performed on that showed persistent abscesses in the pelvis and r pericolic gutter. however, after patient's drain was adequately flushed, the drain began to put out purulent material. radiology felt the drain was in good position and did not need to be re-adjusted. the patient was sent home on meropenem, vancomycin, and fluconazole per id's recommendations. prophylaxis: patient was started on sqh and encouraged to ambulate often. dispo: patient received ostomy teaching, picc line teaching, and wound care teaching. he understood all of this and agreed with the plan. he was given discharge instructions and told to keep all follow up appointments as scheduled. medications on admission: zyrtec discharge medications: 1. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 2. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours). 3. vancomycin 500 mg recon soln sig: 1.5g recon solns intravenous q 8h (every 8 hours): through . disp:*12 grams* refills:*0* 4. meropenem 500 mg recon soln sig: 500mg recon solns intravenous q6h (every 6 hours): through . disp:*23 grams* refills:*0* 5. fluconazole 200 mg tablet sig: two (2) tablet po once a day: through . disp:*22 tablet(s)* refills:*0* 6. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. disp:*30 syringes* refills:*0* 7. normal saline flush 0.9 % syringe sig: one (1) syringe injection prn as needed for drain or picc line flush. disp:*100 * refills:*0* 8. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. disp:*30 tablet(s)* refills:*0* 9. loperamide 2 mg capsule sig: capsules po with meals and at bedtime as needed for ostomy output greater than 1200cc/day. disp:*30 capsule(s)* refills:*0* 10. outpatient lab work lab tests: cbc, bun, crea, lfts, esr, crp frequency: qweekly all laboratory results should be faxed to infectious disease r.ns. at ( discharge disposition: home with service facility: of southeastern mass. discharge diagnosis: wound infection, intra-abdominal abscesses discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call your doctor or nurse practitioner if you experience the following: *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 8-12 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. . general discharge instructions: *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 do not engage in any strenous activity until instructed to do so by your surgeon. . wound care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the wound site. *no showering, tub baths, or swimming until cleared by dr. at your follow-up appointment. you may sponge bath until then. *please perform wet-to-dry dressing changes three times daily. you will have a visiting nurse come to help assist you with dressing changes, and they will teach you how to perform these dressing changes yourself. . drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. *be sure to empty the drain frequently. record the output daily. *keep the insertion site clean and dry otherwise. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . monitoring ostomy output/prevention of dehydration: *keep well hydrated. *replace fluid loss from ostomy daily. *avoid only drinking plain water. include gatorade and/or other vitamin drinks to replace fluid. *if ostomy output is greater than 1200ml in one day, please use immodium to slow down the output: 2-4mg with meals and at bedtime, as needed. do not exceed 16mg/24 hours. . picc line care: *please monitor the site regularly, and your md, nurse practitioner, or nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * your md to the emergency room immediately if the picc line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. do not use the picc line in these circumstances. *please keep the dressing clean and dry. contact your nurse if the dressing comes undone or is significantly soiled for further instructions. . antibiotic instructions: *you will be receiving iv antibiotic therapy through your picc line. per infectious disease recommendations, you will be on the following regimen: vancomycin 1.5g iv every 8 hrs start date: stop date: meropenem 500mg iv every 6 hrs start date: stop date: fluconazole 400mg po daily start date: stop date: required laboratory monitoring while on iv antibiotics: lab tests: cbc, bun, crea, lfts, esr, crp frequency: weekly all laboratory results should be faxed to infectious disease r.ns. at ( all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. at ( or to on md in when clinic is closed. followup instructions: 1. provider: scan phone: date/time:. please come to dr. clinic at 8:15am to receive the contrast for your scan. you will then have the cat scan at 9:30am. 2. provider: , md phone: date/time: 10:45am. you will see dr. after your cat scan to go over the results. 3. provider: , md phone: date/time: 9:30am Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Other postoperative infection Unspecified pleural effusion Asthma, unspecified type, unspecified Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Peritoneal abscess Other candidiasis of other specified sites Hypogammaglobulinemia, unspecified Attention to ileostomy Ehlers-Danlos syndrome

allergies: iodine; iodine containing attending: chief complaint: respiratory distress major surgical or invasive procedure: none history of present illness: the patient is a 65-yo woman with interstitial lung disease on chronic immunosuppression, and h/o left breast ca s/p partial mastectomy + adjuvant chemo-xrt, who presented to the ed with dyspnea. pt has been feeling unwell since thursday of last week, when she initially developed symptoms of headache, dizziness, body aches, decreased appetite, and inability to get out of bed. these symptoms have continued since, and since sunday she has had significant dyspnea as well. she has been using her home o2 continuously since sunday (at baseline she only uses 2l nc as needed for dyspnea). she denies any associated cough or sputum production, but endorses mild wheeze, stating it feels like a bronchitis or pneumonia. overnight last night she developed subjective chills and sweats, and this morning she found her temperature to be 101.7f, so she was brought to the ed for evaluation. in the ed, vs - temp 98.0f, bp 128/57, hr 102, r 34, sao2 78% on 2l nc. labs were remarkable for an elevated wbc at 11.6 with 90% pmns, and lactate 3.6, and negative ua. blood cx sent x2. cxr showed low lung volumes, increased interstitial markings c/w chronic fibrotic changes, and interstitial edema; an underlying atypical pneumonia cannot be ruled out. she was given solumedrol 125mg iv x1, levofloxacin 750mg iv x1, vancomycin 1g iv x1, and 2l ns ivf for sbps ~100. she seemed to improve and was changed from nrb to 3l nc, but desaturated to 85% on 3l so was restarted back on the nrb, with good response. cta was done to r/o pe, which showed no pe or acute aortic syndrome; lung fibrotic changes, increased in left lung at site of radiation tx; and no underlying pneumonia. she is being admitted to the micu for further care. on the floor, pt feels significantly improved. she has been on daily steroids and azathioprine for several months, with a recent decrease in her methylprednisolone dose and corresponding increase in her azathioprine dose on her last visit with dr. on . she also complains of mildly painful "pimples" on the sides of her tongue, which she relates to the increase in her azathioprine. she also endorses having stopped her bactrim pcp , but was unsure as to when this was stopped. past medical history: - interstitial lung disease, followed by dr. , last seen , with increase in azathioprine to 150mg daily and decrease in methylprednisolone to 16mg daily - left breast carcinoma grade 3, t1c, n0, er positive, pr negative, her-2/neu negative, s/p partial mastectomy, sentinel node dissection, adjuvant chemotherapy and radiation therapy - hypertension - hypercholesterolemia - depression - gastritis - arthritis - h/o low positive social history: married, lives with husband and three children. originally from el , spanish-speaking only. no history of smoking or drinking. family history: no family history of lung disease. no early cad. sister with breast cancer at 50. no other cancers in the family. physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 12:00pm wbc-11.6* rbc-4.29 hgb-13.4 hct-40.1 mcv-93 mch-31.3 mchc-33.6 rdw-15.2 12:00pm neuts-90.3* lymphs-5.9* monos-3.2 eos-0.4 basos-0.3 12:00pm plt count-246 12:00pm pt-12.5 ptt-20.6* inr(pt)-1.1 12:00pm albumin-4.0 12:00pm ck-mb-1 ctropnt-<0.01 12:00pm lipase-50 12:00pm alt(sgpt)-23 ast(sgot)-46* ld(ldh)-700* ck(cpk)-60 alk phos-66 tot bili-0.6 12:00pm glucose-116* urea n-11 creat-0.8 sodium-136 potassium-5.0 chloride-102 total co2-22 anion gap-17 12:11pm lactate-3.6* 09:35pm ck-mb-1 ctropnt-<0.01 09:35pm ld(ldh)-292* ck(cpk)-26* 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. bal gram stain: no polymorphonuclear leukocytes seen. 4+ (>10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. 4+ (>10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): budding yeast. studies: ecg: normal sinus rhythm. axis at 0 degrees. poor r wave progression. non-specific st-t wave changes in leads v1-v3. compared to the previous tracing of -109 the q-t interval prolongation is no longer present. the t wave inversions in leads v1-v3 persist unchanged. the prior t wave inversions in leads v4-v5 are no longer present. otherwise, no diagnostic interval change. these t wave changes are non-specific. cxr: low lung volumes with increased interstitial markings consistent with chronic fibrotic changes with some component of interstitial edema; an underlying atypical pneumonia cannot be ruled out, so repeat radiograph after diuresis is recommended. ct chest: 1. no pe or acute aortic syndrome. 2. chronic interstitial fibrotic changes in the lungs with increased fibrosis and bronchiectasis of the lingula with subpleural fat consistent with post-radiation changes. tte: the left atrium is elongated. 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) appear structurally normal with good leaflet excursion and no aortic stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: preserved global and regional biventricular systolic function. mild to moderate aortic regurgitation. mild pulmonary artery systolic hypertension. brief hospital course: 65-yo woman with ild on chronic immunosuppression and prn home o2 for symptoms of dyspnea, also with h/o left breast ca s/p partial mastectomy and adjuvant chemo-xrt, admitted to the micu with respiratory distress and hypoxia. #. hypoxia, respiratory distress: pt admitted with worsened hypoxia from baseline, somewhat acute and in setting of recent systemic symptoms. she was also febrile on admission. cxr and cta had a faint suggestion of possible pneumonia, with diffuse faint ground glass opacities new compared to prior cta from 1 year ago, making multifocal pneumonia a possibility. she continued to have o2 sats in the high-90s on 6l nc, but with desaturations to the 60s-70's even with small movements in bed. she was initially started on ceftriaxone and levofloxacin to cover for community acquired pneumonia, and was continued on levofloxacin for a total 5 day course. she was also placed on iv steroids (125mg iv methylprednisolone q6h) for three days and then given high-dose prednisone. she was also started on nac and continued on her home azathioprine. her respiratory status minimally improved with this treatment. she underwent bronchoscopy to rule out occult infection. at the time of discharge, her only positive culture was yeast in the fungal culture that hadn't been speciated. the pulmonary team planned to follow this culture and contact the rehab after discharge if an organism grew that needed treatment. it was not felt that this was likely to be aspergillus. ultimately, it was felt that she likely had an infection on admission that caused a flare of her underlying ild and her persistent hypoxia was a result of worsening of ild. she was discharged still requiring 5l nc and on 40mg prednisone daily. #. interstitial lung disease: she is followed closely by dr. . her pfts have declined considerably over time. she received steroids as above and was continued on azathioprine. it was felt that this presentation resulted from worsening of her ild in the setting of acute infection. it was discussed with the patient that her degree of ild is severe and her oxygenation is unlikely to substantially improve in the future. #. left breast cancer: grade 3, t1c, n0, er positive, pr negative, her-2/neu negative, s/p partial mastectomy with sentinel node dissection and adjuvant chemotherapy and radiation therapy. she was maintained on daily tamoxifen. #. hypertension: she was slightly hypertensive during her stay and is not on any antihypertensives at home. #. gastritis: continued home ppi #. hypercholesterolemia: continued on her home statin #. depression: continued on her home celexa #. thrush: she was started on fluconazole for thrush for a total 14 day course. #. code status and goals of care: she was full code initially during this admission but she decided to change to dnr/dni status during this admission. a long goals of care discussion was held and the patient was also interested in exploring any services that will help her to spend more time with her family. she is being discharged to a rehab facility with plans to possibly transition to hospice depending on her clinical course. medications on admission: - azathioprine 150mg po daily - chlorpheniramine-hydrocodone 10mg-8mg/5ml tsp po q12hr prn severe cough - celexa - methylprednisolone 16mg po daily - omeprazole 20mg po daily - simvastatin 20mg po daily - sulfamethoxazole-trimethoprim 800mg-160mg po 3x/week - pt states this was stopped - tamoxifen 20mg po daily - acetaminophen 500mg po prn - ergocalciferol - loratadine discharge medications: 1. azathioprine 50 mg tablet sig: three (3) tablet po daily (daily). 2. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 4. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 5. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 6. tamoxifen 10 mg tablet sig: two (2) tablet po daily (daily). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 8. ergocalciferol (vitamin d2) 400 unit tablet sig: one (1) tablet po once a day. 9. fluconazole 100 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 10 days: last day . 10. insulin lispro 100 unit/ml solution sig: per sliding scale while on steroids subcutaneous asdir (as directed). 11. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for sleep. 12. prednisone 20 mg tablet sig: two (2) tablet po daily (daily). 13. acetylcysteine 20 % (200 mg/ml) solution sig: six hundred (600) mg miscellaneous tid (3 times a day). 14. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. discharge disposition: extended care facility: roscommon on the parkway - discharge diagnosis: primary diagnoses: - interstitial lung disease - community acquired pneumonia secondary diagnosis: - history of breast cancer - left breast carcinoma - hypertension - hypercholesterolemia - depression - gastritis - arthritis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). o2 sats: 93-97% on 5l nc, desats to 60's-70's with ambulation but recovers when rests. needs oxygen supplementation at all times. discharge instructions: you were admitted to the hospital with shortness of breath and increasing oxygen requirements. you were treated for a pneumonia and for a worsening of your interstitial lung disease. you continued to require a large amount of oxygen supplementation and you are being discharged to a rehabilitation facility. changes to your medications: added fluconazole 100mg by mouth daily for 10 more days (last day ) restarted bactrim 1 double strength tablet 3 times weekly increased prednisone to 40mg by mouth daily added trazodone 25mg by mouth at bedtime as needed for sleep increased omeprazole to 20mg by mouth twice daily added acetylcysteine 20% 600mg po by mouth three times daily added guaifenesin 100mg/5ml syrup: 5-10ml by mouth every 6 hours as needed for cough followup instructions: you have the following appointments scheduled: department: medical specialties when: monday at 2:00 pm with: , m.d. building: campus: east best parking: garage Procedure: Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Pure hypercholesterolemia Unspecified essential hypertension Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Candidiasis of mouth Postinflammatory pulmonary fibrosis Hypoxemia Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Arthropathy, unspecified, site unspecified

allergies: percocet / vicodin attending: chief complaint: shortness of breath, exertional dyspnea major surgical or invasive procedure: mitral valve replacement (33mm st. tissue)/ coronary artery bypass grafts x 4 (lima-lad, svg-om, svg-dg, svg-pda) left and right heart catheterization, coronary angiography history of present illness: 80m with history of coaornary disease who was in usual health until two weeks ago when he noted progressively worsening dyspnea and orthopnea. his symptoms progressively worsened and he presented to on and was found to be in heart failre with a bnp of 2351 and a borderline troponin of 0.15. an echo was performed and showed lvef of 25%. he was diuresed with iv lasix and was oxygenating well on 2l nc but still had dyspnea. of note, the patient's last stress test was in and was unremarkable with preserved lvef. he received metformin and lovenox on morning of transfer and was not given plavix. he was transferred to for catheterization. at cath, he was found to have severe three vessel coronary artery disease, moderate to severely elevated right and left sided filling pressures and depressed cardiac index and ejection fraction with diffusely hypokinetic left ventricle. he was referred for surgical revascularization. past medical history: osteoporosis spinal stenosis hx of asbestos exposure kidney stones- s/p lithotripsy colon polyps hyperlipidemia glaucoma peripheral vascular disease. diverticulosis colonic polyps hypertension diabetes social history: quit smoking 44 years ago, previously had a 15 pack-year history. there is no history of alcohol abuse. family history: there is no family history of premature coronary artery disease or sudden death. father died of cva. no other known fh of cvd. pertinent results: cardiac cath: 1. coronary angiography of this right dominant system revealed severe, calcific three vessel coronary artery disease. the lmca did not have focal stenoses. the lad had a 90% stenosis in the mid-vessel. the proximal portion of the major diagonal branch had a 70% stenosis. the lcx had a 99% stenosis at the origin, with left to left collaterals. the rca was totally occluded proximally, with left to right collaterals. 2. resting hemodynamics revealed moderate to severely elevated right and left sided filling pressures (rvedp 19 mm hg, lvedp 25 mm hg, respectively). the pcwp mean was elevated at 28 mm hg. there was moderate pulmonary artery hypertension (pasp 59 mm hg). the systemic arterial blood pressure was low-normal (sbp 105 mm hg). the cardiac index was depressed at 1.7 l/min/m2. the systemic and pulmonary vascular resistances were mildly elevated at 1697 dynes-sec/cm5 and 315 dynes-sec/cm5, respectively. 3. left ventriculography demonstrated a dilated left ventricle with global, severe hypokinesis to akinesis, with estimated ejection fraction of 25%. there was moderate to severe mitral regurgitation. echo: the left atrium is dilated. the right atrium is markedly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is moderate to severe regional left ventricular systolic dysfunction with inferior/inferolateral and inferoseptal akinesis. overall left ventricular systolic function is moderately depressed (lvef= 30 %). with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. an eccentric, medially directed jet of at least moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: mr. was found to have triple vessel disease on catheterization, with right heart pressure elevated and mitral regurgitation. he was taken to the operating room on where coronary bypass grafting and mitral valve replacement were performed. see operative note for details. he weaned from bypass on milrinone,epinephrine and neosynephrine. postoperatively he was relatively stable and was extubated on . his epinephrine was weaned and discontinued as was his neosynephrine by pod 2. the milrinone was then slowly weaned and he remained stable. he was gently diuresed, however, he became hypotensive each time he received a lasix bolus. a lasix drip was instituted with a good diuresis and stable blood pressure. consult was obtained from the chf service-- we appreciate their recommendations. the patient was transitioned from the lasix gtt to bolus treatment, which he tolerated well. he made good progress with physical therapy before discharge. by the time of discharge, the patient was ambulating with assistance, the pain was controlled with oral analgesics, and the woundf was healing. he was discharged on pod 15 to the rehab of and islands for further recovery. medications on admission: prilosec 20 qd altace 10 qd metformin 1000 qam, 500 qpm crestor 10 qd asa 81 mvi ca vit d actonel 35 qfriday lasix timolol 0.5% to l eye discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. crestor 40 mg tablet sig: one (1) tablet po once a day. 4. captopril 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 5. furosemide 10 mg/ml solution sig: four (4) injection (2 times a day). 6. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. metformin 500 mg tablet sig: one (1) tablet po three times a day. 9. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po bid (2 times a day). 12. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 15. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed. 16. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 17. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous asdir (as directed). 18. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 19. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. discharge disposition: extended care facility: hospital of & islands - discharge diagnosis: congestive heart failure coronary artery disease diabetes mellitus dyslipidemia hypertension peripheral vascular disease h/o nephrolithiasis chronic anemia spinal stenosis glaucoma osteoporosis diverticulosis colonic polyps discharge condition: good discharge instructions: no lifting more than 10 pounds for 10 weeks no driving for 4 weeks and off all narcotics report any temperature greater than 100.5 report any redness or drainage from incisions shower daily, no baths or swimming take all medications as directed no lotions, powders or creams to incisions followup instructions: dr. in 4 weeks () dr. in 2 weeks dr. in weeks Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart Open and other replacement of mitral valve with tissue graft Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Chronic kidney disease, unspecified Osteoporosis, unspecified Personal history of urinary calculi Acute combined systolic and diastolic heart failure Asbestosis Cervicalgia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory failure, acute renal failure, emergent dialysis major surgical or invasive procedure: hd catheter placement femoral line placement hemodialysis x 6 history of present illness: this is a 26 yo spanish speaking m, otherwise healthy, who presented initially to the ed with a history of couple of weeks of cough, more recently n/v, blurry vision in the last few days which then developed into acute dyspnea with pink frothy sputum. at , he was found to have a low grade fever, and multiple electrolyte abnormalities, most notably a creatinine of 21.6, hct 16, plts 88, and k 6.0. he was given blood, kayexalate, insulin, d50, amp bicarb x 1, protonix, and was sent to the ed for further management. . on arrival here, he was tachypneic with lots of pink frothy sputum, and was satting 92% on a 100%nrb. his other vitals were af 98.7 240/110 80's. on exam, he was diffusely rhonchorous and crackly on exam. he was started on a nitro gtt which quickly became maxed without benefit to either his blood pressure or his breathing. he was initially tried on cpap but did not tolerate the mask secretions and was intubated with etom/succ. 2 large bore iv's. propofol gtt started. bedside u/s showed hyperdynamic heart function, no effusion. he is undergoing a head ct for headache and elevated bp's and will be sent to the icu for emergent dialysis and respiratory failure. pressure 220's currently. . on arrival to the icu, the patient is intubated and sedated, maxed on nitro gtt with bp's in the 170's, tachycardic. past medical history: none social history: per osh ed notes, no etoh, tobacco or illicits. has a brother/cousin who was with him there. lives with a friend. has a spot for ongoing hemodialysis treatments in , ma but needs to have his essential mass health status upgraded to limited, before they will accept him. they will not accept him with the "limited" number still pending. family history: per patient's brother, family is healthy, there are no renal or pulmonary problems and he denies bleeding dyscrasias, joint or heart disease. physical exam: vitals: t: bp: 177/110 p: 114 sat 100% a/c 500x14 peep 10 fio2 0.5 general: intubated and sedated heent: perrl, pupils pinpoint. sclerae anicteric, mmm, oropharynx clear; nares with crusted blood. unable to visualize discs at this time. neck: supple, jvp to 9cm, no lad lungs: rhonchorous diffusely with scattered rales cv: regular rate and rhythm, 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 neuro: +clonus at ankles pertinent results: 03:14am wbc-10.7 rbc-2.45* hgb-7.5* hct-21.0* mcv-86 mch-30.6 mchc-35.5* rdw-14.4 03:14am neuts-85.5* lymphs-9.5* monos-3.7 eos-1.0 basos-0.3 03:14am glucose-146* urea n-161* creat-21.3* sodium-148* potassium-4.2 chloride-108 total co2-20* anion gap-24* 03:14am alt(sgpt)-26 ast(sgot)-24 ck(cpk)-543* alk phos-75 tot bili-0.6 03:14am ctropnt-0.20* 05:35am urine blood-lg nitrite-neg protein-500 glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 05:35am hcv ab-negative 05:35am hbsag-negative hbs ab-negative hbc ab-negative 05:35am -negative 05:35am anca-negative b 05:35am c3-108 c4-27 01:25pm dsdna-negative 01:25pm pth-424* 01:25pm ld(ldh)-758* ck(cpk)-476* 01:25pm haptoglob-<20* 04:27pm blood hypochr-2+ anisocy-normal poiklo-2+ macrocy-normal microcy-normal polychr-normal ovalocy-occasional burr-occasional stipple-occasional bite-1+ acantho-occasional fragmen-occasional 04:27pm blood plt ct-76* 07:45am blood plt ct-225 01:25pm blood pt-14.2* ptt-73.5* inr(pt)-1.2* 08:10am blood ret aut-2.0 01:25pm blood aca igg-2.5 aca igm-7.2 03:14am blood glucose-146* urean-161* creat-21.3* na-148* k-4.2 cl-108 hco3-20* angap-24* 07:45am blood glucose-121* urean-102* creat-13.8* na-137 k-6.1* cl-100 hco3-15* angap-28* 05:35am blood ld(ldh)-788* totbili-0.6 dirbili-0.2 indbili-0.4 06:45pm blood ld(ldh)-595* totbili-1.4 03:14am blood ctropnt-0.20* 08:10am blood ck-mb-4 ctropnt-0.41* 03:14am blood calcium-6.2* phos-7.3* mg-3.6* 07:45am blood calcium-9.1 phos-7.8* mg-3.0* 06:45pm blood hapto-52 08:55am blood hiv ab-negative 05:35am blood anti-gbm-test - test result reference range/units gbm ab 4 u/ml (high) <3 negative >=3 positive cardiology report ecg study date of 3:10:36 am sinus tachycardia. modest st junctional depression which is non-diagnostic. no previous tracing available for comparison. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 121 108 82 318/424 71 -3 65 , a. eu 3:16 am chest (portable ap) clip # reason: r/o chf medical condition: 26 year old man with desats, pink sputum with new arfand low plt. reason for this examination: r/o chf final report indication: 26-year-old male with desaturation, pink sputum, and new acute renal failure. evaluate for chf. single ap chest radiograph demonstrates bilateral diffuse airspace opacity. differential consideration include non-cardiogenic pulmonary edema, multifocal pneumonia or possibly diffuse hemorrhage. there is no pleural effusion or pneumothorax. the cardiomediastinal contour is normal. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sat 11:25 am , p. med fa2 5:22 pm ct abdomen w/o contrast; ct pelvis w/o contrast clip # reason: patient with new tenderness in left flank s/p renal biopsy ? medical condition: 26 year old man with iga nepropathy in esrd on hd, receiving dialysis. reason for this examination: patient with new tenderness in left flank s/p renal biopsy ? perinephric hematoma contraindications for iv contrast: end stage renal disease;end stage renal disease final report study: ct of the abdomen and pelvis. history: 26-year-old male with iga nephropathy on hemodialysis. new tenderness of left flank. assess for hematoma. technique: non-contrast mdct axial images of the abdomen and pelvis were acquired. coronal and sagittal reformatted images were then obtained. ct of the abdomen without contrast: the lung bases are clear. the liver, gallbladder, spleen, adrenal glands, stomach, pancreas, and abdominal portions of the large and small bowel appear unremarkable. the right kidney is normal in size and there is no perinephric stranding. there is a moderate sized left perinephric hematoma with heterogeneous internal density including a few areas of higher attenuation within the lower pole of the left kidney (2:22, 23, 300b:36). the largest dense area within the lower pole seen best on coronal images measures 2.8 x 2.4 cm (300b:36). the hematoma tracks along the capsule without evidence of large subcapsular component, and tracks within gerota's fascia on the left, extending to the psoas medially. along the inferior margin of the left kidney, the collection measures approximately 5.8 x 6.3 cm (300b:30). the right kidney is unremarkable. there is no free fluid or free air within the abdomen. ct of the pelvis without iv contrast: the prostate, bladder, rectum, sigmoid colon, and intrapelvic loops of small bowel appear unremarkable. there is no free fluid within the pelvis. osseous structures: there are no suspicious lytic or blastic lesions. impression: moderate left perinephric hematoma, status post recent biopsy. brief hospital course: 26 yo m with no pmh admitted with respiratory failure and marked acute renal failure of unknown etiology. # respiratory failure: likely secondary to flash pulmonary edema in the setting of malignant hypertension. mostly pink frothy sputum and not hemoptysis, but on admission, a pulmonary-renal syndrome was within the ddx. cxr showed diffuse infiltrates characteristic of pulmonary edema and bnp was very elevated. mini bal did not show evidence of eosinophilia. due to unstable shortness of breath with decompensating o2 sats, the patient was intubated in the er, started on a propafol drip and transfered to the micu. once dialyzed, the patient was weaned and extubated quickly with no further respiratory issues. throughout the remainder of his stay he was kept on prn albuterol and ipratropium, and never complained of shortness of breath, nor did he suffer and desaturation incidents. . # acute renal failure: in the emergency department the patient's creatinine was elevated to 21.3 and a his bun of 161. the patient met all but one of the indications for dialysis (acidosis, electrolyte derangements, overload and uremia) underwent emergent line placement and hd. etiologies initially considered were ttp/hus (although thrombocytopenia was not profound), vasculitic process including wegener's, microscopic polyangiitis, churg- (but no eos on peripheral smear), hsp (no skin findings on exam), cryoglobulinemia (but he is young for this dx), anti-gbm, and goodpasture's. sle was also on the differential initially. a broad work up was initiated, but ua with large blood and 500 protein without dyspmorphic red cells/red cell casts on sediment seemed to direct away from acute gn or vasculitis, and peripheral smear had relatively few schistocytes with normal bili, and with fairly high platelet count, so ttp also seemed unlikely. renal u/s showed atrophic kidneys and elevated pth, suggesting chronic renal failure. anca, , dsdna, hepatitis serologies were all negative, and c3 and c4 levels were wnl. renal bx was done on . the patient had hiv, hepatitis, and ppd tests that were negative. an anti gbm antibody study came back high at 4 (upper limit of 3) assumed a likely false positive given that biopsy results revealed iga nephropathy with profoundly sclerosed glomeruli. the patient had a tunneled hemodialysis catheter placed and was started on dialysis. over the course of his hospitalization, with dialysis treatments, his weight was reduced from 62.6 kg to 56.4 kg. his symptoms of nausea/vomiting abated early. 6 days post biopsy, the patient developed a 6cm x 6cm perinephric hematoma. the bleeding was contained and his pain treated. . # hypertensive emergency: on nitro gtt initially, but weaned off on arrival to micu with fent/versed. received hd for acute management. ct head without obvious bleed. bp between 140 and 170 systolic in unit. on floor managed with amlodipine 10mg po daily until bp controlled only with hd. final bp of 118/87. had one episode of hypertension post dialysis on hd#5 treated with 10mg iv hydralazine. blurry vision and ha both resolved following first dialysis treatment. no evidence of ongoing end organ damage present. . # anion gap metabolic acidosis - ag was 20, and delta-delta was 1.6 on admission indicating a pure ag metabolic acidosis (although given the renal failure there is likely a component of ng acidosis as well). this was most likely due to uremia; the patients acidosis corrected with regular dialysis treatment. . # elevated ce's: patient was very volume overloaded and with arf so the likely etiology was significant strain; however, we considered myocarditis in the setting of vasculitis, specifically wegener's. ekg had nonspecific findings but no evidence of acute ischemia. these trended downward over the course of admission without the patient complaining of chest pain or difficulty breathing. . # anemia/thrombocytopenia: unclear why platelet count was low as this is not characteristic of uremia, but anemia initially considered to be secondary to malignant htn. hematology was consulted given the possibility of a ttp/hus picture, though there were too few schistocytes, and primitive platelet forms on the peripheral smear to warrant this diagnosis. following the renal biopsy, and the discovery of change more consistent with a chronic etiology to his renal failure, the anemia was believed to be secondary to poor epo output. on hd#7 he received 2 units of packed red blood cells prior to dialysis, however, his hematocrit continued to fall gradually. on hd#9 a 6 cm x 6 cm perinephric hematoma was discovered on ct. the patient's hct was 32 and bleeding was well controlled upon discharge. his platelet count was within normal by time of discharge. . # uti, on hospital day 7 the patient began spiking low grade fevers to the 100.4 range. urinalysis revealed a pattern consistent with a uti and the patient was started on 500mg of po bid ciprofloxacin for treatment. given his hemodialysis this was considered to be safe. . # fen: the patient was intubated at first and kept npo while in the micu, after transfer to the floor, he was placed on a renal diet. he did not enjoy the renal diet. nutrition was consulted to provide him with an appropriate modification of his usual diet at home. . # code: patient is full code medications on admission: none discharge medications: 1. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. disp:*20 tablet(s)* refills:*0* 2. ciprofloxacin 500 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* 3. sevelamer hcl 800 mg tablet sig: three (3) tablet po three times a day. disp:*270 tablet(s)* refills:*2* 4. nephrocaps 1 mg capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: iga nephropathy acute on chronic renal failure. discharge condition: the patient was discharged hemodynamically stable, afebrile, and with appropriate follow up. discharge instructions: you were admitted to the hospital because of your shortness of breath, cough productive of pink frothy sputum, nausea, vomiting, inability to eat, and lab tests that suggested that you had acute kidney failure. because of your pink frothy sputum you could not breathe and had to have a tube placed down your throat to help you. after you received your first dialysis treatment, this tube was removed. afterward, you received an ultrasound of your kidneys which revealed them to be smaller than they should have been. you then had a ct scan that confirmed this. a biopsy was taken of your kidney that revealed the cause of your symptoms to be a condition called iga nephropathy. this condition has likely been present for a very long time and has been damaging your kidneys during that time period without you even being aware of it. because of your kidney failure, you had a hemodialysis catheter(tube for dialysis) placed in your chest, and began to receive hemodialysis treatments every other day. during your hospitalization you were treated with a number of medications: amlodipine for your blood pressure, albuterol and iprotropium for your breathing, sevelamer to remove phosphate from your blood, and pantoprazole to prevent the burning feeling in your stomach. on your 9th day of hospitalization, you experienced some left sided flank pain for which you were evaluated with a ct scan of your abdomen and pelvis. the ct scan showed that you had a small bleed to the side of your kidney where your biopsy had been taken. you were given medication for the pain. please take the sevelamer medication, three pills, three times daily to prevent buildup of phosphate in your blood. please continue to take the antibiotic ciprofloxacin twice a day for 7 days. please take the nephrocaps 1 pill once a day. you have been given some pills for pain, please take one or two every 6 hours for pain. you do not need to take amlodipine. please keep your follow up appointments as listed below. should you experience further nausea, vomiting, headache with blurry vision, coughing up blood, or any other concerning symptoms, please return to the hospital at once. followup instructions: please return to the hospital for dialysis treatment 11:30am , every monday, wednesday, and friday. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Hemodialysis Venous catheterization for renal dialysis Closed [percutaneous] [needle] biopsy of kidney Diagnoses: Thrombocytopenia, unspecified End stage renal disease Anemia, unspecified Urinary tract infection, site not specified Acute kidney failure, unspecified Hematoma complicating a procedure Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney

allergies: demerol / morphine / hydrocodone / codeine attending: chief complaint: s/p fall major surgical or invasive procedure: cardiac catheterization history of present illness: 85 yo f with htn, polymyalgia rheumatica, transferred from for cardiac catheterization. the patient was in her usual state of health until wednesday , when she developed black diarrhea, occuring 5 times daily. the patient attributes the black color to her iron supplements. along with diarrhea, the patient also experienced 2 episodes of vomiting (clear, no blood or coffee grounds). the patient also had fever to as high as 100.6 on friday and saturday . on sunday , the patient became lightheaded when getting up from the toilet and fell, hitting her head and right elbow. she presented to , where head and c-spine ct were negative. she developed chest pain after admission, relieved with metoprolol and nitroglycerin. she received 1 unit of rbcs for hct 27, and became short of breath. she was given 40mg iv lasix and diuresed 500cc. she ruled in for mi with third set of troponins peaking at 0.26. she was transferred to for cardiac catheterization on 100% non-rebreather and a heparin gtt. of note, pt was guaiac positive on admission. on arrival to , the patient was taken to the cardiac catherization lab, where she was found to have severe 3-vessel disease and an elevated lvedp (see below for details). she was transferred to the ccu on a non-rebreather for further management. in the ccu, the patient was weaned to a non-rebreather. she reported that her breathing was improved and had no other complaints. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, cough, hemoptysis, or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. she denies sore throat, sinus congestion, dysuria. she denies weakness, tingling, or numbness. all of the other review of systems were negative. cardiac review of systems is notable for chest pain and lightheadedness as above and two pillow orthopnea. no syncope. the patient reports a recent decrease in exercise tolerance from 100 feet on a flat surface to 50 feet on a flat surface. past medical history: 1. cardiac risk factors: +hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: hypertension diastolic chf chronic kidney disease (baseline 1.5-1.7) right bbb mrsa in nares atrial fibrillation gout cellulitus polymyalgia rheumatica diverticulosis depression and anxiety s/p cholecystecomty/appendectomy s/p tonsillectomy s/p surgery for anal fissure social history: retired. worked as secretary. lives alone at . -tobacco history: quit 40 yrs ago; smoked 1 ppd x 30 years -etoh: denies -illicit drugs: denies family history: father with stroke at 68. mother with mi at 65. two brothers with htn. had 4 children (one died). physical exam: (per admitting resident) vs: t=97.5 bp=129/54 hr=69 rr=18 o2 sat=96%/6l general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. cta anteriorly (could not sit up due to recent cath). abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, or xanthomas. pulses: right: radial 2+ dp 2+ pt 2+ left: radial 2+ dp 2+ pt 2+ pertinent results: admission labs 05:30pm blood wbc-13.7* rbc-3.60* hgb-9.7* hct-29.4* mcv-82 mch-27.0 mchc-33.0 rdw-14.9 plt ct-311 05:30pm blood neuts-92.2* lymphs-5.4* monos-2.1 eos-0.3 baso-0 11:01pm blood pt-12.0 ptt-26.0 inr(pt)-1.0 11:01pm blood glucose-174* urean-31* creat-1.5* na-141 k-3.3 cl-105 hco3-22 angap-17 11:01pm blood ck(cpk)-110 11:01pm blood ck-mb-3 ctropnt-0.14* 11:01pm blood calcium-8.6 phos-4.3 mg-1.9 05:33pm blood type-art o2 flow-15 po2-75* pco2-34* ph-7.46* caltco2-25 base xs-0 intubat-not intuba discharge labs 05:42am blood wbc-14.9* rbc-3.43* hgb-9.8* hct-29.3* mcv-86 mch-28.4 mchc-33.2 rdw-15.2 plt ct-360 05:42am blood pt-12.1 ptt-25.7 inr(pt)-1.0 05:42am blood glucose-103* urean-36* creat-1.4* na-139 k-4.2 cl-98 hco3-32 angap-13 05:42am blood calcium-8.8 phos-2.2* mg-2.1 04:05am blood %hba1c-6.1* eag-128* cxr () - the size of the cardiac silhouette is at the upper range of normal, there is no evidence for overt pulmonary edema. in the right upper lobe as well as in the entire left lung, the interstitial markings are increased, there are patchy areas of opacities, that are ill-defined and distributed in a mainly peribronchial pattern. in addition, a small left basilar atelectasis and a small left pleural effusion is seen. overall, the morphology and distribution of the changes suggests multifocal pneumonia rather than pulmonary edema. no evidence of right basal changes, no evidence of right-sided pleural effusion. cxr () - in comparison with study of , there has been placement of left subclavian picc line extends to the mid portion of the svc. there has been some decrease in the bilateral patchy areas of opacification, most likely consistent with improving pneumonia. cardiac cath () - 1. coronary angiography in this right dominant system demonstrated severe three vessel cad. the lcx was the least stenosed and there was no obvious single culprit stenosis. the lmca had distal calcification with a hazy 30% stenosis. the lad was heavily calcified with diffuse disease throughout with serial 60% stenoses just before a major d4 with a distal 85% stenosis and an 80% apical stenosis. there was a high d1, functionally a large septal branch which was patent. a large d2 and d4 were also patent. the lcx was tortuous proximally with slow flow and mild diffuse disease in the av groove lcx. om branch had a proximal 50% stenosis with a tortuous upper pole and mild diffuse disease in the lower pole. the distal av groove lcx supplied collaterals to the distal rca system. the rca was heavily calcified with a 40% ostial stenosis without pressure dampening. there was proximal diffuse disease up to 75% and distal diffuse disease before the rpda up to 45%. there was moderate diffuse disease throughout the rpda with severe diffuse disease in the distal av groove rca supplying the rpls with slow flow (? severe disease vs. competitive flow from collaterals). septal collaterals from the lad fill the rpda. 2. limited resting hemodynamics revealed mildly elevated ra pressure with a mean rap of 9 mmhg. there was severely elevated left sided filling pressures with an lvedp of 29 mmhg. there was moderate systemic arterial systolic hypertension with an sbp of 160 mmhg. no cardiac index could be calculated as unable to float pwp catheter beyond ra. 3. modest hypoxemia (o2 sat 93% on 15l nrb mask) improved to 96% with the addition of 2l via nasal cannula arguing against significant shunt physiology. final diagnosis: 1. severe three vessel cad. 2. severe left ventricular diastolic dysfunction. brief hospital course: 85 yo f with htn, afib, dchf, ckd, h/o guaiac-positive stools, transferred from for cardiac catheterization in the setting of elevated cardiac enzymes, new focal wall motion abnormalities, and worsened mr. to have extensive 3-vessel disease. # coronary artery disease: pt noted to have a troponin leak at an osh, with peak of 0.26. was transferred to for cardiac catheterization, which revealed three-vessel disease. given this, pt is a poor candidate for pci. after much discussion, pt decided that she would not want cardiac surgery. medical management was pursued. during her hospitalization, she experienced episodes of chest discomfort, particularly at night. she did not exhibit any ecg changes during these episodes. her metoprolol was uptitrated, and she was started on a long-acting nitrate for further antianginal activity. by the time of discharge, she had been free of chest pain for several days. # acute on chronic diastolic hf / worsened ritral regurgitation: echo at osh showing new focal wall motion abnormalities and worsened mr, likely of ischemic etiology. on presentation, she was thought to be hypervolemic. metoprolol and amlodipine were tirated for optimum bp control / afterload reduction. the option of mitral valvular surgery was addressed, but the patient was not interested in cardiac surgery. she was diuresed with bolus iv lasix, which was converted to po lasix prior to discharge. # pneumonia: cxr performed on was suspicious for multifocal pneumonia. pt was initially started on broad-spectrum coverage with vancomycin, cefepime, levofloxacin. she was noted to spike a fever on the night of ; however, she remained afebrile after that. she did also have a leukocytosis throughout her hospitalization, which was improving at the time of discharge. on , her antibiotics were narrowed to levofloxacin, as she had no positive cultures and appeared improved clinically. of note, at the time of discharge, she did continue to have an oxygen requirement, which was likely multifactorial in etiology (see below). # gi bleeding: the patient was noted to have guaiac positive stools during her hospitalization. she did have one episode of a hematocrit drop, for which she received a unit of prbcs. her hematocrit remained stable after that. she also complained of some episodes of dysphagia, with food getting "stuck" in her throat. she states that this has been occuring for some time. she was seen by gi for both of these issues. further evaluation with a barium swallow was recommended as an outpatient. further work-up of her gi bleeding should also be pursued as an outpatient. of note, in the setting of this gi bleeding, her aspirin dose was decreased and her ppi dose was increased. her iron was also discontinued. # oxygen requirment: likely multifactorial in the setting of the patient's pneumonia and severe mr. treatment as above. # positive blood cx: one blood cx positive for gpr's. likely a contaminant. speciation pending and not further cultures positive at the time of d/c. # pre-diabets: pt was noted to have elevated blood sugars in the ccu. a1c was 6.1, consistent with pre-diabetic state. this should be further followed as an outpatient. # chronic kidney disease: baseline creatinine 1.5 to 1.7. the patient remained at her baseline throughout the hospitalization. ace inhibitors was held in the setting of her kidney disease. # diarrhea: pt presented with some recent diarrhea in the setting of recent fever and chills. stool cultures were sent, including c.diff, and were negative. her diarrhea improved. # vitamin d repletion: pt's previous vitamin d regimen was not entirely clear. she is being discharged on 1000 units of vitamin d3 daily. this may be adjusted as an outpatient if more significant vitamin supplementation is desired. # polymyalgia rheumatica: continued on home prednisone dose. # anxiety/depression: continued on nortriptyline and zyprexa at home dose. medications on admission: ativan 0.5 mg daily prn tylenol 650 mg q4h prn prochlorperidzine 10 mg q6h prn lidoderm 5% patch apply to left hip for 12 hours on 12 hours off norvasc 5 mg daily prilosec 20 mg daily nortriptyline 10 mg daily metoprolol er 100 mg daily vitamin d 50,000 units weekly for 4 weeks, then monthy prednisone 10 mg daily drisdol once a month ferrous sulfate 325 mg tylenol 1000 mg po bid calcium carbonate 500 mg tid acidophilus 1 capsule zyprexa 5 mg daily trazodone 12.5 mg po qhs senna 1 tab discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for nausea . 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) topical once a day: to right hip, 12 hrs on, 12 hrs off. 6. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. nortriptyline 10 mg capsule sig: one (1) capsule po hs (at bedtime). 9. metoprolol succinate 200 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day: total dose = 225mg/day. 10. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day: total dose = 225mg/day. 11. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 12. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 13. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 14. acidophilus capsule sig: one (1) capsule po twice a day. 15. olanzapine 5 mg tablet sig: one (1) tablet po once a day. 16. trazodone 50 mg tablet sig: 0.25 tablet po hs (at bedtime) as needed for insomnia. 17. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 18. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual x3 as needed for cp : up to three doses separated by 5 min. if not resolved after three, call physician. 19. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days: start am. 20. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for reflux. 21. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po daily (daily). 22. aspirin 81 mg tablet, chewable sig: two (2) tablet, chewable po daily (daily). 23. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: of discharge diagnosis: primary: acute on chronic diastolic heart failure pneumonia coronary artery disease secondary: chronic kidney disease guaiac positive stool discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: out of bed with assistance discharge instructions: you were admitted to for a heart catheterization to evaluate for coronary disease. we found disease in all 3 blood vessels as well as a leaky mitral valve. you declined to have heart surgery to repair these problems. we removed extra fluid with medications called diuretics and treated you for a pneumonia. please take all medications as prescribed. we have made the following medication changes: stopped: lorazepam (ativan) ferrous sulfate (iron) changed: increased metoprolol succinate to 225mg daily vitamin d to 1000 units daily started: atorvastatin for cholesterol levofloxacin for 4 days (antibiotic for pneumonia) isosorbide mononitrate for chest pain aspirin for blood thinning furosemide to prevent fluid buildup weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow up with the physician at your nursing facility. please call on monday to set up a follow up appointment for 2-3 weeks with one of our cardiologists. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Polymyalgia rheumatica Mitral valve disorders Congestive heart failure, unspecified Long-term (current) use of steroids Acute posthemorrhagic anemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Acute on chronic diastolic heart failure Chronic kidney disease, unspecified Blood in stool Diarrhea Unspecified vitamin D deficiency

allergies: no known allergies / adverse drug reactions attending: chief complaint: headache and unresponsive major surgical or invasive procedure: intubation by osh prior to arrival. extubation with trach placement. history of present illness: mr. is a 63 yo haitian man with history of dm and htn who presented with severe headache and vomiting to . the patient was at home with his wife, when he suddenly developed the worst headache of his life at 11pm. he had previously been in his normal state of health, and his daughter spoke to him at 8pm. the patient apparently did have headache 1 day prior to presentation, but had no other symptoms. when his headache became severe on the night of admission, he was taken to . upon arrival he was vomiting and becoming increasingly somnolent, so was intubated for airway protection. this was a traumatic intubation causing some oral bleeding, most likely because the intubation had punctured the soft palate. nchct showed 19mm r sdh. patient was transferred to for surgical eval. on arrival to ed, patient was intubated and on propofol. head ct showed significant enlargement of r sdh to 21mm, with 19mm l midline shift and compression of the brainstem pushing the brainstem to the left c/w uncal herniation. initial exam showed pupils fixed and dilated, no corneals, not responding to noxious stimuli. neurosurgical consult did not feel that patient would benefit from surgery since pupils were fixed and there was no change in his neurological examination in particular in his pupillary reactions and cornealreflex after he had received a 100g mannitol challenge. pt continued to receive a high dose of mannitol, nicardipine gtt for htn and dilantin for seizure prophylaxis. per patient's family, he had not been ill, no recent trauma or falls, no changes to medications. he takes asa 81 mg daily but no other blood thinning medications. he has never had profuse bleeding with surgery/dental work/injuries/etc, and there is no family history of bleeding disorders. past medical history: htn hl dm for decades c/b peripheral neuropathy social history: lives with wife, no tobacco, etoh or illicits. family history: nc physical exam: at admission: vs: t afebrile hr 80s bp 130s/60s general: intubated, no responding to verbal commands or noxious stimuli even without sedating agents turned off. heent: nc/at, no scleral icterus noted 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 extremities: no c/c/e bilaterally skin: no rashes or lesions noted. neuro: off propfol approx 1 hour: eyes closed. eyes do not open to sternal rub, no response to noxious stimuli. no spontaneous limb movements. pupils 8mm and nonreactive. no vors, very sluggish right corneal reflex noted, no corneal reflex on the left; vestibulo-ocular reflex absent; +strong cough and gag. tone decreased. intermittently a decerebrate posturing in his ue with very severe noxious stimuli. dtr 2+ in bilateral , tri, brachiorad, absent in les, toes mute. at discharge: deceased pertinent results: at admission: 01:50am pt-13.2 ptt-22.4 inr(pt)-1.1 01:50am wbc-14.7* rbc-5.29 hgb-15.8 hct-44.2 mcv-84 mch-29.8 mchc-35.7* rdw-13.5 01:50am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 01:50am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 01:50am urine blood-lg nitrite-neg protein-tr glucose-1000 ketone-10 bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 01:50am urine rbc->182* wbc-8* bacteria-few yeast-none epi-0 cta with and without recon impression: 1. right-sided subdural fluid collection with acute hemorrhage along with hypodense areas which may related to ongoing hemorrhage/coagulopathy. maximum transverse dimension of 23 mm with mass effect on the right erebral hemisphere, lateral ventricles and shift of the midline structures to the left side by approximately 21.3 mm. hypodense appearance of the cerebral hemispheres may relate to a component of cerebral edema. right sided uncal herniation; brain stem compression and distortion with leftward shift. assessment for osseous structures/fractures is limited on the present study. please see the outside study for additional details. to correlate clinically, for trauma/coagulopathy and close followup as clinically necessary. 2. patent major intra- and extra-cranial arteries as described above with decreased caliber of the basilar artery, a1 and a2 segments of the anterior cerebral arteries on both sides, part of which may relate to mass effect/spasm from cerebral edema. 3. small focus of enhancement in the right-sided subdural hemorrhagic collection may relate to contrast extravasation. no abnormally dilated vessels to suggest an obvious vascular malformation in this location. recommended review of the images by neurosurgery to decide on further workup. 4. multilevel degenerative changes in the cervical spine along with a focus of prominent posterior disc osteophyte complex at c5-6 resulting in moderate canal stenosis and varying degrees of foraminal narrowing. mr can be considered if not ci and if clinically necessary. nuclear brain scan: interpretation: following injection of tracer, spect images of the brain were obtained in multiple projections and show no evidence of perfusion to the cerebral cortex. impression: the perfusion abnormalities are consistent with brain death. findings discussed with dr via phone at on . brief hospital course: the patient was admitted to the neuroicu for subdural hematoma. patient was intubated at osh prior to transfer. neurological exam showed patient to be nonresponsive, with pupils fixed and dilated 6mm bilaterally. right corneal reflex could be elicited, but was very sluggish; no left cornealreflex; cough intact, and extensor posturing on applying severe noxious stimuli in the ue. cta showed 23 mm mass effect on the right cerebral hemisphere, lateral ventricles and shift of the midline structures to the left side by approximately 21.3 mm, as well as right sided uncal herniation, brain stem compression and distortion with leftward shift. neurosurgery saw the patient but did not feel there was any surgical intervention that they could offer that would be of benefit given the patient's presenting neuro exam, in particular his fixed pupils and the lack of any change in his neurological exam after he got a mannitol challenge of 100g. neuro: the patient was continued to be treated with mannitol after the initial mannitol challenge to decrease cerebral edema and herniation. administration was limited by checking for hypernatremia and serum hyperosmolality. he was continued on fosphenytoin for seizure prophylaxis. neuro exam initially slight worsened, since he lost a cough and gag reflex and he did not breath over the vent anymore. he continue to have a very sluggish right corneal reflex and some extensor posturing to severe noxious stimuli in his ue. all other brainstem reflexes were absent. his neurological exam worsened on . he no longer had any brain stem reflexes on exam and no posturing to noxious stimuli. given his hemodynamic instability, apnea test was forgoed for fear of worsening hemodymanics. instead a nuclear brain scan was done to evaluate for brain death. the scan showed no activity and subsequently the patient was pronounced brain dead. pulmonary: the patient arrived intubated from the osh. it was discovered that the endotracheal tube was traversing the right tonsillar pillar and ent was consulted. they evaluated the patient and then took the patient for trach in order to remove the endotracheal tube. the trach was placed without complication. the patient was started on unasyn for empiric coverage given the tonsil perforation. infectious disease: the patient was febrile throughout the majority of his stay. initial culture data failed to show any infection. sputum culture on grew staph aureus coag positive and h. influnzae. cardiovascular: the patient became hypotensive on hd 5 and required pressor support. renal: the patient was maintained on ivf as well as free water through his ng tube to maintain hydration with care not to worsen icp. gi: ng tube was placed and tube feeds were started . code: multiple family meetings were had with the patient's wife and daughters who shared that based on previous, specific discussions they had held with him in the past, they felt that he would want all heroic measures done. the patient remained full code through out his hospital course. medications on admission: asa 81 mg daily metformin sitagliptin lisinopril lantus lispro discharge medications: na discharge disposition: expired discharge diagnosis: subdural hematoma with midline shift, uncal herniation and brainstem compression leading to brain death discharge condition: deceased discharge instructions: na followup instructions: na md, Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arterial catheterization Temporary tracheostomy Diagnoses: Unspecified essential hypertension Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Accidental puncture or laceration during a procedure, not elsewhere classified Compression of brain Persistent vegetative state Cerebral edema Accidental cut, puncture, perforation or hemorrhage during other specified medical care Mechanical complication due to other implant and internal device, not elsewhere classified Hyperosmolality and/or hypernatremia Subdural hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: osh transfer for pneumococcal meningitis and cerebritis major surgical or invasive procedure: stereotactic burr hole drainage of subdural empyema. history of present illness: 68m with pmh of dm, htn, hl, cad s/p distant mi, who is transferred from hospital, where he presented on with fever, cough, and sore throat. he was initially treated for pneumonia with ceftriaxone and azithromycin. on the afternoon of admission, he was noted to be acutely aphasic, with word finding difficulty. there was concern for acute stroke. neurology was consulted, he was transferred to the icu, and a stat head ct was performed. given that he was also febrile with an elevated wbc count to 27 with 27% bands, an lp was performed. this revealed 7800 wbcs with 94% polys, a glucose of 5, and a protein of 447. he was initially covered with vanc/ctx/ampicillin/acyclovir. csf and blood cultures from grew strep pneumo. id was consulted, and recommended pcn g and rifampin, which were started on . he was followed by neurology and id. he steadily improved and was transferred out fo the icu on . an mri performed showed right cerebral meningeal enhancement c/w his h/o meningitis, as well as concern for mastoiditis (non-communicating with the meninges). there was no evidence of abscess or hemorrhage, but a small frontal hygroma vs. subdural empyema. nsurg was consulted, and there was ntd per them. on , ent performed a right myringotomy, and a copious amount of seromucoid purulent material was aspirated; tubes were placed. per his report, later that day he developed tingling of both upper extremities and the lle, as well as left hand weakness and general poor coordination. neurology was re-consulted, and exam revealed left sided neglect and poor coordination without frank dysmetria. a repeat mri was performed, the preliminary report of which showed evidence of cerebritis. plans were initiated tranfer him to the neuro icu, but they refused. he was instead accepted by the micu. prior to transfer, rifampin was resumed, and keppra was begun for seizure ppx. his temp was 100.2 and he was hemodynamically stable. on arrival to the micu, he complained of nausea. he endorsed ongoing numbness in his hands and feet since yesterday's ear operation. past medical history: pmh: 1. cad - s/p mi in , tx with angioplasty 2. htn - currently managed w/ toprol xl 200mg 3. dm2 - managed on glucophage 1000mg , glyburide 3.75 4. hyperlipidemia - on lipitor 40mg 5. s/p orif for r zygomatic fx, and orbital fx with 2 plate insertion 6. atypical pneumonia in , complicated by bronchocentric granulomatosis and cold agglutinins hemolytic anemia 7. cystic pancreatic disease 8. bph s/p turp 9. appendicitis s/p appendectomy 10. s/p bladder polypectomy social history: mr. is a retired immunologist at the whose research interest was in monoclonal antibodies. he and his wife live in , ma. he has at least one son and one daughter. daughter is an ob/gyn at . denies etoh. tob use: 20 pack year hx, d/c in . family history: non-contributory physical exam: upon transfer to medical service: vs: 98.9 120/54 106 w/ pvcs 24 95ra gen: well-nourished elderly man, lying in bed, talking to son, not sob, in pain, or otherwise distressed. heent: h: r eye palpabral fissure slightly smaller than l (9mm vs. 12mm), no signs of trauma. e: perrla 3mm->2mm, conjunctiva not pale, anicteric. e: slightly tender to palpation. no drainage appreciated. n: no signs of epistaxis. t: moist mucous membranes, no erythema or exudate. neck: soft, supple. no lad at pre/post auricular, ant/post cervical, submandibular, supraclavicular nodes. no carotid bruits. no mastoid tenderness. cv: tachycardic, reg rhythm with nl s1, s2. no m/r/g. pulses 2+ in all 4 extremities (dp and pt on feet). no splinter hemorrhages. lungs: nl excursion on inspiration. no dullness to percussion. no tactile fremitus. lungs clear to auscult, bilat and ant/post. no crackles, wheezes or rhonchi. diaphragms symmetric. abd: soft, non-tender. slightly distended, but not tympanic. hypoactive bowel sounds. liver percussed at 8cm. no renal bruits. back: no spinal tenderness. no cva tenderness. no paraspinal tenderness. ext: no edema, erythema. wwp. neuro: aaox3. gives identifiers without prompting. able to name past 2 presidents only. can multiply 6x7. cannot subtract 17 from 81. able to talk briefly about his research. three word recall intact at 2min. full strength (unable to break) in deltoids, biceps, triceps, ips, and gastrocs, bilaterally. r does seem slightly stronger however. able to hold pen in l hand, but trouble re-capping. dysmetria w/ finger to nose on the l. cn ii: lower left quadrant cut bilaterally. iii, iv, vi:eoms intact. (son notes no ptosis as compared to baseline) v: sensation intact to light touch. vii/viii: face symmetric aside from eyes as mentioned above. hearing intact to snaps, not light rustle. ix/x: coughs. xii:scm intact, trap intact. xii:tongue midline. upon discharge: c/o sl. ha controlled a&ox3, perrl, follows commands, 5/5 strength, wound c/d/i pertinent results: from outside hospital prior to transfer: micro: csf hsv pcr: negative csf gram stain: gpcs in p+c, culture neg bcx + pansenstive strep pna ucx: <10,000 cfu, mixed flora no right ear fluid cultures sent from or on . osh imaging: ct-a: no evidence of pe. calcified right costophrenic sulcus plaque with associated. . head ct without contrast new small amound of hypodense fluid in the right frontal subdural space/ while this may represent a subdural hygroma, given the patient's h/o bacterial meningitis, a subdural empyema should be considered. complete opacification of the right mastoid air cells with fluid int he right middle ear, as seen previously. . temporal bone ct bilateral cerumen plugs, extensive opacifiaction of the right mastoid air cells, antrum, and middle ear suggesting otomastoiditis. no bony destruction. . mri brain: extra-axial collection right cerebral hemisphere suggestive of meningeal enchancement c/w clinical hx of bacterial meningitis. no abscess or hemorrhage is seen.non-aeration of mastoid air cells with fluid signal c/w mastoiditis. however, this does not appear to have broken through the subjacent meninges. normal venous sinuses. . b/l carotid u/s: < 20% ica stenosis on both sides . tte lvef 40-45%, with inferior and posterior akinesis. normla rv. 2+ mr, 1+ tr. negative bubble study. . cxr fibrosis and scarring at the right base, small right pleural effusion. picc line at jxn of svc and ra. . ct head w/ and w/o contrast: "1. right otomastoiditis. 2. unchanged small right parietal subdural collection, concerning for a subdural empyema. 3. persistent cortical swelling in the right parietal, posterior frontal, and temporal lobes, compatible with known cerebritis." . ct orbits, sella w/ contrast: "findings compatible with severe right otomastoiditis with possible coalescence of the mastoid septae. there is also thinning and demineralization of the tegmen tympani. would recommend mri with skull base protocol to assess for meningeal extension of infection. additionally, there is a tiny subdural collection on the right, again recommend mri for further evaluation and to exclude a subdural empyema." . mr w/ and w/o contrast, mrv head: "1. unchanged small right parietal subdural empyema. 2. right cortical edema consistent with cerebritis is again seen. new mild slow diffusion suggests interval worsening. 3. mild right-sided leptomeningeal enhancement, consistent with meningitis. 4. right otomastoiditis again seen. 5. no evidence of venous sinus thrombosis. " . ct head: "no significant change from prior studies, with unchanged right- sided subdural collection, consistent with previously characterized subdural empyema. persistent opacification of right mastoid air cells and middle ear cavity. " . ct head: "stable examination demonstrating unchanged right subdural collection consistent with previously characterized subdural empyema. no interval change in opacification of right mastoid air cells and middle ear cavity. " . mr : "stable appearance since . evidence of right mastoiditis with adjacent subdural empyema, extensive dural enhancement, leptomeningeal enhancement, and no evidence of infarction or sinus thrombosis. " . cbc: 11:14pm wbc-14.5*# rbc-3.88* hgb-13.0*# hct-35.7*# mcv-92 mch-33.4* mchc-36.3* rdw-13.1 11:14pm neuts-87.7* lymphs-9.3* monos-1.9* eos-1.0 basos-0 11:14pm plt count-399# 04:50am 7.9 4.12* 13.5* 37.6* 91 32.8* 36.0* 13.7 328 coags: 11:14pm pt-15.2* ptt-33.9 inr(pt)-1.3* 04:50am 16.2* 33.7 1.4* chem 7: 11:14pm glucose-114* urea n-15 creat-0.8 sodium-133 potassium-4.0 chloride-98 total co2-24 anion gap-15 04:50am 128* 18 1.0 139 4.1 101 28 14 lfts: 06:17am 29 18 186 66 0.3 head ct there is a new posterior parietal burr hole, and pneumocephalus overlying the left posterior frontal and parietal lobes. small low-density extra-axial collection layers dependently, and appears slightly more dense in comparison to . effacement of the underlying sulci is unchanged. there is no hydrocephalus or shift of normally midline structures. no intracranial hemorrhage is identified. -white matter differentiation remains normally preserved. complete opacification of the right mastoid air cells persist. brief hospital course: 68m with pmh of dm, htn, cad s/p mi, who is transferred from an osh with resolving pneumococcal meningitis and new neurological deficits, found to have mastoiditis, cerebritis, and subdural empyema. . # meningitis: mr. was treated with iv ceftriaxone 2mg iv q12, in addition to 50mg metronidazole upon arrival. metronidazole was replaced with clindamycin following a seizure, but was changed back to metronidazole following the start of levetiracem. since his transfer here, mr. has remained afebrile, with a wbc trending down. clinically, mr. improved dramatically over the course of his stay to the point where no neurological deficits can be noted noted. he has no meningeal signs at present. . #cerebritis - empyema was followed serially by ct and mr imaging without any change over his stay. there was no involvement of the sinuses. the decision was made on by medicine, neurosurgery, and id to surgically drain the fluid collection via stereotactic biopsy. . # mastoiditis- patient has ear tubes bilaterally that have drained minimally. he has remained afebrile since his arrival and w/o pain. hearing remains sensitive to loud snaps only. he continues on ciprofloxicin ear drops 0.3% ophth soln 4-10 drops to the right ear. . # seizure - patient had a single generalized, tonic clonic seizure in the micu on while on keppra 500mg. metronidazole was stopped temporarily and the patient was loaded with additional keppra. pt has not seized since micu stay. he remains on keppra, now tritrated up to 1g for neurosurgical intervention. . # htn - mr. was never hypotensive during his stay and his pressures largely ranged in the 130s sytolic. metoprolol was started at 25 mg and titrated up to 50 mg tid, with the discharge goal of home dosing of 200mg qd. . #diabetes - mr. was initially covered under a sliding scale. when full diet was resumed, his glucose values were in the high 200s. medication was changed to pt's home po metformin and glyburide, with modest effect. hyperglycemia thought to be resultant of stress and illness. . #cad, hx of mi - stable, no events. continued statin. given possibility of intervention, asa was held throughout the stay. . #anemia - pt was down from baseline of 47.7 in to 37.8. because of history of cold agglutinin hemolysis, patient was worked up for anemia. haptoglobin was within normal limits. iron labs were consistent with anemia of inflammation, with normal mcv, lower transferrin, and lower tibc. on he was brought to the or by dr. for a steriotactic burr hole placement and washout of subdural empyema. he tolerated the procedure and was transferred to the floor where he ambulated with nursing and tolerated a regular diet. he was then safe to be d/c'd home with services and follow up appointment medications on admission: home meds: lipitor 40 mg asa 650 mg daily glucophage 1000mg glyburide 3.75mg toprol xl 200 mg mvi . transfer meds: rifampin keppra 250mg po bid ( - ) riss floxin otic gtt to right ear pcn g 4 million units q4h iv metformin 1000mg tylenol q4h prn prn metoprolol 25mg discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. glyburide 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). 4. ciprofloxacin 0.3 % drops sig: 4-10 drops ophthalmic tid (3 times a day): right ear only. disp:*1 1* refills:*2* 5. toprol xl 200 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 6. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 13 days: do not consume alcohol while taking this medication. disp:*40 tablet(s)* refills:*0* 7. keppra 1,000 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 8. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: one (1) intravenous q12h (every 12 hours) for 13 days. disp:*26 iv piggyback* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed: please do not exceed 4 grams per day. . 11. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for headache: please do not drink or drive while taking this medication. disp:*50 tablet(s)* refills:*0* 12. picc line care saline flush 10cc sash prn heparin flush 10u/ml 3cc sash prn discharge disposition: home with service facility: area vna discharge diagnosis: primary: streptococcus pneumoniae meningitis, cerebritis, and mastoiditis. secondary: diabetes mellitus, type ii, non-insulin dependent coronary artery disease htn discharge condition: stable. discharge instructions: you were transferred from hospital with an infection of your brain and your mastoid bone. while you were here, you received intravenous antibiotics, anti-seizure medication, and repeated imaging of your brain. the medicine, disease, and neurosurgery teams decided that having surgical drainage of the collection around your brain would best help clear the infection. you were started on the following new medications, all of which you will continue: 1. ceftriaxone 2 g iv q12h 2. metronigazole (flagyl) 500 mg po q8h 3. ciprofloxicin ear drops 4. levitracetam 1g po bid the first medication will be given through the picc line in your arm. a visiting nurse this. the flagyl will be an oral medication, in the same amount, to be taken three times a day. disease will determine the length of your antibiotics. because of the antibiotic ceftriaxone can interfere with your liver on rare occassion, you will need your liver enzymes tested once per week. please have blood drawn and tested for cbcs, chem 7, and lfts each week and send the results to the disease clinic at (. if you should become febrile, confused, lose bowel or bladder function, have a strong headache, experience any loss in vision, or lose conciousness, please return to the emergency room immediately. you will need follow-up appointments with your pcp, disease, neurology, neurosurgery, and ent. general instructions ?????? 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. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? 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, advil, and ibuprofen etc. -you haven 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?????? f. *******you may resume your asprin on ****** followup instructions: please be sure to follow up with the following physicians: 1. disease - dr. bldg (), basement id west (sb) 11:30am 2. ear, nose and throat - dr. , @ 10:15 am, tuesday 4. pcp at 10am dr , , ma. because of the antibiotic ceftriaxone can interfere with your liver on rare occassion, you will need your liver enzymes tested once per week. please have blood drawn and tested for lfts each week and send the results to the disease clinic at fax number . neurosurgical follow-up appointment instructions ??????please return to the office for removal of your sutures and a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????you have an appointment with dr. on at 9a at , if you have any questions please call ( ??????you are scheduled for an mri of the brain with and without gadolinium contrast on at 730 am in the basement. Procedure: Venous catheterization, not elsewhere classified Incision of cerebral meninges Diagnoses: Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Personal history of tobacco use Other and unspecified hyperlipidemia Bacteremia Old myocardial infarction Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Other specified anemias Intracranial abscess Streptococcal meningitis Lack of coordination Diabetes with unspecified complication, type II or unspecified type, uncontrolled Unspecified mastoiditis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: rectal bleeding major surgical or invasive procedure: none history of present illness: 65 y/o male with 6 prostate cancer. he had a 26 core prostate needle biopsy this afternoon with dr. . he had rectal bleeding shortly after going home from the clinic this afternoon, and was brought to the ed by ambulance after feeling lightheaded with continuous rectal bleeding. he had a syncopal episode on admission to the ed. he denies nausea, vomiting, fevers, chills, chest pain, dyspnea, hematuria, urinary urgency, frequency. the patient had discontinued his aspirin one week prior to the biopsy as instructed. past medical history: htn hyperlipidemia mild copd/asthma colonic polyps social history: past tobacco use (quit 3-4 years ago), +etoh use (approx 4 drinks per day) family history: father, mother: cancer physical exam: vs: afebrile, hr 65, bp 139/49, r 16, 100%ra nad, a&ox3, lying in trendelenburg rrr, no respiratory distress abd: soft, nondistended, nontender gu: no active rectal bleeding on initial exam. on dre, pressure and surgicel were applied to the prostate, and there was no active bleeding or clots after pressure applied. ext: no cyanosis/clubbing/edema. pertinent results: 02:41am blood wbc-8.8 rbc-2.93* hgb-9.1* hct-26.6* mcv-91 mch-31.2 mchc-34.4 rdw-12.6 plt ct-226 02:59am blood pt-15.9* ptt-23.5 inr(pt)-1.4* 02:59am blood glucose-128* urean-13 creat-0.9 na-139 k-4.0 cl-108 hco3-26 angap-9 02:41am blood ck-mb-5 ctropnt-<0.01 brief hospital course: on , the patient was admitted to dr. urology service/sicu from the ed with rectal bleeding and syncope after prostate needle biopsy. in the ed, surgicel and pressure were applied to the prostate and the acute bleeding stopped. the patient was placed in trendelenburg and serial hct's were checked. gi consult was requested by the icu team, and they recommended vit k for elevated inr 1.5. cardiac enzymes were negative. on hd 2, the patient had several bloody bowel movements and remained in the icu for monitoring. hematocrits were stable at 26-27 without transfusion on hd 2. on hd 3, the patient was seen by general surgery, who performed an anoscope. the anoscopy showed old clot, no active bleeding. also on hd 3, the patient was transferred to the floor from the icu in stable condition. serial hct's were monitored, which continued to be stable at 24-26. he received peri-operative antibiotic prophylaxis, and he remained afebrile throughout his hospital stay. at discharge, patient denied pain, was tolerating a regular diet, ambulating without assistance, and voiding without difficulty. he denied chest pain, dyspnea, abdominal pain at discharge. he was given explicit instructions to call dr. office to schedule follow-up appointment. medications on admission: levoxyl 75mcg fluoxetine 20mg simvastatin 10mg levaquin (perioperative) discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. colace 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: rectal bleeding status post ultrasound guided prostate needle biopsy discharge condition: stable discharge instructions: -call dr. office () to schedule follow up appointment. -colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -if you have fevers > 101.5 f, abdominal pain, nausea or vomitting, bright red blood per rectum, call your doctor or go to the nearest emergency room. followup instructions: call dr. office () to schedule follow up appointment. Procedure: Closed [percutaneous] [needle] biopsy of prostate Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Hemorrhage complicating a procedure Malignant neoplasm of prostate Chronic obstructive asthma, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: chief complaint: syncope major surgical or invasive procedure: dual chamber pacemaker placement history of present illness: 77 y/o man with a pmh significant for prostate cancer (t2a, score 9), htn and hyperlipidemia transferred from s/p syncopal episode this morning found to be in complete heart block with ventricular escape. by report, in the he was asymptomatic with a sbp 110 and hr in the 30s. transcutaneous pacing pads were placed with good capture at 50ma and a ct head was negative for mass/shift/bleed. he received 0.5mg atropine and was sent to for further management. . in the ed, he was in complete heart block with a ventricular escape rhythm in the 20s. he was given 5mg iv glucagon concern for atenolol overdose in the setting of cr 1.3 (baseline unknown). labs were notable for trop <0.01. cardiology was consulted and he was admitted to the ccu for temp pacer wire placement. . the pt states that he had been in his normal state of health this morning until rising from his car and walking towards a conveniece store. approximately 2 seconds after rising from his car he fell, hit his head and briefly lost consciouness. there was no prodrome of lightheadedness, nausea, vomiting, diaphoresis, palpitations or changes in vision. he also denies ever experiencing cp/sob and does not recall tripping or any mechanical aspect to the event. he has never had a seizure and was not post-ictal. he is followed by his pcp, he last saw 1 month ago. his last ekg was 1 year ago, and there is a questionable history of pre-existing lbbb per family (pt unaware). he denies any cardiac history and has never been diagnosed with as or other valvular or structural heart disease. . on review of systems, he endoses a stroke in with no residual neuro deficits. he denies 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. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema or palpitation. past medical history: 1. cardiac risk factors: dyslipidemia, hypertension 2. cardiac history: as per hpi - pacing/icd: trans venous pacer in place 3. other past medical history: 1. prostate cancer 2. gerd 3. bph 4. cva (), no residual deficits social history: the patient quit smoking 32 years ago. he does not drink excessively. he lives with his wife and his daughter who is a nurse. family history: no fh of premature death, cardiac disease, early mi. father died of colon cancer, mother died in her 80s of unknown cause. physical exam: admission vs: t 96.3 bp 150/57 hr 60 (paced) rr 18 o2 sat 98% ra weight: 207.3. height: 68.75. bmi: 30.8. general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. neck: supple, jvp difficult to asses r ij cardiac: pmi not palpable. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: superficial abrasion on the r scalp, hand and knee pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ discharge: general appearance: well nourished, no acute distress head, ears, nose, throat: bandage on forehead intact. cardiovascular: (s1: normal), (s2: normal), (murmur: no(t) systolic) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: clear : bilaterally) abdominal: soft, non-tender extremities: right lower extremity edema: none, left lower extremity edema: none skin: left chest dressing clean/dry/intact neurologic: attentive, follows simple commands, responds to: not assessed, movement: not assessed, tone: not assessed pertinent results: 05:14am blood wbc-9.0 rbc-4.11* hgb-12.4* hct-35.3* mcv-86 mch-30.2 mchc-35.2* rdw-15.5 plt ct-138* 10:30pm blood wbc-11.0 rbc-4.17* hgb-12.6* hct-35.6* mcv-85 mch-30.2 mchc-35.5* rdw-15.3 plt ct-185 10:30pm blood glucose-103* urean-21* creat-1.3* na-135 k-4.9 cl-105 hco3-21* angap-14 05:14am blood glucose-114* urean-22* creat-1.3* na-142 k-4.3 cl-109* hco3-27 angap-10 10:30pm blood ctropnt-<0.01 06:10am blood ck-mb-3 ctropnt-0.03* 01:29pm blood ck-mb-3 ctropnt-0.01 06:10am blood totprot-5.4* albumin-3.9 globuln-1.5* calcium-8.8 phos-3.4 mg-2.0 ekg sinus rhythm with slow idioventricular rhythm, complete heart block. no previous tracing available for comparison. sinus rhythm with atrial sensed and ventricular paced rhythm and capture, newas compared to the previous tracing of . echo : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). there is no left ventricular outflow obstruction at rest or with valsalva. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no cardiac cause of syncope identified. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild tricuspid and mitral regurgitation. cxr : cardiomediastinal contours are normal. left transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. thereis no pneumothorax. left pleural effusion is small. right lower lobe atelectasis has improved. left lower lobe atelectasis is stable. lyme serology (final ): no antibody to b. burgdorferi detected by eia. reference range: no antibody detected. negative results do not rule out b. burgdorferi infection. patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. patients with clinical history and/or symptoms suggestive of lyme disease should be retested in weeks. brief hospital course: # bradycardia s/p pacer placement: patient presented with complete heart block and a slow idioventricular rhythm. his troponins peaked at 0.03 but were negative at discharge. his lyme serologies returned negative. he had successful placement of a st. dual chamber pacemaker. follow up chest x-ray was unremarkable and ekg demonstrated atrial sensed and ventricular paced rhythm. following pacemaker placement, atenolol and irbesartan were started. patient tolerated the procedure well and was discharged without incident. # syncopal episode with fall. patient sustained abrasions on the top of his head which were bandaged and cared for. head ct from outside hospital was negative. patient was stable upon discharge. medications on admission: atenolol - (prescribed by other provider) - dosage uncertain atorvastatin - (prescribed by other provider) - dosage uncertain folic acid - (prescribed by other provider) - dosage uncertain irbesartan - (prescribed by other provider) - dosage uncertain omeprazole - (prescribed by other provider) - dosage uncertain tamsulosin - (prescribed by other provider) - dosage uncertain medications - otc aspirin - (prescribed by other provider) - dosage uncertain calcium carbonate - (prescribed by other provider) - dosage uncertain l.acidoph & sali-b.bif-s.therm - (prescribed by other provider) - dosage uncertain multivitamin - (prescribed by other provider) - dosage uncertain omega-3 fatty acids-vitamin e - (prescribed by other provider) - dosage uncertain . chemotherapy/anti-androgens: () lupron 7.5mg im () casodex 50mg po daily discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. irbesartan 300 mg tablet sig: one (1) tablet po daily (). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 2 days. disp:*8 capsule(s)* refills:*0* 8. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 9. tamsulosin 0.4 mg capsule, ext release 24 hr sig: two (2) capsule, ext release 24 hr po once a day. capsule, ext release 24 hr(s) 10. calcium citrate + d 315-200 mg-unit tablet sig: one (1) tablet po once a day. 11. vitamin c 500 mg capsule, extended release sig: one (1) capsule, extended release po once a day. 12. lactobacillus acidophilus tablet, chewable sig: one (1) tablet, chewable po once a day. 13. fish oil 1,000 mg capsule sig: one (1) capsule po once a day. chemotherapy/anti-androgens: () lupron 7.5mg im monthly () casodex 50mg po daily discharge disposition: home discharge diagnosis: 3rd degree heart block syncope bradycardia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr , you were admitted to the hospital after a fall related to your heart rate going too slowly. we have given you a st. xl 5826 pacemaker which will keep the heart rate going at an acceptable rate. we would like you to please follow up with the electrophysiology clinic team to evaluate the pacemaker. followup instructions: department: hematology/oncology when: wednesday at 1 pm with: oncology dietitian building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: thursday at 11:00 am with: dr. building: sc clinical ctr campus: east best parking: garage name: , location: medical associates, pc address: , , phone: appointment: friday 10:45am department: cardiac services when: wednesday at 9:30 am with: device clinic building: sc clinical ctr campus: east best parking: garage department: cardiac services when: friday at 12:00 pm with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Venous catheterization, not elsewhere classified Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Diagnoses: Esophageal reflux Unspecified essential hypertension Personal history of malignant neoplasm of prostate Unspecified fall Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Atrioventricular block, complete Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Syncope and collapse

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension, diarrhea major surgical or invasive procedure: placement of a central venous line history of present illness: this is a 65 year-old female with past medical history significant for r hip replacement post multiple disclocations and reductions and history of c. diff colitis in who presents with profuse watery diarrhea x1 week, hypotension and syncope. she was transfered from hospital after a syncopal event at home. per records, she had been intermittently confused with decreased oxygen saturations. of note, per report, the patient was started on dilaudid 4 mg prn at the time of her laminectomy and has apparently had several episodes of confusion and incoherent speech since starting this medication. the patient states she had been having significant diarrhea for over one week, and in fact took kayopectate which stopped the diarrhea for 2 days. it has been constant for the last week. she had been resting at home, and as she got up to stand last pm, she felt the room spinning and then had a syncopal episode. her husband caught her before she fell. she then presented to for evaluation. there, she had evidence of a right hip dislocation and hypotension and received around 9 l of ns as well as levoflox/flagyl. given persisent hypotension, she was transfered here for further management. of note, the patient has had multiple courses of antibiotics over the last 2 months, first for a uti in , then at the time of her laminectomy, and most recently completed a course for pneumonia last week. in the ed, initial vs 99.2 101/50 87 18 98% on 4l. she received 1 gm ctx, 500 mg flagyl, ativan 1 mg iv and fentanyl (for hip reduction). a rij was placed given concern for shock, though no levophed was required. she rec'd 2 l ns in the ed. r hip was reduced by orthopedics and knee immobilzer placed prior to transfer to icu. ros: the patient denies any fevers, chills, weight change, nausea, vomiting, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, pnd, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. she does report decreased urine output over the last 24 hours prior to admission as well as abdominal discomfort that is new today. past medical history: depression anxiety fibromyalgia recent laminectomy in at nebmc r hip replacement in rls sleep apnea arthritis social history: quit smoking prior to surgery, smoked one pack per 3 days for many years prior, rare etoh, independent adls at home. family history: no recent sick contacts, non-contributory physical exam: on presentation: vitals: t: 97.3 bp:101/50 hr:88 rr: 22 o2sat:100% on 3l nc gen: well-appearing, well-nourished, no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, dry mm, op clear neck: no jvd, carotid pulses brisk, no bruits, trachea midline cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs ctab, no w/r/r abd: soft, mildly distended, tender diffusely to deep palpation only, no hsm, no masses ext: no c/c/e, no palpable cords, knee immobilizer in place, r hip without ecchymoses neuro: alert, oriented to person, place, and time. poor historian skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: 09:30pm blood wbc-17.2* rbc-3.25* hgb-9.6* hct-28.0* mcv-86 mch-29.7 mchc-34.4 rdw-15.5 plt ct-323 04:41am blood wbc-16.9* rbc-3.25* hgb-9.3* hct-29.3* mcv-90 mch-28.5 mchc-31.6 rdw-15.4 plt ct-312 04:41am blood neuts-82.8* lymphs-12.1* monos-4.1 eos-0.9 baso-0.1 04:41am blood pt-14.6* ptt-29.9 inr(pt)-1.3* 09:30pm blood glucose-94 urean-21* creat-1.5* na-140 k-3.5 cl-118* hco3-13* angap-13 04:41am blood glucose-88 urean-18 creat-1.4* na-140 k-3.4 cl-117* hco3-12* angap-14 04:41am blood calcium-7.4* phos-4.3 mg-1.6 09:46pm blood lactate-0.9 04:56am blood lactate-0.6 brief hospital course: this is a 65 year old female with recent history of c. diff colitis (06') and recent mult abx use for uti/pna past couple months who presented after a syncopal episode in the setting of diarrhea/dehydration with c. diff colitis with a r hip dislocation as result of synocopal episode and also noted arf (pre-renal). tx from osh for persistant hypotension - admitted to micu - mgmt only with aggressive ivf resusitation (no pressors were required), tx with po vanc/iv flagyl. . # leukocytosis: pt presented with a leukocytosis of 17.2, most likely due to c. diff colitis given her diarrhea and clinical history. cxr at the osh prior to admission in the showed resolution of prior pna. patient denied cough or fevers at home, though there was a report of hypoxia as noted above. differential shows left shift without bandemia, no recent wbc for comparison. ua negative initially. following onset of flagly and vancomycin regimen pt's leukocytosis started to trend down, however prior to transfer from the icu to the medical floor her wbc increased to 19. given her improving colitis signs as well as a clear pulmonary examination a u/a was sent and noted to be suspicious for infection. pt was then started on a 3 day course of ciprofloxacin by micu. importantly, pt's r ij and foley were the day of transfer from the micu. the patient's leukocystosis remained stable at 19k over the next 72 hours and given good clinical status and no significant documented fevers or symtoms while being observed in the hospital over that time, the patient was discharged to f/u with a repeat cbc the next week at her pcp office to monitor. . # c. diff colitis/diarrhea: vastly improved during her hospitalization. the patient was discharged to complete a prolonged course of po vanc and flagyl. . # osa/oha (sleep apnea): restarted home cpap here (patientused prior but then self d/c 1 mo prior but willing to re-try now). . # hypotension/syncope: likely due to profound dehydration from ongoing severe diarrhea. patient had been unable to maintain hydration and had required upwards of 10 l of ivf since her admission to the osh ed. never required pressors. . # syncope: likely result of orthostatic hypotension secondary to her diarrhea from c. diff colitis. . # hip dislocation: status post reduction in the ed by ed staff and orthopedics. hip had dislocated multiple times in the past, usually reduced in or. patient is currently in knee immbolizer, no plans for surgical intervention at this time. pt was seen by orthopaedics who recommended seeing her as an outpatient given that she was able to ambulate on her hip. . # acute renal failure: on admission pt was noted to be in arf with a reported elevated creatinine of 2.17 at an osh. during hospitalization course pt was given iv hyrdration (7 l in the icu) and her creatinine was noted to trend down back to normal. creatinine elevation most likely pre-renal secondary to her diarrhea. . # depression/anxiety - controlled with pt's home regime. medications on admission: nexium 40 mg daily prozac 40 mg daily asa 81 mg daily lunesta 2 mg qhs celebrex 200 mg oxazepam 10 mg tid lisinopril 10 mg daily buproprion 150 mg tid requip 2 mg daily mvi neurontin 600 mg qid discharge medications: 1. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. ropinirole 1 mg tablet sig: two (2) tablet po bid (2 times a day). 5. celebrex 200 mg capsule sig: one (1) capsule po twice a day. 6. oxazepam 10 mg capsule sig: one (1) capsule po three times a day. 7. lisinopril 10 mg tablet sig: one (1) tablet po once a day. 8. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)): take prior home dose. 9. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). 10. multivitamin tablet sig: one (1) tablet po daily (daily). 11. eszopiclone 2 mg tablet sig: one (1) tablet po at bedtime. 12. vancomycin 250 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 20 days. disp:*80 capsule(s)* refills:*0* 13. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed) as needed for sore throat. disp:*20 lozenge(s)* refills:*2* 14. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 20 days. disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: clostridium difficile colitis hypotension syncope leukocystosis, persistent discharge condition: vitals signs stable discharge instructions: return to ed if having fevers, chills, worsening abdominal pain, worsening diarrhea, rigors, significant lethargy. you have a white blood cell count of 19,000 on day of discharge. this elevated white blood cell count has been stable over the past three days and has not worsened. clinically, you are vastly improved. you should have your white blood cell count followed up next week by your pcp. followup instructions: patient to f/u with her pcp and have her wbc checked and monitored next week. patient to schedule appointment with her pcp: , . . Procedure: Venous catheterization, not elsewhere classified Closed reduction of dislocation of hip Diagnoses: Obstructive sleep apnea (adult)(pediatric) Urinary tract infection, site not specified Acute kidney failure, unspecified Unspecified fall Intestinal infection due to Clostridium difficile Dehydration Hypovolemia Leukocytosis, unspecified Closed dislocation of hip, unspecified site

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea major surgical or invasive procedure: cardiac catheterization history of present illness: this is a 65 yo m who is 5 weeks s/p tricuspid valve replacement for severe nonischemic cardiomyopathy with h/o -v ivcd (lead causing wide open tr) and chronic afib on coumadin, who p/w one day history of worsening doe and orthopnea. pt has noted doe with walking since his operation on . three days ago his doe increased. two nights ago, he noted increased orthopnea and had 2 episodes of pnd. he saw his cardiologist, dr. , for f/u yesterday, at which point he had no complaints. after the appointment he noted increased doe, occurring after a few steps. all of these were acute changes from the past few weeks. no appreciable increase in edema. denies prior pnd. denies cp. has had nonproductive cough since leaving hospital on for constipation. no f/c. no n/v/d. came in today because of acute change in symptoms. . on this am, pt received 100mg iv lasix. went for rhc after which swan was placed. now being admitted to ccu for milrinone +/- lasix gtt for fluid management. . on arrival to ccu, pt was comfortable without complaints. past medical history: s/p tricuspid valve replacement for tr s/p biventricular pacer/icd placement s/p removal of pacer/icd s/p left achilles tendon repair s/p sinus surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia social history: retired pipe fitter. lives with wife in . never smoked. denies illicits. drank etoh only rarely after diagnosed with chf; quit in . family history: mother with renal failure. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission vs - hr 70 bp 89/59 97%ra general - thin elderly m in nad, comfortable, appropriate, aaox3 heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, jvd 1/2 up neck @30 degrees lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, nl s1-s2. no rv heave noted. heart sounds distant. abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, 2+ bilateral pitting edema. skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, grossly non-focal . discharge general - thin elderly m in nad, comfortable, appropriate, aaox3 heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd appreciated lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, nl s1-s2. no rv heave noted. abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no edema. skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, grossly non-focal pertinent results: admission labs 03:25pm blood wbc-6.1 rbc-3.48* hgb-11.2* hct-33.6* mcv-96 mch-32.3* mchc-33.5 rdw-16.5* plt ct-145*# 03:25pm blood neuts-77.9* lymphs-15.0* monos-4.8 eos-1.8 baso-0.5 03:25pm blood pt-24.8* ptt-40.0* inr(pt)-2.4* 03:25pm blood glucose-90 urean-47* creat-1.7* na-138 k-4.7 cl-94* hco3-34* angap-15 05:39am blood calcium-8.9 phos-3.9 mg-2.2. . cardiac enzymes 03:25pm blood ctropnt-0.03* 07:25am blood ck-mb-3 ctropnt-0.03* 07:25am blood ck(cpk)-33* . discharge labs . pertinent labs . pertinent studies cxr findings: frontal and lateral views of the chest were obtained. the patient is status post median sternotomy. there are small bilateral pleural effusions with overlying atelectasis. no overt pulmonary edema is seen. the cardiac silhouette remains top normal to mildly enlarged. impression: small bilateral pleural effusions with overlying atelectasis. . cardiac cath comments: 1. resting hemodynamics revealed right and left filling pressures with rvedp of 20 mmhg and pcw 27 mmhg. there was moderate pulmonary artery systoic hypertension with pasp of 53 mmhg. the cardiac index was low at 1.9 l/min/m2. . final diagnosis: 1. biventricular elevated filling pressures. 2. moderate pulmonary arterial hypertension. . echo conclusions the left atrium is moderately dilated. 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. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. the left ventricular cavity is dilated. systolic function of apical segments is relatively preserved. overall left ventricular systolic function is severely depressed (lvef= 15%). the right ventricular free wall thickness is normal. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. moderate to severe (3+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. the tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . impression: biatrial enlargement. dilated, severely hypokinetic left ventricle with relative preservation of the apical segments. dilated, hypokinetic right ventricle. mild aortic regurgitation. moderate to severe mitral regurgitation. well-seated, normally functioning tricuspid annuloplasty ring. mild pulmonary artery systolic pressure. . compared with the prior study (images reviewed) of , there is worsening left ventricular global and regional systolic function with a decrease in ejection fraction from 25% to 15%. the severity of mitral regurgitation has increased minimally. mild pulmonary artery systolic hypertension is now appreciated; its presence could not be determined previously. tte: the left atrium is moderately dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. there is severe global left ventricular hypokinesis (lvef = 25 %). the right ventricular free wall thickness is normal. the right ventricular cavity is mildly dilated with depressed free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. the tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. compared with the findings of the prior study (images reviewed) of , systolic function of both ventricles is improved. brief hospital course: mr. is a 65-year-old-man who is five weeks status post tricuspid valve replacement for severe tricuspid regurgitation, severe right ventricular enlargement, and severe right heart failure, with recent removal of defibrillator coil that revealed a massively dilated right atrium and right ventricle who is presenting with worsening dyspnea on exertion. . #. acute on chronic heart failure (right-sided, systolic): patient is 5 weeks s/p tricuspid valve replacement, now with worsening right heart failure symptoms. tte with worsening systolic function as well with depressed ef. attempts were made with iv diuresis, but ultimately he required ccu admission for milrinone. initially he was started on milrinone alone and his uop was measured, and ultimately he required a lasix drip as well to maintain good uop. his cardiac output doubled with milrinone therapy. length of stay he was out approximately 9-10l net negative, his edema cleared, his lungs remained clear and his jvp was no longer elevated. symptomatically, he felt much better, having improved exercise tolerance and a greatly increased appetite. milrinone was on for approximately 3.5 days, after which it and the lasix were stopped. he had a repeat echo ~14 hours after cessation of his milrinone, showing improved global function. he was started back on his home torsemide without metolazone and maintained euvolemia. . #. afib/ectopy: patient therapeutic on warfarin with inr of 2.4. also rate-controlled with home digoxin and metoprolol. these medications were continued throughout the admission. his afib was rate controlled well, never having a rapid ventricular rate. he did have a few episodes of ventricular ectopy with small runs of nsvt although these were likely related to hypokalemia and electrolyte shifts rather than the milrinone or other intrinsic cardiac etiology. . #. acute kidney injury: creatinine at 1.7 from a baseline in late of 1.0. etiology is likely secondary to poor forward flow rather than overdiuresis as his diuretics had actually been decreased recently 1.5 weeks ago. his renal function quickly improved with milrinone and at the time of discharge was at his baseline. medications on admission: omeprazole 20 mg ec po bid aspirin 81 mg po daily warfarin 5mg po daily at 4pm trazodone 50mg po qhs prn insomnia polyethylene glycol 3350 17 gram/dose powder one packet daily senna 8.6 mg tablet po bid docusate sodium 100 mg po bid digoxin 125 mcg po daily potassium chloride 10 meq tablet er po tid metoprolol succinate 12.5 mg po daily torsemide 40mg po daily discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. warfarin 5 mg tablet sig: 1-1.5 tablets po once a day. 4. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 8. potassium chloride 10 meq capsule, extended release sig: one (1) capsule, extended release po three times a day. 9. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 tablet extended release 24 hr po daily (daily). 10. torsemide 20 mg tablet sig: three (3) tablet po once a day. 11. losartan 25 mg tablet sig: 0.5 tablet po daily (daily). discharge disposition: home discharge diagnosis: acute on chronic systolic heart failure nonischemic cardiomyoapthy s/p icd later removed chronic af chronic dysphagia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with shortness of breath and found to be in acute heart failure. you were given medication to take off the extra fluid and no longer appear to be fluid overloaded. in the future- please call dr. or the heartline right away if you have symptoms of too much fluid: shortness of breath, swelling in your feet or ankles, weight gain. you should increase your torsemide to 60mg daily. you will need to have your electrolytes repeated in 1 week (you can have it all done on monday when you see dr. . your inr has been low. you should increase your coumadin to 5mg alternating with 7.5mg daily. you should take 7.5mg tonight. you will need to have your inr checked on monday . you should resume your digoxin (seems like you may have been on and off this medication in the past). medication changes: -increase coumadin to 7.5mg alternating with 5mg daily (take 7.5mg tonight) -increase torsemide to 60mg daily -add losartan 12.5mg daily -resume digoxin 125mcg daily for your heart failure diagnosis: weigh yourself every morning, md if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. follow a low salt diet and a fluid restriction of 1500 ml/ day. patient offered vna services at home, declines the need for them at this time. please let us know if you reconsider. followup instructions: dr. () monday 1:45pm *have your blood work repeated at this visit* department: cardiac services when: tuesday at 1 pm with: dr. building: sc clinical ctr campus: east best parking: garage department: cardiac services when: friday at 2:40 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage Procedure: Right heart cardiac catheterization Diagnoses: Other primary cardiomyopathies Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Other chronic pulmonary heart diseases Hypopotassemia Constipation, unspecified Alkalosis Long-term (current) use of anticoagulants Heart valve replaced by transplant Acute on chronic systolic heart failure Other dysphagia

allergies: no known allergies / adverse drug reactions attending: chief complaint: tricuspid regurgitation major surgical or invasive procedure: tricuspid valve replacement(33mm st. tissue) history of present illness: this 65 year old white male has known nonischemic dilated cardiomyopathy for years. he has previously undergone biventricular pacemeker/icd placement and has had progressive tricuspid regurgitation. the device was recently explanted due to concern for the lead interfering with the tricuspid valve. he has continued to have worsening symptoms and was referred for surgical intervention. catheterization previously demonstarted no obstructive coronary disease, severely depressed lv function(15-20%) and elevated right heart pressures. past medical history: s/p biventricular pacer/icd placement s/p removal of pacer/icd s/p left achilles tendon repair s/p sinus surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia social history: retired pipe fitter. lives with wife in . -tobacco history: never smoker -etoh: quit when diagnosed with heart failure -illicit drugs: denies family history: mother: renal failure no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: pulse 80 b/p 85/57 cuff 95/60 by aline o2sat: 100% ra resp: 18 height: 71" weight: 77.2 kgs general: nad skin: dry intact heent: perrla eomi neck: supple full rom mild jvd chest: lungs clear bilaterally heart: rrr irregular murmur holosystolic abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema trace varicosities: lle neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right: - left: - pertinent results: 03:40am blood wbc-5.5 rbc-3.30* hgb-10.5* hct-31.6* mcv-96 mch-31.8 mchc-33.2 rdw-16.0* plt ct-131* 03:29pm blood wbc-3.8* rbc-3.18* hgb-10.5* hct-31.1* mcv-98 mch-33.0* mchc-33.8 rdw-15.2 plt ct-113* 03:40am blood pt-17.3* ptt-33.6 inr(pt)-1.5* 03:59am blood pt-16.2* ptt-33.3 inr(pt)-1.4* 04:13am blood pt-15.0* ptt-33.1 inr(pt)-1.3* 01:26am blood pt-14.6* ptt-34.2 inr(pt)-1.3* 03:00am blood pt-14.8* ptt-36.5* inr(pt)-1.3* 03:29pm blood glucose-106* urean-29* creat-1.5* na-137 k-3.8 cl-98 hco3-30 angap-13 01:49am blood alt-19 ast-25 alkphos-76 totbili-1.4 echo the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is moderate to severe global left ventricular hypokinesis (lvef = 30 %). the right ventricular free wall thickness is normal. right ventricular chamber size is normal. with depressed free wall contractility. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. the prosthetic tricuspid leaflets appear normal. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the tricuspid valve has been replaced by a bioprosthesis. the right ventricle is no longer dilated. trace-to-mild tricuspid regurgitation is present. left ventricular function is improved due to reduction of right ventricular size, as well as reduction of ventricular interaction. electronically signed by , md, interpreting physician 16:10 brief hospital course: he was admitted a day early for pa catheter placement and diuresis. despite ultrasound visualization and an hour's time, the catheter could not be passed across the valve due to the regurgitant jet. diuresis was undertaken. on he went to the operating room where valve replacement was performed (see operative note for details). he weaned from bypass on levophed and milrinone. the pa catheter was placed at the end of the case, with great difficulty. he remained stable,and was extubated the day of surgery. over the next few days the milrinone was weaned off and he did well. he was diuresed toward his pre-operative weight and coumadin was started for atrial fibrillation. carvedilol was started for his cardiomyopathy and the torsemide he was on at home resumed after stopping lasix. wires were removed as were cts. he ambulated in the icu and progressed well. physical therapy was consulted for strength as well. he was cleared for discharge to home on pod# 9 with vna services, on medications as listed with appropriate follow up appointments. coumadin will continue to be managed by dr. his primary cardiologist. medications on admission: losartan 25 mg daily 2. metoprolol succinate 12.5 mg daily 3. omeprazole 20mg daily 4. torsemide 20mg daily 5. coumadin 5mg daily 6 days per week, 7.5mg on tuesday discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 4 weeks. disp:*50 tablet(s)* refills:*0* 2. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po daily (daily) as needed for constipation. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever or pain. 6. outpatient lab work inr/pt on and mon/wed and friday's until inr stable. results to dr. 7. warfarin 5 mg tablet sig: one (1) tablet po once a day: indication afib- inr goal 2.0-2.5 . 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 10. torsemide 20 mg tablet sig: two (2) tablet po twice a day. disp:*80 tablet(s)* refills:*2* 11. potassium chloride 10 meq tablet extended release sig: four (4) tablet extended release po daily (daily). disp:*120 tablet extended release(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: tricuspid regurgitation s/p tricuspid valve replacement nonischemic, dilated cardiomyopathy s/p biventricular pacemaker/icd placement s/p removal of biventricular pacemaker/icd chronic atrial fibrillation s/p achilles tendon repair chronic dysphagia discharge condition: alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon:dr. () on at 1pm in the medical office building cardiologist:dr. on at 1:30pm heart failure: dr 11:00am in 7 echocardiogram date/time: 9:00 in 7 **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication atrial fibrillation goal inr 2.0-2.5 first draw then mon/wed/friday's until stable results to dr. phone: fax : Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of tricuspid valve with tissue graft Diagnoses: Other primary cardiomyopathies Other iatrogenic hypotension Thrombocytopenia, unspecified Congestive heart failure, unspecified Atrial fibrillation Long-term (current) use of anticoagulants Acute on chronic systolic heart failure Diseases of tricuspid valve Stricture and stenosis of esophagus

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: right heart catheterization, picc line placement history of present illness: mr. is a 65 year old man with a pmhx s/f schf (ef 25%), and af who initially presented to hospital in on with five days of gradually worsening weakness, dyspnea on exertion, orthopnea, decreased appetite. he declines any dietary or medication nonadherance. initially he declined any change in weight. whilst in , he was treated for a chf exacerbation with diuresis and milrinone. over the course of his first week, he became increasingly hypotensive requiring increasing doses of milrinone. on following a fall with near syncope while walking, mr. was found to be hypotensive to sbps in the 50s requiring transfer to the ccu. note his only injury suffered with this fall was an excoriation of his left knee. he was maintained on dopamine and milrinone early in his icu course, but this was able to be weaned on . le us demonstrated no dvt. throughout his course, when bp would allow he was gently diuresed with iv boluses of bumex (2mg) and torsemide (10-20mg), but given his low bp this occurred only every other day. troponin i peaked at 0.27 on .12 on transfer. mb remained flat throughout his admission. ischemic etiology was not entertained. echo was performed on demonstrated ef 22%, severe rv dysfunction, dilated la, moderate to severe mr. initial cxr demonstrated rml and lll pneumonia with bilateral pleural effusions, but ct at the osh demonstrated large b/l pleural effusions, several rib fractures on the right, with no evidence of pneumonia. of note, he was afebrile throughout his admission without leukocytosis. labs on day of transfer: na 128, k 3.5, cl 86, bicarb 30, bun 62, cr 1.9. mg 2.3, ca 8.6, pt 16.3, inr 1.7. also of note, mr. was initiated on megace for poor appetite and cachexia. past medical history: chf (ef 25% in ) s/p tricuspid valve replacement for tr s/p biventricular pacer/icd placement s/p removal of pacer/icd s/p left achilles tendon repair s/p sinus surgery chronic atrial fibrillation nonischemic dilated cardiomyopathy chronic dysphagia social history: retired pipe fitter. lives with wife in . never smoked. denies illicits. drank etoh only rarely after diagnosed with chf; quit in . family history: mother with renal failure. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: physical exam on admission: general - cachectic elderly m in nad, comfortable, appropriate, aaox3 heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, jvd 1/2 up neck @30 degrees lungs - rales in rlb, otherwise ctab good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, nl s1-s2. no rv heave noted. heart sounds distant. abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, 2+ bilateral pitting edema up to thighs. skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, grossly non-focal physical exam on discharge: general - cachectic elderly m in nad, comfortable, appropriate, aaox3 heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear. jvp much improved at 12. neck - supple, no thyromegaly, jvd at level of the mandible at 60 degrees lungs ?????? faint bibasilar crackles r>l, improved from prior, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, nl s1-s2, no murmurs. heart sounds distant. abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, 1+ bilateral pitting edema up to knees and in dependent aspect of thighs pertinent results: admission labs: 06:45pm blood wbc-7.1 rbc-3.83* hgb-11.9* hct-36.1* mcv-94 mch-31.0 mchc-32.8 rdw-15.7* plt ct-163 06:45pm blood neuts-73.8* lymphs-17.4* monos-6.5 eos-1.4 baso-0.8 06:45pm blood pt-13.9* ptt-34.3 inr(pt)-1.3* 06:45pm blood glucose-106* urean-42* creat-1.3* na-131* k-3.8 cl-91* hco3-35* angap-9 06:45pm blood calcium-9.3 phos-2.3* mg-2.0 06:45pm blood digoxin-0.8* 04:11am blood hgb-11.1* calchct-33 o2 sat-69 pertinent studies: echo the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. there is severe global left ventricular hypokinesis (lvef = 15-20 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. there is abnormal septal motion/position. 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. the tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , lv systolic function appears slightly less vigorous. cardiac catheterization : 1. hemodynamic catheterization in this patient demonstrates decreased cardiac output at baseline with moderately elevated left ventricular filling pressures. following milrinone infusion the cardiac index signficantly increased from 2.1 to 2.5 l/min/m2 without a change in left ventricular filling pressures. final diagnosis: 1. severe systolic and diastolic ventricular dysfunction. 2. significant improvement in hemodynamic parameters following milrinone infusion. tte : the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. there is severe global left ventricular hypokinesis (lvef = 15-20 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. there is abnormal septal motion/position. 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. the tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. labs on discharge: 03:32am blood wbc-6.4 rbc-3.33* hgb-10.3* hct-31.1* mcv-93 mch-31.0 mchc-33.2 rdw-16.1* plt ct-132* 03:32am blood pt-22.1* ptt-35.2 inr(pt)-2.1* 03:32am blood glucose-110* urean-37* creat-1.5* na-133 k-3.5 cl-86* hco3-34* angap-17 03:32am blood calcium-8.8 phos-3.8 mg-2.1 brief hospital course: mr. is a 65 year old man with a past medical history significant for non-ischemic cardiomyopathy with an ef of 25% who presented with a chf exacerbation and was initiated on homegoing dopamine. active diagnoses: #. acute on chronic heart failure (right-sided, systolic):mr. was initially managed in , fl for a chf exacerbation with milrinone and dopamine. diuresis was deferred due to hypotension. weight on admission of 158 was above discharge weight from of 138. heart failure is primarily driven by dilated rv in the setting of long term wide open tr which had only been repaired 6 weeks earlier. rhc demonstrated improvement in co with milrinone (3.8 to 4.2), but to a less extent than would be inferred by his improvement in clinical status during his last admission. on his second day of admission, support with milrinone only was attempted, but was aborted due to persistent hypotension (maps of 55). dopamine was attempted at 6 mcg/kg/hr with improvement in bp with maps > 60, and improvement in co 5.8 and ci 3.0. a picc was placed for home dopamine infusions. however, diuresis was tapering off even though patient was on lasix 20 and dopamine 10. patient was not maintaining good o2 sats and felt cold in his peripheries and short of breath when talking. a decision was made to transfer him to medical center for heart transplant evaluation. upon discharge, he was 10.8l negative. his discharge weight was . #. afib: patient is anticoagulated for afib, goal . inr 2.1 today. patient was continued on warfarin 7.5mg daily. . #. acute kidney injury: baseline cr 1.0, cr at osh is 1.9 likely secondary to decompensated chf. with continued diuresis, cr initially came downt o 1.2, but then bumped up to 1.5 on transfer. despite further increases in dopamine and lasix drips, his urine output continued to taper off. patient had diuresed -800cc since midnight of the day of transfer. . # thrombocyteopenia: plts slowly downtrending to 132 from 163 on admission. ddx includes malnutrition, marrow suppression, drug effect. hit was thought to be less likely, as there was a less than 50% fall, no evidence of thrombosis. . #.skin discoloration: patient noted to have yellowish skin discoloration on , initially concerning for congestive hepatopathy. however, lfts were normal. most likely etiology is pyridium use (started for bladder spasm). pyridium was discontinued. . #. gerd: patient was continued on home lansoprazole. . #. constipation: patient was maintained on an aggressive bowel regimen with senna, colace, miralax. at one point, patient had not had bowel movement in 3 days, so was given lactulose and fleet enema, to which he responded with a bowel movement. . #. dysphagia: patient has a history of dysphagea and cannot swallow while supine. he tolerated a regular diet, but was willing to consider a soft diet if he was unable to swallow regular food. . # bph: patient had low uop one day and bladder scan confirmed urinary retention. prostate exam revealed enlarged bladder, and patient is known to have hx of bph. he was started on phenazopyridine and tamsulosin. transitional issues: patient was transferred to medical center for heart transplant evaluation. he will be sent with this discharge summary, several recent tte and rhc reports, and several of his outpatient cardiology appointment notes. at , he was evaluated for a lifevest, and most of the paperwork was filled out, but this was deemed no longer necessary upon transfer. if patient is deemed at to still need lifevest, can contact case manager at for additional details. medications on admission: digoxin - 125 mcg tablet - one tablet(s) by mouth once a day losartan - 25 mg tablet - 0.5 (one half) tablet(s) by mouth once a day metoprolol succinate - (prescribed by other provider: ) - 25 mg tablet extended release 24 hr - 0.5 (one half) tablet(s) by mouth once a day omeprazole - (prescribed by other provider) - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth twice a day polyethylene glycol 3350 - (prescribed by other provider) - 17 gram/dose powder - 1 by mouth daily potassium chloride - (prescribed by other provider) - 10 meq capsule, extended release - 1 capsule(s) by mouth at breakfast, lunch & supper torsemide - (prescribed by other provider) - 20 mg tablet - 3 tablet(s) by mouth once a day warfarin - (prescribed by other provider) - 5 mg tablet - 1-2 tablets as directed. tablet(s) by mouth take as directed aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily docusate sodium - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth twice a day sennosides - (prescribed by other provider) - 8.6 mg tablet - 1 tablet(s) by mouth twice a day as needed for constipation discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) solution injection tid (3 times a day). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. polyethylene glycol 3350 17 gram/dose powder sig: one (1) dose po bid (2 times a day) as needed for constipation. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 7. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 9. digoxin 125 mcg tablet sig: one (1) tablet po q48h (every 48 hours). 10. warfarin 2.5 mg tablet sig: three (3) tablet po once daily at 4 pm. 11. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 12. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 13. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 14. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) for 3 days. 15. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 16. metolazone 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). 17. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 18. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 19. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care discharge diagnosis: congestive heart failure atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you at . you were admitted for diuresis for your heart failure. while you were here, we started you on two pressors (milrinone and dopamine) and a lasix drip to help you with urine output. while you were here, you diuresed 10.8l. we ultimately decided to transfer you to for cardiac transplant evaluation because you were not maintaining adequate urine output despite high doses of dopamine and lasix drip. followup instructions: please follow-up with your outpatient cardiologist, dr. , when you are discharged from . Procedure: Pulmonary artery wedge monitoring Right heart cardiac catheterization Central venous catheter placement with guidance Diagnoses: Other primary cardiomyopathies Thrombocytopenia, unspecified Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Constipation, unspecified Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Cachexia Cardiogenic shock Long-term (current) use of anticoagulants Retention of urine, unspecified Heart valve replaced by transplant Acute on chronic systolic heart failure Dysphagia, unspecified Other specified disorders of bladder

allergies: no known allergies / adverse drug reactions attending: chief complaint: transfer for c. cath/stemi major surgical or invasive procedure: cardiac catheterization with drug-eluting stent placed in the left anterior descending artery history of present illness: 79-year-old male with history of cad and prior pci with des to om2 at () that presented to the er at osh with chest pain. the night prior to presentation he experienced indigestion. he then awoke with a "rope-like" non-radiating chest discomfort with no associated symptoms except perhaps chills that resolving except the portion "over the heart." he continued to have this discomfort. his wife called his pcp and told him to report to the nearest er. ekg on presentation showed st elevation in leads v3,4, and 5. troponin was 12.483. he was given 81 mg asa x 4, 4500 units heparin bolus with drip at 1800 units/hr and 5 mg iv lopressor. he was given plavix 600 mg po x 1 prior to transfer to for c. cath. he was chest pain free prior to transfer. vitals at transfer were bp 145/87 hr 63 sr pox 100 % on 3 l o2 and rr 20. he was taken to the c. cath lab showing subtotally occluded lad with successful ptca/stenting with 2.5 x 18 promus stent. lcx and rca were patent. on the floor, patient in nad without any complaints. of note, he was recently hospitalized at medical in early for sepsis from a urinary source secondary to bph. he completed a course of levofloxacin, was placed on flomax, and is scheduled to follow-up with urology. . 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 exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. + palpitations two days before the event . past medical history: 1. cardiac risk factors: diabetes, +dyslipidemia, hypertension 2. cardiac history: cad s/p prior pci - percutaneous coronary interventions: (): has stent placed to om2 with ? mi in setting of shoulder pain. at that time, he was placed on asa/plavix. 3. other past medical history: - bph with urinary retention - history of hl - history of uti - esophageal dilitation social history: he lives with his wife. - tobacco history: none - etoh: glasses of wine/week - illicit drugs: none family history: - brother died of mi at age 60 (sudden death) while shoveling snow. - mother: unknown cancer at age - father: copd at age 85 physical exam: tmax: 35.9 ??????c (96.6 ??????f) tcurrent: 35.9 ??????c (96.6 ??????f) hr: 69 (69 - 69) bpm bp: 125/73(82) {125/73(82) - 125/73(82)} mmhg rr: 21 (21 - 21) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) general appearance: no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, poor dentition lymphatic: cervical wnl cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: clear : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent skin: warm, no(t) rash: neurologic: attentive, follows simple commands, responds to: not assessed, oriented (to): aaox2 (not to date fully), movement: not assessed, tone: not assessed pertinent results: i. cardiology a. cath () ** prelim report ** brief history: 78 m presented to osh with chest pain and transferred to for emergent cardiac catheterization. indications for catheterization: coronary artery disease, stemi transfer procedure: coronary angiography conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. **ptca results lad ptca comments: initial angiography reveald a mid lad 95% subacute thrombus. we planned to treat this thrombus with aspiration thrombectomy/ptca/stenting and heparin/integrilin given prophylactically. an xb lad 4.0 guiding catheter provided good support for the procedure and a prowater wire was advanced into the distal lad with moderate difficulty. we then proceed with an export ap aspiration thrombectomy but unable to deliver device distal to subacute thrombus. we then predilated the mid lad thrombus with an apex otw 2.0x8 mm balloon inflated at 8 atm. we then noted an acute cut-off in the distal lad after flow was re-established and proceeded with cautious dotting of the cut-off area with the balloon and distal delivery of ntg via balloon with minimal improvement of distal lad flow. we then stented the mid lad with a promus rx 2.5x18 mm drug-eluting stent (des) post-dilated with an nc quantum apex mr 2.75x12 mm balloon inflated at 20 atm for 20 sec. final angiography revealed normal timi 3 flow in the vessel, no angiographically apparent dissection and 0% residual stenosis in the newly deployed stent but acute cut-off in distal lad showed diffusely diseased small apical vesswel that remained unchanged despite mechanical dottering and distal ntg delivery via balloon. the r 6fr femoral artery sheath was removed post limited groin angiography and an angioseal closure device was deployed without complications with distal pulses confirmed post deployment. the patient left the cath lab angina-free and in hemodynamically stable condition. technical factors: total time (lidocaine to test complete) = 59 minutes. arterial time = 56 minutes. fluoro time = 15.2 minutes. irp dose = 733 mgy. contrast injected: omnipaque 175 cc total contrast during procedure anesthesia: 1% lidocaine sc, fentanyl 25 mcg iv, versed 0.5 mg iv total anticoagulation: heparin units, integrilin bolus and infusion comments: 1. emergent coronary angiography revealed a right dominant systemt. the lmca, lcx and rca were all patent. the lad revealed a mid 95% occlusion with thrombus. 2. limited resting hemodynamics revealed a sbp of 142 mmhg and a dbp of 80 mmhg. 3. successful aspiration thrombectomy/ptca/stenting of the mid lad with a promus rx 2.5x18 mm -dilated with an nc 2.75 mm balloon. final angiography revealed normal timi 3 flow, no angiographically apparent dissection and 0% residual stenosis in the newly deployed stent with an abrupt cut-off in the distal lad unchagned despite mechanical balloon dottering and distal ntg delivery via balloon. (see ptca comments) 4. r 6fr femoral artery angioseal closure device deployed without complicatons (see ptca comments) final diagnosis: 1. severe coronary artery disease with subtotally occluded mid lad: see comments section. 2. successful aspiration thrombectomy/ptca/stenting of the mid lad with a promus rx 2.5x18 mm -dilated with an nc 2.75 mm balloon. (see ptca comments) 3. r 6fr femoral artery angioseal closure device deployed without complications (see ptca comments) 4. asa indefinitely; plavix (clopidogrel) 75 mg daily for at least 12 months for des 5. integrilin gtt for 18 hours post pci for thrombus and abrupt cut-off of distal small vessel apical lad unchanged despite mechanical balloon dottering and distal ntg delivery via balloon b. tte () conclusions the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with basal to mid lateral hypokinesis and distal septal/distal anterior and apical septal hypokinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the 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. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. c. ecg no prior ecg available for comparison. osh ecg dated at 9:01 showing ?ectopic atrial rhythm, ni, leftward axis. ste in v3, v4, and v5. ii. labs a. admission 03:15pm blood wbc-7.5 rbc-4.21* hgb-13.6* hct-38.9* mcv-92 mch-32.3* mchc-34.9 rdw-12.7 plt ct-253 03:15pm blood pt-13.4 ptt-27.0 inr(pt)-1.1 03:15pm blood glucose-130* urean-15 creat-1.1 na-139 k-4.2 cl-103 hco3-28 angap-12 03:15pm blood calcium-9.4 phos-3.0 mg-2.1 cholest-204* b. cardiac 05:57am blood ck(cpk)-426* 11:13pm blood ck(cpk)-675* 05:57am blood ck-mb-22* mb indx-5.2 ctropnt-1.36* 11:13pm blood ck-mb-41* mb indx-6.1* 03:15pm blood ck-mb-96* mb indx-9.2* ctropnt-3.21* c. misc 03:15pm blood %hba1c-6.0* eag-126* 03:15pm blood triglyc-135 hdl-44 chol/hd-4.6 ldlcalc-133* d. discharge wbc 4.5 hgb 11.2 plt 181 inr 1.2 na 141 k 4.4 cl 108 hco3 29 bun 20 cr 1.4 ca 9.1 ph 3.2 mg 2.1 brief hospital course: 79-year-old male with history of cad and prior pci with des to om2 at () that presented to the er at osh with transferred to , and now s/p successful ptca/stenting with des for lad lesion. # stemi patient has known history of cad given prior stent placement in om2. it is uncertain why the patient is not on any cardiac medications for risk reduction. he presented with chest discomfort. osh ecg notable for ectopic atrial rhythm and st elevations in v3, v4, and v5 and initial troponin 12.483 (unknown if i or t) and ck-mb 68.5. cardiac biomarkers indicated ck-mb 22 and ctrop 1.36. he was transferred to for c. cath with successful ptca/stenting with des for 95 % subacute mid-lad thrombus. final angiography revealed normal timi 3 flow and no angiographically apparent dissection. see cardiac cath report for full details. cardiac biomarkers indicated ck-mb 22 and ctrop 1.36. post-mi echo indicated lvef 35-40 % withmild to moderate regional left ventricular systolic dysfunction with basal to mid lateral hypokinesis and distal septal/distal anterior and apical septal hypokinesis. this may be suggestive of another mi given that these wall motion abnormalities do not necessarily correspond to his lad lesion. he was continued on an integrilin infusion for 18 hours post pci for thrombus and abrupt cut-off of distal small vessel apical lad unchanged despite mechanical balloon dottering and distal ntg delivery via balloon. he was placed on aspirin 325 mg po qd indefinitely, clopidogrel 75 po qd for at least 12 months for des. he was started on crestor given concern for myalgias. he was also started on metoprolol and lisinopril. # hyperlipidemia patient was not on lipid-lowering therapy on admission. cholesterol panel showing total cholesterol 204, tg 135, hdl 44, and ldl 133. he was started on statin as above and advised to initiate lifestyle modifications. a1c was 6 suggestive of pre-diabetic state. # rhythm: patient remained in nsr during hospitalization with telemetry showing bradycardia to low 40s during sleep. # bph with urinary retention patient was recently hospitalized at brothers in the state of for sepsis from a urinary source in the setting of urinary retention per provided records from family. he was continued on flomax during hospitalization and will follow-up with urology after hospitalization. code: full comm: patient, wife (h) (c) medications on admission: - flomax 0.4 mg po qd - multivitamin discharge medications: 1. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*11* 4. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 5. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 6. outpatient lab work please check chem-7 and cbc on at dr. office. 7. crestor 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual as directed as needed for chest pain. disp:*25 tablets* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: st elevation myocardial infarction coronary artery disease acute kidney injury . secondary diagnosis: hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking part in your care at . you were transferred here after it was determined that you had suffered a heart attack prior to arriving at hospital. you underwent a cardiac catheterization procedure where a drug eluting stent was placed in one your heart arteries and you did very well after this. you will need to take a number of medications to keep your heart healthy and make sure the stent stays open. we have made the following changes to your medications: start taking aspirin 325 mg and plavix daily. these medicines work together to prevent the stent from clotting off. you will need to take these medicines daily for the next year and possibly longer. do not stop taking aspirin and plavix unless dr. says that it is ok. start taking rosuvastatin (crestor) to lower your cholesterol. you will need to have your liver function tested with blood tests on a regular hasis on this medicine. if you develop muscle cramps on this medicine, please call dr. . start taking lisinopril to lower your blood pressure and help your heart recover from the heart attack. start taking metoprolol to lower your heart rate and help your heart recover from the heart attack. start taking nitroglycerin if you have chest pain at home. take one tablet under your tongue, sit down and wait 5 minutes. you can take another tablet if you still have chest pain but please call dr. if you take any nitroglycerin. continue to take flomax as before. followup instructions: d', d. appointment already made on at 11:00 am . name: , location: bldg address: 131 ornac, , , phone: appt: at 3:30pm md, Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute kidney failure, unspecified Percutaneous transluminal coronary angioplasty status Acute myocardial infarction of anterolateral wall, initial episode of care Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Retention of urine, unspecified

allergies: cefepime attending: chief complaint: fever major surgical or invasive procedure: none history of present illness: pt's a 53-year-old male patient of dr. is here for evaluation of fever. the patient states fever began two days ago along with a mild dry cough, fever was low-grade at that time. day of admission, pt noticed to be 101.8 has some chills as well. no shortness of breath, no chest pain. denies any headache, ear aches, and some scratchy throat. the patient denied any change in stools, ab pain, urinary sx, has some mild nausea on but thought it more due to fever. no arthralgias or myalgias or rashes. the patient says cough is nonproductive. he did recently have uri symptoms beginning of the month which abated shortely . he then came on the 22nd for routine medical examination and was found to be in pretty good health and stated remains until these last two days. of important note - pts kids had been sick earlier this week (both) - similiar sx - lasting just 3 days. pt reports having the flu shot earlier this week. noted poor po intake past few days. <br> review of systems: <br> constitutional: no weight loss/gain, fatigue, malaise, + fevers, +chills, no rigors, night sweats, or anorexia. heent: no blurry vision, diplopia, loss of vision, photophobia. no dry motuh, oral ulcers, bleeding nose or , tinnitus, sinus pain. cardiac: no chest pain, palpitations, le edema, orthopnea, pnd, doe. respiratory: no sob, pleuritic pain, hemoptysis, does have mild dry-cough as above. gi: + mild nausea but no vomiting, abdominal pain, abdominal swelling, diarrhea, constiatpion, hematemesis, hematochezia, or melena. heme: no bleeding, bruising. lymph: no lymphadenopathy. gu: no incontinence, urinary retention, dysuria, hematuria. skin: no rashes, pruritius. endocrine: no change in skin or hair (has chronic hair loss), no heat or cold intolerance (noted thyroid meds recently adjusted). ms: no myalgias, arthralgias, or back or nec pain. neuro: no numbness, weakness or parasthesias. no dizziness, lightheadedness, vertigo. no confusion or headache. psychiatric: no depression, anxiety. allergy: no seasonal or medication allergies. past medical history: -splenectomy -pericarditis -hodgkin's disease, and bone marrow transplant in , hodgkin's treatment was in social history: no tob, etoh, or drugs. lives with wife and 2 kids, - employment - real estate developer. family history: mother with breast ca/uterine ca physical exam: vitals: 99.5 138/80 95 18 96%ra pain: denies access: rue picc gen: nad, thin man heent: anicteric, mmm cv: rrr, no m resp: ctab, improved l sided crackles, no wheezing abd; soft, nontender, +bs ext; no edema neuro: a&ox3, grossly nonfocal skin: no changes psych: appropriate pertinent results: wbc 20-->15.4-->12.4 (peak 26 ) hgb -->8.8 stable s/p 1u plt 800s inr 1.3 retic 4.7 chem panel unremarkable bun 11/creat 0.9 lfts normalized except alk phos 214, downtrending (peak 385 on , normal prior), albumin 2.8 . . influenza swab +b ag sputum cx mssa x2 blood cx all ntd urine cx ntd stool cx ntd . . imaging/results: cxr : lul consolidation, mod pulm edema, r picc . . ruq us : 1. unchanged appearance of mildly distended gallbladder containing layering sludge, without evidence of acute cholecystitis. 2. no focal liver lesions or biliary ductal dilatation. 3. right pleural effusion. . ct chest: 1. interval decrease in right-sided pleural effusion. left- sided pleural effusion is unchanged. 2. persistent multifocal pneumonia with interval worsening consolidation in the lingula and left upper lobe. 3. nonspecific soft tissue stranding in the left upper quadrant, new from prior study but difficult to assess without oral contrast. consider ct of the abdomen for more complete assessment, if warranted clinically. . . echo: ef 55%, mod pulm htn. cta, no pe . . brief hospital course: 53-year-old male patient with h/o of hodgkins lymphoma in bmt ', h/o splenectomy, h/o pericarditis, hypothyroidism was initially admitted for fever in setting +sick contacts. in er, confirmed influenza b + (rx with tamiflu x7days). pt initially did well first night, but then had rapidly worsened hypoxia am of with ct chest showing new multilobar consolidations. developed septic shock and ards, started broad abx (vanc/cefepime/azithromycin), transfered to micu, was intubated for hypoxemic resp failure . resp cultures grew mssa and abx changed to nafcillin to complete 3week course per id (until via r picc). was finally extubated and transfered to gen med on . on gen med, continued with rapid improvement, weaned off o2. there was some concern initially with persistant leukocytosis in 20s with fevers and imaging with pleural effusions that raised concern for parapneumonic efffuisons or empyema. however, wbc did start to trend down so was deferred. he will have id f/u after abx and needs repeat imaging. still having low grade fevers and imaging with l>r infiltrates but clinically much better. other infectious w/u negative. of note, during hospitalization, pt had some lft elevation with us/ct showing sludge but no evidence of cholecystitis and this was likely acute illness and possible tpn which he recieved for few days (improving by time of discharge). also developed anemia 12-->8 w/o gross evidence of bleeding or hemolysis, s/p 1u prbc with hgb stable 9s thereafter. this can be followed up as outpt. . . see progress note below for details according to each problem: 53 year-old male with a history of hodgkin's s/p bmt in 93, s/p splenectomy, h/o pericarditis, hypothyroidism, anemia, admitted with influenza b (received antiviral treatment in icu) complciated by severe mssa bacterial superinfection-->ards/intubation, extubated , t/f to floor , doing very well, ambulating, tolerating po, plan to d/c home today . . mssa cap, superinfection (influenza b): ards, extubated . doing well, off oxygen. some concern initially with persistant leukocytosis/fevers and ct with persistant l>>r pleural effusions concerning for parapneumonic effusions but white count finally down. pt has been afebrile (low grade temps) - continue nafcillin 2 gm iv q 4hr through for total of 3 weeks per id (confirmed plan) -since downtrending wbc, can hold off on , but needs repeat imaging to ensure resolved effusions, f/u clinic in - continue incentive spirometry - guiafenisin prn, duonebs -note, pt is post splenectomy, asked to confirm pneumovax and meningitis vaccine, but none here while pna . . leukocytosis: as above, 20s for several days, today down to 12, as above, concern for parapneumonic effusions but holding as above with repeat cxr in 1week. currently with low grade temps, no fevers. as for other sources, lij tip not sent, picc site looks good, no urinary complaints, no diarrhea. note, baseline elevated wbc partly due to post-splenectomy. . . anemia and thrombocytosis: baseline hgb 12s, here 9-->7s s/p 1u prbc , now 9s. no obvious bleeding or hemolysis but was acutely ill. -fe studies will be unreliable since got blood t/f, hold supp since fe load with transfusion -will need to be followed as outpt -as for thrombocytosis, likely reactive (anemia, illness) and post-splenectomy . . hodgkins disease s/p bmt', no issues . . hypothyroidism: cont levothyroxine 88mcg . . gerd: protonix 40-->prilosec at home . . dyslipidemia; resume lipitor 10 . . elevated alk phos: ruq with sludge, no dilation, bili normal, no ruq pain -slow trend down, monitor, follow as outpt . medications on admission: atorvastatin - 10 mg tablet - 1 tablet(s) by mouth once a day levofloxacin - 500 mg tablet - 1 tablet(s) by mouth once a day levothyroxine - 88 mcg tablet - 1 tablet(s) by mouth once a day omeprazole - 10 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day discharge medications: 1. picc care per protocol 2. nafcillin 2 gram piggyback sig: two (2) intravenous every four (4) hours for 6 days: total 4g. continue until . disp:*qs doses* refills:*0* 3. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: mls po q6h (every 6 hours) as needed for cough. 5. prilosec otc 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 6. lipitor 10 mg tablet sig: one (1) tablet po once a day. 7. ferrous sulfate 325 mg (65 mg iron) capsule, sustained release sig: one (1) capsule, sustained release po once a day. discharge disposition: home with service facility: critical care systems discharge diagnosis: influenza type b severe mssa multilobar pneumonia as superinfection causing ards anemia s/p blood transfusion discharge condition: good discharge instructions: you were admitted with influeza with superimposed severe bilateral pneumonia due to staph. you will need to complete iv antibiotics until . if you have worsening of fevers/cough/shortness of breath, call your doctor or come to er. your picc line will be removed after the antibiotics are complete. please follow up with dr. on as scheduled so that she can make sure you are stable, you will need repeat chest xray as well. confirm with your primary doctor that you are up to date with your vaccination since you have your spleen removed. your medications are otherwise kept the same. you had anemia during this hospitalization likely from your severe illness, please follow this with your doctor to make sure this is getting better. you recieved 1 unit of blood for this. you can take daily fe supplement to help with this. followup instructions: provider: , md phone: date/time: 9:00 provider: , m.d. phone: date/time: 10:45 provider: , m.d. date/time: 10:40 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Anemia, unspecified Esophageal reflux Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Bone marrow replaced by transplant Other and unspecified hyperlipidemia Acute respiratory failure Septic shock Methicillin susceptible pneumonia due to Staphylococcus aureus Influenza with pneumonia Personal history of hodgkin's disease Essential thrombocythemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: recurrent diverticulitis major surgical or invasive procedure: : laparoscopic sigmoid colectomy, splenic flexure takedown, rigid sigmoidoscopy. . : exploratory laparotomy, lysis of adhesions, omentectomy, washout of abdomen, drain placement and abdominal closure. history of present illness: mr. is a 47-year-old gentleman with a history of diverticulitis in and again in . his last episode required a seven day hospital stay on intravenous antibiotics. subsequently, his symptoms resolved and he was discharged on an oral regimen. he had a colonoscopy after his first attack of . he has no colonoscopies within our system. he feels well now and has no further symptoms. he was admitted for prophylactic operation to prevent recurrence. past medical history: pmhx: type ii dm, htn, diverticulitis . pshx: negative social history: he lives in . he is in a same sex marriage. rarely drinks alcohol. smokes very rarely and at that time smoked four to five cigarettes per day. he is a registered nurse . family history: family history is significant for grandmother with lung cancer, grandfather with strokes, and other family members with hypertension and diabetes. physical exam: pre-admission examination: on physical exam, he is afebrile. vital signs are normal. sclerae are nonicteric. chest is clear. heart is regular. abdomen is soft without rebound or guarding. there is nofullness. testicles are symmetric and descended. he is circumcised. extremities are warm without edema. rectal exam is heme negative, normal tone. . at discharge: avss/afebrile gen: well appearing male in nad. heent: sclerae anicteric. o-p clear. neck: supple. lungs: cta(b) cor: rrr; no m/c/r. abd: midline incision with staples c/d/i. bsx4. appropriately tender along incision, otherwise soft/nt/nd. extrem: no c/c/e neuro: a+ox3. comfortable. non-focal/grossly intact. pertinent results: on admission: 07:28pm potassium-4.1 07:28pm magnesium-1.9 07:28pm hct-39.6* . imaging: cxr: aside from several regions of subsegmental atelectasis at the right base, lungs are clear, though low in volume. there is no pleural effusion or evidence of central adenopathy. severe gastrointestinal gaseous distension present in the upper abdomen raises concern for small-bowel obstruction. . ap cxr: in the interval there has been improvement in the degree of vascular engorgement with the lungs appearing clear. nasogastric tube has been removed. right-sided jugular central venous catheter is in unchanged position. . heel (axial & lateral) left: there is a large dorsal calcaneal enthesophyte. no discrete fracture is identified. there is mild fragmentation within the enthesophyte but there appears to be cortication in the fragment. . microbiology: stool clostridium difficile toxin a & b test- negative. stool clostridium difficile toxin a & b test- negative. urine urine culture- no growth. blood culture: no growth. blood culture not processed. mrsa screen mrsa screen-final {positive for methicillin resistant staph aureus). blood culture: no growth. blood culture: no growth. urine urine culture- <10,000 organisms/ml. blood culture: no growth. blood culture: no growth. brief hospital course: the patient was admitted to the general surgical service on for prophylactic operation to prevent recurrence of diverticulitis. the patient underwent laparoscopic sigmoid colectomy, splenic flexure takedown, rigid sigmoidoscopy, which initially went well (reader referred to the operative note for details). after a brief, uneventful stay in the pacu, the patient arrived on the floor npo on iv fluids, with a foley catheter in place, and a dialudid pca and toradol iv for pain control. the patient was hemodynamically stable. . postoperatively, initially he did well, but he began spiking fevers. his white blood cell count dropped, his urine output dropped, and he began to have a septic etiology. he was pan-cultured, started on empiric antibiotic therapy, and given aggressive iv fluid rescusitation. concern for an anastomotic leak was raised. a chest x-ray showed evidence of pneumoperitoneum. the patient was back to the operating room on and underwent exploratory laparotomy, lysis of adhesions, omentectomy, washout of abdomen, drain placement and abdominal closure, which went well without complication (see operative note). after a prolonged pacu stay where he was extubated, he was transferred to the ticu. he arrived npo with an ng tube, on iv fluids and iv zosyn and vancomycin, a foley catheter and 2 jp drains to bulb suction were in place, and he recived fentanyl for pain control with good effect. post-operative fluid overload and associated hypertension was treated with iv lasix for diuresis as well as metoprolol and hydralazine with good effect. he was transitioned back to home labetolol and clonidine was started. the ng tube was removed. while in the ticu, he began to notice some (l) ankle pain. . on , the patient was transferred back to 9. pain was initially well controlled with a dilaudid pca, which was converted to oral pain medication when tolerating clear liquids. the patient was started on sips of clears upon transfer, which was progressively advanced as tolerated to a low fat, heart healthy regular diet by with good tolerability. the foley catheter was discontinued the morning of . the patient subsequently voided without problem. iv antibiotics were discontinued on . both jp drains were discontinued on as their output was low. the incision with staples remained clean and intact. he was transitioned back to his home anti-hypertensive medications with good bp control. . during this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. the patient received subcutaneous heparin and venodyne boots were used during this stay. the patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. by discharge, he was started back on home metformin for diabetes. labwork was routinely followed; electrolytes were repleted when indicated. . at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating his diet, ambulating, voiding without assistance, and pain was well controlled. he was discharged home wihtout services. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: 1. labetalol 200 mg tablet sig: two (2) tablet po bid (2 times a day). 2. metformin 500 mg tablet sig: one (1) tablet po twice a day. 3. lisinopril 10 mg tablet sig: one (1) tablet po once a day. 4. viagra 50 mg 1 tab po as directed for ed. discharge medications: 1. labetalol 200 mg tablet sig: two (2) tablet po bid (2 times a day). 2. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*60 capsule(s)* refills:*0* 3. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation: over-the-counter. 4. metformin 500 mg tablet sig: one (1) tablet po twice a day. 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 6. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for anxiety/insomnia. disp:*30 tablet(s)* refills:*0* 7. lisinopril 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: 1. recurrent diverticulitis. 2. sepsis with acute abdomen and internal hernia secondary to infarcted omentum with small bowel obstruction. discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: 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 7-10 days after surgery. followup instructions: please call ( to schedule a follow-up appointment with dr. (surgery) in 2 weeks. . please call ( to arrange a follow-up appointment with dr. (pcp) in weeks. Procedure: Percutaneous abdominal drainage Excision or destruction of peritoneal tissue Other lysis of peritoneal adhesions Reopening of recent laparotomy site Rigid proctosigmoidoscopy Peritoneal lavage Laparoscopic sigmoidectomy Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other ascites Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Dehydration Acute vascular insufficiency of intestine Pain in joint, ankle and foot Oliguria and anuria Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) Diverticulitis of colon (without mention of hemorrhage) Unspecified hypertensive heart disease with heart failure Hernia of other specified sites without mention of obstruction or gangrene Other postoperative functional disorders

allergies: bactrim / norvasc / lipitor / cortisone attending: chief complaint: chief complaint: anemia . reason for micu transfer: retroperitoneal bleed major surgical or invasive procedure: coiling of superior gluteal artery history of present illness: ms. is a 65 yof with history of gerd, htn, and hypertriglyceridemia who was recently admitted from to after being transferred from an osh for intractable diarrhea. this hospital course was complicated by pea arrest in the setting of ph 6.98 and she was intubated and had a right femoral cvl placed and was started on a bicarb drip. she was diagnosed with postviral autoimmune enteropathy and was treated with tpn and eventually discharged on budesonide and methylprednisolone with improvement in her diarrhea. notably her hospital course was complicated by hypertensive urgency with sbp above 200, volume overload in the setting of steroids, and an enterococcus uti. she was discharged to rehab 4 days ago. . the following day, she developed some mild pain in her medial knee up her thigh to the groin. this was in the setting of increased mobility - as she had previously been limited by rectal tube during her admission. she had a f/u appointment with her gastroenterologist the following day and when she returned to rehab she complained of the pain and had lenis that were negative for dvt. the following morning (today) she was turing and had increased pain in her right hip and flank. she films and checked a hct that was 14 (down from 27 on ). she denied dizziness, chest pain, or dyspnea. she denied history of trauma and was only on heparin subq for dvt prophylaxis but otherwise no anticoagulation. she was sent to the ed for further eval. . in the ed, vs 97.9 88 85/39 18 99% 3l. she was given fentanyl for pain and hydrocortisone 100 mg (stress doese). she had guiac + brown stool, ng lavage was negative. ct scan showed large rp hematoma. ir rec cta - which showed a small focus at right psoas muscle, concerning for active bleed. she was given 2 units uncrossmatched blood for the hypotension, followed by a unit of cross matched blood and a l of ns. bp remained 100-110 over several hours. . the patient went straight to ir where no active extravasation was seen, but there was an irregular smaller branch that was embolized with 2 small coils. a second arteriogram revealed no more bleeding past medical history: anxiety gerd hypertension anemia of chornic disease malnutrition euthyroid sick s/p hysterectomy social history: patient used to work part-time as a secretary. she is married and has one son. denies tobacco, etoh, or other drug use. family history: mother died at 78, father at 71 from mi. physical exam: admission exam: vitals: t: 97.6 bp: 133/61 p: 65 r: 18 o2: 95% general: alert, oriented, no acute distress heent: slightly pale, sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally cv: regular rate and rhythm, no murmurs abdomen: multiple echymosis from heparin shots, firmness to palpatio over the right abdomen, mild tenderness to palpation in that region, no guarding, + bs ext: warm, well perfused, 2+ pulses, no edema pertinent results: admission labs: 02:04pm blood wbc-21.4*# rbc-1.35*# hgb-4.7*# hct-12.9*# mcv-95 mch-34.5* mchc-36.4* rdw-16.3* plt ct-188 02:04pm blood neuts-84.9* lymphs-9.1* monos-5.0 eos-0.7 baso-0.3 02:04pm blood pt-12.9 ptt-43.9* inr(pt)-1.1 02:04pm blood glucose-206* urean-56* creat-1.2* na-136 k-4.9 cl-105 hco3-22 angap-14 02:04pm blood alt-32 ast-20 alkphos-55 totbili-0.2 dirbili-0.1 indbili-0.1 02:04pm blood albumin-2.0* calcium-7.1* phos-6.0*# mg-1.8 02:04pm blood hapto-160 02:04pm blood d-dimer-664* . cxr 1. minimal right basilar atelectasis. otherwise, no acute intrathoracic process. 2. small bilateral pleural effusions as seen on subsequent ct. . ct ap 1. large right iliopsoas intramuscular hematoma with associated retroperitoneal hematoma. further evaluation with cta is recommended to assess for active bleeding. 2. diverticulosis without evidence of diverticulitis. . cta ap 1. tiny focus of active arterial extravasation within the right psoas muscle (2:124). overall stable size of large right retroperitoneal hematoma. 2. hypodense 3-mm lesion in the body of the pancreas, more fully characterized on the mrcp dated . brief hospital course: ms. is a 65 yof with recent diagnosis of postviral autoimmune enteropathy requiring prolonged hospitalization complicated by acidosis and pea arrest who represented from rehab with acute hct drop and was found to have a retroperitoneal bleed, now s/p coiling by ir with stable hct. # retroperitoneal bleed: unclear etiology. pt was instrumented 3 weeks ag during pea arrest with right femoral line, however, likely not related to bleed as pt was noted to have a stable hct 3 prior to admission (27) and femoral lines do not typically travel far enough to cause a psoas bleed. possible pt had heparin shot into a vessel which caused bleeding? symptoms began wednesday night and she was not symptomatic despite her profound anemia, making a slow bleed most likely. s/p ir coiling of small artery though unclear if it was actually bleeding. hct stable after the procedure around 27. lasix and valsartan were held in setting of iv contrast load during ir procedure. coreg was also held to monitor for tachycardia as sign of re-bleed. blood pressure medications were slowly restarted as blood pressure and blood counts stabilized. # autoimmune enteropathy: continued budesonide and methylprednisolone taper and monitored fingersticks. should continue methylprednisolone 15 mg x 1 day, 12.5 mg x 3 days, 10 mg x 3 days, 7.5 mg x 3 days, 5 mg x 3 days, then off. should follow up with gi as scheduled. # hypertension: has history of poorly controlled bp. pt was hypotensive in ed in setting of anemia and had one episode of bp 80s overnight the night of admission, but was otherwise was normotensive. her home isosorbide mononitrate was continued with holding parameters; and clonidine patch replaced to prevent withdrawal. held valsartan, lasix, and coreg initially as above which were slowly restarted. # gerd: omeprazole instead of esomeprazole while inpatient. # depression/anxiety: continued citalopram and ativan during hospitalization. restarted both on discharge. # 4-mm pancreatic cystic lesion: found within the neck / body of the pancreas during previous hospitalization. concern for ipmn (intrapapillary mucinous neoplasm) of pancreas. will need follow up with mri as outpatient. # hypoxia: likely atelectatis, but may have a component of pleural effusion from hypoalbuminemia. chf possible, but no history of echo in our system. echo done this admission showed normal systolic function and mild pulmonary artery hypertension. incentive spirometer use encouraged. transitional issues: - monitor o2 status - monitor hct daily for 2 days, then again on to ensure stable - monitor bps - outpatient mri - continue methylprednisolone taper as above full code during this admission. medications on admission: 5000 tid trazodone 25 mg hs valsartan 320 mg q day conjugated estrogen 0.625 q day esmompreazole 40 mg q day lorazepam 0.5 mg q 8 prn citalopram 40 mg q day vitamin d 400 units q day acetaminophen 650 mh q 6 prn folic acid 1 mg q day tiamine 100 mg q day budesonide 9 mg q day gemfibrozil 600 mg q day clonidine 0.2 mg patch q thursday furosemide 40 mg q day carvedilol 25 mg isosorbide mononitrate 30 mg q day lidocaine patch q day methylprednisolone 17.5 mg until --> 15 mg x 3 days --> 12.5 mg x 3 days --> 10 mg x 3 days --> 7.5 mg x 3 days --> 5 mg x 3 days discharge medications: 1. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 2. conjugated estrogens 0.625 mg tablet sig: one (1) tablet po daily (daily). 3. esomeprazole magnesium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 4. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po bid (2 times a day). 6. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 9. budesonide 3 mg capsule, delayed & ext.release sig: three (3) capsule, delayed & ext.release po daily (daily). 10. clonidine 0.2 mg/24 hr patch weekly sig: one (1) patch transdermal once a week: change on thursday. 11. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 12. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). 13. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 14. methylprednisolone 8 mg tablet sig: one (1) taper po bid (2 times a day) for 13 days: taper as below: 15mg x 1 days 12.5mg x 3 days 10mg x 3 days 7.5 mg x 3 days 5 mg x 3 days . 15. atovaquone 750 mg/5 ml suspension sig: ten (10) ml po daily (daily). 16. isosorbide mononitrate 10 mg tablet sig: three (3) tablet po bid (2 times a day). 17. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: two (2) tablet, chewable po bid (2 times a day). 18. insulin lispro 100 unit/ml solution sig: one (1) sliding scale subcutaneous asdir (as directed): follow insulin sliding scale enclosed. 19. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 20. dextrose 50% in water (d50w) syringe sig: one (1) syringe intravenous prn (as needed) as needed for hypoglycemia protocol. 21. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 22. valsartan 320 mg tablet sig: one (1) tablet po once a day. 23. citalopram 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: skilled nursing center discharge diagnosis: retroperitoneal bleed autoimmune enteropathy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , you were admitted to for a bleed in your right lower abdomen/back, called a retroperitoneal bleed. it is not clear why this has happened, but it may have been spontaneous (for no apparent reason). you were transfused with blood products to improve your blood counts. interventional radiology doctors placed a in the blood vessel that appeared to be bleeding and you did not have any subsequent problems. you were restarted on your most of your home blood pressure medications after the bleeding was felt to be stable. for your diarrhea and autoimmune enteropathy we continued your steroid regimen which will be tapered down as planned by the gastroenterology doctors. we also discontinued your foley catheter. the following changes were made to your medications: started atovaquone to prevent fungal pneumonia while you are on steroids started calcium supplement increased vitamin d supplement continue methylprednisolone taper for additional 15 days as follows: - 15 mg x 1 days - 12.5 mg x 3 days - 10 mg x 3 days - 7.5 mg x 3 days - 5 mg x 3 days your blood pressure medications were initially stopped when you came in because you were bleeding significantly, but after your blood pressure and your blood counts were stable, we slowly restarted your blood pressure medications. please be sure to discuss with your primary care doctor the possibility of again trying to very slowly taper down your conjugated estrogens because of potential risks of being on these medications. please be sure to keep your followup appointment with your gi doctor as below. followup instructions: department: division of gi when: at 9:00 am with: , md building: ra (/ complex) campus: east best parking: main garage please follow up with your primary care doctor once you are discharged from rehab. they can assist you with this function once you are ready for discharge to home. Procedure: Arteriography of other intra-abdominal arteries Other endovascular procedures on other vessels Diagnoses: Esophageal reflux Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Pure hyperglyceridemia Dysthymic disorder Nontraumatic hematoma of soft tissue Other and unspecified complications of medical care, not elsewhere classified Cyst and pseudocyst of pancreas Hemoperitoneum (nontraumatic) Unspecified intestinal malabsorption Unspecified disorder of intestine

allergies: zantac attending: chief complaint: abdominal aortic aneurysm major surgical or invasive procedure: : groin cutdown with mass excision and endovascular repair of an aortic aneurysm history of present illness: ms. is an 88-year-old female who is currently being evaluated for percutaneous aortic valve replacement due to severe aortic stenosis. she has a known infrarenal aortic aneurysm. this was in the 4-5 cm range when it was first discovered approximately eight years ago. in of this past year, she was evaluated at the and was judged not to be an endovascular candidate. for that reason, repair was deferred. she was recently hospitalized in of this year for flash pulmonary edema and back pain related to vertebral compression fracture. cat at that time demonstrated a 7.5-cm infrarenal aortic aneurysm. she presents for elective endovascular repair. past medical history: past medical/surgical history: cad diabetes dyslipidemia hypertension cabg afib on coumadin dchf (ef 60%) severe as breast cancer s/p right partial mastectomy s/p hysterectomy social history: remote smoking history (quit 30 years ago). lives in with her husband. walks with a walker. has four children, one died from mi. no etoh use. no illicit drug use family history: one child died from mi as above, two brother died of mi in 40s, one sister died of cancer, one sister of heart disease, father died of heart problems, mother died of breast cancer physical exam: physical exam: alert and oriented x 3 vs:bp 138/58 hr 72 carotids: 2+, no bruits or jvd resp: lungs clear abd: soft, non tender ext: pulses: left femoral palp , dp dop ,pt dop right femoral palp , dp dop ,pt dop bilateral groin dressing clean dry and intact. soft, no hematoma or ecchymosis. pertinent results: 02:05am blood wbc-6.4 rbc-2.99* hgb-8.9* hct-28.1* mcv-94 mch-29.8 mchc-31.7 rdw-18.0* plt ct-124* 02:05am blood calcium-8.6 phos-2.5* mg-2.5 brief hospital course: the patient was brought to the operating room on and underwent a right groin cutdown and mass excision and evar. the procedure was without complications. she was closely monitored in the pacu and then transferred to the floor where she remained hemodynamically stable. her diet was gradually advanced. she is ambulatory with ad lib. she was discharged to home on pod # 2 in stable condition. follow-up has been arranged with dr. with surveillance cta in one month. medications on admission: metoprolol 50', lasix 40', simvastatin 20', lisinopril 10', amiodarone 200', coumadin 2.5'(on hold), magnesium 120', mvi, ca/vitamin d discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. warfarin 2.5 mg tablet sig: one (1) tablet po once a day: as per pcp. 7. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 8. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 9. magnesium 120 mg daily 10.calcium/vit d discharge disposition: home discharge diagnosis: abdominal aortic aneurysm aortic stenosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after an endovascular repair of an abdominal aortic aneurym. please restart your coumadin at your home dose of 2.5 mg starting tonight. have your inr checked at your pcps office on . division of vascular and endovascular surgery endovascular abdominal aortic aneurysm (aaa) discharge instructions medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? do not stop aspirin unless your vascular surgeon instructs you to do so. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home: it is normal to have slight swelling of the legs: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? drink plenty of fluids and eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? after 1 week, you may resume sexual activity ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate ?????? no driving until you are no longer taking pain medications followup instructions: department: radiology when: thursday at 11:45 am with: cat scan building: cc clinical center campus: west best parking: garage department: vascular surgery when: thursday at 1:30 pm with: , md building: lm bldg () campus: west best parking: garage Procedure: Endovascular implantation of other graft in abdominal aorta Excision of lesion of other soft tissue Non-coronary intra-operative fluorescence vascular angiography [IFVA] Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of aorta Acute on chronic diastolic heart failure Aortocoronary bypass status Hematoma complicating a procedure Aortic valve disorders Personal history of malignant neoplasm of breast Personal history of tobacco use Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Long-term (current) use of anticoagulants Abdominal aneurysm without mention of rupture Mechanical complication of other vascular device, implant, and graft

allergies: penicillins attending: chief complaint: neurogenic claudication major surgical or invasive procedure: plif l4-5 history of present illness: 63-year-old woman who complains of bilateral lower extremity symptoms that are exacerbated by walking. she receives some amelioration with rest. she denies difficulty with bowel or bladder function. past medical history: htn diabetes angina social history: nc family history: nc physical exam: pre-op on clinic visit: on examination, her motor strength was in hip flexion, extension, quadriceps, hamstrings, dorsiflexion, and plantar flexion bilaterally. her sensory examination was intact with respect to the modality of light touch. her reflexes were normal and symmetric in the patellar and absent in the achilles bilaterally. her pulses were palpable bilaterally. sign was positive on the left and not on the right, but weekly so. upon discharge: a&ox3 perrl eoms: intact motor: ip at r 5 5 5 5 4 4 l 5 5 5 5 5 5 incision: c/d/i- staples pertinent results: ct l-spine w/o contrast 1. postoperative changes in the lumbar spine including posterior fusion of l4-l5. grade 1 anterolisthesis of l4 on l5. 2. drain is identified within the postoperative bed. no evidence of immediate hardware complication. lumbo-sacral spine (ap & lat) status post l4-l5 stabilization. the stabilization material is in correct position. no evidence of complications. brief hospital course: s/p plif l4-5 with dr. . surgery was uneventful and immediately post-operatively she remained stable. pod 1 she had an episode of stridor and feeling like she could not breath, desat to 84-86% - she received an albuterol and racemic neb with good effect, cxr was negative. later that morning she experienced a second episode of stridor and feeling like she could not breath but os sat was 100% and was transferred to the icu for observation. etiology is unclear but appeared to be upper respiratory. sq heparin was started on . on she was transferred to the floor and her jp drain was discontinued. on , patient complained of pain in her back that radiated down both legs. her r ip and were both on exam. she was started on neurontin and a medrol dose pack to help alleviate pain. pt is working with patient to determine if she needs to go to a rehab facility. on , patient reported that her pain was much more controlled. her exam is improved with her r ip , but is . patient will be discharged to center for rehabilitation. medications on admission: atenolol metformin lisinopril nortriptyline hydroxychloroquine discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever > 100.4, pain. 2. nortriptyline 10 mg capsule sig: one (1) capsule po hs (at bedtime). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for sob. 4. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 5. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. 6. methocarbamol 500 mg tablet sig: 1.5 tablets po tid (3 times a day). 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 8. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 11. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 12. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 13. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 14. methylprednisolone 8 mg tablet sig: one (1) tablet po breakfast/lunch/dinner () for 1 days. 15. methylprednisolone 8 mg tablet sig: two (2) tablet po bedtime () for 1 days. 16. methylprednisolone 8 mg tablet sig: one (1) tablet po q6h (every 6 hours) for 1 days: start on . 17. methylprednisolone 8 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 1 days: start on . 18. methylprednisolone 8 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 days: start on . 19. methylprednisolone 8 mg tablet sig: one (1) tablet po qd () for 1 days: start on . 20. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day). 21. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). 22. magnesium citrate 1.745 g/30ml solution sig: three hundred (300) ml po once (once) as needed for constipation. discharge disposition: extended care facility: center - discharge diagnosis: lumbar spondylolisthesis discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - requires assistance or aid (walker or cane) discharge instructions: discharge instructions for spine cases ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ begin daily showers ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, ibuprofen etc. for 3 months. ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits followup instructions: please return to the office in days for removal of your staples please call to schedule an appointment with dr. to be seen in 6 weeks. you will need xrays prior to your appointment Procedure: Lumbar and lumbosacral fusion of the anterior column, posterior technique Excision of intervertebral disc Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Other therapeutic apheresis Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified angina pectoris Stridor Spondylolisthesis